PreTest Surgery: Gastrointestinal Tract, Liver, and Pancreas

Question 1

Describe the management of ITP based on platelet level and bleeding status.

Answer 1

• > 30,000: close observation and follow-up
• 15,000 - 30,000: steroids first, then IVIG as backup
• Acute bleeding: treat with platelets to above 50,000 and give steroids

Question 2

Non-invasive appendiceal adenocarcinoma should be treated with ____________.

Answer 2

right hemicolectomy

Question 3

What is the difference between a colectomy and a proctocolectomy?

Answer 3

Proctocolectomy involves the rectum

Question 4

The definitive treatment for ulcerative colitis is _____________.

Answer 4

Proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy

Question 5

The difference between aspiration and drainage is ____________.

Answer 5

that aspiration takes only a small part for diagnostic purposes while drainage is therapeutically emptying it

Question 6

The most common complication of ileostomies is ______________.

Answer 6

parastomal hernia

Question 7

A patient has obstructive jaundice but the RUQ US shows no gallstones. Next image?

Answer 7

CT

Without gallstones, the diagnosis is likely pancreatic cancer.

Question 8

A patient has a gastric bypass and then complains of postprandial weakness and diarrhea. What’s happening?

Answer 8

Dumping syndrome

Normally, food slowly drips through the pylorus to the small intestine. In a patient with surgical damage to the pylorus, food can rapidly fill into the small intestine. It is often hyperosmolar, so the food pulls water from the body to the intestines, resulting in loss of intravascular volume.

Question 9

What is a Billroth I and a Billroth II?

Answer 9

• Billroth I: gastroduodenostomy

* Billroth II: gastrojejunostomy

Question 10

Gallstone ileus occurs due to a fistula between _____________.

Answer 10

the gallbladder and duodenum

Question 11

In which cases is a colectomy indicated for diverticula?

Answer 11

Abscess, perforation, or diverticulitis refractory to medical management

The proper course is to medically treat (antibiotics, percutaneous drainage) and follow-up with colectomy.

Question 12

CCK-HIDA is used to evaluate for _____________.

Answer 12

biliary dyskinesia, a syndrome in which the gallbladder is inflamed in the absence of inflammation or stones

Question 13

Review the management of gallbladder polyps.

Answer 13

• < 1 cm: observation with repeat US
• ≥ 1 cm: cholecystectomy with frozen section, radical removal (portal lymphadenectomy with liver wedge resection) if positive

Question 14

Sudden onset abdominal pain with fever, elevated WBCs, and mass in the abdominal wall on imaging is likely ______________.

Answer 14

rectus hematoma

Question 15

Compare the treatment of amebic and bacterial liver abscesses.

Answer 15

• Amebic: medical first line, add more drugs second line, laparotomy if that fails
• Bacterial: percutaneous drainage

Question 16

You need to get a ___________ to evaluate a sliding hernia.

Answer 16

endoscopy

Question 17

Discuss mesenteric ischemia versus ischemic colitis.

Answer 17

• Mesenteric ischemia:

• Presents in vasculopaths with fever, hematochezia, elevated WBCs, and duskiness of splenic flexure on colonoscopy
• Treat with bowel rest and vascular management

•Ischemic colitis:

• Presents as sudden-onset hematochezia and fever in someone with a thromboembolic disorder (ahem, atrial fibrillation)
• Treat with thrombectomy

Question 18

True or false: those with major colectomies typically have chronic diarrhea.

Answer 18

False

The reserve capacity of the colon is immense. A majority of it can be removed with little change in the quality of the stool and the nutritional health of the person.

Question 19

Hepatic adenomas should be managed with _____________.

Answer 19

resection if they are greater than 4 cm; they carry a small risk of transitioning to HCC or hemorrhaging

Question 20

How should focal nodular hyperplasia of the liver be treated?

Answer 20

Nothing

It is benign and carries no risk of malignant transformation.

Question 21

A teenager has acute-onset RLQ pain, fever, and nausea. Upon surgical intervention you notice a normal appendix and a fibrinopurulent exudate on the terminal ileum. Diagnosis and management?

Answer 21

Crohn’s with appendectomy for prevention of future Crohn’s tissue

Question 22

Iatrogenic bile duct strictures should be treated with _______________.

Answer 22

Roux-en-Y bypass

Question 23

The most accurate assessment of the T stage of esophageal cancer is an ____________.

Answer 23

endoscopic ultrasound

Question 24

Most gastrinomas form within _____________.

Answer 24

the triangle formed by the duodenum, pancreas, and bile duct

Question 25

What are Ranson’s criteria?

Answer 25

They are a set of criteria used to prognosticate acute pancreatitis: 
•Admission: 
- Age
- WBC
- LDH
- AST
- Glucose
•Next 48 hours: 
- Hct fall
- BUN 
- Calcium
- Base deficit

Question 26

Describe the presentation of insulinoma.

Answer 26

• Persistent release of insulin causes hypoglycemia with subsequent release of epinephrine (and thus sweating, shaking, and anxiety)
• Revealed by high insulin during hypoglycemic state

Question 27

How is anal cancer treated?

Answer 27

Radiation and chemotherapy

It metastasizes quickly. Studies of wide excision have revealed disappointing outcomes.

Question 28

A man has acute abdominal pain. Abdominal x-ray reveals large air distention of the colon. What should be the next diagnostic step?

Answer 28

Sigmoidoscopy

The most likely cause of acute colonic distention is volvulus, which would be diagnosed by sigmoidoscopy. Contrast enema is also diagnostic but to be avoided if there are any signs of perforation.

Celiotomy should follow a positive sigmoidoscopy.

Question 29

A woman presents with a kidney-shaped, air-filled object in her LUQ after an AAA repair. What is this and how should you treat?

Answer 29

Cecal volvulus and right hemicolectomy

Question 30

Echinococcal cysts should be treated with _____________.

Answer 30

pericystic resection

Question 31

Compare and contrast the two types of hiatal hernia.

Answer 31

•Sliding hiatal hernia:

• Both stomach and distal esophagus slide up and down
• Less worrisome. Surgical correction not necessary for all cases.

•Paraesophageal hiatal hernia:

• Distal esophagus remains in place but nearby stomach slides up through a hole in the diaphragm.
• More worrisome because larger hernia can disrupt lung expansion. Symptomatic (as in reflux or dysphagia

Question 32

A patient hospitalized with pancreatic cancer develops abdominal distention. X-ray reveals dilated colon. What likely happened?

Answer 32

Opioid ileus

Discontinue all opiates and anticholinergics.

Another potential diagnosis is hypercalcemia of malignancy (which can cause constipation).

Question 33

First-line treatment for major hemobilia is ____________.

Answer 33

transarterial embolization (same as for any major GI bleed)

Question 34

Bleeding from the ileocecal valve (seen on colonoscopy) in a 25-year-old should be further assessed with ____________.

Answer 34

Tc scan

Bleeding from proximal to the ileocecal valve is likely a Meckel’s.

Question 35

Describe the three tiers of management of carcinoid tumors of the appendix.

Answer 35

• < 1 cm: appendectomy
• 1 - 2 cm: depends on how close the tumor is to the colon
• > 2 cm: right hemicolectomy

Question 36

Cystic dilations of the bile duct should be treated with _____________.

Answer 36

Roux-en-Y bypass

Question 37

Describe the presentation of stress ulcers.

Answer 37

Multiple shallow ulcers in the fundus

Question 38

Critically ill patients with multisystem disease who have acute cholecystitis should be treated with __________.

Answer 38

tube cholecystectomy (percutaneous drainage of the gallbladder)

Question 39

Bleeding Dieulafoy lesions should be treated with _____________.

Answer 39

wedge resection

Question 40

In which cases should a person get a right hemicolectomy for an appendiceal carcinoid tumor?

Answer 40

If it’s greater than 2 cm or near the base of the appendix.

Small ones that are distal can be treated with appendectomy.

Question 41

Describe the management of gallbladder polyps.

Answer 41

Most gallbladder polyps are benign (90% are cholesterol pseudotumors). Features that correlate with increased risk of malignancy are age >50 and mass > 1 cm. If either of those features are met or if the person has obstruction, then remove the mass.

Question 42

What is brittle diabetes?

Answer 42

A form of IDDM that occurs when the pancreas is taken out. There is no glucagon so hypoglycemia develops more easily.

Question 43

The definitive treatment for UC is _______________.

Answer 43

total proctocolectomy with ileoanal pouch or ileostomy

Question 44

The treatment for refractory anal cancer or rectal cancer is ______________.

Answer 44

abdomino-perineal resection