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129 Cards in this Set
- Front
- Back
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Calot's Triangle: borders and what passes thru? |
Hepatobiliary triangle:
medially: common hepatic duct inferiorly: cystic duct superiorly: liver cystic artery (& sometimes R hepatic artery) passes thru, Calot's node |
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Small ducts that drain bile directly into the gallbladder from the liver?
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Ducts of Luschka
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Which artery is susceptible to injury during cholecystectomy? Why?
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R hepatic artery, because of its proximity to the cystic artery (cystic a comes from hepatic) and Calot's Triangle
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Name of the valves of the gallbladder?
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spiral valves of Heister
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Where is the infundibulum of the gallbladder?
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near the cystic duct
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What is the source of alkaline phosphatase?
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Bile duct epithelium.
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Is alk phos elevated or depressed in bile duct obstruction?
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Elevated.
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What is in bile (4)?
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cholesterol
lecithin (phospholipid) bile acids bilirubin |
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What does bile do?
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Emulsify fats
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What is the enterohepatic circulation?
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circulation of bile acids from liver to gut and back to the liver
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Where are most of the bile acids absorbed?
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terminal ileum
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What stimulates gallbladder emptying (2)?
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CCK and vagal input
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What is the source of CCK?
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duodenal mucosal cells
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What stimulates the release of CCK?
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fat, protein, amino acids, HCl
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What inhibits the release of CCK?
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Trypsin and chymotrypsin
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What are the actions of CCK (4)?
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Gall bladder emptying
Opening of ampulla of Vater Slowing of gastric emptying Pancreas acinar cell growth and release of exocrine products |
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At what level of serum total bilirubin does one start to get jaundiced?
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>2.5
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What is thought to be the anatomic location where one first finds evience of jaundice?
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under the tongue
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With good renal fx., how high can the serum total bilirubin go?
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very rarely, >20
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What are the Si/Sx of obstructive jaundice (6)?
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Jaundice
Dark Urine Clay colored stool (acholic) Pruritus Anorexia Nausea |
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What causes the itching in obstructive jaundice?
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BILE SALTS (not bilirubin) in the dermis
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Cholelithiasis
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Gallstones in gallbladder
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Cholecystitis
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Inflammation of gallbladder
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Choledocholithiasis
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Gallstone in common bile duct
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Cholangitis
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Infection of the biliary tract
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cholangiocarcinoma
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adenocarcinoma of bile ducts
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Klatskin's tumor
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Cholangiocarcinoma of bile duct at the junction of the R and L hepatic ducts
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Biliary colic - What? Where? When?
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Pain due to gallstones usually at cystic duct. Located in the RUQ, epigastrium or R subscapular region. Usually postprandial, esp fatty foods.
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ERCP
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Endoscopic Retrograde CholangioPancreatography
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PTC
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Percutaneous Transhepatic Cholangiogram
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IOC
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IntraOperative Cholangiogram (lap or open to r/o choledolithiasis)
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Types of biliary tract radiographic evaluations (5)
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Abdominal films
US ERCP PTC HIDA/PRIDA |
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Initial diagnostic study of choice?
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US
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Kocher incision?
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Right subcostal incision
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Sphincterotomy?
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cut through spincter of Oddi to allow passage of gallstones from common bile duct; most often done at ERCP
aka: papillotomy |
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What is obstructive jaundice?
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Jaundice due to obstruction of bile flow to the duodenum (hyperbilirubinemia >2.5)
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Initial study of choice for obstructive jaundice?
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US
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Labs assoc. with obstructive jaundice?
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Elev. alk phos; elev. bilirubin with or without elev. LFTs
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Incidence of cholelithiasis?
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(formation of gallstones) 10% of US pop.
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Risk Factors for Gallstones?
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Four "Fs": Female, Fat, Forty, Fertile
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Two types of stones?
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Cholesterol stones (75%) and pigment stones (25%)
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Types of pigmented stones?
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Black: calcium bilirubinate
Brown: biliary tract infxs |
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Cause of black-pigmented stones?
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Cirrhosis, hemolysis
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Pathogenesis of cholesterol stones?
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Secretion of bile supersaturated with cholesterol
Cholesterol ppt's out and forms solid crystals --> gallstones |
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Is hypercholesterolemia a risk factor for gallstone formation?
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NO - hyperlipidemia is
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Boas' Sign?
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referred R subscapular pain of biliary colic
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4 complications of gallstones?
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acute cholecystitis
choledocholithiasis gallstone pancreatitis gallstone ileus |
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MCC of acute pancreatitis?
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gallstones
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How often does US detect cholelithiasis vs. choledocholithiasis?
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98% v. 33% of the time
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4 possible complications of lap chole?
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CBD injury
R hepatic duct/artery injury cystic duct leak biloma (collection of bile) |
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Indications for a cholecystectomy in an asymptomatic patient?
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SCD
porcelain/calicified GB child large gallstone >2-3cm |
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IOC - what is it?
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IntraOperative Cholangiogram: dye in bile duct by way of cystic duct with fluoro/xray
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Meds to dissolve a cholesterol gallstone?
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Chenodeoxycholic acid
ursodeoxycholic acid (Actigall) |
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Pathogenesis of acute cholecystitis?
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obstruction of cystic duct that leads to inflammation of the gallbladder; 95% due to calculi, 5% acalculus
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Si/Sx of acute cholecystitis?
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UNRELENTING RUQ pain
Painful palpable GB F/N/V + Murphy's sign R subscapular pain epigastric discomfort |
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Lab results assoc. with acute cholecystitis?
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Increased WBC
slight elev. in alk phos, LFTs slight elev. in amylase, t. bili |
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Diagnostic test of choice for acute cholecystitis?
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US
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Signs of acute cholecystitis on US (5)?
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thickened GB wall (inflamm)
pericholecystic fluid distended gallbladder gallstones sonographic Murphy's sign |
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Tx of acute cholecystitis?
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IVFs
Abx cholecystectomy |
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Pathogenesis of acute acalculus cholecystitis?
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GB disuse and biliary stasis - perhaps 2ary to absence of CCK
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Risk factors for acute acalculus cholecystitis?
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Prolonged fasting
TPN Trauma Multiple tranfusions Dehydration Prolonged postop or ICU setting |
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Diagnostic test of choice for acute acalculus cholecystitis?
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US
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Management of acute acalculus cholecystitis?
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cholecystectomy or cholecystostomy tube (if pt. is unstable)
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What is cholangitis?
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Bacterial infx of biliary tract due to obstruction; potentially life threatening
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Common causes of biliary tract obstruction?
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Choledocholithiasis
Stricture (postop) Neoplasm (ampullary) Extrinsic compression (pancreatic pseudocyst/pancreatitis) ERCP/PTC Biliary stent |
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MCC of cholangitis?
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choledocholithiasis (gallstones in the CBD)
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Si/Sx of cholangitis?
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Charcot's triad: f/c; RUQ pain; jaundice
Reynold's pentad: Charcot's + altered mental status + shock |
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Charcot's Triad
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f/c
RUQ pain jaundice |
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Reynold's Pentad
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Charcot's: f/c, RUQ pain, jaundice
altered mental status shock |
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Lab results assoc. with cholangitis?
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Increased WBC
Increased bilirubin Increased alk phos |
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Organisms most commonly isolated with cholangitis?
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GNO (E. coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia)
MC GP: Enterococci |
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Diagnostic tests of choice for cholangitis?
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US followed by contrast study (PTC or ERCP) after pt. has "cooled off" with IV abx.
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What is suppurative cholangitis?
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severe infx with sepsis (pus under pressure)
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What other vessels besides the LIMA and SVG are occassionally used for grafting?
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Gastroepiploic and inferior epigastric veins
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Dressler's syndrome?
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pericarditis after an MI
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What is used to anticoagulate during CPB? How is it reversed?
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Heparin, reversed by Protamine
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What is heparin rebound?
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Incr. anticoagulation after bypass due to incr. heparin levels
increase in peripheral blood flow after bypass returns heparin residual that was in the peripheral tissues |
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What is the method of lowering SVR (Systemic Vascular Resistance) after bypass?
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Warm the pt.
sodium nitroprusside (SNP) dobutamine |
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Sodium nitroprusside?
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Nitric oxide
peripheral vasodilator of both arterioles and venules - but more venules |
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dobutamine?
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sympathomimetic drug - stimulates B1 receptors - positive inotropic effect
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3 main cardiac electrolytes
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1. Ca - inotropic
2. K - arrhythmias 3. Mg - arrhythmias |
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Sx. of aortic stenosis
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(Aortic Stenosis Complications)
1. Angina 2. Syncope 3. CHF 5-3-2 |
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Si. of aortic stenosis
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murmur: crescendo-decrescendo systolic second right intercostal space with radiation to the carotids
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Causes of Aortic Insufficiency
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Bacterial endocarditis (S. aureus, S. viridans)
Rheumatic Fever Annular ectasia due to collagen vascular disease (Marfan's) |
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Causes of Aortic Stenosis
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Calcification of bicuspid aortic valve
Rheumatic Fever Acquired calcific aortic stenosis (80-90 y/o) |
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Sx. of aortic insufficiency
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1. Palpitations - arrhythmias and dilated LV
2. Dyspnea/orthopnea - LV failure 3. Angina - decreased diastolic BP and coronary flow |
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Austin Flint Murmur
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reverberation of regurgitant flow
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Water hammer pulse is most often associated with what?
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aortic insufficiency
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Symptoms of mitral stenosis
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1. Dyspnea - increased LA pressure causing pulmonary edema
2. Hemoptysis 3. Hoarseness - dilated LA impinging on recurrent laryngeal nerve |
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Signs of mitral stenosis
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crescendo diastolic rumble at apex
irreg. pulse from afib due to dilated LA stroke due to systemic emboli from LA (afib + obstructed valve allows blood to pool in LA --> thrombus formation) |
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MCC of post-op fever during POD 1 and 2
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atelectasis - collapse of alveoli
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In a healthy adult, what is the largest component of his/her body by mass?
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water
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ICU: arterial catheter is used for?
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blood pressure
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ICU: pulmonary artery catheter is used for?
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cardiac outputs, pulmonary artery wedge pressures, mixed venous oxygen saturation
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ICU: intracranial catheter is used for?
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intracranial pressure monitoring
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Information gathered from the pulmonary artery catheter?
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1. LA and LV preload pressures (balloon)
2. CO (heat) 3. SVO2 (mised venous oxygen saturation (aspirate) 4. SVR and PVR (calculate) |
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Order of hemostasis?
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1. Constrict
2. Plug (platelet) 3. Clot (intrinsic/extrinsic) 4. Dissolve (fibrinolytic) |
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Neck Sx. + perioral/extremity numbness
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hypocalcemia
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MCC hypocalcemia
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parathyroid sx. to treat hypercalcemia
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Most reliable measurement of arterial blood pressure?
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arterial line mean
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Delayed primary closure is appropriate for what type of wounds?
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Contaminated
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What kinds of wounds should heal by secondary intention?
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Infected
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4 things that inhibit resolution of fistulas
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1. distal obstruction
2. infx. 3. foreign body (suture) 4. epithlialization |
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Cardiac arrhythmia + sudden onset of severe abdominal pain + gut emptying
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Triad for embolic mesenteric ischemia
surgical emergency! Tx: vigorous rehydration then arteriography to confirm then embolectomy |
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Why are bilateral carotid endarterectomies usually not performed?
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risk of recurrent laryngeal nerve trauma - if b/l, could result in a tracheostomy
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Persantine thallium scan
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non-exercise stress test
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impedance phlebography
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measures small changes in electrical resistance --> blood volume changes
indirectly indicates presence/absence of venous thrombosis |
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Initial treatment of DVT
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IV heparin therapy
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When to wean someone from mechanical ventilation?
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vital capacity >15ml/kg
Neg. Inspiratory Force of at least -20 |
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Why is mannitol administered to head-injured patients?
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temporarily decreases intracranial pressure allowing time to accurately diagnose
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Major variables contributing to increased perioperative risk during major NONCARDIAC surgery
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1. CAD
2. AS 3. arrhythmia 4. h/o MI 5. CHF 6. age >70 7. surgical emergencies |
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significantly increased calcitonin levels
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C-cell hyperplasia of thyroid
occult medullary carcinoma |
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intrinsic factor comes from?
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parietal cells
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What POD do UTI's usually occur?
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POD 3-5
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Common causes of Post-Op Fever?
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5 W's
Wind (POD 1-3) Water (POD 3-5) Wound (POD 5-8) Walk Wonder drug |
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isograft
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tissue transfer between two genetically identical ppl (twins)
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heterotopic
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transplant in a different position (kidney)
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orthotopic
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transplant in to the same position (liver)
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single most important factor affecting prognosis for oropharyngeal cancer
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presence of nodal disease
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high fever + new cardiac murmur in IV drug user
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endocarditis
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large air leak + failure of expansion s/p chest tube insertion
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suspect bronchial injury - broncoscopy
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MC benign tumor found in liver
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hemangioma
Tx: observation, if asymptomatic |
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uncomplicated cystitis should be tx'd with abx for how many days
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1-3 days
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MC lung carcinoma
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adenocarcinoma
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Pancoast tumor
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superior sulcus
Horners |
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MC skin cancer
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basal cell carcinoma
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best initial screening for suspected cardiac contusion
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EKG - cardiac arrhythmias commonly seen in cardiac contusion pts.
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MC presentation of carcinoma of the bladder
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painless hematuria
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Classic Sx. of achalasia
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dysphagia
bird's beak deformity |
