Surgery

Question 1

Management of peds umbilical hernia

Answer 1

> 90% spontaneous resolute, rarely symptomatic
Surgery if persists @ 3-5 yrs

Question 2

What acid-base abnormality would be likely to result from pyloric stenosis?

Answer 2

Hypochloremia, hypokalemic metabolic alkalosis

Question 3

Age of pyloric stenosis typically?

Answer 3

3 weeks - 3 months

Question 4

Fluids for pyloric stenosis

Answer 4

NS with potassium at 2x maintenance

Question 5

Most common cause of bowel obstruction in early childhood (<2yo)

Answer 5

Intussusception

Question 6

Intussusception most often occurs near…

Answer 6

The ileocecal junction (ileo-colic)

Question 7

What is a meckel diverticulum

Answer 7

Congenital sacculation of the antimesenteric border of the distal ileum
TRUE diverticulum (contains all layers of the intestinal wall)
May contain heterotopic tissue (usually gastric, sometimes pancreatic or other)

Question 8

Symptoms of Meckel diverticulum

Answer 8

Obstruction –> pain, N/V
Meckel Diverticulitis –> similar pain to appendicitis. vomiting
Repeat episodes of BRBPR

Question 9

Currant jelly stool is a sign of what? Other symptoms?

Answer 9

Inruccusception
Episodes of inconsolable crying
Vomit once obstruction progresses

Question 10

Meckel’s rule of 2s (6 things)

Answer 10

2% of population
Present @ 2 yrs
2 inches in length
Within 2 ft of ileocecal valve
Males:females 2:1
2% develop complication

Question 11

Complications of Meckel’s

Answer 11

OHIP:
Obstruction (most common complication in adults)
Hemorrhage (most common complication in children)
Inflammation
Perforation

Question 12

Ultrasound sign of intussuception

Answer 12

Target sign

Question 13

Treatment for intussusception

Answer 13

Air/CO2 enema (diagnostic & therapeutic)
85% success rate, 5-10% recurrence

Question 14

Drooling baby should raise concern for…

Answer 14

Esophageal atresia & tracheoesophageal fistula

Question 15

Meconium should be passed within…

Answer 15

24 hours

Question 16

“Double bubble” sign on ultrasound typically indicates…

Answer 16

Duodenal atresia (bubbles = stomach + duodenum)

Question 17

How to tell SBO & LBO apart on X-ray

Answer 17

LBO: peripheral, haustration (don’t go fully across), diameter up to 8cm
SBO: plicae cicrulares (AKA valvulae conniventes), central, diameter up to 5cm

Question 18

Congenital absence of ganglion cells in rectum/distal colon =

Answer 18

Hirschsprung’s disease

Question 19

Normal transition zone between normal & abnormal bowel in Hirschsprung’s disease is…

Answer 19

Rectosigmoid junction

Question 20

Diagnosis & treatment of hirschsprung’s disease

Answer 20

Rectal biopsy
Pullthrough procedure (bringing normally innervated bowel to the anus with preservation of the anal sphincters)

Question 21

When should an asymptomatic meckel’s be reseted?

Answer 21

Narrow opening
Palpable gastric mucosa

Question 22

Most common GI emergency in neonates

Answer 22

Necrotizing enterocolitis

Question 23

Cystic hygroma = a common peds subtype of…

Answer 23

Lymphangioma

Question 24

Lump in sternomadoid of 3-6 week old baby with their head turned away from it is typically…
Treatment?

Answer 24

Congenital muscular torticollis
Typically treated with passive stretching exercises, rarely surgery

Question 25

Ddx for painless abdominal mass in child <5 yrs

Answer 25

Neuroblastoma (usually suprarenal, sick pt, mets, poor prognosis) Wilms' tumor = nephroblastoma (renal, no mets, good prognosis)

Question 26

Atresia of jejunum or ileum is thought to occur due to what? Duodenal?

Answer 26

Vascular accident in utero--> necrosis + reabsorption of fetal intestine (e.g. with cocaine use/tobacco) vs duodenal is associated with chromosomal abnormalities

Question 27

Hallmark x-ray finding of necrotizing enterocolitis

Answer 27

Air in the bowel wall = Pneumatosis intestinalis Portal venous air also common due to transmigration of gas from bowel wall to mesenteric & portal veins Pneumoperitoneum can be see if there's a perf

Question 28

Neuroendocrine tumors usually in distal SI, proximal colon, and lung, with strong propensity for mets to liver. What can result from mets to liver

Answer 28

Carcinoids Carcinoid syndrome

Question 29

Pts on warfarin needing emergency surgery should receive what for reversal?

Answer 29

Prothrombin complex concentrate IV Vitamin K

Question 30

How long should ASA be held before/after surgery

Answer 30

72 hours before Restart 8-10 days after major surgery

Question 31

Maintenance fluid rule. Target urine output?

Answer 31

4:2:1 rule (per Kg per HOUR) To maintain 0.5mg/kg/hr for adults, 1mL/kg/hr for kids

Question 32

Contents of normal saline

Answer 32

154 mEq/L Na 154 mEq/L Cl

Question 33

Electrolyte contents of Ringers

Answer 33

130 mEg/L Na 109 mEq/L Cl 4 mEq/L K 28 mEqL HCO3-

Question 34

Admission orders mnemonia

Answer 34

Admit to Diagnosis Diet Activity Vitals Ins/Outs IVs/fluids Investigations Drugs, Drains, Dressings

Question 35

How to estimate maintenance fluid requirements based on operative losses

Answer 35

#hrs NPO x maintenance req + # hrs case x maintenance + operative blood loss + insensible losses (varies based on extend of procedure)

Question 36

Cause of post-op fever in the first 48 hours?

Answer 36

Atelectasis Necrotizing infections Med reactions/blood products Malignant hyperthermia

Question 37

Causes of post-op fever days 3-5

Answer 37

Pneumonia UTI IV site infection Early wound infections? (usually ~day 5+)

Question 38

Causes of post-op fever day 5+?

Answer 38

Anastomotic leak Abscess formation Wound infx Infx related to catheters/foreign bodies

Question 39

When does function typically resume for each part of the GI tract post op after paralytic ileus?

Answer 39

Small bowel - 24h Colon - 24-48h Gastric - 48-72h

Question 40

Practice guidelines recommend biopsy for all BI-RADS _____ lesions

Answer 40

4 & 5 (for 3 do short-interval followup with mammogram q6-12 month and biopsy if it grows)

Question 41

What is Prehn's sign? Name 2 diagnoses where it would be positiev and 1 where it would be negative

Answer 41

Relief of pain with lifting of testicle, e.g. in epididymitis & orchitis NEGATIVE in testicular torsion

Question 42

Rule out testicular torsion with...

Answer 42

U/S doppler

Question 43

Crohn's tends to have ___ on microscopy, whereas UC will have ____

Answer 43

Crohns --> granulomas UC --> crypt abscesses

Question 44

Most common CRC mets

Answer 44

Liver (usually first), peritoneum, lung *from rectum can "skip" liver and go to lungs bc it drains into IVC not portal veins

Question 45

___ lymph nodes are required for staging CRC

Answer 45

12+

Question 46

What autosomal dominant disease (APC gene mutation) has 100% colon cancer rate by 40s

Answer 46

Familial adenomatous polyposis

Question 47

Normal thickness of GB wall & CBD

Answer 47

Wall <3mm CBD <7mm

Question 48

Normal appendix thickness

Answer 48

1cm

Question 49

Recurrence of appy with non-surg management

Answer 49

30% in 1 year 40% in 5 yrs

Question 50

___% of hernias managed by "watchful waiting" are converted to surgical repair annually (i.e. become symptomatic)

Answer 50

10%

Question 51

Lichtenstein repair for inguinal hernia AKA

Answer 51

Open or "tension-free"

Question 52

Diagnostics for pancreatitis

Answer 52

2/3 of: biochemical (lipase), radiological, clinical (Sx)

Question 53

In infants, delay elective procedures until when?

Answer 53

60 wks postconceptual age

Question 54

Breast cancer usually originates in the...

Answer 54

Ducts

Question 55

Breast cancer screening guideline Ontario for regular-risk pts

Answer 55

Mammogram q2 years from age 50-74

Question 56

Core needle biopsy vs FNA?

Answer 56

FNA has high false-neg rate so can't rule out Core needle is more accurate

Question 57

Is surgical management indicated in acute pancreatitis?

Answer 57

NOT USUALLY, VERY HIGH M&M Only if pt has infected pancreatic necrosis and hasn't responded to perc drain using step-up approach

Question 58

Is urine acidic or alkaline in pyloric stenosis

Answer 58

Paradoxic aciduria due to rental retention of Na, exchanged for K+ & H+

Question 59

Positive pyloric stenosis ultrasound

Answer 59

Pylorus with length of 14mm+ and wall thickness of 4mm+