Surgery Clerkship Flashcards
Cause and clinical features of air embolism
- Caused by severe chest trauma resulting in damage to the airways and vessels which cause mixing of the air and blood.
- Patients present with neurological deficits, hemoptysis, and circulatory arrest.
Telling difference between SBO and paralytic ileus:
- SBO will have “tinkling” as opposed to absent bowel sounds
- SBO will show proximal distension on plain films and distal collapse, as opposed to pan-distension in paralytic ileus
Findings on exam and imaging in perforated viscus:
- Exam will show peritonitis
- Imaging will reveal air under the diaphragm
Pathogenesis of paralytic ileus:
Not really well known, but can happen post-op or from injuries causing vertebral fractures and retroperitoneal hemorrhage.
Important causes of post-op fevers and the post-op day on which they occur:
Atelecatasis - Day 1
- “Wind” (Pneumonia) → 1-2 days post-op
- “Water” (UTI) → 3-5 days post-op
- “Walking” (DVT) → 4-6 days post op
- “Wound” (Wound infection) → 5-7 days
- “Wonder Drugs” (Drug associated) → ≥7 days
Signs of splenic injury:
Fluid (blood) in the spleno-renal space on FAST
LUQ pain
Kehr’s Sign
Left Sided Lower Rib Fractures
DVT treatment
Bridging heparin + coumadin
Coumadin tx should continue for approximately 3 months
Best treatment for acute cholecystitis:
Intial supportive care with fluids and observation
Laparoscopic cholecystectomy within 72 hours of presentation
Define “Mild TBI” and explain how to manage it:
Mild TBI is a head injury with a GCS of 13-15 and a brief LOC, vomiting, headache, or disorientation
Management = head CT; if normal then send home with clear instructions to return if any abnormalities arise
Clinical features, pathogenesis, and prevention of Bacterial Parotitis
- Presents with parotid swelling, oral purulent exudate, fever, leukocytosis
- Typically S. aureus infection of the parotid duct.
- Prevent with adequate oral hygiene and hydration of patients.
Fat necrosis:
- Similarities to breast malignancy:
- Differences from breast malignancy:
- Nipple retraction, fixed mass, calcifications, similar US findings
- Calcifications are coarse in fat necrosis–not fine; biopsy reveals fat globules and foamy histiocytes.
Nasopharyngeal Carcinoma (NPC)
Define
Clinical presentation
Risk Factors
This is an undifferentiated carcinoma of sqaumous cell origin.
Patients typically present late in the course, once the disease has already spread. There is recurrent epistaxis, sinusitis, otitis media, nasal obstruction.
Risk factors include Mediterranean or far Eastern decent; smoking; EBV infection.
Treatment for pneumothorax:
Chest tube inserted in the 2nd intercostal space on the midclavicular line
Explain directionality of trachea shift:
Trachea shifts toward the problem in (1) spontaneous PTX; (2) pneumonectomy
Trachea shifts away from the problem in (1) tension PTX; (2) traumatic PTX.
Different types of foot ulcers and their specific findings:
- Venous Insufficiency Ulcers: typically located on the medial aspect of the leg, just above the medial malleolus and associated with overlying stasis dermatitis, and chronic lower extremity edema
- Arterial Insufficiency Ulcers: Lateral aspect of the ankle or the distal digits
- Diabetic Ulcers: typcially on the sole of the foot and are painless.
Pathogenesis of diabetic foot ulcers:
Combination of:
(1) Neuropathy
(2) Microvascular insufficiency
(3) Relative immunosuppression
Etiology of whistling sound on respiration in rhinoplasty patient:
Septal Perforation
Septal cartilage has a very poor blood supply–coming completely from the overlying mucosa. Therefore minor septal trauma can cause ishemia of the underlying collagen.
Acalculous cholecystitis
Clinical Presentation
Diagnosis
Treatment
Patients will present with other severe illness, like burns, trauma, sepsis, etc. Due to the bad nature of these inciting injuries, they also commonly have paralytic ileus. Other than that they will have exactly the same symptoms as a patient with acute calculous cholecystitis if they can interact with you.
Diagnose with the various imaging studies, which should reveal dilated gall bladder, thickened wall, pericholecystic fluid, and no stones.
Can treat immediately with percutaneous drainage and supportive care and quickly move onto cholecystectomy.
Complicated Diveritculitis
Define
Treatment
This is diverticulitis that has associated obstruction, perforation, fistula, or abscess.
Treat with IV antiobiotics and drainage if an abscess, and the appropriate therapies for the other causes.
Most common and serious complication of Roux-en-Y gastric bypass surgery:
Leakage of the gastro-jejunal anastomosis
Role of steroids in Crohn’s Disease:
These are only used in patients refractory to antimicrobial (metronidazole / cipro) and anti-inflammatory drugs (5-ASA).
They are not indicated for maintenance therapy–only treatment of acute exacerbations.
Budesonide
Define
Indications
Pros and cons
This is a corticosteroid.
Used for asthma, COPD, and Crohn’s disease.
It is metabolized more rapidly than prednisone and therefore has few side effects. However it is not as potent, and therefore in Crohn’s disease it is only used in mild to moderate flare-ups–as opposed to the more severe flare-ups which are treated with prednisone.
Factors associated with disease recurrence in Crohn’s
Smoking
NSAIDs
Infliximab
Define / MOA
Indications in Crohn’s Disease
Drawbacks
This is a chimeric monoclonal antibody directed against the TNF-a receptor, and is used in inflammatory conditions such as Crohn’s.
In Crohn’s it is used in (1) patients refractory to all other medical treatments; and (2) as a first line therapy for fistulizing Crohn’s in order to stear clear of operations.
Drawbacks include: opportunistic infections and development of B-cell lymphomas.
Most common site for Crohn’s Disease:
Terminal Ileum + Cecum
Clinical Features of IBD
UC?
CD?
UC: (1) Bloody diarrhea; (2) Abdominal Pain; (3) Small frequent bowel movements; (4) rarely fever, anorexia, and weight loss; (5) Tenesmus; (6) Extra-intestinal symptoms
CD: (1) Watery diarrhea; (2) Commonly malabsorption and weight loss; (3) Abdominal pain; (4) Fever, malaise; (5) Extra-intestinal symptoms
The Extra-Intestinal Symptoms of IBD:
- Uveitis
- Erythema Nodosum (esp. CD)
- Pyoderma gangrenosum (esp. UC)
- Migratory monoarticular arthritis
- Ankylosing Spondylitis (esp. UC)
- Thrombo-embolic hypercoaguable state
- ITP
- Osteoporosis
- Gallstones (in CD due to ileal involvement)
- Sclerosing Cholangitis (UC)
Medications used for Crohn’s
- Start with 5-ASA (which is best for the colon, and inhibits prostaglandin release)
- Metronidazole + Cipro if 5-ASA fails
- Steroids if anti-microbials fail and for acute exacerbations
- Azathioprine + 6-mercaptopurine + steroids if steroids fail.
- Infliximab (anti-TNFa) if all others fail or first line for fistulas.
UC involves _____ in all cases.
the rectum
Most serious and severe complications of UC:
- Colon Cancer
- Cholangiocarcinoma
- Sclerosing Cholangitis (even with colon removed)
- Toxic Megacolon
- Iron deficiency anemia (hematochezia)
- Hemorrhage
- Electrolyte disturbances
- Strictures
- Growth Retardation
Medical Management of UC:
5-ASA is the mainstay
Prednisone for acute flares
What is going on here?
This is an “ileal J pouch” which is what is used to create a new anus for a UC patient who had their entire colon resected due to their disease.
Main indications for surgery in UC:
- Fulminant colitits / Toxic Megacolon
- Dysplasia
- Cancer
- Intractable Disease
Define fulminant colitis / Toxic Megacolon
Fulminant colitis: characterized by severe abdominal pain, fever, and sepsis which is normally caused by IC, but can also be caused by CD or pseudomembranous colitis.
Toxic Megacolon: is essentially fulminant colitis with proven dilation of the colon proven by radiographic evidence. This occurs when there is invasion of the muscularis propia by the disease.
Typical symptoms of sciatica:
Lower back pain and radicular pain shooting down the leg.
Worsened by moving around, sitting, and lifting extended leg straight up.
Improved by lying supine.
The most commonly herniated disc:
L4-L5
Followed closely by L5-S1
Cauda Equina Syndrome
Clinical presentation
Etiology
Diagnosis
Treatment
Patients present with lower back pain, accompanied by difficulty voiding urine and making bowel movements
A number of causes including: (1) herniated disc; (2) Trauma; (3) Spinal stenosis; (4) Tumor
Diagnose by MRI
Treatment with surgical decompression of nerves.
Treatment for herniated discs:
Initially conservative by resting and NSAIDs. This can resolve many disc herniations.
If no improvement or worsening then perform laminectomy.
What is this?
This is a diagram of the Kasai Procedure in which a the biliary tree is cut down flush to the liver–leaving the porta-hepatis.
A roux-en-Y procedure is then performed in which the jejunem is attached to the porta hepatitis and the distal duodenum is anastomosed to the jejunem.
Primary complications of Kasai Procedure and how they are managed:
Cholangitis - IV antibiotics against gram negatives + steroids
Cessation of Bile Flow - Steroids + Cholerectic agents
Portal HTN - liver transplant, management of related complications
Presentation of cholangitis following Kasai Procedure:
Fever
Leukocytosis
Conjugated hyperbilirubinemia
Management of biliary atresia based on age of patient:
Biliary atresia is optimally treated by Kasai procedure before patient is 120 days old.
If the patient is older than this at time of diagnosis they need to be on the list for a liver transplant.
What to do preoperatively for a patient with biliary atresia or choledochal cyst:
Perform coagulation study and appropriately administer vitamin K and FFP.
Assess anemia, and appropriately administer Cross-matched blood.
Differential diagnosis for dysphagia (break it up):
Broken down into issue swallowing solids and liquids or solids alone.
- Solids and Liquids: If only intermittent –> likely a spasm. If progressive –> achalasia, or scleroderma.
- Solids only: If intermittent –> lower esophageal ring. If progressive –> cancer or peptic ulcer.
Risk factors for SCC vs Adenocarcinoma of the esophagus
SCC: (1) EtOH; (2) Caustic material; (3) Smoking; (4) Nitrite / Nitrate containing foods.
Adenocarcinoma: (1) GERD; (2) Obesity; (3) Acid Suppression medications
Esophageal Cancer
(P / D / T)
Presents with dysphagia most commonly, and possibly other symptoms related to neoplasms like weight loss and cachexia.
Diagnose with first a barium esophagram, then a esophagogastroduodenoscopy + biopsy, and TES-US to stage depth and regional nodes, and CT or PET for distant metastasis.
Treat with chemoradiation and (1) transthoracic esophagectomy or (2) transhiatal esophagectomy for stages I-III. Stage IV can be treated palliatively with chemo.
Schatzki’s Ring
Submucosal circumferential ring in the lower esophagus often associated with hiatal hernia.
Can cause dysphagia.
Most common infections in the post transplant period and timing:
Best way to prevent:
Bacterial are most common in the first month after transplant
After that opportunistic infections are more common (CMV, Pneumosystis, aspergillous, toxoplasmosis, cryptococcus, blastomycosis).
Prevent with prophylactic trimethoprim-sulfamethoxazole
Most common anti-rejection drugs used for transplant and their specific uses and mechanisms:
Corticosteroids - used for acute rejection, works at several sites in the anti-rejection pathway.
Cyclosporin - used for more long term therapy; inhibits calcineurin and IL-2
Tacrolimus - More long term therapy; inhibits calcineurin, IL-2, IL-3, and IL-4
Sirolimus - longer term therapy; T-cell inhibitor
Mycophenolate Mofetil (MMF) - longer term therapy; inhibits B and T cell proliferation, often combined with cyclosporin.
Azathiopurine - longer term therapy; inhibits B and T cell proliferation, often combined with cyclosporin. Used when MMF doesn’t work.
OKT3 - Induction or acute rejection treatment; monoclonal Ab against CD3 receptor of T-cells
GFR cutoffs for transplant and dialysis:
20 for transplant
15 for Dialysis
Radiosensitivity of esophageal SCC
Extremely sensitive`
Chronic Allograft Nephropathy =
Refers to fibrotic changes in transplanted kidneys which are accelerated due to their allograft (non-autograft) state. This occurs years down the line.
Presents with progressive increases in serum Creatinine, protein, oliguria, and microscopic hematuria
Diagnosis is by biopsy
No treatment
Best imaging for acute osteomyelitis
Radionucleide scan with gallium or something else
Splenomegaly in ITP
Rare.
If present look for another cause of thrombocytopenia
OPSS:
P / D / T
“Overwhelming Post-Splenectomy Sepsis”
Presents as non-specific symptoms like: fever; malaise; headache; confusion. But can rapidly progress to shock and death.
Diagnosed clinically
Treatment is primarily based on prevention with administration of vaccines for encapsulated bacteria; as well as medical surveillance.
Factors predisposing to OPSS:
Children
Splenectomy for hematologic rather than traumatic disorder
Explain the grades of splenic injury:
What is this?
Greenstick fracture
An incomplete and angulated fracture of long bones common in children due to the thick periosteal membrane
What is going on here?
What else needs to be checked?
Bilateral comminuted calcaneal fracture aka “Jumper’s Fracture”
Pelvic and spinal fractures need to be assessed–particularly the thoracolumbar junction.
What is going on here:
Salter Harris Type II Fracture of the radius close to the growth plate
What do you think is going on here?
This patient had a pathologic fracture of the humerous–most likely due to cancer in the bone.
The divots in the bone here are sites of tumors
