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Surgery 3 Flashcards

1
Q

3 risk factors for emphysematous cholecystitis?

A

DM
Vascular compromise (obstruction or stenosis of the cystic artery)
Immunosuppression
Gallstones

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2
Q

Presentation of emphysematous cholecystitis?

A

Fever, RUQ pain, N/V

Crepitus in abdominal wall adjacent to gallbladder

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3
Q

Dx emphysematous cholecystitis?

A

Confirmed with imaging demonstrating air-fluid levels in gallbladder, gas in gallbladder wall, occasional pneumobilia (air in hepatobiliary system)

Cultures with gas-forming Clostridium, E. coli

Unconjugated hyperbilirubinemia, mildly elevated aminotransferases

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4
Q

Rx emphysematous cholecystitis?

A

Emergent cholecystectomy

Broad-spectrum IV ABX with Clostridium coverage (eg, amp-sulbactam)

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5
Q

How does the presentation of acute cholangitis differ from emphysematous cholecystitis?

A

Both will have high fever and RUQ pain, but would expect jaundice and significant elevations in alk phos and conjugated bilirubin + imaging with bile duct dilation

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6
Q

What is gallstone ileus?

A

Intestinal obstruction due to a gallstone that has passed through a biliary-enteric fistula

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7
Q

How are hip fractures classified?

A
  1. Anatomic location
  2. Fracture type

Intracapsular (eg, femoral neck and head) vs. extracapsular (eg, intertrochanteric, subtrochanteric)

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8
Q

Which type of hip fracture has a higher change of avascular necrosis? Which type of hip fracture has a greater need for implant devices?

A

AVN - intracapsular fractures

Implant - extracapsular

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9
Q

In general, surgical repair should be done as soon as feasible to relieve pain, minimize complications, and reduce length of hospital stay. However, surgery may be delayed up to 72 hours in what situation?

A

To address unstable medical comorbidity

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10
Q

Appearance of meningioma on MRI?

A

Extra-axial well-circumscribed or round homogenously enhancing dural-based mass

Usually calcified, can appear hyperdense on non-contrast head CT

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11
Q

Presentation of meningiomas?

A

Benign primary brain tumors arising from meningothelial cells

More common in middle-age to elderly women

Significant neuro symptoms (mass effect)

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12
Q

Dx and Rx meningiomas?

A

Confirm dx intraoperatively

Rx of choice in symptomatic patients - complete resection (cure in most individuals)

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13
Q

When should chemotherapy be considered for brain tumors?

A

Not first-line treatment for meningioma

May be coupled with surgical resection and radiation in patients with highly malignant primary brain tumors (glioblastoma multiforme, medulloblastoma, etc.); consider in patients with highly chemosensitive metastatic brain disease (testicular germ cell tumor)

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14
Q

Appearance of brain mets on imaging?

A

Multipel ring-enhancing lesions at the gray-white junction (intra-axial)

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15
Q

Causes of esophageal perforation?

A

Spontaneous rupture (Boerhaave syndrome)
Instrumentation (endoscopcy, etc.)
Esophagitis (infectious, pills, caustic, etc.)
Esophageal ulcer

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16
Q

Presentation of esophageal perforation?

A 
Chest and abdominal pain (retrosternal), systemic findings (eg, fever)
Subcutaneous emphysema in the neck
Hamman sign (crunching sound on chest auscultation)
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17
Q

Dx esophageal perforation?

A

CXR or CT - wide mediastinum, pneumomediastinum, pneumothroax, air around paraspinal muscles, pleural effusion (late)

CT - esophageal wall thickening, mediastinal air fluid level

Water-soluble contrast esophagogram - leak at perforation site

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18
Q

Management of esophageal perforation?

A

ABX and supportive care for all patients (make patient NPO, IV PPIs, broad-spectrum ABX, nutrition, surgical drainage and debridement of infected or necrotic areas)

Surgical repair for significant leakage with systemic inflammation response

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19
Q

Presentation of Mallory-Weiss tear?

A

Incomplete mucosal tear at the gastroesophageal junction, usually due to protracted vomiting; it frequently presents with self-limited hematemesis without pneumomediastinum

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20
Q

What is the most common complication of thyroidectomy and why?

A

Hypocalcemia 2/2 hypoparathyroidism

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21
Q

Presentation of hypocalcemia?

A

Can be asymptomatic (found incidentally)
Non-specific symptoms (fatigue, anxiety, depression)
Involuntary contractions (tetany) involving the lips, face, and extremities ,and seizures
EKG with QT prolongation

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22
Q

Persistent hypothyroidism can be seen post-thyroidectomy and can cause ___ without thyroid hormone supplementation.

A

Hyponatremia

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23
Q

What is the sphincter of Oddi?

A

Muscular valve controlling the flow of bile and pancreatic juice into the duodenum

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24
Q

Sphincter of Oddi dysfunction can develop following any inflammatory process. It encompasses 2 separate physiologic entities - what are they?

A

Dyskinesia and stenosis of the sphincter of Oddi

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25
Q

Cause and presentation of sphincter of Oddi dysfunction?

A

Obstruction of flow through the sphincter may result in retention of bile, causing a functional biliary disorder that mimics a structural lesion

Recurrent episodic pain in the RUQ or epigastric region with corresponding aminotransferase and alk phos elevations

Visualization of a dilated common bile duct in the absence of stones

Opioid analgesics may cause sphincter contraction and precipitate symptoms

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26
Q

Dx and Rx Sphincter of Oddi dysfunction?

A

Gold standard Dx - SOD manometry

Rx of choice - sphincterotomy

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27
Q

What organisms are responsible for most deep infections following puncture wounds?

A

S. aureus
P. aeruginosa (particularly prevalent after puncture wounds through the sole of a shoe as the warm, moist environment is quite hospitable to this microorganism

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28
Q

Radiographs are usually required to evaluate for underlying osteomyelitis when deep-penetrating injuries occur; however, bone changes consistent with osteomyelitis often take ___ weeks to form.

A

2+

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29
Q

Management of osteomyelitis following a puncture wound?

A

BCx
Bone biopsy with culture
Rx with IV ABX and surgical debridement

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30
Q

What is Peyronie disease and what is the pathophysiology?

A

Common condition affecting ~5% of men that arises due to repetitive blunt trauma to the penis during sexual intercourse with subsequent aberrant wound healing

Characterized by the formation of fibrous plaques (2/2 TGF-1 upregulation) in the tunica albuginea, which reduces tissue elasticity and expansion during erections

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31
Q

Presentation of PYeronie disease?

A

Dorsal penile plaque
Pain/curvature with erection
Penile pain

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32
Q

Dx Peyronie disease?

A

Most diagnosed clinically, but U/S is sometimes necessary

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33
Q

Rx Peyronie disease?

A

Pain and deformity resolve spontaneously over 1-2 years in many people

Those with ctive or progressive PD often require NSAIDs for pain, pentoxifylline to reduce fibrosis, and/or intralesional injections of collagenase

Surgery in refractory cases

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34
Q

Presentation - clusters of small painless pink or skin-colored papules on the genitals?

A

Genital warts (condyloma acuminata)

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35
Q

Presentation - painless erythematous plaque on the penil shaft?

A

Bowen disease (cutaneous SqCC in situ), may progress to penile cancer

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36
Q

Presentation - painless genital ulcer?

A

Primary syphilis

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37
Q

Presentation of type 2 HIT?

A

Suspected with heparin exposure >5 days AND any of the following:

Platelet count reduction >50% from baseline
Arterial or venous thrombosis
Necrotic skin lesions at heparin injection sites
Acute systemic (anaphylactoid) reactions after heparin

38
Q

Dx type 2 HIT?

A

Serotonin release assay (gold standard confirmatory test)

Start treatment in suspected cases PRIOR to confirmation tests

39
Q

Rx type 2 HIT?

A

Stop ALL heparin products

Start a direct thrombin inhibitor (eg, argatroban) or fondaparinux (synthetic pentasaccharide)

40
Q

What are the complications of HIT?

A

Venous and arterial thrombotic risk is significant (as high as 50% in untreated HIT)

Thrombocytopenia (mild to moderate), minimal bleeding risk

41
Q

When is warfarin the setting of HIT?

A

Anticoagulation maintenance, but only after the patient has received another anticoagulant and the platelet count is >150,000

42
Q

Why is initial treatment with warfarin contraindicated in patients with HIT?

A

It rapidly lowers protein C levels, which may transiently increase the risk of thrombus

43
Q

Discuss how TPN or prolonged fasting may lead to gallbladder stasis.

A

Presence of proteins and fatty acids in the duodenum acts as a stimulus for release of CCK, which in turn stimulates the contraction of the gallbladder; patients on TPN or prolonged fasting do not have this normal stimulus

Small bowel resection also contributes due to decreased enterohepatic circulation of bile acids resulting in altered hepatic bile composition (supersaturated with cholesterol)

44
Q

What is the mechanism for the development of cholesterol gallstones during pregnancy and in women taking OCs?

A

Estrogen-induced increase in cholesterol secretion

During pregnancy, progesterone also reduces bile acid secretion and slows gallbladder emptying

45
Q

Initial medical and surgical management of perforated peptic ulcer?

A

NG suction, IV fluids, broad-spectrum ABX, IV PPIs

Urgent ex lap

46
Q

If CXR does not confirm suspected perforated viscus, what should be done?

A

CT scan of the abdomen with water-soluble oral contrast

47
Q

Gold standard for evaluating mesenteric ischemia?

A

Mesenteric angiography

48
Q

Diverticulosis is characterized by what pathologic features?

A

Herniation of the colonic mucosa/submucosa through the circular and longitudinal muscle layer due to elevated intraluminal pressure

49
Q

Risk factors for diverticulosis?

A

Obesity, poor diet (lower fiber, high meat), and tobacco use

50
Q

Common symptoms of compartment syndrome?

A

Pain out of proportion to injury
Pain increased on passive stretch
Rapidly increasing and tense swelling
Paresthesia (early)

51
Q

Uncommon symptoms of compartment syndrome?

A

Decreased sensation
Motor weakness (within hours)
Paralysis (late)
Decreased distal pulses (uncommon)

52
Q

Causes of compartment syndrome?

A

Most common following traumatic injuries or prolonged compression of an extremity

Also occur following reperfusion of an acutely ischemic limb due to interstitial edema and possibly intracellular swelling

53
Q

Dx compartment syndrome?

A

Measure compartment pressures with needle manometry

Delta pressure (diastolic BP - compartment pressure) of 30 mm Hg or less is strongly suggestive

54
Q

Definitive management of compartment syndrome

A

Urgent fasciotomy

55
Q

Indications for urology consult in the setting of symptomatic ureteral stone?

A
  1. Urosepsis
  2. Acute renal failure
  3. Complete obstruction
  4. Stone 10+ mm
  5. Uncontrolled pain
  6. No stone passage in 4-6 weeks
56
Q

Medical management of ureteral stones <10 mm?

A

Hydration
Pain control (NSAIDs preferred over opioids)
Antiemetics (metoclopramide, etc.)
Alpha blockers (tamsulosin, etc.) can facilitate passage
Strain the urine to recover the stone and confirm passage

57
Q

Causes of Mallory-Weiss tear?

A

Sudden increas ein abdominal pressure (eg, forceful retching)
Mucosal tear in the esophagus or stomach (sub-mucosal arterial or venous plexus bleeding)
Risk factors - hiatal hernia, alcohol use

58
Q

Clinical presentation of MW tear?

A

Vomiting, retching
Hematemesis
Epigastric pain

59
Q

Dx Mallory-Weiss tear?

A

Longitudinal laceration on endoscopy

60
Q

Rx MW tear?

A

Most heal spontaneously (90%)

Endoscopic therapy for persistent bleeding (electrocoagulation or local injection or epinephrine)

61
Q

What is hidradenitis suppurativa?

A

Chronic inflammatory occlusion of folliculopilosebaceous units that prevents keratinocytes from properly shedding from the follicular epithelium; most common in intertriginous areas

62
Q

Risk factors for hidradenitis suppurativa?

A 
Family history of HS
Smoking
Obesity
DM
Mechanical stress on the skin
63
Q

Presentation of HS?

A

Solitary, painful, inflamed nodules that can last for several days to months; may regress or progress to abscesses that open to the surface with purulent or serosanginuous drainage

Chronic relapsing course

64
Q

Complications of HS?

A

Sinus tracts, comedones, scarring (severe scarring can lead to dense, rope-like bands in the skin with strictures and lymphedema)

65
Q

Dx HS?

A

Clinical

66
Q

What type of lymph nodes are always suspicious for cancer?

A

Hard, unilateral, non-tender lymph nodes

67
Q

What are two fo the most common solid organ injuries 2/2 blunt abdominal trauma?

A

Liver

Spleen

68
Q

Common manifestations of hepatic laceration?

A

Hypotension
Free intraperitoneal fluid
RUQ pain and bruising
R shoulder pain due to phrenic nerve irritation

69
Q

Presentation of peritonsillar abscess (aka quinsy)?

A

Fever
Pharyngeal pain/sore trhoat/difficulty swallowing
Trismus
Muffled “hot potato” oice
Uvula deviation away from enlarged tonsil
Saliva pooling
Earache

70
Q

Rx peritonsillar abscess?

A

Needle aspiration
I&D
ABX coverage of GAS and respiratory anaerobes

71
Q

Why are cat bites much more likely to cause serious infection than dog or human bites? What bacteria are typically involved?

A

Cats have long, sharp teeth that can inoculate oral flora deep into skin, reaching soft-tissue structures;

Pasteurella multocida (GN coccobacilli)
Anaerobic bacteria
72
Q

Management of cat bites?

A
  1. Copious irrigation and cleaning
  2. Prophylactic amox/clav (amox - P. multocida, clav - oral anaerobes)
  3. Tetanus booster as indicated
  4. Avoid closure
73
Q

Presentation of Zenker’s diverticulum?

A

Most common in elderly patients, especially men
Occurs in the posterior lower cervical esophagus near the cricopharyngeus muscle
Dysphagia, regurgitation
Halitosis 2/2 pooling of material in the diverticulum; if large, may e palpable

74
Q

Patients with ZD are at risk for ___.

A

Aspiration pneumonia

75
Q

Dx ZD?

A

Contrast esophagram

76
Q

Rx ZD?

A

Surgical repair

77
Q

Presentation of varicocele?

A

Soft scrotal mass (bag of worms) that decreases in supine positions and increases with standing/Valsalva maneuvers
Subfertility
Testicular atrophy

78
Q

Why is the left testis frequently affected by varicocele?

A

Drainage of the L spermatic (gonadal) vein into the L renal vein, which is subject to compression between the superior mesenteric artery and aorta

79
Q

Dx varicocele?

A

Clinically; U/S - retrograde venous flow, tortuous, anechoic tubules adjacent to testis, dilation of pampiniform plexus veins

80
Q

Why can varicocele cause decreased fertility in males?

A

Mildly increased scrotal temperatures -> testicular atrophy, reduced sperm production, impaired spermatic motility

81
Q

Rx varicocele?

A

Gonadal vein ligation or embolization (boys and young men with testicular atrophy)
Scrotal support and NSAIDs (older men who do not desire additional children)

82
Q

In the setting of suspected variceal hemorrhage, what are the next steps in management?

A
  1. Place 2 large-bore IV catheters.
  2. Volume resuscitation (crystalloid, pRBCs to maintain Hgb 7+) + IV octreotide + ABX + NPO
  3. Urgent endoscopic therapy of esophageal varices.
83
Q

What should be done following urgent endoscopic therapy of esophageal varices in the setting of:

  1. No further bleeding
  2. Continued bleeding
  3. Early rebleeding
A

No further bleeding -> initiate second prophylaxis (beta blocker + endoscopic band ligation 1-2 weeks later)

Continued bleeding -> balloon tamponade (temporary) -> TIPS or shunt surgery

Early rebleeding -> repeat endoscopic therapy -> recurrent hemorrhage -> TIPS or shunt surgery

84
Q

Who would get a contrast angiography rather than upper endoscopy in the setting of variceal bleeding?

A

Not stabilized sufficiently

Upper endoscopy unsuccessful

85
Q

Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggests ___. Name 2 other associated findings.

A

Tracheobronchial rupture; pneumomediastinum, subQ emphysema

86
Q

Most important initial diagnostic study in all stabilized patients following blunt chest trauma?

A

CXR

87
Q

What is most commonly injured in tracheobronchial rupture?

A

R main bronchus

88
Q

Dx and Rx tracheobronchial eprforation?

A

Confirm Dx with high-resolution CT, bronchoscopy, or surgical exploration; operative repair is indicated

89
Q

___ classically causes tachycardia, new bundle branch blocks, or arrhythmia; sternal fracture is commonly associated.

A

Myocardial contusion

90
Q

___ causes cardiac tamponade, which manifests with muffled heart sounds, hypotension, and distended neck veins.

A

Myocardial rupture

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