Surgery Block 1 Cram Flashcards
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
? 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
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
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
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
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
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
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
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
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
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
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
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
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
90% of colonic polyps are ? type
How are neoplastic polyps classified
Non-neoplastic: juvenile hyperplastic inflammatory
hamartomas
Haggitt- lowest is ‘in situ’
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
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
IDA is Dx as ? until further workups
What labs are drawn
Colon Ca
CBC CMP CXR
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
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
What PTHx indicates considering prophylactic colectomy
What is done prior to resection?
Familial polyposis
Neoadjuvant radiation and/or Chemo
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
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
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
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
