Hurley Misc Lecture Flashcards
1
Q
Where is the appendix located
A
where tenia join at the cecum
2
Q
At what point in life is appendicitis most common
A
second and third decade of life
3
Q
What are some risk factors for appendicitis
A
- sex (males)
- age
- family hx
- low fiber diet
- hx of trauma
4
Q
What is the pathogenesis of appendicitis
A
inflammation–>ischemia–>perforation–> peritonitis/abscess
5
Q
How does the inflammation typically occur in appendicitis
A
obstructed process at the lumen of the appendix
6
Q
What types of things can cause an obstruction of the appendix
A
- fecolith, stricture, foreign body
- dietary factors
- bacterial proliferation
- tumor
- lymphoid hyperplasia
7
Q
What are some common organisms that can cause gangrenous and perforated appendicitis
A
- e coli
- peptostrep
- bacteriodes
- pseudomonas
8
Q
Common presentation of appendicitis
A
colicky periumbilical pain that progresses to dull constant right iliac fossa pain
9
Q
What physical exam signs will a patient with appendicitis have
A
- McBurney’s point tenderness
- Rocsing’s sign
- Psoas sign
- Obturator sign
- Pointing Sign
10
Q
What labs are done in a patient with appendicitis
A
- CBC w/ diff
- electrolytes
- LFTs
- urinalysis
11
Q
What is the treatment plan for a patient with appendicitis?
A
-surgery eventually But first -NPO -IVF -IV abx
12
Q
What abx are given for a patient with appendicitis
A
3rd gen ceph or gentamycin + flagyl
13
Q
When do you not operate if a patient has appendicitis
A
- peritonitis
- presence of appendicular mass
- if appendicitis has resolved (can do elective surg later)
14
Q
What are some complications of an appendectomy
A
- perforation
- intra abdominal abscess
- fecal fistula
- DVT
- hernia
15
Q
Where does most of the midgut get its blood supply
A
superior mesenteric artery
16
Q
What are the signs of small bowel obstruction
A
- distension
- tinkering bowel signs (high pitched)
17
Q
What are some causes of a SBO
A
- abdominal mass
- hernia
- abdominal scar
18
Q
What is evidence of a small bowel strangulation/ischemia or perforation
A
- peritonism (pain, vomiting, tenderness, shock)
- fever
19
Q
What would an xray show if a patient had a small bowel obstruction
A
- multiple loops of small bowel
- prominent vasculature
- rectum is not visible
20
Q
What is the most common cause of a SBO
A
postoperative adhesions
21
Q
What is the most common cause of SBO in the developing world
A
hernias
22
Q
What are other less common causes of SBO
A
- malignant tumors
- intussusception
- volvulus
- Crohn’s
- gall stones
23
Q
What are the different types of SBO? (location)
A
intraluminal, intramural, extramural
24
Q
What are examples of intraluminal obstructions
A
- foreign bodies
- bezoars
- gallstones
- parasites
25
What are example of intramural obstructions
- stricture
- Crohn's
- intussusception
- voluvulus
26
What are examples of extramural obstructions
- bands/adhesions
| - hernia
27
What are types of SBO?
- simple
- closed loop
- strangulated
28
What happens above the obstruction in a simple obstruction?
persistalsis increases-->intestine dilates-->reduction in perstaltic strength-->flaccidity and paralysis
29
What happens below the obstruction in a simple obstruction
normal peristalsis and absorption until it empties then it contracts and becomes immobile
30
What does a strangulated obstruction cause
impaired venous return and increased congestion, impaired arterial blood supply
31
What causes distention
accumulation of gas and fluid
32
What is the gas from in abdominal distention from
swallowed air, bacterial overgrowth, diffusion from blood
33
What are the fluids from in abdominal distention
ingested fluids, saliva, gastric and intestinal juices, bile and pancreatic secretions
34
What labs are done in a patient with SBO
- CBC with diff
- Chem 7
- abdominal x ray
- ABG
35
What would elevated WBCs indicate in a SBO
ischemia
36
What would a low Hgb and MCV in a SBO suggest
tumor
37
What type of contrast should be used for a CT if a SBO is suspected
water soluble
38
When is urgent surgery indicated in SBO
- evidence of strangulation
- perforation
- irreducible hernia
39
What is the treatment for SBO
- NPO
- IVF
- ? abx
- NGT
- surgery
40
How do you manage a SBO cause by a hernia
OR
41
How do you manage a SBO caused by adhesion
conservative measures
42
How do you manage a SBO casued by a volvulus
derotate and operate
43
How do you manage a SBO caused by an abscess or peritonitis
drain and treat
44
How do you mange an SBO caused by mesenteric ischemia
operate
45
How do you manage an SBO caused by intussusception
pneumatic or barium reduction then to the OR
46
What is postoperative paralytic ileus
obstipation and intolerance of oral intake resulting from a non mechanical insult that disrupts the normal coordinated propulsive motor activity of the GI tract
47
How do you treat an ileus
- treat the underlying medical condition
- NGT for decompression
- contrast study to r/o mechanical obstruction
- NSAIDs
48
Mesenteric ischemia
ischemia of the small bowel
49
What is mesenteric ischemia typically secondary to
an acute cause involving the SMA or SMV
50
Ischemic colitis
ischemia of the colon
51
Causes of mesenteric ischemia
- SMA occlusion (most common)
- nonocclusive mesenteric ischemia
- mesenteric venous thrombosis
52
What can cause an SMA occlusion
MI, afib, endocarditis, valve disorder, atherosclerosis
53
What causes mesenteric venous thrombosis
primary clotting disorder
54
What is the classic presentation of ischemic bowel disease
- rapid onset of severe, unrelenting periumbilical pain
- pain out of proportion to findings of physical examination
- N/V
- forceful/urgent bowel evacuation
55
Labs for ischemic bowel disease
CBC and chem 12
56
What imaging is done for ischemia bowel disease? What do they show?
plain films: thumbprinting, thickened bowel
CT: thickened/dilated bowel, intramural hematoma, pneumatosis
Mesenteric angiography: can identify the type of ischemia (test of choice)
57
How do you treat ischemic bowel disease
- fluids and blood products
- anticoagulation
- infusion of a vasodilator
58
How do you treat ischemic bowel disease when it becomes infarction
-emergent laporatomy
59
When do you know ischemic bowel disease turns to infarction
peritoneal signs and fever
60
What is the most frequent form of mesenteric ischemia
colonic ischemia
61
What portion of the colon is most commonly affected by colonic ischemia
left colon
62
Etiology of colonic ischemia
- hypotension
- a fib
- post MI
- post AAA surg
- closed loop construction
- mesenteric vein thrombosis
63
Toxic megacolon
total or segmental non obstructive colonic dilation plus systemic toxicity
64
Etiology of toxic megacolon
- IBD
- bacterial: C diff, salmonella, shigella, campylobacter, yersinia
- parasitic: E histolytica, cryptosporidium
- viral: CMV
65
What is the pathogenesis of toxic megacolon
mucosal inflammation-->release of inflammatoryo mediators and bacterial products--> generation of excessive nitric oxide--> colonic dilation
66
How does toxic megacolon present
-abdominal distension and acute/chronic diarrhea
-radiographic evidence of colonic distension
PLUS three of the following
-fever >38
-HR >120
-WBC >10,500
-anemia
PLUS at least one of the following
-dehydration
-altered sensorium
-electrolyte distrubances
-hypotension
67
What is the first line treatment for toxic megacolon
medical therapy
- IVF
- correction of lab abnormalities
- broad spectrum abx and steriods for pts w/ IBD
- NPO
- NGT for decompression
68
What is the second line treatment for toxic megacolon
surgery- subtotal colectomy with en ileostomy
69
What are risk factors for pancreatic cancer
- chronic pancreatitis
- smoking
- diabetes mellitus
- family hx
70
What will a history show in a patient that has pancreatic cancer
- jaundice
- weight loss
- pain
- recent onset of atypical DM
71
What would a physical exam show if a patient had pancreatic cancer
- palpable mass/acites late in the disease
| - Courvoisier sign (non tender palpable gallbladder with jaundice)
72
What is the treatment for pancreatic cancer
-surgery
| whipple, distal pancreatomy
73
What is the most common cause of pancreatic cancer
ductal adenocarcinoma
74
Where do most of the tumors arise in pancreatic cancer
head, neck or uncinate process
75
Where has pancreatic cancer metastasized to by the time it is discovered
peripancreatic lymph nodes
76
What are premalignant lesions for pancreatic cancer
- intraductal papillary mucinous neoplasms
| - mucinous cystadenoma
