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Surgery > Gastrointestinal Surgery: Part 2 > Flashcards

Gastrointestinal Surgery: Part 2 Flashcards

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1
Q

Indications of Bariatric surgery

A
  1. BMI >40 kg/m2
  2. BMI >35 kg/m2 with obesity complications
  3. Asian population: Lower cutoff for Sx
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2
Q

Types of Bariatric surgery

A
  1. Sleeve gastrectomy
  2. Roux-en-Y gastrojejunostomy
  3. Duodenal switch/Biliopancreatic diversion
  4. Gastric banding and intragastric balloon placement
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3
Q

Irreversible Bariatric procedures

A
  1. Biliopancreatic diversion and Duodenal switch
  2. Roux-en-Y gastrojejunostomy
  3. Lap sleeve gastrectomy
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4
Q

Reversible Bariatric procedures

A
  1. Gastric banding
  2. Intragastric balloon placement
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5
Q

Common channels thru which BPD and DS can be done

A

Biliopancreatic switch: 50 cm
Duodenal switch: 100 cm

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6
Q

Disadvantages of BPD and DS

A

Max surgical complications
Max weight loss (D/t malabsorption)

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7
Q

Roux limb length in Roux-en-Y gastrojejunostomy

A

100 cm

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8
Q

Nutritional deficiencies seen in Roux-en-Y gastrojejunostomy

A

Iron (M/C)
Vit D3/Ca 2+
Vit B12

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9
Q

Limbs in Roux-en-Y gastrojejunostomy

A

Biliary limb: Bypassed duodenum
Roux limb: Jejunum

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10
Q

M/C Bariatric procedure done

A

Lap sleeve gastrectomy

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11
Q

What is Lap sleeve gastrectomy?

A

Restrictive surgery:
Greater curvature of stomach is removed

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12
Q

Complications of Lap sleeve gastrectomy

A
  1. M/C: Bleeding from staple line
  2. Nutritional deficiencies
  3. Leak from angle of His (Most distressing: Peritonitis)
  4. Redistension of sleeve (Mx: Transoral gastroplasty)
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13
Q

What is Gastric banding?

A

Band placed 6 cm from GE junction
Reversible pressure adjustable balloon -> Weight loss can be titrated

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14
Q

Complications of Gastric banding

A
  1. Prolapse (M/C)
  2. Nutritional complications
  3. Erodes into stomach
  4. Rupture
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15
Q

What is Intragastric balloon placement?

A

Balloon is distended in the stomach
Removed after weight loss is achieved
Self dissolvable balloon: Dissolves after 3 months

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16
Q

Features of Bariatric Sx
Just study

A
  1. M/C cause of death: DVT -> Pulmonary embolism
  2. AKA metabolic surgery: Weight loss + Improvement in DM/HTN/Hyperlipidemia
  3. Nutrient replacement:
    > Iron
    > Vit B12
    > Vit D3 and Ca 2+
    > Fat soluble vitamins: In sleeve gastrectomy and Roux-en-Y bypass
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17
Q

IOC for Mesenteric cyst

A

CECT

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18
Q

Tillaux triad for Mesenteric cyst

A
  1. Periumbilical swelling
  2. Tillaux sign: Swelling moves at right angle to attachment of mesentery
  3. Transverse band of resonance
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19
Q

Types of Mesenteric cyst

A
  1. Chylolymphatic cyst (M/C)
  2. Enterogenous cyst
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20
Q

Tissue seen in Chylolymphatic cyst

A

Sequestered lymphatic tissue

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21
Q

Tissue seen in Enterogenous cyst

A

Sequestered bowel tissue

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22
Q

Diff b/w Chylolymphatic and Endogenous cyst

A

Chylolymphatic cyst. Enterogenous cyst
Cyst wall Thin Thick
Fluid Clear. Turbid
Blood supply Independent. Shared with bowel
Rx Enucleation. Resection and anastomosis

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23
Q

What is upper GI hemorrhage?

A

Bleeding proximal to ligament of Treitz

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24
Q

Causes of Non-varicella bleeding

A
  1. Peptic ulcer: Duodenal > Gastric
  2. Mallory Weiss tear
  3. Gastritis
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25
Types of Gastritis
1. Type A 2. Type B 3. Stress induced 4. NSAIDS induced 5. AIDS induced
26
What is Type A Gastritis?
Autoimmune gastritis (AutoAb against parietal cells) Natural sparing, pernicious anemia, achlorhydria
27
What is Type B Gastritis?
H. Pylori induced (Affects antrum)
28
Types of Stress induced Gastritis
1. Cushing’s ulcer 2. Curling ulcer
29
What is Cushing’s ulcer?
In head injury, involves the stomach
30
What is Curling ulcer?
In burns, involves first part of duodenum
31
Vessel involved in Mallory Weiss tear
Left gastric artery
32
What is GAVE?
Gastric Antral Vascular Ectasia Seen at antrum Autoimmune
33
Endoscopy of GAVE shows
Watermelon stomach (D/t dilated venules)
34
Management of GAVE
Argon photocoagulation
35
Portal gastroplasty is seen in
Portal hypertension
36
Endoscopy of Portal gastroplasty shows
Strawberry stomach (Reddish nodules)
37
What is Menetrier’s disease?
Hypertrophy of gastric mucosal folds d/t over expression of TGF ALPHA Inc risk of cancer
38
C/F of Menetrier’s disease?
1. Protein losing enteropathy (Earliest) 2. Upper GI hemorrhage
39
Management of Menetrier’s disease
Fails Cetuximab (Monoclonal Ab against EGFR) ———-> Gastrectomy (Severe cases)
40
Varicella cause of upper GI bleeding
Portal hypertension
41
Hepatic Venous Pressure Gradient (HVPG)
Doppler (Diagnosis) 1-5 mmHg: Normal 6-10 mmHg: Preclinical sinusoidal portal HTN >=10 mmHg: Clinically significant portal HTN -> Variceal formation >= 12 mmHg: Inc risk for rupture of varices
42
Porto-systemic shunts seen in portal HTN
1. Left gastric + short gastric veins -> Distal Esophageal veins 2. Left gastric/gastroepiploic vein -> Esophageal/paraesophageal veins 3. Caput medusae: Periumbilical 4. Rectum 5. Bare area of liver (Segment 7)
43
C/F of Portal HTN
1. Upper GI hemorrhage 2. Splenomegaly 3. Ascites 4. Signs of liver failure
44
Management of Portal HTN
Bleeding | V ABC management | V IV drugs: 1. Best: IV terlipressin 2. M/C used: IV octreotide 3. Not used: IV propranolol | Patient stabilised V Upper GI endoscopy: Banding (M/C) > Sclerotherapy (Sodium tetradecyl sulphate) | Assess bleeding | | V V Controlled 2nd attempt at UGI-scopy |. | Fails V V 24 hour observation Sengstaken blakemore tube | | V V Discharge on oral propanolol Prepare for TIPSS
45
What is TIPSS?
Transjugular Intra-hepatic Portosystemic Shunt Shunt b/w Portal vein and hepatic vein
46
Complications of TIPSS
1. Rupture of capsule: Earliest 2. Blocked -> Rebleeding (M/C) 3. Encephalopathy: D/t non selective shunt
47
Scoring systems for Portal HTN
1. Rockall’s score 2. BLEED score 3. Child Pugh Turcotte score
48
Cardinal features of Bowel obstruction
1. Non passage of flats and faeces (Obstipation) 2. Vomiting 3. Distension 4. Abdominal pain
49
Investigations for Bowel obstruction
1. X ray abdomen erect and supine: Initial Ix 2. CECT: IOC in adults 3. USG: IOC in children
50
X ray features in Bowel obstruction
1. Erect X ray: >3 air fluid levels 2. Supine X ray: > Jejunum: Feathery appearance, Valvulae conniventes (Concertina effect) > Ileum: Featureless (Loops of wangensteen) > Large bowel: Incomplete haustrations
51
Management of Bowel obstruction
1. NPO 2. IV fluids 3. IV antibiotics and painkillers 4. Ryle’s tube insertion 5. Sx: Emergency laparoscopy
52
Caecum is visualised 1st before surgery. Why? Just study
Distended: Large bowel obstruction Collapsed: Small bowel obstruction
53
What is Intussception?
Telescoping of one bowel loop into another Intussuscipiens: Receiving loop Intussusceptum: Loop going inside
54
Types of Intussception
Primary: 6 months-2 years age group Secondary: Adults
55
Triggers of each type of Intussception
Primary: Hypertrophy of Peyer’s patches Secondary: Secondary of pathological lead point: Polyp, diverticulum, cancer
56
Features of Primary Intussception
Ileocolic (M/C) Red currant jelly stools Sign of dance: Empty RIF (Lump is in lumbar region)
57
Investigations for Intussception
1. X ray abdomen: Erect and supine (Initial) 2. USG: Target/Donut/Pseudokidney sign 3. Contrast enema: Pincer/claw sign > Diagnostic and therapeutic > C/I: Perforation, recurrence or secondary to pathological lead point
58
Pre-disposing factors for Sigmoid volvulus
1. Long and narrow mesentery 2. Redundant sigmoid 3. Loaded sigmoid
59
Sigmoid volvulus commonly seen in
On antipsychotic meds With constipation
60
D/D coffee bean sign
1. Sigmoid volvulus (Apex points towards RT shoulder, large bowel dilated) 2. Caecal volvulus (Apex points towards Lt shoulder, large bowel collapsed)
61
Management of Sigmoid volvulus
Stable, no peritonitis: Sigmoidoscopic decompression (Flatus tube) -> Definitive Sx: Sigmoidectomy Unstable, peritonitis: Hartmann’s procedure
62
What is Hartmann’s procedure?
1. Resect perforated segment 2. Proximal colostomy 3. Distal end closed and kept inside
63
Causes of Intestinal stricture
1. Cancer 2. Post radiotherapy 3. TB 4. Crohn’s disease
64
Management of Intestinal stricture
1. Strictures are close: Resection and anastomosis 2. Strictures are far apart: Heineken Mikulicz stricturoplasty
65
What is Meckel’s diverticulum?
Remnant of vitellointestinal duct Present along antimesenteric border True diverticulum: All layers + Independent blood supply: Safe resection possible
66
Rule of 2 in Meckel’s diverticulum
2% of population 2 inches long 2 feet from ileocolic junction
67
Vitellointestinal duct abnormalities
1. Completely patent: Fecal discharge 2. Fibrous band formation: Leads to volvulus 3. Patent umbilical end: Umbilical cyst/polyp -> Purulent discharge +/- 4. Ideal end patent: Meckel’s diverticulum
68
What is Duodenal atresia?
Duodenum not continuous Common in Down’s syndrome C/F: Bilious vomiting since brith
69
D/D of Duodenal atresia
CHPS
70
X ray of Duodenal atresia
Double bubble sign
71
Management of Duodenal atresia
Duodenoduodenostomy
72
X ray feature of Jejunal atresia
Triple bubble sign
73
M/C cause of Dynamic small bowel obstruction
Adhesive intestinal obstruction
74
Causes of Adhesive intestinal obstruction
1. Post surgery (M/C) 2. Non surgical causes: > Crohn’s disease > PID > TB > Endometriosis > Cancer
75
IOC for Adhesive bowel obstruction
CECT
76
Management of Adhesive intestinal obstruction
Fails Conservative for 48-72 hours ————-> Surgery (Adhesiolysis)
77
What is Superior Mesenteric artery syndrome?
Normal angle b/w aorta and SMA: 25-45 deg Angle < 22 deg compresses D3 (Content)
78
Causes of SMA syndrome
1. Rapid weight loss 2. Spinal cast
79
C/F of SMA syndrome
Bilious vomiting after meals
80
IOC for SMA syndrome
CT Angiography
81
Treatment for SMA syndrome
1. Encourage weight gain 2. Strong’s procedure: Duodenal Derotation (Cut ligament of Trietz) 3. Duodeno-jejunostomy
82
M/C intestinal malrotation abnormality
Ladd’s band
83
What is Ladd’s band?
Runs from right hypochondrium to cecum -> Duodenal compression
84
Management of Ladd’s band
Excision of band
85
What is Hirschsprung’s disease?
AKA Congenital megacolon Absence of ganglion cells in Auerbach and myenteric plexus -> Adynamic/functional obstruction
86
Mutation in Hirschsprung’s disease
GDNF (Glial derived neurotropic factor)
87
Hirschsprung’s disease is common in
Down’s syndrome and MEN 2A/2B
88
C/F of Hirschsprung’s disease
1. Non-passage of meconium (M/C) 2. Distension 3. Constipation
89
IOC for Hirschsprung’s disease
Full thickness rectal biopsy: 1. Loss of ganglion cells 2. Hypertrophied nerve trunks 3. IHC: Acetylcholinesterase +
90
Finding of Hirschsprung’s disease in Barium enema
Dilated normal proximal bowel -> Transition zone -> Constricted distal part (Lack ganglion cells)
91
Management of Hirschsprung’s disease
Bypass/resection of abnormal portion -> Intraoperative frozen section
92
What is Paralytic ileus?
Stunned bowel -> Functional block
93
Causes of Paralytic ileus
1. Surgical 2. Hypokalemia (M/C cause of prolonged ileus) 3. Hypothermia 4. Uremia
94
Last to recover in Paralytic ileus
Rectum
95
Causes of Mesenteric Ischemia
1. Acute Mesenteric artery embolism (M/C cause) 2. Acute Mesenteric artery thrombosis
96
Etiology of diff types of Mesenteric Ischemia
Acute Mesenteric artery embolism: Source (Heart), RF: IHD, A fib Acute Mesenteric artery thrombosis: Secondary to atherosclerosis
97
C/F of Acute Mesenteric artery thrombosis
Bowel angina: 1. Post prandial abdominal pain (Starts 15-20 mins after food) 2. Food avoidance and weight loss
98
C/F of Acute Mesenteric artery embolism
1. Irregularly irregular pulse 2. Bowel attacks: Sudden abdominal pain -> Ends with peritonitis
99
IOC for Mesenteric Ischemia
CT Angiography
100
Management of Acute Mesenteric artery embolism
1. Early presentation (6-8 hours): Embolectomy 2. Late presentation (Gangrene +): Resection and anastomosis
101
Management of Acute Mesenteric artery thrombosis
Bypass grafting
102
Symptoms of Appendicitis
1. Pain abdomen 2. Nausea and vomiting (M/C) 3. Anorexia 4. Fever
103
What is Rovsing’s sign?
Pain in RIF on pressing LIF
104
What is Psoas sign?
Pain in RIF on flexion against resistance
105
What is Obturator sign?
Flexion + internal rotation of hip -> Pain
106
What is Dunphy’s sign?
Pain on coughing
107
Modified Alvarado (MANTRELS) score Just study
Score >7: Likely appendicitis
108
Investigations for Appendicitis
1. CECT: IOC in adults 2. USG: IOC in children > Blind ending tubular structure > Probe tenderness > Periappendiceal fluid collection
109
Management of Appendicitis
1. Inflamed base: > Do not crush the base > Bury with purse string suture 2. Gangrenous base: Right hemicolectomy 3. Appendix not inflamed: Rule out Meckel’s diverticulum (Distal 2 feet of ileum)
110
Incisions used in Appendicectomy
1. McBurney’s incision 2. Lanz/Skin crease/Bikini incision 3. Lower midline abdominal incision
111
Structures passed in Appendicectomy
1. Skin 2. Superficial fascia 3. External oblique aponeurosis 4. Muscles 5. Peritoneum
112
Types of McBurney’s incision
1. Grid iron: Muscle splitting 2. Rutherford Morrison: Muscle cutting
113
Complications of Appendicectomy
1. Wound infection (M/C) 2. Bleeding 3. Portal pyemia 4. Stump appendicitis (If stump >4 mm)
114
What is Appendicular perforation?
Omentum dysfunction Seen in: 1. Children 2. Elderly 3. Adhesions 4. Pregnant females 5. Immunocompromised patients
115
M/C non obstetrical emergency
Appendicitis in pregnancy
116
C/F of Appendicitis in pregnancy
Pain in RIF (Can be higher up also) Inc risk of preterm labor/abortions
117
Investigation for Appendicitis in pregnancy
If unconfirmed USG —————————-> MRI
118
Management of Appendicular lump
Oschner Sherren regime (Conservative): Monitor: 1. Size of lump 2. Tenderness 3. Temperature 4. Pulse rate Management: 1. NPO 2. IV fluids 3. IV antibiotics 4. Analgesics
119
Outcomes in Oschner Sherren regime
Recovers: 1. Discharge 2. Interval Appendicectomy after 6 weeks Deteriorates (Inc pain,fever and lump size): 1. Suspect abscess 2. Extraperitoneal drainage (Pigtail catheter)
120
M/C tumor of appendix
Neuroendocrine tumor (NET) of appendix
121
M/C site of NET of appendix
Tip of appendix
122
C/F of NET of appendix
1. Pain and appendicitis 2. May be detected incidentally
123
Management of NET of appendix
1. Close to the base and >2 cm: Right hemicolectomy 2. Close to the tip and <2 cm: Simple Appendicectomy
124
Types of Epithelial appendicular tumors
1. Non-mucinous: Adenocarcinoma (Mx: Same as colorectal cancer) 2. Mucinous: Gives rise to pseudomyxoma peritonii
125
What is Pseudomyxoma peritonii?
Mucinous deposits in the peritoneum -> Obstruction, distension
126
Management of Pseudomyxoma peritonii
Cytoreductive surgery -> HIPEC (Hyperthermic intraperitoneal chemotherapy)
127
HIPEC is done with
Paclitaxel/Mitomycin-C at 41-44 deg C
128
Pseudomyxoma peritonii is seen in
Appendicular, ovarian and primary peritoneal tumors

Surgery (18 decks)

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