GI-Surgery Flashcards
Headache, vomiting, focal neurologic deficit : Indication? Next step in Management?
- Increased ICP
- MRI of the brain
Elderly, intermittent hematochezia, anemia, fever, LLQ pain,
Diverticulitis ( common in sigmoid colon, associated with constipation)
Oil cysts on mammography after chest trauma. Next step in management (NSIM)?
Reassurance- It is pathognomonic for fat necrosis of the breast. Biopsy confirmation:foam cells and multinucleate giant cells
Drugs that decrease intestinal motility (2 listed)
amlodipine, chlorpromazine
abd distention and marked dilation of the colon and cecum on imaging indicates? possible causes?
acute megacolon; complication of interventional procedures and/or SE of medications that decrease motility
Acute N/V, bloating, absent bowel sound, and uniform gas pattern in small bowel, colon and rectum without air-fluid level on x-ray is
paralytic ileum
Connects the lesser curvature of the stomach with liver and must be cut in surgery to access for removal of pancreatic tumor
gastrohepatic ligament
Tx for refractory ascites that has not responded to diuretics? consider complication?
large-volume paracentesis, albumin level (electrolyte abnormalities)
Sign of mechanical obstruction and X-ray with accumulation of gas in the biliary system (Pneumobilia) and dilated bowel with air-fluid levels is?
Cholecystoentreic fistula
Salmon-colored fluid from incisional wound after open abd surgery? NSIM?
wound dehiscence; secure wound with tape & abd binding and OR
fever, abd pain, changes in mental status, ascites fluid with >250 polymorphonuclear leukocytes/mm3 is
Spontaneous Bacterial peritonitis (SBP)
Tarry stool, BP 90/50, HR 110, on naproxen, Dx? NSIM?
Upper GI bleeding, EGD
4YO, acute intermittent umbilical abd pain, , draws up his knees to the chest when in pain, Hgb 10.6, abd US with concentric rings of bowel in transverse section, Dx? Pathological lead point?
Intussusception, Meckel’s diverticulum (older than 3 think lead point)
5YO, abd pain, hyperactive bowel sounds, US normal, Dx? NSIM?
constipation, give polyethyelene glycol
10YO, Vomiting, RLQ pain without guarding, normal BS, Leukocyte count 12,800. Dx? Imaging?
Acute appendicitis; abd ultrasound for children
36, fatigue for 4 month, generalized itching, ALK 480, AMA antibody +, ANA +, abd US gallbladder sludge, Dx? NSIM?
Primary biliary cholangitis (PBC), Ursodeoxycholic acid ( 1st line therapy)
26, fatigue for 6 months, diarrhea for 5 weeks with occasional bloody, ESR 80, Dx? NSIM?
Inflammatory bowel disease; colonoscopy (used for IBD, colorectal cancer screening and diagnosing)
On colonoscopy; inflamed, reddened mucosa, bleeding on contact with then endoscope, and fibrin-covered ulcers. Dx?
Ulcerative colitis
66F, profuse watery diarrhea with streaks of blood, UTI 3 weeks ago, 14 day course of ciprofloxacin, N/V, leukocytosis. Dx? Abd xray will show?
Toxic megacolon-complication of pseudomembranous colitis, abdXray- dilation of the colon with loss of haustration
treatment for intussusception
Air enema or hydrostatic enema
treatment for nonmetastastatic pancreatic head carcinoma
Whipple procedure- Pancreaticoduodenectomy
32m, Crohn’s disease with small bowel resection for midgut volvulus at birth, laparotomy with two discrete strictures in the mid-ileum. NSIM? Two things pt at risk for?
Strictureplasty of individual strictures; risk for short bowel syndrome (prior SB reception hx) & adhesions/fistulas (crohn’s disease hx)
56F, difficulty swallowing solid and now liquid, wt loss, smoker, Esophageal manometry monitoring shows lower esophageal sphincter fails to relax. Dx? NSIM?
Achalasia; Gastroesophageal endoscopy. It can present as distal esophageal cancer also achalasia predisposes to cancer
Surgical procedure for GERD
Myotomy of LES with fundoplication
Screening test for C-diff ( 3)
- Enzyme immunoassay (EIA) for glutamate dehydrogenase antigen ( GDH);
- PCR testing;
- bacterial culture;
- Fecal lactoferrin (Not specific enough to confirm diagnosis)
Testing for malabsorption
stool acidity test
Testing for Inflammatory bowel disease (IBD)
Fecal lactoferrin
unstable pt with severe retrosternal pain radiating to the back and left shoulder, nonbillious vomiting, hx of daily beer, crepitus over the thorax. Dx?Appropriate test? and what if pt is stable ?
- Boerhaave syndrome
- CT scan of the chest (unstable)
- Contrast esophagram with gastrografin (NO barium)
Pt close proximity with animals, RUQ abd pain, N/V, eosinophilia, Liver cysts on US. Dx? Tx? SE?
Hydatid cyst disease (echinococcosis): albendazole SE Leukopenia (CBC q2weeks during therapy)
Hypoechoic heterogenous lesion at the caudal border of liver with surrounding hyperemia. RUQ pain, fever, elevated LFT, leukocytosis. Dx? NSIM
Pyogenic liver abscess; percutaneous draining (if less than 3cm and pt stable tx with abx only)
secondary prophylaxis to prevent variceal bleeding is ? using?
Variceal ligation: using Endoscopic variceal ligation (EVL) q 1-2 weeks until the variceal have been obliterated then 3-6 months endoscoping exam
Tx of acute variceal hemorrhage but not for secondary prophylxis due to drug tolerance (down regulation of receptors)
Octreotide (splanchnic vasoconstriction)
32M, hx HTN & ulcerative colitis , generalized fatigue and severe pruritus, abd US focal bile duct dilation, elevated conjugated bilirubin & ALK pha. DX?
Primary sclerosing cholangitis
32F, hx HTN & ulcerative colitis , generalized fatigue and severe pruritus, abd US focal bile duct dilation, elevated conjugated bilirubin & ALK pha + antimitochondrial antibodies. DX?
Primary biliary cholangitis (PBC)
CP radiating to the back, Tachy, Tachypnea, crepitus over the chest, endoscopic procedure one day ago. Dx?
esophageal perforation
What is the most likely cause of postop hemorrhage within 24hr after surgery in pt with normal coagulation parameter?
Insufficient mechanical hemostasis due to slipped suture or tie
fever, malaise, tender abd, raised amylase, lipase following an episode of acute pancreatitis, abd US with complex cystic fluid collection with irregular walls and septations in pancrease. Dx?
Pancreatic abscess
fever, malaise, tender abd, raised amylase, lipase following an episode of acute pancreatitis, abd US anechoic or hypoechoic, smooth, round structure. Dx
Pancreatic pseudocyst
22F, Chronic abd pain, bloody diarrhea, wt loss, procititis, + p-ANCA. Dx? Colonoscopy will show?
Ulcerative colitis; confluent inflammation of the colonic mucosa with edema, linear ulcers and loss of vascular pattern
upper abd pain, achy and crackling with every heartbeat associated with lucency of the mediastinum is called? diagnosis? How to diagnose?
Mediastinal emphysema (Hamman’s sign); iatrogenic esophageal perforation (after upper endoscopy); contrast esophagography with gastrografin
new born, with Polydromnios before birth, cyanotic attack that does not improve with crying suggests?
developmental anomaly, esophageal atresia
1st line therapy to treat initial episode of C-diff infection
- Oral fidaxomicin or oral Vancomycin
Why LR and not NS?
LR reduces the risk of SIRS and large quantities of NS can cause non-anion gap hypercholoremic acidosis
54M, Abd distension with shifting dullness, cloudy ascitic fluid, serum-ascites albumin gradient (SAAG) < 1.1 and Triglycerine count >200, non-pitting pedal edema is
Lymphedema (Chylous ascties) caused by Lymphoma
68M, increased in the frequency of bowel movement and occasional bloody stools, smoker, digital rectal exam shows a large internal hemorrhoid, stool + for occult blood, NSIM?
colonoscopy
what disease could cause chronic, progressive changes in bowel habits and hematochezia in an elderly man with a history of smoking?
Colorectal cancer
What lab test helps determine the severity of pancreatitis quickly?
Hematocrit (severity), Lipase is good for diagnosis but correlated poorly with disease severity
Tx for acute diverticulitis complicated by a large abscess (>3cm) is
CT-guided percutaneous drainage
Young boy with painless lower GI bleeding, DX? NSIM?
Meckel Diverticulum, Technetium-99m pertechnetate scan
1st-line treatment for an obstructing Schatzki ring/esophageal ring is
mechanical dilation using bougie or ballon dilators
Dysphagia, esophageal obstruction, ring like appearance of obstruction with normal mucosa on biopsy is
Schatzki ring
Achlohydria, overgrowth of nitrite-producing bacteria, and reflux of bile through the gastrojeunal anastomosis after partial gastrectomy will have risk for
gastric cancer
name for absent of HCL in gastric is called
achlorhydria
secretory diarrhea, episodic cutaneous flushing, abd pain, heart valve dysfunction, and wheezing
Carcinoid syndrome due to excess serotonin recreation from Carcinoid tumor
Young woman on oral contraceptive pill with 3cm hepatic mass. Dx? NSIM?
hepatic adenomas, reimagined in 6 month after stoping oral contraceptives (OCPs)
Ingestion Scerotherapy is used for tx of
rectal prolapse
Tx of anogenital warts (condylomata acuminate)
Local cytostatic 5-fluorouracil therapy
Tx of choice for pt with anal SSC cancer is
Radiochemotherapy, shown to be superior to surgery
Elderly, hx of multiple medical conditions, with abd pain and distention. Imaging colonic dilation with haustral preservation in absence of an obstructing lesion is
acute colonic pseudo-obstruction (oglivie syndrome)
Disease of GI characterized by impairment of the autonomic nervous system
Oglivie syndrome
How do you treat Oglivie syndrome
Neostigmine therapy- causes increase in acetylcholine to stimulate bowel peristalsis
Viscous, dark green substance draining after 12hrs abd surgery, Dx? NSIM?
enterocutanous fistula, Total parenteral nutrition and stony pouch
Risk factors of cholecystitis
Female Fat Forty Fair-skinned Family history Fertile (Multiparity)
Tx of acute Acalculous cholecystitis
- IV fluid
- Broad-spectrum antibiotics (piperacilin-tazobactam)
- Cholecystostomy
Bulimic pt with retrosternal pain and leakage of contrast from lower esophagus after serval episode of vomiting. No sepsis, pneumothorax, pleural effusion or mediastinal emphysema, leak contained to the mediastinum. Dx? Tx?
Boerhaave syndrome, IV ampicillin therapy .
Surgical repair only if therapy fails or sever tear
17M, Progressive high fever, leukocytosis, add pain and abd fluid collection seen on CT in right pelvis, Dx? NSIM?
appendices abscess, Continue conservative management (bowel rest, IV fluids, and abx) and schedule appendectomy in 6-8 weeks
Elevated cholestatic parameters and a dilated common bile duct without evidence of stones in the biliary system after cholecystectomy. Dx? Tx?
Postcholecystectomy syndrome( residual gallstones within biliary tree or sphincter of oddi dysfunction) - ERCP with sphincterotomy
Down syndrome new born with bilious vomiting, abd distention, explosive stool release upon rectal exam, late passage of meconium.Dx? NSIM?
Hirschsprung’s disease; Rectal suction biopsy ( 2cm proximal to the dectate line)
Recommended procedure for pt with hematochezia and hemodynamic instability despite resuscitation efforts
Angiography
Mutation in mismatch repair genes(MLH1, MSH2)- Lynch syndrome risk of developing 3 different cancers
- Colorectal
- Gastric
- Endometrial (might require Hysterectomy and bilateral salpingo-oophorectomy
Newborn with abd distention, multiple episodes of billow vomiting, and dilated large bowel loop, delayed passage of meconium, absent of air in the rectum, and narrow sigmoid colon with dilated colon segment on x-ray suggest
Hirschsprung’s disease
Defective migration of neural crest cells
Hirschsprung’s disease
Gastric outlet obstruction (GOO) caused by ACUTE peptic ulcer disease causes vomiting from
inflammation-induced edema
tissue deformation of the gastroduodenal junction
Gastric outlet obstruction (GOO) caused by Chronic peptic ulcer disease related to H.Pylori-induced chronic gastritis & chronic NSAID use causes vomiting due to
scarring and tissue remodeling
Changes in Na, pH, K, Cl from vomiting from pyloric stenosis in the early stages of dehydration
Na (hyponatremia), pH(normal in early stage due to respiratory and kidney compensation), K ( Normal), Cl (normal)
Triple bubble sign in a new born with bilious vomiting
Jejunal atresia
Double bubble sign in a new born with bilious vomiting
Duodenal atresia
What would be the best approach to evaluate abdominal injuries in a hemodynamically unstable patient with inconclusive FAST test?
Diagnostic peritoneal lavage (DPL)
Abd X-ray on a new born low birth weight with pneumatosis intersitnalis (gas within the wall of the intestine) is indicative of? NSIM?
Necrotizing enterocolitis; Exploratory laparotomy
Indication for familial adenomatous polyposis (FAP) is
proctocolectomy with ileana anastomosis
A smooth, bony hard, and nontender mass in the midline of the hard palate is
torus palatines-benign bone tumor
Crepitus in the abd wall and thickened gallbladder with gas
emphysematous cholecystitis
US with bile duct wall thickening and focal strictures and dilations of the interahepatic and extra hepatic bile ducts
Primary Sclerosing Cholangitis (PSC)
neonate with acute-onset bilious vomiting, mildly distended abd, no gas in the small intestine on x-ray, Dx? NSIM?
Intestinal malrotation with midgut volvulus (misplaced ligament of Treitz and duodenojejunal auction on the right of the mid-line)
Upper GI contrast series
Obvious signs of malrotations are
misplaced ligament of Treitz and duodenojejunal junction on the right of the mid-line
Recommended treatment of chronic pancreatitis
pancreatic enzyme therapy
Bloody diarrhea and cramps abd pain
Inflammatory Bowel disease
Friable and inflamed mucosa that bleeds on colonoscopy Dx?, Tx?
- ulcerative colitis;
- Mesalamine therapy (for mild UC), 5-aminosalicyclic acid derivatives (sulfasalazine and olsalazine)
Therapy only for management of steroid-refractory UC in pt not willing to have surgery and who have contraindication for calcineurin inhibitors
infliximab therapy
Therapy for Crohn’s disease
Infliximab
A prognostic grading scale for cirrhosis (mortality)
Child-Pugh score /CTP score (Child-Turcotte-Pugh score)
on the bases of; bilirubin, albumin, PT and degree of cities and encephalopathy (Graded A-mild to C-severe)
Higher CTP score on cirrhotic patient with ascites who need surgery, what you should be done to prevent surgical morbidity?
abd paracentesis
abd pain and distention with obstipation, x-ray with coffee-bean sign indicates? NSIM?
Sigmoid volvulus endoscopic detorsion (via sigmoidoscopy)
1st line of tx for gastroparesis
Metoclopramide (Reglan)
Abd x-ray with cecal and right colon dilation, Dx? Tx?
colonic pseudo-obstruction, neostigmine therapy
Congenital umbilical hernias close spontaneously by what age?
5
Pt with cholecystitis needs what therapy before lap cholecystectomy?
Antibiotic therapy- Piperacillin-tazbactam IV (Zosyn)
Emergent open cholecystectomy is indicated for (2)
gangrenous cholecystitis or gallbladder empyema
Trauma pt with paralytic ileum (tx opioids), ileum with bilateral flank pain, seatbelt sign, Grey Turner sign, obliteration of the psoas outline on x-ray and fluid-responsive hemodynamic changes make?
retroperitoneal hemorrhage
Flank ecchymosis due to retroperitoneal bleeding dissecting through fascial planes is called
Grey Turner’s sign
Five days after pancreaticoduodenectomy presenting with hyperchloremic normal anion gap metabolic acidosis needing testing of drain fluid for amylase is due to
Pancreatic fistula
Tx for pancreatic fistula include
-conservational tx (Octreotide, TPN) or with stunting of the pancreatic duct
Fever, jaundice, & RUQ abd pain is called
Charcot’s triad
right upper abd pain on pregnant women who has vomiting, fever, leukocytosis and mild pyuria
Appendicitis- gravida uterus can displace the appendix to the RUQ. Pyuria if appendicitis is proximal to ureters
Vomiting, abd pain, RUQ tenderness in pregnant women with high LFT, hemolysis and low plt. Dx?
HEELP syndrome
Initial management of bleeding esophageal varies involves (4)
- Fluid resuscitation
- blood product to stabilize coagulation
- octerotide
- prophylactic abx
When should Endoscopic band ligation be performed on a patient with esophageal varies
within 12 hrs of presentation, after medical treatment and prophylaxis
4 weeks old infant with scleral icterus and play stools suggests
direct hyperbilirubinemia (biliary atresia)
Immediately following birth child with jaundice, normal stool color is
indirect hyperbilirubinemia (Crigler-Najjar syndrome)
Pregnant women with pruritus, elevated direct bilirubin levels, elevated bile acid indicates
intrahepatic cholestasis of pregnancy
After 1 day of MVA abd pain, nausea and vomiting. X-ray with large gastric bubble with mild gastric distention. Dx? Tx?
- Duodenal hematomas causing upper intestinal obstruction
- NG decompression and TPN
Epigastric pain, N/V and history of multiple episodes of acute pancreatitis with walled off pancreatic fluid on CT, Dx? Tx?
- Pancreatic pseudocyst
- CT-guided percutaneous drainage
Pt of Asian descent with saccular or fusiform dilation of the biliary tree or as a dilated masses that communicate with the biliary tree is
Biliary cysts
MVA 8hrs ago, HR 140, bp 80/50, CVP 19, JVD, abd is tense and distended;Dx? NSIM?
- Abd compartment syndrome (from resuscitation)
- Reopen abd and cover with plastic
Sudden compromises of blood flow to bowel causing necrosis and infection
Ischemic colitis (absent bowel sound , tenderness in palpation of all quadrant, x-ray with air-filled distended bowel)
When direct and indirect hernias happen together, it is called
Pantaloon or Saddle bag hernia
