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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
Q

What is cholecystitis?

A

syndrome of RUQ pain, fever, and leukocytosis associated with gallbladder inflammation (usually related to gallstones)

can occur without stones –acalculus cholecystitis

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26
Q

How does cholecystitis present?

A

prolonged, STEADY, severe RUQ or epigastric pain
fever
leukocytosis w/ bands
+/- N/v

+ murphy’s sign

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27
Q

Why do you test for lipase when you suspect cholecystitis?

A

r/o pancreatitis

most common cause of pancreatitis is gallstones??
second MC is EtOH

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28
Q

What tests are done to confirm dx of cholecystitis?

A

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

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29
Q

MRCP

A

special MRI of bile ducts used to find stones

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30
Q

Chronic cholecystitis

A

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

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31
Q

What imaging modality do you use to dx gallbladder polyps?

A

US

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32
Q

Why do we care about gallbladder polyps?

A

they have the risk of being malignant

> 2cm = malignant

> 1cm is automatic recommendation for cholestyectomy

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33
Q

Biliary Dyskinesia

A

gallbladder dysfunction

suspect pt is having biliary dyskinesia if they are experiencing gallstone sxs without having gallstones

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34
Q

How do you dx biliary dyskinesia?

A

HIDA scan with CCK (cholecystokinin) provocation

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35
Q

What are the ABX prophylaxis for cholecystectomy?

A

cephazolin or clindamycin

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36
Q

IOC

A

intraoperative cholangiogram
injection of radioopaque dye to make sure you are clamping the correct anatomy during surgery –lighting up the biliary tree

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37
Q

When might you do a cholecystostomy?

A

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

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38
Q

Charcot’s triad

A

fever
abdominal pain
jaundice

seen with cholangitis

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39
Q

When should you suspect cholagnitis?

A

fever, chills, and hight EBC, CRP or ESR
+
Jaundice or abonormal LFTs

definitive with biliary dilatation, stricture, stone, or stent

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40
Q

What is the treatment for cholangitis?

A

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)

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41
Q

What happens if you can’t access the bile duct with ERCP when treating cholangitis?

A

PTC with rendezvous procedure

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42
Q

Primary sclerosing cholangitis?

A

basically a progressive form of stenosis
unknown why
associated with UC -ulcerative cholitis
typically need liver need transplant within 10 years of dx

43
Q

viscus

A

hollow organ

44
Q

How do you dx perforated viscus?

A

X-ray and/or CT

45
Q

Why is the esophagus the most vulnerable to perorated viscus?

A

lacks serosa

neither does the pancreas

46
Q

What is the most common cause of esophagus perforated viscus?

A

iatrogenic from instrumentation

47
Q

Mallory Weiss tear

A

longitudinal, non-penetrating

esophageal perforated viscus

48
Q

Boerhaave syndrome

A

through and through tear of the esophagus

15% of esophagus perforated viscus

49
Q

Upper or lower esophagus is the most common location of perforations?

A

90% are lower 1/2 of esophagus

50
Q

Which type of contrast do we use when suspecting perforation of viscus? Why?

A

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
Q

What is the most common cause of stomach and small bowel perforation?

A

peptic ulcer disease

52
Q

Where is the most commonly location of colon perforation?

A

cecum

thinnest part of the colon

53
Q

How do we dx/tx colon perforation?

A

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
Q

What are the major causes of colon obstruction?

A

tumors

volvulus

55
Q

Apple core lesion

A

typical finding in colon ca

seen on imaging –colon obstruction

56
Q

What is the most common cause of small bowel obstruction?

A

intra-abdominal adhesions

57
Q

Target sign

A

seen on CT with intusseception d/t bowel being inside bowel

58
Q

What is the difference between abdominal wall hernia and internal hernia?

A

both can either be congenital or acquired
abdominal wall hernias are from wall weakness

internal hernias are defects in the mesentary

59
Q

What diameter indicates dilated small bowel?

A

> 2.5cm

60
Q

What are some complications of small bowel obstructions?

A

ischemia
closed-loop
perforation

61
Q

What are the symptoms of SBO?

A 
bloating 
nausea 
vomiting 
cramping abdominal pain 
obstipation (severe constipation)
62
Q

What laboratory studies will you do for SBO?

A

CBC with diff
CMP
serum lactate (will tell you if there is ischemia)
ABG (metabolic acidosis)

63
Q

Dx of SBO?

A

plain films - upright and supine + CXR

abdominal and pelvis CT with IV contrast

64
Q

To say SBO it must have….

A

a physical point of obstruction at which dilated bowel proximally gives way to non-dilated bowel distally

on abd/pelvic CT!

65
Q

What is the treatment for SBO?

A 
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
Q

What is the best test for small bowel function?

A

passing gas

67
Q

Diverticulosis

A

sack like protrusions of the colonic wall mucosa (out pouching)

rarely symptomatic

60% risk by the age of 60

68
Q

Painless rectal bleeding

A

suspect diverticulosis

69
Q

How do you dx bleeding diverticulosis?

A

colonoscopy

70
Q

What is treatment of diverticulosis?

A

resuscitation
endoscopic therapy

never really goes in for surgery

71
Q

Signs and sxs of acute diverticulitis

A 
lower abdominal pain 
LLQ > RLQ 
N/V
fever
abdominal tenderness 
constipation (diarrhea less common)
72
Q

LQ TTP + fever + leukocytosis

A

highly suggestive of diverticulitis

73
Q

What is the treatment for diverticulitis in a clinically stable pt with uncomplicated disease?

A

outpt with oral ABX

Metronidazole + ciprofloxacin (flouroquinolone)

74
Q

What is the treatment for diverticulitis in a clinically stable pt with complicated disease?

A

(pts with free perforation, abscess, fistula, stricture or obstruction) requires hospitalization, IV fluids, ABX and bowel rest

75
Q

What is the most common GI fistula?

A

colon communicating with the bladder

76
Q

Hartmann procedure

A

surgical option for diverticulitis to keep the rectum

77
Q

Where is the most common location of diverticulosis?

A

sigmoid colon

78
Q

What diameter of colon is at risk of perforation?

A

13-17cm

79
Q

Where is a FB in the colon typically stuck?

A

rectosigmoid junction

80
Q

What is the most common cause of SBO?

A

intra-abdominal adhesions - 70% (recent surgery?)
tumors
hernias

81
Q

What is the treatment for appendicitis?

A

Surgery - laproscopic ideal

Cephalosporin single dose
OR
Cephazolin + metronidazole

82
Q

What is the size cut off for a normal appendix?

A

<6mm

83
Q

Asymptomatic gallstone treatment

A

Supportive plus pt education on diet

Exception:
DM or immunocompromised pts

84
Q

Acalculus cholecystitis

A

Acute cholecystitis without obvious stones

85
Q

Where do pts complain of the pain being located for cholecystitis?

A

RUQ

86
Q

What if a pt presents with SBO and no recent hx of abdominal surgery?

A

its considered a tumor until proven otherwise

87
Q

What is the best imaging test for abdominal wall hernias?

A

CT withOUT contrast

88
Q

What the ABX of choice for complicated SBO?

A

cefazolin plus metroniadzole

PCN allergy?
Clinda or metronidazole plus gentamicin or fluorquinolone

89
Q

Why do we order a serum lactate when we suspect complicated SBO?

A

it will be increased if there is ischemia

90
Q

What are the possible complications of SBO?

A

all time sensitive

  • closed loop
  • ischemia
  • perforation
91
Q

What is the treatment for SBO?

A

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
Q

What can cause Ileus?

A 
it occurs to some degree after almost all open abdominal surgery 
also:
peritonitis
trauma
intestinal ischemia
medications
exacerbated by K+ and Mg+ imbalance
93
Q

Ogilvie’s Syndrome

A

acute colonic pseudo obstruction

acute dilation of the colon in the absence of lesion

typically involves the cecum and right colon (ascending colon?)

94
Q

What is the treatment for Ogilvie’s syndrome?

A

colonoscopy
IR decompression
cecostomy

95
Q

What is the initial eval of a pt with suspected diverticulitis?

A 
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
Q

How do you obtain imaging for a pregnant pt you suspect of diverticulitis?

A

US or MRI

same for renal insufficiency pts

avoiding CT and contrast

97
Q

How do you treat diverticulitis?

A

nonoperative (if stable this can be done in an outpt setting)

  • fluoroquinolone plus metronidazole
  • dietary modifications

operative

98
Q

What defines a complicated diverticulitis?

A 
perforation 
abscess
fistula
stricture 
obstruction

tx: hospitalization, IV fluids, ABX, bowel rest

99
Q

What are the preventive measures we can educate our acute diverticulitis pts about to avoid other episodes?

A

high fiber diet

regular exercise

100
Q

There is significant overlap on CT between ______ and diverticulitis?

A

colon cancer

get colonoscopy after acute episode for definitive dx

101
Q

_____should be considered after an attack of acute complicated diverticulitis

A

elective resection

102
Q

What makes acute diverticulitis need emergency surgery?

A

pts with diffuse peritonitis
massive free air (seen on CT)
pts with failed nonoperative management

103
Q

What is the treatment for diverticulitis?

A

For nonoperative cases
Fluoroquinonlones and metronidazole (PO or IV)

Or

Ceftriaxone and metronidazole IV

Clin Specialties - Surgery (11 decks)

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