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CLINICAL YR: Gen Surgery > GI/Nutritional 50% > Flashcards

GI/Nutritional 50% Flashcards

1
Q

(PPP 158)

MC pathogenic offender causing acute cholecystitis

A

E. coli

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2
Q

(PPP 158)

name three clinical manifestations of acute cholecystitis

A

CONTINUOUS pain - RUQ or epigastric
pain may be precipitated by fatty foods or large meals
nausea may be associated

may also show nausea, guarding, anorexia

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3
Q

(PPP 158)

four primary findings on PE for acute cholecystitis

A

FEVER (low-grade)
GALLBLADDER is PALPABLE, ENLARGED
+ Murphy’s sign
+ Boas sign

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4
Q

(PPP 158)

what is Murphy’s sign?

A

RUQ pain or inspiratory arrest with palpation of the gallblader

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5
Q

(PPP 158)
what is Boas sign?

what causes it?

A

referred pain to R shoulder or subscapular area

phrenic nerve irritation

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6
Q

(PPP 158)

you suspect acute cholecystitis - what is the initial diagnostic imaging test of choice?

A

ULTRASOUND = “initial test of choice”

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7
Q

(PPP 158)

what are you looking for with u/s in suspected acute cholcystitis?

A

thickened or distended gallbladder
pericholecystic fluid
sonographic Murphy’s sign

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8
Q

(PPP 158)

when do we order CT scan for acute cholecystitis?

A

mmm…it’s an alternative….not sure when we order it…

“CT scan: alternative to ultrasound & can detect complications”

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9
Q

(PPP 158)

what lab changes might be seen for diagnosing acute cholecystitis?

A

CBC with diff: INCREASED WBC (leukocytosis with left shift)
increased bilirubin
increased alk phos
increased LFTs

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10
Q

(PPP 158)

what is the most accurate test for acute cholecystitis?

A

HIDA SCAN!!

most accurate test
“cholecystitis is present if there is no visualization of the gallbladder”

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11
Q

(PPP 158)

mainstays of management of acute cholecystitis

A

NPO
IVF
ABX
cholecystectomy w/in 72 hrs (laproscopic is preferred)

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12
Q

(PPP 158)

what abx may be used for acute cholecystitis?

A

ceftriaxone + metronidazole

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13
Q

(PPP 158)

what do you do for acute cholecystitis if pt is nonoperative?

A

cholecystostomy (percutaneous drainage of the gallbladder)

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14
Q

(PPP 159)
what is chronic cholecystitis?

what is associated with it?

A

fibrosis and thickening of the gallbladder due to chronic inflammatory cell infiltration of the gallbladder evident on histopathology

almost always associated with gallstones

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15
Q

(PPP 165)

MC site for anorectal abscess

A

posterior rectal wall

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16
Q

(PPP 165)

what is MC pathogen causing anorectal abscess?

A

Staphylococcus aureus

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17
Q

(PPP 165)

what usually causes anorectal abscess?

A

“often results from bacterial infection of anal ducts or glands”

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18
Q

(PPP 165)

what is the primary management intervention for anorectal abscess & fistulas?

A

I&D
followed by

WASH = 
Warm-water cleansing
Analgesics
Sitz baths
High-fiber diet
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19
Q

(PPP 165)

define anal fissure

A

“painful linear tear/crack in the distal anal canal”

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20
Q

(PPP 165)

define FISTULA

A

open tract b/w two epithelium-lined areas, seen esp w/ deeper abscesses

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21
Q

(PPP 165)

what are the PE findings of anal fissures?

A

LONGITUDINAL TEAR in the anoderm that usually extends no more proximally than the dentate iine

MC at posterior midline
(99% men, 90% women)

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22
Q

(PPP 165)

what is a common PE finding in chronic anal fissure patients?

A

skin tags

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23
Q

(PPP 165)

what are first line management measures for anal fissures?

A 
warm water Sitz baths
analgesics
high fiber diet
increased water intake
stool softeners
laxatives
mineral oil
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24
Q

(PPP 165)

what is second line treatment for anal fissures?

A

TOPICAL VASODILATORS:

  • nitroglycerin
  • nifedipine ointment
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25
Q

(PPP 165)

what treatment option may reduce spasm of internal sphincter for anal fissures?

A

Botox injections (may be more effective than topical dilators)

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26
Q

(PPP 165)

when is surgery considered for anal fissures? what procedure?

A

refractory cases

consider lateral internal sphincterotomy

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27
Q

(PPP 165)

two primary facts about management of anal fissures

A

> 80% RESOLVE SPONTANEOUSLY

SUPPORTIVE MEASURES ARE FIRST LINE MANAGEMENT

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28
Q

(PPP 165)

clinical manifestations of anal fissures

A

severe painful rectal pain and bowel movements

causing the pt to

refrain from defecating,

bright red blood per rectum

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29
Q

(MDWise)

what is a common electrolyte problem that leads to an ileus or impaired bowel motility?

A

hypOkalemia

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30
Q

(MDWise)

MC mechanical etiologies for small bowel obstructions (4)

A

adhesions
incarcerated hernias
IBD/Crohn’s
CA/tumor

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31
Q

(MDWise)

MC mechanical etiologies for large bowel obstructions (3)

A

volvulus
diverticulitis/ischemic strictures
colorectal CA

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32
Q

(MDWise)

MC functional etiology for large bowel obstruction

A

Ogilvie’s Syndrome (colonic ileus)

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33
Q

(PPP 224)

describe disease process of acute pancreatitis

A

acinar cell injury –> INTRACELLULAR ACTIVATION OF PANCREATIC ENZYMES –> AUTODIGESTION OF PANCREAS

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34
Q

(PPP 224)

two MC causes of acute pancreatitis - and which is THE MC?

A

gallstones & alcohol abuse

gallstone MC (40%)

(ETOH 35%)

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35
Q

(PPP 224)

four drugs that can cause/contribute to acute pancreatitis

A

thiazides
protease inhibitors
exenatide
valproic acid

(also estrogens and didanosine)

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36
Q

(PPP 224)

clinical manifestations of acute pancreatitis

A

EPIGASTRIC PAIN: constant, boring pain often RADIATES TO THE BACK

- pain is worse if pt is supine or eating
- pain RELIEVED BY LEANING FORWARD

N/V
FEVER

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37
Q

(PPP 224)

Two common PE exam findings with acute pancreatitis

A

EPIGASTRIC TENDERNESS

tachycardia

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38
Q

(PPP 224)

two extreme signs of acute pancreatitis only seen if the case is necrotizing or hemorrhagic

A

Cullen’s sign (periumbilical ecchymosis)

Grey Turner sign (flank ecchymosis)

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39
Q

(PPP 224)

diagnosing acute pancreatitis requires 2 of the three diagnostic criteria - name them

A

1 - acute onset of PERSISTENT SEVERE EPIGASTRIC PAIN often radiating to back
2 - lipase or amylase 3x ULN
3 - acute pancreatitis findings on imaging (CT, MRI, US)

aka
1 - RUQ/epigastric pain
2 - lipase 3x ULN
3 - imaging

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40
Q

(Jerrica’s Cards)

What are the diagnostic criteria for acute pancreatitis?

A

2/3 must be present:
- Epigastric pain

  • Lipase 3x UNL
  • Imaging w/ evidence
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41
Q

(Jerrica’s cards)

What imaging modality is best for diagnosing acute pancreatitis?

A

CT with contrast is best

US can be done

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42
Q

(Jerrica’s Cards)

Epigastric pain with significantly elevated lipase and ALT (3x UNL) is indicative of what condition?

A

Gallstone pancreatitis

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43
Q

(PPP 224)

four lab findings indicative of acute pancreatitis

A 
amylase/lipase
ALT
hypocalcemia
leukocytosis
   - - (also elevated glucose, bilirubin, triglycerides)
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44
Q

(PPP 224)

what are best initial tests for acute pancreatitis?

A

amylase/lipase

lipase is more specific than amylase

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45
Q

(PPP 224)

Why do we see hypocalcemia with acute pancreatitis?

A

necrotic fat binds to calcium lowering serum calcium levels (saponification)

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46
Q

(PPP 224)

when is transabdominal U/S recommended in suspected acute pancreatitis?

A

assess for gallstones and bile duct dilation

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47
Q

(PPP 224)

what is a ‘SENTINEL LOOP’ found on abdominal radiograph of suspected pancreatitis?

A

LOCALIZED ILEUS of a segment of small bowel in the LUQ

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48
Q

(PPP 224)

What is a COLON CUTOFF SIGN on abdominal radiograph of suspected acute pancreatitis?

A

abrupt collapse of colon near pancreas

pancreatic calcification is suggestive of chronic pancreatitis

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49
Q

(PPP 224)

when might we use MRCP for suspected acute pancreatitis?

A

to detect stones, stricture or tumor

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50
Q

(PPP 224)

what is the primary goal of management of acute pancreatitis?

A

REST THE PANCREAS

90% recover w/o complications in 3-7 days, require supportive measures only

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51
Q

(PPP 224)

what are the supportive measures of managing acute pancreatitis?

A

NPO
IVF - high-volume resuscitation (LR preferred)
ANALGESIA (meperidine (Demerol))

no abx

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52
Q

(PPP 224)

what is the thought process when considering abx for acute pancreatitis?

A

abx are not routinely used

IF severe infected pancreatic necrosis is seen (eg >30% necrosis on CT or MRI), then broad spectrum abx (imipenem) may be used

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53
Q

(PPP 225)

What is Ranson’s Criteria?

A

a way to determine prognosis of acute pancreatitis

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54
Q

(PPP 225)

five factors of Ranson’s Criteria for admission for acute pancreatitis

A 
glucose   (>200 mg/dL)
age          (>55 yrs)
LDH         (>350 IU/L)
AST          (>250 IU/dL)
WBC        (>16,000/microL)
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55
Q

(PPP 224)

how do we score or interpret Ranson’s Criteria?

A

> or = 3: severe pancreatitis likely

<3: severe pancreatitis unlikely

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56
Q

(PPP 225)

what is the MC etiology for CHRONIC pancreatitis?

A

ETOH abuse (70%)

sometimes it is idiopathic

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57
Q

(PPP 225)

what is the hallmark triad of clinical manifestations of CHRONIC pancreatitis?

A

1 - calcifications
2 - steatorrhea
3 - DM

(only seen in 1/3 of pts though)

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58
Q

(PPP 225)

what are common findings for amylase/lipase in CHRONIC pancreatitis?

A

amylase & lipase usually normal (or only mildly elevated)

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59
Q

(PPP 225)

common CT findings in CHRONIC pancreatis?

A

calcification of pancreas

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60
Q

(PPP 225)

what are common findings on abdominal radiographs for CHRONIC pancreatitis?

A

calcified pancreas

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61
Q

(PPP 225)

pancreatic function testing - what’s it for? what do we usually get from it?

A

FECAL ELASTASE is most sensitive and specific to chronic pancreatitis

pancreatic stimulation with secretin & CCK (not usually done)

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62
Q

(PPP 225)

mainstays of management of chronic pancreatitis

A 
ETOH abstinence
pain control
low fat diet
vitamin supplementation
oral pancreatic enzyme replacement

pancreatectomy only if rectractable pain despite med therapy

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63
Q

(SmartyPance)

list 4 common BILIARY causes of RUQ abdominal pain

A

biliary colic
acute cholecystitis
acute cholangitis
sphincter of Oddi dysfunction

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64
Q

(SmartyPance)

list 4 HEPATIC reasons for RUQ abdominal pain

A 
acute hepatitis
perihepatitis (Fitz-Hugh-Curtis syndrome)
liver abscess
Budd-Chiari syndrome
portal vein thrombosis
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65
Q

(SmartyPance)

list four common causes of LUQ abdominal pain

A

splenomegaly
splenic infarct
splenic abscess
splenic rupture

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66
Q

(SmartyPance)

list 8 common causes of EPIGASTRIC abdominal pain

A 
acute MI
acute pancreatitis
chronic pancreatitis
peptic ulcer disease
GERD
gastritis
functional dyspepsia
gastroparesis
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67
Q

(SmartyPance)

list 7 common causes of lower abdominal pain

A 
appendicitis
diverticulitis
nephrolithiasis
pyelonephritis
acute urinary retention
cystitis
infectious colitis
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68
Q

(SmartyPance)

Pt presents with anorexia - what are some common items on the differential?

A 
appendicitis
gastric ulcers
duodenal ulcers
gastric cancer
lower GI bleed
carcinoma of gallbladder
pancreatic carcinoma
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69
Q

(PPP 233)

two MC etiologies for appendicitis

A

fecalith

lymphoid hyperplasia

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70
Q

(PPP 233)
anorexia
periumbilical or epigastric pain followed by RLQ abdominal pain (12-18 hrs later)
n/v, vomiting occurring after pain

A

appendicitis clinical manifestations

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71
Q

(PPP 233)

Rovsing sign, and what diagnosis it’s associated with -

A

RLQ pain with LLQ palpation

appendicitis

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72
Q

(PPP 233)

obturator sign and associated diagnosis

A

RLQ pain with internal & external hip rotation with flexed knee

appendicitis

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73
Q

(PPP 233)

what is psoas sign and what associated diagnosis?

A

RLQ pain with right hip flexion/extension (raise leg against resistance)

appendicitis

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74
Q

(PPP 233)

what is McBurney’s point tenderness and associated diagnosis

A

point 1/3 the distance from the anterior superior iliac spine & navel

appendicitis

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75
Q

(PPP 233)

what is preferred imaging of choice in adults with suspected appendicitis

A

CT scan

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76
Q

(PPP 233)

management of appendicitis

A

appendectomy, laparoscopic preferred when possible

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77
Q

(PPP 229)

post-surgical adhesions are the most common etiology for…..

A

small bowel obstruction

60% are caused by adhesions

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78
Q

(PPP 229)

what is the one MC cause of large bowel obstruction?

A

malignancy

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79
Q

(PPP 229)

SBO acronym CAVO =

A

Crampy abd pain
Abd distention
Vomiting
Obstipation (no flatus)

= four hallmark symptoms of small bowel obstruction (these are usually late findings)

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80
Q

(PPP 229)

what bowels sounds are usually found upon PE for bowel obstruction?

A

high-pitched tinkles on auscultation and visible peristalsis (early obstruction)

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81
Q

(PPP 229)

what signs on abd xray indicate bowel obstruction?

A

multiple air-fluid levels in a STEP-LADDER appearance,

dilated bowel loops

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82
Q

(PPP 229)

Abd XRay showing multiple air-fluid levels in a STEP-LADDER appearance and dilated bowel loops

A

think bowel obstruction

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83
Q

(PPP 229)
CT scan showing a transition zone from dilated loops of bowel with contrast to an area of bowel with no contrast….think:

A

bowel obstruction

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84
Q

(PPP 229)

what do you do to manage NONSTRANGULATED bowel obstruction?

A

NPO (bowel rest)
IVF
bowel decompression (NG suction if severe vomiting

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85
Q

(PPP 229)

what do you do to manage strangulated bowel obstruction?

A

surgery

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86
Q

(PPP 228) BUZZWORDS

BENT INNER TUBE or COFFEE BEAN SIGN on xray

A

think VOLVULUS

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87
Q

(PPP 228)

What is a volvulus?

A

twisting of any part of the bowel at its mesenteric attachment site

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88
Q

(PPP 228)

What is the MC site for volvulus in older adults?

A

sigmoid colon and cecum

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89
Q

(PPP 228)

what is the MC site for volvulus in children?

A

midgut and ileum

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90
Q

(PPP 228)

what are clinical manifestations of obstruction caused by volvulus?

A 
crampy abd pain
distention
n/v
constipation
TYMPANIC ABD  with tenderness to palpation
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91
Q

(PPP 228) BUZZWORDS

BIRD-BEAK appearance on abd CT

A

volvulus

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92
Q

(PPP 228)

first step in management of volvulus

A

endoscopic decompression (proctosigmoidoscopy) is initial treatment of choice

often rectal tube is left in place to decrease acute recurrent and decrease distention

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93
Q

(PPP 228)

what usually follows decompression in the management of volvulus?

A

elective surgery

due to the high rate of recurrence

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94
Q

(PPP 228)

when is immediate surgical correction required when considering a patient’s volvulus?

A

if pt has

  • peritonitis
  • gangrene
  • endoscopic decompression is unsuccessful
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95
Q

(PPP 228)

two surgical options for correcting volvulus

A

primary anastomosis

Hartmann’s procedure

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96
Q

(SmartyPance)

NIH BMI-related guidelines for bariatric surgery

A

BMI >40 (basically 100 pounds above ideal body wt)

BMI >35 with a medical problem related to morbid obesity

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97
Q

(SmartyPance)

three non-BMI related NIH guidelines for bariatric surgery

A
  • must have failed other non-surgical wt loss programs
  • must be psychologically stable
  • must be able to follow post-op instructions
  • obesity is not caused by a medical disease such as endocrine disorder
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98
Q

(SmartyPance)

three types of RESTRICTIVE types of bariatric surgery

A

adjustable gastric banding
vertical banded gastroplasty
sleeve gastrectomy

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99
Q

(SmartyPance)

what are two types of MALABSORPTIVE PROCEDURES of bariatric surgery

A

biliopancreatic diversion

biliopancreatic diversion with/without duodenal switch

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100
Q

(SmartyPance)

what is a type of a COMBINATION type of bariatric surgery (combination of restrictive and malabsorptive procedures)

A

Roux-en-Y Gastric Bypass

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101
Q

(SmartyPance)

what are the most common types of bariatric procedures used in the US?

A

Roux-en-Y (RNYGB)
Adjustable Gastric Banding (AGB)
Vertical Banded Gastroplasty (VBG)
Biliopancreatic Diversion with/without Duodenal Switch (BPD/DS)

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102
Q

(SmartyPance)

early complications of bariatric surgery

A 
anastomotic leak
DVT & PE
bleeding
infection
splenic injury
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103
Q

(SmartyPance)

what are late complications for bariatric surgery?

A 
malnutrition and nutritional problems
marginal ulcer and anastomotic strictures
internal hernia
cholelithiasis
band slippage
band erosion
esophageal dilatation
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104
Q

(SmartyPance)

Charcot’s triad

A

fever
jaundice
RUQ abd pain

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105
Q

(PPP 159)

what is ascending cholangitis?

A

biliary tract infection secondary to obstruction of the common bile duct (eg gallstones, malignancy)

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106
Q

(PPP 159)

MC gram negative pathogen causing cholangitis

A

E. coli is MC

2nd place goes to Klebsiella, then Enterobacter, B. fragilis

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107
Q

(PPP 159)

Does Charcot’s triad apply to acute ascending cholangitis? what is it?

A

yes - common clinical manifestations of acute ascending cholangitis

Charcot’s Triad = fever chills + RUQ pain + jaundice

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108
Q

(PPP 159)

What is Reynold’s Pentad?

A

Charcot’s Triad PLUS

  • hypOtension/shock
  • AMS
109
Q

(PPP 159)

what might labs for acute ascending cholangitis show?

A

LEUKOCYTOSIS (may have left shift)

INCREASED ALK PHOS AND GGT (may indicate cholestasis)

INCREASED BILIRUBIN > increased ALT & AST

110
Q

(PPP 159)

what is the initial imaging of choice for suspecting cholangitis?

A

ULTRASOUND: “initial imaging test of choice”

111
Q

(PPP 159)

what is the MOST ACCURATE imaging test for suspecting ascending cholangitis?

112
Q

(PPP 159)

what is the GOLD STANDARD for diagnosing acute ascending cholangitis?

A

CHOLANGIOGRAPHY: GOLD STD via ERCP or PTC (percutaneous transhepatic cholangiography)

(usually performed once pt has been afebrile/stable for 48 hrs after IV abx)

113
Q

(PPP 159)

initial mgmt of acute ascending cholangitis

A

IV abx

    • followed by CBD DECOMPRESSION, then
        • STONE EXTRACTION once stable (i.e. ERCP)
114
Q

(PPP 159)

what abx are used for initial mgmt of acute ascending cholangitis (five possibilities)

A 
ampicillin/sulbactam
piperacillin/tazobactam
ceftriaxone + metronidazole
FQ + metronidazole
or
ampicillin + gentamicin
115
Q

(PPP 159)

three major components of CBD decompression and stone extraction

A

ERCP & sphincterotomy

PTC (percutaneous transhepatic cholangiogram)

Open surgical decompression + T-tube insertion

(“eventually the pt should undergo elective cholecystectomy”)

116
Q

(PPP 160)

what is the MC type of gallstone?

A

cholesterol

mixed & pure

117
Q

(PPP 160)

What are the five F’s of increased risk factors for cholelithiasis?

A 
Fat
Fair
Female
Forty
Fertile
118
Q

(PPP 160)

clinical manifestations of cholelithiasis: MOST gallstones are ____________

A

ASYMPTOMATIC. May be an incidental finding

119
Q

(PPP 160)

symptomatic manifestations of cholelithiasis

A 
EPISODIC
ABRUPT RUQ PAIN
 - - LASTING 30 MIN TO HRS
may be ass'd with NAUSEA
may be ass'd with FATTY FOODS or LG MEALS
120
Q

(PPP 160)

what is the initial test of choice for suspected cholelithiasis

A

ULTRASOUND is the initial test of choice

CT or MRI may also be used

121
Q

(PPP 160)

what is choledocholithiasis?

A

gallstones in the common bile duct

can lead to cholestasis due to blockage

122
Q

(PPP 160)

choledocholithiasis - how does it typically present?

A

PROLONGED BILIARY COLIC
- - pain is USUALLY MORE PROLONGED due to presence of stone blocking bile duct

RUQ OR EPIGASTRIC TENDERNESS
JAUNDICE

123
Q

(PPP 160)

increased alk phos and GGT might indicate what? which may indicate what two possible diagnoses?

A

cholestasis —-> choledocholithiasis or acute ascending cholangitis

124
Q

(PPP 160)

what is the usual INITIAL imaging of choledocholithiasis?

125
Q

(PPP 160)

what is the DIAGNOSTIC TEST OF CHOICE for choledocholithiasis?

A

ERCP (diagnostic as well as therapeutic)

126
Q

(PPP 160)

what is the preferred management of choledocholithiasis?

A

ERCP stone extraction

preferred over laparoscopic choledocholithotomy

127
Q

(PPP 168)

nonobstructive, extreme colon dilation >6cm + signs of systemic toxicity - what is it?

A

TOXIC MEGACOLON

128
Q

(PPP 168)

list etiologies of toxic megacolon (esp the first two, there are seven)

A

IBD COMPLICATIONS LIKE ULCERATIVE COLITIS

INFECTIOUS COLITIS FROM C.diff OR CMV

ischemic colitis
volvulus
diverticulitis
radiation
obstructive CRC
129
Q

(PPP 168)

one major clinical manifestation of toxic megacolon - and four others

A

PROFOUND BLOODY DIARRHEA
abd pain & distention
n/v
tenesmus

130
Q

(PPP 168)

Two major findings on PE of Toxic Megacolon:

A

lower abd tenderness & DISTENTION

SIGNS OF TOXICITY: AMS, fever, tachycardia, hypotension, dehydration

may have signs of peritonitis (rigidity, guarding, rebound tenderness)

131
Q

(PPP 168)

what is initial imaging of choice for toxic megacolon

A

abd radiographs

CT scan may be used to assess for complications
radiologic evidence of colon > 6cm

132
Q

(PPP 168)

what is the management of toxic megacolon?

A

supportive mainstay: bowel rest, fluid and electrolyte replacement
bowel decompression w/ NG tube
broad spectrum abx (Ceftriaxone + metronidazole)

133
Q

(PPP 193)

functional gastric outlet obstruction caused by hypertrophy and hyperplasia of pyloric muscles

A

pyloric stenosis

134
Q

(PPP 193)

three risk factors for pyloric stenosis

A

first 3-12 weeks of life (MC)
erythromycin use w/in first 2 weeks of life

Caucasian, first-born, males 4:1

135
Q

(PPP 193)

hallmark of pyloric stenosis

A

nonbilious projectile vomiting, esp after eating

136
Q

(PPP 193) BUZZWORDS

OLIVE-SHAPED nontender mobile hard mass found to the right of the epigastrium on PE

A

pyloric stenosis

137
Q

(PPP 193)

initial test of choice for pyloric stenosis

138
Q 
(PPP 193) BUZZWORDS
string sign (upper GI)
A

pyloric stenosis

139
Q

(PPP 193)

what might be found on labs of pyloric stenosis

A

hypokalemia
hypochloremia
metabolic alkalosis
(from vomiting)

140
Q

(PPP 193)

initial management of pyloric stenosis

A 
rehydration via IVF
electrolyte repletion (K+ replacement)
141
Q

(PPP 193)

definitive management of pyloric stenosis

A

pyloromyotomy

142
Q

(SmartyPance)

MC presenting symptom of small bowel carcinoma and it’s nature

A

abdominal pain
- - typically intermittent and crampy in nature

(abd pain 43%)

143
Q

(SmartyPance)

four RF for small bowel carcinoma

A
  • hereditary cancer syndromes like hereditary nonpolyposis colorectal cancer (HNPCC)
  • CF
  • Crohn’s
  • lifestyle: ETOH, refined sugar, red meat, salt-cured and smoked foods
144
Q

(SmartyPance)

imaging for small bowel carcinoma

A

CT scan
small bowel series
wireless capsule endoscopy

145
Q

(SmartyPance)

majority of small bowel adenocarcinomas are _________ for CEA

A

positive

The maority of small bowel adenocarcinomas are positive for CEA by immunohistochemist

146
Q

(SmartyPance)

treatment for small bowel carcinoma

A

surgery - wide segmental surgical resection

adjuvant chemo to pts with lymph node - positive

147
Q

(PPP 174)

Most colorectal cancers arise from _______

A

adenomatous polyps

148
Q

(PPP 174)

list three RF’s for colon cancer

A

age > 50 yrs (peaks at 65 yrs)

ulcerative colitis (more than Crohn’s)

diet and lifestyle: diet (low fiber, high in red or processed meat), obesity, smoking, ETOH

149
Q

(PPP 174)

list two autosomal dominant genetic conditions that are linked to CRC

A

Peutz-Jehgers Syndrome: ass’d w/ hamartomatous polyps, mucocutaneous hyperpigmentation (lips, oral mucosa, hands)

Lynch Syndrome: 2/2 loss-of-fxn in DNA mismatch repair genes, has 40% risk of colon cancer, ass’d extra-colonic cancers: ENDOMETRIAL, ovarian, sm. intestine, brain, skin

150
Q

(PPP 174) BUZZWORDS

genetic mutation of the APC GENE

A

familial adenomatous polyposis

151
Q

(PPP 174)

FAP relation to colon cancer

A

almost all will develop colon cancer by age 45 yrs

152
Q

(PPP 174)

what is the MC cause of lg bowel obstruction in adults?

A

colorectal cancer

153
Q

(PPP 174)

what are the clinical manifestations of right-sided (proximal) CRC (4)?

A

CHRONIC OCCULT BLEEDING
IRON DEFICIENCY ANEMIA
positive Guaiac test
diarrhea

154
Q

(PPP 174)

what are clinical manifestations of left-sided (distal) CRC?

A

BOWEL OBSTRUCTION
CHANGES IN STOOL DIAMETER

may develop Strep bovis endocarditis

155
Q

(PPP 174)

diagnostic test of choice for CRC

A

colonoscopy with biopsy

156
Q

(PPP 174) BUZZWORDS

apple core lesion

A

colorectal cancer

157
Q

(PPP 174)

when might you find an apple core lesion

A

during barium enema for suspected CRC

158
Q

(PPP 174)

what is the MC cause of occult GI bleeding in adults?

159
Q

(PPP 174)

what is the classic lab finding for CRC?

A

iron deficiency anemia

160
Q

(PPP 174)

what is the MC monitored tumor marker for CRC?

A

CEA

not specific, use it to monitor progression

161
Q

(PPP 174)

localized mgmt of CRC

A

surgical resection

- - followed by post-op chemo

162
Q

(PPP 167)

three RF for diverticulosis

A

low fiber diet
constipation
obesity

163
Q

(PPP 167)

what is the MC cause of acute lower GI bleeding (i.e. painless hematochezia)?

A

diverticulosis

164
Q

(PPP 167)

Once upper GI bleed has been ruled out, what is the test of choice for diverticulosis?

A

colonoscopy

165
Q

(PPP 167)

what is the MC area for diverticulitis?

A

sigmoid colon

166
Q

(PPP 167)

What are the MC clinical manifestations of diverticulitis?

A

LLQ ABD PAIN (MC)
FEVER, LOW-GRADE

LLQ tenderness
may have n/v/c/d, flatulence, bloating, changes in bowel habits

167
Q

(PPP 167)

what is the initial imaging test of choice for diverticulitis?

A

CT scan

no colonoscopy or barium enema are no-no’s, you could perf the bowel

168
Q

(PPP 167)

what might labs show for diverticulitis?

A

leukocytosis

169
Q

(PPP 167)

What is the management of uncomplicated diverticulitis?

A

Outpatient Tx:
oral abx (metronidazole + either ciprofloxacin or levofloxacin) x7-10 days
and
clear liquid diet

alternate abx: TMP-SMX + metronidazole

170
Q

(PPP 167)

when do we consider surgery for diverticulitis?

A

if refractory to med therapy, frequent recurrences, perf or strictures

171
Q

(PPP 180)

what is MC type of esophageal cancer in US?

A

adenocarcinoma

172
Q

(PPP 180)

MC location for esophageal cancer

A

distal esophagus, esophagogastric junction

173
Q

(PPP 180)

adenocarcinoma esophageal cancer is most common in ________ (what demographic)

A

Caucasian males

174
Q

(PPP 180)

what is the MC type of esophageal cancer WORLDWIDE?

A

squamous cell (90-95%)

175
Q

(PPP 180)

what is the MC location for squamous cell esophageal cancer

A

MC in mid to upper third of the esophagus

176
Q

(PPP 180)

RF for adenocarcinoma esophageal cancer

A

Barrett’s esophagus (GERD complciations)

high BMI

177
Q

(PPP 180)

RF for squamous cell esophageal cancer

A

smoking

ETOH

178
Q

(PPP 180)

two major clinical manifestations for esophageal cancer

A

PROGRESSIVE DYSPHAGIA
- - > solid food dysphagia progressing to include fluids
ODYNOPHAGIA (20%)
WT LOSS

179
Q

(PPP 180)

What is the diagnostic study of choice for suspected esophageal cancer?

A

upper endoscopy with biopsy

180
Q

(PPP 180)

What imaging do we use for pretreatment staging of esophageal cancer?

A

endoscopic ultrasound

is preferred method for locoregional staging

181
Q

(SmartyPance)

list four possible reasons for OBSTIPATION

A

bowel obstruction
small bowel intussusception
ileus
gastroparesis

182
Q

(SmartyPance)

If a patient has mild water foul-smelling diarrhea what might you consider for a diagnosis?

A

pseudomembranous colitis (= inflammation of the colon caused by bacteria C.diff)

183
Q

(SmartyPance)

antibiotic treatment for pseudomembranous colitis (C.diff)

A

IV metronidazole
- or -
PO vancomycin (this is the only use for oral vanc)

184
Q

(RR)

three major symptoms of diverticulitis per RR ~

A

LLQ abd pain

fever

change in bowel habits

185
Q

(RR)
A purple, nodular protrusion from the anus found on PE, coupled with s/s of bleeding with bowel movements and sensation of fullness in anal area.
From what anatomical location did this issue likely arise?

A

superior hemorrhoidal cushion

186
Q

(RR)

Internal hemorrhoids are located in what areas of the rectal canal?

A

R ant
R post
L lateral

and arise from the SUPERIOR HEMORRHOIDAL CUSHION

187
Q

(RR)

Describe external hemorrhoid location and composition

A

veins located BELOW THE DENTATE LINE and are SUPERFICIAL VESSELS covered with SQUAMOUS EPITHELIUM

188
Q

(PPP 166)

which type hemorrhoids hurt?

A

external hemorrhoids

“External hemorrhoids tend to be painful and don’t usually bleed”

189
Q

(PPP 166)

two characteristics of internal hemorrhoids (i.e. bleeding or pain)

A

internal hemorrhoids TEND TO BLEED and are usually PAINLESS

190
Q

(RR)

symptomatic Meckel diverticulum is MC diagnosed in ______________

A

boys aged 10 yrs and younger

191
Q

(RR)

Pts with Meckel diverticulum typically present c/o _____________-

A

hematochezia

192
Q

(RR)

if Meckel diverticulum is suspected, what is the scan of choice?

A

a nuclear medicine scan known as TECHNETIUM-99m PERTECHNETATE SCAN (aka “Meckel Scan”)

193
Q

(RR)

what is the treatment of choice for all symptomatic Meckel diverticulum pts?

A

diverticulectomy

194
Q

(RR)

A patient less than 5 years old with painless rectal bleeding - - think of:

A

Meckel Diverticulum

195
Q

(RR)
A 72 y/o man with hx of pancreatic CA presents with jaundice, mild epigastric tenderness, scleral icterus. What lab study results would be most consistent with suspected diagnosis?

A

predominant alk phos elevation

196
Q

(RR)

PREDOMINANT ELEVATION OF SERUM ALK PHOS in relation to the serum aminotransferases suggests what?

A 
INTRAHEPATIC CHOLESTASIS or
BILIARY OBSTRUCTION (potentially caused by a tumor) instead of acute hepatic injury
197
Q

(RR)

an elevation in both GGT and alk phos suggests what?

A

cholestasis

198
Q

(RR)

Two most common sites of volvulus

A

1st: sigmoid colon
2nd: cecum

199
Q

(RR) BUZZWORDS

Whirl Sign on abdominal CT

A

cecal volvulus

90% of patients

200
Q

(RR) BUZZWORDS

coffee-bean or comma cecum on plain film

A

cecal volvulus

201
Q

(RR)

how do we fix cecal volvulus?

202
Q

(RR)

What is used to prevent gallstone formation in patients with rapid weight loss?

A

ursodeoxycholic acid

it’s a bile salt

203
Q

(WiseMD)
A 26 y/o female w/ RLQ pain x1day, with low grade fever and WBC 13.2, she’s not pregnant, and CT shows appendicitis w/o perf.

What do we do for her?

A

IV abx and emergent laparoscopic appendectomy

204
Q

(RR)

When would generalized peritoneal signs be associated with acute cholecystitis?

A

when PERFORATION of gallbladder has occurred

205
Q

(RR)
56 y/o man w/ c/o increasing difficulty swallowing, esp solid foods, regurgitating chunks of food, terrible smelling breath, no chest pain, no dyspnea, no wt loss.

What is best test for diagnosis?

A

barium swallow

206
Q

(RR)

what is the MC type of esophageal diverticula?

A 
Zenker diverticulum
(a sac-like outpouching of mucosa and submucosa, which makes it a false diverticulum b/c true diverticula contain all three layers of intestinal wall)
207
Q

(RR)

MC management of Zenker diverticulum

208
Q

(RR)

what is the anatomic area of muscular weakness where Zenker diverticulum is located?

A

Killian triangle

209
Q

(RR)
55 y/o man w/ alcoholic liver disease w/ c/o upper abd pain, wt loss, anemia. Endoscopy revleals small-to medium-sized esophageal varices. What med is used as primary prophylaxis for prevention of variceal hemorrhage?

A

propanolol

210
Q

(RR)

what is the aim of treatment for esophageal varices?

A

preventing variceal hemorrhage - - nonselective beta-blockers (i.e. propranolol) are first line agents

211
Q

(RR)

second-line agents for esophageal varices treatment

A

vasodilators (i.e. isosorbide mononitrate)

212
Q

(RR)

four points of acute management of bleeding of esophageal varices

A

hemodynamic resuscitation
octreotide
banding, sclerotherapy
prophylactic abx (i.e. ceftriaxone)

213
Q

(RR)

what are two common causes of esophageal varices?

A

portal hypertension

hx of chronic liver disease or ETOH use

214
Q

(RR)

prophylaxis for esophageal varices

A

nonselective beta-blockers (nadolol, propanolol)

endoscopic ligation

TIPS for select patients

215
Q 
(RR)
Which of the following anatomical locations is the MC site for ulcerative colitis?
a) L colon
b) rectum
c) R colon
d) terminal ileum
216
Q

(RR)
uninterrupted chronic inflammation that involves the rectum in all cases and moves proximally to involve the colon partially or entirely

A

ULCERATIVE COLITIS

217
Q

(RR)

Where is the inflammation for UC?

A

limited to MUCOSA and SUBMUCOSA (not transmural like Crohn’s)

218
Q

(RR)

In UC, what accumulates in the crypts of the colon, causing crypt abscesses?

A

polymorphonuclear neutrophils

219
Q

(RR)

clinical manifestations of UC

A

HEMATOCHEZIA (BLOODY DIARRHEA)
TENESMUS
FECAL URGENCY
CONSTITUTIONAL SYMPTOMS (FEVER, WT LOSS, anorexia)
EXTRAINTESTINAL SYMPTOMS (jaundice, uveitis, arthritis, ankylosing spondylitis, skin lesions, primary sclerosing cholangitis and more)

220
Q

(RR)

positive pANCA….think:

221
Q

(RR) BUZZWORDS

abdominal Xray THUMBPRINTING

A 
ULCERATIVE COLITIS
(abdominal XRay demonstrates colonic dilation and mucosal thickening that appears as "thumbprinting")
222
Q

(RR)

what is curative for UC?

A

total colectomy

unlike in Crohn disease

223
Q

(RR)

mainstay of medical therapy for UC

A

sulfasalazine

224
Q

(RR)

if a pt has UC and sulfasalazine doesn’t work, what do we try next?

A

oral glucocorticoids

225
Q

(RR)

what if glucocorticoids and sulfasalazine don’t work in treatment of UC….or what if the UC is really bad?

A 
TNF inhibitors (infliximab, adalimumab)
thiopurines (6-mercaptopurine, azathioprine)
226
Q

(RR)

“What are examples of the cutaneous manifestation of ulcerative colitis?”

A

“erythema nodosum and pyoderma gangrenosum”

227
Q

(RR)

or, in other words, what are the treatments for mlld to moderate ulcerative colitis?

A

mesalamine (aka 5-ASA),

topical or oral steroids

228
Q

(RR)

what are two complications to UC?

A

toxic megacolon

INCREASED COLON CANCER RISK

229
Q

(RR)

Anal fistulas are associated with

A

Crohn’s disease

230
Q

(RR)

which type of hernia reduces when the pt reclines or lays down?

A

DIRECT
“bulge decreases upon reclining”

(protrudes DIRECTLY through Hesselbach triangle and MEDIAL to inferior epigastric artery)

231
Q

(RR)

mnemonic about hernias

A

MDs don’t LIe

Medial to iea: Direct
Lateral to iea: Indirect

232
Q

(RR)

if a pt with avg risk for CRC gets a CT colonography, how often must he/she be screened?

A

q 5 yrs

“CT colonography uses software based on helical radiopgraphs to produce a 3D imagine fo the colonic lumen….USPSTF recommends screening every 5 years”

233
Q

(RR)

what test is used to confirm the diagnosis of achalasia?

A

esophageal manometry

it reveals incomplete relaxation of LES

234
Q

(RR) BUZZWORDS

bird-beak appearance of barium swallow test

235
Q

(RR) BUZZWORDS

Xray: STACK OF COINS

A

small bowel obstruction

236
Q

(RR) BUZZWORDS

Xray: STRING OF PEARLS

237
Q

(SmartyPance)

aggressive tumor that occurs in the setting of chronic liver disease and cirrhosis

A

hepatocellular carcinoma

238
Q

(SmartyPance)

four things that increase risk of hepatocellular carcinoma

A

HBV
chronic HCV
hereditary hemochromatosis
cirrhosis

239
Q

(SmartyPance)

tumor marker for liver cancer

A

alpha-fetoprotein

240
Q

(SmartyPance)

diagnosis of hepatocellular carcinoma (HCC) - three items:

A

lesions less than 1 cm –> image w/ MRI

cirrhotic or Hep B pts –> watch for rise in AFP

if there are radiologic hallmarks of HCC, get a biopsy

241
Q

(SmartyPance)

mainstay of hepatic carcinoma therapy

A

surgical resection

242
Q

(SmartyPance)

when is liver transplant a possibility for hepatic carcionma?

A

if tumors are small and few

single tumors < 5cm or multiple tumors and all are <= 3 cm

243
Q

(SmartyPance)

though surgical resection may be done for hepatic carcinoma….

A

…the cancer usually recurrs

244
Q

(SmartyPance)

what is the MC liver cancer?

A

metastatic disease outnumbers primary tumors 20:1; primary site is usually GI tract

245
Q

(PPP 164)

Name two drugs that may cause slow colonic transit (i.e. constipation)

A

verapamil

opioids

246
Q

(PPP 177)

what is pill-induced esophagitis? What two meds commonly cause it?

A

esophagitis 2/2 prolonged pill ocntact with the esophagus

NSAIDS, bisphosphonates

247
Q

(SmartyPance)

MC cause of esophageal stricture

A

GERD

“GERD accounts for approx 70 - 80% of all cases of esophageal stricture”

248
Q

(SmartyPance)
Which of the following is NOT a cause of distal esophageal stricture?

a) GERD
b) adenocarcinoma
c) scleroderma
d) infectious esophagitis

A

D) INFECTIOUS ESOPHAGITIS

249
Q

(SmartyPance)

what are the two most common causes of dysphagia?

A

1st: chronic GERD
2nd: esophageal strictures

250
Q

(SmartyPance)

three possible treatment modalities for esophageal striture

A

PPI
endoscopic dilatation
endoscopic intralesional steroid

251
Q

(SmartyPance)

what is a Schatzki ring?

A

diaphragm-like mucosal ring that forms at esophagogastric junction (the B ring)

252
Q

(SmartyPance)

How does a Schatzki Ring tend to present itself?

A

intermittent, nonprogressive dysphagia for solid food that occurs while consuming a heavy meal that was “wolfed down”…hence the pseudonym “steakhouse syndrome”

253
Q

(SmartyPance)

strictures are often due to __________—-

A

…scarring from the healing process of ulcerative esophagitis

254
Q

(SmartyPance)

what is Plummer-Vinson?

A

esophageal webs + dysphagia + iron deficiency anemia

255
Q

(PPP 192)

what is the MC type of gastric carcinoma?

A

adenocarcinoma (90%)

256
Q

(PPP 192)

what is the BIGGEST risk factor for gastric carcinoma?

A

H. pylori (90%)

257
Q

(PPP 192)

what is initial test of choice for most gastric cancers?

A

upper endoscopy with biopsy

258
Q

(RR)

what criteria are used to assess the prognosis of patients with pancreatitis based on initial and 48-hour labs?

A

Ranson criteria

259
Q

(RR)

After initial hemodynamic stabilization, pts with upper GI bleeding should undergo _____ w/in 24 hrs

A

EGD

esophagogastroduodenoscopy

260
Q

(RR)

MC cause of traveler’s diarrhea?

A

ETEC

enterotoxigenic Escherichia coli

261
Q

(RR)
A 63 yo man w/ a hx of cholecystectomy and appendectomy presents with abd cramping, vomiting, decreased bowel movements. Bowel sounds decreased. What is true about the choice of imaging for this patient?

A

ABD CT SCAN of the abd is highly specific for this diagnosis
(which is SBO)

it is both highly sensitive and highly specific
(Abd Xray has poor sensitivity and specificity)

262
Q

(RR)

pericolonic bubbles, i.e. air bubbles outside of the colon seen on abd CT scan - think:

A

microperf (a contained perf)

263
Q

(RR)

What do you do if a pt shows symptomatic diverticula and signs of microperforation on CT scan?

A

admit for IV abx, IVF, and NPO bowel rest

264
Q

(RR)

s/s of strangulated loop of bowel incarcerated w/in a ventral hernia:

A 
HIGH PITCHED BOWEL SOUNDS 
abd distension
emesis
abd pain
fever
erythema
265
Q

(RR)

Direct inguinal hernias pass through a weakness or defect in the ______

A

TRANSVERSALIS FASCIA

which forms the floor of Hesselbach triangle

266
Q

(RR)

After polypectomy for 1-2 small (<10 mm) tubular adenomas, when should the colonoscopy be repeated?

A

w/in 5-10 yrs

or 7-10 yrs

267
Q

(RR)

s/s of perforation in a pt w/ acute cholecystitis (which happens 10% of the time)?

A

hypoactive bowel sounds

268
Q

(RR)

Achalasia pathogenesis

A

degeneration of ganglion cells in myenteric plexus of esophageal wall

(bird-beak sign on barium esophagram)

CLINICAL YR: Gen Surgery (8 decks)

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