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