Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery > small intestine and appendix > Flashcards

small intestine and appendix Flashcards

1
Q

the duodenum

A
  • extends from pylorus to ligament of treitz
  • retroperitoneal
  • 4 segments: duodenal bulb and descending duodenum which house major/minor duodenal papillae
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

minor and major papilla

A

minor- drainage of dorsal pancreatic duct (accessory duct of Santorini)

major- drains common bile duct and main pancreatic duct (duct of wirsung)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

jejunum

A

more prominent plica circualres and longer vasa recta than ileum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

blood supply of small intestine

A

primarily the superior mesenteric artery (SMA)

duodenum also supplied by gastroduodenal artery, originating from celiac axis via common hepatic artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

venous drainage of small intestine

A

superior mesenteric vein (SMV) which is joined by splenic and inferior mesenteric veins to constitute the portal vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

lymphatic drainage of small intestine

A

lacteals and lymphatic channels paralleling the venous drainage, joining at the cisterna chyli in upper abd below the aortic hiatus of the diaphragm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

lymphatic tissue of terminal ileum

A

known as Peyer’s patches and terminates at ileocecal valve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

nerve supply of small intestine and appendix

A

autonomic nervous system

parasympathetic fibers from vagus nerve and traverse to gut via celiac plexus

sympathetic fibers travel via splanchnic nerves from ganglion cells in superior mesenteric plexus

intestinal distention- sympathetic visceral afferent fibers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

appendix

A

arises from the cecum at the confluence of the taenia coli and accompanied by an adjacent mesentery (mesoappendix) which courses the appendiceal artery as a terminal branch of ileocolic artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

how is the primary function of digestion and absorption of the small intestine accomplished

A

intestinal motility, activity of digestive enzymes, secretion of digestive juices, and absorptive processes predicted on both simple diffusion and active transport

autonomic and endocrine regulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

4 phases of migrating motor complex (MMC)

A
  1. quiescent w no spikes or contractions
  2. accelerating and intermittent spike and contractile activity
  3. sequence of high amplitude spiking activity and corresponding strong, rhythmic gut contractions
  4. brief migrate down the small intestine

total duration of cycle is 90-120m

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

where is vit b12, a, d,e,k and bile salts, calcium and iron absorbed

A

b12,a,d,e,k,bile salts- terminal ileum

ca/fe- duodenum and proximal small bowel

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what does IgA for the gut immune system

A

suppress bacterial growth and adherence to epithelial cells

neutralizes bacterial toxins and viruses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what happens with SBO

A

lumen of the small intestine is blocked causing small bowel effluent to back up resulting in abd distension, n, v

mesentery can be compromised causing strangulation of the intestine w resulting ischemia and potentially bowel necrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

closed loop bowel obstruction

A

complete obstruction where a portion of small intestine is obstructed both proximally and distally

high risk for strangulation and requires immediate surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

intraluminal causes of SBO

A

foreign bodies, barium inspissation (colon), bezoar, inspissated feces, gallstone, meconium (cystic fibrosis), parasites, intussusception, polypoid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

intramural causes of SBO

A

congenital (atresia, stricture, stenosis, web, meckels diverticulum)
inflammatory process (crohns, diverticulitis, ischemia, radiation enteritis, medication induced)
neoplasms (primary bowel, seconday)
trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

extrinsic causes of SBO

A

adhesions, congenital (ladd/meckels bands, postop, postinflammatory)
hernias (ext/int)
volvulus
external mass effect (abscess*, annular pancreas, carcinomatosis, endometriosis, pregnancy, pancreatic pseudocyst)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

MC SBO cause in industrialized and nonindustrialized

A

indust- postsurgical adhesions or scar tissue

nonind- inguinal or umbilical hernia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

SBO due to internal hernias after laparoscopic gastric bypass

A

small mesenteric defects can be created through which small bowel can herniate and cause obstruction and potentially strangulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

metastatic peritoneal cancer as cause of extrinsic SBO

A

metastatic peritoneal implants, commonly from ovarian or colon cancer, may compress the small bowel lumen causing an intestinal obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

how do instrinsic causes affect the small bowel

A

causes thickening of the bowel wall and causes lumen to compromise forming a stricture within the small intestine not allowing solids to pass through the narrow lumen causing abdominal crampy pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

MC cause for benign stricture

A

Crohn’s disease

less common- radiation enteritis, ulcers from nsaids, previous small bowel resection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

is strangulation assoc w bowel obstructions caused by strictures

A

not likely since mesentery is not compromised

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

how a foreign body (intraluminal cause) causes SBO

A

in some the ileocecal valve produces a slight narrowing that may form a barrier for some larger foreign bodies so they become impacted at the valve and an obstruction develops

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

what is the most serious complication of SBO

A

strangulation of the involved intestine because the bowel becomes ischemic and eventually infarcts as edema and kinking of the mesentery impact mesenteric vascular patency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

indicators of a higher risk of strangulation

A

fever
tachycardia
leukocytosis
localized abd tenderness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

pt w intermittent, intense, colicky pain relieved by vomiting of the epigastric region

A

proximal sbo (open loop)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

pt with intermittent to constant pain that is diffuse and progressive, moderate abd distention, obstipation, and mild vomiting

A

distal sbo (open loop)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

pt with progressive diffuse pain that was intermittent but rapidly worsened and is now constant, no abd distention

A

sbo closed loop

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

pt w continuous diffuse pain, w intermittent vomiting, marked abd distention and obstipation

A

colon and rectum obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

what should you be concerned about if pain and tenderness begin to localize in a more somatic pattern

A

bowel ischemia and peritonitis w attendant parietal peritoneal irritation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

in an obese pt what may be the only clue to bowel incarceration within an otherwise occult hernia

A

areas of focal contour change, erythema or tenderness near a surgical scar

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

when will diffuse mild tenderness improve usually w sbo

A

after acute decompression via a nasogastric tube

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

initial imaging studies for sbo

A

abd series- supine and upright abd films

upright chest radiograph

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

imaging findings for sbo

A

bowel distention proximal to point of obstruction and collapse of bowel distal to same point

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

what do air fluid levels on an upright film indicate

A

lack of normal propulsive activity in affected loops of intestine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

what represents closed loop obstruction on abd series

A

focal loops of intestine that are persistently abnormal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

if the bowel is massively distended with air and it is difficult to distinguish the small and large bowel what should be done

A

water soluble contrast enema to exclude the possibility of a large bowel obstruction mechanism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

when are contrast studies of the small intestine useful

A

pt w persistent partial obstructive symptoms or when it is difficult to distinguish paralytic ileus from mechanical obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

lab tests for sbo

A

helpful in excluding other causes

leukocytosis- if persists despite ng decompression and fluid resuscitation can mean progression toward ischemia

electrolytes closely monitored

hypokalemic- contraction of alkalosis w adv dehydration

hyperamylasemia- sbo but w marked degree heighten suspicion for acute pancreatitis

UA- excluding evidence for infection or stone

lactic acidosis- bowel ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

what is the most frequent ddx considered in setting of possible sbo

A

paralytic ileus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

process of paralytic ileus

A

bowel motility is suppressed as a consequence of systemic or inflammatory illness and bowel may become distended and pt obstipated ; no mechanical obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

pt with minimal abd pain, n/v, obstipation, cant pass gas, abd distention, dec/absent bowel sounds, gas in small intestine and colon on xray

A

paralytic ileus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

pt with crampy abd pain, n/v, obstipation, abd distention, norm/inc bowel sounds, gas in small intestine on xray

A

sbo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

cause of POI

A

stress of surgery, fluid and electrolyte imbalances, pain management with narcotics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

fast tract protocol

A

used to try and minimize POI by avoiding ng tubes, early ambulation, avoidance of fluid overload and early intro of diet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

medication approved to dec length of POI

A

alvimopan- opioid antagonist that specifically targets the mu receptor responsible for the gi side effects of opioids

doesnt cross bbb so selectively blocks the peripheral receptors contributing to POI wout sig altering central analgesic effects of opioids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

what does tx for sbo begin with

A

resuscitation, correction of fluid and electrolyte deficits

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

what is the best tool for assessing adequacy of volume replacement

A

foley catheter to assess urine output

at least 0.5mL/kg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

what does an ng tube placement do

A

control emesis, relieve intestinal distention proximal to obstruction, lower risk of aspiration, allow monitoring of ongoing fluid and electrolyte losses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

reduction en mass

A

hernia sac is reduced w the contents as a unit and therefore the contents may remain compromised despite being internalized

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

if there is question in regard to bowel viability what is an intraoperative assessment that is done

A

intraop assessment w fluorescein dye or doppler us to asses perfusion along with clinical evaluations of bowel viability such as color, bleeding, and peristalsis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

what should be done if intussusception if found in adults

A

resection because of high likelihood of a lead point lesion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

what are some complications that may complicate operative intervention for sbo

A

wound infection, anastomotic leak, abscess, peritonitis, and fistula formation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

features of crohns ds

A

involves segments of GI tract other than the colon
sparing or skip lesions between affected areas
transmural involvement and assoc tendency to dev fistulas
noncaseating granulomata on histology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

gradual onset with progression of abd pain, diarrhea, and weight loss

A

crohns

as progresses have malaise, fatigue, fever, weight loss, anorexia, n/v

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

dx crohns

A

colonoscopy w visualization of terminal ileum or barium enema w inspection of terminal ileum and small bowel contrast studies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

biologies for crohns

A

infliximab
adalimumab
certolizumab

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

indications for surgery w crohns disease

A

perforation
fibrotic stricture- acute complete or chronic partial BO
fistula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

what if a pt w a fistula fails to respond to medical management

A

resection of the communicating bowel and simple debridement or limited excision of the communicating cutaneous or nonenteric visceral tract

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

how long does the small intestine have to be maintained in order for them to sustain oral intake

A

100cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

complications of crohns

A

malnutrition, obstruction, fistulous ds, electrolyte distrubances
medication se
progression of ds resistant to medical therapy
wound infx, short bowel syndrome, wound healing problems, fistulae
anal incontinence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

4 major etiologies for acute mesenteric ischemia (AMI)

A

sma embolism
sma thrombosis
mv thrombosis
nonocclusive mesenteric ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

SMA embolism

A
  • originate from heart and assoc w afib
  • thrombus forms win the heart and becomes dislodged, the clot passes downt he sma and lodges as the vessel narrows just distal to the take off of the middle colic artery completely occluding downstream flow
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

sma thrombosis

A
  • freq assoc w vascular ds like CAD,PVD, chronic renal insuff
  • chronic stenosis of the sma and if the vessel forms an acute thrombosis, ami may occur
  • usually begins at origin of SMA and more likely to lead to complete SB infarction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

smv thrombosis

A
  • result of hypercoag state

- clot forms in smv obstructing venous outflow which results in venous htn, inc bowel wall edema and dec arterial flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

nonocclusive mesenteric ischemia (NOMI)

A
  • usually dx in ICu setting in critically ill pts
  • hx of toehr sig atherosclerotic ds
  • in severe shock, blood shunted away from GI tract and if process cont there can be sig vasospasm of the splanchnic circulation, resulting in ischemia of sm/lg intestine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

pt presents w severe rapid onset of pain, abd exam unimpressive

A

AMI

pain out of proportion to PE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

presentation of SMV thrombosis and NOMI

A

smv- insidious onset, pain for several days or weeks, diffuse and nonspecific

nomi- min abd pain that is overshadowed,**hemodynamic instability (primary cause)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

dx mesenteric ischemia

A

direct visualization of vascular tree via mesenteric arteriogram

delayed films to obtain a venous phase to determine if smv is thrombosed

CT is replacing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

initial tx for mesenteric ischemia

A

rapid resuscitation and correction of any metabolic abnorm
abx

rapidly restore blood flow to gut, resect necrotic bowel and min reperfusion injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

tx for pt w sma embolism

A

immediate embolectomy via laparotomy

sma isolated and arteriotomy is performed

catheter placed directly into artery above clot and balloon inflated and catheter removed along with clot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

tx for sma thrombosis

A

revasc required since sma chronically narrowed by severe atherosclerotic ds

sma bypass procedure or sma endovasc stent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

tx for smv thrombosis

A

supportive and prompt anticoag w iv heparin

76
Q

tx nomi

A

underlying pathology and aggressive resucitation efforts

avoid alpha adrenergic vasopressors and digoxin since the induce spasm and vasospasm is major part of nomi

77
Q

mc benign lesion of small intestine

A

leiomyomas, which occur mc in jejunum but can occur anywhere in digestive tract are on the benign spectrum of mesenchymal tumors of the GI tract and now referred to as GI stromal tumors (GISTs)

78
Q

where do leiomyomas or GISTs arise from

A

interstitial cells of cajal

79
Q

other nonepithelial benign small bowel lesions

A

hemangiomas important potential cause of occult bleeding Osler Weber Rendu syndrome
hamartomas- peutz jeghers syndrome
lymphangiomas
neurogenic tumors (schwannomas, neurofibromas)

80
Q

epithelial benign lesions of small intestine

A

tubular adenomas
villous adenomas- more likely malignant so need to be excised
brunner’s gland adenomas- duodenum, asymp

81
Q

mc malignancy affecting individuals w familial polyposis after proctocolectomy

A

duodenal carcinoma of periampullary region

82
Q

adenocarcinomas of small intestine

A

mc in duodenum w dec incidence as move distally
obstruction assoc w wl mc presentation
occult bleeding and anemia
endoscopic screening of periampullary region

83
Q

carcinoid tumors of small intestine

A
  • arise from kulchitsky cells in crypts of lieberkuhn part of APUD
  • mc in ileum
  • obstruction is mc finding due to intense desmoplastic reaction that occurs in adjacent bowel mesentery, others inlcude anorexia, fatigue and wl
  • dx made laparotomy
  • tx wide excision of bowel and adjacent mesentery
84
Q

carcinoid syndrome

A
  • episodic cutaneous flushing, bronchospasm, intestinal cramping/diarrhea, vasomotor instability, pellagre like skin lesions and right sided valvular heart ds
  • dx urinary measurement of 5-hiaa, serum measurement of serotonin or chromogranin a
  • tx resection
85
Q

lymphoma (small intestine mc site of extranodal lymphoma)

A
  • ileum mce to peyers patches
  • nonspecific symp: vague abd pain, wl, fatigue, malaise
  • nodularity and thickening of wall on contrast studies or ct
  • surgical resection w subsequent chemo or radiation
86
Q

what is the mc congenital anomaly of small intestine

A

meckel’s diverticulum- represents a remnant of the embryonic vitelline or omphalomesenteric duct

87
Q

rule of twos for meckels diverticulum

A

2% of population
2:1 male to female
2 types mucosae
located within 2 ft of ileocecal valve

88
Q

anatomy of meckels diverticula, where does the diverticulum arise from, and blood supply

A
  • evolve when there is incomplete obliteration of the viteline duct which arises from the midgut and typically closes between 8th and 10th week of gestation
  • arises from antimesenteric border of ileum usually within 60cm (2ft) of ileocecal valve
  • blood supply from vitelline vessels, arising from ileal blood supply
89
Q

what is the most common type of heterotopic mucosa found within the diverticulum

A

gastric-may cause ulceration of adjacent small intestinal mucosa and hemorrhage because of its capacity to produce acid in direct proximity to small bowel mucosa

less freq is pancreatic and colonic

90
Q

what happens if there is a complete persistence of vitelline duct

A

sinus from the umbilicus to ileum may result presenting as an enteric fistula at the umbilicus itself

91
Q

what happens if the vitelline duct obliterates but leaves a fibrous cord remnant

A

remnant may act as a point of fixation of the small intestine to the abd wall and facilitate bowel obstruction

92
Q

clinical presentations in meckels diverticula

A

hemorrhage-bright red/maroon per rectum, painless, infants under 2
ileus
intussusception
diverticulitis
perforation
misc.- obstruction, inflammation, umbilical fistula

93
Q

how i hemorrhage related to meckels dx

A

radionuclide scanning using technetium-99m pertechnetate which is taken up by ectopic gastric mucosa

enhanced by cimetidine or pentagastrin

94
Q

how does an intestinal obstruction occur in meckels

A

because of volvulus of the small bowel around the diverticulum or constrictive effect of a mesodiverticular band

95
Q

tx of meckels

A

resection of the diverticulum

if outside of pediatric age- narrow base, when a mesodiverticular band is present, or when heterotopic tissue is evident

base of diverticulum is closed transversely to minimize luminal narrowing

96
Q

intestinal malrotation

A
  • 4th-10th weeks of gestation
  • 270deg rotation of proximal midgut places duodenum in retroperitoneum behind superior mesenteric vessels
  • 270deg rotation of distal midgut places cecum in rlq and transverse colon draped anterior to superior mesenteric vessels
  • if both turns are incomplete or not made at all abnorm exist
97
Q

what is the mc manifestation of malrotation

A

midgut volvulus in an infant w an incomplete rotation

  • the proximal midgut fails to rotate beyond the midline remaining to the right of sup mes vessels w the duodenum covered ant by Ladd’s bands
  • distal midgut only rotates 90-180 and cecum becomes fixed to abd wall in ruq near duodenum
  • twisting becomes small bowel volvulus leading to ischemia and necrosis
98
Q

signs, dx and tx of midgut volvulus

A
  • bilious emesis w progression to distention, tenderness/shock late findings
  • radiographic upper GI series
  • emergent laparotomy w detorsion of the bowel, division of Ladd’s bands, broadening of the mesentery and placement of the small intestine on the right and colon on the left side of abdomen
  • also do appendectomy
99
Q

what is short bowel syndrome (short gut)

A
100
Q

vermiform appendix anatomy

A
  • located in rlq at confluence of taenia coli on cecal apex
  • appendiceal artery travels in mesoappendix and originates from ileocolic artery
  • lined by columnar epithelium and rich in lymphatic follicles

location determines the location of tenderness as ds progresses

101
Q

what causes acute appendicitis

A
  • consequence of obstruction of appendiceal lumen
  • mc is lymphoid hyperplasia causing luminal obstruction
  • also accumulation of fecal material or fecalith
102
Q

what happens as the appendiceal lumen becomes compromised

A

-mucus secretion by the epithelium leads to distention of the appendix distal to the narrowed lumen w eventual compromise of venous outflow as the organ becomes increasingly turgid and ischemic

103
Q

what can progression of swelling, infection and ischemia assoc w acute appendicitis lead to

A

gangrene and perforation

the resulting peritonitis may be walled off by omentum or other adjacent visceral structures

if ifx not controlled, spread of infx into portal system via venous effluent (pylephlebitis)may result giving rise to air in portal system or liver abscesses

104
Q

mcburneys point

A

located 1/3 of distance from anterior superior iliac spine to the umbilicus (appendicitis)

105
Q

tx for appendicitis

A
  • preop IV fluid resucitation coverage suitable for colonic flora
  • 2nd gen ceph, broad spectrum penicillin or fluroquinolone and anaerobic coverage w metronidazole (no perf=24hr, perf=afebrile,norm wbc, gi function)
  • surgery
106
Q

open appendectomy

A

open: muscle splitting incision centered on McBurneys pt, appendix mobilized into wound and mesoappendix taken down allowing isolation of base of appendix where it joins the cecum; appendix removed after ligature control of its base

107
Q

lap appy

A

less postop pain and lower wound infection rates allows inspection of peritoneal cavity before committing to given operative exposure

108
Q

complications of appy

A

wound infx, pelvic abscess, fecal fistula, appendiceal remnants

109
Q

appendiceal tumors

A
  • carcinoid, carcinoma, mucocele

- 2cm in diameter, a right hemicolectomy to allow removal of lymphatic drainage pathway

110
Q

43yo w 3d hx abd distention, n, v, dec urine outpt. hx of total abd hysterectomy 5yrs ago for benign ds. no meds. pulse is 110beats/min. abd distended and mild diffuse tenderness. bowel sounds hyperactive. serum electrolytes are sodium 140, chloride 90, bicarb 32, potassium 4.0. most appropriate initial iv fluid to administer

A

normal saline

K not added until volume restoration is achieved, lactated ringers may worsen metabolic alkalosis because lactate converted to bicarb in the liver, and colloidal solutions do not correct the hypochloremia and electrolyte imbalances and are not called for in resuscitating hypovolemic dehydrated pt

111
Q

what 3 segments is the small intestine composed of

A

duodenum- pylorus to ligament of treitz
jejunum-first 40% of small bowel distal to duodenum
ileum- remaining 60%

112
Q

A 38-year-old man has undergone four operations for Crohn’s disease in the last 10 years and recently underwent the last of these for treatment of recurrent disease proximal to a prior ileocolic anastomosis. Which of the following agents Is most useful for managing acute exacerbations rather than helping to maintain him in remission from active disease?

A

prednisone

113
Q

A 65-year-old woman comes to clinic with a vague history of diffuse abdominal discomfort over the past 3 weeks. She denies any history of trauma or prior abdominal surgery and has no known stigmata of peripheral vascular disease. She takes vitamin D and calcium supplements. On exam, she has diffuse mild to moderate subjective tenderness without guarding or peritoneal signs. She is In sinus rhythm on EKG. Which of the following is the most likely diagnosis?

A

mesenteric venous thrombosis

114
Q

A 63-year-old woman comes to clinic with symptoms of nonspecific abdominal pain. Her past medical history is unremarkable. She takes vitamins and calcium supplements. A recent CT scan shows a small bowel mass lesion. Laboratory evaluations show an elevated serum level of c-kit protein, with normal chromogranin A. Which of the following intestinal tumors is this consistent with?

A

gastrointestinal stromal tumor

The elevated c-kit level is specific to gastrointestinal stromal tumor (GIST) tumors and Is the key information leading to this answer. The other small bowel lesions mentioned could present with similar vague symptoms but are not associated with the c-kit proto-oncogene mutation and associated serum protein marker. Carcinoid tumors may be associated with elevated levels of 5-HIAA (5-hydroxyindole acetic acid) on 24 urine testing. Osler-Weber-Rendu lesions are telangiectasias and may be associated with bleeding and characteristic visible telangiectasias in other mucosal areas including the oral cavity and skin. Hamartomas may be associated with Peutz-Jeghers syndrome. Brunner’s gland adenomas are seen In the proximal duodenum, where these glands are part of the mucus and alkaline mucosal protection mechanism of the proximal small Intestine.

115
Q

A 24-year-old female graduate student comes to the emergency department because of abdominal pain for the past 12 hours. Initially she had vague mid-abdominal pain that has localized to the RLQ about 3 hours ago. She is otherwise healthy and takes no medications. Her temperature is 37°C. There Is guarding and rebound tenderness in the right lower quadrant and a positive Rovsing’s sign. A CT scan shows fat stranding around a dilated appendix. At surgery, there is a 2.5-cm firm, smooth yellowish mass at the base of an inflamed appendix. There Is no evidence of perforation and no other abnormalities are found. Frozen section biopsy is consistent with a neuroendocrine tumor. Which of the following is the most appropriate management at this time?

A

right hemicolectomy

This patient has a carcinoid tumor. A right hemicolectomy Is needed because of the heightened risk of lymph node metastases. A simple appendectomy would not be appropriate for a carcinoid at the base of the appendix but would be appropriate for a carcinoid tumor

116
Q

A 38-year-old man has undergone four operations for Crohn’s disease in the last 10 years and recently underwent the last of these for treatment of recurrent disease proximal to a prior ileocolic anastomosis. Which of the following agents Is most useful for managing acute exacerbations rather than helping to maintain him in remission from active disease?

A

prednisone

117
Q

A 65-year-old woman comes to clinic with a vague history of diffuse abdominal discomfort over the past 3 weeks. She denies any history of trauma or prior abdominal surgery and has no known stigmata of peripheral vascular disease. She takes vitamin D and calcium supplements. On exam, she has diffuse mild to moderate subjective tenderness without guarding or peritoneal signs. She is In sinus rhythm on EKG. Which of the following is the most likely diagnosis?

A

mesenteric venous thrombosis

118
Q

A 63-year-old woman comes to clinic with symptoms of nonspecific abdominal pain. Her past medical history is unremarkable. She takes vitamins and calcium supplements. A recent CT scan shows a small bowel mass lesion. Laboratory evaluations show an elevated serum level of c-kit protein, with normal chromogranin A. Which of the following intestinal tumors is this consistent with?

A

gastrointestinal stromal tumor

The elevated c-kit level is specific to gastrointestinal stromal tumor (GIST) tumors and Is the key information leading to this answer. The other small bowel lesions mentioned could present with similar vague symptoms but are not associated with the c-kit proto-oncogene mutation and associated serum protein marker. Carcinoid tumors may be associated with elevated levels of 5-HIAA (5-hydroxyindole acetic acid) on 24 urine testing. Osler-Weber-Rendu lesions are telangiectasias and may be associated with bleeding and characteristic visible telangiectasias in other mucosal areas including the oral cavity and skin. Hamartomas may be associated with Peutz-Jeghers syndrome. Brunner’s gland adenomas are seen In the proximal duodenum, where these glands are part of the mucus and alkaline mucosal protection mechanism of the proximal small Intestine.

119
Q

A 24-year-old female graduate student comes to the emergency department because of abdominal pain for the past 12 hours. Initially she had vague mid-abdominal pain that has localized to the RLQ about 3 hours ago. She is otherwise healthy and takes no medications. Her temperature is 37°C. There Is guarding and rebound tenderness in the right lower quadrant and a positive Rovsing’s sign. A CT scan shows fat stranding around a dilated appendix. At surgery, there is a 2.5-cm firm, smooth yellowish mass at the base of an inflamed appendix. There Is no evidence of perforation and no other abnormalities are found. Frozen section biopsy is consistent with a neuroendocrine tumor. Which of the following is the most appropriate management at this time?

A

right hemicolectomy

This patient has a carcinoid tumor. A right hemicolectomy Is needed because of the heightened risk of lymph node metastases. A simple appendectomy would not be appropriate for a carcinoid at the base of the appendix but would be appropriate for a carcinoid tumor

120
Q

what marks the end of the duodenum and start of the jejunum

A

ligament of treitz

121
Q

what provides blood supply to small bowel

A

branches of superior mesenteric artery

122
Q

what does the terminal ileum absorb

A

b12, fatty acids, bile salts

123
Q

pt w abd discomfort, cramping, n, abd distention, emesis, high pitched bowel sounds

A

sbo

124
Q

what labs are performed w sbo

A

electrolytes, cbc, type/screen, ua

125
Q

what are electrolyte/acid base findings w proximal obstruction

A

hypovolemic hypochloremic, hypokalemia, alkalosis

126
Q

what must be ruled out on pe in pts with sbo

A

incarcerated hernia

127
Q

what major axe findings are assoc w sbo

A

distended loops of small bowel air fluid levels on upright film

128
Q

what is the danger of complete sbo

A

close loop strangulation of the bowel leading to bowel necrosis

129
Q

initial manage of all pts w sbo

A

npo, ngt, ivf, foley

130
Q

abc’s of sbo

A

adhesions
bulge (hernia)
cancer/tumors

131
Q

besides abc’s what are other causes of sbo

A 
gallstone ileus
intussusception
volvulus
external compression
sma syndrome

bezoars, bowel wall hematoma
abscesses
diverticulitis

crohns
radiation enteritis
annular pancreas
meckels diverticulum
peritoneal adhesions
stricture
132
Q

what is sma syndrome

A

seen w wl, sma compresses duodenum causing obstruction

133
Q

tx for complete sbo

A

lap and lysis of adhesions (LOA)

134
Q

tx for incomplete sbo

A

conservative tx w close observation plus ngt decompression

135
Q

intraop how can level of obstruction be determined in pts w sbo

A

transition from dilated bowel proximal to decompressed bowel distal to obstruction

136
Q

mc cause abd surgery w crohns

A

sbo due to strictures

137
Q

after sb resection why should mesenteric defect always be closed

A

prevent internal hernia

138
Q

what may cause sob if pt is on coumadin

A

bowel wall hematoma

139
Q

what are the signs of strangulated bowel w sbo

A

fever, shock, peritoneal signs, acidosis

severe/cont pain, hematemesis, gas in bowel wall or portal veing, abd free air

140
Q

absolute indication for operation w partial sbo

A

peritoneal signs, free air on axr

141
Q

what tumor classically causes sob due to mesenteric fibrosis

A

carcinoid tumor

142
Q

s/sx of sb tumor

A

abd pain, wl, obstruction, perforation

143
Q

mc benign sb tumor

A

leiomyoma

144
Q

mc malignant sb tumor

A

adenocarcinoma

145
Q

workup of small bowel tumor

A

ugi w small bowel follow through, enteroclysis, ct scan, enteroscopy

146
Q

tx for malignant sb tumor

A

resection and removal of mesenteric draining lymph nodes

147
Q

what malignancy is classically assoc w metastasis to small bowel

A

melanoma

148
Q

usual location of meckels diverticulum

A

within 2ft of ileocecal valve on anti mesenteric border of bowel

149
Q

major ddx assoc w meckels

A

appendicitis

150
Q

complications of meckels

A

intestinal hemorrhage, intestinal obstruction, inflammation

151
Q

s/sx meckels

A

lower gi bleed, abd pain, sbo

152
Q

meckels scan

A

scan for ectopic gastric mucosa in meckels diver; uses technetium pertechnetate iv which is taken up by gastric mucosa

153
Q

hernia assoc w incarcerated meckels diver

A

Littre’s hernia

154
Q

mc cause small bowel bleeding

A

small bowel angiodysplasia

155
Q

what vessel provides blood supply to appendix

A

appendiceal artery- branch of ileocolic artery

156
Q

mesentery of appendix

A

mesoappendix

157
Q

how to locate appendix once find cecum

A

follow taenia coli down

158
Q

what is appendicitis

A

inflammation of appendix causes by obstruction of appendices lumen, producing closed loop w resultant inflammation that can lead to necrosis and perforation

159
Q

causes of appendicitis

A

lymphoid hyperplasia, fecalith

160
Q

s/sx appendidicitis

A

periumbilical pain
n/v
anorexia
pain migrates to rlq

161
Q

valentines sign w append

A

rlq pain/peritonitis from succus drainage down to rlq from perforated gastric or duodenal ulcer

162
Q

labs for append

A

cbc- inc wbc w left shift

ua- look for pyelo or stones (can have hematuria/pyuria w append)

163
Q

in acute append what comes first pain or vomiting

A

pain

164
Q

radiographic signs of append on axr

A

fecalith, sentinel loops, scoliosis away from right because of pain, abscess, loss of psoas shadow, loss of pre peritoneal fat stripe, free air

165
Q

ct findings of append

A

periappendiceal fat stranding, appendiceal diameter >6mm, periappendiceal fluid, fecalith

166
Q

preop meds/prep

A

rehydration w iv fluids (LR)

abx

167
Q

tx for nonperf acute append

A

prompt appy, 24hrs of abx, discharge home POD 1

168
Q

tx for perf acute append

A

iv fluid resuscitation and prompt appy
all pus is drained w postop abx cont for 3-7d
wound left open in most cases of perf after closing fascia

169
Q

tx appendiceal abscess that is dx preop

A

percutaneous drainage of abscess
abx
elective appy 6 wks later

170
Q

duration abx for nonruptured append and what abx

A

24hrs

cefoxitin, cefotetan, unasyn, cipro, flagyl

171
Q

abx for perf appy

A

broad spectrum abx- amp/cipro/clinda or penicillin like zosyn

until normal abc, afebrile, ambulating, eating reg diet

172
Q

complications of append

A

pelvic abscess, liver abscess, free perf, portal pylethrombophlebitis

173
Q

what bacteria assoc w mesenteric adenines closely mimic acute append

A

yersinia enterolytica

174
Q

complications of appy

A

sbo, enterocutaneous fistula, wound infx, infertility w perf, inc incidence of right inguinal hernia, stump abscess

175
Q

mc postop complication of appy

A

wound infx

176
Q

difference between mcburneys incision and rocky davis incision

A

mcburnerys is angled down (follows ext oblique fibers)

rocky straight across (transverse)

177
Q

layers of abd wall during mcburney incision

A 
skin
subq fat
scarpai fascia
ext oblique
int oblique
transversus muscle
trasversali fascia
pre peritoneal fat
peritoneum
178
Q

steps in lap appy

A
  1. id append
  2. staple mesoappendix
  3. staple and transect appendix at base
  4. remove append from abdomen
  5. irrigate and aspirate until clear
179
Q

which way should finger sweep trying to find appendix

A

lateral to medial along lateral peritoneum so don’t tear mesoappendix

180
Q

how to get to retrocecal and retroperitoneal appendix

A

divide lateral peritoneal attachments of cecum

181
Q

why use electrocautery on exposed mucosa on appendices stump

A

kill mucosal cells so don’t form mucocele

182
Q

if find crowns in terminal ileum, will you remove appendix

A

yes if cecal/appendiceal base is not involved

183
Q

mc appendiceal tumore

A

carcinoid tumor

184
Q

tx of appendices carcinoid

A

appy

185
Q

tx of appendices carcinoid >1.5cm

A

right hemicolectomy

186
Q

what type of appendices tumor can cause pseudomyxoma peritonea if appendix ruptures

A

malignant mucoid adenocarcinoma

187
Q

appendicitis definition

A

inflammation of the appendix caused by obstruction of the appendiceal lumen, producing a closed loop w resultant inflammation that can lead to necrosis and perforation

Surgery (21 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions