Emma Holliday for Surgery: Part IV

Question 1

Zenker’s Diverticulum pres and tx

Answer 1

Bad breath and snacks in the AM

Tx with surgery

Question 2

Is Zenker’s a true diverticulum? Why?

Answer 2

False. Only has mucosa. True would be full thickness

Question 3

Someone has dysphagia to liquids and solids? What do we do

Answer 3

Achalasia. Tx w/ CCB, nitrates, botox, or heller myotomy

Question 4

Two things we associate with achalasia

Answer 4

Assoc w/ Chagas dz and esophageal cancer.

Question 5

Dysphagia that is worse with hot or cold liquids or with chest pain that feels like an MI with NO regurg

Answer 5

Diffuse esophageal spasm. Treat with CCB or nitrates

Question 6

Epigastric pain worse after
eating or when laying down
cough, wheeze, hoarse.

Answer 6

GERD.

Most sensitive test is 24-hr pH monitoring.

Do endoscopy if “danger signs” present.

Tx w/ behav mod 1st, then antacids, H2 block, PPI.

Question 7

GERD Indications for surgery?

Answer 7

bleeding, stricture, Barrett’s, incompetent LES, max dose PPI w/ still sxs, or no want meds.

Question 8

When to suspect Boerhaave’s or Esophageal Rupture

Answer 8

If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase

Question 9

Pt presents with hematemesis. Next?

Answer 9

CXR, gastrograffin esophagram. NO endoscopy

Tx? surgical repair if full thickness

Question 10

Gastric Varices pres

Answer 10

If gross hematemesis unprovoked in a cirrhotic w/ pHTN.

Question 11

Pt with hematemesis and hypovolemic shock

Answer 11

do ABCs, NG lavage, medical tx w/ octreotide or SS. Balloon tamponade only if you need to stablize for transport

Question 12

Tx of choice for bad varices?

Answer 12

Endoscopic sclerotherapy or banding

*Don’t prophylactically band asymptomatic varices. Give BB.

Question 13

If progressive dysphagia/wgt loss.

Answer 13

Esophageal carcinoma

Question 14

Esophageal carcinoma, two types and how we know which is which

Answer 14

Squamous cell in smoker/drinkers in the middle 1/3.

Adeno in ppl with long standing GERD in the distal 1/3.

Question 15

Best 1st test if you think esophageal cancer?

Answer 15

barium swallow, then endoscopy w/ bx, then staging CT.

Question 16

Acid reflux pain after eating, when laying down

Answer 16

Hital hernia

Question 17

Type 1 vs 2 hiatal hernia

Answer 17

Type 1: Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs.

Type 2: Paraesophageal. Abd pain, obstruction, strangulation Tx with surgery

Question 18

Gastric ulcer pres

Answer 18

Mid epigastric pain worse with eating. H.Pylori and NSAIDs and steroids big hitters on this.

Question 19

Workup for potential gastric ulcer:

Answer 19

Double-contrast barium swallow-punched out lesion w/ reg margins.

EGD w/ bx can tell H. pylori, malign, benign.

Surgery if lesion persists after 12wks of treatment.

Question 20

Most common gastric cancer

Answer 20

Adeno. Especially in Japan

Question 21

Krukenberg tumor

Answer 21

Ovarian tumor often met from the stomach

Question 22

Virchow’s nodes

Answer 22

L supraclavicular fossa, met from gastric

Question 23

Lymphoma with gastric cancer

Answer 23

2/2 HIV

Question 24

Blummer’s shelf mets

Answer 24

From gastric, feel on DRE

Question 25

Sister Mary Joseph node

Answer 25

Umbilical node indicating mets

Question 26

MALT-Lymphoma caused by

Answer 26

H Pylori

Question 27

What is Mentrier's Disease

Answer 27

protein losing enteropathy, enlarged rugae.

Question 28

Gastric varices caused by:

Answer 28

Splenic vein thrombosis

Question 29

Dieulafoy's:

Answer 29

massive hematemesis mucosal artery erodes into stomach. It'll poke it's ugly head in and out, you'll see a patient with repeated history of negative endos but has hematemesis randomly

Question 30

If the mid epigastric pain improves with eating, what do we think?

Answer 30

Duodenal ulcer

Question 31

How do we diagnose duodenal ulcers?

Answer 31

blood, stool or breath test for H. pylori but endoscopy w/ biopsy (CLO test) is best b/c it can also exclude cancer.

Question 32

Tx for duodenal ulcers

Answer 32

PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.

Question 33

Cause of duodenal ulcer

Answer 33

95% 2/2 H. Pylori

Question 34

If you have that mid epigastric pain and are assuming duodenal ulcers but they don't resolve, what could it be?

Answer 34

ZE syndrome. Do a Secretin Stim Test (find inapprop high gastrin) Treat with Surgical resection of pancreatic/duodenal tumor

Question 35

A patient has bilious vomiting and post-prandial pain. Recently lost 200lbs on “Biggest Loser”.

Answer 35

SMA Syndrome 3rdpart of duodenum compressed by AA and SMA Treat by restoring weight/nutrition. Can do Roux-en-Y

Question 36

Most common causes of pancreatitis?

Answer 36

Gallstones and EtOH

Question 37

How do we diagnose pancreatitis?

Answer 37

Increase amylase and lipase, CT is best imagine technique

Question 38

Treatment of pancreatitis

Answer 38

NG suction, NPO, IV rehydration and observation

Question 39

Bad prognostic factors for pancreatitis (9)

Answer 39

``` old WBC over 16K Glc over 200 LDH over 350 AST over 250 drop in HCT decr calcium acidosis hypox ```

Question 40

Complications (4) for pancreatitis

Answer 40

pseudocyst (no cells!), hemorrhage, abscess, ARDs

Question 41

Steatorrhea

Answer 41

Think chronic pancreatitis

Question 42

How can chronic pancreatitis lead to gastric varices?

Answer 42

Can cause a splenic vein thrombosis leading to gastric varices

Question 43

Adenocarcinoma in he head of the pancreas presents how

Answer 43

Courvoisier's sign: Large non-tender GB, itching, jaundice

Question 44

Trousseau's sign

Answer 44

Migratory thrombophlebitis linked to pancreatic cancer

Question 45

Diagnosing pancreatic cancer

Answer 45

EUS and FNA bx

Question 46

When do we treat pancreatic cancer with a Whipple?

Answer 46

thrombophlebitisoutside abdomen, no extension into SMA or portal vein, no liver mets, no peritoineal mets.

Question 47

How does an insulinoma present?

Answer 47

sxs (sweat, tremors, hunger, seizures) + BGL

Question 48

Presentation of glucagonoma

Answer 48

Hyperglycemia, diarrhea, weight-loss

Question 49

Characteristic rash of glucagonoma?

Answer 49

necrolytic migratory erythema

Question 50

Presentation of a somatistatinoma

Answer 50

Commonly malignant. see malabsorption, steatorrhea, ectfrom exocrine pancreas malfxn

Question 51

Presentation of a VIPoma

Answer 51

Watery diarrhea, hypokalemia, dehydration, flushing. Looks very similar to a carcinoid tumor

Question 52

Treat VIPoma?

Answer 52

Octreotide

Question 53

Presentation of Acute cholecystitis

Answer 53

- RUQ pain to the back - N/V - Fever - Worse with fatty foods

Question 54

Best diagnosis and tx for acute cholecystitis

Answer 54

U/S and treat with cholecystectomy. If unstable, do a percutaneous cholecystostomy

Question 55

Choledocolithiasis presentation

Answer 55

- RUQ pain - High bili - Alk Phos

Question 56

Dx/Tx for choledoco

Answer 56

U/S will show CBD stone Treat with Chole +/- ERCP to remove stone

Question 57

Pres for ascending cholangitis

Answer 57

- RUQ pain - Fever - Jaundice - Low BP - AMS

Question 58

Tx for ascending cholangitis

Answer 58

Fluids and broad spectrum Abx.ERCP and stone removal

Question 59

Type 1 vs Type 5 choledochal cysts

Answer 59

1: Fusiform dilation of the CBD, treat with excision 5: Caroli's Disease. Cysts in the intrahepatic ducts. Need a liver transplant

Question 60

Cholangiocarcinoma is super rare. What puts someone at risk?

Answer 60

Primary sclerosing cholangitis (UC), liver flukes and thorothrast exposure. Tx w/ surgery +/-radiation.