Surgery - Acute abdomen and peritonitis Flashcards
SUR - 3.1
Peritonitis caused by perforation of the gastric and duodenal ulcer:
A) is exclusively chemical because the content of stomach and duodenum is sterile
B) initially chemical, but bacterial peritonitis develops within hours due to overinfection
C) bacterial origin from the beginning
D) caused by anaerobic pathogens
ANSWER
B) initially chemical, but bacterial peritonitis develops within hours due to overinfection
EXPLANATION
The secretion produced by the mucous membrane of a healthy and ulcerative stomach is highly acidic and therefore practically sterile. In the case of perforation of gastroduodenal peptic ulcers, the fluid entering into the free abdominal cavity causes a violent chemical reaction on the large surface of the peritoneum, resulting in knifelike epigastric pain and diffuse reaction of the abdominal wall. The latter manifests itself in abdominal hardening of the abdominal wall, called „défense musculaire”. The fluid that entered into the abdomen is quickly overinfected, while the secretion of the duodenum containing the bile and the pancreatic fluid is not sterile. On the other hand the lack of the the acid content of the stomach will be resulted in the free passing of the flora of the mouth and esophagus containing highly pathogenic bacterias. The resulting peritonitis and sepsis can only be prevented by immediate surgery. Surgery means by closing the ulcerative perforation opening, removing the abdominal fluid (“aspiration”), and rinsing the abdominal cavity several times.
SUR - 3.2
The most common place for gastroduodenal ulcers is:
A) the fundus of the stomach
B) the lesser curvature of the stomach in the middle third
C) the posterior wall of the antrum
D) the anterior wall of the duodenum directly below the pylorus
ANSWER
D) the anterior wall of the duodenum directly below the pylorus
EXPLANATION
Digestion of gastroduodenal peptic ulcer is the most often a complication of ulcers on the anterior wall of the duodenum. One of the reasons for this phenomenon is that peptic ulcers occur most frequently in the first 1-2 cm part of the duodenum bulb following pylori. The other reason is that the front wall of the duodenum is connected to the abdominal cavity in contrast to the posterior wall that is situated in the retroperitoneum. Posterior wall ulcers can adhere or penetrate to the underlying retroperitoneal organs ie. to the the pancreas or head of the pancreas, so here the destruction caused by the ulcer does not pass into the free abdominal cavity. Howevere the penetration to pancreas can be resulted in the erosion of the pancreaticoduodenal artery. This anatomic situation is the explanation of the most common complication of duodenal ulcers occurs in free abdominal perforation, while bleeding is a typical complication of posterior wall ulcers.
SUR - 3.3
The optimal time for surgery of gastroduodenal ulcer perforation:
A) within 48 hours after the onset of complaints
B) within 24 hours after the onset of complaints
C) within 6 hours after the onset of complaints
D) scheduled in advance after the investigation is completed
ANSWER
C) within 6 hours after the onset of complaints
EXPLANATION
As explained in the note SEB-3.1. surgical treatment of gastroduodenal peptic ulcer perforation is one of the most urgent surgical intervention. Symptoms of the disease meets the criteria of an acute abdominal disaster, and if the correct surgical intervention (see SEB-3.1) is not performed within 6 hours, the rapidly progressing peritonitis can cause sepsis, septic shock, and death of the patient. If the surgical therapy is missed, the chances of survival after 24 hours of perforation will dramatically decrease. There is no effective conservative treatment of perforation of gastroduodenal ulcer.
SUR - 3.4
Mallory-Weiss Syndrome:
A) vomiting related stomach rupture of fundus and peritonitis
B) severe inflammation on the mucosa of the fundus
C) rupture of the wall in the middle third of the lesser curvature of the stomach and peritonitis
D) serious bleeding from the rupture of the gastroesophageal mucosa during severe vomiting
ANSWER
D) serious bleeding from the rupture of the gastroesophageal mucosa during severe vomiting
EXPLANATION
Vomiting is a disorder of co-ordination of the sphincters regulating the passage of the stomach causing intense stomach contractions, while pylorus and cardia are beeing closed. In that situation, a sudden increase in the pressure can occur int the cavity of the gut. Intracavital pressure does not stretch the stomach wall alike. The thick muscular antrum and corpus are resistant, and the thin-walled fundus is extremely dilated and strained. These factors lead to a rupture of the mucous membrane of the fundus nearby the cardia and resulting in acute bleeding. The rupture of the mucosa and bleeding of the fundus is called Mallory-Weiss syndrome. Note that in the esophagus the same vomiting mechanism causes rupture of all the layers of the wall (Boerhaave syndrome), in contrast to the stomach, where no interruption of all layers of the wall is ever detected.
SUR - 3.5
The most common cause of peritonitis related to gastric disorders:
A) perforation of peptic ulcer
B) bacterial phlegmone of gastric wall
C) perforation caused by Crohn’s disease
D) tumor-induced perforation caused by tumor disintegration
ANSWER
A) perforation of peptic ulcer
EXPLANATION
Peptic ulcer is the most common disease affects the gastric mucosa. Bacterial phlegmon of the wall f the stomach and Crohn’s disease limited to the stomach are extremely rare, so perforation or other complication of it is exceptional. Perforation is a very rare complication of gastric carcinoma, but in practice it is more common than the previous two diseases.
SUR - 3.6
When is the surgical treatment required for solitaire liver abscess ?
A) In case of failure of the percutan drainage
B) Only surgical intervention is an effective method for treating liver abscess
C) Never
ANSWER
A) In case of failure of the percutan drainage
EXPLANATION
In the surgical treatment of abscesses, such as liver abscess, UH- or CT-controlled drainage is becoming increasingly prominent. The method is less invasive and its effectiveness is close to surgical treatment. Therefore surgical treatment comes into wiev in the case of failure of the percutan drainage.
SUR - 3.7
Which statement is correct?
A) The stomach of patients with peptic ulcers contains a large amount of pathogen bacteria.
B) The use of non-steroid anti-inflammatory drugs (NSAIDs) predisposes to gastric carcinoma.
C) Anterior wall ulcers of the duodenum tend to perforation, posterior wall ulcers tend to bleed.
D) Malignancy is a dangerous and frequent complication of duodenal ulcers.
ANSWER
C) Anterior wall ulcers of the duodenum tend to perforation, posterior wall ulcers tend to bleed.
EXPLANATION
Explanation of the correct answer has already been given in SEB-3.2.. The content of stomach of patients with ulcers do not contain pathogen bacteria, NSAID does not predispose to carcinoma and transformation of duodenal ulcers to cancers are literary rarities
SUR - 3.8
The most common acute complication of gastric lymphoma is:
A) perforation
B) cachexia
C) sepsis
D) bleeding
ANSWER
D) bleeding
EXPLANATION
Presence of primary solitary or partial phenomen of disseminated non-Hodgkin’s lymphoma (NHL) in the stomach is common (15-20%). 4 - 6% of primary malignant gastric tumors are NHL. In 80-90% of cases, the disease causes ulceration of the mucosa. 18% of patients suffer from acute complications (bleeding, perforation, stenosis), the most common of which is bleeding.
SUR - 3.9
Causes of peritonitis associated with infected pancreatitis, except:
A) Hematogen spreading
B) Rupture of abscess
C) Penetration
D) Propagation through anatomically preformed route
ANSWER
A) Hematogen spreading
EXPLANATION
Peritonitis, a complication of bacterially over infected pancreatitis due to anatomical conditions, always occurs when the process spreads directly to the peritoneum. The direction and target organ of the hematogen spread is not peritoneum; it can occur in the liver.
SUR - 3.10
Necrotising pancreatitis may be associated with peritonitis except:
A) Localised peritonitis
B) Secunder peritonitis
C) Fibrinopurulent peritonitis
D) Primary peritonitis
ANSWER
D) Primary peritonitis
EXPLANATION
As explained in SEB-3.9. peritonitis associated with necrotizing pancreatitis is always a consequential process, and therefore the primary peritonitis cannot be used for this purpose. Primary peritonitis refers to the inflammatory process on the peritoneal surfaces, without prior or concurrent disease of an other abdominal organ. This disease is also called “spontaneous” peritonitis. Pathomechanism is the inflammation of the peritoneum by hematogen spread or direct translocation (“migration) of bacterias from the large bowel, but can develop from urinary tract, female genitalia etc. as an ascending infection. Special forms include pneumococcus-, Streptococcus-, gonococcus- peritonitis and tuberculous peritonitis.
SUR - 3.11
Complications of large bowel diverticulitis, except:
A) Obstruction of large bowel
B) Malignant transformation
C) Bleeding
D) Small pelvic abscess
E) Colon perforation - peritonitis
ANSWER
B) Malignant transformation
EXPLANATION
Colon diverticulitis may result in a variety of complications, mimicking tumor resulted in colon ileus, but bleeding, perforation, abscess forming and diffuse peritonitis is frequent as well. Transforming to malignant urmo is not known yet.
SUR - 3.13
We find necrotic small intestine during the operation of incarcerated hernia. What to do?
A) surgery is postponed and elective surgery is performed later
B) performing hernioplasty
C) removing the necrotic section and make an anastomosis between intact intestinal ends
D) the necrotic small intestine is placed in front of the abdominal wall
ANSWER
C) removing the necrotic section and make an anastomosis between intact intestinal ends
EXPLANATION
Surgical treatment of incarcerated hernia is a life-saving, urgent intervention. The incarcerated bowel usually dies, which is the source of peritonitis, and the lethality of untreated disease is very high. The postponation of the operation is malpractice. The closure of the herinal ring or defect (hernioplasty) does not solve the source of the peritonitis (i.e.. removal the necrotic part of the bowel) and does not restore the continuity of the digestive tract. Placing the necrotic small bowel in front of the abdominal wall eliminates the source of peritonitis and also provides defecation. However, this is an obsolete process that should be avoided if possible. The correct procedure is the resection of the deceased intestine and restoration of the continuity of the bowel (anastomosis). This is followed by the closure of the hernial gate, or by reconstruction of the abdominal wall (hernioplasty).
SUR - 3.14
Possible cause of perforation of appendix:
A) bacterial inflammation
B) benign tumor lesion
C) carcinoid
D) helmets
E) typhus
ANSWER
A) bacterial inflammation
EXPLANATION
The most common of the diseases of the appendix vermifromis is the inflammation of the bacterial infection, so called appendicitis. This process is almost the only reason for the perforation of the appendix. Intestinal helminthiasis can be a predisposing factor to appendicitist, but does not cause perforation alone. Carcinoid and benign tumors may occur in theappendix and may cause suspicions of appendicitis but do not cause perforation. Typhus abdominalis is a disease of the small intestine that can cause perforation, today it is a rare disease. Sometimes it may cause suspicion of appendicitis, but it does not cause appendicitis and its perforation.
SUR - 3.17
When is the periappendicular infiltrate diagnose probable:
A) The complains started 3 hours ago
B) The complains started 6 weeks ago, without fever, and haven’t been treated
C) The complains started 2 days ago, did got fever, did vomit, has leukocytosis
D) When right lower abdominal resistance is palpable, the stool is Weber-positiv, apyretic
E) When in the last 5 days right lower abdominal pain, vomiting, fever is present and painful right lower abdominal resistance can be detected
ANSWER
E) When in the last 5 days right lower abdominal pain, vomiting, fever is present and painful right lower abdominal resistance can be detected
EXPLANATION
Periappendicular infiltration is a complicated form of advanced appendicitis, which requires 5-7 days to develop. The six weeks existed right lower quadrant abdominal resistance, without the general symptoms of inflammation (pain, vomiting, fever, leukocytosis), possibly with Weber positivity refers to tumor, therefore a colonoscopy should be performed. In case of 1-4 days existed symptoms indicating appendicitis, immediate surgery should be done. After 5-7 day “appendicitis like” anamnesis the developed painful, circumscribed resistance with fever and with abdominal sonography (or with CT) detected solid structure inflammatory conglomerate composes the periappendicular infiltration.
SUR - 3.18
The most common cause of big bowel ileus:
A) Ring tumor of the sigma
B) Cecal tumor
C) Diverticulitis conglomerate
D) Villous adenoma
E) Abdominal adhesions
ANSWER
A) Ring tumor of the sigma
EXPLANATION
Diameter of the colon in the sigma area is the smallest (4-5 cm), and this section most often develops shrinking circular “ring” tumors. This explains the experiential fact that sigma adenocarcinomas are the most common cause of large bowel ileus. The large diameter (10-13 cm) coecum tumors are predominantly polypoid lesions that grow to the lumen, which often grow to a very large extent without causing passage disturbances. In the case of diverticulitis, the inflammatory symptoms dominate and the passage disorder is less common. A typical symptom of the villous adenomas is large-scale mucus passage, or bleeding, so they are usually detected before they cause ileus. Adhesive ileus is more likely to be a disorder of small bowel that is mobile, and can be easily refracted, clamped, or twisted aroud the axis. Adhesions rarely cause large bowel ileus.
SUR - 3.19
Which statement is true?
A) The fecal peritonitis is a banal complication of colon surgery.
B) The fecal peritonitis is an extremely dangerous complication of colon surgery.
C) The peritonitis caused by diverticulitic perforation is milder than the peritonitis caused by appendicitis.
D) After rich meal evolved foreign body colon-perforation’s treatment is the suture of the opening.
ANSWER
B) The fecal peritonitis is an extremely dangerous complication of colon surgery.
EXPLANATION
Due to the presence of pathogen bacterias in the colon safe sutures can only be made after mechanical preparation and antibiotic profilaxis. In the case of colon perforation caused by any etiology after eating, treating the opening primere suture is a wrong procedure, which means the patient’s endangerment. The colon contains the most dangerous pathogenic aerobic and anaerobic bacteria (fecalflora) of the human body. In any case where the abdominal cavity is contaminated by colon content, severe septic peritonitis (fecalperitonitis) occurs, followed by a septic shock. The bacterial flora of the appendix is similar to the colon, therefore appendicitis and diverticulitis caused peritonitis is equally dangerous.
