Surgery Marrow Pg 121-130 (GIT)
53 Questions
0 Views

Choose a study mode

Play Quiz
Study Flashcards
Spaced Repetition
Chat to lesson

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What type of injury does alkali cause compared to acid?

  • No damage and shallow penetration
  • Less damage and shallow penetration
  • Equal damage and shallow penetration
  • More damage and deeper penetration (correct)

    • Early skilled endoscopy within 48 hours is essential for managing corrosive injuries.

    True

    What is the definitive management for perforation due to corrosive injury?

    Emergency surgery

    In Zargar's classification, a normal endoscopic finding is rated as _____ grade.

    <p>0</p> Signup and view all the answers

    Match the following grades of Zargar's classification with their corresponding endoscopic findings:

    <p>Grade 1 = Superficial edema/erythema Grade 2A = Deep or circumferential ulceration Grade 3 = Focal necrosis Grade 4 = Perforation</p> Signup and view all the answers

    Which of the following is NOT part of the mnemonic VICTERL used for associated anomalies?

    <p>Neurological defects</p> Signup and view all the answers

    Upfront surgery is recommended for infants with a birth weight greater than 2.5 kg and no pneumonia.

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

    Which type of Tracheoesophageal Fistula is the most common?

    <p>Type C</p> Signup and view all the answers

    What does the 'R' in the VICTERL mnemonic stand for?

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

    Polyhydramnios is associated with Tracheoesophageal Fistulae before birth.

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

    What is the confirmatory test for Tracheoesophageal Fistulae?

    <p>Contrast Study</p> Signup and view all the answers

    Infants weighing between 1.8 kg and 2.5 kg may require antibiotics and to ______ weight.

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

    Match the following weight categories with their management plans according to the Waterston Criteria:

    <blockquote> <p>2.5 kg = Upfront Surgery 1.8 - 2.5 kg = Antibiotics and Weight Management &lt;1.8 kg = Further Assessment Required</p> </blockquote> Signup and view all the answers

    Excessive drooling of saliva occurs after birth when inserting an organic (OA) tube and may indicate a __________.

    <p>Tracheoesophageal Fistula</p> Signup and view all the answers

    Match the type of Tracheoesophageal Fistula with their corresponding characteristics:

    <p>Type A = Esophageal Atresia Type B = Proximal TEF with distal EA Type C = Proximal EA with distal TEF Type F = Esophageal stenosis</p> Signup and view all the answers

    What is the strongest layer of the esophagus?

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

    The esophagus has a serosal layer.

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

    At which vertebral level does the esophagus pass through the diaphragm?

    <p>T10</p> Signup and view all the answers

    The left gastric artery is involved in __________ tear.

    <p>Mallory Weiss</p> Signup and view all the answers

    Match the following segments of the esophagus with their corresponding blood supply:

    <p>Upper 1/3 = Inferior thyroid artery Middle 1/3 = Descending thoracic aorta Lower 1/3 = Left gastric artery</p> Signup and view all the answers

    Which site has the highest distribution percentage for neuroendocrine tumors?

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

    Carcinoid syndrome only occurs when serotonin is metabolized in the lungs.

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

    What is the most common symptom associated with carcinoid tumors?

    <p>Cutaneous flushing</p> Signup and view all the answers

    The urine test used to investigate carcinoid tumors measures levels of _______.

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

    Match the following carcinoid tumor sites with their respective distributions:

    <p>Appendix = 40% Small bowel = 25% Rectum = 15% Lung = 10%</p> Signup and view all the answers

    What is the primary function of the lower esophageal sphincter (LES)?

    <p>Maintains a high resting pressure to prevent reflux</p> Signup and view all the answers

    Killian’s Dehiscence is a site for Zenker’s diverticulum.

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

    What happens during primary peristalsis?

    <p>A propulsive wave pushes food down the esophagus.</p> Signup and view all the answers

    Which type of gastric carcinoid is characterized as low-grade malignant and differentiated?

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

    Adrenocortical carcinoma is most common in children.

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

    If the primary peristalsis fails, a __________ wave pushes the food down.

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

    What is the most common functional presentation of adrenocortical carcinoma?

    <p>Cushing's syndrome</p> Signup and view all the answers

    Which symptom is most commonly associated with foreign body in the esophagus?

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

    Match the following terms with their descriptions:

    <p>Dysphagia = Difficulty swallowing GERD = Gastroesophageal reflux disease Achalasia = Failure of esophageal sphincter to relax Stridor = Harsh, high-pitched breath sound</p> Signup and view all the answers

    The primary treatment for adrenocortical carcinoma involves _____ and chemotherapy.

    <p>open adrenalectomy</p> Signup and view all the answers

    Match the gastric carcinoid types with their histological patterns:

    <p>Type 1 = Benign, non-functional, well differentiated Type 2 = Benign or low-grade malignant, differentiated Type 3 = Low-grade malignant, differentiated Type 4 = Intermediate or small cell type, high grade malignant</p> Signup and view all the answers

    Button batteries should be observed if they traverse beyond C6 and are asymptomatic.

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

    What imaging technique is used to evaluate foreign body in the esophagus?

    <p>X-ray</p> Signup and view all the answers

    Which of the following tumors is characterized by small round blue cells in histopathology?

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

    Wilms' tumor typically presents with an abdominal mass that crosses the midline.

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

    What is the main treatment regimen for Wilms' tumor?

    <p>Chemotherapy with Etoposide and Cisplatin, followed by surgery.</p> Signup and view all the answers

    Carcinoid tumors arise from __________ cells.

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

    Match the following variables with their corresponding prognostic implications:

    <p>Stage 1 = Favorable Age &lt; 18 months = Favorable Stage 3 = Non-favorable N-MYC amplified = Non-favorable</p> Signup and view all the answers

    What is the primary management approach for malignant pheochromocytoma?

    <p>Surgery followed by chemotherapy</p> Signup and view all the answers

    Neuroblastoma is the most common abdominal malignancy in adults.

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

    What is the most common symptom presented in children with neuroblastoma?

    <p>Abdominal mass</p> Signup and view all the answers

    In cases of tachycardia associated with pheochromocytoma, it is recommended to add a __________.

    <p>β-blocker</p> Signup and view all the answers

    Match the following features associated with neuroblastoma:

    <p>Blueberry muffin lesions = Atypical metastasis N-myc amplification = Genetic feature Raccoon eyes = Atypical metastasis Crosses midline = Symptom of abdominal mass</p> Signup and view all the answers

    What is the primary surgical approach for localized stage malignancy?

    <p>Radical resection</p> Signup and view all the answers

    Appendiceal carcinoid tumors larger than 1 cm require right hemicolectomy.

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

    What is the aim of treatment for distant stage malignancy?

    <p>To avoid obstructive complications.</p> Signup and view all the answers

    A patient with an appendiceal carcinoid less than 1 cm has an __________ prognosis.

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

    Match the following disease stages with their respective surgical approaches:

    <p>Localized (I/II) = Radical resection Regional (III/NI) = Radical – Curative intent Distant (IV/MI) = Palliative resection</p> Signup and view all the answers

    Study Notes

    Tracheoesophageal Fistulae (TEF)

    • A/w: N-myc gene mutation.
    • Intra-uterine/Before birth: A/w polyhydramnios. Can be detected on prenatal scans.
    • After birth: Excessive drooling of saliva → on organic (OA) tube insertion. Respiratory distress.
    • Types:
      • Type A: Esophageal Atresia (EA)
      • Type B: Proximal TEF with distal EA
      • Type C: Proximal EA with distal TEF (m/c type)
      • Type D: Proximal and distal TEF
      • Type E: TEF without EA
      • Type F: Esophageal stenosis
    • Diagnosis:
      • Confirmatory test: Contrast Study (Iodexol > Dinosil)
      • IOC for Type H: Combined Tracheo-esophagoscopy
      • Esophagus: patent
      • X-ray: Stomach gas seen → Distal TEF
    • Additional Notes: Coiling of OA tube (Type C: m/c)

    Associated Anomalies (Mnemonic: VICTERL)

    • Vertebral defects
    • Anorectal malformations
    • Cardiac abnormalities
    • TE fistula
    • Renal
    • Limb abnormalities

    Waterston Criteria (Management of TEF)

    • Birth weight >2.5 kg & no pneumonia: Upfront surgery.
    • Birth weight 1.8 - 2.5 kg & +/- pneumonia: Antibiotic and weight building strategies before surgery.

    Corrosive Injury

    • Cause:
      • Alkali: D/t saponification; penetrates deeper, causing more damage.
      • Acid: Coagulation of proteins; does not penetrate as deep; more gastric damage; pylorospasm in stomach.
    • Management:
      • IV fluids
      • Avoid blind insertion of NG tube (can cause perforation)
      • No prophylactic antibiotics
      • Early & skilled endoscopy within 48 hrs (most important)
      • No role of steroids
      • Definitive Management:
        • Stricture management: Dilatation, Esophagectomy
        • Perforation: Emergency surgery
    • Grading of Injury:
      • Zargar's Classification:
        • Grade 0: Normal
        • Grade 1: Superficial edema/erythema
        • Grade 2: Mucosal/submucosal ulceration (superficial edema/erythema: 2, deep or circumferential: 2A)
        • Grade 3: Transmural ulcerations with necrosis (focal necrosis: 3, extensive necrosis: 3B)
        • Grade 4: Perforation
      • X-ray esophageal stricture shown on the right side.

    Esophageal Sphincters

    • Upper Esophageal Sphincter:
      • Anatomical (narrowing) & physiological (high pressure) entity
      • Length: 3-5 cm (abdominal length: 2-4 cm)
      • Parts:
        • Thyropharyngeus-Oblique Fibres
        • Cricopharyngeus-Horizontal Fibres
      • Killian's Dehiscence: Site for Zenker's diverticulum
    • Lower Esophageal Sphincter (LES):
      • Only physiological entity
      • Resting Pressure: 16-26 mmHg
      • Functions:
        • Frequent relaxation → GERD (gastroesophageal reflux disease)
        • Doesn't relax → Achalasia cardia

    Peristalsis

    • Primary Peristalsis: Propulsive wave that pushes food down.
    • Secondary Peristalsis: If primary peristalsis fails, then secondary wave pushes food down (Propulsive).
    • Tertiary Peristalsis: Non-propulsive wave in b/w meals; frequency increases with age.

    Disorders of Esophagus

    • Foreign Body (FB)
      • m/c in children.
      • Site:
        • Esophagus: C/F: Dysphagia
        • Respiratory tract/Trachea: C/F: Choking; O/E: Stridor
      • Management:
        • Ix: X-ray
        • Rx of Esophageal FB:
          • Impacted at C6 & symptomatic: Endoscopic removal
          • Traversed beyond C6 & asymptomatic: Observation
          • Button batteries: Endoscopic removal irrespective of site (corrode/perforate)

    X-ray Images (Foreign Body)

    • Coin in Trachea:

      • Side face on AP view
      • End face on AP view
      • End face on lateral view
      • Side face on lateral view

    • Coin in Esophagus:

      • Side face on AP view
      • End face on AP view
      • End face on lateral view
      • Side face on lateral view

    Surgical Anatomy

    • Constrictions of Esophagus:

      • U-upper incisor
      • 15 cm from U-upper incisor
      • 25 cm from U-upper incisor
      • 40 cm from U-upper incisor

    • Diaphragmatic Openings:

      • "I T 10 E G S AT 12"
        • T8: IVC, Phrenic N.
        • T10: Esophagus, Vagus, Lt.Gastric A.
        • T12: Aorta + Thoracic Duct.
      • Foreign body impaction: Most common site of iatrogenic esophageal perforation

    Blood Supply

    • Segmental in nature

    • Segment & Arteries and Veins:

      • Upper 1/3: Inferior thyroid artery, Inferior thyroid vein
      • Middle 1/3: Descending thoracic aorta, Bronchial artery, Azygous vein
      • Lower 1/3: Left gastric artery (involved in Mallory Weiss tear), Left gastric vein

    • Joins:

      • Portal circulation
      • Involved in liver metastasis
      • Site of porto-systemic shunts
      • Varices

    Lymphatics

    • Longitudinal spread
    • Skip metastasis
    • Esophagectomy
    • Long proximal margin (10 cm): Prevent recurrence

    Layers

    • Esophagus lacks serosa.
    • Strongest layer: Submucosa

    Carcinoid Tumors and Neuroendocrine Tumors

    • Distribution:

      • Appendix (m/c): 40%
      • Small bowel: 25%
      • Rectum: 15%
      • Lung: 10%
      • Colon: 6%
      • Stomach: 5%
      • Duodenum: a (Exact percentage not specified)

    • Carcinoid Tumors:

      • Arise from neuroendocrine cells.
      • New term: Neuroendocrine tumors.
      • Foregut: Lungs, Stomach (m/c mets: Bones)
      • Midgut: Small intestine, Appendix
      • Hindgut: Colon, Rectum

    • Carcinoid Syndrome:

      • Clinical features: Cutaneous flushing (m/c symptom), Pain (m/c symptom of abdominal carcinoids), Diarrhea, Weight loss. Carcinoid syndrome: When Serotonin enters systemic circulation. Bronchospasm, Right-sided valvular lesions (m/c tricuspid valve).
      • Investigations: Urine: 5 HIAA (hydroxy indole acetic acid: metabolite of Serotonin), Blood: Chromogranin A (Metabolized in the liver)
      • 10% of cases: Carcinoid syndrome present if liver mets (+)

    Gastric Carcinoids: Classification

    Type Histological pattern Causative factor and prognosis
    1 Benign, non-functional, well differentiated ECLomas in chronic atrophic gastritis, hypergastrinemia
    a Benign or low-grade malignant, differentiated ECLomas with hypergastrinemia as result of gastrinoma in MEN I
    3 Low-grade malignant, differentiated Sporadic ECLomas not related to hypergastrinemia
    4 Intermediate or small cell type, high grade malignant (neuroendocrine carcinoma) Causative factor unknown; prognosis poor

    Adrenocortical Carcinoma

    • Bimodal distribution: Children and 4th-5th decade.
    • Non-functional >> functional (Aggressive)
    • Features: Lump, Cushing's syndrome (m/c functional presentation), Pain.
    • Investigations: IOC: MRI > CECT.
    • mc Farlane classification: Based on size.
    • Management: Open adrenalectomy + Chemotherapy.

    Neuroblastoma

    • Most Common Abdominal Malignancy in Children: Neuroblastoma > Wilms' tumor
    • Features:
      • Arises from Adrenal medulla → Sympathetic chain
      • N-myc amplification (+)
      • Sporadic/Familial
    • Presentation:
      • Most common age: 5 years
      • Most common symptom: Abdominal Mass, crosses midline
      • 60-70% present with metastasis at diagnosis
    • Atypical Metastases:
      • Blueberry muffin lesions
      • Raccoon eyes (Swollen eyes + bruising)

    Neuroblastoma: Investigations and Histopathology

    • Investigations:
      • IOC → MRI → CT
      • Mets: MIBG scan
      • Rule out Wilms' tumor: Origin: Kidney, Abdominal mass: Does not cross midline, Calcifications +/-
    • Histopathology: Small round blue cells.

    Neuroblastoma: Prognostic Factors

    Variable Favourable Non-favourable
    Stage 1, 2A, 2B, 4S 3, 4
    Age < 18 months > 18 months
    N-MYC Not amplified Amplified

    Neuroblastoma: Management

    • Chemotherapy: Etoposide + Cisplatin
    • Surgery:
      • Mets: Aggressive management (Good survival chance)
      • Localized: Radical resection aiming for R0 resection (microscopic freedom from disease)
      • Regional: Radical resection aiming for R0 resection (microscopic freedom from disease)
      • Distant: Palliative resection (R1 resection, if applicable due to various factors)

    Appendiceal Carcinoid

    • m/c: Present at the tip of the appendix.
    • Can present as appendicitis.

    Appendiceal Carcinoid: Treatment

    • a. < 1 cm (excellent prognosis): Appendicectomy.
    • b. 1-2 cm: Treatment based on mitotic figures and Ki67.
    • c. > 2 cm: Right hemicolectomy, close to the base, in filtration of mesoappendix.

    Appendiceal Carcinoid: Investigative Imaging

    • CT scan
    • Serotonin/somatostatin receptor scintigraphy
    • High Ki-67
    • Dotatate PET scan is used for localizing and assessing malignancy/mets.

    Pheochromocytoma

    • Management:
      • Medical:
        • Phenoxybenzamine 10mg OD → Dosage increases until postural hypotension develops
        • If tachycardia (+): add β-blocker
        • If β-blocker given before α-blocker: unopposed α-agonist action → vasospasm and hypertensive crisis
      • Surgery:
        • Laparoscopic/Open adrenalectomy
        • Malignant pheochromocytoma: β-blocker → Open adrenalectomy → Chemotherapy
        • Adrenal vein clipped: Sudden hypotension
      • Prevention (Sudden Hypotension): Administer large amounts of IV fluids +/- vasopressors.

    Pheochromocytoma in Pregnancy

    • 1st and 2nd trimester: β-blocker → Surgery
    • 3rd trimester: β-blocker → Early delivery → Surgery

    Image Description

    • The image shows a Dotatate PET scan.

    • The scan displays a 2D image of a patient's body highlighting potential malignancy.

    • Several brightly colored spots (reddish or yellowish) on different organs or tissues highlight possible areas of increased metabolic activity often corresponding to cancerous tissue.

    • Abbreviations:*

    • mets: metastases

    • RI: Right hemicolectomy

    • R0: microscopic freedom from disease.

    • a: Exact percentage not specified.

    Studying That Suits You

    Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

    Quiz Team

    Description

    This quiz covers the important aspects of Tracheoesophageal Fistulae (TEF), including associated congenital anomalies, types, diagnosis methods, and management criteria. It summarizes the conditions, symptoms, and the Waterston Criteria for effective management of TEF, providing a comprehensive understanding for medical students and professionals.

    More Like This

    Use Quizgecko on...
    Browser
    Open
    Browser
    Browser