Set 4 (10/14) Flashcards
Blood Supply to appendix
appendiceal artery (branche of ileocolic artery)
Obturator Sign
pain with internal rotation of leg w/ hip and knee flexed
(+) in appendicitis
Rovsing’s Sign
rebound pressure of LLQ causes pain in RLQ
seen in appendicitis
Differential Diagnosis of Appendicitis
Meckel’s diverticulum, Crohn’s disease, perforated ulcer, pancreatitis, mesenteric lymphadenitis, constipation, gastroenteritis, volvus, intussusception, UTI, pyelonephritis, cholecystitis, fiverticulitis
Females: ectopic pregnancy, ovarian cyst, ovarian torsion, PID
Urinalysis in Appendicitis
can have mild hematuria and pyuria d/t pevlic inflammation → inflammation of ureter
CT Findings in acute appendicitis
periappendiceal fat stranding, appendiceal diameter >6mm, periappendiceal fluid, fecalith
Treatment of non-perforated appendicitis
appendectomy, 24h of Abx, go home on POD#1
Treatment of perforated appendicitis
IV fluid resuscitation, appendectomy, post-op Abx for 3-7 days, wound left open after closing fascia
Abx Options: Cefoxitin, Cefotetan, Unasyn, Cipro, Flagyl
Treatment of appendiceal abscess diagnosed pre-op
percutaneous drainage of abscesss, Abx, elective appendectomy ~6wks later
Abx: broadd spectrum (Amp/ Cipro/ Clinda or Zosyn)
Layers of abdominal wall with McBurney’s incision
Skin, SQ fat, Scarpa’s fascia, external oblique, internal oblique, transversus muscle, transversalis fascia, periotneal fat, peritoneum
Most common appendiceal tumors
carcinoid tumor
Carcinoid Tumor
tumor arising from neuroendocrine cells (Kulchitsky cells)
secretes serotonin
Most common sites of carcinoid tumors
“AIR”: Appendix, Ileum, Rectum, and bronchus
Pellagra-like symptoms
can occur in carcinoid tumors
Dermatitis, Diarrhea, Dementia
d/t ↓niacin production
Sx of Carcinoid Syndrome
“B FDR”: Bronchospasm, Flushing (skin), Diarrhea, Right-sided heart failure (Tricuspid insifficiency and pulmonary stenosis: “TIPS”)
Caused by serotonin and vasoactive peptides
Tx of carcinoid syndrome
Octreotide IV
If only diarrhea then treat with Ondansetron (Zofran) which is serotonin antagonist
What does liver break down serotonin into?
5-HIAA (5-hydroxyindoleacetic acid) which is elevated in urine in 50% of patients w/ carcinoid
Prognosis of Carcinoid tumors
66% alive at 5 years
50% with liver metss or carcinoid syndrome are alive at 3 years
Causes of enterocutanoeus fistula
(GI tract to skin)
anastomosis leak, trauma to bowel/ colon, Crohn’s disease, abscess, diverticulitis, inflammation/ infection
Colonic Fistula Most common
colovesical fistula (tx: segmental colon resection)
External Pancreatic Fistula
drainage of pancreatic exocrine ecretions through to skin
Tx: NPO, TPN, skin protection, octreotide
Most common carcinoma of anus
Squamous cell carcinoma (ASS: anal squamous superior) (80%)
Cloacogenic (tansitional cell) and adenocarcinoma/ melanoma/ mucoepidermal also occur
Anal epidermal carcinoma treatment
NIGRO Protocol
Chemo w/ 5-FU and mitomycin C
Radiation
Postradiation therapy scar Bx (6-8wks after radiation)
Goodsall’s Rule
fistulas anterior to anus will have a straight course; those exiting posterior will have curved tract
Dog has straight nose (anterior) and curved tail (posterior)
Seton
thick suture placed through fistula tract to allow slow transection of sphincter muscle; scar tissue will hold muscle in place allowing for continence after transection
Degrees of Hemorrhoids
- 1st degree: does not prolapse
- 2nd degree: prolapses w/ defecation but returns on own
- 3rd degree: prolapses with valsalva and requires active manual reduction
- 4th degree: prolapsed hemorrhoid that cannot be reduced
Hematochezia
bright red blood per rectum
Causes of Lower GI Bleed
diverticulitis, vascular ectasia, colon cnacer, hemorrhoids, trauma, intussusception, volvus, ischemic colitis, IBD (esp UC), rectal cancer, Meckel’s diverticulum, stercoral ulcer, infectious colitis, chemo, irradiation injury, infarcted bowel, strangulated hernia, anal fissure
What must be ruled out in lower GI bleed
upper GI bleed (get NGT aspiration with bile, if clear then most likely no upper GI bleed)
Tests for Lower GI bleeding
- NGT aspiration to r/o upper GI bleed
- slow to moderate bleeding = colonoscopy
- faster bleeding = mesenteric angiography to locate source
Child’s Classification (liver)
A BEAP: Ascites, Bilirubin, Encephalopathy, Albumin, PT
Class A has 10% operative mortality
Class B has 30% mortality
Class C has 75% mortality
MELD Score
uses INR, total bilirubin, serum creatinine
increased mortality by 1% for every 1pt up to 20 then 2% for every MELD point
Liver Tumors
most common is metastatic disease
most common primary malignant tumor is hepatocellular carcinoma
most common primary benign tumor is hemangioma
Chemicals that increase risk for liver hemangiomas
Vinyl chloride, arsenic, thorotrast contrast
Hepatocellular Adenomas
- normal hepatocytes without bile ducts
- Risks: women, birth control pills, anabolic steroids, glycogen storage disease
- avg age of 30-35yo
- SSx: RUQ pain/ mass/ fullness, bleedign (rare)
- Tx: stop OCPs if small or surgical resection
Focal Nodular Hyperplasia
benign liver tumor; liver mass with central scar; more common in women; normal hepatocytes and bile ducts (adenoma has no bile ducts)
more common in women
Tx: resection or embolization if symptomatic; stop OCPs
Risks for Hepatocellular Carcinoma
Hep B, cirrhosis, aflatoxin
Tumor Marker for Hepatocellular Carcinoma
α-fetoprotein
Indications for Liver Transplant
cirrhosis and NO distant or LN mets and no vascular invasion; <5cm tumor or 3 nodules all <3cm
Causes of Liver Abscesses
- Bacterial- E Coli, Klebsiella, Proteus
- Causes: cholangitis, diverticulitis, liver cancer, liver mets
- Amebic- Entamoeba histolytica (typically intestinal amebiasis that goes through portal vein)
Hydatid Liver Cyst
Cause: Echinococcus granulosus
SSx: RUQ pain, jaundice, RUQ mass
Dx: serologic testing, Casoni skin test, US, CT (calcified outline of cyst)
MUST NOT rupture cyst when removing → fatal anaphylaxis
Tx: mebendazole then surgical resection
Hemobilia
bleeding from liver through portal vein to GI tract; occurs after liver trauma
most common physical findings in protal HTN
splenomegaly (most common), esophageal varices (via coronary vein), caput medusae (engorgemetn of periumbilical veins), hemorrhoids
spider angiomas, palmar erythema, ascites, truncal obesity, peripheral wasting, encephalopathy, asterixis (liver flap), gynecomastia, jaundice
Budd-Chiari Syndrome
thrombosis of hepatic veins
Tx of bleeding Esophageal Varices
- IV fluids, type and cross, correct coag, +/- intubate
- Emergent endoscopic sclerotherapy
- Endoscopic Band Ligation
- Somatostatin or IV vasopressin to cause vasoconstriction
- Sengstaken-Blackmore Tube- gastric/ esophageal balloon for tamponade of esophageal bleed
- TIPS: Transjugular Intrahepatic Portosystemic Shunt
Which lab correlates with degree of hepatic encephalopathy?
Serum ammonia level
