surgery - GI, Trauma, Neuro Flashcards
most common causes of acute pancreatitis in men, women and kids?
men- EtOH, women - gallstones, kids- mumps
Cullen’s (periumbilical ecchymosis), Grey Turner (flank ecchymosis) - these are signs of what?
acute pancreatitis
S+S: epigastric pain (constant, boring, radiating to back), worse if supine/eating/walking, relieved w/ leaning foward/sitting/fetal position. What is the GI Dx?
acute pancreatitis
abd Xray = sentinel loop = localized ileus (dilated small bowel in LUQ), “colon cutoff” = abrupt collapse of colon near pancreas. what is the Dx?
acute pancreatitis
txt for acute pancreatitis? what if its severe necrotizing? what if there is obstructive jaundice?
“rest the pancreas”- supportive (NPO, IV fluids, analgesia)
Abx only if severe necrotizing
ERCP only if obstructive jaundice
triad of S+S for chronic pancreatitis?
triad- 1. Calcifications 2. Steatorrhea 3. DM. Also weight loss
labs for acute vs chronic pancreatitis?
acute- amylase/lipase elevated
chronic- amylase/lipase NOT elevated
pathophys of acute cholecystitis? what are the organisms?
gall bladder (cystic duct) obstruction by gallstone → inflammation/infection. Same bacteria as cholangitis: MC - Ecoli, Klebsiella, Enterococci.
what is a positive Boas sign?
referred pain to right shoulder (phrenic nerve irritation) - occurs with acute cholecystitis
US (gallbladder thickened >3mm, distended, sludge, gallstones, pericholecystic fluid)
cholecystitis
what is a HIDA scan used for? what is a positive finding?
confirms cholecystitis after US, no visualization of gallbladder = positive
cholecystitis txt plan
NPO, IV fluids, abx (ceftriaxone + metronidazole) → cholecystectomy.
*if nonoperative - drainage of gallbladder (cholecystotomy)
Pain control w/ NSAIDs + narcotics
acute acalculous cholecystitis - what is it and what is it from?
due to sludge not stones. MC is severely ill from dehydration, prolonged fast, total parenteral nutrition, gallbladder stasis, burns, DM
what is the Dx? Strawberry GB (interior of GB resembles strawberry from cholesterol submucosal aggregation) → porcelain GB (premalignant condition)
chronic cholecystitis
MC area for diverticular dz?
sigmoid colon (highest intraluminal pressure).
MC cause lower GI bleeding but usually asymp?
diverticulosis
txt for diverticulosis if bleeding persists even after a high-fiber diet?
vasopressin
txt plan for diverticulitis
clear liquid diet, abx (cipro or bactrim + metronidazole)
2 most common causes of small bowel obstruction?
post-op adhesions. 2nd incarcerated hernias
4 hallmark signs of small bowel obstruction?
“CAVO”
Cramping abdominal pain
Abdominal distension (more distal = more prominent, +/- dehydration and electrolyte d/o)
Vomiting (bilious if proximal)
Obstipation - late finding, diarrhea is early
abdominal xray = air fluid levels “step ladder”, dilated bowel loops
SBO
small bowel obstruction txt? what if its from a strangulated hernia?
NPO (bowel rest), IV fluids, bowel decompression w/ NG suction.
Strangulated = Sx
indirect vs direct hernia: proximity to epigastric vessels + scrotum?
indirect: origin of sac LATERAL to epigastrics and DOES reach scrotum
direct: origin MEDIAL to epigastrics (in hasselbach’s triangle) and does NOT reach into scrotum
hernia: indirect or direct more common? what is it from?
indirect - persistent patent process vaginalis (congenital)
why do direct hernias form?
weakness in floor of inguinal canal (transverse fascia)
incarcerated vs strangulated hernia in pt presentation?
Incarcerated: painful, enlarged irreducible area.
Strangulated: ischemic, incarcerated w/ systemic toxicity. Severely painful BMs
ventral hernia: what is it? what is the MC cause?
herniation through weakness in abdominal wall.
- Incision hernias MC with vertical incisions and in obese pts.
txt for ventral hernia?
Sx
MC cause of peptic ulcer dz?
H pylori
also NSAIDS, zoster ellison syndrome, steroid use, alcohol/smoking/physciologic stress
gastric vs duodenal ulcer - what is the difference in pathophys?
Gastric Ulcer- DECR mucosal protective factors
Duodenal Ulcer- INCR damaging factors (acid, pepsin)
PUD: duodenal vs gastric ulcer, which has pain relieved with food vs worse with food?
relieved with food (DU) or worse with food (GU)
Dx of PUD
Endoscopy, Bx if GU (to r/o malignancy), H Pylori testing (Bx, urea breath, stool antigen)
PUD - H pylori positive: txt
triple therapy - Clarithromycin + Amox + PPI. Metronidazole if PCN allergic. Quadruple therapy - Bismuth subsalicylate + tetracycline + PPI + metronidazole
PUD - H pylori negative: txt
PPI, H2 blocker, misoprostol, antacids, Bismuth compounds, sucralafate
refractory PUD txt? (2 options)
parietal cell vagotomy. Bilroth II Surgical procedure (gastrojejunostomy)
what is “dumping syndrome” ?
post-removal of part of the stomach, food contents may dump into the intestines too soon = full feeling, N/V, tachycardia, sweating, diarrhea.
upper vs lower GI bleeding causes
Upper: MC cause is PUD, mallory-weiss, esophageal varices, esophagitis
Lower: diverticulitis, IBD, tumors (weaken walls), polyps, hemorrhoids, anal fissures, proctitis (inflamed rectal lining)
txt for GI bleed
usually self-limited, if not- upper = PPI to stop stomach acid, IV fluids, blood transfusion, Sx
internal vs external hemorrhoids - what vein?
internal: Superior hemorrhoid vein - proximal to dentate line
external: Inferior hemorrhoid vein - distal to dentate line
classification of internal hemorrhoids based on degree of prolapse from anal canal (I-IV)
I - does not prolapse (confined to canal).
II - prolapse w/ defecation or straining but spontaneously reduce
III - prolapse w/ defecation or straining but DONT spont reduce (requires manual)
IV - irreducible + may strangulate
internal or external hemorrhoids likely to be painful?
external
sx tsxt for hemorrhoids?
Procedure: if failed conservative, extreme pain, strangulation or stage IV.
= rubber band ligation (MC), sclerotherapy, infrared coagulation
Hemorrhoidectomy: for all stage IV or those not responsive to all other therapy
what is the MC pathophys of testicular torsion?
spermatic cord twists + cuts off testicular blood supply (“bell clapper” deformity of process vaginalis) - allows testicle to freefloat in tunica vaginalis =twist.
ABRUPT onset scrotal, inguinal or lower abd pain - what other symptoms will help differentiate epididymitis from testicular torsion?
N/V w/ torsion
what are 3 characteristic signs of testicular torsion?
Negative prehn’s sign (no relief w/ scrotal elevation)
Absent cremasteric reflex
“Blue dot sign” at upper pole = torsion of appendix of testis
txt for testicular torsion?
detorsion + orchiopexy (testicular fixation in scrotum) w/in 6 hrs of obvious case. Orchiectomy if not salvageable
what is the medication txt for UC and crohns? (step-up approach with three drug types)
Aminosalicylates → corticosteroids → immune modifiers
what are the 5-ASA (aminosalicylates) used in the txt of crohn’s and UC? (3)
oral mesalamine (best for maintenanc), topical mesalamine (suppository/enema), sulfasalazine (works primarily in colon- UC)
when would you prescribe corticosteroids for UC and crohn’s?
acute flare txt
what immune modifiers are used to tread IBD?
steroid-sparing- 6-mercaptopurine, azathioprine, methotrexate
can surgery be curative in crohn’s and UC?
UC = curative, Crohn’s = not curative
what complications can arise from BOTH Crohn’s and UC outside of the GI system?
both: arthritis, systemic (fever, sweats, fatigue), skin (erythema nodosum, pyoderma gangrenosum)
UC vs Crohn’s: location and depth
CROHNS - any segment of GI (mouth → anus). MC terminal ileum. Depth - transmural
ULCERATIVE COLITIS - limited to colon (starts in rectum → contiguous spread to colon). Depth - mucosa + submucosa only
perianal Dz (anal fistula, strictures, abscesses, granulomas) and malabs. (Fe, B12) - complications of UC or Crohn’s?
Crohn’s
primary sclerosing cholangitis (inflamed bile duct system), colon CA, toxic megacolon. - complications of UC or Crohn’s?
UC
Dx? : LLQ pain, tenesmus (recurrent need to evacuate the bowels), urgency, BLOODY diarrhea w/ mucus.
UC
how does crohn’s dz present? (S+S)
crampy RLQ pain, weight loss, diarrhea W/O blood.
Dx: of Crohn’s - what are the results of colonoscopy? barium? labs?
Colonoscopy: upper GI series w/ small bowel followthrough = “skip lesions”, cobblestone appearance
Barium: “string sign”
Labs: + ASCA
Dx of UC: - what are the results of colonoscopy? barium? labs?
Colonoscopy: uniform inflammation +/-ulcers. Pseudopolyps
Barium: “stovepipe sign” (loss of haustral markings)
Labs: + P-ANCA
Barium enema: “string sign” vs “stovepipe sign”
string- Crohn’s (from strictures)
stovepipe - UC (loss of haustral markings)
what causes pseudomembranous colitis?
overgrowth of C diff = swelling/inflammation
txt for pseudomembranous colitis?
stop causative agent, give metronidazole, vancomycin, fidaxomicin. Fluids, Stool transplant
what is the pathophys of mallory-weiss tears?
longitudinal mucosal lacerations @ gastroesophageal jxn or gastric cardia. Sudden rise in intragastric pressure or gastric prolapse into esophagus (i.e. persistent retching from EtOH or bulemia).
Dx: Upper endoscopy = superficial longitudinal mucosal erosions near gastroesophageal jxn/ gastric cardia?
mallory-weiss tear
txt for mallory-weiss tear ? what if its severe?
supportive (most stop bleeding w/out intervention). Acid suppression promotes healing.
If severe bleeding → epi injection, sclerosing agent, band ligation, hemoclipping or balloon tamponade (sengstaken-blakemore tube or minnesota tube)
Trauma: primary vs secondary survey
primary (concurrent with rescucitation) - assess ABCDE
secondary - head-to-toe check for bruises/breaks
ABCDE in trauma?
(airway, breathing, circulation, disability (neuro), environment/exposure)
does a negative FAST rule out hemorrhage?
NO! can’t see retroperitoneum
what is the first sign of hemorrhagic shock?
tachycardia= first sign of shock = hypovolemic = hemorrhage
what patient populations rarely exhibit signs of shock? (3 pt types, 3 medical causes)
elderly, pregnant, athletes, medications, hypothermia, pacemaker
what are the most common blunt trauma scenarios that need further workup?
falls, motor vehicle accidents, contact sports and assaults. (includes deceleration, shearing of tethered organs/vasculature)
3 parts to assessment/txt of blunt trauma wound?
- Fluid replacement (saline, blood)
- Clean wound + infection prevention (abx)
- Laparotomy: a large incision in the abdomen to provide access to the abdominal cavity in order to assess internal injury or prepare the patient for surgery
at what level of splenic injury do you consider surgery?
grade III+ (intraparenchymal hematoma >5cm or expanding OR laceration >3cm depth or involving trabecular vessels)
what are grades 4 and 5 of splenic injury?
4: laceration involving segmental or hilar vessels w/ major devascularization
5: shattered spleen/ devascularized spleen
at what level liver injury do you consider surgery? what does this mean for depth, diameter and surface area of injury?
grade III/IV + ( >3cm depth, >10cm diameter or active bleed, >50% surface area)
two considerations for Sx of pregnant female with trauma injury
Pregnant female w/ stab wound in lower abdomen- less likely to need Sx as organs have shifted upwards
Perimortem C-section: fetus can survive up to 30min after death of mom (but best w/in 5min)
trauma: 10 indications for surgery (laparotomy)
- Blunt trauma + hypotension + positive FAST
- Hypotension + penetrating abdominal wound
- Penetrating trauma into peritoneal cavity
- Gunshot wound that traverses peritoneal cavity
- Evisceration (bowels outside of body)
- Bleeding from stomach, rectum or GU tract
- Peritonitis
- Free air, retroperitoneal air, rupture of hemidiaphragm
- CT findings suggestive of rupture
10 . Pelvic ring fx (ORIF)
empiric abx for trauma wound
single dose - cover Gram + and Gram - . 2nd generation cephalosporin: augmentin (amox clav), cefuroxime. Maximum 24hr course unless level 2 (established infection)
gunshot wound: when is Sx indicated versus not?
No Sx indicated: Low velocity, no bone involvement, clean wound edges
Sx indicated: low velocity + bone/joint involvement, abdominal involvement. + high velocity or hemodynamic instability
low vs high velocity gun shot wound
In low- velocity bullets the direct tissue destruction with its localized area proportional to the size of the projectile plays the major role, whereas in high-velocity injuries the lateral tissue expansion (“cavitation”) becomes more important
4 indications for chest tube?
> 30% collapse
Tension pneumo
Unstable + pneumo
Hemothorax/Hemopneumothorax:
no chest tube indicated:non-traumatic w/
15%
do most thoracic penetrating trauma need surgery?
NO, need airway control/ decompression of chest w/ tube/needle/finger
what is a brain contusion?
bruising of the brain (small blood vessels/capillaries in the parenchyma)
txt for brain contusion?
MC observation, possible medical-induced coma, if increased ICP → craniotomy (remove a piece of the skull) +/- removing parenchyma.
how long is recovery from a brain contusion?
3-6mo
epidural hematoma: arterial or venous? MC mechanism? artery?
arterial, temporal bone fx, middle meningeal artery
brief LOC → lucid interval → coma
epidural hematoma
if there is tentorial herniation with an epidural hematoma, what CN deficit will there be?
CN III - pupil response
epidural hematoma on Ct scan?
convex “lens”-shape. Does NOT cross suture lines.
txt for epidural hematoma
Observation if small. If inc ICP → mannitol, hyperventilation, head elevation +/- shunt
subdural hematoma: MC cause, venous or arterial blood, where is it located? what vessel?
blunt trauma in elderly - bleed on the opposite site of injury
venous blood
between dura and arachnoid matter
tearing of cortical bridging veins
what is a subdural hematoma like on CT?
concave “crescent shaped”, CAN cross suture lines
subdural hematoma txt
hematoma evacuation (if massive or >5mm midline shift) vs supportive.
subarachnoid hemorrhage: where is it located, MC cause, what vessel?
between arachnoid + pia mater, MC AVM aneurysm –> rupture, MC berry aneurysm
thunderclap HA (“worse HA of my life”)
subarachnoid hemorrhage
what is terson syndrome?
retinal vitreous hemorrhage from subarachnoid hemorrhage
subarachnoid hemorrhage Dx: CT and LP?
CT first → LP = xanthochromia (RBCs), inc CSF pressure (ICP)
txt for subarachnoid hemorrhage
supportive (rest, stool softeners, lower ICP). Sx coiling/clipping. +/- lower BP gradually (nicardipine, nimodipine, labetalol)
herniation at L4, L5, S1 dermatome distribution, weakness + reflex deficit
L4: sensory = anterior thigh to medial ankle. weakness= ankle dorsiflex. Reflex diminished = loss of knee jerk/weak knee extension w/ quad
L5: sensory = lateral thigh/hip/groin to dorsum of foot. Weakness = big toe dorsiflex and walking on heels. Reflex = normal
S1: sensory = posterior leg/calf to plantar of foot. Weakness = plantar flexion and walking on toes. Reflex = loss of ankle jerk
