GI

From number 22
Total pericystectomy(The removal of a cyst and the surrounding area) to remove a liver
cyst and eventual resection/enucleation pr evacuation
Use 0.5% silver nitrate or hypertonic saline to apply on the cyst
Have epi and steroids available just incase pf anaphylactic reactions
Metronidazole id used to treat amebic abscesses of the liver
Carcinoid tumors arise from enterochromaffin cells in the crypts of Lieberkhn. When the tumors are
larger than 1 to 2
cm or involve the base of the appendix a right hemicolectomy should be performed. When they are
encountered in the tip of the appendix and are less than 1 cm in
size, simple appendectomy is the procedure of choice.
The patient has a pilonidal abscess which develops from an infected pilonidal cyst. It typically presents
as a
painful fluctuant mass extending from the midline and is located between the gluteal clefts. Perianal
and perirectal abscesses are usually much closer to the anus and are
very painful on rectal examination. A fistula-in-ano is a chronically draining tract in the perianal region.
It may become plugged and develop a perianal or perirectal
abscess. An anal fissure is a linear ulcer along the anal canal and is not associated with an abscess
Achalasia=birds beak=esophagomyotomy (dysphagia, chest pain and regurgitation of saliva and
undigested food).
Ninety percent of gastrinomas are located within the gastrinoma trianglethe 3 corners of the triangle
are defined by the
junction of the second and third portions of the duodenum, the junction of the neck and body of the
pancreas, and the junction of the cystic and common bile duct.
Gastric ulcer=partial gastrectomy
Sudden onset of abdominal pain and distention post resection of an abdominal aneurysm with
radiograph shoing an air filled kidney bean shaped structure,=cecal volvulus. You do a right
hemicolectomy for treatement.

The patient has a cecal volvulus and the procedure of choice is a right hemicolectomy. A cecal volvulus
involves
axial rotation of the terminal ileum, cecum, and ascending colon with concomitant twisting of the
associated mesentery. Immediate operation is required to correct the
volvulus and prevent ischemia. Colonoscopic decompression is usually unsuccessful and does not
prevent recurrence of a cecal volvulus. A transverse colostomy
decompression would not decompress the cecum, nor would it provide detorsion of the cecal
mesentery to allow restoration of adequate blood supply to the right
colon.
The patient most likely has bleeding from the small bowel, given the findings on endoscopy, and the
most common
cause of small intestinal bleeding in patients under the age of 30 is a M eckel diverticulum. Because M
eckel diverticula can contain ectopic gastric mucosa, acid secretion
can cause small-bowel ulcerations. Use technetium pertechnetate scan to diagnose

Appendicitis complicates approximately 1 in 1700 pregnancies at an incidence comparable with that in

nonpregnant women matched for age. It is the most prevalent extrauterine indication for laparotomy in
pregnancy. The duration of gestation does not influence the
severity of the disease, but the diagnosis does become more difficult as the pregnancy progresses. By
the twentieth week of gestation, the appendix often lies at the
level of the umbilicus and more lateral than usual. Pregnancy should not delay surgery if appendicitis
is suspected; appendiceal perforation greatly increases the chance
of premature labor and fetal mortality (approximately 20% for each). After appendicitis, biliary tract
disease (biliary colic, cholecystitis) is the second most common
nonobstetric surgical disease of the abdomen during pregnancy.

Focal nodular hyperplasia is rarely symptomatic and unlike a hepatic adenoma does not carry an
associated risk of
malignant degeneration or rupture with hemorrhage. Therefore, surgical resection for FNH is indicated
only if the lesion is symptomatic. If FNH cannot be
distinguished from a hepatic adenoma on CT scan, a nuclear medicine scan can be obtained that may
demonstrate a hot lesion in the setting of FNH and a cold
lesion in the setting of hepatic adenoma.

The patient most likely has an infected pancreatic pseudocyst. Pseudocysts are nonepithelialized fluid
collections
that can present at earliest 4 to 6 weeks after an episode of acute pancreatitis. The treatment for
infected pancreatic pseudocysts is similar to that for pancreatic
abscessespercutaneous catheter drainage with antibiotics.

Fistula formation in itself is not an indication for surgery

Patients with appendiceal adenocarcinoma(right hemicolectomny=( Open

right
hemicolectomy (open right colectomy) is a procedure that involves removing the cecum, the
ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the
first one-third of the transverse colon, and part of the terminal ileum, along with fat and lymph
nodes.), a rare neoplasm accounting for less than 0.5% of GI tumors, should undergo
formal right hemicolectomy. Often affecting older patients, they may present with symptoms
mimicking those of acute appendicitis. A thorough initial workup and
follow-up are necessary because of the high rate of synchronous and metachronous tumors. Five-year
survival is 55% but depends on the tumor stage.

Endoscopy is an important step prior to undergoing operative intervention for GERD. It has the ability
to exclude
other diseases, such as tumors, and document the degree of peptic esophageal injury. Surgical
treatment for sliding esophageal hernias (type I paraesophageal hernias)
should be considered only in symptomatic patients with objectively documented esophagitis or
stenosis. The overwhelming majority of sliding hiatal hernias are
totally asymptomatic, even many of those with demonstrable reflux. Even in the presence of reflux,
esophageal inflammation rarely develops because the esophagus is
so efficient at clearing the refluxed acid.

Initial medical
treatment with prednisone (1 mg/kg), and intravenous immunoglobulin is used in patients with severe
bleeding or preoperatively prior to splenectomy. Platelet
transfusions are reserved for patients with acute bleeding. Splenectomy is indicated in patients who
have severe symptomatic thrombocytopenia, patients in whom
remission is achieved only with toxic doses of steroids, patients with a relapse after initial steroid
therapy, patients with persistent thrombocytopenia for more than 3
months and a platelet count less than 30,000/L, and possibly in patients with a persistent platelet
count of less than 10,000/L after 6 weeks of therapy
Total proctocolectomy with leal pouch-anal anastomosis and diverting ileostomy for ulcerative colitis
Can involve rectum and also have the complication of toxic megcolon.

Amebic liver abscesses should be treated initially with metronidazole monotherapy, as opposed to
pyogenic liver
abscesses, which are treated initially with percutaneous catheter drainage and antibiotics against
gram-negative and anaerobic organisms (eg, Essherichia coli, Klebisella
pneumoniae, bacteroides, enterococcus, and anaerobic streptococci). If improvement fails to occur,
then other antimicrobial agents can be added. Abscesses that are
refractory to medical therapy may require laparotomy.
Ischemic colitis presents as hematochezia, fever, and abdominal pain. Unlike acute mesenteric
ischemia, which
affects the small intestine and requires emergent intervention, ischemic colitis rarely requires surgical
intervention unless full-thickness necrosis, perforation, or
refractory bleeding is present. Expectant management with intravenous fluids, bowel rest, and
supportive care is the treatment of choice.

The most appropriate treatment for a 1-cm carcinoid tumor at the tip of the appendix is an
appendectomy. Therapy for a
carcinoid tumor of the appendix is based on tumor size and location. Simple appendectomy is
adequate treatment for appendiceal carcinoid tumors less than 1 cm.
Tumors larger than 2 cm should be treated with a right hemicolectomy to decrease locoregional
recurrence. Treatment for tumors between 1 and 2 cm is based on
location. Tumors located at the base of the appendix or invading the mesentery are best treated with a
right hemicolectomy. No further treatment is needed after an
appendectomy for a 1- to 2-cm tumor located at the tip of the appendix.

A secretin stimulation test is highly useful to confirm the diagnosis of Zollinger-Ellison syndrome (ZES)
(gastrinoma). In this test a fasting gastrin level is measured before administration of intravenous
secretin and further samples of serum gastrin are obtained at 2, 5, 10,
and 20 minutes after secretin administration. A rise in serum gastrin levels greater than 200 pg/mL
above baseline after secretin administration is found in patients with
ZES.
Anal cancers e.g epidermal cancers=combined radiation therapy and chemotherapy

Radical surgical approaches are now generally reserved for treatement failures and recurrences

Congenital cystic dilatations of the extrahepatic biliary ducts=cholecystectomy with resection of the
extrahepatic biliary tract and roux-en-Y hepaticojejunostomy

Variceal bleeds from liver disease=transjugular intrahepatic portosystemic shunt(TIPS){b-blockade and

endoscopic therapy are usually used for intial therapeutic options for patients with variceal bleeds.
Hepatic transplantation is contradicted in a patient who is actively drinking.
Diverticulosis-sigmoid resection with primary anastomosis

The patient has acute gallstone pancreatitis. Ranson criteria consist of 5 criteria on admission and 6
during the first 48
hours that predict mortality: less than 2 criteria are associated with 0% mortality, 3 to 5 criteria with
10% to 20% mortality, and 6 or more with greater than 50%
mortality. The criteria are slightly different for gallstone pancreatitis and nongallstone pancreatitis.
The first five criteria assess age, WBC count, low-density
hormone (LDH), aspartate aminotransferase (AST), and glucose. The second set of criteria assesses
hematocrit fall, blood urea nitrogen (BUN) elevation, serum
calcium, base deficit, and estimated fluid sequestration. Amylase, lipase, total bilirubin, and albumin
are not part of the criteria and do not correlate with the severity of
disease.

Restoration of circulating blood volume is the first priority in patients with an acute variceal bleed.
Initial
resuscitation should be with isotonic crystalloids followed by transfusion of blood. Elevated
prothrombin times should be corrected with fresh-frozen plasma, and
although mild hypersplenism and thrombocytopenia are associated with portal hypertension, platelet
transfusion is indicated only for platelet counts less than
50,000/L. Medical therapy consists of either octreotide or vasopressin to decrease splanchnic blood
flow. Because of coronary vasoconstrictive effects, nitroglycerin
is usually administered concomitantly with vasopressin.

Small bowel obstruction=with history of gallstones

Sigmoid volvulus may be ruled out quickly by proctosigmoidoscopy, which is preferable to barium
enema, since
sigmoid volvulus may be treated successfully by rectal tube decompression via the sigmoidoscope

sigmoidoscopy for distended colon

paraesophageal hernia, on the other hand, leaves the patient at substantial risk for both strangulation
and obstruction. Either result would be a surgical
catastrophe; with rare exceptions, paraesophageal hernias should be surgically repaired whenever
diagnosed.

The first line of therapy for major hemobilia is transarterial embolization (TAE). The classic Quincke
triad of
abdominal pain in the right upper quadrant, jaundice, and GI bleeding is present in 30% to 40% of
patients with hemobilia. With more frequent use of percutaneous
liver procedures (eg, transhepatic cholangiogram, transhepatic catheter drainage), iatrogenic injury
has replaced other trauma as the most common cause of bloody bile
intrahepatic bleeding can be controlled by angiographic embolization in up to 95% of cases.

The term carcinoma in situ refers to the presence of malignant cells in the mucosal layer only.
Endoscopic polypectomy
is adequate treatment when malignant cells are identified in a colonic polyp, even if an invasive
component is identified, if: (1) no vascular or lymphatic invasion is
present; (2) there is an adequate negative margin (2 mm), and the cancer is not poorly differentiated.

Iatrogenic injury of common bile duct=Roux-en-Y hepaticojejunostomy

The malignant potential is low in carcinoid tumors when they are less than 2cm in diameter
When in anal region they are curable by wide local transanal transection that includes the muscle
layer.
Endoscopic treatement leaves tumor cells near the margin of resection and is felt to increase the risk
of recurrence.
Carcinoid syndrome=tumor most likely to be greater than 2cm

Hepatic adenomas are associated with oral contraceptives. Lesions greater than 4cm have increased
risk of rupture with hemorrhage. They also have a high risk of malignant transformation to a well
differentiated hepatocellular carcinoma.

Symptomatic lesions should be removed regardless of their size.

High-risk, critically ill patients with multisystem disease and cholecystitis experience a significant
increase in morbidity
and mortality following operative intervention. Tube cholecystostomy can be performed under local
anesthesia in the operating room or via a percutaneous approach
in the radiology suite. Open or laparoscopic procedures would carry the same general anesthetic risk
whether done urgently or in a delayed (elective) fashion.

A cholecystectomy would not provide drainage of the obstructed common bile duct.
Cholangitis is suggested by the presence of the Charcot triad: fever, jaundice, and pain in the right
upper quadrant.
In patients with suppurative cholangitis who fail to respond to intravenous antibiotics and fluid
resuscitation, the nonoperative approach is the preferred intervention
via either percutaneous or endoscopic drainage of the obstructed common bile duct. If endoscopic
retrograde cholangiopancreatography (ERCP) or percutaneous
transhepatic biliary drainage (PTBD) fails, surgery is indicated.

The chance of development of carcinoma of the colon in patients with familial polyposis is essentially
100%.

Peutz-Jeghers syndrome is characterized by intestinal polyposis and melanin spots of the oral mucosa.
Unlike the
adenomatous polyps seen in familial polyposis, the lesions in this condition are hamartomas, which
have no malignant potential. Surgery for symptomatic polyps
involves polypectomy.

Stress ulceration refers to acute gastric or duodenal erosive lesions that occur following shock, sepsis,
major
surgery, trauma, or burns. These lesions tend to be superficial and can involve multiple sites. Unlike
chronic benign gastric ulcers, which are generally found along the
lesser curvature and in the antrum, acute erosive lesions usually involve the body and fundus and
spare the antrum. McClelland and associates showed that patients
subjected to trauma and subsequent hemorrhagic shock do not have increased gastric secretion, but
rather show decreased splanchnic blood flow. Ischemic damage to
the mucosa may therefore play a role.
Stress ulceration=multiple shallow lesions with discrete areas of erythema along with focal
hemorrhage in the fundus

Asymptomatic Hemangioma=observe, they are typically benign

In colorectal cancer= CEA will be elevated

An indirect inguinal hernia leaves the abdominal cavity by entering the dilated internal inguinal ring
and
passing along the anteromedial aspect of the spermatic cord. The internal inguinal ring is an opening
in the transversalis fascia for the passage of the spermatic cord; an
indirect inguinal hernia, therefore, lies within the fibers of the cremaster muscle. A femoral hernia
passes directly beneath the inguinal ligament at a point medial to the
femoral vessels, and a direct inguinal hernia passes through a weakness in the floor of the inguinal
canal medial to the inferior epigastric artery.

This patient most likely has Crohn disease. In about 10% of patients, especially those who are young,
the onset of the disease is abrupt and may be mistaken for acute appendicitis. Appendectomy is
indicated in such patients as long as the cecum at the base of the
appendix is not involved. Interestingly, about 90% of patients who present with the acute appendicitislike form of regional enteritis will not progress to development
of the full-blown chronic disease.(still do your standard appendectomy).

The patient has a pancreatic pseudocyst after his episode of acute pancreatitis. Pancreatic
pseudocysts are cystic
collections that do not have an epithelial lining and therefore have no malignant potential. Most
pseudocysts spontaneously resolve

The carbon-labeled urea breath test is the noninvasive method of choice to document eradication of a
H pylori
infection. This test samples the entire stomach and has sensitivity and specificity both greater than
95%. The test is performed by having the patient ingest a carbonisotope
labeled urea. After ingestion the urea will be metabolized to ammonia and labeled bicarbonate if a H
pylori infection is present. The labeled bicarbonate is

excreted in the breath as labeled carbon dioxide, which can then be quantified.

Mallory-weiss syndrome=massive painless hematemesis with longitudinal mucosal tears. They resolve
spontaneously

A patient with symptomatic cholelithiasis has pain from the gallbladder as it

contracts against a gallstone lodged in the cystic duct. If the stone gets dislodged with the
contractions, then the pain resolves until another stone gets lodged in the
cystic duct. If the gallstone remains stuck in the cystic duct, then the abdominal pain worsens as the
gallbladder becomes more and more inflamed. The gallstones
harbor bacteria and, if the bile becomes static with an obstructed cystic duct, infection develops. At
this point the patient has acute cholecystitis and needs antibiotics
or urgent cholecystectomy. Eventually the pressure in the wall of the gallbladder exceeds the perfusion
pressure of the vessels in the gallbladder and the gallbladder
becomes ischemic. At this stage the gallbladder becomes necrotic and can perforate causing lifethreatening peritonitis and sepsis. A gallstone remaining in the common
bile duct is called choledocholithiasis. Dilation of the common bile duct occurs and a CBD size > 4 mm
is suspicious for a CBD stone. These patients may be
asymptomatic, have abdominal pain, or progress to develop cholangitis depending on the status of the
gallstone in the common bile duct. Stones that are not lodged in
the sphincter of Oddi allow bile to empty out of the bile duct. Stones that become stuck in the common
bile duct cause stasis of bile in the biliary system which can
lead to cholangitis. The symptoms of cholangitis are right upper quadrant abdominal pain, fever, and
jaundice (Charcot triad). Cholangitis is a life-threatening condition
requiring emergent ERCP with stone extraction and common bile duct decompression. Sometimes
patients develop acute pancreatitis with passage of the gallstone past
the ampulla of Vater as it exits the common bile duct into the duodenum.

Paraesophageal hernia=surgical treatement as bleeding, ulceration, obstruction, necrosis of the

stomach wall and perforation can occurl

Endoscopic ultrasound (EUS) provides the most accurate T staging of an esophageal carcinoma. An
experienced
endoscopic ultrasonographer can identify the depth and length of the tumor, the degree of luminal
compromise, the status of regional lymph nodes, and involvement of
adjacent structures. In addition, biopsy samples can be obtained of the mass and the regional lymph
nodes. The accuracy of EUS for T staging increases with the depth
of invasion. For T1 lesions, EUS is 84% accurate, and increases to 95% accuracy for T 4 lesions.
Computed tomography is helpful, but its accuracy is only 57% for T
staging. An MRI can accurately detect T 4 lesions and metastatic lesions but overstages T and N status
with only 74% accuracy. A PET scan is reliable for detecting
metastatic disease but is equal to a CT scan for T staging. Bronchoscopy is useful in patients who
present with a cough or cervical esophageal carcinoma to rule out a
tracheoesophageal fistula or growth of tumor into the trachea.

Increased alkaline phosphatase=choledocholithiasis

Omeprazole inhibits H+/K+ ATPasein the secretory canaliculus of the gastric parietal cell.

Risk of end colostomy=parastomial hernia

Colostomy=a

surgical operation in which a piece of the colon is diverted to an artificial opening in

the abdominal wall so as to bypass a damaged part of the colon.

Painless jaundice with weight loss is suspicious for a pancreatic cancer involving the head or uncinate
process of
the pancreas. A helical contrast-enhanced CT scan is the most appropriate study to evaluate for a
pancreatic mass. CT has a specificity of 95% or better with
sensitivity exceeding 95% for tumors larger than 2 cm in diameter. PET scan may be of value in
detecting small pancreatic tumors that are not seen on CT scan but the
sensitivity and specificity remain to be established. An acute abdominal series is composed of three xrays (upright chest, upright abdomen, supine abdomen) and is
useful in evaluating patients for bowel perforation or bowel obstruction. An ERCP is helpful in
evaluating patients with obstructive jaundice without a detectable mass
on CT scan. An EGD is not useful in the evaluation of a patient with a pancreatic mass

femoral hermia=inferiorly by coopers ligament, laterally by the femoral vein, and medially by the
junction of the iliopubic tract and cooper ligament. The iincidence of strangulation of the femoral
hernias is high, therefore all even asymptomatic ones should be repaired. So do (elective surgical
repair of the hernia)