General Surgery

Front 1

it is the ----- most common
site of new cancer cases and deaths in the United States

Back 1

the colorectal area (the colon and rectum combined) is now the third most common site of new cancer cases and deaths in the United States.

Front 2

what are the risk factors ?

Back 2

* is highest for people older than 85 years of age
* family history of colon cancer
* IBD
* polyps
* High-fat, high-protein (with high intake of beef ), low-fiber diet

Hint 2

5

Front 3

Etiology

Back 3

idiopathic

Front 4

distribution of cancer sites throughout the colon

Back 4

*ascending=22%
*transeverse=11% *descending=6%
*sigmoid=33%
*rectum=27%

Hint 4

5

Front 5

the most common site of colorectal cancer is

Back 5

sigmoid

Front 6

survival rates

Back 6

If the disease is detected and treated at an early stage, the 5-year survival
rate is 90%

but only 34% of colorectal cancers are found at
an early stage

Front 7

what is the most common type among all colorectal cancers

Back 7

adenocarcinoma (95%)

Front 8

adenocarcinoma histology

Back 8

arising from the epithelial lining of the intestine

Front 9

clinical manifistation depends on ...

Back 9

1.location of the cancer
2.the stage of the disease
3.function of the intestinal
segment in which it is located

Hint 9

3

Front 10

most common symptoms

Back 10

1.change in bowel habits
(most common)
2.hematochezia
3.unexplained anemia, anorexia, weight loss, and
fatigue

Hint 10

5

Front 11

The symptoms most commonly associated with right-sided lesions are

Back 11

*dull abdominal pain
*melena

Hint 11

2

Front 12

The symptoms most commonly associated with left-sided lesions are

Back 12

*abdominal pain and
cramping
*narrowing stools
*constipation
*distention
*well as bright red blood in the stool

Hint 12

those associated with obstruction (5)

Front 13

Symptoms associated with rectal lesions

Back 13

*ineffective, painful straining at stool
*rectal pain
*the feeling of incomplete evacuation after a bowel movement
*alternating constipation and diarrhea
*bloody stool

Hint 13

tenesmus (5)

Front 14

the most important diagnostic procedures for cancer of the colon are

Back 14

*fecal occult blood testing, *barium enema *proctosigmoidoscopy
*colonoscopy

Hint 14

4

Front 15

(CEA) studies

Back 15

Carcinoembryonic antigen studies

*may not be a highly reliable indicator in
diagnosing colon cancer
(because not all lesions secrete CEA)
*are reliable in predicting prognosis.

Hint 15

2

Front 16

when the elevated levels of CEA should return to normal

Back 16

*within 48 hours

Front 17

Elevations of CEA at a later date (after 48hrs)suggests...

Back 17

*recurrence

Front 18

complications

Back 18

1.partial or complete bowel obstruction
2.hemorrhage
(Extension of the tumor and ulceration into the surrounding blood vessels)
3.Perforation, abscess formation, peritonitis,
sepsis, and shock

Hint 18

3

Front 19

medical management

Back 19

depends on the stage of the
disease

Front 20

medical management

Back 20

1.The patient with symptoms of intestinal obstruction :
- intravenous fluids and nasogastric suction
2.patients with Dukes’ class C colon cancer :
*adjuvant therapy
** the 5-fluorouracil + levamisole regimen
3.Patients with Dukes’ class B or C rectal cancer given *5-fluorouracil and high doses of pelvic irradiation

Front 21

Radiation therapy

Back 21

Radiation therapy is used before,during, and after surgery to shrink the tumor, to achieve better results from surgery, and to reduce the risk of recurrence

Front 22

For inoperative or unresectable tumors, irradiation is used to...

Back 22

provide significant relief from symptoms

Front 23

surgical management

Back 23

1.Segmental resection with anastomosis
2.Abdominoperineal resection with permanent sigmoid colostomy
3.Temporary colostomy followed by segmental resection and anastomosis and subsequent reanastomosis of the colostomy
4.Permanent colostomy or ileostomy
5.Construction of a coloanal reservoir called a colonic J pouch

Hint 23

(5)

is the primary treatment for most colon and rectal cancers

It may be:
*curative/palliative

*depends on the location
and size of the tumor *Cancers limited to one site can be removed through the colonoscope

Front 24

Laparoscopic colotomy with polypectomy

Back 24

minimizes the extent of surgery needed in some cases

Front 25

Segmental resection with anastomosis is...

Back 25

removal of the tumor and portions of the bowel on either side of the growth, as well as the blood vessels and lymphatic nodes

Front 26

Temporary colostomy followed by segmental resection and
anastomosis and subsequent reanastomosis of the colostomy allows

Back 26

initial bowel decompression and bowel preparation
before resection

Front 27

Construction of a coloanal reservoir called a colonic J pouch is

Back 27

A temporary loop ileostomy is
constructed to divert intestinal flow, and the newly constructed J pouch (made from 6 to 10 cm of colon) is reattached to the anal stump. About 3 months after the initial stage, the ileostomy is reversed, and intestinal continuity is
restored. The anal sphincter and therefore continence are
preserved.

Hint 27

performed in two steps

Front 28

Staging of Colorectal Cancer: Dukes’ Classification

Back 28

Class A: Tumor limited to muscular mucosa and submucosa
Class B1: Tumor extends into mucosa
Class B2 : Tumor extends through entire bowel wall into serosa or pericolic fat, no nodal involvement
Class C1: Positive nodes, tumor is limited to bowel wall
Class C2 : Positive nodes, tumor extends through entire bowel wall
Class D: Advanced and metastasis to liver, lung, or bone

Front 29

The TNM classification, may be used to describe ...

Back 29

the anatomic extent of the primary tumor

Front 30

The colostomy begins to function...

Back 30

3 to 6 days after surgery

Front 31

Potential complications that may develop include

Back 31

-Intraperitoneal infection
-Complete large bowel obstruction
-GI bleeding
-Bowel perforation
-Peritonitis, abscess, and sepsis

Hint 31

5

Front 32

The major goals for the patient may include

Back 32

-attainment of optimal
level of nutrition
-maintenance of fluid
and electrolyte balance
-reduction of anxiety
-learning about the diagnosis, surgical
procedure, and self-care after discharge
-maintenance of optimal
tissue healing
-protection of peristomal skin
-learning how to irrigate
the colostomy and change the appliance
-expressing feelings
and concerns about the colostomy and the impact on himself or herself
-avoidance of complications

Hint 32

8

Front 33

Physical preparation for surgery involves

Back 33

-building the patient’s
stamina in the days preceding surgery
-cleansing and sterilizing
the bowel the day before surgery

Hint 33

2

Front 34

A full-liquid diet may be prescribed --- hours before surgery to decrease bulk

Back 34

24-48 hours

Front 35

Antibiotics such as --- are administered the day before surgery to reduce intestinal bacteria

Back 35

sulfonamides, neomycin, and cephalexin

Hint 35

3

Front 36

A nasogastric tube may be inserted to

Back 36

-drain accumulated fluids
-prevent abdominal distention

Hint 36

2

Front 37

Monitoring serum electrolyte levels can detect

Back 37

-the hypokalemia
-hyponatremia

Hint 37

occur with GI fluid loss

Front 38

signs of hypovolemia

Back 38

-tachycardia
-hypotension
-decreased pulse volume
-decreased skin turgor
-dry mucous membranes
-concentrated urine

Hint 38

6

Front 39

The nature of the discharge

Back 39

varies with the site

Front 40

With a sigmoid colostomy the
feces are

Back 40

solid

Front 41

With a descending colostomy the feces are

Back 41

semimushy (полу-кашеобразный)

Front 42

With a transverse colostomy the feces are

Back 42

mushy

Front 43

With an ascending
colostomy the feces are

Back 43

fluid

Front 44

The nurse monitors the patient for complications such as

Back 44

-leakage from the site of the
anastomosis
-prolapse of the stoma
-perforation
-stoma retraction
-fecal impaction
-skin irritation
-pulmonary complications associated with abdominal surgery

Hint 44

7

Front 45

It is important to help patients with a colostomy ---on the first postoperative day and encourage them to begin participating
in managing the colostomy

Back 45

out of bed

Front 46

The patient avoids foods that cause --- including foods in the cabbage family, eggs, fish,beans, and high-cellulose products such as peanuts

Back 46

excessive odor and gas

Front 47

which drugs help control the diarrhea?

Back 47

1.Intestinal absorbents :
-bismuth subsalicylate
(Pepto-Bismol,Kalbeten)
-bismuth subcarbonate

2.Non-specific antidiarrhea drugs:
-diphenoxylate+atropine
(Lomotil)
- Paregoric=diluted tincture of opium

3.Mg

Hint 47

2 groups

Front 48

For constipation,

Back 48

1.prune/apple juice
2.a mild laxative :
-plantago ovata seeds+ispaghula husk+
senna (Agiocur)
-Psyllium+Sena
(Perdiem)

Front 49

The nurse suggests fluid intake of at least --- of fluid per day

Back 49

2 L

Front 50

If the patient has a colostomy, the stoma is examined for

Back 50

-swelling
-color
((a healthy stoma is pink or red)
-discharge
-bleeding

Hint 50

4

Front 51

If the malignancy has been removed using the perineal route,the perineal wound is observed for

Back 51

-signs of hemorrhage
-infection
-necrosis

Front 52

The nurse monitors vital signs

Back 52

-which may indicate an intra-abdominal infectious process

Hint 52

increased temperature, pulse, respirations and decreased BP for

Front 53

---complications are always a concern with abdominal surgery; patients older than 50 years of age are at risk, especially if they are or have been receiving sedatives or are being maintained on bed rest for a prolonged period

Back 53

Pulmonary

Front 54

Two primary pulmonary
complications are

Back 54

-pneumonia
-atelectasis

Front 55

what can reduce the
risks for pulmonary complications?

Back 55

-turning the patient from side to side every 2 hours
-deep breathing, coughing
-early ambulation

Hint 55

3

Front 56

The incidence of complications related to the colostomy is about one half that seen with an ---

Back 56

ileostomy

Front 57

Some common complications with ileostomy are

Back 57

-prolapse of the stoma (usually from obesity)
-perforation
(from improper stoma irrigation)
-stoma retraction
-fecal impaction
-skin irritation

Leakage from an anastomotic site can occur if the remaining bowel segments are diseased or weakened.

Front 58

Care of the peristomal skin is an ongoing concern because

Back 58

-excoriation (сдирание кожи)or ulceration can develop quickly

Other skin problems include:
-yeast infections
-allergic dermatitis

Front 59

The stoma is measured to determine the correct size for the pouch; the pouch opening should be about

Back 59

0.3cm

Hint 59

pouch=мешочек

Front 60

After the skin is cleansed (around stoma), the patient applies the peristomal skin barrier such as

Back 60

-wafer, paste, or powder(Stomahesive powder)
before attaching the pouch

Front 61

A stoma has/does not have
voluntary muscular control and may empty at regular/irregular intervals

Back 61

does not have;irregular

Front 62

באיזה סוג ניתוח חולה
לחולה יש /אין שליטה
על היציאות

Back 62

colostomy כן מרגיש
ileostomy לא מרגיש בכלל

Front 63

איזה כלכלה מתאימה לחולה עם
colostomy

Back 63

רבת תאית

Front 64

השיטה האמינה והמקובלת ביותר
היום לשם איתורסרטן המעי הגס
אצל אוכלוסייה מעבר לגיל 50 ללא תלונות היא

Back 64

קולונוסקופיה גמישה

Front 65

A 19-year-old college freshman undergoes colonoscopy because of a family history of multiple polyps in his young siblings. His brother underwent total proctocolectomy at age 23, and his sister underwent a total proctocolectomy at age 29, after both were found to have hundreds of colonic adenomas on colonoscopy. Both siblings are alive and well 5 years later and without any other findings of neoplasms. The patient undergoes sigmoidoscopy and is found to have several dozen small colonic polyps within the rectosigmoid. Five of these are biopsied and are all benign adenomas. Which of the following is the most appropriate next step in management?

A. Schedule a repeat sigmoidoscopy in 1 year
B. Schedule a colonoscopy in 1 year
C. Evaluate the more proximal colon with a barium enema
D. Schedule a full colonoscopy
E. Schedule a total proctocolectomy

Back 65

The correct answer is E. This patient has two first-degree relatives who have undergone total proctocolectomies for a polyposis syndrome. This most likely represents the familial polyposis coli syndrome in that both siblings had high numbers of colonic adenomas and underwent an appropriate total proctocolectomy. If this patient is found to have several dozen polyps during the flexible sigmoidoscopy, it is evidence that he is expressing the phenotypic trait of the familial adenomatous polyposis (FAP) gene. Rather than wait for any of these polyps to undergo malignant degeneration, he should have a total proctocolectomy in the immediate near future. Once many polyps have been demonstrated, the likelihood of one of these becoming malignant is high.

Scheduling repeat sigmoidoscopy (choice A) or colonoscopy (choice B) in 1 year is wrong because this patient with already extensive polyposis has passed the point of needing only periodic monitoring.

Evaluating the complete colon with either a barium enema (choice C) or full colonoscopy (choice D) is not needed, since there is already sufficient evidence to warrant total proctocolectomy.

Front 66

A 37-year-old accountant presents to ask for advice regarding the future management of his ulcerative colitis. He has had pancolitis for the past 19 years and has been told that he is at an increased risk for developing colorectal cancer. He asks for the physician's recommendation regarding appropriate surveillance. Which of the following is the most appropriate response?

A. Annual stool guaiac testing
B. Barium enema
C. Colonoscopy
D. Colonoscopy and multiple biopsies
E. Flexible sigmoidoscopy with multiple biopsies

Back 66

The correct answer is D. Patients with longstanding extensive ulcerative colitis for at least 10 years' duration are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia.

None of the other choices allows sampling of the entire colonic mucosa for histologic examination for the precancerous lesion of low- or high-grade dysplasia.

Front 67

A 63-year-old man, who weighs 65 kg, is in his 2nd postoperative day after an abdominoperineal resection for cancer of the rectum. An indwelling Foley catheter was left in place after surgery. The nurses are concerned because, even though his vital signs have been stable, his urinary output in the past 2 hours has been zero. In the preceding 3 hours, they had collected 56 mL, 73 mL, and 61 mL. Which of the following is the most likely diagnosis?

A. Acute renal failure
B. Damage to the bladder during the operation
C. Damage to the ureters during the operation
D. Dehydration
E. Plugged or kinked catheter

Back 67

The correct answer is E. In the presence of normal perfusion pressure, biological problems do not suddenly drive the urinary output from normal to zero. Such a change is invariably due to a mechanical problem.

Acute renal failure (choice A) does not result in a urinary output of zero. Some urine is still produced, although it is a small volume, on the order of 5 or 10 mL per hour.

Intraoperative damage to the bladder (choice B) or the ureters (choice C) would have become obvious immediately after the operation.

Dehydration (choice D) would have produced a gradual decline in the urinary volume. The 3 hours preceding the onset of the problem had shown normal values (about 1 mL per kg of body weight per hour), with no downward trend.

Front 68

A 56-year-old man has been having bloody bowel movements on and off for the past several weeks. He reports that the blood is bright red, it coats the outside of the stools, and he can see it in the toilet bowl even before he wipes himself. When he does so, there is also blood on the toilet paper. After further questioning, it is ascertained that he has been constipated for the past 2 months and that the caliber of the stools has changed. They are now pencil thin, rather the usual diameter of an inch or so that was customary for him. He has no pain. Which of the following is the most likely diagnosis?

A. Anal fissure
B. Cancer of the cecum
C. Cancer of the rectum
D. External hemorrhoids
E. Internal hemorrhoids

Back 68

The correct answer is C. The combination of red blood coating the stools and a change in bowel habit and stool caliber spells out cancer of the rectum in someone in this age group.

Anal fissure (choice A) is typically seen in young women who have very painful bowel movements with streaks of blood. Pain is the dominant symptom in this condition.

Cancer of the cecum (choice B) leads to anemia and occult blood in the stools, but the blood is rarely seen. If it is, the entire stool is bloody. Furthermore, there is no change in bowel habit or stool caliber when the tumor is so proximal in the colon.

External hemorrhoids (choice D) hurt and itch, but they rarely bleed.

Internal hemorrhoids (choice E) do indeed bleed, but they do so without changing the pattern of bowel movements or the caliber of the stools.

Front 69

A 76-year-old man is undergoing an abdominoperineal resection for rectal cancer. During the surgery, unexpected severe bleeding is encountered, and the patient is hypotensive on and off for almost an hour. The anesthesiologist notes ST depression and T-wave flattening on the ECG monitor. Which of the following is the most likely diagnosis and the expected mortality?

A. Intraoperative air embolus, 100%
B. Myocardial infarction, 5% to 10%
C. Myocardial infarction, 50% to 90%
D. Pulmonary embolus, 5% to 10%
E. Pulmonary embolus, 50% to 90%

Back 69

The correct answer is C. Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is prolonged hypotension. Furthermore, the mortality greatly surpasses that of a myocardial infarction de novo (ie, unrelated to surgery), reaching the levels quoted.

Air embolism (choice A) can happen when big veins are open, allowing air to be sucked in; however, the location of the open veins is typically the upper chest or lower neck. The patient dies while undergoing a procedure under local anesthesia, breathing spontaneously rather than having air blown into his lungs.

Choice B correctly identifies the problem, but assigns it a low mortality more typical of infarcts that do not happen during surgery.

Pulmonary emboli (choices D and E) are not usually seen during surgery; they typically occur 5-7 days later.