GI Surgery

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GI Surgery
2011-05-21 22:55:15
DPAP2012 GI Surgery

GI Surgery cards made by previous students
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  1. implies severe abdominal pain arising rather suddenly and of less than 24 hours duration
    acute abdomen
  2. pain arising from the foregut (stomach, pancreas, duodenum and biliary tree) localizes to the
  3. pain from structures arising from the midgut (small bowel, and right transverse colon) localizes to the
    periumbilical region
  4. pain from structures arising from the hindgut (left colon, sigmoid colon, rectum) localizes to the
    hypogastric region
  5. intermittent colicky, poorly localized abdominal pain is found with
    GI Tract obstruction
  6. steady, well localized pain usually occurs after
    perforation, ischemia, inflammation, or hemorrhage
  7. classic signs and symptoms are mild fever and focal right lower quadrant pain with rebound tenderness
  8. commonly occurs in women between the ages of 40-60 who are overweight and have a previous history of pregnancy
    acute cholecystitis
  9. patients will have right upper quadrant pain that is accentuated on inspiration, and is accompanied by nausea and vomiting
    acute cholecystitis
  10. Murphy's sign
    acute cholecystitis
  11. McBurney point
  12. laparoscopic approach has been proven safe in both acute and chronic settings
  13. pain that localizes to right lower quadrant accompanied by anorexia, nausea, and vomiting is classic
  14. the normal anatomic position of the appendix
    anterior intraperitoneal
  15. results in an increased risk of perforation due to delayed diagnosis
    hidden position of appendix
  16. during the 5th month of pregnancy the appendix may rise as high as the
    right upper quadrant
  17. in western populations the lifetime risk of appendicitis is __%
  18. appendicitis is primarily a disease of
    adolescents and young adults
  19. incidence of ____ declines after age 30
  20. ____ is seen in approximately 70% of appendicitis cases
    obstruction of the appendiceal lumen
  21. the appendiceal lumen can be obstructed by
    fecaliths, foreign bodies, tumors, parasites, and lymphoid hyperplasia
  22. the number of ___ in the vermiform appendix peaks between the ages of 10-30
    lymphoid follicles
  23. rare causes of appendicitis
    diverticula, and duplications
  24. after obstruction of the appendiceal lumen ___ continue
    mucosal secretions of lining cells
  25. ___ follows appendiceal obstruction
    bacterial overgrowth and increased intraluminal pressure
  26. ___ which ultimately leads to ulceration, necrosis, gangrene, and perforation
    increased intraluminal pressure causes vascular congestion
  27. ____ alone should make the diagnosis of acute appendicitis in most patients
    history and physical exam
  28. after 1-12 hours of diffuse mild to moderate pain, appendicitis pain will usually
    migrate to the right lower quadrant and become more intense
  29. Vomiting and diarrhea may be present in acute appendicitis but ___
    are usually not excessive
  30. if vomiting precedes abdominal pain or if anorexia is not present ____
    the diagnosis of appendicitis should be questioned
  31. ___ should be present in 75%-85% of all patients with acute appendicitis
  32. a temperature will rarely be highter than __ unless the appendix is grossly perforated
    38 degrees
  33. with appendicitis vital signs are
    usually normal with slight tachycardia due to pain, fever, or dehydration
  34. patients with acute appendicitis prefer to
    lie motionless
  35. patients with colicky-type pain may appear
  36. palpation of left lower quadrant causing right lower quadrant pain
    Rovsing's sign
  37. deep palpation of right lower quadrant followed by a sudden release
    rebound examination
  38. assessing for rebound tenderness can lead to a
    false positive
  39. a positive ___ sign may indicate an inflamed appendix lying anterior to the ___ muscle
  40. this sign is best demonstrated by extension of the hip or flexion against resistance
    psoas sign
  41. ___ is produced by stretching this muscle with passive internal rotation of the thigh, with the hips in a flexed position
    obturator sign
  42. both the obturator and psoas signs are
    non-specific and only present on occasion
  43. a ___ exam is also important in evaluating any patient with abdominal pain
  44. tenderness with a rectal exam is most commonly seen when the inflamed appendix lies
    within the pelvis
  45. ____ on fecal exam should be quite rare and lead to the consideration of a diagnosis other than appendicitis
    gross blood
  46. administer prophylactic antibiotics
    before incision
  47. the base of the appendix is located at
    the junction of the three tenia
  48. the ___ lies posterior to the cecum or terminal ileum
    appendiceal artery
  49. after incision if appendicitis is not present
    a thorough search for other pathology is important
  50. consider ___ of the wound for advanced and perforated appendicitis
    open packing
  51. the gold standard for the treatment of appendicitis is
    exploratory laparotomy, and appendectomy
  52. laparotomy can be accomplished through a ____ incision
  53. 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
  54. a right-lower-quadrant transverse ___ incision is preferred by many for appendicitis
  55. in the elderly where other disease processes may be encountered, many surgeons would prefer a ____ incision
    lower midline laparotomy
  56. ____ are usually indicated if a well-formed intraabdominal or pelvic abcess is encountered
    intraabdominal drains
  57. 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
  58. 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
  59. as a diagnostic procedure ____ is by far the most accurate, but it is invasive
  60. laparoscopic appendectomy is especially useful
    when the diagnosis is in question
  61. laparoscopic appendectomy is especially useful
    in women of reproductive age
  62. laparoscopic appendectomy is especially useful
    in obese patients
  63. laparoscopic appendectomy is especially useful
    in the elderly
  64. antibiotic therapy in early appendicitis
    should be of short duration
  65. in uncomplicated appendectomy patients should be moved to a diet and discharged within ___hours
  66. ___ complications are by far the most frequently seen problem after appendectomy
  67. once a wound infection is diagnosed the primary treatment is
    to open the wound and to allow drainage of the purulent material
  68. if cellulitis is present in an infected wound
    antibiotics are indicated
  69. early recognition, aggressive surgical debridement, and administration of broad spectrum antibiotics are critical in
    necrotizing fasciitis
  70. ___ is the result of the abdominal host defenses attempting to wall off an infectious threat
  71. drainage and antibiotics are the treatments for
    postoperative abscess
  72. an abscess after appendicitis most commonly occurs in the
    right paracolic gutter, pelvis, or intra loop position
  73. the most common treatment for postoperative abscess is
    CT-guided catheter drainage
  74. the radiographic finding of air in the portal vein
  75. this is a rare presentation of an advanced septic process due to gas-forming organisms
  76. is often seen in the elderly, immunocompromised, or in advanced sepsis, and is often a preterminal finding
  77. appendicitis is seen in approximately 1 in ___ pregnancies
  78. the most common nonobstetric emergency in pregnant women
  79. WBC count in a pregnant woman is unreliable, however a ___ can be seen in appendicitis
    left shift
  80. the risk of conventional diagnostic radiographs such as a KUB or CT scans is ___ after the first trimester
  81. abdominal wall hernias occur in __% of the United States population
  82. 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
  83. 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
  84. the spermatic cord travels the length of the inguinal canal and exits through the
    external oblique aponeurosis at the external inguinal ring
  85. ____ hernias come through the internal inguinal ring and enter the inguinal canal
    indirect inguinal
  86. with time indirect inguinal hernias may extend along the canal and exit through the internal ring into
    the scrotum
  87. ____ are usually caused by a lack of obliteration by the processus vaginalis during development
    indirect inguinal hernias
  88. ____ hernias come through the posterior wall of the inguinal canal and are a defect in the transversalis fascia
    direct inguinal
  89. direct inguinal hernias infrequently enter
    the scrotum
  90. the main etiologic factor in direct inguinal hernias is
    any maneuver that increases intraabdominal pressure, such as frequent heavy lifting
  91. risk factors for direct inguinal hernias
    cigarette smoking, advanced age, chronic illness
  92. ____ hernias are more common in women
  93. because of the risk of ____ nonsurgical management of hernias is not recommended
    incarceration and strangulation
  94. wearing a ___ does NOT guarantee that a hernia will remain reduced and not incarcerate or strangulate
  95. ___ is a surgical emergency
    acutely incarcerated hernia
  96. the ___ approach is best for recurrent hernias (open or laparoscopic)
    posterior or preperitoneal
  97. the us of a prosthesis for herniorrhaphies is mandatory
    only when a suture repair would be under undue tension
  98. Ventral, incisional hernias frequently occur because of
    wound infection, obesity, or malnutrition
  99. 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
  100. the results of ____ in inguinal hernia repair have been very good
    various plug techniques
  101. a large piece of material is fixed with only a few sutures
    Stoppa technique
  102. the anterior boundary of the inguinal canal
    external oblique aponeurosis
  103. the posterior boundary of the inguinal canal
    transversalis fascia and transversus abdominis aponeurosis
  104. the inferior boundary of the inguinal canal
    inguinal and lacunar ligaments
  105. the superior boundary of the inguinal canal
    internal oblique and transversus abdominis muscle and aponeuroses
  106. ___ come through the posterior wall of the inguinal canal
    direct inguinal hernias
  107. ___ come through the internal or deep inguinal ring
    indirect inguinal hernias
  108. inguinal herniorrhaphy in which the transversus abdominis aponeurosis and the internal oblique aponeurosis superiorly are sutured to the inguinal ligament
    Bassini repair
  109. inguinal herniorrhaphy in which the conjoined tendon superiorly is sutured to Cooper's ligament inferiorly
    McVay (Cooper's ligament repair)
  110. the transversus abdominis aponeurosis, and the internal oblique aponeurosis
    conjoined tendon
  111. the anterior boundary of the femoral canal
    iliopubic tract and inguinal ligament
  112. posterior boundary of the femoral canal
    Cooper's ligament
  113. medial boundary of the femoral canal
    lacunar ligament
  114. lateral boundary of the femoral canal
    femoral vein
  115. the only acceptable approach to the treatment of femoral hernias is
  116. congenital umbilical hernias usually close spontaneously by age
  117. umbilical hernias are usually
  118. ____ umbilical defects should be repaired
    those that persist beyond age 4 or those larger than 2cm at an earlier age
  119. recurrence of umbilical hernia is
    very uncommon
  120. umbilical hernias have ___ complications
    very few
  121. if a hernia bulges with a Valsalva maneuver it will reduce when the patient
  122. if a primary repair can be accomplished without excessive tension, yet the tissues appear weak ____
    an onlay of polypropylene mesh should be performed
  123. inflammation of the gallbladder
    acute cholecystitis
  124. in the vast majority of cases (>90%) of acute cholecystitis ___ is the initiating event
    obstruction of the cystic duct by a stone
  125. acute cholecystitis is distinguished from an attack of biliary colic by
    persistent RUQ pain, fever, elevated WBCs, and alteration in liver chems.
  126. acute cholecystitis is associated with ___ in 50-75% of cases
    bacterial pathogens
  127. if cholecystitis is left untreated ___ may develop (most often seen in diabetic patients)
    severe gangrenous cholecystitis
  128. ____ leads to increased morbidity and mortality from perforation of the gallbladder or overwhelming sepsis
    severe gangrenous cholecystitis
  129. patients suspected of having acute cholecystitis should
    be admitted to the hospital, made NPO, and started on intravenous fluids
  130. contraindications to cholecystectomy
    myocardial ischemia, pancreatitis, cholangitis
  131. unless contraindications exist, ___ should be performed in the first 24-36 hours after admission
  132. the inflammatory process of cholecystitis is the most severe between ____ of the onset of symptoms, the technical challenge of successful laparoscopic removal is greatest during this period
    72 hours to 1 week
  133. if the patient is diagnosed with cholecystitis 4-5 days after onset of symptoms
    there may be some benefit in managing with antibiotics and deferring definitive treatment to 6 weeks
  134. the success rates with this technique where low, and the complications high. Therefore this procedure has been abandoned
    Extracorporeal shock wave lithotripsy for gallstones
  135. contraindications for laparoscopic cholecystectomy
    portal hypertension, cirrhosis, previous RUQ surgery
  136. the treatment of choice for most patients with symptomatic gallstones
    laparoscopic cholecystectomy
  137. after laparoscopic cholecystectomy, N/V and increasing abdominal pain are often early warning signs of
    postoperative biles leak
  138. ____ in an otherwise healthy patient is carcinoma of the biliary system until proven otherwise
    painless jaundice
  139. after laparoscopic cholecystectomy patients should have
    minimal pain and be able to eat
  140. what are the 4 F's of gall stones
    female, fertile, fat, forty
  141. cholelithiasis
    gallstones in the cystic duct
  142. choledocholithiasis
    gallstones in the common bile duct
  143. __% of gallstones are radiopaque
  144. inflammation of the common bile duct
  145. cholecystectomy is performed for
    cholelithiasis, cholecystitis, gallstone pancreatitis, gallbladder cancer
  146. now the procedure of choice for gallbladder disease
    laparoscopic cholecystectomy
  147. causes less pain, shorter hospital stay
    laparoscopic cholecystectomy
  148. complications of laparoscopic cholecystectomy
    abscess, bile leak, common bile duct injury, bowel injury, wound infection
  149. what do you want to see on the critical view for cholecystectomy
    the cystic artery and cystic duct both going into the gallbladder
  150. common bile duct injury is ___ with lap approach
    more common
  151. ___ hernias go through Hesselbach’s triangle
  152. 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
  153. which is a recurrent hernia by definition
    incisional hernia
  154. male:female ratio of inguinal hernia __:1
  155. hernia below the inguinal ligament
    femoral hernia
  156. elements of both direct and indirect hernia
    pantaloon hernia
  157. ____ 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
  158. inability to reduce hernia contents
  159. compromise of intestinal vascular supply secondary to incarceration
  160. no mesh hernia repair
  161. most common hernia repair using mesh
  162. the only time you want to do a laparoscopic hernia repair
    recurrent hernia (failed repair), or bilateral hernia
  163. Laparoscopic hernia repair has not been shown ___ than open repair
    more cost-effective or less morbid
  164. function of the colon
    absorption (water, electrolytes/carbohydrates), storage, propulsion, digestion
  165. Most common colonic bacteria
    Bacteroides fragilis
  166. most common aerobes in colon
    E. coli, Klebsiella
  167. outpouching of the wall of a hollow viscus
  168. true diverticula (13%)
    contain all layers of colon wall, congenital, usually solitary, and uncommon
  169. pseudodiverticula (87%)
    herniation of submucosa and mucosa through circular muscle
  170. 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
  171. inflammation or microperforation of diverticula, fever, LLQ pain, palpable mass, may produce abscess/colonic obstruction, does not usually cause bleeding
    acute diverticulitis
  172. surgery for acute diverticulitis is indicated for
    peritonitis, obstruction, intractable disease, recurrence, presence of fistula
  173. Non-operative management for diverticulitis
    bowel rest, IV fluids, IV antibiotics, abscess drainage if present
  174. communication between colon and bladder
    colovesical fistula
  175. torsion of redundant sigmoid colon on itself
    sigmoid volvulus
  176. classical clinical picture of ____: elderly patients with a history of chronic constipation
    sigmoid volvulus
  177. bright red blood per rectum
  178. most common cause of hematochezia
    upper GI bleed
  179. most common cause of lower GI bleed hematochezia
  180. signs of hypovolemia
    tachycardia, hypotension, orthostatic hypotension
  181. Inflammatory disorder of unknown etiology with non-caseating granulomas in submucosa
    Crohn’s Disease
  182. Discontinuous involvement --> skip lesions, Transmural (full-thickness) inflammation
    Crohn's disease
  183. 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 loss. Complications: fistula, stricture
    Crohn's disease
  184. most common area affected by Crohn's disease
    terminal ileus
  185. Crohn's disease is a medical disease managed by __
  186. mainstay of medical treatment for Chron's disease
    antiinflammatories-sulfasalazine, steroids, immunosuppressants, monoclonal antibodies, antibiotics
  187. indications for surgery in Crohn's
    obstruction, perforation, fistula, cancer, perianal disease, failure of medical therapy, failure to thrive (pediatrics)
  188. Surgery cannot cure __
    Crohn's disease
  189. Goal of surgery for Crohn's disease
    treat complications, and palliate symptoms
  190. Superficial inflammatory process involving mucosa of colon
    ulcerative colitis
  191. Involves the rectum and moves proximally
    ulcerative colitis
  192. Surgery can cure __
    ulcerative colitis
  193. colorectal cancer is the __ leading cause of death in the US
  194. colorectal cancer risk factors
    excess fat and alcohol intake, obesity, and sedentary lifestyle
  195. colorectal cancer screening recommendations include and annual DRE and FOBT starting at age
  196. Family History or Inherited Colon Cancer Syndrome. Annual screening with colonoscopy beginning at __ years of age younger than the earliest detected familial cancer
  197. 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
  198. four types of colon polyps
    submucosal, hyperplastic, hamartomatous, adenomatous(premalignant lesion)
  199. staging for colorectal cancer involves
    abdominal CT, Chest X-ray, Endorectal Ultrasound
  200. Result from sliding downward of anal cushions
  201. Predisposed by age, gravity, shear forces, increased abdominal pressure
  202. 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
  203. above dentate line & covered by columnar epithelium, may prolapse, bleed, and/or thrombose
    internal hemorrhoids
  204. internal hemorrhoidal disease without significant external disease or other benign anorectal disease, can be
  205. ____ use for large mixed hemorrhoids or when other benign anorectal diseases present
    Surgical hemorrhoidectomy