Set 4 (10/14)

Question 1

Blood Supply to appendix

Answer 1

appendiceal artery (branche of ileocolic artery)

Question 2

Obturator Sign

Answer 2

pain with internal rotation of leg w/ hip and knee flexed

(+) in appendicitis

Question 3

Rovsing’s Sign

Answer 3

rebound pressure of LLQ causes pain in RLQ

seen in appendicitis

Question 4

Differential Diagnosis of Appendicitis

Answer 4

Meckel’s diverticulum, Crohn’s disease, perforated ulcer, pancreatitis, mesenteric lymphadenitis, constipation, gastroenteritis, volvus, intussusception, UTI, pyelonephritis, cholecystitis, fiverticulitis

Females: ectopic pregnancy, ovarian cyst, ovarian torsion, PID

Question 5

Urinalysis in Appendicitis

Answer 5

can have mild hematuria and pyuria d/t pevlic inflammation → inflammation of ureter

Question 6

CT Findings in acute appendicitis

Answer 6

periappendiceal fat stranding, appendiceal diameter >6mm, periappendiceal fluid, fecalith

Question 7

Treatment of non-perforated appendicitis

Answer 7

appendectomy, 24h of Abx, go home on POD#1

Question 8

Treatment of perforated appendicitis

Answer 8

IV fluid resuscitation, appendectomy, post-op Abx for 3-7 days, wound left open after closing fascia

Abx Options: Cefoxitin, Cefotetan, Unasyn, Cipro, Flagyl

Question 9

Treatment of appendiceal abscess diagnosed pre-op

Answer 9

percutaneous drainage of abscesss, Abx, elective appendectomy ~6wks later

Abx: broadd spectrum (Amp/ Cipro/ Clinda or Zosyn)

Question 10

Layers of abdominal wall with McBurney’s incision

Answer 10

Skin, SQ fat, Scarpa’s fascia, external oblique, internal oblique, transversus muscle, transversalis fascia, periotneal fat, peritoneum

Question 11

Most common appendiceal tumors

Answer 11

carcinoid tumor

Question 12

Carcinoid Tumor

Answer 12

tumor arising from neuroendocrine cells (Kulchitsky cells)

secretes serotonin

Question 13

Most common sites of carcinoid tumors

Answer 13

“AIR”: Appendix, Ileum, Rectum, and bronchus

Question 14

Pellagra-like symptoms

Answer 14

can occur in carcinoid tumors

Dermatitis, Diarrhea, Dementia

d/t ↓niacin production

Question 15

Sx of Carcinoid Syndrome

Answer 15

“B FDR”: Bronchospasm, Flushing (skin), Diarrhea, Right-sided heart failure (Tricuspid insifficiency and pulmonary stenosis: “TIPS”)

Caused by serotonin and vasoactive peptides

Question 16

Tx of carcinoid syndrome

Answer 16

Octreotide IV

If only diarrhea then treat with Ondansetron (Zofran) which is serotonin antagonist

Question 17

What does liver break down serotonin into?

Answer 17

5-HIAA (5-hydroxyindoleacetic acid) which is elevated in urine in 50% of patients w/ carcinoid

Question 18

Prognosis of Carcinoid tumors

Answer 18

66% alive at 5 years

50% with liver metss or carcinoid syndrome are alive at 3 years

Question 19

Causes of enterocutanoeus fistula

Answer 19

(GI tract to skin)

anastomosis leak, trauma to bowel/ colon, Crohn’s disease, abscess, diverticulitis, inflammation/ infection

Question 20

Colonic Fistula Most common

Answer 20

colovesical fistula (tx: segmental colon resection)

Question 21

External Pancreatic Fistula

Answer 21

drainage of pancreatic exocrine ecretions through to skin

Tx: NPO, TPN, skin protection, octreotide

Question 22

Most common carcinoma of anus

Answer 22

Squamous cell carcinoma (ASS: anal squamous superior) (80%)

Cloacogenic (tansitional cell) and adenocarcinoma/ melanoma/ mucoepidermal also occur

Question 23

Anal epidermal carcinoma treatment

Answer 23

NIGRO Protocol

Chemo w/ 5-FU and mitomycin C

Radiation

Postradiation therapy scar Bx (6-8wks after radiation)

Question 24

Goodsall’s Rule

Answer 24

fistulas anterior to anus will have a straight course; those exiting posterior will have curved tract

Dog has straight nose (anterior) and curved tail (posterior)

Question 25

Seton

Answer 25

thick suture placed through fistula tract to allow slow transection of sphincter muscle; scar tissue will hold muscle in place allowing for continence after transection

Question 26

Degrees of Hemorrhoids

Answer 26

* 1st degree: does not prolapse * 2nd degree: prolapses w/ defecation but returns on own * 3rd degree: prolapses with valsalva and requires active manual reduction * 4th degree: prolapsed hemorrhoid that cannot be reduced

Question 27

Hematochezia

Answer 27

bright red blood per rectum

Question 28

Causes of Lower GI Bleed

Answer 28

diverticulitis, vascular ectasia, colon cnacer, hemorrhoids, trauma, intussusception, volvus, ischemic colitis, IBD (esp UC), rectal cancer, Meckel's diverticulum, stercoral ulcer, infectious colitis, chemo, irradiation injury, infarcted bowel, strangulated hernia, anal fissure

Question 29

What must be ruled out in lower GI bleed

Answer 29

upper GI bleed (get NGT aspiration with bile, if clear then most likely no upper GI bleed)

Question 30

Tests for Lower GI bleeding

Answer 30

* NGT aspiration to r/o upper GI bleed * slow to moderate bleeding = colonoscopy * faster bleeding = mesenteric angiography to locate source

Question 31

Child's Classification (liver)

Answer 31

A BEAP: Ascites, Bilirubin, Encephalopathy, Albumin, PT Class A has 10% operative mortality Class B has 30% mortality Class C has 75% mortality

Question 32

MELD Score

Answer 32

uses INR, total bilirubin, serum creatinine increased mortality by 1% for every 1pt up to 20 then 2% for every MELD point

Question 33

Liver Tumors

Answer 33

most common is metastatic disease most common primary malignant tumor is hepatocellular carcinoma most common primary benign tumor is hemangioma

Question 34

Chemicals that increase risk for liver hemangiomas

Answer 34

Vinyl chloride, arsenic, thorotrast contrast

Question 35

Hepatocellular Adenomas

Answer 35

* normal hepatocytes without bile ducts * Risks: women, birth control pills, anabolic steroids, glycogen storage disease * avg age of 30-35yo * SSx: RUQ pain/ mass/ fullness, bleedign (rare) * Tx: stop OCPs if small or surgical resection

Question 36

Focal Nodular Hyperplasia

Answer 36

benign liver tumor; liver mass with central scar; more common in women; normal hepatocytes and bile ducts (adenoma has no bile ducts) more common in women Tx: resection or embolization if symptomatic; stop OCPs

Question 37

Risks for Hepatocellular Carcinoma

Answer 37

Hep B, cirrhosis, aflatoxin

Question 38

Tumor Marker for Hepatocellular Carcinoma

Answer 38

α-fetoprotein

Question 39

Indications for Liver Transplant

Answer 39

cirrhosis and NO distant or LN mets and no vascular invasion; \<5cm tumor or 3 nodules all \<3cm

Question 40

Causes of Liver Abscesses

Answer 40

* Bacterial- E Coli, Klebsiella, Proteus * Causes: cholangitis, diverticulitis, liver cancer, liver mets * Amebic- Entamoeba histolytica (typically intestinal amebiasis that goes through portal vein)

Question 41

Hydatid Liver Cyst

Answer 41

Cause: Echinococcus granulosus SSx: RUQ pain, jaundice, RUQ mass Dx: serologic testing, Casoni skin test, US, CT (calcified outline of cyst) MUST NOT rupture cyst when removing → fatal anaphylaxis Tx: mebendazole then surgical resection

Question 42

Hemobilia

Answer 42

bleeding from liver through portal vein to GI tract; occurs after liver trauma

Question 43

most common physical findings in protal HTN

Answer 43

splenomegaly (most common), esophageal varices (via coronary vein), caput medusae (engorgemetn of periumbilical veins), hemorrhoids spider angiomas, palmar erythema, ascites, truncal obesity, peripheral wasting, encephalopathy, asterixis (liver flap), gynecomastia, jaundice

Question 44

Budd-Chiari Syndrome

Answer 44

thrombosis of hepatic veins

Question 45

Tx of bleeding Esophageal Varices

Answer 45

* IV fluids, type and cross, correct coag, +/- intubate * Emergent endoscopic sclerotherapy * Endoscopic Band Ligation * Somatostatin or IV vasopressin to cause vasoconstriction * Sengstaken-Blackmore Tube- gastric/ esophageal balloon for tamponade of esophageal bleed * TIPS: Transjugular Intrahepatic Portosystemic Shunt

Question 46

Which lab correlates with degree of hepatic encephalopathy?

Answer 46

Serum ammonia level