PESTANA2 Flashcards
What is one cause of an “acute abdomen” that will not have peritoneal signs?
Acute pancreatitis, it is a retroperitoneal organ
How do you diagnose Boerhaave tears? Tx?
Gastrograffin swallow first, Barium if negative (don?t want barium in the mediastinum); followed by emergent surgical repair
How do ureteral stones classically present? What is the best diagnostic test?
Colicky flank pain that radiates toward the scrotum or labia; CT (UA will show microhematuria)
What scan helps to locate the culprit parathyroid gland for hyperparathyroidism?
Sestamibi scan
What is the diagnostic test of choice for coarctation of the aorta?
CT angiography
Why do all mechanical obstructions of hernias go to the OR?
Because you can repair the hernia, if it is caused by adhesions, taking the pt to OR for LOA only increases risk of more adhesions
How does right sided colon CA often present? Dx? Tx?
Anemia for no good reason in an elderly person; Colonoscopy w/ Bx; Right hemicolectomy with oncologic resection (i.e. need 12 LN)
When should C diff colitis be operated on?
If it is unresponsive to tx with WBC > 50,000 and serum lactate > 5
What is a thyroid nodule in a hyperthyroid pt
Usually a “hot adenoma” and almost never cancer
Which form of breast CA has the worst prognosis and requires pre op chemotherapy
Inflammatory breast CA
Why do a full coloscopy before operating on a left sided cancer?
To rule out a synchronous right sided primary
How do you diagnose a pyogenic liver abscess? What is the tx?
CT scan or US; CT guided drain placement
What is the key finding in ascending cholangitis?
Extremely elevated ALP
What is the usual antecedent disease for a pyogenic abscess of the liver?
Acute cholangitis (Charcot’s triad or Reynolds pentad); dx is CT and tx is CT-guided drainage
What is the final common pathway that should be anticipated in a person with hemorrhagic acute pancreas?
Development of multiple pancreatic abscesses that will need to be drained; do daily CT scanning
How do you diagnose a hepatic adenoma? What is the concern?
CT scan (NOT intraoperative bx); the concern is that they may spontaneously rupture and bleed into the abdomen
Tx of acute pancreatitis
NPO, NGT, and IVF
What breast masses occur in very young adolescents and have rapid growth
Giant juvenile fibroadenomas
What are the most likely locations in the bone that breast CA will go to
Vertebral pedicles (back pain)
When is surgery indicated in necrotizing enterocolitis?
If abdominal wall erythema, pneumatosis intestinalis, air in portal vein, or pneumoperitoneum develops
What is the usual cause of an isolated indirect hyperbilirubinemia?
Hemolytic jaundice, direct dx towards cause of RBC destruction
What drug is used in pts who start developing pancreatic abscesses in acute pancreatitis?
IV meropenem
How do babies with gastroschisis get nutrition?
Need vascular access for TPN since the bowel will not work for about 1 month
What are the labs for hepatocellular jaundice? What should diagnostics be geared towards?
Elevated direct/indirect fractions of bilirubin; very high transaminases with modest ALP; gear towards hepatitis so get serologies
What are the 3 basic types of jaundice?
Hemolytic, Hepatocellular, and Obstructive
How do you diagnose hypertrophic pyloric stenosis if no palpable mass
US
When do you do surgery for partial and complete bowel obstructions (i.e. due to adhesions)?
Partials can be done after a few days if medical therapy failed (NPO, IVF, and NGT); Complete obstructions should be operated on within 24 hrs if medical tx fails
What is the best test to confirm carcinoid syndrome?
24 hour urinary collection for 5-hydroxyindole acetic acid
What is the big clinical test for esophageal atresia?
Coiling of the NGT in the chest on CXR (note in a traumatic situation in an adult this may point towards traumatic rupture of the diaphragm)
What is the goal gastric pH in an ICU pt to prevent stress-related mucosal disease?
> 4.0
What is a key laboratory difference between edematous pancreatitis and hemorrhagic pancreatitis?
Edematous has a high hematocrit from hemoconcentration whereas hemorrhagic has low hct from hemorrhage
What is Nelson syndrome?
Adrenal insufficiency from removal of adrenals
Describe the presentation of an acute abdomen due to ischemic processes
Will have severe abdominal pain with blood in the lumen of the gut
Necrotizing soft tissue infxn can occur in pts who have perirectal abscess and what dz?
DM
What do you do if the results of FNA of the thyroid are indeterminate
Thyroid lobectomy
What is the first diagnostic test in working up Cushings disease?
Low dose dexamethasone suppression test
How is anal cancer treated?
Nigro Chemoradiation protocol; 5 weeks of chemoradiation and if residual tumor surgery. But rarely is surger ever needed
What is often present in glucogonomas?
Migratory necrolytic dermatitis
Describe the general presentation of an acute abdomen caused by inflammation
Has a GRADUAL onset and slow buildup that is very poorly localized and then becomes severe with peritoneal signs in the area; often pw systemic signs like leukocytosis and fever
What test is diagnostic for sigmoid volvulus? Describe the findings
AXR; Shows a “Parrot’s beak” dilated loop up in the RUQ that tapers down in the LLQ
Blood per rectum in a child is most likely from what?
Meckel Diverticulum
What are the aldosterone and renin levels in Conn’s?
Aldosterone high and renin low
What is the presentation of biliary pancreatitis?
A mixed cholangitis/pancreatitis picture with elevation of transaminases and ALP as well as lipase and amylase
What are 3 things that mimic acute abdomens that should be ruled out? How would you rule them out?
1) Inferior wall MI (EKG troponins) 2) Lower lobe pneumonia (CXR) and 3) PE (D-dimer, US, or CTA)
What are the labs like for obstructive jaundice?
Elevated direct/indirect fractions of bilirubin; modest transaminase bumps (vs. hepatocellular causes) and very high ALP (vs. hepatocellular)
What is nesidioblastosis? Tx?
Devastating hypersecretion of insulin in a newborn (often of DM mom); requires a 95% pancreatectomy
How does esophageal atresia present?
excessive salivation shortly after birth or choking spells when feeding is first attempted
How is diagnosis made in Hirschsprung?
Full thickness rectal bx (i.e. see adipose tissue on slide representing the mesorectum)
What test will confirm the dx of an acute abdomen caused by perforation?
AXR to show free air under the diaphragm
How do you treat necrotizing enterocolitis?
Stop all feedings, broad spectrum abx, IVF, and TPN
What is the mgmt of intussusception?
Barium or air enema is diagnostic and therapeutic but if doesnt work then surgery
What are 3 causes of green vomiting in a baby with a double bubble on xray
duodenal atresia (Downs), annular pancreas, and malrotation
What does it mean if there is suppression of cortisol with a high dose dexamethasone suppression test?
That identifies a pituitary microadenoma; failure to suppress = adrenal adenoma or paraneoplastic syndrome (small cell CA)
What should you think if you see a breast abscess in a woman who is not lactating?
It is breast CA until proven otherwise
In whom does a fistual in ano develop? Tx?
Ppl who have had a perirectal abscess drained; if not suspect crohns; fistulotomy
What key finding of acute edematous pancreatitis helps to identify it as edematous by labs?
High hematocrit (hemoconcentration)
If for any reason surgical repair of esophageal atresia has to be delayed what must be done?
Placement of a gastrostomy to prevent chemcial pneumonitis
What is the real issue in congenital diaphragmatic hernia?
The resultant pulmonary hypoplasia
How is the presentation of acute cholecystitis different from that of biliary colic?
Biliary colic is characterized by attacks that are self-limited but acute cholecystitis becomes constant and is accompanied by peritoneal signs and systemic signs of inflammation
What is the tx for a single focus of DCIS? Why
Lumpectomy and radiation; DCIS cannot metastasize; if multicentric then simple mastectomy incase invasive focus was missed
What is the best diagnostic test to work up melena?
Upper Endoscopy
When is SBO a surgical emergency?
If it is strangulated i.e. white count, declining, and peritoneal signs
What is the surgical tx of necrotic pancreas?
Necrosectomy usually 4 weeks after development of necrotic pancreas since that allows time for the necrotic tissue to delineate
What is the best diagnostic test for acute diverticulitis? What is the best initial Tx?
CT; NPO, IVF, Abx 7-10 d
What is the best way to Dx C diff?
Toxin in stool
What is the diagnostic and therapeutic therapy for meconium ileus?
Gastrograffin enema showing microcolon and insipissated mucus in terminal ileum; gastrograffin draws in fluid and dissolves the pellets
What is the tx of perirectal abscess?
I/D
What is the initial diagnostic test for pheochromocytomas?
24 hour urinary collection for VMA, metanephrines (more specific) or free catecholamines
What is the usual presentation (classic) for mesenteric ischemia
Develops when there is an acute abdomen in a person with hx of afib or debilitating MI (LV hypokinesis) = they threw a clot down the SMA
What will US show in acute cholecystitis?
Gallstones, thickened GB wall, and pericholecystic fluid
What is the key finding in primary hyperaldosteronism?
Hypokalemia in a hypertensive pt who is not on diuretics
What is the first step in the work up of labs that point towards hepatocellular jaundice? Obstructive jaundice?
Serologies for hepatitis viruses; US for bile duct dilatation
What is the tx for acute cholangitis?
IV abx and emergency decompression of the CBD by ERCP or by Percutaneous Transhepatic cholangiogram
What is the next diagnostic step if working up ZE syndrome and gastrin is markedly elevated
Contrast CT to identify the gastrinoma and remove it; Calcium level to check for parathyroid adenoma to determine if part of MEN I
How do you manage large pancreatic pseudocysts (>6 cm)
percutaneous drainage, surgical drainage into GI tract, endoscopic drainage into stomach
What test can be done if you suspect ZE syndrome but gastrin levels are equivocal
Secretin stimulation test
What is the tumor marker for hepatocellular carcinoma? What is the tx?
AFP; resection if possible
What is the usual tx of pts with a hot adenoma?
Radioactive iodine
How is malrotation diagnosed?
Contrast enema or upper GI series
What is the first step in treating C diff colitis?
Discontinue the offending antibiotic
How does an acute abdomen due to perforation differ from that due to obstruction?
Perforation is often constant and generalized whereas obstruction is more colicky and localized
Which disease classically presents with dysphagia that is worse for liquids?
Achalasia
What is the diagnostic method of choice in thyroid nodules in euthyroid pts?
FNA
How can you determine if a palpable nodule in a hyperthyroid pt is the source of the hyperthyroidism?
Nuclear scan
How does an acute abdomen due to obstruction differ from that due to inflammation?
One due to obstruction will be colicky in nature and localize, one from inflammation will start out generalized and become more localized with time and have systemic signs of inflammation (wct and fever)
Where is the most common location of pancreatic pseudocysts?
Lesser Sac
Describe the pain of acute abdomen due to perforation
Constant, generalized, and very severe; the pt is reluctant to move and very protective of the abdomen
A medically sophisticated pt that wants to go after the whole Munchausen-insulinoma thing can use what instead of injectable insulin?
Sulfonylureas since they induce the actual secretion of insulin which would also elevate C-peptide thus obscuring the Munchausen picture
Upon what is inoperability of a breast cancer based?
Local extent not metastasis
What are the 3 ways to workup active LGIB after UGIB and hemorrhoids have been excluded?
If it is not much blood then you can do colonoscopy, if it is a lot of blood then you do angiography, and if it is in between you do a tagged RBC study
How is the dysphagia of achalasia classically different from that of esophageal CA?
Achalasia is often worse for liquids than solids whereas CA starts out as dysphagia for solids then progresses to liquids
What is the big general rule in congenital anomalies?
When there is one there are usually more
What is the usual tx for internal hemorrhoids vs. external? Which bleed?
Internal = banding; external = surgical removal; internal bleed
What hormonal therapy for breast CA do premenopausal women get? Postmenopausal?
Premenopausal = tamoxifen; Postmenopausal = anastrazole
What is the tx of the acute issue in sigmoid volvulus
Proctosigmoidoscopic exam with decompression and leave in a rectal tube; later you can electively do a sigmoid resection with primary anastomosis
How does acute abdomen due to obstruction present?
P/w onset of colicky abdominal pain and if due to obstruction of a small duct i.e. cystic or ureter will refer pain to associated area. Pt will writhe in pain and not be comfortable
What type of medications can abort biliary colick
Anticholinergics
How is the presentation of amebic liver abscess different from that of pyogenic abscess? How is the treatment different?
Pyogenic abscess often arises due to complication of ascending cholangitis and needs CT guided drainage; Amebic abscess is often assoc with a “mexico connection” and tx is metronidazole
What is a study to do when upper and lower endoscopy have not shown a source of bleeding and you want to evaluate a small bowel etiology?
Capsule endoscopy
What are the 3 types of acute pancreatitis?
Edematous, hemorrhagic, or suppurative (pancreatic abscess)
What is the mgmt of biliary pancreatitis?
NPO, poss NG suction, IVF? Wait on it and possibly do ERCP with sphincterotomy and then elective cholecystectomy
What is the cardinal symptom of Hirschsprung disease?
Chronic constipation
When can you do a metastatic resection for a met to the liver?
If restricted to one lobe of the liver
What are the insulin and C peptide levels in insulinoma?
Both elevated vs. Munchausen
What are the symptoms of chronic pancreatitis
DM, steatorrhea, and constant epigastric pain
What are 4 indications for surgical Tx of UC? What is the Tx?
Disease for greater than 20 years, need for high dose steroids or immunosuppresants, severe interference with nutrition, multiple hospitalizations, or TOXIC MEGACOLON; Total proctocolectomy with end ileostomy (Brooke Ileostomy)
Tx for axymptomatic gallstones
Leave em alone
What other tests should be done in a kid with esophageal atresia (4)
Anal exam for imperforate anus, renal US for abnormalities, echo for heart abnormalities, and xray for radial and vertebral abnormalities
What is the tx for mallory-weis tears?
Endoscopy with photocoagulation
Discuss the treatment of obstructive jaundice due to CBD stone
ERCP followed by cholecystectomy
What do you do when working up Cushings if there is no supression after a low dose dexamethasone test?
Collect 24 hour free urine cortisol and if elevated go to a high dose dexamethasone suppression test
How does an acute abdomen due to perforation differ from that due to ischemia?
One with perforation is severe, constant and generalized; one from ischemia will also have blood
What diagnostic study can guide surgical resection of an intraductal papilloma?
Galactogram
How does the tx of gastric lymphoma differ from gastric adenocarcinoma?
The best tx of gastric adenocarcinoma is surgery whereas that of gastric lymphoma is chemoradiation (lymphoma has better prognosis)
What is the mgmt of exstrophy of the bladder?
Immediate surgery within 1-2 days of life; increased risk of SCC of bladder
How do you determine the level of the pouch in imperforate anus?
Take an xray upside down with a metal marker on the anus so that gas rises up
