GI and Abdomen Flashcards
1
Q
Division between “upper” and “lower” Gi bleeding
A
ligament of treitz
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
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
4
Q
male with right flank colicky pain of sudden onset radiating to scrotum with microscopic hematuria
A
ureteral colic
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
6
Q
type of liver abscess which is not drained
A
amebic abscess (entamoeba histolytica)
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
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
9
Q
what surgery may cure a cholangiocarcinoma of the lower common duct
A
pancreatoduodenectomy (whipple)
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
11
Q
what is ERCP likely to show in a pancreatic head cancer
A
obstruction of both common and pancreatic ducts
12
Q
Tx of acute ascending cholangitis
A
emergency decompression of biliary tract
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
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
15
Q
on third post op day after open cholecystectomy, pt has temp of 101
A
UTI
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
17
Q
after hemicolectomy, dressing from midline incision soaked with clear pink fluid
A
wound dehiscence- need surgery for re-closure
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
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)
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
21
Q
hiatal hernia management
A
tx for GERD, no surgery
22
Q
management of paraesophageal hiatal hernia and a mixed type hernia
A
both can pose risk for strangulation and necrosis- so surgery needed
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
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
25
how long are peptic ulcers treated for
4-6 weeks, with severe disease treated for up to 12 weeks
26
choice of surgery for uncomplicated PUD refractory to meds
Highly selective vagotomy (denervate the antrum and pylorus, leaving the rest of the stomach which can still mix food)
27
gastric ulcer follwup
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
28
what if benign gastric ulcers dont heal with meds after 18wks
can do partial gastrectomy- anterectomy
NO Vagotomy performed unlike in PUD
29
how does surgery differ with 1/4 vs 2/3 gastric ulcers
2/3 are higher acid producting, so along with some sort of gastrectomy, a truncal vagotomy also done
30
distal gastric ulcer indicating cancer. next step?
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
31
first step in man presenting with severe epigastric pain, fever, guarding (rigid abdomen)
upright cxr looking for free air under diaphragm from a perforation of GI tract
32
tx for a few hours old perforated duodenal ulcer
what if pt was on H2 blockers for 6mons
close perforation, using pieces of omentum (graham patch)
with hx- need closure of perforation and a HSV (vagotomy) or a VP (vagotomy and pyloroplasty)
33
pt with perforated duodenal ulcer is septic
need to finish surgery asap- just do a graham patch, stabilize pt with fluids and acid block and then return
34
pt on NG tube with coffee ground material in drainage
due to upper GI bleed
| use H2 block, sucralafate, antacids, with gastric pH monitoring
35
management of bright blood up a patients NG tube
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
36
likely location of a high risk duodenal ulcer
posterior duodenum, which can involve the gastroduodenal artery
37
steps to control active esophageal varices bleeding
1) banding
2) correct coagulopathy (high PT due to liver dysfunction) with FFP
3) octreotide IV
38
what is a balloon tamponade?
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
39
abx recommended for a cholecystectomy for an uncomplicated symptomatic cholelithiasis
single preop first gen cephalosporin, generally lot of abx not required
clean-contaminated wound
40
next step after diagnosing acute cholecystitis
antibiotics (cover gm- and anaerobes)
(2nd gen cephalosporin+ metranidazole)
IV resuscitation
NG tube if have nausea/vomiting
41
if needed,when is a cholecystectomy safest in pregnancy
second trimester
42
how to proceed when have symptomatic gallstones and cute pancreatitis
delay cholecystectomy (pancreatitis has high fluid requirements, can get hypocalcemia, oliguria, hypotension)
43
finding of gallbladder distended with fluid and gallstones on US
empyema of gallbladder- requires IV abx and emergent exploration with cholecystectomy
44
ultrasound showing gallbladder removed, with dilated common duct and air in biliary system
suppurative cholangitis- bacterial infection with bile duct obstruction
45
palpable gallbladeder in elderly sick man
palpable implies a inflamed gallbladder with omentum walling it off. emergent cholecystectomy due to high risk of gallbladder rupture
46
cholangitis in pt who had a cholecystectomy within 2 years
common duct stone= retained stone
47
follow up after lap chole
look for leaks and infection with HIDA scan, ultrasound
| may need biliary drainage if obstruction of bile duct seen
48
next step for patient with obstructive jaundice who doesnt have any masses seen on ultrasound
CT better for distal common duct because in ultrasound intestinal gas obscures the view
49
criteria for proceeding with surgery on pancreatic cancer
acceptable med condition, no distant mets (LIVER must be FREE of mets), normal chest xray, no neuro sx
50
first phase of pancreatic cancer surgery involves assessment of what
distant mets- looks at liver, peritonum, lymph node. mets indicate unresectability.
51
painless jaundice with dilated intrahepatic but not extrahepatic ducts
cholangiocarcinoma (klatskin tumor)- tumors of biliary tree at bifurcation of hepatic ducts
ercp to see obstruction
52
pt with elevated amylase levels develops hypotension, hypoxemia, multiorgan failure
necrotizing pancreatitis with massive third spacing of fluid
53
acute pancreatitis patient continues to have abdominal pain, elevated amylase, and inability to eat due to early satiety
pancreatic pseudocyst
| confirmed with CT of abdomen
54
when to intervene with a pancreatic pseudocyst?
initial management by NPO, TPN, observation. surgery if doesnt resolve in 6 weeks (cystogastostomy- let fluid drain into the GI tract)
55
cystic lesion in liver
what if the cyst was multilocular with calcifications
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)
56
diagnosis of hemangioma
labeled RBC scan
| if discovered, removal is not necessary since usually asx.
57
criteria for surgical removal of benign hepatic masses
if symptomatic, have risk of rupture, or if uncertain diagnosis of lesion
HEMANGIOMAS should not be biopsied
58
CT showing a central stellate scar of hepatic mass
focal nodular hyperplasia
no tx indicated
59
hepatic adenoma management
may regress if stop OCP
| resect persistent large lesions due to risk of rupture and some link to devpt of HCC.
60
favorable profile of HCC
resectable with 1cm margin, solitary, less than 5cm, non cirrhotic liver , no vascular invasion, low grade malignancy
61
peripheral rim enhancement lesions in liver
abscesses- IV abx for 4-6wks
if one large abscess- can do percutaneous drainage
62
how might a proximal SBO differ in presentation?
lesser abdominal distension on PE
63
what type of cancer can manifest many years later as bowel obstruction
melanoma
64
metabolic acidosis with abdominal pain and xray suggestive of SBO
ischemic or necrotic- may need urgent exploration or mesenteric arteriography to check for an arterial occlusive lesion
65
post op management after fixing obstruction in small bowel
NPO via NG tube for several days til bowel function returns
66
management after a closed loop bowel obstruction
need to ensure that the bowel is viable after untwisting the segment. a planned re-exploration 24h later (second look)
67
main risk of entering the bowel while lysing adhesions
may get small bowel fistula development
68
next step after detection of mesenteric ischemia
even if patient improves with hydration and abx, these events recur. Should go undergo semielective revascularization of mesenteric circulation
69
bloody diarrhea in a pt with mesenteric ischemia
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
drug used for management for perianal problems
metronidazole
71
difference in crohns in colon vs small bowel
colon- 5-ASA have some effect, but little efect if in small bowel
72
when does the risk of colon cancer increase with ulcerative colitis
after 8-10yrs with UC
73
surgery of choice for UC
proctocolectomy- removes mucosa (thus risk of cancer) and makes a ileal pouch and connects it to the anus
74
reason to do rectal exam in patient with RLQ pain
can detect pain in right pelvis due to recrocecal appendicitis
75
establishing diagnosis of IBD
colonoscopy or barium enema
76
children are more likely to present how with appendicitis
more likely with rupture
77
when is there an indication to perform a right colectomy with a found appendix mass
a carcinoid tumor size 2cm or larger with involvement of the base of appendix or cecum suggests malignant behavior
78
how to followup for recurrence of carcinoid tumors of small bowel
CT scan of abdomen + octreotide scan to localize neuroendocrine tumor
79
intervals after first occult blood test and flexible sigmoidoscopy at 50yo
colonoscopy?
5 year intervals
10 years
80
when to start screening if person has first def relative with colorectal cancer or adenomatous polyp
40yo instead of 50
81
followup after finding a fungating perianal mass
biopsy (anal carcinoma), transanal ultrasound to determine depth of invasion
82
what to do if carcinoma is in the stalk of a pedunculated colonic polyp
now polypectomy is not enough unless there is a good margin, cancer isnt poorly diff, and there is no vascular or lymphatic invasion
83
anemia and black stools in suscpected colon cnacer of which side
cecum or right colon
84
with colon cancer colonoscopy what other tests should be done
cxr, cea measurement, ct of liver
85
at what stage of colon cancer has adjuvant therapy shown help
stage 3, using 5FU and leucovorin to decrease recurrence
86
62 yo woman with heme positive stools with intermittent constipation and diarrhea
symptom suggest high grade obstructive colon ca, usually at left colon. urgency of operation, with poor prognosis
87
finding a 1cm vs 8cm liver lesion while operating to remove colon due to colon ca
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
feculent vomiting after a colectomy
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
2 major concerns after colectomy if patient is distended and vomiting
1) leakage from anastomosis causing ileus
| 2) obstruction due to adhesions, internal hernia, obstructed anastomosis
90
pt with colon cancer who underwent colectomy returns in 6 mos with crampy abdominal pain, decreased stool caliber, constipation
anastomotic recurrence of cancer and stricture formation
91
complications for man who had adenocarcinoma of rectum undergoing surgery
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
staging of colon carcinoma
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
level of lesion from anal verge affecting operation of rectal cancer
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
when is preop radiation involved for rectal cancer management
if cancer is large, bulky, and extending into surrounding tissue- higher chance of recurrence
95
what to do if patient with anal cancer doesnt want colostomy?
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
how to manage unresectable liver mets?
ablation and cryotherapy, injection of ethanol, destruction with radio-frequency waves, chemoembolization
97
4cm lesion on anal verge indicating squamous cancer, with no local extension and neg lymph node
no surgery- nigro protocol followed with chemo and radiation
smaller, superficial mobile lesions can be excised
98
followup on elderly woman who has recovered from diverticulitis
colonoscopy or barium enema to ensure absence of colon cancer
99
what s the next step after a second episode of diverticulitis in same patient?
elective resection 4-6wks after inflammation has resolved. resection due to risk of perforation and abscess formation
100
management for patient who presents with diverticulitis and initially doesnt improve with rest, IV hydration, and abx. She has a pericolic collection of fluid
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
assessment of 70yo woman who comes in with signs of hypovolemia
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
how to deal with vascular ectasias? How do they form?
```
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
why are diverticula associated with bleeding?
colonic diverticular bleeds result from underlying vasa recta artery penetrating the bowel weall
104
how to evaluate site of bleeding during active bleed?
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
after what conditions may surgery be considered for patient with rebleeding?
continued bleeding, requiring 4-6 units of blood
106
how to temporarily manage active bleeding from colon when doing angiography
can give vasopressin or embolization
embolization poses higher risk intestinal necrosis
107
management of volvulus- sigmoid vs cecal
electrolytes, with a rigid proctosigmoidoscopy and placement of a rectal tube
cecal- require urgent surgery
108
Ogilvie's syndrome
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
management for rectal prolapse that is external resulting in bleeding
rectopexy- attach rectum to sactum
low anterior resection
perianal approach removing prolapsed rectum
110
location of anal fissures, what may be seen on anal verge.
posterior midline, sentinel tag may be seen
111
pt presents with persistent anal drainage, sinus tract with granulation tissue present.
fistula-in ano
| chronic tract formed from internal abscess to anal crypt
112
pt with severe anal pain, tender fluctuant perianal mass, fever
perianal abscess
| drain not abx
113
abscess found in sacrococcygeal area
pilonodal abscess- infection in a hair containing sinus
114
which type of hernia account for most bowel strangulation
femoral>indirect>direct
115
nerves that can be interrupted during hernia repair
genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous nerves
116
instructions for patient undergoing hernia repair
avoid lifting for first 6 weeks after hernia surgery
117
why is repair limited with pediatric inguinal hernias
high ligation of the sac with no abdominal wall defect (persistent processus vaginalis)
118
most common cause of free air under diaphragm
perforated peptic ulcer
119
surgery of choice for achalasia
esophagomyotomy >> dilation via balloon
120
corkscrew esophagus on barium swallow
diffuse esophageal spasm
| in contrast to achalasia, the LES is in its normal diameter
121
mallory vs boerhave typical locations
mallory- right posterior distal esophagus vs boerhave usually left (hence usually also have left pleural effusion)
122
which esophageal diverticulum is "true"
midesophageal- due to traction while zenker and epiphrenic are due to increased pressure (pulsion)
123
what may dysphagia indicate in patient with GERD
peptic stricture formation, evaluated by barium swallow and esophagoscopy
124
what drug may be used to increase LES tone for severe GERD
metoclopramide
125
why does anterior perforation of duodenum show free air under diaphragm, but posterior doesnt
posterior duodenum is retroperitoneal
126
secretin test for ZE
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
Classification of gastric ulcers and corresponding tx
1- lesser curvature------antrectomy
2- gastric and duodenal ---antrectomy
3- prepyloric ---highly selective vagotomy
4- gastric cardia ----subtotal gastrecomy with esophagogastrojejunostomy
128
tx of dumping syndrome
avoid high sugar food, or excessive water intake. can be treated with octreotide
129
afferent loop syndrome
obstruction of afferent limb following gastrojejunostomy - RUQ pain, bilious vomiting, steatorrhea.
- vomiting relieves suffering
tx: endoscopic ballon dilation or surgical revision
130
how much of upper Gi blood loss will start producing melena
60cc of blood or more
| bright red per rectum if very fast bleed
131
next step for patient with hypotension, abdominal echymmosis, and facial injury through MVA blunt abdominal trauma
FAST (ultrasound to assess for intraperitoneal fluid, hemoperitoneum,pericardial effusion)
if positive- indicative for emergent exploratory laparotomy
132
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
diaphragmic rupture with abdominal contents coming up- lead to lower lobe (usually left) atelectasis.
Dx: barium swallow
133
johnson's gastric ulcers
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
pt presents with swollen, painful leg after femoral artery embolectomy, with hx of atrial fib, perforated peptic ulcer. DP and TB pulses are normal
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
abrupt onset of flaccid paralysis, bowel dysfunciton, loss of pain in extremities after surgery of AAA
spinal ischemia
- infarction causing anterior spinal syndrome
- radicular arteries most susceptible
136
vertical band gastroplasty vs roux bypass for bariatric
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
pathology types of stomach adenocarcinoma
Polyploid- no substantial necrosis or ulceration
Ulcerative- sharp margin
Superficial- best prognosis (mucosa+ submucosa)
Linitis plastica- all layers, poor prognosis
138
carney triad
woman under 40 with gastric leiomyosarcomas, pumonary chondromas, extra-adrenal paraganglionoma
139
How to treat patient with decreased gastric secretion and barium swallow revealing large rugae in stomach
Menetrier's Disease- protein losing enteropathy
tx: anticholinergics, H2 blockers- reduce protein loss (decreased stimulation)
protein diet
140
Dieulafoy;s lesion
mucosal end artery causes pressure necrosis and ruptures in stomach. massive recurrent hematemesis.
141
what is the most likely structure involved in bleeding from a duodenal ulcer penetrating the posterior wall of the duodenal bulb
duodenal bulb= first part of duodenum
| so artery would be gastroduodenal
142
how to distinguish jejunum and ileum
jejunum- long vasa recta, few short arcades
| ileium- many arcades
143
what is enteroclysis
double contrast study passes a tube to proximal small intestine and injects barium and methylcellulose. can detect tumors.
144
order of common benign neoplasms of small intestine
adenoma>leiomyoma>lipoma
145
carcinoid in appendix <2 cm vs larger
appendectomy if less than 2, rt hemicolectomy if larger
146
why do proximal fistulas cause more problems in the small intestine
more acidic contents, more absorptive materials lost, more fluids and electrolytes lost
147
male develops weight loss, night sweats, and a fistula draining from his RLQ after appendectomy.
actinomyces israieli
| tx: surgical trainage and abx (tetracyclines, penicillin)
