GenSurg Flashcards
? is the name of the duodenal/jejunal feeding tube
How are positions verified
What are the E+ abnormalities seen w/ refeeding syndrome
Dobhoff tube
KUB films
Hypo K, Mg, Phos
What surveillance order is needed on Pts receiving TPN
Feeding tubes can be placed/started ? soon after surgery
Define Visceral vs Parietal pain
Weekly liver enzymes
Day 2 post-op
V: afferent fibers, pain MC midline d/t bilateral innervation
P: sharp/precise pain d/t peritoneal irritation
Sequence of x-ray assessment
What is a 3-way abdomen image and what is it used for
Abdominal x-rays normally show air in ? three areas
Adequacy Bones Calcifications Deformity/Density Extra air Foreign body/Fx
Flat, Upright, CXR for hemo/pneumo-peritononeum
Stomach Small bowel, Rectosigmoid
How are mechanical obstructions distinguished from ileus’
Ileus are more common after ? d/t ?
Sub-diaphragmatic air on x-ray suggests ? issue
Mechanical- more localized, severe pain
Ileus- diffuse and milder
Post-op d/t inc sympathetic nerve activity
Perforated viscous
Where does the appendix arise from
What land mark is used to locate it during removal
What causes this to become obstructed in adults/peds
Postero-medial cecum, 2cm inferior of IC valve
Taeniae of colon converging at base
Adult: fecalith Peds: lymphoid hyperplasia
What are the 3 PE tests performed to locate appendicitis
Mnemonic for Alvarado Score
McBurney: iliac fossa
Obturator- pelvis
Psoas- retroperitoneal/cecal
Migration to R iliac fossa- 2pts Anorexia N/V Tenderness in R iliac fossa Rebound pain Elevated temp Leukocytosis- 2pts (>75% neutrophils) Shift to left of WBCs
5-6: compatible 7-8: probable 9-10: very probable
What ABX are used during appendicitis
Appendix are routinely removed even if not inflamed during ? GI surgery
What PE test is used for rectus sheath hematoma
Cipro+Metronidazole: Perf’d
Cefoxitin: non-perf’d
Meckels Diverticulum
Neg Fothergill sign
Where are Boerhaave perfs most likely to occur
What images are done
What lab result would be elevated from thoracentesis after Boerhave perfs
Left posterolateral wall- causes Hamman crunch
Cervical x-ray
Esophagogram w/ contrast
Chest CT to localize
Amylase
? is the most sensitive imaging study for suspected esophageal cancers
How are Pts managed
? is the most important prognostic factor
Endoscopic US w/ FNA of lymph nodes
Neoadjuvant chemo and rad
Stage of Dz
What are the 2 MC complications to occur within 30days after bariatric surgery
What is the most concerning early complication
? is the MC performed bariatric surgery
Dehydration, E+ imbalance
Anastomotic leak
LSG
? is the most accurate method to Dx gastric ulcers
When is a Dx of Zollinger Ellison Syndrome considered
What lab test is used for Dx
Endoscopy
Ulcer refractory to PPI
Ulcer in distal duodenum/jejunum
Recurrent ulcers despite Tx
Fasting gastrin, d/c PPI one week prior
? pre-op image is used to localize Zollinger Ellison tumors and all are Tx w/ ?
? triple therapy is used for Tx
Why is maintenance therapy done w/ Omeprazole
Somatostain receptor scintigraphy; Resection
Amox Clarith w/ PPI
Inhibits parietal cell ATP tor educe ulcer recurrence
Test of choice for post-gastric ulcer Tx eradication
What procedures done to Tx high risk Pts w/ gastric ulcers
How are perforated duodenal ulcers Tx
Urea breath test
Billroth I- gastroduodenal anastomosis
Bilroth 2- gastrojejunal anastomosis
Roux en-Y gastrojejunostomy
Omental/Graham patch
Complications after antrectomy
Complications after Truncal Vagotomy
? type of diet do Pts adopt to Tx Dumping Syndrome
Leakage from duodenal stump
Delayed emptying, Dumping syndrome, Diarrhea
Low carb, High fat/protein
What is the most sensitive and specific test for suspected Pyloric Stenosis and how is this Tx
? type of ulcer is not associated w/ Ca risk
These ulcers can be Tx by ? methods
US; Laparoscopic pyloromyotomy
Duodenal
EGD <24hrs if hermorrhaging, Selective vagotomy
? is the MC form of volvulus
How are these Dx
Pts w/ ? signs need immediate surgery or ? if no signs are present
Sigmoid then Cecal
Colonic- X-ray; Small bowel- CT
Toxic, Bloody d/c, Fever, Leukocytosis, Peritonitis- surgery
None- sigmoidoscopy
Define Rigler Triad
How is this Dx
How is this Tx
Abdominal radiograph findings for gallstone ileus: Pneumobilia Obstruction Gallstone
CT
Enterolithotomy- incision made proximal to obstruction for relief and removal
Meckel’s Diverticulum is d/t a remnant of ?
What is the Rule of 2s
Omphalomesenteric duct
2% of peds population
2 tissue types: gastric, pancreatic
2 feet from ileocecal valve
? are the MC benign tumors of the small bowel
? are the MC malignant tumors of the small bowel
? are the MC endocrine tumors of the small bowel
Leimyoma, Adenoma
Adenocarcinoma
Carcinoid tumor: hot flash, bronchospasm, arrhythmias
Define Bezoar
How are these conditions Dx by images
How are they Tx
Compacted, retained foreign material in GI tract: Phyto- fiber Lacto- milk Pharma- meds Tricho- hair
AP films
Endoscopy then surgery
? is the most sensitive and specific study to Dx acute cholecystitis
MCC of cholelithiasis
What are the RFs to develop this MCC
Cholescintigraphy: Hida scan
Cholesterol stones
Age Female Obesity Parity
What causes pigmented stones in the gallbladder
When are pigmented stones seen
What are the non-surgical Tx options for cholecystitis in Pts inelligible for surgery
Inc unconjugated bilirubin, turns into Ca bilirubinate
Sickle Thalassemia Spherocytosis
Ursodeoxycholic acid: stones <15mm
ESWL- breaks stones <2mm for passing
Optimum time for cholecystectomy or ? is performed
What is the MC complication that arises from acalculous cholecystitis
Choledocholithiasis leads to ? Dx
<72hrs from Sx onset; Percutaneous cholecystostomy
Gangrene > Perf, Empyema
Cholangitis
Common Bile Duct dilation more than ? suggest choledocolithiasis
What are the high risk features for suspected choledocholithiasis
How are mild or mod/sev cases of cholangitis Tx w/ ABX
> 10mm/1cm
Age >55y/o Bili >30mmol CBD >6mm Dx US w/ stone
Mild/Mod: Cefazolin/Cefoxitin
Sev/Deterioration: Aminoglycoside + Clinda or Metro
Severe or unremitting cholangitis despite ABX are best Tx w/ ?
How much gas is used to inflate the abdomen during lap procedures
What is the name of the incision used for open cholecystectomy procedures
Endoscopic sphincterotomy then to laparotomy
15mmHg of CO2
Kocher’s in RUQ
Post-cholecystectomy ABX are continued for how long
When are Pts f/u w/ and when can they return to normal activity
What system breaks up the liver into segments
Until afebrile and normal leukocytosis
F/u 1wk, normal routine in 6-8wks
Couinaud into 8 sections
Common hepatic artery arises from ? structure
What structure marks the point of origin for the artery
Why is vascular control within the abdomen difficult
Celiac axis
Gastroduodenal artery
Hepatic veins are very short prior to entering IVC
What 3 structures make up the portal triad
These three structures enter the liver through ?
Bile is composed of ? four components
Hepatic artery, Portal vein, Biliary duct
Hepatic hilum
Formed in hepatocytes out of:
Conjugated bile acid, Cholesterol, Phospholipid, Protein
What are the Vitamin K dependent clotting factors
MC injured organ w/ abdominal blunt trauma and w/ ? MC sequelae and ? is the Tx strategy for this injury
What is a rare sequelae to liver trauma
2 7 9 10
Liver- biliary fistulae after central injury pattern:
Non-op management
Pneumobilia
Define Bilioma
How are these Tx if major leakage occurs
MC type of liver cyst
Loculated collection of bile
ERCP and spincterotomy
Simple hepatic: anechoice lesion w/ smooth contours
What is the name of the pre-malignant liver cyst and how are they Tx
Polycystic Liver Dz occur in Pts w/ ? MedHx
How are the different types Tx
Cystadenoma- internal septae w/ irregular lining and papillary projections; Tx: resection
PCKDz
Type 1: cyst fenestration w/ <10 cysts >10cm
Type 3: transplant d/t parenchymal involvement
? is the MC liver tumor
How are these results different on imaging
Hepatic adenomas are associated w/ ? RFs and managed how
Hemangioma d/t congenital vascular malformation
T1: hypointense T2: hyperintense Cold: NucMed scan
OCP/Androgen steroid use;
<3cm: observe while d/c OCPs
Resection: >5cm, expanding, malignant suspicion
Histologically, Hepatocellular Adenomas consist of ?
How are Focal Nodular Hyperplasia growths of the liver ID’d w/ imaging
What is the major RF for developing Hepatocellular Carcinoma
Benign hepatocytes
Hot on NucMed imaging
Chronic Liver Dz: Chronic hep B/C
How is Hepatocellular Carcinoma Dx
After Dx of Hepatocellular Carcinoma, what f/u schedule do Pts have
What are the 4 palliative options for these Pts
High resolution CT/MRI
US w/ A-fetoprotein q6mon
TACE TARE SBRT Sorafenib
What is the MC classification system used for liver failure
How are Pts w/ Chronic Liver Dz Tx
What is the name of the main/accessory duct in pancreas
Child-Pugh: Class C is c/i for hepatic resection
TIPSS: shunt placed and BBs to reduce risk of first bleed
Main Wirsung Accessory: Santorini
Define Budd Chiari Syndrome
When is this MC seen
Initial Tx is ? followed by ?
Hepatic vein thrombosis
Hypercoagulable female w/ RUQ pain, Ascites, Megaly
TIPS then portal decompression before hepatic necrosis occurs (Fullament failure Tx w/ transplant)
Why does Acute Pancreatitis prominently present w/ N/V
What are the 6 parts of the Ranson Criteria
What scoring system is used as a bed side index of severity
Accompanying paralytic ileus
GA LAW:
Glucose>200 Age>55 LDH>350 AST>250 WBC>16K
BASAP:
BUN>25mg AMS SIRS Age>60 Pleural effusion
Pancreatic Pseudocysts form d/t and occur more commonly in Pts w/ ?
What complication can occur as a result of severe pancreatic inflammation
D/t fluid sequestration, how is hypovolemia Tx during acute pancreatitis
Acute pancreatitis fails to recover after 1wk of Tx; Duct abnormalities
Pseudoaneurysm- acute exacerbation of abdominal pain
3-6L 9% NS or LR over first 24hrs
MCC of Chronic pancreatitis
What is the clinical tetrad for this condition
Name of Tx operation for large/small pancreatic duct chronic pancreatitis
Alcoholism
Pain Weight loss Diabetes Steatorrhea: assess A1c, fecal elastase, check for HyperCa/Tglc
Large: Puestow Small: Whipple, Beger
What is the traditional resection operation to Tx chronic pancreatitis
MC type of pancreatic neoplasms
What is the defining characteristic of this neoplasm
Pancreaticoduodenectomy- removed pancreatic head, duodenum and distal CBD (Whipple)
Ductal adenocarcinoma (2nd MC GI tract malignancy), Bili levels average 18mg/dL
Aggressiveness- early dissemination
How is pancreatic cancer Tx surgically
What is the MC type of functional PNETs
What triad is used for Dx of this MC
Pancreaticoduodenectomy- whipple procedure removing pancreatic head, duodenum, distal biliary system
Insulinoma- Sxs of cerebral glucose deprivation
Whipple Triad:
Symptomatic fasting hypoglycemia w/ glucose <50 that is relieved w/ IV glucose
How are Insulinomas Dx
? is the MC PNET of MEN-1
These are MC found in ? anatomical triangle
72hr monitored fasting
Gastrinoma- abdominal pain, diarrhea, refractory PUDz
Pancreatic neck
Junction of 2nd and 3rd duodenum
Junction of cystic and common ducts
How are gastrinomas Dx
All Pts w/ MEN-1 and gastrinomas should be screened for ?
What is the most important determinant for Pt survival
Fasting serum gastrin >1000
Borderline: order secretin provocative test
Parathyroid adenoma/hyperplasia/hyperCa
Liver mets
Where are the majority of accessory spleens found
What are the 3 zones and their function
What are the two MC reasons for splenectomy
Splenic hilum- persistent dz if unrecognized
Red: hematologic
White: immunoglobulins
Marginal: macrophages B-cells
Sx relief of splenomeglay, ITP unresponsive to Pred
When are post-splenectomy Pts vaccinated
What microbes are the vaccinated against and why are these needed
Splenectomy can induce ? increase in heme results that is managed w/ ?
2wks prior to elective ectomy
2wks after emergent ectomy or at d/c if <2wks
3mon after chemo/rad
H-flu Strep pneumo Meningococcus- avoid Overwhelming Post-Splenectomy Infection
Thrombocytopenia induced risk for emoblisms- Tx w/ ASA and anti-platelet when Plt >600K
What are the 5 layers of the colon from in to out
What are the only two parts of colon w/out taenia coli
? parts of the colon are retro/intra-peritoneal
Mucosa Submucosa Circle/Long muscle Serosa
Longitudinal ribbons of smooth muscle outside of intestines: Appendix, Rectum
Retro: ascending, descending
Intra: transverse
What causes diverticulosis to bleed
? is the most optimal imaging modality for lower GI bleeds
What are the indications for surgery
Thinning of out pouching of superficial vasa recta
Colonoscopy
Persistent/Massive hemorrhage
Transfusion or >4units <24hrs
Recurrent bleed
Colorectal polyps are classified per ? criteria
? tumor marker is used post-op for colorectal recurrence
What Dx initiates colonoscopies regardless of age
Haggitt
CEA
UC- risk for Ca
Colonic obstruction d/t ? tends to be more localized and severe
Pain from ? part of the colon is diffuse and milder
? image finding is highly suggestive of colon cancer
Mechanical obstruction
Ileus
Barium enema w/ apple core lesion- can be Dx and therapeutic
Crohns Dz causes ulcers in ? shape
? histology results will be seen
How is UC surgically cured
Bear claw
Non-caseating granulomas
Total proctocolectomy
What are the 3 zones where hemorrhoids can develop
Internal hemorrhoids are lined by ?
External hemorrhoids are lined by ?
R-anterior, R-posterior, L-lateral
Columnar mucosa epithelium
Squamous epithelium
? med is a stool softener
? med is fiber
Define Rectal Procidentia
Colace
Metamucil
Rectal prolapse- full thickness protrusion through anus
What are the 4 RFs for rectal prolapse
Majority of cancers at the anal margin are ? type
Neoplams of the anal margin appear as ?
Post-menopause Female Constipation Surgery
SCC- well differentiated and rarely w/ distant mets
Rolled, everted edges w/ central ulcerations
What is the best initial management strategy for malignant neoplasms at the anal margin
Majority of anal fissures are found ?
What type are more commonly found in females
Chemoradiation
Posterior anal canal
Anterior fissures
Why are lateral internal spincterotomys preferred over posteriors
Why do Pts not experience incontinence after surgery
? type of anal abscess tend to be larger and complex
Avoid keyhole deformities
Intact external sphincter
Ischirectal- cryptoglandular infection w/in anal canal
? type of anal abscess have increased rates of fistulas
Pilonidal dz is AKA ? Dz
What is the name of the procedure for Pilonidal Dz
Horse shoe abscesses
Jeep seat dz- hair follicles in gluteal cleft infected w/ keratin leading to infection/abscess formation
Bascom
Define the Chamberlain Procedure
What procedure is used as an alternative
MC indication for needle biopsy of the lung
Anterior mediastinotomy for biopsy x3
VATS
Solitary pulm nodule
? form of imaging is particularly good for evaluating Pancoast Tumors
? image is used to detect cancer spread to mediastinal lymph nodes
Define Infiltrate and Effusion
MRI
PET
In: fluid in lung; Eff: fluid in pleural space (meniscus sign on CXR)
? is the standard image to Dx Ptx
Ptx are the MC ? problem
? are the MC Sxs of pleural Dzs
PA and Lat CXR w/ exhalation
Pleural- no innervation to visceral layer
Pain, Dyspnea d/t innervation from somatic intercostal/phrenic nerve
Pleural effusions develop d/t ? changes
How much fluid does it take to blunt CV angles or an entire hemithorax on CXR
How much fluid is needed on thoracentesis for evaluation
Inc hydrostatic press, capillary permeability
Dec colloid oncotic press, intrapleural press, lymph drainage
CVA: 300-500mL Hemi: 2-2500mL
20mL at least
Transudate and Exudates are caused by ?
What lab results are seen in Transudate results
Once full lung expansion is achieved after pleural effusions, ? is the next step
Trans: CHF, LF Ex: Ca, Pneumonia, PE
Total protein <3g (ratio <0.5)
LDH ration <0.6
SpecGrav <1.016
Pleurodesis w/ Doxy/Talc
? size tube are used for malignant effusion, hemothoraces Tx
MCC of exudative pleural effusion is ?
? microbe is the MCC of empyema
Ca: 20-28F Heme: 32-36F
Malignancy
Staph A
? parasite can induce thoracic empyema
? is the most important non-invasive test for thoracic empyema
All PTs need ? procedure and ? is the procedure of choice for Dx
Entamoeba histolytica
CXR
Bronchoscopy; Thoracentesis
? is the MCC of death in men and women in the US
Pancoast tumors are more likely to be ? type
? is Horners Triad
Lung Ca
Squamous cell Ca in apex
SCC in apex causing Mitosis Anhydrosis Ptosis
? types of lung Ca are more likely to be peripheral or central
Non-Small Cell Lung Ca is more likely to secrete ? while Small Cell Lung Ca is more likely to secrete ? substance
? nerve can become compressed by pancoast tumors in the apex
Peripheral: adenocarcinoma (painless)
Central: Small Cell
Non: PTH-like: HyperCa
Small: ADH-like: SIADH, MSH, ACTH
Ulnar
CT scans for lung neoplasms include the upper abdomen because of ? two common met sites
? lab result is essential because then ? tests are ordered
? is used for the staging test and is most effective for assessing distant/occult Dzs
Liver, adrenals
AlkPhos- bone scan brain MRI/CT
Fluorodeoxyglucose PET scan
Lung neoplasms are more likely benign w/ ? characteristics
? is the most predictive factor for successful surgical outcome in these Pts
Difference between Neoadjuvant and Adjuvant chemo
<2cm, Concentric, Smooth, Solitary
CardioPulm reserve, Fitness
Neo: pre-op to shrink tumor,
Adj: after Tx to prevent recurrence
TNM Staging
What is the difference between Unresectable and Inoperable
T- 1: <3cm 2: 3-7cm 3: >7cm 4: invasive
L:
0: none 1: ipsilat broncho/hilar 2: ipsilat mediastinal/subclavicular 3: contralateral
M: 0: none 1: mets
Un: invaded structures In: unstable Pt
MCC of arterial aneurysm
What are the 3 types of pseudo-aneurysms
? is the MCC of pseudo-aneurysms
Atherosclerosis
Saccular: out-pouch of vessel wall
Fusiform: diffuse
Mycotic: MCC Staph infection
Trauma
? law of physics is applied to AAA
MC Sx of AAA leak
Image modality for tracking, Dx and elective planning
Law of Laplace:
Back pain d/t leak in left posterior corner below L-renal artery origin
Track: US
Dx at rupture: CTA
Elective: Aortogram
AAA characteristics at increased risk for rupture
Repair is indicated in ? 3 conditions
Define Blue Toe Syndrome
> 5.5cm
Expands >0.5cm/6mon
Female > Male
Saccular > Fusiform
ASx and >5.5cm, Sx, Expands >1cm/yr
Distal embolization from AAA
Aortic Transections are usually d/t ? mechanism and occur ?
Pts can survive this injury if ? structure holds
Best image for Dx and best method to control/dec shearing forces
Deceleration, Distal to subclavian artery
Adventitia
CTA; BBs then dilators
? is the MC catastrophic event involving the aorta
Ruptures are more likely seen w/ ? Stanford type and have ? murmur
Name of procedure to Tx mesenteric ischemia
Acute dissection- AR
Type A
Percutaneous Transluminal Angioplasty w/ stenting
? is the MCC of carotid related CVAs
? may be the first Sx of carotid artery dz
? is the most useful test for carotid artery dz assessment while ? is the gold standard but only used if surgery is planned
Emboli- MC
Frank CVA
Duplex US; Carotid arteriography w/ >75% occlusion= need for surgery
(MRI/A- better for ischemic CVAs)
What medication is needed after carotid endarterectomy procedures
Subclavian Steal Syndrome causes blood to be ‘stolen’ from ?
Periphral Vascular Dz pain in calf, butt, groin means source is ?
Clopidogrel x 6wks
Subclavian steals from vertebral artery
Calf: femoral artery
Butt/Thigh: iliac
Impotence: aortic
What are 3 critical characteristics of limb ischemia
AMI measurement below ? means occlusive Dz present
What is the most important RF
Pain w/ rest
Inc pain at night
Hanging leg off bed/chair to dec pain
<1.0
Smoking
What 3 meds are used for peripheral vascular dz and what are their MOAs
What are the 6 Ps of acute arterial occlusions
Which one indicates the beginning of irreversible ischemic changes
Cilostazol: PD-5 inhibitor to dilate vessels
Anti-platelets: ASA
Pentoxiphylline: dec blood viscosity
Statins
PooP Color Pulse Movement Temp Numb
Sensory deficit
Arterial transections must be repaired within a few hrs to prevent ?
How are arterial occlusions Tx
? type of knee injury leads to an arterial stretch injury
Gangrene
Heparin- atraumatic
Arteriorgram if light touch intact
Thrombolytics or Embolectomy- emergent if neuro compromise present
Anterior dislocation
What causes popliteal artery entrapments
How does this entrapment present
Thromboangiitis Obliterans is AKA ? Dz
Medial head of gastrocnemius w/ abnormal insertion causing medial deviation of artery
ASx w/ rest, Ischemia w/ exercise
Buerger Dz
What causes venous dilation in AV fistulas
? thyroid Ca follows a FamHx path
Radiation during childhood puts Pts at risk for ? type of thyroid Ca
Arterial pressure
Medullary carcinoma in MEN-2
Papillary- MC type of thyroid Ca MC d/t iodine deficiency
? is the first line investigation test for solitary thyroid nodules
? scintigraphy result means nodule is likely benign
Toxic adenomas need to be removed if ? size
US guided FNA
Hot- hormonally active (low TSH, high T3/4)
> 4cm
How are the two MC types of thyroid cancer spread
MEN-1 is AKA while MEN-2 is AKA ?
? medication is used during thyroid tumors to suppress mets
Pap: lymph Foll: heme
1: Werner’s 2: Sipple’s
Thyroxine
