Surgery Flashcards
How to dx presence of reflux
PH monitoring. Correlation with sxs. In setting of long hx, do endoscopy and bx to look for Barrett esophagus
When to do surgery for GERD
Long standing sx dz that cannot be controlled by medicine. Necessary in anyone with complications like Ulceration and stenosis-> resection. Severe dysplastic-> lap nissen
Pt with crushing pain with swallowing in uncoordinated massive contraction. Solids swallowed with less difficulty than liquids
Motility problems
Dyspjagia worse with liquids. Dx? Tx?
Achalasia. Dx: manometry. Tx: balloon dilatation
Esophageal SCC vs adenocarcinoma
SCC- men with hx of smoking and drinking, esp blacks
Adeno- long standing GERD
But need endoscopy with bx and barium swallow before to prevent inadvertent perf
Gastric andenocarcinoma versus gastric lymphoma tx
Surgery as tx for adenocarcinoma. Tx for lymphoma based on chemo or radiotherapy (do surgery if you fear perforation as tumor melts away)
Maltoma? Tx?
Type of gastric lymphoma. Can be reversed by getting rid of H. Pylori
Presentation for stomach cancer
Adenocarcinoma and lymphoma both have anorexia, wt loss, vague epigastric distress
Sxs of carcinoid syndrome
Small bowel carcinoid with liver mets. Diarrhea, face flushing, wheezing, right sided heart valvular damage
DX of carcinoid syndrome
24 hour urinary collection for 5-hydroxyindoloacetic acid. Whenever syndromes have episodic attacks or spells, offending agent will be in high concentration in blood only at time of attack
Colonic polyps In descending order of prob for malignant degeneration
Familial polyposis, familial multiple inflammatory polyps, villous adenomyosis, adenomyosis polyp: non malignant polyps: juvenile, peutz jeugers, isolated inflammatory, hyperplastic
Causes of c diff
Celhalosporins, clindamycin
Anal fissure tx
Usually in young women. Tx: relax tight sphincter. Stool softener, topical NO, local injection of botulinum, forceful dilatation, lateral internal sphincterotomy. CCB for 6 weeks have an 80-90% success rate
SCC of anus epidemiology and tx
HIV+ men. Tx with NIGRO protocol is 90% effective so usually don’t need surgery
MC cause GI bored
3/4 originate in upper GI tract before lig of Treitz. As age increases, lower GI bleed becomes more common
First steps if BRBPR.
NG tube- aspirate gastric contents. If no blood and fluid is NOT GREEN AND BILE TINGED , do upper GI endoscopy to Check duodenum. Then anoscopy for hemorrhoids.
BRBPR steps after you’ve rules out upper GI source and hemorrhoids.
If >2ml/min: angiogram. If
Blood per rectum in kids MC cause and work up
Meckels diverticulitis. Start with technetium scan looking for ectopic gastric mucosa
Massive upper GI bleeding in stressed multiple trauma or complicated post op pt.
Stress ulcers. Endoscopy to confirm. Tx: angiographic embolization. Try to maintain gastric pH above 4 to avoid.
Severe abdominal pain with blood in lumen of the gut
Ischemic processes
Child with nephrosis and ascites or adult with mild abdomen and equivocal physical findings.
Primary peritonitis. Cultures of ascites fluid will usually show one organism. Tx with antibiotics not surgery.
Alcoholic with upper Acute abdomen. DX? Tx?
Acute pancreatitis. DX: serum or urinary amylase or lipase (12-48 hrs- serum, 3rd-6th day- urinary). CT if not clear. Tx: NPO, NG, IVF
Fat female forty
Biliary tract dz
Sudden onset colicky flank pain radiating to inner thigh and scrotum/labia. Urinary freq and urgency. Microhematuria.
Urethral stones. CT for dx.
Acute abdominal pain in LLQ. Dx? Tx?
Acute diverticulitis. Do CT. Start tx with NPO, IVF, antibx. If that doesn’t help, radiologically guided percutaneous drainage of abscess OR emergency surg.
Surgery for diverticulitis indications?
If medical therapy doesn’t work. If 2 or more attacks.
How to dx sigmoid volvulus
X-rays show air fluid levels in small bowel, very distended bowel, huge air filled loop in RUQ that tapers down to LLQ in shape of parrots beak.
Tx for sigmoid volvulus
Proctosignoidoscopic exam with the old rigid instrument. Recital tube is left in. If recurrent you need elective sigmoid resection
Pt with a fib or recent MI gets an acute abdomen
Mesenteric ischemia- clot lodges in superior mesenteric artery.
Pt with hx colon cancer who gets rising CEA
Mets to liver. Met dz 20x more common than primary liver dz
Pt on birth control win hepatic mass
Hepatic adenoma. Tendency to rupture and bleed in abdomen. Dx: CT. Tx: emergency surgery required
Person with biliary tract dz (ascending cholangitis) gets fever, leukocytosis, and a tender liver)
Dx: sonogram or CT scan for pyogenic liver abscess. Tx: percutaneous drainage
Old pt with acute abdominal pain and blood in bowel lumen. Acidosis and sepsis.
Mesenteric ischemia- old people dont always mount impressive acute abdomen
Pt with cirrhosis and vague RUQ discomfort and wt loss. Ne t steps
Primary hepatoma. Get AFP. CT will show location and extent. Resection if technically possible.
Mexican man with liver mass
Amebic abscess of the liver. Dx: serology but takes weeks so start empiric tx. Tx with MDZ(as opposed to drainage for pyogenic liver abscess).
jaundice with bili 6 all unconjugated with no elevation of direct bili. no bile in urine
hemolytic jaundice. do workup to see what is chewing up RBC
jaundice with elevated direct and indirect bill. elevated transaminases. modest elevation in alk phos.
hepatocellular jaundice. ex: hepatitis.
jaundice with elevated direct/indirect bill, modest transaminitis, very high alk phos.
obstructive jaundice. dx: sono. could see stones in gallbladder. could see malignancy.
malignant obstruction jaundice on sonogram
courvoisier-terrier sign:large, thin walled, distended gallbladder
obese fecund woman in 40s with high alk phos, dilated ducts on soon, and non dilated gallbladder full of stones. dx? tx?
obstructive jaundice. dx: ERCP to get dx do sphincterotomy, remove common duct stone
what happens after you see courvoisier-terrier sign on sono in jaundice
do CT scan. if you see pancreatic cancer, do percutaneous bx. if CT negative, do ERCP (ampullarf cancers and cancers of the common duct can produce obstruction when very small)
causes of malignant obstructive jaundice. which have the best prognosis?
adenocarcinoma of the head of the pancreas, adenocarcinoma of the ampulla of water, or cholangiocarcnoma in the CBD itself. ampullarf cancer and cancer of the lower end of the CBD have better prognosis- 40% cure
malignant obstructive jaundice plus anemia and positive blood in stools
think ampullary cancer (ampulla of vater) can bleed into lumen like any other obstructive malignancy but it can also obstruct bile flow by virtue of its location. first step- endoscopy
how to abort biliary colic
anticholinergics
biliary pain with modest fever, leukocytosis, RUQ peritonitis pain. next steps?
acute cholecystitis. NG suction, NPO, IVF, and antibx to slow down sxs and allow elective cholecystectomy. men and diabetics do not respond.
acute cholecystitis with prohibited surgical risk next steps
emergency percutaneous transhepatic cholecystostomy (drain gallbladder with drain)
pt with high fever, chills, high WBC, some hyperbili, HIGH ALK PHOS. dx? tx?
acute ascending cholangitis. give IV antibx and emergency decompression of CBD by ERCP (or percutaneous through liver). eventual cholecystectomy
pt with mild and transitory sxs of cholangitis AND elevated amylase/lipase
biliary pancreatitis. stones impacted distally in ampulla-> block pancreas and biliary ducts.
tx for biliary pancreatitis
conservative tx (NPO, NG, suction, IVF) and then elective chole. if not, ERCP and sphincterotomy to dislodge impacted stone
acute hemorrhagic pancreatitis sxs
like edematous pancreatitis but with lower hematocrit that lowers even more th next morning. also then the calcium is low, BUN, goes up, metabolic acidosis, and low arterial PO2
tx for acute hemorrhagic pancreatitis
ICU. drain pancreatic abscesses. daily CT scans. IV imipenem or meropenem.
ranson criteria
criteria for acute hemorrhagic pancreatitis. elevated WBC, elevated blood glucose, low serum calcium
necrotic pancreas tx and timing
do necrosectomy but wait at least 4 weeks before debriding dead pancreatic tissue.
pt with pancreatitis and no follow up care gets persistent fever and leukocytosis 10 days later
pancreatic abscess. imaging studies will reveal collection of pus. many are not amenable to percutaneous drainage and will require open drainage or debridement.
5 weeks s/p acute pancreatitis or upper abdominal trauma. pt has early satiety, vague discomfort, deep palpable mass.
pancreatic pseudocyst. collection of pancreatic juice outside pancreatic ducts (usually in lesser sac) which causes pressure sxs. dx: CT or sono.
tx for pancreatic pseudocyst
6cm or >6 weeks: more likely to rupture and bleed->need drainage (percutaneously, surgically into GI tract, endoscopically into stomach)
28 yo woman with large, fast growing mass in breast that is not fixed.
cystosarcoma phyloddes. most are benign but have potential to become malignant sarcomas. need core or excision biopsy (FNA not enough) and removal is mandatory
tx for breast cancer in pregnancy
no radiotherapy during pregnancy and no chemo in first trimester. don’t need to terminate pregnancy.
which breast cancer has worse prognosis than DCIS.
inflamamtory cancer. needs pre-op chemo.
where does DCIS like to metastasize to
TRICK! it can’t metastasize. but it does have very high incidence of recurrence if only local excision is done.
tx for DCIS with multicentric foci throughout breast
recommend total simple mastectomy for multi centric lesions thought the breast and even add in sentinel node bx in those.
tx for DCIS confined to 1/4 of breast
lumpectomy followed by radiation
what makes breast cancer inoperable? what do you do?
based on local extent, not mets. tx with chemo +/- radiation which might make it operable.
adjuvant systemic therapy for breast cancer
should follow surgery in all pts, especially if axially does are positive. usually chemo and hormonal if applicable. premenopausal women get tamoxifen. postmenopausal women get anastrozole.
frail old women s/p resection of not too aggressive breast cancer
hormonal therapy alone as adjuvant systemic therapy.
favorite met of breast cancer
vertebral pedicles in the spine
workup for cushing
low dose dexamethasone suppression test. If no suppression, do 24 hour urine free cortisol. if elevated, do high dose suppression test. if suppressed: pituitary adenoma. if not suppressed: adrenal adenoma or paraneoplastic syndrome.
pt with virulent peptic ulcer dz, resistant to all usual therapy (including eradication of H pylori) and more extensive than it should be. +/- watery diarrhea.
zollinger ellison syndrome. measure gastrin and do secretin test if values are equivocal. locate tumor with CT scan (with contrast). tx: remove tumor. omprazole helps with metastatic dz.
insulinoma lab values
high insulin and high C peptide
nesidioblastosis
devastating hyper secretion of insulin in the newborn, 95% needing pancreatectomy
pt with mild diabetes, bad rash, bit of anemia, glossitis, stomatitis
glucagonoma. rash is severe migratory necrolytic dermatitis. dx: glucagon assay. CT scan to locate tumor. Dx: resection. if metastatic inoperable disease, use somatostatin and streptozocin.
hypertensive hypokalemia female not on any diuretics
primary hyperaldosteronism. high aldo, low renin. hyperplasia has appropriate responses to postural changes and tx is medical. adenoma does not respond to postural changes and tx is surgical removal after adrenal CT scans localize it.
four causes of surgical HTN
primary hyperaldo (adeno or hyperplasia), pheochromocytoma, coarctation of the aorta, renovascular HTN (fibromuscular dysplasia or arteriosclerotic occlusive dz)
if pt has c spine injury and noisy gurgly breath
secure airway before dealing with c spine injury
how is airway most commonly inserted
orotracheal intubation under direct vision with a laryngoscope, assisted in the awake patient with help of topical anesthesia
how is airway inserted in c spine injury
can still do orotracheal intubation if head is secured and not moved. or- use nasotracheal intubation over a fiber optic bronchoscope
how to secure airway if there is subcutaneous emphysema in the neck
this is a sign of major traumatic disruption of the tracheobronchial tree. you must use fiberoptic bronchoscope. if there is laryngospasm, maxillofacial injury, etc, you may need to do a cricothyrotomy.
pt has SBP
shock. MC= hypovolemic hemorrhgaic. also trauma to chest can cause paricardial tamponade or tension pneumothorax.
CVP in various kinds of shock
low in hemorrhagic bc veins are empty. high in pericardial tamponade and tension pneumothorax- big distended neck veins. high in cariogenic shock.
shock with big distended neck veins and respiratory distress with no lung sounds on one side/hyperressonant and mediastinum displaced to one side. dx? tx?
tension pneumothorax. do not wait for X-ray or blood gases! start with with big needle of big IV catheter into affected pleural space. then can chest tube connected to underwater seal (both inserted high in anterior chest wall)
shock with big distended neck veins and no respiratory distress. tx?
pericardial tamponade. DO not order xrays- get sonogram if dx not clear. tx: prompt evacuation of pericardial sac ((pericardiocentesis, tube, pericardial window, open thoracotomy). while setting up, glue and blood admisinitration
tx of hemorrhagic shock in non urban settin.
volume replacement before surgery to stop bleeding (unlike trauma center). 2L Ringer lactate (without sugar) follow by PRBC) until urinary output reaches 0.5 to 2 ml/kg/hr. do not exceed CVP of 15 mm Hg.
pt with shock is flushed and pink and warm with low CVP. tx?
vasomotor shcok- anaphylaxis and high spinal cord transection or high spinal anesthetic. give pharm tx to restore peripheral resistance.
pt with linear scull fx tx
if closed (no overlying wound)- livelong. if open- need wound closure. if comminuted (fragmented) or depressed-> go to OR.
person with head trauma and LOC. next step?
get head CT to look for ICH. if negative and neurologically intact, go home and have family wake them up frequently to make sure they are not going into a coma.
pt with raccoon eyes, rhinorrhea, otorrhea, or ecchymosis behind ear
base of skull fracture. very severe head injury- assess C spine with CT. avoid endotracheal intubation.
neurologic damage from trauma? tx?
- initial blow-no tx
- hematoma that displaces midline structures- surgery
- later development of increased ICP- medical treatment to prevent/minimize
pt hits head-> LOC-> lucid interval-> gradual lapsing into coma-> fixed dilated pupil-> contralateral hemiparesis with decerebrate posture. dx? tx?
acute epidural hematoma. CT shows biconvex lens shaped hematoma. tx: emergency craniotomy= dramatic cure.
pt hits head-> LOC-> gradual lapsing into coma-> fixed dilated pupil-> contralateral hemiparesis with decerebrate posture. dx? tx?
acute subdural hematoma- like epidural hematoma but more severe, w/o lucid interval. CT shows semilunar crescent shaped hematoma. tx: emergency craniotomy if shift in midline structures but prognosis is bad. no deviation- medical therapy to prevent further damage from increased ICP.
how to prevent increased ICP in head injury
elevate head, hyperventilate (goal of PCO2 of 35), avoid fluid overload, give mannitol or furosemide. sedation to decrease brain activity and oxygen demand. also do hypothermia to reduce O2 demand.
head injury pt with CT scan that shows diffuse blurring of the gray white interface and multiple small punctate hemorrhages. tx?
diffuse axonal injury. w/o hematoma, don’t need surgery. tx: prevent further damage from increased ICP
pt with head injury and hypovolemic shock
trick! hypovolemic shock can’t happen from intracranial bleed bc not enough space in head. look for another source of bleeding.
severe alcoholic has several weeks of deterioration of mental function. dx? tx?
chronic subdural hematoma (also in very old). shrunken brain is rattled around head by minor injuries-> tear venous sinuses. hematoma forms and mental function slowly deteriorates. dx: CT. Tx: surgical evacuation-> dramatic cure
pt with stab to neck. when should you do surgical exploration?
expanding hematoma, deteriorating vital signs, clear signs of esophageal or tracheal injury (coughing or spitting up blood). if asx pt-> can safely observe
next steps for gunshot wound to upper neck
arteriographic diagnosis and management
next steps for gunshot wound to base of neck
arteriography, esophogram (water soluble, followed by barium if negative), esophogoscopy, bronchoscopy before surgery
pt with paralysis and loss of proprioception distal to injury on one side, and loss of pain perception distal to injury on the other side
hemisection- brown sequard - typically from clean cut injury
paint with loss of motor function and loss of pain and temperature sensation on both sides distal to injury. preservation of vibratory and positional sense
anterior cord syndrome. typically seen in burst fractures of the vertebral bodies.
elderly person after rear end collision. paralysis and burning pain in the upper extremities. preservation of most functions in LEs.
central cord syndrome. occurs in elderly with forced hyperextension of neck.
management of spinal cord injuries
dx is best done with MRI. CT is easier to do if we just have the bone. some feel that high dose corticosteroids immediately after the surgery might help.
rib fracture in elderly person. should you be worried?
yes! pain-> hypoventilation-> atelectasis-> PNA. treat with local nerve block and epidural catheter.
pentrating trauma-> broken rib-> moderate SOB, one side of thorax has no breath sounds and is HYPER resonant to percussion. next steps?
plain pneumothorax. get CXR,place chest tube (upper anterior), and connect to underwater seal
penetrating trauma-> moderate SOB, one side of thorax has no breath sounds and is DULL to percussion. next steps?
hemothorax. CXR. place chest tube low to evacuate blood and prevent empyema.
in hemothorax, how do you stop bleeding?
lung is usual blood source. it is low pressure system. it will usually stop by itself. in rare cases, a systemic vessel (intercostal artery) is bleeding. then you need a thoracotomy.
hemothorax from systemic vessel rupture. how do you know when to do surgery?
1500mL or more when chest tube is inserted. OR collecting >600mL in tube drainage over the ensuing 6 hours.
pt has severe blunt trauma to chest. how to measure for hidden injuries?
pulm contusion: get blood gases and CXR. myocardial contusion: get EKG and troponin. seek out traumatic transection of the aorta
flap that sucks air with inspiration and closes with expiration.
sucking chest wound. untreated-> deadly tension pneumothorax. first aid is with occlusive dressing that allows air out (taped on 3 sides) but not in.
person after trauma with paradoxical breathing. what is real thing you’re worried about?
flail chest from multiple chest fractures. real prob= underlying pulmonary contusion.
how to treat pulmonary contusion
contused lung is very sensitive to fluid overload- thus tx is to fluid restrict and use diuretics. monitor blood gases for pulmonary dysfunction. if respiratory needed- b/l chest tubes are advisable to prevent a tension pneumothorax from developing.
pt 48 hours after trauma with deteriorating blood gases and white out of the lungs on CXR.
pulmonary contusion. can also happen right after trauma.
pt with sternal fracture. concern? how to monitor?
myocardial contusion. EKG and troponin. tx: focus on complications like arrythmias
pt with bowel in chest.
dx by physical exam and X-rays. traumatic rupture of the diaphragm. always on the left side! evaluate all suspicious cases with laparoscopy. surgical repair is done from the abdomen.
how does traumatic rupture of the aorta present.
hidden injury in severe deceleration injury! big deceleration injury. totally asx until hematoma contained by adventitia blows up and kill the patient.
how to test for traumatic injury of the aorta
noninvasice: TEE, spiral CT scan, MRI angiography. most practical test in trauma test = spiral CT- enhanced by IV dye= CT angio
pt with subcutaneous emphysema in the upper chest and lower neck, or with a large air leak from a chest tube. dx? next steps?
traumatic rupture of trachea or major bronchus. CXR confirms presence of air in the tissues. fiberoptic bronchoscopy identifies the lesion and allows intubation to secure an airway beyond the lesion. surgical repair follows.
ddx of subcutaneous emphysema
rupture of esophagus (usually after endoscopy), tension pneumothorax (usually in setting of shock and respiratory distress)
chest trauma pt intubated and on respiratory has sudden death.
air embolism.
subclavian is exposed to air and then sudden death
air embolism
CVP lines become disconnected-> sudden collapse and cardiac arrest
air embolism
tx and prevention of air embolism
cardiac massage w/pt positioned left side down. prevention= trendelenberg position when the great veins at the base of the neck are about the be entered
pt with multiple trauma to long bones-> petechial rashes in the axillae and neck, fever, tacky, low plt count. hypoxemia and b/l patchy infiltrates on CXR. tx?
fat embolism. respiratory support. precise dx of fat droplets in urine is not needed. DISPROVEN: heparin, steroids, alcohol, LMW dextran.
initial treatment for SBO
NG, NOP, IVF in hopes that it will spontaneously resolve if that doesnt work, try surgery.
68 year old man has 3 large bowel movements with dark red blood. NG tube is placed and showed clear green fluid without blood. where is bleed?
distal to the ligament of treitz (duodenum, jejunum, and duodenojejunal flexure). The entire upper GI (tip of nose to ligament of treitz) has been excluded. no need to do upper GI endoscopy now.
68 year old man has 3 large bowel movements with dark red blood. NG tube is placed and showed white fluid without blood. where is bleed?
the territory from the tip of the nose to the pylorus has been excluded, but the duodenum is still a potential source
32 yo woman in second month of pre has infiltrating ductal carcinoma. tx?
appropriate surgical excision now, derring other therapeutic modalities. no chemo in first TM and no radiotherapy at all during preg.
53 year old woman who gets regular mammograms notices a lump on self exam which is movable within the breast. she is due for another mammo in 3 months. next steps?
do mammographically or monographically guided core biopsies
66 year old woman picks up a bag of groceries and her arm snaps broken at the middle of her humerus. we are probably dealing with
metastatic osteolytic bone cancer. X-rays, CT, MRI is h best. sometimes present with pain and sometimes present with pathological fracture by event that would not justify it.
55 yo old HIV positive man has a fun gating mass growing out of the anus and rock hard enlarged lymph nodes on both groins. for the past 6 months he has noticed blood on the toilet paper and coating the outside of the stools. he has lost wt and looks emaciated and ill. he probably has.
SCC of the anus. HIV+ men who has anal sex. fungating mass out of anus and metastatic inguinal nodes felt. dx with bx. TX= NIGRO CHEMORADIATION PROTOCOL, followed by surgery if there is a residual tumor. 5 week chemoradiation protocol has a 90% success rate, so surgery is rarely required.
44 year old woman is recovering from acute ascending cholangitis. she develops fever and leukocytosis with some RUQ tenderness. minimal elevation of the LFTs, and a sonogram shows a normal size biliary duct and a liver abscess 8 cm in diameter. therapy?
percutaenous drainage of liver abscess. it is a pyogenic liver abscess, which is a complication of biliary tract disease, particularly acute ascending cholagnitis.
62 yo woman with 4cm mass just under nipple and areola of small breast that covers most of breast though is easily movable from the chest wall. radiologically guided core bx have diagnosed infiltrating ductal carcinoma. therapy?
modified radical mastectomy and sentinel node axillary sampling. another option would be lumpectomy plus axillary sampling, but only can be offered when tumor is small in a large breast.
in prep for surgery, a pt has spinal anesthetic placed. his level of sensory block turns out to be much higher than intended. shortly afterwards, his BP-> 75/20, he looks warm and flushed, and his CVP is near 0. next steps?
vasomotor shock from high spinal anesthetic (also from high spinal cord transection or high spinal anesthetic). pharm tx to restore peripheral resistance and additional fluids.
62 year old man noncompliant with meds for GERD for years now has peptic esophagitis, barrett esophagus, and minimal dysplastic changes. next steps?
lap nissen fundoplication. surgery for GERD is necessary in anyone with complications like ulceration or stenosis and it is imperative if there are severe dysplastic changes. for the latter, resection is needed.
