Term
| What is the most important therapeutic objective in caring for a patient with short bowel syndrome? |
|
Definition
| maintenence of nutritional status |
|
|
Term
| What is short bowel syndrome? |
|
Definition
| malabsorption and maldigestion due to extensive resection of small bowel; characterized by diarrhea, dehydration, electrolyte disturbance, malabsorption, and progressive malnutrition |
|
|
Term
| What is necrotizing enterocolitis? |
|
Definition
| extensive ulceration and necrosis of the ileum and colon and premature infants in the neonatal period; possibly due to perinatal intestinal ischemia and bacterial invasion |
|
|
Term
| What causes short bowel syndrome? |
|
Definition
| extensive bowel resection or a functional defect such as radiation enteritis or severe inflammatory bowel disease |
|
|
Term
| How long is the small bowel? |
|
Definition
|
|
Term
| At what small bowel length do you develop problems with short bowel syndrome? |
|
Definition
| 90-180 cm of small bowel (or 1/3 of normal intestine) may develop transient diarrhea and malabsorption; whereas, individuals withless than 60 cm of small bowel may require permanent parenteral nutrition |
|
|
Term
| What are the most common causes of short bowel syndrome in adults? |
|
Definition
| Crohn disease and mesenteric infarction |
|
|
Term
| What are the most common causes of short bowel syndrome in children? |
|
Definition
| necrotizing enterocolitis, small bowel vovlulus |
|
|
Term
| What are the structural and functional adaptations that occur after extensive small bowel resection? |
|
Definition
| structural changes include elongation, increase in villous height, mucosal surface area, bowel luminal circumference and wall thickness; functionally there is an incresae in nutrient absorption and a decrease in diarrrhea and malabsorption |
|
|
Term
| When does the adaptive process take place after small bowel resection? |
|
Definition
| begins in 12 to 24 hrs and continues for 1 to 2 years |
|
|
Term
| The degree of intestinal adaptation after small bowel resection depends on what? |
|
Definition
| length and site of intestinal loss, functional status of remaining bowel and the elapsed time from the insult |
|
|
Term
| What nutrients can the colon adapt to abosrp if there is extensive bowel resection? |
|
Definition
| short chain fatty acids; can also reduce infectious complications |
|
|
Term
| What are the adverse effects of colonic adaptation for short bowel syndrome? |
|
Definition
| increase diarrhea (from bile acid malabsorption) and increase in calcium oxalate kidney stone formation |
|
|
Term
| What are the disadvantages of parenteral nutrition? |
|
Definition
| intestinal atrophy, intravenous line sepsis, high cost, high morbidity and mortality (liver dysfunction), poor quality of life |
|
|
Term
| What specific intestinal nutrients can promote adaptation in a pt with short bowel syndrome? |
|
Definition
| glutamine, ornithine, triglycerides, and soluble and short chain fatty acids |
|
|
Term
| What medications can be used to reduce gastrointestinal motility and secretion and can be used for short bowel syndrome to reduce diarrhea and improve absorption? |
|
Definition
| loperamide, codeine phosphate, proton pump inhibitors, octreotide, clonidine (reduces fluid secretion), cholestyramine (if diarrhea is related to bile acid malabsorption, e.g. ileum resection), glutamine and rHGH may help |
|
|
Term
| What are surgical treatment options for short bowel syndrome? |
|
Definition
| small bowel transplant, lengthening of the intestine, implantation of artificial intestinal valves, reversed intestinal segments or a recirculating loop |
|
|
Term
| What is the prognosis of a pt with small bowel transplant for small bowel resection? |
|
Definition
| 1 yr survival of 69% with 3/4 surviving without TPN |
|
|
Term
| Which hepatic tumor is associated with oral contraceptive use? |
|
Definition
|
|
Term
| What percent of the population has a benign focal liver mass? |
|
Definition
|
|
Term
| What is the treatment for hepatic adenoma? |
|
Definition
| should undergo resection unless they are small andasymptomatic in which case they can be initially treated with cessation of the use of oral contraceptives and close surveillance at 3-6 month intervals |
|
|
Term
| Why do we take out hepatic adenomas? |
|
Definition
| because they are likely to produce symptoms, cause hemorrhage and undergo malignant transformation |
|
|
Term
| What are the three most common primary benign liver tumors? |
|
Definition
| hemangioma, adenoma, and focal nodular hyperplasia |
|
|
Term
| What are the most common primary malignant liver tumors in adults? |
|
Definition
| hepatocellular carcinoma and cholangiocarcinoma |
|
|
Term
| What is the most common metastatic tumor found in teh liver? |
|
Definition
|
|
Term
| What is the typical demographic of patients with focal nodular hyperplasia? |
|
Definition
|
|
Term
| What is the typical appearance of FNH on CT scan? |
|
Definition
|
|
Term
| What is the prognosis of FNH? |
|
Definition
| benign tumor without malignant potention, asymptomatic usually |
|
|
Term
| When is surgery indicated for FNH? |
|
Definition
| when malignancy can not be excluded or when FNH produces severe symptoms |
|
|
Term
| What is THE most common benign liver tumor? |
|
Definition
|
|
Term
| What are the symptoms associated with hemangioma? |
|
Definition
| sometimes can cause vague abdominal pain but is frequently asymptomatic |
|
|
Term
| T/F Hemangiomas can spontaneously rupture. |
|
Definition
|
|
Term
| What are surgical indications for surgical removal of a hemangioma? |
|
Definition
| severe symptoms, inability to rule out the possibility of malignancy and rupture |
|
|
Term
| Name some modalities that can be used to visualize liver tumors. |
|
Definition
| U/S, CT scan, CT with angioportography, MRI, angiography, laparoscopic u/S |
|
|
Term
| Name the characteristics associated with secondary liver tumors. |
|
Definition
| resection of a primary tumor with known metastatic potential within the previous 5 years; current signs and symptoms of an untreated primary withknown metastatic potential, miliary or diffuse distribution of hepatic lesions; significant elevation of tumor marker levels (>10 fold) in the setting of a new liver mass |
|
|
Term
| How can you determine the prognosis of pts with liver mets? |
|
Definition
|
|
Term
| T/F Liver transplant can be used as a last resort in patients with secondary liver tumors. |
|
Definition
| false; liver transplant is never used to treat secondary liver mets |
|
|
Term
| What is the gold standard test to detect hemangioma of the liver? |
|
Definition
|
|
Term
| What is the gold standard test for hepatocellular carcinoma? |
|
Definition
|
|
Term
| What is the gold standard for diagnosis of metastatic adenocarcinoma to the liver? |
|
Definition
|
|
Term
| What are the best imaging tests for hemangioma of the liver? |
|
Definition
| angiography is the gold standard, MRI and CT angioportography are also good |
|
|
Term
| CT angioportography with "early contrast enhancement with peripheral outlining of tumor"= |
|
Definition
|
|
Term
| What tests are good to diagnose focal hyperplasia of the liver? |
|
Definition
| angiography is the best (CT angioportography and MRI have low specificity but central scar is characteristic finding) |
|
|
Term
| What is the best test for hepatic adenoma? |
|
Definition
| laparoscopic ultrasound is helpful when combined with laparoscopic biopsy |
|
|
Term
| Which liver lesions need a biopsy to diagnose? |
|
Definition
| hepatocellular carcinoma dn metastatic adenocarcinoma |
|
|
Term
| What are the best tests for metastatic adenocarcinoma? |
|
Definition
| CT angioportography is gold standard; MRI also has high sensitivity and specificity; laparoscopic ultrasound is highly sensitive when combined with laparoscopic biopsy |
|
|
Term
| CT angioportography is best at picking out what liver tumors? |
|
Definition
| hemangioma and metastatic adenocarcinoma |
|
|
Term
| MRI is best at picking out what liver tumors? |
|
Definition
| hemangioma, metastatic adenocarcinoma |
|
|
Term
| Angiography is good at picking out what liver tumors? |
|
Definition
| hemangioma, focal hyperplasia |
|
|
Term
| What liver tumors is laparoscopic u/s good at picking out? |
|
Definition
| adenoma and metastatic adenocarcinoma (when combined with biopsy), gold standard for HCC, |
|
|
Term
| What are the "points" in teh 5 point scoring system for patients undergoing liver resection for metastatic colorectal cancer? |
|
Definition
| node positive primary tumor, disease-free interval <12 months, >1 liver metastasis, metastasis >5cm, CEA > 200 |
|
|
Term
| CA 125 is a tumor marker for... |
|
Definition
|
|
Term
| CA 50 is a tumor marker for... |
|
Definition
|
|
Term
| Neuron-specific enolase is a tumor marker for... |
|
Definition
|
|
Term
| CA 15-3 is a tumor marker for... |
|
Definition
|
|
Term
| Ferritin is a tumor marker for... |
|
Definition
|
|
Term
| Why isn't radiation of liver mets performed? |
|
Definition
| produces unacceptable liver toxicity |
|
|
Term
| What are some associated complications of diverticulitis? |
|
Definition
| perforation, abscess formation, bowel obstruction, and development of fistulas |
|
|
Term
| How do you treat an abscess due to diverticulitis? |
|
Definition
| small mesenteric abscesses may resolve with antibiotic therapy alone; whereas large abscesses may require CT-guided drainage in addition to antibiotic therapy, and multiple abscesses and abscesses in inaccessible locations may require operative drainage; if the patient fails to improve clinically after 72 hrs with nonoperative treatment, surgical intervention is usually warranted |
|
|
Term
| What is cecal diverticulosis? |
|
Definition
| diverticulum of the ascending colon; more common in asian pts |
|
|
Term
| What percent of pts with diverticulosis will remain free of recurrences? |
|
Definition
|
|
Term
| When should pts be hospitalized for diverticulitis? |
|
Definition
| systemic toxicity (fever, tachycardia, peritonitis) |
|
|
Term
| When should pts with uncomplicated diverticulitis get surgery? |
|
Definition
| if theyare immunocompromised or have had 4 or more episodes of diverticulitis or have significantly compromised quality of life due to diverticulitis |
|
|
Term
| What determines whether you should perform a colostomy with Hartman's pouch or primary anastomosis for diverticulitis? |
|
Definition
| if the pt is hemodynamically unstable or has fecal peritonitis=surgical resection, colostomy, closure of the recal stump; reanastomosis if no significant contamination |
|
|
Term
| T/F Perforation with diverticulitis always needs surgical correction. |
|
Definition
| false; perforation that results in localized fluid collection or a diverticular abscess can be initially managed with nonoperative therapy in teh absence of peritoneal signs or systemic toxicity |
|
|
Term
| Contrast tx of mesenteric vs pelvic abscesse 2ndary to diverticulitis. |
|
Definition
| mesenteric= antibiotic therapy; pelvic= percutaneous drainage |
|
|
Term
| How does diverticulitis lead to intestinal obstruction? |
|
Definition
| can occur immediately due to inflammation or at a later date due to a stricture |
|
|
Term
| What type of surgery should be performed for pts with diverticulitis and resulting obstruction? |
|
Definition
| if partial= resection with anastomosis may be feasible after bowel prep; complete= urgent surgical intervention |
|
|
Term
| Where are diverticular fistulas most common? |
|
Definition
| bladder, vagina, skin, or another segment of bowel |
|
|
Term
| What can be used to visualize a fistula associated with a diverticula? |
|
Definition
| barium enema, CT scan and sigmoidoscopy; cystocopy or vaginal spectulum exam for fistulas there |
|
|
Term
| How do you treat a fistula associated with a diverticula? |
|
Definition
| resection of the sigmoid colon, excision of the fistulous tract,and repair or resection of the other involved organ |
|
|
Term
| What is the most common cause of GI tract fistula? |
|
Definition
| diverticulitis, usually causing a colovesical fistula |
|
|
Term
| T/F Younger age is an indication for colectomy in diverticulitis treatment. |
|
Definition
|
|
Term
| What arethe complications associated withAAA? |
|
Definition
| rupture, thrombosis, distal embolism, other peripheral aneurysms |
|
|
Term
|
Definition
|
|
Term
| 90% of AAA are located... |
|
Definition
|
|
Term
| What is the law of Laplace? |
|
Definition
| wall tension is proportional to thesquare of the radius and the inverse ofwall thickness |
|
|
Term
| Rupture rate/year of a AAA <5cm? |
|
Definition
|
|
Term
| Rupture rate/year of a AAA that is 5cm? |
|
Definition
|
|
Term
| Rupture rate/year of AAA that is 6cm? |
|
Definition
|
|
Term
| Rupture rate of a AAA that is 7 cm? |
|
Definition
|
|
Term
| How can you decrease surgical risk of pts with AAA? |
|
Definition
| perioperative beta blocker and statin therapy; lifestyle modifications |
|
|
Term
| What percent of patients with ruptred AAA survive emergency surgery? |
|
Definition
|
|
Term
| Whatis the mortality rate of "good risk" pts for AAA repair? |
|
Definition
|
|
Term
| What is the standard criterion for recommending repair for AAA? |
|
Definition
| equal to or more than 5.5 cm in men; equal to or more than 5.0 cm in women |
|
|
Term
| What is the most common cause of perioperative morbidity and mortality in pts with AAA repair? |
|
Definition
|
|
Term
| What other studies besides U/S would you get on a AAA? |
|
Definition
| CT can assess suitability for endovascular aneurysm repair or conventional open surgery; arteriography cannot diagnose AAA but can help in operative planning for both EVARand open repairs |
|
|
Term
| What are the two ways you can repair AAAs? |
|
Definition
| endovascular aneurysm repair (EVAR) and conventional open surgery |
|
|
Term
|
Definition
| pts with higher risk for open repair complications= severe coronary artery disease, COPD, obesity, malignancy, adhesions, etc. |
|
|
Term
| What is the risk of rupture/year with EVAR? |
|
Definition
|
|
Term
| What is the followup needed with EVAR? |
|
Definition
| intensive imaging follow-up every 3 to 6 months |
|
|
Term
| What is the "ultimate" perioperative risk profile for EVAR? |
|
Definition
|
|
Term
| What is the next step in management if you suspect ruptured AAA? |
|
Definition
| immediate operative repair (no need for radiologic imaging) |
|
|
Term
| How do you followup/observe a AAA? |
|
Definition
|
|
Term
| T/F AAA can cause symptoms of gross hematuria. |
|
Definition
| true; its rare but AAA can erode into a ureter |
|
|
Term
| Why does EVAR repair fail? |
|
Definition
| continued enlargement of the aorta and migration of the device causes leakage around the device |
|
|
Term
| What are the best methods to provide ongoing assessment of a pt in post op shock? |
|
Definition
| place central venous pressure (CVP) monitor and arterial catheter for continuous blood pressure monitoring; consider echo/pulmonary artery (PA) catheter placement to assess ventricular function or cardiac output |
|
|
Term
| What is the volume of each unit of PRBCs? |
|
Definition
|
|
Term
| What is a central venous catheter? |
|
Definition
| an intravenous catheter of adequate length to measure pressures in the superior vena cava when placed via internal jugular vein or subclavian vein |
|
|
Term
| What can a PA catheter tell you? |
|
Definition
| can approximate right atrial pressure; can also measure cardiac output by the thermodilution method |
|
|
Term
| What are the drawbacks of using UOP to indicate adequate resuscitation? |
|
Definition
| hyperglycemic pts will have falsely high UOP, pts who may developlow urine output from acute renal insufficiency following severe or prolonged shock |
|
|
Term
| What are the different types of shock? |
|
Definition
| hypovolemic, distributive, cardiac: intrinsic vs extrinsic, mixed |
|
|
Term
| What are causes of hypovolemic shock? |
|
Definition
|
|
Term
| What are causes of distributive shock? |
|
Definition
| sepsis, neurogenic, anaphylaxis, medications |
|
|
Term
| What are causes of extrinsic cardiac shock? |
|
Definition
| cardiac tamponade, tension pneumothorax, massive pulmonary edema |
|
|
Term
| What can you monitor as a resuscitation endpoint? |
|
Definition
| foley catheter, central venous catheter for frequent CVP measurements, arterial catheter for continuous blood pressure monitoring (preferred) or frequent noninvasive blood pressure measurements; serial hemoglobin measurements; serial arterial blood gases (ABGs) for trends in lactate level or base deficit |
|
|
Term
| ddx for post surgical pt who initially responds to crystalloid resuscitation but then has a subsequent drop in arterial BP... |
|
Definition
| ongoing surgical bleeding if drops suddenly, microvascular leak syndrome if more gradual decrease in blood pressure |
|
|
Term
| What should you do if hormagge is suspected and cysrtalloid only stabilizes the pt transiently? |
|
Definition
| transfuse with PRBC; coagulation profile (INR, PTT and platelets) should be checked to rule out nonsurgical sources of bleeding |
|
|
Term
| What is the hallmark of spinal shock? |
|
Definition
| normal or low heart rate in someone who is not on a beta blocker |
|
|
Term
| Where does an injury that causes neurogenic shock occur? |
|
Definition
| cervical or upper thoracic spine |
|
|
Term
| How does cardiac tamponade affect ventricular filling? |
|
Definition
| limits righ theart filling by compressing the thin-walled right ventricle and shifting th eseptum toward the more robust left ventricle, thus decreasing left ventricular end diastolic volume |
|
|
Term
| What is a normal cardiac index? |
|
Definition
|
|
Term
| What is anormal systemic vascular resistance? |
|
Definition
|
|
Term
| What is a normal pulmonary capillary wedge pressure? |
|
Definition
|
|
Term
| What is the cardiac index in distributive shock? |
|
Definition
|
|
Term
| What is the cardiac index in cardiogenic shock? |
|
Definition
|
|
Term
| What is the cardiac index in hypovolemic shock? |
|
Definition
|
|
Term
| What is the cardiac index in obstructive cardiac shock? |
|
Definition
|
|
Term
| What is the PCWP in distributive shock? |
|
Definition
|
|
Term
| What is the PCWP in pts with cardiogenic shock? |
|
Definition
|
|
Term
| What is the PCWP in pts with cardiogenic shock? |
|
Definition
|
|
Term
| What is the PCWP in pts with hypovolemic shock? |
|
Definition
|
|
Term
| What is the PCWP in obstructive cardiogenic shock? |
|
Definition
|
|
Term
| At equilibrium, what percent of isotonic crystalloid remains in the intravascular space? |
|
Definition
|
|
Term
| Which is better for acute blood loss: cystalloids or colloids? |
|
Definition
|
|
Term
|
Definition
| colloid solution that tends to remain in the intravascular space at equilibrium |
|
|
Term
| T/F The initial therapy for hypotension in most patients in whom sepsis is suspected should be vasopressors. |
|
Definition
| false; should be aggressive fluid resuscitation |
|
|
Term
| Invasive monitoring using pulmonary artery catheterizationshould be considered when... |
|
Definition
| pts do not respond appropriately to initial therapy with stabilization of organ function and vital signs |
|
|
Term
| What types of pts may not exhibit the expected tachycardia response to hemorrhage until late in the course of shock? |
|
Definition
| pts under 30 with a good cardiac reserve and patients on beta blockers |
|
|
