Surgery Marrow Pg 261-270 (GIT)
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Questions and Answers

What is the purpose of a HIDA scan?

  • To visualize the heart's function
  • To assess the biliary tree (correct)
  • To evaluate kidney function
  • To diagnose lung diseases

    • Severe cholecystitis is classified under Grade I according to the Tokyo consensus guidelines.

    False

    What is the first-line definitive management for a patient with Grade I cholecystitis who is fit for surgery?

    Early laparoscopic cholecystectomy

    In acute cholecystitis, a non-visualization of the gallbladder during a HIDA scan indicates __________.

    <p>inflamed neck</p> Signup and view all the answers

    Match the features of the Tokyo consensus guidelines with their corresponding grades:

    <p>Grade I = Mild cholecystitis Grade II = Moderate cholecystitis Grade III = Severe cholecystitis + Organ dysfunction</p> Signup and view all the answers

    Which of the following is the most common encapsulated bacteria associated with OPSI after splenectomy?

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

    Basophilic stippling is a permanent hematological change found on a peripheral smear.

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

    What is the recommended management for preventing thrombosis in patients with transient increases in all cell lines following splenectomy?

    <p>Prophylactic aspirin</p> Signup and view all the answers

    Vaccination against Pneumococcus and Meningococcus is repeated every ______ years after splenectomy.

    <p>5</p> Signup and view all the answers

    Match the vaccine with its frequency after splenectomy:

    <p>Pneumococcal = Every 5 years Meningococcal = Every 5 years H. influenzae = Every 10 years Influenza = Yearly</p> Signup and view all the answers

    What is a significant risk that increases after a splenectomy?

    <p>Increased risk of opportunistic infections</p> Signup and view all the answers

    True or False: Splenunculi are common findings within the spleen itself and do not have clinical significance.

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

    What type of splenic cyst is typically associated with a history of trauma?

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

    A hydatid cyst in the spleen is associated with exposure to __________.

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

    Match the following splenic conditions with their descriptions:

    <p>Pseudocyst = Not lined by epithelium, related to trauma True Cyst = Lined by epithelium, may require splenectomy Splenosis = Deposits of splenic tissue in abnormal locations Hydatid Cyst = Associated with infection by Echinococcus</p> Signup and view all the answers

    What is the function of the cystic plate in relation to the gall bladder?

    <p>Covers the gall bladder fossa</p> Signup and view all the answers

    The R4U line connects Rouviere's sulcus to the umbilical fissure.

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

    What happens when the CBD is present below the R4U line during surgery?

    <p>Injury occurs.</p> Signup and view all the answers

    The __________ does not increase the risk of cancer in the gall bladder.

    <p>Phrygian Cap</p> Signup and view all the answers

    Match the following anatomical features with their descriptions:

    <p>Cystic Plate = Covers the gall bladder fossa Rouviere's Sulcus = Undersurface of the right lobe of liver R4U Line = Connects Rouviere's sulcus to segment 4 Phrygian Cap = Physiological variant of gall bladder</p> Signup and view all the answers

    What is the primary imaging technique used for diagnosing splenic abscesses?

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

    Trauma is the most common indication for splenectomy.

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

    What is the primary management option for Grade II patients when an advanced technique is available?

    <p>Early Lap Cholecystectomy</p> Signup and view all the answers

    Name one malignant tumor that may require splenectomy.

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

    Acalculous cholecystitis occurs with the presence of gallstones.

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

    Injury to the tail of the pancreas during splenectomy presents with _______ in the drain.

    <p>amylase-rich secretions</p> Signup and view all the answers

    What factors are considered predictive of a poor surgical outcome in patients being evaluated for cholecystectomy?

    <p>Negative predictive factors</p> Signup and view all the answers

    Match the indications for splenectomy with their respective categories:

    <p>Trauma = Most common indication Oncological = Part of en bloc resection Benign Tumors = No treatment required Hematological = Spherocytosis and ITP</p> Signup and view all the answers

    In cases where the patient is unfit for surgery and shows no improvement, __________ cholecystostomy may be performed.

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

    Match the grade of cholecystitis with the associated management strategy:

    <p>Grade II = Antibiotics and supportive care Grade III = Early or delayed Lap Cholecystectomy Acalculous Cholecystitis = Supportive care and IV antibiotics Unfit = Tube cholecystostomy</p> Signup and view all the answers

    What are the boundaries of Calot's triangle?

    <p>Cystic artery, cystic duct, common hepatic duct</p> Signup and view all the answers

    The Critical View of Safety involves clipping the cystic lymph node.

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

    What is the clinical significance of Moynihan's Hump during surgery?

    <p>Injury to the tortuous right hepatic artery can lead to bleeding.</p> Signup and view all the answers

    The __________ is the sentinel node of the gall bladder located within Calot's triangle.

    <p>cystic lymph node of Lund</p> Signup and view all the answers

    Match the following terms with their descriptions:

    <p>Hepatocystic Triangle = Bounded by the inferior edge of liver, common hepatic duct, cystic duct Calot's Triangle = Bounded by cystic artery, cystic duct, common hepatic duct Critical View of Safety = Procedure to ensure safe cholangiography Moynihan's Hump = Tortuous branch of the right hepatic artery</p> Signup and view all the answers

    What is the most common etiology that can lead to splenic artery aneurysm?

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

    Splenic infarcts are always symptomatic.

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

    What imaging technique is considered the investigation of choice for diagnosing splenic artery aneurysms?

    <p>CT angiography</p> Signup and view all the answers

    In cases of splenic artery aneurysm rupture, the pain may be referred to the __________ shoulder tip.

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

    Match the following conditions with their management approaches:

    <p>Splenic artery aneurysm = Embolization Splenic infarct (symptomatic) = Surgical excision Splenic artery aneurysm (last resort) = Splenectomy Splenic infarct (asymptomatic) = Conservative management</p> Signup and view all the answers

    What is the most common type of gall stone?

    <p>Mixed stones</p> Signup and view all the answers

    Seagull sign refers to a triradiate stone.

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

    What are black pigment stones primarily associated with?

    <p>Hemolytic disorders</p> Signup and view all the answers

    Brown pigment stones contain ________ and are often seen in infected bile.

    <p>calcium bilirubinate</p> Signup and view all the answers

    Match the type of gall stone with its description:

    <p>Pure Cholesterol Stones = Greater than 90% cholesterol content Brown Pigment Stones = Seen in infected bile Black Pigment Stones = Associated with hemolytic disorders Mixed Stones = Most common type of gall stones</p> Signup and view all the answers

    Which condition is indicated for surgery due to an increased risk of cancer?

    <p>Porcelain gall bladder</p> Signup and view all the answers

    Acute cholecystitis is characterized by pain in the left side of the abdomen.

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

    What is the classical USG finding in acute cholecystitis that indicates increased wall thickness?

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

    The symptom of __________ is characterized by pressing on the right hypochondrium, which causes the patient to catch their breath.

    <p>Murphy's sign</p> Signup and view all the answers

    Match the following symptoms of acute cholecystitis with their descriptions:

    <p>Pain in the right side of abdomen = Main symptom of acute cholecystitis Nausea &amp; vomiting = Common gastrointestinal symptoms Anorexia = Loss of appetite Fever = Systemic sign of inflammation</p> Signup and view all the answers

    Study Notes

    Gall Bladder & Bile Ducts: Part 1

    • HIDA Scan: Used to diagnose acute cholecystitis. The scan works by injecting a radioactive substance that travels through the biliary tree. If there is inflammation, the gall bladder will not be visible.
    • Tokyo consensus guidelines for severity grading of acute cholecystitis: The severity of acute cholecystitis is classified into three grades based on clinical features.
      • Grade III: Severe cholecystitis with organ dysfunction
      • Grade II: Moderate cholecystitis with signs such as increased white cell count, palpable tender mass, and duration of more than 72 hours.
      • Grade I: Mild cholecystitis.
    • Management of Acute Cholecystitis:
      • Grade I: Surgery is recommended. Early laparoscopic cholecystectomy is the preferred treatment.
      • Grade II: If surgery is contraindicated, antibiotics and supportive care are recommended.
      • Grade III: Antibiotics and supportive care are recommended for managing the infection.
    • Hematological Changes post Splenectomy:
      • Transient increase in all 3 cell lines: There is a temporary increase in the white blood cell count, platelet count, and red blood cell count.
      • Predisposition to thrombosis: The increase in platelet count increases the risk of blood clots. Prophylactic aspirin is often recommended.
    • Permanent Hematological Changes on Peripheral Smear:
      • Basophilic stippling: A characteristic feature of lead poisoning
      • Howell Jolly bodies: Small, round inclusions seen in red blood cells, often seen in patients with splenectomy.
      • Reticulocytes: Immature red blood cells, indicating increased red blood cell production.
      • Hypersegmented WBC's: Neutrophils with more than 5 lobes, indicative of megaloblastic anemia or vitamin B12 deficiency.
    • Left lower lobe atelectasis/pneumonia (m/c): A common post-splenectomy complication due to decreased lung expansion.
      • Prevention: Chest physiotherapy using incentive spirometry and pain control to promote deep breaths.
    • OPSI: Opportunistic overwhelming post splenectomy infections: A serious complication that occurs due to the loss of the spleen's immune function.
      • Etiology: Encapsulated bacteria such as pneumococcus, meningococcus, and H. influenzae.
      • Occurrence: More common in children than adults and typically occurs within the first two years following splenectomy.
      • Vaccination: Vaccination against pneumococcus, meningococcus, and H. influenzae is highly recommended.
    • Spleen Functions:
      • Immunological: Produces antibodies and plays a critical role in immune function.
      • Acts as graveyard for blood cells: Filters out old and damaged blood cells.
      • Hematopoiesis (Physiological): Occurs during the 3rd-5th week of intrauterine life.
      • Reservoir function: Stores white blood cells, red blood cells, and platelets.
    • Applied Aspects of Splenic Tissue:
      • Splenunculi: Accessory splenic tissue that can occur in the hilum of the spleen. Important in hematological conditions like ITP. Removal of the spleen may lead to recurrence if splenunculi are not removed.
      • Splenosis: Splenic tissue deposits in the omentum and bowel often following trauma.
    • Benign Conditions of the Spleen:
      • Splenic Cyst: A fluid-filled sac within the spleen.
        • Pseudocyst: A false cyst not lined by epithelium often caused by trauma. Usually resolves spontaneously.
        • True Cyst: Lined by epithelium. Hydatid cysts are true splenic cysts caused by infection with Echinococcus.
    • Couinaud Segments: Functional Division: A way to divide the liver into eight segments based on the distribution of hepatic veins and portal veins.
    • Cystic Plate: A sheet of tissue that covers the gall bladder fossa and is continuous with liver capsule of segments 4 & 5. Important to identify for safety during laparoscopic cholecystectomy.
    • Rouviere's Sulcus: Present on the undersurface of the right lobe of the liver.
    • R4U Line: A line drawn from the roof of the Rouviere sulcus to the umbilical fissure (u) - important for minimizing CBD injury during laparoscopic cholecystectomy.
    • General Anatomy of the Gall Bladder: Important to remember that the Gallbladder lacks a submucosa and contains subserosal lymphatics.
    • Spread of Gallbladder Cancer into the Liver: Can occur through subserosal lymphatics, direct infiltration, and hematogenous spread.
    • Phrygian Cap: A physiological variant in which the fundus of the gallbladder is folded and appears like a cap. Not a cause for concern and does not increase the risk of cancer.
    • Gastrointestinal and Abdominal Surgery:
      • Decision Tree for Cholecystectomy: A guide to manage cholecystectomy based on patient grade and the presence of gallstones.
      • Acalculous Cholecystitis: Cholecystitis without gallstones.
        • Risk Factors: Commonly seen in ICU patients, post-CABG patient, or those with prolonged total parenteral nutrition
      • Management of Acalculous Cholecystitis: Supportive care, IV fluids, IV antibiotics, and analgesics.
    • Splenic Abscess: Infection within the spleen, associated with immunocompromised patients and post-splenic infarcts.
      • Clinical Features: Fever and pleuritic pain.
      • Imaging: CECT (Computed Tomography Enhanced) is the imaging of choice.
      • Management: Pigtail catheter drainage.
    • Splenectomy: Surgical removal of the spleen.
      • Indications: Trauma, oncological conditions, hematological disorders.
      • Complications: Hemorrhage, Portal hypertension.
    • Steps for Splenectomy (Dissection):
      • Dissection of the aspect of spleen.
      • Dissection of the lateral aspect and retroperitoneal attachments.
      • Transection of the splenic hilum.
      • Dissection of short gastric vessels.
      • Removal of the spleen.
    • Splenic Artery Aneurysm: Enlargement of the splenic artery.
      • Etiology: Visceral artery aneurysm, pancreatitis, trauma, atherosclerosis, pregnancy.
      • Clinical Features: Often asymptomatic but can cause pain if rupture occurs.
      • Management: Embolization, grafting, or splenectomy.
    • Splenic Infarct: A blockage of blood flow to the spleen.
      • Etiology: Hypersplenism due to conditions like portal hypertension or myelodysplastic syndromes.
      • Clinical Features: Often asymptomatic but can cause pain, left upper quadrant pain, pleuritic pain, or referred left shoulder pain.
      • Management: Conservative or surgical excision.
    • Gall Bladder Functions:
      • Reservoir of bile: Stores bile produced by the liver.
      • Secretion of mucin: Mucin production in the gall bladder protects the lining from the harsh digestive juices.
      • Concentration of bile: Gallbladder concentrates and stores bile, increasing its digestive capabilities.
    • Gall Stones:
      • Types: Cholesterol, pigment, and mixed stones.
      • Cholesterol Stones: Pure cholesterol stones are more common.
      • Pigment Stones: Consist of bilirubin, calcium palmitate, and calcium bilirubinate.
        • Brown pigment stones: Associated with infections like ascariasis, clonorchis, and cholangitis.
        • Black pigment stones: Common in hemolytic disorders such as G6PD deficiency, sickle cell anemia, and spherocytosis.
    • Risk Factors for Gall Stones:
      • Lithogenic bile (excess cholesterol).
      • Obesity.
      • Post-ileal resection.
      • Stasis in the gallbladder.
      • Pregnancy.
      • Oral contraceptives (OCP).
      • Post-vagotomy.
    • Investigation
      • X-ray:
        • Most gallstones are radiolucent and do not show up on an X-ray.
        • About 10% of stones are radiopaque (visible on X-ray)
      • SIGNS:
        • Seagull sign: A biradiate stone.
        • Mercedes Benz sign: A triradiate stone.
    • Presentation & Management
      • Asymptomatic stones:
        • Observation: If asymptomatic, no treatment is normally required.
        • Indications for Surgery:
          • Porcelain gall bladder: Calcification of the gall bladder wall (increased risk of gallbladder cancer).
          • Salmonella typhi carrier: Removal of the gallbladder can help to eliminate infection.
          • Diabetes: First attack of gallstones can cause severe pain.
          • > 2 cm stone: Large stones have an increased risk of causing complications.
      • Acute Cholecystitis:
        • Symptoms: Pain in the right upper abdomen, nausea, vomiting, and anorexia.
        • Signs:
          • Murphy's sign: Pain on palpation of the right upper abdomen.
          • Boa's sign: Hyperesthesia over the 12th rib.
        • Tokyo consensus guidelines diagnostic criteria:
          • Localized signs of inflammation: Murphy's sign.
          • Systemic Signs of inflammation: Fever.
          • Imaging findings: Characterisitic ultrasonographic findings of acute cholecystitis.
        • Diagnosis: Suspected diagnosis: 1 of A + 1 of B or Definite diagnosis: 1 of B + 1 of A + C.
        • Investigation: Ultrasound is the primary imaging for diagnosis.
        • Ultrasound: Shows thickened gall bladder wall (>3 mm), pericholecystic fluid, and probe tenderness.

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    Description

    This quiz covers essential concepts related to the gall bladder and bile ducts, focusing on the diagnosis of acute cholecystitis using HIDA scans and the Tokyo consensus guidelines for severity grading. It also addresses management strategies based on the severity of cholecystitis. Test your understanding of these critical aspects of biliary health.

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