PANCE Exam: Surgery Review Questions & Answers

Question: How many days should sutures remain in the following areas: face, scalp, trunk, hands, back, and extremities?
Face: 3–5 days
Scalp: 5–7 days
Trunk: 7–10 days
Hands, back, and extremities: 10 days and 14 days if over a joint

Question: What is the onset of effect, duration, and maximum dose of the two most commonly used local anesthetics (LAs)?
Lidocaine: 2–5 minute onset of effects with a 1–2 hour duration. The maximum dose of 4.5 and 7 mg/kg if epinephrine is added.
Bupivacaine: 3–7 minute onset of effects with a duration of 90 minutes to 6 hours. The maximum dose is 2 and 3 mg/kg if epinephrine is added.

Question: What are the lines of Langerhans?
Lines of tension in the skin that incisions should follow when possible for the best cosmetic results. In the forehead, these lines run horizontally, while in the lower face they run vertically.

Question: Why is epinephrine added to local anesthesia?
To increase the duration of the anesthesia and provide hemostasis. Epinephrine causes vasoconstriction and therefore decreases bleeding and slows the systemic absorption of lidocaine.

Question: Which is more painful to the patient, plain lidocaine or lidocaine with epinephrine?
Lidocaine with epinephrine, because it has a very low pH. To avoid this pain, buffer the solution with sodium bicarbonate by adding 1 mL of sodium bicarbonate to 9 mL of lidocaine +/− epinephrine. The injection should be administered very slowly and subdermally.

Question: In what areas should you avoid the infiltrative administration of lidocaine with epinephrine?
Lidocaine with epinephrine should not be used on fingers, toes, ears, nose, or the penis because the limited vascularity in these regions might be compromised.

Where is a local anesthetic injected for an ulnar nerve block?
On the anterior wrist, in the proximal volar skin crease, between the ulnar artery and the flexor carpi ulnaris.

Question: Where is a local anesthetic injected for a median nerve block?
On the anterior wrist in the proximal volar skin crease, between the tendon of the palmaris longus and the flexor carpi radialis.

Question: What are the primary advantages of performing a digital nerve block?
Less anesthetic agent is required, better anesthetic effects are obtained, and the tissues do not become distorted.

Question: What nerve block is used to anesthetize of the sole of the foot?
Tibial nerve block. Tibial nerve block does not provide anesthesia to the lateral aspect of the heel and foot.

Question: What is the preferred route for anesthesia for deep lacerations of the anterior tongue?
Lingual nerve block.

Question: How should hair be removed prior to wound repair?
Clip the hair around the wound. A razor preparation can increase the infection rate.

Question: What three elements are common to a surgical infection?
An infectious agent, a susceptible host, and a closed, poorly perfused space.

Question: Define the term closure by primary intention:
Primary intention occurs when tissue is cleanly incised and reapproximated and repair occurs without complication. Primary healing is simpler and requires less time and material than secondary healing.

Question: What is meant when a wound is closed by secondary intention?
Secondary intention occurs in open wounds through formation of granulation tissue and eventual coverage of the defect by spontaneous migration of epithelial cells. Most infected wounds and burns heal in this manner.

Question: What is delayed primary closure?
When a wound is allowed to heal open under a carefully maintained, occlusive dressing for about 5 days and is then closed as if primarily. Such wounds are less likely to become infected than if closed immediately because their oxygen needs are better met.

Question: What components create the perfect host for a surgical wound infection?
Areas with or surrounded by poorly vascularized tissue and that have a natural space. The common denominators are poor perfusion, local hypoxia, hypercapnia, and acidosis. Some natural spaces with narrow outlets, such as those of the appendix, gallbladder, ureters, and intestines, are especially prone to becoming obstructed and then infected. The peritoneal and pleural cavities are potential spaces, and their surfaces slide over one another, thereby dispersing contaminating bacteria.

How long can a “clean” wound closure be delayed before proliferation of infection-causing bacteria develops?
6 hours, though the high vascularity of the face and scalp can allow for longer delays in these areas.

Question: What factors increase the likelihood of wound infection?
Dirty, contaminated wounds or wounds with retained foreign bodies. Stellate or crushing wounds, wounds longer than 5 cm, wounds older than 6 hours, and wounds in infection prone anatomic sites are at increased risk.

Question: A patient presents to your office after stepping on a nail that went right through the shoe and punctured the plantar aspect of the foot. What gram-negative organism would be most commonly involved in this type of injury?
Pseudomonas aeruginosa.

Question: Which has greater resistance to infection, sutures or staples?
There are no significant differences in the healing of wounds closed by suture or staples; however, staples do not provide a conduit for infective organisms thereby making them more resistant to infections.

Question: Which factors determine the ultimate appearance of a scar?
The wounds alignment, either parallel or perpendicular, to the skins tension lines. Static and dynamic tension on surrounding skin. Static tension refers to the width of the wound at rest. Dynamic tension is determined by determining the width of the wound during range of motion of the involved body part.

Question: Can tetanus develop after surgical procedures?
Yes. Although most cases of tetanus in the United States develop after minor trauma, there have also been reports of tetanus following general surgical procedures, especially those involving the abdomen and pelvis.

Question: What are the indications and contraindications to tetanus prophylaxis?
Consideration for prophylaxis should be made on every patient presenting with a wound, however slight. Patients with clean, minor, wounds should be considered for prophylaxis if their previous dose was taken more than 10 years ago. Prophylaxis should be considered for all other wounds if their previous dose was taken more than 5 years ago. The only contraindication to tetanus prophylaxis is a history of severe systemic reaction after a previous dose.

Question: How long should a repaired laceration need be kept out of the sun?
Patients should be instructed to keep the repaired area out of the sun during the time of healing, about 2–3 months, and also to cover the area with sunblock for the following 6–12 months. Sun exposure may case hyperpigmentation to the wound area.

Question: What organisms are most common in wound infections?
Staphylococcus, primarily S. aureus.

What is the most likely cause of a postoperative fever which occurs (1) the day after the operation (POD 1), (2) 3 days postoperative (POD 3), (3) 5 days postoperative (POD 5), (4) 7 days postoperative (POD 7), and(5) 2–3 weeks postoperative?

1. WIND: Atelectasis
2. WATER: Urinary tract infection (UTI)
3. WALK: Deep vein thrombosis (DVT)
4. WOUND: Postoperative infection
5. WONDER DRUGS: Hypersensitivity reaction most common caused by antibiotics

Mnemonic: Wind, Water, Walk, Wound, and Wonder drugs

Question: What gas is used to create a pneumoperitoneum during a laparoscopy? Why is this gas used? What are the associated risks?
Carbon dioxide (CO2). CO2 is noncombustible and has a high rate of diffusion, which results in a low risk of gas embolism. The use of CO2 can also result in tachycardia, increased central venous pressure, hypertension, decreased cardiac output, and occasionally, transient arrhythmias due to its rapid rate of absorption into the systemic circulation, which increases PCO2 and decreases pH. Alternative, and significantly less popular, gases include helium and argon.

Question: A 32-year-old female patient is under general anesthesia for a cholecystectomy. Part way into the operation her body tenses up, she develops tachycardia and a fever of 101.8°F. What anesthetic-related complication is she experiencing and what is the recommended treatment? This patient is suffering from malignant hyperthermia, a muscular response to general anesthetics that causes the release of calcium. A patient’s susceptibility to malignant hyperthermia may be established with the caffeine-halothane contracture test. Dantrolene may be used prophylactically or in the acute treatment of patient’s experiencing this complication. Its effects will inhibit the release of calcium while aiding in the prevention of acute renal failure.

Question: What is the maintenance IV fluid rate for a child weighing 30 kg?
The 100/50/20 rule would apply in this patient:
100 mL/kg/day for the first 10 kg + 50 mL/kg/day for the next 10 kg + 20 mL/kg/day for the next 10 kg. This child should receive 1700 mL/day at an IV flow rate of 71mL/h.

Question: What is the appropriate bolus for a dehydrated child weighing 15 kg?
The recommended IVFB for a child is calculated at 20 mL/kg.
20 mL × 15 kg = 300 mL

Question: What is the composition of sodium in normal saline and lactated ringers IV solutions?
Normal saline (0.9% sodium chloride) 154 mEq/L
Lactated ringers 130 mEq/L

Question: What solutes determine serum osmolality?
Sodium, chloride, bicarbonate, proteins, and glucose. To a much lesser extent magnesium, calcium, and potassium are also present.

What are the laboratory criteria for intubating patients and placing them on mechanical ventilation?
Room air PaO2 < 60 mm Hg or PacO2 > 45 mm Hg
Basing your decision to intubate on laboratory criteria alone is a critical error. The clinical indications of a respiratory rate > 36 breaths/min, labored respiratory efforts, the use of accessory muscles, and tachycardia are much more significant. The patient’s clinical status provides the primary indication for intubation.

Question: What negative pressure must be generated by an intubated patient for weaning to be successful?
At least 20–30 cm of H2O. Other important factors include Pao2, arterial saturation, pH, spontaneous respiratory rate, minute volume, tidal volume, and PEEP.

Question: What is the Whipple procedure?
Pancreaticoduodenectomy. The procedure involves resection of the distal stomach, pylorus, duodenum, proximal pancreas, and the gallbladder, plus a truncal vagotomy. The jejunum is then anastomosed to the stomach, biliary, and pancreatic ducts. This procedure is used for treating pancreatic, duodenal, ampulla of Vater, and common bile duct cancers.

Question: What are the Billroth I and II procedures?
Billroth I anastomosis is a gastroduodenostomy, and Billroth II is a gastrojejunostomy.

Question: What is the Roux-en-Y operative procedure?
An end-to-side anastomosis between the distal segment of small bowel and the stomach or esophagus. This forms a Y shape. This procedure is used in gastric bypass surgery for obesity and to treat reflux of bile and pancreatic secretions into the stomach secondary to ductal tumors, injury, obstruction, or infection.

Question: What fungal infection is most common in transplant patients?
Candida albicans.

Question: Differentiate between visceral and parietal pain:

Visceral pain: Diffuse and poorly localized pain caused by the stretching of a hollow viscus. It is frequently associated with autonomic nervous system responses.

Parietal pain: Sharp and localized pain due to irritation or inflammation of a parietal surface and associated with guarding, rebound, and a rigid abdomen.

Question: What is the most common cause of bleeding in postoperative patients?
Failure to achieve operative local hemostasis.

A fire victim suffers from partial and full thickness burns over the complete surface of both legs, his entire back, and his entire right arm. What percentage of his body is burned?
Follow the “rule of 9s”.
Anterior/posterior legs = 18% × 2 36%
Entire back = 18%
Entire right arm = 9%

TBSA 63%

Question: A patient who has been burned over the entire top of his body (arms and torso, front and back) develops severe difficulty breathing and appears to be going into respiratory arrest. What should be done?
An emergent escharotomy. The patient is most likely suffering ventilatory restriction due to the circumferential eschar about his chest resulting in constriction of the chest cavity. Anesthesia is rarely required when performing an escharotomies and frequently are performed at the bedside because of their emergent nature.

Question: What is the caloric requirement of a 100-kg firefighter who was burned over 20% of his body?
3300 kcal. (25 kcal/kg of body weight + 40 kcal/1% burned surface.)

Question: What is the 24-hour fluid resuscitation requirement for the above patient?
4 L in the first 8 hours (500 mL/h) and 4 L in the next 16 hours (250 mL/h). The Parkland formula gives the requirement as 4 mL per kg body weight X% burned (4 mL X of 100 kg X 20-8L). Give half the volume in the first 8 hours and the other half in the next 16 hours.

Question: What does an increase in pulmonary arterial wedge pressure indicate?
Fluid overload. Normal pulmonary wedge pressure is 4–12 mm Hg. Higher levels can indicate left ventricular failure, constrictive pericarditis, or mitral regurgitation with stenosis.

Question: What are the two most commonly injured genitourinary organs?
Kidneys and bladder.

Question: What should be checked prior to inserting a chest tube in an intubated patient with respiratory distress and decreased breath sounds on one side?
Position of the ET tube.

Question: A patient presents with fever and shoulder pain 4 days following a splenectomy. What is the most probable postoperative complication?
Subphrenic abscess. This condition can cause fever as well as irritation to the diaphragm and to the branch of the phrenic nerve that innervates it.

Question: What organisms are most commonly responsible for overwhelming postsplenectomy sepsis?
Encapsulated organisms: pneumococcal (50%), meningococcal (12%), E. coli (11%), H. influenza (8%), staphylococcal (8%), and streptococcal (7%).

What is a sentinel loop?
A distended or dilated loop of bowel detected by X-ray that lies near a localized inflammatory process.

Question: What is a delphian node?
A palpable node on the trachea, which is just above the thyroid isthmus. This is indicative of thyroid disease (malignancy or thyroiditis).

Question: Which types of nodules are more likely to be malignant on a thyroid scan, hot or cold?
Cold. These cells most commonly do not produce thyroid hormones and do not absorb iodine. This procedure should not be considered confirmatory and fine-needle aspiration (biopsy) is strongly suggested to obtain a diagnosis.

Question: What test should be performed to distinguish a benign cystic nodule from a malignant nodule?
Fine-needle aspiration with biopsy and cytological evaluation.

Question: Name the function and spinal innervation level of the biceps, triceps, flexor digitorum, interossei, quadriceps, extensor hallucis, biceps femoris, soleus and gastrocnemius, and rectal sphincter:


Question: What dose of methylprednisolone should be used to treat acute spinal cord injury?
30 mg/kg load over 15 minutes in the first hour, followed 45 minutes later by 5.4 mg/kg per hour over the next 23–47 hours.

Question: What is the sensory innervation to the nipple, umbilicus, and perianal region?
Nipple: T4
Umbilicus: T10
Perianal: S2–S4

What is the most common etiology of a solitary thyroid nodule?
A nodular goiter (50%). Other possibilities to consider include cancer (20%), adenoma (20%), cyst (5%), or thyroiditis (5%).

Question: Which nerve must be located and then avoided when performing a thyroidectomy?
The recurrent laryngeal nerves, which are located immediately posterior to the gland.

Question: What is the most common type of thyroid carcinoma?
Papillary carcinoma accounts for about 75% of thyroid carcinomas and statistically present with an excellent prognosis.

Question: A 15-year-old female adolescent comes to your office complaining of a mass in the midline of her neck near the hyoid bone. It is tender and raises when she swallows or if she sticks her tongue out. What is your diagnosis?
An infected thyroglossal duct cyst. This is a remnant from the embryological descent of the thyroid in the neck. Treatment includes antibiotics, drainage, then excision once the inflammation subsides if necessary.

Question: What is the most common benign salivary gland tumor?
Pleomorphic adenomas make up about 85% of these tumors.

Question: What is the most common type of malignant parotid gland tumor?
Mucoepidermoid carcinoma is the most common malignant tumor of the parotid gland, accounting for 30% of parotid malignancies

Question: What type of contrast medium should be used to evaluate the esophagus if a perforation is suspected?
Gastrografin (diatrizoate meglumine). This is an iodinated, water-soluble media that is not harmful in the presence of a mucosal tear.

Question: What are the most significant risk factors for esophageal cancer?
Age 65 or older, being male, smoking, heavy drinking of alcohol, diets low in the intake of fruits and vegetables, obesity, and acid reflux disease

Question: Cancer occurs more frequently in which third of the esophagus?
Adenocarcinoma of the distal esophagus is the most common form of esophageal cancer in the United States.

Question: Which other forms of cancer cell types may occur in esophagus?
Squamous cell carcinoma most frequently occurs in the proximal region of the esophagus and is less common in the United States but is the most common worldwide

Question: Which types of cancer metastasize to bone?
Prostate, thyroid, breast, lung, and kidney. (Remember the mnemonic: “P.T. Barnum Loves Kids.”)

What is Hamman sign?
This is associated with a tracheobronchial injury resulting in a pneumomediastinum or pneumopericardium. The sound is heard best over the left lateral position and has been described as a series of precordial crackles that correlate with the cardiac contraction and not respiration.

Question: What is the most common site of rupture in Boerhaave syndrome?
The left posterolateral wall of the lower third of the esophagus, 2–3 cm proximal to the gastroesophageal junction.

Question: What is the most common acute surgical condition of the abdomen?
Acute appendicitis.

Question: What is the most common cause of appendicitis?
Fecaliths. Fecaliths are found in 40% of uncomplicated appendicitis cases, 65% of cases involving gangrenous appendices that have not ruptured, and 90% of cases involving ruptured appendices

Question: How does retrocecal appendicitis most commonly present?
Dysuria, hematuria, and urinary frequency (due to the proximity of the appendix to the right ureter). Poorly localized abdominal pain, anorexia, nausea, vomiting, diarrhea, mild fever, and peritonitis are also common signs.

Question: Differentiate between McBurney point, Rovsing sign, the obturator sign, and the psoas sign:

McBurney point: Point of maximal tenderness in a patient with appendicitis. The location is two-thirds the way between the umbilicus and the iliac crest on the right side of the abdomen.

Rovsing sign: Palpation of LLQ causes pain in the RLQ.

Obturator sign: Internal rotation of a flexed hip causes pain.

Psoas sign: These signs are all indicative of an inflamed appendix. Extension of the right thigh causes pain.

Question: What kind of wound closure should be used in a patient with a perforated appendix?
Delayed primary closure with direct drainage of the infection. Wound infection occurs in 20% of patients with perforated appendices.

Question: A 27-year-old man who smokes heavily complains of tingling in his fingers. On examination he has cyanotic digits with ulcers forming. What is the diagnosis?
Thromboangiitis obliterans or Buerger disease. This is a disease that affects young smokers (males 20–40 years of age). Inflammatory changes (vasculitis) in the small- to medium-sized vessels cause constriction or occlusions.

Question: Where is the most common site of intracranial aneurysms?
The circle of Willis (most common in the anterior communicating artery.

Question: What are the clinical signs of CSF leakage?
A headache that improves when supine and worsens when sitting up, otorrhea, and rhinorrhea.

What is the most common type of brain tumor in adults?
Glioblastoma multiforme (40%). This is additionally the most aggressive (malignant) type of primary brain tumor in adults.

Question: What is the most common primary central nervous system tumor that arises in childhood.
Medulloblastoma.

Question: What are the most common microorganisms found in brain abscesses?

Direct extension—Sinus, odontogenic, and otogenic sources: Streptococcus species (aerobic and anaerobic), Bacteroides, Enterobacteriaceae, and Pseudomonas.

Hematogenous spread (Pathogens depend on predisposing source)
Endocarditis—Streptococcus viridans and Staphylococcus aureus
Pulmonary infections—Streptococcus, Fusobacterium, Corynebacterium, and Peptococcus species
Cardiac defects with right-to-left shunt—Streptococcus species
Intra-abdominal infections—Klebsiella species, E. coli, other Enterobacteriaceae, Streptococcus species, and anaerobes
Urinary tract infections—Enterobacteriaceae and Pseudomonas species
Wound infection—S. aureus

Penetrating head trauma
S. aureus is most commonly isolated.
Enterobacteriaceae, other gram-negative bacilli, S. epidermidis, Clostridium species, anaerobes, and Pseudomonas species may also be found.
Opportunistic infection (organ transplant, HIV, and immunodeficiencies). Common organisms include Toxoplasma gondii and Nocardia, Aspergillus, and Candida species.

Question: How many minutes of cerebral anoxia will result in irreversible brain injury?
Greater than 4–6 minutes.

Question: Match the following terms with their definitions:

Question: You detect hard mass in the upper outer quadrant of the right breast of a 45-year-old woman. What are the next steps?
Mammogram followed by a biopsy. The options for biopsy are as follows:

Fine-needle aspiration with cytology—Easily performed, inexpensive, false negative rate ~10%

Large-needle (core) biopsy—Cost-effective, office-based procedure with false negative rates secondary to sampling errors

Open biopsy—Reliable means of diagnosis when previous attempts are nondiagnostic; performed with local anesthetic through an open incision

What is the most common histologic type of breast cancer?
Infiltrating ductal carcinoma (80%–90%) with subtypes: medullary, colloid, papillary, and tubular.

Question: A 30-year-old woman comes to you worried that she has breast cancer in both breasts. She is concerned because she experiences soreness in the upper outer quadrants of her breasts and what she describes as “lumpy” feeling upon self-examination with a mild swelling that seems to come and go. Further questioning reveals that her pain begins 1 week before she menstruates then disappears when her menses is over. What do you tell her?
She most likely has fibrocystic breast changes but these are frequently clinically indistinguishable from carcinoma. First, provide her reassurance and let her know that fibrocystic changes are not a premalignant syndrome. Secondly, schedule her for a mammogram with plans to perform fine-needle aspiration of suspicious lesions.

Question: Which is the most common type of noncystic breast tumor?
Fibroadenomas. These are most common in women younger than 25 years and presents as round, rubbery, mobile, nontender masses of 1–5 cm in diameter.

Question: What does a high cathepsin D level indicate in a woman with breast cancer?
These levels serve as an independent prognostic indicator and have been shown to be related to an increased risk of metastasis.

Question: What is the most aggressive form of lung cancer and most likely to be involved in metastasis?
Small-cell lung cancer comprises about 15%–20% of lung cancers and is the most aggressive form of the disease. It frequently metastasizes to the liver, bone, and brain.

Question: What is Westermark sign?
Decreased vascular markings on chest X-ray, indicative of pulmonary embolism.

Question: What do muffled heart tones, hypotension, and distended neck veins indicate?
This is Beck triad and is classic for pericardial tamponade.

Question: What is the most common kidney tumor in a child’s first year of life?
Wilms tumor (nephroblastoma).

Question: What is the average age for pediatric patients to develop Wilms tumor?
Peak occurrence is at 3 years and it is rare after 8 years of age. Children with a localized tumor have a 90% cure rate when treated with surgery and chemotherapy; or with surgery, radiation, and chemotherapy combined.

Question: One to two percent of patients with Wilms tumor will develop secondary malignancies. Which types are most common?
Hepatocellular carcinoma, leukemia, lymphoma, and soft tissue sarcoma.

What are Grey-Turner and Cullen signs?

Cullen sign: Periumbilical ecchymosis indicative of intraperitoneal hemorrhage, first recognized in patients experiencing a ruptured ectopic hemorrhage.

Grey Turner sign: Flank ecchymosis that develops in 24–48 hours, and is indicative retroperitoneal or intraabdominal hemorrhage. This is most commonly associated with severe acute pancreatitis, abdominal aortic aneurysm, abdominal trauma, and ruptured ectopic pregnancies.

Question: Serum amylase is frequently elevated in acute pancreatitis. What other conditions can cause a similar rise in amylase?
Bowel infarction, cholecystitis, mumps, perforated ulcer, and renal failure. Lipase is more specific to pancreatic etiologies.

Question: What are the most common causes of pancreatitis?
Alcoholism (40%) and gallstone disease (40%). Additional causes pancreatitis are due to hypercalcemia, hyperlipidemia, iatrogenic pancreatitis, and protein deficiency.

Question: Name some abdominal X-ray findings associated with acute pancreatitis:
Approximately two-thirds of patients will have an abnormal abdominal radiograph. The most common finding is the presence of a sentinel loop (either of the jejunum, transverse colon, or duodenum). Additionally a colon cutoff sign, an abrupt cessation of gas in the mid or left transverse colon due colonic spasm secondary to inflammation of the adjacent pancreas.

Question: What are Ranson criteria?
A means of estimating the severity and prognosis for patients with acute pancreatitis.

Criteria at initial presentation:
Age > 55 years
LDH > 350 IU/L
WBC > 16,000/mm3AST > 250 UI/L
Serum glucose > 200 mg/dL

Criteria developing during first 24 hours:
Hematocrit falling > 10%
Increase in BUN > 8 mg/dL
Serum Ca+ < 8 mg/dL
Arterial PO2 < 60 mm Hg
Base deficit > 4 mEq/L
Fluid sequestration > 6L

Morbidity and mortality:
0 to 2 criteria = 2% mortality
3 to 4 criteria = 15% mortality
5 to 6 criteria = 40% mortality
7 to 8 criteria = 100% mortality

What is the most common cause of pancreatic pseudocysts in children and adults?
Children: The etiology for pancreatitis in children is widely varied with abdominal trauma being the most common case at 23% of the cases. Additionally, anomalies of the pancreaticobiliary system (15%), multisystem disease (14%), drugs and toxins (12%), viral infections (10%), hereditary disorders (2%), and metabolic disorders (2%) are also involved in this etiology.

Adults: Acute pancreatitis secondary to alcoholism or gallstone disease are the most common etiologies.
Pseudocysts are generally filled with fluid and pancreatic enzymes that arise from the pancreas and should be suspected in patients who fail to improve within 1 week of appropriate treatment.

Question: What is the treatment for pancreatic pseudocysts?
In the absence of symptoms and radiographic evidence of enlargement expectant management for the first 6–12 weeks is recommended. The spontaneous resolution is expected in 40% of these cases. For pseudocysts greater than 5 cm or those that persist greater than 12 weeks treatment with percutaneous catheter drainage or surgical drainage into the stomach or intestine is recommended.

Question: A 44-year-old gentleman presents with a deep, dull pain in the center of his abdomen that radiates to his back and will not go away. He states he has not “felt like himself” for a few weeks and that he has been kind of depressed. He also notes that he has lost a lot of weight, about 30 pounds in 3 weeks. On physical examination you notice that he has mild jaundice, a palpable hepatomegaly, and an abdominal mass in the epigastrium. What is your diagnosis?
This presentation is classic for carcinoma of the head of the pancreas. The ability to palpate a mass suggests surgical incurability secondary to advanced disease progression.

Question: Where is the most common anatomic and histologic location of pancreatic cancer?
Head of the pancreas (66%–75%). Pancreatic cancer is generally adenocarcinoma and located in the ducts.

Question: What gender and age group most commonly presents with pancreatic cancer?
Middle-aged men, 35–55 years of age.

Question: What is the overall 5-year survival rate for pancreatic carcinoma?
10%: However only 60% of these patients have had a complete tumor resection. Patients with metastatic pancreatic cancer who have symptoms of weight loss or pain, the chance of surviving 1 year is less than 20% for those undergoing chemotherapy and less than 5% for those who choose not to receive chemotherapy.

Question: What is Courvoisier law?
This states that in the presence of (obstructive) jaundice if the gallbladder is palpable, then the jaundice is unlikely to be due to gallstones.

Question: What is the most common endocrine tumor of the pancreas?
An insulinoma, only 10% are malignant. The classic diagnostic criteria is “Whipple triad”:
1. Hypoglycemic symptoms produced by fasting
2. Blood glucose < 50 mg/dL during symptomatic episodes
3. Relief of symptoms with administration of IV glucose

Where do Glucagonomas arise?
A glucagonoma is a rare neuroendocrine tumor with nearly exclusive pancreatic localization. Malignant glucagonomas are islet cell pancreatic tumors that originate from the alpha-2 cells of the pancreas.

Question: Which type of operation is associated with a higher incidence of common bile duct injury, laparoscopic cholecystectomy or conventional cholecystectomy?
Laparoscopic.

Question: What is the typical size of an adrenal carcinoma when diagnosed?
The mean diameter is 12 cm with an average range of 3–30 cm.

Question: What compounds are produced by a Pheochromocytomas?
Catecholamines. This group of chemicals trigger an increase in blood pressure, perspiration, heart palpitations, anxiety, and weight loss.

Question: If vanillylmandelic acid, normetanephrine, and metanephrine are detected in the urine, what is the likely cause?
Pheochromocytoma.

Question: Where are the majority of pheochromocytomas located?
90% are found in the adrenal medulla.

Question: What is the pheochromocytoma rule of 10s?
10% are malignant; 10% are multiple or bilateral; 10% are extra-adrenal; 10% occur in children; 10% recur after surgical removal; 10% are familial.

Question: What is the most common benign liver tumor?
Hemangioma is the most common benign tumor affecting the liver and are composed of masses of blood vessels that are atypical or irregular in arrangement and size

Question: All types of hepatomas are associated with underlying liver disease except:
Fibrolamellar hepatocellular carcinoma, or fibrolamellar carcinoma, is an uncommon malignant neoplasm of the liver.

Question: Hepatic cancer most commonly metastasizes to where?
The lungs (bronchiogenic carcinoma).

Question: What is the 5-year survival rate for patients with liver cancer who present with a single tumor less than 5 cm in diameter and undergo transplant surgery?
70%.

Where will colorectal cancer most commonly metastasize?
The liver and the lungs.

Question: Alpha-fetoprotein (AFP) will be elevated in which types of tumors?
Primary hepatic neoplasms and testicular tumors.

Question: What is the most common cause of portal hypertension?
Cirrhosis (85%) secondary to heavy alcohol use. The second most common cause is extrahepatic portal venous thrombosis or occlusion.

Question: What are the most commonly isolated organisms in pyogenic hepatic abscesses?
E. coli, Klebsiella pneumoniae, Proteus vulgaris, and Enterobacter aerogenes most commonly as a result of ascending cholangitis secondary to biliary obstruction.

Question: What clinical sign can assist in the diagnosis of cholecystitis?
Murphy sign: pain on inspiration with palpation of the RUQ. As the patient breaths in, the gallbladder is lowered in the abdomen and comes in contact with the peritoneum just below the examiner’s hand. This will aggravate an inflamed gallbladder, causing the patient to discontinue breathing deeply.

Question: What is the difference between cholelithiasis, cholangitis, cholecystitis, and choledocholithiasis?
Cholelithiasis: Gallstones in the gallbladder.
Cholangitis: Inflammation of the common bile duct often secondary to bacterial infection or choledocholithiasis.
Cholecystitis: Inflammation of the gallbladder most commonly as a result of gallstones.
Choledocholithiasis: Gallstones that have migrated from the gallbladder to the common bile duct.

Question: What percentage of people with gallstones will eventually require surgery?
About 30%.

Question: Which ethnic group has the largest proportion of people with symptomatic gallstones?
Native Americans and Mexican American populations.

Question: What percentage of patients with cholangitis are also bacteremic?
25%–40% of patients may present with or develop fever, chills, or rigors.

Question: What is the diagnostic test of choice for a patient suspected of having gallstones?
Ultrasound is the diagnostic procedure of choice and is very sensitive at seeing abnormalities in the biliary system, including stones or signs of inflammation or infection.

Question: What is the most common etiology of cholecystitis?
Obstruction of the cystic duct secondary to cholelithiasis.

What is Charcot triad?
1. Fever
2. Jaundice
3. Abdominal pain
*Hallmark of acute cholangitis.

Question: What is Reynolds pentad?
Charcot triad plus hypotension and mental status changes.
*Hallmark of acute ascending cholangitis.

Question: What are the majority of gallstones composed of?
Cholesterol stones are more common in the United States, making up about 80% of all gallstones. They form when there is too much cholesterol in the bile. The remaining are pigmented stones that form when there is excess bilirubin in the bile.

Question: What are the majority of kidney stones made of?
Calcium oxalate (60%). The remainder consists of uric acid, struvite, cystine, and calcium phosphate.

Question: What percentage of patients with cancer of the gallbladder will also have cholelithiasis?
75%–90% of patients diagnosed with gallbladder cancer will have cholelithiasis.

Question: What is the diagnostic test of choice for acute cholecystitis?
Biliary scintigraphy (hydroxy iminodiacetic acid (HIDA) scan) is the gold standard. The HIDA scan uses a gamma-ray–emitting isotope that is selectively extracted by the liver into bile. The labeled bile can then be used to determine if there is cystic duct obstruction or extrahepatic bile duct obstruction, which is based whether the bile fills the gall bladder or enters the intestine. Clinically the diagnosis is most commonly made using clinical impressions, CBC, and RUQ ultrasound.

Question: How effective is oral dissolution therapy with bile acids for patients with symptomatic gallstones?
Oral therapy with bile acids can be administered in monotherapy or in combination therapy with bile acids having different mechanisms of action. Monotherapy has shown results of complete dissolution in 19%–37% of patients while combination therapy provided complete dissolution in 63% of patients. The expected dissolution rate is approximately a 1-mm decrease in stone diameter per month of treatment and is assessed by ultrasound every 3–6 months. Common side effects with this treatment are diarrhea, increased serum cholesterol levels, and possible hepatotoxicity.

Question: What are the contraindications to extracorporeal shockwave lithotripsy (ESWL) lithotripsy?
Absolute contraindications include
acute urinary tract infection or urosepsis
uncorrected bleeding disorders or coagulopathies
pregnancy
uncorrected obstruction distal to the stone

What is the most common major complication associated with laparoscopic cholecystectomy?
Bile duct injury.

Question: Is it possible for gallstones to form in patients’ S/P cholecystectomy?
Yes. Stones may form as a result of bile backing up in the duct and a narrowing of the duct after surgery.

Question: Where is the most common site for fibromuscular dysplasia?
The renal arteries. Fibromuscular dysplasia is a rare arterial disease that presents in 4/1000 people and is more common in women than men.

Question: Where is the most common site of a hernia?
Inguinal (groin) hernia: Making up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect.

Question: Do infants and children most commonly present with direct or indirect inguinal hernias?
Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. If this pathway does not close it may remain a possible site for a hernia to develop in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age.

Question: Differentiate between reducible, incarcerated, strangulated, Richter, and complete hernias:
Reducible: An uncomplicated hernia which returns, either spontaneously or after manipulation, to its original site.
Incarcerated: Contents of the hernia sac cannot be returned to the abdomen by manipulation.
Strangulated: An incarcerated hernia so tightly constricted as to compromise the blood supply of the hernial sac, leading to gangrene of the sac and its contents.
Richter: An incarcerated or strangulated hernia in which only part of the circumference of the bowel wall is involved.
Complete: A hernia in which the sac and its contents have passed through the hernial orifice.

Question: What are the boundaries of Hesselbach triangle?
Medial to the inferior epigastric artery, superior to the inguinal ligament, and lateral to the rectus sheath. Hesselbach triangle is the site through which direct hernias pass.

Question: What weakened tissue does a direct hernia pass through?
The transversalis fascia that makes up the floor of Hesselbach triangle.

Question: Indirect inguinal hernias occur secondary to what defect?
A failure of embryonic closure of the internal inguinal ring after the testicle has passed through it. This forms a temporary connection called the process vaginalis, which the resulting hernia can then pass through.

Question: Which type of hernia is most common in females?
Males are 25 times more likely to develop a hernia but in females the direct inguinal hernia is the most common. While femoral hernias are more common in females than in males, they are still less common than direct hernias.

Of all hernias involving the abdominal wall, which is most likely to strangulate?
Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible and strangulated.

Question: What type of hiatal hernia is most common, sliding or paraesophageal?
A sliding hiatal hernia where the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus.

Question: Where is the most common site of duodenal ulcers?
The first portion of the duodenum (duodenal bulb) accounts for 95% of duodenal ulcers.

Question: What is the most common site for benign gastric ulcers?
The most common site is the lesser curvature of the stomach; however, they can occur anywhere. Malignant ulcers usually have irregular heaped-up margins that protrude into the lumen of the stomach.

Question: What are the signs and symptoms of intestinal obstruction in the newborn?
Signs and symptoms of newborn proximal bowel obstruction can be subtle and nonspecific; however, the most common presentation in distal obstruction involves abdominal distention, delayed passage of meconium, and absence of transitional stools (meconium mixed with normal stool content).

Question: What amount of residual volume suctioned from the stomach of a newborn is diagnostic of obstruction?
> 25–40 mL.

Question: A newborn’s vomit will be stained with bile if the obstruction is distal to what anatomical structure?
The ampulla of Vater.

Question: What is the differential diagnosis for neonatal intestinal obstruction?

Disorders of the small intestine:
Duodenal atresia
Jejunoileal atresia
Malrotation and volvulus
Meconium ileus

Disorders of the large intestine:
Meconium plug syndrome
Anorectal malformation
Hirschsprung disease
Small left colon syndrome

Other causes:
Narcotics
Electrolyte abnormalities; hypermagnesemia, hypokalemia, hypercalcemia
Hypothyroidism
Sepsis
Congestive heart failure

Where is the most prevalent location for atresia of the bowel?
The duodenum (40%) is twice as common as in the jejunum (20%) and ileum (20%). In nearly half of all cases multiple congenital anomalies are present (Down Syndrome, being the most common).

Question: What is the “double bubble” sign?
The appearance of a distended stomach and duodenum on the X-ray of a patient with duodenal obstruction. This is classically seen in duodenal atresia of the newborn.

Question: What is the most common cause of bowel obstruction in children?
Intussusception is the most common cause of intestinal obstruction in infants and children aged 3 months to 6 years.

Question: What are the most common causes of small bowel obstruction in adults?
The most common causes of mechanical obstruction are adhesions, hernias, and tumors.

Question: Volvulus of the colon most frequently involves which segment?
The sigmoid colon is the most common site for colonic volvulus (65%) occurring often in patients older than 60 years, with a history of chronic constipation.

Question: Where is the most common site of intestinal obstruction secondary to gallstones?
Gallstone Ileus occurs in the terminal ileum in 55%–60% of patients. A clinical presentation involves Rigler triad of pneumobilia, small bowel obstruction, and impacted gallstones at the ileocecal valve.

Question: What is the differential diagnosis for a 65-year-old man who has abdominal pain and bloody diarrhea a few days after the repair of an abdominal aortic aneurysm?
Ischemic colitis is the most likely condition. The most common etiology resulting in this condition is diminished bowel perfusion resulting from low cardiac output and is often seen in patients with cardiac disease or in patients with prolonged shock of any etiology.

Question: Is colovesicular fistula more common among men or women?
Men (3:1) more than women because a woman’s uterus lies between her colon and bladder. This is condition is occasionally seen in women S/P hysterectomy.

Question: What is Osler-Weber-Rendu syndrome?
Also known as hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder typically identified by the triad of telangiectasia, recurrent epistaxis, and a positive family history for the disorder. The major cause of morbidity and mortality due to this disorder lies in the presence of multiorgan arteriovenous malformations (AVMs) and the associated hemorrhage that may accompany them.

Question: How much blood must be lost in the GI tract to cause melena?
Between 50 and 100 mL. Normal healthy patients lose 2.5 mL of blood per day in their stools.

What are the most common causes of upper GI bleeding?
Peptic ulcer disease (PUD), esophageal varices, gastritis, and Mallory-Weiss syndrome account for 90% of all etiologies.

Question: What percentage of patients with upper GI bleeds will stop bleeding within hours of hospitalization?
About 85% of UGIB will spontaneously stop bleeding within a few hours.

Question: What are the most common causes of rebleeding in patients with upper GI bleeds?
PUD, esophageal varices, amenia, or shock. Most cases of rebleeding occur within 2 days from the time of the first episode.

Question: What percentage of patients with PUD bleed from their ulcers?
About 20%, which result in 40% of the deaths related to this condition.

Question: Bleeding ulcers are more predominant in patients with which blood type?
Type O. The reason is not known.

Question: Where are bleeding duodenal ulcers most commonly located?
On the posterior surface of the duodenal bulb.

Question: How soon after an episode of duodenal bleeding has occurred can an ulcer patient be fed?
12–24 hours after the bleeding has stopped in a patient that feels hungry.

Question: Which type of ulcer is more likely to rebleed?
Gastric ulcers are three times more likely to rebleed compared to duodenal ulcers.

Question: What is the surgical treatment of choice for a bleeding peptic ulcer?
Oversewing the ulcer combined with a bilateral truncal vagotomy and pyloroplasty. Other treatments are proximal gastric vagotomy and Billroth II gastrojejunostomy. The decision to perform surgery is based on the rate of bleed, not on the location of the bleed.

Question: What percentage of patients with large intestinal bleeding will spontaneously stop before transfusion requirements exceed two units?
90%.

Question: If blood is recovered from the stomach after an NG tube is inserted, where is the most likely location of the bleed?
A site above the ligament of Treitz (Upper GI Bleed).

Question: Where do the majority of Mallory-Weiss tears occur?
In the stomach (gastric cardia), the esophagogastric junction, and the distal esophagus (5%).

What is angiodysplasia and where is it most frequently found?
It is an acquired condition of focal submucosal vascular ectasia that has a propensity to bleed spontaneously. Most frequently it is located in the cecum and proximal ascending colon. Lesions are generally singular; bleeding is intermittent and seldom massive.

Question: What is the major cause of death in patients with Hirschsprung disease?
Nonbacterial/nonviral enterocolitis.

Question: Is Hirschsprung disease more common in men or women?
Men (4:1 men-to-women-ratio).

Question: Are tumors located in the jejunum and ileum more likely malignant or benign?
Benign. Tumors of the jejunum and ileum comprise only 1%–5% of all GI tumors. The majority (90%) are asymptomatic.

Question: What is the most common remnant of the omphalomesenteric (vitelline) duct?
Meckel diverticulum.

Question: What is the Meckel diverticulum rule of 2s?
2% of the population has it; it is 2 inches long; 2 feet from the ileocecal valve; occurs most commonly in children under 2; and is symptomatic in 2% of patients.

Question: What is the most likely cause of rectal bleeding in a patient with Meckel diverticulum?
Peptic ulceration of the adjacent ileum caused by ectopic gastric mucosa.

Question: What is the most likely cause of cellulitis of the umbilicus in a pediatric patient with an acute abdomen?
A perforated Meckel diverticulum.

Question: What is the difference in the prognosis between familial polyposis and Gardner disease?
Although both are inheritable conditions of colonic polyps, Gardner disease rarely results in malignancy, while familial polyposis virtually always results in malignancy.

Question: Clinically, how is right-sided colon cancer differentiated from left-sided?
Right-sided lesions present with occult blood in the feces, unexplained weakness or anemia, dyspepsia, palpable abdominal mass, and dull abdominal pain.
Left-sided lesions present with gross rectal bleeding, obstructive symptoms, and noticeable changes in bowel habits with the common presentation of “Pencil thin” stools.

Question: Adenocarcinoma develops from adenomatous polyps. What percent of asymptomatic patients have adenomatous polyps when a routine colonoscopy is performed?
25% with the prevalence increasing with age: At age 50: 30%, age 60: 40%; age 70: 50%; and age 80: 55%.

The advancement to adenocarcinoma of the colon from adenoma is significantly related to the size of the adenoma. What is the risk of developing cancer if a 1.5 cm polyp is found upon colonoscopic examination?
10%. The risk for developing adenocarcinoma is 1% if the polyp is less than 1 cm, 10% if it is 1 to 2 cm, and 45% if the polyp is greater than 2 cm.

Question: Is a villous, tubulovillous, or tubular adenoma more likely to become malignant?
40% of villous adenomas will become malignant, compared to 22% of tubulovillous adenomas and 5% of tubular adenomas.

Question: Which are more likely to turn malignant, pedunculated or sessile lesions?
Sessile lesions are more likely to become malignant.

Question: Where are the majority of colorectal cancers found?
In the rectum (30%), ascending colon (25%), sigmoid colon (20%), descending colon (15%), and transverse colon (10%).

Question: What is the surgical treatment of choice for cecal cancer?
Colonic resection from the vermiform appendix to the junction of the ascending and transverse colon.

Question: What is the treatment of choice for a plantar wart?
Cryosurgery with liquid nitrogen. Additional options include electrodesiccation and curettage, surgical excision, and laser therapy.

Question: Where are soft tissue sarcomas most often found?
About 60% occur in the arms, legs, hands, or feet.

Question: A 41-year-old patient complains of severe but short rectal spasms but has not noticed any bleeding. He is known to be stressed and overtaxed at work. What is your diagnosis?
Proctalgia fugax. Proctalgia fugax is transient, severe rectal pain related to spasm of levator ani and coccygeal muscles that may last seconds or up to 20 minutes.

Question: A patient complains of severe pain when defecating. He is constipated, has blood-streaked stools, and a bloody discharge following bowel movements. What is the diagnosis?
Anal fissure.

Question: Differentiate between mucosal rectal prolapse, complete rectal prolapse, and occult rectal prolapse:
Mucosal rectal prolapse: Involves only a small portion of the rectum protruding through the anus and have the appearance of radial folds.
Complete rectal prolapse: Involves all the layers of the rectum protruding through the anus. Clinically, this condition appears as concentric folds.
Occult rectal prolapse: Does not involve protrusion through the anus but rather intussusception.

Which are more painful, internal or external hemorrhoids?
External. The nerves above the pectinate or dentate line are supplied by the autonomic nervous system and have no sensory fibers. The nerves below the pectinate line are supplied by the inferior rectal nerve and have sensory fibers.

Question: Differentiate between first-, second-, third-, and fourth-degree internal hemorrhoids:
Classification is based upon the following history:

First degree: Presence of only bleeding
Second degree: Bleed and prolapse but reduce spontaneously
Third degree: Bleed, prolapse, and require manual reduction
Fourth degree: Bleed, cannot be reduced, and may strangulate

Question: What portion of the colon most common presents with diverticular disease?
The sigmoid colon is involved in 95% of patients.

Question: What percentage of patients with diverticula are symptomatic?
20% and most commonly diagnosed by barium enema radiography or endoscopic procedures.

Question: What percentage of 40 year olds will have diverticula?
10% and 65% will have diverticular by the age of 80.

Question: What are the signs and symptoms of diverticulitis?
Abdominal pain, generally in the left lower quadrant with significant tenderness to palpation, a low-grade temperature, change in bowel habits, nausea, and vomiting. If perforated, patients may have peritoneal signs and appear toxic.

Question: What is the treatment for diverticulitis?
Specific details of the treatment depend upon the severity of the patient’s condition. Generally patients are hospitalized, made NPO, NG tube placed to suction, IV fluids are initiated with broad-spectrum IV antibiotics.
Surgical treatment should be considered for patients who do not improve with medical therapies or develop signs of peritonitis.

Question: Ulcerative colitis has two peaks of incidence. When do they occur?
The most significant peak is in the second (15–30 years old) decade. A second lower peak occurs during the sixth to eigth decades of life.

Question: What are some extraintestinal manifestations of ulcerative colitis?
Lesions of the skin and mucus membranes: Erythema nodosum, erythema multiforme, pyoderma gangrenosum, pustular dermatitis, and aphthous stomatitis.
Ocular: Uveitis.
Bone and joint lesions: Arthralgia, arthritis, and ankylosing spondylitis.
Hepatobiliary and pancreatic lesions: Fatty infiltration, pericholangitis, cirrhosis, sclerosis cholangitis, bile duct carcinoma, gallstones, and pancreatic insufficiency.
Hematologic: Anemia (Most commonly iron deficiency anemia).

Kultschitzsky cells are the precursors to what tumor?
Carcinoid tumors arise from Kultschitzsky cells, granular cells within the intestinal and bronchial.

Question: What is the most probable cause of colovesicular fistulas?
Diverticulitis.

Question: A 47-year-old man complains of impotence as well as pain and coldness in both legs after exercise. What would you expect to find on examination?
This patient probably has Leriche syndrome, which is a vascular disorder marked by gradual occlusion of the terminal aorta, bilateral iliac arteries, or both; intermittent claudication in the buttocks, thighs, or calves; absence of pulsation in femoral arteries; pallor and coldness of the legs; gangrene of the toes; and, in men, impotence. Symptoms are the result of chronic tissue hypoxia caused by inadequate arterial perfusion of the affected areas.

Question: What is the most commonly obstructed artery in the lower extremity? The superficial femoral, which is a branch of the common femoral.

Question: A 64-year-old man presents with jaundice, upper GI bleeding, anemia, a palpable nontender gallbladder, a palpable liver, and rapid weight loss. What is your initial diagnosis and what confirmatory test would you order?
This is the clinical picture of a tumor of the ampulla of Vater and the results of an ERCP would demonstrate the tumor as an exophytic papillary lesion, an ulcerating tumor, or an infiltrating mass. You would also expect to identify dilation of the biliary and pancreatic ducts.

Question: Testicular torsion occurs most commonly in what age group?
Teens with the left testicle most commonly involved.

Question: What is the maximum amount of time a testicle can remain torsed without being irreversibly damaged?
4–6 hours.

Question: What is definitive treatment for testicular torsion?
Medical: The “Open Book Maneuver.”
Surgical: Emergent surgical scrotal exploration.

Question: What percentage of palpable prostate nodules are malignant?
Nearly 50%. Surgical cure of patients who present with asymptomatic nodules and no metastasis is attempted with radical prostatectomy or radiation therapy.

Question: What are mycotic aneurysms?
A mycotic aneurysms is a localized, irreversible arterial dilatation due to destruction of the vessel wall by infection. A mycotic aneurysm can develop either when a new aneurysm is produced by infection of the arterial wall or when a preexisting aneurysm becomes secondarily infected.

Where is mesenteric ischemia more serious, in the small or the large bowel?
The small bowel. Embolization in the superior mesenteric artery affects the entire small bowel with mortality from small bowel ischemia being nearly 60%. Embolization to the large bowel is not as serious due to collateral circulation and ischemia of the large bowel rarely result in a full thickness injury or perforation.

Question: Where do glomus tumors develop?
Glomus jugulare tumors are rare, slow-growing, hypervascular tumors that arise within the jugular foramen of the temporal bone.

Question: What is an ABI, and why is it significant?
The ankle-brachial index (ABI) is a quick screening test used to evaluate peripheral vascular disease or traumatic arterial injury. It consists of measuring the resting systolic BP in the brachial artery and comparing it to the resting systolic BP in the posterior tibial or dorsalis pedis arteries of the lower extremity. The ABI is calculated by dividing the LE systolic BP by the brachial artery BP. A normal ABI is 1 or greater while a value of less than 1 indicates occlusive disease or arterial injury.

Question: What technical factors can affect the accuracy of the ABI?
Doppler probe pressure, rapid deflation of the BP cuff, and arterial wall calcifications.

Question: Cricothyroidotomy is not recommended in children under what age?
Children younger than 10–12 years old pose a relative contraindication to this procedure.

Question: Is succinylcholine a depolarizing or a nondepolarizing neuromuscular blocking agent?
Depolarizing. Succinylcholine is the only commonly used depolarizing agent. It binds to postsynaptic acetylcholine receptors, thereby causing depolarization. The material is enzymatically degraded by pseudocholinesterase (serum cholinesterase). Onset is within 1 minute; paralysis last 7–10 minutes. The recommended adult dose is 1–2 mg/kg.

Question: What is the rationale for pretreating a patient with a subpolarizing (defasciculating) dose of a nondepolarizing agent prior to treatment with succinylcholine?
This primarily reduces the fasciculations secondary to succinylcholine-induced depolarization. Additionally it may also be helpful in decreasing intracranial and intraocular pressure is associated with the administration of succinylcholine.

Question: What dosage of midazolam (Versed) causes a loss of consciousness and amnesia during rapid sequence induction?

0.1 mg/kg; 5 mg is effective for most people.

Question: Etomidate is the recommended agent to obtain sedation and induction while performing Rapid Sequence Intubation. What is the appropriate adult dose?

0.2–0.3 mg/kg.

Question: What is the “defasciculating” or the “priming” dose of vecuronium?
~0.01 mg/kg or commonly 1 mg or 1/10th of the total dose.

What dose of vecuronium should be administered for paralysis (no “priming”)?

0.08–0.1 mg/kg providing a NMR effects for 15–30 minutes.

Question: What is the appropriate initial dose of pancuronium (Pavulon)?

0.04–0.1 mg/kg, which commonly provides 45 minutes of NMR.

Question: What pain medications are not recommended for the treatment of pain arising from acute diverticulitis?
Opioid pain medications should be avoided, if possible. Their use may increase intraluminal colonic pressure and precipitate constipation and decreased bowel motility.

Question: What are the most common causes of large bowel obstruction?
Carcinoma, followed by volvulus, diverticulitis inflammatory disorders, and fecal impaction, all of which most commonly occur in the sigmoid.

Question: What is the most common cause of massive upper GI tract hemorrhage?
Duodenal ulcers.

Question: What layers of the bowel wall and mesentery are affected by regional enteritis?
All layers.

Question: Which hernia is the most common in women?
Inguinal hernia. It is also the most common in men.

Question: What is the most common cause of paralytic ileus?
Abdominal surgery. This is a routine complication following abdominal surgery.

Question: An elderly woman presents with pain in the knee and medial aspect of the thigh. What GI diagnosis should be considered?
Obturator hernia. This presentation is most common in elderly women and is difficult to diagnose and is frequently missed, which makes these the most lethal of all abdominal hernias (mortality 13%–40%).

Question: Where is the most common site of volvulus?
The sigmoid colon in nearly 65% of patients.

Question: Describe the location of an indirect inguinal hernia:
Lateral to the epigastric vessels, protruding through the inguinal canal and commonly into the scrotum.

Question: Describe the location of a femoral hernia:
Descends through the femoral canal and beneath the inguinal ligament.

Describe the location of a spigelian hernia:
This is an acquired ventral hernia through the linea semilunaris, the line where the sheaths of the lateral abdominal muscles fuse to form the lateral rectus.

Question: What is a pantaloon hernia?
A hernia with both direct and indirect inguinal hernia components that occur on the same side.

Question: What is a sliding hernia?
A hernia in which one wall of the hernia sac includes viscus.

Question: Describe a Richter hernia:
A hernia involving only one sidewall of the bowel, which can more easily result in bowel strangulation.

Question: Which is the most common type of hernia in children?
Indirect. Direct inguinal hernias are more common in the elderly.

Question: In the pediatric esophagus, where is a foreign body most commonly lodged?
The most common site of esophageal impaction is at the thoracic inlet, defined as the area between the clavicles on chest radiograph, this is the site of anatomical change from the skeletal muscle to the smooth muscle of the esophagus. More specifically most foreign bodies (70%) lodge at the cricopharyngeus sling.

Question: Of the following, which is not a common cause of large bowel obstruction: diverticulitis, adhesions, sigmoid volvulus, or neoplasms?
Adhesions. Adhesions are the most common cause of small bowel obstructions are uncommon in the colon.

Question: Describe the clinical presentation of a patient with sigmoid volvulus:
Most common in geriatric patients presenting with colicky abdominal pain with a dull discomfort between spasms. Patients commonly have abdominal distention and occasionally vomiting. Characteristic abdominal X-ray findings are a significantly dilated cecum with a distended loop that assumes a “coffee bean” shape.

Question: Describe a typical patient with intussusception:
It usually occurs in children ages 3 months to 6 years, although the majority are 7–8 months old. It is more common in boys (3:1). The typical presentation is a previously healthy infant boy aged 6–12 months with sudden onset of colicky abdominal pain 10–20 minutes apart with vomiting.

Question: What is the most common anatomical abnormality in the arterial blood supply to the liver?
The right hepatic artery branches from the superior mesenteric instead of the common hepatic, which arises from the proper hepatic in 15%–20% of the population.

Question: What is Kehr sign?
Pain in the shoulder made worse in Trendelenburg. Pain in the left shoulder is a classic presentation indicating splenic injury.

What spinal level provides motor innervation to the diaphragm?
C3, C4, C5. (Phrenic nerve.) Remember: “3, 4, and 5 keep the diaphragm alive!”

Question: Where are the most common sites of the hematologic spread of breast cancer?
Bones, liver, and brain.

Question: What characteristics are associated with the best prognosis in breast cancer?
The (TNM) staging of breast cancer is the most reliable indicator of prognosis.
T1 Tumor < 2cm
N0 No Regional lymph node metastasis
M0 No distant metastasis

Question: What is the most commonly injured nerve during parotidectomies?
Most serious complications result from damage to the facial nerve (either temporary or permanent paralysis). Injury to the greater auricular nerve results in hypesthesia of the ear.

Question: If medical management fails to relieve symptoms of gastroesophageal reflux after a 1-year trial period, what surgical methods might be attempted?
Previously antireflux surgery as considered only for patients that did not respond to medical treatment. Currently the following indications are considered:
Young patients who require chronic therapy with proton pump inhibitors for control of symptoms.
Patient in whom regurgitation persists during therapy.
Patients with respiratory symptoms (cough).
Patients with vocal cord damage.
Patients with Barrett esophagus.
The goal of surgical therapy is to restore the competence of the lower esophageal sphincter and the surgical procedure of choice is a laparoscopic Nissen fundoplication.

Question: Other than laparotomy, what invasive examination will confirm suspected mesenteric ischemia?
For many years, angiography has been considered to be the criterion standard for the diagnosis of acute arterial occlusion with reported sensitivities 74%–100% and specificity 100%. Currently the nonevasive multidetector row CT has emerged as a valuable tool for the evaluation of mesenteric ischemia.

Question: What is the most common cause of postsplenectomy (postsplenic) sepsis?
Streptococcus pneumonia and Haemophilus influenza to a lesser extent. All postsplenectomy patients should receive the pneumococcal conjugate vaccine (Prevnar), Hib vaccine, and the meningococcal vaccine.

Question: What are the X-ray findings in ischemic bowel disease?
“Thumb printing” (mucosal dilation) on plain film with dilation of the colon and thickening of the valvulae conniventes.

Which local anesthetic, ester or amide, is responsible for most allergic reactions?
Ester (Procaine). However, allergic reactions that occur are usually not in response to Procaine, but rather to para-aminobenzoic acid (PABA), which is a major metabolic product of all ester-type local anesthetics.

Question: What are the most common signs and symptoms of mild, moderate, and severe dehydration?



REFERENCES
Britt L, Trunkey DD, Feliciano DV Acute Care Surgery—Principles and Practice. New York, NY: Springer-Verlag; 2007.
Doherty GM, Way L. Current Surgical Diagnosis and Treatment. 12th ed. New York, NY: McGraw-Hill; 2006.
Tintinalli MJ, Kelen MG, Stapczynski MJ, Ma MO, Cline MD. Tintinalli’s Emergency Medicine—A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004.