GI surgery

Most common histology for gastric cancer?

Adenocarcinoma

RFs for gastric adenocarcinoma?

Smoked foods, high salt diet, gastritis, H. Pylori, fam hx, pernicious anemia, smoking, low Vit C

Gallbladder disease

Diagnostic test of choice for cholilithiasis?

Ultrasound

Cholangitis pentad:

Fever + RUQ pain + jaundice 

Hypotension + shock (AMS)

Leading cause of cholilithiasis?

Gallstones caused by cholesterol

Describe patho of cholangitis?

Gallstone obstruction in common bile duct and hepatic duct

Boas sign?

Pain radiating to right shoulder associated with cholilithiasis

Best treatment for cholangitis?

ERCP

Pancreas

Diet recommended for chronic pancreatitis:

Low fat diet

Highest RF for chronic pancreatits?

Alcohol abuse

Symptoms associated with chronic pancreatitis?

Pancreatic calcification, steatorrhea, and DM.

Dx of acute pancreatitis? What imaging?

Ultrasound first. Follow up with ERCP. 

Disposition for acute pancreatitis?

Admit. Severe cases may require aspiration or surgical debridement

Screening recommendations for pancreatic cancer:

CT or MRCP if fam history

Tumor marker for pancreatic cancer?

CA-199

Risk factors for pancreatic cancer?

DM (leading), tobacco use, gastric ulcers, arsenic or catemine exposure

Best treatment for pancreatic cancer?

Whipple (pancreaticoduodenectomy)

Which part of pancreas is most likely to develop cancer?

Pancreatic head

What’s couverser sign?

Painless jaundice with palpable gallbladder associated with pancreatic cancer. 

MC cause of acute appendicitis:

Fecolith

First line treatment for SBO:

Keep NPO and do nasogastric inflammation

May require surgery

Clinical presentation of SBO?

Nausea, vomiting of partially undigested foods, high pitched bowel sounds. Cramping abd pain,

How to diagnose bowel obstruction?

CT with contrast or abd x-ray showing free air levels and dilated loops of bowel or colon. 

First line for gallbladder imaging?

Ultrasound

Gold standard for gallbladder imaging?

HIDA

Crohns vs UC

Which disorder is characterized by transmural inflammation with skip lesions and loud boroboric pain

Crohn’s disease

How to diagnose Crohns dz?

CT with contrast

On colonoscopy, granulomas are highly suggestive of Crohns. 

How to diagnose UC?

Sigmoidoscopy is preferred. Can do CT with contrast. Don’t do colonoscopy because it can cause bowel perforation. 

Supplements for Crohns disease patients:

Vit D and B12

Supplement for UC?

Iron

3 complications/comorbidities associated with UC?

Toxic megacolin, anemia, fulminant colitis, osteoporosis, cancer

Complications/Comorbidities associated with Crohns?

Apthous ulcers, anterior uveitis, erythema nodosum, DVT, gallstones, cancer

Meds for UC flare-up?

Aminosalicylates like sulfasazine or mesalamine

Can use steroids or infliximab. 

Meds for Crohns flare-up?

Steroids like budesonide or prednisone are first line. 

Consider adding monoclonal antibodies like infliximab. 

Screening recommendations for colon cancer in Crohns patients?

Annual screening in ppts with Crohns for 8 or more years. 

Imaging shows lead-pipe appearance and diffuse friability and erosions in colon. Most likely diagnosis?

UC

Anal disorders:

Severe dyschezia and hematochezia. Linear ulcer at posterior midline of rectum

Anal fissure

Treatment for anal fistula?

Surgery

Treatment for perforated viscus?

IV abx and surgical repair

Preferred treatment for external hemmorhoids?

Stool softeners and sitz bath

Preferred treatment for internal hemmorhoids?

Rubber band ligation or electrocautery. 

First line treatment for anal fissures?

Bulking agents like selium and sitz baths. Meds include topical nitro and continuous symptoms can be treated with botox injections. 

Contraindications to laparoscopic hernia repair?

Incarceration or strangulation

Active infection 

Ascites

Prior pelvic hx

GERD

Ppt with hx of GERD is experiencing dysphagia to solids and odynophagia with associated heartburn. What’s next best step to determine diagnosis?

Barium swallow

60 y/o male experiencing hematemsis after meals, reports abd pain and 5 lbs weight loss

Gastric ulcer

Virchow’s node?

Palpable supraclavicular lymph node from gastric cancer

Primary sclerosing cholangitis?

Autoimmune fibrosis in hepatic ducts. Associated with UC. Can progress to cholangiocarcinoma

Diagnostic workup for pancreatic psuedocysts?

CT with contrast

Tx for pancreatic psuedocysts?

Usually benign. Can do endoscopic or percutaneous drainage

Dx pancreatic cancer?

CT with contrast

Alcoholic presents with hematemesis. What’s most likely diagnosis?

Esophageal varices are most common cause of upper GI bleeds

Procedures to treat esophageal varices?

Banding, sclerotherapy, or TIPS

List 3 RFs for esophageal cancer:

Smoking, alcohol use, GERD

Which type of esophageal cancer is associated with Barrett’s esophagus, obesity, and white race?

Adenocarcinoma (less common than squamous cell carcinoma)

Dx esophageal strictures?

Barium swallow followed with endoscopy

Age for pyloric stenosis?

2-5 weeks

Dx zollinger ellison syndrome?

Fasting serum gastric level> 150. Confirm with endoscopy and biopsy. 

Which derm condition is associated with hepatocellular carcinoma?

Seborrhiec keratosis

Tumor marker for hepatocellular carcinoma?

AFP

Leading cause of hepatocellular carcinoma?

Viral cirrhosis from Hep B or hep C

Dx volvulus?

Abd x-ray

3 week old infant with sudden onset of bilious vomiting. An x-ray shows a large dilated loop of bowel. Best treatment?

NG decompression and endoscopic detorsion (has volvulus)

X-ray showing free air should make you think of?

Perforated viscus

Reccurent vomiting is associated with which electrolyte abnormalities?

Low potassium and chloride

Diff between conjugated and unconjugated bilirubin?

Conjugated: past the liver - stored in gallbladder & duodenum. Elevated conjugated bili is associated with infections, SJS, and wilson dz. 

Unconjugated: majority, in liver. Physiologic and genetic causes like criggler najjar and gilbert syndrome. 

Dx of hepatocellular carcinoma?

Ultrasound is first line. CT is preferred. Biopsy is definitive. Labs show low albumin, low clotting factors, and elevated AFP. 

Dx Toxic megacolon?

Abd x-ray shows colonic dilation > 6 cm and loss of haustra. May be thumbprinting sign. Don’t do barium study or colonoscopy to avoid perforation. 

Treatment for toxic megacolon?

Bowel rest, IV abx, and NG decompression. Colectomy if no improvement after 72 hrs. 

Thin stools should raise concern for which diagnosis?

Colorectal cancer

Ppt is 2 days post-bariatric surgery and develops fever and tachycardia. Most likely cause?

Anastomic leak (any abnormal vital sign especially tachycardia within 72 hrs of surgery is an anastomic leak until proven otherwise). 

Ppt presents with heartburn, epigastric pain, belching, and dysphagia. Symptoms worst after meals. Next best step in working up diagnosis?

GERD can be clinical diagnosis. But first do barium swallow to r/o strictures followed by endoscopy with biopsy to confirm diagnosis of GERD. 

Best treatment for pyloric stenosis?

Pyloromyotomy

Diagnosis of pyloric stenosis?

Ultrasound

Triple therapy for H.Pylori? CLAP

Clarithromycin

Amoxicillin

PPI

Quadruple therapy for H. Pylori? Treat My Belly Pain

Tetracycline

Metronidazole

Bismuth

PPI

Which ppts are eligible for bariatric surgery?

BMI>40

OR BMI>35 with comorbidities

List post-op complications of bariatric surgery?

Tachycardia (think anastomotic leak - treated with surgery within 24 hrs), infection, ulceration, bleeding, refeeding syndrome, thiamine deficiency which can lead to Wernicke encephalopathy (confusion, ataxia, and ophthalmoplegia) etc.

What is sentinel pile?

Skin tag lesion on outside of rectum. Associated with anal fissure. 

How to confirm diagnosis of inguinal hernia?

CT with contrast

Ultrasound in children or pregnant women.

Which abx are recommended prior to abdominal surgeries?

Metronidazole + Cipro or Ceftriaxone

How many lymph nodes are required to stage colon cancer?

12 lymph nodes

Which meds are thought to cause pyloric stenosis?

Macrolides like arithromycin

MC cause of hereditary jaundice?

Gilbert syndrome - isolated jaundice from too much unconjugated bilirubin

Best treatment of complex diverticulitis?

IV abx and consult surgery (ppt might require colectomy or sigmoid resection)

Diff between strangulated or incarcerated hernia?

Incarcerated - can’t be reduced. 

Strangulated - are incarcerated, become ischemic and necrotic.