Part 34 Flashcards
Different types of abdominal pain (3)
- visceral (dull, poor localization, cramping, burning, gnawing, often perceived around the dermatome corresponding to the nerve fiber origins, often 2ndary autonomic effects)
- somatic (sharp, intense, well localized, often retroperitoneal)
- referred (distant from organ of origin resulting from convergence of visceral afferent and somatic afferent fibers from different anatomic regions)
Extra-abdominal causes of abdominal pain (5)
- MI
- herpes zoster
- women or diabetics unusual presentations of MI and others
- pneumothorax
- nerve root compression
Acute onset abdomen pain within seconds to minutes is often due to ___, within hours is often due to ___
infarct or rupture, inflammation or obstruction
Migration vs radiation
The pain begins in one area and functionally moves to another area alleviating in the origin vs the pain moves thru to another organ but maintains its pain at the site of origin
Positioning in abdominal pain (5)
- lying perfectly still (peritonitis worsens with movement)
- leg flexed (relaxes iliopsoas)
- fetal position
- cannot get comfortable
- writhing in pain (ischemic bowel)
Pathognomotic finding of ischemic bowel
pain out of proportion of physical exam - pressing on abdomen doesn’t worsen
Appendicitis common features
Hour to days onset, periumbilical early and right lower quadrant late, dull ache, radiates to right lower quadrant
Cholecystitis common features
Onset over minutes to hours, right upper quadrant pain that is sharp and radiates to scapula
Pancreatitis common features
Onset minutes to hours, locatted in the epigastric back area and described as boring pain that radiates to midback
Diverticulitis common features
Onset hours to days causing left lower quadrant aching with no radiation
Perforated peptic ulcer common features
Onset within minutes located in the epigastrium causing sharp burning pain
Small bowel obstruction common features
Onset hours to days causing periumbilical pain that is crampy and does not radiate
Mesenteric ischemia/infarct common features
Onset minutes in the periumbilical area described as agonizing pain that does not radiate
Ruptured abdominal aortic aneurysm common features
Onset in minutes in abdomen, back, flank, causing tearing pain that radiates to back and flank
Gastroenteritis common features
Onset hours to days, causes periumbilical spasmodic pain
PID common features
Onset hours to days with either lower quadrant or pelvis pain described as an ache perhaps radiating to upper thigh
Ruptured ectopic pregnancy common features
Onset minutes causing either lower quadrant or pelvis pain, severe pain that doesn’t radiate
Enteroscopy
Viewing of the small intestine with an endoscope inserted down the esophagus
Choledocho- meaning
Common bile duct
Indications for Esophageogastroduodenoscopy (EGD) (5)
- unexplained anemia
- GERD
- abdominal pain
- dysphasia
- barret’s esophagus
EGD prep (3)
- NPO after midnight
- no anticoagulation
- optional sedation (propofol)
EGD complications (2)
- bleeding
-perf
Black eschar lesions at the GE junction indicates
Gastritis, often 2nd to NSAID use
ERCP (Endoscopic retrograde choleopancreatography) indications (2)
- obstructed common bile duct (choledocholithiasis, pancreatic neoplasm, bile duct neoplasm)
- diagnostic and therapeutic
Endoscopic ultrasound indications (4)
- UGI neoplasm (esophagus, stomach, liver, pancreas, duodenum)
- lymph node biopsy and staging
- choledocholithiasis
- small missed cholelithiasis
Colonoscopy indications (5)
- anemia
- rectal bleeding without identifiable cause
- diverticulitis
- alternating diarrhea and constipation
- screening
Colonoscopy prep (5)
- mechanical bowel prep
- clear liquid diet
- NPO after midnight
- no anticoagulation
- optional sedation
Colonoscopy complications (3)
- bleeding
- perforation
- splenic injury
Types of colonic polyps (4)
- hyperplastic (benign)
- serrated (same as hyperplastic but higher risk of becoming cancer)
- inflammatory
- neoplastic (adenomatous)
Sessile polyp vs pedunculated
Sessile is flatter and covers more surface, pedunculated has a stalk protruding out from a base into a large head
Clinical manifestations of adenomatous polyps (4)
- mostly asymptomatic
- hematochezia
- occult blood loss
- diarrhea
How are adenomatous polyps typically detected? (3)
- sigmoidoscopy
- colonoscopy
- CT scan (virtual colonscopy)
What type of adenoma polyp is most likely to be cancerous?
Villous
Dividing area of upper and lower GI
Ligament of trietz
3 manifestations of GI bleed
- hematemesis
- melena (black dark tarry stool)
- hemotochezia (bright red blood)
Initial management of GI bleed (3)
- resuscitation (2 large bore IV, saline, type o neg packed RBC, same ratio of plasma and platelets)
- labs (beware that the H&H will be maintained in acute losses)
- NG tube
Common causes of upper GI bleed (4)
- gastric and duodenal ulcers (most common)
- varices
- mallorey weis tears
- neoplasms
Ulcer bleeding treatment options (4)
- PPI or H2 blockers
- endoscopic hemostasis via injection therapy of 1:10,000 epi
- coagulation via cauterization
- surgery (failed or recurrent cases)
Anterior wall of the duodenum exits to the ___, posterior wall exits to the ___
free abdomen (perforation), pancreas (gastroduodenal artery bleeding, highest risk of rebleeding)
Gastric/duodenal ulcer that has a clean base treatment options (2)
- nothing endoscopically
-ppi
-
Varices treatment options (4)
- resuscitation
- balloon tamponade
- endoscopic therapy
- surgical therapy
4 categories of surgical varices therapy
- esophageal transection (stapling off varices)
- nonselective shunting (redirect portal vein flow and put into vena cava - high rates of encephalopathy)
- selective shunting (adjunctive tube redirecting some flow into vena cava, easy at clotting)
- orthotopic liver transplantation
Transjugular Intrahepatic portosystemic shunt (TIPSS)
Lower rates of encehpalopathy and only 50% thrombosis rate at 2 years, making it a great option for patients who will receive a transplant within 2 years, involves putting catheter into internal jugular vein into right atrium and down to vena cava, connect a shunt between the portal and hepatic veins positively effecting varices treatment without changing the vasculature
Erosive gastritis treatment options (3)
- self limiting
- NSAIDS
- ASA
Mallory weiss tear is most often a rip in the ___ mucosa
gastric
Mallory weiss tear pattern of bleeding
-Vomit initially then see bleeding with vomiting
Is diverticular bleeding painful?
No, most often painless and self resolving but can lead to hypovolemic shock, can be difficult to localize
Meckel’s diverticulum
An outpouching or bulge in lower part of small intestine (2 feet of the ileocecal valve) often congenital and leftover part of umbilical cord, can see heterotrophic mucosa within the diverticulum, most of the time these are asymptomatic
Meckel’s scan
A radionucleotide imaging study that can detect the presence of different types of mucosa that will proceed to illuminate where they should be located (for example gastric mucossa in te stomach) and where it shouldn’t be (on the diverticulum
Therapy options for lower GI bleed (4)
- colonoscopy
- surgery (removal of part of colon localizing bleeding)
- barium enema
- angiographic embolization (close off vessels to prevent bleeding)
Gallbladder anatomy review
Gallbladder empties into cystic duct, liver empties into common hepatic duct, the two combine into the common bile duct, combine with the pancreatic duct and empty at the ampulla of vater at the spinchter of oddi into the duodenum
The triangle of calot significance and borders
- cystic artery is found within the triangle
- cystic duct, common hepatic duct, and edge of liver make up the borders
Indications for cholecystectomy (5)
- biliary colic
- acute cholecystitis
- chronic cholecystitis
- complications of gallstone disease (choledocholithiasis and such)
- dysfunctional gallbladder (theorized to not be real, more valid if responds to cholecystokinin reproducability test)
Pre op prep for cholecystectomy (4)
- antibiotics
- DVT prophylaxis (compression stockings and maybe lovenox)
- patient understanding of possible need to convert to open procedure
- cardiac clearance
When does a cholecystectomy have to be converted to an open one? (4)
- cannot identify landmarks or structures
- marked inflammation with adhesions of surrounding viscera
- bleeding
- bile duct injury
Complications of cholecystectomy (6)
- bile duct injury
- perforation of major vessel
- perforation of small or large bowel
- bile leak
- infection
- CO2 absorption and potential pneumothorax
Cholecystostomy definition and indications (4)
- Percutaneous or open tubing of the gall bladder under CT guidance
- indicated in patients with acute cholecystits, acute acalculus cholecystitis, obstructive cholangitis (jaundice), or in patients who will not tolerate cholecystectomy
Choledocholithiasis diagnosis (2)
- U/S
- ERCP (also therapeutic)
Choledocholithiasis treatment options (2)
- ERCP
- surgery (common bile duct exploration, if stone impacted at the sphincter of oddi then can do choledochoduodenostomy bipass)
Falciform ligament of the liver
Fibrous structure that connects the anterior liver to the ventral wall of the abdomen, located approx midline of the abdomen dividing “right” and “left” liver lobes, round ligament also known as ligamentum teres is a remnant of the umbilical vein that protrudes from the anterior free face of this ligament
Indications for liver resection (5)
- primary liver neoplasm
- hepatic stick
- hemangioma (benign lesion but can rupture and bleed)
- carcinoma of the gallbladder
- severe trauma to liver that cannot be repaired
You can remove __% of liver tissue and the patient will survive, the liver also regenerates and is the only solid organ to do so
80
Preop for liver resection (5)
- maximize nutritional status (removal of glycogen stores occurs during resection
- normalize INR because liver produces a lot of proteins responsible for clotting cascade
- blood typing and crossmatching
- DVT prophylaxis
- antibiotics
Blood typing screening vs crossmatching
Type and screen determines ABO and Rh and minor antigens vs crossmatch tests patients blood and serum against the donor to see if theres no compatibility issues with minor antigens, problematic as removes blood from use so an individual that needs it in a hurry can’t have it
Liver lobes***
Left lobe of the liver is NOT left of the falciform, the left lobe vs right lobe anatomically speaking is based on where the hepatic arteries, ducts, and the portal veins go, the division is a line thru the gallbladder and the inferior vena cava, falciform divides lateral segment of left lobe from medial segment of left lobe, but doesn’t separate right lobe from left. There are 8 segments of the entire liver
Segmental resection vs Left lateral segmentectomy vs left medial segmentectomy vs left lobectomy vs right lobectomy vs extended right lobectomy (trisegmentectomy)
Removal of one lobe in a wedge resection vs removal of the lobes left of the falciform ligament vs removal of the lobes part of the left liver but right of the falicform vs taking out the entire left lobe vs taking out the entire right lobe vs taking out the entire right lobe + the medial portion of the left lobe
Complications of liver resection (3)
- Infection
- excessive bleeding
- hypoglycemia
Indications for pancreatic surgery (4)
- neoplasm (exocrine, endocrine, in the duodenal exit)
- trauma
- chronic pancreatitis
- acute necrotizing pancreatitis
Pancreatic surgery options (5)
- distal pancreatectomy (spleen side)
- pancreaticdudenectomy (whipple procedure)
- total pancreatectomy
- peustow procedure
- pancreatic head resection
Pancreas blood supply (3)
- direct branches from splenic artery
- gastroduodenal artery
- pancreaticoduodenal artery
Whipple procedure
-surgery involving hooking the jejunum to the pancreas(pancreatojejunostomy) followed by common bile duct attachment to jejunum (choledochojejunostmy) and the stomach attached as well (gastrojejunostomy) while removing the duodenum (can be done to try to preserve the pylorus to limit dumping syndrome
Peustow procedure
Chronic pancreatitis surgical treatment involving distal pancreatectomy and opening of pancreatic duct and draining it into jejunum eliminating constrictures
Pancreatic resection complications (4)
- anastamotic leak (need drains inserted until it seals off)
- infection
- pancreatic exocrine insufficiency resulting in malabsorption
- endocrine insufficiency making diabetes difficult to manage
The right adrenal gland’s main vein (right suprarenal vein) drains directly into the ___, the left drains ___
- vena cava
- renal vein
Layers of the adrenal gland and hormones secreted in each (4)
Zona Glomerulosa - aldosterone
Zona fasciculata - cortisol
Zona reticularis - androgens
Medulla - catecholamines
4 common extramedullary locations of pheochromocytoma (catecholamine secreting paragangliomas that only secrete norepi)
- Organ of Zuckerkandl (near bifurcation of abdominal aorta along spine)
- neck
- upper abdomen (most common)
- bladder
Classic triad of pheochromocytoma and another pathognomonic finding
- palpitations
- sweating
- headache
-feeling of impending doom
Other associated conditions with pheochromocytoma (3)
- MEN II a and B
- neurofibromatosis
- von hipple-lindau (retinal hemiangioblastomas, CNS hemiangioblastomas, multiple renal cysts)
Pheochromocytoma diagnostic studies (4)
- 24 hour catecholamine (metanephrine, norepi, VMA (most diagnostic))
- CT to localize
- MIBG (idonine scan where pheo takes up as well as thyroid so give Lugols solution)
- PET scan
Pheochromocytoma treatment options (1) and what is the pre op prep?
- surgical resection only (dissection with minimal tumor manipulation to prevent catecholamine surge, venous drainage first*** then arterial)
- Pre op prep involving preventing hypertension and tachycardia beginning 1 week before (alpha adrenergic antagonist like phenoxybenzamine THEN B receptor antagonist like propranolol
Aldosteronoma pathognomonic findings (2)
- hypertension
- hypokalemia (not on diuretics)
Recall the RAAS system
- at the level of the kidneys hypovolemia causes release of renin from juxtaglomerular aparatus
- angiotensinogen released from liver is converted by renin to angiotensin I
- angiotensin I is converted by lungs that release ACE into angiotensin II
- angiotensin II causes aldosterone secretion at the adrenal gland and has peripheral vasoconstriction effects
- aldosterone causes retention of sodium and therefore water but loss of potassium
Diagnostic labs of aldosteronoma (4)
- increased plasma aldosterone but decreased plasma renin (inappropriate release of aldosterone)
- rule out bilateral adrenal hyperplasia (unknown cause) via CT scan
- oral sodium loading (should suppress aldosterone secretion)
- captopril administration test (should cause decrease in adlosterone and increased renin but in primary hyperaldosteronism there is no change)
Cushing syndrome vs cushing dz
Syndrome is signs and symptoms associated with elevated cortisol level vs in cushing dz see pituitary tumor hypersecreting ACTH resulting in excess cortisol
Glucocorticoid producing tumor diagnostic studies (3)
- increased 24 hr urine free cortisol
- dexamethasone suppression test
- CT scan
Cushing syndrome signs and symptoms (8)
- weight gain
- peripheral muscle wasting
- hirsutism
- buffalo hump
- moon face
- menstrual irregularity
- amenorrhea
- impotence
Cortisol release pathway
- cortosol levels sensed in hypothalamus and releases CRH when low
- Anterior pituitary receives CRH and this stimulates release of ACTH
- this acts at the adrenal gland increasing cortisol in the blood stream to be sensed in hypothalamus
Cushings disease has __ ACTH and ___ cortisol, noncushings disease cushings syndrome has ___ ACTH and ___ cortisol
Elevated, elevated, low, elevated
Dexamethasone suppression test
-24 hr urine for 3 consecutive days, .5 mg of dexamethasone given every 6 hours on day 2 and 3, urinary free cortisol should be <10mcg/day on day 2, if not suppressed then must have adenoma
Adrenal cortex incidentaloma
Seen in patients often getting CT or screening for something else, if it isn’t presenting symptomatic then don’t need surgical intervention, can do fine needle aspiration after ruling out a pheo*** to determine cause
How far is the ampulla of vater from the pylorus
7cm
Majority of islets of langerhans cell types for the pancreas are located in what part of it?
The tail
Pancreatic islet cell tumors localization techniques (5)
- CT scan
- visceral angiography
- transhepatic portal venous sampling
- intraoperative exploration
- intraoperative ultrasound
Most common functional pancreatic endocrine tumor
Insulinoma
Whipples triad and what is it pathognomic of?
- symptoms of hypoglycemia, blood glucose level <50mg/dl, and relief of symptoms following ingestion of glucose
- pathognomonic of insulinoma
Diagnosis of insulinoma (3)
- insulin and glucose determinations during a 72 hr fast
- insulin to glucose ration >.3 after overnight fast
- elevated c peptide and proinsulin levels
Proinsulin is cleaved to insulin from removal of a free ___, measuring this rules out ___ insulin as a source
C peptide, exogenously injected
Zollinger Ellison syndrome/gastrinoma suspicious findings (5)
- ulcers in unusual locations (not antrum or prepyloric area)
- persistent ulcers despite medical management and chronic diarrhea
- ulcers and manifestations of other endocrine tumors
- strong family history of ulcer dz
- recurrent ulcers after antiulcer surgery
Gastrinoma diagnostic studies (2)
- fasting gastrin >200 or >1000 highly suspicious
- secretin stimulation increasing gastrin levels >200 is diagnostic***
Gastrinoma treatment options (2)
- control gastric hypersecretion (gastrin, Ach from vagus, histamine all contributors) so give PPI
- surgical localization, assess for mets, and remove
Pyramidal lobe of the thyroid
Remnant of thyroglossal duct sometimes present extends upward torward cricoid cartilage from isthmus
Thyroid arterial supply (2)***
- Inferior thyroid artery from the thyrocervical trunk (or thyroid ima)
- Superior thyroid artery off carotid
Thyroid venous supply (3)***
- Inferior thyroid vein draining into subclavian
- middle thyroid vein (has NO arterial equivalent)
- superior thyroid vein draining into jugular
Aortic aneurysms are present when vessel (not the lumen) exceeds ___ x normal diameter. Most common area to see development?
1.5x, abdominal infrarenal most often
Risk factors for aortic aneurysm (5)
- smoking***
- hypertension
- age most important**
- diabetes
- dyslipidemia
Prognosis of ruptured AAA
Majority never make it to hospital, 40-80% do not survive so rather variable, only 10-15% overall survive, best results is to repair before rupture
Median rate of expansion of an aneurysm approx ___cm per year but highly variable
.5cm
Screening for AAA (3)
- physical exam (feeling for pulsatile mass)
- age appropriate noninvasive screening >65 or younger if family hx of aneurysm
- ultrasound is continuing screening test of choice
AAA clinical presentation (4)
- many asymptomatic
- gnawing steady discomfort lower back or hypogastrium unaffected by movement
- severe lower abdomen or back pain with radiation to groin and legs
- evidence of other peripheral vascular disease or coronary artery disease
- embolization and thrombosis
- GI hemorrhage (duodenum and aorta fistula)
Ruptured AAA clinical presentation (6)
- abrupt onset back and abdominal pain
- abdominal tenderness
- palpable pulsatile mass
- hypotension
- shock
- often mimics GI bleed
- flank hematoma (grey turners sign) if retroperitoneal rupture
Diagnostic studies for ruptured AAA (3)
- ultrasound
- CT if hemodynamically stable
- angiography if planning on operating
Most common site of embolism in a patient with “blue toe syndrome”
the heart - 2nd most common is the aorta!
Repair of AAA options (3)
- percutaneous placement of implantable endovascular stent (has to be infrarenal)
- insertion of synthetic graft
- resection of aneurysm (not common)
Surgical mortality of repair of AAA
Increases greatly if rupture impending or has ruptured
What cutaneous level to the iliacs bifurcate from the aorta?
Just below the umbilicus
Rare complication of AAA repair that results in permanent lower extremity paralysis
Having to suture off the lumbar vessels that exit the posterior abdominal aorta due to backflow bleeding after removal of the aneurysm
Pathogenesis of stroke
- ischemic due to plaque development, most often at bifurcations, platelet aggregation and thrombus formation that potentially embolizes occluding a vessel, majority are these
- hemorrhagic often due to injury or rupture
Thrombosis vs embolism
Thrombosis is narrowing due to blood clot formation vs embolism is when piece of clot comes loose and lodges at a downstream location
Risk factors of stroke (4)
- hypertension
- smoking
- lipids
- excessive alcohol
Management of carotid artery disease - indications for carotid endarterectomy (1)
-surgery of symptomatic stenosis (post TIA or minor stroke) greatly reduces ipsilateral stroke risk after undergoing carotid endarterectomy
The workup studes for carotid artery disease (3)
- ultrasound/doppler
- angiography
- look for associated illness
Carotid endarterectomy (CEA) procedure (4)
- isolate stenosis location (ultrasound guidance frequently)
- SCM and jugular vein retracted laterally
- place a shunt proximal and distal and clamp off vessels to prevent leakage (collateral flow thru circle of willis)
- plaque removal, shunt removal, and suturing of artery closed
Periperal artery disease to the lower extremity definition
Chronic build up of atherosclerosis of femoral and popliteal arteries, results in pain (reproducible claudication), ulcers, or nonhealing wounds, requires intervention or amputation
Vasclar claudication definition, what occurs when it becomes more severe?***
Reversible muscle ischemia causing cramping or ache like pain that develops during exercise and increases until patient must stop due to intolerable pain, unilateral or bilateral and very reproducible
-when it occurs at rest then it has become ischemic - progression from claudication and far more severe vascular disease, often describe having to dangle feet off bed to restore flow***
Neurogenic claudication, unlike vascular, is often not ____
easily reproducable
Signs and symptoms of peripheral artery disease (5)
- cool/cold feet to touch
- loss of pulses in legs or feet
- dependent rubor
- nonhealing wound or ulcer
- loss of muscle or fatty tissue or gangrene
Ankle brachial index (ABI)
Measure of lower extremity systolic pressure divided by upper extremity systolic pressure, normal ratio should be between .9-1.3, but the lower it is indicates the severity of the peripheral artery disease
Imaging studies for peripharal artery disease (3)
- ultrasound
- invasive arteriography
- MRA
Acute arterial ischemia definition
Occlusion of existing graft, embolism formation, or native vessel thrombosis resulting in sudden cold leg with the 5 P’s (pulseless, pain, pallor, paresthesia, paralysis) that is much more sudden onset than peripheral artery disease
Acute arterial ischemia treatment options (3)
- heparin anticoag to prevent
- thrombolytics
- referral to vascular surgeon for angiography or bypass surgery
Peripheral artery disease treatment options (5)
- medical management first - not surgical!!!
- smoking cessation
- aspirin therapy
- clopidogrel (plavix)
- surgical revascularization with angioplasty or arterial bypass
Complications of peripheral vascular surgery (4)
- graft failure up to 50% of time
- amputation
- infection
- seroma (serum buildup under skin often at site of surgical incision
