Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 4 > General surgery > Flashcards

General surgery Flashcards

1
Q

What are the general principles in preventing complications during the post-operative period?

A
  • Frequent examination of the patient (daily or more) and their wound
  • Removal of surgical tubes as soon as possible
  • Early ambulation
  • Monitor fluid balance and electrolytes
  • Analgesia - enough to adequately address pain, but not excessive
  • Skillful nursing care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the 5 Ws of post-operative fever?

A
  1. Wind POD 1-2 (pulmonary - atelectasis, pneumonia)
  2. Water POD 3-5 (urine - UTI)
  3. Wound POD 5-8 (if ealier think streptococcal or clostridial infection)
  4. Walk POD 8+ (thrombosis - DVT/PE)
  5. Wonder drugs POD 1+ (drugs)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Describe in more detail causes of post-operative fever and its treatment?

A
  • fever does not necessarily imply infection particularly in the first 24-48 h post-operative
  • fever may not be present or is blunted if patient is receiving chemotherapy, glucocorticoids, or immunosuppression
  • timing of fever may help identify cause
    • hours after surgery – POD #1 (immediate)
      • inflammatory reaction in response to trauma from surgery
      • reaction to blood products received during surgery
      • malignant hyperthermia
    • POD #1-2 (acute)
      • atelectasis (most common cause of fever in first 48 h after surgery)
      • early wound infection (especially Clostridium, Group A Streptococcus – feel for crepitus and look for “dishwater” drainage)
      • aspiration pneumonitis
      • other: Addisonian crisis, thyroid storm, transfusion reaction
    • POD #3-7 (subacute): infections more likely
      • UTI, surgical site infection, IV site/line infection, septic thrombophlebitis, leakage at bowel anastomosis (tachycardia, hypotension, oliguria, abdominal pain)
    • POD #8+ (delayed)
      • intra-abdominal abscess, DVT/PE (can be anytime post-operative, most commonly POD #8-10), drug fever
      • other: cholecystitis, peri-rectal abscess, URTI, infected seroma/biloma/hematoma, parotitis, C. difficile colitis, endocarditis, sinusitis (from nasogastric tube)
  • Treatment:
    • treat primary cause
    • Antipyrexia (e.g. acetaminophen)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the 7 As of drugs that are to be started post-operatively?

A
  • Analgesia
  • Anti-emetic
  • Anticoagulation
  • Antibiotics
  • Anxiolytics
  • Anticonstipation
  • All other patient meds (home meds, stress dose steroids, and ß-blockers)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the pre and post-operative orders that need to be done for all patients?

Hint: ADDAVIDS

A
  • Admit to ward X under Dr. Y
  • Diagnosis
  • Diet
  • Activity
  • Vitals (q4h from ED and post-operative is standard)
  • IV, Investigations, Ins and Ots
  • DRugs, Dressings, Drains
  • Special procedures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the general rules for wound care for a post-operative patient?

A
  • Can shower POD 2-3 (epitheliasation of wound occurs within 48 h)
  • Dressings can generally be removed POD #2 and left uncovered if dry (check with attending to
    be sure)
  • examine wound if wet dressing, signs of infection (fever, tachycardia, pain)
  • skin sutures and staples can be removed POD #7-10
    • exceptions: incision crosses crease (groin), closed under tension, in extremities (hand) or patient factors (elderly, corticosteroid use, immunosuppressed) removed POD #14, earlier if signs of infection
  • negative pressure dressings consist of foam and suction, promote granulation
    • ideal for large (grafted sites) or non-healing wounds (irradiated skin, ulcer)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the general rules for drain care in a post-operative patient?

A
  • sometimes placed intraoperatively to prevent fluid accumulation (blood, pus, serum, bile, urine)
    • can be used to assess quantity of third space fluid accumulation post-operatively
  • potential route of infection, bring out through separate incision (vs. operative wound) to decrease risk of wound infection and remove as soon as possible
    • types of drains
      • open (e.g. Penrose), higher risk of infection
      • closed: 1) Gravity drainage (e.g. Foley catheter); 2) Underwater-seal drainage system (e.g. chest tube); 3) Suction drainage (e.g. Jackson-Pratt)
      • sump (e.g. NGT)
    • monitor drain outputs daily
    • drains should be removed once drainage is minimal (<30-50 cc/24 h)
    • evidence does not support routine post-operative drainage of abdominal cavity
    • drains do not guarantee that the patient will not form a collection of fluid
    • ridged drains can erode through internal structures, and excessive suction can cause necrosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the 5 principles of consent?

A
  1. Assumption of capacity (unless it is established that a person lacks capacity)
  2. A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
  3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision
  4. An act done, or decision made for or on behalf of a person who lacks capacity must be done, or made, in his best interests
  5. Before the act is done or the decision is made, regard must be paid as to whether the purpose for which it is needed can be effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How do we determine that a patient has capacity?

A

All adults are assumed to have capacity, but they must be able to:

  1. Understand the information
  2. Retain the information
  3. Are able to weigh the information uo
  4. Communicate their decision and any questions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Describe the regimes used to prevent VTE post-operatively?

for enoxaparin, heparin, warfarin, rivaroxaban and apixaban.

A

Enoxaparin (LMWH) prevention of VTE

  • Moderate risk patients: 20 mg daily subcut. Start 2 hours pre-surgery.
  • High risk patients: 40 mg subcut daily for 7-10 days or until mobilized. Start 12 hours pre-surgery.
  • Use with caution in renal failure: 20 mg daily subcut for CrCl <30 ml/min.
  • Monitor with factor Xa inhibition (anti-factor Xa activity) if clinically indicated.
  • Half life is 3-6 hours.

Heparin (unfractionated) prevention of VTE:

  • General surgery: 500 units subcut 2 hours pre-surg, then 5000 units 2-3 times daily for 7-10 days or until mobilized.
  • Monitor with APTT. Aim for 1.5-2.5 normal, check local guidelines.
  • Half life is 60 minutes.

Warfarin prevention of VTE:

  • Target INR is 2-3 for all indications except heart valves.

Rivaroxaban prevention of VTE:

  • Used to prevent VTE after hip/knee replacement.
  • 10 mg daily starting 6-10 hours post-surgery.
  • Continue 2/52 for TKR or 5/52 for hip.

Apixaban prevention of VTE:

  • Used to prevent VTE after hip/knee replacement.
  • 2.5 mg BD starting 12-24 hours post-surgery.
  • Continue 10-14 days for TKR or 32-38 days for hip.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe the regimes used to treat VTE?

for enoxaparin, heparin and warfarin

A
  • Enoxaparin (LMWH)
    • 1 mg/kg subcut BD, or 1.5 mg/kg daily for 5-10 days.
    • Twice the daily dose for high-risk patients (eg. With cancer).
    • CrCl <30 ml/min – use 1 mg/kg daily subcut.Moderate risk patients: 20 mg daily subcut.
  • Heparin (unfractionated)
    • IV bolus 5000 units, followed by IV infusion 1300 units/hour (often 30 000 units/24 hours) or
    • Subcut 17,500 units every 12 hours
    • Or IV bolus 80 units/kg, followed by IV infusion 18 units/kg/hour.
    • Adjust doses according to APTT
  • Warfarin
    • Target INR is 2-3 for all indications except heart valves.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the general rules for antibiotic prophylaxis prior to surgery?

A

Guiding principles:

  • Always guided by the local guidelines and Therapeutic guidelines. The Therapeutic Guidelines section on surgical prophylaxis is 36 pages long…
  • The classical abdominal surgeon’s friend is MAG:
    • Metronidazole – G+ and G- anaerobes, C. difficille, others.
    • Ampicillin – broad spectrum penicillin, notably strep and many anaerobes
    • Gentamycin – G- cover, enterococci.
  • Therapeutic Guidelines states: “a first generation cephalosporin remains the preferred drug for the majority of procedures”.
  • If MRSA is highly likely, add vancomycin 15 mg/kg IV 30-120 minutes before surgical incision.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Describe some common antibiotic prophylaxis regimes used?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What two main patterns in abdominal pain constitute urgent referal to general surgery?

A
  • Peritonitis
  • Obstruction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Describe the layers of the lateral abdominal wall and their continous spermatic and scrotal structures (superfical to deep)?

A
  1. skin (epidermis, dermis, subcutaneous fat)
  2. superficial fascia
    1. Camper’s fascia (fatty) → Dartos fascia
    2. Scarpa’s fascia (membranous) → Colles’ superficial perineal fascia
  3. muscle
    1. external oblique → inguinal ligament → external spermatic fascia and fascia lata
    2. internal oblique → cremasteric muscle/fascia
    3. transversus abdominis → posterior inguinal wall
  4. transversalis fascia → internal spermatic fascia
  5. preperitoneal fat
  6. peritoneum → tunica vaginalis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Describe the midline abdominal wall layers (superfical to deep)?

A
  1. skin
  2. superficial fascia
  3. rectus abdominis muscle: in rectus sheath, divided by linea alba
    1. above arcuate line (midway between symphysis pubis and umbilicus)
      1. anterior rectus sheath = external oblique aponeurosis and anterior leaf of internal oblique aponeurosis
      2. posterior rectus sheath = posterior leaf of internal oblique aponeurosis and transversus abdominis aponeurosis
    2. below arcuate line
      1. aponeuroses of external oblique, internal oblique, transversus abdominis all pass in front of rectus abdominis
  4. arteries: superior epigastric (branch of internal thoracic), inferior epigastric (branch of external iliac); both arteries anastomose and lie behind the rectus muscle (superficial to posterior rectus sheath above arcuate line)
  5. transversalis fascia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Name the following anatomy.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Name the anatomy.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Name the anatomy.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Which arteries supply the liver?

A

Left and right hepatic (branches of hepatic proper)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Which arteries supply the spleen?

A

Splenic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Which arteries supply the gallbladder?

A

Cystic (branch of right hepatic artery)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Which arteries supply the stomach?

A
  1. Lesser curvature: right and left gastric
  2. Greater curvature: right (branch of gastroduodenal) and left (branch of splenic) gastroepiploic.
  3. Fundus: short gastrics (branch of splenic)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Which arteries supply the duodenum?

A
  1. Gastroduodenal
  2. Pancreaticoduodenals (superior branch of gastroduodenal, inferior branch of superior mesenteric)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Which arteries supply the pancreas?

A
  • Pancreatic branches of splenic
  • Pancreaticoduodenals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Which arteries supply the small intestines?

A

Superior mesenteric branches: jejunal, ileal, ileocolic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Which arteries supply the large intestine?

A
  1. Superior mesenteric branches: right colic, middle colic
  2. Inferior mesenteric branches: left colic, sigmoid, superior rectal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Name the anatomy

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What tests should be ordered in all patients with an acute abdomen?

A

Key tests for specific diagnosises:

  • LFTs
  • Amylase/ lipase
  • urinalyss
  • ß-HCG
  • troponin
  • ABG/VBG

Key tests for or preparation:

  • FBC, UECs, Glucose
  • CXR + ECG
  • PT/INR and aPTT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

DDx for RUQ pain?

A
  • Hepatobiliary
    • Biliary colic
    • Cholecystitis
    • Cholangitis
    • CBD obstruction (stone, tumor)
    • Hepatitis
    • Budd-Chiari
    • Hepatic abscess/mass
    • Right subphrenic abscess
  • Gastrointestinal
    • Pancreatitis
    • Presentation of gastric, duodenal, or pancreatic pathology
    • Hepatic flexure pathology (CRC, subcostal incisional hernia)
  • Genitourinary
    • Nephrolithiasis
    • Pyelonephritis
    • Renal: mass, ischemia, trauma
  • Cardiopulmonary
    • RLL pneumonia
    • Effusion/empyema
    • CHF (causing hepatic congestion and R pleural effusion)
    • MI
    • Pericarditis
    • Pleuritis
  • Miscellaneous
    • Herpes zoster
    • Trauma
    • Costochondritis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

DDx for epigastric pain?

A
  • Cardiac
    • Aortic dissection/ruptured AAA
    • MI
    • Pericarditis
  • Gastrointestinal
    • Gastritis
    • GORD/oesophagitis
    • PUD
    • Pancreatitis
    • Mallory-Weiss tear
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

DDx for LUQ pain?

A
  • Pancreatic
    • Pancreatitis (acute vs. chronic)
    • Pancreatic pseudocyst
    • Pancreatic tumors
  • Gastrointestinal
    • Gastritis
    • PUD
    • Splenic flexure pathology (e.g. CRC, ischemia)
  • Splenic
    • Splenic infarct/abscess
    • Splenomegaly
    • Splenic rupture
    • Splenic aneurysm
  • Cardiopulmonary (see RUQ and Epigastric)
  • Genitourinary (see RUQ)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

DDx for diffuse abdo pain?

at least 15

A
  • Gastrointestinal
    • Peritonitis
    • Early appendicitis, perforated appendicitis
    • Mesenteric ischemia
    • Gastroenteritis/colitis
    • Constipation
    • Bowel obstruction
    • Pancreatitis
    • Inflammatory bowel disease
    • Irritable bowel syndrome
    • Ogilvie’s syndrome
  • Cardiovascular/Hematological
    • Aortic dissection/ruptured AAA
    • Sickle cell crisis
  • Genitourinary/Gynecological
    • Perforated ectopic pregnancy
    • PID
    • Acute urinary retention
  • Endocrinological
    • Carcinoid syndrome
    • Diabetic ketoacidosis
    • Addisonian crisis
    • Hypercalcemia
  • Other
    • Lead poisoning
    • Tertiary syphilis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

DDx for RLQ pain?

A
  • Gastrointestinal
    • Appendicitis
    • Crohn’s disease
    • Tuberculosis of the ileocecal junction
    • Cecal tumor
    • Intussusception
    • Mesenteric lymphadenitis (Yersinia)
    • Cecal diverticulitis
    • Cecal volvulus
    • Hernia: femoral, spigelian, inguinal obstruction, Amyand’s (and resulting cecal distention)
  • Gynecological
    • See ‘suprapubic’
  • Genitourinary
    • See ‘suprapubic’
  • Extraperitoneal
    • Abdominal wall hematoma/abscess
    • Psoas abscess
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

DDx for suprapubic pain?

A
  • Gastrointestinal (see RLQ/LLQ)
    • Acute appendicitis
    • IBD
  • Gynecological
    • Ectopic pregnancy
    • PID
    • Endometriosis
    • Threatened/incomplete abortion
    • Hydrosalpinx/salpingitis
    • Ovarian torsion
    • Hemorrhagic fibroid
    • Tubo-ovarian abscess
    • Gynecological tumors
  • Genitourinary
    • Cystitis (infectious, hemorrhagic)
    • Hydroureter/urinary colic
    • Epididymitis
    • Testicular torsion
    • Acute urinary retention
  • Extraperitoneal
    • Rectus sheath hematoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

DDx for LLQ pain?

A
  • Gastrointestinal
    • Diverticulitis
    • Diverticulosis
    • Colon/sigmoid/rectal cancer
    • Fecal impaction
    • Proctitis (ulcerative colitis, infectious; i.e. gonococcus or chlamydia)
    • Sigmoid volvulus
    • Hernia
  • Gynecological
    • See ‘suprapubic’
  • Genitourinary
    • See ‘suprapubic’
  • Extraperitoneal
    • Abdominal wall hematoma/abscess
    • Psoas abscess
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Describe where referred pain of biliary colic goes to?

A

Right shoulder or scapula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Describe where referred pain of renal colic goes to?

A

groin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Describe where referred pain of appendicitis goes to?

A

periumbilical to right lower quadrant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Describe where referred pain of pancreatitis goes to?

A

to back

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Describe where referred pain of ruptured aortic aneurysm goes to?

A

to back or flank

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Describe where referred pain of perforated ulcer goes to?

A

RLQ (via right paracolic gutter)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Describe where referred pain of hip pain goes to?

A

to groin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What are the DDx for abdominal masses separated by quadrants

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

What are the indication for surgery in gastrointestinal bleeding?

A
  • failure of medical management
  • exsanguinating hemorrhage: hemodynamic instability despite vigorous resuscitation
  • recurrent hemorrhage after initial stabilization procedures (up to two attempts of endoscopic control)
  • hypovolemic shock
  • prolonged bleeding with transfusion requirement >4 units
  • bleeding at rate >1 unit/8 h
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

DDx for GI bleeding.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What are the biochemical signs for differentiating jaundice?

Hepatocellular

Cholestatic

Haemolysis

A
  • Hepatocellular: Elevated bilirubin + elevated ALT/AST
  • Cholestatic: Elevated bilirubin + elevated ALP/GGT ± duct dilatation upon biliary U/S
  • Hemolysis: ↓ haptoglobin ↑ LDH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Fill in the following table for bilirubin levels.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

What is the aetiology of post operative dyspnea?

A
  • respiratory: atelectasis, pneumonia, pulmonary embolus (PE), ARDS, asthma, pleural effusion
  • cardiac: MI, arrhythmia, CHF
  • Inadequate pain control
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Describe the clincial features, risk factors and Rx for atelectasis partiuclar post-operatively ?

A

ATELECTASIS

  • comprises 90% of post-operative pulmonary complications

Clinical Features

  • low-grade fever on POD #1, tachycardia, crackles, decreased breath sounds, bronchial breathing, tachypnea

Risk Factors

  • COPD, smoking, obesity, elderly persons
  • upper abdominal/thoracic surgery, oversedation, significant post-operative pain, poor inspiratory effort

Treatment

  • pre-operative prophylaxis
    • smoking cessation (best if >8 wk pre-operative)
    • provide incentive spirometer and instruct how to use
  • post-operative prophylaxis
    • incentive spirometry, deep breathing exercise, chest physiotherapy, intermittent positive- pressure breathing
    • selective NGT decompression after abdominal surgery
    • short-acting neuromuscular blocking agents
    • minimize use of respiratory depressive drug, good pain control, early ambulation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Describe the clincial features, risk factors and Rx for pneuomia/pneumonitis particularly post-operatively?

A

PNEUMONIA/PNEUMONITIS

  • may be secondary to aspiration of gastric contents during anesthetic induction or extubation, causing a chemical pneumonitis

Risk Factors

  • aspiration: general anesthetic, decreased LOC, GERD, full stomach, bowel/gastric outlet obstruction + non-functioning NGT, pregnancy, seizure disorder
  • non-aspiration: atelectasis, immobility, pre-existing respiratory disease

Clinical Features

  • productive cough, fever
  • tachycardia, cyanosis, respiratory failure, decreased LOC
  • CXR: pulmonary infiltrate

Treatment

  • prophylaxis: see atelectasis prophylaxis, pre-operative NBM/NGT, rapid sequence anesthetic induction
  • immediate removal of debris and fluid from airway
  • consider endotracheal intubation and flexible bronchoscopic aspiration
  • IV antibiotics to cover oral nosocomial aerobes and anaerobes (e.g. ceftriaxone, metronidazole)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Describe the clincial features and Rx for pulmonary embolus particularly post-operatively?

A

Clinical Features

  • unilateral leg swelling and pain (DVT as a source of PE), sudden onset shortness of breath, tachycardia, fever
  • most commonly POD #8-10, but can occur anytime post-operatively

Treatment

  • IV heparin, long-term warfarin (INR = 2-3) for 3 mo
  • Greenfield (IVC) filter if contraindications to anticoagulation or develops a complication while on anticoagulation
  • prophylaxis: subcutaneous heparin (5,000 U bid) or LMWH, compression stockings (TED™ Hose)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Describe the aetiology, clincial features and Rx for pulmonary oedema particularly post-operatively?

A

Etiology

  • cardiogenic vs. noncardiogenic
  • circulatory overload: excess volume replacement, LV failure, shift of fluid from peripheral to pulmonary vascular bed, negative airway pressure, alveolar injury due to toxins (e.g. ARDS)
    • more common with pre-existing cardiac disease
  • negative pressure pulmonary edema due to inspiratory efforts against a closed glottis upon awakening from general anesthesia

Clinical Features

  • SOB, crackles at lung bases, CXR abnormal

Treatment (LMNOP)

  • Lasix (furosemide)
  • Morphine (decreases symptoms of dyspnea, venodilator and afterload reduction)
  • Nitrates (venodilator)
  • Oxygen + non-invasive ventilation
  • Position (sit patient up)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Describe the clincial features and Rx for respiratory failure particularly post-operatively?

A

Clinical Features

  • dyspnea, cyanosis, evidence of obstructive lung disease
  • earliest manifestations – tachypnea and hypoxemia (RR >25, pO 2 <60)
  • pulmonary edema, unexplained decrease in SaO 2

Treatment

  • ABCs, O 2 , ± intubation
  • bronchodilators, diuretics to treat CHF
  • adequate blood pressure to maintain pulmonary perfusion
  • if these measures fail to keep PaO 2 >60, consider ARDS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Describe the indicence, risk factors and clincial features for MI particularly post-operatively?

A

Incidence

  • surgery increases risk of MI
  • incidence
    • 0.5% in previously asymptomatic men >50 yr old
    • 40-fold increase in men >50 yr old with previous MI

Risk Factors

  • pre-operative HTN, CHF
  • previous MI (highest risk ≤6 mo, but risk never returns to baseline)
  • increased age
  • intraoperative hypotension
  • operations >3 h
  • angina

Clinical Features

  • majority of cases on day of operation or POD #3-4 (shifting of third space fluid back into intravascular compartment)
  • often silent without chest pain, may only present with new-onset CHF (dyspnea), arrhythmias, hypotension
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Define abdominal hernia.

A

Defect in abdominal wall causing abnomral protrusion of intra-abdominal contents.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Describe the epidemiology of abdominal hernias?

A
  • M:F = 9:1
  • lifetime risk of developing a hernia: males 20-25%, females 2%
  • frequency of occurrence: 50% indirect inguinal, 25% direct inguinal, 8-10% incisional (ventral), 5% femoral, 3-8% umbilical
  • most common surgical disease of males
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

What are the risk factors for developing an abdominal hernia?

A
  • activities which increase intra-abdominal pressure
    • obesity, chronic cough, asthma, COPD, pregnancy, constipation, bladder outlet obstruction, ascites, heavy lifting
  • congenital abnormality (e.g. patent processus vaginalis, indirect inguinal hernia)
  • previous hernia repair, especially if complicated by wound infection
  • loss of tissue strength and elasticity (e.g. hiatus hernia, aging, repetitive stress)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Describe the clincial features of an abdominal hernia?

A
  • mass of variable size
  • tenderness worse at end of day, relieved with supine position or with reduction
  • abdominal fullness, vomiting, constipation
  • transmits palpable impulse with coughing or straining
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

What Ix need to be done on an abdominal hernia?

A
  • physical examination usually sufficient
  • ultrasound ± CT (CT required for obturator hernias, internal abdominal hernias and Spigelian and/or femoral hernias in obese patients)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What are the classifications for an abdominal wall hernia?

A
  • complete: hernia sac and contents protrude through defect
  • incomplete: partial protrusion through the defect
  • internal hernia: sac herniating into or involving intra-abdominal structure
  • external hernia: sac protrudes completely through abdominal wall
  • strangulated hernia: vascular supply of protruded viscus is compromised (ischemia)
    • requires emergency repair
  • incarcerated hernia: irreducible hernia, not necessarily strangulated
  • Richter’s hernia: only part of bowel circumference (usually anti-mesenteric border) is incarcerated or strangulated so may not be obstructed
    • a strangulated Richter’s hernia may self-reduce and thus be overlooked, leaving a gangrenous segment at risk of perforation in the absence of obstructive symptoms
  • sliding hernia: part of wall of hernia sac formed by retroperitoneal structure (usually colon)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

What are the anatomical types of abdominal hernias?

A
  • groin
    • indirect and direct inguinal, femoral
    • pantaloon: combined direct and indirect hernias, peritoneum draped over inferior epigastric vessels
  • epigastric: defect in linea alba above umbilicus
  • incisional: ventral hernia at site of wound closure, may be secondary to wound infection
  • other: Littre’s (involving Meckel’s), Amyand’s (containing appendix), lumbar, obturator, peristomal, umbilical, Spigelian (ventral hernia through linea semilunaris), Grynfeltt-Lesshaft hernia (superior lumbar hernia), Petit’s hernia (inferior lumbar triangle)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

What are the complications that can occur to an abdominal hernia?

A
  • incarceration
  • strangulation
    • small, new hernias more likely to strangulate
    • femoral >> indirect inguinal > direct inguinal
    • intense pain followed by tenderness
    • intestinal obstruction, gangrenous bowel, sepsis
    • surgical emergency
    • DO NOT attempt to manually reduce hernia if septic or if contents of hernial sac gangrenous
      • will cause closed loop SBO – and EMERGENCY
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

What is the treatment for abdominal hernias?

A
  • surgical treatment (herniorrhaphy) is only to prevent strangulation and evisceration, for symptomatic relief, for cosmesis; if asymptomatic can delay surgery
  • repair may be done open or laparoscopic and may use mesh for tension-free closure
  • most repairs are now done using tension-free techniques – a plug in the hernial defect and a patch over it or patch alone
  • observation is acceptable for small asymptomatic inguinal hernias
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

What are the post-operative complications of abdominal hernia repair?

A
  • recurrence (15-20%)
    • risk factors: recurrent hernia, age >50, smoking, BMI >25, poor pre-operative functional status (ASA ≥3), associated medical conditions: type 2 DM, hyperlipidemia, immunosuppression, any comorbid conditions increasing intra abdominal pressure
    • less common with mesh/”tension-free” repair
  • scrotal haematoma (3%)
    • painful scrotal swelling from compromised venous return of testes
    • deep bleeding: may enter retroperitoneal space and not be initially apparent
    • difficulty voiding
  • nerve entrapment
    • ilioinguinal (causes numbness of inner thigh or lateral scrotum)
    • genital branch of genitofemoral (in spermatic cord)
  • stenosis/occlusion of femoral vein
    • acute leg swelling
  • ischemic colitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Describe the anatomy of a direct inguinal hernia.

A
  • Through Hesselbach’s triangle
  • Medial to inferior epigastric artery
  • Usually does not descend into scrotal sac
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Describe the anatomy of an indirect inguinal hernia?

A
  • Originates in deep inguinal ring
  • Lateral to inferior epigastric artery
  • Often descends into scrotal sac (or labia majora)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Describe the anatomy of a femoral hernia?

A
  • Into femoral canal, below inguinal ligament but may override it
  • Medial to femoral vein within femoral canal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

What is the contents of the spermatic cord?

A
  1. vas deferens
  2. testicular artery/veins,
  3. genital branch of genitofemoral nerve,
  4. lymphatics
  5. cremaster muscle,
  6. ± hernia sac
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Describe the anatomy.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

What are the general and specific risks of a laprascopic hernia repair?

A

Common risks:

  • troublepassing urine due to spasm of bladder sphincter
  • swelling of testicle and scrotum
  • damage to local structures: vas deferens
  • Chronic pain at site of surgery
  • Bleeding
  • seroma formation
  • Atelectasis, pneumonia
  • Wound infection
  • DVT/PE
    *
72
Q

What are the general and specific risks of a laprascopic cholescystectomy?

A

General:

  • Infection
  • Bleeding
  • Atelectasis
  • Pneumonia
  • Wound infection
  • MI and stroke
  • DVT/PE
  • Death

Specific:

  • Damage to surrounding structures: blood vessels, bile duct, and other organs
  • Gas in abdo causing heart and lung issues
  • may need to convert to open surgery
  • Stone may be found outside of gallbladder, spill from gallbladder into abdo cavity or be left in bile duct - needing further treatment
  • Clips and ties may come off
  • Abnormal wound healing - keloid scars, wound dehesence
  • Hernia at wound site
  • Adhesions
  • symtpoms pre surgery may not resolve
  • Allergy to injected contrast
73
Q

Describe the pathogenesis of gallstones?

A
  • imbalance of cholesterol and its solubilizing agents (bile salts and lecithin)
  • excessive hepatic cholesterol secretion → bile salts and lecithin are “overloaded” → supersaturated cholesterol can precipitate and form gallstones
  • cholesterol stones (80%), pigment stones (20%)
74
Q

What are the risk factors for developing gallstones?

A
  • cholesterol stones
    • obesity, age <50
    • estrogens: female, multiparity, OCPs
    • Ethnicity: Caucasian > Black
    • terminal ileal resection or disease (e.g. Crohn’s disease)
    • impaired gallbladder emptying: starvation, TPN, DM
    • rapid weight loss: rapid cholesterol mobilization and biliary stasis
  • pigment stones (contain calcium bilirubinate)
    • cirrhosis
    • chronic hemolysis
    • biliary stasis (strictures, dilation, biliary infection)
  • protective factors: statins, vitamin C, coffee, exercise
75
Q

What is the clinical consequence of gallstones?

A
  • asymptomatic (80%)
    • most do NOT require treatment
    • consider cholecystectomy if: increased risk of malignancy (choledochal cysts, Caroli’s disease, porcelain or calcified gallbladder), sickle cell disease, pediatric patient, bariatric surgery, immunosuppression
  • biliary colic (10-25%)
  • cholecystitis
  • choledocholithiasis (8-15%)
  • cholangitis
  • gallstone pancreatitis
  • gallstone ileus (0.3-0.5%)
  • other: empyema of the gallbladder, liver abscess, gallbladder perforation with bile peritonitis
76
Q

What Ix need to be done on a patient with symptomatic gallstones?

A
  • Labs
    • CBC, LFTs, amylase and lipase
  • U/S – diagnostic procedure of choice
    • image for signs of inflammation, obstruction, localization of stones
    • 95% specific for detecting stones
    • signs: gallbladder wall thickening >4 mm, edema (double-wall sign), gallbladder sludge, pericholecystic fluid, sonographic Murphy’s sign
  • ERCP
    • visualization of upper GI tract, ampullary region, biliary and pancreatic ducts
    • method for treatment of CBD stones in periampullary region
    • complications: traumatic pancreatitis (1-2%), pancreatic or biliary sepsis
  • MRCP
    • same information gained as ERCP but non-invasive
    • cannot be used for therapeutic purposes
  • PTC
    • injection of contrast via needle passed through hepatic parenchyma
    • useful for proximal bile duct lesions or when ERCP fails or not available
    • requires prophylactic antibiotics
    • contraindications: coagulopathy, ascites, peri/intrahepatic sepsis, disease of right lower lung or pleura
    • complications: bile peritonitis, chylothorax, pneumothorax, sepsis, hemobilia
  • HIDA scan
    • used less commonly
    • radioisotope technetium-99 injected into a vein is excreted in high concentrations into bile, allowing visualization of the biliary tree
    • does not visualize stones; diagnosis by seeing occluded cystic duct or CBD
77
Q

Name the following anatomy.

A
78
Q

What are the indications for cholecystectomy?

A
  • Symptomatic cholelithiasis with or without complications
  • Asymptomatic cholelithiasis in patients who are at increased risk of gallbladder carcinoma or gallstone complications
  • Acalculous cholecystitis
  • Gallbladder polyps >0.5 cm
  • Procelain gallbladder
79
Q

What is the clinical presentation of cholecystitis?

A
  • RUQ or epigastric pain which radiates to the back
  • Colicky pain but can be dull and constant
  • Dyspepsia, flatulence
  • Food intolerance particualrly to fats
  • Alteration in bowel frequency
  • N/V
80
Q

What are the DDx for cholecystitis?

A
  • Common
    • appendicitis
    • perforated peptic ulcer
    • acute pancreatitis
  • Uncommon
    • Acute pyelonephritis
    • myocardial infarction
    • pneumoina - right lower lobe
81
Q

Describe the pathogenesis if appendicitis?

A
  • luminal obstruction g bacterial overgrowth → inflammation/swelling → increased pressure → localized ischemia → gangrene/perforation → localized abscess (walled off by omentum) or peritonitis
  • aetiology
    • children or young adult: hyperplasia of lymphoid follicles, initiated by infection
    • adult: fibrosis/stricture, fecolith, obstructing neoplasm
    • other causes: parasites, foreign body
82
Q

Where/What is McBurney’s sign?

A

Tenderness 1/3 the distance from the ASIS to the umbilicus on the right side

83
Q

What are the clinical features of appendicitis?

A
  • most reliable feature is progression of signs and symptoms
  • low grade fever (38ºC), rises if perforation
  • abdominal pain then anorexia, N/V
  • classic pattern: pain initially periumbilical; constant, dull, poorly localized, then well localized pain over McBurney’s point
    • due to progression of disease from visceral irritation (causing referred pain from structures of the embryonic midgut, including the appendix) to irritation of parietal structures
    • McBurney’s sign
  • signs
    • inferior appendix: McBurney’s sign (see sidebar GS28), Rovsing’s sign (palpation pressure to left abdomen causes McBurney’s point tenderness). McBurney’s sign is present whenever the opening of the appendix at the cecum is directly under McBurney’s point; therefore McBurney’s sign is present even when the appendix is in different locations
    • retrocecal appendix: psoas sign (pain on flexion of hip against resistance or passive hyperextension of hip)
    • pelvic appendix: obturator sign (flexion then external or internal rotation about right hip causes pain)
  • complications
    • perforation (especially if >24 h duration)
    • abscess, phlegmon
84
Q

What Ix need to be done for a patient with ?appendicitis?

A
  • laboratory
    • mild leukocytosis with left shift (may have normal WBC counts)
    • higher leukocyte count with perforation
    • β-hCG to rule out ectopic pregnancy
    • urinalysis
  • imaging
    • ultrasound: may visualize appendix, but also helps rule out gynecological causes – overall accuracy 90-94%, can rule in but cannot rule out appendicitis (if >0.2 in, SENS/SPEC/NPV/PPV 98%)
    • upright CXR, AXR: usually nonspecific – free air if perforated (rarely), calcified fecolith, loss of psoas shadow, RLQ ileus
    • CT scan: thick wall, appendicolith, inflammatory changes – overall accuracy 94-100%, optimal investigation
85
Q

What is the Rx for appendicitis?

A
  • hydrate, correct electrolyte abnormalities
  • surgery (gold standard, 20% mortality with perforation especially in elderly) + antibiotic coverage
  • if localized abscess (palpable mass or large phlegmon on imaging and often pain >4-5 d), consider radiologic drainage + antibiotics x 14 d ± interval appendectomy in 6 wk (controversial)
  • appendectomy
    • laparoscopic vs. open
    • ƒcomplications: spillage of bowel contents, pelvic abscess, enterocutaneous fistula
    • ƒ perioperative antibiotics:
      • Š cefazolin + metronidazole (no post-operative antibiotic unless perforated)
      • Š other choices: 2nd/3rd generation cephalosporin for aerobic gut organisms
  • colonoscopy in the elderly to rule out other etiology (neoplasm)
86
Q

What signs of appendicitis relate to the position of the appendix and why is it relavent to know where the position of the appendix is?

A
  • Inferior appendix: McBurney’s sign), Rovsing’s sign (palpation pressure to left abdomen causes McBurney’s point tenderness). McBurney’s sign is present whenever the opening of the appendix at the cecum is directly under McBurney’s point; therefore McBurney’s sign is present even when the appendix is in different locations
  • Retrocecal appendix: psoas sign (pain on extension of hip against resistance or passive hyperextension of hip
  • Pelvic appendix: obturator sign (extension then external or internal rotation about right hip causes pain).
  • Relavent so that appropriate surgical planning can be made, this will change incision points depending on where the appendix is located.
87
Q

Describe the blood supply to the appendix?

A
  • Appendix is a midgut structure therefore arterial supply is from a branch of the superior mesenteric artery.
  • The appendicular artery branches off the ileocolic artery and runs through the appendix mesentery to supply the appendix
88
Q

What are the general and specific risks of appendicectomy?

A
  • General:
    • Infection, bleeding, converting to open
    • Atelectasis and pneumonia
    • MI/ stroke
    • DVT /PE
    • Death
  • Specific:
    • Damage to local vessels and organs
    • May need to conver to open surgery
    • Hernia developement in surgical scars
    • Deep bleeding into the abdo cavity - needing blood transfusion or fluid replacement.
    • surgical drainage of abscess that can occur after surgery
    • wound dehescience
    • abnormal scaring
    • adhesions
89
Q

What are the causes of small bowel obstruction?

A
  • Intraluminal:
    • Intussusception
    • gallstones
  • Intramural:
    • Crohns
    • Raditation strictures
    • Adenocarcinoma
  • Extramural:
    • adhesions
    • incarcerated hernia
    • peritoneal carinomatosis
90
Q

What is the treatment of small bowel obstruction?

A
  • consider whether complete or partial obstruction, ongoing or impending strangulation, location and cause
    • SBO with history of abdomen/pelvic surgery → conservative management (NGT decompression, GI rest, serial abdominal exams) → surgery if no resolution in 48-72 h or complications
    • complete SBO, strangulation → urgent surgery after stabilizing patient with fluid resuscitation
    • SBO with no previous surgery and no evidence of carcinomatosis → operate
    • trial of medical management may be indicated in Crohn’s, recurrent SBO, carcinomatosis
    • special case: early post-operative SBO (within 30 d of abdominal surgery) – prolonged trial of conservative therapy may be appropriate, surgery is reserved for complications such as strangulation
91
Q

What are the causes of large bowel obstruction?

A
  • Intraluminal
    • Constipation
  • Intramural:
    • Adenocarcinoma
    • Diverticulitis
    • IBD stricture
    • Radiation stricture
  • Extramural
    • Volvulus
    • Adhesions
92
Q

What are the clinical features of a large bowel obstruction (unique to LBO)?

A
  • open loop (10-20%)
    • incompetent ileocecal valve allows relief of colonic pressure as contents reflux into ileum, therefore clinical presentation similar to SBO
  • closed loop (80-90%) (dangerous)
    • competent ileocecal valve, resulting in proximal and distal occlusions
    • massive colonic distention → increased pressure in cecum → bowel wall ischemia → necrosis → perforation
93
Q

What is the pathogenesis of a bowel obstruction?

A
  • disruption of the normal flow of intestinal contents leading to proximal dilatation and distal decompression
  • may take 12-24 h to decompress, therefore passage of feces and flatus may occur after the onset of obstruction
  • bowel ischemia may occur if blood supply is strangulated or if bowel wall inflammation leads to venous congestion
  • bowel wall edema and disruption of normal bowel absorptive function can lead to increased intraluminal fluid and transudative fluid loss into peritoneal cavity, electrolyte disturbances
94
Q

What are the risk factors for a bowel obstruction?

A
  • prior abdominal or pelvic surgery
  • abdominal wall or groin hernia
  • history of malignancy
  • prior radiation
95
Q

What are the clinical features of a SBO, LBO and paralytic ileus?

A
96
Q

What are the complications of total obstruction of the bowel?

A
  • strangulating obstruction (10% of bowel obstructions) = surgical emergency
    • cramping pain turns to continuous ache, hematemesis, melena (if infarction)
    • fever, leukocytosis, tachycardia
    • peritoneal signs, early shock
    • Intestinal Ischemia
  • other
    • perforation: secondary to ischemia and luminal distention
    • septicemia
    • hypovolemia (due to third spacing)
97
Q

What investigation need to be ordered in a suspected bowel obstruction?

A
  • Bloods:
    • UECs, FBC, LFT, coags
    • Amylase/ lipase
    • ABG/VBG
    • group and hold
  • Imaging
    • Upright CXR or left lateral decubitus to rule out free air, usually seen under the right hemidiaphragm
    • abdominal x-ray (3 views) to determine SBO vs. LBO vs. ileus
      • if ischemic bowel look for: free air, pneumatosis, thickened bowel wall, air in portal vein, dilated small and large bowels, thickened or hose-like haustra (normally finger-like projections)
    • CT: provides information on level of obstruction, severity, cause
      – important to rule out closed loop obstruction, especially in the elderly
98
Q

What is the treatment of bowel obstruction prior to surgery?

A
  • stabilize vitals, fluid and electrolyte resuscitation
  • NGT to relieve vomiting, prevent aspiration, and decompress small bowel by prevention of further distention by swallowed air
  • Foley catheter to monitor ins/outs
99
Q

What is the treatment of a large bowel obstruction?

A
  • surgical correction of obstruction (usually requires resection + temporary diverting colostomy)
  • volvulus requires sigmoidoscopic or endoscopic decompression followed by operative reduction if unsuccessful
    • if successful, consider sigmoid resection on same admission
  • cecal volvulus can be a true volvulus or a cecal ‘bascule’ (cecum folds anteriorly to the ascending colon producing a flap valve occlusion to cecal emptying) – both need surgical treatment
100
Q

What are the general and specific risks of a colectomy?

A
  • General:
    • infection, bleeding, scaring
    • atelectasis and pneumonia
    • MI and stroke
    • DVT/PE
    • Death
  • Specific:
    • Damage to local organs and vessels that may need further surgery
    • Paralytic bowel - causes N/V. Usual this is temporary
    • WOund infection/UTI/ Abdo infection
    • May need to form a stoma if unable to join bowel
      • Stoma specific issues:
        • blood supply to stoma fails
        • excess fluid loss
        • stoma prolapse
        • parastomal hernia
        • local skin irritation
    • Erectile dysfunction
    • Thickened, red, painful scar
    • Diarrhoea
    • adhesions - causing obstruction
    • Death
101
Q

Describe the blood supply to the colon.

A
102
Q

Define what colorectal polyps are?

A
  • polyp: protuberance into the lumen of normally flat colonic mucosa
  • sessile (flat) or pedunculated (on a stalk)
103
Q

Describe the clinica features of colorectal polyps?

A
  • 50% in the rectosigmoid region, 50% are multiple
  • usually asymptomatic, do not typically bleed, tenesmus, intestinal obstruction, mucus
  • usually detected during routine endoscopy or familial/high risk screening
104
Q

What are the different types of colorectal polyps?

Think neoplastic vs non neoplastic.

A
  • non-neoplastic
    • hyperplastic: most common non-neoplastic polyp
    • mucosal polyps: small <0.2 in, no clinical significance
    • inflammatory pseudopolyps: associated with IBD, no malignant potential
    • submucosal polyps: lymphoid aggregates, lipomas, leiomyomas, carcinoids
  • neoplastic
    • hamartomas: juvenile polyps (large bowel), Peutz-Jegher syndrome (small bowel)
      • malignant risk due to associated adenomas (large bowel)
      • low malignant potential → most spontaneously regress or autoamputate
    • adenomas: premalignant, often carcinoma in situ:
      • some may contain invasive carcinoma (“malignant polyp” – 3-9%): invasion into muscularis
      • malignant potential: villous > tubulovillous > tubular
105
Q

What Ix need to be done with suspected colorectal polyps?

A
  • colonoscopy is the gold standard for diagnosis and treatment of colonic polyps
  • CT colonography: increasing in availability; patients still require bowel prep and will require colonoscopy if polyps are identified
  • other: flexible sigmoidoscopy if polyps are detected, proceed to colonoscopy for examination of entire bowel and biopsy
  • Polyps sent to path for ID
106
Q

What is familial adenomatous polyposis?

A
  • Autosomal dominant inheritance, mutation in adenomatous polyposis coli (APC) gene on chromosome 5q21.
  • hundreds to thousands of colorectal adenomas usually by age 20 (by 40s in attenuated FAP)
  • extracolonic manifestations
    • carcinoma of small bowel (i.e. polyps in colon), bile duct, pancreas, stomach, thyroid, adrenal, small bowel
    • congenital hypertrophy of retinal pigment epithelium presents early in life in 2/3 of patients; 97% sensitivity
    • virtually 100% lifetime risk of colon cancer (because of number of polyps)
  • Variants:
    • Gardner’s syndrome: FAP + extraintestinal lesions (sebaceous cysts, osteomas, desmoid tumors)
    • Turcot syndrome: FAP + CNS tumors (childhood cerebellar medulloblastoma)
107
Q

What Ix need to be done in FAP?

A
  • genetic testing (80-95% sensitive, 99-100% specific)
  • if no polyposis found: annual flexible sigmoidoscopy from puberty to age 50, then routine screening
  • if polyposis or APC gene mutation found: annual colonoscopy and consider surgery, consider upper endoscopy to evaluate for periampullary tumors
108
Q

What is the Rx for FAP?

A
  • surgery indicated by age 17-20
  • total proctocolectomy with ileostomy or total colectomy with ileorectal anastomosis
  • doxorubicin-based chemotherapy
  • NSAIDs for intra-abdominal desmoids
109
Q

What is hereditary non-polyposis colorectal cancer aka lynch syndrome?

A
  • Pathogenesis
    • autosomal dominant inheritance, mutation in a DNA mismatch repair gene (MSH2, MSH6, MLH1) resulting in microsatellite genomic instability and subsequent mutations
    • microsatellite instability account for approximately 15% of all colorectal cancers
  • Clinical Features
    • early age of onset, right > left colon, synchronous and metachronous lesions
    • mean age of cancer presentation is 44 yr, lifetime risk 70-80% (M>F)
      • HNPCC I: hereditary site-specific colon cancer
      • HNPCC II: cancer family syndrome – high rates of extracolonic tumors (endometrial, ovarian, hepatobiliary, small bowel)
110
Q

How is hereditary non-polyposis colorectal cancer diagnosed?

A
  • Amsterdam Criteria
    • 3 or more relatives with verified Lynch syndrome associated cancers, and 1 must be 1st degree relative of the other 2
    • 2 or more generations involved
    • 1 case must be diagnosed before 50 yr old
    • FAP is excluded
  • genetic testing (80% sensitive) – colonoscopy mandatory even if negative
    • refer for genetic screening individuals who fulfill EITHER the Amsterdam Criteria (as above) OR the revised Bethesda Criteria
  • colonoscopy (starting age 20) annually
  • surveillance for extracolonic lesions
111
Q

What is the treatment for hereditary non-polyposis colorectal cancer?

A

Total colectomy and ileorectal anastomosis with annual proctoscopy

112
Q

Elderly persons who present with iron-deficiency anaemia should be investigated for what?

A

Colon cancer

113
Q

Describe the epidemiology of colorectal carcinoma.

A

4th most common cancer (after lung, prostate, and breast), 2nd most common cause of cancer death

114
Q

What are the risk factors for colorectal cancer?

A
  • most patients have no specific risk factors
  • age >50 (dominant risk factor in sporadic cases), mean age is 70
  • genetic: FAP, HNPCC, family history of CRC
  • colonic conditions
    • adenomatous polyps (especially if >1 cm, villous, multiple)
    • IBD (especially UC: risk is 1-2%/yr if UC >10 yr)
    • previous colorectal cancer (also gonadal or breast)
  • diet (increased fat, red meat, decreased fiber) and smoking
  • DM and acromegaly (insulin and IGF-1 are growth factors for colonic mucosal cells)
115
Q

Describe the clinical features of colorectal carcinoma?

A
  • often asymptomatic
  • haematochezia/melena, abdominal pain, change in bowel habits (e.g. overflow diarrhoea, secondary to constipation)
  • others: weakness, anemia, weight loss, palpable mass, obstruction
  • 20% patients have distant metastatic disease at time of presentation
  • spread
    • direct extension, lymphatic, hematogenous (liver most common, lung, bone, brain; tumor of distal rectum → IVC g lungs)
    • peritoneal seeding: ovary, Blumer’s shelf (pelvic cul-de-sac)
116
Q

What Ix need to be done for colorectal carcinoma?

A
  • colonoscopy (best), look for synchronous lesions (3-5% of patients); alternative: air contrast barium enema (“apple core” lesion) + sigmoidoscopy
  • if a patient is FOBT +ve, or has microcytic anemia or has a change in bowel habits, do colonoscopy
  • laboratory: FBC, urinalysis, liver enzymes, liver function tests, carcinogenic embryonic antigen (CEA) (pre-operative for baseline, >5 ng/mL have worse prognosis)
  • staging: CT chest/abdomen/pelvis; bone scan, CT head only if
    lesions suspected
  • rectal cancer: pelvic MRI or endorectal ultrasound to determine T and N stage
117
Q

What is the Rx for colorectal carcinoma?

A
  • colon cancer
    • wide surgical resection of lesion and regional lymphatic drainage; usually colectomy with primary anastomosis
      • curative: wide resection of lesion (2 in margins) with nodes and mesentery
      • palliative: if distant spread, local control for hemorrhage or obstruction
      • care is taken to not spread tumor by unnecessary palpation
      • cancer-bearing portion of colon is removed according to vascular distribution of segment
    • adjuvant chemotherapy (5-FU or oral capecitabine with oxaliplatin) can be considered for stages II or III
  • rectal cancer
    • choice of operation depends on individual case; types of operations
      • low anterior resection of rectum (LAR): curative procedure of choice if adequate distal margins; uses technique of total mesorectal excision
      • Šabdominoperineal resection of rectum (APR): if adequate distal margins cannot be obtained; involves the removal of distal sigmoid colon, rectum, and anus – permanent end colostomy required
      • local excision: for select T1 lesions only
      • palliative procedures: electrocoagulation or laser photocoagulation for unresectable cancers for symptom relief
    • adjuvant therapy
      • combined neoadjuvant chemoradiation therapy followed by post-operative adjuvant chemotherapy for stages II and III
118
Q

What is the different between Billroth I, billroth II, Roux-en Y, and gastric bypass surgeries?

A
119
Q

Name the anatomy of the breast

A
120
Q

What are the DDx for a breast mass?

A
  • Benign
    • Fibrocystic changes
    • Fibroepithelial lesions (fibroadenoma most common; benign phyllodes also)
    • Fat necrosis
    • Papilloma/papillomatosis
    • Galactocele
    • Duct ectasia
    • Ductal/lobular hyperplasia
    • Sclerosing adenosis
    • Lipoma
    • Neurofibroma
    • Granulomatous mastitis (e.g. TB, granulomatosis with polyangiitis, sarcoidosis)
    • Abscess
    • Silicone implant
  • Malignant
    • Breast cancer (likely invasive, DCIS rarely forms a breast mass)
    • Malignant phyllodes
    • Angiosarcoma (rare)
121
Q

Describe the risks of, clinical features, Ix and Rx for fibroadenoma?

A
  • most common benign breast tumor in women <30 yr
  • risk of subsequent breast cancer is increased only if fibroadenoma is complex, there is adjacent atypia, or a strong family history of breast cancer
  • clinical features
    • nodules: smooth, rubbery, discrete, well-circumscribed, non-tender, mobile, hormone-dependent
    • unlike cysts, needle aspiration yields no fluid
  • Investigations
    • core or excisional biopsy required
    • U/S and FNA alone cannot differentiate fibroadenoma from Phyllodes tumor
  • treatment
    • generally conservative: serial observation
    • consider excision if size 2-3 cm and growing on serial U/S (q6mo x 2 yr is usual follow-up), if symptomatic, formed after age 35, or patient preference
122
Q

Describe the risks of, clinical features and Rx for fibrocystic changes in the breast?

A
  • also known as chronic cystic mastitis, mammary dysplasia
  • benign breast condition characterized by fibrous and cystic changes in the breast
  • no increased risk of breast cancer
  • age 30 to menopause (and after if HRT used)
  • clinical features
    • breast pain, focal areas of nodularity or cysts often in the upper outer quadrant, frequently bilateral, mobile, varies with menstrual cycle, nipple discharge (straw-like, brown, or green)
  • treatment
    • evaluation of breast mass and reassurance
    • if >40 yr old: mammography every 3 yr
    • no strong evidence for avoidance of xanthine-containing products (coffee, tea, chocolate, cola)
    • analgesia (ibuprofen, ASA)
    • for severe symptoms: OCP, danazol, bromocriptine
123
Q

What is intradudctal papilloma, how does it present and what is the Rx?

A
  • solitary intraductal benign polyp
  • present as nipple discharge (most common cause of spontaneous, unilateral, bloody nipple discharge), breast mass, nodule on U/S
  • can harbor areas of atypia or DCIS
  • treatment: excision of involved duct to ensure no atypia
124
Q

What are the risk factors for developing breast cancer?

A
  • gender (99% female)
  • age (80% >40 yr)
  • important risk factors are prior history of breast cancer and/or prior breast biopsy (regardless of pathology)
  • 1st degree relative with breast cancer (greater risk if relative was premenopausal)
  • increased risk with high breast density, nulliparity, first pregnancy >30 yr, menarche <12 yr, menopause >55 yr
  • decreased risk with lactation, early menopause, early childbirth
  • radiation exposure (e.g. mantle radiation for Hodgkin’s disease)
  • >5 yr HRT
125
Q

What Ix need to be performed on a breast mass?

A
  • mammography
    • indication
      • screening, women aged 50-74 every 2 years.
    • findings indicative of malignancy
      • mass that is poorly defined, spiculated border
      • microcalcifications
      • architectural distortion
      • interval mammographic changes
      • normal mammogram does not rule out suspicion of cancer based on clinical findings
  • other radiographic studies
    • U/S: differentiate between cystic and solid
    • MRI: high sensitivity, low specificity
    • galactogram/ductogram (for nipple discharge): identifies lesions in ducts
    • metastatic workup as indicated (usually after surgery or if clinical suspicion of metastatic disease): bone scan, abdominal U/S, CXR (or CT chest/abdomen/pelvis), CT head (only if specific neurological symptoms)
126
Q

What types of diagnostic procedures can be done for breast cancer?

A
  • needle aspiration: for palpable cystic lesions; send fluid for cytology if blood or cyst does not completely resolve
  • U/S or mammography guided core needle biopsy (most common)
  • fine needle aspiration (FNA): for palpable solid masses; need experienced practitioner for adequate sampling
  • excisional biopsy: only performed as second choice to core needle biopsy; should not be done for diagnosis if possible
127
Q

When should genetic testing be done for breast cancer?

A
  • consider testing for BRCA1/2 if:
    • patient diagnosed with breast AND ovarian cancer
    • strong family history of breast/ovarian cancer
    • family history of male breast cancer
    • young patient (<35 yr)
    • bilateral breast cancer in patients <50 yr
128
Q

WHat information is used to stage breast cancer? Clinically and pathologically.

A
  • clinical
    • tumor size by palpation, mammogram
    • nodal involvement by palpation
    • metastasis by physical exam, CXR, and abdominal U/S (or CT chest/abdomen/pelvis), bone scan (usually done post-operative if node-positive disease)
  • pathological
    • tumor size
    • grade: modified Bloom and Richardson score (I to III) – histologic, nuclear, and mitotic grade
    • number of axillary nodes positive for malignancy out of total nodes resected, extranodal extension, sentinel node positive/negative
    • oestrogen receptor (ER) + progesterone receptor (PR) testing
    • Her2Neu receptor testing
    • margins: negative, <1 mm, positive
    • lymphovascular invasion (LVI)
    • extensive in situ component (EIC): DCIS in surrounding tissue
    • involvement of dermal lymphatics (inflammatory) – automatically Stage IIIb
129
Q

WHat are the non-invasive and invasion breast cancers?

A
  • Non-invasive: cannot penetrate basement membrane
    • ductal carcinoma in situ (DCIS)
    • Lobular carcinoma in situ (LCIS)
  • Invasive:
    • Invasive ductal carcinoma (most common 80%)
    • Invasive lobular carcinoma (8-15%)
    • Pagets disease (1-3%)
    • Inflammatory carcinoma (1-4%)
    • male breast cancer (<1%)
    • Sarcomas: rare
    • Lymphmoa: rare
    • Other: papillary, medullary, mucinous, tubular cancers
130
Q

What treatment is offered to breast cancer patients by stage?

A
131
Q

Describe the primary surgical treatment that women with breast cancer can get and what they involve?

A
  • Breast conserving surgery: lumpectomy with wide local excision
    • for treatment of stage I and II disease
    • must be combined with radiation for survival equivalent to mastectomy
    • contraindications
      • high risk of local recurrence: extensive malignant-type calcifications on mammogram, multifocal primary tumors, or failure to obtain tumor-free margins after re-excision
      • contraindications to radiation therapy (pregnancy, previous radiation, collagen vascular disease)
      • large tumor size relative to breast
  • mastectomy
    • radical mastectomy (rarely done anymore): removes all breast tissue, skin, pectoralis muscle, axillary nodes
    • modified radical mastectomy (MRM): removes all breast tissue, skin, and axillary nodes
    • simple mastectomy: removes all breast tissue and skin
    • breast reconstruction
  • axillary lymph node dissection (ALND)
    • performed if SLNB is positive or nodes are clinically concerning
    • risk of arm lymphedema (10-15%), decreased arm sensation, shoulder pain
  • sentinel lymph node biopsy (SLNB)
    • technetium-99 ± blue dye injected at tumor site prior to surgery to identify sentinel node(s)
    • intraoperative frozen section
    • proceed with ALND if positive
    • 5% false negative rate
132
Q

Describe the adjuvant and neoadjuvant treatments for breast cancer and what they involve?

A
  • radiation
    • indications
      • decrease risk of local recurrence; almost always used after BCS, sometimes after mastectomy (if >4 nodes positive or tumor >5 cm)
      • inoperable locally advanced cancer
    • axillary nodal radiation may be added if nodal involvement
  • hormonal
    • indications
      • ER positive plus node-positive or high-risk node-negative
      • palliation for metastases
    • tamoxifen if premenopausal or aromatase inhibitors (e.g. anastrozole)
    • ovarian ablation (e.g. goserelin/GnRH agonist, oophorectomy), progestins (e.g. megestro acetate), androgens (e.g. fluoxymesterone) are other options
  • chemotherapy
    • indications
      • ER negative plus node-positive or high-risk node-negative
      • ER positive and young age
      • stage I disease at high risk of recurrence (high grade, lymphovascular invasion)
      • palliation for metastatic disease
133
Q

Where do breast cancers metastasis to?

A

bone > lungs > pleura > liver > brain

134
Q

What are the indications and contraindications for thyroidectomy?

A
  • indications: thyroid cancer, symptomatic thyroid mass or goiter, medically refractory Graves’ or hyperthyroidism
  • contraindications: uncontrolled severe hyperthyroidism (i.e. Graves’) due to risk of intraoperative or post-operative thyroid storm
135
Q

What needs to be done in the pre-operative workup for thyroidectomy?

A
  • thyroid U/S for thyroid nodules
  • FNA for large nodules
  • U/S of the neck for lesions suspicious for papillary or medullary thyroid cancer
  • CT neck useful to rule out extension, vocal cord function
136
Q

What are some complication of a thyroidectomy that are medically revelant?

A
  • hypocalcemia secondary to hypoparathyroidism
  • recurrent/superior laryngeal nerve injury
  • neck haematoma
  • infection
  • thyrotoxic storm
137
Q

Name the anatomy of the thyroid.

A
138
Q

What are the general and specific risks of thyoirdectomy?

A
  • General
    • Infection, bleeding
    • Atalectasis and pneumonia
    • MI/stroke
    • DVT/PE
    • Death
  • Specific
    • Haematoma
    • Recurrent laryngeal nerve damage resulting in hoarseness, if damaged enough may need respiratory support for life
    • parathyroids removed
    • Will need TFT and thyroid supplementation
    • Keloid scar
139
Q

WHat are the types of thyroid cancers and there prevalence?

A
  • Papillary 70-75%
  • Follicular 10%
  • Medullary 3-5%
  • Anaplastic <5%
  • Lymphoma <1%
140
Q

What are the histological findings for papillary thyroid carcinoma?

A
  • Orphan Annie nuclei
  • Psammoma bodies
  • Papillary architecture
141
Q

What are the 5 P’s of papillary thyroid cancer?

A
  • Popular (most common)
  • Palpable lymph nodes
  • Positive I 131 uptake
  • Positive prognosis
  • Post-operative I131 scan to guide treatments
142
Q

What is the Rx for papillary thyroid cancer?

A
  • Small tumors: Near total thyroidectomy or lobectomy
  • Diffuse/bilateral: Total thyroidectomy ± post-operative I131 treatment
143
Q

What are the histological features of follicular thyroid cancer?

A
144
Q

What are the 4 F’s of follicular thyroid cancer?

A
  • Far away mets
  • Female (3:1)
  • NOT FNA (cannot be diagnosed by FNA)
  • Favorable prognosis
145
Q

What is the Rx for follicular thyroid cancer?

A
  • Small tumors: Near total thyroidectomy/lobectomy/ isthmectomy
  • Large/diffuse tumors: Total thyroidectomy
146
Q

What does medullary thyroid cancer look like histologically?

A
  • Amyloid
  • May secrete calcitonin, prostaglandins, ACTH, serotonin, kallikrein, or bradykinin
147
Q

What are the 3 M’s of medullary thyroid cancer?

A
  • Multiple endocrine neoplasia (MEN IIa or IIb)
  • aMyloid
  • Median node dissection
148
Q

What is the Rx for medullary thryoid cancer?

A
  • Total thyroidectomy
  • Median lymph node dissection if lateral cervical nodes +ve
  • Modified neck dissection
  • Post-operative thyroxine
  • Tracheostomy
  • Screen asymptomatic relatives
149
Q

Describe the approach taken with Ix for a thyroid nodule?

A
  • all patients with thyroid nodules require evaluation of serum TSH and ultrasound
  • any nodule >5 mm with suspicious sonographic features (particularly microcalcifications) should undergo FNA
  • any nodule >1 cm should undergo FNA
  • when performing repeat FNA on initially non-diagnostic nodules, U/S-guided FNA should be employed
  • nuclear scanning has minimal value in the investigation of the thyroid nodule
150
Q

What symptoms need to be excluded in a pt who presents with a head and neck mass?

A
  • Dyspnea or stridor (positional vs. non-positional)
  • Hoarseness or dysphonia
  • Otalgia
  • Non-healing oral ulcer
  • Dysphagia
  • Haemoptysis, haematemesis
151
Q

How are lung cancers classified?

A
  • lung tumors can be classified as primary or secondary, benign or malignant, endobronchial or parenchymal
  • bronchogenic carcinoma (epithelial lung tumors) are the most common type of primary lung tumor (other types make up less than 1%)
    • small cell lung cancer (SCLC)
    • non-small-cell lung cancer (NSCLC)
      • squamous cell carcinoma: arise from the proximal respiratory epithelium
      • adenocarcinoma: incidence is increasing; most common subtype in nonsmokers – bronchoalveolar carcinoma: grows along the alveolar wall in the periphery; may arise at sites of previous lung scarring
      • large cell undifferentiated cancer: diagnosis of exclusion
  • benign epithelial lung tumors can be classified as papillomas or adenomas
152
Q

What are the risk factors for developing lung cancer?

A
  • cigarette smoking: the relative risk of developing lung cancer is 10-30 times higher for smokers than for non-smokers
  • other risk factors include:
    • cigar, pipe smoking
    • second-hand smoke
    • asbestos without smoking (relative risk is 5)
    • asbestos with smoking (relative risk is 92)
    • metals (e.g. chromium, arsenic, nickel)
    • radon gas
    • ionizing radiation
    • genetics
153
Q

WHat are the signs and symptoms of a primary lung lesion?

A
  • cough (75%): beware of chronic cough that changes in character
  • dyspnea (60%)
  • chest pain (45%)
  • haemoptysis (35%)
  • other pain (25%)
  • clubbing (21%)
  • constitutional symptoms: anorexia, weight loss, fever, anemia
154
Q

What are the signs and symptoms of metastatic lung cancer?

A
  • lung, hilum, mediastinum, pleura: pleural effusion, atelectasis, wheezing
  • pericardium: pericarditis, pericardial tamponade
  • oesophageal compression: dysphagia
  • phrenic nerve: paralyzed diaphragm
  • recurrent laryngeal nerve: hoarseness
  • superior vena cava syndrome
    • obstruction of SVC causing neck and facial swelling, as well as dyspnea and cough
    • other symptoms: hoarseness, tongue swelling, epistaxis, and haemoptysis
    • physical findings: dilated neck veins, increased number of collateral veins covering the anterior chest wall, cyanosis, edema of the face, arms, and chest, Pemberton’s sign (facial flushing, cyanosis, and distension of neck veins upon raising both arms above head)
    • milder symptoms if obstruction is above the azygos vein
  • lung apex (Pancoast tumor): Horner’s syndrome, brachial plexus palsy (most commonly C8 and T1 nerve roots)
  • rib and vertebrae: erosion
  • distant metastasis to brain, bone, liver, adrenals
155
Q

What Ix need to be done in lung cancer?

A
  • initial diagnosis
    • imaging: CXR, CT chest + upper abdomen, PET scan, bone scan
    • cytology: sputum
    • biopsy: bronchoscopy, EBUS, CT-guided percutaneous needle biopsy, mediastinoscopy
  • staging workup
    • TMN staging system: T – primary tumor (size); N – regional lymph nodes; M – distant metastasis
    • blood work: electrolytes, LFTs, calcium, ALP
    • imaging: CXR, CT thorax and upper abdomen, bone scan, neuroimaging
    • invasive: bronchoscopy (EBUS), mediastinoscopy, mediastinotomy, thoracotomy
    • screen adenocarcinoma for EGFR mutations
156
Q

What are the treatment options for lung cancer?

A
  • options include surgery, radiotherapy, chemotherapy, and palliative care for end-stage disease
  • surgery not usually performed for SCLC since it is generally non-curable
  • contraindications for surgery
    • spread to contralateral lymph nodes or distant sites
      • patients with potentially resectable disease must undergo mediastinal node sampling since CT thorax is not accurate in 20-40% of cases
    • poor pulmonary status (e.g. unable to tolerate resection of lung)
  • chemotherapy (used in combination with other treatments)
    • common agents: etoposide, platinum agents (e.g. cisplatinum), ifosfamide, vincristine, anthracyclines, paclitaxel, irinotecan, gefitinib (an endothelial growth factor receptor inhibitor)
    • complications
      • acute: tumor lysis syndrome, infection, bleeding, myelosuppression, hemorrhagic cystitis (cyclophosphamide), cardiotoxicity (doxorubicin), renal toxicity (cisplatin), peripheral neuropathy (vincristine)
      • chronic: neurologic damage, leukemia, additional primary neoplasms
157
Q

What is Charcots triad (1877) and what disease does it indicate?

A

Cholangitis

  • (RUQ) pain
  • rigors
  • jaundice
158
Q

Describe the epidemiology of diverticulosis?

A
  • 95% left-sided in patients of Western countries, 75% right-sided in Asian populations
159
Q

What are the risk factors for diverticulitis?

A
  • lifestyle: low-fiber diet (predispose to motility abnormalities and higher intraluminal pressure) inactivity, obesity
  • muscle wall weakness from aging and illness (e.g. Ehler-Danlos, Marfan’s)
160
Q

Describe the pathogenesis of diverticulitis?

A
  • erosion of the wall by increased intraluminal pressure or inspissated food particles → inflammation and focal necrosis g micro or macroscopic perforation
  • usually mild inflammation with perforation walled off by pericolic fat and mesentery; abscess, fistula, or obstruction can ensue
  • poor containment results in free perforation and peritonitis
161
Q

Describe the clinical features of diverticulitis.

A
  • depend on severity of inflammation and whether or not complications are present; hence ranges from asymptomatic to generalized peritonitis
  • LLQ pain/tenderness (2/3 of patients) often for several days before admission
  • constipation, diarrhea, N/V, urinary symptoms (with adjacent inflammation)
  • complications (25% of cases)
    • abscess: palpable tender abdominal mass
    • fistula: colovesical (most common), coloenteric, colovaginal, colocutaneous
    • colonic obstruction: due to scarring from repeated inflammation
    • perforation: generalized peritonitis (feculent vs. purulent)
      • recurrent attacks rarely lead to peritonitis
  • low-grade fever, mild leukocytosis common, occult or gross blood in stool rarely coexist with acute diverticulitis
162
Q

What Ix need to be done on a patient with suspected diverticulitis?

A
  • AXR, upright CXR
    • localized diverticulitis (ileus, thickened wall, SBO, partial colonic obstruction)
    • free air may be seen in 30% with perforation and generalized peritonitis
  • CT scan (test of choice): very useful for assessment of severity and prognosis; this is usually done with rectal contrast
    • 97% sensitive, 99% specific
    • increased soft tissue density within pericolic fat secondary to inflammation, diverticula secondary to inflammation, bowel wall thickening, soft tissue mass (pericolic fluid, abscesses), fistula
    • 10% of diverticulitis cannot be distinguished from carcinoma
  • elective evaluations: establish extent of disease and rule out other diagnoses (polyps, malignancy) after resolution of acute episode
    • colonoscopy or barium enema and flexible sigmoidoscopy
163
Q

How is diverticulitis treated?

A
  • uncomplicated: conservative management
  • outpatient: clear fluids only until improvement and antibiotics
  • hospitalize: if severe presentation, inability to tolerate oral intake, significant comorbidities, fail to improve outpatient management
  • treat with NPO, IVF, IV antibiotics (e.g. IV metronidazole, ampicillin, gentamicin)
  • indications for surgery
    • unstable patient with peritonitis
    • Hinchey stage 3-4
    • after 1 attack if immunosuppressed
    • consider after 2 or more attacks, recent trend is toward conservative management of recurrent mild/moderate attacks
    • complications: generalized peritonitis, free air, abscess, fistula, obstruction, hemorrhage, inability to rule out colon cancer on endoscopy, or failure of medical management
  • surgical procedures
    • for emergency or complex cases: Hartmann procedure: colon resection + colostomy and rectal stump g colostomy reversal in 3-6 mo
    • elective cases or minimal contamination of the abdominal cavity: consider colon resection + primary anastomosis
164
Q

Dermatone for:

Anterior aspect of thigh and knee.

A

L3/4

165
Q

Dermatome for anus

A

S4

166
Q

Dermatome for:

Medial aspect of dorsum of the fott and great toe.

A
167
Q

Dermatome for:

Posterior aspect of the calf and knee

A

S2

168
Q

Dermatome for:

Sole and lateral aspect of foot.

A

S1

169
Q

Define Courvoisier’s law (or Courvoisier syndrome, or Courvoisier’s sign or Courvoisier-Terrier’s sign)?

A

states that in the presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones.

This sign implicates possible malignancy of the gallbladder or pancreas

170
Q

Define carcinoid tumours.

A

Carcinoid tumours are a type of neuroendocrine tumour that can occur in a number of locations. Carcinoid tumours arise from enterochromaffin (argentaffin) cells that can be found throughout the gastrointestinal tract as well as other organs (e.g. lung). In general, they are slow growing tumours but are nevertheless capable of metastasizing.

171
Q

What is the clinical presentation of someone with a carcinoid tumour?

A
  • Can be variable, dependent on the location:
    • carcinoid tumours involving the jejunum and ileum can be large at presentation but are usually found incidentally
    • rectal carcinoids may cause pain
    • gastrointestinal tract carcinoid can present as vague abdominal pain
  • carcinoid syndrome: in 8% of patients with a carcinoid tumour
172
Q

What are the classic symptoms of carcinoid syndrome?

A
  • Diarrhoea
  • Flushing with hypotension
  • Telangectasia
  • Bronchospasm.
173
Q

Where are carcinoid tumours found?

A
  • gastrointestinal tract carcinoid (60-85% of all carcinoids)
    • small bowel: ~40% of gastrointestinal carcinoids, mostly in the terminal ileum
    • rectum (~22.5%)
    • colon (~15%)
    • appendix (~10%)
    • stomach (~7.5%)
    • pancreas (~7.5%)
  • carcinoid tumours of the lung (~25% of all carcinoids)
    • bronchial carcinoid
    • peripheral pulmonary carcinoid tumours
  • primary hepatic carcinoid
  • ovarian carcinoid: accounts for 0.5% of carcinoid tumours and 0.3% of ovarian tumours
  • thymic carcinoid
174
Q

What substances can be secreted by carcinoid tumour and what are used as markers of carcinoid tumours?

A
  • Secretes:
    • 5 hydroxytryptamine (5-HT)
    • bradykinin
    • histamine
    • substance P
    • prostaglandins
  • Markers
    • 5-HIAA (5-hydroxyindoleacetic acid): usually suggests a functioning carcinoid tumour
    • chromogranin A (CgA): considered a valuable tool in the diagnosis of neuroendocrine neoplasia in general.
175
Q

What are the complications of carcinoid tumours?

A
  • Cardiac valve lesions resulting in heart failure.

Year 4 (25 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions