Exclusive

   
ABSITE  SURGERY  TIDBITS  
2014  

Cracking  D’  Boards  

Study  &  Review  Center,  Inc.  
When and where is iatrogenic injury to the
common bile duct most common?!

•  D u r i n g l a p a r o s c o p i c
cholecystectomy at the triangle of
Calot!
What is the most common type of lipid
profile associated with pancreatitis?!
•  HYPERTRIGLYCERIDEMIA!
 What are the Ranson’s criteria for
severity in biliary pancreatitis on
admission?!
•  Age > 70 years!
•  WBC > 18/mm3!
•  glucose > 220 mg/dL!
•  LDH > 400  U/L  
•  AST  >  250  U/L  
Should antibiotics be given empirically to
patients with severe pancreatitis?!

•  Imipenem - most popular choice!

What is the mortality of acute
pancreatitis?!

•  1% : 2 or less factors by the

Ranson’s criteria, !
•  16% : 3 or 4!
•  40% : 5 or 6!
•  100% : 7  or  8  factors  
What is the clinical presentation of familial
Mediterranean fever?!

•  fever and abdominal pain !

•  intermittent chest and joint pain!
What are the structures in portal triad?!

•  Portal vein—Posterior!
•  CBD—right anteriorly!
•  Hepatic artery—left anteriorly!
What bacteria are the most common
agents of biliary sepsis?!
•  Escherichia coli and Klebsiella!
What does Charcot’s triad imply?!
•  Fever!
•  RUQ tenderness!
•  jaundice!
•  indicative of cholangitis!
Adding hypotension and mental status
changes!

•  Reynold’s pentad!
 What are the dangers of porcelain
gallbladder?!

•  Risk of cancer is 30% to 65%!

What should be the treatment for cholecystitis in a
patient 16 weeks pregnant? 32 weeks?!

•  Laparoscopic cholecystectomy!
•  before 20 weeks!

•  open cholecystectomy !
•  after 20 weeks!
 What is Mirizi’s syndrome?!

•  A large gallstone in the neck of the

gallbladder, compressing the
common bile duct and inducing
biliary obstruction!
 What is the most common presentation of Budd–Chiari
syndrome?!

•  Hypercoagulable patient who

presents with ascites and
abdominal distention!

•  TX: PORTOSYSTEMIC SHUNT!

•  hepatic vein thrombosis!
What is the most common site of
obstruction in gallstone ileus?!

•  terminal ileum!
What is the normal pancreatic
anatomy in patients with pancreas
divisum?!

Divisum—Santorini = major duct!

What is the most common islet cell tumor?!

•  Insulinoma!
What pathologic features of hepatocellular
carcinoma (HCC) are associated with improved
survival?!

•  T u m o r s e x h i b i t i n g t h e
fi b r o l a m e l l a r v a r i a n t ,
encapsulated tumors, and
pedunculated tumors.!
 What is the Sigura procedure?!

•  bleeding esophageal varices in !

•  transection of the esophagus and
reanastomosis!
What is the most common cause of portal
hypertension in children?!

•  Portal vein thrombosis!

What pressure defines portal
hypertension!

•  12 mmhg!
What is the mechanism of portal
hypertension caused by schistosomiasis?!

•  Presinusoidal obstruction!
What are the most common
causes of spontaneous splenic
rupture?!

•  Complications of malaria
and mononucleosis!
What are the clinical
manifestations of pancreatic
exocrine insufficiency?!

•  S t e a t o r r h e a and
malabsorption!
What is the significance of
Gray Turner’s syndrome/
sign?!

•  h e m o r r h a g i c
pancreatitis!
What would you expect the serum
amylase level to be in a patient with
acute pancreatitis?!

•  2-5 x normal!
What is the most common finding on plain
abdominal X-ray in a patient with acute
pancreatitis?!

•  Dilatation of an isolated loop of

intestine adjacent to the pancreas
(sentinel loop)!
What is the most common islet
cell tumor in MEN-1?!

•  Gastrinoma!
Where are 90% gastrinomas
located?!

•  Gastrinoma triangle—!
•  cystic/CBD junction—
pancreas neck—third
portion duodenum.!
What skin condition is associated
with glucagonoma?!

•  M i g r a t o r y n e c r o l y t i c
erythema!
What syndrome is associated with
vasoactive intestinal polypeptide
(VIP) oma?!

•  WDHA syndrome!
•  watery diarrhea!
•  hypokalemia!
•  achlorhydria!
When should a lateral pancreaticojejunostomy
(Puestow procedure) be performed?!

•  diameter of the main pancreatic

duct increases to 7 mm or more in a
patient with chronic pancreatitis
refractory to alcohol abstinence,
p a n c r e a t i c e n z y m e
supplementation, and analgesics!
What is meant by a modified
Whipple?!

•  Preservation of the
stomach and pylorus!
What is the most common benign
neoplasm of the exocrine
pancreas?!

•  Serous (microcystic)
cystadenomas!
what test must be done to confirm the
diagnosis of gastrinoma?!

•  secretin provocative test!

What conditions are associated with
annular pancreas?!

•  Down’s syndrome!
•  duodenal atresia!
•  peptic ulcer!
What is the most common type of
biliary enteric fistula?!

•  Cholecystoduodenal!
Which benign hepatic lesions are
associated with exogenous estrogen use?!

•  Hemangiomas!
•  hepatic adenomas!
What is the most common clinical
manifestation of decompensation in a
cirrhotic patient?!
•  Ascites!
What is the most common
benign hepatic tumor?!

•  C a v e r n o u s
hemangiomas!
Fitz–Hugh–Curtis syndrome !

•  i n t r a - a b d o m i n a l
dissemination of pelvic
inflammatory disease!
 Klatskin tumor!

•  cholangiocarcinoma that
presents at the confluence
of the right and left hepatic
ducts?!
What is the first line of therapy for
patients with bleeding
esophageal varices?!

•  Endoscopic banding or
sclerotherapy.!
What is Courvoisier’s sign and what does
its presence suggest?!

•  It is a distended and palpable

gallbladder in a jaundiced patient. It
suggests malignant obstruction!
What is the significance of the colon cutoff
sign?!

•  It is caused by inflammation of
the pancreas, which induces
spasm in the adjacent colon.!
What are the treatment options available to an
otherwise healthy patient with achalasia?!

•  Endoscopic balloon dilation !

•  Heller esophagomyotomy!
What is meant by a highly selective
vagotomy?!

•  Division of individual branches of the

nerve of Latarjet, preserving the
crow’s foot!
What is the classic metabolic abnormality
associated with gastric outlet obstruction?!
•  H y p o c h l o r e m i c , h y p o k a l e m i c
metabolic acidosis!
What is a Schatzki’s ring?!

•  A dense annular band in the

submucosa at the squamocolumnar
junction!
An 80-year-old man presents with dysphagia that
prevents him from adequately clearing his
pharynx of food. He also notices gurgling in his
neck when he swallows. What is the most likely
diagnosis?!

•  A Zenker’s diverticulum!
What is the most common visceral
complication secondary to cocaine
use, which requires abdominal
exploration?!

•  Gastric or duodenal ulcer with

perforation!
Where does most water
absorption occur?!

•  Jejunum!
•  What is the most common type of
tracheoesophageal fistula?

•  A blind-ending proximal esophageal
pouch with a fistula from the lower
esophagus to the trachea (85%).

•  What is the clinical picture of pyloric
stenosis?

•  Nonbilious projectile vomiting. The defect

occurs in 1/300 births and is most common
in first-born males. Olive may be palpable
in epigastrum on PE.

•  ❍
What are the characteristics
of gastroschisis?

•  Absence of peritoneal
covering. Abdominal wall
defect typically to the right of
midline

• What is the most
common primary bone
malignancy?

•  Osteosarcoma

•  What is the most
appropriate donor site for
grafting the skin of the
hand?

•  Inner aspect of the arm

•  What is the recommended
excisional margin for a 3-
mm depth melanoma?

•  2 cm.

•  What is the most appropriate
donor site for grafting the skin
of the face?

•  Postauricular

•  ❍
What is the most
frequently utilized flap for
head and neck
reconstruction?

• 

•  The deltopectorial flap

•  What is a Marjolin’s ulcer?

•  Squamous cell carcinoma
that develops in a chronic
wound or ulceration.

•  What is the most common
benign cardiac tumor?
Myxoma

• What is the most frequently used
palliative procedure for patients
with tetralogy of Fallot?

•  A subclavian artery-to-pulmonary
artery (Blalock–Taussis) shunt

•  What radiographic finding is
associated with
transposition of the great
vessels?

•  An egg-shaped heart

•  A chest X-ray of a smoker reveals
a popcorn lesion. This slow
growing tumor is needle biopsied
(sensitive). What is the diagnosis?

•  Hamartoma

•  What is the most common
etiology of a spontaneous
pneumothorax?

•  Rupture of a pulmonary bleb

A 65-year-old male has a large opacity in the
anteromedial aspect of the right thorax on a
routine chest X-ray. The opacity appears to have
air within it. The patient is asymptomatic and has
not had a previous chest X-ray. What is the most
likely diagnosis?!

•  A f o r a m e n o f ( a n t e r i o r
diaphragmatic) Morgagni hernia!
•  What is a Krukenberg tumor?

•  Adenocarcinoma metastatic to
the ovaries

•  Which testicular tumor is the
most radiosensitive? Seminoma.

•  What is the most common
cancer affecting the kidney in
childhood?

•  Wilm’s tumor

•  What is the classical triad of
clinical manifestations seen in
patients with renal tumors?

•  Pain, palpable mass, and

hematuria.

•  An 8-year-old boy has a draining
ear filled with friable tissue. CT
demonstrates a punched-out lytic
lesion of the temporal bone.
Biopsies show only lipid-laden
histiocytes. What is the most likely
diagnosis?

•  Histiocytosis X.

•  What is the treatment of
choice for patients with
biliary atresia?
Hepatoportoenterostomy
(Kasai procedure)

 Boerhaave’s syndrome!
• pressure rupture
of the esophagus!
What is a Diulafoy’s lesion?!
•  submucosal defect
overlying an artery in
the muscularis!
Which gastric neuroendocrine tumor
is more commonly seen in patients
with pernicious anemia (chronic
atrophic gastritis)?!

•  Carcinoid!
In which region of the colon does
volvulus most frequently occur?!

•  The sigmoid colon!

Ogilvie’s syndrome!
• colonic pseudo-
obstruction!
What is the most common clinical
manifestation of Meckel’s diverticulum in
pediatric patients?!

• Bleeding!
What is melanosis coli?!
•  A benign condition with
hyperpigmentation of the colonic
mucosa secondary to chronic
hyperactivity!
•  laxative abuse !
• What is the source of
bleeding from a subdural
hematoma?

• Shearing of bridging veins
between the dura and
brain.

•  What is the most common
source of bleeding from an
epidural hematoma?
Laceration of the middle
meningeal artery.

•  What is the mechanism of
diffuse axonal injury?
Rotation of the brain within
the skull secondary to
sudden deceleration.

•  What is Brown–Sequard
syndrome?

•  Penetrating trauma with 1/2
cord transaction. Loss of
ipsilateral motor and
contralateral pain and temp.

• What is the most common
primary malignant brain
tumor?

•  G l i o b l a s t o m a
multiforme (GBM)

• What is the most common
lesion of the
cerebellopontine angle or
skull base?

• Acoustic neuroma

•  An infant presents with
coughing, choking, and
cyanosis during feeding.
What process does this
clinical triad suggest?

•  A tracheoesophageal fistula.

• Which muscle is the sole
abductor of the vocal
cords?

•  Posterior cricoarytenoid

An elevated level of which chemical compounds is
associated with malignant carcinoid syndrome?!

•  5-Hydroxyindoleacetic acid (5-

HIAA) and vanillylmandelic acid
(VMA)!
Which segment of the GI tract is the most
common location for a Kaposi’s
sarcoma?!
• The duodenum!
What is the most common cause of a
rectus sheath hematoma?!

•  Rupture of the epigastric artery

or vein secondary to trauma.!
What is the most frequent site of rupture
of the appendix?!

• The antimesenteric
border!
What ultrasound findings are consistent
with acute appendicitis?!

•  Diameter > 6 mm!

•  noncompressibility of the
appendix!
•  presence of a complex mass!

What is the obturator sign?!

•  Pain on internal
rotation of the right hip!
Where does a Spigelian hernia
occur?!

• Through the linea

semilunaris!
What is Amyand’s hernia?!

•  The hernia sac contains

a ruptured appendix!
 What is Littre’s hernia?!
•  An inguinal hernia with an
incarcerated Meckel’s
diverticulum!
What is a paraduodenal (Treitz)
hernia?!
•  intra-abdominal hernia
to the left of the SMV
creating a closed-loop
bowel obstruction!
What is a Richter’s hernia ?!

•  the contents include one side

(usually the antimesenteric
side) of the intestinal wall!
What is a Cooper’s hernia?!

•  The hernia sac follows the

femoral canal but tracks down
to the scrotum, labia majorus,
or the obturator foramen!
 PANTALOON  HERNIA  
•  COEXISTING  DIRECT  &  
INDIRECT  HERNIA  
What are the boundaries of the superior
lumbar triangle of Grynfelt?!
•  superior border: 12th rib!
•  inferior border: internal oblique!
•  posterior: sacrospinalis!
What are the boundaries of the inferior
lumbar triangle of Petit?!

•  posterior: latissimus dorsi!

•  anterior: external oblique!
•  inferior: iliac  crest  
What is the Howship Romberg sign?!
•  Pain passing down the inner
side of the thigh to the knee in
an obturator hernia with
internal thigh rotation.!
What is a Lichtenstein repair?!

•  tension-free replacement
of the transveralis fascia
with nonabsorbable mesh!
Wound contraction is mediated by
what cells?!

• Myofibroblasts!
Why is the left kidney preferred for donor nephrectomy?!

•  The longer left renal vein.!

What is the most common
pathology leading to
infantile liver
transplantation?!

• Congenital biliary
atresia !
 What are the most common viral organisms
causing rejection in renal transplant patients?!

•  The herpes group DNA

viruses (particularly
CMV)!
What is the expected increase in the platelet
count following transfusion with six platelet
packs?!

•  40,000–50,000/mm3 !
What systemic chemotherapeutic
agents are used for Stage IV
colon cancer?!

•  5-FU and leucovorin!

What is the most important factor in predicting
the efficacy of progestin therapy in endometrial
cancer?!

•  Progesterone receptor status of

the tumor.!
What is the mechanism of action of vinca
alkaloid-type drugs?!

•  Binding of tubulin to produce

mitotic arrest.!
How long will ASA affect the platelet?!

•  7 days,the entire life of the

platelet, because it irreversibly
binds cyclo-oxygenase!
 What is vincristine belly?!

•  Constipation caused by autonomic

neuropathy secondary to
vincristine.!
What is the most central
natural anticoagulant
protein?!

• Antithrombin III!
What is the most frequent
gastrointestinal site of Crohn’s
disease?!

•  ileocecal region.!
 What percentage of patients with
untreated FAP develop colon cancer?!

• 100%!
 What is the most common type of
adenomatous colonic polyp?!

•  Tubular adenoma (65%–

80%)!
What minimum length of small
bowel is required for enteral
absorption of nutrients?!

•  100 cm!
Name the hallmarks of hypokalemia!

•  Respiratory impairment!
•  paralysis!
•  hyporeflexia!
•  flattening of T waves, and depressed
ST segments!
 What are the treatments for
hyperkalemia?!
•  Kayexelate!
•  insulin!
•  Ca2+ for arrhythmia!
•  bicarb and glucose!
•  dialysis !
Can you name some features of banked
packed red blood cells?!

•  citrate in banked blood is

converted to bicarbonate once
transfused--> metabolic
alkalosis with massive
transfusion!
What is the tumor lysis syndrome?!
•  rapid spontaneous lysis of
malignant cells!
•  hyperkalemia!
•  urate-induced acute renal
failure!
What is the most common cause of acute
adrenal insufficiency?!

•  W i t h d r a w a l o f c h r o n i c
administration of exogenous
corticosteroids!
Burn patients develop a green slime
infection on their burns, which smell
sweet. What is the most likely
offending organism?!

• Pseudomonas!
What is the best initial fluid management
for a patient with hemorrhagic shock?!

•  Lactated Ringer’s!
A trauma patient presents with a
decreasing level of consciousness
and an enlarging right pupil. What is
the most likely diagnosis?!

•  U n c a l h e r n i a t i o n w i t h
oculomotor nerve
compression.!
• What is the cause of most
cases of WDHA?

•  An islet cell tumor of the
pancreas that produces VIP.

• What is the most
common benign hepatic
tumor?

•  C a v e r n o u s
hemangiomas

•  What is Courvoisier’s sign and
what does its presence suggest?

•  It is a distended and palpable

gallbladder in a jaundiced
patient. It suggests malignant
obstruction.

• What is the standard
prophylactic antibiotic for
gastric surgery?

• First-generation cephalosporin
(cephazolin)

• Why is the left kidney
preferred for donor
nephrectomy?

• The longer left renal
vein

• What is the most common
pathology leading to infantile
liver transplantation?

• Congenital biliary atresia

accounts for more than 50%.

• What vaccines should be given
before elective splenectomy?
H. flu, Meningococcus, and S.
pneumonia 1 week before
surgery

! s urgery because the
immunization is an antibody-
based response.

•  What are the most common
viral organisms causing
rejection in renal transplant
patients?

•  The herpes group DNA
viruses (particularly CMV)

•  ABO incompatibility is an
example of what type of
hypersensitivity reaction?

•  Type II

• What is vincristine
belly?

• Constipation caused by
autonomic neuropathy
secondary to vincristine

•  W h a t systemic
chemotherapeutic agents
are used for Stage IV
colon cancer?

• 5-FU and leucovorin

• What is the expected
increase in the platelet
count following
transfusion with six
platelet packs?

• 40,000–50,000/mm

•  What finding on a
peripheral blood smear is
characteristic of surgical or
functional splenectomy?
Howell–Jolly bodies.

• What is the mechanism
of action for naloxone
(narcan)?

•  O p i o i d receptor
blockade