General surgery Flashcards by Unknown Unknown

pt with longterm GERD, has severe esophageal dysplastic changes. tx?

surgery (Nissen fundoplication) + radiofrequency ablation

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diagnostic study (one first and then another one confirms) and tx for achalasia?

dx: barium swallow first -> manometry CONFIRMS
tx: balloon dilatation done by endoscopy, or myotomy

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dysphagia with solids worse than liquids, progressing to liquids as well, is suggestive of what?

progressive dysphagia, it’s a mechanical/obstructive problem. seen in esophageal cancer, strictures, or rings.

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dysphagia that is worse for liquids is suggestive of what

motility problem. seen in achalasia, scleroderma, esophageal spasm

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Boerhaave syndrome vs mallory weiss

presentation and diagnostic study and treatment

mallory weiss = vomiting -> NON transmural esophageal tear.
dx by endoscopy
tx is laser photocoagulation (assisted by endoscopy)

Boerhaave syndrome = vomiting -> transmural tear + chest pain, fever, leukocytosis.
dx by contrast swallow (gastrograffin first, barium if negative)
tx is emergent surgery repair

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you do endoscopy on a guy. shortly after he gets lots of pain in his throat. +/- emphysema in neck
diagnostic study + tx?

esophagus perforation. contrast studies and emphysema are diagnoistic
tx: prompt surgical repair

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if clinical picture and physical exam isn’t clear enough, what study confirms dx of acute appendicitis?

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cancer of left colon: before surgery is done, what study needs to be done to rule out what?

colonoscopy, to rule out synchronous second primary

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1st and 2nd line antibiotics for tx for pseudomembranous enterocolitis

need emergency colectomy if what? (2)

stop offending drug obvis (clindamycin, cephalosporins)

give metronidazole (1st choice) or vancomycin (2nd choice)

emergency colectomy if WBC>50000 and serum lactate >5, (virulent form, unresponsive to abx)

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the high success rate treatment for anal fissure

calcium channel blocker ointment (diltiazem) 2% TID for 6 weeks

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person has anal surgery for fissure, and now it won’t heal. what do you suspect they have?

Crohn’s disease.
anus normally heals really well
if you know person has Crohn’s dz, do not do anal surgery! find other ways to intervene

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Pt has C. diff. what tx should you consider before colectomy? (2)

abx and fecal enema

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Pt had an ischiorectal abscess drained. later starts to leak stool and have some perineal discomfort. dx? findings? tx?
what do you need to rule out?

fistula-in-ano

cordlike tract may be felt on exam. need to rule out necrotic and draining tumor.

tx: fistulotomy

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if SCC of anus metastasizes to lymph nodes which ones will it be?

inguinal nodes

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tx for SCC of anus

Nigro chemoradiation protocol FIRST

surgery after only if residual tumor

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what landmark separates upper from lower GI tract?

ligament of Treitz

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most common cause of lower GI bleed? (in older ppl or in general???)

diverticulosis

AV malformation

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pt has GI bleed. you do NG tube and aspirate. no blood is retrieved and fluid is white (no bile). what areas have you excluded as source of bleeding? what do you do next?

upper GI up to pylorus is excluded, but duodenum is still potential source -> upper GI endoscopy should follow

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pt has GI bleed. you do NG tube and aspirate blood. next step?

upper GI endoscopy

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pt with recent history of blood per rectum. how to work them up in old vs young adult people?

young ppl - upper GI endoscopy only (bc it’s so much more common in young ppl)

old ppl - need both upper and lower GI endoscopy

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blood per rectum in child. dx and study?

Meckel diverticulum -> technetium scan finds ectopic gastric mucosa

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normally you would give PPI post op to prevent stress ulcers. but if they do get stress ulcers and have upper GI bleed, what is tx?

angiographic emoblization

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acute abdomen. acute constant generalized pain. patient is reluctant to move, lots of guarding. xray shows free air under diaphragm. dx?

perforation (e.g. peptic ulcer perforation)

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acute abdomen. acute colicky localized pain. pt moves constantly, seeking comfortable position. dx?

obstruction

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child with nephrosis, ascites, culture of ascitic fluid shows single organism. dx and tx?

primary peritonitis. suspect in child with nephrosis and ascites (or adult with ascities and mildish acute abdomen) tx: abx, not surgery!

if pt has generalized acute abdomen, they need exploratory laparotomy! so what do you need to rule out in case they don't actually need surgery lol. and what studies to rule them out (6) hint: think of anything that could cause abdominal or chest pain that does not require surgery

1. acute abdomen from primary peritonitis (culture ascitic fluid) 2. MI (order EKG, troponins) 3. lower lobe pneumonia (chest xray) 4. PE (high risk pt, like they're immobilized) 5. pancreatitis (amylase/lipase) 6. urinary stones (abdominal CT)

timeline for using serum or urinary amylase/lipase for diagnosing acute pancreatitis?

use serum for 12-48 hours from onset | use urine from days 3-6

middle aged or older male, pain in lower left quadrant. fever, leukocytosis, +/- blood in stool. dx? tx?

acute diverticulitis 90% treated with NPO, IV fluids, abx. if still bad look for abscess that needs to be drained. recurrent episodes -> surgery to remove affected bowel

parrot's beak sign of bowel

volvulus of sigmoid colon different from birds beak of esophagus = achalasia

CEA marker for:

colorectal carcinoma

CA 15-3 marker for

breast carcinoma

CA 19-9 marker for

pancreatic and biliary carcinomas

hepatic adenomas may arise as a complication of what medication?

birth control pills

hepatic adenoma significant complication: | what study for dx? tx?

rupture -> massive abdominal bleed dx: CT tx: emergent surgery

complication of biliary tract dz (e.g. acute ascending cholangitis) that requires percutaneous drainage

pyogenic liver abscess

what is tx for amebic abscess of liver (NOT pyogenic liver abscess from acute ascending cholangitis)

abx like metronidazole is first line. only do percutaneous drainage if they don't improve

how to confirm dx of amebic abscess of liver

serology (not culture bc ameba doesn't grow in the pus) | but this takes forever so you empirically treat with metronidazole anyways if it's suspected

what kind of jaundice has modest elevation of alk phos but super high levels of transaminases?

hepatocellular jaundice. both fractions of bilirubin are elevated

what kind of jaundice has super high elevation of alk phos, modest elevated of transaminases?

obstructive jaundice. both fractions of bilirubin are elevated

next step in management for suspected choledocholithiasis (risk factors for cholecystitis + obstructive jaundice + high alk phos + dilated ducts on US + nondilated gallbladder full of stones (aka it's not cholecystitis but this is where the stone came from))

ERCP with sphincterotomy for dx and tx | cholecystectomy after that

pt has weight loss and back pain. you suspect pancreatic cancer. what imaging do you do? (____this first, then _____ if that one is negative bc will find smaller tumors)

CT scan first. | if negative, MRCP will find smaller tumors

type of biopsy for large pancreatic mass

CT guided percutaneous biopsy

type of biopsy for ampullary pancreatic mass

endoscopic biopsy

type of biopsy for pancreatic ductal neoplasm

ERCP guided biopsy

type of biopsy for tiny tumors within head of pancreas

ultrasound guided biopsy

pt has obstructive jaundice (dark urine, pale stools) + anemia + positive blood in stool. what do you suspect and whats next step

suspect pancreatic ampullary cancer -> endoscopy

what med can abort an episode of biliary colic (like from obstructing gallstones)

anticholinergics

tx for acute cholecystitis (4) (like besides the later cholecystectomy)

NG suction NPO IV fluids antibiotics

pt with acute cholecystitis can't get surgery b/c theyre too sick. what should you do for temporary fix? (besides nonsurgical tx like fluids and abx)

percutaneous transhepatic cholecystostomy (PTC)

acute ascending cholangitis is caused by a stone obstructing where? presentation? tx?

stone in common bile duct PARTIAL obstruction presents as obstruction + super high alk phos + high fever and leukocytosis (sepsis) tx: IV abx -> decompression by ERCP or PTC -> eventually also cholecystectomy

stone in common bile duct with partial obstruction causes acute ascending cholangitis. what about if it completely obstructs? findings on US?

``` obstructive jaundice (nondilated gallbladder with stones) can also be caused by tumors (dilated and thin walled gallbladder) ```

pt has an episode of cholangitis but then they also have elevated lipase and amylase. what is going on?? what do you do

stone blocks ampulla -> pancreatic and biliary ducts both blocked = biliary pancreatitis tx: NPO, NG suction, IV fluids. usually stone will pass. if not -> ERCP and sphincterotomy. + later elective cholecystectomy

acute pancreatitis is usually caused by _____ in women and _____ in men

stones in women | chronic alcoholic men

key lab finding for EDEMATOUS acute pancreatitis

elevated hematocrit

labs for acute HEMORRHAGIC pancreatitis (4 abnormalities. 2 elevated, 2 decreased)

low hematocrit elevated WBC elevated blood glucose lower serum calcium later: BUN goes up, metabolic acidosis, low arterial PO2

tx/management for acute hemorrhagic pancreatitis (2 things, but be specific on abx)

1. abx: carbapenems, quinolones, or metronidazole (they penetrate infected necrotic pancrease) 2. daily CT to find the many pancreatic abscesses -> drain them

best way to deal with necrotic pancreas where the dead tissue is well delineated, usually after 4 weeks of episode

necrosectomy. literally scoop out the necrotic tissue

pancreatic pseudocyst is more likely to have complications if what? (2) in these cases you need to surgically intervene and drain it.

bigger (>6 cm) | older (>6 weeks)

5 weeks after acute pancreatitis or pancreatic/upper abdominal trauma. collection of pancreatic juice outside of ducts. pressure/mass sx of early satiety, vague discomfort, and deep palpable mass. what do you suspect and what will confirm dx?

pancreatic pseudocyst | CT or sonogram to dx

all abdominal hernias need to be surgically repaired except for which exceptions? (2)

1. umbilical hernias in patients 2-5 yrs old. bc they may close themselves 2. esophageal sliding hiatal hernias (bc they're not true hernias)

cancers that metastasize hematogenously do so to these 4 distant organs (the 2 Ls and the 2 Bs)

liver lung brain bone

sarcomas usually metastasize through what route (lymph blood or both) and to what organ classically?

hematogenously spread to lungs

women with known BRCA gene mutation need to be screened frequently and from a young age. what study do you use to do this?

NOT mammography! bc its carcinogenic if done frequently | use MRI's!

fibroadenoma in breast , dx is confirmed by what kind of biopsy? is removal mandatory or elective?

fine needle aspiration (FNA) OR sonogram elective removal

cystosarcoma phyllodes have potential to become what?

malignant sarcomas

cystosarcoma phyllodes needs what kind of biopsy to confirm dx? is removal mandatory or elective?

core or incisional biopsy. (FNA doesn't work!) mandatory removal

term for breast dz that follow menstrual cycle. | age groups?

``` mammary dysplasia (fibrocystic dz, cystic mastitis) 30s - 40s ```

management for mammary dysplasia where multiple lumps come and go without any dominant or persistent mass

mammogram

management for mammary dysplasia with a dominant or persistent mass (diff dx?)

either a cyst or a tumor. after mammogram, need to aspirate the mass. if clear fluid, it was a cyst the end. if bloody fluid -> send to cytology. if mass persists or recurs -> formal biopsy

20s to 40s woman with bloody nipple discharge. what do you suspect, what study confirms dx?

intraductal papilloma dx: galactogram (mammogram will show other lesions if present but doesnt visualize papillomas they are too teeny tiny)

breast abscess is seen only in what type of women?

lactating women | ergo, if you see a breast abscess in a non lactating woman. it's not an abscess it's probs cancer. rip

tx of breast abscess

I and D. + biopsy to rule out malignancy

woman has breast mass and wonky looking breast (orange peal or retraction of nipple) but she has history of breast trauma. does that rule out cancer aka do you still have to workup?

no. must still rule out cancer.

tx/management for small cancer lesion of a large breast, located far away from nipple and areola

segment of breast removed = lumpectomy. followed by radiotherapy

tx/management for large cancer lesion of a small breast, located close to nipple and areola

simple total mastectomy. no radiation

what if anything do you do to axillary lymph nodes for resecting breast cancer when none of them are palpable? what if they are palpable?

not palpable -> sentinal node biopsy | palpable ones -> resected

study that confirms dx of thyroid cancer

FNA of the lesion (papillary, medullary, anaplastic) | lobectomy for follicular thyroid cancer

medullary cancer comes from what tissue/cells specifically? clinical application?

C cells that make calcitonin | thus calcitonin level is useful for follow up

hairy fat lady with bunch of other hypercortisolism related signs/sx. what is the first step in workup for cushings?

low dose dexamethasone test. if it suppresses cortisol, she doesn't have cushings she's just a hairy fat lady lol

low dose dexamethasone = no suppression high dose = suppression what is the cause of this pt's hypercortisolism and what's next step?

cushing's dz from a pituitary adenoma. get an MRI of pituitary.

low dose dexamethasone = no suppression high dose = no suppression what is the cause of this pt's hypercortisolism and what's next step?

ectopic ACTH secretion (adrenal adenoma or paraneoplastic syndrome). get CT of chest/abdomen/pelvis

pt with CNS sx and hypoglycemia. usually with fasting but sometimes attacks occur after eating (reactive hypoglycemia). what is dx?

insulinoma. or exogenous insulin administration (check C peptide and sulfonylurea levels) the CNS sx are caused by the hypoglycemia

what kind of study to find insulinoma in pancreas

CT with contrast

what is nesidioblastosis and what is tx?

hypersecretion of insulin in newborn. requires 95% pancreatectomy

knee jerk for severe migratory necrolytic dermatitis in a pt with mild diabetes? what other problems might they have? (3)

glucagonoma can be accompanied by slight anemia, glossitis, and stomatitis.

somatostatins and _____ can be used medically in those with inoperable endocrine tumor like glucagonoma

streptozocin

pt has primary hyperaldosteronism. what test would you do to suggest if this is operable or not?

if aldosterone increases when sitting upright (vs lying down) = hyperplasia -> treat medically if no changes from posture = adenoma -> CT to find. surgically resect.

if pt has thyroid medullary cancer, what else do you need to do to complete workup?

look for pheochromocytoma. part of MENII! often coexist

MENI

1. pituitary tumor (prolactin or GH) 2. pancreatic endocrine (ZES, VIP, insulinoma) 3. parathyroid adenoma

MENII A

1. parathyroid hyperplasia 2. thyroid medullary 3. adrenal medullary (pheo)

MENII B

Medullary thyroid carcinoma Pheochromocytoma neuromas + marfinoid habitus

chest x ray shows scalloping of ribs

coarctation of aorta. scalloping caused by erosion from large intercostal collaterals

what study confirms dx for coarctation of aorta?

CT angio

renovascular htn in an old man with _____________. resistant to meds and faint bruit over flank

arteriosclerotic occlusive disease. causing renovascular htn

charcots triad (acute cholangitis) reynold's pentad (obstructive ascending cholangitis)

triad: RUQ pain, fever/chills, jaundice pentad: triad + shock (hypotension,tachycardia) + CNS sx (encephalopathy)

3 abx that can be used for infected necrotizing pancreatitis bc they can penetrate the necrotic pancreas

carbapenema quinolones metronidazole

which one of the thyroid cancers do you need to do lobectomy to dx, b/c FNA biopsy usually doesn't work?

follicular cancer