Jeef Surgery Notes 1-4

Front 1

A 47 year old lady describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to “make it through”. Occasionally she regurgitates large amounts of undigested food.
Dx?
Diagnostic test? (3)
Tx? (3 possible)

Back 1

Dx: Achalasia

Diagnostic test:
1. Manometry studies (gold standard)
2. CXR w/ barium swallow
3. Endoscopy

Tx:
1. Pneumatic dilation
2. Surgical Myotomy
3. Botox injection (if pt >50 yo is first Tx)

Hint 1

None

Front 2

A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood.
Dx?
Diagnostic test?

Back 2

Dx: Mallory Weiss tear

Diagnostic test: Endoscopy

(Photocoagulation may be used if needed)

Hint 2

None

Front 3

A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting and he feels a very severe, wrenching epigastric and low sternal pain of sudden onset. On arrival at the E.R. one hour later he still has the pain, he is diaphoretic, has fever and leukocytosis and looks quite ill.
Dx?
Diagnostic test?
Tx?

Back 3

Dx: Boerhave’s syndrome

Diagnostic test: Gastrographin swallow

Treatment: Emergency surgical repair

(Prognosis depends on time elapsed between perforation and treatment)

Hint 3

None

Front 4

A 55 year old man has an upper G.I. endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant, retrosternal pain that began shortly after he went home. He looks prostrate, very ill, is diaphoretic, has a temperature of 104 and respiratory rate of 30.
Dx?
Diagnostic test?

Back 4

Dx: Instrumental perforation of the esophagus

Diagnostic test: Gastrographin swallow

Hint 4

None

Front 5

A 72 year old man has lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.
Dx?
Diagnostic test?

Back 5

Dx: Cancer of the stomach

Diagnostic test: Endoscopy and biopsies

Hint 5

None

Front 6

A 55 year old patient w/ known PUD presents w/ sudden onset of severe epigastric pain. Physical exam reveals guarding and rebound tenderness.
Dx?
Diagnostic test?

Back 6

Dx: Anterior Perforated ulcer

Diagnostic test: Chest or Abdominal x-ray to show free air under diaphragm

Hint 6

None

Front 7

A 52 year old woman presents due to 3 months of early satiety, weight loss and non-bilious vomiting.
Dx?

Back 7

Dx: Gastric Outlet Obstruction

Hint 7

None

Front 8

A 55 year old patient w/ known PUD presents w/ sudden onset of severe epigastric pain that radiates to the back. Physical exam reveals guarding and rebound tenderness. An Abdominal x-ray does not show free air under diaphragm.
Dx?

Back 8

Dx: Posterior Perforated ulcer

(An Abdominal x-ray will not show free air under diaphragm if it is a posterior perforation)

Hint 8

None

Front 9

A 45 year old Japanese male smoker presents with weight loss and epigastric pain exacerbated by eating.
Dx?
Diagnostic test?

Back 9

Dx: Gastric Ulcer

Diagnostic test: Endoscopy w/ Bx

Hint 9

None

Front 10

A 24 year old patient who was recently a burn victim over 36% of his body presents with epigastric pain exacerbated by eating.
Dx?

Back 10

Dx: Curling’s Ulcers

(Gastric stress ulcers w/ severe burns. “Burnt paper CURLS”)

Hint 10

None

Front 11

A 72 year old recent stroke patient begins to have severe epigastric pain that is exacerbated by eating.
Dx?

Back 11

Dx: Cushing’s Ulcers

(Gastric ulcer related to severe CNS damage)

Hint 11

None

Front 12

A 58 year old woman who is 6 days post-op from a gastrojejunostomy for PUD presents w/ postprandial RUQ pain and nausea. She reports that vomiting relieves her suffering.
Dx?
Diagnostic test?
Tx?

Back 12

Dx: Afferent Loop syndrome

Diagnostic test: UGI series w/ contrast
(will show afferent loop w/o contrast)

Tx: Endoscopic Balloon dilatation or Surgical revision

Hint 12

None

Front 13

(5) causes for an Upper GI Hemorrhage

Back 13

Mallory’s Vices Gave (her) An Ulcer:

Mallory-Weiss Tear;
Varices;
Gastritis;
AV malformation;
Ulcer

Hint 13

None

Front 14

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen.
Dx?
Management?

Back 14

Dx: Mechanical Intestinal Obstruction, due to adhesions

Management: Nasogastric suction, I.V. fluids and careful observation

Hint 14

None

Front 15

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched loud bowel sounds that coincide with the colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on nasogastric suction and I.V. fluids, he develops fever, leukocytosis, abdominal tenderness and rebound tenderness
Dx?
Management?

Back 15

Dx: Strangulated Obstruction
(a loop of bowel is dying –or dead- from compression of the mesenteric blood supply)

Management: Emergency surgery

Hint 15

None

Front 16

A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. On physical exam a groin mass is noted, and he explains that he used to be able to “push it back” at will, but for the past 5 days has been unable to do so.
Dx?
Management?

Back 16

Dx: Mechanical Intestinal Obstruction, due to an incarcerated (potentially strangulated) Hernia.

Management: After suitable fluid replacement needs urgent surgical intervention

Hint 16

None

Front 17

A 55 year old lady is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent jugular venous pulse is noted on her neck.
Dx?
Diagnostic test? (2 steps)
Tx? (3 depending on position)

Back 17

Dx: Carcinoid syndrome.

Diagnostic test:
1. 24 hour Serum determinations of 5-hydroxy-indoleacetic acid (5-HIAA) or 5-HTP;
2. CT scan of abdomen

Tx: Serotonin antagonists;
then...
If Appendiceal < 2cm = Appendectomy.
If Appendiceal > 2cm = Right hemicolectomy;
Small intestinal = resect tumor w/ mesenteric LN

Hint 17

None

Front 18

A 22 year old man develops vague periumbilical pain that several hours later becomes sharp, severe, constant and well localized to the right lower quadrant of the abdomen. On physical examination he has abdominal tenderness, guarding and rebound to the right and below the umbilicus. He has a temperature of 99.6 and a WBC of 12,500, with neutrophilia and immature forms.
Dx?
Management?

Back 18

Dx: Acute Appendicitis

Management: Exploratory laparotomy and appendectomy

Hint 18

None

Front 19

A 70 year old male with a history of peripheral vascular disease and hyperlipidemia presents to the ER with diffuse abdominal pain. His BP is 170/100 and his pulse is 90bpm. Supine abdominal radiographs shows air in the wall of the small intestine.
Dx?

Back 19

Dx: Small bowel Infarction

Hint 19

None

Front 20

A patient presents with pigmented spots on his lips and a history of recurrent colicky abdominal pain.
Dx?

Back 20

Dx: Peutz-Jeghers syndrome

Hint 20

None

Front 21

A 5 year old child presents with increasing irritability, colicky abdominal pain and rectal bleeding w/ stools that have a currant jelly appearance. A mass is palpated in the right lower quadrant.
Dx?
Diagnostic test? (2)

Back 21

Dx: Intussussception

Diagnostic test: Abdominal x-ray showing air-fluid levels with a stepladder pattern;
Barium enema (which is also therapeutic)

Hint 21

None

Front 22

A 59 year old is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical exam is remarkable only 4+ occult blood in the stool. Lab studies show a hemogoblin of 5.
Dx?
Diagnostic test?
Tx?

Back 22

Dx: Cancer of the right colon

Diagnostic test: Colonoscopy and biopsies

Treatment: Blood transfusions and eventually Right Hemicolectomy

Hint 22

None

Front 23

A 56 year old man has bloody bowel movements. The blood coats the outside of the stool, and has been constipated, and his stools have become of narrow caliber.
Dx?
Diagnostic test?

Back 23

Dx: Cancer of the distal, left side of the colon

Diagnostic test: Endoscopy and biopsies

(If given choices start with Flexible Sigmoidoscopy)

Hint 23

None

Front 24

A 42 year old man has suffered from chronic ulcerative colitis for 20 years. He weights 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Due to a recent relapse, he has been placed on high dose steroids and immuran. For the past 12 hours he has had severe abdominal pain, temperature of 104 and leukocytosis. He looks ill, and “toxic”. His abdomen is tender particularly in the epigastric area, and he has muscle guarding and rebound. X-Rays show a massively distended transverse colon, and there is gas within the wall of the colon.
Dx?
Management?

Back 24

Dx: Toxic megacolon

Management: Emergency surgery for the toxic megacolon and removal of the rectum

(but the case illustrates many other indications for surgery: chronic malnutrition, “intractability” and risk of developing cancer)

Hint 24

None

Front 25

A 27 year man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and tobramycin for seven days. Eight hours ago he developed watery diarrhea, crampy abdominal pain fever and leukocytosis
Dx?
Diagnostic test?
Management?

Back 25

Dx: Pseudomembranous colitis from overgrowth of Clostridium Difficile

Diagnostic test: Stool cultures (but proctosigmoidoscopy can show a typical picture before the cultures are back)

Management: Stop the clindamycin, give either Vancomycin or Metronidazole, and avoid lomotil

Hint 25

None