Pain in the..
A 65F with hx of ex lap for peritonitis due to perforated diverticulitis presents with abdominal pain and fevers. WBC is 17 and CT demonstrates multiple loculated, rim enhancing collections in the liver (ranging from 4-9cm). What is the treatment of choice?
Percutaneous drainage
Pain with internal rotation the right hip indicates a pelvic appendicitis
Obturator sign
72F has new diagnosis of diabetes and intermittent diarrhea. Found to have a 2cm pancreatic head mass and somatostatin level is found to be high. What is the next step in treatment?
Whipple - pancreaticoduodenectomy
Glucagonomas, VIPomas, somatostatinomas, and gastrinomas are often malignant. Insulinomas and gastrinomas <2cm may be enucleated
54F admitted for COPD underwent a tracheostomy 10 days ago. The nurse is reporting new onset of bright red bleeding through the tracheostomy tube. What is the most likely cause of death secondary to the anticipated tracheostomy complication?
Tracheoinnominate fistula
56M with history of ESRD is involved with a MVC and undergoes exploratory laparotomy. He is found to have a colonic injury and is transferred to the ICU intubated. What is the correct DVT ppx (type and dose of medication) for this patient?
Unfractionated heparin 5000U q8h
50 bonus points: What can be used to reverse heparin?
A patient with Crohn's disease has abdominal pain and vomiting. She is found to have multiple strictures located at the proximal duodenum. After 1 week of conservative management she has not improved. What is the next step?
Gastrojejunostomy
Bonus 50 points: What is the name of the strictureplasty that is for long strictured segments (7-15cm)?
A trauma patient comes in with a stab wound to the cardiac box. A cardiac fast demonstrates fluid around the heart and there is concern for cardiac tamponade. What are the 3 components of Beck's triad?
What test can be used to diagnose a gastrinoma in patients with gastrin levels less than 1000pg/ml?
Secretin stimulation test
A positive secretin stimulation test will show an increase in gastrin of >200 pg/mL
65yo with COPD is undergoing preoperative split-lung function testing before undergoing pneumonectomy for lung cancer. How much postoperative forced expiratory volume in 1 second should he have in order to proceed safely?
predicted post op pulmonary FEV1 800ml or >40%
Bonus 100 points: What does a patient's pre-op FEV1 and DLCO need to be?
What are the two most common variants of hepatic artery anatomy?
Replaced right hepatic artery arising from the SMA
Replaced left hepatic artery arising from the left gastric artery
53F with RUQ undergoes lap chole and is found to have gallbladder carcinoma invading the perimuscular connective tissue without involvement of the serosa. What is the appropriate next step?
Re-resection with wedge of hepatic segments 4b and 5 with portal lymphadenectomy
>T1b need re-resection to achieve negative margins has many of these patients have been found to harbor residual disease
T1a- lamina propria; T1b- muscle layer
T2- Perimuscular connective tissue
T3- Serosa
T4- invades portal vein, hepatic artery, or extrahepatic organs
What is the name for superficial edema and bruising around the umbilicus in patients with acute pancreatitis?
Cullen's sign- where methemalbumin formed from digested blood tracks around the abdomen from the inflamed pancreas
Bonus 50: What is the name of the sign when you have bruising of the flank which may be indicative of pancreatic necrosis with retroperitoneal bleeding?
Which oncogene is activated in more than 95% of pancreatic cancers?
KRAS
KRAS2 is activated by point mutation (codon 12, 13, or 61), which causes constitutive activation and loss of regulation of mitogen-activated protein kinase cell signal transduction.
What is Light's Criteria?
Uses cytology to determine whether an effusion is transudative or exudative. If any criteria are met the effusion is considered exudative
Pleural:serum fluid protein >0.5
Pleural:serum fluid lactate dehydrogenase (LDH) >0.6
Pleural fluid LDH>2/3 upper limit of normal
34F presents to the hospital after MVC. Patient opens her eyes in response to pain, demonstrates decorticate posturing and only making incomprehensible sounds. What is her GCS?
7
Eyes- 2
Verbal- 2
Motor- 3
72M with hx of antrectomy and BII reconstruction 30 years ago presents with intermittent epigastric pain x2 weeks. Vomiting accompanies these episodes and partially relieves the pain. CT scan reveals a dilated loop of bowel leading to the bilroth II reconstruction. What is the name of this condition and what is the treatment?
Afferent loop syndrome. Convert to Billroth 1 or Roux-en-Y reconstruction
The syndrome usually occurs when the afferent limb is greater than 30-40 cm in length and has been anastomosed to the gastric remnant in an antecolic fashion. May arise due to angulation of the afferent limb, internal herniation behind the efferent limb, stenosis at GJ, adhesions, volvlus of afferent limb. HIDA scan can help to diagnose.
Blind loop syndrome can develop where bacterial overgrowth binds with B12
The occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity
Kehr's sign
Classic example of referred pain. Irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collar bone. Supraclavicular nerves have the same cervical nerve origins as the phrenic nerve (C3, C4)
56F with hx of 2 episodes of pancreatitis in the past 3 years presents with UGIB. She has had 2 episodes of blood emesis and is HD stable. EGD shows only gastric varices. What is the definitive management of her condition?
Splenectomy
Definitive treatment of isolated gastric varices caused by splenic vein thrombosis is splenectomy.
52M presents with fatigue and dyspnea. CXR shows right sided pleural effusion. On analysis pleural fluid has a triglyceride level of 115mg/dL. The patient is kept NPO and has 700ml/day of drainage into the pigtail catheter. What is the next step in management?
Octreotide
Low output (<1L/day) ->diet with medium-chain triglycerides, TPN, administration of octreotide
High output (>1L/day) ->ligation of the thoracic duct or lymphangiography with embolization of the thoracic duct
The most widely accepted theory to explain the etiology of jejunal atresia is?
Intrauterine focal mesenteric vascular accident
What is the most common presentation of a symptomatic Meckel's diverticulum in an adult?
Diverticulitis and obstruction
Meckel's diverticulum is a failure of the omphalomesenteric duct to close. 2% symptomatic, usually by 2yo. Most found incidentally as an adult, which are historically left alone. If bleeding then patient should undergo a segmental resection. Recently, prophylactic diverticulectomy has been advocated to decrease risk of later complications.
Bonus 50 points: Which are higher risk to develop symptoms, narrow or broad base diverticulum?
An 85yo female has had obstipation for 3 days. On physical exam the resident found the patient had inner thigh pain on thigh extension and internal rotation of the hip.
Howship-Romberg sign
Suggestive of an obturator hernia, caused by hernia compression on the obturator nerve as abdominal contents protrudes through the obturator foramen
What drainage procedure for severe chronic pancreatitis involves creating a longitudinal incision of at least 7cm along the main pancreatic duct and anastomosed to a loop of jejunum without any resection of the pancreatic head?
The Puestow Procedure (lateral pancreaticojejunostomy)
-Frey pancreatic head cored out and lateral pancreaticojejunostomy
-Beger Procedure removes head of the pancreas but leaves duodenum, a thin rim of pancreas around the medial aspect of duodenum and intrapancreatic bile duct intact
65M active smoker presents with difficulty swallowing and a 20lb weight loss in the past year. EGD demonstrates a lesion 2cm distal to the upper esophageal sphincter, consistent with T2N0 squamous cell cancer. No metastatic lesions on CT. What is the best definitive therapy for this lesion?
Chemoradiation- surgical resection usually requires removal of portions of the pharynx, the larynx, the thyroid gland, and portions of the proximal esophagus so esophagectomy is avoided when possible
Neoadjuvant chemorads followed by esophagectomy would be the correct treatment for T2 adenocarcinoma in the middle or lower third of the esophagus
Endoscopic resection is an option for T1a cancers (lamina propria, muscularis mucosae, submucosa), T2= invasion into the muscularis propria
What features make something a high risk polyp and what are the surveillance recommendations after removal?
Tubolovillous or villous features, >1cm, high-grade dysplasia
Repeat colonoscopy in 3 years
Bonus 50 points: When do you repeat colonoscopy for adenoma removed in piecemeal?