GI Clinicals Flashcards
(388 cards)
1
Q
prune belly syndrome aka
A
eagle barrett syndrome
2
Q
prune belly syndrome
A
partial or complete absence of abdominal wall muscle
accompanied by undescended testes + distended urinary tract often caused by urethral obstruction
95% in males
3
Q
prune belly cause
A
abdominal wall muscle atrophy due to wall distention from the expanded/distended urinary tract
4
Q
disappearance of properitoneal fat line indicates
A
inflammation in the fatty layer
may be due to abdominal abscess
5
Q
abdominal wall exercise supports back why?
A
aponeuroses of ab muscles end on the lumbar vertebrae
6
Q
paracentesis
A
needle drainage or sampling of peritoneal cavity
7
Q
locations to perform paracentesis
A
linea alba
laterally near linea semiluminaris
8
Q
peritoneal lavage
A
rinsing of peritoneal cavity
9
Q
purpose of peritoneal lavage
A
treat hypothermia
chemo to treat peritoneal seeded metastases
temporary dialysis for kidney failure
10
Q
penetrating wound that can involve pleural cavity, peritoneal cavity, and spleen or liver
A
between 9th and 10th rib
11
Q
point used to esitmate point for lumbar puncture
A
Touffer’s Line (supracristal plane)
top of iliac crests (L4)
12
Q
how to prevent herniation of gut through inguinal defect
A
when transversus abd and int oblique muscles contract they partially block the defect (like during valsalva)
13
Q
rectus hematoma
A
violent contractions cause vessels to rupture around arcuate line –> blood fill rectus sheath
(inf. epigastric can be injured during severe coughing/vomiting)
usually on right (right handed)
14
Q
femoral pulse location
A
below mid-inguinal point (midway btwn ASIS and pubic tubercle along course of inguinal ligament)
15
Q
femoral stick location
A
access to femoral vein/artery is just medial of femoral pulse
16
Q
good catheter placement
A
lateral to rectus abdominus to avoid epigastric arteries/veins and don’t interfere w/ muscle contraction
17
Q
perforations through linea alba
A
heal slowly - lack of good blood supply
18
Q
portal hypertension
A
venous blockage in liver makes blood back up and unprocessed blood enter the axillary + femoral veins
eventually affects other organs and CNS
19
Q
portal hypertension Sx
A
caput medusa
hepatic encephalopapthy
issues w/ other organs
20
Q
caput medusa
A
result of portal hypertension
high P causes varicose radial tributaries around umbilicus
21
Q
causes of portal hypertension
A
alcoholic or hepatic cirrhosis
22
Q
hepatic encephalopathy
A
unfiltered blood w/ toxins travels to brain due to blockage/portal hypertension
23
Q
most common type of penile cancer
A
squamous cell carcinoma of the glans or prepuce
24
Q
penile cancer metastasis
A
drainage pattern provides deep route of metastsis glans tumor (isolated to pelvic cavity): use deep dorsal vein of penis prepuce: sup dorsal vein --> external pudental veins --> venous plexus --> IFC
25
anesthesia of L1 nerves
block superomedial to ASIS (by McBurney)
| blocks: 1. ant scrotal/mons+labium majora (inguinal nerve) 2. deep ring thru superficial ring (genitofemoral nerve)
26
abdominal reflex checks for
segmental motor innervation
27
abdominal reflex
dermatome scratched --> if everything intact then underlying muscle will pull umbilicus to that side
pt sits up --> if segmental paralysis, umbilicus will be pulled toward NORMAL side
28
viscerosomatic referred pain
irritation of an internal organ (visceral nerves) projected to somatic region
(shoulder pain for MI)
29
somatsomatic referred pain
irritation of somatic nerves projected to another somatic region
(shoulder pain w/ phrenic nerve irritation)
30
appendicitis referred pain
starts as periumbilical pain (innervated by T10 symp fiberS)
| then when inflammation spreads to parietal peritoneum --> local, RLQ pain
31
projected pain
brain interprets pain from a somatic region when nerve is irritated proximally (same nerve)
ex: lower lobar pneumonia can cause abdominal pain
32
peritonitis (localized)
```
cause guarding (spasms of myotomes)
may see segmental paaralysis (umbilicus pulled to normal side)
```
33
peritonitis (generalized)
cause board-like rigidity (widespread spasmodic contraction of anterolateral ab wall)
may see wide-spread paralysis
34
rebound tenderness
P applied w/ 1 finger @ site of possible inflammation then released
look for pain on release
35
clinical test for peritonitis
rebound tenderness
| pain on release --> peritonitis
36
incisions parallel to abdominal nerves
spare abdominal nerves
| risk injuring vertically running vessels
37
vertical incisions
lateral to rectus abdominis --> sever nerves --> hypesthesia or anesthesia
38
kocher incisions
incisions along costal margin
| run into problems of vertical incisions
39
linea alba incisions
least damage to nerves and vessels
| risk of dehiscence (poor wound healing)
40
paramedian incisions
medial to rectus abdominis through rectus sheath
| avoid linea alba
41
lymph nodes near round ligament
superficial inguinal lymph nodes
| may be involved for cancer of intramural uterine tube or infections
42
pregnancy referred pain
traction of right round ligament and pain in groin/ labium majus will mimic appendicitis referred pain (periumbilical pain?)
43
congenital umbilical hernia
aka omphalocele, exomphalos
part of midgut not in abdominal cavity
covered by sac of wharton's jelly and amnion
continuous w/ umbilical cord
44
acquires infantile umbilical hernia
weakness in linea alba around scar of umbilicus
| herniated sac covered by subcutaneous tissue and skin
45
acquired adult umbilical hernia
aka paraumbilical hernia
through linea alba near umbilicus
or by gradual yielding of cicatricial scar tissue that closed umbilical ring
46
epigastric hernia
btwn xiphoid process (T6) and umbilicus (T10)
| often just off midline of linea alba (can be through it)
47
spigelian hernia
aka lateral ventral hernia
through linea semiluminaris @ lateral edge of rectus abdominus
rare
usually where arcuate line meets linea semilunaris
48
ventral hernia
separation of recti abdominis muscles
rectus sheath altered by multiple pregnancies, ascites or large ab tumors
could be due to surgery thru linea alba (incisional hernia, postoperative scar hernia)
49
lumbar hernias
petit's hernia
| grynfeltt hernia
50
Petit's hernia
most common lumbar hernia
caused by external oblique having free post border
--> triangle btw ex/in obliques, lat dorsi and serratus post inf
51
grynfeltt's hernia
most common in young athletic women
| deeper and more superior than Petit's
52
R vs L testis
R descends later than L
| R has greater incidence of cryptorchidism
53
cryptorchidism
failure of testis to descend into scrotum
untreated --> impotence, high risk testicular Ca
Tx surgically w/ orchidoexy btwn 6-18 mo
54
indirect inguinal hernia chirality
more common on right
55
cremasteric reflex
ipsilateral testis raises when thigh is stroked
56
cremasteric reflex innervation
```
L1/L2 spinal cord segments
genitofemoral nerve (genital branch)
```
57
cremasteric reflex used to
check spinal cord segments in spinal injuries or spina bifida.
58
indirect inguinal hernia
through dimple in a patent processus vaginalis, enters deep ring and traverses inguinal canal (exits superficial ring)
congenital (regardless of age)
59
direct inguinal hernia
above inguinal ligament
directly through Hesselbach's triangle (inguinal ligament + lateral border of rectus ab + inf epigastric vessels)
lateral or medial
brings in extra layers in addition to spermatic cord layers
60
Hesselbach's triangle
inguinal ligament + lateral border of rectus ab + inf epigastric vessels
61
femoral hernia
through femoral canal
| dangerous because can be trapped @ strong lacunar ligamnet (incarceration/strangulation)
62
obturator hernia
through obturator canal (larger in some pts)
| most dangerous kind of inguinal hernia
63
lateral direct hernia
pushes thru medial inguinal fossa
64
medial direct hernia
pushes thru small part of supravesical fossa
| lateral to rectus ab muscle
65
complete indirect inguinal hernia
hernia goes thru tunica vaginalis
66
vasectomy
ductus deferens (aka vas deferens) is ligated and divided
67
torsion of spermatic cord
scrotal lig fails to secure testis --> bell clapper deformity (testis is free to rotate in scrotum)
emergency (testicular infarction occurs in 4-6 hrs)
no cremasteric reflex
68
tests for torsion of spermatic cord
```
phren sign (-)
nuclear scan (bull's eye sign)
```
69
phren sign
```
+ = relief of pain occurs when testis is gently lifted
- = no relief
```
70
epididymitis phren sign
+
71
nuclear scan
```
homogenous density = normal blood flow
cold spot (bull's eye sign) = ischemic testis
```
72
varicocele
varicose pampiniform plexus (dilated veins)
feels like bag of worms
common in L scrotum
usually asymp unless occluse testicular artery
73
varicocele (R)
R is rare but more clinical significance (may be due to tumor in duo, panc or R ureter)
74
why is varicocele more common in L
L test vein is longer w/ greter column P
| L renal vein (where L test vein drains) has slowed blood flow due to sup mesenteric artery crossing it
75
spermatoceles
cysts containing sperm that develop in epididymis and ductus deferens
large ones look like hydroceles, but have cloudy water
76
things caused by persistent processus vaginalis
hydroceles
indirect inguinal hernia
hematocele
77
hydroceles
contain straw colored peritoneal fluid
usually in ant scrotum
can be transluminated in a dark room
78
canal of Nuck
remnants of the process vaginalis in females
| hernias/cysts that form here make a bulge in labium majora
79
hematocele
rupture through visceral layer of tunica vaginalis --> hemorrhage and ischemia of testis
bleeding into tunica vaginalis --> clot --> occluded artery
due to trauma
80
makes up 1/3 of female hernias
femoral hernias
| rare in men
81
inguinal hernia Tx
repair by returning hernia to cavity and sewing edges to ab wall (herniorrhaphy) or using mesh (hernioplasty)
82
test for inguinal hernia
insert index finger into superficial ring (superolateral to pubic tubercle) and ask pt to cough:
+ = detect sudden impulse w/ cough = hernia
83
hernia descriptors
reducible: easily returned to abdominal cavity (surgically or spontaneously)
incarcerated/irreducible: not easily returned to ab cavity
obstructed: prevent passage of feces
strangulated: block blood supply --> ischemia
84
pantaloon hernia
herniated loop on wither side of lateral umbilical fold --> indirect + direct inguinal hernia
looks like two bulging sacs on either side of inf epi vessels (legs of baggy pants)
85
richter hernia
strangulated hernia which eventually reduces
may be missed during operative repair and later perforates --> peritonitis
no obstructive signs - may be pain
86
Littre's hernia
involves Merckel's diverticulum
rare
always on R (on ileum)
87
merckel's diverticulum
ileal diverticulum
occurs in 2% pop
2x more likely in mlaes
2 inches long
on antimesenteric surface 2 ft from ileocolic jxn
has 2+ kinds of mucosa
2% of diverticula are symp, often before age 2
88
Amyand's hernia
involves veriform (worm-like) appendix
may present w/ appendicolith (calcified feces in appendix --> appendicitis)
inguinal hernia
89
Garengeot's hernia
rare
involve veriform appendix
femoral hernia
often incarcerated
90
obturator hernia common in
elderly women
91
tests for obturator hernias
howship-romberg sign (obturator sign)
| Hannington-Kiff sign
92
howship-romberg test
extra pain in medial thigh when thigh extends, abducts or rotates
present in < 50% pts
93
hannington-kiff sign
tap on medial femoral condyle or medial tibial condyle
| + = absence of knee jerk reflex
94
hypospadias
urigenital folds fail to fuse properly in males --> penike urethra is open, ventrally
often occurs @ balanopenile jxn
normal external urethra fails to develop
hallmark: doral hooded prepuce
95
chordee
hypospadias that occurs further back on shaft, closer to scrotoperineal region
glans tethered and curved ventrally
96
extreme straddling
severe rupture of penile urethra
voided bloody urine can get into superficial perineal poucg
sx: fluid crepitus over abdomen; expanded scrotum, elongated penis, disproportionately small glans
97
smegma
thickening of secretions w/ collections of exfoliated cells
98
results of smegma/bacteria
```
balanitis
posthitis
balanoposthitis
phismosis
paraphimosis
```
99
balantitis
inflammation of glandular skin
100
posthitis
inflammation of preputial skin
101
balanoposthitis
inflammation of glandular skin and preputial skin
102
phismosis
inability to retract prepuce
| "draped penis"
103
paraphismosis
persistently retracted penis
mech: phomotic ring - excessive SM, excessive constrction can lead to glans ischemia
Tx: circumcision or preputioplasty
104
phomotic ring
phomotic ring - excessive SM, excessive constrction can lead to glans ischemia
105
preplutioplasty
cut part of prepuce
106
how to anesthetize perineum (female)
pudendal nerve block will do most
| may have to block perineal branch from thigh as well
107
how to anesthetize whole penis
must block both dorsal and perineal nerves
108
ED could be a sign for:
peripheral artery disease
type 2 diabetes
metastasizing prostate/rectal cancer
109
priapism
prolonged erection over 4 hrs even after orgasm
| may lead to ischemia
110
Peyronie's disease
scarring of the corpora cavernosa casing results in unequal enlargement and unusual bending of penis
dorsal bend more common
111
results of ruptured corpora cavernosa
erection failure, painful erection, Peyrione's disease
112
penis "fracture" mech
high turgor P in corpora cavernosa during erection
| no bone
113
how to rupture penile suspensory ligament
ventrally directed force to an erect penis (push down too far)
114
results of ruptured PSL
penile instability, deformity and erectile dysfunction
115
bartholin gland infection/cyst sx
pain during sex or defecation
116
results of botched episiotomies
cut perineal body and pubovaginalis
| loss of sexual pleasure and orgasm
117
gallbladder/ducts referred pain
right phrenic nerve --> referred pain to right shoulder (somatosomatic)
118
intraperitoneal and retroperitoneal organs referred pain
symp nervous system
| dermatomes T6-L2
119
subperitoneal viscerosomatic referred pain
parasympathetic nervous system
| dermatomes S2-S4
120
pelvic peritoneum referred pain
area above knee via obturator nerve (somatosomatic)
121
Pringle maneuver
clamping of hepatoduodenal ligament in hepatic hemorrhage
122
pouches for pancreatic lesions
standing: pouch of Morrison (hpatorenal)
supine: pouch of douglas (rectouterine) or pouch of Proust (retrovesical)
123
results of pubic bone fracture
burst urinary bladder
| male: sheer membranous urethra
124
if males sheer membranous urethra...
bloody urine fills sapce of Retzius and moving up in a triangular pattern between the median/medial umbilical ligamnets towards the umbilicus
125
urachal cyst
isolated bubble of urachal endoderm along tract of MEDIAN umbilical ligament
can fill with mucus get infected and burst
126
urachal sinus
closed section of living urachal endoderm that is opened to the umbilicus
can allow entrance of bacteria and formation of ab wall abcess
127
urachal fistula
connection btwm apex of bladder to umbilicus
sx: infected foul smelling urine and exudate ooze out of belly button
may --> abcess + UTI
128
Blumer's shelf
thickening of the lining parietal peritoneum btwn rectur and uterus which can be palpated through rectum
129
causes of blumer's shelf
seeded metastasis, inflammation or abcess
130
enteroceles
caused by deepinging of rectouterine (pouch of douglas) or less commonly the vesiculouterine pouch
happens in older, multiparous women
form rectovaginal or vesiculovaginal pouch
parts of ileum may lodge + pain (internal hernia)
131
abscess in left subhepatic space
either 1. get stuck btwn liver and ant surface of stomach or 2. flow down ant surface of stomach into peritoneal cavity
132
abscess in right subhepatic space
lodge in omental bursa or pouch of morrison (hepatorenal space)
133
ascites
excess peritoneal fluid
134
ascites causes
hepatic portal hypertension
metastatic cancer
when gravity can counteract capillary flow the fluid falls into peritoneal cavity
135
cancer and metastases
metastases can use peritoneal fluid to move/spread
136
peritoneal seeding
cancer cells run with cap flow to spread throughout the peritoneal cavity
137
peritoneal seeding (abdominopelvic ca)
invade veins and lymph
138
ca/bacteria in systemic venous system metastasize where?
lung
139
ca/bacteria in hepatic portal system metastasize where?
liver
140
hallmark of pelvic abscesses
presence of abnormal gas pockets in SI and LI
141
disease process of omental bursa
leak into pouch of morrison
down right paracolic gutter
to right ditch btwn rectum and bladder
142
pararecto- or paravesicular fossa
right ditch btwn rectum and bladder
143
right pelvic abscess -->
up paracolic gutter
to pouch of morrison
to right subphrenic space
where peritoneal fluid is absorbed by lymphatics
144
internal hernias
often at transition from retroperitoneal to intraperitoneal
has a lifted mesenteric fold
high freq in preg women from uterus pushing bowels
145
foramen of winslow hernia
hernia through foramen into omental bursa
| danger of ischemic bowel
146
foramen of winslow hernia (Dx feature)
presence of bowel behind stomach, in front of pancreas
147
chilaiditi's syndrome
transverse colon in front of stomach
148
paraduodenal hernias
in mesenteric folds around duodenojejunal juncture and flexure, (where retroperitoneal duodenum becomes peritoneal jejunum)
149
left paraduodenal hernia
stretches the paraduodenal fossa (fossa of landzert) going leftwards towards descending colon
150
fossa of landzert
pouch behind paraduodenal fold, free edge contains inf mesenteric vein (drains into splenic vein)
151
key feature of left paraduodenal hernia
crowded bowel loops that do not move w/ change in position
152
right paraduodenal hernia
stretches recess behins beginning of the root of the mesentery going rightward toward ascending colon
153
fossa of Waldeyer
recess behind beginning of the root of the mesentery
| formed by superior mesenteric vessels
154
pericecal hernia
through folds around the cecum or appendix
155
intersigmoid hernia
can lie over left ureter which courses over left common iliac vessels
156
pneuemoperitoneum
diaphragm density separate from liver density
157
falciform ligament sign and round ligament sign
gas rises and caught on either side of the diaphragm
158
Rigler's sign
one bowel wall overlaps the other
| both walls visible cuz of intervening gas
159
Ladder sign
loops of bowel piling up
| indicates small bowel obstruction
160
triangle sign
gap btwn lateral bowel and cavity wall
161
gastroesophageal varices
worm-like lesions of varices projecting into the lumen in an esophagogram
portal HTN effect on anastamoses around stomach and esophagus
162
caput medusae
portal HTN effect on anastamoses connecting left branch of portal vein w/ thoracoepigastric system
varices or venous distension
163
internal hemorrhoids
varices in anastomoses connecting the superior rectal vein, (termination of the inferior mesenteric vein) w/ middle and inferior rectal veins
164
portal HTN and portosystemic anastamoses
may become varicose leading to bleeding problems
| rupture of varices + hemorrhage has a 50% mort --> major cause of death in alcoholics
165
Banti's disease
splenomegaly due to venous congestion of the spleen
due to portal HTN
lead to stretching of splenic capsule (if ruptures, blood pools in perisplenic space)
166
types of hepatic lesions
prehepatic
hepatic
posthepatic
167
prehepatic lesion
lesions of the portal vein and its tributaries
168
hepatic lesions
diseases w/in the liver, like hepatic cirrhosis
169
posthepatic lesions
lesions of the hepatic veins and inferior vena cava
170
Laennec's cirrhosis
cirrhosis from alcohol or protein malnutrition
| fatty changes --> inflammation and fibrosis --> compression of hep portal vein branches
171
Laennec's cirrhosis Sx
gastroesophageal varices
caput medusa
banti's disease
internal hemorrhoids
172
portal HTN mmHgs
norm: 10 mm Hg
| portal HTN: 30 mm Hg
173
Senstaken-Blakemore tube
to tamponade esophageal hemorrhage due to gastroesophageal varices
expanded above and below diaphragm to stop hemorrhage to allow cauterization
174
why newborns are more prone to spitting up
LES normally straddles esophageal hiatus (1.5 inches long)
| newborn LES above hiatus (0.5 inches) -- more normal location @ 3 mo
175
reason for old age GERD or EERD
loss of subhiatal fat ring w/ age
176
gastric juice in hypopharynx Sx
```
hoarseness
wheezing
chronic cough
pharyngitis
chronic throat clearing
(may be diagnosed as nasopharyngeal problem)
```
177
structures indenting the esophagus in the mediastinum
aortic arch
left atrium
LES/B-ring
178
gastric changes w/ diabetes mellitus
dysphagia (due to destruction of NO releasing enteric neurons)
gastroparesis diabeticorum: poor gastric peristalsis + pyloric sphincter dysfxn
179
congenital Schatziki's ring
redundant ring of esophageal mucosa; if lumen gets less than 12 mm --> dysphagia
can be dilated endoscopically w/ balloon
180
problems at angle of His
Boerhaave's syndrome
| mallory-weiss syndrome
181
angle of HIs
leftward angle of esophagus at the hiatus
182
Boerhaave's syndrome
tear ABOVE the diaphragm at the angle of His, a full thickness tear involves the mediastinum and sometimes the left pleural cavity
183
Mallory-Weiss syndrome
a tear at the angle of His BELOW the diaphragm in which there is a tear in the stomach mucosa
usually minor mucosa, rarely full thickness
filling defect in esophagogram
184
epiphrenic esophageal diverticulum
outpouching of the mucosa just above the LES
| may (true diverticulum) or may not (false) contain all the wall layers
185
esophageal leiomyoma
non-malignant abnormality disrupting the normal esophagogram, formed of SM w/ smooth rounded contours
186
achalasia
LES can't relax
| affected segment constricted, proximal eso becomes dilated and torturous
187
causes of achalasia
```
varicella zoster virus
trypanosome cruzi (chagas)
```
188
signs of achalasia
string sign
| bird's beak sign
189
string sign
sign of achalasia
| thin stream of contrast agent through the constricted segment in esophagogram
190
bird's beak sign
sign of achalasia or volvulus
| tapering of contrast approaching the constriction in esophagogram
191
esophageal hiatal hernias
stretching of the phrenoesophageal ligaments
| collar of parietal peritoneum accompanies the hernia and produces a sac connected to peritoneal cavity
192
types of esophageal hiatal hernias
paraesophageal
| sliding esophageal
193
paraesophageal hiatal hernia
fundus slides to L of esophagus but intrinsic LES and squamocolumnar line remain in norm location
may compress esophagus
194
paraesophageal hiatal hernia Sx
midsternal P and pain, especially after eating
| may have intermittent cardiac dysrhythmia
195
paraesophageal hiatal hernia referred pain
referred pain to the ear (otalgia) due to vagal trunk irritation (Arnold's nerve)
196
Arnold's nerve
auricular branch of the vagal nerve which innervates the posterior wall of the external acoustic meatus
197
complications of paraesophageal hiatal hernia
incarceration
strangulation
gastritis w/ hemorrhage + chronic blood loss
volvulus
198
volvulus
stomach/gut twists on itself --> compresses its blood supply and obstructs lumen
coffee bean shape
199
sliding esophageal hiatal hernia
intrinsic LES and squamocolumnar line are above the esophageal hiatus
prone to GERD
untreated long term --> erosive esophagus
Sx like paraesophageal hernia
200
complications of untreated GERD
esophagitis (--> ulceration, scarring, strictures)
risk of fistula w/ trachea, aorta, heart
usually --> some degree of sliding edo hiatal hernia
metaplasia of the lower esophagus
201
acquired metaplasia of the loweresophagus
normal squamous cell lining of the lower esophagus replaced with abnormal columnar gastric mucosa
tongue like circumferential extension of salmon-pink gastric type epi into esophagus
202
adenocarcinoma
low if metaplasia is stomach like epi
| barrett's has more risk (intestinal like -- columnar)
203
Barrett's esophagus
when metaplasia progresses to intestinal like epi (columnar lined) w/ goblet cells
small but substantial risk of adenocarcinoma
204
esophageal cancer - signs of metastasis
angulation and shifting of esophageal shadow indicates metastasis
205
types of esophageal cancer
fungating
| annular
206
fungating type esophageal cancer
appears as a shelf-like space-taking lesions w/ irregular luminal contours
207
annular type esophageal cancer
annular space-taking lesions, w/ irregular luminal contours
208
one of the first signs of potal HTN
dilated short gastric veins in CT
209
Tx for intractable peptic ulcers
may be treated by vagotomy procedures to reduce acid secretion
210
truncal vagotomy
cuts the vagal trunks at the abdominal esophagus
--> entire stomach prasympathetically denervated --> pyloric sphincter paralysis (constantly closed) + GI dysfunction since entire foregut and most midgut denervated of ANS
211
pyloroplasty/pyloromyotomy
cut in the sphincter
| necessary after truncal vagotomy (due to pyloric paralysis) to allwo stomach drainage into duodenum
212
selective gastric vagotomy
nerves of Lataret cut
spare celiac bunch of the posterior vagal trunk and hepatic branch (includes pyloric branch) of the ant vagal trunk
--> gastric acid secretion
maintain innervation to liver and pyloric sphincter
213
proximal gastric/parietal cell vagotomy
cuts branches to the proximal 2/3 of the stomach
| spare terminal crows foot portion that goes to pyloric antrum and pyloric canal
214
peptic ulcer disease location
usually attacks stomach close to angular notch on lesser curvature and duodenal cap
(high chance to fuse w/ pancreas)
215
peptic ulcer disease perforation location
usually occur anteriorly into the greater sac in the greater peritoneal cavity
216
posterior gastric ulcer perforations
may drain into omental bursa --> erosion of pancreas and/or
| --> erode into artery (--> hemorrhage)
217
posterior duodenal cap ulcer
other major area for peptic ulcer disease
| can erode into the gastroduodenal artery causing fatal hemorrhage
218
sunburst lesion
in imaging, barium contrast often collects in ulcer cavity + radiating furrows
sign of peptic ulcer disease
219
gastrinoma
gastrin secreting tumor, usually in duodenum or pancreas
220
results of gastrinoma
gastrin causes excess acid secretion --> ulcers
221
Zollinger-Ellison syndrome Sx
distorted duodenal cap
thickening/distortion of duodenal mucosa
thickening of valculae conniventes
peptic ulcers past first part of duodenum
222
hypertrophic pyloric stenosis
longer and thicker pyloric sphincter --> gradual stenosis
223
hypertrophic pyloric stenosis causes
in infants, prob due to failure of the development of NO enteric neurons
224
signs of hypertrophic pyloric stenosis
cervix sign
antral nipple sign/teat sign
pyloric tilt
string sign
225
hypertrophic pyloric stenosis Sx
enlarged, hardened pylorus may be palpated to right of midline near the right costal margin
abnormally large peristaltic waves
develop gradually more severe non-bilious projectile vomiting after feeding
226
hypertrophic pyloric stenosis Tx
pyloromyotomy/pyloroplasty --> cuts pylorus to relieve stenosis
227
cervix sign
paristaltic wave hits pylorus
stenosis causes region to become draped w/ wave
forces pylorus to pucker back into pyloric antrum
228
antral nipple sign/teat sign
canal mucosa squeezed to the point of bulging into the pyloric antrum
229
pyloric tilt
in contrast imaging, bulging pylorus looks like a 3
230
pyloric tilt mech
as pyloric wave hits the hardened sphincter, the antral region bends on the sphincter
231
lesions in upper vs lower GI bleeding
vomiting blood --> lesion in proximal ligamnet (cephalad)
| bloody feces --> lesion in distal ligament (caudad)
232
absence of ligament of treitz -->
malrotation of the gut
233
indications of malrotation of gut
corkscrew sign
shifted superior mesenteric artery (shift to R of sup mesenteric v.)
Ladd bands
double-bubble sign
234
corkscrew sign
vovulus of jejunum (barber-shop-like twisting of SI)
| --> ischemia
235
Ladd bands
abnormal mesenteric bands that obstruct the duodenum --> gas bubbles
236
double bubble sign
one bubble in duodenum and one bubble in stomach (separated by pylorus)
sign of ladd bands, annular pancreas, sup mesenteric artery syndrome, duodenal obstruction
237
risk in splenectomy (panc)
if nick the tail of pancreas --? chemical peritonitis
238
choleduchal cysts
from pancreatic secretions refulxing into bile duct
239
acute pancreatitis
from bile reflux into the pancreatic duct
240
long hepatopancreatic duct
bile and pancreatic ducts unite before ampulla --> long hepatopancreatic duct
241
annular pancreas
ventral and dorsal pancreas fuse abnormally, surrounding and consreicting the duodenum
242
annular pancreas Sx
postprandial vomitus and bilious vomitous (bile in vomit)
243
pancreas divisum
ducts dont unite properly
244
effects of pancreas divisum
ducts dont unite properly so most of the pancreas drains into the dorsal duct (usually to ventral)
dorsal duct is narrower --> increased risk of pancreatitis
245
pancreatitis may result in
fistulas w/ stomach
inflammatory aneurysm in sup mes artery
thrombophlebitis and embolism of sup mes vein
246
pancreatic fluid in omental bursa -->
chemical peritonitis and pancreatic ascites
247
pancreatic fluid in L crus of diaphragm and L hemidiaphragm -->
L sided pleural effusion
248
pancreatic fluid in aortic hiatus -->
mediastinitis
249
pseudocysts from pancreatitis can burst into
omental bursa
L crus of diaphragm and L hemidiaphragm
aortic hiatus
250
signs of hemorrhagic pancreatitis
Grey-Turner's sign
| Cullen's sign
251
pancreatic enzymes in blood stream -->
upset delicate blood-tissue borders
252
Grey-Turner's sign
blood collecting unders kin in flank/lateral region
| sign of retroperitoneal hemorrhage
253
Cullen's sign
blood collecting in preumbilical region
| sign of retroperitoneal hemorrhage
254
indication for pancreatic adenocarcinoma
obstructed bile or cystic duct w/ jaundice and a swollen, non-tender gallbladder
255
Courvoiser's Law
if pt has obstructed bile or cystic duct w/ jaundice and a swollen, non-tender gallbladder its UNLIKELY due to gallstones
256
pancreatic adenocarcinomas location
75% occur in pancreatic head and obstruct ampulla of Vater
257
Budd-Chiari syndrome
blockage of hepatic veins by thrombus
258
possible complications of Budd-Chiari syndrome
since caudate lobe may not be affected by thrombus it may hypertrophy and compress the IVC
259
Hartmann's pouch
aka infundibulum
near the neck, not always present
commonly seen in gallbladder disease
260
biliary disease ducts
1 cm
| usually 6-8 mm or 1/10th age
261
biliary colic
gallbladder related pain
| usually from biliary tract inflammation or obstruction
262
cholangitis
inflammation of any part of biliary tract
263
biliary colic referred pain
right T7-TP dermatomes
264
gallbladder referred pain
referred R shoulder pain
265
cholecystolithiasis
gallstone disease
266
stones that block ampulla of Vater
> 5mm
267
cause of biliary tree distension
if gallstone block the common bile duct or cystic duct
268
cholecystitis
inflammation of gallbladder
269
murphy's sign
pain upon palpation
happens during cholecystitis
(sonographic - happens during ultrasound)
270
Mirrizi's syndrome
gallstone in long cystic duct can compress common hepatic duct against the hepatoduodenal ligamnet
271
chronic gallbladder disease
cholecystoenteric fistulas
272
cholecystocolonic fistulas -->
no problems (gallstones pass through colon easily)
273
cholecystoduodenal fistulas -->
may obstruct a region of SI or ileocecal valve
274
gallstone ileus
gallstone posing a barrier to peristalsis
| shows Rigler's triad
275
Rigler's triad
pneumobilia
Ladder sign
finding gallstones
276
pneumobilia
gas in gallbladder and biliary tree
277
jejunum and ileum referred pain
paraumbilical region
278
Crohn's disease
may have regional enteritis in jejunum or ileum
severe ulceration and erosion of mucosa
valvulae conniventes destroyed
severe narrowing of affected segment and dilation just proximal to it
279
superior mesenteric artery syndrome
after rapid weight loss --> less mesenteric fat --> branch angle reduces --> structures clamped
- -> duodenal obstruction
- -> L renal vein obstruction
280
superior mesenteric artery syndrome - sx of duodenal obstruction
referred abdominal pain, malaise, nausea, vomiting
| leaning forward relieves P
281
superior mesenteric artery syndrome - sx of L renal vein obstruction
increase hydrostatic P in L testicular vein
| may lead to L scrotal varicoceles
282
omphalaceles
GI stuck outside abdomen through umbilicus
283
when midgut loop doesn't return to cavity (in utero) -->
omphaloceles
congenital umbilical hernias
omphalomesenteric duct may persist
284
persistant omphalomesenteric duct -->
fibrous band (connect umbilicus w/ ileal diverticulum)
umbilical cyst/sinus
umbilicoileal fistula
Meckel's diverticulum
285
hematochezia
blood in stool
286
intussusception
telescoping of proximal segment of bowel into distal segment
common @ iliocolic jxn
--> abnormal peristaltic waves
can lead to current jelly stool (mix of mucoous, blood and feces)
287
intussusception vocab
intussusceptum = invading segment
intussusceipiens = recipient of segment
lead point = abnormality causing it
288
possible signs of intussusception
```
dance sign
rim of gas sign
meniscus sign
coiled spring sign
doughnut sign (CT)
speudokidney sign (CT)
```
289
dance sign
relatively empty RLQ
| palpable mass in RUQ
290
dance sign mech
cecum and ascending colon lifted upward by the intussusception
291
rim of gas sign
btwn lead point and intussuscipiens
| look like "target sign" if head on (solid center, gas around it)
292
meniscus sign
inteussusceptum pushes against a meniscus of gas
293
coiled spring sign
intussusceptum piles up and lalvulae conniventes piles up like a slinky
294
doughnut sign
intussusception looks like a doughnut in head-on cut CT
295
pseudokidney sign
intussusception look like kidney in oblique cut CT
296
wandering spleen
gastrosplenic and splenorenal ligaments stretch in old age --> spleen wanders around peritoneal cavity
297
Kehr's sign
referred left shoulder pain
from enlarge or ruptured spleen (irritates diaphragm)
may be from trandelenburg
298
trendelenburg position
head down 30-45 degrees w/ respect to feet
299
middleton maneuver
used to assess and monitor size of enlarged spleen
spleen 2x bigger can be palpated under left costal margin w/ deep inspiration
never use when mononucleosis is suspected (could --> rupture)
300
splenic infarct
blockage of segmental arteries --> wedge shaped infarct region of spleen (due to lack of collateral circulation)
301
Mattox and Cattell Maneuvers
FXN: gain access to retroperitoneal space
| cut along paracolic gutters and lift them --> ascending and descending colon in the intraperitoneal space again
302
cancers in ascending colon undiagnosed -- why?
liquid feces can squeeze by tumor
303
high intraluminal pressure in cecum and ascending colon -->
occlusion of blood --> ischemia, gangrene, perforation (perforation mort = 40%)
why? they have thinner walls and larger luminal diameter than rest of colon
304
cecal perforation risk by diameter
contrast imaging - 10-12 cm
305
inflammatory bowel disease imaging
```
colonoscopy contraindicated (perforation)
use double-contrast barium enema (can reveal abnorm lesions)
```
306
CT colonography
double contrast barium enema coupled w/ CT and 3D reformation
307
Griffith's point aka
avascular area of riolan
308
griffith's point
ischemic prone region at the splenic felxure
| incidence 30%
309
sudek's point
ischemic prone region at the rectosigmoid junction
| incidence 40%
310
right colic-ileocolic anastamosis
weak-point btwn ileocolic and right colic arteries affecting a segment of the ascending colon
incidence 12%
311
ischemic colitis
most common form of acute intestinal ischemia
| can be a major complication of CV procedures
312
types of ischemic colitis
occlusive ischemia
| non-occlusive ischemia
313
occlusive ischemia
emboli occlude sup mes artery distal to the take-off of the middle colic artery
314
occlusive ischemia aka
acute superior mesenteric ischemia
315
non-occlusive ischemia
ischemia due to acute mesenteric vasconstriction
occurs w/ dehydration or shock
no thrombus involved
316
arc of riolan
anastamosis btwn inf and sup mesenteric artery
| if present --> less prone to occlusive ischemia
317
acute appendicitis cause
2/3 caused by obstruction of the lumen of the appendix via an appendicolith (fecalith)
kids - lymphoid hyperplasia
318
acute appendicitis referred pain
initially - periumbilical pain referred to T10 dermatome
| later - peritoneum - via iliohypogastric/obturator nerve --> projects to RLQ
319
signs of acute appendicitis
```
Aaron's sign
McBurney's sign
Rovsing's sign
Psoas sign
Obturator sign
```
320
Aaron's sign
increase in periumbilical pain w/ P over McBurney's point
| no involvement of pelvic parietal peritoneum
321
McBurney;s sign
RLQ pain w/ P over McBurney's point --> somatic pain due to spread of inflammation to pelvic parietal peritoneum
322
Rovsing's sign
RLQ pain w/ counterclockwise palpation starting in the LLQ and continuing to McBurney's point --> inflammation is so bad that P in LLQ maeks pain in RLQ
323
psoas sign
pain when pt passively stretches the psoas by extension at hip
due to inflammation involving the psoas fascia
324
obturator sign
pain w/ passive stretching of obturator muscles (hip flexion)
due to region of obturator muscles inflamed
325
acute appendicitis Tx
decompressing an unperforated appendix: use a plastic ring to push aside Gerlach's valve + insert stent to drain the pus from the inflamed appendix
326
normal appendix in CT
homogenous
soft-tissue density
normal hypodense surrounding fat
327
appendicitis in CT
thickened appendix w/ periappendiceal fat stranding due to spread of inflammation + often presence of appendicolith
328
normal appendix in ultrasound
collapsed, blind ended lumen and low mural blood flow w/ color-flow doppler
329
appendicitis in ultrasound
lumen is apparent and blind ended, high mural blood flow indicating inflammatory hyperemia
transverse: target appearance called the ring sign
330
appendix in XR
w/ periappendical abcesses, the paracolic fat stripe (hypodense fat stripe) disappears on the right side
331
bird's beak/ace of spades sign
sigmoid volvulus twists and pinches off the barium (in barium enema)
332
cecal volvulus
single distended bowel segment at the cecum w/ semilunar folds
333
ulcerative colitis
similar to Crohn's but may progress to carcinoma
| highest incidence in rectosigmoid jxn
334
omental appendagitis
when fatty tags of colon undergo torsion resulting in inflammation and abscess
335
pseudodiverticula
diverticula not having all the layers of the gut represented
336
colonic diverticulosis
mainly mucosal sacs protruding through weak points in the muscularis propria
up to 4 per haustra
337
colonic diverticulosis location
mostly sigmoid colon
cuz of high P zone from large contractions
retrograde to deep penetrating arterial branches
often thru omental appendices
338
feces in diverticula
can lodge, harden and calcify --> fecaliths
339
diverticulitis
transient perforation of diverticula and inflammation of the peridiverticular tissues
340
uncomplicated diverticulitis
self limiting
341
complicated diverticulitis
abscess, perforation, stricture or fistula
| transmural inflammation --> strictures
342
diverticulitis in women
sigmoid diverticulitis can --> fistulas w/ the uterus
343
colovesical fistula
fistulas to the urinary bladder
| may cause cystitis
344
cystitis
bladder infection
345
pneumaturia
foul smelling urine due to colonic gas
346
fecaluria
brown urine due to dissolved feces
347
Hirschsprung's disease aka
aganglionic megacolon
348
Hirschsprung's disease
aganglionic segment of bowel extends from proximal anal canal into the sigmoid colon
349
colonic cancer types
mostly adenocarcinomas
350
colonic cancer location
most frequently in rectosigmoid region (50%) (more common in men)
25% in cecum and ascending colon (more common in women)
351
colonic cancer and obstruction
more common in descending colon cuz luminal diameter in smaller and feces is more solid
352
colonic cancer lesions
apple core
353
copremesis
fecal vomiting
354
toxic megacolon
dangerous acute colonis dilation
| complication of colon cancer
355
signs/results of toxic megacolon
ischemic colitis (thumbprinting/pseudopoly sign)
pneumatosis coli
colonic rupture and fatal peritonitis
356
ischemiic colitis
passive colonic dilation puts P on walls and chokes off blood supply
signs: thumbprinting /pseusopolyp sign
357
pneumatosis coli
anareobic gas pockets develop in gut wall as it begins to die
358
colonic rupture and fatal peritonitis
when colonic wall dies
359
fixation of rectal walls indicates
scarring from infection, abscess or metastatic disease
360
pelvic enterocele
loops of ileum get trapped in deep rectouterine pouch causing incarceration of the bowel loop
361
rectocele
prolapse of rectum
362
rectocele -->
retention of feces and tenesmus
| can be mucosal prolapse w/ or w/o peritoneal folds
363
urethrocele
prolapse of the urethra
364
cystocele
prolapse of urinary bladder against the vagina
partially occludes vagina
causes urine retention --> bladder infections
365
procidentia
complete prolapse of uterus through vagina
| can result in severe ulceration and infection of exposed cervix
366
cancer above pectinate line metastasis
metastasize to the para-aortic lymph nodes
367
cancer above pectinate line to liver path
superior rectal vein
inf mes vein
hepatic portal vein
368
cancer before pectinate line metastasis
metastasize to superficial inguinal lymph nodes
| nodes become enlarged, fixed, hard and craggy
369
cancer before pectinate line path to lungs
inferior anal veins
| systemic venous circulation
370
perforations above middle rectal valve -->
pararectal fossa
| --> peritonitis
371
perforations below middle rectal valve -->
pelvirectal space/supraelevator space
372
internal hemorrhoids
dilations in the internal rectal venous plexus
painless
tenesmus
expand in portal HTN (prolapsed rosette)
373
pylephlebitis
inflammation of hepatic portal tributaries
| caused by infected internal hemorrhoids
374
pylethrombophlebitis
thrombi occlude hepatic portal vein
375
external hemorrhoids
dilations in external rectal venous plexus
(in perianal space near anal verge)
burning, itching, throbbing (inferior rectal nerves)
376
anal fissure mech
produced when hard fecal bolus is forced through the anal canal
catches anal valve
tears the anoderm
377
anal fissure to anal ulcer
if fecal retention occus and fissure damaged
378
anal ulcer triad
hypertrophied papilla
sentinel hemorrhoid
anal fissure
379
anal ulcer location
posterior anal crypt
380
anal cryptitis
infection of anal crypt
| may --> cryptoglandular abscess or anal fistula
381
cryptoglandular abscess
infected crypt infects the anal gland
382
fistulotomy
drainage of infected fistula
383
salmon-goodsall rule
if abscess or fistula is:
anterior or on transverse anal line --> infected crypt closest to abscess/fistula
posterior to transverse anal line --> originates from posterior midline anal crypt
384
fistulectomy
removal of entire fistulous tract
385
anal stenosis
narrowing of anal sphincter/canal
386
anal stenosis causes
rectal or anal cancer
387
anal stenosis -->
compressed lumen --> pencil stools
| may retain feces to prevent pain --> hypertrophy of external sphincter and fecal impaction
388
perianal muscles
contract to end urination
| contract during orgasm
