Pancreatic, Hepatobiliary, Lower GI Flashcards
(143 cards)
0
Q
DDx for RUQ pain, N/V, anorexia, guarding, tenderness
A
- Sx cholelithiasis
- Biliary colic
- Acute cholecystitis
1
Q
Management of asx gallstones?
A
Surgery not necessary (< 10% develop sx requiring surgery w/in 5 years)
2
Q
Typical gallstone disease pain?
A
RUQ or epigastrium, can radiate to back or scapula
3
Q
Typical US findings in gallbladder disease?
A
- Thickening of gallbladder wall
- Pericholecystic fluid
- Gallstones
4
Q
Management of sx cholelithiasis?
A
Cholecystectomy
5
Q
ABx in uncomplicated, sx cholelithiasis?
A
Nope. Single pre-op dose of Cefazolin is sufficient
6
Q
Consequences of common bile duct injury in cholecystectomy?
A
Chronic biliary strictures, infection, cirrhosis
7
Q
Post-op management of lap chole?
A
W/in 7-24 hrs most ready for d/c … f/u in 7-10 days
8
Q
Acute cholecystitis management?
A
- 2nd gen ceph pre-op and 24 hours post-op
2. IV fluids, NPO, NGT if N/V
9
Q
ABx coverage of acute cholecystitis?
A
Gram (-) rods and anaerobes
- E. coli, Klebsiella, Enterobacter, Enterococcus
10
Q
Expected course of acute cholecystitis?
A
improvement in 1-2 days on IV fluids and ABx … lap chole in 48-72 hours
11
Q
Sx cholelithiasis + elevated ALP and TB (4)
A
Common bile duct obstruction
12
Q
Sx cholelithiasis and gallstone pancreatitis in pregnancy?
A
Majority can be managed nonoperatively
13
Q
Safest time to operate on pregnant women?
A
2nd trimester
14
Q
Most important indication for cholangiogram?
A
Biliary pancreatitis - MANDATORY
15
Q
Management of gallbladder empyema?
A
IV ABx + emergent exploration w/ cholecystectomy … can do percutaneously if in poor health
16
Q
Suppurative cholangitis
A
infection w/ bile duct obstruction –> can see air in biliary system from gas-forming organisms –> emergent ERCP w/ sphincterotomy, decompression and stone removal
17
Q
Alternate sepsis presentation for elderly?
A
Hypothermia and leukopenia
18
Q
Pancreatic cancer w/ distal bile duct obstruction in pt w/ biliary sepsis?
A
Very unlikely. PC presents w/ abdominal/back pain, weight loss, jaundice
19
Q
Prior cholecystectomy w/ sx of obstruction?
A
Possible retained stone in CBD
- < 2 yrs w/ stone = retained stone
- > 2 yrs w/ stone = primary stone
20
Q
Transcutaneous abdominal US for viewing distal CBD and head of pancreas?
A
No, intestinal gas obscures the view
21
Q
Imaging required for uncomplicated pancreatitis?
A
Obstructive series only, CT not necessary
22
Q
Tx of pancreatitis?
A
NPO, IV fluids, pain control, observation … most improve quickly … if not, TPN may be necessary
23
Q
Correlation of amylase w/ severity of pancreatitis
A
NO CORRELATION
24
Abdominal pain + inc. amylase in elderly
Look for other dx besides pancreatitis --> volvulus, mesenteric ischemia
25
Pseudocyst wait time to surgery
6-7 weeks
26
Echinococcal cyst tx
Hypertonic saline + resection w/out spillage
27
Central stellate scar on US
Focal Nodular Hyperplasia, requires bx to dx, no tx
28
Appendicitis in woman... workup? Management?
Rectal and pelvic exams. Hydration, NPO, observation w/ serial exams and repeat CBC. Mild does not warrant ex-lap.
29
Analgesia for appendicitis?
No, avoid masking sx.
30
DDx of RLQ pain
UTI, appendicitis, appendiceal abscess, PID, ovarian and tubal issues, mesenteric adenitis, Meckel diverticulum, terminal enteritis, diverticulitis
31
Minimal dysuria and urinary WBC count of 8-10/hpf
Appendicitis still high on DDx as inflammation can be in continuity w/ urinary tract
32
RLQ pain w/ too many RBCs on U/A to count... Imaging?
severe UTI or kidney stone... IV pyelogram or CT
33
Hx of PID
Tends to recur, but appendicitis could still occur. Careful pelvic exam
34
IBD tx?
Steroids, 5-ASA ... CT or barium enema dx
35
What must you be aware of when tx a suspected IBD?
Appendicitis can still develop. Steroids added to a missed appendicitis will create complications and delay or obscure the correct dx of appendicitis
36
Appendicitis etiology?
Bimodal distribution - 25 yrs and 65 yrs
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Elderly presentation of appendicitis?
Vague abdominal complaints, sepsis, altered consciousness, failure to thrive
38
Who more commonly presents w/ ruptured appendix?
Children (5 yrs)
39
Where is appendicitis pain more commonly found in pregnancy?
RUQ due to uterus pushing appendix superior-laterally
40
Yellow, firm mass at tip of appendix
| Can also present as pedunculated mass in terminal ileum (adenocarcinoma as well)
Carcinoid tumor. Bx not necessary. < 2 cm = simple appendectomy
> 2 cm = possible malignancy --> right colectomy
41
Management of carcinoid?
Baseline 5-HIAA, CT, octreotide scan (localizes to neuroendocrine tumors)
42
Eval of 60 yo M s/p appendectomy 1 week ago now w/ fever, chills, anorexia, malaise
Pelvic abscess, wound infection (if closed) --> CT, US
43
Management of pelvic abscess?
Drainage percutaneously if possible, or open drainage. Can do transrectal or transvaginal. W/ resolution, associated cecal fistula would be unusual
44
Colon cancer screening options
1. Yearly fecal occult blood test (high FN rate)
2. Yearly FOBT + flexible sigmoidoscopy (1st at 50, then every 5 years) --> misses 50% of colorectal polyps and cancers (higher in colon)
3. Colonoscopy (1st at 50, every 10 years)
45
Modifications to colon cancer screening recommendations
1. 1st degree relative w/ colorectal cancer or adenomatous polyp (screen at 40)
2. FAP in family --> yearly flexible sigmoidoscopy (100% progression to cancer) , colectomy is only tx recommended
3. HNPCC in family --> genetic testing and colonoscopy every 1-2 years, beginning at 20 and 30 and every year after 40
4. Hx of polyps removed by colonoscopy --> colon exam every 3 yrs
5. Hx of resected colorectal cancer --> colonoscopy every year w/ screening at 3 and then 5 year intervals
46
Screening for colon cancer recurrence
CEA every 2-3 mo for 2 years (detects 80% of recurrences)
47
What designates Stage III colon cancer and what is tx?
LN invasion, 5-ASA and levamisole
48
Feculent vomiting POD 3 after colectomy. DDx?
1. Leakage from anastomosis --> persistent ileus
2. Mechanical obstruction --> adhesions, internal hernia, obstructed anastomosis
Tx = NPO feeds, IV fluids, NGT + CT or obstructive series
49
Wound infection management
Open involved portion down to fascia
50
Post-op enterocutaneous fistula management
Anastomotic leak --> NPO feeding and IV fluids usually sufficient for most fistulas and will close w/ this therapy
51
Pt returns to hospital 10 days post-op from colectomy w/ fever 104 and RLQ pain
Abscess --> right paracolic gutter or pelvis
52
Rectal carcinoma eval
1. Digital rectal
2. Colonoscopy (visualize entire colon to r/o synchronous lesions)
3. Determine depth of invasion (transrectal US)
4. Adjacent structures (CT/MRI)
5. CXR and CEA warranted prior to surgery
53
Rectal carcinoma tx
Resection (abdominoperineal --> entire rectum + LN + permanent colostomy --> early-stage lesion (no neoadjuvant therapy)
54
Rectal cancer lymphatic spread ?
Superior hemorrhoidal vessels --> internal iliac nodes, sacral nodes, inferior mesenteric nodes, inguinal nodes
55
Perioperative risks of abdominoperineal resection?
Sympathetic plexus located around the rectum --> impotence (50%)
Bladder function can be impaired (Foley's in place for 1 week post-op)
Venous bleeding from presacral spsace, ureter injury
Retraction, prolapse, stricture, and obstruction of colostomy
56
Proximity to anal verge affecting operative management?
Possible to remove most rectal cancers > 5 cm proximal to the verge using anterior approach.
< 5 cm requires abdominoperineal resection because lateral margins include sphincter mechanism
57
Common mode of rectal carcinoma resection failure?
Local recurrence --> ample, clear margins (2 cm for well/moderately-well differentiated ; 5 cm for poorly differentiated, anaplastic, or "signet" cell)
Abdominoperineal more likely for lesions > 5 cm
58
Post-op management of rectal Stage II or > lesions
Adjuvant chemotherapy similar to colon cancer
59
When might preop radiation in rectal carcinoma be considered?
Large, bulky lesions or extension outside the bowel into surrounding tissue. Over weeks to reduce size
60
Alternatives to colostomy in rectal resection?
Sphincter-preserving proctectomy
local resection of tumor
61
Abdominoperineal resection differences in women?
Posterior vaginal wall resected w/ maintenance of urethra innervation
62
CEA elevation during yearly f/u... next step?
CXR and CT abdomen for mets look + repeat colonoscopy
63
New 2 cm liver lesion in colon cancer recurrence. Tx?
Surgical resection if no extrahepatic mets, no local recurrence, and resectable lesion (+ anesthetic and cardio clearance)
64
Types of unresectable lesions?
multiple lesions in both lobes of liver, intimate w/ vascular structures (hepatic veins, portal vein), local structure invasion (diaphragm), cirrhotic liver
65
Survival in pts w/ solitary liver mets from colon cancer
35% at 5 years
66
Liver met resection procedure?
Hepatic lobectomy or segmentectomyy or nonanatomic wedge resection, w/ > 1 cm margins
67
Non-resectable lesion management
Cryotherapyy, EtOH, RF ablation, chemoembolization
68
MC cancer of anal canal?
SqCC (epidermoid carcinoma) and can have strange sx: bleeding, drainage, pain, pruritis
69
Where do anal canal SqCCs commonly met to?
Inguinal nodes and superior rectal nodes
70
How to determine depth of invasion in anal canal cancer?
CT or transrectal US
71
4 cm rectal carcinoma w/ no local extension and no LN
Nigro protocol --> chemoradiation to eliminate cancer
| usually provides complete local control
72
What is the Nigro protocol?
External Radiation
Systemic chemo (5-FU cont. for 4 days, starting day 1 of radiation and repeated days 28-31)
Mitomycin C
73
Diverticulitis tx?
Liquid diet + outpatient broad-spectrum ABx
74
Elderly w/ fever and LLQ?
Diverticulitis --> NPO, IV fluids, parenteral ABx
75
Analgesia of diverticulitis?
Not morphine (inc. intracolonic pressure) --> Meperidine instead as it lowers intracolonic pressure. Also may need obstructive series to check for free air
76
Dx of diverticulitis
CT inflammation, abscess, diverticula, THICKENED SIGMOID BOWEL WALL ... not mandatory in uncomplicated pts
77
Management of diverticulitis following improvement?
Fiber + ABx x 7-10 days
78
Chances of diverticulitis recurrence?
70% have no further recurrence. Elective resection 4-6 weeks after resolution of 2nd episode (risk of perf/abscess inc. w/ each episode)
79
Massive lower GI bleeding w/ tachycardia and 105/70 w/ signs of dehydration
2 large bore IVs and 1-2 L of NS or LR. Place on monitor. Routine blood studies and CXR + coag eval + Foley cath. NGT for eval for upper GI bleed
80
MCC of rapid lower GI bleeding?
bleeding diverticula and vascular ectasias ... others include Meckel's, aortoenteric fistula, ischemic colitis, IBD, hemorrhoids, varices, colonic neoplasms
81
Rebleeding risk in lower GI?
Diverticulitis - 25% rebleed risk, 20% cont. to bleed and require operative intervention
Vascular ectasias stop spontaneously in 90% but have 25% and 46% rebleed risk at 1 and 3 years
82
Vascular ectasia tx?
Coagulation w/ monopolar current w/ risk of perforation
83
Resolved bleeding diverticula tx?
Iron and fiber
84
What causes diverticula to bleed?
Underlying vasa recta erosion
85
Right vs left diverticula
Left MC, Right more apt to bleed
86
Persistent massive lower GI bleed management?
pRBCs , labeled RBC scan (better for stable pts bleeding more slowly; cannot precisely locate site of bleeding) mesenteric angiography (better for less stable pts due to better monitoring and resuscitation capabilities, and for those bleeding more rapidly)
87
Rapid bleeding, less stable pt?
Mesenteric angiography
88
Slow bleeding, stable pt
labeled RBC scan
89
Indication for surgery in persistent massive lower GI bleed?
Cont. bleeding (relative), CV instability (relative), 4-6 units pRBCs (relative) ... angiogram tends to be a pre-operative test
90
Indication for surgery prior to 4-6 units pRBCs?
Unstable w/ bleeding .. esp. w/ CAD and angina w/ unstable vitals
Hard-to-determine blood types including unusual Ab's or pts who do not wish to have transfusion (Jehovah's)
91
How to lessen persistent lower GI bleeding?
Vasopressin (short time --> coronary vasoconstrictor, 50% have rebleeding w/in 12 hrs of d/c)
Embolization (inc. risk of transmural necrosis and therefore saved for poor surgical candidates)
92
Anal fissure triad?
Razor blades/broken glass sensation
Bright red blood
Aching spasms
93
Anal fissure exam?
External exam (anterior or posterior midline usually)
94
Tx of anal fissure?
1. Sitz baths + fiber/stool softeners (80% cure)
2. Topical nitroglycerin (0.2%) --> NO donor (vasodilation)
- bad headaches (can use nifedipine, Viagra too)
3. Botox (women) --> inhibits AChEase
4. Sphincterotomy (internal - divide) --> incontinence rare
95
1 day, 32 week premature infant w bloody stools, distention, inability to tolerate feeds
Necrotizing enterocolitis
96
Etiology of NE?
Stress, respiratory failure, hypoxemia, HoTN
97
Clinical features of NE?
Distention (70-90%), palpable bowel or crepitus, Peritonitis, erythema of wall, bloody NG aspirate or stool
98
Dx of NE?
WBC < 6000 if gram (-) septicemia, thrombocytopenia, metabolic acidosis, pneumatosis intestinalis **, portal venous gas
99
Tx of NE?
NPO, TPN, IV fluids
ABx
Op: pneumoperitoneum, (+) paracentesis, portal venous gas, deteriorating
100
Where does NE most often occur?
Small bowel
101
MC location for strictures from healed NE?
Splenic flexure of colon (poor blood supply)
102
3 week old former full term w/ inability to tolerate feeds and projectile emesis
Pyloric stenosis (3/4 mm x 14 mm)
103
Is pyloric stenosis present at birth? Familial? Progressive? Self-resolving?
No. Yes (first-born MC). Yes (hypertrophy increases). Yes (as long as feeds get through via tube or TPN)
104
Age of pyloric stenosis?
2 weeks to 2 months
105
Metabolic derangement in pyloric stenosis? Fluids?
Hypokalemic hypochloremic metabolic alkalosis. NS (10/kg as LR can inc. alkalosis due to HCO3
106
2 1/2 yo former full term male w/ painless bloody stools (can be very significant bleeding)
Meckel's diverticulum
107
Causes of GI bleeding in neonates
Swallowed maternal blood, hemorrhagic dz of newborn, anal fissure, NEC, malrotation, volvulus
108
Causes of bleeding in infants (3-18 mo)
Anal fissure, Intussusception, Volvulus (bilious emesis), Duplication, GE, food allergy (milk)
109
Toddlers (2-5 yrs)
Anal fissure, rectal prolapse (Cystic fibrosis), GE (E. coli, shigella, campylobacter), Meckel's, juvenile polyp, trauma
110
Older children (6-18 yrs)
Polypoid dz, UC, Hemorrhoids, Meckel's (usually toddlers)
111
Marginal ulcer
gastrojejunostomy --> acid eroding jejunum
112
Cannot have Meckel's bleeding w/out what?
gastric mucosa
113
Meckel's: True or false diverticulum?
True
114
Rule of 2's
2%, 2 ft of ileocecal valve, 2 types of ectopic tissue ...
115
10 yo male w/ RLQ pain, N/V, anorexia
appy
116
Appy hx/lab/exam
hx (GI upset), U/A + WBC (total or diff abnormal in 90%, teenagers break the rules w/ nml WBC) + BHCG
117
Dx of appy
US (donut or target sign; thin pts), CT most sensitive
118
16 yo F w/ RLQ pain, N/V, anorexia
Ovarian torsion (appy also in DDx)
119
29 yo F G2P0 w/ hx of polyhydramnios, gest diabetes, and sickle cell w/ abnormal prenatal US at 34 weeks w/ double bubble sign
Duodenal atresia (could be part of Down Syndrome - 1/3) ... failure of recanalization
120
Associated conditions of double bubble
Annular pancreas*, malrotation (usually gasless abdomen)
121
8 mo male w/ severe right-sided abdominal pain, nausea, distention, "currant jelly" stool
Intussusception
122
Intussusception dx
Waves of pain, US, air-contrast enema (attempt to reduce it)
123
Etiology of intussusception
Lymphoid hypertrophy, typically from virus (Rota), and can be caused by Rota vaccine. HSP is commonly associated w/ intussusception as well ... most occur b/w 5-9 mo (65% < 1 yr old)
124
Management of intussusception
IV fluids, r/o peritonitis --> can recur w/in 1-2 days
125
Groin hernia can commonly occur (communicating) when?
During illness w/ some extra fluid retention moving through the communication
126
Associated abnormalities w/ omphalocele
Chromosomal (trisomy 13, 18, 21), ToF, ASD, Beckwith-Wiedeman (large tongue; watch for malignancy), Pentology of Cantrell (Sternal cleft/diaphragmatic hernia, ectopic cordis, pericardial defect, cardiac anomaly, midline abdominal defect), Prune-Belly syndrome
127
Gastroschisis associated anomalies?
Uncommon, atresia and nonrotation of midgut
128
Bilious emesis in child?
surgical emergency (malrotation)
129
88 yo F in a nursing home w/ *hx of constipation* w/ recent mental status deterioration, HoTN, tachycardia, distention, abdominal tenderness
Sigmoid volvulus
130
Management of sigmoid volvulus?
Hydration, electrolytes, CBC, obstructive series, sigmoid colectomy , can do rigid proctosigmoidoscopy w/ placement of rectal tube
131
Etiology of sigmoid volvulus?
Debilitated pts in nursing homes, often from chronic laxative use, chronic illness, dementia. Clockwise twist around mesentery --> closed loop obstruction
Barium enema confirms dx
132
Ogilvie's or pseudo-obstruction?
Massive right colon dilation w/out mechanical obstruction
133
When do you normally see Ogilvie's
Hospitalized pts in ICU that are intubated and seriously ill
134
Management of Ogilvie's
< 9-10 cm = non-op
> 11-12 cm = endoscopic decompression, neostigmine (parasympatholytic), surgical decompression
135
Rectal prolapse tx?
```
Internal = fiber + non-op trial
External = Rectopexy (pinned to sacrum), low anterior resection (transabdominal rectosigmoid resection), perineal approach
```
136
Persistent perianal drainage
fistula-in-ano --> unroofing, allow to reepithelialize --> if through sphincter (seton)
137
Colostomy complications
Leakage around the bag
138
Types of stomas (colostomies)
Following abdominoperineal resection w/ end sigmoid colostomy
Ileostomy following total proctocolectomy for UC
Ileal conduit draining the urinary system to skin
139
Pouchitis tx
Metronidazole
140
Margins for anorectal cancer resection?
2 cm well-differentiated and 5 cm poorly differentiated
141
Ranson criteria?
Prognostic signs associated w/ acute pancreatitis?
142
Ranson Criteria:
On admission:
Age > 55 , WBC > 16 , Glucose > 200 , LDH > 350 , AST > 250
48 hours:
Hct dec = 10% , BUN inc. = 5 , Ca < 8 , PaO2 < 60 , Base deficit >4
Fluid sequestration > 6 L
