Surgery Marrow Pg 241-250 (GIT)
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Surgery Marrow Pg 241-250 (GIT)

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Questions and Answers

What condition is characteristic of males with a high level of anomaly?

  • Rectovaginal fistula
  • Rectovesical fistula (correct)
  • Anal atresia
  • Anal stenosis

    • Females with a low anomaly commonly present with anorectal malformation.

    False

    What is the first surgical step for managing a high anomaly in males?

    Diverting colostomy

    The surgery known as _____ is used to create an opening for the anal canal.

    <p>PSARP</p> Signup and view all the answers

    Match the following anomalies with their corresponding level:

    <p>Anorectal agenesis = High Rectourethral fistula = Intermediate Anal atresia = Low Rectovaginal fistula = Intermediate</p> Signup and view all the answers

    What is a primary advantage of using a cutting seton in the treatment of high fistula?

    <p>Gradual cutting of the tract</p> Signup and view all the answers

    Complete prolapse is more commonly seen in children than in adults.

    <p>False</p> Signup and view all the answers

    Which arteries provide blood supply to the liver, and in what percentage?

    <p>Portal vein (80%), Hepatic artery (20%)</p> Signup and view all the answers

    What is the primary treatment method for the first episode of partial mucosal prolapse in children?

    <p>Digital repositioning</p> Signup and view all the answers

    Left Trisectorectomy involves segments 5 and 8.

    <p>True</p> Signup and view all the answers

    A perforation through the rectal wall and epithelium seen in Crohn's disease is primarily treated with a ______ seton.

    <p>draining</p> Signup and view all the answers

    What is the primary function of the liver related to clotting factors?

    <p>Synthesis of clotting factors</p> Signup and view all the answers

    Match the type of prolapse with its characteristic:

    <p>Partial Mucosal Prolapse = Involves only the mucosal layer and is common in children Complete Prolapse = Involves all layers and is primarily seen in adults Intussusception = Differential diagnosis for complete prolapse in children Thiersch wiring = A treatment option for recurrent partial prolapse</p> Signup and view all the answers

    The primary imaging technique used to differentiate between HCC and metastases is ______.

    <p>Triple phase CT (IOC)</p> Signup and view all the answers

    Match the types of liver resections with their respective segments involved:

    <p>Left Hepatectomy = 4A, 4B, 2, 3 Right Hepatectomy = 5, 6, 7, 8 Left Trisectorectomy = 4A, 4B, 2, 3 + 5, 8 Right Trisectorectomy = 5, 6, 7, 8 + 4A, 4B</p> Signup and view all the answers

    What is the initial treatment for an amoebic liver abscess?

    <p>Metronidazole (800 mg TID)</p> Signup and view all the answers

    A pyogenic liver abscess is commonly treated with metronidazole.

    <p>False</p> Signup and view all the answers

    Name two indications for aspiration of a liver abscess.

    <p>Abscess cavity &gt; 5 cm, pregnant patient</p> Signup and view all the answers

    The common complication of an amoebic liver abscess includes _____ in the sub-diaphragmatic space.

    <p>rupture</p> Signup and view all the answers

    Match the treatments with the type of liver abscess:

    <p>Amoebic liver abscess = Metronidazole and Diloxanide furoate Pyogenic liver abscess = Broad spectrum IV antibiotics Post-treatment care for amoebic abscess = Continue Rx for 2-3 weeks Aspiration procedure = Pigtail catheter</p> Signup and view all the answers

    Which of the following organisms is primarily responsible for Hydatid Disease of the liver?

    <p>Echinococcus granulosus</p> Signup and view all the answers

    The liver is the least commonly affected organ in Hydatid Disease.

    <p>False</p> Signup and view all the answers

    What clinical feature is commonly associated with Hydatid Disease of the liver?

    <p>Right hypochondrial pain</p> Signup and view all the answers

    In the life cycle of Echinococcus granulosus, the definitive host is the ______.

    <p>dog</p> Signup and view all the answers

    What is the maximum score for severe encephalopathy in the Child-Turcotte-Pugh score?

    <p>3</p> Signup and view all the answers

    Bilirubin levels of 3.5 mg/dL receive a higher point score than levels between 2.8–3.5 mg/dL in the Child-Turcotte-Pugh score.

    <p>True</p> Signup and view all the answers

    Match the WHO-IWGE classification with its corresponding description:

    <p>CEI = Unilocular cyst, double line sign CEA = Multiseptate honeycomb cyst</p> Signup and view all the answers

    What does the Child-Turcotte-Pugh score evaluate?

    <p>Liver dysfunction</p> Signup and view all the answers

    In the Child-Turcotte-Pugh score, ascites with a severe presentation is assigned _____ points.

    <p>3</p> Signup and view all the answers

    Match the following criteria with their corresponding points in the Child-Turcotte-Pugh score:

    <p>Encephalopathy (None) = 0 Ascites (Severe) = 3 Bilirubin (2.8-3.5 mg/dL) = 2 Prothrombin time (severe) = 3</p> Signup and view all the answers

    What is the most common organism responsible for pyogenic liver abscess?

    <p><em>Escherichia coli</em></p> Signup and view all the answers

    Amoebic liver abscess typically results in neutrophil-rich pus.

    <p>False</p> Signup and view all the answers

    Which imaging technique is typically used for the evaluation of liver abscess?

    <p>CECT (Computed tomography)</p> Signup and view all the answers

    The predominant clinical feature of both amoebic and pyogenic liver abscess is _____ and fever.

    <p>pain</p> Signup and view all the answers

    Match the type of liver abscess with its characteristic:

    <p>Amoebic Liver Abscess = Usually solitary, occurs via portal vein Pyogenic Liver Abscess = Can be solitary or multiple, polymicrobial Pus Characteristics of Amoebic Abscess = Anchovy sauce pus Pus Characteristics of Pyogenic Abscess = Neutrophil-rich pus</p> Signup and view all the answers

    What is the most common complication after surgery related to the rectum and anal canal?

    <p>Constipation</p> Signup and view all the answers

    Solitary Rectal Ulcer Syndrome (SRUS) typically presents with an ulcer located on the posterior wall of the rectum.

    <p>False</p> Signup and view all the answers

    What investigation is considered the best for delineating anatomy in cases of anorectal malformation?

    <p>MRI</p> Signup and view all the answers

    In an invertogram, the presence of a gas shadow indicating a low anorectal malformation occurs when the distance between the metallic coin and gas shadow is less than _____ cm.

    <p>2</p> Signup and view all the answers

    Match the following associated abnormalities with the VACTERL syndrome:

    <p>V = Vertebral defects A = Anorectal malformations C = Cardiac abnormalities L = Limb abnormalities</p> Signup and view all the answers

    Which segment of the liver is independent and drains bile into both the left and right lobes?

    <p>Segment 1</p> Signup and view all the answers

    Which of the following is an advantage of perineal procedures for complete prolapse?

    <p>Easier to perform</p> Signup and view all the answers

    Segment 1 undergoes hypertrophy in Budd Chiari syndrome.

    <p>True</p> Signup and view all the answers

    What are the three major fissures of the liver?

    <p>Right hepatic vein, left hepatic vein, middle hepatic vein</p> Signup and view all the answers

    Abdominal procedures for complete prolapse are more likely to result in recurrence than perineal procedures.

    <p>True</p> Signup and view all the answers

    The liver is divided into _____ functional segments.

    <p>8</p> Signup and view all the answers

    Name one example of a perineal procedure used for complete prolapse.

    <p>Thiersch wiring</p> Signup and view all the answers

    Match the following segments with their respective characteristics:

    <p>Segment 1 = Caudate lobe, drains bile into both lobes Spigelian lobe = Part of Segment 1 Left medial segment = Located in the left lobe of the liver Segment 9 = Subdivision of Segment 1</p> Signup and view all the answers

    The surgical technique that involves placing mesh between the rectum and sacrum is known as _____ .

    <p>rectopexy</p> Signup and view all the answers

    Match the surgical procedures with their correct descriptions:

    <p>Thiersch wiring = Digitally reduces prolapse and closes with a purse-string suture Delorme repair = Repair of mucosa and prolapse Altemeier repair = Cutting the redundant sigmoid to prevent recurrence Rectopexy = Placing mesh between the rectum and sacrum</p> Signup and view all the answers

    Study Notes

    Anorectal Malformations

    • Males: Fecal matter passed during urination, recurrent UTI.
    • Females: Anorectal malformation.
    • Anomaly Levels:
      • High (Males): Anorectal agenesis, rectovesical fistula.
      • High (Females): Rectovaginal fistula.
      • Intermediate (Males): Rectourethral fistula.
      • Intermediate (Females): Rectovestibular fistula, Rectovaginal fistula.
      • Low/Miscellaneous (Females): Anal atresia, anal stenosis, persistent cloacal anomaly.
    • Management:
      • Low Anomaly: Definitive surgery.
      • High Anomaly: Diverting colostomy followed by definitive surgery.
    • Definitive Surgery: Posterior Sagittal Anorectoplasty (PSARP)- creating an anal canal opening.

    Brisbane Classification of Liver Resection

    • Left Hepatectomy: Segments 4A, 4B, 2, 3.
    • Right Hepatectomy: Segments 5, 6, 7, 8.
    • Left Trisectorectomy (Extended Left Hepatectomy): Segments 4A, 4B, 2, 3 + 5, 8.
    • Right Trisectorectomy (Extended Right Hepatectomy): Segments 5, 6, 7, 8 + 4A, 4B.

    Liver Anatomy and Blood Supply

    • Dual Blood Supply: Portal vein (80%), Hepatic artery (20%).
    • Right Hepatic Artery: Larger, supplies majority of the liver.
    • Liver Pedicle: Portal vein (posterior), Common Bile Duct (right), Hepatic Artery (left). This arrangement resembles "Mickey Mouse Sign".

    Liver Functions

    • Maintaining core body temperature.
    • pH balance and correction of acidosis.
    • Synthesis of clotting factors.
    • Glucose metabolism.
    • Bilirubin formation from Hb degradation.
    • Drug & hormone metabolism and excretion.
    • Removal of endotoxins and foreign antigens.

    Liver Dysfunction and Investigations

    • Causes of Encephalopathy: Liver Dysfunction.
    • Investigations:
      • Liver Function Tests (LFT)
        • Liver Enzymes
        • Clotting Factor Tests
      • Ultrasound (USG) abdomen
      • Triple Phase CT (IOC)
        • Differentiate between Hepatocellular Carcinoma (HCC) and Metastases (mets).

    Rectal Prolapse

    • High Fistula Treatment: Seton - Thread inserted, tightened over intervals.

      • Draining Seton: Crohn's disease.
      • Cutting Seton: High fistula.

    • Rectal Prolapse Types:

      • Partial Mucosal Prolapse (Children): Mucosal layer prolapses, incomplete sacral curve.
      • Complete Prolapse (Adults): All layers prolapse, weak pelvic floor.
      • Complete Prolapse in Children: Different diagnosis (Intussusception).

    • Management of Prolapse:

      • Partial: Digital repositioning for first episode, Thiersch wiring/sclerotherapy if recurrent.
      • Complete: Requires specific surgical interventions (e.g., rectopexy).

    Liver Abscess Treatment

    • Amoebic Liver Abscess Treatment:
      • Tissue Amoebicide: Metronidazole (Double Strength)
      • Duration: 4-5 days.
      • If not responding: Aspiration of pus using USG/CT guidance.
      • Other indications for Aspiration: Abscess cavity > 5 cm, pregnant patient, impending rupture, left lobe abscess.
      • Continue medication for 2-3 weeks: Luminal Amoebicide (Diloxanide furoate).
      • Pigtail Catheter: Used for aspiration of pus in abdominal cavity (USG/CT guidance).
    • Pyogenic Liver Abscess Treatment:
      • IV Antibiotics: Broad spectrum.
      • Aspiration: Low threshold (If patient not responding, aspirate quickly).
    • Complications of Amoebic Liver Abscess:
      • Rupture: Sub-diaphragmatic space (most common), pleural cavity, peritoneal cavity, pericardial cavity.
      • Secondary Infection

    Liver Dysfunction Scores

    • Child-Turcotte-Pugh Score (CTP Score): Evaluates liver dysfunction.
      • Encephalopathy: None, 3 (Mild/Moderate).
      • Ascites: None, 3 (Mild/Moderate).
      • Bilirubin (mg/dL): <2.8, 2.8-3.5, >3.5.
      • Prothrombin Time (s) or INR:

    Liver Abscess: Types and Clinical Features

    • Amoebic Liver Abscess
      • Organism: Entamoeba histolytica.
      • Route of Spread: Flask-shaped ulcers in the gut -> portal vein -> Bare area (segment 7).
      • Number of Abscesses: Usually solitary.
      • Labs: Increased PT/INR, positive serology for Entamoeba.
      • Clinical features: Pain, fever, severe illness, jaundice.
      • Epidemiology: Males > Females.
      • Pus: "Anchovy sauce pus" (lacks neutrophils).
    • Pyogenic Liver Abscess
      • Organism: Polymicrobial (40%), most common: E. coli, Klebsiella (Asia), S. aureus (children with CGD).
      • Number of Abscesses: Solitary or multiple
      • Labs: Increased ALP, PT/INR, bilirubin.
      • Clinical Features: Pain, fever, severe illness, jaundice.
      • Epidemiology: Males > Females, immunocompromised individuals.
      • Pus: Neutrophil-rich.
    • Management and Complications
      • IOC: CECT abdomen.
      • Features: Abscess cavity with hypoechoic liquefied pus.
      • Resolution: Radiological resolution takes months post-treatment.

    Hydatid Disease of the Liver

    • Organism: Echinococcus granulosus, E. multilocularis (malignant hydatid).
    • Definitive host: Dog.
    • Intermediate host: Sheep.
    • Accidental intermediate host: Man, male = female.
    • Organs affected: Liver (most common), lungs, kidneys, spleen.
    • Clinical features: Asymptomatic (majority), Right hypochondrial pain, hepatomegaly.
    • Gross anatomy: Pearly white cyst.
    • Classification:
      • WHO-IWGE 2001: CEI, CEA.
      • Gharbi 1981: Type I, Type III.
      • Stage: Active.
      • CT Image: Differentiate between unilocular and multiseptate cysts.

    Rectum and Anal Canal

    • Complication of Surgery: Constipation (most common), hemorrhage, recurrence, nerve injury, fistula, bladder dysfunction, retrograde ejaculation.

    Solitary Rectal Ulcer Syndrome (SRUS)

    • Location: Ulcer in anterior wall of rectum, 3-10 cm from anal verge.
    • Pathology: Ulcer → Intussusception/Prolapse.
    • Histopathology: Fibromuscular obliteration of lamina propria.
    • Management: STARR (Stapled Transanal Rectal Resection of Intussusception).

    Anorectal Malformation

    • Definition: Absence of normal anal opening.
    • Associated Abnormalities: VACTERL (Vertebral defects, Tracheo-esophageal atresia/fistula, Anorectal malformations, Renal, Cardiac abnormalities, Limb abnormalities).
    • Investigation:
      • MRI: Best for delineating anatomy.
      • Invertogram: Done after 24 hours, metallic coin placed at proposed site of anal opening.
        • Low Anorectal Malformation: < 2 cm between coin and gas shadow.
        • High Anorectal Malformation: > 2 cm between coin and gas shadow.

    Liver - Part 1

    • Functional Anatomy (Couinaud): Divided into 8 functional segments based on portal vein and hepatic vein.
      • Sectors: Right posterior, right anterior, left medial, left lateral.
      • Major Fissures: Right hepatic vein, left hepatic vein, middle hepatic vein.
      • Minor Fissures: Right portal vein, left portal vein, fissure of Ganz.
    • Segment 1: Caudate lobe (posterior to left of IVC), independent segment, drains bile into both lobes, receives blood from both lobes, direct venous drainage into IVC, undergoes hypertrophy in Budd Chiari Syndrome.
      • Subdivisions: Spigelian lobe and segment 9.

    Surgical Management of Complete Prolapse

    • Perineal Procedures: Easier, less complications, less recurrence, suitable for frail patients.
      • Thiersch Wiring: Digitally reduce prolapse, close with purse-string suture.
      • Delorme Repair: Repair of mucosa and prolapse.
      • Altemeier Repair (Perineal rectosigmoidectomy): Redundant sigmoid cut to prevent recurrence.
    • Abdominal Procedures: More difficult, more operative complications, more recurrence, suitable for young, fit patients.
      • Rectopexy: Mesh placed between rectum and sacrum.
      • Well's Repair: Ripstein Repair, Frykman Goldberg Resection.

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    Description

    This quiz covers anorectal malformations and the Brisbane classification of liver resection. It explores different anomaly levels, management strategies, and surgical techniques associated with these conditions. Test your knowledge on these critical surgical topics!

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