GI Tract, Liver, Pancreas Flashcards
What is the most appropriate elective operation for a patient with ulcerative colitis?
Total proctocolectomy with ileal pouch anal anastomosis and diverting ileostomy
What is the safest and most effective treatment for achalasia?
Esophagomyotomy– The operation of choice is a modified laparoscopic Heller myotomy.
Surgery results and improvement in more than 90% of patients, compared with 70% of patients treated by forceful dilatations
Treatment of choice for noninfected pancreatic pseudocyst
Internal drainage
Treatment of choice for infected pancreatic pseudocyst
External drainage – percutaneous catheter drainage with antibiotics
Most frequent serious complication of and colostomies
Parastomal herniation – commonly occurs when the stoma is placed lateral to The rectus muscle
Best study to evaluate for a pancreatic mass?
Helical contrast enhanced CT
Treatment for acute variceal bleed?
– Isotonic crystalloids followed by transfusion of blood
– Elevated prothrombin times should be corrected with fresh frozen plasma
–Octreotide or vasopressin to decrease splanchnic bloodflow
–Balloon tamponade
Treatment for persistent gastric ulcer unresponsive to medical therapy. What is the next best step in management?
– Distal gastrectomy with gastroduodenostomy
Or with gastrojejunostomy to definitively rule out a malignancy
This is a partial gastrectomy with vagotomy
Method to document the eradication of H. pylori infection?
Carbon labeled urea breath test
Sensitivity and specificity greater than 95%
Type of polyps seen in peutz jeghers syndrome
Hamartomas – no malignant potential
What are the indications for surgical intervention for diverticular disease?
– Hemorrhage secondary to diverticulosis
– Recurrent episodes of diverticulitis
– Intractability to medical therapy
– Complicated diverticulitis
Treatment for diverticular abscess
– Percutaneous drainage
–Sigmoid resection with primary anastomosis
Treatment for perforated diverticulitis?
Hartman procedure – sigmoid resection with end colostomy and rectal stump or
Sigmoid resection, anastamosis, diverting loop ileostomy
How do you diagnose biliary dyskinesia? What is the treatment?
A gallbladder ejection fraction of less than 35% at 20 minutes is diagnostic
Treatment is cholecystectomy
48-year-old with right lower quadrant pain that develops a playing tennis. Progresses with low-grade fever, leukocytosis, anorexia nausea. Ultrasound shows mass and abdominal wall. Most likely diagnosis?
Hematoma of the rectus sheath
Treatment for amoebic liver abscesses?
Metronidazole monotherapy
Treatment for pyogenic liver abscesses?
Percutaneous catheter drainage and antibiotics against gram-negative and anaerobic organisms
Best way to determine the proper treatment for his sliding hiatal hernia?
Flexible endoscopy
72-year-old man with hematochezia, fever, abdominal pain. What is it? Management.
Ischemic colitis
Expectant management – IV fluids, bowel rest, supportive care
Definitive treatment for hepatic adenoma?
Resection
Lesions greater than 4 cm in size of an increased risk of rupture with hemorrhage
Hepatic adenomas also have a risk of malignant transformation to well-differentiated hepatocellular carcinoma
Treatment for focal nodular hyperplasia?
Resection only if lesion is symptomatic.
FNH cannot be distinguished from hepatic adenoma on CT scan, nuclear medicine scan may demonstrate hot lesion for FNH or cold lesion for hepatic adenoma
Treatment for iatrogenic injury of the common bile duct resulting in stricture?
End to side choledochojejunostomy (Roux-en-y) performed over a stent. Primary repair of the common bile duct may result in recurrent structure
When is polypectomy adequate treatment when malignant cells are identified in colonic polyp, and invasive component is identified?
(1) no vascular or lymphatic invasion is present
(2) there is an adequate negative margin – 2 mm
(3) cancer is not poorly differentiated
Where do most gastrinoma’s occur?
90% are located within the gastrinoma triangle – the three corners are defined by the junction of the second and third portions of the duodenum, junction of the neck and body of the pancreas, junction of the cystic and common bile duct
Treatment for epidermoid cancers of the anal canal
Combined external radiation with synchronous chemotherapy (fluorouracil and mitomycin) also known as the Nigro protocol
Differential for distended bowel?
Tumor, foreign body, colitis, cecal or sigmoid volvulus
Best diagnostic test for sigmoid volvulus?
Sigmoidoscopy
75-year-old woman with abdominal radiograph demonstrating air filled kidney bean shaped structure in the left upper quadrant. What is it? Management.
Cecal volvulus
Right hemicolectomy
45-year-old right upper quadrant pain and fever. CT shows large calcified cystic mass in the right lobe of liver. Echinococcus is suggested by the CT findings. Management.
Total pericystectomy
Agents such as .5% silver nitrate or hypertonic saline are introduced into the cyst at the time of surgery
What is the most common nonobstetric surgical disease of the abdomen during pregnancy?
Appendicitis
Which type of hernia is more dangerous? Sliding hernia or paraesophageal?
Paraesophageal – Substantial risk for both strangulation and obstruction
Surgical repair required!
Management of Ogilvie’s syndrome?
Discontinue anticholinergics, narcotics, medications that contribute to ileus.
Strict bowel rest with IV hydration and correction of electrolytes
Persistent distention or a dilated cecum greater than 10 cm, cautious endoscopic colonic decompression can be performed or sympatholytic agent such as neostigmine
First-line treatment for major hemobilia
Transarterial embolization
Risks associated with a paraesophageal hernia?
Bleeding, ulceration, construction, the cross of the stomach wall, perforation
Which type of pancreatic tumors are deemed unresectable?
T4 lesions – extension beyond the pancreatic capsule and into the retroperitoneum, involvement of neural or nodal structures surrounding the origin of the celiac axis or superior mesenteric artery, extension into the hepatoduodenal ligament
Most common cause of small intestinal bleeding in patients under 30?
Meckel diverticulum
What is a stress ulcer?
Acute gastric or duodenal erosive lesions that occur following shock, sepsis, major surgery, trauma, or burns
– Characteristics – multiple show lesions with discrete areas of erythema along with focal hemorrhage in the fundus
Involve the body and fundus and spare the antrum
Most common location of common benign gastric ulcers
lesser curvature and antrum
Treatment for high risk critically ill patients with multisystemic disease and cholecystitis?
Tube cholecystostomy
What is a dieulafoy lesion?
abnormally large submucosal artery that protrudes through a small, solitary mucosal defect, located 6 cm distal to the GE junction.
Tx for dieulafoy lesion
Upper endoscopy with injection sclerotherapy, electrocoagulation or heater probe.
If surgery is required, gastrotomy and simple ligation or wedge resection.
When is risk of malignancy low in carcinoid tumor?
When tumors are < 2 cm. Malignant potential increases when size > 2cm and metastasis to liver occurs causing carcinoid syndrome.
Management of patient with asymptomatic hemangioma
Safely observed
risk of rupture and severe hemorrhage is extremely low
Definitive treatment for patients with UC
total proctocolectomy with either end ileostomy or ileoanal J-pouch anastomosis.
Indications for operation in UC
High grade dysplasia or carcinoma
Toxic megacolin
Massive colonic bleeding
Intractability to medical therapy
Tx for 60 year old woman with recurrent SCC of the anus after chemoradiation?
Abdominoperineal resection with formation of a permanent end colostomy.
Surgical tx for toxic megacolon
subtotal colectomy with end ileostomy
Treatment for distal rectal cancers involving the sphincters or that are too close to obtain an adequate margin (2cm)
Abdominoperineal resection (APR)
Treatment for proximal and midrectal cancers
Low anterior resection (LAR)
33 y/o with chron disease develops fever, abdominal pain and marked dilation of the large bowel. What is it? Management.
Toxic megacolon
Subtotal colectomy with end ileostomy
Treatment for diffuse esophageal spasm?
Long myotomy guided by manometric evidence
20-year-old man admitted to hospital with acute onset left-sided chest pain. What is it? Management.
Spontaneous pneumothorax resulting from rupture of subpleural blebs.
Thoracotomy with bleb excision pleural ablation
50 year old has severe vomiting and retching spell punctuated by sharp substernal pain. Four hours later CXR shows left descending aorta is outlined by air density. What is it? Management.
The presence of air in the mediastinum after an episode of vomiting and retching is virtually pathognomonic for spontaneous rupture of the esophagus - Borehaave syndrome
-Contrast esophagram: Barium for suspected thoracic perforation and gastrografin for suspected abdominal perforation
Thoracotomy, Repair, and drainage for leaks that are less than 24 hours old
Treatment for chylothorax
Low-fat, medium chain triglycerides diet reduces the flow of chyle.
Repeated thoracentesis or tube thoracostomy drainage
Strategies to prevent spinal cord ischemia during operation on thoracic aorta aneurysms
Aggressive reattachment of segmental intercostal and lumbar arteries, minimizing cross-clamp time, hypothermia, moderate systemic heparinization, left heart bypass, cerebrospinal fluid drainage using a lumbar drain
Indications for CABG
– Patients with angina
– Asymptomatic patients with ischemia on cardiac stress test
– Multivessel disease
–Treatment of choice in diabetic patients
treatment for thoracic outlet syndrome
Physical rehabilitation
Indications for pulmonary metastectomy?
-Controlling the primary lesion
– No evidence of extra thoracic disease
– Ability to tolerate pulmonary resection including possible sing-along ventilation
– Predicted ability to complete resection
– Lack of a more effective systemic therapy
May be performed for sarcomas, melanomas, germ cell tumors, carcinomas including colon, renal cellit’ll sell, endometrial, head and neck
What is the treatment for chylothorax after drainage of chest cavity, bed rest, TPN fails?
If drainage of chyle continues to be greater than 500 mL per day, operative ligation of thoracic duct should be performed
Ligated from diaphragm to C6
Primary therapy for a bronchial carcinoid?
Operatively resection – lobectomy or lesser section as long as tumors excised
Mediastinal lymph node sampling or dissection
Thoracic aortic aneurysm can because by this disease
syphillis
