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DU PA GI Surgery

Duke PA Gastrointestinal Surgery

implies severe abdominal pain arising rather suddenly and of less than 24 hours duration acute abdomen
pain arising from the foregut (stomach, pancrease, duodenum and biliary tree) localizes to the epigastrum
pain from structures arising from the midgut (small bowel, and right transverse colon) localizes to the periumbilical region
pain from structures arising from the hindgut (left colon, sigmoid colon, rectum) localizes to the hypogastric region
intermittent colicky, poorly localized abdominal pain is found with GI Tract obstruction
steady, well localized pain usually occurs after perforation, ischemia, inflammation, or hemorrhage
classic signs and symptoms are mild fever and focal right lower quadrant pain with rebound tenderness appendicitis
commonly occurs in women between the ages of 40-60 who are overweight and have a previous history of pregnancy acute cholecystitis
patients will have right upper quadrant pain that is accentuated on inspiration, and is accompanied by nausea and vomiting acute cholecystitis
Murphy's sign acute cholecystitis
McBurney point appendicitis
laparoscopic approach has been proven safe in both acute and chronic settings cholecystitis
pain that localizes to right lower quadrant accompanied by anorexia, nausea, and vomiting is classic appendicitis
the normal anatomic position of the appendix anterior intraperitoneal
results in an increased risk of perforation due to delayed diagnosis hidden position of appendix
during the 5th month of pregnancy the appendix may rise as high as the right upper quadrant
in western populations the lifetime risk of appendicitis is __% 7
appendicitis is primarily a disease of adolescents and young adults
incidence of ____ declines after age 30 appendicitis
____ is seen in approximately 70% of appendicitis cases obstruction of the appendiceal lumen
the appendiceal lumen can be obstructed by fecaliths, foreign bodies, tumors, parasites, and lymphoid hyperplasia
the number of ___ in the vermiform appendix peaks between the ages of 10-30 lymphoid follicles
rare causes of appendicitis diverticula, and duplications
after obstruction of the appendiceal lumen ___ continue mucosal secretions of lining cells
___ follows appendiceal obstruction bacterial overgrowth and increased intraluminal pressure
___ which ultimately leads to ulceration, necrosis, gangrene, and perforation increased intraluminal pressure causes vascular congestion
____ alone should make the diagnosis of acute appendicitis in most patients history and physical exam
after 1-12 hours of diffuse mild to moderate pain, appendicitis pain will usually migrate to the right lower quadrant and become more intense
Vomiting and diarrhea may be present in acute appendicitis but ___ are usually not excessive
if vomiting precedes abdominal pain or if anorexia is not present ____ the diagnosis of appendicitis should be questioned
___ should be present in 75%-85% of all patients with acute appendicitis fever
a temperature will rarely be highter than __ unless the appendix is grossly perforated 38 degrees
with appendicitis vital signs are usually normal with slight tachycardia due to pain, fever, or dehydration
patients with acute appendicitis prefer to lie motionless
patients with colicky-type pain may appear restless
palpation of left lower quadrant causing right lower quadrant pain Rovsing's sign
deep palpation of right lower quadrant followed by a sudden release rebound examination
asessing for rebound tenderness can lead to a false positive
a positive ___ sign may indicate an inflamed appendix lying anterior to the ___ muscle psoas
this sign is best demonstrated by extension of the hip or flexion against resistance psoas sign
___ is produced by stretching this muscle with passive internal rotation of the thigh, with the hips in a flexed position obturator sign
both the obturator and psoas signs are non-specific and only present on occasion
a ___ exam is also important in evaluating any patient with abdominal pain rectal
tenderness with a rectal exam is most commonly seen when the inflamed appendix lies within the pelvis
____ on fecal exam should be quite rare and lead to the consideration of a diagnosis other than appendicitis gross blood
administer prophylactic antibiotics before incision
the base of the appendix is located at the junction of the three tenia
the ___ lies posterior to the cecum or terminal ileum appendiceal artery
after incision if appendicitis is not present a thourough search for other pathology is important
consider ___ of the wound for advanced and perforated appendicitis open packing
the gold standard for the treatment of appendicitis is exploratory laparotomy, and appendectomy
laparotomy can be accomplished through a ____ incision McBurney
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
a right-lower-quadrant transverse ___ incision is preferred by many for appendicitis Rocky-Davis
in the elderly where other disease processes may be encountered, many surgeons would prefer a ____ incision lower midline laparotomy
____ are usually indicated if a well-formed intraabdominal or pelvic abcess is encountered intraabdominal drains
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
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
as a diagnostic procedure ____ is by far the most accurate, but it is invasive laparoscopy
laparoscopic appendectomy is especially useful when the diagnosis is in question
laparoscopic appendectomy is especially useful in women of reproductive age
laparoscopic appendectomy is especially useful in obese patients
laparoscopic appendectomy is especially useful in the elderly
antibiotic therapy in early appendicitis should be of short duration
in uncomplicated appendectomy patients should be moved to a diet and discharged within ___hours 24-48
___ complications are by far the most frequently seen problem after appendectomy septic
once a wound infection is diagnosed the primary treatment is to open the wound and to allow drainage of the purulent material
if cellulitis is present in an infected wound antibiotics are indicated
early recognition, aggressive surgical debridement, and administration of broad spectrum antibiotics are critical in necrotizing fasciitis
___ is the result of the abdominal host defenses attempting to wall off an infectious threat abscess
drainage and antibiotics are the treatments for postoperative abscess
an abscess after appendicitis most commonly occurs in the right paracolic gutter, pelvis, or intraloop position
the most common treatment for postoperative abscess is CT-guided catheter drainage
the radiographic finding of air in the portal vein pylephlebitis
this is a rare presentation of an advanced septic process due to gas-forming organisms pylephlebitis
is often seen in the elderly, immunocompromised, or in advanced sepsis, and is often a preterminal finding pylephlebitis
appendicitis is seen in approximately 1 in ___ pregnancies 2000
the most common nonobstetric emergency in pregnant women appendicitis
WBC count in a pregnant woman is unreliable, however a ___ can be seen in appendicitis left shift
the risk of conventional diagnostic radiographs such as a KUB or CT scans is ___ after the first trimester negligible
abdominal wall hernias occur in __% of the United States population 1.5
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
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
the spermatic cord travels the length of the inguinal canal and exits through the external oblique aponeurosis at the external inguinal ring
____ hernias come through the internal inguinal ring and enter the inguinal canal indirect inguinal
with time indirect inguinal hernias may extend along the canal and exit through the internal ring into the scrotum
____ are usually caused by a lack of obliteration by the processus vaginalis during development indirect inguinal hernias
____ hernias come through the posterior wall of the inguinal canal and are a defect in the transversalis fascia direct inguinal
direct inguinal hernias infrequently enter the scrotum
the main etiologic factor in direct inguinal hernias is any maneuver that increases intraabdominal pressure, such as frequent heavy lifting
risk factors for direct inguinal hernias cigarette smoking, advanced age, chronic illness
____ hernias are more common in women femoral
because of the risk of ____ nonsurgical management of hernias is not recommended incarceration and strangulation
wearing a ___ does NOT gaurentee that a hernia will remain reduced and not incarcerate or strangulate truss
___ is a surgical emergency acutely incarcerated hernia
the ___ approach is best for recurrent hernias (open or laparoscopic) posterior or preperitoneal
the recurrence rate for direct inguinal hernias is __% 5-10
the recurrence rate for indirect inguinal hernias is __% 1-5
the us of a prosthesis for herniorrhaphies is mandatory only when a suture repair would be under undue tension
Ventral, incisional hernias frequently occur because of wound infection, obesity, or malnutrition
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
the results of ____ in inguinal hernia repair have been very good various plug techniques
a large peice of material is fixed with only a few sutures Stoppa technique
the anterior boundry of the inguinal canal external oblique aponeurosis
the posterior boundry of the inguinal canal transversalis fascia and transversus abdominis aponeurosis
the inferior boundry of the inguinal canal inguinal and lacunar ligaments
the superior boundry of the inguinal canal internal oblique and transversus abdominis muscle and aponeuroses
___ come through the posterior wall of the inguinal canal direct inguinal hernias
___ come through the internal or deep inguinal ring indirect inguinal hernias
inguinal herniorrhaphy in which the transversus abdominis aponeurosis and the internal oblique aponeurosis superiorly are sutured to the inguinal ligament Bassini repair
inguinal herniorrhaphy in which the conjoined tendon superiorly is sutured to Cooper's ligament inferiorly McVay (Cooper's ligament repair)
the transversus abdominus aponeurosis, and the internal oblique aponeurosis conjoined tendon
the anterior boundry of the femoral canal iliopubic tract and inguinal ligament
posterior boundry of the femoral canal Cooper's ligament
medial boundry of the femoral canal lacunar ligament
lateral boundry of the femoral canal femoral vein
hematomas and infections occur in __% of inguinal herniorrhaphies 1-2
the only acceptable approach to the treatment of femoral hernias is operative
congenital umbilical hernias usually close spontaneously by age 2
umbilical hernias are usually congenital
____ umbilical defects should be repaired those that persist beyond age 4 or those larger than 2cm at an earlier age
recurrence of umbilical hernia is very uncommon
umbilical hernias have ___ complications very few
if a hernia bulges with a valsalva maneuver it will reduce when the patient exhales
if a primary repair can be accomplished without excessive tension, yet the tissues appear weak ____ an onlay of polypropylene mesh should be performed
inflammation of the gallbladder acute cholecystitis
in the vast majority of cases (>90%) of acute cholecystitis ___ is the initiating event obstruction of the cystic duct by a stone
acute cholecystitis is distinguished from an attack of biliary colic by persistant RUQ pain, fever, elevated WBCs, and alteration in liver chems.
acute cholecystitis is associated with ___ in 50-75% of cases bacterial pathogens
if cholecystitis is left untreated ___ may develop (most often seen in diabetic patients) severe gangrenous cholecystitis
____ leads to increased morbidity and mortality from perforation of the gallbladder or overwhelming sepsis severe gangrenous cholecystitis
patients suspected of having acute cholecystitis should be admitted to the hospital, made NPO, and started on intravenous fluids
contraindications to cholecystectomy myocardial ischemia, pancreatitis, cholangitis
unless contraindications exist, ___ should be performed in the first 24-36 hours after admission cholecystectomy
the inflammatory process of cholecystitis is the most severe between ____ of the onset of symptoms, the technical challenge of successful laparascopic removal is greatest during this period 72 hours to 1 week
if the patient is diagnosed with choecystitis 4-5 days after onset of symptoms there may be some benefit in managing with antibiotics and deferring definitive treatment to 6 weeks
the success rates with this technique where low, and the complications high. Therefore this procedure has been abandoned Extracorporeal shock wave lithotripsy for gallstones
contraindications for laparoscopic cholecystectomy portal hypertension, cirrhosis, previous RUQ surgery
the treatment of choice for most patients with symptomatic gallstones laparoscopic cholecystectomy
after laparoscopic cholecystectomy, N/V and increasing abdominal pain are often early warning signs of postoperative biles leak
____ in an otherwise healthy patient is carcinoma of the biliary system until proven otherwise painless jaundice
after laparoscopic cholecystectomy patients should have minimal pain and be able to eat
what are the 4 F's of gall stones female, fertile, fat, forty
cholelithiasis gallstones in the cystic duct
choledocholithiasis gallstones in the common bile duct
__% of gallstones are radioopaque 15
inflammation of the common bile duct cholangitis
cholecystectomy is performed for cholelithiasis, cholecystitis, gallstone pancreatitis, gallbladder cancer
now the procedure of choice for gallbladder disease laparoscopic cholecystectomy
causes less pain, shorter hospital stay laparoscopic cholecystectomy
complications of laparoscopic cholecystectomy abscess, bile leak, common bile duct injury, bowel injury, wound infection
what do you want to see on the critical view for cholecystectomy the cystic aretery and cystic duct both going into the gallbladder
common bile duct injury is ___ with lap approach more common
___ hernias go through Hasselbach's triangle direct
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
which is a recurrent hernia by definition incisional hernia
male:female ratio of inguinal hernia __:1 10
hernia below the inguinal ligament femoral hernia
elements of both direct and indirect hernia pantaloon hernia
____ 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
inability to reduce hernia contents incarceration
compromise of intestinal vascular supply secondary to incarceration strangulation
no mesh hernia repair Bassini
most common hernia repair using mesh Lictenstein
the only time you want to do a laparoscopic hernia repair recurrent hernia (failed repair), or bilateral hernia
Laparoscopic hernia repair has not been shown ___ than open repair more cost-effectiveor less morbid
function of the colon absorption (water, electrolytes/carbohydrates), storage, propulsion, digestion
Most common colonic bacteria Bacteroides fragilis
most common aerobes in colon E. coli, Klebsiella
outpouching of the wall of a hollow viscus diverticula
true diverticula (13%) contain all layers of colon wall, congenital, usually solitary, and uncommon
pseudodiverticula (87%) herniation of submucosa and mucosa through circular muscle
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 diverticulosis
inflammation or microperforation of diverticula, fever, LLQ pain, palpable mass, may produce abscess/colonic obstruction, does not usually cause bleeding acute diverticulitis
surgery for acute diverticulitis is indicated for peritonitis, obstruction, intractable disease, recurrence, presence of fistula
Non-operative management for diverticulitis bowel rest, IV fluids, IV antibiotics, abscess drainage if present
communication between colon and bladder colovesical fistula
torsion of redundant sigmoid colon on itself sigmoid volvulus
classical clinical picture of ____: elderly patients with a history of chronic constipation sigmoid volvulus
bright red blood per rectum hematochezia
most common cause of hematochezia upper GI bleed
most common cause of lower GI bleed hematochezia diverticulosis
signs of hypovolemia tachycardia, hypotension, orthostatic hypotension
Inflammatory disorder of unknown etiology with non-caseating granulomas in submucosa Crohn’s Disease
Discontinuous involvement --> skip lesions, Transmural (full-thickness) inflammation Crohn's disease
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 lossComplications: fistula, stricture Crohn's disease
most common area affected by Crohn's disease terminal ileus
Crohn's diseas is a medical disease managed by __ surgeons
mainstay of medical treatment for Chron's disease antiinflammatories-sulfasalazine, steroids, immunosuppressants, monoclonal antibodies, antibiotics
indications for surgery in Crohn's obstruction, perforation, fistula, cancer, perianal disease, failure of medical therapy, failure to thrive (pediatrics)
Surgery cannot cure __ Crohn's disease
Goal of surgery for Crohn's disease treat complications, and palliate symptoms
Superficial inflammatory process involving mucosa of colon ulcerative colitis
Involves the rectum and moves proximally ulcerative colitis
Surgery can cure __ ulcerative colitis
colorectal cancer is the __ leading cause of death in the US 3rd
colorectal cancer risk factors excess fat and alcohol intake, obesity, and sedentary lifestyle
colorectal cancer screening recommendations include and annual DRE and FOBT starting at age 50
Family History or Inherited Colon Cancer SyndromeAnnual screening with colonoscopy beginning at __ years of age younger than the earliest detected familial cancer 10
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
four types of colon polyps submucosal, hyperplastic, hamartomatous, adenomatous(premalignant lesion)
staging for colorectal cancer involves abdominal CT, Chest X-ray, Endorectal Ultrasound
Result from sliding downward of anal cushions hemorrhoids
Predisposed by age, gravity, shear forces, increased abdominal pressure hemorrhoids
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
above dentate line & covered by columnar epithelium, may prolapse, bleed, and/or thrombose internal hemorrhoids
internal hemorrhoidal disease without significant external disease or other benign anorectal disease, can be banded
____ use for large mixed hemorrhoids or when other benign anorectal diseases present Surgical hemorrhoidectomy
Created by: bwyche
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