Surgery: Block 1 Flashcards
What is one of the most important features of a SurgHx?
What is the first part when investigating this feature?
What is the most important aspect of this feature?
Pain
How it began
PTs reaction to it
PT shrieking/thrashing is either ? or could have ?
PT in true pain due to infection, inflammation or vascular dz may present what type of movement?
Gross over reaction
Renal/biliary colic
Extremely restricted movement
What is a common complaint found during a pre-op Hx that is not of much significance?
When does this become an issue?
Change in bowel habits
Constant/regular becomes cyclic diarrhea/constipation= suspect colon Ca
What is the MC error when providers are presented with bleeding from the rectum?
A complete exam of a surgical PT includes what five steps?
Hemorrhoid Dx
PE Special Labs X-rays F/u exams
What is the first and second thing immediately assessed when conducting an elective surgery PE?
What are the objectives of doing Labs during a pre-op work up?
Why is a Neg GI study not truly negative?
Physique/habitus and then, hands
Screening for ASx Dz (anemia, DM)
Dz c/i elective/req Tx prior to surgery (DM, HF)
D/o requiring surgery (HyperThyroid, Pheo)
Metabolic/septic complications
Ulcers/Neoplasms not excluded, especially in R colon
Ordering INR/PTT would be warranted during a Pre-Op prior to ? procedures?
What is the relation w/ the blood bank prior to a surgery?
Little post-op bleeds threshold (brain, spine, neck)
INR- bile obstruction, malnutrition, absent terminal ileum= dec Vit K absorption
Blood typing alone
Pre-op labs include ?
What is a True Liver function test?
What is MC acquired nosocomial infection and RFs
CBC CMP PT/INR
PT/INR + Total Bili, Albumin
Lower UTI- Retention Instrumentation Contamination
Dx by exam, confirm w/ culture
Who signs a pre-op consent form?
When can consent form signing be waived?
Who can sign for the PT if they’re unavailable or physically able to sign
Surgery team member, PT, Witness NOT on team
Emergencies, two Drs sign
Medical power of attorney
If emergency surgery is needed and signed consent may be affected, who needs to be notified?
What is the universal protocol for pre-op precautions
When/how is hair removed from a surgical site?
Hospital administrator
Site/sign location
Time out prior to first cut
Electric clippers immediately prior
What meds may be taken on the day of surgery w/ sip of water
HN
Hormones Neuro
BARHOPS
BB Alpha ant/agonist Reflux HTN OCP Psych
CCC
CBC Cardiac rhythm COPD
HNP
Hormone Nitrate Peptic diatheses
Why may PTs be advised to NOT take their ACEI prior to surgery
When are ABX given prior to surgery
If additional ABX are needed during surgery, when are they given?
General anesthesia refractory HOTN
W/in 1hr of incision
Every 2 t1/2 (q4hrs for Cefazolin*, Augmenten)
Operations that involve bacteroides should have ? ABX added to the regime
Surgical ABX are chosen by ?
Multiple doses or prolong ABX use post-op are more likely during ? procedures?
Metronidazole
Hospital antibiogram
GI Tract
Implantation
Contaminated wounds
ImmComp PTs
ABX given to PTs for prophylaxis are not continued after surgery except for ? procedures?
What is the ASA Classification system for?
Vascular grafts
Cardiac surgery
Joint replacement
Degree of perioperative risk for PTs
1: health PT, no systemic d/o
5: moribund, won’t survive 24hrs w/out operation
What are examples of Cat 5 ASA PT
What is the APACHE II System for?
How is the Mallampati classification scoring done?
Trauma w/ shock
Ruptured AAA w/ shock
Cerebral trauma w/ inc ICP
Massive PE
Severity of illness in ICU PTs to predict mortality
Open mouth, tongue out w/out saying ‘ah’
What are the 6 things evaluated when conducting a Mallampati
NTC PST
TMJ C-spine Dentition Short neck Tracheal deviation Neck mass
Respiratory complications are bad because of what 4 increased things
Pulmonary complications can be as minor as ? and extend in severity up to ?
Most costly
Inc re/admission, 30 day mortality
Atelectasis
Pneumonia/Resp Failure
What are the risk factors for a PT to develop post-op pulmonary complications?
What PE findings may indicate an underlying pulmonary Dz
Functional dependence AMS Malnutrition
CHF Alcohol COPD Inc age ASA
Dec breath sounds
Wheeze
Rhonchi
Prolonged expiratory phases
If PT has mitigating pulmonary complications during pre-op, what two tests may be done prior to surgery, especially ? procedure
How are PTs w/ very low, low, mod or high risk of VTEs managed post-op?
PFT ABG
Lung resection
Very Low= early ambulation Low= mechanical prophylaxis and ICPs
Mod= LMWH, UFH, IPC
High= IPC and LMWH/UFH
What are the 6 independent factors in a RCRI
If PT has findings indicative of ischemic heart dz, cardiac Sxs or abnormal EKG on pre-op have what f/u test ordered?
Deck 1, Slide 24
Hx ischemic Heart Dz CHF- JVD/S3 CerebroVDz High risk operation Pre-op Tx w/ insulin Pre-op SrCr >2.0mg
Stress test: Treadmill,
Dipyridamole/Adenosine-thallium
Dobutamine echo
What is the most widely used Dx test to evaluate for CADz
If there is a risk of a peri-operative re-infarct after an MI, try to postpone surgery by ? mon
Exercise electrocardiography until Sxs or ST segment shifts, enhanced w/ T-201
> 6mon
What are the two goals of pre-op fasting?
Avoid drinking/eating how far in advance to surgery?
Min volume, max pH
No drinking 2hrs prior
No light/heavy meals 6-8hrs
Infant- 4hrs breast milk, 6hrs formula
What would be signs that liver failure is occurring post-op and what labs would be ordered?
Pre-op eval of the hepatic system includes ? two measurements used for calculating ?
Spider telangiectasis
Jaundice
PT INR PTT
Total bili and INR
CTP or MELD
What are PTs given who are identified to have bleeding risks and when are they given?
If PT w/ hepatic issues develops worsening encephalopathy, ? is accumulating and it’s Tx w/ ?
Vit K/FFP- on call to OR
Ammonia tx w/ Lactulose
PTs w/ liver dz risk ? outcome w/ surgery
What are the decompensation risk %s per CTP scoring
Decompensation
Class A: 2-10%
Class B: 12-30%
Class C: 12-82% w/ 63% mortality rate
PT w/ elevated pre-op BUN= ?
PT w/ elevated creatinine= ?
All Pts w/ ? need to have these two labs drawn during the pre-op
Dehydration
Inc mortality
Renal impairement
Proteins/glucose found in a UA mean?
Casts found in urine mean ?
What can the urine Na/Creatinine can be used to calculate?
Injured glomeruli
Nephritis Glomerulonephritis Tubular necrosis
Fractional excretion of sodium- determines if origin of renal failure is pre/post renal
What would be seen in a UA indicating an infection?
What part of the UA results indicate the PTs hydration level?
What is the name of the peri-operative fluid management program showing to reduce incidences of adverse post-op events?
Leukocyte esterase
Nitrites
SpecGrav- norm 1.010
Goal directed/Protocol based fluid restriction
If post-op PT has oliguria, what is it due to and how is it corrected?
What step may be done during pre-op neuro eval to examine for occult Dzs?
Secondary to hypovolemia
IV fluids, not diuretics
Carotid artery stenosis (bruit)
Define Neuropraxia
How is Neuropraxia classified
Mildest form of nerve injury from over stretching joints; MC Sx- loss of motor function
Transient conduction block of motor/sensory function w/out nerve degeneration
? type of PT Hx may indicate greater chance for development of a Surgical Site infection?
These chances are higher following ? procedures
DM
Cardiac
Or inc stay/infection risk in non-cardiac PTs
What is the desirable glucose range for critically ill PTs
Chronically hyperglycemic PTs are frequently ? and ? is used in the InPT setting for fluids
<140 fasting
<180 regular
Dehydrated
IV Dextrose
Pain causes ? release and subsequent ? release
Intravascular volume loss will cause PT to develop ? Na
ACTH- Epi, NorEpi, Cortisol
ADH from PostPit
Low serum Na due to water retention
Why should pre-op PTs not suddenly stop use of steroids
What is the recommendation instead of stopping
PTs must have ? thyroid prior to surgery
What can happen if this requirement is not met
Addisonian crisis- HOTN, HypoNa, HyperK+
Stress dose steroids
Euthyroid
Hyper: thyroid storm
Hypor: cardiac failure
Why would supplemental steroids be given to PTs pre-op
PTs undergoing ? moderate or ? major stress procedures should have addistional CCS administered
1* or 2* adrenal insufficiency
Currently on >20mg of Pred
Hx chronic steroid use and
Cushingoid appearance
Mod: LE revascularization, total joint replacement
Sev: cardiothoracic, abdominal, CNS
What is used to prevent a thyrotoxicosis development
What med is used for Graves PTs to reduce the vascularity of the gland and control hyperthyroidism
Methimazole or Propylthiouracil and BBs
Potassium Iodide
What findings are seen if PT has perioperative hypothermia
How is this corrected
Hypothyroidism
PO Levothyroxine
PTs w/ thyroid goiters should avoid ? imaging procedure
PTs need to stop blood thinners ? before surgery
? PE finding can indicate PT has hemophilia
CT w/ contrast, may provoke thyrotoxicosis
Warfarin- 5 days
7 days
Deformed joints
Joint bleeds
? blood component is an independent risk factor for developing SSI?
If PT is mod/sev malnourished, how long will it take on re-feeding regime before changes are seen?
Hypoalbuminemia <3.0mg
1wk
What use/benefit does albumin have?
What blood component is preferred and considered more superior?
Long t1/2, low Sen/Spec
Malnutrition PTs don’t always have hypoalbuminemia
Critical care PT- reflects Dz severity
Preablbumin- High sensitivity, short t1/2
Inc PAB= dec inflammation, response, not improved nutrition
What lab finding may suggest chronic malnutrition?
What result would suggest acute malnutrition?
Albumin <3g, t1/2 of 14 days
Prealbumin <16mg, t1/2 of 2 days
__% weight loss can result in delayed wound healing, anergy or decreased pulmonary reserve
Anergy is also indicative of ?
12% or more
Immune response failure
What fluids are used in the pre-op setting for fluid resuscitation
If internal milieu is lost, what system can suffer irreversible consequences
Crystalloids- NS, LR
PRBCs
Neuro
? of body fluid is ? while the remaining is ?
Of the remaining fluid, how is it divided up?
2/3 intracellular (K+)
1/3 extracellular (Na)- 1/3 similar to seawater
3/4 interstitium
1/4 intravascular
How are intracellular Na levels kept low?
Hypovolemic induced oliguria produces ? type of urine
What purpose does the FENa hold?
NaKATP pump
Low volume/Na, hypertonic
Differentiating cause of oliguria
1% or less= Prerenal azotemia, aggressive Na reclamation
>1%= Tubular injury preventing proper Na reclamation
Hypovolemia in surgical PTs is due to loss of ? fluid
Hypovolemia stimulates aldosterone to be secreted from ? causing ?
Isotonic
Zone glomerulosa adrenal cortex
Inc Na/water absorption
What post-op findings are indicative the kidneys are trying to retain volume
Oliguria is also a consistent finding of early ?
Na <20 mEq Chloride- useless unless metabolic alkolosis Osmolality >500 SrCr ratio >20 BUN >20
Shock in the absence of hyperosmolar induced diuresis
? is a consistent finding of early and moderate shock
All hypovolemic PTs have inadequate output if urine output is less than ? after 30min wait
What is considered normal urine output for an adult
Oliguria
Adult: <0.5mL/kg/hr
Child: <1mL/kg/hr
Infant: <2mL/kg/hr
1L/24hrs
0.5mL/kg/hr
How much insensible fluid loss occurs from skin, lungs and GI tract
SpecGrav > ? indicates hypovolemia
Skin/lung: 600ml/24hrs
GI: 250ml/24hrs
> 1.020
What is an early but non-specific sign of shock?
What is the most sensitive of all the early signs of shock?
PTs w/ distended neck veins while elevated to 30* and no cardiac compression need to have ? r/o
Cold skin
Dec blood flow to skin
Hypovolemic shock
Criteria for profound hypovolemic shock is ? and will have ? VS always be low
After resuscitating hypovolemic shock, ? finding will always be present
> 30%
BP
Metabolic acidemia
What are three reasons to start an IV?
What are early signs of shock?
There is always a low filling pressure to ? chamber of the heart during hypovolemic shock?
Volume depletion
About to be NPO > 12hrs
Inc insensible losses
Diminished flow to skin*
Difficulty getting IV access
Cold skin- early, non-specific
RA
What is the purpose of doing a PAC
This procedure is only done for ? PTs
Swan Ganz in central venous to distal PulmArt to measure:
central venous pressure
capillary wedge pressure
RV SV
Cardiac instability w/ multiple comorbidity
3 benefits of placing a Foley
What are the indications to place a Foley
Hematuria
Output monitoring
Empties bladder
Prolonged sedation
I/Os
Pre-Op
Neurogenic bladder
S/Sxs PT has cystitis?
S/Sxs PT has pyelonephritis
Dysuria, mild fever
High fever Flank pain Ileus
Following few days post-surgery, what type of fluid balance change is commonly seen?
Post-op PT w/ HypoNa is Tx w/ ? but NOT ?
Post-op PT w/ dec UOP is Tx w/ ?
Fluid/E+ retention due to ADH secreted from pain, N/V, opiates or PPV
NS and water restriction
No hypertonic saline
Bolus IVF, not diuretic
In PTs w/ normal renal function, what are some of the best indicators of fluid volume status?
How much urine output indicates successful resuscitation for shock has occurred?
Mental status
Urine output
HR/BP
30cc/hr
What are 5 issues that can cause hyponatremia
PTs w/ CNS S/Sxs related to HypoNa are Tx w/ ?
CHF CSWS Hyperglycemia Liver Dz SIADH
NS and free water restriction
What is the adverse outcome from increase Na too quickly?
Why are DM PTs at higher risk of developing HypoNa post-surg?
Osmotic demyelination
Hyerpglycermia- draws water from intracellular space to extracellular space
In surgical settings, HypoK is developed by ? 3 things
What are the S/Sxs of HypoK
Refractory HypoK to parenteral Tx methods get ? as the next step?
GI loss Diuretic Malnutrition
Diaphragm paralysis
Flat/inverted T
Prominent U
HypoMg Tx
PTs w/ prolonged alkalosis from HypoK can develop ? issue
What are the hallmark signs of HypoK
Paradoxical aciduria- nephron conserves HCl and K, loss of H+
Dec muscle contraction leading- diaphragm paralysis, ECG changes (flat T, prominent U, arrythmias)
HyperK is often cause by ? but can also be due to ?
How does HyperK present on EKG
Renal/adrenal insufficiency
Crush Burns
Flat P
Peaked T
Wide QRS
What level of HyperK is considered a medical emergency?
How is it Tx
> 6.5mmol, reqs conitinuous EKG monitoring
IV 50% dextrose in water
10u regular insulin
Ca gluconate
Inhaled B adrenergic agonist
What does the HyperK Tx meds to for protection/Tx
What Tx step can be added to Tx of HyperK if PTs kidneys are intact and normal?
What is the method if kidney function is severely decreased?
BIG- push K from extra to intracellular spaces
CaGlu- inc excitability threshold to protect myocardium
Loop/TZD diuretic
Hemodialysis
If PT developed HyperK w/ slow/gradual onset, what PO med can be used for Tx?
What is an automated hydration status device used for monitoring and what is it used in conjunction with?
PO Sodium Polystyrene sulfonate
Edwards EV1000 w/ serum lactate
After severe trauma/sepsis, how do PTs show signs of Intravascular coagulation?
When would a hemodynamically stable but critically ill PT receive blood transfusion?
Prolonged clotting times
Low platelets, fibrinogen
Production of fibrin degeneration products/monomers
Hgb <7.0 (Hct 21%)
What is the antifibrinolytis used for adjuncts to hemorrhage control?
How does initial fluid resuscitation begin?
What fluid is preferred in the ER trauma bays?
Tranexamic acid
Warm crystalloid: NS or LR
Severe shock AND arterial pH <7.20= LR
Lactate + H+= lactic acid
LA liver oxidized into H2O/CO2, removed by lung/kidney
Isotonic crystalloid LR- lower Cl (NS Cl ions hyperchloremic metabolic acidosis)
Bile and fluids in small intestine have an E+ content similar to ?
Saliva, gastric juice and R colon fluids have high ? and low ?
LR
High K, low Na
What fluids are used in resuscitation secondary to hypovolemia?
Avoid adding extra ? in first 24hrs post-surg because?
Crytalloids- LR or NS
K, aldosterone inc post-surg= saved K+ ions
Define Maintenance Rate
How is Maintenance Rate maintained?
Define Replacement Rate
Dehydrated or NPO >12hrs,
Factored at 30ml/kg/24hr
5% Dextrose in 0.45% NaCl w/ 20mEq K/L
LR replacement to avoid causing E+ imbalance
Fluid losses exceeding ?mL need to have E+ concentrations measured
Heparin/saline locks are useful when?
Abdominal pain assessment divides area into ? 3
1500mL
ABX, PRN pain meds
GI Biliary GU
What is the bloody vicious triad
Type specific blood products should be available w/in ? long, otherwise use ?
What does whole blood contain and when is it used?
Hypothermia Coagulopathy Acidosis
20min: O- PRBCs, if unavail-
O+
Factors RBCs Ags Plasma 5/8 Anticoagulanta
Non-functional platelets and granulocytes
Massive loss/hypovolemia
In a non-bleeding 70kg PT, a transfusion of one RBC unit will inc Hgb by ? and Hct by ?
What is the first step in a massive transfusion protocol?
1g, 3%
1L isotonic crystalloid- LR/NS
Empiric transfusion
No excess crystalloids, worsens coagulopathy/vicious triad
Per TCCC guidelines, what is the fluid of choice for resuscitation from most to least?
What type of Trauma PT would receive the 1:1:1 fluid resuscitation?
Whole Plasma/RBCs Platelets Plasma RBCs Plasma or RBCs Hextend Crystalloids- LR/PLA
Severe shock
Intraperitoneal blood
Complex pelvic Fx
Bilateral femur Fx
What are the colloids?
FFP- clotting factors, 30min thaw
Whole blood: RBCs, plasma from walking donors w/ Ag, low titer O-
Albumin- not for acute resuscitation; volume expansion- LF, burns, nephrotic syndrome
PRBC- preferred over whole blood
PLT- for active bleeds w/ platelets <50K; 1unit inc x 25K
Hextend
Tranexamic Acid
Hypertonic Saline
6% hetastarch in lactated E+ w/ large sugars to inc intravascular volumes; max 1500ml/24hr- inc mortality/AKI
Antifibrinolytic- strengthens clots, improves survival <3hrs of injury (CRASH-2 Trial- HOTN/Tachy w/in 8hrs)
3-23.4%- fluids to intravascular space during head injuries- inc cerebral perfusion pressure, dec ICP
Not through peripheral IVs
Define Uremic bleeding and how it’s Tx
Cryoprecipitate
Renal Dz- platelet dysfunction w/ severe anemia and uremia
Tx w/ DDAVP, Conjugated Estrogen, Cryoprecipitate or RRT- stims vWF release
Cardiac surgery- soluble coag factors: vWF, Fibrinogen/ectin, Factor 8/9
Multiple factor deficiencies
vWF levels below _% are at risk for massive hemorrhage
How is VWDz corrected
Antifibrinolytics are preferably used in ? setting
30%
Desmopressin, Cryoprecipitate or vWF/F8
Massive hemorrhage- Aprotinin, TranAcid, AminoCaproic Acid: reduce transfusions in elective/cardiac surgeries
If LE veins used for IV access, must be decannulated w/in __hrs to minimize risk for ?
IO infusions target veins where but is not recommended for longer than ?
24hrs: thrombosis, infxn
Medullary sinus
24hrs
Where can central lines be placed
Central lines are placed using ? technique
Subclavian Jugular Femoral Cephalic vein
Seldinger
What is unique about the PICC
Indications for arterial line
What are the three broad categories of peripheral IV complications
Peripheral vein to SVC= central venous catheter
No risk for PTx
Arterial pressure monitor
Repeat ABGs/blood samples
NOT for volume replacement
Mechanical (MC thrombophlebitis) Infection
Metabolic
MC adverse effect of internal jugular and femoral venous line attempts?
MC adverse effect of subclavian line attempts?
Artery puncture
Pneumothorax
How does an air embolism present and how is it Tx
How can this adverse outcome be avoided during line placement?
Severe distress HOTN
Cogwheel murmur
Durant position: Trandelenburg and LLD- emoblus to apex of RV, needle aspiration
PT in Trandelenburg position
IV hydration methods are good for up to ?days before need to consider ? methods
? route is used in ICU/sedated w/ secured airway?
7 days, P/TPN
Orogastric tube- not for conscious PT, stims gag reflex
PTs receiving TEN need to have ? weekly/daily checks?
If PT has eaten w/in 6hrs of a surgery, what can be used to remove the contents?
When is this method c/i?
E+ daily
Pre-albumin weekly
Gastric tube: NG/OG under Low Suction
Gastric tube is NOT feeding tube
Cribifrom/basilar skull Fxs
Name of tube used for duodenal/jejunal nasoenteric feeding
Why metabolic condition may develop in PTs undergoing prolonged gastric suction/vomiting?
Define Refeeding Syndrome
Dobhoff tube- post-pyloric placement
Metabolic alkalosis- loss of Cl
Tx w/ K+Cl
Inc inuslin moves E+ from extra to intra= HypoK, Mg, PHO4
What are early complications in TPM therapy
PTs can start eating through feeding tubes starting ? long after placement
Hyperglycemia
Hyperchloremia acidosis
Day 2
How are visceral sensations carried within the abdomen
Why is visceral pain commonly felt at midline?
Afferent C fibers- viscera walls, solid organs capsule from distention/inflammation/ischemia
Slow dull onset
Bilateral sensory supply of spinal cord
How are parietal pain sensations carried?
Why is parietal pain better localized?
Cutaneous sensation of the parietal pain is due to ? spinal levels
Direct irritation of parietal peritoneum, C/A delta fibers: A-d carries sharp/localized pain
Somatic afferent fibers directed to one side of NS
T6-L1
Abdominal parietal pain is done by dividing the abdomen into ?
An ‘acute’ abdomen is any non-traumatic pain lasting ? and the fundamental aspect of eval is ?
4 quadrants, epigastric or central areas
<24hrs
Hx, PE w/ MC and predominant Sx: pain
What causes rectus muscle rigidity during an abdominal exam
What effect does pressing on a PT w/ guarding have?
Rare neuro d/o
Renal colic
Peritoneal inflammation
Voluntary- relaxes
Involuntary- remain board like
Scaphoid appearing abdomen are indicative of ?
When causes visible peristalsis to be seen?
What is the cause if PTs abdomen is soft/doughy
Perforated ulcer
Advanced bowel obstruction
Paralytic ileus/mesenteric thrombus
What would be heard in abdomen w/ mechanical bowel obstruction
Absent bowel sounds indicates PT has?
High pitched tinkle/rushes
Paralytic ileus
What could it mean if these signs are positive
Tympany on percussion indicats?
Iliopsoas- abscess Obturator- trapped bowel Rovsings- appendicitis Kehr- hemoperitonium \+CVA- pyelonephritis
Bowel obstruction
Hollow viscus perf
Sequence of abdominal exam
? pre-op test is mandatory in elderly Pts
What lab result would be elevated in PTs w/ pancreatitis
Inspect Ausc Perc Palp
Electrocardiography
Lipase
? is DDx in PT w/ abdominal POP w/ Hx of CAD
What is the most efficient imaging modality for assessing abdominal masses?
? image test is essential in all acute abdomen cases?
Bowel ischemia due to mesenteric ischemia
Helical/spiral CT
Upright CXR, more sensitive for intraperitoneal air
What 3 lab tests are almost always obtained prior to making a decision to operate?
What are the 4 steps in reading a plain abdomen x-ray
What is a 3-way abdomen
CBC Blood chemistry UA
Gas pattern
Extraluminal air
Abdominal calcifictions
Soft tissue masses
Flat/upright abdomen + CXR to look for hemo/pneumo peritoneum
What does subdiaphragmatic air indicate?
What does a thumbprint impression an an abdominal x-ray indicate
What finding indicates a pylephlebitis
Perforated viscous
Ischemic colitis
Air in portal venous system
How can the first portion of duodenum be isolated on visual exam from the second part
Where does the small intestine travel after the stomach connection?
The most dilated portion of the small bowel is ? w/ the most narrow portion at ?
Kerkring folds- plicae circulares/valvulae conniventes
L1-2, over R renal A/V and IVC
Wide: distal LoTreitz
Narrow: prox ileocecal valve
How are ileus obstructions differentiated from mechanical ones?
Reflex ileus is often induced by afferent fibers of ? nerve
What drug can be used w/ ERAS w/ ability to accelerate GI recovery
Mech: localized, severe, MC in small bowel
Ilius; diffuse, milder, more common post-op
Splenic
Alvimopan- selective Mu receptor antagonist
Constipation is not indicative of obstruction, but what combo is?
NG tubes should be placed in PTs presenting w/ ? 4 things
Obstipation + painful distention/repeat vomit
Hematemesis Suspected obstruction Severe vomit/ileus
What are the MC causes of SBOs and LBOs
Image finding of a ‘step-ladder’ appearance is indicative of ? and begin ?
Sm: Hernia Adhesion Tumor
L: Volvulus Ca Diverticula
Mechanical SMO
LUQ
Calcification of the bladder wall is uncommon in ? 3 Dzs
What does a cloud-like amorphous/popcorn appearance indicate?
Linear/track like calcifications imply ?
Schistosomiasis
Bladder Ca
TB
Calc/tumor in solid organ
Calcification in walls of tubular structures
Lamellar calcification indicates calcification has occurred ?
DM should avoid metformin for how long before and after receiving IV contrast
What is the name of the contrast used if suspected bowel perforation
Around nidus inside hollow lumen
24hrs, 48hrs
Gastrografin (Meglumine Diatrizoate)
What secondary signs may be seen on CT scans?
Upper GI w/ follow through means ? and is assessed by ?
Fat stranding
Extravasation
Esophagus to duodenum
Barium swallow
CT contrast enhances vessels and ?
? imaging test can be therapeutive and Dx for GI issues
What image is ordered to see bladder and urethra
Parenchyma
Limited BE
Retrograde urethrogram, shorter catheter than cystogram
? NucMed test for intra-abdominal abscesses?
Which one IDs slow intestinal bleeds
What is the ‘strict return’ policy for PTs after released from GI assessments
HIDA/gallium
Tc-sulfur colloid scan
Tech-pertechnetate in Meckels
F/N/V/intractable pain
Normally PTs are not sent home for GI issues if ? is needed but w/ ? exception
Four examples of urgent surgery needed done w/in 24hrs
Define Vermiform Appendix
Narcotics, Renal colic
Appendicitis Ectopic
Incarcerated hernia
LUQ pain
Blind intestinal diverticulum from posteromedial aspect of cecum, 2cm inferior to ileocecal valve, acts as 2* lymphoid organ (MALT)
Emergent surgery examples
During appendectomy, what anatomical landmarks can help locate the appendix
Blunt/Penetrating trauma
Aoritc transection
Ruptured aneurysm
Taeniae of colon, converge at base
What blocks appendix
Appendicitis has what 3 processes occurring
Fecalith- adults
Hyperplasia- kids
Tumors
Obstruction= distention Infection= ischemia Perforation= peritonitis
What is Alvarado’s Scoring method
MANTRELS Migrate to R iliac fossa (2) Anorexia N/V Tender R fossa Rebound pain Elevated fever Leukocytosis+10K, neutrophils (2) Left Shift
9-10: very probably
7-8: probable, CT
5-6: compatible
Where would pain be localized if appendix was in Iliac Fossa, pelvis, retro peritoneal/cecal or RUQ?
? locations of appendicitis can present w/ hematuria?
What type would cause inc WBCs in UA?
Fossa: McBurneys
Pelvis: rectal/obturator
Retro/Retro: psoas
RUQ: pregnant, pelvic mass
Retrocecal or Pelvic
Retrocecal
What are the most useful CT findings of appendicitis?
How are Pediatric appendicitis cases imaged?
What are the MC microbes isolated from peritoneal cultures during appendicitis?
Inc wall thickness, >6mm
Fat stranding
MRI
Aerobic/faculative bacteria
anaerobes
What ABX can be used for appendicitis
What microbes are usually isolated?
Pef: Cipro + Metronidazole
No Perf: Cephalosporin w/ Cefoxitin at pre-op
Milophila wadsworth Lactobacillus V Strep B Fragilis E Coli Enterococci P Melaninogenica
? duct is remnant of embryonic yolk sac and can fail to fully dissolve
Define Fothergill Sign
Omphalomesenteric/vitelline duct- MC= meckels
Rectus sheath hematoma- PT raises head when supine= accentuated= inc tenderness/swelling
Masses/pain that dec w/ head raise= intra-abdominal mass
Pregnant female that has appendectomy can have ? sequelae
What is the MC non-OB surgical Dz of the abdomen during pregnancy and how does it present
Pre-term labor, rarely delivery
Appendicitis
RUQ pain Tenderness Leukocytosis
Appendicitis perfs are more common in ? PT populations
What populations benefit from laproscopic appendectomy’s?
What is the MC rare pathology report for appendectomy and what other possibilities could it be
Kids, Developmental delay, Elderly
Obese Pregnant
Carcinoid- MC site of carcinoids in GI tract
Lymphoma
Adenocarcinoma
What is the name of the procedure to gain access to the abdomen for laprascopic appendectomy and what is then made?
What hole is larger?
Veress needle/Hasson trocar- pneumoperitoneum w/ CO2
Midline infraumbilical port- 12mm
What’s the name of the esophagus/stomach junction
Pertaining to the esophagus, what are the most important veins?
Why is this drainage important?
Antrum cardiacum
Lower, drain to coronary veins, part of portal vein
Direct communication between portal circulation and venous drainage of lower esophagus/upper stomach
Where does blood back flow into during portal HTN?
What is the MC diverticulae
Coronary vein/esophageal venus plexus to azygos vein to SVC
Zenker- pulsion type false diverticulae in Killian triangle, superior to cricopharyngeus muscle
What are the Sxs of a Cricopharyngeal diverticulum
What is the first Dx test if this is suspected and what is avoided
Dysphagia Regurg Halitosis Mass , Possible recurrent aspiration pneumonia
Barium Swallow- shows size/location
DONT do endoscopic exam
How is Zenkers Tx and how fast is recovery
? is present in 80% of PTs w/ GERD
Cricopharyngeal myotomy- division of the muscle, PT eats day after surgery
Hiatal hernia
Sxs of esophageal GERD
Sxs of extraesophageal GERD
Criteria to Dx GERD
Burn Regurg Angina Dysphagia
Hoarse Cough Laryngitis Asthma Dental erosion
+ pH test
Esophageal muscle breaks on endoscopy
Barret esophagus on biopsy
Peptic stricture w/out Ca
? procedure is important when evaluating GERD?
What is the gold standard and additional criteria for Dx GERD?
What prep do PTs need to do before the gold standard test?
EGD
Ambulatory pH monitor*
Mucosal breaks during scope
Barrett esophagus on biopsy
Peptic stricture w/out Ca
Stop H2s 3 days prior
Stop PPIs 7 days prior
Maintain diet/exercise
When is an ambulatory pH monitoring test conducted
What is the best way to manage PTs w/ typical GERD Sxs
No response to medical therapy
Relapse after d/c medical therapy
Before anti-reflux surgery
Eval Atypical Sxs- cough, hoarse, chest pain
PPIs- strongest acid suppressors- take 5 days for relief x 8wk trial
What is the MC anti-reflux procedure performed in the US
What is the first initial Dx test for suspected ingestion?
Lapraoscopic Nissen fundoplication
AP xray of neck, chest and abdomen
What are the 3 locations of the esophagus ingested objects can become lodged?
When is monitoring justified for swallowed objects?
Esophageal sphincter at Cricopharyngeus muscle
Level of aortic arch
Diaphragmatic hiatus- level to LES
Blunt/short <6cm
Narrow <2.5cm
Distal to pylorus
What is almost guaranteed to be present in an esophageal perforation >24hrs old
What is the MC cause
Where do Spontaneous Perf/Boerhaave Syndromes usually occur?
Severe contamination
Medical instrumentation, MC in cercival esophagus at cricoparyngeal area
Left posterolateral wall, above GE junction
How do spontaneous perfs of the cervical or thoracic region present
Perfs of the thoracic region usually affect ? side
What finding may be heard on EP?
Cervical: pain radiating to back, crepitus, dysphagia, Sxs of infection
Thoracic: tachy, tachy, dyspnea HOTN
L
Mediastinal crunch w/ systole- Hamman sign
What will be seen on x-rays of esophageal perfs in cervical or thoracic regions?
What is the first and second test performed on all PTs w/ suspected esophageal perf?
What would be seen on fluid analysis of a thoracentesis?
Cervical: air in soft tissues
Thoracic: mediastinal widening, effusion, PTX
Esophogram w/ water soluble contrast, if no leak-
Repeat w/ barium
Chest CT- best to localize
Inc Amylase along w/ serum amylase if long standing
All spontaneous esophageal perfs receive ? ABX immediately
What type of PT is suspected of having Mallor Weis tear and what is the rule about them
Broad due to polymicrobes- Staph, Strep, Pseudo and Bacteroides
Non-bloody vomit to bloody vomit, stop w/out therapy
Since most resolve spontaneously, what surgical procedure is done if needed?
Ingestion of acids lead to ? necrosis and ingestion of alkalines leads to ? necrosis and result in ? perf
Injection, clipping, banding
Oversewn w/ anterior gastronomy and ligation
Coagulation- protein precipitation, eschar
Liquefactive- Frank perforation
How is the severity of a chemical injury in esophagus determined
How are these PTs Tx
pH, Volume, Contact time
Fluid and Support
Possible EGD
Frank perf/instability= surgery, reconstruction w/ colonic interposition
3 adverse outcomes from chemical burns on esophagus
Webs- fold into lumen in middle/lower 1/3, Dx w/ BSwallow; Tx dilation w/ Savary Bougies/balloon
Rings- lower 1/3, mucosal or muscular (no dysphagia/Schatzki at z-line w/ GERD; same Tx as webs
Stricture- end stage of reflux ulcerative esophagitis; Tx w/ acid suppression, biopsy and dilation
Carinoma of esophagus is primarily in ? PTs
Adenocarcinoma of esophagus usually appears in ? PTs
What are the MC RFs to squamous cell carcinomas?
Asia Africa Iran men w/ association to smoking, ETOH, Nitro and hot drinks
M w/ barretts, GERD*, obesity tobacco (lifestyle)
Smoking, Chronic alcohol
What is the MC Sx of esophageal Ca since they’re usually ASx
How are these growths viewed
What test is the most sensitive to assess the depth of penetration?
Dysphagia
Barium- location/extent
Endoscopy- visualization/biopsy
Bronchoscopy- if in upper/midesophagus
Endoscopic US- also allows for FNAspiration of nodes
How are esophageal Cas Tx
What is the goal of non-op Tx
What is the most important prognosis factor for esophageal Ca
pT1a- EMR/RFA
T1b/T2- esophagectomy
Rad/Chemo for advanced
Relief of dysphagia
Staging
Stomach passes through what two compartments of the body
Jejunum is AKA and starts at ?
Retro and Intraperitoneal
Vasa Recta
Ligament of Treitz
What are the 4 types of hiatal hernias
What test is excellent for assessing and which one is difficult to assess w/
1: sliding, GI contents move into mediastinum w/ burn/regurg MC sxs
2-4: paraesophageal hernia; risk for strangulation
Upper GI series w/ barium
-EGD
What test is done to assess hernias if PTs have functional dysphagia
What is the gold standard Tx for hiatal hernias
Cine-esophogram
Laproscopic Nissen fundo w/ MGJR
Obese is classified as BMI > ? and the only effective intervention is ?
What are the MC adverse effects of LAGB procedure
What are the criteria for PTs to be considered for surgery
> 30kg/m^2, bariatric surgery
Slippage
Pouch dilation
BMI >40/>35 w/ apnea, cardiomyopathy, DM
12-18/>65y/o w/ BMI 30-34.9 w/ obesity comorbidity
Non-surg Tx failure
? GI procedure has shown to inc survivability x 10yrs
What is the MC adverse Sx after surgery
What is the MC weight loss surgery done in the US?
RYGB
Dehydration, E+ imbalance
Most concerning- anastomotic leak
LSG
Gastric/pyloric ulcers are caused by ?
Difference in Sxs between gastric and duodenal ulcer?
What is the average incidence of gastric ulcers
H pylori NSAIDs Hypersecretory state (Zollinger Syndrome)
D: better w/ food
G: worse w/ food, less common though
40-60 or 10yrs older than duodenal ulcers
What is the most accurate method to Dx peptic ulcers
What lab test is useless unless PT has Zollinger Syndrome?
What does an ulcer seen on x-ray signify?
Endoscopy
Fasting serum gastrin
Ulcerated malignant tumor
What is the difference in ridges seen on endoscopy of Ca or benign ulcers
How many biopsys are taken during this procedure?
Ca- rolled edges w/ meniscus sign
Benign- flat edges
6 and brush biopsy from edge
What are the characteristic findings of PTs w/ ZES?
When are PTs screened for ZES?
Hypergastremia
Severe PUD
Non-B islet pancreatic tumors
Distal d/j ulcer
Refractory to PPIs
Recurrent despite Tx
How is ZES Dx
What is the imaging study of choice and how is it Tx
Inc fasting serum gastrin
Dec gastric pH
Inc basal acid
After 1wk of no PPIs
Somatostatin receptor scintigraphy
What is the H Pylori Tx of choice
What is the test of choice for confirming successful eradication?
Amoxicillin, Clarithromycin, Omeprazole x 7 days
Urea breath test
Surgical intervention is needed for bleeding ulcers if mor than ? packs are needed for transfusion
How are perforated duodenal ulcers Tx
> 6
Graham pathc- omental patch, patch w/out vagotomy needed
What are 3 complications that can occur after upper GI surgery
How is dumping syndrome managed
It is typically seen in PTs that had ? procedure
Post-antrectomy- leakage
Delayed emptying
>60% of stomach removed= loss of reservoir function
Diet therapy w/ low carb/high fat/protein diet to reduce jejunal osmolality
RYGB and foods w/ sugars
Dumping Syndrome can have ? 2 system Sxs
Gastric CA is predominantly seen in ? PT population
What is the primary Dx test
Cardio/GI
Japan, China
M>F , peak in 7th decade
Endoscopy w/ biopsy
? is the MC surgical d/o producing emesis in infants
What is the most sensitive/specific test for this condition?
Duodenal ulcers are not associated w/ ?
Pyloric stenosis
Abdominal US when muscles are >4mm thick/pylorus >16mm long
Cancer
Infants w/ pyloric stenosis will present in ? metabolic condition
PTs w/ duodenal ulcers must have ? procedure w/in 24hrs
Hypocholremic HypoK metabolic alkalosis
EGD
Initial management of PTs w/ UGI bleeds is ?
What is the therapeutic alternative if endoscopy fails to control bleeds?
Hemodynamic stability IV PPIs (Pantoprazole)
Angiographic embolization
Ulcers lasting longer than ? need to be resected to r/o GI Ca
What is the acid reducing procedure of choice in PTs w/ duodenal ulcers?
12wks
Selective vagotomy
What is the MC cause of SBOs
What is the difference in presenting Sxs of an upper or lower SBO
How does the PT present if there is a strangulation present?
Incarcerated hernias
Upper- emesis after eating
Lower- poorly localized abdominal pain
Fever, crampy pain turns to peritonitis
What Tx is mandatory for PTs presenting w/ SBO and strangulation
What are ominous signs of an incarcerated hernia?
Fluids, E+ correction
Cath to monitor I/Os
Decompress w/ NG tube
Fever Tachy AMS
Define Volvuli
How do PTs present
How are volvuli Dx
Closed loop obstruction w/ high risk of strangulation/infarct/perf
MC sigmoid then cecal
N/V massive distension, acute pain
Colonic- x-ray
SmInt: CT
PTs with a sigmoid volvulus will need surgery if presenting w/ ? Sxs or if volvulus is ? to sigmoid
Volvulus proximal to sigmoid have higher chances of ?
If Dx is unclear, what test is next
Toxic Blood per Rectum Leukocytosis/fever
Sxs absent= sigmoidscopy
Proximal
Strangulation
Barium enema
What type of sign may be seen on barium images in PTs w/ volvulus
What will be seen if volvulus is in cecal region?
Target
No air distally
Intussusception usually develops between ? ages in ? way
Other than obstruction Sxs and bloody stools, PTs present w/ ?
How is it Dx
How is it Tx
6mon-2yrs
Invagination of small bowel into cecum
Lethargy
Target sign on sonogram
Air and Contrast enema
High speed MVCs can generate ? abdominal trauma
Define Radicle
Mesenteric bucket handle tear= SBO
Smallest branch of vessel/nerve
What is a rare complication of gallstones that is actually a misnomer
Define Rigler Triad
Ileus- obstruction of small bowel by cholecystoenteric fistula
Gallstone ileus Dx:
Pneumobilia
Bowel obstruction
Gallstone in bowel
How are gallstone ileus’ Dx
What are the buzz words for Crohns
Normal Crohns is Tx w/ ?
CT
Cobble stone Skip lesion
5-ASA
Steroids ABX
What surgical procedure may provide Crohns PTs relief
What are the MC benign and Ca tumors of the small bowel
Malignant tumors tend to inc in frequency when heading in ? direction of the GI tract but w/ ? exception
Small bowel strictureplasty- longitudinal enterotomy close in horizontal fashion
B :Leiomyomas Adenomas
Ca: adenocarcinoma
Prox to Dist
Adenocarcinomas
What are the MC endocrine tumors of the GI tract
What is the MC presentation of benign tumors
Carcinoid
Episodic cramps w/ intussception, then chronic bleeds/IDA
Define Carcinoid Syndrome
Hot flashes
Bronchospasm
Arrhythmias
Associated w/ carcinoid tumors in GI tract and liver can’t compensate
Majority of small bowel malignancy are ? 3
Adenocarcinomas in the duodenum are Dx by ?
Lesions in first 100cm of small bowel are evaluated viz ?
Carcinoid
Adenocarcinoma
Lymphoma
EGD
Push enteroscopy
Define Bezoar
What are the 4 types
What is the MC culprit
Foreign material stuck in stomach/tract usuallly in post-gastreoectoy PTs
Phyto- vegetable fiber
Lacto- milk
Pharm- meds
Tricho- hair
Orange segments
Fruits w/ high cellulose
Cystic duct joins ? to form the ?
? artery feeds the R side of the liver and gallbladder
Common hepatic
Common bile duct
Cystic, branch of R hepatic
Location and function of Sphincter of Odi
Define Chole
Defie Cholecyst
Surrounds common bile duct w/ Ampulla of Vater.
Directs bile into duodenum/gallbladder
Bile/gall
Define Cholecystitis
Define Cholelithiasis
Define Choledocho
Inflammation of gallbladder
Stone in gallbladder
Bile duct
Define Choledocholithiasis
Normal gallbladder wall is ? thick
Name of therapeutic preferred procedure to view biliary tree, remove stones and view ducts in gallbladder
Stones in bile duct
4mm or less
ERCP
What test is a non-invasive way to view biliary tree and is equivalent to ERCP/cholangiogram
What is the advantage of this procedure
MRCP
No contrast
What is the most sensitive/specific study for Dx acute cholecystitis
If cystic duct is blocked, what will be seen during this procedure?
Cholescintigraphy (HIDA)- gives anatomic and functional info
Gallbladder not visualized
CBD and duodenum fill w/ tracer after 1hr
What is the MC abdominal surgery
What factors inc the formation of bile stones
Cholecystectomies
Estrogen- inc cholesterol
Hemolysis- inc unconjugated bili, collects as CaBilirubinate
Syptomatic Cholelithiasis usually present how?
What PTs w/ chornic cholecystitis are recommended for MRCP
Post-high fat meals
Transaminitis
H/o biliary pancreatitis
CBD dilation
If PT is not candidate for cholecystectomy, what can be attempted for non-surg Tx
How do PTs w/ acute cholecystitis present
When/why would a HIDA be done?
PO ursodeoxycholic acid (UCDA), most effective if stone is <15mm
ESWL if stones are <2mm
Pain N/V/F
Neg/equivocal US
What is the optimum time for performing laproscopic cholecystectomy
Define Primary/Secondary Choledocholithiasis
72hrs since Sx onset
P: stricture and choledochal cyst
S: gallstone in CBD
How does choledocholithiasis present
This condition is a leading etiology of ?
What will be seen on lab results
Abd pain radiating to back
Acholic stool
Jaundice
Pancreatitis
Leukocytosis
Inc Serum bilirubin
Inc ALP
What PTs are considered high risk w/ suspected choledocholithiasis
Define Charcot’s Triad
Define Reynold pentad
> 55y/o
Bili >30
CBD >6mm
Visible stone on US
Cholangitis- Biliary colic Jaundice Fever
Charcot w/ HOTN and AMS
What are the predominant microbes in cholangitis
What procedure is dangerous during this condition
E coli Klebsiella Pseudomonas Enterococci Proteus
Cholangiography
Most cases of cholangitis can be Tx w/ ? ABX
What are the indications for a cholecystectomy
Cipro + Metron
Sx cholelithiasis
Cholecystitis
Cholangitis
Cholangiocarcinoma
Open cholecystectomy is done via ? incision
? division puts liver in 8 segments
Where does the common hepatic artery arise from
Kochers
Couinaud
Celiac axis
What is the portal triad
Liver is the only source for ? and ?
Production of ? is the primary index of hepatic function
Hepatic artery
Portal vein
Biliary duct
Albumin Alpha globulin
Serum protein
Vit K dependent clotting factors made in the liver
What is the MC sequelae injury after the MC trauma of blunt force trauma?
If arterial psuedoaneurysm forms, how are they best Tx
2 7 9 10
Biliary fistulae
Hepatic arteriography/embolization
What are the findings if pneumobilia is present
Define Biloma and how are they Tx
Ischemic bowel
Necrotic gall bladder
Isolated collection of bile
ERCP and sphincterotomy
What is the most common hepatic cyst
What type of liver cyst should not be aspirated but only resected
What is the name of a pre-malignant liver cyst
Simple
Echinococcosis
Cystadenoma
Define Cyst Fenestration
What type of Polycystic liver dz needs a transplant
What is the MC liver tumor
Type I PLD: <10 cysts 10cm or larger
Type 3
Hemangioma
Hepatic adenomas may be associated w/ ? Hx
Define Focal Nodular Hyperplasia
What is the major RF for hepatocellular carcinoma
OCP
Androgen steroid use
Female 30-50 w/ hot nodule
Liver Dz- Hep B/C Aflatoxin B1 A1-antitrypsin Hemachromatosis Primary cirrhosis
Define Acute Liver Failure
Define Fulminant hepatic failure
What is the primary cause of Acute liver failure
No liver Dz, dz develops w/in 8wks of onset
Encephalopathy w/in 2wks of jaundice onset
Tylenol toxicity
What can be give to PTs w/ chronic liver dz to prevent first bleed
Define Budd-Chiari syndrome
BBs
ALF in women w/ hpercoagulable states
Main pancreatic duct is called ?
Accessory duct is called ?
First sign of pancreatic head adenocarcinoma
Wirsung
Santorini
Jaundice
Exocrine glands of pancreas are called
Best Dx imaging for pancreatitis is ?
Dx reqs two of what 3 criteria
Acini- enzymes, pancrease fluid, E+
CT w/ contrast
Abd pain
Serum amylase/lipase
CT/MRI finding
Define BISAP acronym
What is the most useful serum test in pancreatitis
Bedside index of acute pancreatitis severity BUN >25 Impaired mental status SIRS Age >60 Pleural effusion
CRP >150
? Tx step is required in all pancreatitis PTs
What is the clinical tetrad of chronic pancreatitis
What metabolic abnormalities are sometimes seen
Chemoprophylaxis
Abd pain
Weight loss
Diabetes
Steatorrhea
Hyper Ca/TG
Large duct pancreatitis are Tx w/ ? procedure?
Smalle duct is Tx by ?
Puestow or Frey
Whipple Beger Frey
What is the 2nd MC GI tract malignancy
What is a defining characteristic of this type of Ca
Ductal adenocarcinomas
Aggressive
How does pancreatic cancer present
These PTs get ? scans in order
Biliary obstructions w/: courvoiser sign, acholic, dark urine, jaundice
All get CT
ERCP if no masses
Upper GI series
What is the operative procedure of choice for pancreatic cancer
What is the most common PNET
What are the Sxs related to
Whipple- pancreaticoduodenectomy
Insulinoma
Cerebral glucose deprivation
Weight gain
Define Whipple Triad
How are insulinomas Dx
Dx criteria for insulinoma:
Hypoglycemic
Glucose <50 during Sxs
Relief of Sxs by IV glucose
72 monitored fast: glucose insulin, c-peptide, proinslin, b-hydroxybutyrate
What is the MC type of gastrinoma
Most are located within ?
PNET in MEN-1
Gastrinoma triangle:
pancreatic neck
2 and 3rd portion of duodenum junction
Cystic and Common duct juntion
How do PTs w/ gastrinoma present
How is it Dx
All PTs w/ MEN-1 should be screened for ?
Abd pain and diarrhea w/ absent PUD
Fasting serum gastrin >1000pg
If level is borderline, do secretin provocation test
HyperCa
Parathyroid adenoma
75% of accessory spleens are located ?
What are the major functions of the spleen
Splenic hilum
Red pulp- hematologic
White pulp- ImmGbn
Marginal zone- macrophage, B-cell
PTs w/ ? Sxs due to trauma may need spleenectomy
What procedure may be done it PT is responding to bleeding control/resuscitation efforts
HOTN
Coagulopathic
Acidotic
Hypothermic
Splenorrhaphy/mesh wrap
? type of micrboes are of concern in post-op spleen PTs
When do these PTs need to get vaccines
Encapsulated: Strep Pneumo, H flu, Meningococcus
2ks prior to elective surgery
2wks after emergent surgery
On day of d/c if <2wks
3mon after chemo/rad
