Surgery Block 1 Cram Flashcards by brandon lovin

Taenia coli run the length of the colon except for where?

What compartment does the large intestine pass through at different points

Appendix
Rectum

Ascending: retro
Transverse: intra
Descend: retro

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? part of the large intestine is vulnerable to volvulus

Where do diverticula grow

Sigmoid

Between mesneteric tenia and two non-mesenteric teniae
Majority: pseudo: miss muscular layer
Minority: true, predominant in R colon

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Define Diverticulitis

Diverticulitis usually present s w/ ? but absent of ?

Diverticulosis usually presents ? PT population and in ? part of the colon

Inflammation of diverticulum

Pain, no bleeding

> 80y/o, sigmoid

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What are the RFs for developing diverticulosis

What medications could be considered protective

Constipation + low fiber diet
NSAIDs/acetylsalicylic acid
R side diverticula
HTN or Ischemic heart Dz

CCBs
Statins

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What is the MC cause of lower GI bleeds

What process causes this to happen

Diverticulosis- BRBPR w/out abdominal pain

Thinning in vasa recta wall of out pouching

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Ligaement of Treitz is at the junction of what two parts of small intestine

How are all suspected GI bleeds investigated

How is the source identified

Duodenum
Jejunum

DRE
Anoscopic

NG lavage- r/o upper
Colonoscopy- optimal, Dx and Thx

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What does endoscopic therapy done for GI bleeds include

What is the next step for lower GI bleeds after negative colonoscopy

Epi injection
Bipolar coagulation
Mechanical therapy

Tagged RBC scan before angiography
CT angiography- Dx and Thx

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Indications for surgery due to lower GI bleeds

What two procedures are considered fro Tx

Hemorrhage
>6 unit transfusion <24hrs
Recurrent diverticular bleed

Segmental resection
Total colectomy

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Classic Sxs of UnComp Diverticulitis

What is seen on PE

LLQ pain
Low fever
Const/Diarrhea w/ urgency

LLQ guarding/rebound tender
Palpable mass
Trace stool blood

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How is complicated diverticulitis Tx

Define Colovesical fistula

Define Colovaginal fistula

Small abscess- ABX, rest
Large- ABX Rest Percutaneous drainage

Pneumaturia, pain, fecaluria; Tx w/ elective resection

Gas/stool through vagina or foul smelling d/c

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What type of diverticulitis complication required immediate emergent surgery

What is the standard of care imaging modality for diverticulitis

What is avoided in these PTs

Free perf

CT w/ contrast- MC findings: thickened wall, inflammation, diverticula

Colonoscopy, 8wks later
Flex Sigmoid

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How is acute uncomplicated diverticulitis Tx

If these PTs are admitted for Sxs, complications or PO intolerant, how are they managed?

Bowel rest
ABX gram- and aneareobes: Cipro and Metronidazole x 7-10 days
Colonoscopy 8wks later for Ca screening

Clear liquid diet
Repeat CT
IV ABX
Surg consult

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When is elective Tx offered for diverticulitis

What is the name of the procedure

Stricture High risk Abscess
Perf Fistula

Hartmann procedure: sigmoid resection + end colostomy (preferred for perfs)
Primary anastomosis w/ or w/out diversion
Interval colectomy

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What are the most significant RFs for colorectal cancer?

What colon finding indicated PT is at increased risk for CRC?

Non-modifiable
Mod: red/processed meat consumption, smoking/ETOH

Adenomas- villous* tubular tubularvillous
Tx: polypectomy w/ inc surveillance
Surgery if endoscopic resection not possible

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90% of colonic polyps are ? type

How are neoplastic polyps classified

Non-neoplastic: juvenile hyperplastic inflammatory
hamartomas

Haggitt- lowest is ‘in situ’

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When are colorectal screenings started

What is Tier 1

What is Tier 2

What is Tier 3

USMSTF- 50y/o
ACS- 45y/o

No Ca/adenoma in any FamHx: colonoscopy q10yrs or FIT q1year; start 45 AfAm, 50 for others

Ca/adenoma in Fam Hx >60y/o: CT colonoscopy q5yrs, FIT q3yrs or FlexSig q5yrs

Capsule endoscopy q5yrs

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CRC is the MC cause of colon obstruction in adults, how does it present if it’s L sided, R sided or rectal?

L: hematochezia obstruction thin stools

R: anemia occult blood
RUQ mass

Rect: hematochezia
tenesmus, metastass in PoD/Blumer shelf

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IDA is Dx as ? until further workups

What labs are drawn

Colon Ca

CBC CMP CXR

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What lab is drawn post-op to monitor for colon Ca recurrence

What procedure is done if colonoscopy can’t be done for colon Ca staging

What test is reserved only for high risk PTs

CEA

CT colonography or,
Air contrast barium enema

PET

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What is curative/palaltive Tx for colon Ca

What two organs need to be examined for metastases

Cur: removes all Ca and nodes
Pall: remove tumor to avoid obstruction/bleeding

Liver Lungs

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What PTHx indicates considering prophylactic colectomy

What is done prior to resection?

Familial polyposis

Neoadjuvant radiation and/or Chemo

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How is the extent of colon resection dictated by the location of the primary tumor?

Cecum/ascending: R hemicolectomy

Hepatic: extended R colectomy

Transvserse: R/L/transverse colectomy

Splenic- L hemicolectomy

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What are the two procedures done for CRC

What are the MC causes of colonic obstruction

Anterior resection
APR- loss of rectum, incontinence

Colon Ca*
Stricture
Diverticulitis

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Bowel obstruction typically present w/ ? Sx then progresses to ?

What is the single most useful test during a colon obstruction work up

Pain
Distention N/V Obstipation

CT of abdomen/pelvis

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What are the DDx for colon obstruction

Volvulus: cecal or sigmoid, more common in elder; Colonoscopy w/ f/u surgery Abscess- perf appendicits or diverticulitis; suspected if PT has persistent leukocytosis Hirschprung- lack of relaxation builds up feces UC: no granulomas, distal to proximal inflamation CD: bear claw ulcer, noncaseating granulomas

How does UC present How does CD present Both can present w/ or w/out ? extraintestinal manifestations

Proctitis, bloody/mucus stool CD: systemic Sxs, aphthous ulcer, dysphagia, anal dz Skin lesion Osteopenia Sclerosing cholangitis Eye stuff

What is the only 'cure' for UC What is makes the hemorrhoid cushion

Total proctocolectomy R anterior/posterior L lateral aspect of anal canal

Internal hemorrhoids are lined w/ ? and innervated by ? External hemorrhoids are lined w/ ? and innervated by ?

Columnar mucosa, visceral (outpt) Squamous, somatic (anesthesia)

What are the MC Sxs of hemorrhoids? What procedures are warranted for pts w/ hematochezia and IDA

Bleed Protrusion Pain Anoscopy Proctosigmoidoscopy

How are internal hemorrhoids graded What is the goal of Tx

1: bleeds 2: prolapse, reduces alone 3: prolapse, manual reduction 4: always prolapsed Large soft stools w/ colace/metamucil

What meds can be used topically for hemorrhoids What surgical procedures can be done for Tx

Nitro or CCB Sclerotherapy Band ligation Excision- if acute large thrombosed and ID'd w/in 72hrs

Rectal prolapse is AKA What populations are these likely in?

Rectal procidentia Constipated Female/post-meno SurgHx

What is the difference between prolapse or hemorrhoid Majority of anal malignancy are ?

Pro: circumferential folds of mucosa Hem: radial pattern of 3 bundles Squamous cell- rolled everted edge w/ central ulcer Tx: excision Chemo: best initial Tx APR: recurrent, residual or bulky

What is the MC endocrine tumor of the GI tract When are these concerning?

Carcinoid- hot flashes, arrhythmia, bronchospasms 1-2cm: 50% chance of node involvement >2cm: 80% have + nodes

Who is more likely to have anterior fissures What is the etiology if the fissure is lateral or in multiple locations What are the leading causes of these?

Women Crohns Syphilis TB SCCa Const/diarrhea Strain/heavy lifting

How are fissures Tx w/ topicals What surgical procedure is done and why is it preferred

Nitro and Nifedipine Lateral intenal sphincterotomy- avoid key hole deformity

# Define Perirectal abscesses Define Perianal abscess

Crypto infection Tx w/ InD Superficial abscess, Tx in ED Horse shoe abscess= inc risk of fistula

Perianal abscess post-Tx doesn't include ABX unless ? is present What causes Pilonidal dz

Cellulitis Jeep Seat Dz: infect hair follicles develop abscesses

What is the MC condition that simulates Pilondial Dz How are Pilondials Tx w/ surgery

Hidradenitis suppurativa: infection in axilla, groin and perineum, not just in intergluteal cleft Bascom

What are the three functional folds that prevent rectum from being strait? Main and accessory duct of pancreas

Valve of Houston Main: Wirsung Acc: Santorini

Why is jaundice often the first presenting sign of pancreatic head adenocarcinoma How does the Cullen sign form Exocrine glands of pancreas are called

Close relation to CBD Extravasation follows falciform ligament to umbilicus Acini

Inc pancreatitis prevalence is linked to ? epidemic Biliary pancreas Dx is suspected w/ ? lab results

Obesity Galls stones seen Abnormal LFTs

Why does pancreatitis present w/ N/V What is the gold standard for IDing acute pancreatitis

Paralytic ileus Serum pancreatic enzyme: Amylase cleared quickest Lipase/Elastase last >96hrs Most accurate: serum lipase > 3x N

What images are taken for pancreatitis Dx requires two of thwat 3 criteria

CXR- effusion means poor prognosis RUQ sonogram CT w/ contrast- most accurate, establishes Dx, staging, severity Abd pain Serum amylase/lipase CT/MRI findings

Severity of acute pancreatitis can be estimated w/ ? scoring systems What is GALLA How much fluid can be gained

Glasgow Ranson APACHE II BISAP Glucose Age Leukocytosis/Lactate AST 6L

What is BISAP What is the most useful serum test for acute pancreatitis for severity measurement

``` Bedside pancreatitis severity measurement BUN >25 Impaired AMS SIRS- systemic inflamm Age >60y/o Pleural effusion ``` CRP

What type of fluids are used for pancreatitis resuscitation What chemoprophylaxis is mandatory for all PTs

.9% NS or LR for first 24hrs Gastric antisecretory Anticoagulants

How are different severity of pancreatitis Tx

Mild edematous- let PT eat PO as long as no N/v Mild biliary- elective laparascopic cholecystectymy and chlangiography Severe and evidence of cholangitis- ERCP w/ or w/out endoscopic sphinctertomy for stone extraction

How are pancreatic pseudocysts Tx Define pseudoaneurysms

Parenchymal resection Sequelae of pseudocyst: confirm w/ cross section image,

What lab result may be elevated due to pancreatic trauma How is it Dx Injuries to the ? need to be r/o

Amylase Intraoperatively w/ laparotomy- drain or resect Lumbar spine

How does chronic pancreatitis develop What is the clinical triad

Chronic alcohol Inflammation of glandular fibrosis causes end/exocrine insufficiency (DM/steatorrhea) Steatorrhea Ab pain Weight loss DM

What functions need to be assessed in PTs w/ chronic pancreatitis What metabolic abnormalities may be seen?

Renal Hepatic Nutrition HgA1c and fecal elastase HyperCa HyperTG

How is chronic pancreatitis Dx Majority of pancreatic neoplasms are ?

Duct w/ MRCP/ERCP Morhology w/ CT/MRI Ductal adenocarcinomas- 2nd MC GI tract malignancy

What is the defining characteristic of pancreatic ductal adenocarcinomas What is the MC manifestation of pancreatic cancer

Aggressiveness Biliary obstruction: acholic stool, dark urine, jaundice Courvoiser sign

What labs are drawn on all PTs w/ jaundice or epigastric pain What image is ordered

Serum aminotransferase Alkaline phosphatse Bilirubin (18mg if +neoplasm) CT No mass= ERCP

How are pancreatic Cas Tx What is the MC functional PNET and how do they present

Resection Whipple- TxOC Chemo/rad Insulinoma- cerebral glucose deprivation= AMS/LoC Palpitations Sweat/Tremor

How are Insulinomas Dx criteria How is it Dx

Whipple Triad: Hypoglycemic Sxs Glucose <50 Sx fixed w/ IV glucose 72hr monitored fast

Gastrinomas are MC in ? PTs They're normally in the gastrinoma triangle which is ? How do they present

60-90% malignancy in PNET in MEN-1 Pancreatic neck 2/3rd duodenum sections Cystic/CBD junction Abd pain/diarrhea* w/ refractory PUD

How are gatrinomas Dx All PTs w/ MEN1 need to be screened for ?

Fasting gastrin >1---pg= Dx Borderline gastrin= secretin provocation HyperCa Parathyroid adenoma/hyperplasia

What is the most important prognosis factor of gastrinomas Define Splenomegaly Define Hypersplenism

Liver metastases Enlarged spleen from EBV/T cell lymphoma Unregulated intrinsic activities, panctyopenia

Why would spleens be removed What are the MC reason for splenectomy

Benign hematologic Dz Sx relief of splenomegaly ITP that fail 60mg Prednisone Tx

? type of trama indicates need for splenectomy ? indicates option of a splenorrhaphy

HTON Coagulopathic Acidotic Hypothermic + response to bleeding control/resuscitation

What is the post-op splenectomy complication

``` OPSI- Tx w/ ABX empircally Post-op vaccines: Strep pneumo H Flu and Meningococcus (encapsulated) 2wks prior to elective 2 weeks after emergent removal On day of discharge if <2wks 3mon after chemo/rad ``` Thrombocytosis- Tx w/ ASA