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Flashcards in ana surge 2 Deck (199):
1

Extension of the breast

From ribs 2-6

2

Level of the nipple

4th ICS

3

Retraction of the nipple is caused by:

Pulling on the lactiferous ducts

4

Skin dimpling in Breast Ca is caused by:

Shortening of Cooper's ligament

5

Interference with lymphatic drainage of the breast

Peau d' orange sign - thickened, leather like appearance of the skin

6

Innervation: muscles of facial expression

Cervical branch of CN VII

7

Level of hyoid bone

C3 or C4

8

Infrahyoid muscle that depresses the larynx

Sternothyroid

9

Hyoid muscles innervated by C1 nerve

Geniohyoid, Thyrohyoid

10

Weakness of Trapezius muscle - cannot shrug and abduct the arm

Accessory nerve lesion - crosses the occipital triangle

11

Triangle crossed by external jugular vein and subclavian artery

Subclavian/Suboccipital Triangle

12

Level of Thyroid Gland

C5 to T1 vertebra

13

Narrow tube that connects the thyroid gland to the tongue

Thyroglossal Duct - normally atrophies and disappears

14

Condition associated with esophageal atresia resulting to Polyhydramnios

Tracheoesophageal Fistula

15

Abducts the vocal cords

Posterior cricoarytenoid

16

Adducts the vocal cords

Lateral cricoarytenoid

17

Relaxes the vocal cords

Thyroarytenoid

18

Tenses the vocal cords

Cricothyroid - external branch of SLN

19

RLN more commonly injured

Left - hooks around arch of the aorta

20

Nerve supply to the diaphragm

Phrenic - motor (from C3, C4 and C5)

21

Blood supply of nose

Hasselbach's plexus (anterior), Woodruff's plexus (posterior)

22

Odontogenic tumor that may erode the bone cortex. Radioluscent soap bubble appearance on xray

Ameloblastoma - Tx is resection

23

Innervates the muscles of mastication

3rd division CN V

24

Sentinel node of laryngeal SCC

Delffian node - prelaryngeal node

25

Facial nerve exits what foramen

Stylomastoid foramen

26

Most common salivary gland malignant tumor

Mucoepidermoid Ca

27

Nerves protected during Mandibulectomy

Hypoglossal nerve inferiorly, Lingual nerve superiorly

28

Location of thyroid isthmus

C2-C4

29

Anatomic landmark where RLNs are prone to injury

Ligament of Berry

30

RAI imaging for lingual thyroid or to search for residual thyroid after thyroidectomy

Iodine 123

31

RAI used to screen and treat differentiated thyroid Ca

Iodine 131

32

Screening method for undifferentiated or anaplastic thyroid Ca

PET scan

33

Most common thyroid Ca and has the greatest tendency to invade LN

Papillary Ca

34

Medullary thyroid Ca: worst prognosis

Familial type - MEN 2B

35

FNAB of Anaplastic Thyroid Ca

Giant multinucleated cells

36

Tx for Thyroid Lymphoma

CHOP regimen - Cyclophosphamide, Doxorubicin, Oncovin/Vincristine, and Prednisone

37

Most common malignancy that metastasize to the thyroid

Renal Cell Ca

38

Sharp indentation that approximates the junction of the body and pyloric part of the stomach

Angular incisure/notch

39

Portal vein is made of:

Superior mesenteric vein + splenic vein

40

Rule out what Ca in gastric ulcer

Gastric adenocarcinoma

41

Most common type of Gastric Ulcer

Type I - found in antral lesser curvature, blood type A

42

Caused by destruction of the pyloric sphincter resulting to abrupt delivery of hyperosmolar load to the small intestines

Dumping Syndrome

43

Most common pancreatic tumor in patients with MEN I

Gastrinoma

44

Diagnosis of ZES

Serum gastrin more than 200pg/mL after a secretin challenge

45

Gastrinoma Triangle or Passaro's Triangle

Pancreatic neck, Porta hepatis, 3rd portion of duodenum

46

Clinical Triad of ZES

Hypersecretion of HCl, severe PUD, Gastrinoma

47

Large, tortuous submucosal artery in the proximal stomach. Pulsations cause ulceration of the overlying mucosa causing intraluminal bleeding

Dieulafoy's Lesion

48

Most common form of Gastric Ca

Gastric Adenocarcinoma - dysplasia as universal precursor

49

Tx for gastric adenocarcinoma <2 cm

Endoscopic Mucosal Resection - tumors limited to mucosa or submucosa

50

Diffuse neoplasm involving the entire stomach giving it a "leather bottle" appearance

Linitis plastica

51

Periumbilical node in Gastric Adenocarcinoma

Sister Mary Joseph's Node

52

Peritoneal nodes in Gastric AdenoCa, palpable on rectal examination

Blumer's Shelf

53

Tx goal of Gastric AdenoCa

Resection of all tumor with 5cms grossly negative margins

54

Standard operation in Gasttic AdenoCa

Radical Subtotal Gastrectomy - remove distal 75%

55

Gastric Lymphoma arises from MALT. Majority are what type?

Non Hodgkin's B Cell Type

56

Presents like gastric adenocarcinoma with B symptoms (fever, weight loss, night sweats)

High grade MALT lymphoma

57

Tx for low grade MALT lymphoma

H. Pylori eradication

58

GIST arise from the?

Interstitial cells of Cajal - pacemaker in GI tract

59

Tumor markers of GIST

c-KIT (CD 117) and CD 34

60

Most common type of GIST

Epithelial cell stroma

61

Tx for GIST

Wedge resection, Imatinib (Gleevec) for unresectable or metastatic GIST

62

Gastric carcinoids arise from?

Gastric ECL cells

63

Most common type of Gastric Carcinoid

Type I - women with hypergastrinemia, small but multiple, low malignant potential

64

Type of Gastric Carcinoid that occurs in MEN I and ZES

Type II - higher malignant potential

65

Type of Gastric Carcinoid that presents with Carcinoid Syndrome

Type III - solitary, among men

66

Biopsy: diffuse hyperplasia of surface mucus secreting cells and decrease parietal cells

Hypertrophic Gastropathy (Menetrier's Disease) - protein losing enteropathy and hypochlorhydia

67

Presentation is dilated mucosal blood vessels in the distal stomach

Watermelon Stomach (Gastric Antral Vascular Ectasia)

68

Most common position of the appendix

Retrocecal

69

Nerve that can be possibly injured during appendectomy

Iliohypogastric nerve - weakening of anterior abdominal wall

70

Used as a landmark during OR to identify the location of the appendix

Anterior taenia

71

Where is McBurney's Point?

Lateral 1/3 from ASIS to umbilicus

72

Appendicitis: pain on extension of right thigh

Psoas sign - tip of appendix is retrocecal

73

Appendicitis: pain on passive internal rotation of the flexed right thigh with the patient in the supine position

Obturator Sign - tip of the appendix is on the pelvis

74

CT scan findings in Appendicitis

Enlarged enhancing appendix (>6mm), periappendiceal fat stranding, wall thickening

75

Complication of appendicitis. A mass of inflamed, matted intestine and omentum with little or no discrete collection of pus

Phlegmon - complication of gangrenous acute AP

76

Most important pathogen in AP related infection

Bacteroides fragilis

77

When is an incidental appendectomy routinely performed?

Ladd's procedure - correction of intestinal malrotation with volvolus in children

78

Most common malignancy of the appendix

Carcinoid - usually at the tip

79

Tx for adenocarcinoma of the appendix

Right hemicolectomy

80

Diffuse collection of gelatinous fluid and mucinous implants on peritoneal surfaces and omentum

Pseudomyxoma peritonei - Tx with surgical debulking (appendectomy, omentectomy, TAHBSO)

81

Fatty tags in the large intestine

Appendices epiploicae

82

Longest, largest and most mobile part of the large intestines

Transverse colon

83

Blood supply of cecum

Anterior/posterior cecal artery from ileocolic artery (SMA)

84

Blood supply of appendix

Appedicular artery from ileocolic artery (SMA)

85

Venous drainage of appendix

Appendicular vein to posterior cecal vein (SMV)

86

Blood supply of ascending colon

Ileocolic and right colic artery from SMA

87

Blood supply of transverse colon

Middle colic artery from SMA and L colic artery from IMA

88

Blood supply of descending colon

L colic and sigmoid artery from IMA

89

Blood supply of sigmoid colon

Sigmoid artery from IMA

90

5 inches long, begins in front of 3rd sacral vertebrae and ends in front of the tip of the coccyx

Rectum

91

Blood supply of the rectum

Superior rectal from IMA, middle rectal from internal iliac and inferior rectal from internal pudendal

92

Muscles in internal and external anal sphincter

Internal - circular muscles, external - 3 striated voluntary muscles

93

Dentate/Pectinate/Anorectal Line

Junction between the superior (endoderm) and inferior (ectoderm) parts

94

Muscle that forms a U shaped sling resulting to a 90 degree perineal flexure

Puborectalis Muscle

95

Disease due to absence of ganglionic cells in the myenteric and submucosal plexuses. Mutations of RET proto-oncogene

Hirschsprung Disease (Colonic Aganglionosis) - sigmoid colon and rectum, failure of internal anal sphincter to relax

96

Blood supply to the upper part of the anal canal

Superior rectal artery from IMA

97

Lymphatic drainage of upper part of anal canal

Inferior mesenteric LN

98

Blood supply of lower anal canal

Inferior rectal artery from internal pudendal artery

99

Lymphatic drainage of lower part of anal canal

Superficial inguinal nodes

100

Sensations: Upper vs Lower Anal canal

Upper - stretch, Lower - pain temperature touch pressure

101

Outpouching of a remnant of the proximal portion of the yolk sac

Meckel's Diverticulum

102

Diverticulum located 2ft from ileocecal junction, 2in long, and may contain ectopic gastric or pancreatic cells

True Diverticulum - bleeding with ulceration of ectopic cells

103

True or false: R and L colon are retroperitoneal while transverse and sigmoid colon are intraperitoneal

TRUE

104

Widest portion of the colon with the thinnest wall

Cecum - high risk of perforation

105

Most common area of obstruction in the colon and high risk for volvulus

Sigmoid - narrowest portion

106

Twisting of an air filled segment of bowel about its narrow mesentery

Colonic volvulus - counterclockwise usually, apex is opposite where it twists

107

Abdominal x-ray of sigmoid volvulus

Inverted U shape, sausage like loop

108

Indicates successful reduction in sigmoid volvulus

Passage of air and feces through soft rectal tube

109

Emergent procedure for a septic patient with volvulus (bowel unprepared)

Hartmann's Procedure - resection of sigmoid colon with construction of an end colostomy

110

Proctoscope findings in sigmoid volvulus

Swirl sign or the area where it twists, procedure contraindicated for necrotic tissue

111

Type of colostomy where midline laparotomy needed for take down

Devine's colostomy

112

Plain abdominal x-ray of Cecal Volvulus

Kidney shaped, air filled structure in the LUQ - does not resolve with NGT placement

113

Tx for cecal volvulus

R hemicolectomy with primary ileotransverse anastomosis

114

Transverse colon loops that are interposed between the liver and diaphragm

Chilaiditi's syndrome - at risk for volvulus

115

Tx of rare, R sided diverticulitis

Segmental ileocecal resection

116

Most common cause of life threatening colonic hemorrhage

Diverticular disease

117

IBD that cannot be cured with surgery

Crohn's Disease

118

Most common location of Crohn's disease

Terminal ileum, but can happen anywhere

119

Pathologic findings of Crohn's Disease

Transmural involvement, skip lesions, non caseating granulomas, perianal fistulas, cobblestoning strictures

120

Most common type of colonic polyp

Hyperplastic, not pre-malignant

121

Colonic polyp that can be malignant if it occurs with a syndrome

Hamartomatous or Juvenile - occurs at any age

122

Colonic polyp where malignancy is related to its size (>2cm)

Adenomatous

123

FAP with extraintestinal manifestations (mandibular osteomas, hypertrophy of pigmented retinal epithelium, desmoid tumors)

Gardner's Syndrome

124

FAP with brain tumors (glioblastoma)

Turcot's Syndrome

125

Polyposis + epidermal changes (alopecia, cutaneous pigmentation, atrophy of nails)

Cronkite Canada Syndrome (AD)

126

Hamartomatous polyps of all 3 embryonal cell layers

Cowden's Syndrome - with breast Ca, leiomyomas, thyroid disease and facial trichilemmomas

127

Polyposis on jejunum, ileum and rectum. With melanin spots on lips and buccal mucosa

Peutz-Jegher's Syndrome

128

Mutation in FAP resulting to 100% lifetime Ca risk

SPC mutation, chromosome 5q

129

Mutations in Hereditary Nonpolyposis Colon Cancer

hMLH1 and hMSH2 mutation - 85% risk Ca, screening colonoscopy at 20 to 25yrs

130

Distinct curvatures that project into the lumen of the rectum

Valves of Houston

131

Retrosacral fascia of rectum

Waldeyer's fascia

132

Anterior fascia of rectum

Denonvillier's fascia

133

Levator ani muscles that make up the pelvic floor

Pubococcygeus, Ileococcygeus, Puborectalis muscle

134

Surgical anal canal

From anorectal ring to anal verge

135

At most risk during lateral mobilization of the rectum

Pudendal nerve - supplies pain, temperature and touch sensation to lower anal canal

136

At most risk during posterior mobilization of the rectum

Hypogastric plexuses - retrograde flow of sperm to the bladder

137

Etiology of rectal prolapse

Internal intussusception, outlet obstruction, long term laxative use

138

Thiersch procedure for rectal prolapse

Use a wire to tighten the sphincter

139

Common locations of hemorrhoids

3, 7 and 11 o'clock position

140

Tear in anoderm just distal to the dentate line

Anal fissure - pain causes spasm of the internal sphincter

141

Surgical Tx for anal fissure

Lateral internal sphincterotomy to relieve spasm

142

Complication of posterior sphincterotomy as a repair of anal fissure

Keyhole deformity - frequent soiling of underwear

143

Chronic form of anorectal abscess

Fistula-in-ano

144

Fistula-in-ano: Goodsall's Rule

Anterior straight, posterior curved

145

Well differentiated keratinizing anal neoplasm often caused by HPV infection

Squamous cell Ca - Tx with wide local excision with 2cm margin, if sphincter affected do APR

146

Intraepidermal squamous cell Ca of anus treated with wide excision

Bowen's Disease

147

From apocrine glands, patients present with severe pruritus. Treat with wide excision of APR for advanced disease

Paget's Disease

148

Treatment for Epidermoid Ca of anus

Nigro protocol - 5 FU, Nitromycin, External Beam Radiation

149

Pain, fever and ileus appearing 2-3 weeks after an attack of pancreatitis

Pseudocyst - fibrous wall surrounding a collection of pancreatic juice and necrotic or suppurative pancreatic tissue

150

Best Tx for pseudocyst of pancreas

Internal drainage

151

Most common pancreatic malignancy

Adenocarcinoma - usually at the head

152

Definitive and potentially curative Tx of periampullary Ca of pancreas

Whipple's surgery - pancreaticoduodenectomy

153

How do you know if the pancreatic head is resectable?

If you can palpate the SMA posteriorly

154

Dreaded complication of Whipple's surgery

Leak from pancreaticojejunostomy - peritoneal cavity digested by pancreatic enzymes

155

Most common functional endocrine tumor of the pancreas

Insulinoma - ?insulin and C peptide, ? glucose

156

Whipple's Triad of Insulinoma

Symptomatic fasting hypoglycemia, serum glucose <50mg/dL, relief of symptoms with glucose administration

157

Tx for Insulinoma

Enucleation, if >2cm and close to main pancreatic duct Whipple's Procedure

158

Pancreatic tumor located at the tail. Causes watery diarrhea, hypokalemia, and achlorhydia

VIPoma - usually malignant

159

Pancreatic tumor with presence of necrolytic migratory erythema

Glucagonoma - found at body and tail, metastatic

160

Gastrinoma Triangle

Cystic duct, junction of the 2nd and 3rd portions of the duodenum, junction of the neck and body of the pancreas

161

First, shortest, widest and fixed (retroperitoneal) part of the small intestine

Duodenum - C shaped, 25cm long

162

Duodenum: attachment site for hepatoduodenal ligament of lesser omentum

Superior (1st) - anterolateral to L1

163

Duodenum: descends along the R sides of L1 to L3

Descending (2nd)

164

Blood supply upper part of duodenum

Superior pancreaticoduodenal artery (gastroduodenal - hepatic - celiac)

165

Blood supply of lower duodenum

Inferior pancreaticoduodenal (SMA)

166

Venous drainage of duodenum

Superior/Inferior pancreaticoduodenal veins to portal vein

167

Most common location of duodenal ulcers

Anterior wall on first part - most common site of perforation

168

Duodenal wall ulcers that may lead to severe hemorrhage and perforate into the pancreas

Posterior wall ulcer - erode gastroduodenal artery

169

Anatomic landmark of GIT that also supports the duodenojejunal flexure

Ligament of Treitz - demarcates duodenojejunal junction

170

True or false: jejunum lies in RLQ while ileum lies in LUQ

False - Jejunum lies in LUQ, Ileum lies in RLQ

171

Blood supply of jejunum and ileum

SMA - arterial arcades - vasa recta

172

Jejunum vs Ileum

Jejunum - red color, wall thick and heavy, greater vascularity, long vasa recta, few and large arcades, less fat, large and tall plicae circularis, few lymphoid nodules

173

Jejunum vs Ileum

Ileum - pink color, thin and light wall, less vascularity, short vasa recta, many arcades, more fat, sparse plicae circularis, many lymphoid nodules (Peyer's Patches)

174

Most common location of intussusception

Ileocecal - R sided colicky pain, currant jelly stools

175

Mucosal folds in the small intestine

Plicae circulares, Valvulae conniventes, Valves of Kerkring

176

Strongest layer of small intestine

Submucosa

177

Development of small intestines

Duodenum - foregut, Jejunum and Ileum - midgut

178

Lymph node aggregates in the ileum

Peyer's Patches

179

Produce an alkaline secretion to protect the GI against acidic gastric chyme

Duodenal Brunner's Glands

180

Cells in the SI that aids in digestion and absorption of dietary nutrients

Enterocytes

181

Found at the base of the crypts of Lieberkuhn. Role on phagocytosis and mucosal defense

Paneth Cells

182

Found above Peyer's Patches in ileum. For antigen presentation.

Microfold (M) Cells

183

Development of SI

5th week AOG - extracoelemic herniation. 10th week AOG - return to abdominal cavity, rotation around the SMA

184

Absorption of Na, Cl, K, Ca, Mg, Iron and H2O

Jejunum

185

Most common surgical disorder of the SI

Small bowel obstruction - 75% due to adhesions

186

Most common cause of SBO among pediatric patients

Hernias

187

Abdominal Xray SBO:

Dilated small bowel loops (>3cm), air fluid levels, paucity of air in the colon

188

"Intestinal housekeeper". Determines the pattern of contraction during the fasting state

Migrating Myoelectric Complex (MMC) - peristaltic contraction every 90 to 120 min

189

Cause of intestinal fistulas

80% iatrogenic - between 5th to 10th day post op, Dx through CT with oral contrast

190

Most common small bowel neoplasm

Adenocarcinoma in the duodenum - 80% metastasis at the time of diagnosis

191

Most common type of lymphoma in small bowel

B cell lymphoma in the ileum

192

Tx for jejunal and ileal tumors

Segmental resection with at least 5cm tumor free margins

193

Most prevalent congenital anomaly of the GIT

Meckel's Diverticulum - true diverticula

194

Etiology of Meckel's Diverticulum

Persistence of the omphalomesenteric duct or vitelline duct

195

Modality of choice to diagnose Meckel's Diverticulum

Tc pertechnetate scan

196

Segmental resection for Meckel's Diverticulum

Bleeding, wide base, inflamed and perforated base

197

Most common etiology of mesenteric ischemia

Arterial embolus - from L atrial thrombi, lodges to SMA

198

Etiology of chronic mesenteric ischemia

Atherosclerotic lesions in the main splanchnic arteries (celiac, SMA, IMA)

199

Gold standard diagnostic modality of choice for mesenteric ischemia

CT scan angiography