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Senoir 21-2 > Surgical Block I > Flashcards

Surgical Block I Flashcards

1
Q

What is the most frequent acquired nosocomial infection

A

UTI

Tx prior to any surgery

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2
Q

When should pts stop taking ACEI prior to SRGRY

A

Advise patients to not take on the day of surgery
—refractory hypotension during general anesthesia

—should be resumed shortly after the operation

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3
Q

Should pts stay on diuretics prior to SRGRY

A

For operations with potentially significant amounts of fluid losses and resuscitation

commonly withheld on the morning of

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4
Q

When are pre op ABX given

A

Within 1 hour of incision

-give full dose, parenteral, and DC within 24hours post surgery

(Cephazolin 1g is typically used)

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5
Q

In evaluating a pt pre surgery

What is the risk assessment and reduction approach

A

ASA cat determination

Prior intubation?

Previous Anesthetic Reactions

Underlying Metabloic Dz

Current Meds and Allergies

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6
Q

ASA I

A

A NML healthy Pt

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7
Q

ASA II

A

A pt with mild systemic Dz

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8
Q

ASA III

A

A pt with severe systemic Dz

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9
Q

ASA IV

A

A pt with severe systemic dz that is a constant threat to life

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10
Q

ASA V

A

A Morbund pt who is not expected to survive without the operation

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11
Q

ASA VI

A

A declared brain dead pt whose organs are being removed for donor purposes

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12
Q

ASA E

A

Emergency

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13
Q

What is the pt driven tools that mitigate pulmonary complications s/p surgery

A

Incentive spirometry

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14
Q

What are the 6 independent predictors of cardiac complications for surgery

A

history of ischemic heart disease,

congestive heart failure
(JVD/ S3 Gallop)

cerebrovascular disease

a high-risk operation

preoperative treatment with insulin

a preoperative serum creatinine greater than 2.0 mg/dL

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15
Q

Any pt with a MACE score greater than 1 should get what reflexive testing?

A

Stress testing

  • Excercise treadmill
  • dipyridamole or thallium – increase accuracy
  • dobutamine or adenosine echocardiogram – if pt unable to exercise
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16
Q

If a pt is bable to do excercise stress testing

What risk stratifying assessment (CV) should they do prior to surgery

A

Dobutamine or adenosine echocardiogram

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17
Q

What is the postponement timeline for pts with recent Hx of MI

A

Postpone 6 months

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18
Q

When should pts stop eating prior to Surgery

A

before receiving anesthetics or sedatives

avoid eating light meals for at least 6 hours and fatty meals for 8 hours

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19
Q

How do we treat worsening ammonia levels prior to surgery

A

Lactulose

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20
Q

What is neuropraxia

A

Typically self resolving condiotn post op

-peripheral nerve injury

Loss of motor function is the most common finding

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21
Q

What is the glucose mgmt goal pre op

A

The goal is to obtain acceptable blood glucose levels
(< 140 mg/dL fasting and < 180 mg/dL otherwise)
while avoiding hypoglycemia

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22
Q

What is the steroid approach pre op

A

Give a “stress” dose prior to surgery to avoid addisonian crisis

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23
Q

Albumin less than 3g/dl suggests

A

Chronic malnutrition

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24
Q

Prealbumin less than 16mg/dl indicates

A

Acute malnutrition

More sensitive

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25
Q

What is a normal UOP

A

Approx 1L/24 hours, estimated at 0.5 mL/kg/h in an adult

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26
Q

What serum Cr change is the threshold for AKI

A

Greater than 2mg/dl

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27
Q

If a pt is NPO for 12 hours what should you give them.,.

A

A maintenance fluid to prevent hypovolemia

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28
Q

What is the threshold for Blood transfusion

A

hemoglobin concentration
< 7.0 g/dL
(hematocrit 21%) = transfusion

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29
Q

What is the most reliable sign of moderate shock/?

A

Oliguria

successful resuscitation is indicated by a return of urine output to 0.5-1 mL/kg/h

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30
Q

If correcting HypoK, what also should you correct

A

Hypo Mg2+

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31
Q

What is the medical emergency threshold for hyperK+

A

A serum K+of 6.5 mmol/L or greater is a medical emergency

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32
Q

Initial treatment for Hyperkalemia

A

IV administration of 50% dextrose in water

10 units of regularinsulin

calcium gluconate

inhaled β-adrenergic agonists like albuterol

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33
Q

What is the preferred IV solution in the trauma bay

A

Blood>LR>NS

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34
Q

What is the maintence fluid of choice

A

D5W 1/2NS

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35
Q

What should be added to D51/2NS to prevent Hypokalemia

A

Add 20mEq of K to prevent hypokalemia

should usually not be added during the first 24 hours after surgery

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36
Q

What is the maintenance fluid rate

A

Adults: 30ml/Kg/24h

Multiply patient’s weight in kilograms times 30
eg, 1800 mL/24 h in a 60-kg patient

**Bolus 500-1000ml and adjust
UOP to 1ml/Kg/hour

“Maintain with dextrose 5% in 0.45% NaCl + 20 mEq K”

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37
Q

What is a massive transfusion protocol

A

6 units or more (at least 10) as fast as you can

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38
Q

Most to least perferred blood products

A
  1. Cold stored low titer O whole blood
  2. Pre-screened low titer O fresh whole blood
  3. Plasma, red blood cells (RBCs) and platelets in a 1:1:1 ratio
  4. Plasma and RBCs in a 1:1 ratio
  5. Plasma or RBCs alone
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39
Q

What is the role of DDVAP

A

Stimulates endothelial cells to release von Willebrand Factor (vWF)

Uremic bleeding as a result of platelet dysfunction

Persistent oozing in the operating room

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40
Q

When using a feeding tube, when can you start feeding post operatively?

A

2nd post op day

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41
Q

If giving a pt TPN

What is the approach

A

Get daily electrolytes
(Watch for re-feeding syndrome)

Weekly liver enzymes

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42
Q

What is re-feeding syndrome

A

Increased Insulin ->
Hypo: K, Mg & P

DRIVEN BY HYPOPHOSPATEMIA!

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43
Q

What are the 3 areas of the abdomen (generally divided)

A

Divide abdomen into 3 general areas

GI tract: mouth to anus

Biliary: Liver, gall bladder, pancreas

Genito-Urinary: Kidney to urethra

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44
Q

In history taking of an abdominal pain pt always ask what…

A

ABOUT the recent CSP/EGD!

Colonoscopy

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45
Q

A pt with a tensely distended abdomen with an old surgical scar
Think

A

Adhesions

Small bowel obstruction

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46
Q

A scaphoid abdomen..

Think

A

Perforated ulcer

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47
Q

A pt with visible peristalsis

Think

A

Advanced bowel disease

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48
Q

A pt with an abdomen that feels like soft doughy fullness

Think

A

early paralytic ileus or mesenteric thrombosis

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49
Q

A pt with a everted umbilicus

Think

A

IAP

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50
Q

Tympany of the bowel indicates

A

bowel obstruction

hollow viscus perforation /free air

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51
Q

What is the role of CXR in the review of abdominal pain

A

More sensitive than abdominal plain films for free intraperitoneal air

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52
Q

What distinguishes the 1st and 2nd portion of the duodenum

A

Concentric mucosal folds, “Kerckring folds”

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53
Q

If NO air is seen at all in the stomach of the colon

Suspect

A

If no air seen, rule out gastric outlet obstruction

a giant gastric bubble, with no air in small bowel or colon

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54
Q

Air is not normally seen in the small intestine so if air is seen in the small intestine

Think

A

rule out ileus or obstruction

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55
Q

What is acute obstination

A

Inability to pass gas

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56
Q

What is the approach to an Ileus

A

If abdominal distention, abdominal pain, nausea, or vomiting,
then nasogastric decompression and IV rehydration are indicated

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57
Q

What is Alvimopan used for

A

a selective mu opioid receptor antagonist,

shown to accelerate GI recovery,

Postoperative
(non-opioid-based) pain management + ERAS protocol may decrease rates of postoperative ileus.

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58
Q

Most common cause of small bowel obstructions

A

adhesions from previous surgery (50 to 70%),

hernias (25%),

and tumor

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59
Q

Most common causes of Lower Bowel Obstruction

A

Cancer (65%),

diverticular stricture (20%),

and volvulus (5%)

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60
Q

What is the threshold for risk of ischemia and perforation of the colon

A

Risk of ischemia and perforation increases with the degree and duration of colon distention
> 12 cm and duration of dilation > 6 days

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61
Q

What is the contrast medium of choice for a suspected bowel perforation

A

Iodine based- Gastrografin

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62
Q

What is the criteria for strict return post op

A

Fever, increased N/V, intractable pain

Normally not sent home if narcs are needed

Exception: renal colic

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63
Q

What is ADC-VAN-DISMEL

A

Admit to floor

Diagnosis

Conditions

Vitals

Activity (lie flat? Fall risk?)

Nursing (always I/Os)

Diet

IVF

Studies

Meds
(Anti ulcer, Anti DVT, Anit N/V, Anti-pain, ABX)

Allergies

Labs

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64
Q

Location of the appendix

A

~2 cm inferior to the ileocecal valve

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65
Q

Common causes of appendixcitis in adults and children

A

obstruction due to fecalith in adults

lymphoid hyperplasia in children

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66
Q

What is alvarados score

A

2- Abd pain that moves to R iliac Fossa

1- N/V

1- Anorexia w/ or W/o ketones

1- Pain on pressure in R iliac fossa

1- Rebound tenderness

1-Fever of 37.3 or more

2- Leukocytosis

1- Neutrophilia

A score of 5-6 compatible with DX

7-8 probable Dx

9-10 very very likely Dx

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67
Q

Gold standard of imaging for appendicitis

A

CT with IV contrast

looking for inflammation

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68
Q

What are the rule of 2s of Meckels Diverticulum

A

Rule of 2s

  • Gastric or pancreatic tissue
  • 2 feet from ilio-cecal junction
  • 2% of the pediatric population
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69
Q

What is a postive fotherfgill sign?

A

Careful palpation will reveal a tender mass within the abdominal wall

DDx for Apendicitis versus Rectus Sheath hematoma

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70
Q

What is the appropriate ABX coverage for Appendicitis

A

Ciprofloxacin plus Metronidazole (if perforated)

Cephalosporin (nonperforated)

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71
Q

What is the most common cancer assoc with appendicitis

A

Carcinoid.

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72
Q

What is the most common diverticula observed in GI?

A

Zenkers

Arises in the killian triangle

Located just superior to the cricopharyngeus muscle

Common Cc is regurgitation of undigested food

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73
Q

Should you do a endoscopic exam zenkers diverticulum ?

A

No, increased risk of perforation

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74
Q

What is the 1st Dx step of Zenkers Diverticulum

A

Barium swallow study

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75
Q

What is the treatment approach to Zenkers Diverticulum

A

Treatment is surgical and must include the division of the cricopharyngeus muscle

“Cricopharyngeal myotomy”

If more than 2 cm in diameter
excised with a linear stapler

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76
Q

What is the gold standard to eval GERD

A

PH testing

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77
Q

4 criteria to Dx GED

A

positive pH testing
(Gold standard)

esophageal mucosal breaks on endoscopy in patients with typical symptoms

confirmed Barrett esophagus on biopsy

peptic stricture in the absence of malignancy

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78
Q

MGMT of GERD

A

Trial of acid suppression with PPI x 8 weeks Daily or BID

SRG: Laproscopic Nissan Fundoplication

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79
Q

What are the three main areas of physical narrowing for esophageal FB

A

most proximal : cricopharyngeus muscle

followed distally by the level of the aortic arch

the lower esophageal sphincter.

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80
Q

A esophageal perforation greater than 24 hours,.,.

A

Severe contamination

the esophageal defect usually breaks down if it is surgically closed and is insufficient for treatment

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81
Q

What is the most common cause of esophageal perforations

A

Instrumental (Dx or Tx)

Most likely to occur in the cervical esophagus

Most common site - Cricopharyngeal area

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82
Q

What imagining should we get for boorhave syndrome

A

X ray : air in the soft tissues

Esophogram using water soluble contrast- promptly in every pts

(If no leak seen, repeat with barium)

CT Scan of chest

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83
Q

Tx appraoch to Boorhave Syndrome

A

Broad Spec ABX and Urgen Surgical Referral with 24 hours

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84
Q

What is the general resolution of Mallory-Weiss tears

A

Expectant managment with spont recovery

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85
Q

MGMT for corrosive esophagitis

A

Fluid resuscitation and supportive care

Consult GI for possible EGD

Immediate flexible endoscopy is required

Perforation or instability mandates surgical exploration and resection

Do not induce emesis, blindly neutralize chemical or insert NG tube

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86
Q

A pt presents with hoarsness, and dysphagia, wt loss, and pain over bony structures

Think

A

Carcinoma of the esophagus

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87
Q

What is the most sensitive test for staging of Exophageal cancer

A

Endoscopic U/S

Determines depth of penetration by the tumor

presence of enlarged periesophageal lymph nodes

invasion of structures next to the esophagus

allows a fine-needle aspiration of lymph nodes

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88
Q

Treatment options for Carcinoma of the Esophaggus

A

Curative: Neoadjuvant Chemo+rads
Or Esophagectomy

Palliative: cytotoxic (chemo)
Rads, or a stent

5 year survival 25%

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89
Q

What is the Dx imaging for Hiatal Hernias

A

Upright CXR

Barium Contrast Study

EGD is difficult but necessary to r/o cancer

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90
Q

What is the Gold standard Treatmetn for Hiatal Hernia

A

Laparoscopic Nissen fundoplication

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91
Q

What are the indications for Bariatric Surgery

A

BMI greater than or equal to 40 kg/m2

BMI greater than or equal to 35 kg/m2 in patients with high-risk conditions

severe sleep apnea, obesity-related cardiomyopathy, or severe diabetes mellitus

Patient-documented previous failure of nonsurgical weight loss attempts

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92
Q

What is the most commonly performed bariatric procedure

A

LSG is the most commonly performed bariatric procedure
technically easier to perform

shorter learning curve

effective in sustainable excess weight loss, resolution of comorbidities, and improving survival of morbidly obese patients.

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93
Q

A pt presents with stomach pain that occurs with in 2-3 hours post mean, is relived with food or antacids, and awakens the pt from sleep

Think

A

Duodenal Ulcer

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94
Q

A pt presents with hyper gastrinemia,. Severe PUD, and non B-islet cell tumors of the pancreas

Think

A

Zollinger Ellison syndrome

Tumor near pancreas which produces excess gastrin leads to hypersecretion of gastric acid which leads to multiple gastric/duodenal ulcers

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95
Q

How do you Dx Zollinger Ellison Syndrome

A

Elevated fasting serum gastrin

Be sure to Dc PPIs for 1 week prior to testing

If borderline then get a secretin provocative test

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96
Q

What is the tx for Gastric Ulcers

A 
2 ABX (amox + clarith) 
And a PPI for a week

Maintenance therapy with PPI can reduce recurrence

If hemodynamic unstable or rebleeding the SRGRY

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97
Q

What is the treatment for refractive gastric ulcers

A

Antrectomy

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98
Q

What is the tx for performated ulcers

A

omental (Graham) patch

defect is plugged with omental pedicle

vagotomy is usually not required

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99
Q

What is dumping syndrome and what is the treatment

A

Shortly after eating : palpitations, sweating, weakness, dyspnea, flushing, nausea, abdominal cramps, belching, vomiting, diarrhea, and, rarely, syncope

Treatment: Diet therapy to reduce jejunal osmolality

low in carbohydrate and high in fat and protein

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100
Q

A pt presents with burning, gnawing epigastric pain, that was not present until an hour post breakfast

Think

A

Duodenal Ulcer

Get an EGD, and UGI

Gastric analysis and a fasting serum gastrin

Somatostatin receptor scintogrpahy is the pre op study of choice

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101
Q

An ulcer that fails to heal after 12 weeks of med tx

Then

A

Send for surgery

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102
Q

What is the only curative tx for localized gastric cancer

A

Surgical resection

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103
Q

What is the most common surgical disorder producing emesis in infancy

With an “olive” pit in the Epigastrum

A

Hypertrophioc pyloric stenosis

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104
Q

An infant presents with projective, nonbillious emesis 4-6 weeks after birth

Think

A

hypertrophic pyloris stenosis

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105
Q

What is the most common form of volvulus

A

Sigmoid

Immediately get sigmoidoscopy

High index of strangulation

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106
Q

What is the dx OC for Intussusception

A

Barium enema

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107
Q

What is riglers triad

A

pneumobilia, bowel obstruction, and a gallstone within the bowel

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108
Q

What are the hallmarks of Crohns

A

Cobblestone, skip lesions, transmural

Normally treated with 5-ASA drugs, steroids, antibiotics

109
Q

What is the major area of concern for hepato-biliary anatomy

A

Common bile duct obstruction

110
Q

What is the cystic duct

A

joins the common hepatic duct to form the common bile duct

111
Q

Where and what is the sphincter of oddi

A

surrounds the common bile duct at the ampulla of Vater
controls the flow of bile into the duodenum
prevents regurgitation
diverts bile into the gallbladder

112
Q

Where does the common hepatic artery arise from

A

The common hepatic artery arises from the celiac axis
-The gastroduodenal artery
—marks the point of origin of the proper hepatic artery
—divides into right and left hepatic branches

113
Q

What is the portal triad

A

(hepatic artery, portal vein, and biliary duct)

enter the hepatic hilum

114
Q

Why is hemorrhage control difficult in the Liver

A

The hepatic veins are typically very short prior to entering the inferior vena cava,

making vascular control of hemorrhage difficult

115
Q

What makes bilirubin

Conjugated

A

Liver has processed it and it is now no longer attached to albumin

116
Q

What vitamins does the liver metabolize

A

Metabolism of fat-soluble vitamins (A, D, E, K).
—absorbed in the intestine

—Vitamin K-dependent clotting factors, II, VII, IX, and X.

117
Q

What is the most commonly injured solid organ in trauma

A

Liver

118
Q

What is the most common sequelae of hepatic trauma

A

Biliary fistulae - most common sequelae of hepatic trauma

Central injury patterns warrant close surveillance for biliary leaks- Billoma

119
Q

A rupture into the bile duct leads to…

A

Arterial pseudoaneurysms - potential for rupture

Rupture into a bile duct results in hemobilia
-intermittent episodes of right upper quadrant pain, upper gastrointestinal hemorrhage, and jaundice

Best managed with hepatic arteriography and embolization

120
Q

Air in the biliary tree

Think

A

Pneumobilia - air in biliary tree

Rare with trauma

May occur if infected with gas producing bacteria

  • Ischemic bowel
  • Necrotic gall bladder
121
Q

Major Liver leaks are treated with

A

ERCP (Tx and Dx)
And sphincerotomy
(Sphinter of oddi)

Minor leaks can resolve with conservative MGMT

122
Q

What are the two malignant liver diseases

A

Primary- Hepatocellular Carcinoma (HCC)

Metastatic

LOOK for colon cancer any time you have metz to the liver

123
Q

A smooth, contoured anechoic lesion with a well-defined interface between tissue and fluid in the liver think

A

Simple Hepatic Cyst

Usually AS/s

Requires no treatment

124
Q

What is the tx approach for a Echinococcosis Cyst of the liver

A

This is a parasitic infection

DO NOT ASPIRATE!

Should be resected

125
Q

On U/S of the liver you see Complex, internal septae, irregular lining, papillary projections

Think

A

Cystadenoma

-premalignant

Should be resected

126
Q

Define Polycystic Liver Dz

A

Occurs in patients with
-autosomal dominant polycystic kidney disease

  • Gene mutation
  • a progressive condition
  • cystic replacement of virtually the entire liver

Most patients asymptomatic
rarely result in hepatic insufficiency

127
Q

What is the treatment approach for Polycystic liver with less than 10 cysts that are lager than 10cm

What is the approach

A

Cyst fenestration (Type I PLD)

128
Q

What is the tx threshold for Polycystic Liver Dz Type III

A

Liver transplant

129
Q

What is the most common liver tumor

A

Hepatic Hemangioma
(PANCE!!)

Congenital Vascular Malformations

On MRI - sensitivity & specificity of 98%
-hypointense lesion on T1-weighted imaging
and
-a hyperintense lesion on T2-weighted sequences

130
Q

How does hepatic hemangioma appear of a T1 and T2 MRI

A

On MRI - sensitivity & specificity of 98%

hypointense lesion on T1-weighted imaging and a hyperintense lesion on T2-weighted sequences

131
Q

What is the tx for a Hemangioma of the liver

A

Observation

Indications for operation include
severe pain, compressive symptoms, hemorrhage, or uncertain diagnosis with a suspicion of malignancy

132
Q

What is risk to the liver with OCPs and Androgen steroid use

A

Hepatocellular Adenmo

133
Q

How will a Hepatic Adenoma appear on a Nuclear Medicine Scan

A

COLD!

DDx for Heptocellualar carcinoma

134
Q

What is the tx appraoch to hepatic ADENOMA

A

Complete surgical resection with negative margins indicated for:

-Hepatocellular adenomas >5 cm in diameter, those demonstrating rapid growth, or tumors suspicious for malignant transformation

135
Q

How will Focal nodular Hyperplasia appear on Nucelar scans

A

Will be “hot” on nuclear medicine scan

  • Diagnostic uncertainty
  • core-needle biopsy; open or laparoscopic resection

DDx for HCC: The fibrous septations appear grossly as a central scar in FNH

136
Q

is Focal nodular Hyperplasia malignant?

A

NO

137
Q

What are the major risk factors for HCC in chronic liver dz

A

chronic hepatitis B virus (HBV) or C virus (HCV) infections!!!

~ alcohol abuse, nonalcoholic steatohepatitis, aflatoxin B1 exposure, a1-antitrypsin deficiency, hemachromatosis, and primary biliary cirrhosis

138
Q

What is the workup for HCC

A

For high-risk patients - -ultrasonography with or without serum α-fetoprotein (AFP) testing every 6 months

To properly diagnose - either a high-resolution CT or MRI

139
Q

What are the palative options for HCC

A

transarterial chemoembolization (TACE),
transarterial radioembolization (TARE),
stereotactic body radiation therapy (SBRT),
and SORAFENIB!!

140
Q

How do you find Colorectal/ Liver Metz

A

Most patients with CRLMs are asymptomatic
-identified through preoperative staging or intraoperative examination

CRLMs can be identified by CT, MRI, or PET/CT

-PET/CT - when there is a high clinical suspicion for metastatic disease but equivocal imaging

141
Q

A pt presents with jaundice, encephalopathy, and coag d/o

Think

A

Acute liver failure

ALF - no evidence of chronic liver disease and in which liver disease develops within 8 wks after the initial onset

142
Q

DefineL Fluminant Hepatic Failure

A

Fulminant hepatic failure (FHF)
- ALF complicated by encephalopathy within 2 weeks!! of the onset of jaundice
—portends a more severe course

143
Q

What is the threshold for Acute Liver Failure

A

Onset within 8 weeks on insult

144
Q

What is the threshold of Fulminant Hepatic Failure

A

Encephalopathy within 2 weeks of Jaundice onset

145
Q

What is the primary cause of Acute liver failure in the USA

A

Acetaminophen

Accounts for 40-60% of cases

146
Q

A pt presents with massive liver necrosis, jaundice, profound coagulopathy, cerebral edema, brain damage, coma, and death

2 weeks after onset of jaundice

Think

A

Fulminant Liver failure

147
Q

What is the initial lab eval for ALF

A

CBC, a platelet count, liver function tests, a coagulation profile, and assessment of renal function

148
Q

What is the most commonly used system to classify Acute liver failure

A 
The Child-Pugh classification remains the most commonly used system 
-class C designation is normally a contraindication to hepatic resection

The MELD score - more than 11 reliably predicting POHF

149
Q

Treatment appraoch to chronic liver Disease

A

Admission and resusc

Shunts for the transcutaneous intrahepatic portosystemic shunt
(Short term and stabilizing)

B.Blockers can prevent first bleed in the 1st year

Abstinence of alcohol

And Lactulose to bind free NH3

150
Q

Define Budd-Chiari Syndrome

A

An unusual cause of ALF is the Budd-Chiari syndrome

acute hepatic vein thrombosis - -Hepatic outflow obstruction

-Mostly women in hypercoagulable state

The typical patient is a young woman who presents with
right upper quadrant pain of acute onset, hepatomegaly, and ascites

W/u: US or CT

Tx: Anti-coagulation initially
TIPS or other portosystemic shunt
-Portal decompression if done before massive hepatic necrosis
occurs
Otherwise Liver transplant is the only option

151
Q

Chole vs Cholecyst

A

Chole- bile or gall

Cholecyst- gall bladder

152
Q

What is the imaging modality of choice for Chole D/o

A

U/S

hyperechoic, mobile structures with acoustic shadowing= stone

Differentiate between symptomatic cholelithiasis and acute cholecystitis 
-gallbladder wall thickening
 (> 3 mm)
-pericholecystic fluid
-sonographic Murphy sign
153
Q

How do you DDx cholelithiasis vs cholecystitis

A

gallbladder wall thickening (> 3 mm), pericholecystic fluid, and sonographic Murphy sign
= Choilecytitis

154
Q

What is the risk associated with ERCP

A

Complication includes pancreatitis

155
Q

What is the role of ECRP

A

Tx and Dx for the biliary treat d/o and can remove stones

156
Q

What is the role or MRCP

A 
Noninvasive way of visualizing the biliary tract
-compared with abdominal US (AU)
better sensitivity (93%) and specificity (94 to 100%)

-equivalent to ERCP and cholangiogram

Avoids a contrast load or invasive instrumentation

-a screening tool

IS NOT THERAPEUTIC!!

cannot be used in certain patients with implants,
has a poor detection of small stones less than 6 mm,

157
Q

What is the role of a HIDA scan

A

The most sensitive & specific study to diagnose acute cholecystitis is cholescintigraphy
aka HIDA; Radionuclide Scan

-Injecting a radioisotope tracer taken up by the liver, excreted into biliary system, passes through duodenum,

Provides both anatomic and functional information about the liver, gallbladder, and biliary system

158
Q

What is the threshold for obstruction of the cystic duct on HIDA scan

A

a lack of visualization of the gallbladder, but filling of the CBD and duodenum 1 hour after injection of the tracer

159
Q

When is HIDA used over U/S for biliary D./o

A

Cholescintigraphy is generally used when ultrasonography is equivocal or limited due to a patient’s body habitus (HEB+)

160
Q

What are the major risk factors of cholelithiasis

A

Female, obese , pregnant

Mexican or Native Americans

(think mom)

161
Q

Why does pregnancy increase gall stones

A

Pregnancy (Estrogen-> increases cholesterol secretion ; Progesterone decreases bile acid secretion)

162
Q

What type of stones in the gall bladder are seen in Sickle cell, Thalessema, and Spherocytosis

A

Pigment gallstones occur in the setting of hemolysis

The amount of unconjugated bilirubin is increased in bile, precipitates out as calcium bilirubinate

163
Q

A pt presents with Transient colicky right upper quadrant pain,
often occurring after meals (especially high-fat meals)

Nausea and vomiting may accompany the pain,
which can last anywhere from 30 minutes to several hours

episodes increase in both frequency and intensity over time

NON-FEBRILE!

Think

A

Chronic Cholecystitis

biliary colic

164
Q

If a pt presents with chronic cholecystitis and transient episodes of hyperbilirubinemia

What should you do

A

suggests transient episodes of choledocholithiasis

should be further investigated
-Review previous LFTs determine if cholangiography is warranted

165
Q

Is US is equivocal for cholecystisis

What is the next step

A

HIDA scan

US - most practical and cost-effective
sensitivity of approximately 80%
-sonographic Murphy sign
-thickened gallbladder wall, -pericholecystic fluid, gallbladder distention, and a hyperemic gallbladder wall

But if it doesnt show that get a HIDA scan (more sensitive and specific)

166
Q

Role of MRCP in Acute cholecystisis

A

Pt is jaundiced and you think there is choledoclithiasis

167
Q

What are the perferred ABX for abdominal surgeries

A

Ciprofloxacin and metronidazole

168
Q

What is the definitive tx for Acute Cholecystitis

A

Definitive management - Laparoscopic cholecystectomy

Optimum timing - within 72 hrs of symptom onset

169
Q

Pts that are not good surgical candidates for gall bladder surgery

Can get what intervention

A 
Percutaneous cholecystostomy (PCT) 
-Candidates not suitable for operation

-clinical improvement within 48 hours

-If patients recover sufficiently
elective cholecystectomy at a later date

170
Q

What is the most common complication of Acalculous Cholesytitis

A

Gangrene is most common;

Perforation & gallbladder empyema

171
Q

What is the risk of biliary stasis in critically ill pts

A

Acalculous cholecystitis

172
Q

What is the treatment for Acalculous cholecystitis

A

Treatment - Mortality = 30%
early laparoscopic cholecystectomy
poor surgical candidates -> cholecystostomy tube

173
Q

Slide 41-45 internet failure

A
174
Q

High risk pts for suspected choledocholithiasis

A 
High risk: 
age >55 years, 
bilirubin >1.7mg/dL
CBD >6 mm, 
and visible stone on US
175
Q

What is Charcots triad

A

Charcot’s Triad: RUQ pain, Fever, Jaundice

176
Q

What ist Reynolds Pentad

A

Charcot’s Triad: RUQ pain, Fever, Jaundice

+ HOTN and AMS

177
Q

A pt presents wtih abdominal pain that radiates to the back, jaundice, nausea, and stools and dark urine

Think what biliary D/o

A

Choledocholithiasis

MAy have Charcots triadL:
RUQ Pain, Fever, and Jaundice

178
Q

What is the best individual lab result for Choledocholithiasis

A

A rise in serum bilirubin -best individual lab result
usually remains under 10 mg/dL
most in the range of 2-4 mg/dL

179
Q

Can MRCP detect stones less than 6 cm

A

Not as good

180
Q

What is the treatment approach to Choledocholithiasis

A

Systemic antibiotics & other measures as above

-usually controls the attack within 24-48 hours

If worsens - endoscopic sphincterotomy or surgery

Typical pt: Laparoscopic cholecystectomy

181
Q

What are the predominant organisms in the bile

A

E coli, Klebsiella, Pseudomonas, Enterococci, and Proteus

182
Q

What is the approach to Cholangitis

A

Cholangiography is dangerous during active cholangitis

Further workup (THC, ERCP, etc) can proceed later after the acute manifestations are brought under control

Resuc and Do not delay ABX
(Cipro and Metro)

Decompress the biliary duct

  • emergency ERCP
  • if unsuccessful then laparotomy
183
Q

Where is the cut made for open cholecystectomy

A

Kockers Point incision

184
Q

What is an IOC

A

Intra-Operative Cholangiogram (IOC)
-Cystic duct stump cannulated
-Contrast introduced and fills CBD channels
-Used to identify CBD injury
(extravasation of contrast) or CBD obstruction

(CBD: Common bile duct)

185
Q

What is the worst complication of A Cholecystectomy

A

Damage to the CBD- evaluated with IOC

186
Q

Post cholesctectomy

What are the major complications to look out for

A

Stricture ( months to weeks s/p)
2/2 cautery

Intrahepatic abcess

CBD damage

187
Q

Poor surgical candidate for surgery with cholecyst d/o

A

If surgery is a poor option, a cholecystostomy tube can be placed to decompress the gallbladder

Done at bedside under US guidance

Should show improvement post procedure within 24 to 48 hours!

Should remain in place till fully recovered

(T-Tubes)

188
Q

Biliary pancreatitis should be suspected if

A

gallstones are identified on a sonogram or CT scan

or if the liver function tests are abnormal

189
Q

What are the lead metabolic and mechanical etiologies of acute pancreatitis

A

Metabolic
-alcohol!!, hyperlipidemia, hypercalcemia, drugs, genetic, scorpion venom

Mechanical
cholelithiasis!!, postoperative, pancreas divisum, posttraumatic, ERCP, pancreatic duct obstruction, pancreatic ductal bleeding, duodenal obstruction

190
Q

What are the infx causes of Acute panc.

A

mumps, coxsackie B, cytomegalovirus,Cryptococcus

191
Q

What is the clinical presentation of Acute Panc.

A

severe in intensity,
boring and constant in character,
and upper abdominal
(supra umbilical) in location.

N/V are prominent
+Fever
(underlying inflammation/ infx)

Dry sunken membranes
+scleral icterus (biliary cause)
+Grey/Turner Sign (rare)

+/-Plueral effusions
+/- Ileus
(abdominal distention, tympani, and hypoactive bowel sounds)

Maybe a peritinic abd

192
Q

What is the most accurate single test for Acute Panc.

A

Lipase > 3x normal
most accurate single test

Gold standard is Lipase and Amylase

CRP can be used but it used to TRACK the disease process
(Necrotizing)

193
Q

What does Acute Panc. Look like on plain film

A

calcifications or sentinel loop

194
Q

What is the single most accurate imaging test for Acute Panc.

A

Contrast-enhanced CT

  • quantifying the inflammatory process
  • staging the severity of the disease process
195
Q

What is the Dx criteria for Acute Panc.

A

The diagnosis of acute pancreatitis requires two of three features:
(1) abdominal pain suspicious for pancreatic origin,

(2) serum amylase and/or lipase activity
- usually at least three!! times greater than the upper limit of normal, or

(3) characteristic findings on either CT or MRI

196
Q

What are 2 prognostics for morbidity and mortality for Acute Panc.

A

Ranson criteria , BISAP score

Are good scoring systems but not very useful in treatment approach

197
Q

What is the most useful serum test for Acute Panc.

A

CRP to Trend and Lipase to Dx

198
Q

Tx approach to Acute Panc.

A

3-6 L of LR over 24hrs to a UOP of 30/ml hr

Close Glucose Control (less than 180 or 140 fasting)

NaRCs NARCS NARCS (IV)

+/- NG tube (ileus or distention)

PPI and anticoagulant is mandatory in all pts

199
Q

What is the Tx approach to Mild Biliary Panc.

A

-elective laparoscopic -cholecystectomy and IOC
-after acute pancreatic inflammation has subsided
but prior to their hospital discharge

200
Q

Tx approach to severe acute panc. With evidence of cholangitis

A

ERCP +/- endoscopic sphincterotomy (ES) for stone extraction

201
Q

Look at treatment slide 17 in lecture 7

A
202
Q

If acute panc fails to recover within a week of treatment

Think

A

Pseudo cyst

Commonly occur in patients with duct abnormality – Complicates surgery

The majority should not be treated by cyst drainage alone

Also pancreatic duct drainage, ~parenchymal resection

203
Q

On cross-sectional imaging

You see density increase in the fluid w/in the panc.

Think

A

Pseudo cyst or Psuedoaneurysms

204
Q

The two primary options of intraoperative for Panc trauma treatment are

A

Drainage vs resection

205
Q

What does chronic alcoholism do to the panc

A

characterized by glandular fibrosis leading to pancreatic endocrine (diabetes mellitus) and exocrine (steatorrhea) insufficiency

Distinguishing features of acute vs/ chronic panc

206
Q

What is the clinical triad of Chronic Panc.

A

Abdominal pain
Weight loss
Diabetes
Steatorrhea

207
Q

How do you Gauge both the overall functional (renal, hepatic) and nutritional status of the patient with chronic panc

A

Assessment of both the endocrine (hemoglobin A1C) and the exocrine (fecal elastase) function

208
Q

What is the imaging approach to Chronic Panc.

A

Both ductal and parenchymal information is required to accurately classify patients

pancreatic duct: MRCP/ERCP

pancreatic morphology: CT/MRI

209
Q

What is the srg op for large duct pancreatitis (chronic)

A

The Puestow or Frey

210
Q

What is the the srg op for small duct chronic panc

A

the Whipple, Beger, or Frey procedure

211
Q

What is the tx option for panc. Cancer

A

Operative management of all four is identical (pancreaticoduodenectomy)

212
Q

A pt presents with painless jaundice.. think

A

Panc. Cancer

+acholic stools, dark urine, pruritus, and cutaneous jaundice
anorexia and weight loss
+Courvoisier sign
Palpable, nontender gallbladder in presence of clinical jaundice

+bilirubin level in the 18s

Draw serum lipase

213
Q

What is the imaging for all panc cancer pts

A

CT SCAN !

214
Q

If no mass is found on CT for panc cancer

What is the next step

A

ERCP

215
Q

A pt presents with bizarre behavior, memory lapse, or unconsciousness
palpitations, sweating, and tremulousness

Think

A

Insulinoma

2/2 glucose deprivation

216
Q

What is the WHipple Triad

A

(1) hypoglycemic symptoms produced by fasting,
(2) blood glucose below 50 mg/dL during symptomatic episodes, and
(3) relief of symptoms by intravenous administration of glucose

Dx for Insulinoma

217
Q

Tx approach to Insulinoma

A

If Whipples triad is pos.

Surgery should be done promptly

218
Q

A pt presents with abdominal pain and diarrhea
in the presence of refractory peptic ulcer disease

Think

A

Gastrinoma

Assoc with MEN1
(screen all pts with MEN1)

Gastrin Level greater than 1000
If not met then secretin provocative test

Primary Tx: Surgical Resection

219
Q

What is the spleen treatment for idiopathic Thrombocytopenic purpura

A

60 mg of prednisone daily until the platelet count returns to normal

Splenectomy indicated for patients who do not respond to corticosteroids

220
Q

What is the most common reason for splenectomy

A

symptomatic relief of splenomegaly

hypersplenism secondary to chronic illnesses

221
Q

What is the criteria for a Explore. Lap

In spleen truama

A

blunt abdominal trauma + diffuse peritonitis or hemodynamically unstable (+/- Kehr sign)

222
Q

What is the immunization appraoch to post op complications of splenectomy

A

2 weeks prior to elective splenectomy
2 weeks after emergent splenectomy
or
on day of discharge if <2 weeks; 3 months after chemo/radiation

Then give vaccines for Strep Pneumo and H. Flu, and Meningococcus

Expect to see VTE - platelet counts >600,000 - 800,000/μL
incidence of about 5%

Not an indication for anticoagulants

Can use Aspirin

223
Q

How many layers does the colon have

A

5 layers: mucosa (innermost layer), submucosa, circular muscle, longitudinal muscle, and serosa (outermost layer)

224
Q

What are the two areas of the colon not covered by taenia

A

the appendix and the rectum

helps identify transection lines during surgery

225
Q

Define Small outpouchings of colon mucosa and submucosa

Occur at sites of vascular penetration within colon wall

A

Diverticula

226
Q

What is the difference between psuedo and true diverticula

A

Occur between the mesenteric tenia and the two nonmesenteric teniae

Termed diverticulosis
-Majority are pseudodiverticula
missing the muscular layer

-Minority are true diverticula
predominantly in the right colon

227
Q

What is the most common cause of LGI bleeding

A

Diverticulosis

228
Q

What is the vulnerable site of bleeding in diverticulosis

A

Thinning of the colonic wall at the outpouching

-superficial vasa recta - vulnerable to bleeding

229
Q

When should SRGRY be considered for for pts with diverticulosis

A

70-80% will stop on its own without therapy

Consider surgery for:
multiple episodes of confirmed bleeding from a specific location

230
Q

How do you investigate the source of LGI bleed/ UPGi bleed

A

Upper: Nasogastric (NG) lavage
To rule out upper GI source of bleeding
If blood= upper endoscopy

Lower: Colonoscopy
the optimal imaging modality
Allows for diagnosis and therapy

231
Q

What is the approach to a slow LGI bleed

A

Colonoscopy

232
Q

What is the approach to brick bleeding in the LGI

A

CT angiogram

If source not identified, colonoscopy

233
Q

A pt with an ongoing bleed but a negative colonoscopy

What is the approach

A

Tagged RBC scans - used before angiography
-help target vessels accurately during angiography

CT angiography

  • to localize extravasation of blood into the GI lumen
  • Can be diagnostic and therapeutic
234
Q

Indications for SRGRY in ongoing bleeding treatment

A

persistent massive hemorrhage, transfusion requirement or more than six units in 24 hours, and recurrent diverticular bleeding

segmental colonic resection vs. total abdominal colectomy

235
Q

What is the treatmetn for a colovesical fistula

A

pneumaturia, abdominal pain, fecaluria, recurrent urinary tract infections, hematuria, and urinary frequency

Treatment - elective surgical resection

236
Q

What is the treatment for a colovaginal fistula

A

passage of gas or stool through the vagina or presence of persistent foul smelling discharge

Speculum examination may reveal a site of drainage

237
Q

A pt with a free wall perforation

What is the tx

A

Emergent surgery

238
Q

What is the current standard of cancer for the Dx and triage

A

CT is the current standard of care for diagnosis and triage

IV contrast is routinely used

Oral/rectal contrast can help visualize, but can add delays

The most frequent CT findings are

  • bowel wall thickening
  • pericolonic inflammation
  • and diverticula

Complications of diverticulitis : colovesical fistula

239
Q

Tx approach to UNCOMP diverticulitis

A

Bowel rest with ABX
(Metro/ Cipro)

Colonoscopy in 6-8 weeks for cancer screen (very important)

240
Q

Modifiable risk factors for colorectal cancer

A

Meat consumption, smoking, and alcohol

241
Q

What is the common colorectal cancer type

A

Adenomas - common

indicates an increased risk for CRC, may harbor malignancy

242
Q

Haggit Classification for colorectal cancer

A
243
Q

Polyps greater than 1 cm =

A

Complete excision with a 2 mm margin

244
Q

Tier 1 colorectal screening

A

Q10yrs starting at age 45

245
Q

Tier 2 screening for colorectal cancer

A

CT colonography q 5 years or a FIT DNA q 3 years
Or flex sigmoid q5

(If not desiring a colonoscopy)

246
Q

A pt with a 1st degree FAMHx of colorectal cancer should be screened when

A

Colonoscopy q5yrs starting at age 40 or 10- years prior to FAMHx onset age

247
Q

What is the most common cause of colon obstruction in adults

A

Colorectal cancer

248
Q

Left sided colorecatal cancer

A

Hematochezia
Obstruction
Change in bowel habits ->stool thinner

249
Q

R sided CR cancer

A

Acute blood loss anemia
Occult blood > Melena > Hematochezia
Palpable right sided abdominal mass

250
Q

Rectal Cancer

A

Hematochezia
Tenesmus
DRE - drop metastases in the Pouch of Douglas (Blumer shelf)

251
Q

Any pt with Iron Def. Anemia has colorectal cancer until proven otherwise

A
252
Q

What is the approach to clinical staging of colorectal cancer if a colonoscopy cannot be performed

A

CT colonography or air-contrast barium enema

253
Q

What are the main sites of Metx for colorectal cancer

A

Liver and lungs

254
Q

What is the approach to pts with familial polyposis

A

Prophylactic colectomy

255
Q

Obstipation =

A

Obstruction

256
Q

Where is the most likely place for a volvulus

A

Colonic volvulus – 5% of all cases of LBO in the US

  • Twisting of cecal or sigmoid colon
  • Sigmoid more common in elderly
  • Colonoscopy to remove trapped air and f/u surgery to prevent recurrence
257
Q

Pain with defecation

Think

A

Ulcerative colitis

258
Q

What is the treatment for inflammatory bowel

A

Admission and resuscitation

  • mIVF and NPO with NGT suctioning
  • Abx’s if necrotic bowel or perforation suspected

Upright abdominal film
-Air fluid levels suggestive of obstruction

Barium enema – largely replaced by CT

  • May be both diagnostic and therapeutic
  • Apple core lesion highly suggestive of colon cancer

CT abdomen/pelvis with rectal contrast
-Most useful single test

Colonoscopy – stable pts for diagnostic biopsy of mass

259
Q

Grading of a hemmrhoid

A

I- Bleeding, no tissue prolapse out of anus
II- prolapse with Valsalva and spontaneously reduces
III- prolapse with Valsalva and requires manual reduction
IV- incarcerated (always prolapsed)

260
Q

Hemorrhoid Tx

A

Stool softener (colasce)

Sitz bath

Lidocaine jelly

Nitroglycerin ointment
Or CCB ointments

Sclerotherapy

Band Ligation

261
Q

Treatment for post banding sepsis in the hemorrhoid pt

A

early antibiotic treatment coupled with aggressive surgical drainage

262
Q

Everted edges of the rectum with a central ulceration

Think

A

SCC of the rectum/ anus

263
Q

When to do abdomino-perineal resection for anal cancer

A

recurrent disease, residual disease after radiation, or bulky tumors

264
Q

MC endocrine tumors of the GI system

A

Carcinoid

S/S hot flashes, bronchospasms, and arrhythmias
carcinoid syndrome
liver is not able to metabolize the active substances

265
Q

Anal fissures that are lateral or in multiple locations think

A

Indicators of other disease :

Crohn disease, syphilis, tuberculosis and even squamous cell carcinomas

266
Q

What is the majority of tx for anal fissures

A

Two thirds successfully treated with conservative measures
-Topical nitroglycerin (0.2% NTG) and nifedipine (2%)

Symptoms that do not resolve may improve with injection of botulinum toxin

267
Q

Cryptoglandual infections of the anal canal

A

Perirectal abcess

PRIMARY CARE MANTRA: “NEVER LET THE SUN GO DOWN ON A PERIRECTAL ABSCESS”

268
Q

What is the post op Care for perianal abcess

A

Antibiotics are not necessary except in patients with significant cellulitis

Use a pad as necessary, drainage & pain should decrease in several days

Pain medication, stool softeners, and laxatives
i
nstructed to shower or take warm tub soaks for perianal hygiene.

269
Q

What is the threshold for SRGRY for pilonidal dz

A

Persistent drainage x 2-3 months are surgical candidates

If the abscess is greater than 5 cm or recurrent, it may include loculated segments separated by subcutaneous septae
these patients are best operated on

Bascom is the mc surgry

Senoir 21-2 (77 decks)

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