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surgery questions for test Flashcards

1
Q

What is the composition of body fluids?

A

42L(60%) of Total body water
of this: 28L (40%) is ICF and 14L(20%) is ECF

muscle mass is 75% water
blood is 83% water
fat is 25% water

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2
Q

What is the composition of ICF? ( you don’t access this)

A
  • K+(140mmol/L)
  • Mg2+
  • PO4
  • high protein concentration
  • 25% is dry component of proteins
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3
Q

What is the composition of ECF( you access this since IV fluids go here and water loss comes from here)

A

Na:145 in plasma and 142 in ISF
Cl:105 in plasma and 110 in ISF

25% of ECF is quickly equilibrating water component (plasma and ISF)
8% of ECF is slowly equilibrating dry component ( proteins, collagen and bones)

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4
Q

What is the daily water and electrolyte balance?

A

Basic fluid needed: 30mL/kg/24hr

intake

fluid: 1000-1500mL
food: 500-700mL
metabolism: 200mL

output
urine: 800-1500mL(increased with diuretics, RF)
lungs/skin: 800-1000mL (increased with temperature, fever, hyperventilation, burns)
sweat: 0-200mL
feces: 200mL(increased with fistula, diarrhea, ileus)

Na: normally intake 150-200mEq/day
K: normally intake 40-120mEq/day

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5
Q

What are the water, electrolyte, and acid base disturbances in pyloric stenosis?

A

vomiting: loss of H+, Cl-, K+, and fluid
hypovolemia from vomiting increases aldosterone release causing increased Na retention and K excretion

result: hypovolemia, hypochloremia, metabolic alkalosis

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6
Q

What are the water, electrolyte, and acid base disturbances in ileus?

A

normally there is 7L in the transcellular bowel space and 98% is reabsorbed (fecal loss is only 200mL)

small bowel obstruction: 1500mL of fluid is pooled in bowel by osmotic drag, by the time vomiting occurs there is 3000mL of fluid pooling
in a hypotensive patient: 6000mL of fluid is pooled in the intenstines

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7
Q

In ileus, what does the 7L of pooled fluid in the small intestines represent?

A
  • 50% of ECF (2L from plasma and 5L from ISF)
  • no absorption and full secretion leads to loss of 7L over 24hr which leads to hypovolemic shock
  • centralization of blood to brain and heart
  • hypoperfusion of tissues including lactic acid
  • hypoperfusion of kidneys results in aldosterone release

result: hypokalemic metabolic acidosis

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8
Q

What are types of hypovolemic shock in a surgical patient?

A

absolute, hemorrhagic, oligovolemic, relative, cardiogenic, anaphylactic/neurogenic

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9
Q

What are the causes of hypovolemic shock in a surgical patient?

A
  • bleeding
  • burns
  • GI losses: vomitting, NG tube, diarrhea, fistulae, peritonitis
  • excessive diuretics
  • polyuric phase of RF
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10
Q

What are the symptoms of hypovolemic shock in a surgical patient?

A
  • thirst
  • hypotension, tachycardia, tachypnea
  • centralization, temperature difference
  • decreased urine output
  • drowsiness, apathy
  • sweating
  • increased Hct and increased urea
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11
Q

Types, causes, symptoms and treatment of electrolyte disturbances: hypernatremia (>145mEg/L)

A

causes:

  • impaired thirst
  • osmotic diuresis
  • diabetes insipidus
  • sweating/diarrhea
  • iatrogenic, hypertonic saline

symptoms (cellular dehydration): restlessness, lethargy, hyperreflexia, seizures, coma, death

treatment: hypotonic fluid (5% dextrose)
if there is an increase in total body sodium: loop diuretics
if there is hypovolemia: first replace the volume deficit with isotonic fluid

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12
Q

Types, causes, symptoms and treatment of electrolyte disturbances: hyponatremia (<135mEq/L)

A

causes:

  • diuretics
  • mineralocorticoid deficiency osmotic diuresis
  • vomiting, diarrhea, sweating, burns
  • polydipsia
  • SIADH
  • CHF cirrhosis
  • nephrotic syndrome

symptoms (of increased ICF): asymptomatic, anorexia, weakness, lethargy, confusion, seizures, coma, death

treatment: isotonic saline, fluid restriction

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13
Q

Types, causes, symptoms and treatment of electrolyte disturbances: hyperkalemia (>5,5mEq/L)

A

causes:

  • hemolysis(massive transfusion, crash injury), rhabdomyolysis
  • acidosis
  • RF
  • K+sparing diuretics
  • Drugs: ACE inhibitors, NSAIDS

symptoms: GI(cramping diarrhea), weakness, cardiac( elevated T waves, widended QRS, asystole)

treatment: Ca-gluconate protects heart
- glucose and insulin, B-agonist, epinephrine, sodium bicarbonate, diuretics, dialysis

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14
Q

Types, causes, symptoms and treatment of electrolyte disturbances: hypokalemia(<3,5mEq/L)

A

causes:

  • mineralocorticoid excess
  • diuresis
  • vomiting, diarrhea
  • pyloric stenosis
  • fistulas, NG tube, ileostomy

symptoms: GI (papalytic ileus), weakness and tetany, cardiac (flat and inverted T waves, ST depression, arrhythmias)
treatment: IV K+ replacement, oral potassium chloride, digoxin (protects heart)

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15
Q

What is the etiology and management of acid base disturbances in a surgical patient: metabolic acidosis

A

cause:
- acid accumulation
- RF
- diabetic ketoacidosis
- lactic acidosis (shock, sepsis, MI)
- toxins (methanol)
- HCO3 loss from diarrhea and fistula

management: give HCO3- if pH <7,2 or if the primary defect is HCO3 loss

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16
Q

What is the etiology and management of acid base disturbances in a surgical patient: metabolic alkalosis

A

most common

causes:

  • GI loss, vomiting, NG tube, pyloric stenosis
  • drugs: steroids, diuretics
  • iatrogenic: large transfusions(citrate), or acetate containing colloids(converted to HCO3 in the liver)

management: isotonic saline and K+ supplementation

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17
Q

What is the etiology and management of acid base disturbances in a surgical patient: respiratory acidosis

A

causes:

  • inadequate ventilation
  • aspiration and airway obstruction
  • ARDS
  • respiratory arrest, trauma, stroke
  • drugs: analgesics, sedatives, alcohol

management: restore adequate ventilation giving O2

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18
Q

What is the etiology and management of acid base disturbances in a surgical patient: respiratory alkalosis

A

causes:

  • hyperventilation, pain, anxiety, sepsis, shock
  • iatrogenic

management: decrease ventilator, increase sedatives and analgesics?

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19
Q

What are the energy requirements and sources in physiology?

A

BMR: 2100kcal/day in a 70kg man
Daily protein requirement: 1g/kg/day

Energy values:
fat: 9kcal/g, protein: 4kcal/g, carbs: 4kcal/g

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20
Q

Which procedures increase the energy requirement needed by the body?
What are methods of nutrition in a surgical patient?
What are some indications of such methods?

A 
elective surgery: 25% increase
skeletal trauma: 30% increase
blunt trauma: 35%
head injury: 61%
sepsis: 80%

methods of nutrition:
enteral(preferred), oral, NG tube, nsojejunal, gastrostomy, TPN

indications:
tubes: unconscious, ventilated, chronically malnourished
elemental diet: short bowel syndrome, fistula, IBD

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21
Q

What are factors contributing to surgical trauma?

A
  • bleeding, hypovolemia
  • tissue injury (cytokines, distribution of barrier)
  • fear, anxiety, pain
  • starvation
  • infection (toxins, cytokines, temperature)
  • hypoxia or hypercarbia
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22
Q

What is the endocrine system’s response to surgery?

A
  • increased secretion of pituitary hormones and activation of sympathetic nervous system
  • corticotrophin stimulates adrenal cortex
  • vassopressin acting on the kidney
  • glucagon released from pancreas while diminishing insulin secretion

overall effect: increased catabolism for energy, retain salt and water, maintain cardiovascular homeostasis

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23
Q

What is the sympathoadrenal response to surgery?

A

hypothalamus stimulates increased secretion of catecholamines from adrenal medulla

  • release of NE from nerve terminals into the circulation
  • tachycardia and hypertension
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24
Q

What are the phases of body response to surgical trauma? (3)

A
  1. Adrenergic phase (<24hr): maintain blood volume, vasoconstriction, centralization of circulation, decrease BMR, temperature, O2 consumption
  2. Catabolic phase (3-10days): maintain energy, increase BMR, temp, O2 consumption
  3. Anabolic phase (10-60days): replace lost tissue, negative water balance, hormones GH and IGF
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25
Q

What is the mechanism and symptoms of neurohormonal response to trauma?

A
  • sympathetic system activation and catecholamine release

- maintain blood volume and provide energy for organs

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26
Q

What is the ethiopathogenesis of SIRS?

A

cause: infectious-> sepsis
noninfectious-> trauma, shock, pancreatitis, retained necrotic tissue
-exaggerated immune response; does more harm than good

diagnosis: 2 or more present
- HR>90
- RR>20 or PaCO238 or 12000 or <4000

Automatic response
hormonal response: catecholamines, RAAS, ADH, ANF, ACTH and glucocorticoids
local tissue response: IL1,2,6; TNF, IFN, histamine, serotonin,
vascular endothelial response: NO, PAF, PG
single cell response: heat shock proteins, ROS

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27
Q

What is the alteration of carbohydrate metabolism in surgical trauma?

A
  • peripheral use of glucose is decreased, blood glucose increases due to catecholamine release
  • catecholamines increase gluconeogenesis and glycogenolysis
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28
Q

What is the alteration of protein metabolism in surgical trauma?

A
  • catabolism of protein stimulated by catecholamines
  • skeletal muscle is mainly broken down to be used as energy or to make acute phase proteins
  • marked weight loss and muscle wasting in patients after a traumatic surgery
  • loss of protein can be marked by nitrogen increases in the urine
  • patients given arginine or glycine benefit from a faster recovery
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29
Q

What is the alteration of fat metabolism in surgical trauma?

A
  • fat breakdown stimulated by cortisol, catecholamines, and GH
  • fat breakdown inhibited in the presense of insulin
  • glycerol produced from lipolysis is a substrate for gluconeogenesis in the liver
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30
Q

What is the alteration of water-electrolyte metabolism in surgical trauma?

A
  • preservation of body fluids
  • ADH release for 3-5 days
  • renin release due to sympathetic activation
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31
Q

What are the types, definitions, and pathology of shock?

A

definition: the clinical symptoms resulting from inadequate tissue perfusion to maintain normal cellular metabolism

pathology;

  1. cadiogenic:MI, CHF, valvular disease, tamponade, PE, trauma
  2. anaphylactic: type 1 anaphylactic reaction
  3. neurogenic: loss of sympathetic tone leading to peripheral vasodilation, high spinal injury, spinal anesthesia, vasovagal reflex
  4. hemorrhagic: hypovolemia
  5. oligovolemic: burns, 3rd spacing
  6. septic: infection, release of toxins
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32
Q

What are the symptoms and causes of hypovolemic shock in a surgical patient?

A
  • thirst, tachycardia, tachypnea, hypotension, centralization of circulation, decreased urine output neurological changes, sweating
  • weak, rapid pulse
  • cold, pale hands (except in neurological/anaphylactic)
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33
Q

What is the neuroendocrine response to hypovolemia?

A
  • stimulation of SNS, release of hormones and mediators
  • centralization of circulation
  • decreased renal perfusion
  • tissue hypoxia
  • vasodilation -> irreversible shock
34
Q

What are the components and pathomechanism of multiple organ failure?

A

shock-> neurohormonal response to trauma->systemic release of metabolites and mediators->SIRS

  • ARDS(72hrs)
  • upper GI bleed(10-15days), intestinal ischemia
  • liver failure (5-7days)
  • RF(11-17days)
  • heart(decreased preload and afterload)
35
Q

What is the pathomechanism, symptoms, and management of ARDS?

A
  • damage to pulmonary capillary endothelium and alveolar epithelium->increased permeability causes capillary leak->interstitial edema
  • V/Q mismatch and decreased lung compliance

causes: SIRS, inhalation injury, diffuse infection

symptoms:

  • hypoxemia unresponsive to increased O2 concentration
  • decreased lung compliance
  • interstitial edema->diffuse infiltrates->consolidations-> initially hyperventilation->alkalosis then acidosis

management: PPV

36
Q

What is the GI’s response to MODS? etiology, prophylaxis, treatment

A

etiology: upper GI bleed, stress ulcer, hemorrhagic gastritis, intestinal ischemia, mucosal injury, perforation, liver failure, bacterial translocation
treatment: stop bleeding!, ischemia: cut it out or return it to life, bacterial translocation: antibiotics and fluids
prophylaxis: PPIs for upper GI bleeds, enteral feeding

37
Q

What are the causes of renal failure in surgical patients?

A

prerenal: hypoperfusion,
renal: nephrotoxins, infections, contrast media
postrenal: nephrolithiasis

38
Q

What is the definition, types, and treatment of septic shock?

A

definition: acute circulatory failure that is unresponsive to adequate volume resuscitation in a patient with sepsis
acute circulatory failure

types
hyperdynamic (warm/still fighting): fever and chills, dec PVR, pink dry extremities, tachycardia, hypotension, increase in cardiac output, leukocytosis

hypodynamic(cold/body gives up): falling cardiac output, increase in PVR: cold hands, pale; leukopenia, thrombocytopenia

39
Q

What is the the initial management and monitoring of a patient in shock?

A

IV catheter, bladder catheter, monitoring vascular system, blood sampling, intubation, give O2, maintain temperature

treat underlying cause!

hemmorhage: stop bleeding, give fluids, give transfusion
cardiogenic: dobutamine, NTG if ischemia
anaphylaxis: steroids
septic: antibiotics

40
Q

What is the definition of acute abdomen?

A

definition: group of life threatening rapidly developing conditions that require of may require immediate surgical intervention
components: paralytic ileus, mechanical ileus, perforation, ischemia, trauma, obstruction

41
Q

What is the cause, mechanism, and symptoms(with physical examination) of paralytic ileus?

A

causes: peritonitis!;acute appendicitis, gallstones, pancreatitis, PID, perforated peptic ulcer
- bowel ischemia
- postoperative adhesions

symptoms:
- pain: constant with increasing intensity
- inability to pass stool
- vomiting
- hypovolemia and sepsis

on physical:

  • decreased wall movement
  • muscle guarding, rebound tenderness
  • areas of tenderness
  • decreased or absent bowel sounds

mechanism: irritation of peritoneum

42
Q

What is found on physical examination in patients with paralytic and mechanical ileus?

A

Paralytic;
- constant pain with increased intensity, inability to pass stool, hypovolemia, sepsis
exam:
-decreased wall movements,
-muscle guarding and rebound tenderness,
-confirmed areas of max tenderness,
-decreased bowel sounds

Mechanical;

  • intermittent pain, inability to pass stool
    exam: distention or visible peristalsis
  • nothing/tumor/hernia
  • tympany
  • intermittent high pitched peristaltic rushes
43
Q

What are the causes of peritonitis?

A
  • acute appendicitis
  • gallstones and pancreatitis
  • PIDS and salphingitis
  • perforated peptic ulcer
44
Q

What is the pathomechanism of the symptoms of acute abdomen?

A

viceral pain: poorly localized, develops early, NV
parietal pain: well localized, develops later due to peritoneal irritation
referred pain: usually on ipsilateral side related to embryonal development

45
Q

What is the ethiopathogenesis and symptoms of acute appendicitis?

A
  • fecalith, hypertrophy of lymphoid or other reasons leading to obstruction of appendectal lumen
  • pressure increases due to continuous mucus secretion leading to a decrease in venous capillary circulation
  • edema and infiltration of wall: appendicitis

symptoms:
-early:poorly localized pain starting at umbilicus, NV, inability to pass stool

-later:well defined pain over McBurneys point, muscle guarding, rebound tenderness

46
Q

What are the principles of evaluation and treatment of acute appendicitis and its complications?

A

physical exam is the main diagnosis
Xray: fecalith, distended loop, gas filled appendix
treatment: classic vs laproscopic appendectomy

complications:
- periappendicular inflammatory psudotumor; treatment:antibitioics, fluids
- periappendecular abcess;treatment: drainage
- rupture: generalized peritonitis, sepsis

47
Q

What is the differential diagnosis for acute appendicitis?

ABCDEFGHJK

A
  • acute mesenteric adenitis
  • Boys: testicular torsion, acute epudymidis, seminal vesiculitis
  • cecum cancer
  • divertidula(Merkel)
  • erupted peptic ulcer
  • Female: PID, ectopic pregnancy, ruptured Grafian follicle, torsion of adnexa, Merkels diverticulum
  • Gastroenteritis (acute)
  • Henoch-Schonlein purpura
  • intussusception
48
Q

What are the clinical presentation of cholelithiasis treatment strategies?
This question includes:
-surgical emergencies related to biliary stone diseases
-treatment of cholecystitis and related diseases

A
  • asymptomatic or biliary colic
  • RUQ pain, radiating to the back or along intercostal margin, NV

Cholecystitis: signs of local peritonitis, rebound tenderness, muscle guarding, increase in WBC, CRP, fever
Empyema: localized peritonitis, high fever, increase in WBC, CRP
Hydrops: chronic pain
Perforation: generalized peritonitis

Treatment:painkillers, spasmolytics, fluids , antibiotics

  1. Elective cholecystectomy: symptomatic biliary colic (never for asymptomatic)
  2. Emergency cholecystectomy:acute cholecystitis, pericholecystitis, empyema, hydrops, perforation or necrotic gallbladder, generalized biliary peritonitis
49
Q

What are complications of biliary surgery?

A
  • biliary tree injury!
  • biliary peritonitis
  • bile duct damage: very serious to leak/hemorrhage
  • ascending cholangitis

other:

  • wound infection
  • inscisional hernia
  • intraabdominal abcess
  • intestinal fistula or obstruction
50
Q

What are ethiopathogenesis of acute pancreatitis?

A
  • gall stones(40-90%)

- alcohol(40-60%)!! most common

51
Q

What are clinical forms and symptoms of acute pancreatitis?

A

forms:
1. Edematous pancreatitis: mild form (80%)
2. Necrotizing pancreatits: severe form (20%)
acute fluid collection and pancreatic abcess

symptoms:

  • epigastric pain radiating to the back
  • history of biliary colic or alcohol intake
  • anorexia, NV
  • rebound tenderness and muscle guarding
  • palpable mass
52
Q

What is the diagnostic work up of patients with acute pancreatitis?

A

-diagnosis of exclusion!
-clinical picture
-amylase/lipase
-imaging: stones in gallbladder perhaps, swelling of pancreas, fluid collection, necrosis, biliary pathology
CT/MRI

53
Q

What are the complications of acute pancreatitis and its management?

A
  • fluid accumulation: spontaneously resolves, if lasts >6 months->pseudocyst
  • pseudocyst
  • abcesses
  • phlegmon
  • sepsis

management:

  • IV, fluids, nutrition, antibiotics if necrotic or septic, PPIs
  • ECRP within 24hr, cholecystectomy within 48hr
  • surgery:necrotomy
  • drainage of abcess and fluids (not needed if fluid is sterile)
54
Q

What are the treatment strategies for patients with acute pancreatitis?

A
  • IV fluids
  • analgesics
  • NG tube
  • PPIs and somatostatin blockers
  • antibiotics in necrosis and septic complications
55
Q

How do you treat all etiologies of pancreatitis?

A
  • drain all fluid collections, sterile(wait) vs infected(immediately)
  • removal of necrosis; sterile(prolong as long as possible) vs infected(immediately)
  • exploration to confirm diagnosis(<5%)

biliary pancreatitis:

  • emergency ERCP within 24 hours from administration
  • laproscopic cholecystectomy within next 24 hours (48 hrs from admission)
56
Q

What are complications of peptic ulcer disease? Epidemiology, symptoms, and treatment strategies?

A

bleeding; duodenum, gastroduodenal artery
S: melena, fresh blood in stools(massive bleeding), hematemesis, IDA, hypovolemia
D:endoscopy
T:endoscopy or surgical suture if massive

Stenosis/obstruction:
S:crampy, pain, NV, bloating, fullness, dilated stomach
D: XRAY, endoscopy
T:NG suction to decompress stomach, vagotomy(will close pylorus), balloon dilation

Perforation:
duodenum,1st portion of anterior wall–>peritonitis
gastric: lesser curvature, anterior wall–>peritonitis
Epidemiology: m>f; duodenual<gastric
S:sudden onset of severe pain radiating to shoulder; mimicking appendicitis, NV, muscle guarding, rebound tenderness, tympany over liver, no bowel sounds
D:Xray; free air under diaphragm on R side
T: surgical closure with patch of omentum, eradication of Hpylori

57
Q

What is the evaluation and treatment of a patient with symptoms of generalized peritonitis?

A

Diffuse abdominal pain:

  • acute pancreatitis
  • early appendicitis
  • mesenteric ischemia
  • peritonitis

RUQ pain:

  • cholesystitis
  • hepatomegaly
  • perforated duodenal ulcer

LUQ pain:

  • gastritis
  • splenic disorders

RLQ pain:
appendicitis
-cecal diverticulus

LLQ pain:
-sigmoid diverticulitis

58
Q

What is the surgical treatment for perforated peptic ulcer?

A
  • laperoscopic simple suture with omental patch(omentoplasty)
  • subsequent medical treatment ( eradicate H pylori)
59
Q

What are the types, causes and symptoms of mechanical ileus?

A

Causes and types:

  • obturation :cancer, foreign body, gallstones, inflammation,
  • strangulation: hernia, adhesions, volvulus
  • mixed: intussuception

Symptoms:

  • intermittent pain
  • NV, inability to pass stool or gas
  • hypovolemia
  • distended lower abdomen, visible peristalsis,
  • tympany over whole abdomen
  • intermittent high pitched rushes

All can lead to perforation and peritonitis!

60
Q

What is the diagnostic and therapeutic approach to a patient with symptoms of a mechanical ileus?

A

History and physical examination: Xray, distended loops, obstruction, cancer, inflammation, foreign body
USG: distended loops and visible peristalsis
colonoscopy

Treatment strategy:
-confirm diagnosis with contrast study or colonoscopy
-decompress if possible to convert elective surgery, if possible: tumor resection with anastamoses
Adhesions: adhesiolysis or bowel resection
Volvulus (sigmoid): detorsion and fixation or resection and fixation in the late phase
Intussuception(ileocecal, children): reduction with edema or air or manual reduction
Strangulated hernia: emergency operation, assessment of viability and site of anastomoses, resection
Cancer: resection

61
Q

What are the causes and pathomechanism and management of a bowel ischemia?

A

Causes:
-Thrombosis and embolism of mesenteric artery:MC
-venous thrombosis
Complication: septic peritonitis and progression to SIRS or MOF, mediated by bacterial translocation from the dying intestinal wall

Strangulation: closed loop causes continuous secretion and decreased reabsorption->distention ->increased intraluminal pressure->impaired venous, capillary and arterial circulation->ischemia->necrosis

Cancer: causing increased pressure from inside/outside leads to volvulus
management: untwist if volvulus, remove embolus by angiography, resect tumor or necrotic bowel, give IV fluids and Abs, give thrombolytics and heparin if thombosis

62
Q

What is the pathomechanism, epidemiology, clinical symptoms, and treatment for strangulation?

A

Cause: hernia, intussuception or volvulus
Epidemiology: inc intraabdominal pressure, pregnancy, heavy lifting, obesity, straining
Volvulus: abnormal intestinal contents, adhesions, previous surgery

Mechanism of strangulation: closed loops->continous secretions and dec reabsorption->distention->inc intraluminal and intramural pressure->impaired venous capillary and arterial circulation->ischemia->necrosis

Symptoms: colicky abdominal pain, NV, constipation, dehydration, abdominal distention

Treatment: emergency surgery

63
Q

What are the indications for emergency intervention in patients with large bowel disease?

A
  • active bleeding
  • acute ischemia; strangulation, volvulus, perforation
  • severe ileus
64
Q

What are the symptoms of an upper GI bleed?

A
  • hematemesis
  • melena
  • diarrhea
  • IDA
  • systemic: hypovolemia, tachycardia, hypotension, decreased urinary output, thirst
65
Q

What are the symptoms of a lower GI bleed?

A
  • hemotochezia (fresh blood in the stool)
  • currant jelly (blood mixed with mucus)
  • IDA
  • systemic: hypovolemia, tachycardia, hypotension, decreased urinary output, thirst
66
Q

What is the treatment of a patient with suspected GI bleed?

A

treat hypovolemia and shock!

  • IV catheter, bladder catheter, monitoring blood gases, blood tests
  • intubation: give O2
  • fluid resuscitation: vasopression
  • pulmonary support: analgesics, Antibiotics

perform: gastroscopy to visualize bleed and stop it!
- rule out cancer!

67
Q

What are the etiologies of upper GI bleeding?

A
  • duodenal ulcer: 40%
  • gastric ulcer: 10-20%
  • diffuse erosive gastritis: 15-20%
  • esophageal varices: 10%
  • Mallory-Weiss tear: 10%
  • gastric cancer: <5%
68
Q

What are the etiologies of lower GI bleeding?

A
  • hemorrhoids
  • diverticula
  • angiodysplasia
  • malignancy
  • polyps
  • IBD
  • anal fissure
69
Q

What are non-operative managements of upper GI bleeding?

A

Medical:

  • fluids for hypovolemia, transfusion, vasoconstrictors, NE, vasopressin for esophageal varices
  • antacids, PPIs
  • Hpylori eradication
  • clotting factors
  • B blockers

Emergency:

  • endoscopic banding
  • sengenstaken tube
  • TIPS: wire placed from hepatic vein to portal vein in a transhepatic path; balloon is inflated in this path to dilate and a stent is placed to maintain patency

Elective:

  • endoscopic handing indicated if previous bleeding, high risk of rebleeding
  • TIPS: if no response to banding
70
Q

What is the operative management of upper GI bleeding? What are the indications and methods?

A

Indications:

  • unsuccessful endoscopic treatment
  • high risk of recurrence
  • poor prognosis in elderly, forrest 1a and forrest 1b, massive hemorrhage, and rare blood groups

Acute hemorrhage:

  • forrest 1a: spurting
  • forrest 1b: oozing
  • forrest 2a: visible vessel
  • forrest 2b: adherent clot
  • forrest 2c: hematin on ulcer base
  • forrest 3: lesions without signs of recent hemorrhage

Methods:

  • simple suture
  • procedures that decrease the risk of recurrence: vagotomy, pylotoplasty, TIPS
  • surgical shunt
  • transplantation
71
Q

What is the diagnostic work-up and management of lower GI bleeding?

A

History: weight loss, bowel habits, examination
Manage hypovolemia if present
Rule out upper GI bleed if massive: gastroscopy/colonscopy
Rule out cancer: colonoscopy

Start at top and go down if precious was unsuccessful:

  • spontaneous hemostasis, give fluids IV and blood
  • endoscopy: injectional sclerotherapy or electrocoagulation
  • radiology: selective angiography and embolization
  • surgery: bowel resection
72
Q

What can prevent GI bleeding?

A

prevention: enteral feeding, PPIs, hydration, Antibiotics

treat underlying disease

73
Q

What is the role of flexible endoscopy in patient with GI bleeding?

A

Evaluate the bleeding:
-bleeding or not? active/stopped bleeding? what was/is bleeding? intensity of bleeding?

Stop bleeding:

  • banding, sclerotherapy, clips, tissue glue, electrocoagulation
  • rule out cancer-take biopsy
74
Q

What are endemic cancers? Epidemiology and possible risk factors?

A 
Hepatocellular carcinoma: Africa, HBV
Esophageal cancer: China, diet
Gastric cancer: Japan, diet
Oropharyngeal cancer: India, betel nuts
Skin cancer: Australia, sun exposure
Gallbladder cancer: Chile, cholelithiasis
75
Q

What are diagnostic methods in suspected neoplasms?

A

Microscopic proof of malignant disease is required
Excisional biopsy is best; needle or incisional

  • large needle cutting biopsy (histology)
  • fine needle aspiration biopsy (cytology)
76
Q

What is the modern concept of surgical and multi-modality in the treatment of cancer?

A

Surgery, radiotherapy, chemotherapy, immunotherapy, hormonal therapy, rehabilitation, psychological support

Curative: destroy any visible tumor with the intention to cure, prevent vascular dissemination
Paliative: relieve or prevent specific symptoms of complication of cancer without the intent to cure
Symptomatic: addressing specific symptoms to improve quality of life without intention to cure
Debulking: removal of the majority tumor to allow for successful chemotherapy/radiotherapy leaving residual disease

Local resection: resection of tumor with margin of normal tissue
Radical local resection: resection with wide margin of uninvolved tissue
Radical resection+lymphagiectomy
Super radical resection: removal of tumor, lymph nodes, and adjacent organs

77
Q

What are treatment strategies for soft tissue infections?

A

antibiotics, immobolize, drain/removal of abcesses, necrectomy

78
Q

What are the indications for systemic antibiotics in soft tissue infections?

A

all

  • generalized infection
  • dangerous location
  • chance for severe disability
  • rapid progression
79
Q

What are the types and healing of surgical wounds? methods of treatment related to the type of wound

A

Clean wound (hernia repair)

  • incision under sterile conditions, AB prophylaxis for patient with implanted foreign bodies, suture, primary closure
  • <0.5% risk of infection

Clean contaminated (cholecystectomy, colon resection, appendectomy, bladder surgery)

  • same but entry into natural cavities
  • no evidence of active infection in natural cavities
  • Antibiotic prophylaxis
  • primary closure
  • 5% risk of infection

Contaminated (bowel obstruction with spillage of contents, acute choleocystitis with pus in gallbladder and spillage of pus)

  • obvious contamination during procedure
  • antibiotic prophylaxis (1h before incision)
  • mechanical cleaning, suture deep layers
  • primary delayed, interrupted sutures, or leave open
  • 30% risk of infection

Infected/dirty (appendices access, traumatic wound, perforated viscus)

  • established infection is present before wound is made in the skin
  • antibiotics
  • 40% risk of infection

after 6 hours all wounds are considered contaminated

80
Q

What is the assessment and treatment strategies of thermal burns?

A
  • describe degree, area, localization and site
  • history: source of burn, temperature, duration, inhalation of noxious gas
1st degree:
-only involves epidermis
-erythema, hyperemia, pain edema
-no risk of infection
T: removal of clothes, cold ice/water
Hospitalize: >15% of body surface

2nd degree:

  • involves epidermis and dermis
  • blisters, swelling and moist surface, pain
    2a: blisters with clear fluid; 2b: blisters with blood
  • remove blisters in sterile environment
  • use topical silver ointment and regularly change dressing

3rd degree:

  • whole thickness lesion
  • waxy, leathery, may be grey or white, appear dry
  • hospitalize patient
  • treat as 2nd degree burn, treat by specialist, maintain sterile environment
  • antibiotics, necrotic tissue does not bleed thus remove it until bleeding or use green due in vein, skin grafts may be necessary

4th degree:

  • involves muscle, bone, organs
  • replace HCO3 if metabolic acidosis,replace K+
  • hydrate
81
Q

What is the rule of 9 in burns?

A
  • anterior and posterior trunk: 18% each
  • head: 9%
  • arm: 9%
  • leg: 18%
  • genitalia: 1%

Major burns >20%: require fluid resuscitation
Fluids:kg*%burned(x2)=mL; give over 8hr then over 16hr
Monitor CVP, replace electrolytes
Proteins given after 48hr

surgery (1 decks)

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