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159 Cards in this Set
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Direct inguinal hernia is
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A direct inguinal hernia is when abdominal contents press through the posterior inguinal wall of the inguinal triangle (aka Hesselbach's triangle)
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What are the boundaries of Hesselbach's triangle (aka inguinal triangle, through which occurs a direct hernia) ?
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Lateral: lateral rectus
Superior: inferior epigastrics Inferior: Inguinal ligament |
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Compare causes of a direct vs indirect inguinal hernia.
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direct hernias are more likely in older men, cause is due to increased pressure, no true sac, the least likely hernia to incarcerate.
An indirect hernia is usually congenital due to a patent processes vaginalis. It has a true sac which is a remnant of the processes vaginalis which must be excised. An indirect hernia is the most likely to incarcerate |
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What is a femoral hernia?
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Due to enlarged femoral ring due to short attachment of transversus abdominalis to Coopers ligament. Is acquired.(Between last rib and iliac crest)
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Compare omphalocele vs gastrochisis.
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Both are the incomplete closure of abdominal wall in newborns. In an omphalocele there is a thin membrane of peritoneum and amion while in gastrochisis there is no covering and the abdominal contents are open to the outside world.
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Where does a lumbar hernia occur?
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A Grynfelt's hernia aka lumbar hernia occurs in the superior lumbar triangle (sacrospinalis, internal oblique, 12th rib)
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Anteriormedial thigh paresthesias can be due to what kind of hernia?
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An obturator hernia which protruds through the obturator canal can cause intermittant bowel obstruction and thigh paresthesisas.
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What is a Spigelian hernia?
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Herniation through the semilunar line (lateral connection of rectus muscle). Is superior to the inferior epigastric vessels.
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What are the layers of the abdominal wall?
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Skin
Superficial fascia (Camper's fascia and Scarpas fascia-deep) External Oblique Internal Oblique Transversalis Transversalis fascia Preperitoneal fat |
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What are the layers of the spermatic cord:
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Skin
Superficial (dartos) fascia External spermatic fascia Cremaster muscle and fascia Internal spermatic fascia Parietal and visceral layers of tunica vaginalis |
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Compare the incidence of femoral vs inguinal vs ventral hernias?
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5% of people will have a hernia repair (500,000- 1mil a year). 50% indirect, 25% direct, 10% ventral, 6% femoral W>M.
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Define acute abdomen.
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Signs and symptoms of intra abdominal disease usually treated best by surgical operation.
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Define referred pain.
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Organs that share DRG fibers with somatic innervation the somatic fibers have the highest priority and thus pain in an organ can be felt in another area of the body ie pancreatitis and shoulder pain.
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Define visceral pain:
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Visceral pain is mediated by afferent C fibers in viscera of organs. This pain is slow, dull, localized and protracted. In comparison parietal pain has A delta fibers which has more acute sharp, well localized pain.
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How do you evaluate abdominal pain?
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WILDA: words to describe it, intensity, location, duration, aggravating and alleviating factors. Is the mode of onset explosive or slowly progressive. Is it colicy. Is there associated anorexia, N/V/D, constipation, blood. What is the menstrual history. Drugs? FH? Travel?
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Intense involuntary guarding resulting in a pathoneumonic "board abdomen" is characteristic of what?
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Boardlike abdomen..... think perforated duodenal ulcer.
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What do you look for on PE to determine peritonitis?
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Rebound = peritonitis
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The absence of bowel sounds makes you think of ?
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ileus or small bowel obstruction.
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What ddx would you think of with a positive iliopsoas sign with the flexing of the hip?
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+ iliopsoas sign can indicate retrocecal appendix or psoas abscess.
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How do you test for obturator's sign?
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Move the hip in internal or external rotation.
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Describe PE findings in appendicitis?
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Rebound tenderness at McBurney's point
Rovsing's sign- pressure in LLQ causes pain in RLQ Psoas sign- pain on flexion/ext of R hip Obturator sign- passive rotation of flexed R thigh causes pain Rebound tenderness |
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What is the presentation of acute appendicitis and what further studies would you order?
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Abdominal pain in periumbilical area migrating to McBurney's point. Nausea / vomiting, fever, anorexia.
Get CBC- look for leukocytosis Xray - not generally useful, can occasionally 10% of time show fecalith US- good sensitivity CT- useful if case is not clear cut |
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Most common age group for appendicitis?
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Children 5-10 get appendicitis more frequently as they have a high # of lymphoid follicles and increased secretions leading to blockage and inflammation.
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Where do you have pain in a pregnant woman with appendicitis?
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Appendix will be displaced above fundus, which is now in RUQ.
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Give a differential for acute appendicitis?
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PID, pylonephritis, gastroenteritis, IBD, endometriosis, ovulatory pain, ovarian cyst, Meckel's diverticulitis, acute ileitis, cholecystitis, perforated PUD, kidney stones, UTI, hepatitis, PNA
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Abx for acute appendicitis?
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2nd or 3rd gen ceph, piperacillin + metronidazole, AG, ampicillin or clindamycin.
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How frequuenty is an appendix tumor carcinoid? What % of carcinoid tumors in the GI tract are in the appendix?
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Carcinoid tumors are 0.5% of all appendix tumors. These account for 50% of all carcinoid tumors of the GI tract. However only 3% are malignant.
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What are the 4 primary malignant tumors of teh appendix?
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1. carcinoid tumor
2. adenocarcinoma 3. malignant mucocele 4. carcinoma |
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Describe the anatomy of the biliary system.
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There are R and L hepatic ducts which join to form the common hepatic duct. The common hepatic duct and the cystic duct from the gallbladder form to make the common bile duct, which later joins the pancreatic duct. The CBD then enters the duodenum at the spinctor of Oddi.
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What are some causes of increased indirect bilirubin?
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Newborns
Crigler Najiar (glucuronyl transferase deficency) Hemolysis |
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What are some causes of increased direct bilirubin?
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Obstructive
See increased Alk phosphatase and GGT from biliary tree obstruction Increased in AST.ALT- hepatocellular disease |
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Treatment for CBD obstruction?
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ERCP with excision of stones.
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What are the 4 major risk factors that increase risk 4x for breast cancer.
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1. Family history (BRCA 1/2)
2. Atypical hyperplasia 3. Personal history of prior Breast CA 4. DCIS(ductal carcinoma in situ)/LCIS (lobular carcinoma in situ) dx as they have high rate of recurrance |
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How does an intraductal papilloma usually present?
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bloody nipple discharge is seen with intraductal papillomas
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You palpate a breast mass, what do you do?
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If <30 do u/s if >30 do mammogram.
If mass is cystic and simple, reexamine in 2-3 mo If mass is cystic and complex- aspirate, if fluid is bloody then bx If mass is solid do FNA or core biopsy. If nondiagnositc bx then reassess with mammogram. |
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How do you treat 0-1 stage breast CA
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Treat 0-1 stage BCA with lumpectomy either alone or with radiation
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How do you treat 2-3 stage breast CA
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Treat Stage 2-3 BCA with lumpectomy or masectomy, then radiation therapy, systemic chemo, treatment with tamoxifen or aromatase inhibitor tx if Estrogen receptive and possibly herceptin if HER2+
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How do you tx stage 4 BCA?
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Treat stage 4 BCA with systemic chemo and surgery.
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Treatment of DCIS entails?
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lumpectomy + radiation or simple mastectomy
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For DCIS you have to Do something for LCIS you can Leave it alone.
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Treatment of Paget's?
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Excision of nipple, radiation, if diffuse do mastectomy
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Contrast the 3 types of mastectomies:
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1. simple- breast removal with pectoralis major fascia removed
2. modified radical- simple with axillary dissection 3. radical- removal of breast as well as pectoralis muscles, axillary contents and overlying skin. |
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Describe survival rates for the 4 stages of BCA?
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Stage I – 96% 5 year survival
Stage II – 82% Stage III – 53% Stave IV – 18% |
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How large a tumor is lumpectomy appropriate for?
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<4cm in size... no metastatic disease. Must follow with radiation.
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How frequently must a woman have a mammogram in her CL breast after a radical masectomy? How about after a lumpectomy?
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1. With masectomy get mammo in CL breast every 3-6 mo for 3 years then annually.
2. With lumpectomy get bilateral mammos Q6 months after radiation completed and then yearly. |
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What is BRCA1?
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BRCA1 is a protein that maintains stability after DNA damage, it activates p53 which mediates apoptosis. BRCA1 lesions are often aneuploid, high grade lesions. It is responsible for about 5% of cancers.
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Risk factors for CA of colon or rectum
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Low fiber/ high fat diet, older age, exposure to carcinogens, genetics, UC, prev radiation or prev CA
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Risk factors for anal cancer
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chronic inflammation ie fistula, abscess, infection, Condyloma (warts), Chron's , Herpes, Smoking
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What type of tumors are seen in anal cancer?
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Epidermoid, melanoma CA seen in anal cancer
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Signs of colon, rectal, anal cancer
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rectal bleeding, anemia, pain, mass, weight loss, obstruction
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Treatment for colon CA
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hemicolectomy or colectomy with ostomy , nodal dissection and chemotherapy.
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Most common site of colon obstruction and most common cause?
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Sigmoid colon is most commonly obstructed... due to adenocarcinoma, scaring from diverticulitis or volvulus.
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What is this disease?
bimodal disease 15-30 and >55 continuous are of disease in rectum and colon Only affects mucosa and submucosa seen toxic megacolon surgery is curative |
Ulcerative Colitis
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What is the disease?
-affects full thickness of intestine -any region of the GI tract -skip lesions and fistulas -surgery is palliative -see string sign on XR -Note granulomas -Cobblestoning |
Chron's Disease
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Contrast hemorrhoids, anal fissure and anal abscess.
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anal abscess- infection of anal crypt presenting with pain, fever, swelling, pus/ discharge (need I&D)
Hemorrhoids- engorged veins, painful, occurs in the anal canal anal fissure- horrific pain, tearing in anal canal below the dentate line resulting from sphincter spasm. |
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What is the Na/ K/ HCO3/ Cl of the following:
Serum |
Na 135-150
K 3.5-5.0 HCO3 22-30 Cl 98-106 |
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What is the Na/ K/ HCO3/ Cl of the following:
Gastric aspirate |
Na 10-150
K 4-12 HCO3 0 Cl 120-160 |
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What is the Na/ K/ HCO3/ Cl of the following:
Bile |
Na 120-170
K 3-12 HCO3 30-40 Cl 80-120 |
Think of bile as very alkalotic. Bicarb is increased while other values are around normal. Bicarb and pancreatic juices are coming out of the spinctor of oddi together... recall the pancreas makes a ton of bicarb.
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What is the Na/ K/ HCO3/ Cl of the following:
Ileostomy aspirate |
Na 80-150
K 2-8 HCO3 20-40 Cl 70-130 |
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How do you calculate TBW?
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0.6 x body weight in kg.
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How do you calculate ECF and ICF?
How do you calculate IVF? |
ECF = 1/3 x TBW
ICF = 2/3 x TBW IVF = 8% x ECF Recall TBW = kg x 0.6 |
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How do you define pre renal azotemia
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urine Na <20
BUN:Cr >20:1 Urine osm >400 |
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What are the fluid losses for 24 hours:
urine sweat respiratory feces total insensible losses |
urine 12000-1500 ml
sweat 200-400 ml respiratory 500-700ml feces 100-200ml Total: 2000-2800 ml/ day |
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Causes of hypernatremia?
-hypovolemic -euvolemic -hypervolemic |
-hypovolemic: Renal causes (osmotic diuresis), extra renal (diarrhea, fever, sweat)
-euvolemic: DI -hypervolemic: hypertonic saline, cirrhosis, heart failure |
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Calculate H20 deficit:
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H20 deficit= TBW x (serum Na-140)/140
TBW = 0.6 x body weight (0.85 if elderly or female) |
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Causes of hyponatremia:
hypovolemic euvolemic hypervolemic |
hypovolemic- renal losses(diuretics, adrenal insufficiency)
euvolemic- SIADH, polydypsia hypervolemic- CHF, cirrhosis, nephrotic syndrome, renal failure. |
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Treatment of hyponatremia and daily max?
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Na needed = (140-Na ) x TBW
Give 1/2 needed Na in first 12 hours and remaining over 48 hours not to exceed 12 mEQ/L / day |
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DDx of hyperkalemia and tx?
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Hyperkalemia:
renal failure, crush injuries, hemolysis, catabolism, acidosis, dig toxicity EKG shows peaked T waves, long PR, flat P waves, wide QRS, sine wave Tx: insulin with glucose, bicarbonate, Ca gluconate, hemodialysis |
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Ddx for hypercalcemia and tx
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hyperparathyroidism, malignancies, milk-alkali syndrome, Williams syndrome, Vit A intoxication
treatment of hypercalcemia- loop diuretics, bisphosphonates, corticosteroids |
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Ddx hypocalcemia
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PTH deficiency, pancreatitis, vit D deficiency, hypoalbuminemia (Correct for albumin).
Treat with Ca gluconate, chloride IV, thiazide iduretics |
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Normal ABG values
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pH 7.4
pO2 100 pCO2 40 O2 sat >95% HCO3 25 Base -2 to +2 |
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Name 4 endogenous factors that control Na and H20.
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aldosterone from adrenal cortex
ADH from posterior pituitary Renin-angiotensin axis osmole receptors sensing volume balance. |
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What is the content of NS?
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NS contains:
Na 154 Cl 154 |
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What is the content of LR?
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Lactated Ringers contains:
NA 130 K 4.0 Cl 109 HCO3 27 Ca2+ 3.0 |
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Content of D5W?
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D5W only has 50 mg of glucose.
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Content of D5 Ringers?
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Glucose 50
Na 130 K 4.0 Cl 109 HCO3 27 Ca 3.0 |
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What is the primary cause of the electrolyte imbalance?
Na 140 K 3.0 HCO3 22 Cl 90 pH >7.45 |
Loss of bicarb and Cl points toward GI losses ie vomiting causing alkalosis.
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A high volume pancreatic fistula would present with what electrolyte imbalance?
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Excessive loss of HCO2 ie 15 instead of 25.
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What electrolyte disturbance would you see with diarrhea?
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Na 140
K 3.0 slightly low HCO3 22 low Cl 95 slightly low ph <7.35 Main point... isotonic losses, everything can be slightly low with slight acidosis if prolonged. |
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What electrolyte disturbance would you see with closed head injury?
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Na 130 low!
K 3.5 normal HCO3 20 low! Cl 90 low pH acidotic |
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Normal values for pH, PCO2, pO2, HCO3
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pH 7.4, PCO2 40, pO2 100, HCO3 25
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ACh is released by what never to stimulate stomach contractions?
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vagus n activates peristalsis to the stomach via ACh.
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What type of cancer is associated with Chron's Disease?
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Adenocarcinoma of the ileum.
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What are the pharmacological treatments of Crohn's diseas?
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Sulfasalazine and mesalazine are antiinflammatory drugs.
Corticosteroids and metronidazole are also helpful. |
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Name 4 indications for surgery for Crohn's disease?
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abscess
perforation bleeding fistula |
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What is the most common congenital anomaly of teh small itnestine? hing it's a failure of the vitelline duct to close from the umbilicus.
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Meckel's diverticulum. heterotopic tissue is found in 30-50% including gastric of pancreatic tissue that can secrete hormones.
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Rule of 2's in Meckel's diverticulum.
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2 feet from ileocecal valve
2% of population 2 in long contains 2 types of heterogenous tissue most common cause of painless rectal bleeding in children <2 yr old |
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What are the 4 types of tumors that affect the small bowel
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adenocrcinoma, GI stromal tumors, carcinoid and lyphoma
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Most common endocrine tumor of the GI tract? What are the associated symptoms?
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carcinoid tumors are the most common and they secrete serotonin primarialy although they can secrete histamine, dopamine, peptides and prostaglandins. They are all considered malignant. Symptoms include flushing, diarrhea, sweating and wheezing. Most common site is the appendix.
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Medical treatment of carcinoid syndrome?
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injections of octreotide, the somatostatin analogue inhibits the serotonin release.
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3 layers of a true divericulum
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submucosa
mucosa muscularis propria |
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Most common location of carcinoid tumors?
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the appendix.
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Your patient presents as follows, what do you do? Syncope, tachycardia, hypotension, hematemesis, acute abdomen.
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First get 2 large bore IVs and stabilize with isotonic fluids ie NS. Check Hct and prep blood. Get CXR to check for perf. NG can be placed for suction. Endoscopy can be performed, if unhelpful consider angiography. IF serial Hcts continue to decline transfuse. if >6 units in 12 hrs then go to OR emergently. Long term tx with PPI or H2 blocker. Band varices, electrocautery, embolization or resection.
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3 branches of the celiac artery?
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Common hepatic, splenic, L gastric are all branches of the celiac artery.
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innervation of the stomach is through the?
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vagus nerve innervates the stomach
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The hormone gastrin is released from what cells, from where and what does it do?
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Gastrin is released from G cells in the antrum of the stomach. It is released into teh blood and then acts on parietal cells to increase acid secretion
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What causes the release of secretin and what does it do?
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Acidic chyme in the duodenum signals the release of secretin. Secretin then inhibits gastric acid secretion and prolongs gastric emptying.
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What are the 3 phases of gastric emptying?
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cephalic: Before food is ingested... gastric secretion increases but as the stomach is still very acidic no additional gastrin or somatostatin is produced.
Gastric: distension of antrum promotes gastrin release from G cells. CCK receptors and ECL cells are activated. Parietal cells release HCl Intestinal: histamine and peptides reach small intest, pyloric sphincter tightens to control rate of entry. |
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3 types of gastric ulcers?
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type I: in lesser curvature of stomach, transition zone of antrum
type II: gastric and duodenal ulcers. typeIII: pyloric type II and III are due to acid hypersecretion. |
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symptoms of ulcer?
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epigastric pain radiating to back that increases with food, weight loss. Type I with normal or low gastric acid secretion is the most common type of ulcer.
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What two different complications arise depending on where the duodenal ulcer is located?
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anterior duodenal ulcer can spill out into the abdomen.
posterior duodenal ulcer can erode the gastroduodenal artery. The gastroduodenal artery is from the common hepatic artery and bifurcates into the pancreatoduodenal artery and the gastroepiploic artery. |
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which improves with food a gastric or a duodenal ulcer?
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gastric gets worse with food more gastrin while duodenal improves with food.
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What tests are used to diagnose ZE (zollinger ellison syndrome?
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basal acid output measures unstimulated stomach acid output.
maximal acid output is measured after pentagastrin or histamine is administered. In ZE measures are done before and after pentagastrin is given. Since the cause is gastrin secreting tumor the level of stomach acid output would be high before and not increase substantially after stimulation. |
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Most common gastric tumor and gold standard diagnosis?
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Most common gastric tumor is adenocarcinoma. Dx with upper endoscopy. Cause is usually H pylori.
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2nd most common primary tumor of stomach?
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lymphoma is the second most common ca of stomach. Do barium swallow test to look for lesion, gastroscopy and biopsy for dx, CT can then be done for staging of nodes. In 50% of patients you can palpate epigastric mass.
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GIST tumors- grow intraluminally and are CT tumors, most are benign and most occur in the stomach. How do you diagnose them.
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SBFT, barium swallow (aka upper GI series) or CT used for dx. These tumors are usually CD117 or kit positive and have spindle cells. It is the most common type of sarcoma (CT tumor)
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What is tripple therapy for H. pylori.
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Tripple H. pylori therapy includes: metronidazole or amoxicillin or clarithromycin, PPI like omeprazole, and bismuth
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Free intraperitoneal air indicates....
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perforation
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What is the significance of anatomic locations of ulcers in the stomach and duodenum:
posterior duodenum anterior duodenum pyloric channel gastric |
gastric- risk for malignancy
pyloric channel- risk for obstruction posterior duodenal - risk for bleeding anterior duodenal- risk for perforation |
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Describe vagotomy in terms of PUD treatment.
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Resect distal vagal nerve as it enters the abdomen at teh distal esophagus. However the decrease in vagal tone leads to decrese in emptying so therefore patient has issues with gastric emptying.
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What is an antrectomy?
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Antrectomy is a distal gastrectomy which removes gastrin producing cells.
It inhances vagotomy. |
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What is a pyloroplasty?
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Pylorus is cut vertically and restitched horizontally to improve gastric emptying.
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What is dumping syndrome and when does it occur?
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Dumping syndrome occurs with rapid gastric emptying where osmotic balance is skewed causing tachycardia, anxiety, palpitations, borborygmi and diarrhea. It is seen with anterectomy.
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What distinguishes the BAO vs MAO of ZE vs duodenial ulcers.
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In Zollinger Ellison the basal acid output is elevated but and because it is so high the maximal acid output is about the same. In contrast gastric and duodenal ulcers have higher maximal acid outputs
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What is Charcot's triad in relation to cholangitis?
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jaundice, fever/chills, RUQ pain
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What two additional markers are added to Charcot's triad for cholangitis making it Reynold's pentad.
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Charcot's triad for cholangitis: RUQ pain jaundice, fever
Reynold's pentad: confusion and hypotension indicating ascending cholangitis or sepsis. |
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What are the 5 components of Child's criteria to rate the severity of cirrhosis.
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Child's criteria
serum bilirubin, albumin, ascites, encephalopathy, PT/INR Classifies pt into A, B, C with C being a poor surgical candidate. |
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What is Ranson's criteria and how does it affect a patient's odds of recovery from pancreatitis?
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Ranson's criteria is as follows:
age>55, WBC >16000, glucose >200, LDH >350, AST >250. Having 3 or more criteria increases the risk for major complications during an episode of pancreatitis. |
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How do you stage for pancreatic ca?
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do CT, MRCP, ERCP, endoscopic US. Looking for liver mets, vascular invasion.
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What secretory substances does the pancreas make and what activates them.
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bicarbonate, insulin, lipase, amylase and trypsin.Trypsin is activated by enterokinase in the intestine.
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Most common benign tumor of the liver?
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You are thinking cyst which is true but if it's not a cyst hemangiomas are the most common. Cysts are concerning if the walls are thick, if there are many septations or calcifications. Hemangiomas are usually congenital.
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What is the most common type of primary liver malignancy?
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Hepatomas are the most common primary liver malignancy. >90%. Associated with Hep B and C. AFP is elevated.
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In what group do hepatic adenomas occur?
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Adenomas occur in women age 30-50. It is usually estrogen related. Small risk for cancer but remove due to risk of rupture.
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3 Indications for splenectomy?
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1. splenic rupture due to trauma/injury
2. hypersplenism- hemolytic anemia ie hereditary spherocytosis, hemoglobinopathies, G6PD hyposplenism- asplenia or infarct of spleen 2/2 sickle cell 3. Hematologic malignancy ie chronic leukemia causing splenomegaly |
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What 3 immunizations would you recommend to an individual before splenectomy and why?
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Spleen is responsible for removing encapsulated organisms.
Vaccinate against N. meningitis, H flu S. pneumo |
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Causes of pancreatitis?
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Metabolic- alcohol
Mechanical- Gallstone pancreatitis from obstruction Ischemic- hypotension. |
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cause of pancreatitis?
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diffuse inflammation of the pancreas due to release and activation of pancreatic enzymes into the parenchyma. Treat by NPO, possibly by NG tube, ERCP for stone
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Most common type of pancreatic cancer?
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Adenocarcinomas are the most common pancreatic cancer. They originate from the ductal epithelium.
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What is normal urine output in ml/kg/day?
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Urine output should be 3ml/kg/day. Ie 70 kg male shoudl put out minimum of 210/day.
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basic rule for UOP in children?
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1000 ml for the first 10 kg + 50 ml/kg/day for each additional kg.
ie 15 kg child makes 1250 ml/day. |
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Determine blood volume in infants. When do you start to replace?
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Blood volume is 75 ml/kg. Start repletion when >10% lost
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Non billious, projectile vomiting, with visible epigastric olive indicates what? What metabolic abnormality will also likely be present?
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pyloric stenosis.
also common to note hypocholremic hypokalemic metabolic alkalosis. |
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polyhydramnios, vomiting, abdominal distension and failure to pass meconium signify?
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SBO in neonate.
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Dds for SBO in newborn?
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meconium ileus, intrasusception, malrotation, intestional atresia/stenosis, hirschprung's disease, annular pancreas.
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You suspect a child has intrasusseption. They have current jelly stools and have episodes where they cry and double up in pain. What test would you use to confirm? Where is the intrasusseption most likely located?
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Most common location at ileocecal junction.
Do barium enema to look for obstruction and get CBC which will show PMNs. |
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What is the atomical defect in hirschprungs disease?
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Hirschsprung's is an absence in the ganglion cells of the colon. The parasympathetic mysenteric and submucosal plexi did not migrate.
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Where do most diaphramatic hernias occur?
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left posterior
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describe the most common type of esophageal atresia? How does the child present?
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85% the esophagus dead ends. Then the inferior esophagus anastamoses with the trachea forming a tracheoesophageal fistula. Childpresents with coughing and choking with feeding, cyanosis,gas below the diaphram seen on CXR
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Describe when and how the neonatal intestine rotates?
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AT 10 weeks of gestation the intestine rotates around the SMA 270 degrees counterclockwise.
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how do you treat necrotizing enterocollitis and when do you have to operate?
Recall NEC occurs in the first 2 weeks of life in premature infants whose bowels become ischemic. |
Treat with broad spectrum abx, NG decompression, fluid resuscitation and blood transfusions if necessary. OR intervention is indicated if there is acidosis, or perforation.
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What is the difference between claudication and rest pain?
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Rest pain is more advanced peripheral ischemia. It is usually relieved by dangling the limb over the side of the bed. Both represent PVD and can progress to skin ulceration and gangrene in the most severe form.
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3 Methods of testing for PVD?
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1 Doppler ultrasounds- triphasic wave form becomes biphasic
2. Ankle Brachial Index <0.8 is claudication, <0.4 is rest pain/tissue loss. Ratio is the highest brachial /ankle SBP. 3. Arteriography: radioopaque dye is injected in the abdominal aorta to map the vascular tree. |
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Describe a few of the pharmaceutical approaches to managing claudication.
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1. BB (these people will die of MI not claudication, protect their heart)
2. Statin reduce cholesterol 3.ACEI prevent atherosclerotic progression. 4. Cilostazol (Phosphodiesterase inhibitor) All of these along with exercise, healthy diet, good diet Also can consider decreasing BP |
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6 Ps of major arterial occlusion?
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pallor, pain , paresthesias, paralysis, pulselessness, poikilothermia
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Presentation and tools for dx of AAA?
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AAA presents as pulsatile mass on exam, if ruptured acute back pain, hypotension.
Diagnose by u/s, CT. |
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Cutoff for operation for AAA
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Must be >5 cm. Otherwise mortality from operation outweighs mortalilty from possible rupture
Can use graft to bypass eneurysm or stent. |
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Signs of PE
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pleuritic chest pain, dyspnea, tachypnea, tachycardia, cough, hemoptysis.
Get D dimer, VQ scan or pulm angiogram |
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Compare TIA vs RIND
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TIA- transient ischemic attack , <24 h attack usually involving MCA resulting in stroke liek symptoms.
RIND- Reversible ischemic neurologic defect. Stroke like defect lasting 24-72 hours up to 3 weeks. |
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Treatment of cerebrovascular incidents?
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anticoagulation, thrombolytics ie TPa if thrombotic stroke within 3-4.4 hrs. Carotid endarectomy (CEA), angioplasty, with stent placement.
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Virchow's Triad for DVT
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venous stasis, endothelial injury, hypercoagulable state.
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What is Homans sign and what does it indicate?
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Homan's sign is calf pain with dorsiflexion of the foot indicating DVT.
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PE finding in chronic venous insufficiency?
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hyperpigmentation (orange brown skin from hemosiderin from hemoglobin breakdown) and chronically swollen legs, as well as venous stasis ulcers.
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Symptoms of chronic intestinal ischemia.
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postprandial abdominal pain, bloating, weight loss, early satiety.
Cause is occlusion of vessels at watershed areas, colaterals- gastroduodenal and marginal s. |
Recall that the asc colon = ileocolic and transverse colon = middle colic both from SMA. The desc colon = left colic from IMA. Between at splenic flexure is watershed area.
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Triad that indicates surgical therapy for chron's disease
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abdominal pain, diarrhea, slow progressive weight loss.
These patients can have colicky pain due to abdominal obstruction. There is no blood unless they perf. |
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6 causes of small bowel obstruction.
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hernia, adhesions, volvulus, intrassusception, chron's, gallstone ileus.
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Contrast SBO vs. paralytic ileus.
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SBO: increased risk with prior abdominal surgeries, hernias, vague abdominal sx. exam shows n/v/, abdominal distension, normal/increased BS. XR shows gas only in small intestine
Paralytic ileus: history of narcotic use, bed rest, trauma, sepsis, hypothyroidism, anesthesia. Exam shows minimal pain, n/v/, distension, absent BS. XR shows gas in both small intestine and colon. |
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Contrast SBO and colonic obstruction etiologies and diagnostic procedures.
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SBO etiologies: hernia, adhesions, volvulus, gallstone ileus, chron's disease,
vs colonic etiologies of adenocarcinoma, diverticular scarring and inflammatory disorders. Dx. SBO with CT, endoscopy with small bowel follow through. Dx. colonic obstruction with barium enema and colonoscopy. |
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Diagnosis and treatment for SBO
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Diagnose with small bowel follow through or CT contrast studies. CBC, BMO, UA to look for stones, Correct fluid/electrolyte imblances. NG placement for decompression. NPO. Surgery in 24-48H if no improvement. Give abx. preoperatively.
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s/s and causes of peritonitis.
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acute abdomen with fever, leukocytosis, board like abdominal rigidity. Tx with volume resuscitation. Abx or aerobic, anaerobic and Gram neg bacteria.
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Most common sitres of intra abdominal abscesses.
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pelvis, morrison's pouch (betwen liver and kidney), subphrenic, paracolic gutters, periappendiceal, lesser sac.
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