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DU PA GI Surgery
Duke PA Gastrointestinal Surgery
| Question | Answer |
|---|---|
| implies severe abdominal pain arising rather suddenly and of less than 24 hours duration | acute abdomen |
| pain arising from the foregut (stomach, pancrease, duodenum and biliary tree) localizes to the | epigastrum |
| pain from structures arising from the midgut (small bowel, and right transverse colon) localizes to the | periumbilical region |
| pain from structures arising from the hindgut (left colon, sigmoid colon, rectum) localizes to the | hypogastric region |
| intermittent colicky, poorly localized abdominal pain is found with | GI Tract obstruction |
| steady, well localized pain usually occurs after | perforation, ischemia, inflammation, or hemorrhage |
| classic signs and symptoms are mild fever and focal right lower quadrant pain with rebound tenderness | appendicitis |
| commonly occurs in women between the ages of 40-60 who are overweight and have a previous history of pregnancy | acute cholecystitis |
| patients will have right upper quadrant pain that is accentuated on inspiration, and is accompanied by nausea and vomiting | acute cholecystitis |
| Murphy's sign | acute cholecystitis |
| McBurney point | appendicitis |
| laparoscopic approach has been proven safe in both acute and chronic settings | cholecystitis |
| pain that localizes to right lower quadrant accompanied by anorexia, nausea, and vomiting is classic | appendicitis |
| the normal anatomic position of the appendix | anterior intraperitoneal |
| results in an increased risk of perforation due to delayed diagnosis | hidden position of appendix |
| during the 5th month of pregnancy the appendix may rise as high as the | right upper quadrant |
| in western populations the lifetime risk of appendicitis is __% | 7 |
| appendicitis is primarily a disease of | adolescents and young adults |
| incidence of ____ declines after age 30 | appendicitis |
| ____ is seen in approximately 70% of appendicitis cases | obstruction of the appendiceal lumen |
| the appendiceal lumen can be obstructed by | fecaliths, foreign bodies, tumors, parasites, and lymphoid hyperplasia |
| the number of ___ in the vermiform appendix peaks between the ages of 10-30 | lymphoid follicles |
| rare causes of appendicitis | diverticula, and duplications |
| after obstruction of the appendiceal lumen ___ continue | mucosal secretions of lining cells |
| ___ follows appendiceal obstruction | bacterial overgrowth and increased intraluminal pressure |
| ___ which ultimately leads to ulceration, necrosis, gangrene, and perforation | increased intraluminal pressure causes vascular congestion |
| ____ alone should make the diagnosis of acute appendicitis in most patients | history and physical exam |
| after 1-12 hours of diffuse mild to moderate pain, appendicitis pain will usually | migrate to the right lower quadrant and become more intense |
| Vomiting and diarrhea may be present in acute appendicitis but ___ | are usually not excessive |
| if vomiting precedes abdominal pain or if anorexia is not present ____ | the diagnosis of appendicitis should be questioned |
| ___ should be present in 75%-85% of all patients with acute appendicitis | fever |
| a temperature will rarely be highter than __ unless the appendix is grossly perforated | 38 degrees |
| with appendicitis vital signs are | usually normal with slight tachycardia due to pain, fever, or dehydration |
| patients with acute appendicitis prefer to | lie motionless |
| patients with colicky-type pain may appear | restless |
| palpation of left lower quadrant causing right lower quadrant pain | Rovsing's sign |
| deep palpation of right lower quadrant followed by a sudden release | rebound examination |
| asessing for rebound tenderness can lead to a | false positive |
| a positive ___ sign may indicate an inflamed appendix lying anterior to the ___ muscle | psoas |
| this sign is best demonstrated by extension of the hip or flexion against resistance | psoas sign |
| ___ is produced by stretching this muscle with passive internal rotation of the thigh, with the hips in a flexed position | obturator sign |
| both the obturator and psoas signs are | non-specific and only present on occasion |
| a ___ exam is also important in evaluating any patient with abdominal pain | rectal |
| tenderness with a rectal exam is most commonly seen when the inflamed appendix lies | within the pelvis |
| ____ on fecal exam should be quite rare and lead to the consideration of a diagnosis other than appendicitis | gross blood |
| administer prophylactic antibiotics | before incision |
| the base of the appendix is located at | the junction of the three tenia |
| the ___ lies posterior to the cecum or terminal ileum | appendiceal artery |
| after incision if appendicitis is not present | a thourough search for other pathology is important |
| consider ___ of the wound for advanced and perforated appendicitis | open packing |
| the gold standard for the treatment of appendicitis is | exploratory laparotomy, and appendectomy |
| laparotomy can be accomplished through a ____ incision | McBurney |
| this is an oblique incision, which divides the fascia parallel to its fibers, and a muscle splitting technique is used (used for appendicitis) | McBurney incision |
| a right-lower-quadrant transverse ___ incision is preferred by many for appendicitis | Rocky-Davis |
| in the elderly where other disease processes may be encountered, many surgeons would prefer a ____ incision | lower midline laparotomy |
| ____ are usually indicated if a well-formed intraabdominal or pelvic abcess is encountered | intraabdominal drains |
| if a case of perforated appendicitis with generalized peritonitis is encountered, the wound should be considered grossly contaminated and | packed open for closure by second intention or a delayed primary closure |
| incindental appendectomy should not be performed if ___ is found to be affecting the cecum, as the incidence of fistulization may be quite high | Chron's Disease |
| as a diagnostic procedure ____ is by far the most accurate, but it is invasive | laparoscopy |
| laparoscopic appendectomy is especially useful | when the diagnosis is in question |
| laparoscopic appendectomy is especially useful | in women of reproductive age |
| laparoscopic appendectomy is especially useful | in obese patients |
| laparoscopic appendectomy is especially useful | in the elderly |
| antibiotic therapy in early appendicitis | should be of short duration |
| in uncomplicated appendectomy patients should be moved to a diet and discharged within ___hours | 24-48 |
| ___ complications are by far the most frequently seen problem after appendectomy | septic |
| once a wound infection is diagnosed the primary treatment is | to open the wound and to allow drainage of the purulent material |
| if cellulitis is present in an infected wound | antibiotics are indicated |
| early recognition, aggressive surgical debridement, and administration of broad spectrum antibiotics are critical in | necrotizing fasciitis |
| ___ is the result of the abdominal host defenses attempting to wall off an infectious threat | abscess |
| drainage and antibiotics are the treatments for | postoperative abscess |
| an abscess after appendicitis most commonly occurs in the | right paracolic gutter, pelvis, or intraloop position |
| the most common treatment for postoperative abscess is | CT-guided catheter drainage |
| the radiographic finding of air in the portal vein | pylephlebitis |
| this is a rare presentation of an advanced septic process due to gas-forming organisms | pylephlebitis |
| is often seen in the elderly, immunocompromised, or in advanced sepsis, and is often a preterminal finding | pylephlebitis |
| appendicitis is seen in approximately 1 in ___ pregnancies | 2000 |
| the most common nonobstetric emergency in pregnant women | appendicitis |
| WBC count in a pregnant woman is unreliable, however a ___ can be seen in appendicitis | left shift |
| the risk of conventional diagnostic radiographs such as a KUB or CT scans is ___ after the first trimester | negligible |
| abdominal wall hernias occur in __% of the United States population | 1.5 |
| a cleft in the anterior abdominal wall that is bound anteriorly by the external oblique aponeurosis and posteriorly by the transversalis fascia | the inguinal canal |
| the spermatic cord in males and the round ligament in females enter ____ through the transversus abdominis fascia at the interanl inguinal ring | the inguinal canal |
| the spermatic cord travels the length of the inguinal canal and exits through the | external oblique aponeurosis at the external inguinal ring |
| ____ hernias come through the internal inguinal ring and enter the inguinal canal | indirect inguinal |
| with time indirect inguinal hernias may extend along the canal and exit through the internal ring into | the scrotum |
| ____ are usually caused by a lack of obliteration by the processus vaginalis during development | indirect inguinal hernias |
| ____ hernias come through the posterior wall of the inguinal canal and are a defect in the transversalis fascia | direct inguinal |
| direct inguinal hernias infrequently enter | the scrotum |
| the main etiologic factor in direct inguinal hernias is | any maneuver that increases intraabdominal pressure, such as frequent heavy lifting |
| risk factors for direct inguinal hernias | cigarette smoking, advanced age, chronic illness |
| ____ hernias are more common in women | femoral |
| because of the risk of ____ nonsurgical management of hernias is not recommended | incarceration and strangulation |
| wearing a ___ does NOT gaurentee that a hernia will remain reduced and not incarcerate or strangulate | truss |
| ___ is a surgical emergency | acutely incarcerated hernia |
| the ___ approach is best for recurrent hernias (open or laparoscopic) | posterior or preperitoneal |
| the recurrence rate for direct inguinal hernias is __% | 5-10 |
| the recurrence rate for indirect inguinal hernias is __% | 1-5 |
| the us of a prosthesis for herniorrhaphies is mandatory | only when a suture repair would be under undue tension |
| Ventral, incisional hernias frequently occur because of | wound infection, obesity, or malnutrition |
| when mesh prosthesis is used in inguinal hernia repair, the mesh is sutured to | cooper's ligament, the iliopubic tract, and or the inguinal ligament inferiorly, and the conjoined tendon or internal oblique aponeurosis superiorly |
| the results of ____ in inguinal hernia repair have been very good | various plug techniques |
| a large peice of material is fixed with only a few sutures | Stoppa technique |
| the anterior boundry of the inguinal canal | external oblique aponeurosis |
| the posterior boundry of the inguinal canal | transversalis fascia and transversus abdominis aponeurosis |
| the inferior boundry of the inguinal canal | inguinal and lacunar ligaments |
| the superior boundry of the inguinal canal | internal oblique and transversus abdominis muscle and aponeuroses |
| ___ come through the posterior wall of the inguinal canal | direct inguinal hernias |
| ___ come through the internal or deep inguinal ring | indirect inguinal hernias |
| inguinal herniorrhaphy in which the transversus abdominis aponeurosis and the internal oblique aponeurosis superiorly are sutured to the inguinal ligament | Bassini repair |
| inguinal herniorrhaphy in which the conjoined tendon superiorly is sutured to Cooper's ligament inferiorly | McVay (Cooper's ligament repair) |
| the transversus abdominus aponeurosis, and the internal oblique aponeurosis | conjoined tendon |
| the anterior boundry of the femoral canal | iliopubic tract and inguinal ligament |
| posterior boundry of the femoral canal | Cooper's ligament |
| medial boundry of the femoral canal | lacunar ligament |
| lateral boundry of the femoral canal | femoral vein |
| hematomas and infections occur in __% of inguinal herniorrhaphies | 1-2 |
| the only acceptable approach to the treatment of femoral hernias is | operative |
| congenital umbilical hernias usually close spontaneously by age | 2 |
| umbilical hernias are usually | congenital |
| ____ umbilical defects should be repaired | those that persist beyond age 4 or those larger than 2cm at an earlier age |
| recurrence of umbilical hernia is | very uncommon |
| umbilical hernias have ___ complications | very few |
| if a hernia bulges with a valsalva maneuver it will reduce when the patient | exhales |
| if a primary repair can be accomplished without excessive tension, yet the tissues appear weak ____ | an onlay of polypropylene mesh should be performed |
| inflammation of the gallbladder | acute cholecystitis |
| in the vast majority of cases (>90%) of acute cholecystitis ___ is the initiating event | obstruction of the cystic duct by a stone |
| acute cholecystitis is distinguished from an attack of biliary colic by | persistant RUQ pain, fever, elevated WBCs, and alteration in liver chems. |
| acute cholecystitis is associated with ___ in 50-75% of cases | bacterial pathogens |
| if cholecystitis is left untreated ___ may develop (most often seen in diabetic patients) | severe gangrenous cholecystitis |
| ____ leads to increased morbidity and mortality from perforation of the gallbladder or overwhelming sepsis | severe gangrenous cholecystitis |
| patients suspected of having acute cholecystitis should | be admitted to the hospital, made NPO, and started on intravenous fluids |
| contraindications to cholecystectomy | myocardial ischemia, pancreatitis, cholangitis |
| unless contraindications exist, ___ should be performed in the first 24-36 hours after admission | cholecystectomy |
| the inflammatory process of cholecystitis is the most severe between ____ of the onset of symptoms, the technical challenge of successful laparascopic removal is greatest during this period | 72 hours to 1 week |
| if the patient is diagnosed with choecystitis 4-5 days after onset of symptoms | there may be some benefit in managing with antibiotics and deferring definitive treatment to 6 weeks |
| the success rates with this technique where low, and the complications high. Therefore this procedure has been abandoned | Extracorporeal shock wave lithotripsy for gallstones |
| contraindications for laparoscopic cholecystectomy | portal hypertension, cirrhosis, previous RUQ surgery |
| the treatment of choice for most patients with symptomatic gallstones | laparoscopic cholecystectomy |
| after laparoscopic cholecystectomy, N/V and increasing abdominal pain are often early warning signs of | postoperative biles leak |
| ____ in an otherwise healthy patient is carcinoma of the biliary system until proven otherwise | painless jaundice |
| after laparoscopic cholecystectomy patients should have | minimal pain and be able to eat |
| what are the 4 F's of gall stones | female, fertile, fat, forty |
| cholelithiasis | gallstones in the cystic duct |
| choledocholithiasis | gallstones in the common bile duct |
| __% of gallstones are radioopaque | 15 |
| inflammation of the common bile duct | cholangitis |
| cholecystectomy is performed for | cholelithiasis, cholecystitis, gallstone pancreatitis, gallbladder cancer |
| now the procedure of choice for gallbladder disease | laparoscopic cholecystectomy |
| causes less pain, shorter hospital stay | laparoscopic cholecystectomy |
| complications of laparoscopic cholecystectomy | abscess, bile leak, common bile duct injury, bowel injury, wound infection |
| what do you want to see on the critical view for cholecystectomy | the cystic aretery and cystic duct both going into the gallbladder |
| common bile duct injury is ___ with lap approach | more common |
| ___ hernias go through Hasselbach's triangle | direct |
| It is defined by the following structures:Rectus abdominis muscle (medially), Inferior epigastric vessels (superior and laterally). Inguinal ligament, sometimes referred to as Poupart's ligament (inferiorly) | Hesselbach's triangle |
| which is a recurrent hernia by definition | incisional hernia |
| male:female ratio of inguinal hernia __:1 | 10 |
| hernia below the inguinal ligament | femoral hernia |
| elements of both direct and indirect hernia | pantaloon hernia |
| ____ is especially useful for obese patients when the differential diagnosis includes simple weakness of the abdominal wall in addition to an incisional or epigastric hernia | Computed tomography (CT) scan |
| inability to reduce hernia contents | incarceration |
| compromise of intestinal vascular supply secondary to incarceration | strangulation |
| no mesh hernia repair | Bassini |
| most common hernia repair using mesh | Lictenstein |
| the only time you want to do a laparoscopic hernia repair | recurrent hernia (failed repair), or bilateral hernia |
| Laparoscopic hernia repair has not been shown ___ than open repair | more cost-effectiveor less morbid |
| function of the colon | absorption (water, electrolytes/carbohydrates), storage, propulsion, digestion |
| Most common colonic bacteria | Bacteroides fragilis |
| most common aerobes in colon | E. coli, Klebsiella |
| outpouching of the wall of a hollow viscus | diverticula |
| true diverticula (13%) | contain all layers of colon wall, congenital, usually solitary, and uncommon |
| pseudodiverticula (87%) | herniation of submucosa and mucosa through circular muscle |
| presence of multiple diverticula, present in majority of people >70 years, >90% in sigmoid, usually asymptomatic, common cause of massive lower GI bleed from right-sided location | diverticulosis |
| inflammation or microperforation of diverticula, fever, LLQ pain, palpable mass, may produce abscess/colonic obstruction, does not usually cause bleeding | acute diverticulitis |
| surgery for acute diverticulitis is indicated for | peritonitis, obstruction, intractable disease, recurrence, presence of fistula |
| Non-operative management for diverticulitis | bowel rest, IV fluids, IV antibiotics, abscess drainage if present |
| communication between colon and bladder | colovesical fistula |
| torsion of redundant sigmoid colon on itself | sigmoid volvulus |
| classical clinical picture of ____: elderly patients with a history of chronic constipation | sigmoid volvulus |
| bright red blood per rectum | hematochezia |
| most common cause of hematochezia | upper GI bleed |
| most common cause of lower GI bleed hematochezia | diverticulosis |
| signs of hypovolemia | tachycardia, hypotension, orthostatic hypotension |
| Inflammatory disorder of unknown etiology with non-caseating granulomas in submucosa | Crohn’s Disease |
| Discontinuous involvement --> skip lesions, Transmural (full-thickness) inflammation | Crohn's disease |
| Clinical Presentation: abdominal pain is most common symptom, frequent bowel movements - diarrhea, abdominal distention with nausea and vomiting, rarely blood in stool, symptoms caused by eating --> weight lossComplications: fistula, stricture | Crohn's disease |
| most common area affected by Crohn's disease | terminal ileus |
| Crohn's diseas is a medical disease managed by __ | surgeons |
| mainstay of medical treatment for Chron's disease | antiinflammatories-sulfasalazine, steroids, immunosuppressants, monoclonal antibodies, antibiotics |
| indications for surgery in Crohn's | obstruction, perforation, fistula, cancer, perianal disease, failure of medical therapy, failure to thrive (pediatrics) |
| Surgery cannot cure __ | Crohn's disease |
| Goal of surgery for Crohn's disease | treat complications, and palliate symptoms |
| Superficial inflammatory process involving mucosa of colon | ulcerative colitis |
| Involves the rectum and moves proximally | ulcerative colitis |
| Surgery can cure __ | ulcerative colitis |
| colorectal cancer is the __ leading cause of death in the US | 3rd |
| colorectal cancer risk factors | excess fat and alcohol intake, obesity, and sedentary lifestyle |
| colorectal cancer screening recommendations include and annual DRE and FOBT starting at age | 50 |
| Family History or Inherited Colon Cancer SyndromeAnnual screening with colonoscopy beginning at __ years of age younger than the earliest detected familial cancer | 10 |
| Presentation of ___ includes: Change in Bowel Habits (pencil thin stool), Rectal Bleeding, Change in Stool Caliber, Colon Obstruction, Perforation and Abscess Formation, Fistula Formation, Abdominal Pain, Weight Loss, Jaundice | Colorectal cancer |
| four types of colon polyps | submucosal, hyperplastic, hamartomatous, adenomatous(premalignant lesion) |
| staging for colorectal cancer involves | abdominal CT, Chest X-ray, Endorectal Ultrasound |
| Result from sliding downward of anal cushions | hemorrhoids |
| Predisposed by age, gravity, shear forces, increased abdominal pressure | hemorrhoids |
| below dentate line & covered by squamous epithelium, more common in women due to enlargement during pregnancy, large skin tags usually remain & may become inflamed, may thrombose | External hemorrhoids |
| above dentate line & covered by columnar epithelium, may prolapse, bleed, and/or thrombose | internal hemorrhoids |
| internal hemorrhoidal disease without significant external disease or other benign anorectal disease, can be | banded |
| ____ use for large mixed hemorrhoids or when other benign anorectal diseases present | Surgical hemorrhoidectomy |
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bwyche
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