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Clin Specialties - Surgery > Surgery Abdomen Lectures > Flashcards

Surgery Abdomen Lectures Flashcards

1
Q

Clean wound classification

A

uninfected operative wounds in which no viscus is entered, no purulence is encountered, and the wound is closed primarily

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2
Q

Clean contaminated wound classification

A

operative wounds in which a viscus is entered under controlled conditions and without unusual contamination

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3
Q

Contaminated wound classification

A

include wounds in which purulence was encountered during the procedure, wounds from operations with major breaks in sterile technique, or wounds from operations with gross viscus spillage

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4
Q

Dirty wound classification

A

old traumatic wounds which retained devitalized tissue, foreign bodies, or fecal contamination or wounds that involve existing clinical infection or perforated viscus

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5
Q

Which organisms are typical in causing SSI after a clean procedure?

A

skin flora
strep
s. aureus
coagulase-negative staph

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6
Q

What is a common ABX used for a clean case?

A

none or Cephazolin IV or Clindamycin IV

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7
Q

What is a common ABX used for clean contaminated?

A

Laparoscopic cholecystectomy - none or IV cephazolin

Laparoscopic appendectomy: cefazolin or cefoxitin or cefotetan + METRONIDAZOLE

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8
Q

What is a common ABX used for contaminated?

A

cefoxitin, ciprofloxcin, or levofozacin + METRONIDAZOLE
or
clindamycin + gentamicin

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9
Q

When is prophylactic ABX typically given?

A

60 minutes prior to surgery

unless pt has MRSA then give Vanco 120 minutes prior to surgery

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10
Q

What is the most frequent cause of emergent surgery in the US?

A

appendicitis

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11
Q

When is appendicitis most commonly seen?

A

2nd to 3rd decade of life

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12
Q

What is the typical presentation of appendicitis?

A

RLQ pain
anorexia
Nausea (+/- vomiting)

usually low-grade fever (up to 101)

leukocytosis with left shift

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13
Q

What are the imaging modalities for appendicitis?

A

abdomen and pelvis CT with IV and PO contrast
+ if >6mm or fat stranding

U/S - useful in children and those pts with relative contraindications to CT

MRI

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14
Q

What physical exam findings will you see with appendicitis?

A

low grade fever (up to 101)
TTP over McBurney’s point
Peritoneal signs

leukocytosis with left shift

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15
Q

McBurney’s Sign

A

Between umbilicus and ASIS

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16
Q

Rovsing’s Sign

A

When you push down in the LLQ you elicit pain in the RLQ

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17
Q

Psoas sign

A

have the pt extend their leg at the hip against the resistance of my hand on their thigh –ask where they feel pain

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18
Q

Obturator sign

A

Bend their knee and internally rotate the hip

ask where they feel pain

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19
Q

Dunphy’s sign

A

abdominal pain with coughing

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20
Q

What lab findings will you see with appendicitis?

A

Leukocytosis (12-13,000)

any higher worry about gangrene

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21
Q

Meckel’s

A

A congenital diverticulum in the LLQ
a connection between the small bowel and the umbilicus (omphalomesenteric duct)
presents similarly to appendicitis but is on the left side

commonly presents as a young child

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22
Q

Why don’t we do more nonsurgical appendectomies?

A

presence of carcinoid or carcinoma
risk of need for surgery at a later time
prolonged recovery period

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23
Q

Gallstones without symptoms treatment?

A

supportive care and pt education

not an indication for surgery in general

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24
Q

When do you treat asymptomatic gallstones?

A

pts with DM or immunosuppressed

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25
What is cholecystitis?
syndrome of RUQ pain, fever, and leukocytosis associated with gallbladder inflammation (usually related to gallstones) can occur without stones --acalculus cholecystitis
26
How does cholecystitis present?
prolonged, STEADY, severe RUQ or epigastric pain fever leukocytosis w/ bands +/- N/v + murphy's sign
27
Why do you test for lipase when you suspect cholecystitis?
r/o pancreatitis most common cause of pancreatitis is gallstones?? second MC is EtOH
28
What tests are done to confirm dx of cholecystitis?
gallbladder wall thickening or edema or fluid around the gallbladder with positive murphys sign or HIDA scan US - best for anatomy HIDA - best for function
29
MRCP
special MRI of bile ducts used to find stones
30
Chronic cholecystitis
usually associated with gallstones result of increased inflammation secondary to mechanical irritation from stones or repeated attacks of cholecystitis resulting in fibrosis and thickening of the gallbladder wall
31
What imaging modality do you use to dx gallbladder polyps?
US
32
Why do we care about gallbladder polyps?
they have the risk of being malignant >2cm = malignant >1cm is automatic recommendation for cholestyectomy
33
Biliary Dyskinesia
gallbladder dysfunction suspect pt is having biliary dyskinesia if they are experiencing gallstone sxs without having gallstones
34
How do you dx biliary dyskinesia?
HIDA scan with CCK (cholecystokinin) provocation
35
What are the ABX prophylaxis for cholecystectomy?
cephazolin or clindamycin
36
IOC
intraoperative cholangiogram injection of radioopaque dye to make sure you are clamping the correct anatomy during surgery --lighting up the biliary tree
37
When might you do a cholecystostomy?
if the pt cant go to the OR for some reason maybe they are on elloquist (apixiban) this works by putting a drain into the gallbladder
38
Charcot's triad
fever abdominal pain jaundice seen with cholangitis
39
When should you suspect cholagnitis?
fever, chills, and hight EBC, CRP or ESR + Jaundice or abonormal LFTs definitive with biliary dilatation, stricture, stone, or stent
40
What is the treatment for cholangitis?
if they aren't septic rn they will be shortly --send to ICU treat for sepsis (fluid + zosyn, blood cultures) ERCP for CBD clearance (open up the bile duct)
41
What happens if you can't access the bile duct with ERCP when treating cholangitis?
PTC with rendezvous procedure
42
Primary sclerosing cholangitis?
basically a progressive form of stenosis unknown why associated with UC -ulcerative cholitis typically need liver need transplant within 10 years of dx
43
viscus
hollow organ
44
How do you dx perforated viscus?
X-ray and/or CT
45
Why is the esophagus the most vulnerable to perorated viscus?
lacks serosa neither does the pancreas
46
What is the most common cause of esophagus perforated viscus?
iatrogenic from instrumentation
47
Mallory Weiss tear
longitudinal, non-penetrating | esophageal perforated viscus
48
Boerhaave syndrome
through and through tear of the esophagus 15% of esophagus perforated viscus
49
Upper or lower esophagus is the most common location of perforations?
90% are lower 1/2 of esophagus
50
Which type of contrast do we use when suspecting perforation of viscus? Why?
Gastrografin We noramlly use barium unless we suspect perforation because barium is not water soluble so if it gets out of the GI tract it will stay there FOREVER
51
What is the most common cause of stomach and small bowel perforation?
peptic ulcer disease
52
Where is the most commonly location of colon perforation?
cecum | thinnest part of the colon
53
How do we dx/tx colon perforation?
plain films and CT with IV contrast tx" - conservative management in stable pt with no signs of peritonitis - surgery: - -peritoneal lavage - -closure of small colotomy in absence of gross contamination, diverting ilecostomy, colostomy
54
What are the major causes of colon obstruction?
tumors | volvulus
55
Apple core lesion
typical finding in colon ca | seen on imaging --colon obstruction
56
What is the most common cause of small bowel obstruction?
intra-abdominal adhesions
57
Target sign
seen on CT with intusseception d/t bowel being inside bowel
58
What is the difference between abdominal wall hernia and internal hernia?
both can either be congenital or acquired abdominal wall hernias are from wall weakness internal hernias are defects in the mesentary
59
What diameter indicates dilated small bowel?
>2.5cm
60
What are some complications of small bowel obstructions?
ischemia closed-loop perforation
61
What are the symptoms of SBO?
``` bloating nausea vomiting cramping abdominal pain obstipation (severe constipation) ```
62
What laboratory studies will you do for SBO?
CBC with diff CMP serum lactate (will tell you if there is ischemia) ABG (metabolic acidosis)
63
Dx of SBO?
plain films - upright and supine + CXR | abdominal and pelvis CT with IV contrast
64
To say SBO it must have....
a physical point of obstruction at which dilated bowel proximally gives way to non-dilated bowel distally on abd/pelvic CT!
65
What is the treatment for SBO?
``` IV hydration PUT IN THE NG TUBE bowel rest replace electrolytes +/- ABX check them daily with a plain film watch for change to ischemic pain, etc ``` up to 25% of hospitalized pts with SBO ultimately have surgery
66
What is the best test for small bowel function?
passing gas
67
Diverticulosis
sack like protrusions of the colonic wall mucosa (out pouching) rarely symptomatic 60% risk by the age of 60
68
Painless rectal bleeding
suspect diverticulosis
69
How do you dx bleeding diverticulosis?
colonoscopy
70
What is treatment of diverticulosis?
resuscitation endoscopic therapy never really goes in for surgery
71
Signs and sxs of acute diverticulitis
``` lower abdominal pain LLQ > RLQ N/V fever abdominal tenderness constipation (diarrhea less common) ```
72
LQ TTP + fever + leukocytosis
highly suggestive of diverticulitis
73
What is the treatment for diverticulitis in a clinically stable pt with uncomplicated disease?
outpt with oral ABX Metronidazole + ciprofloxacin (flouroquinolone)
74
What is the treatment for diverticulitis in a clinically stable pt with complicated disease?
(pts with free perforation, abscess, fistula, stricture or obstruction) requires hospitalization, IV fluids, ABX and bowel rest
75
What is the most common GI fistula?
colon communicating with the bladder
76
Hartmann procedure
surgical option for diverticulitis to keep the rectum
77
Where is the most common location of diverticulosis?
sigmoid colon
78
What diameter of colon is at risk of perforation?
13-17cm
79
Where is a FB in the colon typically stuck?
rectosigmoid junction
80
What is the most common cause of SBO?
intra-abdominal adhesions - 70% (recent surgery?) tumors hernias
81
What is the treatment for appendicitis?
Surgery - laproscopic ideal Cephalosporin single dose OR Cephazolin + metronidazole
82
What is the size cut off for a normal appendix?
<6mm
83
Asymptomatic gallstone treatment
Supportive plus pt education on diet Exception: DM or immunocompromised pts
84
Acalculus cholecystitis
Acute cholecystitis without obvious stones
85
Where do pts complain of the pain being located for cholecystitis?
RUQ
86
What if a pt presents with SBO and no recent hx of abdominal surgery?
its considered a tumor until proven otherwise
87
What is the best imaging test for abdominal wall hernias?
CT withOUT contrast
88
What the ABX of choice for complicated SBO?
cefazolin plus metroniadzole PCN allergy? Clinda or metronidazole plus gentamicin or fluorquinolone
89
Why do we order a serum lactate when we suspect complicated SBO?
it will be increased if there is ischemia
90
What are the possible complications of SBO?
all time sensitive - closed loop - ischemia - perforation
91
What is the treatment for SBO?
NGT decompression bowel rest IV hydration check them daily with plain film if they don't improve in 5 days you are sending to surgery (~25% go to surgery)
92
What can cause Ileus?
``` it occurs to some degree after almost all open abdominal surgery also: peritonitis trauma intestinal ischemia medications exacerbated by K+ and Mg+ imbalance ```
93
Ogilvie's Syndrome
acute colonic pseudo obstruction acute dilation of the colon in the absence of lesion typically involves the cecum and right colon (ascending colon?)
94
What is the treatment for Ogilvie's syndrome?
colonoscopy IR decompression cecostomy
95
What is the initial eval of a pt with suspected diverticulitis?
``` H and P CBC (infection and bleeding?) UA (UTI/fistulas?) Abdominal xray (r/o stones, SBO) CT of abdomen and pelvis (PO and IV contrast) ```
96
How do you obtain imaging for a pregnant pt you suspect of diverticulitis?
US or MRI same for renal insufficiency pts avoiding CT and contrast
97
How do you treat diverticulitis?
nonoperative (if stable this can be done in an outpt setting) - fluoroquinolone plus metronidazole - dietary modifications operative
98
What defines a complicated diverticulitis?
``` perforation abscess fistula stricture obstruction ``` tx: hospitalization, IV fluids, ABX, bowel rest
99
What are the preventive measures we can educate our acute diverticulitis pts about to avoid other episodes?
high fiber diet | regular exercise
100
There is significant overlap on CT between ______ and diverticulitis?
colon cancer get colonoscopy after acute episode for definitive dx
101
_____should be considered after an attack of acute complicated diverticulitis
elective resection
102
What makes acute diverticulitis need emergency surgery?
pts with diffuse peritonitis massive free air (seen on CT) pts with failed nonoperative management
103
What is the treatment for diverticulitis?
For nonoperative cases Fluoroquinonlones and metronidazole (PO or IV) Or Ceftriaxone and metronidazole IV

Clin Specialties - Surgery (11 decks)

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