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SURGERY_Pestana > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What is the surgical treatment for GERD (that cant be controlled by medical means or who has developed complications like ulceration, stenosis, or severe dysplastic changes = Barrett’s esophagus)?

A

1) severe dysplastic changes = resection

2) otherwise, laparscopic Nissen fundoplication

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2
Q

In achalasia, which is swallowed easier: liquids or solids? In cancer of the esophagus?

A

Achalasia: Solids easier
Cancer: liquids easier

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3
Q

What is the treatment of achalasia?

A

Endoscopy with balloon dilatation

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4
Q

Which cancer of the esophagus is seen in history of smoking and drinking?

Which in history of GERD?

A

smoking & drinking = squamous cell

GERD = adenocarcinoma

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5
Q

What is the treatment of Mallory-Weiss tear?

A

Endoscopy to allow for photocoagulation therapy

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6
Q

What is the management of Boerhaave syndrome?

A

Gastrografin contrast swallow. Followed by barium if negative

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7
Q

Emphysema in the neck following endoscopy:

A

instrumental perforation of the esophagus (the most common reason for esophageal perforation)

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8
Q

What is the difference in treatment of gastric adenocarcinoma vs gastric lymphoma?

A

Gastric adenocarcinoma: surgery is the best tx

Gastric lymphoma: chemotherapy or radiotherapy; surgery if perforation

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9
Q

When is surgery performed in uncomplicated complete obstruction? Uncomplicated partial obstruction?

A

complete: 24h
partial: few days

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10
Q

Carcinoid syndrome, seen in patients with a small bowel carcinoid tumor with liver metastases, includes what symptoms?

A

1) diarrhea
2) flushing
3) wheezing
4) right-sided heart valvular damage

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11
Q

How do you diagnose carcinoid syndrome?

A

24 hour urinary collection for 5-HIAA

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12
Q

What is the surgical treatment for cancer of the right colon (iron deficiency anemia, 4+ occult blood in stool)?

A

right hemicolectomy

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13
Q

Bloody bowel movements, constipation, stools with narrow caliber. Next step?

A

Flexible proctosigmoidoscopic exam (45 or 60 cm) and biopsies for potential cancer of the left colon

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14
Q

Before surgery for left colon cancer, a colonoscopy and a CT are performed in order to:

A

1) colonoscopy to rule out second, synchronous primary CA
2) CT to assess operability and extent
sometimes pre op chemo or radiation for large rectal cancers

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15
Q

T/F: Isolated inflammatory polyps are premalignant, but hyperplastic are not.

A

False: BOTH ARE NOT PREMALIGNANT

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16
Q

Surgical treatment of UC requires removal of what?

A

affected bowel, including all of the rectal mucosa (which is always involved)

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17
Q

Which are more likely to be premaligant: villous adenomas or adenomatous polyps?

A

villous adenomas

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18
Q

Although clindamycin was the first antibiotic described to cause pseudomembranous colitis, ____________ are the most common cause.

A

cephalosporins

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19
Q

A virulent form of pseudomembranous colitis that is unresponsive to treatment with WBC > __ and serum lactate > ___ requires emergency colectomy.

A

WBC > 50K, serum lactate > 5

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20
Q

T/F: In all anorectal disease a proctosigmoidoscopic exam should be performed.

A

True: to rule out cancer

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21
Q

T/F: Diltiazem ointement can be used to treat anal fissure.

A

True. Helps to soften a tight sphincter (botox, forceful dilatation, lateral internal sphincterotomy, stool softeners, and topical nitroglycerin also help)

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22
Q

Patients who have had an ischiorectal abscess drained who report subsequent fecal soiling and occasional perineal discomfort with physical exam showing a cordlike tract and an opening lateral to the anus…Treatment?

A

fistula-in ano. Treatment is fistulotomy

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23
Q

Fungating mass growing out of the anus in HIV+ homosexual. Treatment?

A

Squamous cell carcinoma of the anus. Nigro chemoradiation, with surgery if residual tumor (only 10% of tumors)

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24
Q

Overall, most GI bleeding comes from the (upper/lower) GI tract.

A

3/4 cases of GI bleeding are from upper GI

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25
Q

What are four causes of bleeding in colon?

A

1) angiodysplasia
2) polyps
3) diverticulosis
4) cancer

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26
Q

Where is the ligament of Treitz located?

A

the duodenojejunal flexure

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27
Q

If you use an NG tube to aspirate stomach contents in someone with active GI bleeding and the fluid is white with no blood, do you perform an endoscopy?

A

Yes! But if there is bile, you have ruled out the upper GI tract (from nose to ligament of Treitz) as the source of bleeding and endoscopy is unneccessary

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28
Q

If upper GI source has been ruled out in GI bleeding, next step?

A

anoscopy to rule out hemorrhoids (not a colonoscopy because blood will obscure field!)

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29
Q

If GI bleed in lower tract >2 mL/min (1 u of blood every 4 h), next step?

If <0.5 mL/min, next step?

A

fast: angiogram and may allow for angiographic embolization
slower: wait till bleeding stops then do colonoscopy, or tagged red cell study

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30
Q

Blood per rectum in a child. Next step?

A

Technetium scan to look for ectopic gastric mucosa in Meckel diverticulum

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31
Q

Massive upper GI bleeding in the stressed, multiple trauma, or complicated post=op patient is probably due to _________. Treatment?

A

stress ulcers. Confirm with endoscopy and then angiographic embolization to treat.

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32
Q

Sudden onset of colicky flank pain radiating to inner thigh and scrotum (or labia):

A

ureteral stones

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33
Q

Abdominal pain in the LLQ:

A

acute diverticulitis (can sometimes have palpable tender mass, fever, leukocytosis)

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34
Q

“Parrot’s beak” or “coffee-bean” seen on X ray with severe abdominal distention and signs of intestinal obstruction:

A

sigmoid volvulus

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35
Q

What is the treatment of sigmoid volvulus?

A

Proctosigmoidoscopic xam with old rigid instrument; rectal tube is left in. Recurrent cases need elective sigmoid resection

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36
Q

A person with A-Fib or recent MI may develop an acute abdomen due to mesenteric ischemia when a clot breaks off and lodges in which artery?

A

superior mesenteric artery

37
Q

Acute pain and GI bleeding?

A

acute mesenteric ischemia

38
Q

Who develops primary hepatoma? What is the serum marker?

A

Primary hepatoma = hepatocellular carcinoma. Seen in people with cirrhosis. The serum marker is a-fetoprotein

39
Q

Metastatic colon cancer to the liver serum marker is:

A

CEA

40
Q

Pyogenic liver abscess is seen most often as a complication of biliary tract disease, particularly ___________

A

acute ascending cholangitis

41
Q

What is the treatment of amebic abscess of the liver?

A

The Mexico connection! Metronidazole! If not improving, then percutaneous drainage.

42
Q

Work up of high level of bili and transaminases with modest elevation of alk phos:

A

hep serologies (most common cause of this picture)

43
Q

Work up of elevations of bilirubin, transaminases, and high levels of alk phos:

A

sonogram looking for dilatation of the biliary ducts

44
Q

What is Courvoisier-Terrier sign?

A

thin-walled distended gallbladder due to malignant obstruction (like adenocarcinoma of head of pancreas, adenocarcinoma of ampulla of Vater, or cholangiocarcinoma)
NOTE: gallbladder is palpable on physical exam, vs shrunken in gallstones

45
Q

What is next in the treatment of obstructive jaundice caused by stones with sonogram showing dilated ducts and nondilated gallbladder full of stones?

A

ERCP: confirms diagnosis, spinchterotomy, removes duct stone

cholecystectomy to follow

46
Q

What is the next step when there is obstructive jaundice (high bili, modest elevation of transaminases, and high alk phos) and sonogram showing dilated gallbladder?

A

1) CT to look for adenocarcinoma of head of pancreas. If negative, then
2) ERCP. Endoscopy (“E”) to look for adenocarcinoma of ampulla of Vater and cholangiogram (“C”) to look for cholangiocarcinoma or smaller pancreatic cancers not seen on CT

47
Q

What cancer is suspected when malignant obstructive jaundice coincides with anemia and positive blood in stool?

A

Ampullary cancer

48
Q

What are three findings you would expect to see on sonogram in cholecystitis?

A

1) gallstones
2) thick walled gallbladder
3) pericholecystic fluid

49
Q

Treatment of cholecystitis:

A

1) NG suction, NPO, IV fluids, abx to wait for it to cool down
2) elective cholecystectomy (or emergent if patient does not respond to conservative treatment); men and diabetics less likely to respond
3) in patient with prohibitive surgical risk, emergency percutaneous transhepatic cholecystotomy is a good temporizing option

50
Q

How is the presentation of cholangitis different from cholecystitis?

A

Patients are sicker–more intense fever, chills, very high WBC. Some hyperbilrubinemia but key finding is very high alk phos

51
Q

What is the treatment of cholangitis?

A

IV abx and emergency decompression of the common duct (b ERCP or percutaneously through the liver through percutaneous transhepatic cholangiogram; rarely by surgery). Cholecystectomy ultimately follows

52
Q

Usually, biliary pancreatitis is treated with conservative treatment (NPO, NG suction, IV fluids) because the stones will pass spontaneously; if they don’t, what is indicated to dislodge the impacted stone?

A

ERCP and sphincterotomy

53
Q

How can you distinguish between the edematous form of pancreatitis (commonly seen in gallstone or alcoholic) vs acute hemorrhagic pancreatitis (more deadly)?

A

The latter = lower hematocrit (degree of amylase elevation does not correlate with the severity of the disease)

54
Q

What is the treatment of acute hemorrhagic pancreatitis with multiple abscesses?

A

Imipenem or meropenem (for those with seizure disorder). Daily CT scans

55
Q

Pancreatic pseudocysts are late sequelae of what? They occur about ___ weeks after the original problem

A

acute pancreatitis or pancreatic (upper abdominal trauma). Occur 5 weeks after initial injury

56
Q

What is the treatment of pancreatic pseudocysts?

A

Depend on the size! Under 6 cm = unlikely to have complications and are observed for spontaneous resolution. Greater than 6cm or >6 weeks old = drainage of cyst percutaneously or surgically into GI tract or endoscopically into stomach

57
Q

Which are the hernias which do not require surgical treatment (elective or emergent)?

A

1) Umbilical hernias in children under 2 (may resolve on own)
2) sliding esophageal hernias (not considered true hernias)
Emergent surgeries when they are irreducible (might strangulate)

58
Q

Features of chronic pancreatitis x4

A

1) calcified burned-out pancreas
2) steatorrhea (fixed with pancreatic enzymes)
3) diabetes (insulin)
4) constant epigastric pain (resistant to most therapies)

59
Q

What is the treatment of giant juvenile fibroadenomas?

A

Unlike fibroadenomas which can be observed, these are rapidly growing in young adolescents (teens) and are removed to avoid deformity and distortion of the breast

60
Q

What is the treatment of cystosarcoma phyllodes?

A

Wide local excision; removal is necessary

**don’t invade or become fixed!

61
Q

Bloody nipple discharge in young woman (20s to 40s):

A

intraductal papilloma

62
Q

T/F: Termination of pregnancy is necessary if breast cancer is discovered in a pregnant woman.

A

False! Treated normally, but NO radiation and no chemo in first trimester

63
Q

Which is the only breast cancer with a need for pre-op chemo?

A

Inflammatory breast cancer

64
Q

When is mastectomy recommended for DCIS? When is lumpectomy followed by radiation ok?

A

mastectomy: multicentric lesions thorughout breast; sometimes sentinel node biopsy is recommended because difficult to find invasive focus

lumpectomy followed by radiation when lesions confined to one quarter of the breast

65
Q

T/F: Inoperability of breast cancer is based on extent of local disease, not metastases.

A

TRUE

66
Q

Tamoxifen is an (antagonist/agonist) in the breast and an (antagonist/agonist) in the endometrium.

A

Antagonist in breast

Agonist is endometrium

67
Q

Anastrozole is an aromatase inhibitor used to treat breast cancer in what population?

A

postmenopausal women

68
Q

Persistent headache or back pain with areas of localized tenderness in women who recently had breast cancer suggsts

A

brain or spine metastases

69
Q

What is the favorite location of metastatic breast cancer in the spine?

A

vertebral pedicles (lytic lesions)

70
Q

What is the next diagnostic step in a euthyroid patient with a thyroid nodule?

A

FNA
If benign, can observe.
If malignant or indeterminate, next step is lobectomy

71
Q

A total thyroidectomy should be performed in which type of thyroid cancer?

A

Follicular

72
Q

Those hyperthyroid patients with a hot nodule can have which intervention?

A

surgical excision of the affected lobe

73
Q

Why is elective intervention of asymptomatic patients with hyperparathyroidism (detected serendipitously by high calcium) justified?

A

Asymptomatic patients become symptomatic at a rate of 20% per year

74
Q

What type of scan helps locate the culprit parathyroid gland before curative removal?

A

Sestamibi scan (Tc99m-sestamibi is absorbed faster by a hyperfunctioning parathyroid gland than by a normal parathyroid gland)

75
Q

What is the sequence of tests in diagnosing the source of Cushing syndrome?

A

1) low dose dexamethasone suppression test; if no suppression, then…
2) 24 hour urinary cortisol; if elevated, then…
3) high dose dexamethasone suppression test (if suppression, the pituitary microadenoma). If NO suppression, adrenal adenoma (or paraneoplastic syndrome)

76
Q

Ulcers extending past the first section of the duodenum…think:

A

Zollinger-Ellison syndrome (gastrinoma)

77
Q

Which tests can help confirm Zollinger-Ellison?

A

1) secretin test; if equivocal, then…

2) CT with contrast of pancreas and nearby area to locate tumor

78
Q

What is the treatment of Zollinger-Ellison?

A

Remove tumor. Omeprazole can help those with metastatic disease.

79
Q

What does it mean if someone has high insulin but low C peptide?

A

Exogenous administration of insulin (often a medical professional or a diabetic). in insulinomas, C peptide and insulin levels are both high

Note: some are using sulfonylurea to induce insulin (and this will also increase C peptide); makes it harder to use this diagnostically

80
Q

What is nesidioblastosis?

A

Hypersecretion of insulin in the newborn, requiring 95% pancreatectomy

81
Q

Migratory dermatitis, resistant to all therapy, in patient with mild diabetes, anemia, glossitis, and stomatitis:

A

glucagonoma. Do glucagon assay to diagnose. Resection is curative.

82
Q

What is the treatment of glucagonoma in patients with inoperable, metastatic disease?

A

Somatostatin and streptozocin (toxic to insulin-producing beta cells of pancreas) can help

83
Q

Primary hyperaldosteronism features what key findings (x3):

A

1) hypokalemia (not on diuretics)
2) hypernatremia
3) metabolic alkalosis

84
Q

How can you distinguish between adrenal hyperplasia causing primary hyperaldosteronism vs adenoma?

A

Postural changes (more aldosterone when upright than laying down) suggests hyperplasia, which is treated medically.

No postural chagnes = adenoma, treated surgically after adrenal CT helps locate tumor

85
Q

Patient with attacks of pounding headache, perspiration, palpitations, and pallor. Next step?

A

24 hour urinary VMA (easy, but may give false positives), metanephrines (more specific), or free urinary catecholamines

86
Q

Surgery of pheochromocytoma requires careful pharmacologic preparation with

A

alpha blockers (phenoxybenzamine) or short acting antagonist (terazosin, doxazosin)

87
Q

CXR showing scalloping of ribs:

A

coaractation of aorta (erosion of ribs from large collateral intercostals)

88
Q

Renovascular hypertension is seen in two very distinct groups:

1) young women with ______________
2) old men with ____________

A

young women with fibromuscular dysplasia

old men with arteriosclerotic occlusive disease

89
Q

What is the diagnostic workup and treatment of renovascular hypertension?

A

Workup: Duplex scanning of renal vessels or CT angio

Treatment: esp in the young women with balloon dilatation and stenting (more controversial in old men who have a short life expectancy from other manifestations of arteriosclerosis)

SURGERY_Pestana (14 decks)

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