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General Surgery > Liver, Pancreas and Spleen > Flashcards

Liver, Pancreas and Spleen Flashcards

1
Q

The pancreas is a retroperitoneal organ that extends oblique from the duodenal loop to the hilum of the ___.

A

spleen.

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2
Q

T/F: the vasculature that supplies the pancreas and spleen drains into the portal vein and goes to the liver.

A

True.

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3
Q

Alpha pancreatic cells are associated with:

A

Glucagon production, as well as CCK, endorphin.

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4
Q

A patient with a glucagonoma is MOST likely to present with:

(1) necrolytic migratory erythema
(2) pre-diabetes
(3) HHyperaminoacidemia

A

(1) necrolytic migratory erythema.

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5
Q

Beta pancreatic cells are associated with:

A

insulin production, as well as amylin, CGRP and prolactin.

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6
Q

A patient with an insulinoma is MOST likely to present with:

(1) hyperglycemia
(2) hypoglycemia and associated symptoms.

A

(2) hypoglycemia and associated symptoms.

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7
Q

D pancreatic cells produce

A

Somatostatin

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8
Q

A somatostainoma presents with

A

diabetes, gallstones and steatorrhea.

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9
Q

D2 pancreatic cells produce

A

VIP

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10
Q

A VIPoma presents with

A

High volume secretory diarrhea, hypokalemia, metabolic acidosis and hypochlorhydria.

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11
Q

T/F: Pancreatic G cells are not present in normal physiologic states.

A

True.

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12
Q

The chief physiologic function of the endocrine pancreas is:

A

regulation of body energy.

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13
Q

Insulin causes the physiologic functions:

(1) increasing protein synthesis.
(2) increasing glycogenolysis
(3) increasing lipolysis

A

(1) increasing protein synthesis.

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14
Q

Glucagon release energy by increasing blood glucose level via stimulation of:

A

glycogenolysis, gluconeogenesis and lipolysis.

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15
Q

A patient presents with a skin rash and diabetes. The patient has noticed weight loss and fatigue. Labs show anemia. The patient MOST likely has:

A

A glucagonoma.

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16
Q

A patient with a glucagonoma presents with characteristic skin rash (necrolytic migratory erythema). Reduction of the erythema involves treatment via:

A

parenteral administration of amino acids.

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17
Q

Glucagonoma is treated via:

A

surgical excision of the tumor.

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18
Q

A patient presents with fatigue and mental confusion. Labs show hypoglycemia and catecholamine surge. You diagnose the patient with an insulinoma. Treatment of the condition should involve:

A

IV administration of glucose.

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19
Q

The type of pancreatic tumor that is associated with MEN 1 syndrome

A

Insulinoma

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20
Q

Treatment of insulinoma involves:

A

IV administration of glucose and surgery (enucleation).

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21
Q

Which of the following regarding gastrinomas is TRUE?

(1) Most originate in the duodenum.
(2) It is the most common islet cell tumor but is rarely symptomatic.
(3) 45 - 60% of gastrinomas arise in the “gastrinoma triangle”.

A

(3) The duodenum is the site of gastrinomas in 45 - 60% of patients.

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22
Q

A patient presents with abdominal pain and diarrhea. Endoscopy shows peptic ulcers and increased gastric acid production. You diagnose the patient with Zollinger-Ellison syndrome. The diarrhea will subside upon treatment via:

A

Nasogastric aspiration of gastric secretion.

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23
Q

MOST patients with Zollinger-Ellison syndrome have:

A

MULTIPLE duodenal peptic ulcers.

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24
Q

Diagnosis of Zollinger-Ellison syndrome depends on

A

The presence of gastrinemia in the face of increased secretion of gastric acid (AKA there is no feedback for gastrin secretion).

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25
Q

Clinical clues for patients with ZES include:

(1) a virulent peptic ulcer or GERD diathesis.
(2) Absence of h. pylori or a failure of the peptic ulcer to heal after H2 blocker use.
(3) Secretory diarrhea that resolves.
(4) Absence of MEN-1 syndromes.

A

(1) A virulent peptic ulcer or GERD diathesis.

(2) Absence of h. pylori or a failure of the peptic ulcer to heal after H2 blocker use.

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26
Q

T/F: Pharmacologic control of acid secretion has rendered total gastrectomy unnecessary. Operation is used only for tumor removal.

A

True.

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27
Q

T/F: though gastrinomas have a high rate of malignancy, they are more apt to be cured than is cancer of any other abdominal viscus.

A

True.

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28
Q

ZES may present with:

A

pituitary tumors and abnormal PTH secretion.

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29
Q

A patient presents with diabetes, steatorrhea and gallstones. Labs show hypochlorhydria. You diagnose the patient with a somatostatinoma. Treatment considerations include:

A

70 - 80% of the tumors are malignant and surgical treatment, as well as CHOLECYSTECTOMY should be performed.

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30
Q

Somatostatinoma tumors are most common at:

A

the tail of the pancreas.

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31
Q

A patient presents with profound watery diarrhea, hypokalemia and achlorhydria. The secretory diarrhea persists despite fasting and nasogastric aspiration. Stool volume is more than 700 mUday. The patient’s diagnosis is MOST likely:

A

VIPoma.

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32
Q

A patient presents with profound watery diarrhea, hypokalemia and achlorhydria. The secretory diarrhea persists despite fasting and nasogastric aspiration. You diagnose the patient with a VIPoma. Treatment involves:

A

Surgical removal of VIPoma in ALL patients, as well as treatment with octreotide to control fluid loss.

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33
Q

T/F: acute pancreatitis occurs when there is an insult to the pancreas. When the insult stops, the pancreas goes back to normal.

A

True.

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34
Q

Which of the following regarding pancreatitis is TRUE?

(1) It is more common in males than females.
(2) Acute interstitial pancreatitis presents with severe inflammation.
(3) Pancreatic fluid collections are usually infected.

A

(1) Pancreatitis is more common in males than females.

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35
Q

The MOST common cause of acute pancreatitis worldwide is:

A

gallstone pancreatitis

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36
Q

The risk of gallstone pancreatitis increases with:

A

smaller stones.

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37
Q

Which of the following regarding alcoholic pancreatitis is TRUE?

(1) It is the most common cause of pancreatitis worldwide.
(2) It is more prevalent in young women than in young men.
(3) THere is no genetic predisposition and smoking is not reatled to its development.
(4) Compared with nonsmokers, the relative risk of alcohol induced pancreatitis in smokers is 4.9.

A

(4) Compared with nonsmokers, the relative risk of alcohol-induced pancreatitis in smokers is 4.9.

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38
Q

Abnormal flow of pancreatic juice into the duodenum can result in:

A

pancreatic injury.

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39
Q

Patients with pancreatic cancer usually do not develop:

A

pancreatitis.

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40
Q

T/F: Drugs make up a significant portion of pancreatitis cases.

A

False.

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41
Q

Which of the following is a cause of pancreatitis?

(1) hypertriglyceridemia
(2) hereditary
(3) autoimmune
(4) scorpion sting/gila monster bite
(5) hypercalcemia (hyperPTH)
(6) All of these

A

(6) All of these.

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42
Q

The pathogenesis of pancreatitis begins with:

A

generation of increased active trypsin that has no negative feedback.

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43
Q

The pathogenesis of pancreatitis involves the continued synthesis of pancreatic enzymes. Inflammation, thrombosis and hemorrhage is a result of:

A

enzyme damage to the vascular endothelium, leading to vasoconstriction, capillary stasis and decreased oxygen saturation.

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44
Q

The diagnosis of acute pancreatitis requires two of the following three features:

A

(1) abdominal pain with acute onset, severe epigastric pain that radiates to the back.
(2) threefold or higher elevation of serum amylase or lipase levels above normal.
(3) Characteristic findings of pancreatitis by imaging.

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45
Q

Clinical characteristics of acute pancreatitis include:

(1) hypoglycemia
(2) leukopenia
(3) elevation of liver enzyme levels (ALT).

A

(3) Elevation of liver enzyme levels (ALT).

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46
Q

T/F: simple abdominal radiographs are useful for diagnosis of pancreatitis.

A

False.

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47
Q

In regards to imaging for acute pancreatitis:

A

US should be ordered in ALL patients and CT is the best modality for elevation of the pancreas.

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48
Q

The most valuable CT contrast phase in which to evaluate the pancreatic parenchyma is the:

A

portal venous phase (65 - 70 seconds after injection of contrast material).

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49
Q

The prognosis for acute pancreatitis is:

A

Good (80% of cases are mild-moderate and resolve in a few days with conservative therapy).

50
Q

A 45 year old male presents with symptoms consistent with acute pancreatitis. Blood glucose is 250 mg/dL, WBC < 16,000 cells/mm and lactate dehydrogenase is 200 and AST is 100. The patient has findings that are:

A

not consistent with acute non-gallstone pancreatitis.

51
Q

Which of the following is a criteria for non-gallstone pancreatitis?

(1) Hct decreases < 10%
(2) serum calcium level > 8 mg/dl
(3) Base deficit > 4 mEq/L.
(4) PaO2 > 60 mm Hg.

A

(3) base deficit > 4 mEq/L.

52
Q

Which of the following is NOT a criterium for non-gallstone pancreatitis?

(1) Age < 70 years.
(2) blood glucose > 220 mg/dL
(3) WBC > 18,000 cells/mm
(4) Lactate dehydrogenase > 400
(5) AST > 250 IU/L

A

(1) Age < 70 years.

53
Q

A patient is admitted to the hospital for gallstone pancreatitis. The patient has a decrease of hematocrit of 12%, and base deficit for more than 5, and requires 6 liters of fluids. This type of pancreatitis is considered:

A

Severe pancreatitis.

54
Q

The morality rate from acute pancreatitis is 40% when there is a Ranson’s criteria score of:

(1) 0 - 2
(2) 3 - 4
(3) 5 - 6
(4) > 7

A

(3) 5 - 6 Ranson’s criteria has a mortality rate of 40%.

55
Q

Which of the following regarding the prognosis of acute pancreatitis is TRUE?

(1) Mild pancreatitis has organ dysfunction and local/systemic complications.
(2) Moderate pancreatitis has organ failure lasting more than 48 hours and/or local/systemic complications.
(3) severe pancreatitis is characterized by organ failure lasting beyond 48 hours.

A

(3) severe pancreatitis is characterized by organ failure lasting beyond 48 hours.

56
Q

T/F: When treating acute pancreatitis, enteral nutrition should be used rather than TPN.

A

True.

57
Q

The most common systemic complication of acute pancreatitis is

A

hypoxemia caused by acute lung injury.

58
Q

A patient presents with acute pancreatitis. You have provided enteral nutrition and note that the patient has pulmonary symptoms. Treatment of pulmonary symptoms should involve:

A

supplemental oxygen to maintain arterial saturation above 95%.

Continuous pulse oximetry.

59
Q

Amylase and lipase are ordered in acute pancreatitis cases IF

A

the patient presents with gallstones.

60
Q

Treatment of acute gallstone pancreatitis involves:

A

ERCP and cholecystectomy.

61
Q

Which of the following regarding acute pancreatitis pseudocysts is TRUE?

(1) They occur in all patients who have peripancreatic fluid collections after AP.
(2) 50% of patients develop symptoms (pain, weight loss, elevated pancreatic enzymes).
(3) Observation is indicated for both symptomatic and asymptomatic patients.
(4) Spontaneous regression of pseudocysts is rare.

A

(2) 50% of patients develop symptoms (pain, weight loss, elevated pancreatic enzymes).

62
Q

T/F: A pancreatic cyst can become so large that the kidney and stomach become displaced.

A

True.

63
Q

A patient has a past medical history of pancreatic necrosis. The diagnosis was MOST likely made via:

A

Contrast enhanced CT with infection and evidence of air in the pancreas.

64
Q

T/F: studies have shown that minimally invasive surgery provides more improvement in mortality than an open necrosectomy with a drain.

A

True.

65
Q

A patient has recently been diagnosed with pancreatic necrosis after confirmation via a CT scan. There is an abscess in the pancreas. Surgical treatment of the pancreas should include:

A

Drain the abscess with a catheter and provide antibiotics for 28 days. Follow the catheter drain into the pancreas and remove chunks of dead tissue with a clamp or forceps.

66
Q

A hepatic abscess results from:

(1) viral infections that the liver is unable to clear efficiently.
(2) they most commonly originate from hepatic infections of the biliary tree.
(3) They cannot occur from infection of the gastrointestinal tract.

A

(2) They most commonly originate from hepatic infections of the biliary tree.

67
Q

T/F: pyelophlebitis refers to an ascending portal vein infection.

A

True.

68
Q

A patient presents with a hepatic abscess after recovering from osteomyelitis. In regards to this infection and systemic infections, the liver:

A

the liver can form a hepatic abscess from ANY systemic infection and are usually caused by single organisms.

69
Q

The most common organisms that cause hepatic abscesses in patients with systemic infections:

A

Klebsiella pneumoniae

E. coli.

70
Q

The classic description of the presenting symptoms of hepatic abscesses

A

Fever, jaundice, RUQ pain and tenderness.

This presentation is only present 10% of the time.

71
Q

Which of the following regarding hepatic abscesses is TRUE?

(1) US and CT are the most essential elements of diagnosing hepatic abscesses.
(2) Over the last 20 years, percutaneous catheter drainage is no longer used as treatment.
(3) All patients should have surgical removal of the abscess.

A

(1) US and CT are the most essential elements of diagnosing hepatic abscesses.

72
Q

The classic demographic of patients with amebic abscesses is:

A

Hispanic males aged 20 - 40 with a history of travel to (or origination from) an endemic area.

73
Q

The most useful laboratory evaluation of amebic liver abscesses is:

A

anti-amebic antibodies (they are present in 90 - 95% of patients).

74
Q

The mainstay of treatment for amebic abscesses:

A

Metronidazole 750 mg TID for 10 days.

75
Q

Which of the following regarding hemangioma is TRUE?

(1) It is the most common benign tumor of the liver.
(2) men have it 3 times more than women.
(3) Spontaneous rupture is common.
(4) Surgery is required in symptomatic and asymptomatic cases.

A

(1) A hemangioma is the most common benign tumor of the liver.

76
Q

Kasabach-Merritt syndrome is a thrombocytopenia and consumptive coagulopathy that is associated with:

A

Liver hemangioma

77
Q

On radiographs, focal nodular hyperplasia (FNH) of the liver presents with:

A

central fibrous scar with radiating septae.

78
Q

A benign liver cell adenoma presents on imaging as:

A

Abnomral liver architecture.

79
Q

Which of the following is associated with liver cell adenoma?

(1) Young women 20 - 40 years old.
(2) Steroid hormone use or long term OCP use.
(3) Male anabolic hormone
(4) All of these

A

All of these

80
Q

HCC is the most common primary malignancy of the liver, the most common cancer and the 2nd most common casue of cancer-related death globally.

A

False.

81
Q

The most common cause of HCC worldwide:

A

Hepatitis B.

82
Q

The most common cause of HCC in the United states:

A

Hepatitis C

83
Q

The typical patient and presentation of HCC:

A

Men 50 - 60 y/o presenting with RUQ abdominal pain, weight loss and a palpable mass.

84
Q

T/F: cirrhosis is not required for the development of HCC and HCC is not inevitable result of cirrhosis.

A

True.

85
Q

Chronic alcohol abuse and smoking are both associated with (liver):

A

increased risk of HCC.

86
Q

Which of the following regarding HCC is TRUE?

(1) AFP measurements are not helpful in the diagnosis of HCC.
(2) Survival depends on tumors and cirrhosis.
(3) HCC rarely metastasizes to the lung, bone and peritoneum.
(4) Tumors are hypovascular.

A

(2) Survival from HCC depends on the presence and severity of tumors and cirrhosis.

87
Q

The blood supply from the common hepatic and right hepatic arteries come from the (clock):

A

3 and 9 o’clock.

88
Q

A 45 year old Asian female presents with abdominal pain and jaundice. Palpation and imaging reveals an abdominal mass and cholangitis. The patient’s diagnosis is MOST likely:

A

Choledochal cyst.

89
Q

Treatment of a choledochal cyst is:

A

Complete excision and Roux-en-Y hepaticojejunostomy whenever possible due to development of carcinoma in the cyst.

90
Q

The most common disease of the gallbladder and biliary tree:

A

Cholelithiasis

91
Q

> 70% of gallstones in the USA are form by precipitation of

A

Cholesterol and calcium.

92
Q

Brown gallstones are found in bile ducts and are thought to be

A

secondary to infection.

93
Q

Gallstone formation results from:

(1) supersaturation of secreted bile
(2) concentration of bile in the gallbladder
(3) crystal nucleation
(4) gallbladder dysmotility

A

All of these.

94
Q

T/F: diets high in cholesterol can cause cholesterol.

A

True

95
Q

Which of the following patients is not considered a “higher risk pool” for gallstones (and does not require a prophylactic cholecystectomy)?

(1) Patients with hemolytic anemia, such as sickle cell anemia.
(2) Patients with calcified gallbaldder wall (porcelain gallbladder)
(3) Gallstones < 2.5 cm
(4) Long common channel of bile and pancreatic ducts

A

(3) Gallstones that are < 2.5 cm do not require a prophylactic cholecystectomy.

96
Q

Primary gallstones have features of:

A

They are (1) formed de novo, (2) contain calcium bilirubinate and (3) are discovered > 2 years after cholecystectomy.

97
Q

Reynold’s pentad refers to symptoms consistent with ascending cholangitis. These symptoms are:

A

(1) abdominal pain
(2) fever
(3) elevated bilirubin
(4) shock
(5) coma/confusion

98
Q

T/F: treatment of choledocholithiasis is antibiotics.

A

True.

99
Q

The most common types of bacteria found in biliary infections are

A

Enterobacteriaceae (e. coli, klebsiella and enterobacter)

100
Q

A patient presents with choledocholithiasis due to an E. coli infection. Endoscopic retrograde cholangiopancreatography is indicated with

A

endoscopic sphincterotomy.

101
Q

Percutaneous cholangiography is a procedure that involves:

A

Putting a guy wire in the gallbladder’s dilated hepatic duct.

102
Q

T/F: > 90% of bile leaks and strictures are not due to inadvertent injury.

A

False.

103
Q

Management of bile duct injuries should include:

A

Manage early (1st post-op week) and confirm a suspected leak with HIDA. ERCP can localize.

104
Q

A patient presents with a bile duct injury 4 days post-op. You suspect a bile leakage. ERCP shows that the system is not intact. Treatment is:

A

PTC with stents.

105
Q

A late stricture manifests with symptoms of:

A

recurrent cholangitis.

106
Q

Which of the following regarding bile duct cancer is TRUE?

(1) Carcinomas of the extrahepatic bile ducts are common.
(2) Average age of onset is 60
(3) 70% of patients with cholangiocarcinoma have gallstones.

A

(2) The average age of onset of bile duct cancer is 60 y/o.

107
Q

Bile duct cancer is associated with:

A

(1) Primary sclerosing cholangitis
(2) infestation of clonorchis sinensis
(3) congenital cystic disease of the biliary tract.

108
Q

Surgical resection is the only chance for cure of bile duct cancer. Removal should include:

A

remove common bile duct with 1 cm margins.
Reconstruct Roux-en-Y hepaticojejunostomy.
(3) The distal 1/3 of the common bile duct requires a Whipple procedure.

109
Q

Which of the following regarding sclerosing cholangitis is TRUE?

(1) It is an inflammatory disease of the bile ducts that causes fibrosis and thickening of their walls and multiple short, concentric structures.
(2) Disease is sudden
(3) Is not associated with cirrhosis, portal HTN or hepatic failure.

A

Sclerosing cholangitis is an (1) inflammatory disease of the bile ducts that causes fibrosis and thickening of their walls and multiple short, concentric strictures.

110
Q

The typical demographic for sclerosing cholangitis is:

A

Males under 45 years old.

111
Q

Symptoms of sclerosing cholangitis include:

A

fatigue, anorexia, weight loss, jaundice, pruritis.

112
Q

Diagnosis of sclerosing cholangitis includes:

(1) cholangiogram
(2) clinical findings
(3) liver biopsy

A

All of these.

113
Q

Medical treatment of sclerosing cholangitis is:

A

corticosteroids and immunosuppressants.

114
Q

T/F: The 5 year survival rate of sclerosing cholangitis (Treated via surgery) is 60%.

A

True.

115
Q

Which of the following regarding functions of spleen physiology is TURE?

(1) erythrocytes that cannot be repaired are destroyed in the white pulp.
(2) Heinz bodies contain denatured hemoglobin.
(3) Pappenheimer bodies are nuclear remnants of RBCs.

A

(2) Heinz bodies contain denatured hemoglobin.

116
Q

The specific immune function of the spleen includes:

A

It is the largest producer of IgM.

117
Q

The non-specific immune function of the spleen includes:

A

Contains 25% of the fixed macrophages and is more efficient than liver removal of incompletely opsonized bacteria.

118
Q

Post splenectomy sepsis is increased risk of systemic infection in patients s/p splenectomy. It is associated with:

A

gram positive encapsulated bacteria (STREPTOCOCCAL organisms).

119
Q

A 8 year old patient recently had a splenectomy. The patient has a past medical history of sickle cell anemia. You diagnose the patient with post-splenectomy sepsis caused by streptococcus pneumonia. The patient had symptoms that were MOST likely:

A

(1) hypotension
(2) coagulopathy
(3) MSOF

120
Q

A 11 year old patient s/p splenectomy presented with hypotension, coagulopathy and MSOF. You diagnose the patient with post splenectomy sepsis. The MOST common organisms that cause this are:

A

(1) streptococcus pneumonia
(2) hemophilus influenzae
(3) Neisseria meningitidis

121
Q

Splenic trauma presents with

A

Left hemothorax, rib fractures, LUQ pain and hypotension.

122
Q

T/F: if a patient has splenic trauma, you should remove as much of the spleen as possible.

A

False.

General Surgery (12 decks)

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