Surgery Flashcards
Most common cause of esophageal perforation?
Iatrogenic
Most common type of esophageal diverticula?
Pharyngoesophageal ( Zenker’s Diverticula)
Most potent physiologic stimulus for pepsinogen release?
Food
The highest perforation rate after a caustic esophageal injury occurs during?
Ulceration and granulation phase
Surgical management of uncomplicated Barrett’s esophagus?
Anti-reflux procedure
The most effective surgical treatment for GERD?
Nissen fundoplication
Surgical treatment for ACHALASIA?
Heller’s myotomy +/- Partial fundoplication
Most common primary esophageal motility disorder?
Nutcraker/Supersqueezer esophagus
The only tumor virtually restricted to the Parotid gland?
Warthin’s tumor (Papillary cystadenoma lymphomatosum)
Where are foreign bodies in the head and neck most commonly found?
Ear
A deep neck infection may extend down to the mediastinum through?
Substernal space of Burns
Most common malignant tumor of the parotid gland?
Mucoepidermoid carcinoma
Most common malignant tumor of the minor salivary glands?
Adenoid cystic carcinoma
Most common brachial cleft anomaly?
2nd brachial cleft
Most common type of malignancy arising from a thyroglossal duct cyst?
Papillary carcinoma
Highest perforation rate after a caustic esophageal injury occurs during?
Ulceration and granulation phase
Surgical treatment of uncomplicated Barrett’s esophagus?
Anti-reflux procedure
Most effective surgical treatment for GERD?
Nissen fundoplication
Gold standard in the diagnosis of GERD?
24 hour pH monitoring
Most common organism responsible for acute otitis externa?
Pseudomonas aeruginosa
Most common primary tumor of the middle ear?
Glomus jugulare/ glomus tympanicum
Nasopharyngeal carcinoma is best treated by?
Chemo-radiotherapy (Cisplatin/5-FU)
Structures preserved in a modified radical neck dissection?
Sternocleidomastoid muscle
Internal jugular vein
Spinal accessory nerve
A “butterfly shaped” ulcer involving the hard palate?
Necrotizing sialometaplasia
Otologic meningitis is usually due to?
H. Influenza type B
Painless mass of the jaw associated with an impacted teeth?
Ameloblastoma (Adamantinoma)
Form of mucus retention cyst that involves th sublingual gland?
Ranula
Single most important predictor of survival in breast cancer?
Axillary lymph node metastasis
Breast cancer type confirmed by the presence of intracytoplasmic mucin?
Lobular CA
“Indian file configuration”
Paget’s disease may be confused with type of melanoma?
Superficial spreading melanoma
Most frequent site of metastasis for breast cancer?
Bone (vertebra)
Most important risk factor in the development of breast CA?
Gender
The level of axillary lymph nodes are based on this structure?
Pectoralis minor
Chronic inflammatory condition of the nipple areola complex that originates from areolar glands?
Hidradenitis suppurativa
Epidemic puerperal mastitis is most often transmitted via?
Suckling neonate
Kaposi’s sarcoma is treated primarily by?
Radiation
A rare but aggressive cutaneous malignancy arising from neuroendocrine cells?
Merkel cell carcinoma
Tumors arising from areas of previous radiation/lymphedema?
Angiosarcoma (Stewart-Treves Syndrome)
Mainstay of treatment for severe necrotizing soft tissue infections?
Wide debridement
Gold standard in the diagnosis of Pulmonary Embolism?
Pulmonary Angiogram
Most dreaded complication of placing a Swan Ganz catheter?
Pulmonary artery rupture
Most common cause of graft loss post kidney transplant?
Recipient death (Cardiovascular causes) - 1st
Allograft nephropathy - 2nd
A lethal and rapidly progressive soft tissue infection caused by microaerophilic streptococcus?
Meleney’s synergistic gangrene
Microsatellite instability is the hallmark of what hereditary cancer syndrome?
Lynch Syndrome (HNPCC)
Organism most elevated in primary liver cancer and germ cell tumors?
AFP
Most commonly mutated gene in human cancer?
P53
Earliest known genetic alteration in colorectal cancer?
APC gene
The sudden multiple appearance of seborrheic keratoses?
Lesser Trelat sign
Stressed induced hyperglycemia is primarily due to?
Peripheral resistance to insulin
Basic caloric requirement of a normal healthy adult?
25 kcal/kg per day
Reduced REE is characteristic of this phase of surgical metabolism?
Ebb phase
The primary source of energy during the stressed state?
Fat (50-80%)
Stressed induced hyperglycemia is primarily due to?
Peripheral resistance to insulin
Basal caloric requirement of a normal healthy adult?
25 kcal/kg per day
Mild stress - 25-30
Moderate stress - 30
Severe stress - 30-35
Burns - 35-40
A 60-year-old man with carcinoma of the esophagus is admitted with severe malnutrition. Nutritional support is to be initiated. What should be his daily caloric intake?
30 kcal/kg body weight/day
Reduced REE (resting energy expenditure) is characteristic of this phase of surgical metabolism?
EBB phase
The primary source of energy during the stressed state?
Fat (50-80%)
How many kilocalories does Liter of D5LR provides?
170kcal
Systemic proteolysis following injury is mediated primarily by?
Glucocorticoids
Development of dry, scaly dermatitis and alopecia while on prolonged par enteral treatment is most likely due to?
EFA deficiency
Differentiate VS Zinc deficiency
—–“Eczematoid rash”, diffuse/intertrigenous areas
A 42 y/o man with small-bowel fistula has been receiving TON within standard hypertonic glucose-amino acid solution for 3 weeks. The patient is noticed to have scaly, hyperpigmented lesions over the acral surfaces of elbows and knees, similar to enterohepatic acrodermatitis. What is the most likely cause of the condition?
Zinc deficiency
The most common fluid disorder in surgical patients?
Extracellular volume deficit
A 30 y/o man with a history of Crohn’s disease of the small bowel is admitted with enterocutaneous fistula. The daily output from the fistula is 2L. The approximate composition of the fluids in mEq/L is which of the following?
Na - 140
K - 5
Cl - 104
HCO3 - 30
In cases of persistnt hypocalcemia/hypokalemia, one should request for?
Serum magnesium levels
The most important treatment of metabolic acidosis?
Restore perfusion with volume resuscitation
Characteristic early acid base picture of sepsis?
Respiratory alkalosis
Following an infection, a 68 y/o woman developed gram-negative septicemia. Which statement is true for gram-negative bacterial septicemia?
Adverse changes can be accounted for lipid A release
IVF of choice for patients with closed head injuries?
Hypertonic saline
The earliest stage of hemostasis?
Vascular constriction
The average lifespan of platelets?
7-10 days
Inherited platelet disorder of adhesion?
Bernard-Soulier syndrome
A 75 y/o man is found to have prolonged bleeding from intravenous puncture sites. Platelet aggregation is inhibited by which of the following?
Aspirin
The most common abnormality of hemostasis in surgical patients?
Thrombocytopenia
Treatment of choice for patients with Von Willebrand’s disease?
Intermediate purity Factor 8/ DDAVP
A 24 y/o woman is scheduled for an elective cholecystectomy. The best method of identifying a potential bleeder is which of the following?
A complete history and physical examination
The most common indication for blood transfusion in surgical patients?
Volume replacement
After undergoing a transurethral resection of the prostate, a 65 y/o man experiences excessive bleeding attributed to fibrinolysis. It is appropriate to administer which of the following?
Aminocaproic acid
A 22 y/o man is brought into the emergency department in profound shock after a fall from the fourth floor of a building. After resuscitation, small bowel resection and hepatic segmentectomy are performed at laparotomy. He receives 15 U of packed RBCs, 4 U of fresh-frozen plasma, and 8 L of Ringer’s lactate. On closure, diffuse oozing of blood is noted. What is the most likely cause?
Platelet deficiency
Most important management of immediate transfusion reaction?
Stop the transfusion
A 64 y/o woman undergoing radical hysterectomy under general anesthesia is transfused with 2 U of packed RBCs. A hemolytic transfusion reaction during anesthesia will be characterized by which of the following?
Bleeding and hypotension
Shock that occurs in the setting of adequate intravascular volume?
Cardiogenic shock
A 30 y/o man is brought to the emergency department following a high-speed car accident. He was the driver, and the windshield of the car was broken. On examination, he is alert, awake, oriented, and in no respiratory distress. He is unable to move any of his four extremities; however, his extremities are warm and pink. His vital signs on admission are HR 54 bpm and BP 70/40 mmHg. What is the diagnosis?
Neurogenic shock
The preferred test in the diagnosis of cardiac tamponade?
Echocardiography
Persistently elevated base deficit in a trauma patient is usually due to?
Ongoing bleeding
First priority in the treatment of trauma?
Ensuring an adequate airway
A 32 y/o female falls from the tenth floor of her apartment building in an apparent suicide attempt. Upon presentation, the patient has obvious head and extremity injuries. Primary survey reveals that the patient is totally apneic. By which method is the immediate need for a definitive airway in this patient best provided?
Orotracheal intubation
The most common indication for intubation?
Altered mental status
Surgical airway of choice in patients with laryngeal fractures?
Tracheostomy
An 85 y/o ventilator-dependent male was endotracheally intubated 10 days ago. He remains unresponsive and is not a candidate for early extubation. The intensive care unit (ICU) attending elects to perform tracheostomy at the bedside. During the procedure, copious dark bold is encountered. This is most likely due to transection of which of the following:
Anterior jugular vein
Tracheostomy is performed uneventfully in a 79 year old ventilator-dependent encephalopathic male. After several spontaneous breaths, however, the patient stops breathing. The anaesthesiologist continues to assist the patient’s breathing for several minutes, after which the patient again breathes spontaneously. The most likely cause of apnea is:
Preoperative respiration was driven by hypoxia
Immediate management of patients with tension pneumothorax?
Needle thoracostomy (2nd ICS MCL)
Thoracostomy
4th or 5th ICS MAL
Tube thoracostomy is employed in each of the following conditions EXCEPT: A. Total right pneumonectomy B. Chylothorax C. Hemothorax from rib fracture D. Spontaneous pneumothorax E. After an Ivor-Lewis procedure
A. Total right pneumonectomy
A 70 y/o man is brought into the emergency department following his injury as a passenger in a car crash. He complains of right side chest pain. Physical examination reveals a respiratory rate of 42 breaths per minute and multiple broken ribs of a segment of the chest wall that moves paradoxically with respiration. What should the next step be?
Needle thoracostomy
Trauma patients with hypotension have lost approximately how much of blood volume?
30-40% (Class III shock)
The most reliable indicator for organ perfusion during resuscitation?
Urine output
The most common cause of cardiogenic shock/cardiac failure in trauma patients?
Tension pneumothorax
Prior to catheterization in stable patients at risk for urethral injury, one should perform?
Urethrogram
Gold standard in the diagnosis of presence of intra-abdominal injuries?
DPL
Hemobilia is characterized by the triad of?
RUQ pain
UGIB
Jaundice
QUINCKE’s triad
Most commonly injured part of the diaphragm?
Left hemidiaphragm
Duodenal hematoma is best diagnosed by?
Barium/contrast study (coiled spring sign)
A 60 y/o man is attacked with a baseball bat and sustains multiple blows to the abdomen. He presents to the emergency department in shock and is brought to the operating room (OR), where a laparotomy reveals massive hemoperitoneum and a stellate fracture of the right and left lobes of the liver. Which of the following, techniques should be used immediately?
Packing the liver
The Pringle maneuver is used to control bleeding coming from?
Liver
A 33 y/o man presents to the emergency department with a gunshot injury to the abdomen. At laparotomy, a deep laceration is found in the pancreas just to the left of the vertebral column with severance of the pancreatic duct. What is the next step in management?
Distal pancreatectomy
Left sided medial visceral rotation
Mattox maneuver
Right sided medial visceral rotation
Catell Maneuver
Anatomic structure violated in penetrating neck injuries?
Platysma
Neck region easiest to evaluate?
Zone II
The most sensitive CXR finding suggesting tear of the aorta?
Widened mediastinum
The safest way to lower down ICP?
Ventriculostomy
Single most important factor predicting burn related mortality?
Burn size
Burns that extend into the reticular layers of the dermis?
2nd degree (Deep Partial Thickness Burn)
The standard technique for determining burn depth?
Clinical observation
Recommended fluid resuscitation solution for burns?
PLR
Management of patients with significant intra oral/pharyngeal burns?
Immediate ET intubation
The definitive diagnosis of burn wound sepsis can be made by?
Wound culture
Tx:
parenteral antibiotics
Early wound excision and grafting
Early signs of sepsis
Sudden glucose intolerance
Hypothermia
Thrombocytopenia
Predominant organism causing fatal burn wound infection?
Pseudomonas sp.
Differentiate VS Melting graft wound syndrome
Melting graft wound syndrome is due to STAPHYLOCOCCUS AUREUS
Antidote for chemical burns caused by hydrofluoric acid?
Calcium
Malignancy most commonly developing from a Marjolin’s ulcer?
Squamous Cell CA
Impaired wound healing due to Zinc deficiency is called?
Acrodermatitis Enteropathica
Major cell responsible for wound contraction?
Myofibroblast
The first cells to enter the wound site during wound repair?
Neutrophils
The mechanical strength of a scar is regained after?
NEVER
Non-absorbable sutures
- not biodegradable and permanent
NYLON
PROLENE
STAINLESS STEEL
SILK (Natural, can break down over years)
Absorbable sutures
- Degraded via inflammatory response
VICRYL MONOCRYL PDS CHROMIC CAT GUT (natural)
NATURAL SUTURES
- biological
- cause inflammatory reaction
CATGUT (intestine of cow or sheep)
SILK (silkworm fibers)
CHROMIC CATGUT
SYNTHETIC SUTURES
- synthetic polymers
- do not cause inflammatory response
NYLON VICRYL MONOCRYL PDS PROLENE
MONOFILAMENT SUTURES
- single stranded of suture material
- minimal tissue trauma
- smooth tying but more knots needed
- examples: NYLON, MONOCRYL, PROLENE, PDS
MULTIFILAMENT (braided)
- fibers are braided or twisted together
- more tissues resistance
- easier to handle
- fewer knots needed
- examples: VICRYL, SILK, CHROMIC
The layer of the GIT that imparts the greatest tensile strength and greatest suture holding capacity?
Submucosa
The main characteristic that distinguishes the healing of fetal wounds?
Lack of scar formation
Pressure ulcer stage when there is partial thickness skin loss?
Stage II
Stages:
I - nonblanchable erythema of intact skin
II - full thickness skin loss, not thru fascia
III - FT skin loss + muscle and bone involvement
Suture removal
Average time frame is 7-10 DAYS.
Face: 3-5 DAYS Neck: 5-7 DAYS Scalp: 7-12 DAYS Upper extremity, trunk: 10-14 DAYS Lower extremity: 14-28 DAYS Soles, palms, back or over joints: 10 DAYS
(Note: any suture with pus or signs of infections should be removed immediately)
Virus implicated in the development of Burkitt’s lymphoma?
EBV
The most common arrhythmia seen during laparoscopy procedures?
Bradycardia
Organism most commonly implicated in human bite wounds?
Eikenella corrodens
Differentiate VS Animal bites
Animal bites (Pasteurella multocida)
Taxanes blocks tumor growth at mitosis through?
Formation of excess microtubule polymerization
A lethal and rapidly progressive soft tissue infection caused by microaerophilic Streptococcus?
Meleney’s synergistic gangrene
Differentiate VS Fournier’s Gangrene
(Fournier’s gangrene - polymicrobial, involves genitalia, perineum or abdominal wall)
Most common complication after placing a central venous line?
Arrhythmia
An 85 y/o male is admitted to the ICU in septic shock. A pulmonary artery (PA) catheter is placed. The PA catheter does not directly measure which one of the following? A. PA systolic pressure B. PCWP C. Systemic vascular resistance D. Right ventricular diastolic pressure E. Right atrial pressure
C. Systemic vascular resistance
A 68 y/o man has a history of myocardial infarction. He undergoes uneventful left hemicolectomy for carcinoma of the colon. In the recovery room, he is hypotension and given a fluid bolus of 500mL Ringer’s lactate over 30 minutes. He is intubated, and his neck veins are distended. His HR is 130bpm, his BP is 80/60mmHg, and his urine output is 20mL over the last hour. What should be the next step in his management?
Insertion of a Swan-Ganz catheter
The sudden multiple appearance of seborrheic keratoses?
Lesser Trelat sign
A 29 y/o female develops a pigmented lesion on the right thigh. With reference to a pigmented lesion, there is an increased risk of developing melanoma if it is identified with which of the following?
Congenital nevocellular nevi
Type of nevus that most often occur in a “bathing trunk” distribution?
Giant hairy nevus (congenital)
Most common skin malignancy?
Basal Cell CA
A method of serially excising a tumor until it is entirely removed?
Moh’s micrographic surgery
A 65 y/o light complexioned male presents with a solitary scaly plaque like lesion on his forearm present for many years. The lesion is 0.5 cm in diameter. Shave biopsy reveals intraepithelial squamous cell carcinoma. (Bowen’s disease) incompletely excised.
Excision and repair of this area, ensuring clear surgical margins
Type of melanoma with the best prognosis?
Lentigo maligna
Treatment of melanoma?
Surgical
Extent of lymph node dissection
Groin?
Axilla?
Face, ear, anterior scalp?
Groin - removal of SUPERFICIAL (inguinal) and DEEP (iliac) nodes
Axilla - removal of LEVELS I, II, III
Face, Ear, Anterior scalp - plus SUPERFICIAL PAROTIDECTOMY and MRND
A 40 y/o premenopausal patient has a biopsy showing focal lobular carcinoma in situ (LCIS) in the area of calcification. With regard to the LCIS, you should tell the patient which of the following?
She should just be observed closely
A 46 y/o woman presents to you for evaluation of a breast mass. The patient does not perform breast self-examination and she had never noticed the mass prior to this time. Her past medical history is unremarkable. She has no prior history of breast complaints or trauma. The findings from the physical examination is unremarkable except for the breast examination. A hard, nontender 4 cm mass in the upper outer quadrant of her left breast. The left axilla is without abnormalities. Examination of the right breast without abnormalities. Examination of the right breast reveals no dominant mass or axillary adenopathy. What is your next step?
Bilateral diagnostic mammogram
Form of mucus retention cyst that involves the sublingual gland?
RANULA
Differentiate VS Epulis
(Congenital Epulis - MAXILLA)
(Epulis Gravidarum - GINGIVA, RESOLVES POST PARTUM)
A 41 y/o patient presents to your office with a biopsy proven invasive ductal cancer in the upper outer aspect of her left breast, a suspicious palpable left axillary lymph node, and diffuse calcifications throughout the rest of the breast proven to be DIC on stereotactic biopsy. The best surgical option is:
Modified radical mastectomy
A 36 y/o woman presents with a substantial unilateral breast enlargement. She had presumed that this was normal, but on examination, a large, firm tumor is palpated by the attending physician. There is early erosion on the skin. A favourable outlook can be anticipated if the lesion is which of the following?
Cystosarcoma phyllodes
A 62 y/o man undergoes excision of a cylindroma of the submandibular gland. He is most likely to have an injury to which?
Lingual nerve
Painless mass of the jaw associated with an impacted teeth?
Ameloblastoma (Adamantinoma)
X-ray appearance: “soap bubble sign”
A 58 y/o woman undergoes excision biopsy of a tumor in the left posterior triangle of her neck. Histology suggests that this is a metastatic cancer. What is the most likely site of the primary tumor?
Piriform fossa
A 16 y/o boy complains of difficulty in breathing through his nose. Endoscopy reveals a tumor infiltrating the nasopharynx. Histology reports this as a juvenile nasopharyngeal angiofibroma. The boy’s anxious mother requests information concerning the lesion. What should she be told?
It may proceed to destroy surrounding bone
A 9 month old girl is brought to the physician’s office for noisy breathing. The child is otherwise healthy, and her gestation and delivery were uncomplicated. On physical examination, mild inspiratory stridor is heard. What is the most likely cause of stridor in an infant?
Laryngomalacia
Triad of ACHALASIA
Hypertensive LES
Aperistalsis of esophageal body
Failure of LES to relax
Adenocarcinoma is the predominant malignant lesion in which of the following?
Hard palate
There is immune mediated destruction of myelin confined to the CNS leading to slowing of conduction and neurological dysfunction
MULTIPLE SCLEROSIS
There is immune mediated destruction of myelin in the PNS; illness is often triggered by an infection
Gullain-Barré syndrome
Gold standard in the diagnosis of GERD?
24 hour pH monitoring
Surgical treatment of choice for ACHALASIA?
Heller’s myotomy +/- partial fundoplication
A 48 year old man presents for evaluation of burning epigastric and substernal pain that has recurred almost daily for the past 4 months. He says that these symptoms seem to be worse when he lies down and after meals. He denies difficulty swallowing or weight loss. The patient has been taking a proton pump inhibitor regularly over the past 12 weeks with partial resolution of his symptoms. His past medical history is significant for frequent early morning wheezing and hoarseness that have been present for the past few months. The patient has no other known medical problems and he has had no prior surgeries. He consumes alcohol occasionally but does not use tobacco. On examination, he is moderately obese. No abnormalities are identified on the cardiopulmonary or abdominal examination. What is the most likely diagnosis?
Barrett’s esophagus
A 43 year old man presents to the ER with severe abdominal pain and substernal chest pain. The symptoms began 12 hours earlier after he consumed a large amount of alcohol. Subsequently, he vomited several times and then went to sleep. A short time thereafter, he was awakened with severe pain in the upper abdomen and substernal area. On PE, the patient appears uncomfortable and anxious. His temperature is 38.8C, Pr 120 b/min, BP 126/80 and RR 36/min. The lungs are clear bilaterally with decreased breath sounds on the left side. The cardiac examination reveals tachycardia and no murmurs. The abdomen is tender to palpitation in the epigastric region, with involuntary guarding. Laboratory studies reveal that his WBC is 26,000 and that his Hgb, Hct, and electrolyte levels are normal. The serum amylase, Bilirubin, AST, ALT, and alkaline phosphatase values are within normal limits. A 12-lead ECF shoes sinus tachycardia. His chest radiograph reveals moderate left pleural effusion, a left pneumothorax, and pneumomediastinum. What is the most likely diagnosis?
Boerhaave’s syndrome
The highest perforation rate after a caustic esophageal injury occurs during?
Ulceration and granulation phase
Most frequent encountered surgical disorder of the small intestine?
Mechanical small bowel obstruction
Diagnosis of small bowel obstruction
CT scan - 70-90%
Standard treatment for small bowel obstruction
Expeditious surgery
Post operative ileus is said to be prolonged when the duration exceeds
3 days
To distinguish post operative ileus from post operative SBO, it is best request for
CT scan
Initial test in the diagnosis of intestinal fistulas?
CT scan with contrast
Spontaneous closure of fistulas usually occurs in?
2-3 months
Most common presentation of Meckel’s Diverticula in adults?
Intestinal obstruction
Hallmark clinical presentation of acute mesenteric ischemia?
Abdominal pain
A 66 year old man is admitted to the coronary care unit because of new-onset atrial fibrillation. After 24 hours, he develops acute onset of abdominal pain and distention, and on examination he is found to have diffuse peritonitis. The patient undergoes exploratory laparotomy with resection of necrotic bowel. Post operative treatment for this patient?
Systemic heparinization
Most common cause of obscure GI bleeding in adults
Small intestinal dysplasia
The most sensitive test in the diagnosis of iatrogenic duodenal perforation
CT scan with contrast
Earliest lesion characteristic of Crohn’s disease?
Aphthous ulcer
The area of colon most susceptible to ischemia
Splenic flexure (Griffith’s point)
The transition point between columnar rectal mucosa and squamous anoderm
Dentate line/ Pectinate line
Predominant bacterial isolate in the colon
Anaerobes
A 62 year old man presents to the ER with a 1-week history of left lower quadrant abdominal pain and diarrhea. He complains of increased pain, nausea, vomiting and fever. He has had two prior episodes of similar left lower quadrant pain that resolved with antibiotic treatment alone. He has no cardiac or pulmonary risk factors. On examination, his blood pressure is 140/180, heart rate 100/min and temperature 37C. His abdomen is soft and mildly distended with left lower quadrant tenderness to palpation. He does not have evidence of generalized peritonitis. His write blood cell count is 20,000/mm3. How would you confirm the diagnosis?
Whole abdominal CT scan
Most common site of diverticulitis
Sigmoid colon
The safest procedure to perform on unstable patients with St. IV diverticulitis
Sigmoid colectomy with end colostomy
Most common complication of colostomy
Parastomal hernia
A “lead pipe” colon is characteristic of?
Advanced ulcerative colitis
Surgical procedure of choice for chronic ulcerative colitis
Restorative pronto elections with ideal-pouch anastomosis
Poplyposis syndrome with melanin spots on lips and buccal mucosa
Puts-Jeghers Syndrome
Colorectal carcinomas most commonly metastasize to the?
Liver
First line of treatment for anal epidermoid carcinoma?
Chemo-radiotherapy
Primary peritonitis is diagnosed by?
Peritoneal aspiration GSCS
At open operation a normal appendix is found. What is the most common procedure a surgeon should do if he finds a normal appendix
Removal of appendix
Most common cause of appendicitis in children
Lymphoid hyperplasia
The most accurate way of diagnosing acute appendicitis
None.
History and PE must be at least 85% accurate
CT scan and ultrasound
The single most sensitive test of liver function
INR/FVII/F5 - coagulation function
Vitamin K is most effective in what type of jaundice?
Post-hepatic cause (obstructive)
Rare cause of post-sinusoidal cirrhosis due to hepatic vein thrombosis?
Budd Chiari Syndrome
A 42 year old woman with a known history of esophageal varices secondary to hepatitis and cirrhosis is admitted with severe hematemesis from esophageal varices. Bleeding persists after pitressin therapy. What would the next step in management involve?
Transjugular intrahepatic portasystemic shunt ( TIPS)
The risk of first variceal bleeding is best prevented by?
B-blockers
The most critical treatment of acute variceal bleeding
Prompt endoscopic intervention
Selective shunt that is contraindicated in patients with as cites
Distal splenorenal shunt (Warren Shunt)
A 43 year old woman prevents with a sudden onset of abdominal pain. She denies abdominal complaints. Her systolic blood pressure is 88mmHg on evaluation and becomes stable at 120mmHg after the infusion of 2 L of intravenous fluid. The abdominal examination demonstrates no peritoneal signs. Her bowel sounds are hypoactive and there is mild right upper quadrant tenderness. The hematocrit value is 22%. A computed tomography (CT) scan is performed and demonstrates free intraabdominal blood and a 5-cm solid mass in the right hepatic lobe with evidence of recent bleeding into the mass. The patient denies recent trauma, weight loss, a change in bowel habits, hematemesis, or hematochezia. No prior history of oral contraceptive pills intake. What is the most likely diagnosis
Liver hematoma with hemorrhage
Most common benign tumor of the liver
Simple hepatic cyst
Benign solid liver tumor associated with a central scar
Focal modular hyperplasia (FNH)
Hepatocellular cancer variant with the best prognosis
Fibrolamellar variant
Recommended treatment for solitary pyogenic liver abscesses
Percutaneous drainage
Maximum amount of diseased liver that can be resected
60%
Initial imaging modality of choice in patients with biliary tract disease
Ultrasound
Gallstones that occurs in patients with cirrhosis/hemolytic disorders
Black pigment stones
Most common indication for cholecystectomy
Recurrent biliary colic
A 46 year old woman presents with a 5-hour history of abdominal pain that began approximately 1 hour after a large dinner. The pain initially began as dull ache in the epigastrium but then localized in the RUQ. She describes some nausea but no vomiting. Since her presentation to the emergency department, the pain has improved significantly to the point of her being nearly pain free. She describes having had similar pain in the past with all previous episodes being self-limited. Her past medical history is significant for type II diabetes mellitus. On physical examination, her temperature is 38C, and the rest of her vital signs are normal. The abdomen is non distended with minimal tenderness in the RUQ. Findings from liver examination appear normal. The rectal and pelvic examinations reveal no abnormalities. Her CBC reveals a WBC count of 13,000 serum chemistry studies demonstrate total bilirubin 0.8 mg/dL, direct bilirubin 0.6mg/dL, alkaline phosphatase 100 UIL, AST 45 UIL, and ALT 30 U/L. Ultrasonography of the RUQ demonstrates stones in the gallbladder, a thickened gallbladder wall, and a common bile duct diameter of 4.0 mm. What should you tell the patient?
She should be scheduled for an elective laparoscopic cholecystectomy
Gold standard in the diagnosis of choledocholithiasis?
ERCP
A CBD stone diagnosed 1 year after cholecystectomy is classified as?
Retained stone
Initial treatment of patients with cholangitis
IV antibiotics and fluid resuscitation (85% response)
Elective decompression
Most dreaded complication of laparoscopic cholecystectomy
CBD injury
Surgical management of choice for acute acalculous cholecystitis
Percutaneous US/CT guided cholecystostomy
Cholangiocarcinoma most commonly involves
Hepatic duct bifurcation “Klatskin tumor”
Most common cause of acute pancreatitis worldwide
Gallstones
Most specific serum marker for acute pancreatitis
Serum lipase
Gold standard test for the assessment of severity of acute pancreatitis
CT scan with contrast
Most common cause of death in acute pancreatitis
Infection
Most common cause of chronic pancreatitis
Alcohol consumption and abuse
Most common complication of chronic pancreatitis
Pseudocyst
Most commonly mutated gene in pancreatic adenocarcinoma
K-ras
A palpable nontender gallbladder seen in patients with peri-ampullary tumor?
Courvossier’s gallbladder
The current diagnostic and staging test of choice for pancreatic cancer?
Spiral CT scan with contrast
Etiology for the severe pain experienced by patients with pancreatic cancer
Invasion of retroperitoneal nerve
Drug used for palliative treatment of advanced pancreatic cancer
Gemcitabine
Most dreaded complication of Whipple’s procedure
Disruption of the pancreatic-jejunostomy
Most common pancreatic endocrine neoplasm
Insulinoma
Endocrine tumor of the pancreas with necrolytic migratory erythema
Glucagonoma
Most common islet cell tumor after insulinoma
Non functioning Islet-cell tumor
Most common anomaly of the spleen
Accessory spleen
The process by which the spleen removes intracellular substances
Pitting
The most common indication for splenectomy
Trauma
Test that will distinguish auto-immune from other hemolytic anemias
(+) direct Coombs tests
Gold standard in the diagnosis of GERD?
24 hour pH monitoring
Surgical treatment of choice for ACHALASIA?
Heller’s myotomy +/- partial fundoplication
A 48 year old man presents for evaluation of burning epigastric and substernal pain that has recurred almost daily for the past 4 months. He says that these symptoms seem to be worse when he lies down and after meals. He denies difficulty swallowing or weight loss. The patient has been taking a proton pump inhibitor regularly over the past 12 weeks with partial resolution of his symptoms. His past medical history is significant for frequent early morning wheezing and hoarseness that have been present for the past few months. The patient has no other known medical problems and he has had no prior surgeries. He consumes alcohol occasionally but does not use tobacco. On examination, he is moderately obese. No abnormalities are identified on the cardiopulmonary or abdominal examination. What is the most likely diagnosis?
Barrett’s esophagus
A 43 year old man presents to the ER with severe abdominal pain and substernal chest pain. The symptoms began 12 hours earlier after he consumed a large amount of alcohol. Subsequently, he vomited several times and then went to sleep. A short time thereafter, he was awakened with severe pain in the upper abdomen and substernal area. On PE, the patient appears uncomfortable and anxious. His temperature is 38.8C, Pr 120 b/min, BP 126/80 and RR 36/min. The lungs are clear bilaterally with decreased breath sounds on the left side. The cardiac examination reveals tachycardia and no murmurs. The abdomen is tender to palpitation in the epigastric region, with involuntary guarding. Laboratory studies reveal that his WBC is 26,000 and that his Hgb, Hct, and electrolyte levels are normal. The serum amylase, Bilirubin, AST, ALT, and alkaline phosphatase values are within normal limits. A 12-lead ECF shoes sinus tachycardia. His chest radiograph reveals moderate left pleural effusion, a left pneumothorax, and pneumomediastinum. What is the most likely diagnosis?
Boerhaave’s syndrome
The highest perforation rate after a caustic esophageal injury occurs during?
Ulceration and granulation phase
