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SURGERY CARDS > NMS GI > Flashcards

NMS GI Flashcards

1
Q

What 2 types of gallbladder pathology predispose to gallbladder cancer

A
  1. polyps > 2cm

2. calcified (porcelain) gallbladder

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2
Q

how to work up pancreatitis (imaging)

A

obstructive series imaging;

CT not indicated unless complicated! (really?)

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3
Q

Treatment for pancreatitis

A

palliative: NPO, IVF, pain meds, observation, +/- TPN

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4
Q

how to treat gallstone pancreatitis

A

palliative treatment (npo, ivf, pain meds, observation, +/- TPN) until resolution of pancreatitis symptoms (usually 48h) followed by cholecystectomy and CBD stone removal (ERCP?)

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5
Q

if patient with acute pancreatitis begins to worsen and look ill, what are you worried about? how do you work up and treat it?

A

severe necrotizing pancreatitis with SIRS and thirdspacing of fluid –> need CT to look for other causes of decompensation (Unlike complicated pancreatitis) –> FLUID RESUSCITATION is essential, ventilation if devt of ARDS

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6
Q

correlation of amylase levels and pancreatitis

A

NONE

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7
Q

indications to intubate

A

ABGs (PaO2 45) and CLINICAL STATUS

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8
Q

treatment of pancreatic abscess

A

aspirate and culture for abx, then drain

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9
Q

specificity of amylase for pancreatitis

A

poor –> can be elevated in peripancreatic inflammation eg mesenteric ischemia, volvulus, etc.

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10
Q

How do you treat a pancreatic pseudocyst

A

manage expectantly for 6 weeks: NPO, IVF, TPN; if no improvement after 6 weeks, need to DRAIN surgically

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11
Q

Why wait 6 weeks to operate on pancreatic pseudocyst (2 reasons)

A

1) often resolve spontaneously

2) in 6 wks, enough fibrous tissue has formed to facilitate surgical closure

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12
Q

Are hepatic lesions usually benign or malignant? what are common types of each

A

usually BENIGN

1) benign: cystic (simple cyst) or solid (hemangioma)
2) malignant: HCC, mets, cholangiocarcinoma

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13
Q

what are 3 types of hepatic collections and their treatment

A

1) simple cyst: ntd?
2) multiloculated cyst: operative sterilization and excision
3) abscess: if pyogenic, IV abx + drainage; if amebic, tx with metronidazole (no drainage)

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14
Q

Differential of solid hepatic masses (benign and malignant)

A

1) benign: hemangioma, focal nodular hyperplasia, hepatic adeonoma (+/-)
2) malignant: HCC, metastatic cancer

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15
Q

most common solid hepatic mass

A

hemangioma (benign)

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16
Q

dx of hemangioma in liver

A

RBC scan (inc uptake) or CT with CONTRAST (out –> in enhancement); avoid bx if possible –> risk of bleeding

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17
Q

tx of hemangioma, focal nodular hyperplasia, and hepatic adenoma

A

HEMANGIOMA: none (unless symptomatic)
FOCAL NODULAR HYPERPLASIA: non
HEPATIC ADENOMA: resection if large/persistent (risk of rupture or devt of HCC)

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18
Q

dx of focal nodular hyperplasia. how do you tell its not hepatic adenoma or cancer

A

often see CENTRAL STELLATE SCAR on imaging; hard to distinguish from more dangerous pathology, so BIOPSY necessary

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19
Q

which hepatic lesion is a/w oral contraceptive use/pregnancy

A

hepatic adenoma

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20
Q

tx of HCC

A

if nonmetastatic (do CT first), surgical

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21
Q

tx of hepatic abscess

A

if pyogenic, small/multiple –> IV abx x 6 wk; large/singular –> need to drain + abx; if AMEBIC: just metronidazole (no surg)

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22
Q

mgmt of small bowel obstruction

A

KUB (kidneys, ureter, bladder), NPO, IVF, NG tube; watch for a couple of days (most RESOLVE SPONTANEOUSLY); take to OR if worsened or new indications

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23
Q

indications to take SBO to OR

A
  1. high fever
  2. high WBC
  3. decreased pH (suggests ischemia)
  4. peritonitis/local tenderness
  5. failed medical mgmt (dont improve while observed)
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24
Q

definition and treatment of closed loop obstruction

A

def: inlet and outlet of loop of bowel is obstructed –> tx: operate

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25
Q

operative mgmt of closed loop obstruction

A

assess viability of bowel; if dead, cut it out; if possibly viable, two options:

  1. resect, reanastomose
  2. close, observe, reexplore in 24 h
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26
Q

how to confirm dx of SBO if question of SBO vs. ileus

A

upper GI with SBFT (small bowel follow through:

radiologic examination of the small intestine from the distal duodenum/duodenojejunal junction to the ileocecal valve.

An X-ray examination of the most proximal small bowel (duodenum) is typically done together with an examination of the esophagus and stomach and is called an upper GI series.

  1. Patient drinks radio-opaque contrast, most often barium
    2. X-ray images of abdomen are made at timed intervals.
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27
Q

What post op risks a/w accidental enterotomy (surgical incision into intestine);
(2 things)

A
  1. post op leak

2. small bowel fistula

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28
Q

how to work up and manage stable patient with (possible) ischemic bowel

A

INITIALLY, need dx:

1) sigmoidoscopy (should see ischemic colon) or if negative
2) angiography (gold standard); if no evidence of NECROSIS, medical mgmt : fluids, npo, abx

LATER can do prophylactic revascularization and longterm ASA

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29
Q

What operative risks a/w polycythemia? how do you manage them?

A

polycythemia –> hypercoagulable state; need to correct prior to procedure (phlebotomy, hydration)

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30
Q

what does bloody diarrhea suggest in ischemic bowel? mgmt

A

suggests NECROSIS ; do SIGMOIDOSCOPY –> if just mucosa, can manage medically; if involves full thickness, requires SURGERY

31
Q

difference in etiology of colonic vs. small bowel ischemia

A

colonic is rarely 2/2 an arterial obstruction (more likely low flow state) –> less likely to benefit from or be diagnosed by angiography

(check this)

32
Q

Most common causes of SBO in patient with Crohn’s disease

A

stricture

33
Q

mgmt of fistula or stricture a/w crohns

A

NONOPERATIVE: npo, tpn, bowel rest, observation;

if no resolution tx surgically

34
Q

how to manage perianal problems in crohns

A

metronidazole; surgery if abscess

35
Q

timeline of increased cancer risk with ulcerative colitis? what are implications for surveillance frequency?

A

minimal inc in cancer risk for first 10 years, then increases steadily. after 8 yrs need colonoscopy every 1-2 years –> resection if severe dysplasia on biopsy

36
Q

what is pouchitis? how do you treat it

A

inflammation of ileal pouch after colectomy; seen in 1/3 of patients with ileal pouch; treat with metronidazole (like perianal problems in Crohn’s)

37
Q

treatment of toxic megacolon

A

MEDICAL management: bowel rest, decompression (NG tube), IV steroids –> if no improvement in a few days or new findings (free air, peritonitis, fever, etc.). SURGERY

38
Q

What does air in wall of colon suggest

A

IMPENDING PERFORATION –> operative intervention

39
Q

how to interpret pyuria in workup of appendicitis

A

could be UTI/pyelonephritis, or peri-appendiceal abscess; if not gross pyuria, could STILL BE APPENDICITIS (periappendiceal inflammation)

40
Q

radiographic sign of crohns’ disease

A

string sign

41
Q

how to elicit tenderness with retrocecal appendicitis

A

rectal exam!

42
Q

most common ages for appendicitis

A

BIMODAL (25 and 65)

43
Q

why is appendicitis bad in the very young and very old

A

very young: often present after perf

very old: present with vague, nonspecific symptoms

44
Q

what to do if appendicitis in pregnant woman

A

OPERATE: peritonitis much more dangerous than appendectomy

45
Q

what does carcinoid tumor look like? where is it found? how do you test for it?

A

yellow mass, often in appendix or small bowel; more common in appendix, but more likely to met from small bowel (esp ileum); check for 5-HT and 5-HIAA levels in urine

46
Q

management of carcinoid tumor in appendix-how do size and location affect mgmt?

A

if > 2cm or in base of appendix, need to perform RIGHT HEMICOLECTOMY;
if < 2 cm and at tip, can get away with SIMPLE APPENDECTOMY

47
Q

mgmt of carcinoid tumor in small bowel

A

RESECTION, esp of ileum and lymph nodes (high rate of metastasis to liver)

48
Q

what is recommended for screening of CRC

A

if NORMAL RISK: starting at age 50 y, get
1) colonoscopy q 10y
OR
2) sigmoidoscopy q 5y and FOBT (fecal occult blood test) q 1y

49
Q

what pmh increases recommended screening of crc? how?

A

CHECK THESE

1) FAP: sigmoidoscopy q 1y (will see polyps in sigmoid);
2) HNPCC (Lynch): colonoscopy q 1-2y (few polyps, might be in nonsigmoid)
3) adenomatous polyp or CRC resection: colonoscopy 3y after removal, then q 5y. CEA q 3m for CRC resection

50
Q

initial treatment for hemorrhoids; treatment if refractory

A 
INITIAL: sitz baths, stool softeners, increased fiber;
REFRACTORY: depends on location;
internal: endoscopic banding/ligation; 
external: surgical excision;
COLONOSCOPY/SIGMOIDOSCOPY to r/o cancer
51
Q

types and treatment of polyps (2)

A

1) PEDUNCULATED: usually can excise with snare (polypectomy) –> partial colectomy, else scope every 3 years;
2) SESSILE: excise (2 cm surgically); need f/u surveillance colonoscopies

52
Q

tx of colon cancer

A

SURGICAL RESECTION +/- adjuvant chemotherapy (5-FU, levamisole); NOT radiation

53
Q

what labs to follow with colon cancer

A

CEA (for recurrence) and LFTs (for liver mets)

54
Q

what histology suggests poor prognosis with CRC (3)

A

1) poorly differentiated
2) mucin-producing
3) signet-cell

55
Q

potential causes of obstruction following colectomy (2 big categories)

A
  1. LEAK: from anastomosis –> inflammatory ileus
  2. MECHANICAL: adhesions, internal hernia, obstructed anastamosis; late complications include cancer recurrence and stricture
56
Q

workup and treatment of anastamotic leak

A

WORKUP: often see feculant matter from wound –> CT to see if drainable collection, gastrograffin enema or colonoscopy if unsure about patency of anastomosis; TREATMENT: observation (npo, ivf) –> most will close (unless distally obstructed –> operate)

57
Q

how does location affect tx of rectal cancer

A

if within 5 cm of anal verge: need to abdominoperineal resection (cant keep margins clean without destroying anal sphincter) –> permanent ostomy;

if > 5 cm from anal verge, can do low anterior repair

58
Q

how does rectal cancer spread? to where

A

DIRECT EXTENSION (anterior structures include bladder, ureter, prostate, seminal vesicles) and LYMPHATICS (internal iliac nodes, sacral nodes, inferior mesenteric nodes_

59
Q

what to do with large, bulky rectal cancer

A

PREOP RADIATION (often effective enough to not require surgery!_

60
Q

tx of anal cancer

A

NIGRO PROTOCOL: chemo, radiation, NO SURGERY

61
Q

tx of diverticulitis (depending on patient)

A

HEALTHY patient: liquid diet, abx x 7-10d;
ELDERLY: IVF, NPO, bowel rest, IV abx;
if >1 episode or COMPLICATIONS (perf, abscess): ELECTIVE RESECTION (in 4-8 weeks after colonoscopy to rule out cancer)

62
Q

initial workup upper GI bleed

A

NG lavage to make sure not upper GI bleed –> if positive, get upper endoscopy; else get anoscopy

63
Q

Most common causes lower GI bleed

A

1) AVM

2) diverticulosis

64
Q

does lower GI bleed need to be admitted if bleeding stops

A

YES; need to observe and determine etiology (make sure not cancer); colonoscopy when stable

65
Q

why not perform colonoscopy while pt is actively bleeding

A

1) cant see anything

2) higher perf risk (cant see wall)

66
Q

how to stop diverticular/AVM bleeding?

A

vast majority stop by themselves-just manage expectantly; if dont stop, can try colonoscopic or operate

67
Q

what to do if persistent lower GI bleeding

A

can try colonoscope for tx of AVM or polyps; if persistent bleeding and 4-6 units of blood given, need to ID source (angiogram if stable, RBC scan if unstable) and go to OR

68
Q

dx and mgmt of sigmoid volvulus

A

dx by barium enema; tx: 1) “detorsing” by rigid proctoscope if STABLE; or 2) sigmoid colectomy with colostomy/anastomosis depending on patient stability

69
Q

tx of cecal volvulus? how does it differ from sigmoid volvulus?

A

URGENT SURGERY : detorsion , colectomy, cecopexy; (nonoperative tricks used for sigmoid volvulus don’t work)

70
Q

what is oglvie syndrome, and how is it treated

A

pseudo-obstruction, esp of cecum/rectum; if colon < 8 cm, just watch; if colon > 10 cm decompress endoscopically or surgically

71
Q

most common location and treatment of anal fissure

A

most common location: posteromedial; tx: sitz baths, high fiber diet, stool softeners (like hemorrhoids)

72
Q

name 2 types of esophageal diverticula. where are they located? how do they form? how do you treat them ?

A

1) ZENKER’s (above cricothyroid muscle)
2) epiphrenic (above LES);
form 2/2 inappropriate muscle tone –> increased pressure –> forced diverticulum out; sx include choking, regurgitation of unswallowed food, bad mouth odor; tx by cutting muscle + excising diverticulum

73
Q

tx of achalasia

A

calcium channel blockers + surgical release of lower esophagus (open or endoscopically)

74
Q

how to treat esophageal tumors

A

depends on locations:
lower 1/3 –> surgery
mid 1/3 –> surg vs. chemo/rads
upper 1/3 –> chemorads

SURGERY CARDS (8 decks)

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