Surgery Flashcards
define
Crohn’s disease -
a chronic, segmental inflammation that affects the entire thickness of the wall and potentially every segment of the gastrointestinal tract (that is, from the mouth to the anus).
Crohn’s disease
Symptoms:
diarrhea, abdominal pain, weight loss, weakness, perianal changes, anal fissures, abscesses, fistulas, tumors in the abdomen, leukocytosis
Crohn’s disease
Complications:
ileus, internal and external fistulas (especially perianal ) interloop abscesses, peritonitis, bleeding
Crohn’s disease
Diagnosis:
barium enema (rectal infusion) revealing “rose thorn” or “collar button” appearance
USG, MR
colonoscopy - ulcers, ecchymosis, “cobblestone” appearance
capsule endoscopy
Crohn’s disease
Treatment: conservative:
conservative: high-protein diet with the appropriate amount of vitamins and electrolytes, smoking cessation, pharmacological treatment (GCS, sulfasalazine, antibiotics, antidiarrheals, immunosuppressive, biological agents)
Crohn’s disease
Treatment: surgical:
surgical:
-small intestine disease - conservative resection or intraoperative dilation of small intestinal stenoses
-right or left half of the colon - hemicolectomy
-more extensive changes in the colon - colectomy with ileorectal anastomosis or proctocolectomy with permanent ileostomy
Percutaneous endoscopic gastrostomy (PEG)
is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient’s stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation).
This provides enteral nutrition (making use of the natural digestion process of the gastrointestinal tract) despite bypassing the mouth; enteral nutrition is generally preferable to parenteral nutrition (which is only used when the GI tract must be avoided).
The PEG procedure is an alternative to open surgical gastrostomy insertion, and does not require a general anesthetic; mild sedation is typically used.
PEG tubes may also be extended into the small intestine by passing a jejunal extension tube (PEG-J tube) through the PEG tube and into the jejunum via the pylorus
The most common malignant tumor is stomach is
adenocarcinoma
- reduction in the incidence of peripherally localized stomach cancer
- increase in the incidence of cancer of the proximal part and cardia.
- dissemination of metastases most often via* lymphatic vessels*
- Most often, it is diagnosed at the stage, in which it is not possible to perform an operation leading to cure
Which should you suspect in a female patient complaining of cyclic regular hypogastric pain occurring for a longer time and rectal bleeding that accompanies menstruation?
endometriosis extragenitalis
Endometriosis -
the occurrence of the endometrium (glandular cells and stroma) outside the uterine cavity.
Symptoms:
limitation of fertility
pelvic pain syndrome, tenderness during examination, and palpable nodules in the projection of the uterine ligaments
dysmenorrhea (pain begns several days before the onset of menstruation)
dyspareunia
enlarged tender, weakly mobile appendages
Treatment:
Surgical:
removal of isolated foci
removal of endometrial cysts
removal of the entire ovary
removal of the entire uterus with appendages
pharmacological:
Hormone therapy:
Pain relievers:
Hormone therapy:
Gonadoliberin analogues
progesterone preparations
estrogen-progesterone preparations
IUD with levonorgestrol
aromatase inhibitors
selective progesterone receptor modulators (SPRMs)
Pain relievers:
NSAIDs
obstructive jaundice = ___ = ___
obstructive jaundice = post-hepatic jaundice = cholestasis
-is a result of impaired physiological flow of bile
-dominant symptoms: conjugated hyperbilirubinemia, pruritus of the skin
-if it is caused by an acute disease (e.g. biliary obstruction caused by a gallstone),
-symptoms of biliary colic appear (sudden, severe pain in the right hypochondrium, radiating to the shoulder blade or the shoulder, accompanied by flatulence, nausea, vomiting)
-dark urine and pale stool
Causes:
primary cholangiocarcinoma.
PSC
inflammation of the extrahepatic bile ducts
pancreatic head cancer
choledocholithiasis - deposits in the bile ducts
Acute pancreatitis
is an acute inflammation of the gland associated with damage to the follicular cells of the pancreas, as a result of which active proteolytic enzymes enter the connective tissue stroma, causing a local inflammatory reaction.
In 15-20% of patients, the inflammatory process leads to the formation of necrotic and / or abscesses, which results in severe, necrotizing pancreatitis.
Causes of Acute Pancreatitis (“I get smashed”):
I - Idiopathic ACS
G - Gallstones, urolithiasis
E - Ethanol, alcohol abuse
T - Trauma, injuries of the abdominal cavity
S - Steroids, glucocorticoid abuse
M - Mumps, viral infections (mumps, AIDS)
A - Autoimmune, autoimmune
S - Scorpion, scorpion venom
H - Hyperlipidemia, Hypercalcemia
E - ERCP, iatrogenic
D - Drugs, drug abuse - ACEI, GKS, azathioprine, erythromycin, anti-epileptic
Symptoms: of Acute Pancreatitis
Symptoms:
strong, continuous, rapidly increasing, girdling pain, located in the epigastrium, often radiating to the back, sometimes also to the chest and abdomen, increasing in standing position,
nausea and vomiting
flatulence
fever,
yellowing of the proteins,
in severe acute pancreatitis, tachycardia, hypotonia, tachypnoea, dyspnoea, confusion, impaired consciousness, intestinal paralytic obstruction may develop, DIC may develop.
What is ERCP?
**Endoscopic retrograde cholangiopancreatography, or ERCP,
-is a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas.
-It combines X-ray and the use of an endoscope—a long, flexible, lighted tube.
What is decompensated diabetes?
presence of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS).
What are three signs of diabetic ketoacidosis?
DKA Signs and Symptoms
Fast, deep breathing.
Dry skin and mouth.
Flushed face.
Fruity-smelling breath.
Headache.
Muscle stiffness or aches.
Being very tired.
Nausea and vomiting.
Indicate tests that should be ordered before the abdominal puncture in a patient with hepatic cirrhosis:
- Ultrasound - to assess the amount of free fluid in the abdominal cavity and determine the site of puncture
- **complete blood count **- to assess the number of platelets, hemoglobin concentration
- coagulogram - to rule out possible coagulation disorders that may cause bleeding after the examination
What happens in abdominal compartment syndrome?
In abdominal compartment syndrome, the displacement of the diaphragm cephalad leads to compression of the thorax, which causes an increase in work of breathing, ventilation/perfusion inequality, and increases in both peak and plateau pressures.
What organs are commonly affected in abdominal compartment syndrome?
-Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients.
-ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems
What causes abdominal compartment syndrome 1?
Extensive surgery in your abdomen.
Infection in your abdomen.
Intestinal obstruction (blockage).
Large amount of IV fluids (called fluid resuscitation), often required for surgery or sepsis.
Major burns.
Massive blood transfusion.
Pancreatitis.
What causes compartment syndrome in the abdomen 2…explain ?
Abdominal compartment syndrome is most commonly due to excessive fluid resuscitation (>5 L in 24 hours) or massive blood transfusion (>10 units in 24 hours). Clinical signs are nonspecific and appear late. Classic findings are of increased airway pressure, decreased urine output, and a tense abdomen.
Abdominal Compartment Syndrome (ACS)
define :
- is defined as an abdominal pressure exceeding 20 mm Hg, with a decrease in abdominal perfusion pressure and failure of at least one organ.
- The abdominal compartment syndrome is caused by: progressive ascites, swelling of the intestinal wall, bleeding into the peritoneal cavity or distension of the intestinal loop with gas.
What type of intracranial haemorrhage is associated with damage to the middle meningeal artery?
Epidural Hematoma
The most common vessel damaged is the middle meningeal artery underlying the temporoparietal region of the skull.
A subdural hematoma is a
venous (sternal vein) hemorrhage.
Epidural hematoma occurs as a result of
damage to the middle meningeal artery.
Epidural hematoma:
definition:
Definition: a non-physiological accumulation of blood between the skull bones and the dura mater.
Epidural hematoma:
Pathomechanism & Sequence of events
*Pathomechanism: *
damage to the middle meningeal artery, most often due to trauma.
Sequence of events: trauma => loss of consciousness => bright break (regaining consciousness) => hematoma enlargement => relapse of neurological symptoms (paresis of one half of the body and dilatation of one pupil, lack of its response to light) => increase in ICP => Cushing’s reflex ( increase in blood pressure and bradycardia) => death
Epidural hematoma:
TX
*Treatment: *
surgical, as soon as possible after diagnosis.
-It consists in removing part of the skull bone, removing the hematoma, finding a bleeding vessel and stopping the bleeding.
Subdural hematoma:
Define
Definition: Pathological accumulation of blood between the dura mater and the spider dura usually results from a severe head injury. It is the most common type of traumatic CNS pathology.
Pathomechanism of Subdural hematoma:
Pathomechanism:
it is a consequence of tearing of the bridging veins traversing from the brain to the draining dural-venous sinuses, less often - a consequence of arterial bleeding.
-It is accompanied by damage and swelling of the underlying brain tissue.
Symptoms: of Subdural hematoma:
*Symptoms:
*loss of consciousness without momentary returns of consciousness, mass effect - brain tissue shift resulting in hemiparesis and pupil dilation
Mortality: 60-100%.
Short bowel syndrome
- a condition in which the function of the small intestine is suddenly shut down due to a disease causing damage to it or the surgical removal of all or part of the intestine.
Short bowel syndrome severely impairs the absorption of nutrients and water.
The most common causes of short bowel syndrome are:
- intestinal necrosis of vascular origin (embolism, arterial or venous thrombosis),
2 extensive resections of the small intestine (Crohn’s disease, cancer, trauma and others), - severe malabsorption disorders (e.g. radiation enteritis or refractory celiac disease) resulting in functional short bowel syndrome,
- fistulas (external - causing food loss, and internal - causing food to bypass part of the small intestine).
It occurs in adults with an active small intestine <150-200 cm, but after a few years the organism may adapt.
*Mitotane *
define:
is a steroidogenesis inhibitor and cytostatic antineoplastic medication which is used in the treatment of adrenocortical carcinoma and Cushing’s syndrome.
is used to treat some types of cancer in the adrenal glands. This medicine acts on a part of the body called the adrenal cortex. Mitotane reduces the amount of steroids (cortisone-like hormones) that are produced by the adrenal cortex.
Acute diverticulitis is the most common complication of ?
is the most common complication of colon diverticula (5%). It begins in a single diverticulum, then quickly spreads along the colon, leading quite often to microperforation with the symptoms of local peritonitis.
Symptoms: of Acute diverticulitis
fever,
pain in the left iliac region,
leukocytosis,
palpable tumor,
abdominal guarding,
Blumberg’s sign in the lower left quadrant of the abdomen.
TX of Acute diverticulitis
- most commonly used drugs are *ciprofloxacin *and / or metronidazole at standard doses, or 3rd generation cephalosporin or aminoglycoside in combination with metronidazole.
Prevention of relapse:
compliance with a high-fiber diet,
avoiding the use of NSAIDs other than ASA.
Regional anesthesia (conduction)
is a temporary blockade of pain transmission, used mainly during surgical procedures.
We distinguish between following types of anesthesia:
- topical (application of the drug to the surface of mucous membranes, used in dentistry and endoscopic procedures),
- infiltrative (lidocaine injection of the operating site during small surgical procedures),
- peripheral nerve block ( nerve plexus block ),
- epidural (administration of the drug to the epidural space),
- spinal (subarachnoid block) (administration of the drug into the subarachnoid space),
- intravenous regional anesthesia (administration of the drug to a vein located distally from an applied pneumatic tourniquet, useful in fractures of the upper limb bones and hand surgery).
External hernias:
inguinal,
femoral,
umbilical,
parastomal,
lumbar.
Internal hernias:
diaphragmatic hernia
pericecal hernia,
paraduodenal hernia,
hernia of greater omentum.
We calculate the surface of burns according to the rule of nines :
head
each of the upper limbs
each of the lower limbs
anterior torso
posterior torso
crotch
We calculate the surface of burns according to the rule of nines :
head 9%,
each of the upper limbs 9%,
each of the lower limbs 18%,
anterior torso 18%,
posterior torso 18%,
crotch 1%.
A 30-year-old woman, weighing 60 kg, was referred to the ER with III degree burnings of the left upper extremity, left lower extremity and of the groin. What volume of fluids should be administered within 24 hours?
In this case, the surface of the burn is: left lower limb 18% + left upper limb 9% + crotch 1% = 28%.
In order to calculate the volume of fluids, we use the Parkland formula : 4ml / kg body weight /% of the body surface area affected by burns . 4 ml x 60 kg x 28% = 6720 ml, i.e. about 7 liters , of which 50% should be administered in the first 8 hours and the remaining 50% -in the next 16 hours.
Depth of burns: Grade 1-4 describe
grade I - erythema, involves only the epidermis.
Stage IIa - blister, involves the epidermis and a part of the dermis.
Stage IIb - superficial necrosis, includes epidermis and the whole dermis.
Grade III - deep necrosis, involves the entire skin.
Grade IV - necrosis or charring of deeper tissues.
Complications of enteral nutrition:
- functional (vomiting, diarrhea),
- mechanical (wounds, food in the airways),
- metabolic (overhydration, hyperlipidemia).
Ogilvie syndrome
- acute dilatation of the colon in the absence of any mechanical obstruction in severely ill patients.
-Acute colonic pseudo-obstruction is characterized by massive dilatation of the cecum (diameter > 10 cm) and right colon on abdominal X-ray.
-It is a type of megacolon, sometimes referred to as “acute megacolon,” to distinguish it from toxic megacolon.
(acute pseudo-obstruction of the large intestine) - a specific form of paralytic bowel obstruction, consisting of significant dilatation of the right colon.
A 65-year-old patient 10 years after aorto-aortic prosthesis because of ruptured aortic aneurysm. For the last 3 months periodical fever. Today admitted to the ER with the symptoms of heavy upper gastrointestinal bleeding. On CT features of inflammatory infiltration around the prosthesis with gas vesicles. You should first suspect in this patient:
The aorto-duodenal fistula is the most common form of fistula between the aorta and the gastrointestinal tract. It is formed as a result of a connection of duodenum lumen with the site of anastomosis between the aortic prosthesis and the aorta, which is usually accompanied by massive gastrointestinal haemorrhage .
Moreover, inflammation is often observed there. Such a fistula can be formed after a long time from the treatment of abdominal aortic aneurysm.
The aorto-duodenal fistula
Additional symptoms:
increased parameters of inflammation,
fever,
shock.
Abdominal ultrasound and computed tomography may reveal pseudoaneurysm in the area of the vascular prosthesis and inflammatory infiltration, often caused by staphylococci.
Procedure:
The aorto-duodenal fistula
Removal of the infected vascular prosthesis as soon as possible.
Restoration of proper blood circulation - reconstruction of vessels.
Restoration of the continuity of digestive tract.
The following symptoms, such as rapid and irregular breathing, extension of the limbs in reaction to external stimuli, bilateral Babinski sign, impaired pupil reaction to light, increased blood pressure, pulse acceleration and increased sweating indicate the contusion of:
brainstem contusion
Define
brainstem contusion
Cerebral contusion is a type of brain damage inflicted in the course of head trauma, usually complicated by a severe disturbance of its function.
Cerebral contusion
Pathogenesis:
Pathogenesis: the intracranial pressure increases on the site of impact, while the negative pressure occurs on the opposite side - therefore we can expect injuries on both sides ( contrecoup injury ).
Local swelling develops , small petechiae appear, especially visible in the frontal and temporal lobes.
Cerebral contusion
Symptoms:
*Symptoms: *immediately after an injury, the symptoms may resemble concussion, but sometimes the patient loses consciousness only a few hours after the event. Possible neurological disturbances:
sensory disturbances,
hemiparesis (contusion of the frontal lobe) ,
facial muscle paralysis,
homonymous hemianopsia (contusion of the occipital lobe) ,
aphasia (contusion of the temporal or frontal lobe) ,
gait impairment and nystagmus (contusion of the cerebellum),
accelerated pulse, high blood pressure, breathing disturbances (brainstem contusion).
Cerebral contusion
Diagnosis :
Diagnosis:
computed tomography (oedema and petechial haemorrhages).
Cerebral contusion
Treatment:
Treatment:
symptomatic, in some cases decompressive craniectomy.
Whipple’s triad
- collection of three signs (called Whipple’s criteria)
-symptoms result from hypoglycaemia that may indicate insulinoma. - symptoms of hypoglycaemia, low blood plasma glucose concentration
- and relief of symptoms when plasma glucose concentration is increased.
insulinoma
-is a tumour of the pancreas that is derived from beta cells and secretes insulin.
-It is a rare form of a neuroendocrine tumour.
-Most insulinomas are benign in that they grow exclusively at their origin within the pancreas, but a minority metastasize.
-Insulinomas are one of the functional pancreatic neuroendocrine tumour (PNET) group (“functional” because it increases production of insulin).
-In the Medical Subject Headings classification, insulinoma is the only subtype of “islet cell adenoma”
Tertiary hyperparathyroidism
is the occurrence of hypercalcemia as a result of autonomous excessive secretion of PTH in patients with secondary hyperparathyroidism.
Acute cholangitis -
-it is a segmental or diffuse acute inflammation of the bile ducts caused by infection due to partial or complete obstruction of the outflow of bile.
-The etiological factor is most often Escherichia coli .
Risk factors: of
Acute cholangitis
Risk factors:
cholelithiasis,
tumors that hinder the outflow of bile,
post-inflammatory and iatrogenic obstruction of the bile ducts,
primary sclerosing cholangitis,
pressure on the bile ducts by the pancreatic cyst or enlarged lymph nodes.
Acute cholangitis
Symptoms (Charcot’s triad):
Symptoms (Charcot’s triad):
- severe biliary colic pain in the right hypochondrium or epigastric region,
- fever with chills,
- jaundice.
Reynolds’ pentad ?
Reynolds’ pentad = Charcot’s triad +
- symptoms of shock,
- disturbances of consciousness.
Familial adenomatous polyposis (FAP)
- a syndrome resulting from a mutation in the APC gene, causing formation of polyps in the large intestine (usually above 100) and in the* stomach* and duodenum.
Patients with this genetic syndrome aged > 10 -12 require an annual follow-up colonoscopy and gastroduodenoscopy, because the risk of developing cancer around 35 years of age is almost 100%.
Familial adenomatous polyposis (FAP)
Variations:
Variations:
Gardner syndrome (FAP and osteosarcoma, lesions in the retina and soft tissue cancers),
Turcot syndrome (FAP and CNS tumors).
Familial adenomatous polyposis (FAP)
Treatment:
-usually a *prophylactic colectomy *or proctocolectomy is performed to form a small intestine reservoir in the 2nd or 3rd decade of life
-pharmacological treatment is considered as complementary.
- best effect can be achieved by using NSAIDs.
- The use of COX-2 inhibitors can be included after excluding the presence of factors that increase the risk of cardiac complications.
In case of a* rectum-saving surgery, a follow-up rectoscopy should be performed every 3-6 months on average .*
Total 15
Causes of liver transplantation in adults:
- hepatitis B
- hepatitis C
- primary biliary cholangitis
- poisoning (e.g. Amanita phalloides)
- car accidents that lead to detachment of the vascular bed of the organ with no possibility of surgical correction
- alcoholic liver cirrhosis
- cute liver failure
- liver cancer (mainly hepatocellular carcinoma (HCC)) - hepatic transplantation is allowed in the case of HCC limited to the liver and meeting certain criteria (Milan criteria - a single cancer lesion with a diameter of up to 5 cm or up to 3 lesions with a diameter of up to 3 cm).
- primary sclerosing cholangitis
- metabolic diseases (Wilson’s disease, hemochromatosis, amyloidosis)
- autoimmune hepatitis
- Budd–Chiari syndrome
- secondary biliary cirrhosis
- polycystic liver disease
- cystic fibrosis
Thyroid cancer risk factors:
Papillary cancer:
exposure to ?
-exposure to ionizing radiation, especially if exposure occurred in childhood,
Thyroid cancer risk factors:
Follicular cancer:
resulting from ?
low availability of iodine in the environment.
Thyroid cancer risk factors:
Medullary cancer:
genetic factors (25% of cases due to activating germline mutation of the RET gene).
The most common type of thyroid cancer is
papillary carcinoma
Symptoms depend on the location of the cancer:
Right-sided colon cancer
- progressive anemia and abdominal pain.
Symptoms depend on the location of the cancer:
Left-sided colon cancer
- changes in bowel habits (diarrhea with a lot of mucus or constipation), blood in the stool.
Symptoms depend on the location of the cancer:
Rectal cancer
- a tumor that can be palpable during digital rectal examination.
Lynch syndrome is a
- often called* hereditary nonpolyposis colorectal cancer (HNPCC)*,
- an inherited disorder that increases the risk of many types of cancer, particularly cancers of the colon (large intestine) and rectum, which are collectively referred to as colorectal cancer.
Name 2
-We distinguish two subtypes of Lynch syndrome:
Lynch I syndrome - cancer affects only the large intestine
*Lynch II syndrome *- colorectal cancer is accompanied by malignant tumors of the heart, ovary, stomach, small intestine, kidneys, ureters and less often skin, bile ducts and central nervous system
Features of colorectal cancer in the course of Lynch I syndrome:
- occurs at an early age (<50 years of age)
- it is more often located on the right side or it is multifocal
- has a lower tendency to metastasis
- it is usually poorly differentiated
- it is often resistant to chemotherapy
- In order to prevent colon cancer, it is recommended to perform partial or subtotal colectomy - the best solution seems to be almost complete excision of the large intestine - this reduces the risk of next tumor foci.
ampulla of Vater
small reservoir where common bile duct and pancreatic duct meet
Courvoisier’s sign
- enlarged, painless and palpable gall bladder.
- It occurs in *tumors located within the cystic duct *and common hepatic duct junction or within the common bile duct.
Pancreatic cancer is usually diagnosed as
-* adenocarcinoma*
- 65% of cases it is located in the head of the pancreas
**Pancreatic cancer is usually an adenocarcinoma
Radical Treatment :
- Whipple procedure - removal of the pancreatic head, gall bladder, common bile duct, duodenum and pyloric part of the stomach,
-
Traverso procedure - as above but with pylorus saved
3.* total* pancreatic resection, - partial pancreatic resection.
total 5
Whipple procedure - removal of the
“PPCGD”
pancreatic head,
pyloric part of the stomach,
common bile duct,
gall bladder,
duodenum
Total 8
In an adult, pulse might be palpated on the following arteries:
internal carotid,
radial,
ulnar,
humeral,
femoral
popliteal,
dorsalis pedis,
posterior tibial.
Due to the location of the artery, the pulse will not be palpated on the .
common iliac artery
Abnormal pulse:
pulsus tardus et parvus
- aortic stenosis
Abnormal pulse:
thready pulse
(shock)
Abnormal pulse:
hypokinetic pulse
(reduced left ventricular ejection volume, e.g. in heart failure),
Abnormal pulse:
large pulse
(aortic regurgitation),
Abnormal pulse:
pulsus alternans
(failure of the left ventricle)
Abnormal pulse:
pulsus paradoxus
(cardiac tamponade)
Abnormal pulse:
pulse deficit
(atrial fibrillation)
Abnormal pulse:
differences in pulse amplitude on symmetrical arteries
(aortic dissection, atherosclerotic narrowing of the arteries)
Pulsus paradoxus
- this is a reduction or even disappearance of the pulse on inspiration , which is accompanied by a decrease in systolic blood pressure> 10 mm Hg.
- The size of the pulsus paradoxus can be assessed using a sphygmomanometer - it is present when the first tone of Korotkow is heard only during exhalation.
Forrest classification of ulcer bleeding severity:
Ia -
Ib -
IIa -
IIb -
IIc -
III -
Ia - spurting arterial bleeding (active bleeding).
Ib - oozing bleeding
IIa - visible non-bleeding vessel (recent bleeding).
IIb - adherent clot
IIc - black spot in ulcer base
III - clean ulcer base (history of non-recent bleeding).
Forrest classification is used to assess
- to assess bleeding during gastroduodenoscopy .
- This is the basic diagnostic test for suspected bleeding to the upper gastrointestinal tract (above the Treitz ligament)
Treitz ligament
-The suspensory muscle of duodenum (also known as the ligament of Treitz)
-is a thin muscle connecting the junction between the duodenum and jejunum (the small intestine’s first and second parts, respectively), as well as the duodenojejunal flexure to connective tissue surrounding the superior mesenteric and coeliac arteries.
-The suspensory muscle most often connects to both the third and fourth parts of the duodenum, as well as the duodenojejunal flexure, although the attachment is quite variable.
7
Causes of bleeding to the upper gastrointestinal tract:
- ulcer of the duodenum and stomach,
- acute hemorrhagic gastritis
- esophageal and gastric varices,
- Mallory and Weiss syndrome, inflammation of the mucous membrane of the esophagus or duodenum,
- cancer,
- esophageal ulceration,
- vascular malformations.
Up to 80% of patients with GI tract bleeding are bleeding to its upper part.
Indications for exploratory laparotomy:
- peritoneal signs =
- air under the diaphragm revealed in chest X-ray =
- lack of peristalsis in auscultation test =
- unexplained patient deterioration and shock =
- peritoneal signs (peritonitis),
- air under the diaphragm revealed in chest X-ray (perforation of the gastrointestinal tract),
- lack of peristalsis in auscultation test (paralytic ileus),
- unexplained patient deterioration and shock (internal bleeding).
The ascending aorta is located within the chest. In the case of injuries of this area, the _____ procedure is performed urgently, however, most often the patient’s death occurs immediately.
thoracotomy procedure is performed urgently
In patients after multiple injuries to the body, the so-called ___ ___ is most commonly performed in order to minimize surgery time.
This procedure consists of three stages:
abbreviated laparotomy
3 stages:
1. Opening the abdominal cavity and controlling bleeding (ligating vessels, packing parenchymatous organs).
- In the situation of an open intestinal wound, a resection of a given intestinal segment is performed and the stumps are ligated without the final reconstruction of the continuity of the gastrointestinal tract.
- The abdominal cavity is closed with several temporary stitches.
- Shock treatment.
- Re-opening the abdominal cavity and performing a classic definitive operation.
Pringle’s maneuver
- in abdominal surgery, a procedure involving temporary clamping of the hepatoduodenal ligament during surgery (using surgical forceps, tape or fingers), and** thus closing the underlying hepatic artery and portal vein in the ligament.**
Pringle’s Maneuver
The maneuver allows to reduce intraoperative blood loss during:
resection of liver parenchyma, e.g. due to cancer,
liver injuries,
bleeding from the cystic artery.
Treatment: in case of Liver damage
- In stable patients, conservative treatment may be used, however, frequent imaging of the abdominal cavity (CT) is important.
- Superficial liver damage can heal spontaneously .
- In the case of capsular rupture and damage to the liver parenchyma, laparoscopic drainage and peritoneal lavage prevents inflammation (blood and bile pass into the peritoneal cavity).
- Liver ruptures are *sutured with an ultrasonic or argon knife *.
- Extremely severe damage requires resection of the liver fragment.
The most common neuroendocrine pancreatic tumor is:
The most common neuroendocrine pancreatic tumor is:
**Insulinoma **(islet cell tumor)
-is the most common pancreatic neuroendocrine tumor that can occur in any age group, but most often affects adults.
-In most cases, it is benign (75%) and origins from pancreatic B-cells.
Insulinoma (islet cell tumor)
diagnosis:
Diagnosis: determination of the ratio of serum insulin to blood glucose level after starvation.
Insulinoma (islet cell tumor)
Treatment :
Treatment: surgical enucleation of the tumor or partial pancreatectomy.
Insulinoma (islet cell tumor)
Symptoms: also know as ?
Symptoms -** Whipple’s triad:**
- Impaired consciousness (memory disorders, periodic loss of consciousness, apathy).
- Hypoglycemia.
- Symptoms go away after carbohydrate administration (occur during fasting).
Most common causes of mechanical obstruction of the large intestines are?
Colon cancer
diverticulitis
sigmoid volvulus
6
Causes of small bowel obstruction:
postoperative adhesions,
incarceration of the abdominal hernia,
tumors or gallstones of considerable size,
intussusception,
foreign bodies,
inflammatory bowel diseases, e.g. Crohn’s disease.
5
Causes of large bowel obstruction:
volvulus,
neoplastic tumors,
diverticulitis,
fecal stones,
foreign bodies.
5
External hernias:
“PUFIL”
parastomal,
umbilical,
femoral,
inguinal,
lumbar.
Internal hernias:
“PPDO”
pericecal
paraduodenal
diaphragmatic
omental
Traditional treatment methods:
for Hernia
Bassini,
Halsted,
Shouldicev
Tension-free treatment methods - mesh treatments:
for hernia
Lichtenstein,
Rutkow,
PHS (prolen hernia system).
Meckel’s diverticulum?
It is a remnant of the ?
- is a true diverticulum, i.e. it is *formed by all layers of the intestinal wall. *
- It is a remnant of the fetal omphalomesenteric duct.
Meckel’s Diverticulum
Epidemiology:
Location:
Epidemiology: occurs in about 2% of the population (three times more often in men).
Location: final section of the ileum, about 60 cm from the iliocecal junction, at the iliocecal valve.
Structure of the diverticulum
Structure:
-the diverticulum is usually lined with the mucous membrane of the small intestine, but it can also contain the ectopic focus of the mucous membrane of the stomach, duodenum, pancreas.
-It is characterized by various length, usually 5-15 cm, although it can rarely reach up to 50 cm.
In the TNM classification of colorectal cancer, the “T” feature is as follows:
-Tis means infiltration of the mucous membrane,
-T1 is the infiltration of the submucosa,
-T2 means infiltration of the muscular membrane,
-T3 is infiltration of pericolon / perianal tissues,
-T4 means infiltration of other organs / structures or visceral peritoneum.
Ankle-brachial pressure index (ABPI)
- the ratio of the systolic pressure measured on the foot to the systolic pressure on the arm, patient lying on his back.
-In normal conditions, the blood pressure is equal to or slightly higher within the ankle.
-Values in the range of** 1.0 - 1.4 are the correct values** (borderline values are 0.9 - 1.0).
NOTE:
- value <0.9 indicates the presence of stenoses (in critical ischemia is usually <0.5) ,
- value> 1.4 indicates abnormal vascular stiffness (in diabetic patients, chronic kidney disease, in the elderly).
Chvostek’s sign
- positive when facial muscles spasm after being tapped with a neurological hammer in the point located right in front of the earlobe.
Trousseau sign
- is positive if “hand of the obstetrician” occurs,
- i.e. hand muscle contractions are detected after maintaining the pressure cuff inflated for 20 mmHg higher than the systolic blood pressure for 3 minutes.
Erb’s sign
- is based on increased motor nerve excitability
- (e.g. facial nerve) to electrical stimulation (galvanic current)
Positive Chvostek, Trousseau and Erb’s signs suggest:
PTH deficiency (hypoparathyroidism)
These are symptoms that occur in hypocalcemia (low serum calcium <2.25 mmol/l).
Causes of hypocalcemia:
- insufficient dietary calcium intake
- impaired calcium absorption (malabsorption syndromes)
- excessive deposition of calcium in the bones (taking bisphosphonates, acute pancreatitis)
- excessive loss of calcium in the urine (taking loop diuretics)
- Vitamin D deficiency (celiac disease, chronic kidney disease)
- PTH deficiency (hypoparathyroidism)(choice E)
- tissue resistance to PTH (pseudohypoparathyroidism)v
It should be remembered to remove the margin within healthy tissues (the large intestine is partially retroperitoneal ).
In rectal cancer, ____shall also be removed, meaning the tissues surrounding the rectum together with what ?
-mesorectum
-rectum together with the fascial sheath.
Right-sided hemicolectomy
includes ?
caecum tumor ,
ascending colon,
1/3 of the transverse colon
and the final section of the small intestine),
left-sided hemicolectomy
includes ?
descending colon tumor,
1/3 of the transverse colon
GIST - gastrointestinal stromal tumors
-derived from mesenchymal cells most likely from Cajal “pacemaker” cells of the gastrointestinal tract.
-These are the cells that automatically cause the intestinal muscle to contract, initiating peristalsis.
Tumors:
epithelial -
mesenchymal -
lymphoid tissue and hematopoietic system -
from the primary germ cell -
epithelial - cancers
mesenchymal - sarcomas
lymphoid tissue and hematopoietic system - lymphomas and leukemias
from the primary germ cell - germ cell tumors
gastrointestinal stromal tumors
GIST can occur in
-in the stomach (40-70%) (answer B)
-small intestine (20-50%)
-in the large intestine (approx. 5%) and esophagus (<5%)
A patient is referred to the surgical outpatient clinic because of two tumours: one in the right adrenal gland with the diameter of 4.8 cm and the other in the left adrenal gland with the diameter of 2.1 cm (described as probable adenoma in CT). Laboratory tests excluded hormonal activity of the tumours. Which of the following is the management of choice in this patient?
A patient is referred to the surgical outpatient clinic because of two tumours: one in the right adrenal gland with the diameter of 4.8 cm and the other in the left adrenal gland with the diameter of 2.1 cm (described as probable adenoma in CT). Laboratory tests excluded hormonal activity of the tumours. Which of the following is the management of choice in this patient?
laparoscopic “Right adrenalectomy”
incidentaloma define:
Diagnostic tests to exclude?
- as the name implies the tumor detected accidentally, during routine tests, not hormonally active, giving no symptoms.
- If such a tumor is detected (most often during ultrasound or CT scan), a more detailed diagnostics should be performed:
- Hormonal teststo exclude
- Cushing’s syndrome
- Pheochromocytoma
- Conn syndrome - when hypertension or hypokalemia coexists
hyperandrogenaemia
*Imaging tests *- CT (if not performed) or MR
A fine needle aspiration biopsy is performed only if there is a suspicion of a neoplastic metastasis to the adrenal glands with an unknown primary origin
Klatskin’s tumor is a
-cancer of the bile ducts located at the junction of the right and left hepatic ducts
-Klatskin tumor is a term given to “ Cholnagiocarcinoma”
-Cancer of the bile ducts most often occurs in the extrahepatic ducts and takes the form of adenocarcinoma.
Klatskin’s tumor is a cancer of the bile ducts
Symptoms:
-Mechanical jaundice - the first and most common symptom, it is not accompanied by fever or pain
-pain under the right costal arch at a later stage of the disease
-Courvoisier’s symptom (palpable, painless, enlarged gallbladder) if the tumor is located in the common bile duct
.
Klatskin’s tumor is a cancer of the bile ducts
Laboratory tests
Treatment
Laboratory tests showed** increased levels of bilirubin, CEA and CA 19-9.**
Treatment - radical, surgical removal of the tumor (5-year survival approx. 10%).
Pancreatic head cancer - symptoms:
-epigastric pain, often appearing at night,
-radiating to the left hypochondrium or to the thoracic spine of a “burning” or “pressing” nature.
-Changing the position of the body while tilting forward usually reduces the intensity of the pain.
-Mechanical jaundice and Courvoisier’s symptom (palpable through the integuments, enlarged, painless gallbladder) may be the first symptom of a tumor located in the head of the pancreas.
-Jaundice is caused by the tumor pressing or infiltrating the common bile duct.
-The risk of pancreatic cancer increases with age, and more than 80% of cases are diagnosed after the age of 50, therefore in a 68-year-old patient with painless jaundice, pancreatic head cancer should be ruled out first.
The most frequent localization of* arterial embolisms*:
- Femoral artery - 43%
- Iliac artery - 18%
- Aortic bifurcation - 15%
- Popliteal artery - 15% Typical symptoms are referred to as 5P:
a. Pain
b. Pulseless
c. Paresthesis - disturbance of feeling, numbness
d. Pallor - white skin color
e. Paralysis - muscle weakness
Leriche Syndrome is
-
aortoiliac occlusive disease is a form of central artery disease involving the blockage of the abdominal aorta as it transitions into the common iliac arteries.
-a type of chronic ischemia of the lower limbs in which there is narrowing of: - End/Distal segment of the abdominal aorta - Both Common Illiac Arteries - Both External Illiac Arteries
Hartmann’s procedure
-is a type of colectomy that removes part of the colon and sometimes rectum (proctosigmoidectomy).
-The remaining rectum is sealed, creating what is known as Hartmann’s pouch.
- The remaining colon is redirected to a colostomy.
- It can be reversed later.
Attention!
Mechanical obstruction most frequently (up to __%) concerns the___ intestine.
The most common causes of __ __ mechanical obstruction are postoperative _____, and for large intestine - __ __.
- (80%) concerns the small intestine.
- The most common causes of small intestinal mechanical obstruction are postoperative adhesions, and for large intestine - colorectal cancer.
The boundary between the upper and lower GI tract is the
Treitz ligament;
-therefore, the *lower GI refers to both the small and large intestine *
- which makes *adhesions of the small intestine the most common cause of obstruction! *
Intestinal obstruction
mechanical (obstacle in the gastrointestinal tract):
-80% refers to the small intestine
-occlusion most often concerns the large intestine - colorectal cancer
-bowel infarction most often concerns the small intestine postoperative adhesions (the most common cause), hernia incarceration, intestinal torsion, intussusception
Intestinal obstruction
paralytic (abnormal bowel function):
-caused by irritating effects of various factors on intestinal nerve plexuses (digestive juices, bacteria, after operations)
-reflex (bile and renal colic, spinal and pelvic fractures, injuries and tumors of the CNS, testicular, ovarian torsion)
-systemic complication (decompensated diabetes, uremia, water and electrolyte disturbances)
Complex regional pain syndrome (CRPS) formally known as?
_ also called Sudeck’s atrophy, Sudeck’s disease, Sudeck’s syndrome, algodystrophy, reflex neurovascular dystrophy, reflex sympathetic dystrophy, amplified musculoskeletal pain syndrome, shoulder-hand syndrome or causalgia.
Sudeck syndrome
-is a painful long-term swelling of periarticular tissues with impaired blood supply and atrophic changes in soft tissues and bones.
-It applies to the area of the wrist and ankles.
-The factor conducive to the development of the disease state is incorrectly and too tightly fitted dressing, which makes the limb immobilized in the wrong position.
A Monteggia fracture is an
- isolated fracture of the proximal ulna associated with dislocation of the fragments and dislocation of the radial head.
- A common complication is damage to the deep branch of the radial nerve,
- the symptom of which is impaired straightening of all the fingers and the metacarpus.
- the so-called hand drooping.
- Surgical treatment is indicated.
Galeazzi-type fracture -
an isolated fracture of the shaft of the radial bone with dislocation of the fragments and dislocation of the ulna head
subluxation
partial or incomplete dislocation
Colles type fracture
- fracture of the distal radius bone as a result of a fall on an extended limb during dorsiflexion of the wrist and forearm conversion
The most common cause of upper digestive tract bleeding is
duodenal ulcer disease.
7
The most common causes of lower digestive tract bleeding include:
- haemorrhoids - the most common cause of chronic bleeding
- colon polyps,
- diverticular disease,
- colorectal cancer,
- Meckel’s diverticulum,
- inflammatory bowel diseases - UC and Crohn’s disease,
- angiodysplasias.
Homans’ sign is a symptom found in
- about 30% of patients with deep vein thrombosis within the lower leg.
-It involves the induction of considerable pain within the calf and popliteal fossa during the dorsal flexion of the foot, while maintaining an upright knee.
-This is due to painful inflammation in deep veins when tightening them.
-The finding of this symptom confirms the diagnosis of deep veins thrombosis of the lower limbs.
A 68-year-old patient, previously in good health, who has not needed medical attention for the last year, is referred to the surgical outpatient clinic because of a yellowish shade of his skin observed for 7 days. The physical examination shows the enlarged nonpainful gallbladder. Which of the following is the most probable diagnosis?
**Pancreatic head cancer **- symptoms: epigastric pain, often appearing at night, radiating to the left hypochondrium or to the thoracic spine of a “burning” or “pressing” nature.
-Changing the position of the body while tilting forward usually reduces the intensity of the pain.
-Mechanical jaundice and Courvoisier’s symptom (palpable through the integuments, enlarged, painless gallbladder) may be the first symptom of a tumor located in the head of the pancreas.
-Jaundice is caused by the tumor pressing or infiltrating the common bile duct.
-The risk of pancreatic cancer increases with age, and more than 80% of cases are diagnosed after the age of 50, therefore in a 68-year-old patient with painless jaundice, pancreatic head cancer should be ruled out first.
Appendicitis causes the occurrence of peritoneal signs, which include:
Jaworski’s sign
- increasing pain while lowering the patient’s limb (characteristic for the retrocecal position of the appendix)
Appendicitis causes the occurrence of peritoneal signs, which include:
Rovsing’s sign
- pain in the right iliac area while moving the hands along the colon antiperystically
Appendicitis causes the occurrence of peritoneal signs, which include:
3. Blumberg’s sign
- haracterized by a lack or slightly increased pain during delicate pressure on abdomen, with a characteristic induction of acute, severe pain at the moment of rapid relief of pressure
What is Meckel’s diverticulum
rule of 2?
Meckel diverticulum occurs in:
-about 2% of the population,
-is about 2 inches in length,
-is usually located within 2 feet of the ileocecal valve,
-presents before 2 years of ag
Volkmann’s syndrome (Volkmann’s contracture):
-Supracondylar fractures are the most common elbow fracture in children, especially in the first decade of life.
-The peak age is from 5-8 years.
-The usual mechanism is a fall onto the outstretched hand with hyperextension at the elbow.
Porphyria
is a group of liver disorders in which substances called porphyrins build up in the body, negatively affecting the skin or nervous system.
The type of Porphyria that affect the nervous system is known as
acute porphyria, symptoms are rapid in onset and short in duration.
-Symptoms of an attack include abdominal pain, chest pain, vomiting, confusion, constipation, fever, high blood pressure, and high heart rate.
The attacks usually last for days to weeks.
Claudication
-is pain in the legs or arms that occurs while walking or using the arms.
-The pain is caused by too little blood flow to the legs or arms.
-Claudication is usually a symptom of peripheral artery disease, in which the arteries that supply blood to the arms or legs, usually the legs, are narrowed.
Classification by Fontaine:
I - asymptomatic
IIa - claudication > 200 m - mild claudication
IIb - claudication <200 m - moderate / severe claudication
III - rest pain
IV - ischemic necrosis and ulcers
The Whipple surgery modified by Traverso involves removal of:
pancreas head
duodenum
gallbladder
CBD
Ogilvie syndrome is
- the acute dilatation of the colon in the absence of any mechanical obstruction in severely ill patients
-Acute colonic pseudo-obstruction is characterized by massive dilatation of the cecum (diameter > 10 cm) and right colon on abdominal X-ray.
-It is a type of megacolon, sometimes referred to as “acute megacolon,” to distinguish it from toxic megacolon.
Paresthesia
- refers to a burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body.
- The sensation, which happens without warning, is usually painless and described as tingling or numbness, skin crawling, or itching.
Hinchey classification describes the complications of diverticulitis:
1A - phlegmon
1B - diverticulitis with para-colonic abscess
2 - diverticulitis with a limited pelvic abscess
3 - diverticulitis with diffuse purulent peritonitis
4 - diverticulitis with diffuse fecal peritonitis
Acute cholangitis:
definition
- acute inflammation of the intra- and / or extra-hepatic biliary ducts caused by infection due to obstruction or blockage of the outflow of bile
symptoms:
Charcot’s triad:
- severe pain resembling biliary colic in the right hypochondrium or middle epigastrium area
- fever with chills
- jaundice
Note: I f there are signs of shock and disturbance of consciousness, then* this state is called the Reynolds pentad.*
pain during palpation in the right hypochondrium area
increased tension of the stomach muscles
The angle of His
- also known as the esophagogastric angle, is the acute angle created between the cardia at the entrance to the stomach, and the esophagus.
- It helps to prevent acid reflux of stomach acid into the esophagus.
- It is commonly undeveloped in infants, making acid reflux more common.
A patient was admitted to the surgical ward in duty hours. The patient needs urgent surgery but he receives chronic anticoagulant therapy with vitamin K antagonist (VKA). Which of the following should be used to reverse VKA action promptly?
-When a patient requires urgent surgery, the action of vitamin K antagonists should be immediately reversed.
-Freshly frozen plasma should be administered (recommended dose 15 ml / kg body weight, on average 4-5 units).
-An alternative to this is the transfusion of the prothrombin complex concentrate.
Marasmus
-is a deficiency of all macronutrients
Types of malnutrition:
-chronic protein-caloric malnutrition due to chronic starvation
-progressive weight loss
-leads to disorders of organ function
the albumin concentration is normal for a long time (but sudden illness or injury causes a rapid reduction in albumins)
-most often occurs in patients with chronic diseases and cancers
-in extreme cases it can lead to emaciation (cachexia)
-nutrition via the gastrointestinal tract is recommended
kwashiorkor
-acute malnutrition most often due to acute illness, trauma, surgery
-hypoalbuminemia, edema, water-electrolyte disturbances, disturbances of consciousness occur
-can occur in overweight, obese patients when they receive only crystalline liquids without protein supply
-very rapid development of malnutrition, without losing weight (weight can even increase by water retention and edema)
the patient’s condition quickly deteriorates
parenteral nutrition is recommended
Hypertonic dehydration occurs when
- an individual excretes too much water without also excreting electrolytes, leaving the fluid that surrounds cells (i.e., extracellular fluid) with a high sodium concentration.
- A high concentration of sodium outside a cell will draw water out of the cell, towards the sodium
Symptoms of hypertonic dehydration:
- dryness of mucous membranes and skin, hypotension, tachycardia, oliguria - signs of dehydration
- strong feeling of thirst - a symptom of hypertonia
- confusion, hallucinations, hyperthermia - CNS symptoms
Hypoventilation causes
respiratory acidosis.
The algorithm for the treatment of patients with jaundice is published in Interna by Szczeklik 2018.
First Step
The algorithm for the treatment of patients with jaundice is published in Interna by Szczeklik 2018.
the first examination should be interview, physical examination and laboratory tests of blood:
- total bilirubin and direct (conjugate), ALT, AST, ALP, PT, GGT, albumin.
Second step
The algorithm for the treatment of patients with jaundice is published in Interna by Szczeklik 2018
According to this algorithm
- ultrasound examination of the abdominal cavity should be performed in the presence of conjugated hyperbilirubinemia of the cholestatic type in which* ALP is greater than or equal to 2x the upper norm*.
- **ALT **is less than or equal to the upper norm,
- and the ratio ALT to ALP is equal to or lower than 2.
“Duke” has Colorectal cancer
classification of 6
Colorectal cancer - about ___ % ____ type .
Staging - Dukes classification:
Colorectal cancer - about 85% are adenocarcinomas.
A - a tumor limited to the intestinal wall
B - the tumor exceeds the intestinal wall
C - tumor size is irrelevant because there are metastases in the lymph nodes:
C1 - pericolic
C2 - along the blood vessels
D - distant metastases.
Gastric cancer - ___% is _____.
Type of Classifiction used?
Gastric cancer -** 95% is adenocarcinoma**.
Laurenaclassification - is the most commonly used microscopic classification of gastric adenocarcinoma.
Lauren I - intestinal type - more often endemic, most likely associated with environmental factors, better prognosis
**Lauren II **- diffuse type - worse prognosis, genetic predisposition.
“Lauren” has Gastric cancer…L-II others are involved = genetic
The staging of cancer of the ____ and ___ ___ is based on the TNM classification.
The staging of cancer of the pancreas and hepatocellular carcinoma is based on the TNM classification.
hemangioma or haemangioma
- is a usually benign vascular tumor derived from blood vessel cell types.
- The most common form, seen in infants, is an infantile hemangioma, known colloquially as a “strawberry mark”, most commonly presenting on the skin at birth or in the first weeks of life
liver hemangioma is a
- noncancerous (benign) mass in the liver made up of a tangle of blood vessels.
- Also known as hepatic hemangiomas or cavernous hemangiomas, these liver masses are common and are estimated to occur in up to 20% of the population.
-Liver hemangiomas concern about 3% of the population.
-They are usually accidentally detected during imaging tests. In most patients, hepatic haemangiomas do not cause any symptoms.
-Rare symptoms are pain in the right hypochondrium and pressure on neighboring organs.
hepatic colic (biliary)
- sudden, rapidly growing pain in the right hypochondrium radiating to the right shoulder and/or scapula; usually nausea, vomiting and abdominal distension also occur
acute cholecystitis
- usually caused by obstruction of the cystic duct, diagnosed in 20% of patients; dull pain over the entire epigastric region, are diffuse, intensifying during inhalation; nausea, vomiting, fever (38-39°C), chills, sometimes jaundice
chronic cholecystitis
- a result of mechanical irritation of gallbladder mucosa by gallstones; in 25% leads to bacterial bile infection occurs, symptoms include biliary colic, right upper quadrant (epigastric) pain, burping, nausea, bloating, feeling of fullness after meals
gallbladder hydrops
- as a result of blockage of the cystic duct; colic attack, after which you can feel a slightly painful gallbladder
gallbladder empyema
- the formation mechanism is the same as in hydrops, but is accompanied by bacterial inection/inflammation; the symptoms include high fever (39-40°C), chills, peritoneal symptoms, constant severe pain in the right subcostal (hypochondrium) area with radiation to the right scapula
perforation of the gallbladder
- this is a complication of untreated inflammation (empyema), hydrops or abscess
morphine causing contraction of the ___ -___ ___.
morphine causing contraction of the hepato-pancreatic ampulla
The conservative treatment of cholecystolithiasis is based on:
- diet (elimination or significant reduction of fried products as well as fats, cream, peas, egg yolks and chocolate)
- supply of analgesics and relaxant (most commonly metamizole, hyoscine and papaverine, it is possible to use nitroglycerin sublingually, which is a strong relaxant; avoid morphine causing contraction of the hepato-pancreatic ampulla)
- administering choleretic drugs (Cholestol or Raphacholin, but they do not prevent biliary colic attacks)
- in the case of inflammation or abscess - administration of antibiotics
The indications for surgical treatment are:
- symptomatic gallstones
- asymptomatic cholelithiasis, but only when it is associated with a high risk of gallbladder cancer, i.e. in people:
a. young, especially with multiple gallstones, at risk of acute pancreatitis as a complication
b. with a porcelain gallbladder (especially when the calcification of walls is irregular)
c. with diabetes
d. before extensive cardiac surgeries or organ transplantation
e. treated with immunosuppressants or cytostatics
f. women planning pregnancy
g. with gallbladder polyps (>1 cm or between 6-10 mm, when gallstones are growing and present, or regardless of size in patients with sclerosing cholangitis)
The surgical treatment of umbilical hernia depends on whether the hernia gates are large or small:
- small gats - the operation involves reducing the hernia sac and stitching the gates
- large gates - the operation consists in reducing the sac and closing the gates with the Mayo method, which consists in suturing the doubled patches formed by the sheaths of the rectus abdominis muscles
Complications of thyroid surgery:
- hypoparathyroidism (3-10%) - the most frequent complication after thyroidectomy, caused by parathyroid dysfunction or accidental excision. It is associated with a decrease in the concentration of parathyroid hormone produced by parathyroid glands, which is manifested by hypocalcaemia and tetany. Most often, the symptoms are transient. Treatment consists in the administration of vitamin D and calcium preparations.
- haemorrhage (<1%) - more often during retrosternal, mediastinal and overactive goiter surgery.
- unilateral damage to the recurrent laryngeal nerve (1-5%) - this causes phonation disturbances.
- bilateral damage to the recurrent laryngeal nerves (0.1%) - there is dyspnea that threatens life, what is an indication for tracheostomy.
- thyroid storm - it happens very rarely when the patient was not prepared for the procedure in terms of compensation of thyroid hormones.
- recurrent goiter - recurrence of thyroid cancer after incomplete excision of the gland.
- keloid - a scar with a thick, red, raised surface, going beyond the original cut line.
in pancreatic head cancer - resection using Whipple or Traverso method
Traverso-Longmire operation
- it is a resection of the head of the pancreas and duodenum while preserving stomach
in pancreatic head cancer - resection using Whipple or Traverso method
Whipple operation
- involves the removal of the head of the pancreas, duodenum and part of the stomach.
- Then, anastomoses are made: the pancreas with the end of the intestine, the common bile duct with the side of the intestine, the stomach with the small intestine loop.
- An additional anastomosis is decompressive anastomosis, which consists in suturing the small intestine side to side.
Blumberg sign
- acute, short-lasting abdominal pain, felt at the moment of sudden release of manual skin compression.
- Positive in peritonitis.
- A positive Blumberg sign and abdominal guarding as symptoms of peritonitis can also occur in the perforation of the large intestine.
“B” Be “Positive” B- for bluberg
Rovsing sign
- pain in the right iliac fossa, caused by compression of the left half of the abdomen (this causes the displacement of the contents in the colon, which causes the pain while stretching the ceacum).
- Characteristic of appendicitis.
Jaworski sign
- the patient lying on his back raises the lower leg straightened in the knee joint. The examiner compresses the right hip, instructing the subject to gradually lower the limb.
- The sign is positive when the patient feels pain while lowering the limb.
- The sign is evidence of retrocaecal appendicitis.
The signs of Jaworski and Rovsing are characteristic of?
and usually accompanied by?
-appendicitis.
-Appendicitis is usually accompanied by peritonitis
Acute diverticulitis requires
hospitalization, antibiotic therapy and a liquid diet
incomplete, initial, so called
-so called bubonocele
- hernia is limited in the inguinal canal
complete (or vaginal)
- exceeds the canal; the hernia passed through the superficial inguinal ring
scrotal
- hernia in the scrotum
labial
- hernia near the labia majora
sliding
- partially intraperitoneal organ pulled to the hernia
direct inguinal hernia
- always acquired, rarer than indirect inguinal hernia,
- does not descend into the scrotum, gates are formed by medial inguinal fossa.
- The hernia manifests itself with a bulge above the inguinal ligament, close to the pubic symphysis
The femoral hernia
- the hernia sac enters the femoral ring through the femoral canal. It is an acquired hernia, more common in women.
- The symptom is a bulge in the medial part, below the inguinal ligament.
- The only treatment is surgery.
Riolan arc is in the area of the splenic flexure
-It is the connection
-between the left branch of the central colic artery (branch of superior mesenteric artery) and the ascending branch of the left colic artery (branch of the inferior mesenteric artery).
Takayasu’s arteritis (TA),
- also known as aortic arch syndrome, nonspecific aortoarteritis, and pulseless disease,
- is a form of large vessel granulomatous vasculitis with massive intimal fibrosis and vascular narrowing,
- most commonly affecting young or middle-aged women of Asian descent, though anyone can be affected.
- It mainly affects the aorta and its branches, and pulmonary arteries.
- Females are about 8–9 times more likely to be affected than males.
Buerger’s disease, or
- thromboangiitis obliterans, is an inflammation of all layers of the vessel, which leads to thrombus formation and obliteration of its lumen.
- It most often occurs in the lower extremities and affects both small arteries and veins.
Buerger’s disease, or thromboangiitis obliterans
symptoms:
feeling of cold, numbed toes,
excessive foot sweating,
intermittent claudication - foot pain while walking,
over time, foot pain at rest and necrotic changes.
During the physical examination, the circumferences of both limbs should be compared, as 70% of cases of unilateral edema are caused by?
Deep vein thrombosis (DVT)
Deep vein thrombosis
Useful in diagnostics:
- Homans’s sign - pain within the calf and popliteal fossa during dorsal flexion of the foot
- Mozes sign - increased tension and stiffness of calf muscles
- Payr sign - painfulness of the medial edge of the foot
Ménétrier’s disease
- (protein-losing hypertrophic gastropathy)
- is the idiopathic proliferation of gastric mucosal folds usually located in the gastric fundus and body
- is a rare premalignant hyperproliferative gastropathy characterized by massive overgrowth of foveolar cells in the gastric lining, resulting in large gastric folds, and manifesting with epigastric pain, nausea, vomiting, peripheral edema and, less commonly, anorexia and weight loss.
Sympt/ Diag/TX
Ménétrier’s disease (protein-losing hypertrophic gastropathy)
- belongs to precancerous conditions, necessary endoscopic monitoring every 1-2 years
more often occurs in men, usually around 55 years of age -
the most common symptoms: abdominal pain, weakness, lack of appetite, weight loss, diarrhea
-* diagnostics:*
a. gastroscopy: oversized> 1 cm stomach folds in typical places (see above), and hist-pat . b. examination: disappearance of the glandular ducts
c. *treatment: *from eradication of H.pylori (some allow full recovery), PPI to cetuximab or partial resection of the stomach.
Ménétrier’s disease (protein-losing hypertrophic gastropathy)
If the question about Ménétrier’s disease appeared on the pediatric part, it is worth remembering that in children the etiology is associated with ?
with the CMV virus and after the detection of the disease, ganciclovir is used.
According to the guidelines, the indications for surgical treatment of obesity are:
1) BMI ≥40 kg / m2 without comorbidities:
2) BMI 35-40 kg / m2 with a coexisting disease, the course of which may be improved after bariatric surgery. ( hypertension, type 2 diabetes or dyslipidemia.)
Crohn’s disease - a chronic, segmental inflammation, covering the entire thickness of the wall and potentially each section of the gastrointestinal tract (ie from the mouth down to the anus).
Crohn’s disease
Symptoms:
diarrhea, abdominal pain, weight loss, weakness, perianal changes, anal fissures, abscesses, fistulas, tumors in the abdomen.
Crohn’s disease
Non-GI symptoms:
remember them through the acronym “SEALK”
-the most common are within the osteoarticular system - joint inflammation in the course of inflammatory bowel diseases,
- -additionally: *suttona aphta, erythema nodosum and gangrenous dermatitis, urolithiasis, cholelithiasis, primary sclerosing cholangitis (PSC).
- Skin disorders ( erythema nodosum and gangrenous dermatitis )
E ye inflammation (inflammation of the iris, cornea, sclera)
A rthritis (arthritis)
L iver or gallbladder disease (primary sclerosing cholangitis (PSC).
K idney disorders (urolithiasis)
Short bowel syndrome (SBS) is a condition after
-condition after excision or exclusion from the intestinal passage of some or all of the small intestine,
-which leads to a reduction in absorption to such a large extent that nutrition exclusively by the digestive tract is not sufficient to maintain health.
-SBS can occur when the length of the active small intestine is less than 150-200 cm or when 50% of the intestine is switched off.
Short bowel syndrome (SBS) is a condition after excision or exclusion from the intestinal passage of some or all of the small intestine- The most common cause of extensive excision is?
-upper mesenteric artery thrombus/embolism
Short bowel syndrome (SBS)
Other causes of resection include:
Crohn’s disease (Pl. Leśniowski-Crohn’s disease)
volvulus
abdominal injury
tumor
The McBurney point
- one-third of the distance from the anterior superior iliac spine to the umbilicus, place of attachment of the appendix to the cecum.
- This is the most painful place when examining a patient with appendicitis.
The Lanz point
situated on a line connecting the two anterior superior iliac spines one third of the distance from the right spine
Colles Frature
fracture of the distal head of the radius bone. This type of fracture is the most common within the distal base of the bone.
definition:
erysipelas:
acute inflammatory disease of the skin of streptococcal etiology ( S.pyogenes, beta-hemolytic group A streptococcus)
treatment:
erysipelas:
benzyl penicillin
or
antibiotic treatment
Bloomberg sign
rebound tenderness
Cullen sign is not a
- Cullen sign is not a classic clinical feature of acute appendicitis
- Instead, it is a rare sign of acute pancreatitis describing the foci of subcutaneous tissue necrosis in the form of brown patches found in the umbilical region.
Ulcerative colitis is a disease from the group of inflammatory bowel dis
Mallory-Weiss syndrome
- is characterized by longitudinal mucosal lacerations (intramural dissection) in the distal esophagus and proximal stomach, which are usually associated with forceful or prolonged vomiting or retching.
- The lacerations often lead to bleeding from submucosal arteries.
Sudeck’s syndrome, otherwise known as
algodystrophy, is a painful, long-lasting swelling of periarticular tissues with blood supply disorders and atrophic changes in soft tissues and bones.
-Most commonly, the wrist is affected , less often the knee, foot, ankle, sometimes the whole limb (shoulder-hand or hip-foot syndrome), occasionally the face or trunk.
A factor conducive to the development of the disease is too tightly applied immobilizing dressing or placing the limb in a forced position.
Cullen’s sign is
Cullen’s sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus.
- the inferior epigastric vessels visible in ultrasound lie lateral to the hernial sac
- This hernia is less common than the oblique inguinal hernia,
- has a short canal,
- and never descends into the scrotum.
Paronychia
- an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium Staphylococcus aureus, or gradually when it is commonly caused by the fungus Candida albicans
The angle of His, also known as
- also known as the esophagogastric angle, is the acute angle created between the cardia at the entrance to the stomach, and the esophagus.
- It helps to prevent acid reflux of stomach acid into the esophagus.
- It is commonly undeveloped in infants, making acid reflux more common
