Download Advanced Surgery Exam Review: Key Concepts and Clinical Scenarios and more Exams General Surgery in PDF only on Docsity!
Advanced Surgery Exam I โ Ace Your Exams With Confidence Using This A+ Graded Mastery Pack
A barium swallow of the esophagus experiencing a diffuse esophageal spasm, will show rosary bead or corkscrew esophagus espohageal spasm can mimi MI-- presents with chest pain treatment options for diffuse esophageal spasms include smooth muscle relaxants--> reglan, bentyl nitrates CCB tricyclic AD--> imipramine botulinum toxin sildenafil (PRN for symptomatic relief) surgical--> myotomy or esophagectomy non-pharm tx: hot water and peppermint oil Two surgical interventions for diffuse esophageal spasms include myotomy esophagectomy diagnostic tests for diffuse esophageal spasms esophogram and manometry
you can experience reflux esophagitis from hiatal hernias or medications that cause incompetent LES with inflammation and decreased peristalsis and salivary flow 80% of patients have symptomatic reflux with sliding hiatal hernia reflux esophagitis Inflammatory rxn to esophageal mucosa due to incompetent LES, which leads to decreased peristalsis and salivary flow barretts esophagus a condition that occurs when the cells in the epithelial tissue of the esophagus are damaged by chronic acid exposure and becomes COLUMNAR EPITHELIUM baretts esophagus cells change from squamous to columnar!!! imaging that can be ordered to look for barretts esophagus? barium studies EGD with bc esophageal motility disorders (test sphincter function and pressure) 24 hour Ph probe placement causes of reflux disease incompetent LES valve inefficient clearance of gastric juice abnormal gastric reservoir that augments physiologic reflux
choking on food recently swallowed swelling of the neck testing for zenker's diverticulum includes barium swallow endoscopy (CAN BE DANGEROUS) monometry testing treatment for zenkers diverticulum myotomy and excision of diverticulum primary disorder of LES that results in difficulty swallowing, neurogenic degeneration of the esophagus, absent peristalsis without relaxation of the LES and hypertrophy of the LES achalasia MC sign and symptom of achalasia dysphagia esophogram for achalasia will show bird beak appearance treatment for achalasia includes CCB nitrates botulinum toxin dilation/resection of les
demographics for esophageal neoplasm squamous mc in blacks adenocarcinoma mc in whites esophageal ca mc in males, ~60 yr RF high ETOH and tabacco use distribution of where esophageal cancers are in esophagus 20% in proximal 30% in middle aspect 50% in distal 3rd RF of esophageal ca include smoking, dietary, alcohol, caustic injury, radiation, plummer vinson syndrome tx of esophageal ca includes mostly palliative care --> 5% survival rate esophageal-gastrectomy with gastric pull-up for distal third proximal third-- esophagectomy radiation what is boerhaaves syndrome spontaneous perforation of the esophagus
PUD tx h-2 blockers PPI diet antacids potential surgery (DON'T NEED TO KNOW THEM FOR THE EXAM!!) surgical management for PUD truncal vagotomy highly selective vagotomy Zollinger-Ellison syndrome it's a gastrinoma (malignant) causing hypersectrion of gastrin MC seen in the pancreas hypergastrinemia peptic ulcers Zollinger-Ellison syndrome mc seen in the pancreas sxs of zollinger ellison syndrome sxs PUD diarrhea steotorhea
bleeding perforation testing and treatment for zollinger ellison syndrome includes labs showing increased gastrin levels CT, MRI h2 blockers, ppis, chemo tumor resection gastric ulcer mc seen in the lesser curvature and near the pylorus defect in gastric mucosal defense against acid-pepsin gastric ulcer gastric ulcer type 1 type 2 type 3 gastric ulcer type 1: no clinical disease type 2: located close to the pylorus, low malignant potential type 3: seen in the antrum. NSAID induced. increased risk of ca presentation of gastric ulcer mid-epigastric pain pain seen after eating (30 mins)
scirrhous (linitis plastica) advanced Ca labs/imaging for gastric ca upper endoscopy with biopsy GI series CT scan for staging treatment for gastric ca subtotal gastrectomy adjuvant therapy +/- TNM for staging 5 year survival <10% surgery: vaagotomy and pyloroplasty, bilroth 1 and bilroth 2 upper GI bleeding mcc mc cause from duodenal ulcer things that can cause upper GI bleed ASA, NSAIDs, ACID, ALCOHOL this is secondary to portal HTN esophageal varices esophageal varices can be caused from
alcohol abuse treatment for esophageal varices includes IV vasopression somatostatin endoscopic treatment sclerotherapy varcieal band ligation metal stents balloon placement TIPS procedure mallory-weiss tear followed by forceful retching longitudinal tear at esophagogastric junction and cardia region associated with alcoholism mallory weiss tx resolves spontaneously reducible hernia is a hernia in which the contents of the hernial sac can be returned to their normal position incarcerated hernia is a non-reducible hernia you need an ___ hernia to potentially cause a strangulated hernia
what is hesselbech's triangle inguinal ligament, inferior epigastric vessels and the lateral border of the rectus muscle floor of the triangle: transversalis fascia if the floor of hesselbech's triangle is weak (transversalis fascia) what can happen causes a direct inguinal hernia indirect inguinal hernia cause direct inguinal hernia cause indirect: failure of the processes vaginalis to close direct: weakness in the transversalis fascia direct inguinal hernals can be associated with increased abd pressure, constipation, BPH and chronic cough bilateral direct inguinal vs. indirect 55% bilateral in direct inguinal 30% bilateral in indirect don't need to know the percentages BUT understand direct bilateral is more common demographics for direct inguinal hernia usually men over 40, rare in women
Where do direct inguinal hernias occur? ABOVE the inguinal ligament--> directly behind and through the external inguinal ring tx of inguinal hernias inguinal hernias always need repair --> tension free reconstruction of the inguinal floor and reduce the size of the inguinal ring where are femoral hernias located? located in the femoral canal pass beneath the inguinal ligament into the upper thigh mc hernia in women indirect inguinal hernias femoral hernias are more common in women (esp. multiparous) hernia that passes below the inguinal ligament femoral hernia NEVER PASSES THE SCROTUM treatment for femoral hernia truss or complete excision of the hernia sac where is a hiatal hernia located in the diaphragm at the esophageal hiatus
surgery. usually requires mesh w/o tx we worry about omentum or bowel that may become incarcerated within that opening and blood supply is compromised epigastric hernia hernia through the linea alba above the umbilicus possible causes of hernia multiparous women, cirrhosis with ascites, obesity, large intra-abd tumors, infants by age 5 closure of the umbilical ring is complete in almost all children by 5 years of age spontaneous closure of the umblical ring is less likely to occur in patients who have an opening that is greater than 1.5 cm incisional hernias causes obesity, wound infection, poor surgical technique, increased age, cirrhosis, ca, post op excessive coughing, placement of drains in the primary wound treatment for small hernias direct fascia to fascia repair large hernias tx non-absorbable mesh hernia that occurs at the lateral edge of the rectus muscle at the linea semilunaris usually acquired from heavy lifting
spigelian hernia spigellian hernias may contain peritoneal sac, greater omentum and small intestine or colon richter's hernia consists of one side of the wall of the intestines tx: surgical littre's hernia hernia that contains meckel's diverticulum in the hernia sack mc inguinal mc men ALWAYS ON RIGHT SIDE tx of littre's hernia tx hernia excision of diverticulum (partial ileum resection) obturator hernia herniation of viscera through the obturator canal (obturator foramen) more common in women diagnosis of obturator hernia is usually made intra operatively after presenting with bowel obstruction
peritoneal irritation by chemical or inflammation; sharper, constant and localizing routine labs in an emergency abdominal evaluation CBC with diff. electrolytes- LFTs- UA you must get this for females in emergency evaluation bHCG treatment/consultation for emergency issues must start within 30 mins true aneurysm weakening of all 3 layers in the vessel Pseudoaneurysm pulsatile hematoma, opening in artery leaking blood into surrounding tissue fusiform aneurysm affects the entire circumference of the artery saccular aneurysm involves only a portion of the circumference of the artery 90% of AAA happen from atherosclerosis main risk factor of AAA
cig smoking sxs of AAA palpable, pulsatile mass non tender left lower bain pain left flank plan abdominal pain hypotension due to hemorrhagic shock imaging for AAA ultrasound but does not show rupture get CT !! very sensitive and specific for rupture, leak and measurement <5 cm AAAtx no tx needed vascular surgery referral for eval ruptured AAA tx STAT surgical consult fluids emergent surgical repair mesenteric ischemia
