Surgery Marrow  Pg 467-476 (Vascular Surgery)
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Questions and Answers

What is the primary risk factor for Paget-Schroetter Disease?

  • Repetitive arm movements (correct)
  • Obesity
  • Age over 50
  • Family history of DVT
  • Superficial thrombophlebitis can be caused by trauma to a superficial vein.

    True

    What diagnostic tool is used for confirming primary upper limb DVT?

    Doppler

    The most common cause of superficial thrombophlebitis is _____ insertion.

    <p>IV line</p> Signup and view all the answers

    Match the following features with their respective conditions:

    <p>Tenderness = Superficial Thrombophlebitis Cord-like swelling = Superficial Thrombophlebitis Axillary vein thrombosis = Primary Upper Limb DVT Thoracic outlet obstruction = Secondary Upper Limb DVT</p> Signup and view all the answers

    Which type of mesenteric cyst is characterized by a thin wall and independent blood supply?

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

    Enterogenous mesenteric cysts typically contain sequestered lymphatic tissue.

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

    What is the recommended management procedure for enterogenous mesenteric cysts?

    <p>Resection + Anastomosis</p> Signup and view all the answers

    The clinical features of mesenteric cysts include periumbilical swelling and a sign known as the ______ sign.

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

    Match the following features with the correct type of mesenteric cyst:

    <p>Thin wall = Chylolymphatic Thick wall = Enterogenous Clear fluid = Chylolymphatic Turbid fluid = Enterogenous</p> Signup and view all the answers

    Which of the following pairs of veins contribute to the majority of blood flow in the lower limb?

    <p>Peroneal, Anterior tibial, and Posterior tibial veins</p> Signup and view all the answers

    A previous history of deep vein thrombosis (DVT) is a risk factor for developing another DVT.

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

    What is the definition of Lower Limb Deep Vein Thrombosis (DVT)?

    <p>Semi-solid coagulum in the deep veins.</p> Signup and view all the answers

    The primary complication of DVT that can be life-threatening is called a __________.

    <p>Pulmonary embolism</p> Signup and view all the answers

    Match the following risk factors with their corresponding categories:

    <p>Age = Stasis Obesity = Stasis Thrombophilia = Hypercoagulability Previous DVT = Endothelial injury</p> Signup and view all the answers

    What is the preferred method of ventilation for patients with an internal hernia?

    <p>IPPV (Intermittent positive pressure ventilation)</p> Signup and view all the answers

    Petersen's hernia occurs behind the Roux limb.

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

    What type of hernia occurs through the transverse mesocolon?

    <p>Stemmer's hernia</p> Signup and view all the answers

    A left paraduodenal hernia occurs due to a defect in the fusion of the _______.

    <p>descending colon mesentery</p> Signup and view all the answers

    Match the following types of hernias with their descriptions:

    <p>Stemmer's hernia = Occurs through the transverse mesocolon Left paraduodenal hernia = Occurs due to defective fusion of descending colon mesentery Petersen's hernia = Occurs behind the Roux limb Right duodeno-jejunal hernia = Occurs due to defective fusion of ascending colon mesentery</p> Signup and view all the answers

    Which of the following is a common cause of venous thrombosis related to tissue factor?

    <p>Recent myocardial infarction</p> Signup and view all the answers

    Phlegmasia cerulea dolens is characterized by a painful white limb.

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

    What is the most common vein affected in venous thrombosis?

    <p>Calf/soleal veins</p> Signup and view all the answers

    The condition known as milk leg refers to __________.

    <p>phlegmasia alba dolens</p> Signup and view all the answers

    Match the following signs to their descriptions:

    <p>Moses sign = Pain on squeezing the calf muscles Homan's sign = Resistance in calf on dorsiflexion of the foot Limb edema = Constant sign of venous thrombosis Phlegmasia alba dolens = Painful white limb</p> Signup and view all the answers

    Which of the following is NOT a feature of post-thrombotic limb?

    <p>Severe pain at rest</p> Signup and view all the answers

    Subtherapeutic anticoagulation is a risk factor for post-thrombotic limb after DVT.

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

    Name two types of prophylaxis used to prevent DVT.

    <p>Pharmacological and Mechanical</p> Signup and view all the answers

    The appearance associated with lipödermatosclerosis is an inverted ______ bottle appearance.

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

    Match the following DVT risk factors with their descriptions:

    <p>Proximal DVT = Occurs in veins close to the heart Recurrent DVT = Multiple incidences of deep vein thrombosis Lower limb paralysis = Inability to move the lower limbs due to a condition Major surgical trauma = Significant surgical procedures increasing risk of clotting</p> Signup and view all the answers

    Which type of congenital diaphragmatic hernia is more common?

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

    Pulmonary hypoplasia is the second most common cause of death in congenital diaphragmatic hernia cases.

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

    What is the typical shape of the abdomen in a newborn with congenital diaphragmatic hernia?

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

    The Bochdalek hernia typically involves herniated contents such as the stomach, spleen, and ______.

    <p>transverse colon</p> Signup and view all the answers

    Match the type of hernia with its characteristics:

    <p>Bochdalek = Defective pleuroperitoneal development Morgagni = Defective central tendon of diaphragm</p> Signup and view all the answers

    Which of the following agents is a direct thrombin inhibitor?

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

    IVC filters can be used for patients with contraindications to anticoagulation.

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

    Name one complication of anticoagulation therapy.

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

    Streptokinase and urokinase are agents used in __________.

    <p>direct thrombolysis</p> Signup and view all the answers

    Match the following anticoagulants with their types:

    <p>Fondaparinux = Factor Xa inhibitor Apixaban = Novel anticoagulant Bivalirudin = Direct thrombin inhibitor Rivaroxaban = Novel anticoagulant</p> Signup and view all the answers

    What is the maximum score that can be assigned based on Wells' criteria?

    <p>10</p> Signup and view all the answers

    A score of -2 in Wells' criteria indicates a high probability of DVT.

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

    What is the first-line treatment for new DVT patients during the initial five days?

    <p>LMWH + warfarin</p> Signup and view all the answers

    The target INR for managing anticoagulation in patients with DVT is _____ to _____ for most cases.

    <p>2, 3</p> Signup and view all the answers

    Match the following types of investigations with their purposes:

    <p>Doppler scan = Evaluate for DVT Pulmonary angiography = Confirm pulmonary embolism CT angiography = Investigate pulmonary complications D-dimer = Rule out thrombotic events</p> Signup and view all the answers

    Which of the following does NOT contribute to the Wells' score?

    <p>Age over 60</p> Signup and view all the answers

    Anticoagulants primarily serve to prevent the formation of new clots in DVT treatment.

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

    What is the recommended duration of treatment for a first episode of DVT?

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

    What is the most common type of obturator hernia defect seen in elderly, multiparous women?

    <p>Very narrow defect</p> Signup and view all the answers

    Strangulation is a complication that can occur with an obturator hernia.

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

    Name one characteristic clinical feature associated with obturator hernias.

    <p>Bowel obstruction</p> Signup and view all the answers

    An obturator hernia is characterized by a defect in the tissues that normally hold the ______ closed.

    <p>obturator canal</p> Signup and view all the answers

    Match the following types of hernias with their characteristics:

    <p>Richter's hernia = Characterized by a very narrow defect Maydl's hernia = W-shaped hernia with a large defect Obturator hernia = Commonly occurs in elderly, multiparous women</p> Signup and view all the answers

    Which sign is characterized by shooting pain along the obturator nerve during hip movements?

    <p>Howship Romberg sign</p> Signup and view all the answers

    Obturator hernias are most frequently seen in males.

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

    What is the recommended surgical procedure to repair an obturator hernia?

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

    Study Notes

    Mesenteric Cysts

    • Mesenteric cysts are fluid-filled sacs in the mesentery, the tissue that holds the intestines in place
    • Two main types: Chylolymphatic and Enterogenous
    • Chylolymphatic cysts are more common and contain clear fluid, while Enterogenous cysts contain turbid fluid.

    Clinical features

    • Mesenteric cysts can attach to the mesentery, often near the junction of the duodenum and jejunum (DJ flexure)
    • Tillaux triad:
      • Periumbilical swelling
      • Movement at right angle to attachment of mesentery (Tillaux sign)
      • Transverse band of resonance

    Investigations

    • Imaging studies like Computed Tomography (CT with contrast) are used for diagnosis

    Management

    • Chylolymphatic cysts are usually removed surgically (enucleation)
    • Enterogenic cysts require resection (removal) and anastomosis (reconnection of the bowel)

    Upper Limb Deep Vein Thrombosis (DVT)

    • DVT in the upper limb can be primary or secondary.

    Primary Upper Limb DVT

    • Paget-Schroetter Disease:
      • Thrombosis in the axillary vein, often caused by repetitive arm movements
      • Diagnosed by Doppler ultrasound
      • Managed with anticoagulation

    Secondary Upper Limb DVT

    • Can be caused by thoracic outlet obstruction or cannula insertion

    Superficial Thrombophlebitis

    • Inflammation and thrombosis of superficial veins, often caused by IV line insertion.
    • Symptoms include tenderness and cord-like swelling
    • Treated with Thrombophlebitis gel

    Lower Limb Deep Vein Thrombosis (DVT)

    • Defined as semi-solid coagulum in the deep veins
    • Major complications: Pulmonary embolism and post-thrombotic limb

    Risk factors

    • Virchow's Triad:
      • Stasis (blood flow slowing)
      • Hypercoagulability (increased clotting tendency)
      • Endothelial injury (damage to vessel lining)

    Patient factors

    • Patient factors that increase the risk of DVT:
      • Age, obesity, immobility, varicose veins, pregnancy, puerperium, high-dose estrogen therapy

    Internal Hernias

    • A type of hernia where a loop of intestine protrudes through a defect in the internal abdominal wall.
    • Several types, including:
      • Stemmer's hernia, Left paraduodenal hernia, Petersen's hernia, Right duodeno-jejunal hernia

    Management of Internal Hernias

    • Mechanical ventilation (IPPV) is the preferred method
    • Surgical intervention: Circumferential incision over the diaphragm followed by mesh placement to cover the defect

    Venous Thrombosis

    • Causes of venous thrombosis can be divided into two categories: Disease or surgical procedure and patient factors.

    Disease or surgical procedure

    • Trauma or surgery
    • Malignancies
    • Heart failure
    • Myocardial infarction
    • Paralysis
    • Infection
    • Homocystinemia
    • May-Thurner syndrome: Right iliac artery compressing the left iliac vein

    Patient factors

    • Conditions that increase susceptibility to clots (e.g., inflammatory bowel disease, nephrotic syndrome, polycythemia, paraproteinemia, PNH antibody or lupus anticoagulant, Behcet's disease, Factor V Leiden mutation, Protein C & S deficiency)

    Clinical features

    • Often asymptomatic, especially in the early stages
    • More common in one leg, but can affect both
    • The most common vein affected: Calf/soleal veins

    Pulmonary embolism

    • Most common vein affected: Ilio-femoral veins
    • Symptoms:
      • Chest pain
      • Dyspnea (shortness of breath)
      • Increased jugular venous pressure (↑ JVP)
      • Decreased systolic blood pressure (↓ SBP)

    Signs

    • Signs associated with DVT:
      • Limb edema (swelling)
      • Moses sign: Pain on squeezing the calf muscles
      • Homan's sign: Resistance in calf on dorsiflexion of the foot

    Phlegmasia cerulea dolens

    • Painful blue limbs, due to thrombosis of major axial veins and collaterals, leading to potential venous gangrene

    Phlegmasia alba dolens (aka milk leg)

    • Painful white limb, due to thrombosis of major axial veins without collateral involvement
    • More common during pregnancy

    Wells' Criteria for Predicting DVT

    • A scoring system to predict the likelihood of DVT.
    • Score is calculated based on clinical signs and risk factors.

    Probability based on Score

    • Low probability: Score -2 to 0
    • Moderate probability: Score 1-2
    • High probability: Score >2

    Investigations

    • Doppler/Duplex scan (color Doppler and B-mode ultrasound) is the initial investigation
    • Magnetic Resonance Imaging (MRI) if Doppler inconclusive
    • Pulmonary embolism:
      • Gold standard: Pulmonary angiography (invasive)
      • Initial investigation: CT angiography
      • D-dimer: High negative predictive value

    Management

    • Anticoagulants:
      • Mainstay treatment to prevent clot propagation
      • Low-molecular-weight heparin (LMWH) and warfarin are commonly used
      • Warfarin therapy monitoring is essential (INR)
      • Target INR: 2-3
      • INR target before surgery: 1.4-1.5

    Post thrombotic limb

    • Affects 2/3rd of patients with DVT

    Features

    • Varicose veins, pigmentation, lipodermatosclerosis (inverted champagne bottle appearance)

    Risk factors

    • Proximal DVT, subtherapeutic anticoagulation, recurrent DVT

    DVT risk groups and Prophylaxis

    • High-risk groups: Major orthopaedic surgery, major abdominal/pelvic surgery, major surgery in patients with previous DVT, PE or thrombophilia, lower limb paralysis, major lower limb amputation.

    Prophylaxis: Types

    • Pharmacological:
      • LMWH (low-molecular-weight heparin) is preferred, last dose given 6 hours before surgery
    • Mechanical:
      • Early ambulation
      • Pneumatic compression stockings.

    Congenital Diaphragmatic Hernia (CDH)

    • A birth defect where organs from the abdomen protrude into the chest.
    • Two main types: Bochdalek and Morgagni hernia.

    Bochdalek vs Morgagni hernia

    Feature Bochdalek Morgagni
    Occurrence More common Less common
    Location Left postero-lateral Right antero-medial
    Defect Defective development of pleuroperitoneal canal/membrane Defective central tendon of diaphragm
    Herniated contents Stomach, Spleen, Transverse colon Transverse colon

    Complications

    • Pulmonary hypoplasia (underdevelopment of the lungs): Most common cause of death
    • Pulmonary hypertension (high blood pressure in the lungs): Second most common cause of death

    Features

    • Mother: Polyhydramnios (excess amniotic fluid) during pregnancy
    • Newborn child:
      • Scaphoid abdomen (abnormal shape)
      • Respiratory distress

    Investigations

    • Chest X-ray

    Auscultation

    • Bowel sounds can be heard in the chest cavity

    Venous Thrombosis

    • In-depth information on anticoagulants, direct thrombolysis, IVC filters.

    Anticoagulants

    • Sensitive to heparin:
      • Fondaparinux: Factor Xa inhibitor
      • Bivalirudin: Direct thrombin inhibitor
    • Novel anticoagulants (NOAC):
      • Rivaroxaban
      • Apixaban

    Direct thrombolysis

    • Used to dissolve clots
    • Agents: Streptokinase, urokinase
    • Catheter-induced
    • Reduces the risk of post-thrombotic limb
    • Beneficial for early presentation
    • Suitable for proximal DVT with moderate to severe symptoms

    IVC filter/Greenfield filter

    • Insertion into the inferior vena cava (IVC)
    • Prevents clot embolisms to the lungs

    Indications for IVC filter

    • Recurrent thromboembolism despite anticoagulation
    • DVT with contraindication to anticoagulation
    • Chronic pulmonary embolism with pulmonary hypertension
    • Complications of anticoagulation

    Indications for retrievable IVC filters

    • Prophylactic placement in high-risk trauma patients
    • Short-term contraindication to anticoagulation
    • Protection during venous thrombolytic therapy
    • Extensive iliocaval thrombosis

    Complications of anticoagulation

    • Migration
    • Bleeding
    • IVC blockage by clot

    Obturator hernia

    • A type of hernia that occurs in the obturator canal, located in the pelvis near the hip.
    • The hernia occurs because the tissues that hold the canal closed have a defect, and a part of the intestine might slip through.

    Types

    • Classified as:
      • Children: Small defect
      • Adults: Large defect
      • Complications: Strangulation

    Characteristics

    • Known as Little Old Lady's hernia
    • Most common in elderly, multiparous women
    • Can be categorized by the size of the defect (narrow or large)

    Complications

    • Strangulation: Blood supply to the herniated intestine is cut off
    • Richter's hernia: Very narrow defect

    Clinical features

    • Bowel obstruction
    • Pain

    Signs

    • Howship-Romberg sign: Shooting pain along the obturator nerve during abduction and medial rotation of the hip
    • Hannington-Kiff sign: Diminished or absent adductor reflex and normal patellar reflex.
    • Compression: Often caused by obturator nerve compression.

    Management

    • Hernioplasty: Surgical hernia repair

    Richter's hernia

    • Very narrow defect
    • Associated with paraumbilical, femoral, and obturator hernias
    • Signs: Gastroenteritis, possible strangulation, or progression to peritonitis
    • Rapid transit through the proximal part of the hernia, which contracts vigorously, leading to obstructed bowel and strangulation/peritonitis.

    Maydl's hernia

    • Large defect
    • W-shaped hernia
    • Located in the connecting portion within the intraperitoneal cavity

    Diagrams

    • Anatomical depictions of the hip region showing the obturator canal, surrounding ligaments, and the location of different structures
    • Diagram depicting the progress of Richter's hernia and the progression of Maydl's hernia.
    • The diagrams include labels for different anatomical features and indicate the location of the herniated intestine.

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    Description

    This quiz covers the essential aspects of mesenteric cysts and upper limb deep vein thrombosis (DVT). You'll learn about the types, clinical features, and management strategies for mesenteric cysts, as well as the differences between primary and secondary upper limb DVT. Test your knowledge on these important medical conditions.

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