femoral: women

hernias over all: male predominance

indirect inguinal: male and female

transversalis

internal oblique

external oblique

Pt presents with a hernia describing it as an intermittent bulge in the groin or scrotum.

What type of hernia?

Hernia described as severe pain at the hernia site or in the abdomen or with nausea or vomiting.

What type of hernia?

What are umbilical hernias? Who gets them?

Should you operate?

occur at the umbilicus and are congenital

Most occur in AA

Most resolve spontaneously by age of 2

duodenum 

jejunum

ileum 

extends from the pylorus proximally to the cecum distally

What mechanisms allow for digestion and absorption of nutrients in the small bowel?

What is unique about the small bowel that the large bowel doesn't have?

projections of villi and microvilli

small bowel: plicae circulares: mucosa has sequential circular folds; more numerous in the proximal bowel then in the distal bowel

early in a proximal obstruction

later in a distal obstruction

adhesions 

hernias

Pt presents complaining of internmittent crampy abdominal pain, abdominal distention, obstripation, nausea and comiting.

On PE: pain is out of proportion to physical exam,

small bowel obstruction

pain out of proportion usually indicated ischemic bowel

initial tx: NG decompression to relieve proximal GI distention and associated n/v

IV fluids since pts are usually intravascularly depleted from persistent vomiting

if ischemia or perforation is suspected, but you should first decompress the bowel with NG tube and provide IV fluids first

ileus: impaired peristalsis

small bowel obstruction: usually caused by mechanical obstruction

ask about abdominal operations--bc of poss adhesions

underlying abdominal disorders: IBD, IBS, stomache cancer

Why would you check for blood in the stool for someone with SBO?

What type of labs are you interested in?

suggestive of intestinal strangulation

intravascular volume deprestion consistent of hemoconcentration and electrolyte abnormalities

marked leukocytosis and acidosis suggestive of strangulation

abdominal series, (supine radiograph, erect abdominal film, erect chest film)

upper GI study with contrast

CT: for selected cases

partial SBO

early post op obstruction

IBD: usually respnds to medical therapy

carcinomatosis

RUQ pain/may be more epigastric

n/v

chills, severe vomiting

pain occurs after eating fatty meal

this is dif from PUD: not influenced by oral intak

What type of stool/urine may a pt with choledocolithiasis describe?

why?

stool: clay colored

urine: dark

why? inability of bile pigments to reach the GI tract and subsequent renal clearance

fever, RUQ pain, jaundice

cholangitis

How will gallstones appear on US?

What will you see in acute cholecystitis?

opacity with an echoless shadow posteriorly

acute cholecystits:  fluid around the gallbladder, thickened gallbladder wall, and gallbladder distention

endoscopic retrograde cholangiopancreatography

performed using an endoscope to visulaize the ampulla where the pancreatic and biliary ducts enter the duodenum

In pt with suspected diverticulitis,

what may be indicated in pt with diffuse rebound tenderness or guarding as evidence of generalized peritonitis?

What could it be?

-LLQ acute abdominal pain

            -Fever

            -Constipation or diarrhea

first episode: IV, ABX, NPO (cipro and metronidazole); get colonoscopy after sxs reside to r/o neoplasm

second attack: consider bowel resection

Epi:

who gets diverculosis? (ie. age, population)

age: 80% age over 80 yrs old

due to diets high in fat and low in fiber

3x more likely found in men then women

PUD

Gastritis

Esophageal varices (2^ndary Portal HTN)

Mallory-weiss tear

Diverticulosis

Ulcerative colitis

Ischemic colitis

AVM

Tumors

Polyps

Hemorrhoids

Fissures 

Hematemesis

Melena

dark hematemesis

Hematemesis (Source Proximal to ligament of Treitz)

Melena (black tarry stools) requires at least 50-100ml blood loss

            Dark hematemesis is from digestion of blood (Hgb + gastric acid => metHgb)

Guaiac slide test(hemoccult)

            NGT gastric lavage

            EGD

Tag RBC scan (detects 0.1mL per minute bleeding but only shows general area of bleed)

Angiography with embolization or vasoconstrictive tx (detects bleeding 0.5mL per minute but can show exact location of bleed)

Hydration with IVF

            Frequent H+H checks, transfuse PBRC/FFP/Platelets if needed

            NGT, gastric lavage

            GI consult for EGD with sclerosis or caudery

            Sengstaken-Blakemore Tamponade balloon for esophageal varices

            H₂ blocker or IV PPI

            Angiography with embolization or vasoconstrictive tx

            Surgery, Graham patch, bowel resection 

What is involved in ulcerative colitis (ie. anatomy)?

What age gets it?

Where is pathology?

almost always involves the rectum and extends backward toward the cecum to varying degrees

age: third or fourth decade of life

pathology: confined to mucosa and submucosa. Superficial ulcers, thickened mucosa, crypt abscesses, and pseudopolyps may be present

sclerosing cholangitis

apthous ulcers

anklyosing spondylosis

arthritis

iritis

cholangitis

bloody diarrhea

fever

abdominal pain

weight loss

Pt presents with complaint of bloody diarrhea and abd pain.

On PE:

rectal tenderness due to rectal fissures

abdominal distention-- why?

ulcerative colitis

why distention: toxic megacolon

colonscopy: may see thickened friable mucosa

fissures and pseudopolyps amost always involve rectum and varying portions of the colon

What is initial therapy for pt with ulcerative colitis?

When is surgery indicated?

fluid resuscitation, electrolyte correction, parenteral nutrition

steroids, other immunosuppressives and sulfasalazine.

surgery: colonic obstruction, massive blood loss, failure of med therapy, toxic megacolon, cancer

What serologic test is associated with Ulcerative colitis?

What serologic test is associated with Crohn's disease?

What is the hallmark sign of UC?

What are other symptoms?

bloody diarrhea

tenesmus, fecal urgency, mucoid rectal discharge, crampy abdominal pain, fever

articular disorders

lesions of the skin, oral cavity, liver and biliary tract disorders, thromboembolic disease and vasculitis

1) ileocolitis or inflammation of the lrage and small intestine

2)inflammation isolated to small intestine

3) inflammation isolated to the large intestine

RLQ pain bc most incidences affect ilium and ascending or right colon

diarrhea, weight loss, fever

What are some tx option sfor active UC?

sulfasalazine or 5 ASA (potent anti-inflammatory)

topical corticosteroid

for extensive colitis: give prednisone (40-60 mg)

proctocolectomy

bc of chronic, debilitating nature of the disease and high incidence of relapse

preferred surgery: subtotal colectomy with ileostomy

transmural inflammatory  disease that may affect any part of the GI tract from mouth to anus

characterized by "skip lesions"

granulomata seen microscopically

areas of inflammation assoc with fibrotic strictures, enterocutenaous fisutale and intrabdominal abscesses, all of which require surgical intervention

What population is most susceptible to Crohn's disease?

The muscoa of pt's with Crohn's looks like what?

Ashkenazi Jews more than AA

mucosa has a cobblestone appearance with varying degrees of associated mucosal ulceration

with chrohn's diarrhea is usually loose and watery without frank blood

skin tags

fissures

erythema nodosum, pyoderma gangrenosum, ankylosing spondylitiis

uveitis

blood studies show mild iron deficiency anemia and depressed albumin

small intestine Crohn's diagnosed by barium contrast enteroclysis

fistulograms are helpful to define existing fistula tracks and CT can localize abscesses

ONLY for complications- surgeries should be conservative and only perfromed for complications of the disease (ie stenosis with obstructive sxs, fistulae, abscess, perforation, bleeding)

resections should be avoided due to short bowel syndrome and malnutrition

•Arthritis (axial skeleton in large joints)

•Aphthous oral lesions

•Episcleritis and uveitis

•Thromboembolism

•Gallstones (due to malabsorption of bile salts)

•Dermatologic disorders - erythema nodosum and pyoderma gangrenosum

What is ongoing tx for Crohn's?

What is acute tx?

ONGOING

–Small bowel >> mesalamine

–Large bowel >> sulfasalazine or mesalamine

–Not responsive to aminosalicylates >> metronidazole or ciprofloxacin

•Acute Treatment

–Antidiarrheals agents:  used to inhibit peristalsis and decrease intestinal motility

•loperamide, diphenoxylate/atropine, and cholestyramine

–Antispasmodic agents:  treat pain associated with GI tract spasms.

•dicyclomine and hyoscyamine

–Caution when prescribing medications for diarrhea and abdominal pain – make sure there is NO GI obstruction

What's this:

•Primarily effects mucosal layer causing superficial ulceration and erosion

Lesions form at crypts of Lieberkuhn forming pinpoint hemorrhages 

•CBC → variable degrees of anemia, leukocytosis, or thrombocytosis

•CMP with LFTs → hypokalemic metabolic acidosis; elevated sodium and blood urea nitrogen; elevated alkaline phosphatase, bilirubin, AST and ALT; hypoalbuminaemia

•CRP and ESR → variable degrees of elevation

•Stool Sample → negative cultures, WBC present

What corticosteroids are used in IBD?

when are they used?

Prednisone, methylprednisolone, hydrocortisone, and budesonide

Used in short-term treatment of moderate to severe disease

Long-term use can have serious, irreversible side effects and should be avoided

When would aminosalicylates be used?

What are examples? benefits?

•Sulfasalazine and Mesalamine

•Cornerstone of IBD therapy

•5-ASA has anti-inflammatory effects on GI tract

•Oral mesalamine agents – dissolves in pH of 7.0, releases 5-ASA slowly throughout small intestine and colon

•AZO compounds – contain 5-ASA linked by AZO bond that requires cleavage by colonic bacterial azoreductases to release 5-ASA

•Topical Mesalamine agents – 5-ASA is provided in the form of suppositories and enemas, deliver much higher concentractions of 5-ASA to the distal colon

•Intractability to medical therapy

•Intra-abdominal abscess

•Massive bleeding

•Internal or perianal fistulas

•Intestinal obstruction

•Severe hemorrhage

•Perforation

•Carcinoma

•Fulminant colitis

•Toxic megacolon

What is a volvulus?

What is most commonly involved (ie. anatomy)

occurs when a portion of colon rotates on the axis of its mesentery, compromising blood flow and creating a closed-loop obstruction

Involvement: sigmoid (75%) and cecum (25%)

abdominal radiograph: reveal massively distended colon and a bird's beak a the point of obstruction

tx: sigmoid volulus reduced by revtal tube, enemas or proctoscopy

high rate of recurrence so operative repair after the initial resolution is recommended

tx of cecal volvulus is usually operative at the outset since nonoperative is not usuallly successful

New born presents with bilious vomiting and potential abdominal pain.

Radiograph shows classic double bubble sign. 

What are you thinking it could be?

What lab tests do you want?

Volvulus

metabolic acidosis with low serum bicarb level due to malrotation

What are three types of colorectal polyps?

How are they often described?

When do they occur? (ie. age)

CBC is all that is necessary with hx of bleeding

anorectal ultrasound can look for malignant infacion in a large rectal polyp

adenomas: always remove

small hyperplastic polyps: can be left, but you need to be certain its not an adenoma

most polyps removed via colonscope by using a snare or biopsy forcep.

If polyp too large: formal surgical excision via laparscopic colon resection can be performed

follow up with a repeated colonoscopy in 3-5 yrs.

large or multiple adenomas: follow up in 1-3 years

superior mesenteric artery

bc this embolus stops just beyond the orifice of the middle colic artery, the jejunum, ileum, and right colon are ischemic whereas the transverse colon is frequently viable

Pt presents with abd pain out of proportion to exam, unexplained acidosi, diffuse small bowel dilation, gas in the bowel wall on plan or CT film and portal gas on plain film or CT.

What are you thinking?

What study confirms this?

mesenteric ischemia

confirmed by MRA

early operation and revascularization (may include embolectomy of the SMA or bypass from teh aorta to the SMA)

need to resect inarcted bowel.

pt is reexplored 24 hrs later to remove any necrotic bowel

-Preop hydration(IVF), broad-spectrum ABX, monitor & treat shock

-Definitive tx is resection of involved gut and its mesentery

            -2^nd look reoperative to identify further necrosis

-Sometimes thrombolytics, vasodilators(papaverine is drug of choice), are used or embolectomy is performed.

-Be wary of reperfusion injury

bc the gastric acid prevents bacterial growth, thus making the inoculum too small to cause an active infection.

if untreated- oral bacteria (streptococci, staphylococci, lactobaccil and anaerobes) can produce bacterial infection

second most common cause of cancer death

risk factors:

high fat, low fiber diet

age

family hx

IBD

Gardner's syndrome

When should colon cancer screening be started for person at high risk vs no risk?

what is the screening process?

high risk: start at 40

low risk: start at 50 yo

screening: yearly fecal occult blood test, sigmoidoscopy q 3-5 yrs and colonoscopy or barium enema approx q 10 yrs

left colon: obstructive sxs: change in stool caliber, tenesmus, or constipation

right colon: more significant bleeding

What is the most common site of metastases for colon cancer?

What lab tests should you do?

liver

labs:LFTs and a CEO (carcinoembryonic antigen) level--standard to check for metastatic disease

CT scan

What is the only accepted way to cure pt of colon cancer?

complete surgical excision

proximity to anal sphincter defines whether the pt will need a permanent colostomy

CT and ERCP

ideally, contrast enhanced, three phase, dynamic think section CT

CT: reveals location of mass

ERCP: defines ductal anatomy

Pt presents with vague abdominal pain and wieght loss

obstructive jaundice.

Imaging sows: painless, dilated palpable gallbladder (Courvoiser's sign).

Anorexia, weakness, altered bowel habits and pruritus.

What could it be?

pancreaticoduodenectomy

entalils the en block resection fo the antrum, dudodenum, proximal jejunum, head of pancreas, gallbladder and distal common bile duct

cirrhosis

hep B (leading cause of cirrhosis)

alcoholism

surgical resection or liver transplant

ideal candidate for surgical resection: solitary lesion within a normal liver

what is normal diameter of abd aorta?

what about AAA?

normal diameters 2 cm

AAA- >3 cm

symptomatic or ruptured AAA

all AAA >5 cm

Abdominal ultrasound- screening test of choice (recommended for >3.5 diameter)

-Contrast CT more accurately describes the aneurysm and shows renals and iliac vessels as well

atherosclerosis

HTN

smoking

male gender

advanced age

connective tissue disease

The definitive treatment of compartment syndrome is fasciotomy.

A surgical incision is made along the length of the compartment to relieve the pressure. The wound is left open. Several days later, after resolution of the edema, the patient returns to the operating room for closure of the wound.

Compartment pressures of <15 mm Hg are safe. Pressures between 20 and 30 mm Hg may cause damage if they persist for several hours. Levels in this range may be closely followed clinically with repeat pressure measurements. Pressures of 30 to 40 mm Hg are generally considered grounds for emergent fasciotomy. Injuries resulting in an inability to closely follow borderline elevations in compartment pressures may be an indication for fasciotomy.

What does this describe:

condition in which pts usually are symptomatic with pain, especially in the second half the menstrual cycle. Clinically, multiple nodular densities are palpable. Symptom relief with cold compresses, reduced caffeine intake, properly fitted bras, and occasionally, the use of anti inflammatory agents.

age

poor ventricular function or CHF

cerebrovascular disease

renal failure

diabetes with sequelae

COPD

morbid obesity

PVD

prior cardiac operation

internal mammary artery (aka internal thoracic artery)

radial artery

gastropiploic artery

inf epigastric artery

1. harvesting the conduit

2. preparation for CPB, with insertion of cannulae

3) ob-bypass time, with a subset of that being ischemic or cross-clamp time (actual revascularization is done this time)

4) closing and consists of reversal of anticoag, decannulation, and closure of the chest

HTN

Fhx

hypercholesterolemia

smoking 

smoking 

obesity

physical inactivity

males more than females

PVD with diminished pulses

signs of ventricular failure: cardiomegaly, CHF, S3 or S4

Mitral regurgitation

What is the gold standard for CAD (in terms of studies)

medical therapy: dilate coronary vasculature, reduce O2 consumption, prevent further build up of athersclerosis, inhibit platelet actication and clot formation

cather-based intervention: percuataneous coronary angioplasty and intracoronary stents

surgical revascularization: CABG

left main stenosis greater than 50%,

three vessel disease (LAD, LCx, RCA) with reduced ejection fraction (<40%)

two vessel disease with proximal LAD stenosis (>90%)

What does this describe:

discrete round or ovoid solid rubbery lesions that grow under the influence of estrogen.

Most common solid lesion in women younger than 40

What is this:

discrete lesion that when distended especially before the menstrual period, may feel quite hard. An US will confirm diagnosis.

Name this condition:

presence of ducts ending in the areolar tissue rather than in the nipple. These are often assoicated with a discharge of thick yellow/green secretions.

How do you avoid?

ductal ectasia

good hygiene helps to avoid

Where do breast papillomas occur?

What is tx?

occur in andy duct in the breast. when tehy occur in major ducts close to the nipple, a spontaneous bloody nipple discharge is often the presenting sign.

Surgical excision is recommended and preop radiologic guidance with ductogram is often helpful

fibrocystic disease

fibroadenomas

ductal ectasia

papillomas

phylloide tumors

clinical breast exam

two view mammography

if any findings from either: get biopsy

BRCA 1 is associated with what type of cancer?

BRCA 2?

BRCA 1: hereditary breast and ovarian cancer syndrome

BRCA 2:  male hereditary breast caner and prostate and pancreatic cancer

What are meds for otitis externa?

What are likely pathogens?

staph aureus: yellow

pseudomonas: green

fungus: breadlike

neomycin/polymixin B/hydrocortisone (Cortisporin Otic)

Cipro HC: cipro and hydrocortisone

What is a cholesteatoma?

What is a clinical sx pts usually present with?

cystlike, expansile lesion of the temporal bone consisting of stratified squamous epithelium and trapped desquamated keratin

pts present saying foul otorrhea and slowly progressing hearing loss

What is the most common cause of an empyema? second most common?

what are common pathogens?

1: due to bacterial pneumonia

2: due to complications of surg procedures involving: lung, mediastinum, or esophagus

Pathogens: staphylococci, streptococi, and anaerobic organisms

How do you diagnose an empyema?

What is diagnostic procedure of choice to identify an empyema?

aspirating pus from pleural space

Requires immed aspiration

Diagnostic of choice: CT--helps to differentiate from lung abscess