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Surgery NBME > General Surgery (GI) > Flashcards

General Surgery (GI) Flashcards

1
Q

how do you repair duodenal ulcer in pt with no prior history of ulcer disease and perforation is only several hours old

A

closure of perforation, using Graham patch (piece of omentum placed over perforation)

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2
Q

if pt with perforated ulcer has prior history of peptic ulcer disease - tx?

A

closure of perforation and HSV or V&P

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3
Q

management of patient who is laying in ICU with coffee-ground material in her NG aspirate?

A
  1. initiate H2 blockade, sucralfate or antacids w/ gastric pH monitoring
  2. upper GI endoscopy is not necessary for this type of bleed
  3. prophlyactic therapy may be given for pts at high risk of bleeding
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4
Q

EGD finding of duodenal ulcer with clean, white base and no active bleeding - management?

A

white base = has not bled recently

  • can be observed w/o endoscopic tx.
  • H2 blocker or PPI to maintain gastric pH > 5
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5
Q

EGD finding of duodenal ulcer with fresh clot adherent to the ulcer - management?

A

evidence of recent rebleeding

- endscopic hemostatic therapy

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6
Q

indications for endoscopic hemostatic therapy of bleeding ulcer

A
  1. active or recent bleeding
  2. large initial blood loss
  3. high risk of rebleeding or death from bleed
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7
Q

EGD finding of duodenal ulcer with fresh clot and visible artery at its base - management

A

visible artery - highest risk of rebleeding

  • inject area around artery to attempt local control
  • operate in next 24-48 hours
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8
Q

where is an ulcer with a visible artery presenting with massive bleeding likely found?

A

posterior duodenum and involves the gastroduodenal artery

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9
Q

EGD finding of duodenal ulcer with fresh bleeding in a patient with the onset of hypotension - management?

A

immediate resuscitation w/ normal saline and PRBCs; send to OR

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10
Q

management of duodenal ulcer in pt with ARF and creatinine of 6 mg/dL

A

this pt who has uremia, likely has platelet dysfunction making bleeding more likely; tx. involves dialysis and desmopressin but otherwise, management is the same as other cases

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11
Q

what do you do if a patient presents with bleeding gastric ulcer?

A

management is the same as for duodenal ulcers, but biopsy must be done once patient is stable and bleeding is resolved; if surgery is needed, excision rather than oversewing as with duodenal ulcers

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12
Q

management of gastric varices in setting of chronic cirrhosis pt

A
  • do not respond to banding or sclerotherapy
  • may respond to injection of cyanoacrylate glue
  • if bleeding is severe, TIPs or splenectomy may be needed
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13
Q

management of gastric varices in setting of chronic pancreatitis

A

due to splenic vein thrombosis (left-sided portal HTN) –> Tx. splenectomy

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14
Q

what should patients with esophageal varices be treated with as prophylaxis against rebleeding?

A

B-blocker

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15
Q

what test is useful if diagnosis of GERD is uncertain?

A

24 hr esophageal pH monitoring

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16
Q

approach to patient with symptoms resembling GERD

A

R/O gallstones, cardiac problems, pancreatitis

- if negative, start trial of H2 blockers or PPIs –> if it helps, no W/U; if pt does not improve, order EGD

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17
Q

classic GERD symptoms

A

burning retrosternal pain - brought about by bending over, wearing tight clothes or lying flat in bed at night
antacids provide symptomatic relief

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18
Q

what test should be recommended to someone with long-standing GERD who was never formally diagnosed/treated?

A

EGD with biopsy

- assess for extent of esophagitis and possible complications

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19
Q

you do EGD in pt with symptoms of GERD but find nothing….

A

non-ulcer dyspepsia

- symptomatic tx with PPIs and h.pylori tx

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20
Q

tx. of Barret’s esophagus/esophagitis

A

medical therapy with PPIs (8-12 weeks should resolve it); behavior modification

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21
Q

indications for nissen fundoplication

A

intractable GERD symptoms despite max medical therapy
severe esophagitis
esophageal stricture

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22
Q

what kind of surveillance is needed in pt with diagnosed Barret’s?

A

EGD+biopsy every 18-24 months to monitor for dysplasia

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23
Q

what diagnostic tests should you do in a patient with symptoms of GERD despite max medical treatment?

A

EGD w/ biopsy

esophageal manometry - to demonstrate intact esophageal peristalsis before surgery

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24
Q

Dx. of Zenker’s diverticulum

A

barium swallow followed by upper endoscopy

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25
Q

Tx. of Zenker’s diverticulum

A

transection of cricopharyngeal mm

if large, excision at origin of posterior pharynx

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26
Q

47 yo woman complains of difficulty swallowing (liquids&raquo_space; solids) and she has to sit up straight and wait for fluids to make it through. She occasionally regurgitates large amts of undigested food - dx?

A

achalasia

  • poor peristaltic contractions
  • increased LES tone
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27
Q

diagnostic test for achalasia

A

barium swallow first

confirm with manometry

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28
Q

tx of achalasia

A

CCBs
balloon dilation w/ endoscopy
Heller myotomy w/ surgery

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29
Q

older man with history of smoking and drinking presents with difficulty swallowing meats and solids that has progressed to include liquids; he has history of 30 pound weight loss - dx?

A

esophageal ca

  • likely squamous cell ca.
  • if longstanding GERD hx, think adenocarcinoma
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30
Q

characteristic signs/symptoms of esophageal ca.

A 
progressive dysphagia (solids -> liquids)
odynophagia
constant pain
regurgitation
TE fistula formation
hoarseness/coughing
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31
Q

diagnostic sequence of esophageal ca.

A

barium swallow first
endoscopy with biopsy
CT scan to assess extent
endoscopic USG - for staging

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32
Q

most accurate way to stage esophageal ca.

A

endoscopic ultrasound

- assess wall penetration and adjacent node involvement

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33
Q

pt with history of forceful or persistent vomiting followed by vomiting bright red blood - dx?

A

Mallory Weiss syndrome

- multiple linear erosions in gastric mucosa at GE junction

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34
Q

dx. and tx of Mallory Weiss tears

A

usually resolve on their own so w/u is conservative; if bleeding persists, consider EGD with photocoagulation

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35
Q

if laser coagulation is not working for a Mallory Weiss tear, what should you do next?

A

surgery

- oversew the laceration through anterior longitudinal gastrostomy

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36
Q

patient who has been vomiting repeatedly presents bc during a particularly violent episode he felt a severe, wrenching epigastric/lower sternal pain of sudden onset; on exam, he is diaphoretic, has fever, leukocytosis and looks ill - dx?

A

Boerhaave syndrome - transmural esophageal tear(perforation)

37
Q

management of Boerhaave syndrome

A

gastrograffin (water soluble) swallow

followed by emergent surgery

38
Q

pt who recently had upper endoscopy returns complaining of severe, constant retrosternal pain; he has a very high fever, is diaphoretic and there is a hint of subcutaneous emphysema at the base of the neck - dx?

A

esophageal perforation (due to instrumentation)

39
Q

approach to esophageal perforation

A
  1. gastrografin swallow
  2. emergency surgical repair
    - if < 24 hours: primary closure
    - if > 24 hrs: diversion and exclusion followed by delayed reconstruction
40
Q

approach to bleeding esophageal varices

A 
endoscopic band ligation
correct coagulopathy (FFP, platelets)
IV octreotide or vasopressin
- if pt rebleeds, repeat endoscopy and ligation
41
Q

what can you consider doing if multiple attempts at endoscopic ligation of esophageal varices are unsuccessful?

A

portosystemic shunt - mortality of 50%
balloon tamponade - pt must be intubated; high risk of esophageal necrosis
TIPs

42
Q

management of a duodenal ulcer

A

4-6 weeks of triple therapy for h.pylori (8-12 weeks for severe disease)
- if symptoms persist, repeat EGD: if ulcer still there or it enlarged, consider surgery (highly selective vagotomy)

43
Q

what always must be done for a gastric ulcer?

A

biopsy

44
Q

tx of linitus plastica

A

total gastrectomy with splenectomy

45
Q

pt presents with large weight loss with a history of anorexia and vague epigastric discomfort - what do you do?

A

endoscopy with biopsy
- looking for cancer
if cancer, CT scan to assess for extent/operability

46
Q

pt presents with colicky abdominal pain, protracted vomiting and abdominal distention; he has not had a bowel movement or passed gas for 5 days. On exam he has high-pitched, loud bowel sounds that coincide with colicky pain - what are you considering and what test should you order?

A

consider bowel obstruction

- order abdominal XR

47
Q

XR finding in bowel obstruction

A

distended loops of small bowel and air-fluid levels

48
Q

Management of bowel obstruction due to adhesions

A

NG suction, IVF and careful observation

- surgery if no improvement w/in 24 hours

49
Q

pt is being tx for bowel obstruction and he develops fever, leukocytosis, abdominal tenderness and rebound tenderness - dx?

A

signs of peritoneal irritation in pt with bowel obstruction suggests strangulation from compression of mesenteric blood supply
- need emergency surgery

50
Q

pt presents with signs and symptoms of intestinal obstruction; on physical exam you not a groin mass, the patient says he used to be able to push it back at will but for past 5 days has been unable to do so - dx?

A

intestinal obstruction caused by incarcerated hernia

- tx. with surgical intervention

51
Q

diagnosis of carcinoid syndrome

A

24 hr urine 5-HIA level

CT scan to assess liver mets

52
Q

characteristic symptoms of appendicitis

A

vague periumbilical pain that becomes severe, constant and well localized to RLQ

  • abdominal tenderness, gaurding and rebound
  • high fever
  • elevated WBC with neutrophilia and immature forms
53
Q

an older pt presents with bloody stools; the blood is visible and has been present on and off for last few weeks - he has been constipated for past 2 months with narrow calibre stools - dx?

A

suspect cancer of distal, left colon

54
Q

diagnostic approach to distal, left-sided colon cancer

A

start with flexible proctosigmoidoscopy

eventual colonscopy and CT scan to assess extent

55
Q

premalignant polyps

A

familial polyposis
familial multiple inflammatory polyps
villous adenomas
adenomatous polyps

56
Q

indications for surgery in ulcerative colitis

A 
disease > 20 years (high risk of malignancy)
severe interference with nutrition
multiple hospitalizations
high dose steroids/immunosuppression
toxic megacolon
57
Q

XR findings in toxic megacolon

A

massively distended transverse colon

gas within wall of colon

58
Q

what are the indications for emergent colectomy in a case of pseudomembranous colitis?

A

failure of medical management with:
WBC count > 50 000
serum lactate > 5 mmol/L

59
Q

how can you differentiate between internal and external hemorrhoids?

A

internal - bleed but don’t hurt

external - pain (discomfort when sitting, itching), but less likely to bleed

60
Q

pt presents with symptoms likely due to hemorrhoids, what must you do?

A

must rule out cancer!

- do proctosigmoidoscopic exam with DRE, anoscopy and flexible sigmoidoscope

61
Q

tx. of hemorrhoids

A

internal - rubber band ligation

external or prolapsed - surgery

62
Q

young woman complains for exquisite pain with defection and blood streaks on outside of stool; she avoids having bowel mvts due to pain and when she does they are hard and even more painful

A

anal fissure

- usually posterior, in midline

63
Q

management approach to anal fissures

A

physical exam is diagnostic but cancer must be ruled out

  • in young pts with no risk factors: do flexible sigmoidoscopy
  • all others do colonscopy (esp. if unusual location - anterior/lateral or symptoms of Crohns)
64
Q

tx. of anal fissures

A

sitz baths, fibre/stool softeners
topical anesthetic agents
topical nitroglycerin

65
Q

tx of chronic anal fissure that is not responding/healing

A

surgery - lateral internal sphincterectomy

66
Q

man comes in with exquisite perianal pain; he cannot sit down, bowel mvts are very painful and he has been having chills/fever. On exam there is a hot, tender, red fluctuant mass between anus and ischial tuberosity - dx?

A

ischiorectal abscess

67
Q

management of ischiorectal abscess

A

drainage of abscess

must r/o cancer

68
Q

62 yo man complains of perianal discomfort and reports fecal streaks soiling his underwear. 4 months ago he had a perirectal abscess drained surgically. On exam, there is a perianal opening in the skin and a cord-like tract going from the opening toward the inside of the anal canal; brownish purulent discharge can be expressed from the tract -dx?

A

fistula in ano

- only develops in pts with previous anorectal fistula

69
Q

management of fistula in ano

A

R/O cancer with proctosigmoidoscopy - necrotic tumors can drain
- elective fistulotomy

70
Q

HIV positive man has a fungating mass growing out of anus and rock-hard enlarged LN in both groins; he has lost a lot of weight and looks emaciated and ill - dx?

A

squamous cell carcinoma of anus

- take a biopsy of mass

71
Q

management of squamous cell ca. of anus

A 
Nigro protocol (tumors < 5 cm)
- preop chemotherapy (5FU and mitomycin) and radiation followed by surgery
72
Q

indications for surgery in GI bleed

A
  • failure of medical tx
  • hemodynamic instability despite > 3U of blood transfused
  • recurrent bleed despite 2x endoscopic hemostasis attempts
  • hypovolemic shock
  • > 3U/day of blood needed
73
Q

pt vomits large amt of bright red blood

A

upper GI bleed

- above the ligament of Treitz

74
Q

first test to do in upper GI bleed?

A

endoscopy

75
Q

what is the next step in assessment of a dark red bowel movement?

A

place NGT with aspiration

76
Q

NG tube aspirate returns copious amts of bright red blood - next steps in management?

A

defines upper GI bleed

  • establish IV access
  • give H2 blockers and monitor pH
  • when stable, proceed with endoscopy
77
Q

NG tube aspirate returns clear, green fluid without blood

A

R/O upper GI bleed - must be distal to Ligament of Treitz

78
Q

diagnostic approach to a lower GI bleed

A

always do anoscopy to look for hemorrhoids first
tagged red cell study (0.5-2.0 ml/min)
angiogram (> 2 ml/min i.e. 1 U blood every 4 hrs)
colonscopy (wait; < 0.5 m/min)

79
Q

a pt comes in bc they had dark bloody stools 2 days ago; they are not currently bleeding and NG tube shows clear fluid - dx?

A

young pt - EGD

older pt - EGD and colonoscopy

80
Q

management of stress ulcer in ICU pt

A

keep pH > 4-5 with H2 blockers, antacids or both

- if bleeding happens, endoscopy and angiographic embolization of L.gastric aa may be needed

81
Q

pt with liver cirrhosis and ascites presents with generalized abdominal pain; moderate tenderness, some guarding and rebound with mild fever and leukocytosis - dx?

A

in pt with ascites and history of cirrhosis, think of SBP –> do NOT do surgery

82
Q

tx of SBP

A

culture of ascitic fluid and antibiotics

83
Q

sudden onset excruciating abdominal pain; pt has rigid abdomen, is laying motionless, there are no bowel sounds. XR shows air under diaphragm - dx?

A 
perforated viscus (most likely duodenal ulcer)
- emergent laparotomy
84
Q

diagnosis of acute pancreatitis

A

serum amylase or lipase (more specific)

85
Q

who should receive a CT scan in acute pancreatitis?

A
  • pts who do not improve on conservative tx
  • pts suspected of having complications
  • unclear diagnosis
86
Q

diagnostic test for ureteral colic

A

CT scan

87
Q

older woman with LLQ pain, tenderness and vaguely palpable mass; she has fever and leukocytosis - dx? and test?

A

acute diverticulitis

test - CT scan

88
Q

82 yo man develops severe abdominal distention, NV and colicky abdominal pain; he has not passed any gas or stool; XR shows very large gas shadow in RUQ that tapers toward LLQ with shape of a parrots beak - dx?

A

sigmoid volvulus

89
Q

tx. of sigmoid volvulus

A

proctosigmoidoscopy

- leave rectal tube in place

Surgery NBME (16 decks)

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