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200 Cards in this Set
- Front
- Back
Prophy Abx of choice
|
Amox (or amp if IV)
Pen-allergic: clinda or cephalexin (or cefazolin if IV) |
|
Rx for amebic liver abscess
|
Metronidazole
|
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Rx for pyogenic liver abscess
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Perc drainage + Abx against G- and anaerobes
|
|
Best diagnostic test to determine treatment for sliding hiatal hernia?
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Flexible endoscopy to look for esophagitis
|
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1st test when extrahepatic biliary obstruction is suspected?
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EUS
|
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Increased SGOT and SGPT indicate
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Hepatocellular disease
|
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Increased alk phos indicates
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Biliary obstruction
|
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Obese/hirsute man with painful fluctuant mass btwn gluteal clefts
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Infected pilonidal cyst
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Hematochezia, fever, abd pain
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Ischemic colitis
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Management of ischemic colitis vs. acute mesenteric ischemia
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Expectant (IVF, bowel rest, supportive) vs. surgery
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Pts who undergo major colon resections undergo what change in their bowel habits?
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None, usually; lots of reserve capacity for water absorption
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Pts who undergo major colon resections undergo what change in their bowel habits?
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None, usually; lots of reserve capacity for water absorption
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Work-up of rectal cancer
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Rigid proctoscopy (to assess distance of lesion from anal verge); barium enema or colonoscopy to r/o other lesions; CT abd/pelvis for mets; MRI for extent of local invasion; endorectal US for depth of invasion
|
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Where are most dietary carbs absorbed?
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Duodenum (even in short gut syndrome is in residual jejunum)
All of milk except fat absorbed in duodenum |
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Rx for hepatic adenomas <4cm vs. >4cm
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OCP cessation vs. surgical resection b/c of risk of rupture/hemorrhage
|
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Management of acute hemorrhage from L-sided portal HTN (gastric varices + splenic or portal vein thrombosis w/o cirrhosis)
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Splenectomy
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Management of hepatic focal nodular hyperplasia
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Nothing
|
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Acute appendicitis presentation but w/ terminal ileum edema/fibrinopurulent exudate in OR
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Regional enteritis; in kids, just do appy
|
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Management of iatrogenic injury of CBD --> biliary stricture
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End-to-side choledochojejunostomy (Roux-en-Y) performed over a stent
|
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Acute intestinal radiation injury is manifested by
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Diarrhea or GI bleeding
|
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Chronic intestinal radiation injury causes ___ and can lead to these clinical problems
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Progressive vasculitis and fibrosis
Malabsorption, ulceration, fistulization, or perforation |
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4 things that inhibit intestinal motility
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Sympathetics: drugs, hormones, emotions (fear)
Gastrin |
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Factor that stimulates intestinal motility
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Parasyms: acetylcholine
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Best test for diagnosis of gastrinoma
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Secretin stimulation test
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Another name for gastrinoma
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Zollinger-Ellison syndrome
|
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Most common location of a gastrinoma
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"Gastrinoma triangle" : duodenum, junction of neck/body and pancreas, and junction of cystic and common bile duct
|
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Expected fluid/electrolyte status in SBO
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Dehydration from vomiting and poor oral intake
Contraction alkalosis with hypokalemia (due to loss of H+, Na+, and Cl-) |
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Concern with SBO and heme-positive stool in rectum
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Obstructing tumor or ischemic bowel
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Management of SBO due to inguinal hernia
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Urgent repair and relief of bowel obstruction due to risk of strangulation
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Most common tumor that metastasizes to the intestine
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Melanoma
|
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Indications for surgical exploration with SBO
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Localized abdominal tenderness, fever, tachy, leukocytosis, metabolic acidosis (high risk for strangulation)
|
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2 operative management choices for pt with SBO with uncertain bowel viability
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Resect and anastamose
OR Second look operation 24hrs later |
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Greatest risk associated w/ enterotomy
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Postop leak and development of small bowel fistula
|
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3 causes of abdominal distention other than SBO
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Ileus, air swallowing, constipation
|
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Diagnostic tests for suspected ischemic bowel
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Sigmoidoscopy
Mesenteric angiogram (to determine whether candidate for surgical revascularization) |
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Long-term medical Rx after surgical revascularization
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ASA
|
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Management if full-thickness necrosis found on sigmoidoscopy
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Exploration and resection (vs. mucosal ischemia only, can observe closely)
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Long-term management of pt with necrosis from ligament of Treitz to transverse colon
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Can resect, esp in younger pt, but will have short bowel syndrome and need chronic TPN/ small bowel transplant
|
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Most common location for Crohn's
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Ileocolic
|
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Thickened bowel wall with fibrous strictures and deep fissures
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Crohn's
|
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Epithelial ulceration and crypt abscesses
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UC
|
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Noncaseating granulomas or mesenteric lmphadenopathy can both indicate this type of IBD
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Crohn's
|
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Focal aphthous ulcers can indicate this type of IBD
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Crohn's (whereas general ulceration is usually UC)
|
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What is the "string sign" and what does it indicate?
|
Narrowing of terminal ileum from edema: Crohn's
|
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Rx for acute disease vs. prevention in UC
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Steroids for acute
5-aminosalicylic acid for prevention of relapse |
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Drug for perianal Crohn's
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Metronidazole
|
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Problems associated w/ resection of the terminal ileum
|
Poor reabsorption of bile acids and vita B12 --> diarrhea, malabsorption, oxalate stones, B12 deficiency
|
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Rx for Crohn's disease of the rectum
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Can use 5-acetylsalicylic acid
|
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Screening recommendations for UC of pancolitis vs. L-colon only
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Colonoscopy every 1-2yrs beginning after 8yrs of disease vs. after 10yrs of disease
|
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Why are random biopsies during colonoscopy necessary in UC?
|
Colon cancer of UC doesn't always follow sequence of polyp --> cancer
|
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Fever, blood-tinged diarrhea, and pain on defecation after a total proctocolectomy w/ ileal pouch- anal anastamosis
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Pouchitis
|
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Rx for pouchitis
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Metronidazole
|
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Pt with UC, abdominal pain, distention, fever, and bloody diarrhea
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Worry about toxic megacolon
|
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Diagnostic test for toxic megacolon
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Abdominal series (v. dilated colon w/ mucosal edema and w/o signs of abscess or perforation); often also a CT to r/o abscess or perf
|
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Rx for toxic megacolon
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If stable: NGT, NPO, TPN, IVF, broad spectrum Abx, high-dose IV steroids
|
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Suspected toxic megacolon + free air on upright CXR
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Perforation! Immediate OR
|
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Air in wall of colon on XR
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Impending perforation, likely OR!
|
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PEX manuever that must always be done when appendicitis is suspected?
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Rectal exam to detect pain in the right pelvis from retrocecal appendicitis
|
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Appendicitis like presentation + dysuria/urinary WBCs
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Possibly uncomplicated UTI, but also possibly appendiceal abscess in continuity w/ bladder
|
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Abd pain + urinary RBCs too numerous to count
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Severe UTI or kidney stone
|
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Pregnant woman with RUQ pain
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Worry about appendicits (appendix has been shifted)
|
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Surgical management of perforated appendicitis w/ localized abscess
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Appy + incise, drain, and irrigaet abscess; leave closed drain in abscess draining to outside; close muscle but leave skin open
|
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Suspected appendicitis with small yellow firm mass at TIP of appendix
|
Carcinoid tumor (if not spread, just needs routine appy)
|
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Suspected appendicitis with larger yellow firm mass at BASE of appendix
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Needs excision; if >2cm or at base, suggestive of malignancy and indication for R colectomy
|
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Diagnostic tests needed after carcinoid tumor diagnosed on path
|
Baseline urinary 5-hydroxyindoleacetic acid (5-HIAA) and serum serotonin level (carcinoid determinants of malignancy involve mostly biological behavior of tumor)
|
|
Management of postop pelvic abscess
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Drain w/ perc catheter if possible, other open surgical drainage (or transrectal/ transvaginal drainage)
|
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Colonoscopy screening for pts with first degree relative w/ CRC or adenomatous polyp?
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Starts at 40yo (or 10yrs prior to relative's diagnosis?)
|
|
Colonoscopy screening for pts with FH of FAP?
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Genetic counseling, yearly flex sig
Colectomy once polyps discovered |
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Colonoscopy screening for pts with FH of HNPCC?
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Genetic testing and colonoscopy every 1-2yrs beginning at age 20yo, yearly beginning at 40yo
|
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Colonoscopy screening for pts w/ Hx of large or multiple adenomatous polyps that were remoevd?
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Colonoscopy 3yrs after removal
|
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Colonoscopy screening for pts with Hx of CRC
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Colonoscopy 1yr after initial op, screening at 3yrs and then 5yr intervals
|
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CEA measurement indications after CRC
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Every 2-3mo for 2yrs (detects 80% of recurernces)
|
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Surgical management for external vs. internal hemorrhoids
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External: excision
Internal: excision or banding |
|
Any hemorrhoids w/ bleeding need what?
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Colonoscopy to r/o colon cancer
|
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2 types of polyps
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Pedunculated (on a stalk)
Sessile (flush w/ mucosa) |
|
F/u after polypectomy
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Repeat colonoscopy after 3-6mo to ensure sucessful removal and then surveillance colonoscopy every 3yrs
|
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Management of carcinoma in head sv. stalk of pedunculated polyp
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Head: polypectomy only
Stalk (esp if margin <2cm, poorly differentiated, or vascular/lymphatic invasion): may require bowel resection in addition to polypectomy |
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Staging studies for colon cancer
|
CXR
CEA LFTs |
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Most common presenting symptoms of R or L-sided colon cancer
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Pain/mass
|
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Most common presenting symptoms of sigmoid colon cancer
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Pain or bowel complaints
|
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Most common presenting symptoms of rectal cancer
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Bowel complaints or bleeding
|
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Prep before bowel surgery (3 parts)
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- Bowel prep (polyethylene glycol or mag citrate)
- Oral nonabsorbed Abx (to decrease colonic bacteria) - Single preop dose of 2nd generation cephalosporin (to decrease wound infections) |
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Specific places to explore for colon cancer mets
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Small bowel mesentery, peritoneal surface, diaphragm, liver
|
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Postop management after colon cancer surgery
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NPO w/ IVF until bowel function returns; d/c when tolerating food
|
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Colon cancer prognosis worse for these types of tumors (4)
|
Mucus-producing
Signet ring cell tumors Tumors p/w bowel perf Tumors w/ venous or perineural invasion |
|
What types of adjuvant chemo are used in colon cancer pts and for what stage?
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Stage III
5-FU and leucovorin or levamisole |
|
Screening f/u after colon cancer
|
Repeat colonoscopy at 6mo then 12mo intervals + frequent monitoring of CXR, CEA, and LFTs
|
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Management of colon cancer + large liver lesion
|
Large liver lesions shouldn't be resected at tmie of surgery
|
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Feculent vomiting postop from colectomy ddx (2)
|
Leakaeg from anastomosis --> persistent ileus
Mechanical obstruction |
|
Cause of feculent material draining from inferior wound
|
Anastomotic leak that is spontaneously draining to skin; should close with NPO and IVF; need CT scan to determine if there is undrained collection
|
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Diagnosis and management of distended colon
|
Likely sigmoid or cecal volvulus
Proctosigmoidoscopy first to eval for/hopefully treat sigmoid volvulus; if negative, emergent celiotomy for presumed cecal volvulus (risk of rupture in 1-2hrs) |
|
Common additional site of liver cysts
|
Lung
|
|
2 equivalent management options for echinococcal liver infections
|
Surgical drainage
Albendazole/mebendazole + perc drainage |
|
2 causes of feculent vomiting after colectomy
|
- Leakage from anastomosis --> persistent ileus
- Mechanical obstruction due to adhesions, hernia, or obstructed anastamosis |
|
Management of feculent material draining from inferior aspect of colostomy wound
|
Likely due to anastomotic leak
NPO, IVF, usually will self-close |
|
Pt 6mo s/p colostomy for colon cancer returning w abd pain, constipation, small stools
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Concern for anastomotic recurrence of cancer or stricture at anastomosis
|
|
Rectal carcinomas spread to which lymphatic nodes?
|
Internal iliac
Sacral Inferior mesenteric Inguinal (if <5cm from anal verge) |
|
Type of resection necessary for rectal cancer >5cm above anal verge vs. <5cm
|
>5cm, can do anterior resection
<5cm, need abdominoperineal resection due to margins including sphincter |
|
Which rectal cancers require postop chemo?
|
Stage III (regional LNs) or high-risk stage II
|
|
Which rectal cancer pts receive preop radiation?
|
Those with large/bulky tumors
|
|
2 alternatives to colostomy for rectal carcinoma
|
Sphincter-preserving proctectomy or local resection
|
|
Pelvic pain after rectal cancer
|
Early postop: operative nerve injury or infection
Later: need to r/o local recurrence w/ CT pelvis |
|
Which hepatic mets are unresectable?
|
Multiple lesiosn in both lobes, lesions intimate w/ vascular structures or invading local structures, or lesions in cirrhotic livers
|
|
Most common cause of anal cancer and presenting symptoms
|
SCC
Bleeding, drainage, pain, pruritis |
|
Where does anal cancer metastasize to?
|
Inguinal LNs (also superior rectal LNs)
|
|
Staging w/u for anal cancer
|
CT and transrectal US
|
|
3 treatment regimens for anal cancer depending on location of lesion:
- Superficial, small, mobile - Large w/o extension or LNs - + LNs |
- Local excision alone
- Nigro protocol: chemo (5-FU, mitomycin C) and radiation, then resection only if there's biopsy-proven residual cancer - Chemoradiation, then radical resection |
|
Pain med to be avoided in diverticulitis
|
Morphine (b/c increases intracolonic pressure)
|
|
Management of 2nd episode of diverticulitis
|
Elective resection 4-6wks after inflammation has resolved (b/c risk of significant complication (perf, abscess) increases w/ each recurrence)
|
|
What is required before surgery for diverticulitis?
|
Preop or intraop colonoscopy to identify region w/ diverticula
|
|
Diverticulitis w/ patient deteriorating
|
Free perforation or intra-abdominal abscess
|
|
Eval for suspected perf/abscess from diverticulitis
|
CT
|
|
Management of diverticulitis abscess
|
CT-guided needle insertion of catheter in collection
|
|
What is Ogilvie syndrome?
|
Pseudo-obstruction: massive cecal and colonic dilation in absence of mechanical obstruction
|
|
Management of Ogilvie syndrome?
|
D/c narcotics/ anticholinergics; endoscopic colonic decompression if dilation >10cm; surgery if perforation or ischemia suspected
|
|
Cause of Zenker's diverticulum
|
Premature contraction of cricopharyngeal muscle on swallowing --> partial obstruction
|
|
Symptoms of Zenker's
|
Dysphagia, regurgitation, recurrent aspiration PNA
|
|
Diagnosis and treatment of Zenker's
|
Barium swallow
Diverticulectomy w/ cricopharyngeal myotomy |
|
RUQ pain, jaundice, GI bleeding
|
Quincke triad for hemobilia
|
|
Causes of hemobilia
|
Iatrogenic (from percutaneous liver procedures), anticoagulation, gallstones, parasitic infection, neoplasm
|
|
Diagnosis and treatment of hemobilia
|
Angiography/ endoscopy
Angiographic embolization if intrahepatic Surgery if bleeding from extrahepatic bile ducts or gallbladder |
|
Noncaseating granulomas are associated with this type of IBD
|
Crohn's
|
|
IBD w/ crypt abscess
|
UC
|
|
Sensation of voided air with urination
|
Pneumaturia, e.g. from colovesical fistula
|
|
Most common type of fistula due to diverticulitis
|
Colovesical fistula
|
|
Most common cause of rapid lower GI bleeding
|
Bleeding diverticula and vascular ectasias
|
|
Rx for vascular ectasia
|
Coagulation w/ monopolar current
|
|
Why are diverticula associated w/ bleeding?
|
Underlying vasa recta artery penetrating thru bowel wall
|
|
How to diagnose an ongoing GI bleed w/ negative upper and lower scopes
|
Technetium-labeled RBC scan or mesenteric angiography
|
|
When to use angiography vs.RCN scanning
|
Angiography in less stable pts
RBC scanning in more stable pts, can detect slower bleeds |
|
2 treatment options for bleeding discovered during angiography
|
Vasopressin into the vessel
Embolization |
|
Typical pt/ causes of sigmoid volvulus
|
Debilitated pts from nursing homes due to chronic laxative use, chronic illness, or dementia
|
|
Type of obstruction in sigmoid volvulus
|
Closed loop obstruction
|
|
Rx for sigmoid volvulus
|
Rigid proctosigmoidoscopy and placement of rectal tube
|
|
Definitive Rx for sigmoid volvulus
|
Sigmoid colectomy w/ colostomy or anastomosis
|
|
Rx for cecal volvulus
|
Urgent surgical treatment w/ detorsion alone, cecopexy, or right colectomy
|
|
3 treatment options for Ogilvie's syndrome w/ colon diameter >11-12cm (otherwise conservative Rx)
|
1) Endoscopic decompression
2) Neostigmine (increases colonic tone and counteracts dilation) 3) Surgical decompression |
|
Rx for rectal prolapse
|
Internal: high fiber diet
External w/ bleeding: surgery |
|
3 surgical options for prolapse
|
1) Rectopexy (no removal)
2) Transabdominal rectosigmoid resection 3) Perineal approach w/ removal and anastamosis |
|
Rx for anal fissures (conservative vs. more invasive)
|
Bulk agents/ softeners, sitz baths
If deep and chronic, lateral sphincterotomy +/- biopsy if suspicious for cancer |
|
What are anal fissures and what causes them?
|
Tears in the anoderm (--> painful BM, tenderness on palpation, blood on TP) due to repeated trauma from hard stools or IBD
|
|
Pain and drainage in sacrococcygeal area
|
Pilonidal abscess (infection in hair-containing sinus in sacrococcyx)
|
|
Rx for pilonidal abscesses
|
Unroof, remove all hair, leave open to heal by secondary intention
|
|
Most common complications of stomas
|
#1: leakage around the bag
Also parastomal herniation, bowel obstruction abscess, fistula formation |
|
What is a Hartmann pouch?
|
If distal bowel is closed and not brought to abdominal wall but rather dropped back into pelvis
|
|
Common indication for Hartmann pouch
|
Diverticulitis when bowel can't be safeul reconnected
|
|
Small intestine bleeding in a pt under 30
|
Meckel's diverticulum
|
|
Work-up for suspected Meckel's?
|
99m-Tc pertechnate scan
|
|
What type of tumor is a carcinoid tumor?
|
Apudoma
|
|
Congenital cystic dilation of the extrahepatic biliary duct?
|
Choledochal cyst
|
|
Management of choledochal cyst?
|
Complete resection of cyst (due to risk of malignant changes) and roux-en-y choledochojejunostomy
|
|
What is stress ulceration?
|
Acute gastric or duodenal erosive lesions following shock, sepsis, major surgery, trauma, or burns
|
|
Cause of stress ulceration?
|
NOT increased acid; may be ischemic damage to mucosa; often ulcers are in multiple places
|
|
Treatment of pancreatic pseudocyst?
|
Wait 6wks to allow for spontaneous resolution; then excise, externally drain, or internally drain into GI tract
|
|
Do pancreatic pseudocysts have malignant potential?
|
No, b/c have no epithelial lining
|
|
Complications of pseudocysts
|
Gastric outlet and extrahepatic biliary obstruction
Spontaneous rupture and hemorrhage |
|
What is a Diuelafoy's lesion?
|
Abnormally large submucosal artery that protrudes thru small, solitary mucosal defect 6cm distal to GEJ --> spontaneous bleeding
|
|
Rx for Diuelafoy's lesion?
|
Endoscopic
|
|
When is hemicolectomy needed for appendiceal carcinoid tumors?
|
If >2cm
|
|
Asthma, right heart valvular disease, flushing, hepatomegaly, diarrhea
|
Carcinoid syndrome
|
|
Indication for resection of a gallbladder polypoid lesion?
|
Clinical symptoms
|
|
Electrolyte abnormalities after pancreatectomy
|
Hypocalcemia
Hypophosphatemia Iron deficiency Pernicious anemia |
|
Characteristics of cecal diverticula?
|
Congenital
Solitary True diverticula (involve all layers of bowel wall) |
|
Management of liver hemangiomas?
|
Can usually observe; affected by hormones, but usually only hemorrhage iatrogenically (from attempted biopsy)
|
|
CEA is elevated in these pts w/o cancer
|
Smokers
|
|
High CEA indicates?
|
High likelihood liver involvement/ peritoneal spread
|
|
Management of Mallory Weiss tear?
|
If bleeding stopped: expectant
To control bleeding: balloon tamponade, endoscopic control, gastrostomy/oversewing, or vasopressin (but not in CAD pts) |
|
Types of gastric ulcers and which are acid-associated?
|
I (lesser curvature)
II (gastric and duodenal) III (pyloric) IV (juxtracardial) II and III are acid associated |
|
Rx for Type I ulcer
|
Antrectomy (+/- vagotomy)
|
|
Surgical Rx for type III ulcer?
|
Vagotomy and antrectomy
|
|
Surgical Rx for toxic megacolon?
|
Subtotal colectomy with end ileostomy
|
|
Rx for SCC of the anus refractory to Nigro protocol (chemo and XRT)?
|
Abdominal-perineal resection w/ permanent end colostomy
|
|
Rx for proximal and midrectal cancers?
|
Low anterior resection
|
|
Radiolucency under right hemidiaphragm indicates?
|
Pneumoperitoneum
|
|
Causes of pneumoperitoneum
|
Perforated diverticulum, perforated gastric ulcer, perforated transverse colon carcinoma, or strangulated hernia w/ necrotic bowel
|
|
Intestines in upside down U
|
Sigmoid volvulus
|
|
How does PEEP improve oxygenation?
|
Increasing FRC b ykeeping alveoli open at end of expiration
|
|
Potential negative effects of increased PEEP (3)
|
- Alveolar overdistention --> pneumothoraces
- Decreased venous return/CO - Increased minute ventilation requirements due to increased dead space ventilation |
|
Systemic hypotension, JVD, distant heart sounds
|
Beck's triad for cardiac tamponade
|
|
What is pulsus paradoxus?
|
Decrease in SBP by >10 at end of inspiration
|
|
Risk factors for eriop MI
|
Previous infarction, esp w/in 6mo
DOE Age >70 MR > 5 PVCs/min Tortuous or calcified aorta |
|
When should you not use epi w/ lidocaine?
|
Tissues supplied by end arteries (fingers/ toes, ears, nose, penis)
|
|
What can interfere with measurement of wedge pressure w/ Swan Ganz catheter?
|
PEEP or CPAP
|
|
Increased risk of periop stroke with?
|
History of stroke
|
|
What is the mortality from periop stroke?
|
High
|
|
PaCO2 levels are a reliable indicator of?
|
Adequacy of alveolar ventilation
|
|
Respiratory acidosis from hypercarbia
|
Alveolar hypoventilation
|
|
Hypoxemia with increased PCO2 is NOT
|
PE, pulmonary edema, PNA, or atelectasis (b/c those pts should be hyperventilating (decreased CO2) to improve oxygenation
|
|
Benefits of albumin vs. transferrin/acute phase reactants to eval nutritional status
|
Long life life (3 wks) vs. short (hrs), but not affected by intravascular volume
|
|
The physiologic goal of shivering is to ___, which causes ___
|
Generate heat to maintain core temp
Increases metabolism by 3-5x, which increases O2 consumption/ CO2 production, which is usually counterproductive in critically ill pts |
|
What should be administered preop in a pt with vWD?
|
Cryoprecipitate (provides both FVIII and vWF)
|
|
Best choice for stress ulcer prophylaxis
|
Sucralfate (better than antacids, which cause loss of acidic protection and G- overgrowth)
|
|
Procedure for tracheostomy
|
Skin incision below cricoid cartilage, strap muscles spared and retracted, thyroid isthmus divided if necessary, trachea entered at second tracheal ring
|
|
Rx for malignant hyperthermia
(3) |
Cessation of anesthesia, hyperventilation w/ 100% O2, IV dantrolene
|
|
Effect of PE on CVP
|
Increases by causing RV overload and increasing RAP
|
|
Renal failure with eosinophilia
|
Cholesterol atheroembolism
|
|
Hyperkalemia, hyponatremia, hypoglycemia, fever, weight loss, dehydration
|
Adrenocortical insufficiency (e.g. Addison's disease)
|
|
Why are antacids given before emergency intubation?
|
Risk of intubation, esp if don't know gastric contents
|
|
Rx for necrotizing fasciitis
|
Wide debridement
|
|
Passive rewarming is appropriate for which pts?
|
Mild hypothermia (between 34 and 36C)
|