Surgery Rotation 11

Question 1

Gastric varices are often caused by what?

Answer 1

Splenic vein thrombosis

Question 2

What should you be concerned about if you treat H. Pylori with triple therapy and pain does not improve?

Answer 2

Zollinger Ellison (gastrin-secreting tumor)

Question 3

Test for Zollinger Ellison

Answer 3

Secretin stimulation test = gastrin levels remain high after administration of secretin

Question 4

Tx of Zollinger Ellison

Answer 4

Surgical resection of tumor (most likely in pancreas even though ulcers are in duodenum)

Question 5

What else should you be looking for with Zollinger Ellison

Answer 5

MEN1

• Pituitary tumors (prolactin or GH)
• Pancreatic endocrine tumors (Zollinger-Ellison syndrome, insulinomas, VIPomas, glucagonomas)
• Parathyroid adenomas

Question 6

Diff in tx of pt with acute onset vs gradual onset hypovolemic hypernatremia

Answer 6

acute = D5W

Gradual = D5W 1/2NS (pt has adjusted to hypernatremia so you can’t correct too quickly)

Question 7

What is SMA syndrome?

Answer 7

• When the 3rd part of the duodenum (transverse section) gets compressed between the SMA and aorta
• Due to decrease in aortomesenteric angle
• This blocks food from passing from duodenum to jejunum, causing intestinal obstruction

Question 8

Tx of SMA syndrome

Answer 8

Restore weight and nutrition

Question 9

How do diagnose pancreatitis

Answer 9

• Increased amylase + lipase

- CT

Question 10

Tx of pancreatitis

Answer 10

• Mostly supportive

- NG suction if nauseous, NPO for bowel rest, IV hydration, observation

Question 11

Common complications of pancreatitis

Answer 11

Psuedocysts (no cells), hemorrhage, abscess, ARDS

Question 12

What is Courvoisier’s sign

Answer 12

Large, nontender GB, itching and jaundice

Indicative of pancreatic cancer at head of pancreas

Question 13

What is Trousseau’s sign associated with pancreatic cancer

Answer 13

Migratory thrombophlebitis

Question 14

Diagnosis of pancreatic cancer?

Answer 14

Endoscopic US and FNA biopsy

Question 15

When is a pancreatic tumor deemed “resectable”

Answer 15

No mets outside abd, no extension into SMA or portal vein, no liver mets, no peritoneal mets

Question 16

What is the presentation associated with insulinoma

Answer 16

Whipple’s triad:

• Sxs (sweat, tremor, hunger, seizures)
• BGL < 45
• Sx resolve with glucose administration

Question 17

What labs indicated real insulinoma vs. exogenous insulin administration

Answer 17

Labs: elevated insulin, C-peptide, and pro-insulin

Question 18

Presentation of glucagonoma

Answer 18

Hyperglycemia, diarrhea, weight loss

Characteristic rash = necrolytic migratory erythema

Question 19

Presentation of somatostatinoma

Answer 19

Malabsorption, steatorrhea

Commonly malignant

Question 20

Presentation of VIPoma

Answer 20

WDHA

Watery diarrhea, hypokalemia, achlorhydia

Question 21

Tx of VIPoma

Answer 21

Octreotide

Question 22

Best first test if presumed gallbladder problem

Answer 22

US

Question 23

Diagnose: RUQ pain, high bilirubin, high alkaline phosphotase

Answer 23

Thinking obstruction

Choledocholithiasis

Question 24

Tx of choledocholithiasis

Answer 24

Chole +/- ERCP to remove stone

Question 25

Diagnose: RUQ pain, fever, jaundice, decreased BP, AMS

Answer 25

Ascending cholangitis

Question 26

Tx of ascending cholangitis

Answer 26

Abx Remove stone with ERCP

Question 27

Cause of hepatitis with ALT > AST (with both of them really high)

Answer 27

Viral hepatitis

Question 28

Cause of hepatitis with AST = 2x ALT

Answer 28

Alcoholic hepatitis

Question 29

Cause of hepatitis with AST and ALT high s/o hemorrhage, surgery, or sepsis

Answer 29

Shock liver: Hypotension = liver injury

Question 30

Medical management of cirrhosis and portal HTN

Answer 30

Somatostatins for vasoconstriction to decrease portal pressure Beta blockers to decrease portal pressure

Question 31

What is downside to TIPS

Answer 31

Worsens encephalopathy because it bypasses clearance of pneumonia

Question 32

Tx of hepatic encephalopathy

Answer 32

Lactulose (will poop it out)

Question 33

Main risk factors for hepatocellular carcinom

Answer 33

Chronic HepB carrier > HepC Cirrhosis

Question 34

Tumor marker associated with hepatocellular carcinoma

Answer 34

AFP

Question 35

Diagnose: women on OCP, palpable abd mass or spontaneous rupture, leading to hemorrhagic shock

Answer 35

Hepatic adenoma (tumors are fed by estrogen, which is why OCP is a risk factor)

Question 36

Tx of hepatic adenoma

Answer 36

Stop OCP Surgery usually not needed

Question 37

2nd most common benign liver tumor

Answer 37

Focal nodular hyperplasia Less likely to rupture

Question 38

Most common cause of liver bacterial abscess

Answer 38

E. Coli, Bacterioides, Enterococcus

Question 39

Tx of bacterial liver absces

Answer 39

Drainage + IV abx

Question 40

Tx of amoebic abscess (Entamoeba histolytica - anchovy paste)

Answer 40

DO NOT drain Tx with Metronidazole

Question 41

Diagnose: Pt from south america with RUQ pain and lots of liver cysts

Answer 41

Hydatid cysts from Ecchinococcus - transmitted via dog feces

Question 42

Lab findings in Ecchinococcus

Answer 42

Eosinophilia, + Casoni skin test

Question 43

Tx of Echinococcus liver cyts

Answer 43

Surgery + Albendazole Be careful of cyst rupture and spread