SCPE Surgery Review Questions

what dx must be considered in every pt presenting with an acute abdomen`

acute appendicitis

what is the mcc of abd pain that is out of proportion to findings on PE

mesenteric ischemia

a pt is scheduled for an emergency abd surgery. what would be the most likely reason

acute appendicitis

what are the 6 m/c surgical positions that a pt can be placed in

supine, prone, L&R lateral decubitus, lithotomy, trendelenburg (supine with head lowered)

what kind of surgeries are performed supine

laparoscopic, cardiovascular (coronary arteries, valvular repair/replacement), thoracic (lobectomy, pneumonectomy), breast surgeries (mastectomies and lumpectomies), abd surgeries (appendectomies, cholecystectomy, hernia repair), ortho surgery (hand, wrist, knee), head, neck, and neuro surgeries (thyroidectomies, transsphenoidal pit removal)

what type of surgeries are conducted in the prone position

spinal surgery (spinal fusions, laminectomy), neurosurgery (post cranial fossa), ortho surgery (Achilles tendon repair, foot/ankle), trauma surgery (elbow and forearm), uro and retroperitoneal surgery (adrenal, upper urinary tract), colorectal surgery (anus, rectum)

what types of surgeries are conducted int he lateral decubitus position

thoracic and esophageal (lobectomy, thoracotomy), urologic and kidney (nephrectomy, pyelolithotomy), ortho (shoulder, rotator cuff, hip arthroplasty), neuro and spine (tumor excisions)

what type of surgeries are performed in lithotomy position

gynecological (hysterectomies, d&c, and pelvic reconstruction), uro (prostatectomies, cystoscopies), colorectal and anal (rectal tumors), obstetric (delivery c section, episiotomy)

what surgeries are conducted in trendelenburg position

gyn (hysterectomies, pelvic organ removal), GU (prostatectomies, cystoscopies)

a surgical consult is called to rule out peritonitis. what is the expected classic position of the patient

motionless, still (any movement is super painful)

what is the most common cause of free peritoneal air

perforated peptic ulcer

from which cancer are male and female pts most liekly to die from

lung ca

what is the number one cancer among males

prostate cancer

what is the number one cancer among females

breast

in the liver what is the most common malignant tumor

metastasis

what dx is most likely to be responsible for acute pancreatitis

cholecystitis

what dx is most likely responsible for chronic pancreatitis

alcoholism

pt has epigastric pain in RLQ, a/n/v. fever, rebound tenderness, +mcburneys point, + obturator sign, + rovsings sign.

appendicitis

labs in appendicitis

hi WBC

gold standard dx for appendicitis

CT w contrast

intervention for appendicitis

surgery, IVF, abx (GI coverage, gm- and anaerobes)

pathophys of appendicitis

inflammation of vermiform appendix (attached to cecum), secondary to obstruction—> fecalith, mucosal secretion, lymphoid hyperplasia or infxn leading to distension, inc intraluminal P, arterial insuff, tissue death

gallstones in the gallbladder (usually from cholesterol and bile products, pigmented stones)

cholelithiasis

who is ususally affected by cholelithiasis

female, fat, forty, fertile (OCPs), DM, spinal cord injury

pt is asx, jaundiced, biliary colic, n/v, RUQ pain, bloating. Boa’s/collin’s sign (RUQ pain referred to the R scapula), murphy’s (arrest of inspiration with deep palpation)

cholelithiasis

how to dx cholelithiasis

US

tx cholelithiasis

meperidine

gallstone in common bile duct, elevated AST/ALT

choledocholithiasis

inflammation of gallbladder bc of gallstones, choelsterol stones, or pigment stones in cystic duct

cholecystitis

who is affected by cholecystitis

older, female, fat, fertile (preg or OCPs), rapid weight loss

pt has RUQ pain after a fatty meal about >6 hrs. colicky pain with inspiration, pain ca refer to shoulder, pos murphys sign

cholecystitis

dx cholecystitis

US

tx cholecystitis

laparoscopic cholecystectomy

infx of biliary tree, secondary to ductal obstruction. charcot’s triad or reynolds pentad

cholangitis

what is charcot’s triad for dx cholangitis

fever, RUQ pain, jaundice

what is reynold’s pentad for dx severe cholangitis

fever, RUQ pain, jaundice, HoTN, AMS

diverticular dz is correlated to

inc age, related to low fiber intake

formation of diverticula/outpouching of colonic wall. #1 cause fo lower GI bleed

diverticulosis

in what part of the GI tract is diverticulosis m/c

sigmoid colon

inflammation of diverticula

diverticulitis

pt has single or repeated attacks of LLQ pain, n/d/constipation/flatus, fever. if it becomes complicated then the pt can have abscess formation, fistula, obstruction, rupture.

diverticulitis

RF for diverticulitis

obesity, smoking, FH, NSAIDs

studies to dx diverticulitis

XR (r/o free air), barium enema, CT w contrast, CRP elevated, WBC hi

what test should you NOT conduct when trying to dx diverticulitis

colonoscopy/barium enema

best dx test for diverticulitis

CT w contrast

intervention to tx diverticulitis

abx, liquid diet, admission

tx diverticulitis

broad spectrum abx, hi residue diet/liquid diet, analgesia

pathophys of diverticulitis

inflammation of outpouching of the colonic wall

bleeding prox to ligament of Treitz: usually stops spontaneously. pt has hematemesis and melena

upper GI bleed

causes of upper GI bleed

PUD, tumors, alc abuse —> esophageal varices, mallory weiss tear, boerhaave syn (complete rupture of esophagus).

bleeding distal to ligament of treitz. pts have hematochezia

lower GI bleed

things that can cause hematochezia (bright red blood per rectum)

upper GI bleed, diverticulosis, cancer, polyps, colitis/ulcers, angiodysplasia, anorecta/hemorrhoids

intervention to dx the reason for hematochezia in a lower GI bleed

colonoscopy - dx and therapeutic

in a pt with an upper or lower GI bleed what are some professional practice concerns you have to be aware of

religious beliefs, use of blood products

older obease pt is complaining of heartburn, acidic taste, troubel swallowing, GERD, laryngopharyngeal reflux, CP/SOB.

hiatal hernia

complications of a hiatal hernia

IDA, volvulus, bowel obstruction

studies to dx hiatal hernia

endoscopy, manometry, esophageal pH, CT, barium swallow

dx hiatal hernia

upper endoscopy, barium swallow XR, manometry

interventions for tx hiatal hernia

elevate head of the bed, don’t lie down after meals, weight loss, surgery

med tx for hiatal hernia

H2 blockers, PPIs

pathophys for hiatal hernia

abd organs slip thru diaphragm into chest

what is ileus

intestinal paralysis

pt has abd pain, constipation, distension, n/v/ bilious vomiting, flatulence/lack of bowel movements. belching.

ileus

if a pt had complete ileus then what would you find

no rushes and tinkles

complication of ileus

perforation, necrosis, peritonitis

studies to dx ileus

abd XR, CT abd and pelvis (gold standard), abd US

intervention for ileus

NPO, NG suction, IVF, parenteral nutrition

tx ileus

lactulose, erythromycin

pathophys of ileus

disruption of intestinal propulsion - atony/lack of peristalsis or obstruction

causes of paralysis in an ileus

surgery, electrolyte imbalance (hypokalemia m/c), DM, DKA, hypothyroidism, opioids

what are forms of small bowel obstructions

adhesions, hernias, intussusception, tumor

what are forms of large bowel obstruction

colon ca, vulvulus, adhesions

pt has abd pain, diarrhea, rectal bleeding, malabsorption/weight loss, anemia

IBD

pt has steatorrhea, fever, weight loss (affects terminal ileum)

crohn’s dz

pt has bloody mucousy stool. this dz affects the rectum

UC

IBD are also assoc with what other issues

arthritis, pyoderma gangrenosum, primary sclerosing cholangitis

studies to dx IBD

sigmoidoscopy, colonoscopy, biopsy, barium enema, stool analysis

best studies for dx IBD

colonoscopy, biopsy

tx IBD

prednisone, TNF inhibitors. crohns' (abx better than mesalamine). UC (mesalamine better than abx/surgery)

pathophys for IBD

autoimmune dz, genetic and env factors disrupt immune system, leading to intestinal inflammation.

how to describe crohn’s dz

patchy, transmural, small and large intestine, mouth, esophagus, stomach, anus

how to describe UC

continuous, colon, rectum

cause of crohns dz

lymphatic obstruction, infxn, autoimmune, genetics

cause of UC

possibly autoimmune, genetics

are fems or males more affected by crohn’s

females

are men or women more affected by UC

males

site of crohn’s

entire GI tract, often affecting distal ileum

site of UC

always involves the rectum

appearance of crohn’s lesions

patchy, cobblestone, skipped lesions, transmural, extends into peritoneum. non caseating granuloma, string sign on barium enema, strictures, fistulas

appearance of UC

continuous mucosal lesions, friable mucosal pseudo polyps, ulcers with hemorrhage, abscesses with pus, lead pipe sign on barium enema, no strictures or fistulas

is surgery curative of crohn’s

no

is surgery curative of UC

colectomy to cure

extra intestinal manifestations of UC

HLA-B27 pos

comps of crohn’s

anal fistulas, obstruction, malabsorption, fluid imbalance, peritonitis

comps of UC

obstruction, dehydration, malabsorption, anemia, inc risk of colon ca

m/c gastric cancer

adenocarcinoma

how does gastric cancer spread

direct extension thru gastric wall, lymphatic system, peritoneal spread

RF for gastric cancer

h pylori, cr. gastritis, soked/cured food, smoking, alcohol, pernicious anemia.

pt has dyspepsia, n/v, abd pain not relieved with antacids, feeling fill, weight loss, tarry stools, virchow’s node (L supraclavicular)

gastric ca

gastric ca can spread to

peritoneum, causing dyspareunia and dyschezia