OME Gen Surg June 2017 Flashcards
Components of Child-Pugh score
Low alb, high bili, high INR, ascites, encephalopathy
Why treat dvt with heparin bridge to coumadin
Because coumadin makes hypercoagulable initially (disrupts proteins c and s)
manage a surgical wound infection presenting as fever and wound erythema and tenderness ~7 days postop
US to rule out deep abscess not palpable on exam
PO Abx if cellulitis only
IV Abx if toxic appearing
I and D if abscess
Laparotomy if dehiscence or evisceration
doing all postop care right, but now postop day 3 fever anyway, what is it probably due to
UTI
POD 1 atelectasis POD 2 PNA POD3 UTI POD 5 DVT POD 7+ wound
72 hours after surgery pt has htn tachyc hallucinations diaphoresis and ams
what is it
she is one step from ___
alcohol withdrawal
she is one step from seizing
general mechanism of alcohol withdrawal
upregulation of GABA receptors (compensating for chronic neural inhibition/depression) then withdrawal of the depressant leaves autonomics overly excitatory
order of alcohol withdrawal symptoms
hypertensiona and tachycardia then tremor then diaphoresis and anxiety then hallucinations - visual usually ending with seizure
really old patient with total colonic dilation the only diagnosis is ______
treat with
Ogilvie syndrome
treat with rectal tube for decompression or neostigmine
what part of bowel does Ogilvie syndrome affect
colon only, like a paralytic ileus of the colon only
what part of the bowel does a paralytic ileus affect
the whole thing, the ENTIRE GI SYSTEM
how does duration of anuria after cath removal affect management
6 hours
(normal to urinate 4x/day, so roughly every 6 hours)
reassure before then
intervene after then - in/out cath to assess for residual volume – give fluids if low, leave cath in if high
abdominal compartment syndrome
- classic presentation
- management
ex lap trauma case got tons of fluids to support pressure intraoperatively and can’t close abdomen at end of case because both organs and fascia are swollen
leave open and cover with wound vac or absorbable mesh to prevent infection
why don’t you close abdominal compartment syndrome, aka ex lap trauma case got tons of fluids to support pressure intraoperatively and can’t close abdomen at end of case because both organs and fascia are swollen
because even if forced closed, organs will die from pressure and patient will die
ZERO urinary output in hospitalized patient suspect these 2 things
kinked foley most commonly, very rare even with big hypotensive hit / hemorrhage to have ZERO output, so reposition foley or give it a flush
ATN e.g. from hypotension/ischemia possible but will usually have SOME output early on in first 12 hours or so, so really suspect kinked foley
treat alcohol withdrawal
IV lorazepam or other short acting benzodiazepine
when do you use chlordiazepoxide in setting of alcohol withdrawal
to prophylax against withdrawal (long acting oral benzo)
use short acting benzo like lorazepam, to treat actual withdrawal
72 year old guy postop after significant abdominal surgery gets delirious, what do you do first
first supplement oxygen e.g. 100% non-rebreather
then lots of things as you work him up e.g. BMP blood glucose pause any narcotics cxr
how does a 100% non-rebreather oxygen mask work
what is the advantage
100% O2 inhaled from inflated bag, exhale through one-way valve into room air
allows for higher oxygen delivery than nasal cannula
TF
postop foley urine output gradually declining to concerning levels after a period of hypotension but patient has since been hemodynamically stabilized – first step reposition and flush catheter?
F
reposition and flush if acute ZERO urine output highly suspicious of kinked foley obstruction
gradual urine output drop in setting of just prior episode of hypotension probably prerenal aki – so give 1L NS fluid bolus
painful jaundice in an adult is essentially always caused by…
gallstones
painful jaundice in an adult consistent with probable obstructing gallstone, what do you expect to see on biliary tree sonogram
dilated biliary tree
no obstructing stone
(obstructing stone rarely seen on US but will see on ERCP)
non-obstructing gallstones in gallbladder
(even though obstructing stone difficult to see on US, will probably see other stones in gallblader)
describe acute cholecystitis on US
pericholecystic fluid, thickened gallbladder wall, and gallstones
pericholecystic fluid, thickened gallbladder wall, and gallstones on RUQ US describes what diagnosis
acute cholecystitis
distended thin-walled gallbladder with biliary dilation on RUQ US describes what diagnosis
painless jaundice associated with slowly-progressing cancer
painless jaundice associated with slowly-progressing cancer, what do you expect on RUQ US
distended thin-walled gallbladder with biliary dilation
the only way to get acute onset of an elevated unconjugated bilirubin is ___ so get ___
the only way to get acute onset of an elevated unconjugated bilirubin is HEMOLYSIS so get a BLOOD SMEAR to tell you what type of hemolysis
TF
acute onset of an elevated unconjugated bilirubin, get a RUQ US
F
the only way to get acute onset of an elevated unconjugated bilirubin is HEMOLYSIS so get a BLOOD SMEAR to tell you what type of hemolysis
6 things that put AST and ALT into the thousands
acetaminophen overdose acute viral hepatitis autoimmune hepatitis afla-toxin (death cap mushrooms) budd-chiari syndrom (hepatic vein thrombosis) shock liver
aaaabs
young person gets malaise weakness anorexia jaundice with mixed hyperbilirubinemia and transaminases into the 1000s a few weeks after traveling to a third world country
most likely cause
acute viral hepatitis A
when is liver biopsy the answer
in acute hepatic failure?
liver biopsy is rarely the correct answer, reserved for confirmatory diagnosis of a rarer cause of cirrhosis
rarely the answer in acute hepatic failure
weight loss, migratory thrombophlebitis, painless obstructive jaundice suspect.. order... if negative, suspect.. order...
suspect pancreatic cancer
order CT abdomen (or maybe just get MRCP)
if negative suspect PSC causing stricture (get MRCP) or cholangiocarinoma versus ampullary cancer (get ERCP)
treatment of choice for primary sclerosing cholangitis
ursodeoxycholic acid
ca19-9 is a tumor marker for
pancreatic cancer
progressive painless jaundice, weight loss, smoking history, the most likely diagnosis is
pancreatic cancer
conifirm diagnosis of pancreatic cancer
EUS with biopsy
endoscopic ultrasound
history of PSC and painless jaundice you get an ERCP to diagnose…
cholangiocarcinoma
negative CT scans despite painless jaundice you get an ERCP to diagnose…
ampullary cancer
MRCP is used to diagnose
PSC and Chronic Pancreatitis
structural visualization is the same without the risk of causing pancreatitis – so do MRCP before ERCP, do ERCP if biopsies are needed
for what 3 cancers are biopsies skipped and go straight to resection for diagnosis
renal cell carinoma
lymphoma
testicular cancer
In painless jaundice patient, absence of this
1 demographic
2 presenting symptoms
Make you less concerned for cancer
Absence of
Older age
Weight loss, migratory thrombophlebitis
What is the advantage of MRCP over ERCP
What is the disadvantage?
MRCP does not involve instrumentation, so no 30% risk of pancreatitis and smaller risk of later stricture
But cannot biopsy or remove stones with MRCP
When do you biopsy via EUS vs ERCP
EUS for biopsy outside biliary system, e.g. to confirm dx of pancreatic cancer seen on imaging (MRCP or CT)
Combination of obstructive jaundice and heme positive stool makes you think
Ampullary cancer
-the only lesion really that can obstruct biliary tree and bleed into GI lumen
How common is ampullary cancer
How do you diagnose it
How do you treat it
Ampullary cancer is rare
Dx with ERCP
(CT and MRCP will not see it)
Resection is curative
________ will present with obstructive jaundice in setting of PSC, a stricture on MRCP, no lesion of the head of the pancreas
Diagnose with
CHOLANGIOCARCINOMA will present with obstructive jaundice in setting of PSC, a stricture on MRCP, no lesion of the head of the pancreas
Diagnose with ERCP with Biopsy to rule out a simple stricture
How do Boerhaave’s and Mallory Weiss tears differ with respect to bleeding and toxicity
Boerhaaves is toxic and does not bleed
Mallory Weiss bleeds and is not toxic
Treat Mallory Weiss tear
Support with fluid and blood as necessary, will self-resolve
Transmural esophageal rupture aka
Boerhaave’s
Smoker drinker hot tea drinker with dysphagia suggestive of esophageal SCC
Next 3 steps in management
Barium swallow to map esophagus
EGD with Biopsy to confirm
CT to stage
Risk factors for esophageal SCC
Location
Smoker drinker hot tea drinker
Older Black
Upper third of esophagus before glandular tranformation starts and progresses to the les
Major risk of egd
Perforation
Manage an esophageal perforation disgnosed by history and physical
Gastrografin swallow
Barium swallow if gastrograffin negative
EGD if either swallow positive
Surgery
What is the confirmatory diagnlstic test for GERD
Esophageal pH monitoring
Work up GERD
Start with Lifestyle modification and PPI trial for 6 weeks if no alarm (aka cancer) symptoms (odynophagia dysphagia weight loss nausea vomiting anemia)
EGD to visualize and biopsy - aka rule out cancer and metaplasia and confirm esophagitis, if alarm symptoms or failure of 6 week PPI trial
24-hour pH monitoring to confirm that esophagitis due to reflux
Alarm symptoms in GERD
Cancer signs – odynophagia dysphagia weight loss nausea vomiting anemia
Crunching sounds with each heart beat signifies
Pneumomediastinum
Crunching sounds with each heart beat aka
Hamman’s crunch
Pneumomediastinum
Hamman’s crunch
aka
Crunching sounds with each heart beat signifying pneumomediastinum
Why gastrograffin swallow for pneumomediastinum but barium for odynophagia/dysphagia?
Gastrograffin less toxic to mediastinum (but less sensitive test so if negative still get Barium swallow)
Barium less toxic to lung so better for dysphagia odynophagia in case aspirated
TF
Emergency thoracotomy for pneumomediastinum from esophageal rupture
F Gastrograffin swallow Barium swallow EGD then surgery for esophageal rupture
To emergently open chest you need something emergently threatening like uncontrolled bleeding, traumatic arrest, etc
Marjolin ulcer Define Diagnose Treat Prognosis
SCC that chronically ulcerates and heals at site of chronic wound or scar
Biopsy
Wide resection
Aggressive, poor prognosis, high risk of recurrence and metastasis
Venous stasis ulcer occurs most commonly at
The malleolus
