Surgery Exam 2

Front 1

The GB is located in what quadrant of the abdomen?

Back 1

RUQ and epigastrium

Front 2

Duodenum is located in what quadrant?

Back 2

LUQ, Epigastrium, RUQ

Front 3

what does the abdominal cavity encompass?

Back 3

the nipple line to the privates

Front 4

what structures are located in the suprapubic quadrant?

Back 4

appendix, sigmoid colon, uterus, bladder

Front 5

when ordering a CBC, the WBC tells us what?

Back 5

whether there is inflammation or infection anywhere

Front 6

when ordering a CBC, the H/H tells us what?

Back 6

RBC production/destruction (consider how well hydrated they are)

Front 7

When ordering a CBC, platelets tell us what?

Back 7

production, destruction, ability to clot

Front 8

What factors does a Liver Function tests include?

Back 8

AST/ALT
Bilirubin
Alk Phos
PT, PTT

Front 9

presence of a non-tender palpable gall bladder with jaundice suggests underlying malignant disease such as carcinoma of the pancreas and is known as?

Back 9

Courvoisier's Sign

Front 10

what is the most sensitive PT factor?

Back 10

Factor VII. has the shortest half life.

Front 11

what lab tests tell us about pancreatic function?

Back 11

lipase and amylase

Front 12

WHat test tells you how well the GB is functioning secondary to US?

Back 12

HIDA

Front 13

what are the short falls of using USN for GB screening?

Back 13

its great for looking at the GB but it doesn't tell you how well its working. 50% of the time you ahve a nonfunctioning GB but it looks fine.

Front 14

Can we use US to look for appendicities?

Back 14

no, too much gas in your colon, perhaps for kids becasuse you can compress the bubble out o fth eway but this is painful.

Front 15

Right and left lobes are defined by the ______

Back 15

falciform ligament

Front 16

What line cuts the right lobe into medial and lateral segments?

Back 16

Cantlies line

Front 17

what veins form the portal vein?

Back 17

SMV, IMV, splenic vein

Front 18

What vessels supply blood to the liver?

Back 18

portal vein supplies 75% of the blood and 25% of the oxygen
hepatic artery supplies 25% of the blood and 75% of the oxygen

Front 19

where does all the blood from the intestines go?

Back 19

first stop is the liver then pancreas
liver sees food filled blood and stores glucose as glycogen. Takes first 10% to keep glycogen stores which are important. glycogen stored in liver can go anwhere (glycogen stored in mm has to stay there)
pancreas sees glucose and secretes insulin proportional to the glucose load

Front 20

what system allows first pass?

Back 20

portal system

Front 21

what functions does the liver have?

Back 21

metabolizes drugs
stores glucose
forms bilirubin from hemoglobin
synthesizes albumin, clotting factors (PT), cholesterol

Front 22

why is albumin important?

Back 22

produced in liver, carrier molecule and very important for oncotic pressure

Front 23

what should you do if you find a cyst?

Back 23

no matter where it is, it must be removed - cancer potential.

Front 24

what is biliary atresia?

Back 24

when the biliary tree doesn't form. born with complete liver failure. need transplant or will die

Front 25

what are two anatomic anomalies seen in the liver?

Back 25

R hepatic artery off SMA, by mistake 20-25% of the time
L hepatic artery off L gastric artery just as often

Front 26

WHere do most liver infections come from?

Back 26

from the intestines or gall bladder via the portal system

Front 27

blood borne infections and metastatic tumors favor which lobe?

Back 27

right lobe 2:1
(the right side is a little straigher just like in the bronchiopulmonary branchtes)

Front 28

what is dx of a liver infection?

Back 28

air in the liver

Front 29

what do we do with bacterial abscesses in the liver?

Back 29

must be drained, abx are not enough.

Front 30

when are amebic abscesses present in the liver? and how are they treated?

Back 30

with dysentery, eosinophilia
treated with Flygyl (metronidazole) plus lots of hydration

Front 31

this type of liver cysts is present with pulmonary disease and eosinophilia. How do we get it? how do we treat it?

Back 31

Echinococcal cysts
get them from farm animals, contaminated food, eat parasites which can set up in GI, lungs, liver. The walls of these cysts can survive stomach acid. Also made of proteins which humans are allergic too so if you open them in the OR patient will go into anaphylactic shock.
Tx: drain cysts and really clean it out.

Front 32

What is the venous drainage for the liver?

Back 32

right, left, and middle hepatic veins that drain into the inferior vena cava

Front 33

macrophages in close proximity to hepatocytes that produce IL-1, TNF alpha and other cytokines are called?

Back 33

Kupffer cells

Front 34

what vessels make up the portal triad?

Back 34

hepatic portal vein
hepatic artery
bile duct

Front 35

temporary occlusion of hepatic inflow by vascular clamp to hepatic artery and portal vein in the porta heptits is know as?

Back 35

the pringle maneuver

Front 36

what is normal portal venous pressure?

Back 36

5-10mmHg

Front 37

what are causes of prehepatic portal hypertension?

Back 37

portal or splenic vein thrombosis
something before the liver is inflammed or getting squished

Front 38

what are cuases of intrahepatic portal hypertension?

Back 38

hepatitis, cirrhosis

Front 39

what are causes of posthepatic portal hypertension?

Back 39

Budd-Chiari Syndrome - post hepatic venous occlusion which can result from various thrombotic states or from vascular webs in the vena cava

Front 40

what does the extra portal hypertension pressure create when it backs up?

Back 40

collateral portosystemic channels

Front 41

what kinds of portal hypertension collaterals can develop?

Back 41

1. esophagus (esophageal variceal bleeding)
2. peri-umbilical (CAPUT MEDUSAE)
3. hemorrhoidals
4. all over! adhesions

Front 42

what is the MC form of portal hypertension in the US?

Back 42

Cirrhosis, mostly caused form alcohol

Front 43

how does cirrhosis commonly present?

Back 43

with esophageal vatical bleeding and ascites

Front 44

what is the most deadly complication of portal hypertension?

Back 44

bleeding from esophageal varicies
followed by asciteis and encephalopathy

Front 45

variceal bleeding is known to occur when the portal hypertension is above?

Back 45

12mmhg

Front 46

portal vein is formed by what?

Back 46

SMV, IMV, and splenic vein

Front 47

the liver forms bilirubing from what?

Back 47

hemoglobin

Front 48

The liver synthesizes?

Back 48

cholesterol, bilirubin, albumin, clotting factors and others

Front 49

this disease is a congenital abnormality associated with dilated intrahepatic bile ducts

Back 49

Caroli's Disease

Front 50

______ is a well-circumcsribed benign lesion usually found incidentally. It arises from an arterial malformation

Back 50

FNH, Focular nodular hyperplasia

Front 51

how do we treat amebic abscess?

Back 51

with Flygyl (metronidazole) do not need to aspirate

Front 52

This infection presents with pulmonary disease and esoinophilia.
Which infection presents with dysentery and eosinophilia?

Back 52

1. echinococcal cysts
2. amebic abscess

Front 53

what medication do we use for variceal hemorrhaging?

Back 53

IV somatostatin

Front 54

what is a major SE of TIPS and other shunting methods for variceal bleeding?

Back 54

hepatic encephalopathy -- too many toxins and fluids are bypassing the livers filtering system.

Front 55

what is the initial treatment for variceal bleeding? (first two actions)

Back 55

ABCs specifically volume resuscitation and upper GI endoscopy to see the source of the bleeding.

Front 56

what are some Rx treatments for variceal bleeding?

Back 56

Somatostatin
DDAVP (for bleeding)
Beta Blockade
(Book says: short term abx, IV vasopressin with nitroglycerin as 2nd choice)

Front 57

What are therapies we can use to treat variceal bleeding?

Back 57

1. TIPS (shunt within the liver)
2. Luminal Tamponade -->Sengstaken-Blakemore tube
3. Endoscopic therapy (sclerotherapy of band ligations)

Front 58

What are treatments we can do to prevent future variceal bleeding?

Back 58

1. Beta blockade
2. Endoscopic therapy is primary treatment
3. TIPS is definitive treatment (but high incidence of hepatic encepalopathy)
4. Selective shunts (such as distal splenorenal and coronary-caval shunt)

Front 59

isolated gastric varicies are treated with?

Back 59

splenectomy

Front 60

what is the MCC of ascites?

Back 60

Portal HTN due to chronic liver dz

Front 61

What is HRS, hepato renal syndrome?

Back 61

When the liver is too damaged and stops producing sufficient proteins (albumin) oncotic pressure diminishes and fluids escape into the peritoneum. This causes a decrease in circulating plasma volume in patients with significant ascities. This then leads to decreased renal blood flow which causes the kidneys to panic and increased release of aldosterone which wants to increase the bodies volume by holding onto to sodium.

Front 62

How do we treat ascites according to the book?

Back 62

1. restrict fluid intake
2. limit sodium intake to <40 mEq/d
3. Can use spironolactone ( an aldosterone antagonist) to promote sodium secretion

Front 63

Do we see ascites cause by pre-hepatic portal hypertension?

Back 63

no

Front 64

liver "sweats" a high ____ fluid into the peritoneal cavity

Back 64

sodium

Front 65

How do we treat ascites according to the lecture?

Back 65

Na restriction
Potassium sparing diuretics
PV shuns - Denver, Leveen
porto-caval shunts
draining?!

Front 66

what is the MC benign liver tumor?

Back 66

cavernous hemangioma

Front 67

This benign tumor is believed to be congenital and is often an incidental finding, and usually not painful. Also 5x more common in women

Back 67

cavernous hemangioma

Front 68

this type of benign tumor is usually found incidentally, and is characteristic for its well circumscribed classic stellar scar.

Back 68

FNH - Focal Nodular Hyperplasia

Front 69

this benign liver tumor is usually found in women 30-50 y/o with a hx of estrogen exposure.

Back 69

hepatic adenoma

Front 70

most malignant liver tumors come from where?

Back 70

metastatic spread from colon via portal system

Front 71

this type of liver tumor is 90% of all primary liver malignancies and usually occurs in patient with underlying dz

Back 71

Hepatocellular carcinoma

Front 72

This type of liver tumor arises from the mucosa of the biliary tree

Back 72

cholangiocarcinoma

Front 73

tumor seen at the bifurcation of the left and right hepatic duct is known as?

Back 73

Klatskin tumor

Front 74

which type of malignant tumor is most common in children?

Back 74

hepatoma, hepatocellular carcinoma.

Front 75

in which type of liver tumor will there be high AFP levels and involve the parenchyma?

Back 75

hepatoma, hepatocellular carcinoma

Front 76

how do we dx and tx liver tumors?

Back 76

dx: CT, USN
Tx: resection is always the goal

Front 77

what are the survival rates of metastasized colon cancer?

Back 77

0% 5yr survival if anywhere but the liver
if in the liver and you resect it:
25% 5 yr survival

Front 78

synonyms for the gallbladder neck are?

Back 78

infundibulum or Hartmanns pouch

Front 79

in the gallbladder where does the cystic artery usually come from?

Back 79

right hepatic artery

Front 80

which is water soluable and excreted in the urine, indirect or direct bilirubin?

Back 80

direct (conjugated)
Indirect bilirubin is lipid soluable and is not peed out.

Front 81

what are the fat soluable vitamins?

Back 81

ADEK
you can overdose on these! not excreeted out.

Front 82

the gallbladder contracts in response to what?

Back 82

CCK from the duodenum
CCK is released in the presence of fatty acids and amino acids in the duodenum

Front 83

The presence of CCK in the duodenum causes what two things?

Back 83

the gall bladder to contract
the sphincter of oddi to relax

Front 84

what is the main purpose of the gall bladder

Back 84

to store bile which emulsifies fats

Front 85

what is bile composed of?

Back 85

cholesterol
lethichicin
protein
conjugated bilirubin
bile salts

Front 86

most gallstones in the US are?

Back 86

mixed.
made from cholesterol, bile acids and lethicin

Front 87

brown stones from the gallbladder are associated with what?

Back 87

infection; infected bile

Front 88

___% calcify = positive xray

Back 88

15%

Front 89

Black pigment stones found in the gallbladder are indicative of what dz states?

Back 89

cirrhosis and hemolytic dz
Lecture says: hemolysis

Front 90

what is the 20/20 rule when it comes to gallstones?

Back 90

20% of gallstones have enough calcium to show up on X-ray. 20% of kidney stones will not show up on xray

Front 91

what are the sx of gallstone disease?

Back 91

RUQ, epigastric pain.
biliary colic
dull ache "feels like being stabbed with a finger"
lasts for 30 min
usually 1-2 hrs after eating

Front 92

Who are the most likely to get gallbladder disease?

Back 92

5F's
female, forty, fertile, fatty foods, flatulent

Front 93

What blood work should you check on a patient suspected of gallbladder disease?

Back 93

1. wbc
2. AST/ALT
3. Alk Phos
4. Bilirubin
5. PT/PTT
7. Amylase/Lipase

Front 94

What studies should you order for a patient supsected to have gallbladder disease?

Back 94

US, HIDA, CCK-HIDA

Front 95

pruritus due to GB disease is believed to be caused by?

Back 95

Increased levels of reabsorbed conjugated bile acids in the tissues.
often seen in patients with obstructive jaundice

Front 96

what are the sx of acute cholecystitis?

Back 96

fever
RUQ, epigastric pain
Positive Murphy's sign
localized tenderness and guarding
rebound tenderness
Pain >3-4 hours to several days, aggravated by movement

Front 97

What study do we use to dx gallstones and acute cholecystjts?

Back 97

1.Ultrasonography
2. HIDA scan

Front 98

what are the 3 initial steps to treating acute cholecystits?

Back 98

1. with hold oral intake
2. IV fluids
3. Antibiotic therapy

Front 99

what are the three bacteria most likely associated with acute cholecystits?

Back 99

1. e.coli
2. Klebsiella pneumonia
3. strep. faecalis

Front 100

what are the two surgical options mentioned in lecture to treat galldbladder disease?

Back 100

1. cholecystectomy -- taking the GB out
2. cholecystostomy -- put a tube in through the liver into the GB and drain it.

Front 101

what are three methods we can use to explore the location of a possible gallstone?

Back 101

1. ERCP - GI (can visualize and correct)
2. PTC (radiology) helps dx cause of blockage
3. Commone bile duct exploration (CBD exploration)

Front 102

What is Charcot's triangle and when do we see it?

Back 102

1. jaundice
2. fever
3. RUQ abdominal pain
Acute cholangitis (infection)

Front 103

what is the 5 year survival of adenocarcinoma of GB and cholagniocarcinoma?

Back 103

even with excision 0% survival
Unless you catch GB adenocarcinoma early enough and excise it completely, but once its spread to lymphatics of the liver you are dunzo

Front 104

What is the survival for removal of a klatskin tumor?

Back 104

less than 5%, 5 year survival

Front 105

which pancreatic duct joins the common hepatic duct going to the ampulla of vater?

Back 105

the main pancreatic duct aka Wirsung duct

Front 106

what is the arterial supply to the pancrease?

Back 106

1. gastroduodenal artery
2. splenic artery

Front 107

what are the three main digestive enzymes secreted by the pancrease? and the 2 inactivated ones we covered?

Back 107

Lipase
amylase
protease

1. tripsinogen
2. chymotripsinogen

Front 108

what are the main exocrine secretions we discussed in lecture?

Back 108

1. amylase
2. lipase
3. bicarb
4. trypsinogen
5. chymotripsinogen

Front 109

What are the main endocrine secretions we discussed? and where do they come from? (what part of the pancreas)

Back 109

Come from the islets of langerhans
1. alpha cells secrete gulcagon in the presense of low glucose levels
2. Beta cells secrete insulin in the presence of high glucose levels
3. Delta cells secrete somatostatin in which is a strong inhibitor of pancreatic exocrine secretion

Front 110

what are two test criteria systems we can use to dx pancreatitis?

Back 110

Apache II and Ransons criteria

Front 111

what are the 5 Ransons criteria noted at admission?

Back 111

1. age > 55 (non billiary) >70 (biliary)
2. WBC >16k (non billiary) >18 (billiary)
3. glucose >200 >220
4. LDH >350 >400
5. SGOT (AST) >250 >250

Front 112

what are the 6 Ransons criteria noted within the initial 48 hours?

Back 112

1. Decreased Hct >10 >10
2. BUN >5 >2
3. Calcium <8 <8
4. Arterial PO2 >6 ---
5. Base Deficit > 4 >5
6. Fluid Sequestration >6 >4

Front 113

what dx procedure is most commonly used for definining the pancreatic and bile duct architecture?

Back 113

ERCP

Front 114

How many of Ranson's criteria classifies as severe disease?

Back 114

3 or more. most significant factor of survival is degree of necrotization.

Front 115

What are initial treatements for pancreatitis?

Back 115

1. NPO
2. IVF
3. Pain medication
4. ETOH withdrawal
5. Somatostatin
6. NGT?

Front 116

what is the treatment for pancreatic necrosis and infection?

Back 116

1. debridement
2. drainage
3. abx
4. supportive treatment

Front 117

what is the most common complication of pancreatitis?

Back 117

development of fluid collection in peripancreatic area. (can turn into pseudocyst)

Front 118

fluid collection in the peripancreatic area can either resolve spontaniously or turn into this condition that requires surgery and drainage.

Back 118

pseudocyst

Front 119

what are common factors contributing to the onset of pancreatitis?

Back 119

FESTIVAL
F- furosemide (lasix) familial
E- etoh, ERCP?
S - stones (gallstones) shock, steroids, scorpion
T - tumor, trauma
I- idiopathic
V - viral (CMV) valoproic acid (bipolar)
A - alcohol, azothiprine
L - lasparaginase

hyperlipidemia

Front 120

The most commonly expressed genetic mutation in malignant pancreatic neoplasms occurs in what oncogene?

Back 120

K-ras

Front 121

A palpable non tender gall bladder with painless jaundice is associated with what?

Back 121

malignancy
Courvoisier's sign

Front 122

what is the MC pancreatic tumor?

Back 122

ductal adenocarcinoma 90%

Front 123

a patient may come in unconscious and with a glucose of 10. No hx of diabetes. What can it be?

Back 123

PET - Beta Cell tumor - Insulinoma

Front 124

what is Whipple's triad?

Back 124

1. sx of hypoglycemia
2. low glucose levels (40-50)
3. Sx improvement with glucose

Front 125

how do we treat single insulin producing tumor? what is this tumor techinically called?

Back 125

insulinoma
treat with excsion

Front 126

This PET is usuall benign, and the MC functional tumor

Back 126

insulinoma

Front 127

in a patient with peptic ulcers, diarrhea and ulcers resistant to treatment you should consider this type of PET

Back 127

gastrinoma

Front 128

50% of these tumors are located in duodenal wall, 3/4 occur sporadically, pain comes from acid hyper secretion and will often see abd. pain, persistent diarrhea, and severe esophagitis

Back 128

gastrinoma (D cells signalling your stomach to make more acid. opposite of somatostatin)

Front 129

what is zollinger ellison syndrome?

Back 129

when a tumor secretes too much gastrin usually from pancreas or duodenum

Front 130

This type of PET is usually present with MEN 1 and is usually multifocal

Back 130

gastrinoma

Front 131

if you can not take PET tumors our you can use what two medications to control symptoms?

Back 131

1. somatostatin
2. streptozotocin (abx)

Front 132

what are the three types of PET we learned about in lectures?

Back 132

1. insulinoma - mainly benign, whipples triad, hypoglycemia
2. gastrinoma - usually multifocal, associate with MEN 1 high gastrin levels which means severe abd. pain, esophagitis. Ph very low
3. Vipoma - watery diarrhea uncontrollable. WDHA syndrome

Front 133

what is WDHA syndrome? where do we see it?

Back 133

1. watery diarrhea
2. hypokalemia
3. hypochlorydria
we see this in VIPOMAs

Front 134

The pancreatic tumor presents with bouts of diarrhea, flushing and tachycardia. How do we treat it?

Back 134

VIPOMA
excision is treatment
Can use somatostatin and streptozotocin pre-op or to manage non surgical candidates.