Surgery PIMPS

Terms in this set (262)

What is the Triangle of Calot (Cystohepatic Triangle)?
The anatomic space bordered by the common hepatic duct medially, the cystic duct laterally and the cystic artery superiorly. (incorrect - inferior liver border)
What is Bile made of?
Cholesterol, Lecithin (phospholipid), bile acids, and bilirubin.
What does HIDA stand for?
hepatobiliary iminodiacetic acid. AKA cholescintigraphy.
What is a "positive HIDA"?
Timing a dye visualization greater than 4 hours
What is ERCP?
Endoscopic Retrograde Cholangiopancreatography
What is PTC?
Percutaneous Transhepatic cholangiogram
Why is CO2 most commonly used to inflate the abdomen during a Lap procedure? What other gas types are used?
More rapidly absorbed and decreases the change of acidotic state.
Other types used - O2 (2nd), Nitrogen (3rd).
Less risk of gas embolism and is noncombustible.
Clear/yellow fluid leakage from gallbladder indicates what condition?
Hydrops associated with cystic duct blockage, in which bile salts are reabsorbed leaving mainly Lethicin and Cholesterol fluid. NOT a true Hydrops.
What is the "Violin String" sign? (Fitz-Hugh-Curtis syndrome)
Rare complication of PID, named after Thomas Fitz-Hugh, Jr and Arthur Hale Curtis in in 1934 and 1930 respectively. Causes liver capsule inflammation and perihepatic adhesion's.
Perihepatic gonorrhea
What is the Falciform Ligament?
The large ligament, a remnant of the umbilical vein that separates the left and right liver lobes. It FUNCTIONALLY separates the caudate lobe from the left lobe of the liver.
What happens to the Falciform Ligament in a patient with Portal Hypertension?
Becomes canalized, as blood congestion in the liver forces blood into the ligament and towards the anterior of the abdomen.
How is the Liver divided surgically? What vessels are described?
From a surgical point of view, the liver is divided into right and left lobes of almost equal size by a major fissure (Cantlie's line) running from the gallbladder fossa in front to the IVC fossa behind. This division is based on the right and left branches of the hepatic artery and the portal vein, with tributaries of bile (hepatic) ducts following. The middle hepatic vein (MHV) lies in Cantlie's line. The left pedicle (left hepatic artery [LHA], left branch of the portal vein, and left hepatic duct) has a longer extrahepatic course than the right.
What is the blood supply to the Liver?
Unique dual supply from the proper hepatic artery (20-40%) and from the portal vein (60-80%)
PHA originates from the celiac trunk trifurcation off the abdominal aorta.
Portal originates from the Superior mesenteric and splenic, collecting blood from the GI tract (lower esophagus to upper 1/3rd of rectum), stomach, pancreas, gallbladder and spleen.
What is the Portal System
When a capillary bed pools into another capillary bed through veins, without first going through the heart.
How much oxygen is supplied to the liver via the hepatic artery?
30-40% while only providing 20-40% of the total blood.
What is the Foramen of Windslow?
Passage between the greater and lesser sacs in which the omentum is found.
AKA epiploic foramen.
Why is the Foramen of Windslow surgically important?
Can place fingers through it to occlude the portal vein and hepatic artery in the case of a trauma.
During a surgical procedure, inflation of the abdomen is positive for what physical finding?
Tympany
What is Calots Node?
The sentinel Lymph node of the gallbladder. It increases in size in cholecystitis and cholangitis. It is an anatomic landmark and is removed along with the gall bladder in cholecystectomy. Originally named after Fred Bates Lund (1865-1950), an American Surgeon. Also named after the Italian anatomist and physician, Paolo Mascagni (1752-1815), who first identified it around 1787.
Positioned within the Triangle of Calot.
Who is Dr. Harry Hancock
First doctor to perform appendectomy in 1848.
Who is Dr. Semms
GYN first to perform lap appy in 1983.
What is the most common tumor of the appendix?
Carcinoid
What does a rigid, board-like abdomen mean?
Peritonitis
What is the most common reason for acute appendicitis?
Calcified fecal deposits AKA fecoliths
What are the layers of the abdominal wall during a McBurney incision?
Skin, SubQ fat, Scarpa's Fascia, External obliques, Internal oblique, Transversus muscle, Transversus fascia, Preperitoneal fat, Peritoneum.
What is Scarpa's Fascia
The fascial layer between the abdominal muscles and the superficial fat.
The first identifiable subq layer.
What is Campers Fascia
The layer of superficial fat on the abdomen.
What nerve runs on top of the spermatic cord?
Ilioinguinal nerve
What is in the spermatic cord?
1. Cremasteric muscle fiber
2. Vas deferens
3. Testicular artery
4. Testicular pampiniform venous plexus
5. +or- hernia sac
6. Genital branch of the genitofemoral nerve
What must be done before leaving the O.R. after an inguinal hernia repair?
Pull testicle back down into scrotum.
What is the whitish looking cord when holding the spermatic cord?
Vas Deferens
What is a pantaloons hernia?
Hernia sac exits as both a direct and indirect hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring (two sacs separated by the interior epigastric vessels like a pair of pantaloon pants)
What is a lateral abdominal hernia?
Spigelian - a hernia through the linea semilunaris (spigelian fascia); AKA spontaneous lateral ventral hernia. Usually small, and therefore high risk of strangulation. Generally ABOVE the arcuate line. Rare, and occur between the rectus abdominus medially and the semilunar line laterally.
What is the Median Umbilical Ligament?
Shriveled piece of tissue that represents the remnant of the embryonic urachus. It extends from the apex of the bladder to the umbilicus. Unpaired, on the deep surface of the anterior abdominal wall.
What is the Medial Umbilical Ligament?
Ligament that represents the remnant of the fetal umbilical arteries. Paired, on the deep surface of the anterior abdominal wall.
What is the Lateral Umbilical Fold?
Contents remain functional after birth. Direct hernias originate medial to this, indirect hernias originate lateral to this.
What is the Deep Inguinal Ring?
Space lateral to the lateral umbilical fold which allows the passage of the ductus deferens, testicular artery, and other components of the spermatic cord or round ligament.
What are the top three most common hernias at risk of strangulation?
#1 - Femoral
#2 - Indirect
#3 - Direct
Absolute contraindications for Laparoscopic surgery?
Hypovolemic shock, severe cardiac decompensation
Relative contraindications for Laparoscopic surgery?
Extensive intraperitoneal adheasion, diaphragmatic hernia, COPD.
What is Blind Loop Syndrome?
Bacterial overgrowth of the intestine caused by stasis.
What is Boerhaaves Syndrome?
Esophageal perforation
What is Budd-Chiari Syndrome?
Thrombosis of the hepatic veins
What is Carcinoid Syndrome?
B FDR
Bronchospasm
Flushing
Diarrhea
Right-Sided Heart Failure
What is Compartment Syndrome?
Compartmental hypertension caused by edema, resulting in muscle necrosis of the lower extremity, often seen in the calf; patient may still have a distal pulse.
What is Cushings Syndrome?
Excessive cortisol production
What is Dumping Syndrome?
Delivery of a large amount of hyperosmolar chyme into the small bowel, usually after vagotomy and a gastric drainage procedure (Pyloroplasty/gastrogegunostomy); results in autonomic instability, abdominal pain, and diarrhea.
What is Gardner's Syndrome?
GI Polyps and associated findings of Sebaceous cysts, Osteomas, and Desmoid tumors (SOD); Polyps have high malignancy potential (A Gardner plants SOD).
What is HITT Syndrome?
Heparin-Induced Thrombocytopenic Thrombosis: Heparin induced platelet antibodies cause platelets to thrombose vessels, often resulting in loss of limb or life.
What is Leriches Syndrome?
Claudication of the buttocks and thighs, Impotence, Atrophy of legs. (Seen with iliac occlusive disease) (Think CIA)
What is Mendelson's Syndrome?
Chemical pneumonitis after aspiration of gastric contents.
What is Mirizzi's Syndrome?
Extrinsic obstruction of the common hepatic bile duct from a gallstone in the gallbladder or cystic duct.
What is Peutz-Jeghers Syndrome?
Benign GI Polyps and buccal pigmentation (P for Pigmentation and Polyps)
What is Plummer-Vinson Syndrome?
Esophageal web, Iron-deficiency anemia, Dysphagia, Spoon shaped nails, Atrophic oral and tongue mucosa.
Typically seen in elderly woman; 10% develop SCC.
What is Trousseau's Syndrome?
migratory thrombophlebitis associated with carcinoma.
Most common indication for surgery with Crohn's Disease?
Small Bowel Obstruction.
Most common type of Melanoma?
Superficial spreading
Most common type of Breast Cancer?
Infiltrating ductal
Most common site of Breast Cancer?
Upper Outer Quadrant
Most common vessel involved with a bleeding duodenal ulcer?
Gastroduodenal artery
Most common type of bile duct obstruction?
Choledocholithiasis
Most common cause of cholangitis?
Bile duct obstruction resulting from choledocholithiasis
Most common cause of pancreatitis?
Alcohol ingestion
Most common bacteria in stool?
Bacteroides fragilis (B frag)
Most common cause of SBO in children?
Hernias
Most common cause of emergency surgery in the US?
Appendicitis
Most common abdominal xray finding in SBO?
Air-fluid levels
Most common electrolyte deficiency causing ilius?
Hypokalemia
Most common site of GI carcinoids?
Appendix
Most common cause of blood transfusion deaths?
Clerical error in blood typing
Most common cause of shock in a surgical patient?
Hypovolemia
Most common cause of large bowel obstruction?
Colon cancer
Most common cause of fever <48hours after surgery?
Atelectasis
Most common malignancy of the Liver?
Metastasis or Chronic Hepatitis B or C infection.
Most common hernia?
Inguinal (Right more common than Left)
First surgeon to use antiseptic (Carbolic acid)?
Lister
First lap chole
1987 by Mouret and Dubois in France
First appendectomy
1848 by Hancock
First lap appy
1983 by Semm (GYN Doc)
First gastric resection
1881 by Billroth
What are vascular grafts made out of?
Gortex and Teflon
Why is a cadaver vein in some cases better than a graft vessel?
Less chance of fistula formation.
What are the three layers of an artery?
1. Intima
2. Media
3. Adventitia
What is the most common site of atherosclerotic occlusion the lower extremities?
Superficial Femoral Artery (SFA) in Hunter's canal
What are the signs of PVD?
Absent pulses, bruits, muscular atrophy, decreased hair growth, thick toenails, tissue necrosis/ulcers/infection.
What are the indications for surgical treatment of PVD?
Severe claudication refractory to tx
Tissue necrosis
Infection
Rest pain
"STIR"
Most common cause of postop death after PVD operation?
MI
What is a FEM-POP bypass?
Bypass SFA occlusion (most common type).
What is FEM-DISTAL bypass?
Bypass from femoral artery to peroneal, anterior tibial, or posterior tibial arteries.
What graft material has the longest patency rate?
Autologous vein graft
What type of graft is used for above the knee FEM-POP bypass?
Either vein or Gortex graft. vein has better patency.
What type of graft is used for below the knee FEM-POP or FEM-DISTAL bypass?
Must use vein; prosthetic grafts have a prohibitive thrombosis rate.
What is Blue Toe Syndrome?
Intermittent painful toes or fingers due to microemboli from proximal arterial plaque.
What are the classic signs/symptoms of acute arterial occlusion?
Pain, Paralysis, Pallor, Paresthesia, Polar (cold), Pulselessness.
Six P's
What are the sources of emboli?
Heart - 85%
Aneurysms
Atheromatous plaque
Most common cause of embolus from the heart?
Afib
What is a Fogerty?
Catheter with balloon tip that can be inflated with saline, used for embolectomy. Inflate once past embolus, retract while inflated and pull embolus out.
What is the classic triad of AAA rupture?
Abdominal pain
Pulsatile abdominal mass
Hypotension
What is in the Carotid Sheath?
Vagus Nerve, Common Carotid Artery, External Jugular Vein, Deep Cervical Lymph Nodes.
What animal has the most developed Platysmus muscle?
Horse
What differentiates the Internal and External Carotid upon surgical dissection?
The Superior Thyroid Artery just above bifercation
Where does the external thyroid originate?
Subclavian artery
What is Arteriosclerosis?
thickening, hardening and loss of elasticity of the walls of arteries.
What is Atherosclerosis?
buildup of fatty plaques, cholesterol and some other substances in and on the artery walls
Why are AAA repairs wrapped with Tunica Adventitia?
To avoid graft fistula formation which may lead to unknown GI problem or vomiting of blood at a later time.
Misnomer about inflammatory breast cancer?
Its not actually inflammatory. It is a clinical diagnosis that implies presentation with the cardinal signs of inflammation (calor [warmth], rubor [redness], tumor [mass]) involving the breast, although the warmth may be subtle and the mass may not be appreciated as something discrete
First line treatment for inflammatory breast cancer?
Chemotherapy
What percentage of Mammograms miss breast cancer?
10%
What is the #1 reason women seek care regarding their breasts?
Uneven breast size
Is fibrocystic breast disease a risk factor for cancer?
No, unless they are of preoperative typing or there is a strong familial risk, at which point it is a 2-fold increase.
Axillary Vein
Formed by the Brachial and the Basilic,
originates at the lower margin of the teres major.
deep to the branches of the brachial plexus.
Thoracodorsal Nerve
Originates from ventral rami, innervates the latissiums dorsi. AKA Long Subscapular.
Thoracodorsal Artery
Supplies blood to the Latissimus Dorsi and travels deep to the thoracodorsal nerve.
Long Thoracic Nerve
Descends behind the brachial plexus and the axillary vessels, resting on the outer surface of the serratus anterior. Easily damaged during radical mastectomies with lymph node removal or during contact sports.
Causes "Winged Scapula"
From inferior to superior, what are the branches of the External Carotid Artery?
Arising in the carotid triangle.
1. Superior thyroid
2. Ascending pharyngeal
3. Lingual
4. Facial
5. Occipital
6.Posterior auricular
7. Maxillary
8. Superficial Temporal
Which muscle crosses the Common Carotid Artery?
Omohyoid
Which nerve crosses 1cm distal to the carotid bifercation?
Hypoglossal. If damaged, the tongue will deviate toward the injured side
What is "Milk Leg"
Occlusion of the iliac vein resulting from extrinsic compression by the growing uterus of a pregnant woman. Causes the leg to become whitish as a result of subcutaneous edema.
What is Raynaud's Phenomenon?
Vasospasm of digital arteries with color changes. Usually initiated by cold temperature or emotional changes. White (first) with spasm, blue (second) from cyanosis, red (third) from hyperemia).
What is Takayasu's Arteritis?
Arteritis of the aorta and aortic branches resulting in stenosis/occlusion/aneurysms. MC in woman.
What is Buerger's Disease?
Occlusion of the small vessels of the hands and feet. MC in young men who smoke. Often results in gangrene and amputation. AKA Thromboangiitis obliterans.
What is the Superior Boundary of axillary dissection?
Axillary nerve
What is the Posterior Boundary of axillary dissection?
Long Thoracic nerve
What is the Lateral Boundary for axillary dissection?
Latissimus dorsi muscle
What is the Medial Boundary for axillary dissection?
Lateral to, deep to, or medial to the pec minor muscle, depending on level of nodes taken.
What 4 nerves must the surgeon be aware of during axillary dissection?
Long Thoracic
Thoracodorsal
Medial pectoral
Lateral pectoral
What is the lymphatic drainage of the breast?
Laterally - Axillary nodes
Medially - Parasternal nodes
What is the "Tail of Spence"?
Breast tissue that tapers into the axilla, most common site of breast cancer.
What is the incidence of breast cancer?
12% lifetime risk.
What percentage of women with breast cancer have no known risk factors?
75%
What percentage of all breast cancers occur in woman younger than 30?
~2%
What percentage of breast cancers occur in woman older than 70?
33%
What is the "Triad of Error"?
75% of missdiagnosed BC have these three characteristics.
Age <45
Self-diagnosed mass
Negative mammogram.
What are the risk factors for breast cancer?
NAACP
Nulliparity
Age of menarche younger than 13
Age or menopause older than 55
Hx of BC self or family
First child at age >30
What is the relative risk of BC with hormone replacement therapy?
1-1.5%
What are the most common sites of breast cancer metastasis?
Lymph nodes (MC)
Lungs/pleura
Liver
Bones
Brain
When do you remove the drains after Axillary Dissection?
<30cc's per day
or
POD 14
Father of Modern Abdominal Surgery and performed the first Esophagectomy, Laryngectomy, and Gastrectomy due to gastric cancer
Theadore Billroth
Stages of Wound Healing
Hemostasis
Inflammation
Proliferation
Maturation
Hemostasis Phase
Blood clotting begins within minutes of injury, platelets stick to injured site, release chemical to promote further clotting and activation of fibrin, which forms mesh and "plugs" opening.
Inflammatory Phase
Damaged/dead cells and bacteria are removed via phagocytosis. Platelet-derived growth factors are released into the wound and cause migration and division of cells.
Proliferation Phase
Angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction occur. Fibroblasts grow and form new provisional extracellular matrix via excretion of collagen and fibronectin. Re-epitheliazation of the epidermis occurs. Wound size is decreased via myofibroblasts.
Primary Intention
Wound edges brought together with sutures or glue. Minimal scarring. Most common type or intention.
Secondary Intention
Wound is allowed to granulate. Wound may be packed or use a drainage system prior to closure. Makes for a larger scar. Needs daily wound care.
Tertiary Intention
Delayed wound closure. Wound is initially cleaned, debribed and observed, usually for 4-5 days. Wound is left open and edges are not reapproximarted immediately. May be used in contaminated wounds to allow for phagocytosis to be well underway and foreign materials walled off by macrophages.
Maturation Phase
Remodeling begins and collagen is realigned along tension line. Cells that are no longer needed are removed via apoptosis
Most common cause of SBO in adults in the US?
Post Op peritoneal adhesion's
5 W's of Postop Fever
Wind
Water
Wound
Wonder drugs
Walking
Wind
Atalectasis and Pneumonia - 1st 24-48hrs
Water
UTI anytime after POD#3
Wound
Infection anytime after POD#5
Wonder Drugs
Anesthesia
Walking
Emboli or DVT usually after POD#7
Novel Oral Anticoagulants (NOACS)
Dabigatran, Rivaroxiban, Apixaban - Better than coumarins with less side effects, but have no reversability or antidote
Coumarins
Found in plants, take 48-72 hours to take effect.
Direct Thrombin Inhibitors
Bivaliruden, Dabigatran, Argatroban
Heparin
Inactivates Factor Xa and the conversion of Prothrombin to Thrombin. Inhibits multiple other Factors and Thrombin itself if given in higher dosages.
Lovenox
Inhibits Factor Xa by increasing the inhibitaion rate of clotting proteases that are activated by antithrombin III Does not increase PT or PTT.
Warfarin
Interferes with hepatic synthesis of Vitamin K dependent clotting factors II, VII, IX, X, Protein C and Protein S. Depletes Vitamin K reserves which reduces synthesis of clotting factors.
Xarelto (Rivaroxiban)
Inhibits platelet activation by selectively inhibiting Factor Xa receptor sites.
Pradaxa (Dabigatran)
Prevents thombus development through direct competitive inhibition of thrombin. Prevents thrombin induced platelet aggregation.
Eliquis (Apixaban)
Factor Xa inhibitor. Selectively and reversibly blocks Factor Xa active sites.
The Lateral Umbilical Ligament consists of what?
Inferior Epigastric Vessels
Goodsalls Rule
Fistulas posterior to the transverse anal line have a curved track, while anterior fistulas take a linear track.
What is the portal triad?
Proper hepatic artery
Common bile duct
Portal Vein
What abdominal contents are retroperitoneal?
Primarily - Kidneys, suprarenal glands, uterine cervix
Secondarily - Pancreas, Duodenum, Ascending and descending colon, Upper 2/3rds of Rectum, Aorta and IVC
What is the most common thyroid cancer?
Papillary (then follicular)
Survival rate of Papillary Thyroid Cancer?
96% 5 year survival
What type of thyroid cancer it's associated with MEN2?
Medullary
What is MEN2?
Parathyroid hyperplasia.
Medullary thyroid cancer.
Pheochromocytoma.
What is hepatopetal flow?
Normal forward flow in the Portal Vein
What is hepatofugal flow?
Backwards flow in the Portal Vein
What is the most common cause of pre hepatic portal hypertension?
Pancreatitis
What is the most common cause of intra hepatic portal hypertension?
Cirrhosis
What is the most common cause of post hepatic portal hypertension?
Increased systemic vascular resistance
How does peritoneum heal?
migratory healing
how does the epidermis heal?
expansive healing
what type of cells is the epidermis made of?
epithelial
What type of cells make up peritoneum?
Mesenchymal
How does papillary thyroid cancer Mets?
Lymph nodes
What is Pathomnumonic for Papillary Thyroid Cancer?
Psammoma bodies on light microscopy.
What is the Superficial Inguinal Ring?
Opening in the external oblique aponeurosis; bounded by medial and lateral crus, intercrural fibers, and reflected inguinal ligament.
In what order does the GI tract come back after Ilius?
First - Small Bowel
Second - Stomach
Third - Large Bowel
What contents are infraparitoneal/subperitoneal (organs with NO mesentary)?
Urinary Bladder, Vagina, Prostate, Seminal Vesicles, Cervix, Distal Ureters, Lower 1/3rd of Rectum.
What contents are Intraperitoneal (wrapped in peritoneum and have mesentary)
Stomach, Small intestines, Spleen, Liver, Gallbladder, Cecum, Appendix, Transverse and Sigmoid colon.
Structure that runs along the inferior edge of the Falciform Ligament?
Ligamentum Teres (aka round ligament), a fibrous remnant of the fetal umbilical vein
What is Cirrhosis?
Chronic inflammation of the liver, caused by alcohol of hepatitis damage which causes liver fibrous tissue to regenerate faster than the hepatocytes.
scar tissue shrinks and obstructs blood flow and causes portal HTN.
Area in which the portal vein and the portal artery enter the liver?
Porta Hepatis ("Gateway to the liver")
Liver veins anastamose with what veins that drain in the Venae Cavae?
Inferior esophageal, Hemorrhoidal, and superficial umbilical.
What is Caput Medusa?
Burst umbilical veins due to portal HTN.
What are Esophageal Varices?
Swollen veins in the esophagus
What is Ascites?
Accumulation of fluid in the peritoneal cavity as a result of leakage from the liver
What causes Transudative Ascites?
MC - Cirrhosis
Heart failure
Budd-Chiari or veno-occlusive disease
Constrictive pericarditis
Kwashiorkor
-Result of increased pressure in the portal vein.
What causes Exudative Ascites?
MC - Cancer
Infection (TB, SBP)
Pancreatitis
Nephrotic Syndrome
-Result of actively secreted fluid from inflammation or malignancy.
What are the secretory cells of the pancreas called?
Acini - Exocrine (breaks down all foodstuff)
Islet - Endocrine (Insulin and Glucagon)
What are the fatty tags on the colon called?
Epiploic Appendices
How and where is B12 Absorbed?
Intrinsic factor and a diffusion process in which 1% is absorbed.
Released from protein by gastric acid.
Requires stomach, exocrine pancreas, IF, and small bowel.
What is Pernicious Anemia
Lack of B12 absorption due to lack of intrinsic factor as a result of autoimmune atrophic gastritis, in which antibodies form against parietal cells.
What is the collateral blood supply to the colon?
Wandering Mesenteric and Internal Iliac arteries.
What is the meandering mesenteric artery? (marginal artery of the colon)
Arc of Riolan -Blood vessel that anastomoses the inferior mesenteric with the superior mesenteric.
Proximal middle colic --> left colic
Major Large Bowel Artery branches of the Superior Mesenteric?
Iliocolic, Right Colic, Middle Colic
Major Large Bowel Artery branches of the Inferior Mesenteric?
Left Colic, Sigmoid artery, Superior Rectal artery
What is a Colostomy?
Surgical procedure in which an opening (Stoma) is formed by drawing the healthy end of the large intestine through an incision in the anterior abdominal wall and suturing it into place.
What are the different types of Colostomies?
Loop, End, Double Barrel
Loop Colostomy
Usually used in emergencies and is temporary. One Stoma.
End Colostomy
One stoma with distal end removed or sewn shut. Permanent.
Double Barrel Colostomy
Two stoma with only the proximal being functional.
What coagulation factors does the Liver produce?
I (fibrinogen), II (Prothrombin), V, VII, VIII, IX, X, XI, protein C, protein S, and antithrombin.
What does the Liver make?
Albumin, Angiotensinogen, Amino acids, glucose from glycogen and glycogen from glucose, proteins, cholesterol and triglycerides, bile, insulin-like growth factor 1, ammonia to urea, and thrombopoetin.
What does the Liver breakdown?
Insulin and other hormones, bilirubin, toxic substances, most medications
What does the liver store?
Glucose (as glycogen), Vitamin A (1-2 yrs), Vitamin D (1-4mo), Vitamin B12 (1-3yrs), Vitamin K, Iron, Copper.
What does Albumin do?
Maintenance of oncotic pressure, transports fatty acids and steroid hormones.
What does Angiotensinogen do?
Hormone responsible for raising blood pressure when activated by Renin, which is released by the kidneys.
How much Bile does the liver make per day?
50-1500mL depending on PO intake. More commonly between 400-800mL daily.
What are the classic signs and symptoms of Liver damage?
Pale stools, dark urine, jaundice, swelling, excessive fatigue, easy bruising, RUQ pain
What does the Pancreas make?
Exocrine hormones, Endocrine hormones,
Bicarbonate to neutralize stomach acid, Digestive enzymes to breakdown foodstuff.
What artery is clamped off during a Sigmoid Colon Resection?
Inferior mesenteric if large. Possibly sigmoid arteries if small.
What are local factors that effect wound healing?
Mechanical factors, Edema, Ischemia/Necrosis, Foreign bodies, Low oxygen tension.
What are systemic factors that effect wound healing?
Inadequate perfusion, Inflammation, Diabetes, Nutrients, Metabolic diseases, Immunosuppression, Connective tissue disorders, Smoking
What is the only scientifically proven sterility method that reduces operative infection rates?
Wearing sterile gloves
What is Virchow's Node?
Located in the Left supraclavicular fossa. Associated with lymphatic metastasis of abdominal, specifically gastric, cancer
What are the layers of the Scalp?
Skin, Connective Tissue, Apaneurosis, Loose Connective Tissue, Periostium.
What is Temporal Arteritis?
Medium vessel inflammatory process of unknown origin. May cause blindness and is associated with new onset of HA, jaw claudication, temporal/scalp pain and visual disturbances.
Intrinsic and Extrinsic coagulation cascades lead to what?
Fibrin formation
Intrinsic Pathway
Surface Contact turns XII into XIIa, XIIA turns XI into XIa, XIa turns IX into IXa, IXa with VIII, Platelet membrane phospholipid and Calcium turns X into Xa, Xa with V, platelet membrane phospholipid and Calcium turns Prothrombin into Thrombin, Thrombin turns Fibrinogen into Fibrin and XIII into XIIIA, Fibrin and XIIIa together form stable fibrin clot.
Extrinsic Pathway
Tissue damage releases Tissue Factor and VIIa which together activate IX and Xa, VII is further continuously activated by Thrombin, XIa, XII and Xa, Activated X with V, platelet mambrane phospholipid and Calcium turn Prothrombin into Thrombin, Thrombin turns Fibrinogen into Fibrin and XIII into XIIIa, Fibrin and XIIIa activate stable fibrin clot.
Clotting Cofactors
Calcium, Phospholipid, Vitamin K
Calcium
Mediates the binding of the Xa and IXa to the surface of platelets
Vitamin K
Essential factor for hepatic gamma-glutamyl carboxylase that adds a carboxyl group to glutamic acid on II, IX, X and Ptorein S, Protein C, and Protein Z.
Pharmacological target of Warfarin, which create a deficiency
Coagulation Regulators
Protein C, Antithrombin, Tissue Factor Pathway Inhibitor, Plasmin, Protacyclin
Protein C
Vitamin K dependent, activated by thrombin into active form. Degrades/inactivates Va and VIIIa. Deficiency may lead to Thrombophilia.
Antithrombin
Degrades Thrombin, IXa, Xa, XIa and XIIa and is constantly active at all times. Increased by Heparin. Deficiency leads to Thrombophilia.
Tissue Factor Pathway Inhibitor
Limits the action of tissue factor and inhibits excessive TF mediated activation of VII and X.
Plasmin
Generated by proteolytic cleavage of catalyzed tissue plasminogen activator, which is synthesized and secreted by endothelium. Cleaves fibrin into fibrin degradation products that inhibit excessive fibrin formation.
Prostacyclin
Released by endothelium, activates platelet Gs protein-like receptors, which activates adenylyl cyclase which synthesizes cAMP. cAMP inhibits platelet activation by decreasing levels of Calcium.
Fibrinolysis
Reorganization of blood clots, primarily by plasmin.
Anti Platelet Agents
Aspirin, Dipyridoamole, Ticlopidine, Clopedigrel, Ticagrelor, Prasugrel.
Glycoprotein IIb/IIIa inhibitors used during angioplasty.
Warfarin
Affects vitamin K dependent clotting factors (II, VII, IX, X) protein C and protein S.
Factor I (Fibrinogen)
Forms Fibrin
Factor II (Prothrombin)
Active form activates I, V, VII, VII, XI, XIII, protein C and Platelets
Factor III (Tissue Factor)
Cofactor of VIIa
Factor IV (Calcium)
Required for coagulation factors to bind to phospholipids
Factor V (Proaccelerin)
Cofactor of X with which it forms prothombinase complex
Factor VI
Unassigned, old name for Va
Factor VII (Stable factor, Proconvertin)
Activates IX, X
Factor VIII (Antihemophilic Factor A)
Cofactor of IX with which it forms tenase complex
Factor IX (Antihemophilic B, Christmas Factor)
Activates X, forms tenase complex with VIII
Factor X (Stuart-Prower factor)
Activates II, forms prothrombinase complex with V
Factor XI (Plasmin thromboplastin antecedent)
Activates IX
Factor XII (Hageman Factor)
Activates factor XI, VII, and prekallikrein)
Factor XIII (Fibrin stabalizing factor)
Crosslinks fibrin
Von Willebrand Factor
Binds to VIII, mediates platelet adhesion.
Fibronectin
Mediates cell adhesion
Antithrombin III
Inhibits IIa, Xa, and other proteases
Protein S
Cofactor for activated protein C
Plasminogen
Converts plasmin, lyses fibrin and other proteins
Cancer Procoagulant
Pathological X activator linked to thrombosis in CA
Tissue Plasminogen Activator (tPA)
Activates plasminogen
Types of Liver Cells
Paranchymal and Non-paranchymal
What is the Porta Hapatis?
The central area where the common bile duct, hepatic portal vein, and the hepatic artery enter is the hilum.
What is Budd-Chiari Syndrome
A condition caused by blockage of the hepatic veins (including thrombosis) that drain the liver. It presents with the classical triad of abdominal pain, ascites and liver enlargement.
What is Primary Biliary Cirrhosis
autoimmune. slow progressive destruction of the small bile ducts of the liver, intralobular ducts (Canals of Hering) affected early. bile and other toxins build up (cholestasis) and over time damages the tissue in combination with ongoing immune related damage. This can lead to scarring (fibrosis), and cirrhosis.
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