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FRCPC > General Surgery > Flashcards

General Surgery Flashcards

1
Q

List 5 indications for splenectomy

A 
Traumatic splenic rupture
Anatomic defects
Severe transfusion dependent hemolytic anemia
Refractory immune cytopenias
Metabolic storage diseases
Secondary hypersplenism
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2
Q

List 4 risk factors for pyloric stenosis

A

-Family history PS
Neonate erythromycin use in 1st 2 weeks of life
-First born
-Male
-Conditions-Apert, Zellweger, T18, eosinophilic gastroenteritis, Smith lemli opitz

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3
Q

What is the typical age of presentation of pyloric stenosis?

A

2 weeks – 2 months

Prematures diagnosed later

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4
Q

List 4 clinical features of pyloric stenosis

A

Projectile vomiting

Hungry in between

Visible gastric perstaltic wave

Olive (above and to right of umbilicus)

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5
Q

List the ultrasonographic diagnostic criteria for pyloric stenosis?

A
  1. Pyloric thickness >=4 mm

2. Pyloric length >=14 mm

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6
Q

Why do you need to correct alkalosis prior to pyloromyotomy?

A

Prevent post-op apnea

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7
Q

What fluid should you use for patient with pyloric stenosis and hypokalemic, hypochloremic metabolic alkalosis AND WHY?

A

Give large amounts of chlorinatedfluid=D5W0.45NS +20mmol/L of KCl

A) Chloride will help decrease the bicarb (incr Cl in IVF more strongly correlated with decr in serum HCO3)
B) Solution should correct hyponatremia and hypokalemia as well
C) Want to treat alkalosis prior to surgery to prevent apnea

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8
Q

What is the most common age of presentation of intussuseption?

A

3 months – 3 years

90% <2 years

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9
Q

In a child with intususseption, above what age should you think about a pathologic lead point?

A

> 2 years

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10
Q

List 5 pathologic lead points in intususseption

A 
Meckel’s diverticulum (most common)
Polyps
Intestinal duplication
Neurofibroma
Henoch-Schonlein purpura
Appendix
Hemangioma
Foreign body
Ectopic mucosa
Hamartoma
Peutz-Jaeger’s***
Malignancy (lymphoma, SB tumors, melanoma)
CF
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11
Q

List 3 contraindications to air enema in intususseption

A

Peritonitis
Persistent hypotension
Free air/pneumoperitoneum

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12
Q

List 3 conditions associated with malrotation

A

CDH
Gastroschisis
Omphalocele
Heterotaxy syndrome (CHD, malrotation,and asplenia or polysplenia)

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13
Q

List 3 conditions causing bilious vomiting

A
  1. Midgut volvulus
  2. Malrotation
  3. Duodenal or other atresias
  4. Hirschsprung’s disease
  5. Ileus
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14
Q

List 3 conditions associated with duodenal atresia

A 
Trisomy 21
Malrotation
Congenital heart disease
GU
anomalies
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15
Q

Why should you do hearing test in hirschsprungs?

A

Associated with Waardenburg syndrome

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16
Q

Which is more likely to be associated with other congenital anomalies-omphalocele or gastroschisis?

A

Omphalocele-80% associated with anomalies

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17
Q

List 3 conditions associated with omphalocele

A

Beckwith Wiedmann***most common

CHARGE

OEIS (Omphalocele-exstrophy-imperforate anus-spinal defects)

Pentalogy of Canrell ( defects involving the diaphragm, abdominal wall, pericardium, heart and lower sternum.)

Aneuploidy (trisomies 13>18> 21)

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18
Q

List 3 anomalies associated with gastroschisis

A

Most cases have no extraintestinal abnormalities

Associated GI problems are common:

  1. Intestinal atresia
  2. Malrotation
  3. Stenosis
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19
Q

List 2 steps in the initial management of abdominal wall defects

A
  1. NG tube to decompress the stomach
  2. Wrap bowel in saline soaked gauze and plastic wrap
  3. IV access and start TFI 120 mL/kg/day (include NaCl in maintenance
    solution)
  4. Broad spectrum antibiotics
  5. Keep neonate in thermoneutral environment
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20
Q

List 3 long term complications of gastroschisis

A 
Decreased GI motility
Bowel obstruction***(most common)
Perforated bowel/strictures
GERD
Cholestasis
Short Bowel
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21
Q

What is the natural history of umbilical hernia?

A

Most appear before 6mo and resolve by 1yr

Large hernia disappear by 5-6yrs

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22
Q

Above what size are umbilical hernias unlikely to close spontaneously?

A

> 2 cm

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23
Q

Indications for surgery for umbilical hernia

A

Persists beyond 5yrs
Symptomatic
Strangulated
Progressively larger after 1-2 yrs

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24
Q

What is the anatomy of indirect hernia?

A

Most common!

Due to patent process vaginalis

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25
Q

When is the risk of incarceration highest for inguinal hernia?

A

1st year of life

26
Q

List risk factors for inguinal hernias

A

Prematurity

Urogenital
• Cryptorchidism
• Exstrophy of the bladder or cloaca
• Ambiguous genitalia
• Hypospadius/epispadius

Increased peritoneal fluid
• Ascites
• Ventriculoperitoneal shunt
• Peritoneal dialysis catheter

Increased intra-abdominal pressure
• Repair of abdominal wall defects
• Severe ascites (chylous)
• Meconium peritonitis

Chronic respiratory disease
• Cystic fibrosis

Connective tissue disorders
• Ehlers-Danlos syndrome
• Hunter-Hurler syndrome
• Marfan syndrome
• Mucopolysaccharidosis
27
Q

When should hernias be repaired?

A

Early repair (6-12mo) reduces risk of incarceration and complications

Urgent referral if child is <1yr

28
Q

Management of incarcerated hernia

A

Attempt reduction

Surgical repair 24-48 hours later

29
Q

Management of strangulated hernia

A

Surgery ASAP

30
Q

Anatomy of direct inguinal hernia

A

Rare in children
Acquired
Groin masses that extend toward femoral vessels due to muscular defect

31
Q

What is the anatomy of malrotation?

A

Failure of the cecum to move into the right lower quadrant which prevents normal broad based adherence to the posterior abdominal wall

The mesentery, including SMA, is tethered by narrow stalk–>prone to volvulus

Ladds bands between cecum and RUQ can compress duodenum

32
Q

List 5 risk factors for gall stones

A 
Hemolytic disorders (sickle cell, HS)
Obesity
Crohn's disease
Short gut (esp ileal resection)
CF
TPN
Diuretic use
Cephalosporin use
33
Q

List 3 conditions that have increased risk of hirschsprungs

A 
T21
Goldberg-Shprintzen
Smith-Lemli-Opitz
Shah-Waardenburg
Cartilage-hair hypoplasia
Congenital hypoventilation syndrome
34
Q

Differential for delayed passage of meconium

A 
HD
Meconium ileus
Small left colon syndrome
Intestinal atresia
ARM
35
Q

What was the risk of re-intussuseption after air enema reduction?

A

10%

Should be observed 12-24 hours

36
Q

What serum marker is elevated antenatal in abdominal wall defects (gastroschisis and omphalocele)?

A

Elevated maternal serum AFP

37
Q

What antenatal US finding in omphalocele is associated with aneuploidy?

A

80% contain part of the liver

Non-liver containing is associated with fetal aneuploidy

38
Q

List 2 differences on physical exam between gastroschisis and omphalocele

A
  1. Presence of covering membrane
    - Present in omphalocele
  2. Location of defect
    - Gastroschisis: right of the umbilical cord insertion site
    - Omphalocele: midline
  3. Liver location
    - Gastroschisis: intracorporeal
    - Omphalocele: extracorporeal
39
Q

Of the following, which is most commonly associated with extraintestinal anomalies:

1) Duodenal atresia
2) Jejunal atresia
3) ileal atresia

A

Duodenal atresia-Most commonly T21 (33%)

40
Q

List 3 congenital anomalies assocaited with duodenal atresia

A 
CHD
Malrotation
Annular pancreas
Renal anomalies
EA
Skeletal malformations
ARM
41
Q

Why is rectal biopsy gold standard to diagnose Hirschsprungs instead of contrast enema?

A

10% of Hirschsprung’s won’t have transition zone on constrast enema

42
Q

During what weeks GA does intestine usually rotate during fetal development?

A

5th-12th week gestation

43
Q

List 2 contraindications to air enema reduction in intussusception (past SAQ)

A
  1. Prolonged intussusception
  2. Signs of shock
  3. Peritonitis
  4. Intestinal perforation
  5. Pneumatosis intestinalis
44
Q

List 2 situations in which air enema reduction for intussusception would be unsuccessful (past SAQ)

A
  1. Intussusception due to pathologic lead point

2. SB-SB intussusception

45
Q

In what age group is appendicitis most common?

A

12-18 years

Rare in children <5 years

46
Q

List the criteria of the Pediatric Appendicitis score

A
  • Fever >38°C (1)
  • Anorexia (1)
  • Nausea/vomiting (1)
  • Cough/percussion/hopping tenderness (2)
  • Right lower quadrant tenderness (2)
  • Migration of pain (1)
  • Leukocytosis >10,000 (109/L) (1)
  • Polymorphonuclear-neutrophilia >7,500 (109/L) (1)
  • Score of ≤2= very low likelihood of appendicitis
  • Score of ≥8 are highly associated with appendicitis
47
Q

What are the ultrasound criteria for diagnosis of appendicitis?

A
  • Wall thickness ≥6 mm
  • Luminal distention
  • Lack of compressibility
  • Complex mass in the RLQ or a fecalith
  • Normal appendix must be visualized to exclude appendicitis by ultrasound
48
Q

When should patients with appendicitis have surgery?

A

Semi-elective

Within 24-48 hr of diagnosis

49
Q

Management of perforated appendicitis

A
  1. Fluid resuscitation
  2. Antibiotics-Amp, gent, flagyl
  3. Percutaneous drainage of collections by IR
  4. Delayed appendectomy
50
Q

List 3 complications of appendicitis

A
  1. Wound infection
  2. Intrabdominal abscess***most common
  3. Post-op ileus
51
Q

Treatment of perianal abscess

A

In infants:
1. No treatment, even if fistula

In children:

  1. Large abscesses require I+D
  2. Limited role for antibiotics (unless systemically unwell or immunocompromised)
  3. Surgery if fistulas
52
Q

List three conditions associated with perianal fistulas

A
  1. Repaired HD
  2. TB
  3. Crohns
53
Q

List 3 initial management priorities in CDH

A
  1. Immediate intubation and sedation
  2. Avoid prolonged PPV
  3. Treat PHTN
54
Q

When are most CDHs repaired?

A

Most centers wait at least 48 hr after stabilization and resolution of the pulmonary hypertension

55
Q

List 3 long term complications of CDH

A 
BPD
GERD
Delayed growth in first 2 years of life
Bowel obstruction
Neurocognitive defects
Scoliosis
56
Q

What is diaphragmatic eventration?

A

Abnormal elevation of the hemidiaphram, because of thinned diaphragmatic muscle

Elevated hemidiaphgram on CXR

57
Q

How do you differentiate between diaphgragmatic eventration or CDH?

58
Q

List 3 acute complications of G-tube insertion

A
  • Pneumoperitoneum
  • Peritonitis
  • Ileus
  • Perforation
59
Q

How do you treat hypergranulation tissue at a G-tube site?

A
  • Silver Nitrate Ablation

- Hypertonic saline or steroid creams

60
Q

What should be done for a G-tube that is pulled out?

A

If mature tract (>4 weeks):
-Replace with foley

If not mature tract:

  • Do not replace
  • Allow tract to heal
  • Replace G-tube at difference site
61
Q

List 3 complications of short gut syndrome

A 
FTT
Malabsorption
Micronutrient deficiency
Liver disease
Gall stones
Increased risk of infection
Hyperoxaluria and kidney stones
Oral aversion

FRCPC (27 decks)

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