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Surgery > GI and Abdomen > Flashcards

GI and Abdomen Flashcards

1
Q

Division between “upper” and “lower” Gi bleeding

A

ligament of treitz

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2
Q

symptoms of acute abdomen

A

extremely severe generalized abdominal pain, with rigid abdomen, tenderness to palpation, and guarding and rebound tenderness in all quadrants

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3
Q

acute abdomen in cirrhotic patient or child with nephrosis and ascites

A

primary peritonitis- doesnt need surgery

culture fluid from ascites and give abx

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4
Q

male with right flank colicky pain of sudden onset radiating to scrotum with microscopic hematuria

A

ureteral colic

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5
Q

woman has sudden onset generalized abdominal pain and faints, and has hemoglobin of 7. she has been on birth control pills since age 14

A

ruptured hepatic adenoma

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6
Q

type of liver abscess which is not drained

A

amebic abscess (entamoeba histolytica)

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7
Q

19yo male returns from cancun and gets malaise, weakness, anorexia. has high bilirubin (indirect) and high transaminases

A

hepatocellular jaundice

get serology to find out type of hepatitis

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8
Q

patient with progressive jaundice, high direct bilirubin, lost weight. sonogram shows dilated intrahepatic and extrahepatic ducts and a THIN DISTENDED GALLBLADDER

same case but now ERCP showing narrow area in distal common duct and normal pancreatic duct

A

malignant obstructive jaundice

with normal pancreatic duct and affected bile duct= cholangiocarcinoma

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9
Q

what surgery may cure a cholangiocarcinoma of the lower common duct

A

pancreatoduodenectomy (whipple)

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10
Q

older woman with jaundice, higher direct, very high alk phos. asx but slightly anemic with occult blood. sonogram shows dilated intrahepatic duct and extrahepatic ducts and distended thin gallbladder

A

ampullary cancer (know its obstructive jaundice, but bleeding into GI tract indicates Ampulla of Vater)

can be tx with surgery

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11
Q

what is ERCP likely to show in a pancreatic head cancer

A

obstruction of both common and pancreatic ducts

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12
Q

Tx of acute ascending cholangitis

A

emergency decompression of biliary tract

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13
Q

pt who has acute pancreatitis is managed by NPO, NG, and IV fluids but develops sudden decrease in hematocrit, increased BUN, and metabolic acidosis

A

Hemorrhagic pancreatitis

intensive support- main risk of pancreatic abscess forming so need serial CTs

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14
Q

pt with abdominal pain and a large ill defined epigastric mass. was involved in automobile accident hitting upper abdomen against wheel

A

pancreatic pseudocyst- needs to be drained under CT

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15
Q

on third post op day after open cholecystectomy, pt has temp of 101

A

UTI

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16
Q

pt undergoes open cholecytectomy and then gets fever and leukocytosis while wound is healed and is not affected

what if it was an appendectomy?

A

deep abscess (subphrenic or subhepatic)

pelvic abscess if appendectomy

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17
Q

after hemicolectomy, dressing from midline incision soaked with clear pink fluid

A

wound dehiscence- need surgery for re-closure

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18
Q

next step with acute epigastric pain when CBC, amylase, lipase, bilirubin, alk phosp normal. with normal chest and abd xray

A

ultrasound to r/o gallstones

if neg—empirical tx with H2 blocker or PPI- tx GERD, ulcer, gastritis

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19
Q

final step if no etiology found for epigastric pain

A

upper GI endoscopy esp in olfer pt, or pts with high risk of tumor or infection (immunocomp)

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20
Q

tests needed before doing surgery on refractory GERD

A

endoscopy with biopsy
manometry to demonstrate intact peristalsis (assuring pts can swallow post op)

surgery= Nissen fundoplication- restore GE junction and LES to normal position and wrap a part of stomach around distal esophagus which augments LES tone

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21
Q

hiatal hernia management

A

tx for GERD, no surgery

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22
Q

management of paraesophageal hiatal hernia and a mixed type hernia

A

both can pose risk for strangulation and necrosis- so surgery needed

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23
Q

what is a type 2 hiatal hernia

A

paraesophageal involving more organs than just the stomach- GE junction still at same place. stomach can necrose

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24
Q

management of a pyloric ulcer

A

increased acid production/H. pylori indicated with pylorus.
tx: PPI+metronidazole+clarithromycin
Bismuth also interferes with adhesion of H.pylori to gastric epithelium and inhibits urease activity

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25
Q

how long are peptic ulcers treated for

A

4-6 weeks, with severe disease treated for up to 12 weeks

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26
Q

choice of surgery for uncomplicated PUD refractory to meds

A

Highly selective vagotomy (denervate the antrum and pylorus, leaving the rest of the stomach which can still mix food)

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27
Q

gastric ulcer follwup

A

usually produce low acids, but assoc with risk of gastric cancer. 8-12 biopsies from edge of ulcer needed. caused by duodenal reflux (pyloric dysfunction) and decreased mucus and bicarb

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28
Q

what if benign gastric ulcers dont heal with meds after 18wks

A

can do partial gastrectomy- anterectomy

NO Vagotomy performed unlike in PUD

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29
Q

how does surgery differ with 1/4 vs 2/3 gastric ulcers

A

2/3 are higher acid producting, so along with some sort of gastrectomy, a truncal vagotomy also done

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30
Q

distal gastric ulcer indicating cancer. next step?

A

before resecting, need to use CT to assess for distant mets and LN.
endoscopic ultrasound can also show this

tx: distal subtotal gastrectomy (80% of stomach) and regional lymphadenopathy

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31
Q

first step in man presenting with severe epigastric pain, fever, guarding (rigid abdomen)

A

upright cxr looking for free air under diaphragm from a perforation of GI tract

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32
Q

tx for a few hours old perforated duodenal ulcer

what if pt was on H2 blockers for 6mons

A

close perforation, using pieces of omentum (graham patch)

with hx- need closure of perforation and a HSV (vagotomy) or a VP (vagotomy and pyloroplasty)

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33
Q

pt with perforated duodenal ulcer is septic

A

need to finish surgery asap- just do a graham patch, stabilize pt with fluids and acid block and then return

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34
Q

pt on NG tube with coffee ground material in drainage

A

due to upper GI bleed

use H2 block, sucralafate, antacids, with gastric pH monitoring

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35
Q

management of bright blood up a patients NG tube

A

IV fluids, blood for type and cross match
LAVAGE NG tube so blood no longer returns
monitor for hypotension
H2 blockers- monitor PH

once stable- then can do endoscopy

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36
Q

likely location of a high risk duodenal ulcer

A

posterior duodenum, which can involve the gastroduodenal artery

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37
Q

steps to control active esophageal varices bleeding

A

1) banding
2) correct coagulopathy (high PT due to liver dysfunction) with FFP
3) octreotide IV

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38
Q

what is a balloon tamponade?

A

for esophageal varices that wont stop bleeding. place an NG tube with an esophageal and gastric balloon….inflate. and pull gastric baloon against GE junction

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39
Q

abx recommended for a cholecystectomy for an uncomplicated symptomatic cholelithiasis

A

single preop first gen cephalosporin, generally lot of abx not required

clean-contaminated wound

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40
Q

next step after diagnosing acute cholecystitis

A

antibiotics (cover gm- and anaerobes)
(2nd gen cephalosporin+ metranidazole)
IV resuscitation
NG tube if have nausea/vomiting

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41
Q

if needed,when is a cholecystectomy safest in pregnancy

A

second trimester

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42
Q

how to proceed when have symptomatic gallstones and cute pancreatitis

A

delay cholecystectomy (pancreatitis has high fluid requirements, can get hypocalcemia, oliguria, hypotension)

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43
Q

finding of gallbladder distended with fluid and gallstones on US

A

empyema of gallbladder- requires IV abx and emergent exploration with cholecystectomy

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44
Q

ultrasound showing gallbladder removed, with dilated common duct and air in biliary system

A

suppurative cholangitis- bacterial infection with bile duct obstruction

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45
Q

palpable gallbladeder in elderly sick man

A

palpable implies a inflamed gallbladder with omentum walling it off. emergent cholecystectomy due to high risk of gallbladder rupture

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46
Q

cholangitis in pt who had a cholecystectomy within 2 years

A

common duct stone= retained stone

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47
Q

follow up after lap chole

A

look for leaks and infection with HIDA scan, ultrasound

may need biliary drainage if obstruction of bile duct seen

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48
Q

next step for patient with obstructive jaundice who doesnt have any masses seen on ultrasound

A

CT better for distal common duct because in ultrasound intestinal gas obscures the view

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49
Q

criteria for proceeding with surgery on pancreatic cancer

A

acceptable med condition, no distant mets (LIVER must be FREE of mets), normal chest xray, no neuro sx

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50
Q

first phase of pancreatic cancer surgery involves assessment of what

A

distant mets- looks at liver, peritonum, lymph node. mets indicate unresectability.

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51
Q

painless jaundice with dilated intrahepatic but not extrahepatic ducts

A

cholangiocarcinoma (klatskin tumor)- tumors of biliary tree at bifurcation of hepatic ducts
ercp to see obstruction

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52
Q

pt with elevated amylase levels develops hypotension, hypoxemia, multiorgan failure

A

necrotizing pancreatitis with massive third spacing of fluid

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53
Q

acute pancreatitis patient continues to have abdominal pain, elevated amylase, and inability to eat due to early satiety

A

pancreatic pseudocyst

confirmed with CT of abdomen

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54
Q

when to intervene with a pancreatic pseudocyst?

A

initial management by NPO, TPN, observation. surgery if doesnt resolve in 6 weeks (cystogastostomy- let fluid drain into the GI tract)

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55
Q

cystic lesion in liver

what if the cyst was multilocular with calcifications

A

usually asx, needing no further management. can aspirate if have symptoms

multilocular with calcifications= echinococcus (inject with saline and excise cyst- dont want to drain and spill contents)

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56
Q

diagnosis of hemangioma

A

labeled RBC scan

if discovered, removal is not necessary since usually asx.

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57
Q

criteria for surgical removal of benign hepatic masses

A

if symptomatic, have risk of rupture, or if uncertain diagnosis of lesion

HEMANGIOMAS should not be biopsied

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58
Q

CT showing a central stellate scar of hepatic mass

A

focal nodular hyperplasia

no tx indicated

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59
Q

hepatic adenoma management

A

may regress if stop OCP

resect persistent large lesions due to risk of rupture and some link to devpt of HCC.

60
Q

favorable profile of HCC

A

resectable with 1cm margin, solitary, less than 5cm, non cirrhotic liver , no vascular invasion, low grade malignancy

61
Q

peripheral rim enhancement lesions in liver

A

abscesses- IV abx for 4-6wks

if one large abscess- can do percutaneous drainage

62
Q

how might a proximal SBO differ in presentation?

A

lesser abdominal distension on PE

63
Q

what type of cancer can manifest many years later as bowel obstruction

A

melanoma

64
Q

metabolic acidosis with abdominal pain and xray suggestive of SBO

A

ischemic or necrotic- may need urgent exploration or mesenteric arteriography to check for an arterial occlusive lesion

65
Q

post op management after fixing obstruction in small bowel

A

NPO via NG tube for several days til bowel function returns

66
Q

management after a closed loop bowel obstruction

A

need to ensure that the bowel is viable after untwisting the segment. a planned re-exploration 24h later (second look)

67
Q

main risk of entering the bowel while lysing adhesions

A

may get small bowel fistula development

68
Q

next step after detection of mesenteric ischemia

A

even if patient improves with hydration and abx, these events recur. Should go undergo semielective revascularization of mesenteric circulation

69
Q

bloody diarrhea in a pt with mesenteric ischemia

A

suggests an ischemic segment of colon with necrosis of at least the mucosa. need to do sigmoidoscopy.
-if full thickness necrosis- need resection
muscosal only- can optimize with hydration, abx, observation

70
Q

drug used for management for perianal problems

A

metronidazole

71
Q

difference in crohns in colon vs small bowel

A

colon- 5-ASA have some effect, but little efect if in small bowel

72
Q

when does the risk of colon cancer increase with ulcerative colitis

A

after 8-10yrs with UC

73
Q

surgery of choice for UC

A

proctocolectomy- removes mucosa (thus risk of cancer) and makes a ileal pouch and connects it to the anus

74
Q

reason to do rectal exam in patient with RLQ pain

A

can detect pain in right pelvis due to recrocecal appendicitis

75
Q

establishing diagnosis of IBD

A

colonoscopy or barium enema

76
Q

children are more likely to present how with appendicitis

A

more likely with rupture

77
Q

when is there an indication to perform a right colectomy with a found appendix mass

A

a carcinoid tumor size 2cm or larger with involvement of the base of appendix or cecum suggests malignant behavior

78
Q

how to followup for recurrence of carcinoid tumors of small bowel

A

CT scan of abdomen + octreotide scan to localize neuroendocrine tumor

79
Q

intervals after first occult blood test and flexible sigmoidoscopy at 50yo

colonoscopy?

A

5 year intervals

10 years

80
Q

when to start screening if person has first def relative with colorectal cancer or adenomatous polyp

A

40yo instead of 50

81
Q

followup after finding a fungating perianal mass

A

biopsy (anal carcinoma), transanal ultrasound to determine depth of invasion

82
Q

what to do if carcinoma is in the stalk of a pedunculated colonic polyp

A

now polypectomy is not enough unless there is a good margin, cancer isnt poorly diff, and there is no vascular or lymphatic invasion

83
Q

anemia and black stools in suscpected colon cnacer of which side

A

cecum or right colon

84
Q

with colon cancer colonoscopy what other tests should be done

A

cxr, cea measurement, ct of liver

85
Q

at what stage of colon cancer has adjuvant therapy shown help

A

stage 3, using 5FU and leucovorin to decrease recurrence

86
Q

62 yo woman with heme positive stools with intermittent constipation and diarrhea

A

symptom suggest high grade obstructive colon ca, usually at left colon. urgency of operation, with poor prognosis

87
Q

finding a 1cm vs 8cm liver lesion while operating to remove colon due to colon ca

A

1cm- if easily palpable and at edge of liver can be excised. larger lesions should not be resected during the same surgery- because that would increase intraoperative risk of bleeding. Biopsy now and later resection

88
Q

feculent vomiting after a colectomy

A

could be due to postop ileus or obstrcution. feculent vomiting due to bacterial overgrowth in stomach and proximal small bowel.
NPO, IV fluids, NG

89
Q

2 major concerns after colectomy if patient is distended and vomiting

A

1) leakage from anastomosis causing ileus

2) obstruction due to adhesions, internal hernia, obstructed anastomosis

90
Q

pt with colon cancer who underwent colectomy returns in 6 mos with crampy abdominal pain, decreased stool caliber, constipation

A

anastomotic recurrence of cancer and stricture formation

91
Q

complications for man who had adenocarcinoma of rectum undergoing surgery

A

abdominoperineal resection- chance of importence due to presence of sympathetic plexus around rectum
bladder function may be also impaired- foley for 1 wk
venous bleeding

92
Q

staging of colon carcinoma

A

T:
1- limited to mucosa/submucosa
2- invasion into but not beyond muscularis
3- penetration full thickness of bowel wall
4- adjacent structure

N= 1= node mets
M= M1= distant mets
93
Q

level of lesion from anal verge affecting operation of rectal cancer

A

if within 5 cm of anal vergen, then need to do a full abdominoperineal resection since that area also involves lateral margins involving the sphincter mechansism

94
Q

when is preop radiation involved for rectal cancer management

A

if cancer is large, bulky, and extending into surrounding tissue- higher chance of recurrence

95
Q

what to do if patient with anal cancer doesnt want colostomy?

A

1) can do a sphincter preserve proctectomy (due to 2cm instead of 5cm margins being adequate for well diff cancer)
2) local resection of tumors

96
Q

how to manage unresectable liver mets?

A

ablation and cryotherapy, injection of ethanol, destruction with radio-frequency waves, chemoembolization

97
Q

4cm lesion on anal verge indicating squamous cancer, with no local extension and neg lymph node

A

no surgery- nigro protocol followed with chemo and radiation

smaller, superficial mobile lesions can be excised

98
Q

followup on elderly woman who has recovered from diverticulitis

A

colonoscopy or barium enema to ensure absence of colon cancer

99
Q

what s the next step after a second episode of diverticulitis in same patient?

A

elective resection 4-6wks after inflammation has resolved. resection due to risk of perforation and abscess formation

100
Q

management for patient who presents with diverticulitis and initially doesnt improve with rest, IV hydration, and abx. She has a pericolic collection of fluid

A

CT guided needle insertion of cathether . CATHETER SHOULD BE LEFT IN until cavity shrinks and drainage stops.

if cannot tolerate food (has ileus or obstruction from edema), then may require TPN for long time

101
Q

assessment of 70yo woman who comes in with signs of hypovolemia

A

place iv lines for Lactated Ringers solution or 0.9L normal saline
Placement of NG tube to check for upper GI bleed. if positive- endoscopy, and anoscopy

102
Q

how to deal with vascular ectasias? How do they form?

A 
treatment with coagilation with monopolar current
vascular ectasias (AVM) form with degeneration of intestinal submucosal veins, with connectins between submucosal arteries and veins forming. if mucosa is disrupted- bleeding can result
103
Q

why are diverticula associated with bleeding?

A

colonic diverticular bleeds result from underlying vasa recta artery penetrating the bowel weall

104
Q

how to evaluate site of bleeding during active bleed?

A

colonoscopy has risk of perforation.
esp with rebleeding, can use technetium labeled RBC scan or mesenteric angiography

angiography preferred for less stable patients/more rapid bleeding

105
Q

after what conditions may surgery be considered for patient with rebleeding?

A

continued bleeding, requiring 4-6 units of blood

106
Q

how to temporarily manage active bleeding from colon when doing angiography

A

can give vasopressin or embolization

embolization poses higher risk intestinal necrosis

107
Q

management of volvulus- sigmoid vs cecal

A

electrolytes, with a rigid proctosigmoidoscopy and placement of a rectal tube

cecal- require urgent surgery

108
Q

Ogilvie’s syndrome

A

acute massive dilation of cecum and right colon without evidence of mechanical obstruction. seen in very ill hospitalized pts.
usually non operative management
follow, if diameter >11-12cm, endocropic decompression.

109
Q

management for rectal prolapse that is external resulting in bleeding

A

rectopexy- attach rectum to sactum
low anterior resection
perianal approach removing prolapsed rectum

110
Q

location of anal fissures, what may be seen on anal verge.

A

posterior midline, sentinel tag may be seen

111
Q

pt presents with persistent anal drainage, sinus tract with granulation tissue present.

A

fistula-in ano

chronic tract formed from internal abscess to anal crypt

112
Q

pt with severe anal pain, tender fluctuant perianal mass, fever

A

perianal abscess

drain not abx

113
Q

abscess found in sacrococcygeal area

A

pilonodal abscess- infection in a hair containing sinus

114
Q

which type of hernia account for most bowel strangulation

A

femoral>indirect>direct

115
Q

nerves that can be interrupted during hernia repair

A

genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous nerves

116
Q

instructions for patient undergoing hernia repair

A

avoid lifting for first 6 weeks after hernia surgery

117
Q

why is repair limited with pediatric inguinal hernias

A

high ligation of the sac with no abdominal wall defect (persistent processus vaginalis)

118
Q

most common cause of free air under diaphragm

A

perforated peptic ulcer

119
Q

surgery of choice for achalasia

A

esophagomyotomy&raquo_space; dilation via balloon

120
Q

corkscrew esophagus on barium swallow

A

diffuse esophageal spasm

in contrast to achalasia, the LES is in its normal diameter

121
Q

mallory vs boerhave typical locations

A

mallory- right posterior distal esophagus vs boerhave usually left (hence usually also have left pleural effusion)

122
Q

which esophageal diverticulum is “true”

A

midesophageal- due to traction while zenker and epiphrenic are due to increased pressure (pulsion)

123
Q

what may dysphagia indicate in patient with GERD

A

peptic stricture formation, evaluated by barium swallow and esophagoscopy

124
Q

what drug may be used to increase LES tone for severe GERD

A

metoclopramide

125
Q

why does anterior perforation of duodenum show free air under diaphragm, but posterior doesnt

A

posterior duodenum is retroperitoneal

126
Q

secretin test for ZE

A

secretin normally would decrease gastrin production. in ZE syndrome- secretin stimulating pancreas, which is where usually tumor is- so see paradoxical rise in gastrin

127
Q

Classification of gastric ulcers and corresponding tx

A

1- lesser curvature——antrectomy
2- gastric and duodenal —antrectomy
3- prepyloric —highly selective vagotomy
4- gastric cardia —-subtotal gastrecomy with esophagogastrojejunostomy

128
Q

tx of dumping syndrome

A

avoid high sugar food, or excessive water intake. can be treated with octreotide

129
Q

afferent loop syndrome

A

obstruction of afferent limb following gastrojejunostomy - RUQ pain, bilious vomiting, steatorrhea.

  • vomiting relieves suffering
    tx: endoscopic ballon dilation or surgical revision
130
Q

how much of upper Gi blood loss will start producing melena

A

60cc of blood or more

bright red per rectum if very fast bleed

131
Q

next step for patient with hypotension, abdominal echymmosis, and facial injury through MVA blunt abdominal trauma

A

FAST (ultrasound to assess for intraperitoneal fluid, hemoperitoneum,pericardial effusion)
if positive- indicative for emergent exploratory laparotomy

132
Q

pt who underwent resuscitation after blunt abdominal trauma from MVA presents 2 wks later with shortness of breath and chest pain. X ray shows left lower collection

A

diaphragmic rupture with abdominal contents coming up- lead to lower lobe (usually left) atelectasis.
Dx: barium swallow

133
Q

johnson’s gastric ulcers

A

1,4- due to weakened defense, low acid states
1- junction of antrum and pylorus
4- close to the GE junction
2,3- high acid states
2- 2 ulcers, one ulcer in stomach, one in duodenal
3- pyloric channel ulcer
5- can occur anywhere in stomach

134
Q

pt presents with swollen, painful leg after femoral artery embolectomy, with hx of atrial fib, perforated peptic ulcer. DP and TB pulses are normal

A

compartment syndrome due to ischemia-reperfusion. with initial 4-6 hours of ischemia, and then reperfusion- get edema. this causes increased pressure, which in a muscle compartment can present with more ischemia

135
Q

abrupt onset of flaccid paralysis, bowel dysfunciton, loss of pain in extremities after surgery of AAA

A

spinal ischemia

  • infarction causing anterior spinal syndrome
  • radicular arteries most susceptible
136
Q

vertical band gastroplasty vs roux bypass for bariatric

A

vertical band- small proximal pouch which fills up with food, makes you feel full. More recurrences.

Roux- actual bypass of stomach, duodenum, and first part of jejunum. produces more wt loss but associated with more complications

137
Q

pathology types of stomach adenocarcinoma

A

Polyploid- no substantial necrosis or ulceration
Ulcerative- sharp margin
Superficial- best prognosis (mucosa+ submucosa)
Linitis plastica- all layers, poor prognosis

138
Q

carney triad

A

woman under 40 with gastric leiomyosarcomas, pumonary chondromas, extra-adrenal paraganglionoma

139
Q

How to treat patient with decreased gastric secretion and barium swallow revealing large rugae in stomach

A

Menetrier’s Disease- protein losing enteropathy

tx: anticholinergics, H2 blockers- reduce protein loss (decreased stimulation)
protein diet

140
Q

Dieulafoy;s lesion

A

mucosal end artery causes pressure necrosis and ruptures in stomach. massive recurrent hematemesis.

141
Q

what is the most likely structure involved in bleeding from a duodenal ulcer penetrating the posterior wall of the duodenal bulb

A

duodenal bulb= first part of duodenum

so artery would be gastroduodenal

142
Q

how to distinguish jejunum and ileum

A

jejunum- long vasa recta, few short arcades

ileium- many arcades

143
Q

what is enteroclysis

A

double contrast study passes a tube to proximal small intestine and injects barium and methylcellulose. can detect tumors.

144
Q

order of common benign neoplasms of small intestine

A

adenoma>leiomyoma>lipoma

145
Q

carcinoid in appendix <2 cm vs larger

A

appendectomy if less than 2, rt hemicolectomy if larger

146
Q

why do proximal fistulas cause more problems in the small intestine

A

more acidic contents, more absorptive materials lost, more fluids and electrolytes lost

147
Q

male develops weight loss, night sweats, and a fistula draining from his RLQ after appendectomy.

A

actinomyces israieli

tx: surgical trainage and abx (tetracyclines, penicillin)

Surgery (4 decks)

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