Surgery Casebook Flashcards Ii

Front 1

is cholecystectomy recommended in asx pts who have been found with gallstones?

Back 1

NO, exception in IC host, porcelain gb, and stones >3cm

Front 2

three m/c dx in RUQ px?

Back 2

acute cholecystitis--> should have fever
cholelithiasis
biliary colic

others = GE, PUD, hepatitis, renal colic, pneum, pyelonephritis

Front 3

is DM associated with gallstones?

Back 3

no

Front 4

radiation of pain to scapula seen with murphy's sign?

Back 4

gallstone disease (clith, citis, or bcolic)

Front 5

what is murphy's sign?

Back 5

inspiratory arrest during dep palpation of RUQ due to pain

Front 6

elevated bilirubin in cholelithiasis is due to what?

Back 6

not due to cbd obstruction but due to inflammation and cholestasis

Front 7

clithiasis has what on CBC? b/c?

Back 7

MILD leukocytosis
hyperbilirubinemia
alp, elevated mildy

Front 8

tx for symptomatic cholelithiasis?

Back 8

cholecystectomy

Front 9

what type of surgery is cholecystectomy? what kinds of AB's required?

Back 9

clean-contaminated = need only inital dose of 1st gen ceph
UNLESS due to cholecystitis = give 2nd gen cehp tocover e.coli (or other common ones = enterobacter, klebsiella, enterococcus, g-a naerobes)

Front 10

m/c complication of cholecystectomy?

Back 10

injury to CBD --> strictures, infection, or cirrhosis!! or
injury to hepatic artery --> hep ischemic injury or bile duct ischemia and stricture

Front 11

m/c cholecystitis bugs?

Back 11

ECOLI!!!
then enterobacter, klebsiella, enterococcus, g-a naerobes

Front 12

evidence of CBD obstruction?

Back 12

CBD or other bile duct dilations

Front 13

tx for bile duct obstruction?

Back 13

lap cholecystectomy + intraop cholangiogram
or ERCP (pre or post surg)

Front 14

sx cholelithiasis or gallstone pcreatitis in pregnant patient...NSIM?

Back 14

NO surgery; just give hydration and px management and wait until after preg to remove gb
but if cholecystitis, obstr jaundice, or peritonitis, do surgery.

Front 15

biliary pancreatitis - NSIM?

Back 15

wait until pcitis subsided (usually by next day ) and amylase levels return to normal, then do c-cystectomy and cholangiography; if pt is ill, do ERCP first and relieve obstruction before ccystectomy

Front 16

what is mandatory with biliary pcitis?

Back 16

cholangiogram

Front 17

severe illness due to acute pcitis 2ndary to biliary obstruction?

Back 17

delay cholecystectomy; perform ERCP if need to remove stones obstructing cbd

Front 18

gb with distension and fluid causing "internal echoes"? NSIM?

Back 18

=gb empyema
do emergent exploration or percut cstomy for drainage of gb if health is poor

Front 19

air in the biliary system, post -ccystectomy, and dilated bd's? NSIM?

Back 19

think suppurative cholangitis.
tx = IV fluids, urgent decompression, ERCP WITH SPHINCTEROTOMY

Front 20

type of pts that may manifest signs of SEPSIS with hypothermia and leukopenia?

Back 20

elderly

Front 21

cholangitis most often caused by?

Back 21

choledocholithiasis

Front 22

"retained" stone in cbd vs primary stone?

Back 22

retained = seen <2yrs post c-cystectomy. primary = seen after 2 years

Front 23

tx for choledocholithiasis OR cholangitis

Back 23

ERCP with stone removal
followed by cholecystectomy

Front 24

tx of biliary stricture (ie caused by past ccystectomy?

Back 24

=surgical exploration and bypass with choledochojujenostomoy

Front 25

NSIM in post -lapchol pt withfever and abd px, or with jaundice?

Back 25

abd US
HIDA scan (hepatoiminodiacetic acid)
- detects biliary leaks
and acute cholecystitis

Front 26

what if HIDA scan shows normal findings and no US findings of leak or collection?

Back 26

follow pt

Front 27

what does HIDA find?

Back 27

biliary leaks, obstructed cystic ducts, and obstructed CBD's

Front 28

if HIDA and ERCP finds leakage of bile duct, how treat?

Back 28

treat by bile drainage (TEMPORARY) via stent via ERCP...later should do more definiteve tx such as ? (closing leakage with staple?)

Front 29

if both HIDA and ERCP show complete bile duct obstruction? NSIM?

Back 29

attemtp stone removal, if no repair possible, do choledochojejunostomy

Front 30

PAINLESS jaundice with pruritis, direct bilirubinemia, normal lft's, and elevated alp?

Back 30

think biliary tree obstruction due to:
pancr head cxr
periampullary cxr
cholangiocarc
stricture of CBD
cbd impaction in ampulla

Front 31

what is klatskin tumor?

Back 31

cholangiocarcinoma

Front 32

in painless jaundice man, US sees dilated cbd but no gallstones or pancreatic masses...NSIM?

Back 32

CT of abdomen

Front 33

which is actually better, abd US or abd CT for visualizing DISTAL common duct area?

Back 33

abd CT

Front 34

if suspect pancr head cxr but see no mass on US or abd CT, what do next?

Back 34

endoscopic ultrasound (through duod wall to see pancr head)

Front 35

pre op findings that would make a pt with pancr cancer inoperative?

Back 35

poor medical condition
distant mets present
neurologic sx or bone px
liver mets

Front 36

sign of incurable disease in pancreatic cxr?

Back 36

any distant mets, any invation into local structures ie portal vein, aorta, sma, etc

Front 37

only indication for resection in pancr cxr?

Back 37

localized lesion limted to pancr

Front 38

first part of pancr cxr resection should be?

Back 38

b/c ct may miss mets elsewehere, should first check pt/ omentum /ln's for mets....if seen, do frozen section and halt surgery if found to be cxr = indications for unresectability

Front 39

5 year cure rate of pancr cxr after pancreatoduodenectomy? survival after only palliative surg (biliary stent and gastric bypass to prevent obstr)

Back 39

10% only

8mo only

Front 40

painless jaundice with no extrahepatic bd dilation or obstruction? NSIM?

Back 40

think obstruction at hepatic duct level, ie KIlatskin tumor = tumor sof bil tree at bifurcation of hepatic ducts = cause intra not extrahepatic dilation.
NSIM = ERCP or ptca to demonstrate level of obstr; biopsy for dx of cholangiocarc (klatskin tumor)

Front 41

are most klatskin tumors resectable or not?

Back 41

most are not

Front 42

5 yr survival rate for klatskin tumors?

Back 42

15%

Front 43

what is whipple's procedure?

Back 43

pancreatoduodenectomy for ie pancr cxr, cholangiocarcinoma (klatskin tumor) or ampullary adenocarc,

Front 44

does ampullary cxr have high or low cure rate?

Back 44

has higher cure rate (65%) than pancr cxr

Front 45

tx of gallbladder cxr?

Back 45

open cholecystectomy with large 2-3cm margins resected into the liver and surrounding tissues;

Front 46

small polyp <2cm in gb tx? larger?

Back 46

small = observe
larger = cholecystectomy b/c may develop into adenocarc of gb

Front 47

NSIM in acute epigastric pain, elevated amylase/lipase?

Back 47

abd US --> if normal, -->?

then do obstructive abd series to r/o PERFORATION!!

Front 48

tx of pancreatitis?

Back 48

NPO, IV hydration, px control (NSAIDS) and observation

Front 49

gallstone pancreatitis management?

Back 49

manage pcitis, WAIT until passes, then do lap chol-ectomy

Front 50

severe abd px + elev amylase --> progressing to hypotn, hyypoxia, and multiorgan failure? NSIM?

Back 50

NECTROTIZING pcitis, with massive 3rd spacing due to pancr inflammation. + SIRS (severe inflamm response syndr) causing multi organ failure and eventually ARDS
NSIM = fluid resusc, ICU, CT abd, assess Ranson criteria for prognostic signs

Front 51

what is SIRS?

Back 51

'sepsis' without known infection

Front 52

ranson criteria?

Back 52

GA LAW in first 24 hrs
Gluc >200
Age > 55
LDH > 350
Ast > 250
Wbc > 16000

CHOBBS in 48 hrs
Ca <8mg/dL
Hmct decr by 10%
O2 (Pa02) <60 mm Hg
Base def >4 meq/L
BUN incr by 5mg/dL
Seq fluid >6 L

if 3 = 30% mort
if 5-6 = 40%
if 7-8 = 100%

Front 53

do amylase levels correlate with severity ofr pancreatitis or prognosis?

Back 53

No

Front 54

way to evaluate for pancr abscess?

Back 54

dynamic CT = contrast material timed to determinevfacularity of pancreas

Front 55

pancr abscess suspected via CT tx?

Back 55

confirm by percut US/CT guided sample and test for bact, then if so, drainage!!

Front 56

older pt with abd px and increased amylase levels, suspect what?

Back 56

either pancreatitis OR
mesenteric ischemia, OR volvulus could all manifest similarly; amylase is not specific enough

Front 57

cause of early satiety in pt with persistent elevation of amylase and abd px, post acute pcitis?

Back 57

PSEUDOCYST pressing on post wall of stomach!

Front 58

dx of pseudocyst?

Back 58

CT of abd, or US of abd

Front 59

do you drain a pseudocyst? how tx?

Back 59

no; just NPO, TPN, and observation unless signs of infection = AB's; or unless does not resolve with tx after 7 weeks = do surgery

Front 60

what kind of surgery if after 7 weeks pseudocyst remains?

Back 60

cystogastrostomy = drain cyst through post wall of stomach; as well as bx to ensure that cyst is not a cystadenom aor cystadenocarcinoma of pcreas

Front 61

mass in liver in 37 y/old woman with ruq? what causes this?

Back 61

cyst or
hemangioma = due to oc pills, enviro toxins, hep B and C, estrogen therapy, steroid therapy

Front 62

simple liver cyst, NSIM?

Back 62

no further managment if no sx f sx, aspiration

Front 63

liver cyst with internal echoes? tx?

Back 63

think echinococcal cyst;
do serolog tesst ofr echinococcus, then do injection of cyst with hypertonic saline, then excision of cyst...do not spill into pt, which can cause ptitis

Front 64

fever, elev wbc ct, abd tenderness in RUQ, liver cyst, think?

Back 64

ABCESS: tx = IV ab's and CT-guided drainage!!

Front 65

amebic liver abcess, how to tx?

Back 65

Don't need to drain, just give metronidazole

Front 66

echinococcal cyst characteristics?

Back 66

calcified outer wall, multilocular, internal echoes on US

Front 67

90% of hepatic adenmoa pts have what hx?

Back 67

OC usage ( as do hemangiomas)

Front 68

how tx large hepatic adenoma? why?

Back 68

resection
b/c risk of progression to HCC from malignant foci, and/or risk of rupture

Front 69

hepatocellular carcinoma has what marker?

Back 69

elevated alpha -FP

Front 70

m/c solid liver mass in 37 y/0? dx?

Back 70

hepatic hemangioma
dx via labeled RBC scan

Front 71

types of liver lesions to remove?

Back 71

symptomatic; risk of rupture; or uncertain dx lesions

Front 72

how are most hemangiomas discovered?

Back 72

during US for gstones

Front 73

how treat hemangioma of liver?

Back 73

if no sx, just observation.

Front 74

tx of liver with focal nodular hyperplasia?

Back 74

no tx necessary

Front 75

what has a high risk of rupture during pregnancy and should therefor be resected before pregnancy?

Back 75

hepatic adenoma!! (actually should first try to just stop OC's, since most will just regress w/o OC use)

Front 76

NSIM when do bx and find HCC?

Back 76

Staging by CT for mets to lung, abd, hilar ln's, etc

Front 77

when is resection not warranted in liver hcc?

Back 77

multiple lesions, or involvement of critical structure ie portal vn, IFC, hepatic vns

Front 78

margins needed for a liver resection?

Back 78

need 1 cm margins and need to preserve all vasculature

Front 79

tx for multiple , small pyogenic abscesses of liver?

Back 79

broad spectrum ABs for 4-6 weeks..only drain if large, single pyogenic abscess

Front 80

liver amebic abscess tx?

Back 80

Metronidazole alone, no need for drainage.

Front 81

tx of liver abscess caused by e. histolytica?

Back 81

this is amebic; tx with metronidazole only...no drainage necessary

Front 82

45 y.o with crampy abd px, abvd distention, constip, and previous appendectomy...dx? NSIM?

Back 82

sbo caused by strictures, although ileus could also do this
NSIM = abd series

Front 83

what is an abd series for obstruction?

Back 83

upright PA, lateral chest xray, flat and upright radiograph

Front 84

radiograph of sbo?

Back 84

multiple air fluid levels in SMALL bowel, no evicence of air in colon or rectum

Front 85

elyte changes in sbo?

Back 85

VOMITING causes loss of H, CL, NA, and h2o from stomach, causing contraction alkalosis, hypokalemia (H+ pulled out of cells, K+ pushed in), etc.

Front 86

correction of sbo induced elyte abnorms?

Back 86

give fluids + K+, then alkalosis will correct itself

Front 87

in absence of marked lcytosis, fever, acidosis, or localized tendreness, how to manage SBO?

Back 87

ydration, NG drainage and observation only...