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Surgery > Pancreatic, Hepatobiliary, Lower GI > Flashcards

Pancreatic, Hepatobiliary, Lower GI Flashcards

0
Q

DDx for RUQ pain, N/V, anorexia, guarding, tenderness

A
  1. Sx cholelithiasis
  2. Biliary colic
  3. Acute cholecystitis
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1
Q

Management of asx gallstones?

A

Surgery not necessary (< 10% develop sx requiring surgery w/in 5 years)

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2
Q

Typical gallstone disease pain?

A

RUQ or epigastrium, can radiate to back or scapula

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3
Q

Typical US findings in gallbladder disease?

A
  1. Thickening of gallbladder wall
  2. Pericholecystic fluid
  3. Gallstones
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4
Q

Management of sx cholelithiasis?

A

Cholecystectomy

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5
Q

ABx in uncomplicated, sx cholelithiasis?

A

Nope. Single pre-op dose of Cefazolin is sufficient

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6
Q

Consequences of common bile duct injury in cholecystectomy?

A

Chronic biliary strictures, infection, cirrhosis

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7
Q

Post-op management of lap chole?

A

W/in 7-24 hrs most ready for d/c … f/u in 7-10 days

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8
Q

Acute cholecystitis management?

A
  1. 2nd gen ceph pre-op and 24 hours post-op

2. IV fluids, NPO, NGT if N/V

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9
Q

ABx coverage of acute cholecystitis?

A

Gram (-) rods and anaerobes

- E. coli, Klebsiella, Enterobacter, Enterococcus

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10
Q

Expected course of acute cholecystitis?

A

improvement in 1-2 days on IV fluids and ABx … lap chole in 48-72 hours

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11
Q

Sx cholelithiasis + elevated ALP and TB (4)

A

Common bile duct obstruction

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12
Q

Sx cholelithiasis and gallstone pancreatitis in pregnancy?

A

Majority can be managed nonoperatively

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13
Q

Safest time to operate on pregnant women?

A

2nd trimester

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14
Q

Most important indication for cholangiogram?

A

Biliary pancreatitis - MANDATORY

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15
Q

Management of gallbladder empyema?

A

IV ABx + emergent exploration w/ cholecystectomy … can do percutaneously if in poor health

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16
Q

Suppurative cholangitis

A

infection w/ bile duct obstruction –> can see air in biliary system from gas-forming organisms –> emergent ERCP w/ sphincterotomy, decompression and stone removal

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17
Q

Alternate sepsis presentation for elderly?

A

Hypothermia and leukopenia

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18
Q

Pancreatic cancer w/ distal bile duct obstruction in pt w/ biliary sepsis?

A

Very unlikely. PC presents w/ abdominal/back pain, weight loss, jaundice

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19
Q

Prior cholecystectomy w/ sx of obstruction?

A

Possible retained stone in CBD

  1. < 2 yrs w/ stone = retained stone
  2. > 2 yrs w/ stone = primary stone
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20
Q

Transcutaneous abdominal US for viewing distal CBD and head of pancreas?

A

No, intestinal gas obscures the view

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21
Q

Imaging required for uncomplicated pancreatitis?

A

Obstructive series only, CT not necessary

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22
Q

Tx of pancreatitis?

A

NPO, IV fluids, pain control, observation … most improve quickly … if not, TPN may be necessary

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23
Q

Correlation of amylase w/ severity of pancreatitis

A

NO CORRELATION

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24
Q

Abdominal pain + inc. amylase in elderly

A

Look for other dx besides pancreatitis –> volvulus, mesenteric ischemia

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25
Q

Pseudocyst wait time to surgery

A

6-7 weeks

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26
Q

Echinococcal cyst tx

A

Hypertonic saline + resection w/out spillage

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27
Q

Central stellate scar on US

A

Focal Nodular Hyperplasia, requires bx to dx, no tx

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28
Q

Appendicitis in woman… workup? Management?

A

Rectal and pelvic exams. Hydration, NPO, observation w/ serial exams and repeat CBC. Mild does not warrant ex-lap.

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29
Q

Analgesia for appendicitis?

A

No, avoid masking sx.

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30
Q

DDx of RLQ pain

A

UTI, appendicitis, appendiceal abscess, PID, ovarian and tubal issues, mesenteric adenitis, Meckel diverticulum, terminal enteritis, diverticulitis

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31
Q

Minimal dysuria and urinary WBC count of 8-10/hpf

A

Appendicitis still high on DDx as inflammation can be in continuity w/ urinary tract

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32
Q

RLQ pain w/ too many RBCs on U/A to count… Imaging?

A

severe UTI or kidney stone… IV pyelogram or CT

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33
Q

Hx of PID

A

Tends to recur, but appendicitis could still occur. Careful pelvic exam

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34
Q

IBD tx?

A

Steroids, 5-ASA … CT or barium enema dx

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35
Q

What must you be aware of when tx a suspected IBD?

A

Appendicitis can still develop. Steroids added to a missed appendicitis will create complications and delay or obscure the correct dx of appendicitis

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36
Q

Appendicitis etiology?

A

Bimodal distribution - 25 yrs and 65 yrs

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37
Q

Elderly presentation of appendicitis?

A

Vague abdominal complaints, sepsis, altered consciousness, failure to thrive

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38
Q

Who more commonly presents w/ ruptured appendix?

A

Children (5 yrs)

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39
Q

Where is appendicitis pain more commonly found in pregnancy?

A

RUQ due to uterus pushing appendix superior-laterally

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40
Q

Yellow, firm mass at tip of appendix

Can also present as pedunculated mass in terminal ileum (adenocarcinoma as well)

A

Carcinoid tumor. Bx not necessary. < 2 cm = simple appendectomy
> 2 cm = possible malignancy –> right colectomy

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41
Q

Management of carcinoid?

A

Baseline 5-HIAA, CT, octreotide scan (localizes to neuroendocrine tumors)

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42
Q

Eval of 60 yo M s/p appendectomy 1 week ago now w/ fever, chills, anorexia, malaise

A

Pelvic abscess, wound infection (if closed) –> CT, US

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43
Q

Management of pelvic abscess?

A

Drainage percutaneously if possible, or open drainage. Can do transrectal or transvaginal. W/ resolution, associated cecal fistula would be unusual

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44
Q

Colon cancer screening options

A
  1. Yearly fecal occult blood test (high FN rate)
  2. Yearly FOBT + flexible sigmoidoscopy (1st at 50, then every 5 years) –> misses 50% of colorectal polyps and cancers (higher in colon)
  3. Colonoscopy (1st at 50, every 10 years)
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45
Q

Modifications to colon cancer screening recommendations

A
  1. 1st degree relative w/ colorectal cancer or adenomatous polyp (screen at 40)
  2. FAP in family –> yearly flexible sigmoidoscopy (100% progression to cancer) , colectomy is only tx recommended
  3. HNPCC in family –> genetic testing and colonoscopy every 1-2 years, beginning at 20 and 30 and every year after 40
  4. Hx of polyps removed by colonoscopy –> colon exam every 3 yrs
  5. Hx of resected colorectal cancer –> colonoscopy every year w/ screening at 3 and then 5 year intervals
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46
Q

Screening for colon cancer recurrence

A

CEA every 2-3 mo for 2 years (detects 80% of recurrences)

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47
Q

What designates Stage III colon cancer and what is tx?

A

LN invasion, 5-ASA and levamisole

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48
Q

Feculent vomiting POD 3 after colectomy. DDx?

A
  1. Leakage from anastomosis –> persistent ileus
  2. Mechanical obstruction –> adhesions, internal hernia, obstructed anastomosis

Tx = NPO feeds, IV fluids, NGT + CT or obstructive series

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49
Q

Wound infection management

A

Open involved portion down to fascia

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50
Q

Post-op enterocutaneous fistula management

A

Anastomotic leak –> NPO feeding and IV fluids usually sufficient for most fistulas and will close w/ this therapy

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51
Q

Pt returns to hospital 10 days post-op from colectomy w/ fever 104 and RLQ pain

A

Abscess –> right paracolic gutter or pelvis

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52
Q

Rectal carcinoma eval

A
  1. Digital rectal
  2. Colonoscopy (visualize entire colon to r/o synchronous lesions)
  3. Determine depth of invasion (transrectal US)
  4. Adjacent structures (CT/MRI)
  5. CXR and CEA warranted prior to surgery
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53
Q

Rectal carcinoma tx

A

Resection (abdominoperineal –> entire rectum + LN + permanent colostomy –> early-stage lesion (no neoadjuvant therapy)

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54
Q

Rectal cancer lymphatic spread ?

A

Superior hemorrhoidal vessels –> internal iliac nodes, sacral nodes, inferior mesenteric nodes, inguinal nodes

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55
Q

Perioperative risks of abdominoperineal resection?

A

Sympathetic plexus located around the rectum –> impotence (50%)
Bladder function can be impaired (Foley’s in place for 1 week post-op)
Venous bleeding from presacral spsace, ureter injury
Retraction, prolapse, stricture, and obstruction of colostomy

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56
Q

Proximity to anal verge affecting operative management?

A

Possible to remove most rectal cancers > 5 cm proximal to the verge using anterior approach.
< 5 cm requires abdominoperineal resection because lateral margins include sphincter mechanism

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57
Q

Common mode of rectal carcinoma resection failure?

A

Local recurrence –> ample, clear margins (2 cm for well/moderately-well differentiated ; 5 cm for poorly differentiated, anaplastic, or “signet” cell)

Abdominoperineal more likely for lesions > 5 cm

58
Q

Post-op management of rectal Stage II or > lesions

A

Adjuvant chemotherapy similar to colon cancer

59
Q

When might preop radiation in rectal carcinoma be considered?

A

Large, bulky lesions or extension outside the bowel into surrounding tissue. Over weeks to reduce size

60
Q

Alternatives to colostomy in rectal resection?

A

Sphincter-preserving proctectomy

local resection of tumor

61
Q

Abdominoperineal resection differences in women?

A

Posterior vaginal wall resected w/ maintenance of urethra innervation

62
Q

CEA elevation during yearly f/u… next step?

A

CXR and CT abdomen for mets look + repeat colonoscopy

63
Q

New 2 cm liver lesion in colon cancer recurrence. Tx?

A

Surgical resection if no extrahepatic mets, no local recurrence, and resectable lesion (+ anesthetic and cardio clearance)

64
Q

Types of unresectable lesions?

A

multiple lesions in both lobes of liver, intimate w/ vascular structures (hepatic veins, portal vein), local structure invasion (diaphragm), cirrhotic liver

65
Q

Survival in pts w/ solitary liver mets from colon cancer

A

35% at 5 years

66
Q

Liver met resection procedure?

A

Hepatic lobectomy or segmentectomyy or nonanatomic wedge resection, w/ > 1 cm margins

67
Q

Non-resectable lesion management

A

Cryotherapyy, EtOH, RF ablation, chemoembolization

68
Q

MC cancer of anal canal?

A

SqCC (epidermoid carcinoma) and can have strange sx: bleeding, drainage, pain, pruritis

69
Q

Where do anal canal SqCCs commonly met to?

A

Inguinal nodes and superior rectal nodes

70
Q

How to determine depth of invasion in anal canal cancer?

A

CT or transrectal US

71
Q

4 cm rectal carcinoma w/ no local extension and no LN

A

Nigro protocol –> chemoradiation to eliminate cancer

usually provides complete local control

72
Q

What is the Nigro protocol?

A

External Radiation

Systemic chemo (5-FU cont. for 4 days, starting day 1 of radiation and repeated days 28-31)

Mitomycin C

73
Q

Diverticulitis tx?

A

Liquid diet + outpatient broad-spectrum ABx

74
Q

Elderly w/ fever and LLQ?

A

Diverticulitis –> NPO, IV fluids, parenteral ABx

75
Q

Analgesia of diverticulitis?

A

Not morphine (inc. intracolonic pressure) –> Meperidine instead as it lowers intracolonic pressure. Also may need obstructive series to check for free air

76
Q

Dx of diverticulitis

A

CT inflammation, abscess, diverticula, THICKENED SIGMOID BOWEL WALL … not mandatory in uncomplicated pts

77
Q

Management of diverticulitis following improvement?

A

Fiber + ABx x 7-10 days

78
Q

Chances of diverticulitis recurrence?

A

70% have no further recurrence. Elective resection 4-6 weeks after resolution of 2nd episode (risk of perf/abscess inc. w/ each episode)

79
Q

Massive lower GI bleeding w/ tachycardia and 105/70 w/ signs of dehydration

A

2 large bore IVs and 1-2 L of NS or LR. Place on monitor. Routine blood studies and CXR + coag eval + Foley cath. NGT for eval for upper GI bleed

80
Q

MCC of rapid lower GI bleeding?

A

bleeding diverticula and vascular ectasias … others include Meckel’s, aortoenteric fistula, ischemic colitis, IBD, hemorrhoids, varices, colonic neoplasms

81
Q

Rebleeding risk in lower GI?

A

Diverticulitis - 25% rebleed risk, 20% cont. to bleed and require operative intervention

Vascular ectasias stop spontaneously in 90% but have 25% and 46% rebleed risk at 1 and 3 years

82
Q

Vascular ectasia tx?

A

Coagulation w/ monopolar current w/ risk of perforation

83
Q

Resolved bleeding diverticula tx?

A

Iron and fiber

84
Q

What causes diverticula to bleed?

A

Underlying vasa recta erosion

85
Q

Right vs left diverticula

A

Left MC, Right more apt to bleed

86
Q

Persistent massive lower GI bleed management?

A

pRBCs , labeled RBC scan (better for stable pts bleeding more slowly; cannot precisely locate site of bleeding) mesenteric angiography (better for less stable pts due to better monitoring and resuscitation capabilities, and for those bleeding more rapidly)

87
Q

Rapid bleeding, less stable pt?

A

Mesenteric angiography

88
Q

Slow bleeding, stable pt

A

labeled RBC scan

89
Q

Indication for surgery in persistent massive lower GI bleed?

A

Cont. bleeding (relative), CV instability (relative), 4-6 units pRBCs (relative) … angiogram tends to be a pre-operative test

90
Q

Indication for surgery prior to 4-6 units pRBCs?

A

Unstable w/ bleeding .. esp. w/ CAD and angina w/ unstable vitals

Hard-to-determine blood types including unusual Ab’s or pts who do not wish to have transfusion (Jehovah’s)

91
Q

How to lessen persistent lower GI bleeding?

A

Vasopressin (short time –> coronary vasoconstrictor, 50% have rebleeding w/in 12 hrs of d/c)

Embolization (inc. risk of transmural necrosis and therefore saved for poor surgical candidates)

92
Q

Anal fissure triad?

A

Razor blades/broken glass sensation
Bright red blood
Aching spasms

93
Q

Anal fissure exam?

A

External exam (anterior or posterior midline usually)

94
Q

Tx of anal fissure?

A
  1. Sitz baths + fiber/stool softeners (80% cure)
  2. Topical nitroglycerin (0.2%) –> NO donor (vasodilation)
    - bad headaches (can use nifedipine, Viagra too)
  3. Botox (women) –> inhibits AChEase
  4. Sphincterotomy (internal - divide) –> incontinence rare
95
Q

1 day, 32 week premature infant w bloody stools, distention, inability to tolerate feeds

A

Necrotizing enterocolitis

96
Q

Etiology of NE?

A

Stress, respiratory failure, hypoxemia, HoTN

97
Q

Clinical features of NE?

A

Distention (70-90%), palpable bowel or crepitus, Peritonitis, erythema of wall, bloody NG aspirate or stool

98
Q

Dx of NE?

A

WBC < 6000 if gram (-) septicemia, thrombocytopenia, metabolic acidosis, pneumatosis intestinalis **, portal venous gas

99
Q

Tx of NE?

A

NPO, TPN, IV fluids
ABx

Op: pneumoperitoneum, (+) paracentesis, portal venous gas, deteriorating

100
Q

Where does NE most often occur?

A

Small bowel

101
Q

MC location for strictures from healed NE?

A

Splenic flexure of colon (poor blood supply)

102
Q

3 week old former full term w/ inability to tolerate feeds and projectile emesis

A

Pyloric stenosis (3/4 mm x 14 mm)

103
Q

Is pyloric stenosis present at birth? Familial? Progressive? Self-resolving?

A

No. Yes (first-born MC). Yes (hypertrophy increases). Yes (as long as feeds get through via tube or TPN)

104
Q

Age of pyloric stenosis?

A

2 weeks to 2 months

105
Q

Metabolic derangement in pyloric stenosis? Fluids?

A

Hypokalemic hypochloremic metabolic alkalosis. NS (10/kg as LR can inc. alkalosis due to HCO3

106
Q

2 1/2 yo former full term male w/ painless bloody stools (can be very significant bleeding)

A

Meckel’s diverticulum

107
Q

Causes of GI bleeding in neonates

A

Swallowed maternal blood, hemorrhagic dz of newborn, anal fissure, NEC, malrotation, volvulus

108
Q

Causes of bleeding in infants (3-18 mo)

A

Anal fissure, Intussusception, Volvulus (bilious emesis), Duplication, GE, food allergy (milk)

109
Q

Toddlers (2-5 yrs)

A

Anal fissure, rectal prolapse (Cystic fibrosis), GE (E. coli, shigella, campylobacter), Meckel’s, juvenile polyp, trauma

110
Q

Older children (6-18 yrs)

A

Polypoid dz, UC, Hemorrhoids, Meckel’s (usually toddlers)

111
Q

Marginal ulcer

A

gastrojejunostomy –> acid eroding jejunum

112
Q

Cannot have Meckel’s bleeding w/out what?

A

gastric mucosa

113
Q

Meckel’s: True or false diverticulum?

A

True

114
Q

Rule of 2’s

A

2%, 2 ft of ileocecal valve, 2 types of ectopic tissue …

115
Q

10 yo male w/ RLQ pain, N/V, anorexia

A

appy

116
Q

Appy hx/lab/exam

A

hx (GI upset), U/A + WBC (total or diff abnormal in 90%, teenagers break the rules w/ nml WBC) + BHCG

117
Q

Dx of appy

A

US (donut or target sign; thin pts), CT most sensitive

118
Q

16 yo F w/ RLQ pain, N/V, anorexia

A

Ovarian torsion (appy also in DDx)

119
Q

29 yo F G2P0 w/ hx of polyhydramnios, gest diabetes, and sickle cell w/ abnormal prenatal US at 34 weeks w/ double bubble sign

A

Duodenal atresia (could be part of Down Syndrome - 1/3) … failure of recanalization

120
Q

Associated conditions of double bubble

A

Annular pancreas*, malrotation (usually gasless abdomen)

121
Q

8 mo male w/ severe right-sided abdominal pain, nausea, distention, “currant jelly” stool

A

Intussusception

122
Q

Intussusception dx

A

Waves of pain, US, air-contrast enema (attempt to reduce it)

123
Q

Etiology of intussusception

A

Lymphoid hypertrophy, typically from virus (Rota), and can be caused by Rota vaccine. HSP is commonly associated w/ intussusception as well … most occur b/w 5-9 mo (65% < 1 yr old)

124
Q

Management of intussusception

A

IV fluids, r/o peritonitis –> can recur w/in 1-2 days

125
Q

Groin hernia can commonly occur (communicating) when?

A

During illness w/ some extra fluid retention moving through the communication

126
Q

Associated abnormalities w/ omphalocele

A

Chromosomal (trisomy 13, 18, 21), ToF, ASD, Beckwith-Wiedeman (large tongue; watch for malignancy), Pentology of Cantrell (Sternal cleft/diaphragmatic hernia, ectopic cordis, pericardial defect, cardiac anomaly, midline abdominal defect), Prune-Belly syndrome

127
Q

Gastroschisis associated anomalies?

A

Uncommon, atresia and nonrotation of midgut

128
Q

Bilious emesis in child?

A

surgical emergency (malrotation)

129
Q

88 yo F in a nursing home w/ hx of constipation w/ recent mental status deterioration, HoTN, tachycardia, distention, abdominal tenderness

A

Sigmoid volvulus

130
Q

Management of sigmoid volvulus?

A

Hydration, electrolytes, CBC, obstructive series, sigmoid colectomy , can do rigid proctosigmoidoscopy w/ placement of rectal tube

131
Q

Etiology of sigmoid volvulus?

A

Debilitated pts in nursing homes, often from chronic laxative use, chronic illness, dementia. Clockwise twist around mesentery –> closed loop obstruction

Barium enema confirms dx

132
Q

Ogilvie’s or pseudo-obstruction?

A

Massive right colon dilation w/out mechanical obstruction

133
Q

When do you normally see Ogilvie’s

A

Hospitalized pts in ICU that are intubated and seriously ill

134
Q

Management of Ogilvie’s

A

< 9-10 cm = non-op

> 11-12 cm = endoscopic decompression, neostigmine (parasympatholytic), surgical decompression

135
Q

Rectal prolapse tx?

A 
Internal = fiber + non-op trial
External = Rectopexy (pinned to sacrum), low anterior resection (transabdominal rectosigmoid resection), perineal approach
136
Q

Persistent perianal drainage

A

fistula-in-ano –> unroofing, allow to reepithelialize –> if through sphincter (seton)

137
Q

Colostomy complications

A

Leakage around the bag

138
Q

Types of stomas (colostomies)

A

Following abdominoperineal resection w/ end sigmoid colostomy

Ileostomy following total proctocolectomy for UC

Ileal conduit draining the urinary system to skin

139
Q

Pouchitis tx

A

Metronidazole

140
Q

Margins for anorectal cancer resection?

A

2 cm well-differentiated and 5 cm poorly differentiated

141
Q

Ranson criteria?

A

Prognostic signs associated w/ acute pancreatitis?

142
Q

Ranson Criteria:

A

On admission:

Age > 55 , WBC > 16 , Glucose > 200 , LDH > 350 , AST > 250

48 hours:

Hct dec = 10% , BUN inc. = 5 , Ca < 8 , PaO2 < 60 , Base deficit >4
Fluid sequestration > 6 L

Surgery (7 decks)

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