SURGERY USMLE Flashcards
dysphagia that is worse for liquids
Achalasia
Cancer of the esophagus
SCCA- smokers
Adenocarcinoma - GERD
Mallory Weiss tear
junction of stomach and esophagus
forceful vomiting
Bright red hematemesis
Booerhave’s syndrome
prolonged vomiting
esophageal perforation
Gasric adenocarcinoma
Anorexia
Weight loss
Vague epigastric distress or early satiety
Occasional hematemesis
Treatment for gastric lymphoma
Chemotherapy
Surgery if perforation is feared
Low grade lymphomatoid transformation can e reversed by eradication of H. pylori
Mechanical intestinal obstruction
typically caused by adhesions
colicky abdominal pain, protracted vomiting, progressive abdominal distension, and no passage of gas or feces.
Xrays: distented bowel loops of small bowels, with air fluid levels
TX: NPO, NG suction, IV fluids
Surgery if no improvement within 24 hours
Strangulated obstruction
compromised blood supply leading to bowel ischemia
starts as MBO then fever, leukocytosis, constant pain, signs of peritoneal irritation, full blowen peritonitis and sepsis
TX: surgery
Carcinoid syndrome
SB carcinoid tumor with livers mets
Diarrhea, flushing of face, wheezing, R heart valvular damage
DX: 24 hour urinary collection of 5- hydroxyindolacetic acid
Classic picture of acute appendicitis
begins with anorexia, followed by:
vague periumbilical pain -> localizing RLQ
Tenderness, guarding
Modest leukocytosis (10000-15000) with neutrophilia and immature forms
Cancer of the Right colon
presents with anemia (hypochromic)
50-70
stool +4 FOBT
Colonoscopy and biopsies
TX: Right hemicolectomy
Cancer of the Left colon
bloody bowel movements and obstruction
Flexible proctosigmoidoscopic exam (45-60 cm) and biopsies
Full colonoscopy to r/o synchronous second primary lesion proximally
Colonic polyps
may be premalignant (familial polyposis, familial multiple inflammatory polyps, villous adenoma and adenomatous polyp)
not Premalignant ( juvebile, PEutz Jeghers, isolated inflammatory, and hyperplastic)
Chronic ulcerative colitis
managed medically
Surgery: >20 years (high incidence of malignant degeneration, ), severe interference of nutritional status, multiple hospitalizations, toxic megacolon.
Pseudomembranous enterocolitis
overgrowth of Clostridium difficile
Clindamycin - first one to cause
Cephalosporin - most common cause
Profuse watery diarrhea, crampy abdominal pain, fever, leukocytosis.
TX: Metronidazole with vancomycin as alternative
>50 000 WBC and serum lactate >5 mg/dL requires emergency colectomy
Anal fissure
young women
exquisite pain with defecation and blood streaks
TX; stool softeners, topiccal nitoglycerin, local injection of botulinum toxin, diltiazem ointment 2% TID topically for 6 weeks
Crohn’s disease
often affects anal area
starts with a fissure, fistula or small ulceration
dx should be suspected when the area fails to heal and gets worse after surgical intervention
Ischiorectal abscess
febrile with exquisite perirectal pain that does not let him sit down or have bowel movements
Classic findings of abscess in the lateral to the anus
TX: IND
Fistula -in-ano
Epithelial migration from the anal crypts and from the perineal skin form a permanentt tract.
Squamous cell carcinoma of the anus
more common in HIV and in patients with receptive sexual practices.
fungating mass, metatastic inguinal nodes
TX: Nigro chemoradiation protocoal followed by surgery
Steps of wound healing
Coagulation Inflammation Colllagen synthesis aniogenesis Epithelization Contraction
Phases of wound healing
Hemostasis and inflamamtion
Proliferation
maturation
remodelling
Most common cause of post operative fever within th first 24 hours
Atelectasis
Acute abdomen
abrupt onset of abdominal pain usually accompanied by one or more peritoneal signs.
kehr’s sign
pain referred to the left shoulder due to irritation of the left hemidiaphragm.
often seen with splenic rupture and residual pneumoperitoneum after laparoscopy
Pain relieved by vomiting
supportive of SBO, afferent loop syndrome
Bilious vomiting
Proximal SBO
Mucoid diarrhea with blood (red currant jellys tool)
Intussusception
Mcburney’s point
Appendicitis
Beck’s tamponade triad
Hypotension
JVD
Muffled heart sounds
Clinically apparent tamponaded
as little as 60-100mL of blood in the pericardial space
Pneumothorax
air in the pleural space
Chest pain
Dyspnea
Hyperresonant of affected side
Decreased breath sounds on affected sides
TX; tube thoracostomy
tension pneumothorax
life threatening emergency caused by air entering the pleural space and unable to escape
Ipsilateral lung collapse and mediastinal shift (away from the injured lung), impairing venous return and thus decreased cardiac output, resulting to shock
TX: needle decompression followed by tube thoracostomy
Hemothorax
presence of blood in the chest
Indications for thoracostomy
1500 cc initial drainage from the chest tube
200 cc/hr for 4 hours continued drainage;
Thoracic great vessel injury
Esophageal injury
ptients who decompensate after stabilization
Size of chest tube to use:
For adult large hemothorax: 36-40 French
For adult pneumothorax: 24 French or pigtail catheter
For children: four times the size of appropriate endotracheal tube size:
ET tube size = age+16/4
seat belt sign
ecchymotic area found in the distribution of the lower anterior abdominal wall and can be associated with perforation of the bladder or bowel as well as a lumbar distraction fracture
Cullen’s sign
Periumbilical ecchymosis (indicative of intraperitoneal hemorrhage
Grey-Turner’s sign
flank ecchymoses (indicative of retroperitoneal hemorrhage)
Acute pancreatitis
suspected in an alcoholic who develops an upper acute abdomen
rapid onset for an inflammatory process and the pain is constant, epigastric, radiating straight through the back, with nausea, vomiting, and retching
Primary Hepatoma
vague right upper quadrant discomfort and weight loss.
AFP
Resection is done if technically possible
Hepatic adenoma
arise as a complication of birth control pills
tendency to rupture and bleed massively
Pyogenic liver abscess
complication of biliary tract disease, particularly acute ascending cholangitis.
Fever, leukocytosis and a tender liver
Amebic abscess of the liver
Treated with metronidazole abd rarely require drainage
Biliary colic
occurs when a stone temporarily occludes the cystic duct. Causes colicky pain in the right upper quadrant radiating to the right shouder and back.
Charcot’s triad
fever, jaundice, RUQ pain
Reynold’s Pentad
fever, jaundice, RUQ pain, altered mental status, evidence of sepsis (hypotension)
Acute pancreatitis
may be edematous, hemorrhagic, or suppurative
Acute edematous pancreatitis
occurs in the alcoholic or pt with gallastones
Epigastric and midabdominal pain radiating straight through the back, accomapanied by nausea, vomiting, and continued retching
Amylase and lipase is elevated and hematocrit are high due to hypovolemia
Fibroadenoma
firm, rubbery mass that moves easily with palpation.
FNA or core biopsy
Indirect Inguinal hernias
Rule of 5's 5% lifetine incidence in males 5x more common than direct inguinal hernias 5-10x more common in males than females Generally occur by 5th decade of life
Inguinal Hernias
MDs Dont Lie
Medial to the inferior epigastric artery - DIRECT
Lateral to the IEA - INDIRECT
Abdominal HErnia
Defect in the abdominal wall causing abnormal potrusion of intra-abdominal contents
RF:
activities which increase intra-abdominal pressure
Congenital abnormality (patent processus vaginalis)
Previous hernia repair
Loss of tissue strength and elasticity
Hesselbach’s triangle
Lateral : inferior epigastric artery
Inferior: inguinal ligament
Medial: lateral margin of rectus sheath
Inguinal Canal Walls
MALT x 2
2M roof = 2 muscles (internal oblique, trasversus abdominis)
2A Anterior wall - 2 aponeurosis (external and internal oblique)
2L Floor = 2 ligaments (inguinal and lacunar)
2T Posterior wall = Transversalis fascia, conjoint Tendon
Classification of Hernia
Complete: Hernia sac and contents protrude
Incomplete: partial protrusion through the defect
Internal: sac herniating into or involving intra-abdominal wall
External: sac protrudes completely through the abdominal wall
Strangulated: vascular supply of protruded viscus is compromised
Incarcerated: Irreducible hernia, not necessarily strangulated
Sliding: part of wall of hernia sac formed by retroperitoneal structure (colon)
Richter’s Hernia
only part of the bowel circumference *usually anti-mesenteric border) is incarcerated or strangulated
femoral hernia
affects mostly females
Pregnancy - weakness of pelvic floor musculature
Increased intra-abdominal pressure
Into femoral canal, below the ingunial ligament but may override it
Medial to femoral vein within femoral canal
Superdicial Inguinal Ring
Opening in external abdominal aponeuorosis; palpable superior and lateral to pubic tubercle
Medial border: medial crus of external abdominal aponeurosis
Lateral border: lateral crus of external oblique aponeurosis
Roof: intercrural fibers
Deep inguinal Ring
Opening in transversalis fascia: palpable superior to mid-inguinal ligament
Medial: inferior epigastric vessels
Superior-LAteral border: Internal oblique and transversus abdominis muscle
Inferior border: inguinal ligament
Mcburney’s sign
Tenderness 1/3 the distance from the ASIS to the umbilicus n the right side
Crohn’s Major Patterns
Ileocecal 40% (RLQ pain, fever, weight loss)
Small intestine 30% (especially terminal ileum)
Colon 25% (diarrhea)
Findings in Crohn’s disease
Cobblestoning on mucosal surface due to edema and linear ulcerations
Skip Lesions: normal mucosa in between
Creeping fat: mesentery infiltrated by fat
granulomas: 25-30%
Findings in Ulerative colitis
(+) diarrhea with or without blood
colicky abdominal pain, urgency, tenesmus, and incontinence
Presence of extraintestinal manifestaions
Endocoscopically, there is loss of vascular markings, erythema, granularity of mucosa, petechiae, exudates, edema, erosions, and spontaneous bleeding
Biopsy: crypt abscesses, crypt blanching, shortening and disarray and crypt atrophy
Inflammation is continuous and usually involves the rectum
Top 3 cause of LBO
cancer
diverticulitis
Volvulus
Clinical Features of LBO
Open loop *incompetent ileocecal valce) - similar with SBO
Closed loop (80-90%) - competent ileocecal valve resulting in proximal and sital occlusions
Functional LBO
Colonic Pseudo Obstruction (Ogilvie’s Syndrome)
Acute pseudo obstruction
Distention of the colon without mechanical obstruction in distal colon
Diverticulum
abnormal sac like protrusion from the wall of a hollow organ
Diverticulosis vs Divericulitis
Diverticulosis - presence of diverticuli within the colonic wall
Diverticulitis 0 inflammation of one or more diverticuli
Hinchey Staging and treatment for Diverticulitis
1 - Phlegmon/small pericolic abscess (medical)
2 - Large abscess/fistula (Medical, abscess drainage resection)
3 - Purulent peritonitis (resection or hartmann procedure)
4 - Feculent peritonitis (hartmann procedure)
Familial Adenomatous Polyposis
autosomal dominant inheritance, mutation in adenomatous polyposis coli (APC) gene on chromosome 5q21
Gardner’s syndrome
FAP + Extra-intestinal lesions (sebaceous cysts, osteomas, desmoid tumors)
Turcot syndrome
FAP + CNS tumors (childhood cerebellar medulloblastoma)
LYNCH syndrome
Hereditary Non-polyposis colorectal cancer
autosomal dominant inheritance, mutation in a DNA mismatch repair gene (MSH2, MSH6, MLH1) resulting in microsatellite instability genomic instability and sbsequent mutations)
early age of Onset RIGHT>left
Amsterdam criteria for Lynch syndrome
3 or more relatives verified and 1 must be 1st degree relative of the other 2
2 or more generations involved
1 case must be diagnosed before 50 years old
FAP is excluded
Staging for Colorectal cancer
I - T1M2 N0M0
II - T3,4 N0M0
III- TxN + M0
IV - TxNxM1
CRC (right coloon)
25%
Exophytic lesions with occult bleeding
weight loss, weakness, rarely obstruction
Iron deficiency anemia, RLQ mass
CRC (left colon)
35%
Annular, invasive lesions
Constipation +/- overflow (alternating bowel patterns), abdominal pain, decreased stool caliber, rectal bleeding
BRBPR, LBO
CRC (rectum)
30%
ulcerating
Obstruction, tenesmus, rectal bleeding
Palpable mass on DRE, BRBPR
Primary tumor staging of CRC
T0 - no primary tumor
Tis - Carcinoma in situ
T1 - Invasion into submucosa
T2 - Invasion into musculariss propria
T3 - Invasion through muscularis propria and into serosa
T4 - Invasion into adjacent structures or Organs
Regional LN staging CRC
N0 = no N1 = 1-3 N2 = 4 or more
Toxic Megacolon
extension of inflammation into smooth musce layer causing paralysis
Damage to the myenteric plexus and electrolyte abnormalities are not consistently found
Etology:
IBD (UC> CD)
Infectious colitis
Dx Criteria:
Must have both colitis and systemic manifestations
Radiologic evidence of dilated colon
3 of : fever, HR>120, WBC>10.5, anemia
1 of : fluid and electrolyte disturbances, hypotension, or altered LOC
Fistula
abnormal communication between 2 epithelized surfaces
Park’s classification of Perianal fistulas
Transphicteric - Most common, Results form ischiorectal abscesses with extension of the tract through the external sphincter
Intersphicteric - Confinded to the intersphincteric space and internal sphincter, result from perianal abscesses
Suprasphincteric - Pass through the levator ani, over the top of the puboretalis, and into the intersphincteric space. Result from Supralevator abscesses
Extrasphincteric - bypass the anal canal and sphincter mechanism, passing through the ischiorectal fossa and levator ani muscle and open high in the rectu,
Goodsall’s rule
The anal line divides it into anterior and posterior regions. If the abscess is in the posterior region, it usually drains in the midline and follows a curvilinear tract.
In the anterior region, the abscess will usually drain straight to the anus. It follows a radial tract of drainafe except if external canal is beyond 3cm of the line.
