Surgery EOR Cards

Question 1

Presentation of internal hemorrhoids

Answer 1

Originate above the dentate line and are typically painless but may present with bright red rectal bleeding during defecation

Question 2

Presentation of external hemorrhoids

Answer 2

Originate below the dentate line, often causing painful swelling and discomfort, especially if thrombosed

Question 3

7 Risk factors for hemorrhoids

Answer 3

Constipation, straining during bowel movements, pregnancy, prolonged sitting, portal HTN, obesity, anal intercourse, and low-fiber diets

Question 4

Management of external hemorrhoids

Answer 4

Sitz bath, fiber, fluid intake, topical
I&D or surgery for thrombosed or recurrent cases

Question 5

Diagnosis of internal hemorrhoids

Answer 5

Anoscopy - often following symptoms of bleeding or prolapse

Question 6

3 levels of internal hemorrhoid management

Answer 6

Conservative - Fiber, stool softeners, fluids
Office based - Rubber band ligation or sclerotherapy (appropriate for grades I-III)
Surgical - Hemorrhoidectomy for III-IV and strangulation

Question 7

Grades I-IV of hemorrhoids

Answer 7

Grade I: No prolapse, visible on anoscopy
Grade II: Prolapse during straining but spontaneously reduce
Grade III: Prolapse during straining, require manual reduction
Grade IV: Irreducible prolapse, may strangulate

Question 8

Indication for hemorrhoid surgery - 3

Answer 8

Persistent bleeding, thrombosed hemorrhoids, severe pain, or failure of conservative treatment

Question 9

Hemorrhoidectomy with indications

Answer 9

Excision of hemorrhoidal tissue; indicated for large, prolapsed, or thrombosed hemorrhoids.

Question 10

Stapled Hemorrhoidopexy with indications

Answer 10

Uses a circular stapler to reposition and fixate hemorrhoidal tissue; less postoperative pain but higher recurrence rate compared to hemorrhoidectomy.

Question 11

Minimally Invasive hemorrhoid Procedures with indications

Answer 11

Rubber band ligation (first-line for internal hemorrhoids), sclerotherapy, and infrared coagulation for less severe cases.

Question 12

Presentation of an anal fissure

Answer 12

Tearing rectal pain with BRB on tissue paper after defecation
Assoc with constipation
Anoscopy and sentinel pile

Question 13

Conservative management of anal fissures

Answer 13

Sitz baths, increase dietary fiber and water intake, stool softeners or laxatives

Question 14

Second line measures for anal fissure

Answer 14

Lateral Internal Sphincterotomy
Botox

Question 15

3 Topical tx for anal fissure

Answer 15

nitroglycerin, nifedipine, or diltiazem

Question 16

Usual healing timeline for anal fissures

Answer 16

6 weeks

Question 17

Indications for anal fissure surgery

Answer 17

Chronic fissures that do not heal with conservative treatment (topical agents, sitz baths) after 6-8 weeks

Question 18

Lateral Internal Sphincterotomy

Answer 18

Most common procedure; involves cutting a portion of the internal anal sphincter to reduce sphincter spasm and pain, promoting healing. High success rate but carries a small risk of fecal incontinence.

Question 19

Botox for anal fissures

Answer 19

Alternative to LIS; reduces sphincter tone but less effective long-term.

Question 20

Anal Fissurectomy

Answer 20

Removal of the fissure and surrounding scar tissue, less commonly performed

Question 21

Presentation of rectal abcess

Answer 21

Produce painful swelling at the anus as well as painful defecation. Examination reveals localized tenderness, erythema, swelling, and fluctuance; fever is uncommon
Deeper abscesses may produce buttock or coccyx pain and rectal fullness; fever is more likely

Question 22

Diagnosis of rectal abcess

Answer 22

Clinical - CT scan only if recurrent

Question 23

Management of a rectal abcess

Answer 23

I&D (may be in-office), Fiber and stool softeners

Question 24

Indications for abx in rectal abscess

Answer 24

System Infection
Extensive cellulitis
Immune Compromise

Question 25

Anal Fistula Presentation

Answer 25

chronic drainage, pain, and possible recurrent abscess formation Physical exam reveals an external opening near the anus, often with a palpable cord-like tract

Question 26

4 related conditions/comorbiditie/risk factors for anal fistula

Answer 26

Crohn's disease, trauma, radiation, and malignancy

Question 27

Diagnosis of anal fistula

Answer 27

clinical, with MRI or endoscopic ultrasound used for complex cases to delineate the tract

Question 28

Classification system for anal fistulas

Answer 28

Parks classification system: intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric

Question 29

Indication for anal fistula surgeries

Answer 29

All symptomatic anal fistulas require surgical treatment due to the high risk of recurrent abscess formation

Question 30

Fistulotomy for anal fistula

Answer 30

Preferred for simple, low fistulas; involves laying open the fistula tract to heal by secondary intention.

Question 31

Seton placement for anal fistula

Answer 31

Used for complex or high fistulas involving significant sphincter muscle; helps drain infection and allows slow fibrosis

Question 32

Advanced flap placement for anal fistula

Answer 32

For complex or high fistulas where fistulotomy would risk incontinence; flap of healthy tissue is used to cover the internal opening

Question 33

LIFT procedure for anal fistulas

Answer 33

Ligation of the Intersphincteric Fistula Tract: A sphincter-sparing technique for complex fistulas

Question 34

Presentation of pilonidal disease

Answer 34

Growth located at the tailbone containing hair and skin teenager (usually male) with pain, discomfort, and swelling above the anus or near the tailbone that comes and goes Often includes drainage of pus or blood Risk factors include prolonged sitting, obesity, deep natal cleft, and poor hygiene

Question 35

Abx for pilonidal disease

Answer 35

Cefazolin + metronidazole or augmentin used empirically with cellulitis

Question 36

Indications for srugery of pilonidal disease

Answer 36

Recurrent infections or chronic non-healing sinus tracts.

Question 37

3 surgical options for pilonidal disease

Answer 37

Excision with Primary Closure: Complete excision of sinus tract with direct closure; quicker recovery but higher recurrence risk. Excision with Secondary Healing: Excision left open to heal by secondary intention; lower recurrence but longer healing time. Flap Procedures (e.g., Bascom or Karydakis flap): For recurrent or complex cases; flap of skin and subcutaneous tissue is mobilized to cover the defect, reducing tension and recurrence.

Question 38

Presentation of appendicitis

Answer 38

Crampy or "colicky" pain around the navel (periumbilical) → then pain over McBurney’s point (RLQ) There is usually a marked reduction in or total absence of appetite, often associated with nausea, and, occasionally, vomiting and low-grade fever

Question 39

MCC of appendicitis

Answer 39

Fecalith

Question 40

3 Signs of appendicitis

Answer 40

Rovsing – RLQ pain with palpation of LLQ Obturator sign – RLQ pain with internal rotation of the hip Psoas sign - RLQ pain with hip extension while laying on the left side

Question 42

Indications for open appendectomy

Answer 42

Reserved for complicated cases (e.g., ruptured appendix, significant adhesions) or where laparoscopy is contraindicated.

Question 43

Interval appendectomy

Answer 43

In cases of abscess formation, initial nonoperative management with antibiotics and percutaneous drainage may be followed by elective appendectomy.

Question 44

MCC and site of SBO

Answer 44

Adhesions in adults, Intussussception in peds MC locations - Ileum or Jejunum

Question 45

Presentation of SBO

Answer 45

Symptoms include colicky abdominal pain, nausea, bilious vomiting, abdominal distention, and diarrhea High-pitched hyperactive bowel sounds (early) progressing to silent bowel sounds (hypoactive bowel sounds -late) Dehydration + electrolyte imbalances

Question 46

Diagnosis of SBO

Answer 46

Plain abdominal radiographs followed by CT show dilated bowel, sting of pearls, air fluid levels Valvulae conniventes (white lines passing across the full width of the bowel) that are only found in the small bowel

Question 47

Management of SBO

Answer 47

NG tube, surgery if mechanical obstruction suspected

Question 48

MCC of LBO

Answer 48

Cancer

Question 49

Presentation of LBO

Answer 49

Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, constipation, less nausea and vomiting (may be delayed) - late-onset feculent vomiting, blood in stool, more common in the elderly Patients may be febrile and tachycardic => shock may ensue Dehydration + electrolyte imbalances

Question 50

Diagnosis of LBO

Answer 50

Dilated Colon over 5 cm with haustral markings Bird beak, pouches do not transverse the colon

Question 51

Management of LBO

Answer 51

NG tube and bowel rest

Question 52

H&P for SBO

Answer 52

In small bowel obstruction, vomiting is more common, and the pain tends to be periumbilical, cramping, and intermittent – with bouts that last for a few minutes at a time

Question 53

H&P for LBO

Answer 53

In large bowel obstruction, vomiting is less common, and the pain is lower in the abdomen and the bouts of pain are less frequent but last a bit longer

Question 54

3 surgical options for bowel obstructions

Answer 54

Laparotomy: Exploratory surgery to identify and treat the cause of obstruction (e.g., adhesions, hernias, tumors). Lysis of Adhesions: Common cause of obstruction; removal of adhesive bands to restore bowel patency. Resection and Anastomosis: For obstructed segments due to tumors, severe ischemia, or nonviable bowel.

Question 55

Presentation of cholecystitis

Answer 55

5 Fs: Female, Fat, Forty, Fertile, Fair (+) Murphy's sign (RUQ pain with GB palpation on inspiration) RUQ pain after a high-fat meal Low-grade fever, leukocytosis, jaundice

Question 56

Diagnosis of cholecystitis

Answer 56

Ultrasound is the preferred initial imaging - gallbladder wall >3 mm, pericholecystic fluid, gallstones HIDA is the best test (Gold Standard) - when ultrasound is inconclusive CT scan - alternative, more sensitive for perforation, abscess, pancreatitis Labs: ↑ Alk-P and ↑ GGT, ↑ conjugated bilirubin

Question 57

Sign of chronic cholecystitis

Answer 57

Porcelain gallbladder

Question 59

MC type of gallstones

Answer 59

Cholesterol Stones

Question 60

3 Surgical options for cholecystitis

Answer 60

Laparoscopic Cholecystectomy: Standard treatment for symptomatic cholelithiasis and cholecystitis; less postoperative pain and faster recovery. Open Cholecystectomy: Reserved for severe inflammation, perforation, or dense adhesions where laparoscopy is unsafe. Percutaneous Cholecystostomy: Temporary drainage in critically ill patients unfit for immediate surgery.

Question 61

Presentation of diverticulitis

Answer 61

Left-sided "appy" The most common location is the sigmoid colon Avoiding seeds and nuts may prevent episodes (controversial) Fever/chills/nausea/vomiting/left-sided abdominal pain A common cause of massive lower gastrointestinal bleeding

Question 62

Diagnosis of diverticulitis

Answer 62

Diagnose using abdominal and pelvic CT with oral, rectal, and IV contrast; do colonoscopy 1 to 3 months after the episode to look for cancer CT revealing fat stranding and bowel wall thickening

Question 63

None surgical management of diverticulitis

Answer 63

Clear Liquid diet Cipro or Metronidazole Resection of colon for recurrent, complicated, or perfed

Question 64

Indications for surgical management of fiverticulitis

Answer 64

Complicated diverticulitis (e.g., abscess, fistula, perforation, obstruction), recurrent episodes of uncomplicated diverticulitis, or failure of medical management.

Question 65

3 surgical options for diverticulitis

Answer 65

Hartmann’s Procedure: Resection of the diseased segment with end colostomy, often used in emergency settings. Primary Anastomosis with or without Diversion: Resection of the affected segment with reanastomosis; diversion may be added to reduce anastomotic leak risk. Laparoscopic Sigmoid Resection: Preferred in elective cases with recurrent diverticulitis.

Question 66

Indications for surgery with a GI bleed

Answer 66

Failure of endoscopic or medical therapy to control bleeding, recurrent bleeding, or hemodynamic instability.

Question 67

3 surgical options for a GI bleed

Answer 67

Segmental Resection: Removal of the bleeding segment of the bowel (e.g., partial gastrectomy for bleeding gastric ulcers). Subtotal or Total Colectomy: For massive lower GI bleeding not localized or controlled. Laparotomy: In cases where the source of bleeding is unclear, with intraoperative endoscopy or colonoscopy to guide resection.

Question 68

Diagnosis for hiatal hernia

Answer 68

Barium swallow, upper endoscopy, or esophageal manometry

Question 69

Non-surg management for hiatal hernia

Answer 69

Sliding hernias are often managed with lifestyle modifications and GERD medications (e.g., proton pump inhibitors), while surgical repair (e.g., Nissen fundoplication) is indicated for refractory cases or complications

Question 71

3 surgical options for hiatal hernias

Answer 71

Laparoscopic Nissen Fundoplication: Wrapping the stomach around the lower esophagus to prevent reflux; common for Type I (sliding) hernias. Paraesophageal Hernia Repair: Reduction of herniated stomach and reinforcement of the hiatus with sutures or mesh. Gastropexy: Anchoring the stomach to prevent re-herniation in selected cases.

Question 72

Causes and symptoms of ileus

Answer 72

Recent abdominal surgery, electrolyte imbalances, medications (e.g., opioids), and infections Symptoms include abdominal distension, nausea, vomiting, and failure to pass flatus or stool Absent or hypoactive bowel sounds on physical examination

Question 74

Nonsurgical management of ileus

Answer 74

Management is supportive, including bowel rest (NPO), intravenous fluids, and correction of electrolyte imbalances Nasogastric tube may be required for decompression in severe cases Avoid use of opioids, as they can exacerbate ileus

Question 75

Indications for surgery and 2 surgical options for ileus

Answer 75

Evidence of mechanical obstruction or perforation. Exploratory Laparotomy: To identify and treat any underlying mechanical cause when non-operative measures fail. Resection of Nonviable Bowel: If associated with ischemia or perforation.