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SURGERY > PESTANA2 > Flashcards

PESTANA2 Flashcards

1
Q

What is one cause of an “acute abdomen” that will not have peritoneal signs?

A

Acute pancreatitis, it is a retroperitoneal organ

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2
Q

How do you diagnose Boerhaave tears? Tx?

A

Gastrograffin swallow first, Barium if negative (don?t want barium in the mediastinum); followed by emergent surgical repair

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2
Q

How do ureteral stones classically present? What is the best diagnostic test?

A

Colicky flank pain that radiates toward the scrotum or labia; CT (UA will show microhematuria)

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2
Q

What scan helps to locate the culprit parathyroid gland for hyperparathyroidism?

A

Sestamibi scan

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3
Q

What is the diagnostic test of choice for coarctation of the aorta?

A

CT angiography

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4
Q

Why do all mechanical obstructions of hernias go to the OR?

A

Because you can repair the hernia, if it is caused by adhesions, taking the pt to OR for LOA only increases risk of more adhesions

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4
Q

How does right sided colon CA often present? Dx? Tx?

A

Anemia for no good reason in an elderly person; Colonoscopy w/ Bx; Right hemicolectomy with oncologic resection (i.e. need 12 LN)

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4
Q

When should C diff colitis be operated on?

A

If it is unresponsive to tx with WBC > 50,000 and serum lactate > 5

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4
Q

What is a thyroid nodule in a hyperthyroid pt

A

Usually a “hot adenoma” and almost never cancer

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5
Q

Which form of breast CA has the worst prognosis and requires pre op chemotherapy

A

Inflammatory breast CA

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6
Q

Why do a full coloscopy before operating on a left sided cancer?

A

To rule out a synchronous right sided primary

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6
Q

How do you diagnose a pyogenic liver abscess? What is the tx?

A

CT scan or US; CT guided drain placement

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7
Q

What is the key finding in ascending cholangitis?

A

Extremely elevated ALP

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8
Q

What is the usual antecedent disease for a pyogenic abscess of the liver?

A

Acute cholangitis (Charcot’s triad or Reynolds pentad); dx is CT and tx is CT-guided drainage

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8
Q

What is the final common pathway that should be anticipated in a person with hemorrhagic acute pancreas?

A

Development of multiple pancreatic abscesses that will need to be drained; do daily CT scanning

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9
Q

How do you diagnose a hepatic adenoma? What is the concern?

A

CT scan (NOT intraoperative bx); the concern is that they may spontaneously rupture and bleed into the abdomen

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9
Q

Tx of acute pancreatitis

A

NPO, NGT, and IVF

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9
Q

What breast masses occur in very young adolescents and have rapid growth

A

Giant juvenile fibroadenomas

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10
Q

What are the most likely locations in the bone that breast CA will go to

A

Vertebral pedicles (back pain)

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11
Q

When is surgery indicated in necrotizing enterocolitis?

A

If abdominal wall erythema, pneumatosis intestinalis, air in portal vein, or pneumoperitoneum develops

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13
Q

What is the usual cause of an isolated indirect hyperbilirubinemia?

A

Hemolytic jaundice, direct dx towards cause of RBC destruction

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13
Q

What drug is used in pts who start developing pancreatic abscesses in acute pancreatitis?

A

IV meropenem

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13
Q

How do babies with gastroschisis get nutrition?

A

Need vascular access for TPN since the bowel will not work for about 1 month

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14
Q

What are the labs for hepatocellular jaundice? What should diagnostics be geared towards?

A

Elevated direct/indirect fractions of bilirubin; very high transaminases with modest ALP; gear towards hepatitis so get serologies

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15
Q

What are the 3 basic types of jaundice?

A

Hemolytic, Hepatocellular, and Obstructive

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17
Q

How do you diagnose hypertrophic pyloric stenosis if no palpable mass

A

US

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18
Q

When do you do surgery for partial and complete bowel obstructions (i.e. due to adhesions)?

A

Partials can be done after a few days if medical therapy failed (NPO, IVF, and NGT); Complete obstructions should be operated on within 24 hrs if medical tx fails

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19
Q

What is the best test to confirm carcinoid syndrome?

A

24 hour urinary collection for 5-hydroxyindole acetic acid

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19
Q

What is the big clinical test for esophageal atresia?

A

Coiling of the NGT in the chest on CXR (note in a traumatic situation in an adult this may point towards traumatic rupture of the diaphragm)

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20
Q

What is the goal gastric pH in an ICU pt to prevent stress-related mucosal disease?

A

> 4.0

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20
Q

What is a key laboratory difference between edematous pancreatitis and hemorrhagic pancreatitis?

A

Edematous has a high hematocrit from hemoconcentration whereas hemorrhagic has low hct from hemorrhage

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20
Q

What is Nelson syndrome?

A

Adrenal insufficiency from removal of adrenals

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21
Q

Describe the presentation of an acute abdomen due to ischemic processes

A

Will have severe abdominal pain with blood in the lumen of the gut

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22
Q

Necrotizing soft tissue infxn can occur in pts who have perirectal abscess and what dz?

A

DM

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23
Q

What do you do if the results of FNA of the thyroid are indeterminate

A

Thyroid lobectomy

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24
Q

What is the first diagnostic test in working up Cushings disease?

A

Low dose dexamethasone suppression test

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25
Q

How is anal cancer treated?

A

Nigro Chemoradiation protocol; 5 weeks of chemoradiation and if residual tumor surgery. But rarely is surger ever needed

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26
Q

What is often present in glucogonomas?

A

Migratory necrolytic dermatitis

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27
Q

Describe the general presentation of an acute abdomen caused by inflammation

A

Has a GRADUAL onset and slow buildup that is very poorly localized and then becomes severe with peritoneal signs in the area; often pw systemic signs like leukocytosis and fever

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28
Q

What test is diagnostic for sigmoid volvulus? Describe the findings

A

AXR; Shows a “Parrot’s beak” dilated loop up in the RUQ that tapers down in the LLQ

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29
Q

Blood per rectum in a child is most likely from what?

A

Meckel Diverticulum

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29
Q

What are the aldosterone and renin levels in Conn’s?

A

Aldosterone high and renin low

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30
Q

What is the presentation of biliary pancreatitis?

A

A mixed cholangitis/pancreatitis picture with elevation of transaminases and ALP as well as lipase and amylase

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31
Q

What are 3 things that mimic acute abdomens that should be ruled out? How would you rule them out?

A

1) Inferior wall MI (EKG troponins) 2) Lower lobe pneumonia (CXR) and 3) PE (D-dimer, US, or CTA)

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32
Q

What are the labs like for obstructive jaundice?

A

Elevated direct/indirect fractions of bilirubin; modest transaminase bumps (vs. hepatocellular causes) and very high ALP (vs. hepatocellular)

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33
Q

What is nesidioblastosis? Tx?

A

Devastating hypersecretion of insulin in a newborn (often of DM mom); requires a 95% pancreatectomy

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34
Q

How does esophageal atresia present?

A

excessive salivation shortly after birth or choking spells when feeding is first attempted

36
Q

How is diagnosis made in Hirschsprung?

A

Full thickness rectal bx (i.e. see adipose tissue on slide representing the mesorectum)

37
Q

What test will confirm the dx of an acute abdomen caused by perforation?

A

AXR to show free air under the diaphragm

39
Q

How do you treat necrotizing enterocolitis?

A

Stop all feedings, broad spectrum abx, IVF, and TPN

40
Q

What is the mgmt of intussusception?

A

Barium or air enema is diagnostic and therapeutic but if doesnt work then surgery

42
Q

What are 3 causes of green vomiting in a baby with a double bubble on xray

A

duodenal atresia (Downs), annular pancreas, and malrotation

43
Q

What does it mean if there is suppression of cortisol with a high dose dexamethasone suppression test?

A

That identifies a pituitary microadenoma; failure to suppress = adrenal adenoma or paraneoplastic syndrome (small cell CA)

44
Q

What should you think if you see a breast abscess in a woman who is not lactating?

A

It is breast CA until proven otherwise

46
Q

In whom does a fistual in ano develop? Tx?

A

Ppl who have had a perirectal abscess drained; if not suspect crohns; fistulotomy

48
Q

What key finding of acute edematous pancreatitis helps to identify it as edematous by labs?

A

High hematocrit (hemoconcentration)

49
Q

If for any reason surgical repair of esophageal atresia has to be delayed what must be done?

A

Placement of a gastrostomy to prevent chemcial pneumonitis

51
Q

What is the real issue in congenital diaphragmatic hernia?

A

The resultant pulmonary hypoplasia

52
Q

How is the presentation of acute cholecystitis different from that of biliary colic?

A

Biliary colic is characterized by attacks that are self-limited but acute cholecystitis becomes constant and is accompanied by peritoneal signs and systemic signs of inflammation

54
Q

What is the tx for a single focus of DCIS? Why

A

Lumpectomy and radiation; DCIS cannot metastasize; if multicentric then simple mastectomy incase invasive focus was missed

55
Q

What is the best diagnostic test to work up melena?

A

Upper Endoscopy

56
Q

When is SBO a surgical emergency?

A

If it is strangulated i.e. white count, declining, and peritoneal signs

58
Q

What is the surgical tx of necrotic pancreas?

A

Necrosectomy usually 4 weeks after development of necrotic pancreas since that allows time for the necrotic tissue to delineate

59
Q

What is the best diagnostic test for acute diverticulitis? What is the best initial Tx?

A

CT; NPO, IVF, Abx 7-10 d

60
Q

What is the best way to Dx C diff?

A

Toxin in stool

61
Q

What is the diagnostic and therapeutic therapy for meconium ileus?

A

Gastrograffin enema showing microcolon and insipissated mucus in terminal ileum; gastrograffin draws in fluid and dissolves the pellets

63
Q

What is the tx of perirectal abscess?

A

I/D

64
Q

What is the initial diagnostic test for pheochromocytomas?

A

24 hour urinary collection for VMA, metanephrines (more specific) or free catecholamines

65
Q

What is the usual presentation (classic) for mesenteric ischemia

A

Develops when there is an acute abdomen in a person with hx of afib or debilitating MI (LV hypokinesis) = they threw a clot down the SMA

67
Q

What will US show in acute cholecystitis?

A

Gallstones, thickened GB wall, and pericholecystic fluid

68
Q

What is the key finding in primary hyperaldosteronism?

A

Hypokalemia in a hypertensive pt who is not on diuretics

69
Q

What is the first step in the work up of labs that point towards hepatocellular jaundice? Obstructive jaundice?

A

Serologies for hepatitis viruses; US for bile duct dilatation

70
Q

What is the tx for acute cholangitis?

A

IV abx and emergency decompression of the CBD by ERCP or by Percutaneous Transhepatic cholangiogram

71
Q

What is the next diagnostic step if working up ZE syndrome and gastrin is markedly elevated

A

Contrast CT to identify the gastrinoma and remove it; Calcium level to check for parathyroid adenoma to determine if part of MEN I

73
Q

How do you manage large pancreatic pseudocysts (>6 cm)

A

percutaneous drainage, surgical drainage into GI tract, endoscopic drainage into stomach

74
Q

What test can be done if you suspect ZE syndrome but gastrin levels are equivocal

A

Secretin stimulation test

75
Q

What is the tumor marker for hepatocellular carcinoma? What is the tx?

A

AFP; resection if possible

75
Q

What is the usual tx of pts with a hot adenoma?

A

Radioactive iodine

75
Q

How is malrotation diagnosed?

A

Contrast enema or upper GI series

77
Q

What is the first step in treating C diff colitis?

A

Discontinue the offending antibiotic

79
Q

How does an acute abdomen due to perforation differ from that due to obstruction?

A

Perforation is often constant and generalized whereas obstruction is more colicky and localized

80
Q

Which disease classically presents with dysphagia that is worse for liquids?

A

Achalasia

81
Q

What is the diagnostic method of choice in thyroid nodules in euthyroid pts?

A

FNA

82
Q

How can you determine if a palpable nodule in a hyperthyroid pt is the source of the hyperthyroidism?

A

Nuclear scan

83
Q

How does an acute abdomen due to obstruction differ from that due to inflammation?

A

One due to obstruction will be colicky in nature and localize, one from inflammation will start out generalized and become more localized with time and have systemic signs of inflammation (wct and fever)

83
Q

Where is the most common location of pancreatic pseudocysts?

A

Lesser Sac

84
Q

Describe the pain of acute abdomen due to perforation

A

Constant, generalized, and very severe; the pt is reluctant to move and very protective of the abdomen

85
Q

A medically sophisticated pt that wants to go after the whole Munchausen-insulinoma thing can use what instead of injectable insulin?

A

Sulfonylureas since they induce the actual secretion of insulin which would also elevate C-peptide thus obscuring the Munchausen picture

87
Q

Upon what is inoperability of a breast cancer based?

A

Local extent not metastasis

88
Q

What are the 3 ways to workup active LGIB after UGIB and hemorrhoids have been excluded?

A

If it is not much blood then you can do colonoscopy, if it is a lot of blood then you do angiography, and if it is in between you do a tagged RBC study

90
Q

How is the dysphagia of achalasia classically different from that of esophageal CA?

A

Achalasia is often worse for liquids than solids whereas CA starts out as dysphagia for solids then progresses to liquids

91
Q

What is the big general rule in congenital anomalies?

A

When there is one there are usually more

92
Q

What is the usual tx for internal hemorrhoids vs. external? Which bleed?

A

Internal = banding; external = surgical removal; internal bleed

93
Q

What hormonal therapy for breast CA do premenopausal women get? Postmenopausal?

A

Premenopausal = tamoxifen; Postmenopausal = anastrazole

94
Q

What is the tx of the acute issue in sigmoid volvulus

A

Proctosigmoidoscopic exam with decompression and leave in a rectal tube; later you can electively do a sigmoid resection with primary anastomosis

95
Q

How does acute abdomen due to obstruction present?

A

P/w onset of colicky abdominal pain and if due to obstruction of a small duct i.e. cystic or ureter will refer pain to associated area. Pt will writhe in pain and not be comfortable

96
Q

What type of medications can abort biliary colick

A

Anticholinergics

97
Q

How is the presentation of amebic liver abscess different from that of pyogenic abscess? How is the treatment different?

A

Pyogenic abscess often arises due to complication of ascending cholangitis and needs CT guided drainage; Amebic abscess is often assoc with a “mexico connection” and tx is metronidazole

98
Q

What is a study to do when upper and lower endoscopy have not shown a source of bleeding and you want to evaluate a small bowel etiology?

A

Capsule endoscopy

98
Q

What are the 3 types of acute pancreatitis?

A

Edematous, hemorrhagic, or suppurative (pancreatic abscess)

99
Q

What is the mgmt of biliary pancreatitis?

A

NPO, poss NG suction, IVF? Wait on it and possibly do ERCP with sphincterotomy and then elective cholecystectomy

100
Q

What is the cardinal symptom of Hirschsprung disease?

A

Chronic constipation

101
Q

When can you do a metastatic resection for a met to the liver?

A

If restricted to one lobe of the liver

103
Q

What are the insulin and C peptide levels in insulinoma?

A

Both elevated vs. Munchausen

104
Q

What are the symptoms of chronic pancreatitis

A

DM, steatorrhea, and constant epigastric pain

105
Q

What are 4 indications for surgical Tx of UC? What is the Tx?

A

Disease for greater than 20 years, need for high dose steroids or immunosuppresants, severe interference with nutrition, multiple hospitalizations, or TOXIC MEGACOLON; Total proctocolectomy with end ileostomy (Brooke Ileostomy)

106
Q

Tx for axymptomatic gallstones

A

Leave em alone

108
Q

What other tests should be done in a kid with esophageal atresia (4)

A

Anal exam for imperforate anus, renal US for abnormalities, echo for heart abnormalities, and xray for radial and vertebral abnormalities

109
Q

What is the tx for mallory-weis tears?

A

Endoscopy with photocoagulation

110
Q

Discuss the treatment of obstructive jaundice due to CBD stone

A

ERCP followed by cholecystectomy

111
Q

What do you do when working up Cushings if there is no supression after a low dose dexamethasone test?

A

Collect 24 hour free urine cortisol and if elevated go to a high dose dexamethasone suppression test

112
Q

How does an acute abdomen due to perforation differ from that due to ischemia?

A

One with perforation is severe, constant and generalized; one from ischemia will also have blood

113
Q

What diagnostic study can guide surgical resection of an intraductal papilloma?

A

Galactogram

114
Q

How does the tx of gastric lymphoma differ from gastric adenocarcinoma?

A

The best tx of gastric adenocarcinoma is surgery whereas that of gastric lymphoma is chemoradiation (lymphoma has better prognosis)

115
Q

What is the mgmt of exstrophy of the bladder?

A

Immediate surgery within 1-2 days of life; increased risk of SCC of bladder

116
Q

How do you determine the level of the pouch in imperforate anus?

A

Take an xray upside down with a metal marker on the anus so that gas rises up

SURGERY (4 decks)

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