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Pestanas Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Achalasia

A

More commonly in women. Dysphagia is worse for liquids than for solids.
Manometry is diagnostic. Most appealing current treatment is balloon dilatation done by endoscopy.

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2
Q

Cancer of Esophagus

A

Dysphagia starting from solids then to liquids. SCC seen in men with history of smoking and drinking (blacks have high incidence).

Endoscopy with prior barium swallow and biopsy for dx.
Most cases only get palliative surgery, not curative.

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3
Q

Mallory Weiss Tear

A

Occurs after prolonged, forceful vomiting. Endoscopy establishes diagnosis and allows photocoagulation.

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4
Q

Boerhaave Syndrome

A

Forceful vomiting that leads to esophageal perforation.

Sudden onset pain followed by fever and leukocytosis.

Contrast swallow with Gastrografin first, then emergency surgical repair.

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5
Q

Instrumental Perforation of the Esophagus

A

Most common reason for esophageal perforation.

Sudden pain, followed by fever and leukocytosis. Emphysema in neck.
Contrast studies and repair are imperative.

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6
Q

Gastric Adenocarcinoma

A

Common in elderly. Endoscopy, biopsies, CT scan helps assess operability. Surgery is best therapy.

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7
Q

Gastric Lymphoma

A

Common gastric adenocarcinoma. Tx is based on chemo or radiotherapy.

Low grade lymphatoid transformation (MALTOMA) can be reversed by eradication of H. pylori.

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8
Q

Mechanical Intestinal Obstruction

A

Colicky abdominal pain, protracted vomiting, progressive abdominal distention. No passage of gas or feces. Xrays show distended loops of bowel, with air fluid levels.

Tx starts with NPO, NG suction, and IV fluids.

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9
Q

Strangulated Obstruction

A

Eventually patient develops fever, leukocytosis, constant pain, signs of peritoneal irritation, and ultimately full blown peritonitis.

Emergency surgery.

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10
Q

Carcinoid Syndrome

A

Small bowel carcinoid tumor with liver metastases.
Sx: Diarrhea, flushing of face, wheezing, and right sided heart valvular damage.
24 hour urinary collection of 5-hydroxyindoleacetic acid.

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11
Q

Classic Picture of Acute Appendicitis

A

Anorexia, vague periumbilical pain that several hours later becomes sharp, severe, constant, and localized to right lower quadrant of abdomen.

Modest fever, leukocytosis in the 10,000-15,000 range, with neutrophilia and immature forms.

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12
Q

Doubtful Presentation of Acute Appendicitis

A

No classic findings so need CT scan (standard).

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13
Q

Cancer of Right Colon

A

Shows up as anemia (hypochromic, iron deficiency). Stools will be 4+ for occult blood.
Colonoscopy and biopsies are diagnostic; surgery of TOC.

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14
Q

Cancer of Left Colon

A

Bloody bowel movements.
Blood coats outside stool, may be constipation.
Flexible protosigmoidoscopic exam and biopsies for dx.
Full colonoscopy is needed to rule out synchronous second primary (new primary cancer in person with history of cancer)

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15
Q

Colonic Polyps

A

Probability for malignant degeneration are familial polyposis (and variants of Gardner), familial multiple inflammatory polyps, villous adenoma, and adenomatous polyp.

Polyps are not premalignant include juvenile, Peutz-Jeghers, isolated inflammatory, and hyperplastic.

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16
Q

Crohns Disease and Chronic Ulcerative Colitis (CUC)

A

Severe diarrhea with blood and mucus.
Crohns surgery only if bleeding, stricture, or fistulization.
CUC surgery only if active disease for more than 20 years (malignant degeneration), severe nutritional depletion, multiple hospitalizations, need for high dose steroids or immunosuppresants, or development of toxic megacolon (fever, leukocytosis, abdominal pain and tenderness, and massively dilated colon with gas within wall).

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17
Q

Pseudomembranous enterocolitis

A

A virulent form of disease, unresponsive to tx, with WBC above 50,000 and serum lactate above 5, requires emergency colectomy.

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18
Q

Fecal Enema

A

Very effective cure for overgrowth of C. diff.

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19
Q

Hemorrhoids

A

Bleed if internal, hurt if external. Internal hemorrhoids can become painful and produce itching if they are prolapsed.

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20
Q

Anal Fissure

A

Young women; pain with defecation and blood streaks covering the stools. Fear of pain is so intense that they would avoid bowel movements (get constipated) and sometimes refuse proper physical examination of area.

Therapy directed at relaxing sphincter: stool softeners, topical nitroglycerin, local injection of botulinum toxin, forceful dilatation, or lateral internal sphincterotomy.
CCB such as diltiazem ointment 2% TID topically for 6 weeks have had an 80-90% success rate.

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21
Q

Crohn’s Disease

A

Often affects anal area; suspected when area fails to heal.

Remicade will help with healing.

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22
Q

Gastroesophageal Reflux

A

pH monitoring, peptic esophagitis, if severe dysplastic changes then radiofrequency ablation should be added to Nissen fundoplication.

Otherwise just Nissen fundoplication.

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23
Q

Ischiorectal Abscess

A

Exquisite perirectal pain. Incision and drainage are needed. Cancer should still be ruled out.

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24
Q

Fistula-in-ano

A

Develops in pts who had an ischiorectal abscess drained. Fecal soiling and perineal discomfort.

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25
Q

Squamous Cell Carcinoma of Anus

A

Common in HIV+ and in homosexuals.
Metastatic inguinal nodes are often felt.
Dx with biopsy and tx with chemoradiation therapy.

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26
Q

Vomiting Blood

A

Upper GI bleed (tip of nose to Ligament of Treitz); same as NG tube.

Next step? Upper GI Endoscopy.

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27
Q

Melena

A

Indicates digested blood.

Upper GI Endoscopy.

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28
Q

Red Blood Per Rectum

A

If actively bleeding, NG tube and aspirate gastric contents.

  • No blood and white fluid? Duodenum could be bleeding.
  • No blood but bile fluid? No upper GI bleeding, so no upper GI endoscopy.
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29
Q

Upper GI Bleed excluded, now what?

A

1) Rule out hemorrhoids.
2) Bleed 2mL/min, then angiogram.
3) Bleed

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30
Q

Recent h/o blood per rectum

A

Young: upper GI endoscopy
Old: Both upper and lower GI endoscopy

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31
Q

Blood per rectum in child

A

Should be from Meckel Diverticulum.

Start w/ technetium scan, looking for ectopic gastric mucosa.

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32
Q

Massive Upper GI Bleeding

A

Stressed, multiple trauma, or complicated PO pt with stress ulcers.
Dx: Endoscopy
Tx: Angiographic embolization.
Avoid by maintaining gastric pH above 4.

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33
Q

Acute Abdominal Pain: Perforation

A

Sudden onset, generalized, severe.
Patient is reluctant to move and very protective of abdomen.

Free air under diaphragm in upright x-rays. Emergency surgery.

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34
Q

Acute Abdominal Pain: Obstruction

A

Severe colicky pain, with typical location and radiation.

Patient moves constantly. Few physical findings.

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35
Q

Acute Abdominal Pain: Inflammatory Process

A

Gradual onset and slow buildup, constant, ill-defined, then eventually locates to where problem is.

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36
Q

Ischemic Processes

A

Bowel are the only ones that combine severe abdominal pain with blood in lumen of the gut.

37
Q

Primary Peritonitis

A

Culture ascites fluid; Tx with ABX.

38
Q

Mimics of Acute Abdomen

A

Myocardial ischemia (EKG, troponins), lower lobe pneumonia (chest x-ray), PE (immobilized patient), pancreatitis (amylase and lipase) and urinary stones (CT abdominal). .

39
Q

Acute Pancreatitis

A

Alcoholic w/ upper acute abdomen.

Dx w/ serum or urinary amylase or lipase (serum from 12 to 48 hours, urinary from 3rd to 6th day).

40
Q

Ureteral Stones

A

Sudden onset of colicky flank pain radiating to inner thigh and scrotum (or labia), sometimes with other urinary symptoms like urgency and frequency. and Microhematuria in urinalysis.

41
Q

Acute Diverticulitis

A

Acute abdominal pain in lower left quadrant.

Fever, leukocytosis, peritoneal irritation in left lower quadrant, sometimes palpable mass.

42
Q

Volvulus of Sigmoid

A

X-rays are diagnostic, show air-fluid levels in small bowel, very distended colon, and huge air-filled loop in RUQ.

Proctosigmoidoscopic exam resolves acute problem. Rectal tube is left in. Recurrent cases need elective sigmoid resection.

43
Q

Mesenteric Ischemia

A

Development of acute abdomen in elderly with atrial fibrillation or recent MI (embolism). Dx is made late when there is blood in bowel lumen.

In early cases, arteriogram and embolectomy might save the day.

44
Q

Primary Hepatoma (Hepatocellular Carcinoma)

A

U.S. cirrhosis pt, or those with hepatitis B or C.
Develop vague right upper quadrant discomfort and weight loss.
a-fetoprotein is specific blood marker.

45
Q

Metastatic Cancer of Liver

A

Outnumbers primary cancer 20:1.
Rising carcinoembryonic antigen (CEA) in those who had colonic cancer.

Resection if primary is slow or mets confined to one lobe.
Otherwise ablation.

46
Q

Hepatic Adenomas

A

Complication of birth control pills, have tendency to rupture and bleed massively inside abdomen.
CT scan diagnostic, emergency surgery is required.

47
Q

Pyogenic Liver Abscess

A

Complication of biliary tract disease. Acute ascending cholangitis.
Fever, leukocytosis, and tender liver.
Sonogram or CT scan is diagnostic.
Tx: Percutaneous drainage.

48
Q

Amebic Abscess of Liver

A

Favors men all whom have Mexico connection.

Tx with metronidazole and seldom require drainage.

49
Q

Hemolytic Jaundice

A

Elevated unconjugated bilirubin. No bile in urine. Bilirubin overall is low though.
Find out what is chewing up the RBCs.

50
Q

Hepatocellular Jaundice

A

Elevation of both fractions of bilirubin and very high levels of transaminases and modest elevation of alkaline phosphatase.
Hepatitis is most common and work up should proceed in that direction.

51
Q

Obstructive Jaundice

A

Elevations of both fractions of bilirubin, modest elevation of transaminases, and very high level of alkaline phosphatase.
Dx: Sonogram- look for dilatation of biliary ducts.
Obstruction caused by stones. Malignant obstruction- distended gallbladder is often identified (Courvosier-Terrier Sign).

52
Q

Obstructive Jaundice Caused by Tumor

A

Three cancers may be responsible:

1) Adenocarcinoma of ampulla of Vater. - Endoscopy
2) Cholangiocarcinoma of common duct.- ERCP and brushings
3) Adenocarcinoma of head of pancreas. - CT percutaneous biopsy for large mass, or endoscopic ultrasound for tiny tumors

If CT scan is negative, MRCP (which can find smaller tumors).

53
Q

Ampullary Cancers

A

Malignant obstructive jaundice coincides with anemia and positive blood in stools b/c can bleed in lumen.

Dx: Endoscopy

54
Q

Pancreatic Cancer

A

Seldom cured even when huge Whipple (pancreaticoduodenectomy) is done.

Cholangiocarcinomas: achieving margin-free resection is almost impossible.

55
Q

Biliary Colic

A

Stone temporarily occludes the cystic duct. Colicky pain in RUQ radiating to right shoulder and beltlike to back, triggered by ingestion of fatty foods.

N/V but without signs of peritoneal irritation or systemic signs of inflammatory process.

56
Q

Acute Cholecystitis

A

Liver function tests are minimally affected.

Sonogram is GOLD. This is followed by NG suction, NPO, IV fluids, and antibiotics to cool down before cholecystectomy.

57
Q

Acute Ascending Cholangitis

A

Common duct obstruction and ascending infection.
Some hyperbilirubinemia, but key finding is extremely high levels of alkaline phosphatase.

IV antibiotics and emergency decompression of the common duct by ERCP. Cholecystectomy will follow.

58
Q

Biliary Pancreatitis

A

Stones impact distally in ampulla, temporarily obstructing pancreatic and biliary ducts.

Conservative tx allowing for cholecystectomy later. If not, ERCP may be required to dislodge impacted stone.

59
Q

Acute Edematous Pancreatitis

A

Fat food or alcohol leads to pain straight to back. N/V and continued retching.

Elevated serum amylase or lipase early on, or urinary amylase or lipase (after couple of days).
Elevated hematocrit.

Resolution usually follows few days of pancreatic rest (NPO, NG suction, and IV fluids).

60
Q

Acute Hemorrhagic Pancreatitis

A

Starts as edematous pancreatitis, but early clue is lower hematocrit. Serum calcium also gets lower.

ICU.
Development of multiple pancreatic abscesses.
Anticipate them and drain them.

61
Q

Pancreatic Abscesses

A

Fever and leukocytosis develop 10 days after onset of pancreatitis.
Tx: percutaneous drainage.

62
Q

Necrosectomy

A

Operation best done when necrotic tissue is well delineated. Procedure may have to be repeated until dead matter is cleared away.

63
Q

Pancreatic pseudocyst

A

5 weeks elapse from original problem and discovery of the pseudocyst.
Fluid collection on outside of pancreas and pressure symptoms.
CT or sonogram.
6cm= will rupture or bleed so it needs to drained.
- drained percutaneously, into GI tract, or into stomach.

64
Q

Chronic Pancreatitis

A

It sucks. Diabetes and is can be controlled with insulin and pancreatic enzymes. But pain is resistant.

If obstruction or dilation present, may be able to fix.

65
Q

Three Families of Malignant Tumor

A

Epithelial tumors, sarcomas, and adenocarcinomas.

66
Q

In all breast disease, what has to be ruled out?

A

Cancer even if presentation suggests benign disease.
1/8 women gets breast cancer only if over 85 years old.
When breast cancer arises in young women, tend to be very aggressive.

67
Q

Mammography Screening

A

Started at age 40 and earlier if there has been positive history.
Guided core biopsies.

68
Q

Fibroadenomas

A

Young women (late teens, early twenties), firm rubbery mass that moves easily with palpation. FNA or sonogram is sufficient to establish diagnosis. Removal is optional.

69
Q

Cystosarcoma phyllodes

A

Seen in late 20s. Grow over many years and can become large, replacing and distorting the entire breast.
Core or incisional biopsy is needed (FNA is not sufficient). Removal is mandatory.

70
Q

Mammary Dysplasia/ Fibrocystic disease/ Cystic mastitis

A

Seen in thirties and forties, bilateral tenderness related to menstrual cycle,
If cyst is not persistent, then mammogram. If persistent, then large aspiration is needed. If persist after aspiration, then biopsy needed. Bloody fluid should be sent to cytology.

71
Q

Intraductal Papilloma

A

Seen in young women with bloody nipple discharge.

Mammogram, galactogram may be diagnostic and guides surgical resection.

72
Q

Breast Abscess

A

Lactating women, incision, drain, and biopsy of abscess wall.

73
Q

Breast Cancer Indicators

A

Palpable mass, age, ill-defined fixed mass, retraction of nipple, eczematoid lesions of areola, reddish orange peel skin, and palpable lymph axillary nodes.

74
Q

Breast Cancer During Pregnancy

A

Diagnose as if not pregnancy.

No radiotherapy or hormonal mainpulations at any time of pregnancy, and no chemotherapy during first trimester.

75
Q

Lumpectomy vs. Mastectomy

A

Segmental resection requires radiotherapy.
Mastectomy that does not need radiotherapy.
Enlarged lymph nodes? Resect, otherwise sentinel node biopsy.

76
Q

Infiltrating Ductal Carcinoma

A

Standard form of breast cancer. Inflammatroy cancer is worse prognosis.
Lobular has a higher incidence of bilaterality, but not high enough to justify bilateral mastectomy.

77
Q

Ductal Carcinoma In Situ

A

Cannot metastasize but has very high incidence of recurrence if only local excision is done.
Total mastectomy is multiple lesions.
can add sentinel node biopsy.

78
Q

Inoperable cancer of the breast

A

Based on local extent and not metastases. Tx mainly with chemotherapy.

79
Q

Adjuvant Systemic Therapy

A

Should follow in all patients, esp if axillary nodes are positive.
Chemo and only hormonal therapy if receptor is positive.

80
Q

Thyroid Nodules

A

Dx via FNA.
If follicular cancer, lobectomy may be needed to determine if follicular neoplasm is benign or malignant. If positive then total thyroidectomy.
Medullary cancer comes from C cells that make calcitonin. Aggressive and radical surgery is justified.

Work up for pheochromocytoma is indicated and often coexist (MEN, type 2)

81
Q

Hyperthyoidism

A

Tx with radioactive iodine

82
Q

Hyperparathyroidism

A

Found incidentally. Calcium redeterminations, low phosphorus, rule out cancer with bone metastases. PTH determination. Asymptomatic pts become so at 20% per year.

83
Q

Zollinger Ellison

A

Ulcers beyond first portion.

84
Q

Insulinoma

A

CT to located tumor. Look at C-peptide, and also ask about use of sulfonureas.

85
Q

Nesidioblastosis

A

Devastating hypersecretion of insulin in the newborn. 95% pancreatectomy.

86
Q

Glucagonoma

A

Severe migratory necrolytic dermatitis, mild diabetes, anemia, glossitis, and stomatitis.

87
Q

Primary hyperaldosteronism

A

Hypokalemia, HTN, hypernatremia, metabolic alkalosis, aldosterone levels high, renin levels are low.

If adenoma, CT scan and remove.
Hyperplasia (BP changes with posture), tx medically.

88
Q

Pheochromocytoma

A

Surgery requires careful pharmacologic preparation with alpha blockers.

89
Q

Renovascular HTN

A

Young women with fibromuscular dysplasia (balloon dilatation and stenting) and old men with arteriosclerotic occlusive disease.

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