General Surgery Rotation

appendicitis US, or CT of the abdomen

11 y/o male presents with 4 hours of Anorexia, epigastric pain, N/V, and low-grade fever. Pain then shifts to 1/3 distance from ASIS to the umbilicus Leading dx? What imaging is indicated?

-Abdominal Pain -Lipase or Amylase 3x normal -Radiographic evidence of acute pancreatitis (CT is preferred)

2/3 of what three criteria must be met for the diagnosis of acute pancreatitis? -One sx -One lab -One imaging (know the specific imaging of choice)

pectinate line

A cluster of tissue containing arterioles, veins, and smooth muscle above the _________ is an internal hemorrhoid external hemerroids are below this

Gastroparesis Diabetes

A condition that affects the stomach muscles and prevents proper stomach emptying, resulting in nausea and a full feeling after little food is eaten dx? MC cause?

protoporphyrin IX (PP9)

After RBCs are lysed Globin in broken down into amino acids and Heme is broken down into iron and ______ which is converted to Unconjugated bilirubin.

Supportive: 1. NPO 2. Pain Control 3. Lactated Ringers 4. Treat Complications (Hypotension, shock, Thrombus formation, ARDS, Acute renal failure, DIC) Cholecystectomy (If acute pancreatitis d/t gallstones)

After being admitted, how should you treat a patient with acute pancreatitis caused by large ETOH use? What should be added for acute pancreatitis caused by gallstones?

Statins (HMG-CoA Reductase Inhibitors)

Along with increased fibrous vegetable consumption, what medication class can be protective against Acute Pancreatitis?

Fibrosis (chronic anal fissue)

Anal fissures lasting >8 weeks and associated with a sentinel pile are most commonly cause by what disease process?

MC in 10-30 Perforation risk greatest in <5

Appendicitis is MC which patient population? Which population is most at risk for a bowel perforation? age <5 age 10-30 age 60+

ETOH use Calcification of pancreas, DM, and Steatorrhea

Chronic pancreatitis is MC caused by ______ in the US, caused by inflammatory damage to the pancreas causing a decreased in endo- and exocrine function. This results in a triad of:

Ogilvie's syndrome

Colonic pseudo-obstruction causing Acute dilation of the colon in the absence of any mechanical obstruction. Usually seen in elderly patients and post op patients on opioids, electrolyte or metabolic abnormalities. MC in cecum and R hemicolon dx?

Diverticulitis Augmentin/Metronidazole + Cipro/TMP-SMZ Augmented Sipping the Metro Back out of the diverticula.

Inflammation of diverticula secondary to obstruction (fecaliths) or infection dx? Outpatient Treatment?

Giardia Lamblia Metronidazole

Ingestion of contaminated water from remote streams/wells (especially those containing beavers) causing Greasy, frothy, Yellow/ green, Foul-smelling diarrhea lasting up to a month. No pus or blood presents. Associated weight loss, fatigue, abd cramping, and fatigue. dx? tx?

Painless Bloody

Internal hemorrhoids arrise from superior Hemorrhoid vein above the pectinate/dentate line. These are normally _______ and ______ (bloody/non-bloody; painful/painless)

Malignancy (Crohn dz, HIV/AIDS, TB, lymphogranuloma venereum)

Know risk factors for Anal fissure include Large caliber stool, Vaginal delivery, Anal intercourse, Low fiber diet. What is the MC cause for an anal fissure that deviates from the midline? (5)

solutes (lactose intolerance, laxatives, magnesium) malabsorption

Osmotic Diarrhea is caused by Excessive amounts of _________ in intestines, leading to poor absorption of water A common cause of Solute excess in GI tract secondary to _________

Anal Fissures

PAINFUL linear or rocket-shaped ulcers usually <5 mm in the distal anal canal along the posterior midline

Anal fistula 1. I&D + Augmentin (PCN alg Metro + Cipro) if abscess still present 2. Surgery/Fistulotomy

Patient presents with anal itching and uncomfortable purulent discharge. Leading dx? tx?

1. colicky pain 2. bloating/distension 3. vomiting 4. obstipation

Patient with a bowl obstruction will likely have all of the following symptoms: -abd distension/bloating -vomiting -colicky pain -obstipation What order do these normally occur in?

Functional dyspepsia

The presence of one or more of the following: postprandial fullness, early satiation, epigastric pain, or burning

Toxic Megacolon NO ANTI-MOTILITY AGENTS, OPIOIDS, OR ANTICHOLINERGICS!

Toxic appearing Pt presents with Severe bloody diarrhea, AMS, Lower abdomen distention and tenderness that is getting worse. PE shows Fever >38ºC Tachycardia >120 beats/min Neutrophilic leukocytosis >10,500/microL Anemia Hypotension xR is shown dx? What 3 medication type should NOT be used?

Enterotoxigenic E. coli (ETEC) Bismuth Subsalicylate

Traveler from distant land presents with watery stools, Abd cramping and Vomiting after drinking water from a stream and eating wild berries. Dx?tx?

NPO + NG decompression IV Steroids (mthylpred, hydrocortisone)

Treatment for Toxic Megacolon in general? What should be added for UC?

ETOH ERCP - stenting and placement Pancreatic Enzyme

Treatment for a patient with Chronic Pancreatitis includes: -Discontinue ______ use -_______ Procedure -Replacement of _______

NG tube (bowel decompression) NPO (bowel rest) and IVF

Treatment for any bowel Obstruction?

False. Diverticulitis can be associated with colorectal ancer

True or false: Diverticulosis is associated with Colorectal cancer.

Hyperactive bowels / Early bowel obstruction Hypoactive bowels/ late bowel obstruction

High pitched "tinkling" sound when auscultating the bowel is a sign of _____. Absent bowel sounds are a sign of _______.

Endoscopy procedure with tamponade or epinephrine injection

How should you treating bleeding due to diverticulosis that does not resolve spontaneously?

Surgical colectomy if no improvement Subtotal Colectomy w/ End Ileotomy

If a patient with toxic megacolon does not improve with steroids or antibiotics after 48-72h what treatment is necessary?

Rovsing sign appendicitis

Name the sign and the associated dx? rebound RLQ pain w/ LLQ palpation

Diverticulitis Bowel Perforation Test of choice = CT Scan Colonoscopy and colonography are contraindicated during acute phase of diverticulitis!

A patient with known diverticulosis presents with abdominal pain and a low-grade fever. The patient begins vomiting and states the pain is getting worse. You note the fever has spiked to 104.3. What was the initial and second dx? What imaging is indicated? What imaging is contraindicated?

Rome Criteria Iritable Bowel Syndrome

A) Abd discomfort at least 1 day a week for 12 weeks B) PLUS 2 of the 3 following: 1) Related to defecation 2) Change in frequency of stool 3) Change in form of stool (appearance) -NOT nocturnal -NOT interfering with sleep -NO severe constipation -NO hematochezia -NO weight loss -NO fever -NO immediate postprandial BM The above is the ______ criteria and is used to diagnose _______.

obturator hernia

Abdominal contents herniate through pelvic floor, and abdominal/pelvic contents protrude through the obturator foramen

Indirect Hernia

Abdominal contents protrude into the internal inguinal ring, Lateral to the inferior epigastric artery

Incisional (Ventral) hernia

Abdominal contents protrude through incision made for surgical procedure in abdominal wall

Direct Hernia

Abdominal contents protrude through the external inquinal ring at Hesselbach's triangle, Medial to the inferior epigastric artery dx?

B12, Ca2+, D

Bariatric surgery is known to cause deficiencies in what 3 vitamins/minerals?

incr venous pressure Obesity, Constipation

Biggest risk factor for Hemorrhoids?

PCR identification of toxics in stool First line Metronidazole. second line Vancomycin (the only use for oral Vanc)

C Diff toxins A (enterotoxin) and B (cytotoxin) will cause the mild watery diarrhea. The best testing for this condition is ______ How would you treat?

40 35 100lb

Candidates for Bariatric surgery should have a BMI> _____ (or >____ with medical problems related to morbid obesity), or >_____ pounds above ideal body weight

Trypsinogen -> trypsin

Damage from Pancreatitis is cause by intracellular activation of pancreatic enzymes causing auto-digestion of the pancreas. Activation of which enzyme is the most dangerous?

Diarrhea <2 week >1 month

Decreased absorption of nutrient or increased secretion into the bowel, or both, causing >200 mL/day of liquid BM excretion dx? <____ weeks is acute >____ month(s) is chronic

Paralytic Ileus Gradually increase from clear liquids to solids after surgery. D/c Opioids

Decreased bowel sounds in patients directly post-op KUB shows uniformly distended loops of the small and large bowel. dx? How is this prevented? What medications should be discontinued?

Acute Pancreatitis (Ranson's criteria)

Depicted are the Ranson's criteria. Mortality from what diagnosis is associated with these criteria?

Bacillus cereus supportive

Diarrhea, Abd Cramps, and Vomiting that Lasts for 24 hrs beginning 6-15 hrs after eating infected food. dx?tx?

Gastritis PPI, follow up in 4 weeks

Dyspepsia (belching, bloating, distension, and heartburn) and abdominal pain. EGD shows inflammation of the stomach lining Initial dx and tx?

Hemolytic Uremic Syndrome: Acute renal failure Hemolytic anemia Thrombocytopenia DO NOT GIVE ANTIBIOTICS TO EHEC, BACTERIAL DESTRUCTION -> SHIGA TOXIN RELEASE.

Enterohemorrhagic E. coli (EHEC) containing the shiga-toxin is commonly associated with what complication? What is the triad of this condition? How does the increased risk for this complcation affect treatment?

Shigella Febrile seizure Supportive, TMP-SMZ = 1st Line

Explosive watery diarrhea that becomes blood and mucoid coupled with a high fever is most likely what diagnosis? MC complication? Tx?

Painful non-blood

External Hemorrhoids arise from inferior Hemorrhoid vein below the pectinate line. These are normally _______ and ______ (bloody/non-bloody; painful/painless)

women femoral hernias

Femoral hernias is more common in _____, inguinal hernias are more common in common in both genders. which has a higher risk of incarceration and strangulation?

Vibrio cholerae supportive, Tetracyclines

MASSIVE nonbloody diarrhea (up to 15L/day): "Rice water stools" (gray liquid) Exotoxin causes hypersecretion of water and Cl-, leading to severe dehydration dx?tx?

Campylobacter jejuni Azithromycin

MC antecedent event in post-infectious Guillan-Barre syndrome is from what diarrheal bacterium? How can you treat?

Malignancy Lower Quadrent pain

MC cause of Large Bowel obstruction? Where is the pain of this type of obstruction MC located?

1. Gallstones (40%) 2. Heavy alcohol use (40%)

MC cause of acute Pancreatitis in the US? 2nd MC?

Norovirus Rotavirus

MC cause of acute gastroenteritis in adults? In unvaccinated children?

Diverticulosis

MC cause of acute lower GI bleeding (hematochezia) in adults?

NSAIDs

MC cause of erosive gastritis -> Erosion of the superficial gastric mucosa -> upper GI bleed or hematemesis?

inadequate fiber, fluids, or poor bowel habits 24-36 hrs 3

MC causes of constipation? What is Normal colonic transit time? Constipation is defined as <_____ BMs /week

Loperamide

Medication that can be used to decr diarrhea (should only be given to noninvasive diarrhea in patients <65)

Cullen's sign (umbilical echymosis) Acute Pancreatitis

Name the sign and associated diagnosis?

Grey Turner sign (flank ecchymosis) Acute Pancreatitis

Name the sign and associated diagnosis?

Psoas sign appendicitis

Name the sign and the associated dx?

McBurney's point tenderness appendicitis

Name the sign and the associated dx? 1/3 distance from ASIS to umbilicus

Obturator sign appendicitis

Name the sign and the associated dx? RLQ pain w/ internal & external hip rotation w/ flexed knee

Mumps Hypertriglyceridemia

Pediatric acute pancreatitis can be caused by what condition in unvaccinated children? In adults what condition is acute pancreatitis associated with?

The intravenous anaesthetic propofol is currently the least emetogenic general anaesthetic

Postoperative nausea and vomiting (PONV) is a complication affecting 30 percent of children and adults after anesthesia after surgery (Cholecystectomy, gynecologic procedures, laparoscopy, Strabismus surgery, adenotonsillectomy). General surgeries have lower incidences Which of the following has the medications are least associated with PONV? -Nitrous oxide -Opioids -Physostigmine -Propofol

Toxic megacolon Ulcerative Colitis C. diff

Potentially lethal complication of inflammatory bowel disease (IBD) or infectious colitis, Characterized by total or segmental nonobstructive colonic dilatation plus systemic toxicity. What are the MC IBD and infectious causes?

Staphylococcus aureus supportive

Prominent Vommiting, Nausea, HA, Abd Cramps and Diarrhea that occurs 30 min - 6 hrs after eating infected food. dx?tx?

Umbilical hernia New borns If still present at 5 y/o - surgical repair

Protrusion of abdominal contents through the abdominal fibromuscular ring Dx? What patient population is this MC in? When is surgical repair necessary?

Femoral hernia Surgical repair

Protrusion of the abdominal cavity contents below the inguinal ligament, resulting in a Palpable bulge in the upper thigh dx? tx?

Clostridium difficile treatment with broad-spectrum antibiotics - Clindamycin penicillins, cephalosporins, and FQ

Pseudomembranous colitis is Inflammation of the colon caused by the bacteria ________. The MC cause of this condition is ______

Direct Hernia Yes

Pt present with a groin Bulge that does not reach the scrotum Swelling hits side of finger on digital inguinal canal exam dx? Is this associated with Hesselbach's triangle?

Diverticulitis Test of choice = CT Scan Colonscopy and colonography are contraindicated during acute phase of diverticulitis!

Pt presents with LLQ pain, low-grade fever, N/V, constipation (may also be diarrhea), flatulence, and bloating. + fecal occult blood test Leading dx? What imaging should is indicated and what are CIed right now?

Ogilvie's Syndrome aka pseudo-obstruction. dilatation of the colon in the absence of any mechanical obstruction in severely ill patients <12 = IVF + electrolytes, NG tube decompression >12 or conservative measures fail = Neostigmine (medical decompression) All other methods fail = surgical decompression w/ colostomy

Pt presents with N/V, Abdominal distension, with normal bowel sounds. KUB shows Dilated R colon from the cecum w/ cutoff at splenic flexure Leading dx? Tx is >12cm dilation, <12 cm dilation?

Perianal abscess I&D Severe Cases or High risk patients: Add Augmentin (PCN Allergy - Metro + Cipro)

Pt presents with Severe, constant rectal pain that is worse w/ sitting, coughing, & defecation You note Anorectal swelling with a Tender, fluctuant, erythematous mass on palpation Leading dx? Tx?

Anal Fissures Crack in epithelium

Pt presents with Severe, tearing pain during defecation followed by throbbing and Hematochezia. Pt states this came after a week-long bout of Constipation, and the patient has since tried to hold in his stool due to severe pain associated with deification now. dx? What layer of skin does this dx reach?

Acute Pancreatitis

Pt presents with Sudden onset Epigastric Pain with Radiation to the left back. With N/V and Fever Pain is alleviated by Sitting and Leaning forward. Lying down and eating make it worse. + Cullen's sign Leading dx?

Indirect Hernia No

Pt presents with painless scrotal swelling The swelling is reducible and hits your fingertip on digital inguinal canal exam dx? Is this associated with Hesselbach's triangle?

Chronic Pancreatitis

Pt with chronic abd pain, with episodic LUQ exacerbations, anorexia, N/V, steatorrhea flatulence, and weight-loss. Pt was recently diagnosed with DM. a CT is ordered and depicted above. Leading dx?

-IV Cefotaxime (or similar 3rd gen cephalosporin) -Indefinite prophylaxis w/ cipro, bactrim

Spontaneous Bacterial Peritonitis (SBP) with Polymorphouclear (PMN) cell count >250/uL treatment and prophylaxis?

Lipase and Amylase Lipase is more specific

The best initial lab for Acute pancreatitis is ______ and ______ levels, which should be 3x the upper limit or normal? Which is the more specific for this diagnosis?

PAIN 72 hours

The main symptom of a Thrombosed Hemorrhoid is _______ that can last several days, with Discolored perianal mass. Pain w/in ____ (time) of onset can have SURGERY (Excise & Evacuate). Any more time then that and the sx will resolve on their own.

RUQ pain similar to gallbladder, liver or biliary tree pathologies

The pain of a retro-cecal appendicitis will most likely mimic what kinds of pathologies (which location)?

Supportive -Inc fiber, H20 intake -Sitz baths -Analgesics (Topical nitroglycerin, botox) -Stool softeners, laxatives, mineral oil

Tx options for Anal fissures?

Diverticulosis Inc fiber clear liquid diet for a few days

UNINFLAMED Pockets or outpouchings of tissue that can range in size from a few mm to several cm MC occurring in the sigmoid colon. What lifestyle changes can help prevent disease advancement?

I: Visible on anoscopy, does not prolapse II: Prolapses out of anal canal w/ defecation, but reduces spontaneously III: Prolapses out of anal canal w/ defecation, but requires manual reduction IV: Not reducible and may strangulate

What are the 4 grades of internal hemorrhoids and which of them may strangulated?

Parks Classification System

What classification system is used to categorize anorectal fistulas?

Dilated bowel loops Large Bowel Obstruction

What is depicted on this KUB?

APPENDECTOMY Cefoxitin or cefotetan (if non surgical candidate, can just give these for 7 days)

What is the definitive tx for appendicitis? Preop ABX?

1. Begins as vague periumbilical/Epigastric pain 2. Migrates to RLQ (McBurneys Point)

What is the pattern of pain travel in appendicitis?

Low Fiber diets with small meals Metoclopramide (Reglan)

What lifestyle changes and medication can help treat gastroparesis?

-No improvement w/ meds after 72h -Abdominal abscess >=4cm -Development of fistulas -Colonic obstruction

When should diverticulitis receive a surgical consult? (4)

Fecal Elastase is the most sensitive and specific test

Which of the following tests will be elevated in a patient with CHRONIC Pancreatitis? -Lipase -Amylase -Insulin -Elastase -Calcium Where should this labs be drawn?

6 FAN H. fever > 100.4°F, heart rate > 120 bpm, neutrophilic leukocytosis > 10,500/microL anemia PO Vanc & IV Metronidazole

XR of Toxic Megacolon will show Dilation > ____ cm. 3/4 of what other sx must be present? What antibiotcs should be used if C Diff is involved?

Staph Aureus Anal/Rectal Fistulas

bacterial infection of anal glands/ducts commonly results in an anal abscess. MC bacteria? What is the MC complication of this condition?

Hepatic Encephalopathy LACTULOSE

cirrhosis pt with elevated ammonia andAMS. DX?TX?

obstipation

inability to pass flatus or stool, commonly associated with bowel obstruction is known as _________

Petersen's Hernia

internal herniation of SI through mesenteric defect from Roux-en-Y limb after gastric bypas surgery.

Conservative Measures: -Inc fiber in diet -Refrain from lingering on toilet -Sitz bath -Topical Sterroid Medications: -Topical Hydrocortisone/ Lidocaine -Topical Nitroglycerin Procedures: -Rubber Band Ligation -Hemeroidecomy

tx for hemerrhoids? conservative, medicine, surgery?

Sister Mary Joseph node A lot of cancers: Gastric, prostate, colon, pancreatic, lymphoma

umbilical nodule. Name the sign and associated diseases.