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Surgery > NMS > Flashcards

NMS Flashcards

1
Q

Indications to think about AAA repair

A

in men -5.5 cm
in women -5 cm
*with life expectancy of at least 2 years

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2
Q

Aneurysms repaired endovascularly needs long-term f/u. Why?

A
  • f/u for presence of endoleaks (where the anerysm sac is perfused otuside the lumen of the endograft).
  • endotension is the pressure that can occur within the ecluded aneurysm
  • Both will increase risk of rupture
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3
Q

What to do when someone presents with hypotension, syncope and pulsatile abdominal mass?

A

suspect rupture of AAA
immediate to OR
**active resuscitation in the ED may be counterproductive bc and increase in volume and BP could convert a contained rupture into a free intraperitoneal rupture

If hemodynamically stable (no hypotension, no pulsatile mass) –> CT scan or US of abdomen

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4
Q

3 days post-AAA repair, pt develops fever and a small amt of bloody diarrhea. What to suspect? What to do?

A

ischemic injury to colon (usu involves rectosigmoid seg)

  • immediate sigmoidoscopy
    1) if ischemia is limited to mucosa
  • NPO, NG drainage, abx
  • MIVF, hct, O2 and perfusion
  • freq re-examination, repeat endoscopy
    2) if full thickness necrosis of the bowel
  • resection of nonviable bowel, end colostomy and hartman pouch
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5
Q

Any pt with aortic surgery and implantation of a vascular graft who develops upper GI bleeding should be evaluated for?

A

aortoenteric fistula 2/2 to erosion of graft into 3rd or 4th part of duodenum,

dx is confirmed by endoscopy, CT abd, or angiography

*impt bc can have a small or sentinel bleed for 1 or 2 days and then followed by massive bleed
treatment -removal of graft, repair of GI tract, extra-anatomic bypass

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6
Q

If you suspect chronic mesenteric ischemia (post-prandial pain, fear of eating –> weight loss), what to do first to diagnose? How to treat?

A
  • mesenteric arteriogram

- revascularization

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7
Q

gold std to diagnose DVT, management?

A
  • venous duplex US
  • anticoagulation (heparin (half life of 90 min) or LMWH) with 70-100 U/kg bolus followed by maintenance infusion of 15-25 U/kg/hr for 4-6 days
  • anticoagulation is needed fro 3-6 months -usu with coumadin and wants INR btw 2-3
  • monitor PTT (ideally at 1.5-2x normal)
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8
Q

Most common ABG finding of someone with PE

A

decreased PCO2 due to hyperventilation -resp alkalosis

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9
Q

What is phlegmasia cerulea dolens?

A 
phlegmasia = inflammation
cerulea = cyanotic
dolens = painful

acute interruption of venous outflow from obstruction 2/2 to pelvic mass. it is a severe DVT. Treat with anticoagulation and leg elevation and careful observation. Rarely, do you need surgery

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10
Q

Guidelines for preop eval for pts undergoing surgery for reflux

A
  • Upper endoscopy w/ biopsy to confirm cause

- esophageal manometry to ensure intact esophageal peristalsis before surgery to ensure normal swallow post-op

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11
Q

sliding hiatal hernia (type 1) vs paraesophageal hernia

A

Hiatal hernia is when GE junction is herniated upward with the stomach, usu asymp, if symp treat with medical therapy

Paraesophageal hernia: GE junction remains in place, except stomach herniates up into diaphragm next to the esophagus and can incarcerate, cause gastric volvulus

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12
Q

There are 4 types of gastric ulcers. Which ones are assoc with low acid output? Which are assoc with high acid output

A

Type 1, 4 –> low acid output (usu antrectomy without vagotomy)
Type 2, 3 –> high acid output (usu antrectomy with vagotomy

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13
Q

gastric cancer can be divided into intestinal type and diffuse. Which one has more favorable prognosis? What is linitis plastica?

A

intestinal type has better prognosis
linitis plastica is a diffusely infiltrating gastric carcinoma that has very poor prognosis that involves all layers of the stomach

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14
Q

A duodenal ulcer with a fresh clot and a visible artery at its base is at highest risk of rebleeding. This type of ulcer is usu found where and involves which artery? How to treat?

A

usu in posterior duodenum and involves the gastroduodenal artery

manage with either upper endoscopy or surgery

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15
Q

Management of gastric and duodenal ulcers is similar except that you must do what with gastric ulcers

A

biopsy bc gastric ulcers have risk of becoming cancer that must be done weeks later after acute bleed is resolved

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16
Q

TIPS is for?

A

transjugular intrahepatic portosystemic shunt in which an intrahepatic portion of a hepatic vein is cannulated percutaneously followed by the creation of an artifical tunnel btw the hepatic vein and portal vein to help with treatment of consequences of portal HTN (esophageal, gastric varices, etc)

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17
Q

How does h/o of chronic pancreatitis lead to gastritis and gastric varices?

A

gastric varices may result from splenic vein thrombosis (splenic vein lives behind the pancreas –> inflammation –> thrombus –> non-cirrhotic portal HTN)

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18
Q

Endoscopic sclerotherapy or variceal banding controls the bleeding in varices with 1/4 of cases develop rebleeding. Therefore repeat in 48 hours. Which is preferred: sclerosing or banding?

A

banding b/c less injury to esophagus

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19
Q

cirrhotic man presents to ED with bleeding from esophageal varices. How to manage

A

1) initial steps: attempt to band the varices, correct coagulopathy assoc with cirrhosis - increased PT (low factors II, VII, IX, X); fix with FFP; correct thrombocytopenia if 3 options: 1. balloon tamponade should be done only in intubated pts b/c high risk of aspiration, 2. TIPS (1st choice), 3. portosystemic shunt surgically (rare)

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20
Q

A cholecystectomy is a “clean-contaminated situation.” What’s the abx for operation?

When to do cholecystectomy in someone with acute cholecysitis?

A

single, preop dose of a first-gen cephalosporin

If pt presents w/ acute cholecystits, start abx, get blood cultures, 2nd gen cephalosporin, IV resusc, NPO, NG tube if n/v, perform lap cholec w/in 72 hours of symptoms onset

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21
Q

Pancreatic pseudocyst can occur 6 wks after an episode of acute pancreatitis and present with abd pain, anorexia, persistent elevation of serum amylase and inability to eat due to early satiety caused by pseudocyst compressing on posterior wall of stomach. How to confirm? What to do?

A

Confirm with CT abd/pelvis
medical support with NPO feeding, observation and TPN
If fails to improve in 6 wks, intervention (IR guided drainage, stenting of pancreatic duct with ERCP, internal drainage of fluid into GI tract can be done surgically or endoscopically), cystogastrostomy when cyst is connected to posterior wall of stomach.

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22
Q

Multilocular cyst with calcification in the wall and internal echoes in liver, suspect…

A

echinococcal cyst.
serologic test is usu +
treatment: operative sterilization: inject cyst under controlled operative conditions using hypertonic saline, followed by excision of the cyst.
Don’t spill as it can cause anaphylactic rxn

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23
Q

What is the best test to diagnose a hepatic hemangioma?

A

MRI with IV gadolinum

hemangioma will appear as a vascular lesion that fills from the periphery to the center

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24
Q

What’s the most common tumor that metastasizes to the intestine?

A

melanoma

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25
Q

Observation takes place for gallbladder polyps unless the polyp is how big?

A

> 2 cm b/c of the increased risk of developing adenocarcinoma

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26
Q

Usual treatment of acute pancreatitis

A

NPO feeding, IV hydration, pain control and observation
Find the cause of the pancreatitis
If gallstone related, wait 24-48 hrs to do lap cholecystectomy

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27
Q

What to suspect and do when a patient is recovering from percutaneous pancreatic abscess drainage when he suddenly becomes hypotensive and the drainage becomes bloody?

A

erosion of the catheter or abscess into a major artery (splenic, gastroduodenal, superior mesenteric arteries or a pancreatic vessel). Dx involves angiography. manage with embolization.

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28
Q

Which hepatic lesion is most assoc with OCP use

A

hepatic adenoma that shrinks when you stop OCP

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29
Q

Focal nodular hyperplasia requires no treatment as it has 0 malignant potential. Although it requires a liver biopsy for dx, what can you see on CT scan.

A

central stellate scar

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30
Q

What to do with hepatic adenomas in relations to pregnancy

A

hepatic adenomas often increase in size during preg and rupture. therefore impt to remove beforehand

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31
Q

Hepatic resection is most commonly performed for which 2 conditions

A

1) primary HCC
2) colon met to liver

best when lesion is

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32
Q

how long does a pt need to be on IV abx after being diagnosed with hepatic pyogenic absceses

A

4-6 wks

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33
Q

What type of appendix may not present with the classic RLQ pain?

A

retrocecal appendix

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34
Q

Do they respond to radiation, chemo?
rectal cancer
coon cancer
anal cancer

A

rectal cancer responds to radiation
colon cancer responds to chemo
anal cancer responds to both

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35
Q

Best initial step when you suspect a SBO?

A

abdominal x-ray specially an obstructive series which includes an upright P-A, and lateral CXR and a flat and upright abdominal x-ray

36
Q

Conservative management for SBO is possible if pt is hemodyn stable without marked leukocytosis, fever, acidosis, or localized tenderness and no x-ray finding of ischemia, closed loop obstruction or perf. What is involved in conservative management

A

IV fluids
NG tube
serial physical exams, labs, and abd x-rays

37
Q

SBO + heme positive stool in rectum, suspect?

A

obstructing tumor or ischemic bowel

38
Q

SBO + no BM but positive flatus

A

partial SBO

39
Q

SBO + small amt of diarrhea

A

typical of partial obstruction

40
Q

Pt presents with pain out of proportion to physical exam. Suspect what? And do what to confirm dx?

A

Suspect mesenteric ischemia
Can do CT angiogram
Even if pt improves with medical management, impt to do revascularization

41
Q

Elderly person with 1 d h/o of N/V, severe abdominal pain out of proportion to physical exam.
What are some worrisome signs that push for immediate OR

A
  • high WBC count
  • low WBC count
  • worsenign pain over the next hour
  • moderate to severe metabolic acidosis
42
Q

Ileal pouch-anal anastomosis can result in pouchitis which can present as fever, blood tinged diarrhea and pain on defecation. On endoscopy, you can see a hemorrhagic mucosa with edema and small ulcerations. This can happen to half of patients with an ileal puch. How to treat?

A

metronidazole

43
Q

Match the IBD to these characteristics:

1) involves not all the layers; mucosa initially; crypt abcesses, pseudopolyps, raised ulcerations
2) skip lesions, all layers/transmural, severe perineal disease, fistulas, stritures

A

1) UC

2) chrohns

44
Q

someone with UC coming in with abd pain, distension, fever and bloody diarrhea. Suspect? What’s part of management

A

TOXIC MEGACOLON
Initial managemetn:
-NPO, NG tube, TPN, IV fluids, broad spec abx (cipro/flagyl), high-dose IV steroids with close observation (with freq abd exams and radiographs)

If no improvement in 3-6 days, signs of perforation, or worsening clinical picture –> surgery (usu ileostomy with formation of hartman pouch and total abdominal colectomy)

45
Q

Which type of appendicitis causes pain during rectal examination?

A

retrocecal or deeper ones

46
Q

Is biospy necessary of a tumor at the tip of appendix, less than 2 cm in diameter with no evidence of spread to cecum or nearby nodes?

A

No. It’s likely a small carcinoid tumor.

routine appendectomy can be performed.

47
Q

When is it an indication for right colectomy in a pt with carcinoid tumor of appendix?

A

when the tumor is 2 cm or bigger or involvement of base of the appendix or cecum

48
Q

For carcinoid, which 2 baseline levels should be obtained as principal determinants of malignancy involve the biologic behavior of the tumor rather than histologic

A
  • urinary 5-HIAA

- serum serotonin

49
Q

Why are diverticula assoc with bleeding?

A

colonic diverticular bleeds –> underlying vasa recta artery penetrating the bowel wall thru the neck or the apex of a diverticulum and become eroded (right-sided diverticula are more prone to bleeding despite diverticula being more commonly found on left)

50
Q

What are 2 ways in the angio suite that can reduce bleeding in GI system?

A

1) vasopressin -however assoc with coronary vasoconstriction and 50% of pts have recurrent bleeding within 12 hrs after d/c of med
2) embolization -but increased risk of transmural intestinal necrosis of large bowel

51
Q

Risk factors for sigmoid volvulus. How to confirm dx?

A

debilitated older patients in nursing homes often as a result of chronic laxative use, chronic illness, or dementia.

Barium enema confirms the volvulus

52
Q

How to treat sigmoid volvulus

A

If hemo stable, can detorse the sigmid colon by rigid proctosigmoidoscopy and placement of rectal tube.

Definitive treatment involves either sigmoid colectomy with diverting colostomy OR resection with primary anastomosis

53
Q

Acute pseudo obstruction aka Ogilvie syndrome is an acute massive dilation of the cecum and right colon w/o evidence of mech obstruction. How to manage?

A
  • if colon diameter exceeds 11-12 cm, endoscopic decompression is indicated
  • can also try neostigmine, a parasympatholtic agent to increase colonic tone. If unsucessful, can do surgical decompression of cecum or a right colectomy
54
Q

Management of internal vs external rectal prolapse

A

internal –> high-fiber diet, may be possible to avoid surgery

external –> surgery (1. rectopexy: rectum is fixed to sacrum w/o removing a portion of rectum; 2. transabd rectosigmoid resection; 3. perineal approach

55
Q

Anal fissures are almost always located? Management?

A

in posterior midline

  • bulk agents, stool softeners, sitz baths
  • if deep and chronic, can do sphincterotomy
56
Q

Fistula-in-ano. What is it and how to treat?

A

residua of a previous abscess that failed to completely heal leading to a chronic tract formed with an INTERNAL connection to an anal crypt and an external connection to the perianal skin.

Treatment involves unroofing the tract, draining any undrained collection and allowing the tract to re-epitheliaize.

57
Q

Management of perianal, ischioanal, intersphincteric and supralevator involves

A

drainage

NOT ABX

58
Q

pain and drainage in sacrococcygeal area of lower back , suspect…

How to treat?

A

pilonidal abscess –> infection in a hair-containing sinus in the sacrococcygeal area.

Treatment involves unroofing the abscess, removing all hair, and leaving the wound open to heal by secondary itnention

59
Q

FNA of thyroid nodule. How to manage if cytology shows: colloid nodule?

A

benign result. No need for surgery,

f/u w/intermittent US

60
Q

FNA of thyroid nodule. How to manage if cytology shows papillary carcinoma?

A

total thyroidectomy

61
Q

FNA of thyroid nodule. How to manage if cytology shows medullary carcinoma?

A

total thyroidectomy , central LN disection and careful eval of lateral LN basins

62
Q

FNA of thyroid nodule. How to manage if cytology shows psammona bodies

A

total thyroidectomy as psammona bodies are indicative of papillary carcinoma

63
Q

FNA of thyroid nodule. How to manage if cytology shows amyloid deposits

A

amyloid and calcitonin –> medullary so total thyroidectomy and central LN dissection

64
Q

FNA of thyroid nodule. How to manage if cytology shows undifferentiated cells

A

anaplastic cancer

chemo, radiation or salvage operative therapy.

65
Q

FNA of thyroid nodule. How to manage if cytology shows Hurthle cells

A

adenoma or a low grade cancer so lobectomy but if cancer is present then a total thyroidectomy

66
Q

FNA of thyroid nodule. How to manage if cytology shows follicular cells

A

thyroid lobectomy to figure out if follicular cells are either adenoma or carcinoma based on absence of capsular/vascular invasion

67
Q

FNA of thyroid nodule. How to manage if cytology shows lymphocytic infiltrate

A

if lymphoma –> radiation

if thyroiditis –> medical

68
Q

Comp of thyroid surgery

A
  • injury to recurrent laryngeal nerve (u/l hoarsness; if b/l can lead to airway compromise)
  • injury to external branch of superior laryngeal nerve (leading to high pitchedsinging voice)
  • devasc of all 4 parathyroids –> hypocalcemia
69
Q

Operative strategy for gastrinoma (serum gastrinoma > 1000 is diagnostic); can confirm with secretin stimulation test when secretin causes hyper stimulation of gastric when it should be suppressing

A

Location of the tumor (intraop endoscopy and ultrasound), removal with enucleation if small enough

70
Q

When do you remove an adrenal incidentaloma

A

If it’s functional or greater than 5 cm

71
Q

What’s the tumor marker for papillary and follicular cell cancer of thyroid

A

thyroglobulin

72
Q

Common presentation of melanoma metastasis in GI system.

A

Small bowel obstruction

73
Q

Sarcoma presents as a firm, painless mass. What’s the benefits of FNA, adjuvant radiohterapy?

A

FNA is of no use at all
Do wide excision to prevent local recurrennce
Adjuvant radiotherapy is good for preventing recurrence

74
Q

Direct and indirect hernia in relations to inferior epigastric vessels

A

direct: medial to inferior epigastric
indirect: lateral to inferior epigastric

75
Q

blood nipple discharge is most commonly due to? How to treat?

A

most commonly due to intraductal papilloma

needs to be locally excised

76
Q

DCIS usu manifests as incidental microcalcifications on mammography. Is surgery necessary?

A

simple mastectomy is the current gold std for diffuse and multicentric DCIS b/c DCIS has malignant potential with 10-20% of lesions diagnosed as DCIS having infiltrative component at excision. C/l breast can be affected as well.

77
Q

LCIS confers an increased risk of breast cancer in both breasts. How to treatm

A

either excision or close observation w/ exam and mammograms every 6 months for at least the next 2 years.

78
Q

Sclerosing adenosis manifests as clustered microcalcifications on mammography. Assoc with malignancy?

A

1.5-2x increased risk therefore routine f/u is necessary

79
Q

Atypical ductal hyperplasia is assoc with how much increased risk in cancer?

A

4-5x increased risk
should get risk reduction with estrogen blocking meds
needle localization and excision

80
Q

Most common breast mass in a woman younger than 25. What establishes dx. how to treat

A

fibroadenoma
biopsy confirms
can observe but can also excise if pt desires it or too big

81
Q

What is phyllodes tumor? aka cystosarcoma phyllodes

A

large bulky mass of variable malignant potential with occasional ulceration of the underlying skin.

Treat with local excision with generous margins

82
Q

Inflammatory carcinoma of breast presents as red edematous breast with an underlying mass. Worse or better prognosis than infiltrating ductal carcinoma

A

worse

83
Q

What is peuu d’orange assoc with

A

when there’s a breast mass that is edematous and appears like a surface of an orange

84
Q

A breast cancer with LN palpablein the supraclavicular area represents?

A

stage III disease and first-line treatment is systemic not surgical

86
Q

95% of pts with pagets disease of the breast (breast lesion) has assoc?

A

underlying pathology either infiltrating ductal carcinoma or DCIS

therefore presence of paget cells prompt a high suspicion for cancer and should be treated with a central partial masectomy and radiation or mastectomy

87
Q

Hartman’s operation

A

surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy. Its use is limited to emergency surgery when immediate anastomosis is not possible.

Surgery (6 decks)

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