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Surgery NBME > Pancreatic and Hepatic Disorders > Flashcards

Pancreatic and Hepatic Disorders Flashcards

1
Q

first test to do in pt with sx. of biliary colic

A

USG

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2
Q

USG finding of gallstones in asymptomatic pt - management?

A

elective cholecystectomy not recommended unless pt is IC, has porcelain gallbladder or stones > 3 cm in size

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3
Q

tx. of symptomatic gallstones

A

elective cholecystectomy

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4
Q

what USG findings are suggestive of gallbladder disease?

A

thickened gallbladder wall
pericholecystic fluid
presence of gallstones

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5
Q

what type of medications usually help the symptoms of biliary colic?

A

anti-cholinergic medications

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6
Q

does a patient with uncomplicated, symptomatic cholelithiasis require antibiotics?

A

no - just single preop dose of first gen. cephalosporin

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7
Q

major complication of cholecystectomy?

A

injury to common bile duct

- may result in chronic biliary strictures, infection and even cirrhosis

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8
Q

what symptoms will make you think of acute cholecystitis?

A

symptoms of biliary colic along with high WBC count, fever, elevated ALP and signs of peritoneal irritation

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9
Q

tx. approach in acute cholecystitis

A
  1. antibiotics after obtaining culture (2nd gen. cephalosporin)
  2. IVF, NPO and NGT (if nausea/vomiting)
  3. laparoscopic cholecystectomy in 48-72 hours
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10
Q

what is an alternate way to diagnose acute cholecystitis?

A

HIDA scan

- see uptake in liver, CBD and duodenum but no uptake of material in gallbladder

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11
Q

a patient with symptomatic cholelithiasis is admitted with elevated ALP and bilirubin - what do you suspect? what next test do you do?

A
  1. obstruction of CBD

2. USG - will show dilated bile ducts

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12
Q

tx. of common bile duct obstruction

A

ERCP followed by laparoscopic cholecystectomy

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13
Q

what do you do if a pregnant patient presents with symptomatic gallstones?

A

manage non-operatively with hydration and pain medication; cholecystectomy after pregnancy

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14
Q

pt with symptomatic gallstones has an elevated serum amylase?

A

biliary pancreatitis

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15
Q

tx. of biliary pancreatitis

A

conservative - NPO, NGT, IVF
- amylase usually returns to normal quickly and then cholecystectomy can be performed (with intraoperative cholangiogram)

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16
Q

USG examination shows a gallbladder that is distended with fluid that has internal echoes and gallstones - dx?

A

empyema of gallbladder

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17
Q

tx. of empyema of gallbladder

A

IV antibiotics
emergent exploration w/ cholecystectomy
- if risk of surgery too high, percutaneous cholecystostomy to drain gallbladder

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18
Q

USG shows previous removal of gallbladder, dilated CBD and air in the biliary system - dx?

A

suppurative cholangitis

- bacterial infection with bile duct obstruction

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19
Q

tx. of suppurative cholangitis

A

urgent decompression of bile duct (ERCP w/ spincterotomy)

IVF and antibiotics

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20
Q

how might elderly patients present with sepsis?

A

signs of hypothermia and leukopenia

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21
Q

palpable gallbladder in patient with high fever and signs of sepsis

A

inflamed gallbladder

- emergent cholecystectomy after resuscitation due to high risk of rupture (high mortality)

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22
Q

air in the wall of the gallbladder

A

emphysematous gallbladder

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23
Q

basic steps in evaluation and tx of acute cholangitis?

A
  1. resuscitation and antibiotics
  2. urgent USG
  3. ERCP and biliary decompression
  4. cholecystectomy once stable
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24
Q

CBD stone occuring w/in 2 years after a cholecystectomy

A

retained stone

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25
CBD stone occuring after 2 years post cholecystectomy
primary CBD stone
26
tx, if biliary stricture
surgical exploration and bypass with choledochojejunostomy
27
post-op fever and abdominal pain in a pt after cholecystectomy
can be either infection or biliary leak - order an abdominal USG or HIDA scan - maybe CT scan to R/O hepatic abscess
28
what do you do if you find a biliary leak or obstruction following cholecystectomy?
ERCP
29
USG of pt with painless jaundice shows dilated intrahepatic ducts but no dilation of the common bile duct - what do you suspect?
cholangiocarcinoma - Klatskin tumor
30
Klatskin tumor
tumor of the biliary tree at the bifurcation of the hepatic ducts
31
next step after finding dilated intrahepatic bile ducts on USG?
ERCP or percutaneous transhepatic cholangiogram w/ biopsy and cytology - not CT - looking for cholangiocarcinoma
32
tx. of ampullary adenocarcinoma
Whipple's procedure if resectable | - much better prognosis than pancreatic or biliary cancer
33
tx. of duodenal adenocarcinoma
- if it involves ampulla - Whipple's - if in first or fourth segment - segmental resection - usually have worse prognosis due to involvement of nearby structures
34
you find a mass in the gallbladder fossa on USG - what test do you do next? what do you suspect?
- should do a CT scan | - suspect malignant gallbladder adenocarcinoma
35
tx. of gallbladder carcinoma
- open cholecystectomy with wedge resection of liver (2-3 cm margin) and hilar node resection
36
tx. of gallbladder polyps
> 2 cm = cholecystectomy | smaller polyps are usually observed
37
patient with pancreatitis with a drain for pancreatic abscess suddenly becomes hypotensive and has blood in the drain - what do you suspect?
erosion of the catheter or abscess into a major artery (splenic, gastroduodenal or SMA) - dx. with angiography - tx. embolization
38
cystic lesion with no internal echoes found in liver - what might this be? what do you do next?
1. simple cyst | 2. no further management required - usually asymptomatic
39
liver USG finding of multilocular cyst with calcifications in the wall and internal echoes - what might this be? management?
1. echinococcal cyst 2. tx. operative sterilization with injection of hypertonic saline followed by excision of cyst taking extreme caution not to spill
40
you suspect a cavernous hemangioma on USG - how can you confirm the diagnosis?
1. labelled RBC scan | 2. bolus enhanced CT or MRI scan - vascular lesion that fills from the periphery to the centre
41
tx. of liver hemangioma
usually asymptomatic and found incidentally; removal is not warranted
42
indications for surgical removal of benign hepatic masses
1. symptomatic lesions 2. lesions with high risk of spontaneous rupture 3. lesions with uncertainty of diagnosis
43
which two liver lesions have high risk of bleeding with biopsy?
hemangioma | hepatic adenoma
44
CT scan shows a liver lesion with a central stellate scar - what do you do next? and what is your tx?
1. liver biopsy to establish diagnosis of focal nodular hyperplasia 2. no tx. indicated
45
what is the tx. for hepatic adenoma?
surgical resection if large or persistent due to risk of rupture and HCC development
46
preferred tx. for multiple, small pyogenic liver abscesses
broad spec. IV antibiotics for 4-6 weeks
47
first test to do in suspected liver cancer?
CT scan of abdomen and chest
48
diagnostic test to confirm ruptured hepatic adenoma?
CT scan
49
tx. of pyogenic liver abscess
drainage - either percutaneously or surgically | IV antibiotics
50
tx of multiple, small pyogenic liver abscesses
IV antibiotics for 4-6 weeks
51
tx. of amebic abscess
metronidazole | paromomycin - to eliminate intraluminal cysts
52
features of hemolytic jaundice
bilirubin 6-8 - mostly UCB, no CB | no bile in urine
53
management of obstructive jaundice- first test?
USG - look for dilated intrahepatic ducts
54
next test after USG in obstructive jaundice?
ERCP - possibly w/ stone removal if due to gallstones
55
pt comes in with progressive obstructive jaundice and weight loss; on USG you see dilated intra/extrahepatic ducts and a very distended, thin-walled gallbladder - dx?
malignant obstructive jaundice | - MCC is adenoca of head of pancreas, ampulla of vater or cholangiocarcinoma
56
Courvoisier-Terrier sign
dilated intrahepatic and extrahepatic ducts with a very distended, thin-walled gallbladder
57
an USG finding shows thin-walled, distended gallbladder in pt with jaundice - next steps?
CT scan | ERCP - if CT scan is not diagnostic
58
pt with obstructive jaundice also has postive FOBT and anemia - dx?
likely ampullary carcinoma - can bleed into lumen of duodenum
59
dx. of ampullary carcinoma
endoscopy
60
in addition to obstructive jaundice and distended gallbladder on USG, what are the characteristic pain findings in pancreatic cancer?
persistent, nagging mild pain deep in epigastrium and upper back
61
you suspect pancreatic cancer, you do a CT scan and no mass is seen - what is the next step?
upper endoscopy with EUS
62
what features deem a pancreatic cancer unresectable?
distant mets local invasion of visceral vessels LN mets in periaortic or celiac nodes
63
indications for removal of gallbladder in asymptomatic patients?
immunocompromised patients porcelain gallbladder stones > 3 cm
64
pt has signs of biliary colic along with sx of peritoneal irritation, fever and elevated WBC count - dx?
acute cholecystits
65
when do you suspect acute cholangitis?
signs of biliary colic, peritoneal irritation, high fever, elevated WBC count, elevated bilirubin and ALP
66
Reynold's pentad
``` RUQ pain high fever jaundice confusion (neuro sx.) hypotension (shock) ```
67
how do you confirm dx of acute cholangitis?
USG - will show dilated ducts
68
tx of acute cholangitis
IV antibiotics and emergent decompression with ERCP --> follow with cholecystectomy once pt stable
69
tx of biliary pancreatitis if pt does not improve or deteriorates on conservative tx
ERCP w/ sphincterectomy
70
older patient presents with abdominal pain and increased amylase levels - next step?
must R/O other causes such as mesenteric ischemia or volvulus - order CT scan
71
signs of acute pancreatitis, elevated amylase and high hematocrit
acute edematous pancreatitis
72
management of hemorrhagic pancreatitis
intensive support in ICU | serial CT scans daily
73
about 10 days after onset of pancreatitis, patient begins to spike fever and has leukocytosis - what are you considering? what test do you order?
pancreatic abscess | - order CT scan with contrast
74
tx of pancreatic abscess
drainage | imipenem or meropenem (pts with seizures)
75
2 most common ways of presentation of pancreatic pseudocyst
- can occur few weeks after tx of pancreatitis OR after blunt trauma to the abdomen in a car accident for ex
76
CF in pancreatic pseudocyst
``` vague upper abdominal discomfort early satiety (pressure symptoms) ill-defined epigastric mass ```
77
diagnostic test of choice for pancreatic pseudocyst
CT scan
78
approach to management of pancreatic pseudocyst
smaller than 6 cm - observe for spontaneous resolution | > 6 cm or 6 weeks - surgical intervention
79
best surgical tx. for pancreatic pseudocysts
endoscopic cystogastrostomy | - always take biopsy to ensure it is actually inflammatory
80
best diagnostic test in chronic pancreatitis
ERCP - chain of lakes appearance

Surgery NBME (16 decks)

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