Pretest_7_GI, Liver, Pancreas Flashcards
Expectant management with follow-up is the treatment of patients with ITP and platelet count greater than
30,000
What is the initial medical treatment for patients with ITP?
If platelets <50K with bleeding, prednisone for is initial treatment or IVIG if severe bleeding.
What is the indication for splenectomy in ITP?
If persistent thrombocytopenia for >3 months, platelets <10K after 6 weeks, treatment with toxic doses of steroids, etc
Patients with appendiceal adenocarcinoma should undero
formal right hemicolectomy
What is the medical and surgical treatment of achalasia?
Medical: CCBs, nitrates, endoscopic dilation, botox injection into the LES
Surgical: esophagomyotomy
Patietns with achalasia have 7x the risk of developing ________ as the rest of hte population
squamous cell carcinoma
What are indications for surgery in UC?
Acute management of toxic megacolon or fulminant colitis and definitive management for intractable disease or presence of high-grade dysplasia or carcinoma
What is the difference in managment of an infected vs noninfected pancreatic pseudocyst?
Infected = percutaneous catheter (external) drainage with antibiotics (similar to pancreatic abscesses) noninfected = internal drainage with cyst-gastrostomy or Roux-enY cyst-jejunostomy
What findings in pancreatic cyst fluid suggest malignancy?
High CEA level and low amylase level. Note internal drainage is CONTRAINDICATED if malignancy is suspected
What is the most common serious complication of end colostomies?
Parastoma herniation, when stoma is placed lateral to, rather than through, the rectus muscle
Involvement of what vessel by a pancreatic tumor is a contraindication for Whipple pancreaticoduodenectomy?
superior mesenteric artery
What is the treatment of a patient with a perforated duodenal ulcer without a long history of peptic ulcer disease?
simple closure with omental patch
What is early vs late dumping syndrome?
Intestinal symptoms after ingestion of a meal following surgical removal of part of the stomach or alteration to the pyloric sphincter.
Early dumping = occurs within 20-30 minutes of eating; attributed to rapid influx of fluid with high osmotic gradient int othe small intestine from the gastric remnant
Late dumping: 2-3 hours after a meal; symptoms resemble hypoglycemic shock
What is the role of somatostatin?
Decreases acid production by the parietal cells of the stomach; slows gastric motility
How is dumping syndrome managed?
Low sugar, frequent meals, separate solids and fluids
Management of an acute variceal bleed w/ ascites includes the use of ___________ to decrease splanchnic blood flow.
octreotide or vasopressin (because of coronary vasoconstrictive effects, nitroglycerin is usually coadministered with vasopressin)
Patients with poorly compensated liver disease who develop recurrent variceal bleeds should undergo
transjugular intrahepatic portosystemic shunting (TIPS)
What is the role of beta blockade in patients with variceal bleeds?
Propranolol, etc., with or without a long-acting nitrate, has been used to prevent recurrent variceal bleeding (but not used in acutely bleeding patients who are hemodynamically unstable!)
Portocaval, mesocaval, and splenorenal shunts are nonselective shunts and are associated with the (improvement/worsening) of encephalopathy postoperatively.
Worsening (exception is the distal splenorenal shunt, which is a selective shunt procedure)
What factors go into the Child-Pugh score?
total bili (50), serum albumin (>3.5, 2.8-3.5, 1.7 =2, >2.3=3) , ascites, hepatic encephalopathy, INR
What is the surgical intervention of a gastric ulcer resistant to medical therapy (amoxicillin, clarithromycin, PPI…or amox/amp, metronidazole, bismuth like Pepto Bismol)?
Bilroth I reconstruction (distal gastrectomy with gastroduodenostomy) or
Bilroth II reconstruction (distal gastrectomy with gastrojejunostomy)
Need to definitively rule out malignancy via surgical resection
What are the different types of gastric ulcers and which require vagotomy?
Type I = in body of stomach along lesser curvature
Type II = body of stomach, with concomitnat duodenal ulcer (requires vagotomy)
Type III = prepyloric (requires vagotomy)
Type IV = near the GE junction
only ulcers associated with acid hypersecretion require vagotomy
T/F: Radiation therapy is helpful in treating colon cancer and its liver metastases.
False! Radiation therapy has little to offer
Which hernia follows the path of the spermatic cord within the cremaster muscle?
indirect inguinal; the internal inguinal ring is an opening in the transversalis fascia for passage of the spermatic cord
What is a Spigelian hernia?
hernia passing through an anatomic defect along the lateral border of the rectus muscle at its junction with the linea semilunaris
What is an interparietal hernia?
Instead of protruding in the usual fashion, the hernia sac makes its way between the fascial layers of the abdominal wall. Can be preperitoneal (between the peritoneum and the ransversalis fascia), interstital (between muscle layers), or superficial (between external oblique aponeurosis and the skin)
Which hernia is medial to the inferior epigastric artery? Which is lateral?
(direct vs indirect inguinal hernia)
medial = direct lateral = indirect
Air in the biliary tract (aerobilia) in a nonseptic patient is diagnostic of
biliary enteric fistula
Diagnoses of biliary enteric fistula with clinical small bowel obstruction in a patient with not prior abdominal surgery suggests
gallstone ileus (a large chronic gallstone erodes through the wall of the gallbladder into the adjacent stomach or duodenum). The connection between biliary system and GI tract allows air into the biliary tract (aerobilia). When the stone reaches the duodenum, it causes obstruction
The average age of cancer development in patients with chronic UC is
37 years old
The risk of developing cancer in patients with UC is low in the first ___ years, but thereafter rises about 4% per year
10
Treatment of patients with familial polyposis is
total proctocolectomy with ileoanal J pouch
This syndrome is characterized by intestinal polyposis and melanin spots of the oral mucosa:
Peutz-Jeghers. Unlike the adenomatous polyps seen in familal polyposis, the lesions in this condition are hamartoma (no malignant potential)
If there is significant inflammation in the RUQ in gallstone ileus, what should be the surgical procedure?
Ileotomy with removal of the stone and interval cholecystectomy (operating on the biliary enteric fistula doubles the mortality rate compared with simple removal of the gallstone)
What are the indications for surgical intervention for diverticular disease? What do you do about diverticular abscesses?
Hemorrhage secondary to diverticulosis, recurrent episodes of diverticulitis, intractability to medical therapy, and complicated diverticultis (including perforated diverticulitis with or without abscess and fistulous disease). Abscess = percutaneous drainage with sigmoid resection and primary anastamosis
A gallbladder ejection fraction of <__% at 20 minutes is diagnostic of biliary dyskinesia.
<35%
Gallbladder polyps can be observed with serial ultrasounds if they are what size?
<1 cm
If there is evidence of extensive local disease in gallbladder carcinoma, a patient should undergo radical cholecystectomy, which includes
portal lymphadenectomy and either wedge or formal resection of the liver surrounding the gallbladder fossa in addition to cholecystectomy
An abdominal mass that does not change with contraction of the rectus muscles:
hematoma of the rectus sheath
What is the difference in the treatment of amebic liver abscesses (due to E. histolytica) vs pyogenic liver abscesses?
amebic = treat initially with metronidazole pyogenic = percutaneous catheter drainage and antiboitcs against gram negative and anaerobic organisms
Since the majority of sliding esophageal hernias are asymptomatic, what prompts surgical treatment?
esophagitis or stenosis
What are the boundaries of the femoral canal?
superior: iliopubic tract
inferior: Cooper ligament
lateral: femoral vein
medial: junction of the ioliopubic tract and Cooper ligament
Why should all femoral hernias, even asymptomatic ones, be repaired?
the incidence of strangulation in femoral hernias is high
What is different between the treatment of acute mesenteric ischemia and ischemic colitis?
Acute mesenteric ischemia affects the small intestine and requires emergent intervention, but ischemic colitis (hematochezia, fever, abdominal pain) only requires surgical intervention if there is full-thickness necrosis, perforation, or refractory bleeding; only expectant management with bowel rest, IV fluids, and supportive care
Which side of the colon absorbs more water and sodium, right or left?
right
Which electrolyte is absorbed by the colonic epthelium by active transport?
Sodium! Potassium is excreted passively and chloride (absorbed) nad bicarbonate (secreted) are exchanged across the epithelium
Hepatic adenomas may be associated with use of this medication ________, and cessation can allow regression if the lesion is smaller than __ cm
OCPs; <4 cm
Focal nodular hyperplasia is rarely symptomatic, and unlike __________, it is not associated with a risk of malignant degeneration or rupture with hemorrhage.
hepatic adenomas
A surgical resection of focal nodular hyperplasia (FNH) is indicated only if
the lesion is symptomatic
Acute hemorrhage secondary to left-sided portal hypotension is characterized by what? What is the treatment?
gastric varices in the setting of splenic or portal vein thrombosis in the absence of cirrhosis (normal LFTs)
Treatment is splenectomy
Marked edema of the terminal ileum with overyling fibrinopurulent exudate…
regional enteritis (Crohn’s)
Treatment of biliary stricture in the proximal portion of the extrahpeatic biliary system is best treated with
end-to-side choledochojejunostomy (Roux-en-Y) performed over a stent (primary repair may result in recurrent stricture and choledochoduodenostomy cannot be performed because of proximal location of the stricture)
Malignant cells in the mucosal layer only =
carcinoma in situ
T/F: Endoscopic polypectomy is adequate treatment of carcinoma in situ villous adenoma or even if an invasive component is identified. (What are requirements?)
True! But if there is an invaisve component, there
1) can’t be vascular or lymphatic invasion
2) must be adequate negative margin (2mm) with well-differentiated cancer
Malignant tumors in the esophagus are usually squamous cell carcinomas, except for those involving the sophagogastric junction, which are
usually adenocarcinomas
What is the standard of care in esophageal carcinoma?
Neoadjuvant (preoperative) chemo with esophageal resection
What is a secretin stimulation test and what does it confirm?
Fasting gastrin level is measured and serum gastrin is obtained at intervals (short term; longest 20 min) following secretin administration. Rise in gastrum greater than 200 over the baseline following secretin is found in patients with ZOLLINGER-ELLISON syndrome (gastrinoma)
Where are most gastrinomas found?
The gastrinoma triangle – the three corners of the duodenum, the junction of the neck and body of the pancreas, and junction of cystic and common bile ducts
What are the Ranson criteria for gallstone pancreatitis?
ON ADMISSION: age, WBC count, LDH, aspartate aminotransferase (AST), and glucose
48hours later: Hct fall, BUN elevation, serum calcium, base deficit, sequestration of fluids, oxygen (<2 = 0% mortality; 3-5 10-20% morality, 6 or greater 50%
What is Whipple triad?
Clinical findings of patients with insulinomas; 1) attacks precipitated by fasting or exertion (tachy, confusion, HA); 2) fasting blood glucose concentrations <50 mg/dL, and 3) symptoms relieved by oral or IV glucose administration
What is the treatment of epidermoid carcinoma of the anus?
Nigro protocol! Chemo and radiation together! Radical surgical resection has disappointing results
An “apple core lesion” in the rectosigmoid on CT is diagnostic of
large bowel obstruction
When is surgery indicated in Crohn’s?
1) obstruction causing a compromise in nutritional status
2) enterovesical and enterovaginal fistulas
3) perforation of bowel
T/F: Fistulas are always an indication for surgery in Crohn’s
False! For example, an ileum-ascending colon fistula is very common and rarely symptomatic and does not require surgical intervention
Causes of distended colon (x5):
tumor, foreign body, colitis, cecal or sigmoid volvulus
Next diagnostic steps in distended colon:
proctosigmoidoscopy (can treat sigmoid volvulus with rectal tube compression via sigmoidoscope). Next step would be emergency celiotomy
Air-filled, kidney-bean-shaped structure in LUQ in abdominal radiograph:
cecal volvulus!
How do you manage cecal volvulus?
right hemicolectomy
Management of echinococcus hydatid cysts?
Surgical resection, enucleation, or evacuation (with silver nitrate or hypertonic saline introduced into the cyst beforehand)
Treatment with mebendazole or albendazole combined with percutaneous drainage
T/F: Spontaneous rupture of hydatid cysts can cause an anaphylactic reaction.
True
Up to 20-30% of patients with hepatic cysts also have cysts where in their body?
Lungs
T/F: Paraesophageal hernias should be surgically repaired whenever they are diagnosed.
True (substantial risk for strangulation and obstruction)
What is Ogilivie syndrome?
massive cecal and colonic dilation seen in the absence of mechanical obstruction (could also be called colonic ileus or functional colonic obstruction)
Ogilivie syndrome (massive cecal and colonic dilation in the absence of mechanical obstruction) cannot be confirmed until
mechanical obstruction of the distal colon is excluded by colonoscopy or contrast enema
Perforation becomes a distinct hazard as the cecum reaches what degree of dilation?
10-12 cm
What is the Quincke triad?
pain in the RUQ, jaundice, and GI bleeding = hemobilia
What is the most common cause of hemobilia?
iatrogenic injury (percutaneous liver procedures like transhepatic colangiogram, etc), but also spontaneous bleeding during anticoagulation, gallstones, parasitic infections/abscesses, neoplasms
Intrahepatic bleeding can be controlled by _____________, while bleeding from extrahepatic bile ducts or the gallbladder require ___________
intrahepatic = angiographic embolization extrahepatic = surgical treatment
While Crohn’s is a transmural inflammatory process, UC has inflammation confined to _________
mucosa and submucosa
Crypt abscesses and superficial ulcerations are common in which IBD?
UC
What are the types of paraesophageal hernias?
Type I: GEJ above diaphragm
Type II: GEJ below diaphragm, but cardia/fundus above
Type III: GEJ and cardia/fundus above diaphragm
What is the most common cause of small intestinal bleeding in patients under the age of 30?
A Meckel diverticula (can contain ectopic gastric mucosa, and acid secretion can cause small-bowel ulcerations)
T/F: A 99m Tc pertechnetate scan can diagnose Meckel diverticula.
True!
While carcionoid tumors in the appendix can be treated with an appendectomy if __cm should be treated with right hemicolectomy to decrease locoregional recurrence.
> 2 cm should be treated with right hemicolectomy
No further treatment is needed for a 1-2cm carcinoid tumor at the tip of the appendix, but tumors of this size located where are best reated with a right hemicolectomy?
This size located at the base of the appendix or invading the mesentery; (note: also if tumors >2cm)
Immediate surgical repair of inguinal hernias are indicated in cases of
acute incarceration (irreudicibility). Chronic incarceration does not increase risk of strangulation
What is the treatment recommended for choledochal cysts?
Roux-en-Y choledochojejunostomy and complete resection of the cyst
Why is surgery advised in all cases of choledochal cysts?
Malignant changes are frequent; nonsurgical treatment results in high morbidity and mortality
What is stress ulceration?
Acute gastric or duodenal erosive lesions that occur following shock, major surgery, trauma or burns
What is the pathophysiology of stress ulceration?
Decreased splanchnic blood flow and ischemic damage to the mucosa (note: NOT increased gastric secretion)
Stress ulcerations are (superficial/extend to muscularis mucosa=true).
Superficial
T/F: Like chronic benign gastric ulcers, stress ulcers are often found in the antrum.
False! Stress ulcers usually spare the antrum
What is the Charcot triad?
fever, jaundice, pain in RUQ = cholangitis; caused by choledocholithiasis too
What is the management of cholangitis?
IV abx, fluid resuscitation, and then percutaneous or endoscopic drainage of the obstructed common bile duct (if nonoperative approach fails, surgerical placement of a T tube into the duct is indicated)
In patients tha tare high risk and critically ill with multisystem disease and cholecystitis, the best intervention is
tube cholecystostomy (can be done with local anesthesia)
T/F: Pancreatic pseudocysts, which can develop during acute and chronic pancreatitis, have malignant potential.
False! This is because they do not have epithelial lining
Why should you wait 6 weeks to treat for pancreatic pseudocysts?
Most spontaneously resolve in that time frame
What are complications of pancreatic pseudocysts?
gastric outlet and extrahepatic biliary obstructions as well as spontaneous rupture and hemorrhage
What is a Dieulafoy lesion?
Characteristically located within 6 cm distal to the GEJ (proximal stomach), it is an abnormally large submucosal artery that protrudes through a small, solitary mucosal defect. PPIs do not help, but sclerotherapy/electrocoagulation does
Carcinoid tumorsr arise from which cells?
Enterochromaffin cells in the crypts of Lieberkuhn
Why is carcinoid syndrome rare in patients with carcinoid of the appendix?
Tumors are usually discovered before mets occur (usually syndrome associated with mets of htel iver, but can also occur when mets are to sites drained by systemic veins)
Polypoid lesions of the gallbladder are more likely to be malignant if they are bigger than __ cm and solitary and associated with the presence of gallstones
1 cm
What are metabolic consequences of total pancreatectomy? (x7)
total pancreatectomy = resection of the duodenum, distal common bile duct, and gallbladder too
weight loss, malabsorption with hypocalcemia nad hypophosphatemia, diabetes mellitus, diarrhea, and iron deficiency (iron absorption occurs mainly in the duodenum) and pernicious anemia (lack of pancreatic enzymes for B12 absorption). As a result of all of this, pancreaticoduodenectomy is usually preferred.
What is the most common liver tumor?
Hepatic hemangioma (benign)
T/F: The best management of hepatic hemangioma is biopsy and then resection.
False! No evidence these undergo malignant transformation and risk of spontaneous rupture/hemorrhage is low (most are iatrogenic following attempted biopsy). Management is angiographic embolization or resection only if symptomatic or complicated hemangioma.
T/F: CEA is elevated in cigarette smokers.
True
T/F: Very high elevations of CEA suggest extensive liver disease or peritoneal spread of colorectal tumors, which is unresectable.
True
If CEA falls to below ___ ng/mL after resection, the patient has an excellent prognosis.
2-3
T/F: Intraareterial infusion of vasopressin in patients with Mallory-Weiss is contraindicated if they have coronary artery disease.
True (can add nitro though!)
If the Mallory Weiss tear continues to bleed (90% stops on own), what can be done?
balloon tamponade, endoscopic control ofbleeding, and surgical intervention with gastrotomy and oversewing of the tear have all been successful
When patients have passage of a galllstone pass the ampulla of Vater as it exits the common bile duct into the duodenum, they can develop
acute pancreatitis
What is the definitive operation of choice for patients with UC?
total proctocolectomy with either end ileostomy or ileoanal J-pouch anastamosis
What is treatment of toxic megacolon?
subtotal colectomy with end ileostomy
What are the contraindications for sphincter-sparing surgery in DISTAL rectal cancer? What is performed instead?
1) tumors too close to sphincter for adequate margin (2 cm). Note: preoperative or neoadjuvant chemo can cause distal rectal tumors to shrink such that sphincter-sparing surgery can be performed!
2) fecal incontinence
These tumors are treated with abdominal-perineal resection (just like squamous cell carcinoma of the anus that fails with the Nigro protocol = radiation + chemo before surgery)
What is the treatment of proximal and midrectal cancers?
Low anterior resection (removal of the rectum to below the periotenal reflection through an abdominal approach)
T/F: Total proctocolectomy may relieve or resolve extraintestinal manifestations of UC such as peripheral arthritis or ankylosing spondylitis.
True. But the surgery is NOT preventative or curative for PSC.
An infected pancreatic pseudocyst is drained (internally/percutaneously).
Percutaneously!
Internal drainage is the treatment of choice for mature, symptomatic, noninfected pseudocysts.
The involvement of the (SMA/SMV) by a pancreatic tumor precludes resection for cure.
SMA.
If the SMV is involved, 2 to 3 cm of the portal vein/SMV can be resected and an end-to-end anastamosis or bypass can be performed.
