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38 Cards in this Set
- Front
- Back
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All of the following are true except: a. The 1st branch off the superior mesenteric artery (SMA) is the inferior pancreatico-duodenal artery. b. The division between the 3rd and 4th portioms of duodenum is the SMA c. The 2nd and 3rd portions of the duodenum are retroperitoneal d. The 3rd portion of the duodenum contains the Ampula of Vater e. The SMA provides blood flow from the 3rd portion of the duodenum to the proximal 2/3 of the transverse colon |
Answer d. The 2nd portion of the duodenum contains the Ampula of Vater. |
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All of the following are true except: a. Brunner's glands secrete alkaline solution b. Goblet cells secrete mucus solution c. Diarrhea in Carcinoid syndrome is from serotonin d. 5-HIAA is the most sensitive test sensitive for detecting carcinoid tumors e. The primary fuel for small bowel enterocytes is glutamine. |
Answer d. Chromogranin A is the most sesitive test for detection of carcinoid tumor (almost 100% have it) but it would not give location. |
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All of following are true of duodenal diverticula except: a. These should be observed unless highly symptomatic b. The MC location is the 3rd portion of the suodenum c. A chole-duodenal fistula should be ruled out in these patients d. The duodenum is the MC small bowel location for diverticula e. If biliary obstruction is a significant symptom, hepatico-jejunostomy is indicated. |
Answer b. The MC location is the 2nd portion of the duodenum |
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You are considering stricturoplasty in a patient with Crohn's disease. Which of the following is true: a. Recurrent surgical Crohn's after stricuroplasy is most likely to occur in previous stricturoplasty sites b. A 15 cm stricture is best treated with lomgitudinal enterotomy and transverse closure. c. A 5 cm structure is best treated with side to side anastomosis type stricturoplasy d. Longitudinal incision should be made through the anti-mesenteric brothder |
Answer d. Longitudinal icision should be made through the anti-mrsenteric border. Structures<10cm are treated with longitudinal enteroctomyand transverse closure. Strictures 10-25 cm are treated with side to side is ,pst likely to occur in non-stricturoplasty sites. |
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All of the following are true of Crohn's disease except: a. The MC site of occurence is the treatment ileum b. Large perineal skin tags are common c. Surgery is curative d. Peritoneal fistula are usually treated conservatively e. It is more prevalent in smokers. |
Answer c. Unlike UC, surgery is not curative for Crohn's disease. |
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A 35 yo woman with Crohn's disease is started on infliximab and Flagyl for peri-anal fistula. All of the following are true of Infliximab therapy except: a. The MC serious infection in patients taking Infliximab is tubreculosis b. Aggressive surgical resection is inidicated for peri-anal fistulas from Crohn's disease. c. Isoniazid is indicated for patients with a positive PPD d. Long term Flagyl is associated with peripheral neuropathy |
Answer b. Conservative Tx is indicated for Crohn's peri-anal fistulas. |
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All of the following are true of Crohn's disease except: a. Refractory stictures involving the 3nd and 4th portionos of the duodenum would likely benefit best from resection with a 2cm gross margin and duodeno-jejunostomy b. Short strictures in the jejunum and ileum can be treated with stricturoplasty to avoid resection and conserve bowel. c. A Whipple is likely the best treatment for refractory structures in the 1st and 2nd portion of a duodenum d. Creeping mesenteric fat is considered pathognomonic of Crohn's |
Answer c. Duodenal Crohn's disease is unsual. Tx for a refractory structures in the 1st and 2nd portion is gastro -jejunostomy and vagatomy (no Whipple, also can't really perform stricturoplasy here). Some type of vagatomy is needed to avoid marginal ulcers after gastro-jejunostomy. |
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All of the following are true of Crohn's disease except: a. The best maintenance Tx for mild Crohn's disease (eg colitis, ileocolitis) is sulfasalazine b. The best Tx for acute Crohn's exacerbration is corticosteroids c. Aphitohus ulcers are the earliest lesion suggestive of Crohn's d. The MC of mortality small bowel fistula is liver failure e. It is MC in patients pf high socioeconomic status. |
Answer d.. The MCC of mortality with small bowel fistula (in Cronh's or other diseases; also includes other types of fistuulas) is sepsis . Early drainage of any associated abcess and antibiotics are indicated. |
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A 45 woman with Crohn's pancolitis has several areas of dysplasia on surveillance. The most appropriate next step is: a. Total procto-colectomy and ileostomy b. Continued surveillance c. Total procto-colectomy and ileonal pouch d. Segmental colectomy only |
Answer a. Total procto-colectomy and ileostomy. Because of the diffuse nature of the Crohn's and the finding of dysplasia, total procto-colectomy is indicated. Pouch formation is contraindicated in Crohn's disease (high risk of complications and pouch failure) |
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A patient undergoes resection of small bowel carcinoid and an isolated liver metastasis. Two years later she develops vague abdominal complaints but you cannot identify any new lesions on CT scan. The best localize recurrent carcinoid tumor is: a. HIDA scan b. MIBG scan c. Octerotide scan d. MRI |
Answer c. Octerotide scan is the most sensitive diagnostic test for localizing a carcinoid tumor not apparent on CT scan |
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All of the following are true of carcinoid tumors except: a. The MC site for carcinoid tumor and the site with teh highest malignant potential is the ileum. b. Octreotide is very effective Tx for metastatic carcinoid tumors c. Chromogranin A is the most sensitive test for detecting carcinoid tumors (essentially 100% have this) d. The 5-YS for carcinoid tumor with metastases is 5% e. Acute carcinoid crisis is best treated with octeotide. |
Answer d. The 5-YS for carcinoid with metastases is 35%. Pallation is an important part of Tx for these patients (can survive a long time) |
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All of the following are true of appendicitis except: a. The MCC in children is lymohiud tissue b. The MCC in adults is fecalith It is due to a closed loop obstruction d. The MC rupture site is the anti-mesenteric border e, CT scan has decreased negative laparothomy rate. |
Answer d. CT scan has not decreased negative laparothomy rate. |
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All of the following are true of appendicitis except: a. It is more common in males than females (3:1) b. Perforation rate is higher in children and the elderly c. The appendiceal artery is a branch of the right colic artery d. Right lower quadrant pain is due to peritoneal irritation e. Nausea, vomiting visceral pain, and at times diarrhea are due to luminal obstruction and distension of the visceral peritoneum (afferent autonomic nervous system) |
Answer c. The appendiceal artery is a branch of the oleocolic artery. |
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Laparoscopic compared to open surgery for appendendicits is associated with all of the following except: a. Decreased length of stay b. Earlier return to workLower abscess rate d. Lower wound infection rate c. |
Answer c. Abscess rate is about the same for laparoscopic and open procedures |
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A 9 yo boy presents with abdominal pain, somewhat localized to the RLQ. He is diffusely tender. He has had an upper respiratory tract infection (URI) for a few days. CT scan shows adenopathy near the terminal ileum and cecum. All of the following are true this patient most likely diagnosis except: a. Yersinia, shigella, and campylobacter are frequently involved b. This can often occur following and antecedent URI c. Emergency appendectomy is indicated d. Antibiotics may be indicated e. This MC occurs in children |
Answer c, This patient has mesenteric lymphadenitis, so appendectomy is not indicated. The MC organism involvin mesenteric lymohadenitis is yersinia enterocilitica. |
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You perform an appendectomy an a 25 man for presumed appendicitis and find a 1 cm tumor at the tip of the appendix. Pathology comes back on the tumor as carcinoid. The most appropriate next step in management is: a, Right hemicolectomy b. Close c. XRT post-op d. Chemotherapy post-op |
Answer b (see below) |
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You operate on 25 yo man for presumed appendicitis based on CT scan and find a 2.5cm tumor at the tip of the appendix. PAthology comes back on the tumor as carcinoid. The most appropriate next step in management is: a, Right hemicolectomy b. Close c. XRT post-op d. Chemotherapy post- |
Answer a. Appendectomy is adequate teatment for carcinoid tumors localized ti the appendix as long as they are < 2 cm,not at the base, and there is not eivdence of mesenteric lymph node invasion or metastatic disease. If the above criteria not met, perform right hemi-colectomy. Carcinoid tumors have the best 5-YS (85%) of appendiceal malignances.
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All of the following are true of appediceal tumors except: a. The mC benign is non-malignant carcinoid b. The MC malignant tumor is adenocarcinoma c. The MC peresentation for appendiceal adenocarcinoma is bowel obstruction d. The MC malignant subtype is mucinous adenocarcinoma |
Answer c. The MC presentation for appendiceal adenocarcinoma is acute appendicitis. |
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All of the following are true of rectal carcinoid except: a. Carcinoid syndrome is common with rectal carcinoids b. For patients with rectal carcinoids > 2cm, 70% have metastases. c. Small (<2 cm) low rectal carcinoids can undergo local excision d. Muscularis propria invasion requires resection. e. Alpha interferon is more effective than cyclophosphamide and 5-FU |
Answer c. Carcinoid syndrome is common with rectal carcinoids Small (<2cm ) low rectal carcinoids can undergo local excesion. If large (>2 cm) or if invanding the muscularis propria, low rectal carcinoids require formal resection (eg APR) |
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A patinets has localized adenocarcinoma confined ti the junction of the 3rd and 4th portions of the duodenum. Which of the following is most appropriate for this patinet: a. Pancreatico-duodenoctomy b. Distal pancreatectomy and duodenal resection c. Duodenal resection with duodenal-jejunal anastomosis d. Duodenal resection and splenoctomy |
Answer c The best option for distal duodenal CA is remove the 3rd and 4th portions of the duodenum and perform duodenal jeunal anastomosis (not perform a Whipple). Take the duodenum all the way past the ligament of Treitz. adenocarcinoma in the 1st and 2nd portions of the duodenum usually requires Whipple (high likelihood the Ampula is involved) |
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All of the following are true of small bowel tumors except: a. Adenocarinoma is the MC malignant small bowel tumor, with a high propertion arising from the duodenum (40%) b. The duodenum is the MC location for small bowel adenomas c. Ampullary villos adenomas rarely harbor occult CA d. Obstructive jaudince with heme positive stools is classic for amullary villous adenoma (or carcinoma) |
Answer c. Up to 70% of ampullary villous adenomas have CA in them |
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ll of the following are true of lymphoma except: a. Isolated small bowel lymphoma outside 1st and 2nd portions of the suodenum is generally resected b. Isolated pancreatic lymphoma usually requires Whipple c. The MC small bowel site for lymphoma is the ileum d. B cell is the MC type of Lymphoma (Non-Hodgkin's lymphoma) |
Answer b. isolated pancreatic lymphoma should undergo chemo +/- XRT |
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At laparothomy, you find copious amounts of yellowish -gray gelatinous ascites. Which of the following is the most likely source: a.Ovarian mucinous adenocarcinoma b. Appendix mucinous adenocarcinoma c. Pancreatic cyst-adenocarcinoma d. Choledochocyst |
Answer b. The MCC of pseudomyxoma pertonei is appenix mucinous adenocarcinoma. |
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The MC source for pseudomayxoma peritonei is the: a. Ovary b. Stomach c. Appendix d. Colon |
Answer c. Appendix |
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All of the following are true of a mucocele of the appendix except: a. Benign lesions can be left alone b. Pseudomyxoma pertonei is the most dreaded complication c. These may have malignant or benign etiologies d. MCC of death with pseudomyxoma peritoneai is small bowel obstruction e. Gelatinous ascites with peritoneal implants may be present. |
Answer a. Benign mucoceles of the appendix a should undergo appendectomy. Muccoceles of the appendix can arise drom either a retention cyst, mucosal hyperplasia, mucoinous adenoma, or mucinous adenocarcinoma. The mucocele fills with mucoid material and can eventially rupture. |
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The most appropriate Tx for pseudomyxoma peritonei is: a IV chemo only b. Chemo-XRT c. Palliative care only d. Peritoneal catheter drainage of mucoid material e. Cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy |
Answer e. Cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy are appropriate for pseduomyzoma peritonei especially in young patients. These patients can often go to live productive lives. |
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All of the following are true except: a. The MC malignant tumor of the appendix is denocarcinoma b. Chromogranin A level is the most sensitive test for the diagnosis of carcinoid c. The ileum is the MC site for carcinoid tumor. d. The appendix carcinoid is the site with the highhest risk for carcinoid syndrome and metastases e. Tricuspid insufficiency is the MC cardiac valve problem in patients with Carcinoid Syndrome |
Answer d. Carcinoid of the ileum has highest risk for carcinoid syndrome and metastases |
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All of the following are true of appendiceal adenocarcinoma except:
a. The MC presentation is acute appendicitis b. These patients should undergo appendectomy only c. Variants can lead to pseudomyxoma peritoneo d. These tumors have a propensity for early rupture |
Answer b. These patients should undergo right hemicolectomy |
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All of the following are true of intussusception in adults except: a. Most commonly there is a malignant lead poit b. Barium reduction should be performed for ileo-colic intussuception c. The MC scenario in adults is the ileum going into the right colon d, Cecal adenocarcinoma is the MC lead point in adults |
Answer b. Barium enema and air contrast enema reduction are not indicated for adult intussusception.The MC adult scenario is a cecal adenocarcinoma forms the lead point and peristalsis takes the tumor and ileum into right colon, forming the intussusception |
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The most approprite procedure for most adults with ileo-colic intussusception is: a. Barium enema reduction b. Manual reduction d. Air-contrast reduction e. Ileo-colic resection without reduction. |
Anwer e. Ileocolic resection (+ ileocolic anastomosis) without reduction. Do not reduce in the OR as this increases the risk of tumor spread through veins and lymphatic in the cecum. |
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Concerning short bowel syndrome, all of the following are true except: a. This is a clinical diagnosis of inability to absorb enough water and nutritional elements to be off TPN b. The length of bowel in general needs to be at least 75 cm if there is no ileo-cecal valve in order to live without TPN c. The length of bowel in general needs to be at least 50 cm if the ileo-cecal valve is present in order to live off TPN d. High fat diets can help with the syndrome e. Resection of the jejunum is better tolerated than ileal resection. |
Answer d. Short gut syndrome is a clinical diagnosis of inability to maintain appropriate hydration and nutrition without the use of TPN. High fat diets will worsen short bowel syndrome. An early low fat, high protein, high carbohydrate diet is indicated to help intestal adaptation and prevent villous atrophy. |
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You perform laparoscopy on a 25 yo man for presumed appendicitis and find terminal ileitis with edematous mesentery and lymphadenopathy. The cecum is not involved. The iletitis area is non-obstructing. The most appropriate next step in management is: a. Appendectomy b. Close c. Place a drain d. Ileal resection |
Answer a. Patients with presumed appendicitis at surgery but instead have terminal ileitis not involving the cecum should undergo appendectomy so that confusion of ileits with appendicits will not occur in the future. This is the same for ruptured ovarian cyst endimetrosis, thrombosed ovarian vein. Mittlschmerz etc. |
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All of the following are true except of small bowel cutaneous fistulas except: a. The MCC of mortality is sepsis b. Distal obstruction should be ruled out c. Cancer recurrsence is a possibly d. They often occur in imflammatory bowel disease e. Surgery is the primary tgerapy |
Answer e. Conservative Tx is the primary therapy and will help resolve most fistulas. |
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A 65 yo man with previous LAR and chemo-XRT has crampy abdominal pain, nausea and vomiting. He has the following values BP 85/50, HR 110 sodium 150. He has not made urine in the past 24 hours. CT scan reveals a small bowel obstruction with a decompressed distal colon. The most appropriate next step is: a/ Emergent surgery and bowel resection b. Fluid resuscitation c. Palliative care d. Colonoscopy |
Answer c. Fluid resuscitation is appropriate for this patient at this stage. |
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After fluid resuscitation, you explore the above patient and find a moderate amount of matted small bowel. All of the following are true except: a. Bowel resection could result in short bowel syndrome b. Biopsies should be taken to check for tumor recurrence c. Lysis of adhesionsaround the matted bowel carries a high risk of bowel injury d. Entero-enteric bypass can result in a blind loop bacteria proliferation e. If cancer is found, nothing further should be done. |
Answer e. If cancer is found, palliation with entero-enteric bypass or possibly even resection should be performed |
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All of the following are true of appendicitis in pregnancy except: a. The highest RF for fetal mortality is appendiceal ruprure b. RUQ pain is often found in the 3rd trimester c. Fetal loss is 5-10% d. Premature labor occurs in the 10-15% e. Laparoscopic approach is strongly recommended if in the 3rd trimester |
Answer e. Due to the enlarged uterus, laparoscopy is difficult in the 3rd trimester and an open procedure is often best (mark the site of maximal tenderness before putting the patient to sleep - appendix will be more cephalad than usual) |
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A 25 yo man undergoes open appendectomy for perforated appendicitis and on POD 4 is noted to have stool emanating from his RQL incision. The most appropriate next step is: a. Cecostomy tube b. Right hemicolectomy c. Stoma device over the incision d. Percutaneuos drainage only e. Washout, attempt closure of cecum and place drains. |
Answer e. This patient has an appendix stump blow out. Potential consequences of this include peritonitis, sepsis abscess, and necrotizing soft tissue infection. Adhesions have not formed yet (too early - only POD 4) so the leak is not likely contained. Washout, attempt closure of cecum and placement pf drains is appropriate |
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A 70 yo man presents with a 5 day history of RLQ pain, WBCs 16 with a left shift, and a mild fever. He has mild localized tendernes in his RLQ but no gross peritonitis. CT scan shows a plehgmon near the cecum and you cannot identify an appendix, All of the following are true in this patient's management excepts: a. He should be started on IV antibiotics and bowel rest b. If an absces is identified, it should be drained percutaneosly c. This patient should undergo emergent surgery d. Symptoms can be minimal in this population |
Answer c. Perforated appendicitis with delayed predentation and subsequent phelegmon formation is MC in the elderly who can have reduced Sx's from appendicitis. Surgery at this time point (well after the time of rupture) has a high Cx rate and should be avoided. |
