Surgery Rotation

  1. What is Rovsing's sign?
    This is when pushing on the RLQ causes pain on the McBurney area and is indicative of an appy
  2. How can you check for a retrocecal appendix?
    By testing for psoas or obturator sign.
  3. what is the imaging finding that one sees with an appy?
    • "target sign"
    • whic his a distended lumen (non-compressible) and thickened wall of the appendix seen on end.

    Plain films are not good at showing appy nless in rare cases can see a fecalith.
  4. What if someone comes with with chronic appy sx and/or has an abscess identified on imaging ?
    Start pt on broad specterum abx with percutanous drainage of the abscess and interaval appendectomy.

    Interval appendectomy: is for these abscess involving appy cases which includes, broad spectrum abx, a CT-guided abscess drainage and appendectomy in about 6 weeks or so.
  5. What is the "classic" presentation of appendycitis?
    • crampy/vague abdominal pain
    • nausea or vomiting
    • localized pain to the RLQ
  6. Most common neoplasm found in the appendix?
    Carcinoid tumors
  7. What is the Charcot's triad
    This is biliary colic (RUQ) pain, fever (+/- chills), and jaundice which is suggestive of cholangitis.
  8. whats the best imaging modality for gallbladder
  9. what is the Reynold's pentad?
    How should be this managed?
    this is charcot triad (fever, RUQ pain, jaundice) plus mental status change and hypotension. This is suggestive of progression of the disease to sepsis and shock.

    - with cholangitis IV abx are the treatment of choice, but if there is no improvement, then CBD decompression is required which is typically done with ERCP.
  10. how can you get acalculous cholecystitis?
    usually occurs in critically ill patients following trauma, sepsis, vasculitis, gall bladder torsion or infection where gallbladder mobility and emptying is impaired and can lead to dehydration.
  11. Why is colonoscpy contraindicated in diverticulosis cases?
    Because insufflation (inflating) can cause or exacerbate a perforation.

    • Note:
    • Diverticula that are on the right side often bleed, while those on the left often become inflamed.

    some of the complications of diverticulitis include stricture, perforation, fistula (to the bladder, skin, vagina, or other bowel).
  12. what are some risk factors associated with PUD?
    • smoking
    • NSAID
    • alcohol
    • steroid

    Note: pt with gasteric ulcer often have a nrl to below nrl gastric pH, however those with duodenal ulcers have acid hypersecretion.
  13. what is the operation for duodenal perforation?
    a Graham patch (omental patch)

    • But often there should be a procedure performed as well to reduce the chance of recurrence this can include
    • 1. highly selective (parietal cell) vagotomy
    • 2. truncal vagotomy with pyloroplasty
    • 3. vagotomy and atrectomy with billroth reconstruction.

    Any procedure that leaves behind vagus innervation or antrum (gastrin producing) has a higher rate of recurrence. No suprose that the vagotomy with anterectomy has the lowest rate of recurrence (<2%)
  14. Where is the gastrinoma triangle?
    • This is where a gastrinoma tumor (Zollinger-Ellison syndrome) can be found.
    • The triagnle is from the junction of the cystic duct, the second and third part of the small intestine, and the junction neck and the body of the pancreas.
  15. Why would you get gastric outlet obstruction with PUD?
    due to inflamation you can get obstruction.
  16. name a few other sources of amylase except for pancrease?
    • salivary body
    • fallopian tube
    • small bowel

    If suspecting pancreatitis lipase level should also be measured. A few other things noted in pancreatitis is the hemoconcentration and slightly elevated Cr and BUN which are as a result of dehydration 2/2 to "third spacing".

    Plain film typically shows diffuse ileus or a sentinel loop (which is a single dilated, air-filled loop of small bowel in the region of inflamation). CT may show pancreatic inflammation or necrosis.

    Note in alcoholic hepatitis AST:ALT ratio is about 2:1
  17. what is Ranson's criteria? What are included in the criteria?
    This is for acute pancreatitis.

    Amylase and Lipase are not included and have no predictive value.

    • Early (within 24 hrs criteria) Age >55, WBC>16, AST>250, glucose>200, LDH>350
    • Late criteria (>48hrs): Hct drop of 10%, PaO2 <60, total calcium <8, base deficit >4, BUN increase of >5, fluid sequestration of >6L

    If pt has 3 of the criteria there is a 15%-30% chance of mortality.
  18. what are some of the causes of pancreatitis?
    • In the US mcc is alcohol use.
    • In other parts of the world, gallstone pancreatitis is the mcc.

    other things include, infection (Coxsackie B virus), drugs (steriod, diuretics, warfarin), scorpian bite, hypercalcemia, ERCP

    Suspect pseudocyst if there is a persistant pain or ileus after an acute episode of pancreatitis which can be managed by observation, or drainage depending on the size and symptoms.
  19. How is pancreatitis managed?
    • aggresssive IV fluid resusciation is the most important.
    • Foley catheter (close monitoring of fluid status), ABG, serial lab test for any lyte changes.
    • Abx are not indicated for uncomplicated acute pancreatitis but can be used in severe necrosis, sepsis, of failure to imporive with supportive care alone.
    • Surgical debridement and drainage is only indicated for infected necrosis. ERCP, cholecystectomy, other surgical procedures for ductal obstruction are performed in the setting of gallstone pancreatitis.
  20. what does air in the rectum mean?
    It means partial or complete bowel obstruction
  21. difference between UC and Crohn's disease?
    Image Upload 1
  22. How is Crohn's disease managed?
    • Medically pts are treated with anti-inflamatory drugs including budenoside. Other meds include opiotes and antispasmotics for diarrhea flare ups.
    • Surgery is not curative in Crohn's disease (it is in UC with a good resection of the involved rectum and distal colon), strictures are treated with strictoplasty when possible.
    • retrovaginal fistulars are uncommon but when they do occur often can be medically treated with metronidazole and anti-inflammatory medication.
  23. Spinal anesthesia: hypotension or hypertension?
    • Hypotension.
    • This is why it can be dangerous in people who have poor heart or cardiac/vascular problems since they may not be able to correct the hypotension.
  24. How long before a surgery shold ASA and NSAIDS be discontinued?
    • NSAIDs 2 days
    • ASA 7-10 days prior (because they irreversibly inhibit platelet)
  25. Pt comes in for electrive inguinal surgery who is found to have an axila cellulitis, do you procede with the surgery?
    • NOPE.
    • if any infection is present regardless of its location it can result in increase risk of wound infection.

    In case of elective surgeries it should be postpond until infection is cotrolled.
  26. How long before surgery should smoking be stopped?
    Cilia starts beating normally again 2 days after smoking cessation, therefore sputum production increases, at about 2 weeks then sputum production returns to normal.

    However studies show there is no imporovement in postoperative respiratory morbidity until after 6-8 weeks of abstinence.
  27. Laproscopy in a pt with a bad lung (ex. severe COPD)?
    Laproscopy can lead to increased CO2 absorption into the blood, this is contraindicated in a pt with lung problem since it increases the pulmonary work.
  28. MCC of early postoperative death following lower extermity revasculrization is?
    • MI
    • There is a 15% chance of reinfarction with a hx of MI and that raises to 37% if the MI is recent.
  29. can RBBB be normal?
    • Yes in 10% of general population this is a normal variation.
    • However, LBBB is never normal and is highly suggestive of underlying ischemic heart disease → transthoracic pacing capabilities should be readily available.
  30. Pt with a prior CABG is in need to a non-cardiac surgery for revascularization. What is preoperative risk?
    • There is an advantage if CABG was performed as long it was less than 5 years ago.
    • If more than 5 years a stress test must be performed.

    if angioplasty was performed, stress test should be performed.
  31. what is the classification for assessing the risk of operation in the face of liver failure?
    Child's classification. Which looks at Bilirubin, Albumin, ascities, encephalopathy, and nutrition to assess mortality.
  32. What are the two genese invovled in breast cancer?
    BRCA1 and BRCA2

    BRCA1 is also seen in ovarian cancer.
  33. what is the screening guidlines for breast cancer?
    • High Risk patient:
    • * Twice a year visits for breast exam by MD
    • * Initial mamogram at age 30, every subsequent ones 1-2 years apart until 40 when it becomes yearly.

    • Low Risk:
    • * Beast exam by an MD every 2-3 yrs when 20>age>39, and yearly once >40
    • * Initial mamogram at age 40, subsequently once every 1-2 yrs and yearly after 5-0 urs of age todoy.
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