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ABSITE 2021 > ABSITE 2021 > Flashcards

ABSITE 2021 Flashcards

1
Q

Dx of Fibrolamellar HCC

A
  • Labs: normal AFP and elevated neurotensin (vs. FNH)

- Imaging: well circumscribed w/ central scar. Similar to FNH

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2
Q

Hemodyamic parameters:

Septic shock
Neurogenic shock
Cardiogenic shock

A

Septic: high CI, low SVR, +/- wedge

Neurogenic: high CI, low SVR, low wedge

Cardiogenic: low CI, high SVR, high wedge

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3
Q

Pheo w/up:

A
  1. plasma or urine metanephrine (se)
  2. 24-urine metanephrine (sp)
  3. CT (> MRI)
  4. MIBG (if multi-focal)
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4
Q

Mucinous cystic neoplasm dx and tx

A
  • dx: EUS-FNA w/ high CEA (>190), low Amylase

- tx: resect

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5
Q

Tx pelvic fx

A
  1. Binder
  2. Angio OR packing w/ fixation (especially if IR n/a)
  3. Fixation
    - refractory bleed after angio → packing + fixation
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6
Q

STSG vs. FTSG

A
  1. STSG: epi + part dermis
    - higher survival/less resistant
    - more 2’ contxn. (don’t use over joints)
    - ideal use: large wounds (trunk, extremities)
  2. FTSG: epi + full dermis
    - lower survival/more resistant
    - more 1’ contxn
    - ideal use: small, cosmesis, functional area (joints)
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7
Q

F5 Leiden Mechanism

A
  • acts w/ Xa to convert prothrombin to thrombin
  • protein C/S acts by inhibiting factor 5 and 8
  • mutated factor 5 can’t be inactivated by protein C/S
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8
Q

W/up of gastrinoma…

A

Dx:

  1. Off PPI: G > 1000 or >200 w/ secretin stimlation
  2. Can’t get off PPI: SS Scintigraphy

Localize:

  1. Triphasic CT/MRI
  2. SS Scintography (Dotatate PET/CT)
  3. Endoscopic US
  4. Selective intra arterial Ca
  5. OR: Intra-Op US, transduodenal palpation, duodenotomy, palpate HOP
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9
Q

Tx pseudocyst/WON

A

Dx: US or CT
- if can’t r/o cystic neoplasm on imaging must get EUS-FNA

Tx: Only drain if there are persistant sxs. Wait 4-6 weeks for wall to mature

  • near stomach/duo, > 6cm: endoscopic cystogastrostomy/duodenostomy
  • open cysto-enterostomy
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10
Q

Post trx lymphoproliferative disorder - path, px, and tx

A

Path- EBV positive B cell proliferation
Px- B sxs (fever, fatigue, weight loss)
- may cause lymphoma
Tx- reduce IS, rituximab

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11
Q

Tx of Thrombosed external HMHD

A
  1. w/in 48h- excision

2. after 48h- medically manage

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12
Q

Free water deficit

A

TBW x [(Na-140)/140]

TBW = weight x .6 (men) or .5 (women)

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13
Q

Order of contents in thoracic outlet

A
  1. Subclavian VEIN
  2. Phrenic NERVE
  3. Anterior scalene MUSCLE
  4. Subclavian ARTERY
  5. Brachial plexus NERVE
  6. Middle scalene MUSCLE
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14
Q

Corrected Ca

A
  • serum Ca + [ (4 - patient’s albumin) x .8]

- Always falsely low (not high)

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15
Q

Tx of pancreatitis masses

  1. WON sterile
  2. WON infected
  3. Pseudocyst
  4. Infected pseudocyst
A
  1. WON sterile: conservatively
  2. WON infected: step-up approach
  3. Pseudocyst: tx if sxs (infxn, obstruction, pain)
    - - 4-6w → internal drain → cystenterostomy
  4. Infected pseudocyst: drainage (internal, external, endoscopic)
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16
Q

Indications to tx ICA stenosis

A
  1. Asx: > 60%
  2. Sxs: > 50%
    - Sxs: contralateral motor/sensory sxs, ipsi vision sxs
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17
Q

Distal pancreatectomy in a trauma situation

A

Always do splenectomy unless stable and young (<30)

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18
Q

EBV associated with

A
  1. B cell lymphoma (Burkitt)
  2. n/ph cancer
  3. PTLD
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19
Q

Medications for hyperthyroidism - MOA and s/e

A
  1. PTU: thyroperoxidase and de-iodinase inhibitor
    - s/e of aplastic anemia or agranulocytosis. OK for preggo.
  2. Methimazole: thyroperoxidase inhibitor
    - s/e of cretinism, aplastic anemia and agranulocytosis
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20
Q

Mechanism:

VWF
Fibrin

A
  • VWF: binds GP1b on PLTs and attaches them to endothelium

- Fibrin: Links Gp2b/3a to form PLT plug

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21
Q

MRSA tx

A
  1. Vancomycin, Linezolid (best)
  2. Clind, bactrim, and doxy have partial coverage
  3. Ceftaroline (new 5G cephalosporin)
  4. Muporicin for skin burn
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22
Q

Neostigmine

A

MOA: AChE inhibitor

Use: reversal of non-depol muscle relaxants

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23
Q

Bethesda criteria for thyroid

A

**1 cm is cutoff to get an FNA

  1. Non-diagnostic → repeat FNA
  2. Benign → follow-up
  3. Undetermined significance → repeat FNA
  4. Follicular neoplasm → lobectomy, repeat FNA, or genetic testing (no core needle)
  5. Suspicious for malignancy → lobectomy vs. thyroidectomy
  6. Malignant → thyroidectomy
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24
Q

Achalasia - Dx and Tx

A

Dx:

  • no peristalsis
  • high LES pressure > 15 (vs. scleroderma, low)
  • incomplete relaxation

Tx:
- myotomy (6 eso, 2 stomch) is 1st line (avoid Nissen).

  • botox or dilation if high risk.
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25
Q

Ab reactions:

  1. Non-hemolytic
  2. Hemolytic
  3. Urticaria
  4. TRALI
  5. Anaphylaxis
A
  1. Non-hemolytic: fever; cytokine from donor leukocytes
  2. Hemolytic: fever + HOTN; recipient Ab attack donor leukocytes
  3. Urticaria: recipient Ab attack donor plasma
  4. TRALI: donor Ab attack recipient WBC
  5. Anaphylaxis: recipient Ab attack donor IgA
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26
Q

Cowden’s mutation and cancers

A

Mutation: pten
Ca: breast ca + thyroid ca + hamartomas

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27
Q

TLV

A

TLV = RV + ERV + TV + IRV

FRC = RV + ERV
IC = TV + IRV
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28
Q

Umbo ligs remnants:

  • Round
  • Median
  • Medial
  • Omph/M
A
  • Round: umbo vein
  • Median: urachus
  • Medial: umbo artery
  • Omph/M: vitelline duct (Meckel’s)
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29
Q

Octreotide

A
  • Somatostatin analogue

- Inhibits exocrine function of pancreas and CCK release

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30
Q

Drainage of gonadal veins

A
  1. Right- IVC

2. Left- Left renal vein

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31
Q

Tx Medullary thyroid cancer

A
  1. TOTAL thyroidectomy
  2. Bilateral central/level 6 dissection VI dissect
  3. Lateral neck dissection on that side if central+
  4. Start T4 postop. Monitor w/ calcitonin AND CEA
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32
Q

Tx for hyponatermia

A
  1. Acute w/ any sx’s: hypertonic saline bolus

2. Chronic and asxatic: free water restriction

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33
Q

Ulcers:

  • Marginal
  • Cameron
  • Marjolin ulcer
  • Cushing’s ulcer
A
  • Marginal: REYGB at GJ anastomosis
  • Cameron: on lesser curve of large hiatal hernia
  • Marjolin ulcer: chronic wound
  • Cushing’s ulcer: elevated ICP
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34
Q

Tx facial nerve inj

A

relative to lateral canthus of eye

  1. Medial- non op OK (arborization)
  2. Lateral- OR!
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35
Q

Radial scar- Dx and Tx

A
  • Dx: spiculated mass with central sclerosis

- Tx: excisional bx

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36
Q

preA vs. Albumin

A
  1. Prealbumin: >15; t1/2 is 1-2 days

2. Albumin: >3.5; t1/2 is 21 days

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37
Q

Tx pop aneurysm

A

> 2cm- ligation and bypass

<2cm- observation; avoid stents

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38
Q

Tx for ectopic pregnancy

A
  1. Stable– methotrexate or salpingotomy
    - MTX: absolute c/i if patient is breast-feeding
  2. Unstable– salpingectomy
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39
Q

Hyperkalemia EKG

Hypokalemia EKG

A
  • hyperK: peaked T wave, prolonged PR, eventual SINE

- hypoK: QT prolongation, ST depression, U waves

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40
Q

HS reactions

A 
1- IgE allergic rxn
2- Ab rxn
3- immune cx; ex- serum sickness
4- delated; t-cell mediated
5- auto-immune
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41
Q

Tx Pap thyroid ca in preggo

A
  • Postpone until 2T if advanced
  • If stable, postpone until after delivery
  • RAI is c/i
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42
Q

Mastodynia tx

A
  1. OCP/NSAIDS
  2. non-cyc + >30 OR cyclic + mass
    - mammo
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43
Q

Tx Mucinous neoplasm of appendix

A
  1. Confined to appendix: appe only
  2. Involving the base or ruptured: usually R hemicolectomy
  3. Peritoneal disseimation: can dx with perc bx
    - if no appendicitis can postpone appe until cytoreductive surgery
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44
Q

GCS eye opening

A

4- spon
3- to voice
2- to pain
1- none

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45
Q

Torsades

A

“polymorphic ventricular tachycardia”
2/2 hypoK, hypoCa, hypoMg
all cause qt prolongation

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46
Q

Normal values: CVP, WP, SVR, CI

A

CVP 2-6
WP 4-12
SVR 700-1500
CI 2.5-4

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47
Q

When to excise burns

A
  • < 72 hours but not until after appropriate fluid resuscitation
  • Used for deep 2nd-, 3rd-, and some 4th-degree burns
  • Viability is based on punctate bleeding (#1), color, and texture after removal (use dermatome)
  • Wait 1 week for face, palms, genitals, soles
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48
Q

TTP - Path, Px, Tx

A

Path- def in ADAMtS13
Px- TCP purpura, neuro sx, kidney dz, hemo anemia, fever
Tx- plasmapheresis → splenectomy if failed

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49
Q

LE angio

A

AT comes off first and goes lateral

TP trunk- PT behind tibia, peroneal behind fibula

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50
Q 
Liver lesions on arterial phase:	
HCC	
Mets	
Adenoma
Hemangioma	
FNH
A

HCC- Homogeneous enhancement. Rapid w/out.
Mets- Hypoattenuation
Adenoma- Heterogeneous enhancement
Hemangioma- Periph enhancing
FNH- Centrifugal enhancing
**If unclear, MRI can distinguish benign from malig

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51
Q

Methanol and Ethylene glycol toxicity - Px and Tx

A

Px: profound AG metabolic acidosis

  • metabolized in the liver
  • oxalate stones → renal failure

Tx: NaB + fomipazole (ADH inhibitor)
- consider iHD

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52
Q

Ureter anatomy

A

Runs under the vas/uterine arteries

Runs over the iliacs

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53
Q

Elective surgery after stent

A 
ASA lifelong
Plavix
- BMS: 6w
- DES: 6m
Post pone elective surgery until these times

If surgery is needed (i.e. cancer) wait at least 1m for DES

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54
Q

UE Injuries:

  1. supracondylar humerus
  2. DRF
  3. Mid shaft
  4. ant shoulder disloc
  5. post shoulder disloc
A 
supracondylar humerus- brachial artery
DRF- median nerve
Mid shaft- radial nerve
ant shoulder disloc- ax. nerve
post shoulder disloc- ax. artery
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55
Q 
Teg interpretation:
R time
K time
a angle
MA
LY 30
A 
R time- FFP
K time- cryo
a angle- cryo
MA- PLTs
LY 30- TXA
Rule of 6's: 
R > 6 minutes
alpha angle > 60 degrees
MA < 60 mm
LY30 > 6%
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56
Q

DeMeester score and indications

A

pH <4 , changes in position, duration, # of episodes
> 14.7 is positive

Indications:

  1. Scope negative but has sxs
  2. Max medical therapy by has sxs
  3. Post op but has sxs
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57
Q

SD

A

1, 2, and 3 SD = 67%, 95%, and 99.7% of the data

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58
Q

s/e of ileal conduit

A

Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)

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59
Q

Angiodysplasia of the colon - Dx and Tx

A

Dx: usually found in cecum and ascending colon
-2nd MC CO gi bleed (vs. div’s)

Tx: if bleeding or iron deficiency

  1. Endoscopic
  2. Surgery if refractory
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60
Q

Stewart-Treves syndrome

A

Post mastectomy lymphangiosarcoma
- rare and highly malignant
Tx- wide local excision w/ 3-6 cm margin

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61
Q

Tx for gallstone ileus

A

Stable and healthy- stone removal and take down fistula

Unstable, old/frail- stone removal only!

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62
Q

Sorafenib

A

TK inhibitor

Tx of HCC

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63
Q

Stricturoplasties

  • Heineke s’plasty
  • Finney s’plasty
  • Side2Side isoperistaltic s’plasty
A

Heineke s’plasty: <10cm; open long and close transversely

Finney s’plasty: > 10cm; segment folded on itself and common wall created

Side2Side isoperistaltic (MIchellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together

**These can’t be performed in proximal duo. If stricture is in the proximal-duo perform a G-J bypass

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64
Q

Best test to dx gastroparesis

A

Scintigraphic gastric emptying

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65
Q

Burn degrees

A

1D: epidermis
2D superficial: pap dermis, painful, blebs and blisters; hair follicles intact; blanches
2D deep: retic dermis, decreased sensation; loss of hair follicles, need skin grafts
3D burn: subcutaneous fat, leathery
4D: fat/muscle/bone; surg

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66
Q

Tx of ARDS

A 
TV at 4-6 ml/kg
Permissive hypercapnia
Survival benefit: prone, pralayze
-P/F < 100 = severe
**Must get echo to r/o cardiogenic edema
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67
Q

Interleukins 1, 2, 4, 6

A

IL1: fever
IL2: T cell prolif and Ig production
IL4: T/B cell maturation
IL6: hepatic acute phase reactant

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68
Q

Glucagonoma - loc, px, dx, tx

A

Loc: distal (a cells)
Px: dermatitis, DRH, DM, nec mig erythema
- most malignant
Dx: gluc > 1000
Tx: distal panc + splenectomy + LADN’y + CC’y

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69
Q

Aminocaproic acid

A

Plasmin inhibitor

Use: DIC, excess tpa

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70
Q

s/e of carb, protein, and lipid

A

carb- immunosuppression, resp failure
lipid- pro inflammatory
protein- false neurotransmitters, rise in ammonia/urea

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71
Q

Bx and Tx actinic keratosis

A
  • Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
  • Tx: topic 5FU. Photodynamics, imiquimod, cautery
    no margin
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72
Q

Hirschsprung surgeries

  • Duhamel
  • Soave
  • Swenson
A

Duhamel: agang stump in place/gang colon pulled behind; neo-rectum; less dissection/stricture

Soave: pull-through; “reverse alte”; remove M/SM; pull bowel within an aganglionic cuff; least dissection

Swenson: original; aganglionic segment resected to sigmoid colon; oblique anastomosis- colon x rectum.

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73
Q

z11 trial implications

A

If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK

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74
Q

Hard signs of vascular injury

A 
shock
expanding hematoma
pulsatile bleed
thrill/bruit
absent pulse
ischemia

If negative –> ABI – if positive –> CTA (to localize)

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75
Q

Polyps that require surgery instead of endoscopic resection

A 
Submucosal invasion > 1mm
Poorly differentiated
<1 mm margin
LV invasion
Tumor budding
Taken piecemeal
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76
Q

Iron def sxs

A

anemia, glossitis, brittle nails, cardiomegaly

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77
Q

T staging indications for neoadjuvant

  • eso
  • stomach
  • colon
  • rectal
  • lung
A
  • eso: select t1b (SM) or T2 (MP)
  • stomach: t2 (MP)
  • colon: t4b (adjacent organs)
  • rectal: t3 (through MP)
  • lung: n2 nodes
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78
Q

Atlanta classification pancreatits

A
  1. Interstitial:
    <4w- acute peripanc collection
    >4w pseudocyst
  2. Necrotic:
    <4w- acute necrotic collection
    >4w- walled of necrosis
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79
Q

Fuel for SB and LB

A

SB- glutamine

LB- SCFA (acetate, butyrate)

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80
Q

Motilin

A

Motilin – released by intestinal cells of gut; ↑ intestinal motility (erythromycin acts on this receptor)

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81
Q

Screening in IBD patients

A

Start 8 years after sx onset
2-4 random bx every 10 cm throughout the colon + suspicious areas

Repeat schedule:

  • normal: q1-3 years
  • PSC, stricture, or dysplasia w/out colectomy: q1 year

Any dysplasia usually gets a colectomy
- if resectable with negative can consider endoscopic resection with close surveillance

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82
Q

NEC

A

Bloody stools after 1st feed

tx- resuscitation, abx

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83
Q

W/up of thyroid nodule found on exam or incidental imaging

A
  1. U/S and TSH
    a. Nodule + Low TSH ➡ RAI uptake scan
    - hot/functioning: thyrotoxicosis (no cancer)
    - cold: FNA
    b. Nodule + Normal/High TSH ➡ FNA
    c. Any nodule > 1 cm gets an FNA
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84
Q

Tx male breast ca

A

Tx: simple mastectomy w/ SLNBx

  • BCT usually can’t be done b/c not enough tissue
  • if ER+: can use tamoxifen (Her2+ is rare). consider orchiectomy if metastatic.
  • Prognosis similar to W but delay in presentation is common
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85
Q

Nutcracker eso manometery

A

high amplitude/long peristalsis
normal LES pressure
normal relaxation

Tx- (identical to DES)

  1. PPI, CCB, TCA
  2. Long segment myotomy if refractory
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86
Q

MC etiology of ESRD leading to kidney trx

A
  1. DM, 2. HTN, 3. PCKD
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87
Q

Repair of Bile Duct Injury

A
  1. Intro-op:
    - convert to open, intra-op cholangio, repair OR
    - widely drain and send to specialty center
  2. Post-op:
    - Perc cholangiography to define the anatomy
    - Control spillage: external drain +/- stent +/- PTC
    c. Repair in 6-8 weeks

Treatment approach base on Strasburg class:
A- CD stump leak:
- Intraop: clip/ligate and leave drain
- Postop: perc drain + ERCP plasty/stent

B- Aberrant right hepatic ligation:
Asx and < 3mm- ntd
Sxs (cholangitis from occluded seg)- REYHJ

C- Transect aberrant right hepatic:

  • External drain if post op
  • Sxs: REY-HJ

D- Lateral injury to CHD/CBD:

  • No devascularization and small: 1’ T-tube closure
  • Devascularized: REY-HJ

E- full transection of CHD/CBD

  • < 1cm or distal w/out tension: 1’ T-tube closure
  • > 1cm OR proximal injury: REY-HJ
e1- > 2cm
e2- <2cm
e3- at confluence (confluence intact)
e4- at confluence (confluence separated)
e5- abbarent RH duct injury w/ CBD stricture
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88
Q

Eso dysplasia tx

A
  1. LGD- scope q6-12m lifetime (even if fundoplication)
  2. HGD- ablation + Q3m scope
  3. T1a- ablation
  4. t1b- esophagectomy

*Fundoplication does not decrease cancer risk

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89
Q

Superior epigastrics

Inferior epigastrics

A

SE: runs between rectus and posterior rectus sheath; branch of int mammary

IE: runs between transversalis fascia and parietal perit; branch of EI

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90
Q

When to intubate burn patients:

A
  • hypoxia, hypercarbia, severe upper airway edema
  • If stable and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling
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91
Q

Tx hemobilia after trauma

A
  1. EGD → CTA (if stable)
  2. angio embolization (no surgery)
    - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA
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92
Q

Paget Von Schroetter syndrome - path, px, tx

A

path- narrowing of SC/Ax vein 2/2 mech compression
px- acute swelling
Tx- catheter directed thrombolysis before anything else (NOT open thrombectomy)

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93
Q

Tx of AT3 def

A

Tx- recombinant at3 or FFP followed by heparin then warfarin

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94
Q

Vitamin C mechanism

A

hydroxylation of lysine and proline

type 3 collagen cross-linking

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95
Q

Inidications for neoadjuvant chemotherapy for rectal cancer

A

Stage 2 and above

Stage 2: at least t3 (crossing musc prop) or any n (stage 3)

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96
Q

Periop anticoagulation

A
  • High risk pt: afib, MHV, recent TE event (3m)
  • High risk surgery: nsurg, optho, cards
  • Med risk surgery: abdominal operations
  • Low risk surgery: dental
  • bridge for high risk patients
  • stop warfarin 5 days before surgery if not bridging, resume on day of surgery
  • Hold Noac 2 days before surgery and resume 1 day after
  • continue aspirin for low/moderate risk surg
  • stop Plavix 5 days before
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97
Q

What is not suppressed by high dose dexa

A 
Adrenal mass
Ectopic mass (small cell cancer)
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98
Q

Metabolic alkalosis - chloride responsiveness

A
  1. Cl responsive (Ur Cl < 20)
    - temporary loss, replaceable
    - vomiting
  2. Cl resistant (Ur Cl > 20)
    - hormonal, continuous loss
    - conn’s, steroids, hyperaldosterone
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99
Q

Heller myotomy margins

A

6 cm proximal, 2 cm distal

Eso- vertical fibers first (outside), then circular (inside)

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100
Q

Margin for invasives cancer vs. dcis

A

Invasive cancer- no tumor on ink
dcis- 2 mm

**if both in specimen, margin is no tumor on ink

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101
Q

Tx hypertrophic cardiomyopathy

A

beta blockers
avoid inotropes
use neo if needed

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102
Q

ITP- dx and tx

A

dx- of exclusion
tx-steroids → IVIG 2nd line → splenectomy
do not tx unless PLT < 30k or 20k in low risk

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103
Q

Staph species

A

G+/aerobe/clusters; coag+ → aureus

coag- → epidermidis

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104
Q

Cryptorchidism tx

A
  • wait until 6m old
  • if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma
  • risk of ca higher in both testes.
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105
Q

Sarcoma stage and grade

A
  1. Grade ~ differentiation, mitotic count, and necrosis
    - - more important than size, nodal/distal mets for prognosis
2. Stage
Stage 1- G1 w/ any T stage
Stage 2- G2/3 and T1
Stage 3- G2/3 and T2+
Stage 4- N+
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106
Q

Neuroblastoma dx and tx

A

dx
- CT: displacement of renal parencyma (vs. Wilm’s).

tx:

  • S1-2 (low risk) → surg alone
  • S3+ (high risk) → surg + chemo/XRT
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107
Q

Gastrin MOA

A

G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ HCl
Stimulated by ACh, beta ago, AA

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108
Q

Innervation to internal and external anal sphincter

A
  1. Internal: SNS/PSNS fibers from superior rectal and hypogastric plexus
  2. External: Internal pudendal nerve from 4th sacral nerve
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109
Q

Esophagus blood supply

A

Cervical- inf thyroid
Thoracic- aortic branches
Abd- left gastric/inferior phrenic

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110
Q

CBD and PD on ERCP

A

CBD at 11’

BD at 1’ to 3’

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111
Q

Tx Urethral injury

A

Grade:
1/2- contusion/stretch ➡ cath
3- part disruption ➡ OR
4/5-complete disruption ➡ cystostomy + OR

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112
Q

TEF - MC types - dx and tx

A
  1. Type C – most common type (85%)
    - Proximal esophageal atresia (blind pouch) and distal TE fistula
    - dx: AXR: distended, gas-filled stomach
  2. Type A – second most common type (5%)
    - Esophageal atresia and no fistula
    - dx: XR: gasless abdomen

Tx:

  1. Resuscitate w/ repogle tube
  2. G-tube placement to decompress and feed
  3. Delayed right extra-pleural thoracotomy
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113
Q

Tx of Ogilvie’s

A
  1. supportive, dc narcotics, ng tube, neostigmine
  2. if > 10cm ➡ scope decompression and neostimgine
  3. failure ➡ OR

**scope or enema before giving neo to r/u obstruction

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114
Q

Tx of prolactinoma

A
  1. Bromocriptine or carbegoline (both dopa agonists)
    - bromo is safe in pregnancy
  2. Surgery if failure
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115
Q

Pros/Cons:

  • Sevoflurane
  • Isoflurane
  • Halothane
  • NO
A
  • Sevo: rapid induction, less pungent. Good for kids.
  • Isoflurance: good for neurosurgery; no increase in ICP
  • Halothane: slow onset/offset, cards depression, hepatitis.
  • NO: least cardiac depression b/c sympathomimetic (don’t use in cardiac failure). c/i in SBO. Highest MAC.
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116
Q

Atropine MOA

A

competitive inhibitor of ACh at muscarinic receptor liver metabolism

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117
Q

Tx FMD

A

angio + balloon (no stent)

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118
Q

MEN1/MEN2 genes

A

MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene

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119
Q

Birads score

A 
0- redo imaging OR require U/S
1- negative, NTD
2- benign, NTD
3- benign, repeat q6m
4- suspicious, bx
5- highly suspicious, bx
6- confirmed, excise
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120
Q

MOA and use of antifungals:
Azoles
Micafungin
Amphotericin

A

Azoles: ergosterol synth inhibitor
- non systemic candida (yeast infection)

Micafungin: echinocandin; inhibit glucan production
- dissemintated candiasis

Amphotericin: binds ergosterol and inhibits
- invasive mucor or cryptococcal meningitis

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121
Q

Recurrent laryngeal nerve

A

motor to larynx except circothryoid

injury: hoarsness, airway compromise, cord paralysis (permanent ADduction)
- If bilateral may need a trach

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122
Q

PFTs for lung resection

A
  1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing
    - >.8L wedge, >1.5L lobe, >2L pneumo
    - < 80% ➡ lung scan for PPO FEV1, DLCO
  2. PPO FEV1, DLCO > 60% ➡ no further testing
    - < 60% ➡ exercise test
  3. VO2 > 10 ml/min/kg ➡ OK for surgery
    - < 10 ➡ high risk for surgery
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123
Q

Origins of medullary thyroid cancer

A
  • 4th pharyngeal arch releases NCC which form parafollicular C cells
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124
Q

Gastrinoma - loc, px, dx, tx

A

Loc: gastrinoma triangle (CBD, panc neck, 3D)

Px: refractory PUD
- Mostly malignant

Dx: G > 1000 (off PPI) or >200 w/ secretin (off PPI)
- SS Scintigraphy (dotatate scan) if can’t get off PPI

Tx: Screen for MEN1

  • <2 cm: enucleate w/ LADN’y
  • > 2cm: resect w/ LADN’y
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125
Q

qSOFA score

A
  1. AMS (<15)
  2. RR > 22
  3. SBP < 100
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126
Q

MC Benign and Malignant H/N tumors - tx

A
  1. Benign: Pleomorphic adenoma
    - Tx: superficial parotidectomy even if asx
  2. Malignant: mucoepidermoid carcinoma tx
    - Tx: total parotidectomy (facial nerve preservation) + MRND + XRT
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127
Q

Tx frostbite

A

Frostnip: rapid re-warming

2d: clear/milky blister- drain
3d: HMHG blister- leave intact
4d: bone- prostacyclin/TPA, amputate

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128
Q

Tx of Pilonidal cyst

A
  1. ASx: NTD
  2. Acute abscess: drain only
  3. Chronic cyst: offer surgery if effecting QOL
    - - marsupialization and leave open: lower recurrence
    - - primary closure: faster healing. Off midline- less comps (preferred)
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129
Q

MCCO Cancer

A

Male- prostate, lung, CRC
- death: lung, prostate, CRC
Women- breast, lung , CRC
- death: lung, breast, CRC

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130
Q

Tx TCPenia

A

<10k if asx
<20k if septic, chemo/rads, RF’s
<50K if elective surgery

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131
Q

Tx Annular pancreas

A

neonates- duododuodenostomy (mobile duo)

adults- duodenojejunostomy

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132
Q

TNFa

A

produced by macrophages

causes cachexia

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133
Q 
W/up of pancreatic cystic neoplasms:
Pseudocyst
Serous cystadenoma
MCN
IPMN
A
  1. MRI 2. EUS w/ FNA (If unclear):
    - High CEA > 190

Pseudocyst- high Am, low CEA
Serous cystadenoma- low Am, low CEA
MCN- low Am, high CEA (>200)
IPMN- high Am, high CEA (>200)

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134
Q

Propofol - pros and cons

A

Pros

  • rapid distribution and on/off
  • decreases ICP

Cons

  • s/e: hypotension, resp depression, meta acid
  • no analgesia
  • metabolism: liver
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135
Q

Enterohepatic circulation

A

Liver → P BSalts → hepatocytes → conjugated BS:

  1. 80% active ileum absorbed
  2. 20% deconjugated by bacteria → passive colon absorbed
  3. 5% out in stool
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136
Q

Tx CO poison

A
  1. 100% O2 w/ facemask or intubation (not hi flo)
    - Hyperbaric O2 is controversial
  2. intubate if comatose, severe acidosis
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137
Q

Indication for APR

A
  1. Rigid proctoscopy: w/ in 2cm of anal verge (levators)
  2. PE: baseline sphincter dysfxn
  3. Recurrent SqCC (s/p Nigro)
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138
Q 
Cancer associations:
CEA
AFP
CA 19-9 
CA 125 
Beta-HCG 
PSA 
NSE
BRCA I and II
Chromogranin A
Ret oncogene
A 
CEA – colon CA
AFP – liver CA
CA 19-9 – pancreatic CA
CA 125 – ovarian CA
Beta-HCG – testicular CA, choriocarcinoma
PSA – prostate CA
NSE – small cell lung CA, neuroblastoma
BRCA I and II – breast CA
Chromogranin A – carcinoid tumor
Ret oncogene – medullary thyroid CA
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139
Q

Types of esophagectomy compared

A
  1. Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy
    - anastomosis: thoracic
    - theoretically more thorough oncologic resection
    - may be better in more fit patients
  2. Transhiatal: abdominal + L neck
    - anastomosis: cervical
    - theoretically less chance of mediastinal leak, shorter operation
    - may be better if old/frail and distal esophagus tumors
  3. McKeown: abdominal + L neck
    - anastomosis: cervical

***Gastric conduit supply- R gastroepiploic (off GDA/CHA)

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140
Q

Somatostatinoma - loc, px, dx, tx

A 
Loc: head
Px: DM, GALLSTONES (> glucagonoma), steatorrhea, block exo/endo pancreas
- most malignant
Dx: sx's + high fast SS  
Tx: resect + LADN'y + CC'y
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141
Q

Specific to UC

A

Crypt abscess

Psuedopolyps

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142
Q

Etomidate - Pros and Cons

A

Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e
Cons- adrenocortical suppression

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143
Q

W/up and Tx testicular ca:

  • Seminoma
  • Non-seminomatous
A
  1. AFP, HCG, LDH
  2. U/S
  3. Inguinal orchiectomy : based on path/markers decide on RPND
    - Seminoma: XRT
    - Non-seminomatous: retroperitoneal node dissection

**ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection

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144
Q

Liver collection dx and tx:
Pyo
Amoebic
Echino

A

Pyogenic- after div’s;
- drain and abx (+mica if fungal)

Amoebic- after mexico trip
- metronidazole (no drain)

Echinococcal- wall Ca+ and sub-cysts
- albendazole and resect/PAIR

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145
Q

Maneuvers

A
  1. Kocher- lateral peritoneal attachment of D2
  2. Maddox- white line from sigmoid to splenic flex
    - abdominal aorta, left renals, celiac, SMA, left iliac
  3. Cattell- continuation of kocher; from D2 to sigmoid
    - IVC, right renals, right iliac
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146
Q

EVAR specs

A 
Proximal landing: > 1.5 cm
- diameter < 3cm
Common iliac (distal landing): > 1 cm
- diameter > 8 mm
Neck angulation < 60 degrees

EI diameter> 7mm

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147
Q

Tx of anal fissure

A
  1. Sitz bath, fiber, topical nifedipine/nitroglycerin
  2. Good sphincter tone: LATERAL, INTERNAL sphincterotomy
  3. If poor sphincter tone: botox injection

**If 2/2 crohn’s dz: optimize medical management

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148
Q

Lynch genes

A

DNA MM repair gene (MLH1, MSH2, MSH6, PMS2)

EPCAM

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149
Q

Condyloma types

A
  1. acuminatum- HPV (6, 11- benign; 16, 18- Ca)

2. lata- syphilis

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150
Q

Tx of liver lesions:
Hemangioma
FNH
Adenoma

A

Hemangioma: only if sxatic or KM syndrome
FNH: NTD
Adenoma: < 4cm w/out OCP response or > 4cm

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151
Q

REY limbs

A

Roux- 75 to 150 cm

BP- 15 to 50 cm

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152
Q

Dx and Tx congential DPGM hernia

A

-Dx: prenatal dx on US

  • Tx:
    1. intubate (in delivery rm)
    2. NGT +/- ECMO
    3. delay OR when stable
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153
Q

Indications for neoadjuvant therapy for stomach cancer

A

Any T2 lesion or LN involvement

T2: growth into the muscularis propria

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154
Q

Stages of empyema formation

A
  1. Exudative –> drainage or VATS (1-7 days)
  2. Fibrinopurulent –> VATS (7-21 days)
  3. Organizing –> thoracotomy (21+)
  • *VATS between days 3-7
  • Preferred over 2nd CT placement or fibrinolytics.
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155
Q

Vertebral artery occlusion px

A

posterior circulation

sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia

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156
Q

5Ts of cyanosis

A 
TOF	
Transposition of GVs	
Truncus art	
Tricuspid atresia	
TAPVC
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157
Q

DES - Manno and Tx

A

unorganized peristalisis
normal LES pressure
normal relaxation

Tx:

  1. CCB (+TCA if chest pain)
  2. Botox injection (endoscopic)
  3. Last resort: long segment myotomy
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158
Q

Supraceliac aortic control

A
  1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram
  2. Stable: left medial visceral rotation is preferred
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159
Q

Mondor disease - px and tx

A

px- tender, “cord-like” structure

tx- NSAIDs

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160
Q

Dx and Tx Phyllodes

A

Dx:
-Bx w/ stromal overgrowth, atypia, high MI, “leaf-like”

Tx: WLE w/ 1 cm margin
- can spread hematogenous to lung

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161
Q

Replaced Rand L hepatic

A

Right- SMA (behind pancreas and CBD)

Left- left gastric (in gastrohepatic ligament)

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162
Q

Effective for enteroccous

A

Ampicillin/Amoxacillin
Vancomycin
Timentin/Zosyn
(Resistant to all cephalosporins)

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163
Q

Loss in excess weight for each surgery

A

REYGB- 75%
SG- 60%
Lap band- 50%

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164
Q

Acid/Base of Ng suctioning

A

HypoCl, HypoK metabolic alk
Loose HCl and fluid
Turn on RAA system
Retain Na/Excrete acid (paradoxic acidurea)

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165
Q

Types of vagotomy

A
  1. Truncal vagotomy: transect ant/post @ distal eso
    - removes lesser curve and pylorus nerve
    - need pyloroplasty. high r/o dumping syndrome
  2. Highly selective: transect @ crow’s ft, preserve laterjet
    - removes innervation to lesser curvature
    - preserves pylorus → no drainage procedure
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166
Q

Indications for total thyroidectomy (pap and follicular)

A

Indications for total thyroidectomy:

  • Tumor > 4cm
  • Tumor 1-4cm and patient preference
  • Distant mets or extra-thyroid disease
  • Nodal disease
  • Poorly differentiated
  • Prior radiation

*micro-mets do not count as distant disease

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167
Q

Tx Soft tissue sarcoma

A

dx:

  • < 3cm: excisional bx
  • > 3 cm: incisional bx or core needle

tx:

  • resect w/ 2 cm marg
  • neoadj: rhabdomyo, Ewing, high grade, > 10 cm
  • adj XRT: > 5cm, high grade, recurrence, close marg
  • adj chemo: never
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168
Q

Step up approach

A

Infected pancreatic necrosis (WBC + gas on CT)

  1. IV abxs
  2. Perc drain OR endo drain (if stomach is close to pancreas)
  3. 2nd drain
  4. VARD/DEN
  5. lap necrosectomy
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169
Q

CN11

A

spinal accessory nerve
exit jugulars foramen
innervates SCM and trapezius
goes along post triangle

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170
Q
  1. Central cord syndrome

2. Anterior cord syndrome

A
  1. Central cord: loss of pain, temp, motor
    - motor UE> LE loss (vs. anterior syndrome)
    - hyperextension in the setting of SS
  2. Anterior cord: loss of pain, temp, motor
    - below the level of the lesion
    - ASA injury or anterior cord compression
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171
Q

Tx SVT

A

types: af, aflutter, paroxysmal SVT, WPW
1. vagal → adenosine
- may unmask afib/flutter
2. HDS: BB, CCB ➡ sync cardioversion
3. HDUS ➡ sync cardioverison

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172
Q

Von Hippel Lindau - mechanism and surveillance

A

VHL gene - upreg. of VEGF

  1. Brain/retinal hemangioblastoma- q2y brain MRI
  2. Clear cell RCC- q1y US/MRI of abdomen
  3. Pheochromocytoma- yearly metanephrines
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173
Q

Melanoma w/up and tx

A
  1. Punch bx
    - Tumor thickness is strongest prognostic indicator:
    - - MIS- 5mm margin
    - - <1mm- 1cm
    - - 1-2mm- 1-2cm
    - - >2mm- 2cm
  2. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
  3. If SLNBx+ or Cx positive nodes: q4m US surveillance OR completion LN dissection
    - LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes
  • *In-transit disease: lesions > 2cm from primary but not beyond regional tumor basin
  • immunotherapy or BRAF inhibitor
  • only excise if feasible (few lesions)

**MOHS can be use for in-situ disease. Need 5 mm margin.

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174
Q

Steps of rapid sequence intubation

A

c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine

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175
Q

PSC vs. PBC

A

PSC: Male; intra/extra hepatic; onion fibrosis; chain of lakes
a/w UC, cholangioca

PBC: Female; intra hepatic; granulomas; +AMA;
a/w Sjogren, RA

tx both- trx, cholesty., UDCA

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176
Q

CPP

A

MAP - ICP
normal CPP > 60
Normal ICP < 20

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177
Q

Draining peri-rectal abscess

A
  1. Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles)
  2. Supralevator abscesses need to be drained trans-rectally
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178
Q

Dx and Tx malrotation

A

Px: Any child with bilious vomiting needs an emergent UGI to rule out malrotation
Dx: UGI – duodenum does not cross midline
Tx:
1. resect Ladd’s bands
2. widen the mesentery (resect central bands)
3. counterclockwise rotation
4. place cecum in LLQ (cecopexy), duodenum in RUQ
5. appendectomy

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179
Q

Epidural hematoma

A

Biconvex
MMA
DOES NOT suture lines

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180
Q

MEN syndromes

A

1- pancreatic (gastrin), pituitary, parathyroid; menin; AD
2a- Parathyroid,MTC, Pheo; ret; AD
2b- Pheo, MTC, marfanoid/neuroma; ret; AD

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181
Q

CRC staging

A

stage 1- t1 to t2, n0
stage 2- t3 to t4, n0
stage 3- node involvement
stage 4- m1

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182
Q

Nitrogen balance

A 
Protein intake (grams)/6.25 - (UUN + 4 grams)
UUN =grams of nitrogen excreted in the urine over a 24 hour period
4 = stool and insensible losses

Recommended protein = 1g/kg/day
Nitrogen = protein intake/6.25

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183
Q

Periop Warfarin

A

stop 5 days before

Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6

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184
Q

Management of PE

A
  1. no RH strain → acoag
  2. RH strain → IR catheter
  3. RH strain + HDUS → systemic tPA
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185
Q

Methemoglobinemia - px, dx and tx

A

Px: from nitrites such as Hurricaine spray, fertilizers

  • Fe2+ becomes Fe3+ impairing O2 binding
  • can be induced w/ G6PD def or serotonergic drugs
  • Dx: blood gas can measure OR pulse ox says 85%
  • Tx:
    1. G6PD def or serotonergic drugs: vitamin C
    2. Otherwise: methylene blue
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186
Q

Layers of colon/rectum

A
  1. mucosa
  2. sub-mucosa (strongest)
  3. muscularis propria
  4. serosa
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187
Q

LE vascular trauma

A

small- patch plasty
large- contralateral GSV
limited time/unstable- shunt

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188
Q

Tx Post dural puncture headache

A

after epidural

tx with blood patch

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189
Q

Tx for DVT

A
  1. unprovoked: malignancy, inherited –> indefinite
  2. provoked: surgery, travel, preg, OCP, immbility –> 3m

**open thrombectomy –> last resort forthreatened limb loss secondary to extensive (ileofemoral) DVT OR phlegmasia

**IVC filter: if recent intracranial/spine surgery, evidence of ongoing post op bleeding

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190
Q

Loop diuretics vs. Ca sparing diuretics

A

loop- furosemide

Ca sparing- thiazides

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191
Q

MALT lymphoma tx

A

associated w/ h. Pylori.
Tx:
- Low grade: triple therapy (eradicate HP)
- High grade: chemo and XRT (CHOP) +/- rituximab

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192
Q

lower extremity bypass graft failure depends on temporal relation to the surgery.

A
  • <30d: technical error
  • 1m-2y: intimal hyperplasia, (at the distal anastomosis)
  • > 2y: progressive atherosclerotic disease
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193
Q

Tx Parathyroid ca

A
  1. Control hypercalcemia:
    - IV fluids 1st! Then bisphosphonates
    - cinacalcet (sensipar - ca mimetic)
  2. Parathyroidectomy w/ hemithyroidectomy + L6/central neck dissection + XRT
    - no chemo
    - some don’t perform the L6
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194
Q

Tx infected pseudocyst

A

aspirate/gram stain to dx → drainage (internal, external, endoscopic)

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195
Q

Tx Melanoma of anal canal

A

Px- S100+, pigmented. NO chemo-XRT
Tx:
- WLE (1 cm). No SLNBx
- APR if sphincter involved, LADN, or > 4mm

  • *5y-S is 20% w/ R0
  • *WLE = APR
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196
Q

Kaposi’s sarcoma - cause and px

A

HSV8

Violet/brown papules

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197
Q

Mechanism and Tx of thyroid dz:

  1. Graves
  2. TMN
  3. Hashimoto’s
  4. DeQuervains/Subacute
  5. Reidels
A
  1. Graves: IgG stimulates TSHr ➡ hyperT
    - BB, PTU ➡ RAI ➡ thyroidectomy
  2. TMN: chronic TSH stimulation ➡ hyperT
    - BB ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy
  3. Hashimoto’s: antiTPO/TG Ab ➡ hypoT
    - thyroxine ➡ partial thyroidectomy
  4. DeQuervains/Subacute: viral URI
    - NSAIDS/ASA ➡ steroids
  5. Reidels: autoimmune inflammation
    - steroid, thyroxine ➡ extensive fibrosis often need surgery for compression
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198
Q

Sonograph FNA recs

A

cystic- no bx
isoech/hyperech- FNA if > 2cm
hypoech (high sus)- FNA if > 1cm

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199
Q

Tx anal incontinence

A

1st line- fiber/bulking, exercises

refractory- overlapping sphincteroplasty

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200
Q

s/e of silver nitrate, silver sulfadiazene, mafenide, bacitracin

A

Silver nitrate- eletrolytes disturbace (no sulfa)
Silver sulfadizene- neutropenia, sulfa
Mafenide- met acidosis, sulfa (covers pseudo and eschar)
Bacitracin: G+; nephrotoxic

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201
Q

Triple therapy

A

PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks

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202
Q

APC gene

A

chrom5
1st mutn in adenoma to carcinoma
mc mutation in colon ca
a/w FAP.

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203
Q

Contents of post triangle

A
  1. CN 11
  2. subclavian artery
  3. EJV
  4. brachial plexus trunks
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204
Q

Gail model

A
  1. age
  2. age 1st period
  3. age 1st birth
  4. 1d relative
  5. previous bx
  6. race
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205
Q

Associated orthopedic injuries:

  1. post hip disloc’n
  2. post knee disloc’n
  3. DRF
  4. Supracondylar humerus fx
  5. Anterior shoulder disloc’n
A
  1. post hip disloc’n- sciatic nerve (peroneal branch)
  2. post knee disloc’n- popliteal atery
  3. DRF- median nerve
  4. Supracondylar humerus fx- brachial artery
  5. Anterior shoulder disloc’n– axillary nerve
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206
Q

Anti-staph Penicillins

A

Oxacillin
Methicillin
Nafcillin

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207
Q

Dobutamine

A

B1 at low dose
- inotropy

B2 at high dose
- vasodilation

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208
Q

types of endoleak and tx

A
  1. proximal/distal seal- balloon expansion of distal/proximal attachments + stent
  2. back bleeding- coil embolization
  3. graft defect (tear or overlap leak)- additional graft coverage
  4. porosity- resolves on its own
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209
Q

Carcinoid vs. GIST vs. Desmoid

A
  1. Carcinoid- Kulchinsky cells (enterochromaffin-like) tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable
  2. GIST- cajal cells
    tx- resection, imantinib
  3. Desmoid- spindle cells
    tx- resect if extra-abdominal. NSAID/estrogen if intra
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210
Q

Meckel’s Diverticulum Pathophys

A

Anti-mesenteric border of SB
2/2 peristant viteline duct
pancreatic and gastric tissue
2 feet from IC valve

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211
Q

VRE (vancomycin-resistant Enterococcus)

A

Synercid, linezolid

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212
Q

Acetazolamide MOA

A

Inhbitis carbonic anhydrase

non-AG metabolic acidosis

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213
Q

Milrinone

Midodrine

A

Milrinine- PD inhibitor, contractility with vasodilation

Midodrine- a1 agonist

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214
Q

Hyperaldosterone w/up

A

Px: resistant HTN and hypokalemia

  1. AM plasma aldo AND plasma renin
    - A/R < 20: 2nd hyperaldo
    - A/R > 20: primary hyperaldo ➡
  2. Confirmatory test: salt load suppression test
    - give salt load ➡ 24h urine aldo remains elevated
  3. Discern laterality: CT scan
    A. Unilateral: adenoma, unilateral hyperplasia, carcinoma ➡ offer lap adrenal
    B. Bilateral or negative ➡ adrenal vein sampling
    - Lateralization: offer lap adrenal
    - No lateralization: idiopathic hyperplasia ➡ tx medically
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215
Q

Tx and Dx of SBP

A

dx- ↑ascitic PMN and + culture;

tx- 3GC abx AND albumin (survival benefits)

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216
Q

HLA test

A
  • Donor organ: carries Ag (on WBC)
  • Recipient body: carried Ab

Recipient serum with donor wbc

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217
Q

Tx acute variceal HMHG

A

octreotide + antibiotics → endoscopic intervention (ligation/sclerotherapy) → TIPS

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218
Q

Tx SVC syndrome tx

A
  1. Elevate HOB
  2. CXR and CTA
  3. Assess sxs
    A. Life-threatening sxs: secure airway ➡ consider AC ➡ venogram ➡ endovascular stenting
    B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo
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219
Q

Crystalloid and colloid for trauma kids

A

Crystalloid: 20cc/kg
PRBC: 10cc/kg

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220
Q 
Melanoma characteristics:
superficial spreading
lentigo
nodular
acra
A

superficial spreading- MC
lentigo- sun exposed, best prog
nodular- worst prog
acral- AA

**thickness is most indicative of prognosis

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221
Q

Tx appendicitis

A
  1. Uncomplicated: no perforation, abscess, mass
  2. Septic/Unstable: immediate lap appe
  3. Stable w/ abscess
    - < 3cm: lap appe
    - > 3cm: IR drain ➡ interval appe in 6-8 weeks; lap appe if no cx imporvement
  4. Phlegmon:
    - ileocecal resection likely: abx trial 1st
    - ileocecal resection unlikely: lap appe

**Lap appe a/w higher intra-abdominal abscess and OR time (lower overall complication rate)

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222
Q

Tx MEN2A/B

A
  1. urine metanephrine to r/o pheo 1st
  2. tx pheo 1st w/ adrenalectomy
  3. Address thyroid
    - 2A: total thyroid at 5y
    - 2B: total thyroid at 6m
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223
Q

Tx MEN1

A
  1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
  2. Asses other lesions
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224
Q

Tx anaplastic thyroid ca

A

aggressive, undiff
mort ~ 100%; no tx
tx- XRT improves short-term survival +/- surg

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225
Q

Hepatitis seromarkers

A

Vaccinated: surface Ab+
Resolved Hb infection: surface Ab+ and core Ab+
Active: surface Ag+, surface Ab+, and core Ab+ (IgM)
Chronic: surface Ag+, surface Ab+, and core Ab+ (IgG)

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226
Q

GI Hormone Release and action:

Glucagon
Insulin

A

Glucagon – alpha cells of pancreas
- glycogenolysis, gluconeogenesis

Insulin – beta cells of the pancreas
- cellular glucose uptake; promotes protein synthesis

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227
Q

TASC classifcation

A

TASC a and b usually get endovascular repair
A- < 3cm
B- 3-10 cm

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228
Q

Criteria for transanal excision of adenocarcinoma

A

T0 or T1 (submucosa)
< 3 cm
< 30% circumference
Palpable on DRE (<8cm from anal verge)

**local recurrence rate is higher

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229
Q

Merkel cell ca - dx and tx

A

Dx:

  • rare neuroendocrine tumor of the skin
  • looks like BCC w/out rolled edges

Tx:

  • highly radiosensitive
  • Tx (like melanoma): surgical excision + SLNBx! + XRT
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230
Q

Breast abscess tx

A

US aspiration BEFORE I/D if refractory

Bx if > 2 weeks to r/o ca

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231
Q

5 steps to LADDS procedure

A 
resect Ladd’s bands
widen the mesentery
counterclockwise rotation
place cecum in LLQ (cecopexy), place duodenum in RUQ
appendectomy
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232
Q

Beta lactamase inhibitors

A

Sulbactam/Tazobactam

Clavulanic acid

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233
Q

Entamoeba vs. echinococcus - dx and tx

A
  1. Entamoeba
    dx: from mexico; microscopy, antigen testing, or PCR
    - CT: rim enhancement
    tx: even if asx
  2. MEtronidazole
  3. Surgery if refractory
  4. Echinococcus
    dx: enzyme-linked immunosorbent assay
    - CT: calcification + endocyst
    tx: albendazole x2 weeks then PAIR
    - ‘pair’ - puncture, aspiration, injection (etoh), re-aspiration
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234
Q

HNPCC screening and treatment

A
  1. CRC: scope q1-2y starting at 20-25
    - Surgery if:CRC or endoscopically unresectable lesions
    - TAC with IRA w/ q1y rectum surveillance
  2. Endometrial ca
    - childbearing: endometrial sampling q1y
    - completed children: TAH-BSO
  3. Ovarian ca: annual pelvic exam and TVUS
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235
Q

Tx choeldochoal cyst

A
  1. fusiform dilation: REY-HJ
  2. diverticulum: simple excision
  3. choledococele: transduo excision/sphincteroplasty
    4a. intra + extra dilation: hepatic resection + recon
    4b. extra only: excision + recon
  4. intra only: transplant
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236
Q

Vit D vs. PTH

A

Vit D: increase Ca and Ph

PTH: increase Ca and decrease Ph

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237
Q

Arterial content

A

(1.34 x Hb x Sa02) + (.003 x PaO2)

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238
Q

Px, Dx, and Tx:

Duo atresia
TEF
Pyloric stenosis
Intussusception
Malro
A

Duo atresia: newborn; bilious emesis directly after birth

  • a/w down syndrome
  • dx: AXR- doube bubble
  • tx: duodenoduodenostomy

TEF: newborn, spit ups. can’t place NG. resp sxs

  • dx: AXR- gasless (A), gas (C)
  • tx: right extra-pleural thoracotomy

Pyloric stenosis: 1-3 months; NB projectile vomiting

  • dx: U/S- 4mm thick, 14 mm long
  • tx: pyloromyotomy

Intussusception: 3m-3y; currant jelly stool

  • dx: U/S w/ bull’s eye
  • tx: air contrast enema

Malro: 1y-5y; sudden onset bilious emesis

  • dx; UGI- no duo sweep (any child w/ bilious emesis)
  • tx: ladd’s procedure
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239
Q

Cori cycle

A

recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production

provides 40% of glu when starving

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240
Q

Tx of GB cancer

A

1a: LP only
- lap chole only
1b: muscle inovlved
- lap chole + seg 4b and 5 + LADN
- CD margin positive: REY-HJ

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241
Q

Layers of mucosa

A

Epithelium
Lamino Propria
Muscularis mucosa

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242
Q

Stage 3 breast cancer and tx

A

3a- 4 to 9 nodes ➡ +/- neoadj
3b- chest wall (not pec wall) or breast skin ➡ +/- neoadj
3c- supra clavicular nodes ➡ neoadj required

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243
Q

Tx of CBD stone intra-operatively

A
  1. Flush ➡ glucagon x 2
  2. Lap exploration
    A. Transcystic: stone < 1 cm, <8 stones, CD > 4 mm, no CHD stones, normal anatomy
    B: Lap CBD: stone > 1cm, > 8 stones, CBD > 7 mm, CHD or junction stones, abnormal anatomy
  3. Open exploration: if lap exploration failed
    - CBD < 2 cm: trans-duo sphincteroplasty
    - multiple stones, CBD > 2 cm: biliary-enteric drainage.
  • Leave T-tube- avoid spasm and back pressure that could blow out your stump
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244
Q

W/up Hurthle Cell Cancer

A
  1. FNA- hurthle cells
  2. lobectomy 1st for diagnosis
  3. If malig: total thyroidectomy +/- L6 nodes
  4. If palpable nodes: MRND

No RAI

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245
Q

Conduit after esophagectomy

A

Stomach and Right gastroepiploic
- if you notice this is out then stop the procedure and discuss conduit options at a later time (don’t go for colon or jejunum b/c needs to be prepped)

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246
Q 
Cancer Markers:
Ca 126
bHCG
AFP
Inhibin
A

Ca 125- epithelial
bHCG- choriocarcinoma
AFP- germ cell/endodermal/yolk sac
Inhibin- granulosa/sex-cord

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247
Q

Tx of High grade AIN/bowen’s disease of anal margin

A
  1. Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin
    - otherwse: cryo, curettage, 5-FU, laser
  2. Lifetime surveillance even if tx!
  • Bowen disease = SqCC in situ = high grade AIN
  • Actinic keratosis is precursor
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248
Q

Types of rejection - px, path, and tx

A
  1. hyper-acute: w/in 1 hour
    - path: ABO Ab (t2 HS)
    - px: mottled organ
    - tx: remove organ
  2. acute cellular: days-weeks; change in organ function
    - path: B or T (t4 HS)
    - px:
    - - kidney: decrease UOP, elevated Cr; tubulitis
    - - liver: elevated enzymes; endothelitis, portal triad lymphocytosis
    - tx: increase IS, steroids, IVIG
  3. chronic: months-years
    - path: B or T (t4 HS)
    - px: organ dysfunction after months-years
    - - kidney: interstitial fibrosis, tubular atrophy
    - - liver: bile duct atrophy
    - - heart: vasculopathy and atherosclerosis; 1/2 @ 10y
    - - lung: bronchiolitis obliterans; 1/2 @ 5y
    - tx: increase IS or re-trx (no good options)
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249
Q

Tx DPGM injury

A
  • All left sided and most right sided should be repaired
  • Abdominal approach
  • Debride devitlized tissue
  • Repair with absorbable or non-abs monofilament
  • If too large to close primarily can use mesh or tissue flap (if contamination)
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250
Q

Tx of liver abscess:

  • fungal
  • hydatid cyst
  • amoebic
  • pyogenic
A
  • fungal: perc drain + micafungin (ampho is 2nd line)
  • hydatid cyst: albendazole qwks then PAIR
  • amoebic: metronidazole
  • pyogenic: DRAIN! and Abxs (even if multi-loculated)
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251
Q

Periop NOAC

A

stop 2 days before elective surgery

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252
Q

Strep species

A

G+/aerobe/chains;
a hemo- pneumo, viridans
b hemo- GAS(pyo)/GBS(aga)
non hemo- enterococci

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253
Q

Hypocalcemia vs. Hypercalcemia - sxs and ekg

A
  1. HypoCa: tingling, chvostek/trousseau sign
    - EKG: qt prolongation
  2. HyperCa: stones, bones, groans, overtones
    - EKG: shortened QT
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254
Q

Calcitonin

A

Parafollicular C cells
Inhibits osteoclast resorption
Increases Ph excretion

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255
Q

Types of Shunts

A
  1. Total: porto-caval, meso-caval
    - Relieves bleeding and ascites
    - More hepatic encephalopathy
  2. Partial: distal spleno-renal
    - Relives bleeding only
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256
Q

Crohn’s drugs MOA:
Azathioprine/6-MP
Sulfasalazine/5-ASA
Infliximab

A

Azathioprine/6-MP: inhibit DNA synthesis
Sulfasalazine/5-ASA: COX/LOX inhibitor
Infliximab: monoclonal Ab to TNF; moderate crohns, recurrent perianal fistula!

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257
Q 
GI Hormone Release and action:
Gastrin 
Somatostatin
CCK 
Secretin
VIP
A
  1. Gastrin - G cells in antrum
    - ↑ HCl, IF, and pepsinogen
  2. Somatostatin – D cells in antrum
    - inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output
  3. CCK – I cells of duodenum
    - gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells)
  4. Secretin – S cells of duodenum
    - ↑ pancreatic HCO32 release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release
  5. VIP – pancreas and gut
    - ↑ intestinal secretion (water and electrolytes) and motility
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258
Q

Anal canal
Dentate line
Anal verge
Anal margin

A

Anal canal- from levators to verge
Dentate line- w/in the canal; columnar/sq. jxn
Anal verge- sqamous/myoc. jxn
Anal Margin- 5-6 cm from the anal verge

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259
Q

Tx Galactocele

A

dx/tx- aspiration

no tx if asxatic, continue bfeeding

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260
Q

T and N staging for gastric cancer

A 
t1- SM
t2- MP
t3- xMP/subserosa
t4- invade
n1: 1-2, n2: 3-6, n3: >7
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261
Q

Stages of graft healing

A
  1. imbibition (direct diffusion)
  2. inosculation (cap beds meet)
  3. revascularization
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262
Q 
Hernia repairs:
Bassini
McVay
Lichtenstein
Shouldice
A

Bassini: conjoint tendon to inguinal ligament (from pubic tubercle medially to internal ring laterally)
- may need relaxing incision in anterior rectus sheath

McVay: open the floor to ➡ conjoint tendon to cooper’s/pectineal ligament.

  • transitional stitch from conjoint, cooper’s, and femoral sheath at medial aspect of femoral vein
  • re-approximate the rest of the inguinal floor by suturing the conjoint tendon to the inguinal ligament
  • may need relaxing incision

Lichtenstein: mesh to inguinal ligament and conjoint tenown

Shouldice: divide the floor ➡ 4-layer tissue closure

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263
Q

EBUS accesible nodes:

A

2, 3, 4, 7, 10, 11, 12

  • innominate seperates level 3, 4
  • 4: carinal
  • 7: sub-carinal
  • 10: R/L hilar
  • n2 nodes: 1-9
  • n1 nodes: 10-14
  • cannot sample 5, 6 (sub-aortic/AP window) ➡ chamberlain procedure (Parasternal mediastinotomy)
  • 8 (para-eso), 9 (IPL) ➡ EUS or VATS
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264
Q

Child’s Pugh Score

A

Billirubin, Albumin, INR, Ascites, Encephalopathy

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265
Q

Order of cells in healing:

A
  1. Hemostasis: PMNs (24-48h)
  2. Inflammatory: macrophages (48-96h)
  3. Proliferative: lymphocytes (3d)
  4. Maturation: fibroblasts (10d)
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266
Q

Hemophilia A

A

f8 deficiency, SLR
MC inherited disorder
tx- DDAVP (mild), f8 concentrate (severe)

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267
Q

Adenoid cystic carcinoma - px and tx

A

Px: MC minor salivary gland tumor (SM gland)

  • Spread along nerves
  • Remains quiescent for years then metastasizes

Tx: Total parotidectomy w/ facial nerve preservation + MRND + XRT
- don’t aggressively resect b/c very XRT responsive

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268
Q

Tx for cholangiocarcinoma

A
  1. Resectable if:
    - contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor
    - no distant mets or organ invasion
  2. Consider location
    Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
    Middle ⅓: hepaticojejunostomy
    Lower ⅓: pancreaticoduodenectomy (Whipple)
  3. Consider chemo + transplant if unresectable
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269
Q

acid and alkali burns

A
  1. Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis
  2. Acid burns (battery acid) produce coagulation necrosis

** copious water irrigation as soon as possible

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270
Q

IPMN - dx and tx

A

dx- MRI then EUS/FNA; high CEA, high amylase
tx-
1. Branched
- resect if >3 cm, sxs, or signs of malig (nodule)
- Otherwise surveillance
2. Main duct
- resect if > 1 cm or sxs (60% chance of Ca)
- 5-9 mm EUS/FNA. Resect if SOMalig
- < 5mm, surveillance MRIs

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271
Q

Tx PDA

A

to close- indomethacin

to open- PGE1

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272
Q

Airway management - trach vs. crich

A
  1. Elective trach: between 2nd and 3rd trach rings
  2. Crich: CT membrane between thyroid cart and cric
  • Thyroid cart ➡ cricoid cart ➡ rings
  • Avoid nasotracheal intubation w/ basal skill fractures - hemotympanum, CSF rhinorrhea/otorrhea
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273
Q

Dopamine dosing

A

low- d1/2 ago (renal dose)
medium- B ago
high- A ago

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274
Q

Parkland formula

A

4 x weight x TBSA
1st 1/2 in 1st 8h
2nd half next 16

arm = 9, leg = 18, each torso = 18, head = 9, each hand = 1, genitals = 1

UOP: .5-1 cc/hr. 1-2 cc/hr if child < 30 kg

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275
Q

Who needs stress dose steroids and how to dose

A

> 20 mg of steroids for > 3 weeks

Surgery: continue regular dose the day of surgery +

  1. Low risk (inguinal hernia): just continue regular dose day of surgery
  2. Moderate risk: 50 mg HC pre-proc. Then 25q8 x 3
  3. High risk: 100 mg HC pre-proc. Then 50q8 x 3
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276
Q

Tx of Zenkers

A

Dx- UGI (don’t do EGD)

<3cm- open myotomy (left neck incision) +/-diverticulectomy
>3cm- rigid scope division of UES (common lumen)

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277
Q

Tx SIADH

A

Acute – vaptan, demeclocycline

Chronic – fluid restriction, diuresis

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278
Q

Spinal vs. Epidural

A

Spinal- below l1/l2; SA space; fast; n/m block

Epidural- any level; epidural space; slow; no block

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279
Q

VIPoma - loc, px, dx, tx

A 
Loc: distal
Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin
- most malignant
Dx: high VIP
Tx: resct + LADN'y + CC'y
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280
Q

Gastric CA tx

A

neo-adj chemo for T2+ or N
proximal- total gastrectomy
distal- partial
5cm margin; 15 nodes

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281
Q

DDAVP/Vasopressin

A

Made in SON of HT. Stored PP.

Cause endothelium to release f8 and vWF

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282
Q

ASD

A

L to R shunt
Paradoxical emboli
surg if sxs or asx < 5 yo
surg before school

283
Q

Milan criteria

A

indications for trx w/ HCC

  • Single tumor < 5cm
  • No more than 3 tumors each < 3 cm

**Hepatectomy if compensated cirrhosis (no portal HTN), low MELD, and solitary mass < 3 cm is still preferred

**5-year transplant pt survival is 65-90%

284
Q

Posterior and anterior vagal trunk branches

A

Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet

Anterior trunk- hepatic branch, ant laterjet

285
Q

Tx of SqCC of anal margin

A

tx like SqCC of the skin

286
Q

half-lifeacoags:
war
hep
noac

A

war - 36h
noac- 12h
hep- 1.5h
3.5 half lives to ss

287
Q

Insulinoma - loc, px, dx, tx

A 
Loc: throughout (B cells)
Px: whipple's triad. Most benign. 
Dx: I/G > .4 and high C-pep
Tx: < 2cm encucleate, >2cm resect. 
- Diazoxide if can't tolerate surgery
- LADN'y if suspect malignancy
288
Q

Dx and Tx fat necrosis

A

dx- oil cyst w/ Ca+ rim
tx
no trauma- bx
trauma- watch

289
Q

Tx Panc divisum

A

ERCP sph’otomy of MINOR papilla (Santorini/Superior)

290
Q

Indications for neoadjuvant therapy eso cancer

A

high grade t1b or T2 and above OR any nodal involvement

Also get XRT

291
Q

Marfans vs. Ehlers-Danlos

A

Marfans- Fibrillin defect (elastin);
- AD; tall, aortic root dilation, lens defect, arachnodactyly

Ehlers Danlos- t1, t3 , t5 collagen defect
- hyper elastic skin, hypermobile joints

292
Q

Bladder ca dx and tx

A

dx- CT urogram is 1st step for any bladder, kidney, or ureter cancer suspected

  1. T1a- no muscle
    tx- endoscopic resexn + BCG/mitoM
  2. T2a- muscle/beyond LP
    tx- cystectomy + chemo + LND
  3. T3- fat/nodes)
    tx- neoadjuvant
293
Q

Tx tracheal inj

A

Small ➡ absorbable in 1 LAYER w/ strap
- primary repair up to 5-6 rings
Large → tracheostomy
- avoid below 3rd ring (TI fistula)

294
Q

Specific to Crohn’s

A 
Creeping fat
Skip lesions
Transmural
Cobblestoning
Granulomas
Fistulas
295
Q

Uremic PLT dysfunction

A

2/2 renal disease
reversible dysfunction
tx- ddavp

296
Q

Escharotomy indications

A
  • Circumferential deep burns
  • Low temperature, weak pulse, ↓ capillary refill, ↓ pain sensation, or ↓ neurologic function in extremity
  • Problems ventilating patient with significant chest torso burns
  • *Perform within 4–6 hours
  • *May need fasciotomy if compartment syndrome suspected after escharotomy
297
Q

Gastric ulcers: elective classification and management

A

Dx- EGD and Bx (Bx needed to r/o ca!)
Tx-only tx if refractory to max medical management after 12 weeks.

  1. lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2
  2. gastric + duo; high acid ➡ antrectomy + vagotomy
  3. pre pyloric: high acid ➡ antrectomy + vagotomy
  4. GE junction: normal acid ➡ sub-total gastrectomy + REY
298
Q

Emergent vs. Elective UC Tx

A

Emergent:

  1. Steroids +/- abxs
  2. Infliximab, Cyclosporine
  3. TAC with end-ileostomy
    - When stabilized can perform completion proctectomy and IPAA
    - Don’t do proctectomy in emergent situations

Elective:

  • Indications: dysplasia, cancer, refractory disease
  • PC w/ IPAA
    • Surgery reduces: erythema nodosum, arthritis
    • no effect on PSC or ank spondy
299
Q

Kasabach-Merritt Syndrome

A

hemangioma + thrombocytopenia
usually infants
resect!

300
Q

peri-op anti-PLT therapy in pt with stent/PCI

A

No CVdz:

  • stop ASA 7-10 days before surgery.
  • Restart after 24-72h depending on bleeding in surgery

Known CV dz
Elective surgery:
- delay surgery until after optimal time (6w for BMS, 6-12m for DES)

Emergent surgery:
- c/w DAPT unless high bleeding risk

301
Q

Peutz-Jeghers - px and screening

A

Px- intestinal hamartomas, pigmented oral mucosa, polyposis, breast/pancreatic ca
- AD, STK11 mutation

Screening
1. Scope @ 25y then q2 years b/c high r/o GI/pancreas ca

302
Q

Acute hemolytic trx reaction

A

rapid RBC destruction by host IgM/IgG

+direct coomb’s

303
Q

Omphalocele

A 
2/2 failure of umbo ring closure 
11th week gut returns to abdominal cavity
normal bowel (protected)
Other congenital defect are more common
304
Q

Cryo used to treat?

A
  1. VWD
  2. Fibrinogen def
  3. Hemophilia A
305
Q

Zone injuries

A

penetrating:
- zone 1-3 –> explore
blunt:
- zone1 –> explore
- zone 2-3 –> do not explore

306
Q

TOS tx

A

neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
Venous- catheter directed thrombolysis → surgical decompression
Arterial- C7/1r resection, subc artery resection/reconstruction

307
Q

Contents of FFP and Cryo

A

FFP: all clotting factors
Cryo: VWF, f8, fibrinogen

308
Q

FAP Dx and Tx

A

AD; APC mutation
Dx: > 100 adenoma or < 100 w/ fam hx
CA by 40

Tx:

  • sigmoidoscopy q1y at 10 (don’t need colonscopy)
  • TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen)
  • q1y scope post op for duodenal cancer (MC COD)
  • polyposis/high grade dysplasia @ stump → proctectomy +/- pouch
309
Q

BRCA risks and tx

A

female breast, ovarian, male breast
I- 60, 40, 1
II- 60, 10, 10

Tx:

  • pre meno: offer bilateral mastectomy OR q1 MRI starting @ 25
  • post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH)

**SOO decrease r/o OVARIAN Ca (80%) for BRCA1/2
AND breast Ca for BRCA2 only (50%)
**No TAH!

310
Q

When to operate on adrenal mass

A

OR:

  • all functioning tumors
  • all > 6 cm –> open resection (no lap)
  • if < 6cm with suspicious features - >10HU, <50% @ 10m w/out –> open resection (no lap)
311
Q

Tx Neck trauma

A

OR if platysma violation + crepitus, odynophagia, pulsatile bleed, expanding h’oma, bruit, thrill

Non-op w/up: 4V angio, doppler or CTA, UGI (esophagography) or esophagoscopy, bronchoscopy

312
Q

Adjuvent chemo for breast ca

A
  1. Adjuvent chemo: tumor > 1cm, nodal dz, aneuploidy
    - echo before for cardiotox
  2. Tamoxifen/Anastrazole: 5y for HR+ tumors
    - Tamox for men too
  3. Trastuzumab- 1y for Her2/neu+ tumors
    - echo before for cardiotox
313
Q

FNH

A

path- CENTRAL STELLATE SCAR!
bright on arterial phase homogenous
tx- resect if sxatic. no malignant potential.

314
Q

Secretin vs. CCK

A

Both released by duo
S cells ➡ Secretin- duct cells ➡ bicarb
I cells ➡ CCK- acinar cells ➡ enzymes

315
Q

Pancreas drainage procedures

A
  1. duct > 7mm- Peustow, pancreaticojej (for large duct)
  2. duct > 7mm and large head- Frey, pancreasticojej + core out head
  3. duct < 7mm and large head- Berger, pancreatic head resection
316
Q

Tx papillary/follicar thyroid ca

A
  1. Indications for total thyroidectomy:
    - Tumor > 4cm
    - Tumor 1-4cm and patient preference
    - Distant mets or extra-thyroid disease
    - Cervical or central nodes
    - Poorly differentiated
    - Prior radiation
  2. Nodes dissection:
    A. Therapeutic lateral neck dissection: of involved compartments if palpable or bx+ nodes
    B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes.
    - Usually not performed for follicular
  3. Radio iodine indications (6w post op, want TSH high)
    - Only after total thyroidectomy to be effective
    - Tumor > 1 cm
    - Extra-thyroidal disease
317
Q

Heparin - MOA

A

accelerates AT3 activity and INDIRECTLY inhibits thrombin

318
Q

Screening guidelines for breast ca

A

Mammogram every 2–3 years after age 40
then yearly after 50

High-risk screening
- mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative

319
Q

Tx SDH

A
  1. Nonop- HDS, <10 mm, <5 mm shift

2. Evac- > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP

320
Q

Central venous O2 vs. mixed venous O2

A

Mixed venous: from PA

Central venous: from SVC only (estimation of mixed)

321
Q 
Reversals:	
BB	
CCB
Tylenol	
Benzos	
CN/Nitroprusside	
Vecuronium/Rocuronium	
Ethylene glycol	
Methemoglobinemia
A 
BB overdose: fluids/atropine → glucagon	
CCB: Ca + Insulin + Atropine + Pressor
Tylenol: NAC	
Benzos: flumazenil	
CN/Nitroprusside: sodium thiosulfate, amyl nitrite
Vecuronium/Rocuronium: sugammadex	
Ethylene glycol: femopizole and bicarb OR ethanol; iHD
Methemoglobinemia: methylene blue
322
Q

Orientation of portal triad

A

Bile duct lateral
Hepatic artery medial
Portal vein posterior

323
Q

Cryoptococcus
Coccidiomycosis
Histoplasmosis
Mucormycosis

A
  1. Crypto- CNS sxs in AIDs pt
    tx- amphotericin
  2. Coccidio- pulm sxs in the southwest
    tx-amphotericin
  3. Histo- pulm sxs in ohio river valley
    tx- itraconazole → ampho B
  4. Mucormycosis- burns/trauma w/ bloody cough
    tx- emergent debride, ampho
324
Q

Polyps that require surgery instead of endoscopic resection

A
  1. Submucosal invasion > 1mm
  2. Poorly differentiated
  3. <1 mm margin
  4. Lymphovascular invasion
  5. Tumor budding
  6. Sessile polyp (if you can’t get it all)
325
Q 
LN harvest/margin
eso
stomach
colon
rectum
A

eso- 15/7cm
stomach- 15/5cm
colon-12/5 cm
rectum- 12/5 cm

326
Q

Succinylcholine

A 
ONLY depolarizing
short half life and rapid onset (RSI)
Used for "full stomach"
degraded by plasma CE
s/e: rhabdo, hyperK, M/H
c/i: spinal cord injury, renal failure, large burns

tx of M/H: stop drug, dantrolene, Bicarb, cooling, tylenol

327
Q 
Breast nerve:
Thoracodorsal
Intercosto-brachial
Lateral petoral
Medial pectoral
Long thoracic (medial)
A 
Thoracodorsal (lateral)- LD, ADduct
Intercosto-brachial- hypesthesia
Lateral petoral- p major
Medial pectoral- p major/minor
Long thoracic (medial)- SA, wing scap
328
Q

Cohort study vs. Case control

A

Cohort: prosepective; exposed vs. non-exposed
RR- [a/a+b]/[c/c+d]

Case control: retrospective; diseased vs. non-diseased
OR- (a/b)/(c/d)

329
Q

Tx acute limb ischemia

A

Tx: Rutherford
1- no deficits ➡ hep gtt. imaging. eventual revasc
2a- motor intact ➡ imaging. hep gtt (motor intact, sensation). eventual revasc
2b- any weakness, rest pain ➡ hep gtt and immediate revasc (don’t image if delay in tx)
3- paralysis ➡ amputation

Revasc options:

  1. Endovascular: short segment, single lesion
  2. Open: long segment, multiple lesions
330
Q

Warthin tumor/Papillary cystadenoma

A

benign tumor of salivary gland
often BILATERAL and 2/2 smoking
Slow growing
Tx- complete resection with uninvolved margins even if ASx

331
Q

Hemangioma - path and tx

A

path- PERIPHERAL ENHANCEMENT

tx- if rupture, size change, or KM syndrome

332
Q

Pancreatic ducts

A

Wirsung- major, lies inferior

Santorini- minor, lies superior

333
Q

Gluconeo precursors

A

lactate , pyruvate, AA

334
Q

Sirolimus

A 
MOA: mTOR inhibitor
Less nephrotoxic
s/e
- lymphocele (w/ obstruction)
- wound complications/poor wound healing: held or switched to tacro before hernia repairs
335
Q

Tx of rectal prolpase

A

Not past the verge- biofeedback, fiber
Many comorbidities- Altemeir (perineal rectosigmoid’y)
Prolpase < 50cm- Delorme (plication)
Young/healthy- rectopexy +/- resection

336
Q

Px and Tx of Hypertrophic scar

A

Px: 3–4 months after injury secondary to ↑ neovascularity
- More likely to be deep thermal injuries

Tx: steroid injection into lesion (best), silicone, compression; wait 1–2 years before scar modification surgery

337
Q

Li Fraumeni

A

p53 mutation - TSG on Ch17
cell cycle regulation and apoptosis
breast ca + soft tissue sarcoma b4 45

338
Q

Chylothorax dx and tx

A
  • dx: fluid TG > 110
  • tx: chest tube and NPO
    • < 1L/day: MCT diet, octreotide, TPN → 7d: thoracic duct lig (Open R chest or IR)
    • > 1L/day: thoracic duct ligation (Open R chest or IR)
339
Q

Chemotherapy indications for breast ca

A
  • Tumors >1cm
  • Positive nodes
  • Triple negative tumors
340
Q

Tumor lysis syndrome

A

hyperU, K, Ph w/ hypoCa
CaPh crystal ➡ renal failure + hypoCa
tx: IV hydration ➡ iHD

341
Q

CRC T and N

A 
t1- SM
t2- MP
t3- xMP/subserosa
t4- invade
n1- 1-3, n2- >=4
342
Q

Rectovaginal fistula tx

A

wait 3-6m
low- endorectal advancement flap
high- abdominal approach

343
Q

Schiatzki’s Ring - Tx

A

Associated with hiatal hernia

Tx- only if sxatic. dilation only and PPI

344
Q

NNT`

A 
NNT = 1/absolute risk reduction (ARR)
ARR = event rate in intervention group - rate in control group
AR = event rate in intervention / rate in null group
RRR = (rate control - rate experimental) / rate control
345
Q 
Tx childhood GI disease:
Pyloric stenosis 
Intussusception
Duo atresia 
TEF
Malro
A 
Pyloric stenosis: pyloromyotomy
Intussusception: air contrast enema
Duo atresia:  DD or DJ
TEF: right extrapleural thoracotomy
Malro: LADDS proc
346
Q

Tx Panc fistula

A

tx- NPO, TPN x 4-6 wks → ERCP w/ stent → surgery

347
Q

Max dose of lido and bupiv

A

lido = 5mg/kg (7 w/ epi)
bupiv = 2.5 mg/kg
tx- lipid emulsion

348
Q

Tx Aspergillosis

A

MC fungal infxn in IC patients
aspergilloma- resect
aspergillosis- voriconazole!

349
Q

Dx and Tx of GIST

A
  1. Dx- MC GI Sarcoma
    - - EGD: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC.
    - - Bx: cajal cells. c-KIT+
  2. Dx/Tx- wedge resection (gross). no bx unless neoadj
    - can be R0 or R1 resection
  3. Imatinib (TK inhibitor) - > 5cm or >5 mitosis/50 hpf
350
Q

Vitamin K

A 
gamma CARBOXYLATION (not decarb) ofGLUTAMATE on 2, 7, 9, 10, c, s
Px- coagulopathy, suspect if obstructive jaundice
351
Q

Rectum:

  1. Arterial supply
  2. Venous drainage
A
  1. Arterial supply:
    - IMA to superior rectal a.
    - II to middle rectal a
    - II to internal pudendal a. to inferior rectal a.
  2. Venous drainage-
    - SRV ➡ IMV ➡ PV (portal)
    - MRV/IRV –> internal pudendal –> internal iliac (systemic)
352
Q

Kcal per macronutrient

A 
protein = 4 kcal/g
dextrose = 3 kcal/g
lipid = 9kcal/g
carb = 4 kcal/g
353
Q

Hinchey

A

1- pericolic abscess
2- pelvic abscess
3- purulent
4- feculent

354
Q

Contents of ant triangle

A

Carotid sheath, anca cervicalis, CN 12 (hypoglossal)
Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular
Facial vein is the gateway

355
Q

Tx for Leriche syndrome

A

aortobifemoral bypass

356
Q

Benign lesions that require excisional bx

A 
Atypical 
DH/LH	
LCIS/DCIS	
radial scar	
papillary lesion	
any atypia
357
Q

Future Liver Remnant

A

minimum 20% if normal liver
pre-op chemo/some dysfxn = 30%
cirrhosis = 40%

358
Q

Cervical neoplasia

A

CIN1- tx infection, close f/up
CIN2- cryo or leep
CIN3- cryo or leep

359
Q

type 1 vs. type 2 error

A

type 1: false positive

  • say something is true (reject the null) when it’s not
  • minimize by including stat significance

type 2: false negative

  • say something is false (do not reject the null) when it’s true
  • minimize by increasing sample size
  • increases with higher P-value (more likely to make a false negative)

power = 1 - type2

360
Q

clostridium - px and tx

A

anaerobic, GPR
MC CO emphysematous cholecystitis
MC CO gas gangrene
tx- PCN, clinda 2nd line

361
Q

Early excision and graftingf

A
  • Day 1 of burn
  • Can be considered in stable patients with limited burns (< 20%) that are clearly 3rd degree
  • Saves costs; minimizes pain, suffering, and complications
362
Q

hepatic adenoma

A

path- EARLY HETEROGENEOUS enhancement on A phase w/ rapid washout
tx- stop OCP use.
resect if > 5cm or sxatic

363
Q

DVT tx

A

ileofemoral- cather directed thrombolysis

other- anticoagulation

364
Q

Types of mastectomy

A
  1. Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin
  2. MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes
  3. BCT: partial mastectomy + XRT
365
Q

Pyoderma gangrenosum

A

associated w/ IBD
RESOLVES after resection
pre-tibial
tx- steroids

366
Q

AG

A

Na - (Cl+Bic)
NaCl = non-AG, metabolic acidosis

Causes of AG MA: Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, LA, Ethanol/Glycol, Salicylates

367
Q

MOA reglan and erythromcyin

A

reglan: dopamine antagonist
erythromycin: motlin receptor agonist causing SM contraction

368
Q

VIPoma

A

Loc: distal
Px: watery DRH, hypoK, achlorhydria, inhibits gastrin
Tx: resect (distal panc)

369
Q

Thyroid ima

A

supplies medial aspect of both lobes of the thyroid

come off the innominate/brachiocephalic

370
Q

T and N staging eso cancer

A 
t1a- LP and MM	
t1b- SM (where it spreads)
t2- MP	
t3- adventitia	
t4a- resectable structures	
t4b- unresectable structures
n1: 1-2 nodes, n2: 3-6 node, sn3: 7+
371
Q 
Tx of burn types:
Acid burn
Alkalia burn
Hydrofluoric acid burns
Powder burns
Tar burns
A 
Tx of burn types:
Acid burn: irrigation
Alkalia burn: irrigation
Hydrofluoric acid: spread calcium
Powder burns: wipe away before irrigation
Tar burns: wipe with lipophylic glycerol
372
Q

Barrett’s eso surveillance

A

Bx- Goblet cells and columnar cells
No dysplasia- 4 quad every 2 cm q 3-5y
Dysplasia/Nodule- 4 quad every 1 cm q 3-6m

*Fundoplication is only c/i in HGD

373
Q

HNPCC vs. Lynch S Dx and Screening

A

HNPCC- fulfill amsterdam criteria

  • 3+ relatives with Lynch syndrome-associated cancers (CRC, cancer of the endometrium or small bowel, transitional cell carcinoma of the ureter or renal pelvis),
  • 2 generations
  • 1 ca dx < 50 yo

Lynch syndrome- refers to mutation in DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) or the EPCAM gene.

374
Q

Serum osmolarity

A

Osm = 2xNa + Glu/18 + urea/2.8

375
Q

Superior laryngeal nerve

A

motor to cricothyroid
injury: trouble w/ high pitch, voice remins clear
Cord looks normal on laryngoscopy
tx- none

376
Q 
Cause of stones:
CaOx
Uric Acid
Cysteine
CaPh
MgAmPh
A 
CaOx- diet
Uric Acid- protein
Cysteine- AA metab. error
CaPh- high pH
MgAmPh- urease infxn
377
Q

Location of vagus nerve

A

LARP

left anterior, right posterior to esophagus

378
Q

GCS motor

A 
6- obeys commands
5- localized
4- w/draws
3- flexion (decort) - 'flex your core'
2- extension (decErebrate)
1- none
379
Q

LeFort fxs

A

I- palate
II- nose and palate
III- entire face

380
Q

Human bite tx

A

amox/clavulanate (augmentin)

MC for human bites- eikenella

381
Q

tx flank wound

A

HDS- CT w/ triple contrast (oral, IV, rectal)

HDUS- OR

382
Q

Indics and steps for ED thorac

A

trauma with witnessed loss of vital but SOL
SOL = ECG activity, reflexes, GCS > 3

  1. Access thoracic cavity
  2. Pericardiotomy - staple, suture, clamp
  3. Thoracic aorta cross clamp
  4. Cardiac massage +/- defib
383
Q

TRALI

A

DONOR Ab attacks recipient WBC

384
Q

Amphotericin

A

MOA: binds ergosterol and alters permeability
lipid soluble (CNS)
s/e- nephrotoxic, hypoK

385
Q 
MCCO healthcare infection:	
HAP	
central line infection	
SSI	
UTI	
GI infection
SBP
NSTI
ICU infection
A 
HAP: staph aureus (pseudomonas #2)
central line infection- coag negative staph (staph epi)
SSI- staph aureus	
UTI- e. Coli	
GI infection- c. diff
SBP- e. coli
NSTI- polymicrobial
ICU infection- VAP
386
Q

Tx of trx of great vessels

A

1st give PGE1 → ballon atrial septostomy

387
Q

Tx SqCC of anal canal

A

Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC
Recurrence- APR

SqCC equivalents- large cell ker. (SqCC), transitional zone, LCl non-ker, basaloid, mucoepidermoid

388
Q

TOF

A 
Most common cyanotic defect
1. VSD
2. Pulmonary outflow obstruction
3. Over-riding aorta
4. RVH
tx- beta blocker; surgery at 3-6m
389
Q

Spigelian hernia

Richter’s hernia

A

spigelian- found along semilunar line lateral to rectus

richters- protrusion and/or strangulation of part of the intestine’s anti-mesenteric border

390
Q

Cutoff for low risk lung nodules not requiring follow-up

A
  1. 6mm ➡ NTD
  2. 6-8 mm ➡ q6-12m CT
  3. > 8mm
    - low risk pt- q3m CT
    - high risk pt- bx or resection
391
Q

Light’s criteria

A

PLprotein/serum Pr >.5
PLLDH/serum LDH > .6
PL LDH > 2/3 ULN

392
Q

Treatment of colo-cutaenous fistula

A
  1. Start with conservative tx
  2. Quantify output:
    - High output: > 500 cc/day ➡ likely OR
    - Low Output: < 200 cc/dayt ➡ likely conservative
  3. OR if failed after about 6 weeks
393
Q

Most abundant bacteria in the colon

A

Bacteroides fragiles

394
Q

T staging for esophageal cancer

A 
t1a- muscularis mucosa: endo resection
t1b- SM: upfront esophagectomy
t2- muscularis propria: neoadjuvant
t3- adventitia: neoadjuvant 
*no serosa. Ca spread through SM lymphatics
395
Q

Exposing the pancreas

A

Head: kocherize
Body: incise gastrocolic ligament ➡ lesser sac
Tail: mobilize spleen

396
Q

Thoracic duct course

A
  1. originates at L1-L2 @ c. chyli
  2. cross from R to L at T4-5
  3. empties into L SC/IJ jxn
397
Q

Duo vs. stomach ulcer px

A

Duo ulcer: pain 2-3h after meal
- 90% H. pylori, 10% NSAIDS/ASA

Stomach ulcer: pain right after meal
- 75% H. pylori, 25% NSAIDS/ASA

**NSAID/ASA: decrease mucosal mucus secretion and bicarb secretion

398
Q

Effective for Pseudomonas

A
  1. Ticarcillin, Zosyn
  2. 3/4G cephalosporin (ceftriaxone, cefepime)
  3. Aminoglycodies (genta, tobra)
  4. Flouroquinolones (cipro)
  5. Meropenem/Imipenem

**Not linezolid (good for G+/MRSA)

399
Q

Tx hypertrophic cardiomyopathy

A

beta blockers
avoid inotropes
use neo if needed

400
Q

most common organism in burn wound infection

most common viral burn wound infection

A

Pseudomonas (< 10^5 organisms – not a burn wound infection)

HSV

401
Q

Tx Infected panc necrosis

A

stable- wait 4 weeks, IR retroP drain
unstable- debride

Debride: VARD (video-assist retroP)- utilize retoP drain, DEN (endoscope), open necrosectomy

402
Q

Cuff size for kids

A

age/4 + 4

403
Q

Grading and tx of BCVI

A 
1- <25% narrowing  ➡  ASA
2- > 25% narrowing  ➡  ASA
3- PsA  ➡  ASA + IR stent
4- complete occlusion  ➡  ASA only
5- transection  ➡  OR if accessible. Otherwise IR.

*most are not surgically accessible

404
Q

Ectopic parathyroids

A
  1. Superior parathyroids
    - usual location: jxn of RLN and INFERIOR thyroid artery. Posterior to RLN.
    - Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath.
  2. Inferior parathyroids
    - usual location; along inferior thyroid vein. Anterior to RLN.
    - Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass
  3. 4 normal appearing galnds
    - supranumary PT in the thymus

**Overall, thymus is MC location or ectopic gland

405
Q

Trauma to the pancreas

A
  1. Head
    - main duct: drain w/ staged resection
    - no duct: drain
  2. Tail
    - main duct (grade 3+): resect w/ splenectomy (unless young and HDS)
    - no duct (grade 1-2): drain
406
Q

S/e and medications of trx meds

  • Tacro
  • Azathioprine
  • Mycophenolate
  • Sirolimus
  • Cyclosporine
A

Tacro: calcineurin inhibitor; bind fK –> calcineurin –> block IL2

  • 100x more potent than cyclosporine
  • neuro sxs (tremor), nephrotox, hepatotoxic, GI sxs
  • alopecia

Cyclosporine: calcineurin inhibitor; bind cyclophillin –> calcineurin –> block IL2

  • nephrotox, hepatotox, neuro sxs
  • gingival hyperplasia, hypertrichosis

Sirolimus: bind fK –> mTor inhibitor (IL2 inhibitor)

  • impaired wound healing, interstitial lung disease, hyperlipidemia, thrombocytopenia
  • anti neoplastic effects (good for cancer)

MMF: purine (T cell) inhibitor
- GI sxs, myelosuppression, anemia

Basilixamab: il2 inhibitor
- GI sxs

Azathioprine: purine (T cell) inhibitor
- myelosuppression, marrow suppression, pulm fibrosis

407
Q

Interossei and lumbrical innervation

A

palmar- ulnar n, adduct
dorsal- ulnar n, abduct
lumbricals- median (1-2)/ulnar (3-4)

408
Q

S/e of tamoxifen

A

dvt/pe

uterine cancer

409
Q

DCIS tx

A

lumpectomy (2mm) + XRT +/- boost +/- endocrine

  • no SLNBx (does not metastesize)
  • no chemotherapy

if XRT c/i → mastectomy AND SLNBx (b/c 20% have invasive ca)

410
Q

DCIS SLNBx

A
  • does not metastasize
  • not w/ l’omy unless >4cm, multicentric, palpable, high grade
  • required w/ mastectomy b/c 20% have invasive ca
411
Q

Dx and Tx of Cystadenoma

A

low CEA, low Amylase

tx- resect if sxs

412
Q

Post polypectomy screening

A
  1. 1-2 tubular adenomas <5mm in size → 5 years
  2. 3 or more adenomas → 3 years
  3. Advanced adenomas - >1cm, HGD, or villous elements) → 3 years
  4. Hyperplastic polyps → 10 years. 3-5 years if > 1cm.
  5. Piecemeal removal → 2-6 month scope
413
Q

Encapsulate organisms

A

Strep pneumo (MC)
Neisseria
Haemophilus

414
Q

Casues of increased ET CO2

A

Increased muscle activity (shivering)
Increased metabolism (sepsis, fever, malignany hyperT)
Increased CO
Decreased minute ventilation

415
Q

tx of Meckels

A

tx- resection if sxs
base < 2 cm → diverticulectomy
> 2 cm or wide base → seg resection

if appendicits leave Meckel’s alone

  • Only consider taking out incidentally found asx Meckel’s in young/healthy pt
  • Leave if asx in adults or concern for ca
416
Q

Products of posterior pituitary

A

“PAO in the POST”

ADH, Oxytocin2/2 direct stem from neurosecretory cell

417
Q

Hereditary pancreatitis

A

PRSS1 trypsinogen mut’n
AD
smoking cessation is important

418
Q

Cilostazol - MOA and use

A

MOA- PDi, inhibits PLT aggregation
tx for periph claudication
- c/i in any degree of HF (PDi)

419
Q

Esophagus and Trachea access

A

Proximal eso- L cervical
Mid eso/prox thoracic eso- R thoracotomy
Distal eso- L thoractomy

Carina/Either main-stem- R thoracotomy
Aorta- L thoracotomy

420
Q

Ureter injuries

A

proximal ⅓ (U/P jxn and above) → primary ureterourostomy
middle ⅓ → primary or tran uretero urosotomy
lower ⅓ → re-implanation +/- hitch

  1. early: w/in 5 days- stent, explore, or repair
  2. late: > 10 days- perc nephro and delayed repair
421
Q

Vitamin D processing

A

7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3

422
Q

Tx papillary/follicar thyroid ca

A

Start with lobectomy

Indications for total thyroidectomy:

  • Tumor > 4 cm (1-4 cm, close observation or total)
  • Extra-thyroidal disease
  • Multi-centric or bilateral lesions
  • Previous XRT

Indications for MRND
- extra thyroid extension

Radio iodine indications (6w post op, want TSH high)

  • Consider for 1-4 cm, definitely > 4cm
  • Extra-thyroidal disease
  • Need total thyroidectomy to be effective
423
Q

Tx for hemobilia

A

angioembolization

424
Q

Tx Odontoid fx

A

1- upper D, stable, non-op
2- base of D, unstable, worst, +/- surg
3- c2 vert, usually no OR

425
Q

GCS verbal

A 
5- normal
4- confused
3- inappropriate words
2- incomprehensible
1- none
426
Q

MELD

A
  1. Bili
  2. INR
  3. Creatinine
  • At least 15 for trx
  • Pts added for HCC, hilar cholangiocarcinoma
  • HCC gets automatic score of 22
427
Q

Intraductal papilloma dx and tx

A

MCCO bloody nipple dc
dx- contrast ductogram
tx- resection

428
Q

Tx Umbo and Inguinal hernia in child

A

most close by 2
<3cm- primary repair
>3cm- mesh
repair by 5

Inguinal- repair by 2 weeks if reducible
- otherwise, OR then

429
Q

Gastroschisis

A

GastRoschisis to the Right of midline

rare defects…EXCEPTION- instestinal atResia

430
Q

Mineral def:

  • Zn
  • Sel
  • Chromium
  • Copper
  • B1
  • B3
A
  • Zn: wound heal/skin
  • Sel: cardiomyopathy
  • Chromium: hyperglycemia
  • Copper: micro anemia
  • B1 (thiamine): wernicke’s encephalopathy, p. Neuropathy
  • B3 (niacin): pellagra (DRH, demetnia, dermatitis)
431
Q

MC aortic infections

A

aneurysmal- staph

non-aneurysm- salmonella

432
Q

Effective for VRE

A

Synercid

Linezolid

433
Q

Predictors of good outcome after reflux surgery

A
  1. Typical sxs
  2. DeMeester Score > 14.72
  3. Improvement w/ acid suppression
434
Q

UES vs LES

A

UES- cricopharyngeus; higher resting pressure (70)

LES- lower resting pressure (15)

435
Q

Stiewert-Stein Class and Tx

A

Relation to GEJ:

  1. 1-5 cm above; Ivor-lewis
  2. 1 cm above-2 cm below; esophagectomy and prox gastrectomy
  3. 2-5 cm below GEJ; total gastrectomy

*Require 5 cm eso margin, 4 cm gastric margin, 15 nodes for eso CA

436
Q

Esophageal CA tx

A

HGD, TIS, T1a: endoscopic ablation/resection
T1b: upfront esophagectomy
T2 or N: neoadjuvant then esophagectomy
T4b or M: definitive chemo-XRT

< 5cm from cricoP: definitive chemo-XRT
> 5 cm from cricoP: esophagectomy

437
Q

Absolute C/I to anti-reflux surgery

A
  1. Cancer

2. Barrett’s w/ HGD

438
Q

Alarm sxs for GERD

A
  1. dysphagia
  2. odynophagia
  3. bleeding
  4. weight loss
  5. anemia

*Require EGD

439
Q

Tx of Leiomyoma

A
  1. sxs or > 4cm- enucleate
  2. < 4cm- observe
  3. > 8cm or circumferential- esophagectomy

Approach:
Cervical- L
Mid eso- R
Distal eso- L

440
Q

W/up for trauma to the esophagus

A
  1. CT: para-eso air/fluid, subc air, trajectory
    - if negative can trial clear. If +:
  2. Endoscopy:
    - if negative can trial clears. If dysphagia w/ clears:
  3. GG esophagography (UGI): if negative:
  4. Thin barium
441
Q

Required for staging esophageal CA

A
  1. CT of chest, abdomen- M
  2. Whole-body PET scan- M
  3. EUS- T and N stage
442
Q

Caustic injury w/up

A
  1. Avoid NGT. No neutralizing agents
  2. CT scan if stable
  3. Early endoscopy (AFTER CT)
  4. OR if unstable. Otherwise, restart orals in 48h.
  • alkali- liquefaction necrosis. worse outcome
  • acid- coagulation necrosis
443
Q

Steps of Heller myotomy

A
  1. Divide G-H ligament
  2. ID R crus and posterior vagus
  3. ID L crus and anterior vagus
  4. Divid short gastric vessels
  5. Expose GEJ (excise eso fat pad)
  6. Myotomy (6 eso, 2 stomach)
  7. Nissen, dor, or toupet wrap
444
Q

How to mobilize the stomach for intra-thoracic anastamosis

A
  1. Divide G-H ligament
  2. Transect the L gastric. Keep the R gastric.
    - — Lesser Curve Mobilized—-
  3. Transect gastro-colic until prox duo. Avoid R gastro-epiploic!
  4. Extend gastro-colic to take the L gastro-epiploic, short gastric vessels, and gastrophrenic vessels
    - — Grater Curve Mobilized —-

To gain extra length:

  1. Kocher maneuver
  2. Divide the R gastric artery

Greater omentum = gastro-colic + gastroc-splenic + gastro-phrenic ligaments

445
Q

Epiphrenic divertciulum

A

Loc: distal eso. R > L. Pulsion
Tx: only if sxs.
- L diverticulectomy w/ contra myotomy

446
Q

Dx and Tx of Eso perf

A

Dx- XR then contrast esophogography (GG then Ba)

Tx-

  1. abxs (fungus)
  2. Cervical: open neck and place drains
  3. Thoracic: L thoracotomy, extended myotomy, cover w/ 2 layers, buttress, NG, chest tube
    - if achalsia: contra myotomy
  4. Very unstable: exclusion and diversion

Selective non-op:

  1. Contained perf
  2. Minimal signs of sepsis

Stenting: contained perf or minimal extrav after EGD

447
Q

Causes of hyperPh and hypoPh

A
  • HyperPh: hypoPTH, renal failure

- HypoPh: hyperPTH, liver resection

448
Q

FeNa

A 
(Serum Cr x Urine Na) / (Serum Na x Urine Cr) x 10
"USC/UC's"
<1% = Pre-renal
>1% = Intrinsic
>4% = Post-renal
449
Q

Fluid Production/Absorption:

  • Saliva
  • Stomach
  • Biliary
  • Pancreatic
  • SB
  • LB
A

Fluid Production:

  • Salive: 1500
  • Stomach: 1500 ml
  • Biliary: 500 ml
  • Pancreatic: 1500 ml
  • SB: 1500 ml

Absorption:

  • SB: 8.5L
  • LB: 500 ml
450
Q

TBW

A

TBW = 42L

  • 2/3 ICF
  • 1/3 ECF: 3/4 interstitia, 1/4 blood
451
Q

LR formula

A 
130 Na
4 K
109 Cl
2.7 Ca
28 Lactate
452
Q

Refeeding Syndrome

A

HypoMg, Ph, K

Sxs- paresthesia, confusions, RD, cardiac failure

453
Q

pH relation to pCO2

A

10 mmHg increase in pCO2 = .08 decrease in pH

454
Q

Tx of DI

A
  1. Central- DDAVP

2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ

455
Q

Tx of endometrial CA

A

Hysterectomy, bilateral BSO, peritoneal w/out, LN sampling

Required for Tx AND staging!

456
Q

Pregnant lap appe

A

Left lateral decubitus position
Entry port:
- take into account fundal height (6cm above)
- P/S @ 12 wks, half-way @ 16 weeks, umbo @ 20 weeks
- 2T-3T: supra-umbo if possible otherwise LUQ or RUQ

457
Q

Px and Tx of ovarian torsion

A

Sudden pain + adnexal mass w/out bleeding
- vs. ectopic which usually has bleeding
Lap detorsion
Oopherectomy only if- necrosis, CA, recurrent

458
Q

Monitor and reverse TPA

A 
Fibrinogen level (<100 = r/o bleeding)
Reverse: a-CA
459
Q

Tx of Warfarin skin necrosis

A

Stop Coumadin
Give vitamin K
Start hep gtt

460
Q

Intrinsic vs. Extrinsic Pathways

A

Intrinsic: 8, 9, 11, 12
Extrinsic: 7 (shortest t 1/2), Tissue factor
Common: 1, 2, 5, 10

461
Q

Reversal of NOACs:
Apixaban
Rivoroxaban
Dabigatran

A

Apixaban: andexanet
Rivoroxaban: andexanet
Dabigatran: idarucizumab (+iHD)

462
Q

VWD dx and tx

A

dx: normal PLTs. Abnormal BT, PTT
- ristocetin test or measure vWF level

tx-
type 1: not enough; ddavp –> cryo
type 2: qualitative; ddavp –> cryo
type 3: none; VWF/f8 concentrate, cryo

463
Q

Tx of hepatic encephalopathy

A
  1. Correct precipitating cause
  2. Lactulose (goal 2-3 stools/day)
  3. Rifaximin
  4. Neomycin
464
Q

PEP:

  1. HIV
  2. HBV
  3. HCV
A
  1. HIV- 4wks of anti-retroviral combo
  2. HBV- HBIG. +Vaccine if not vaccinated
  3. HCV- No recommendations.
465
Q

Segmental liver anatomy

A

7 - 8 - 4a - 2

6 - 5 - 4b - 3

466
Q

Dx and Tx of Budd-Chiari Syndrome

A 
Dx: doppler
Tx: 
1. Lifelong AC
2. < 4 weeks: thrombolytics
3. > 4 weeks: angioplasty/stenting
4. Refractory: TIPS, transplant, surgical shunt
467
Q

Tx of Isolated Gastric Varices

A

2/2 chronic pancreatitis induced splenic vein thrombosis

tx- Splenectomy

468
Q

PPx for variceal bleeding

A
  1. Varices < 5 mm. Pugh A - no tx
  2. Varices < 5 mm. Pugh B/C- b block
  3. Varices > 5 mm. b-block +/- endo ligation

**TIPS not use for prevention.

469
Q

Effects of pneumoperitoneum

A

Increase preload initially, then decrease
Increase afterload. Decrease CO
Increased PCO2. Decrease FRC
Decrease renal function

470
Q

Steps to Peustow

A
  1. Upper midline incision
  2. Enter the lesser sac
  3. Kocherize the duodenum
  4. Split open the duct AT LEAST 7 cm
  5. Side-to-side REY-PJ in 2 layers

*For main duct > 7 mm

471
Q

Pancreas blood supply and anatomy

A

Head- Superior PD (Off GDA, off CHA, off CeT) and Inferior PD (off SMA)
Body/Tail- Branches of the splenic artery

Head- right of SMA (SMV is right of SMA also)
Uncinate- hugs the SMV and SMA
Neck- over the SMA
Body/tail- left of SMA

472
Q

Indication for ERCP w/ GB dz

A
  1. Bili > 4
  2. CBD stone on U/S
  3. CBD > 6 mm and Billi > 2
  4. Ascending cholangitis
473
Q

Autoimmune pancreatitis

A

Px: pancreatitis w/ normal Lipase and LFTs
Dx: elevated IgG, biopsy to prove.
- CT: dilated w/ no Calcs
- Brush biliary tree if concern for malignancy
Tx: steroids

474
Q

W/up of pancreatic cancer

A
  1. Pancreatic protocol CT
  2. EUS: if questionable LN or vessel involvement
  3. PET/CT: selectively if suspicion for malignancy.
  4. Staging scope: if suspect disseminated dz
  5. Bx: Not if resectable. Only if neo-adj chemo
  6. ERCP: if jaundice or dx uncertainty
475
Q

Tx of chronic pancreatitis

A
  1. Lifestyle changes (EtOH, smoking)
  2. Oral analgesics
  3. Endoscopic sphincterotomy
  4. Surgery
476
Q

Tx of pancreatic ascites

A
  1. NPO, IVF, NGT, TPN, SS (60% resolve)
  2. Endoscopic sphincterotomy/stent
  3. Surgery (REY P-enterosotmy or tail resection)
477
Q

Tx of acute mesenteric ischemia

A

Thrombotic: at origin of SMA; prox. jejunum to transverse colon

Embolic: distal SMA; jejunal sparring

  1. no peritonitis- endovascular embolectomy
  2. peritonitis- ex lap to evaluate bowel, embolectomy/bypass
478
Q

Dx and Tx of chronic mesenteric ischemia

A
  • Dx:
    1. duplex (Celiac > 200, SMA > 275) is 1st line for screening
    2. CTA (>70%) for definitive dx
  • Tx: Sxs + stenosis of > 70%
    1. Endovascular plasty/stent is 1st line. 1V stenting is enough (SMA > celiac)
    2. Open surgery: if can’t tolerate endovascular
  • aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation
479
Q

Tx of renovascular stenosis

A
  1. BB
  2. ACEi: unless 1 kidney or bilateral dz
    - efferent dil’n can worsen kidney dz
  3. PTA: perc trans-luminal angio +/- stent
  4. Nephrectomy
480
Q

Open SMA embolectomy

A
  1. Lift transverse mesocolon
  2. Trace MCA. Palpate the SMA at root of mesentery along inferior margin of pancreas
  3. Incise peritoneum and dissect down to the artery (left of the SMV)
  4. Therapeutic heparinize
  5. Proximal and distal control
  6. Transverse arteriotomy at infra-pancreatic segment
  7. 2 or 3 Fogarty balloon passed proximal and distal
  8. Close arteriotomy with interrupted proline
481
Q

Tx of air embolism

A
  1. LEFT lateral decubitus and Trendelenburg (trap air in the RV)
  2. Aspirate central line
482
Q

Timing of endarterectomy after a stroke

A
  1. Non-disabling stroke or TIA: 2d-2w

2. Big stroke: no consensus

483
Q

Do not cardiovert if

A
  1. High likelihood of cardiac emboli

2. Afib > 48 hours

484
Q

When to consider ppx fasciotomy

A

6+ hours of warm ischemia

485
Q

Femoral embolectomy

A
  • Longitudinal incision over the groin
  • Expose femoral common, SFA, and profunda
  • Control with vessel loops
  • Ensure ACT > 250
  • 4-5F fogarty proximal, then distal to SFA and profunda (2x clean pass for each)
  • Infuse hep saline
  • Close arteriotomy w/ interuppted prolene
486
Q

Exposure of LE arteries:

  1. Femoral
  2. AK Pop
  3. BK Pop
  4. TP Trunk
A
  1. Femoral: vertical incision over the artery from inguinal ligament
  2. AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus lateralis. Incise deep fascia superior to sartorius muscle. Watch out for GSV.
  3. BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment.
    4, TP trunk: MEDIAL incision below the tibia. Dissect to deep compartment. Divide medial solus origin of the tibia to get to the deep compartment.
487
Q

Preference for peripheral fistula

A

Location:

  1. Rad/Ceph
  2. Rad/Bas
  3. Bra/Ceph
  4. Bra/Bas
  5. Prosthetic

Rule of 6’s:

  • flow > 600/min
  • diameter > 3mm before placement. > 6mm after placement
  • depth of 6mm
488
Q

SC Steal syndrome - path and tx

A

Path- Prox SC stenosis. Reversal of flow through ipsilateral vertebral to SC

Tx: if V/B sxs (diplopia, vertigo, dysphagia, ataxia)

  1. PTA w/ stent to SC artery
  2. Carotid to SC bypass
489
Q

Vertebral/Cervical to COW

A

R carotid: off innominate ➡ IC ➡ AC/MC ➡ COW
L carotid: off aorta ➡ IC ➡ AC/MC ➡ COW
R vertebral: off R SC ➡ Basilar ➡ PC ➡ COW
L vertebral: off L SC ➡ Basillar ➡ PC ➡ COW

490
Q

Branches of the external carotid

A
  1. superior thyroid artery
  2. ascending pharyngeal artery
  3. lingual artery
  4. facial artery
  5. occipital artery
  6. posterior auricular artery
  7. maxillary artery
  8. superficial temporal artery

“Some Anatomists Like Freaking Out Poor Medical Students”

491
Q

major branches of internal carotid

A
  1. ophthalmic
  2. anterior choroidal
  3. anterior cerebral
  4. middle cerebral
  5. posterior communicating artery

**posterior cerebral comes off of the vertebro-basillar system

492
Q

Tx of type B dissection

A
  1. Uncomplicated: b-blocker for impulse control, elective repair
    - Then surveillance q3, 6, 12m. TEVAR if progression
  2. Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR
493
Q

Tx of splenic aneurysm

A
  1. > 2cm, sxatic, or fertile age female
    - embolize distal AND proximal (back bleeding from short gastric)
  2. Otherwise, monitor
494
Q

Tx of aneurysms

  • splenic
  • renal
  • iliac
  • femoral
  • pop
A
  • splenic: > 2cm or sxs ➡ embolize
  • renal: > 1.5 cm ➡ covered stent
  • iliac: > 3 cm ➡ covered stent
  • femoral: > 2.5 cm ➡ covered stent
  • pop: > 2 cm ➡ exclusion and bypass
495
Q

Tx of psuedoaneurysm

A

tx- compress 20m → thrombin

immediate surg- infxn, HDUS, pulsatile, skin changes, ischemia, AMS

496
Q

Nerve injuries during CEA:

  • Recurrent laryngeal
  • Marginal mandibular
  • Hypoglossal nerve
  • G/Ph nerve
  • Superior laryngeal
  • Accessory
A
  • Recurrent laryngeal: MC cranial nerve; 2/2 clamping; hoarseness
  • Marginal mandibular: excessive retraction and angle of jaw; Ipsilateral lip palsy
  • Hypoglossal nerve: ipsilateral tongue deviation
  • G/Ph nerve: from high dissection; difficult swallowing
  • Superior laryngeal: high-pitch
  • Accessory: failure to shrug shoulders
497
Q

Tx of Type A dissection

A
  • Treat with immediate surgery
  • Put patient on bypass
  • Median sternotomy
498
Q

May-Thurner Syndrome

A

Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine

tx- venogram, thrombolysis and stenting

499
Q

W/up of non-variceal UGI bleed (M/W tear)

A
  1. NGT+ ➡ EGD w/in 24h- clips, coags, banding, sclerose
  2. NGT-:
    - HDUS: IR angio (must be brisk)
    - HDS- C’scope/consider RBC scan, surgery
500
Q

Surgical options for acid reduction surgery

A

Surgical options:

  1. Truncal vagotomy and drainage
  2. Truncal vagotomy and antrectomy
  3. Proximal gastric vagotomy

Elective indications:

  • refractory to medical management
  • suspicion of a malignancy within an ulcer

Acute indications: HDS, minimal contamination AND:

  1. PUD w/ unknown h. pylori status (if known can just be tx medically) OR
  2. Unable to stop NSAID therapy (NSAID ulcer)
501
Q

Acute surgical options for duodenal ulcer disease

A

Indications: bleeding, perforation, obstruction

  1. Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed
    - can tie off the GDA if continues to bleed
    - close transversely
    - vagotomy not general performed
  2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment
    - If close to pylorus: pyloroplasty (+/- truncal vagotomy)
    - If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy
  3. Obstruction: NGT, resuscitation, anti-secretory ➡ EGD w/ balloon dilation ➡ antrectomy
  • Only do acid surgery acutely (vagotomy/drainage) if:
  • – HDS, minimal contamination AND
  • – PUD w/h. pylori status negative, unknown, refractory OR
  • – Unable to stop NSAID therapy (NSAID ulcer)

**EGD does not require bx for duodenal ulcers

502
Q

Tx of gastric ulcer disease

A

Indications for surgery: bleeding, perforation, refractory, can’t rule out malignancy
- must have a biopsy of some kind (r/o malig is higher than with duo ulcers)

  1. GC, antrum, body: wedge resection
  2. Lesser curve: distal gastrectomy w/ bil 2
  3. GEJ:
    - – bleeding: anterior gastrotomy, over-sew, send biopsy
    - – perf: sub-total gastrectomy w/ REY reconstruction

**Can’t wedge lesser curve b/c prominent L gastric arcade and subsequent deformed stomach

503
Q

Tx of Complications after Billroth 2

A
  1. Afferent limb obstruction
    - convert Bil 1 or REY
  2. Bacterial overgrowth: 2/2 short ante-colic limb
    - try abxs 1st. convert to REY
  3. Duping syndrome: small meals, no sugar –> octreotide
  4. Alkaline reflux gastritis: prevent w/ 50+ roux limb.
    - pro-kinetics, bile-acid binding ➡ convert to REY
504
Q

How to confirm H. pylori eradication

A

4-weeks after triple therapy:

  1. Urea breath test: preferred 1st line
  2. EGD + Bx: preferred if known gastric ulcer (r/o CA)
  3. Fecal Ag test
505
Q

Mesenteric Defects after REYGB

A
  1. Mesocolic: from retrocolic roux limb whole in the mesocolon
  2. J-J defect
  3. Peterson’s defect: mesentery of roux limb and transverse mesocolon
506
Q

Primary fuel source in fasting state

A
  1. 1st 4 hours: exogenous glucose
  2. 4h-1d: Liver glycogen
  3. 1d-1w: gluconeogenesis phase
    - brain uses protein from gluconeo (switches to ketone by day 4)
    - body uses ketones
  4. 1w+: proteins-sparing phase
    - FA/Ketones are used everywhere
    - Only RBCs use glucose
507
Q

Dx and Tx of rectus sheath hematoma

A 
Dx- mass unchanged with contraction
Tx- CTA if HDS. OR if unstable:
1. Observation- no active bleed
2. IR- if active bleeding or T3 (pre-vesicle space)
3. OR- if HDUS or skin necrosis
508
Q

Removal of perc chole tube

A
  1. Remain in place for 3-6 weeks for tract to form
  2. Cholangiogram to assess CD patency
  3. Clamp tube or elective chole if surgical candidate
509
Q

Essential fatty acids and immuno-nutrition

A
  1. Linoleic acid- omega-6 (Cis, Unsturated)
  2. α-linolenic acid- omega-3 (Cis, Unsturated)

Immuno-nutrition = arginine, omega-3 FA
- a/w less infections, shorter LOS

510
Q

Effects of hypomg

A

Sxs- similar to hypoCa ~ chvostek (tetany), tremor, fasciculations

  1. PTH resistance: hypoCa and hypoVitD
  2. NAK ATPase (ROMK) release of K: hypoK
  3. HypoPh
511
Q

RQ interpretation (metabolic cart)

A

CO2/O2

< .7 = underfeeding
.7 = pure fat
.8 = pure protein
.8-.9 = desired
1 = pure carb
>1 = overfeeding
512
Q

BSC vs. SqCC - dx and tx

A

BSC: most common malignancy in US; pearly, rolled borders, peripheral palisading; MC upper lip ca

SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca

Tx:

  • 4 mm for unaggressive
  • 8 mm for aggressive tumors
  • 1 mm for MOHS
  • LADN’y for clinical positive nodes
  • Can consider SLNBx for high risk SqCC
  • Limited role for chemo/XRT
513
Q

Tx of paronychia and felon

A
  1. Pronychia: non-purulent infection of nail fold
    - Non-purulent: clinda only
    - Purulent: lateral incision to nail bed
  2. Felon: fingertip pulp abscess
    - vertical incision over the pulp
    - abxs only if not tense
514
Q

Dx and Tx of Nac Fac

A
  • LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV
  • CT: gas, thick fascia
  • abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage
  • surgery
515
Q

SAAG score

A

Albumin Serum - Albumin in ascites

> 1.1 = portal HTN (cirhosis, HF, budd-chiari, PVT)
< 1.1 = TB, pancreatitis, infection, chylous
- chylous if milky and TG > 200

516
Q

Dx and Tx of pancoast tumor

A
  1. Perc bx- usually sqcc
  2. Mediastinoscopy (or EBUS)
  3. Induction chemo-XRT
  4. Surgical evaluation
    - c/i to oncologic resection: extra-thoracic mets, n2 disease, brachial plexus above T1, spinal canal (vessels are not a c/i)
    - vascular involvement is not c/i
517
Q

Dx and Tx of pancreatic leak

A 
Dx: complication of splenectomy
- drain collection and send for amylase
Tx:
1. ASx: observe
2. Sxs: perc drain, NPO, TPN
3. ERCP, sphincterotomy, internal drain
4. Distal panc
518
Q

Types of hyperPTH

A

1- High Ca/Low Ph: over-secretion
2- Low Ca/High Ph: CKD or VitD def (physiologic)
3- High Ca/High Ph: kidney transplant

519
Q

Dx and Tx of Ewing Sarcoma

A

Dx- “onion skin” in diaphysis

Tx- chemotherapy (1st line) + surgery or XRT

520
Q

Pulmonary sequestration

A

No bronchial commmunication

  1. Intra-lobar: MC; blood from aorta; pulmonary veins
  2. Extra-lobar: systemic arteries and veins

Tx- lobectomy or segmentectomy

521
Q

Lung anatomy: R vs. L

A

Right:

  • oblique/major fissure: separates lower from middle/upper
  • horizontal/minor: separates middle from upper
  • main bronchus 90-degrees; 2 bronchi

Left:
- oblique/major fissure; 1 bronchus

522
Q

RF and Tx of T/I fistua

A

RF- trach below 4th ring OR, high pressure cuff, high innominate cross

  1. Over-inflate the cuff
  2. Intubate from above
  3. Compress against the sternum
  4. Median sternotomy
  5. Ligation AND division of innominate artery
  6. Buttress tracheal hole w/ muscle
523
Q

Indications for pleurodesis

A
  1. Air Leak > 5 days
  2. Recurrent (even if contra side)
  3. High risk occupation (scuba, pilot)
  4. IC (AIDS)
524
Q

Px, dx and tx Lymphocele

A

Px- sudden decrease in UOP weaks after trx
—2/2 lymphatic leak from iliac dissection
—Sirolimus is a RF
Dx- US
Tx- perc drain ➡ peritoneal window

525
Q

Px, Dx, Tx of RAS and thrombosis after kidney transplant

A
  1. Thrombosis: sudden cessation of UOP immediately post op
    - Dx: U/S
    - Tx: nephrectomy unless small branch
  2. Stenosis: refractory HTN and elevated Cr
    - Dx: US (vel > 180, 70%)
    - Tx: perc angio/stent

**No pain with arterial issue (pain = venous issue)

526
Q

Causes of low UOP after kidney trx

A
  1. Immediate: arterial thrombosis- nephrectomy
  2. Weeks: lymphocele- open/lap peritoneal window
  3. Months: polymovirus (BK)- nephrostomy + reconstruction
527
Q

Px, Dx, Tx of PTLD

A

Px- LADN, fevers w/in 1 year
- B cells proliferation 2/2 T cell suppression from IS
Dx- PCR+ for EBV
Tx- reduce IS

528
Q

Inflow and outflow for pancreas transplant

A
  1. Inflow: iliac vessels (kidney- left, pancreas- right)
    - -donor SMA and splenic artery are connected with donor iliac artery Y graft to be plugged into the right iliiac
  2. Outflow: iliac vessels
    - -donor SMV/splenic vein are already connected. Plugged into R iliac vein (or SMV/PV)

**Duo can be connected to SB or bladder

529
Q

w/up of kidney graft dysfunction

A
  1. Elevated Cr. Low UOP.
  2. US: high RI is a non-specific finding
    - Vascular abnormality ➡ angio, stent, or surg
    - Lymphocele/Urinoma ➡ perc drain ➡ perit window
    - Negative: graft dysfunction ➡ Core needle bx
530
Q

Post transplant hepatic artery vs. PV thrombosis

A
  1. HA thrombosis: MC
    - Early: days/weeks- hepatic failure ➡ thrombectomy OR re-trx
    - Late: months- abscess, strictures ➡ temporize, re-trx
    - Stenosis: angio and stent
  2. PV thrombosis: rare
    - Early: days/weeks- FHF ➡ thrombectomy or re-trx
    - Late: months- encephalopathy, varices ➡ AC
    - Stenosis: angio and stent
531
Q

GVHD - px, dx, tx

A
  • Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx
    • WBC from donor recognize recepient as foreign
    • B+T cells
  • Dx: bx
  • Tx: steroids + IS
532
Q

Tx of testicular torsion

A
  1. Surgical de-torsion of involved testes
    - If doubtful viability: <10 keep, >10yo orchiectomy
  2. Exploration and fixation of uninvolved testis as well!

**don’t delay OR for U/S if suspicion is high

533
Q

Dx and Tx of RCC

A

Dx: triple phase CT (don’t need tissue bx unless mets)
- do cystoscopy after CT
Tx: Radical nephrectomy + LND +/- chemo +/- XRT
- TK inhibitor is 1st line chemo

534
Q

Types of hydrocele and Tx

A
  1. Communications: children. 2/2 patent processes
    - <2yo: conservative; >2yo: surgical excision
  2. Non-communicating: adults. 2/2 secretions not connected to peritoneum
    - dont tx if asx. tx w/ excision.
535
Q

Dx and Tx of LCIS

A

Dx

  • usually incidental. pre-menopausal women. mammo negative
  • R/o breast ca is .5% per year

Tx

  • Must perform lumpectomy bc 10-20% chance of surrounding DCIS or CA
  • Don’t need negative margins as long as dx can be made
  • No SLNBx

PPx

  • Surgery can be done for prophylaxis
  • Can get hormonal therapy
  • Surveillance w/ MRI or mammo q6m
536
Q

Dx and Tx of inflammatory breast ca

A

Dx: skin punch bx

Tx:

  1. Neo-adjuvant
  2. MRM
  3. XRT
  4. Endocrine tx
537
Q

TRAM vs. DIEP flap

A

TRAM- skin, fat, and rectus; more functional loss

DIEP- skin, fat only; preferred; slightly more flap loss; less morbidity

538
Q

Fibroadenoma - px, dx, tx

A

Px- pain w/ periods
Bx- fibro-epithileal lesions (if “aggressive” concern for phyllodes)
Tx- resect if > 3cm, sxs, growth, anxiety, discordance

539
Q

Tx of breast ca in preg

A

1T (13w)- mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T

2-3T- lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT

540
Q

Indications for post-mastectomy radiation

A
  1. > 5cm
  2. 4+ nodes
    • margin
  4. skin involvement
541
Q

Boundaries of ax dissection

A
  • medial: p. minor
  • lateral: lat dorsi
  • superior: ax vein
  • posterior: subscapularis
542
Q

Trauma to the chest and abdomen. HDUS.

A

General start with ex-lap b/c significant cardiac or above DPGM bleed would have killed the patient already

543
Q

Bolus fluid and blood in children

A

Fluid: 20cc/kg
Blood: 10cc/kg

544
Q

Repair aortic trauma

A

Access usually with Mattox maneuver
If < 50% closure primary with polypropylene suture
If > 50% perform a PTFE patch

545
Q

Visceral artery trauma

A

Celiac- Mattox; try to reconstruct; can be ligated
SMA- Mattox of follow root of mesocolon; cannot ligate
IMA- Mattox; try to recontruct; can be ligated

546
Q

Proximal Control and Access

A
  1. Supra-celiac: G-H ligament ➡ lesser sac ➡ R
  2. Supra-mesocolic: supra-celiac aorta; mattox
  3. Infra-mesocolic: infra-renal aorta; trans-peritoneal
547
Q

Small bowel trauma

A
  1. Serosal tear: interrupted, non-absorbable
  2. <50%: 1 or 2 layer closure
  3. > 50%: resection and anastaoisis
  4. Multiple short segments: resection and anastamoisis
548
Q

Access to neck zones

A

Zone 1: thoracic inlet to cric ➡ median sternotomy with left neck incision
Zone 2: cric to angle of mand ➡ left neck incision
Zone 3: angle of mand to skull base ➡ IR

549
Q

Causes of R-shift/decrease affinity on Oxy-Hb curve

A

2,3 DPG
Elevated temp
Higher paCO2
Acidosis

550
Q

Shock class

A
  1. No VS changes
  2. Tachycardia
  3. Hypotension and combative
  4. No UOP and obtunded
551
Q

Lung cancer staging

A

T1: <3 cm with no main bronchus
T2: 3-5 cm w/ invasion of main bronchus or pleura
T3: 5-7 cm with chest wall, pericardium
T4: >7cm w/ mediastinum, great vessels, DPGM, trachea, esophagus

n1: ipsi peri-bronchial nodes
- n1 nodes: 10-14
n2: ipsi mediastinal/subcarinal nodes
- n2 nodes: 1-9
n3: contra mediastinal/hilar; any-supraclavicular
* *Need at least least 3x N1 and 3x N2 (6 total) for staging

S1: T1 or T2. No N.
S2: T3 or N1
S3: T3 and N1 or T4 or N2
S4: M1

552
Q

Ketamine c/i

A
  1. MI (b/c increases SNS activtiy and cardiac demand)

2. Space occupying brain lesion

553
Q

SCIP Quality Measures

A
  1. abx 1h prior to incision (for approrpaite pts)
    - include G negative coverage for GI procedures
  2. abx dc w/in 24h
  3. appropriate hair removal
  4. controlled 6am glucose in cards pts
  5. dc foley on POD1-2
  6. normothermia
554
Q

Insulin peri-op

A

On morning of surgery:

  • Don’t take oral hypo-glycemics
  • Don’t take short-acting insulin
  • Take 1/2 of long-acting insulin
555
Q

Indications for pre-op spiromtery

A
  • all lung resections
  • smoking > 20 years
  • suspected pulmonary disease (COPD, ILD)
  • reduced exercise tolerance, unexplained dyspnea
556
Q

Appendicitis PE maneuvers

A
  1. Obturator- pain w/ internal rotation = Pelvic appe
  2. Psoas- pain w/ extension = retrocecal
  3. Rovsing- pain on the right with left push
557
Q

Absolute c/i to PEG

A
  1. Uncorrectable coagulopathy
  2. Unctronolled ascites
  3. Unable to oppose stomach to abdominal wall (inability to transilluminate is only relative)
  4. Survival < 4 weeks
558
Q

Tx of sublgottic stenosis

A

2/2 to traumatic cric placement

tx- resection with re-anastamosis (dilation doesn’t work)

559
Q

Frey Syndrome

A

Gustatory sweating

2/2 auriculotemporal nerve

560
Q

Dx and Tx:
TG duct cyst
brachial cleft cyst
cystic hygroma

A
  1. TG duct: midline through hytoid bone; sistrunk procedure
    - if infected tx w/ abxs first
  2. Brachial cleft: anterior SCM; resection
  3. Cystic hygroma: posterior triangle; resection (avoid infection)
561
Q

Component separation

A
  1. Anterior: EP aponeurosis 2cm lateral to semilunar line from costal margin to inguinal ligament
  2. Posterior: Cut posterior rectus sheath and mobilize retrorectus plane
562
Q

Mesh choices

A
  1. Heavy weight polyprop: micro-porous; lower recurrence but more infections
  2. Light weight polyprop: macro-porous; less infections but high risk of adhesions (coat bottom with PTFE)

Based on contamination:

  • clean: synthetic
  • clean/contaminated: synthetic is preferred! ( even w/ controlled enterotomy w/out gross pillage)
  • contaminated: biologic mesh if > 3 cm
  • dirty/infected: biologic mesh if > 3 cm
563
Q

STITCH trial

A

5 mm bites every 5 mm

564
Q

Boundaries of femoral canal

A

floor- cooper’s/pectineal ligament
anterior- inguinal ligament
medial- lacunar ligament
latera- femoral vein

565
Q

Tx of parastomal hernia

A
  1. ASx- can observe
  2. Sxs- sugarbaker (preferred), or keyhole
    - do not relocate
  • Only repair for obstruction or strangulation
  • LB herniates more than SB
566
Q

Boundaries of triangle of doom/pain

A

Doom: Apex- internal ring. Medial- vas. Lateral-spermatic vessels

Pain: (inverted triangle): Base- inguinal ligament. Medial- spermatic vessels. Lateral- reflected peritoneaum
- Nerves (medial to lateral): femoral, FBFG, AFC, LFC

567
Q

Tx of hiatal hernia

A

Type 1- asx: NTD; sxatic: PPI; Surgery if refractory

Type 2-4: surgery even if asx

568
Q

Type of ventral hernia repair

A
  1. < 2cm: suture repair +/- mesh
  2. 2-10 cm: sublay or underlap w/ mesh
    - Sublay: retro-rectus aka rives-stoppa (under the peritoneum)
    - Underlay: aka IPOM (intra-perionteal only) under the peritoneum
  3. > 10 cm: component seperation w/ mesh
569
Q

Dx and Tx Ischemic Orchitis

A

dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5
tx- NSAID and pain meds. Orchiectomy is last resort.

570
Q

MCCO Cushing syndrome

A
  1. Exogenous steroids
  2. ACTH pituitary adenoma- lap adrenalectomy
  3. Cortisol secreting adrenal adenoma- trans-sphenoidal resection
  4. ACC- open adrenalectomy
571
Q

Tx of ACC

A

OPEN adrenalectomy + mitotane

572
Q

Dx and Tx of Addison’s

A

Cause- AI attack of adrenal cx
Dx- cosyntropin test - cortisol remains low
- deceased cortisol and aldo with high ACTH
Tx- steroids

573
Q

Relative strength of steroids

A
  1. Dex
  2. M-pred
  3. Pred
  4. H-cort
574
Q

w/up of Hypercortisolism

A
  1. Initial tests: choose 1-2
    - 24h urine free cortisol (most se)
    - late night salivary cortisol
    - overnight 1 mg dexa suppression
  2. ACT Level

A. ACTH normal/high - high dose dexa suppresion

  • no suppression: small cell lung ca
  • supperessed: pituitary adenoma

B. ACTH low

  • CT positive: adrenal mass
  • CT negative: exogenous
575
Q

Dx and Distribution of carcinoid tumors

A

Dx: 24H urine HIAA or serum chromo A
- Octreotide scan if can’t locate

Distribution:

  1. Rectum
  2. SI (ileum)
  3. Appendix
  4. Colon
576
Q

Tx of mesenteric vein thrombosis

A
  1. AC
  2. Surgery if peritonitis or failure to improve
    - can also consider endovascular thrombolytics
  3. 2nd look operation 24-48 hours
577
Q

Tx of Grave’s disease

A
  1. Beta blocker
  2. Methimazole. PTU if preggo
  3. RAI once euthyroid- worsens opthalmopathy and c/i in pregnancy
  4. Surgery if refractory, opthalmotaphy, compressive sxs, RAI and methimazole/PTU c/i

**Preggo: beta blocker, PTU. Avoid RAI. Surgery if can’t tolerate PTU

578
Q

W/up of Hashimoto’s disease

A
  1. FNA- r/o ca
  2. Bloodwork- antiTPO/TG Ab
  3. Tx- thyroxine ➡ partial thyroid

**MCCO hypoT in the US

579
Q

Tetanus ppx

A
  1. Full immunized (>= 3 toxoid doses)
    - clean/minor: toxoid vaccine if dose >= 10 years
    - dirty or > 1cm: toxoid vaccine if dose >= 5 years
  2. Unknown or not fully immunized
    - clean/minor: toxoid vaccine
    - dirty or > 1 cm: toxoid vaccine + Ig
580
Q

Dx and Tx of CMV colitis

A

Dx

  • usual CD4 < 50
  • PCR is unreliable b/c does not prove end-organ disease
  • must scope and bx to confirm dx

Tx: gancylovir

  • initiate HAART
  • opthalmic exam to r/o retinitis
581
Q

Standard w/up for lung ca

A
  1. PET/CT
  2. PFTs
  3. Bronchoscopy (can be intra-op)
  4. Mediastinal eval- EBUS or mediastinoscopy
582
Q

Indications for ICP monitor

A
  1. GCS <= 8 AND:
  • CT evidence of pathology OR
  • 2/3: age > 40, HoTN, abnormal posturing

**IF GCS <= 8 with normal CT of the head, 2/3 (age > 40, HoTN, abnormal posturing) to get an ICP

583
Q

Bronchiolitis obliterans

A

MCCO long term lung trx failure
2/2 bronchiole inflammation
Px- serial decline in PFTs. Normal tacro. CT- ILD
Dx- of exclusion
Tx- steroids, IS, reTrx (very poor outcomes)

584
Q

Endovascular head-induced thrombus tx (after RFA)

A
  1. Stop at saph-fem/saph-pop jxn: no tx
  2. <50% of deep vein occluded: surveillance
  3. > 50% of deep vein occluded: AC until clot resolves
  4. Occlusive deep vein: tx as a dvt (3m of AC)

**Prevent by ablating > 2.5 cm from the jxn

585
Q

Pressor for neurogenic shock

A
  1. Above T6: nor-epi (b/c HoTN and brady)

2. Below T6: Phenylephrine (may worsen brady above T6)

586
Q

Discerning idiopathic constipation:

  1. Dyssynergic
  2. Slow transit
A

Discerning idiopathic constipation:

  1. Dyssynergic: lack of external relax w/ push
  2. Slow transit: retained 6+ markers on day 6
587
Q

Vitamin A

A
  • wound healing especially in steroid patients

- def: night blindness

588
Q

PPV and NPV

A 
PPV = of those who test + how many have the dz
NPV = of those who test - how many do not have the dz

Increasing prevalence = increase PPV and decrease NPV

589
Q

Pearson’s R Value

A

Correlation coeff between -1 and 1

1 = very strong positive (direct proportion)
> .7 = strong positive
0 = no correlation
- .7 = strong negative

Do not determine causation

590
Q

Phases of clinical trail

A
  1. Safety in a small group of humans
  2. How well does the drug work
  3. RCT compared to standard of care
  4. Long term safety and monitoring
591
Q

Chest exposures

A
  1. Median sternotomy: ascending aorta, innominate, bilateral carotids, RIGHT subclavian, precordium
    - add neck/supraclav extension for distal control
  2. Left Anterolateral thoracotomy: left subclavian (high), trauma/extremis (heart, lung, aorta)
    - can extend to clambshell in trauma
    - can extend to neck/supraclav for LEFT subclavian
  3. Right Anterolateral: SVC, IVC
  4. Right Posterolateral:
    - airway: distal tracheal, R main bronchus,
    - GI: thoracic esophagus
    - Vasculature: azygous vein
  5. Left posterolateral:
    - airway: L main bronchus
    - GI: cervical and distal esophagus
    - vascular: descending aorta
592
Q

Indications for hepatectomy instead of liver trx in HCC patient who meets Milan criteria

A

Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm

593
Q

Mucor/Rhizopus vs. Aspergillus - path and tx

A
  1. Mucor: DM or IS patients
    Path- broad hyphae w/ irregular branching
    tx- intubation, ampho, and surgery
  2. Aspergillus
    Path- narrow hyphae w/ regularbranching
    tx- voriconazole. resect if aspergilloma.
594
Q

SMA embolus vs. thormbosis

A

Embolus- lodges after the middle colic. Jejunal sparring

Thrombus- at ostium; pan-bowel

595
Q

SMA embolectomy steps

A
  1. Retract transverse colon cephalad
  2. Identify SMA
  3. Arteriotomy proximal to middle colic
  4. Fogarty cathter
  5. Close arrteriotomy
596
Q

Bilateral adrenal trauma

A

Suspect adrenal crisis

Tx- 4mg IV dexamethasone

597
Q

Desmoid Tumor - path and tx

A

A/w FAP (after surgery, 2nd MCCO death)
Path- non calcified, fibrotic, low mit index, spindle cells
Tx- WLE for extra-abd; NSAID, anti-Estrogen if intra!

598
Q

Pseudomyxoma peritonei - px and tx

A

Px- mucinous adenoca 2/2 appendix; scalopped liver

Tx- debulk anything > 2mm + HIPEC (@ 41C)

599
Q

MCCO PD catheter malfunction

A
  1. Infection

2. Outflow failure- MC 2/2 constipation

600
Q

Superior and Inferior epigastric anatomy

A

Superior Epigatric

  • from int thoracic (mammary)
  • Between rectus sheath and trans fascia

Inferior Epigastric

  • from ext iliac
  • Between rectus and transc fascia
601
Q

Serologic work-up for adrenocortical mass

A
  1. Dexa suppression (cortisol)
  2. Urine androgens (sex hormones)
  3. Plasma metanephrines (pheo)
  4. aldo/rennin ratio > 30 (salts)
602
Q

Dx and Tx endometriosis

A

Dx- often require laparoscopy
Tx-
1. Medical therapy
2. Surgery if unresponsive. Ablation if young.

603
Q

Staging laparoscopy

A
  1. Perform before neo-adjuvant, before surgery, or high risk for metastatic disease (especially if CT is resectable but patient seems high risk)
  2. Obtain histo sample, peritoneal lavage, U/S of nodal basins, explore lesser sac
604
Q

MCCO primary hyper-aldosteronism and tx

A
  1. Bilateral adrenal hyperplasia (60%)- medical
  2. Adrenal adenoma (Conn’s syndrome)- lap adrenal
  3. Adrenal adenoca- open adrenal + mitotane
    * Can use adrenal vein sampling to distinguish
605
Q

Dx and Tx of chronic mesenteric ischemia

A

Dx- CT + duplex; SMA > 275 cm/s, Celiac > 200 cm/s

Tx- angio + stent or surgery

606
Q

Resectability of pancreatic tumor

A
  1. Unresctable- distant met, >180 SMA/celiac,
    - EUS/FNA for tissue dx for neoadjuvant
  2. Borderline- <180 SMA/celiac
    - EUS/FNA for tissue dx for neoadjuvant
  3. Resectable- dx lap + whipple
607
Q

Tx of horseshoe abscess

A

Midline drainage incision of deep posterior space

Bilateral lateral counter-incisions for ischiorectal space

608
Q

Tx of anorectal fistula

A

<30% sphincter- fistulotomy or cutting seton

>30% sphincter- draining setons + ARAF or LIFT

609
Q

Tx of Internal HMHDs

A

G1- bleeding, G2- spontaneous reduce, G3- manual reduce:
-1st line: sitz, stool softener, bowel reg, fiber, fluids
-2nd line: rubber band, sclerotherapy, coag.
G4- cant reduce
-1st line: surgical HMHD’ectomy

610
Q

Tx of External HMHDS

A

1st line: sitz, stool softener, bowel reg, fiber, fluids
2nd line: surgical HMHD’ectomy
Thrombosed: incise or excision if w/in 48h

611
Q

Paget’s disease of the anus (px and tx)

A

Px- intractable pruritis, eczematoid rash

Tx- colonscopy (r/u malignancy) + WLE + perianal bx

612
Q

ARAF vs. LIFT

A

ARAF- elevate flap of M/SM, curette the tract from external opening, cover internal opening w/ flap

LIFT- dissect I/S tract, ligate the tract, curette the tract from external opening, +/- core out the tractanal

613
Q

Px Tx of Carcinoid of the rectum, appendix, and small bowel

A

Px:

  • GI tract > pulm > GU
  • Rectal is now > midgut b/c screening scopes
  • Midgut a/w flushing
  • Right sided valvular plaques (lung protects the left heart)

Tx:
< 2 cm- local excision (transanal, appendectomy, segmental)
> 2 cm- formal resection (APR, R hemi-colectomy, cancer resection WITH mesentery)

614
Q

Unresectable cholangiocarcinoma

A

Criteria
- bilateral HA or PV
- unilateral HA with extensive contra duct
Tx
- no extrahepatic dz ➡ neoadj chemo-XRT + liver trx
- extrahepatic dz ➡ chemo-XRT

615
Q

Bismuth classification and tx

A

For hilar cholangioca. Only t4 unresectable.

1: CH duct- REYHJ + LADN +/- lobectomy
2: bifurcation- REYHJ + LADN +/- lobectomy
3: R or L HD- REYHJ + LADN + lobectomy
4: Both ducts- chemo-XRT + liver trx

616
Q

Lap CBD exploration

A
  1. Dissect CD to the level of the duo
  2. Cholodochotomy distal to the CD/CBD junction
  3. Fush, basket, or fogarty balloon the stone out
  4. Close primarily, over a T-tube, or over a stent
617
Q

Advantage of T-tube closure

A
  • Does not prevent leak better than primary closure
  • Allow for future cholangiogram
  • Allow for perc stone removal once tract matures
618
Q

Indications and technique for biliary enteric drainage

A
  • Retained stoned that cannot be cleared with lap CBD exploration
  • Transduo sphincteroplasty c/i b/c CBD > 2cm and there are multiple stones
619
Q

Px and Tx of Chalangitis

A 
Dx: fever, RUQ, and jaundice
- stones > malignancy > stricture
Tx: 
- signs of sepsis: resuscitate/abx then urgent ERCP 
- no sick: US/MRCP
620
Q

Px and Tx of Sphincter of Oddi dysfunction

A

Px: Biliary pain with normal RUQ U/S after years lap chole
Dx: mannometry (no MRCP or CT 1st)
Tx: endoscopic sphincterotomy at 11’ (CCB usually ineffective)
- CBD at 11’, PD at 1-3’
- h/o REY: open transduo sphincterotomy

621
Q

Ideal setting for stone formation

A

Low bile salts
Low lecithin
High cholestersol

622
Q

Mirizzi syndrome tx

A 
px- GB neck/CD stone compresses CHD
types:
1: no fistula- cholecystectomy
2: < 1/3 circ- CC'ectomy + CBD repair w/ T-T
3: < 2/3 circ- CC'ectomy + REY-HJ
4: full circ- CC'ectomy+ REY-HJ
623
Q

Types of GB polyp

A
  1. Cholesterolosis: MC; CE mphages in LP; benign
  2. Adenomyomatosis: benign
  3. Adenoma: malignant; >1cm is RF for CA (resect)
624
Q

Tx strategy for CBD transections

A
  1. Intra-op
    - <50%, not cautery: primary repair
    - >50%, or cautery: REY-HJ
  2. Late phase
    - Place drain
    - Define anatomy w/ ERCP, PTC, or MRCP
    - Place PTC tube
    - CTA to assess for R/L HA injury
    - Delayed reconstruction 6-8 weeks once optimized
625
Q

Open CBD exploration steps

A
  1. Begin LATERALLY on the HD ligaments to ID CBD
  2. Stay sutures at 3’ and 9’. Choledochotomy
  3. Remove stones (forceps, balloon, milking)
  4. Cholangiogram
  5. Close over a T-tube
626
Q

Conditions for trans-cystic CBD exploration:

A
  1. CD > 4 mm, CBD < 7 mm
  2. < 8 stones, < 10 mm
  3. No stones in CHD (distal to CD/CBD junction)
  4. Normal anatomy (no REY-GB)
627
Q

Conditions for lap or open CBD exploration

A
  1. CD < 4 mm, CBD > 7 mm
  2. > 8 stones, > 10 mm
  3. CHD stones (proximal to CD/CBD junction)
  4. Failed trans-cystic or abnormal anatomy (REYGB)
628
Q

Management of GB polyps

A 
Sx:
- sxs, stones, PSC, > 6mm: cc'ectomy
For asx:
- > 18 mm: tx as GB cancer
- > 10 mm: CC'y
- 6-10 mm: q6m U/S for 1 year. cc'ectomy if PSC
629
Q

PSC screening guidelines

A

Cholangioca: US/MRI/MRCP q6-12m. Annual CA 19-9
GB CA: US q6-12m
CRC: colonscopy q1-2 years (regardless of UC)
HCC: US/MRI/MRCP q6-12m

630
Q

Steps of intra-op cholangio

A
  1. Clip juxn of infun. and CD (prevent reflux)
  2. Linear incision along CD
  3. Cathter placed
  4. Shoot contrast and flouro
    * scope can be used to assess masses and remove stones if needed
631
Q

Tx strategy for major burns

A
  1. Resuscitate
  2. Early excision and coverage (day 3-4)
  3. Fluid less than before:
    - UOP: .5 cc/hr in adult, 1-1.5/hr in children
632
Q

Airway burn management

A

Scope if: soot, facial/body burns, singed hairs

Tube if: edema, ulceration, blisters

633
Q

Dx/Tx hypothermia

A 
Dx- temp < 35C/95F; 1'- environ., 2'- illness/substance
Mild: < 94- shivering
Moderate: < 89- agitation, afib
Severe: <84- comatose, osborne waves
Profound: <70- loss of vitals

**moderate = 84-89

634
Q

Thoracic compartment syndrome

A

Dx: Respiratory failure 2/2 circumferential chest wall burn
- high peak pressures
Tx: escharotomy
- box incision along ant ax lines connected with sub-xiphoid transverse incision

635
Q

Dx and Tx of Colovesicular Fistula

A
  1. CT w/ oral/rectal (no IV b/c will obscure bladder)
    (not cystoscopy or colonoscopy)
  2. Colonoscopy to r/o malignancy
  3. Cystoscopy if suspect cancer. Retrograde cysto if CT is equivocal or operative planning

Tx- resect sigmoid even if asx; Don’t need to repair the bladder, just drain

636
Q

Colon cancer and arterial resection

A
  1. R hemi- IC, RC, RBMC
    - cecum/asc colon
  2. Extended R- IC, RC, MC
    - hepatic flex/prox t colon
  3. L hemi- LBMC, LC
    - Distal TV, splenic flex, prox descending
  4. Extended L- LBMC, origin of IMA
    - splenic flex
  5. Sigmoid- IMA (hi- b4 LC, low- after LC)
    - dist desc/sig
637
Q

Colon CA surveillance after curative resection

A
  1. Exam and CEA q3-6m x 3 years
  2. Colonoscopy @ q1, 3, and 5 years
    - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel)
  3. CT CAP q1y x 3 years
638
Q

Staging w/up of rectal cancer

A
  1. TRUS (avoid if > t2) or MRI- T/N stage
    - suspicous nodes on MRI count as clinical stage N (neo-adj)
  2. CT CAP- M stage
  3. C’Scope- for initial dx and sync lesion. not for T stage
  4. Rigid Sig’Scope- for distance from anal verge
    No need for PET
    MRI- circumferential resection margin
639
Q

Tx of refractory Crohn’s pan-colitis

A
  1. Segmental colitis- partial colectomy
  2. Rectal sparing pan-colitis- TAC w/ IRA
  3. Pan-colitis w/ rectum- PC w/ end ileostomy
    - IPAA whether w/ or w/out loop should NOT be done on Crohn’s b/c r/o pouchitis
640
Q

Tx of cecal volvulus

A

Stable- R hemi and primary mosis (no pexy)

Unstable- R hemi with end ileostomy

641
Q

Tx of radiation proctitis

A
  1. Acute: < 6w, no bleeding; alter therapy, supportive, butyrate enema
  2. Chronic: >6w, bleeding; anti-inf, sucralfate enema, laser coag, hyperbaric O2, surgery
642
Q

Lynch syndrome dx

A

AD; MMR gene (MLH, MSH, PMS, EPCAM)

Amsterdam II Criteria - HNPCC/Lynch

  1. Colon/HNPCC Ca b4 50
  2. 2+ generations
  3. 3+ relatives (1 is 1d)
  4. Exclude FAP

*HNPCC Ca: CRC, ovary, uterus, endometrial, gastric, renal/ureter, SB, brain, skin

643
Q

Dx of Juvenile polyposis

A

Dx: 5+ polyps or any polyps w/ family hx
- SMAD4+
Non-adenomatous polyps ~ hamartomas

644
Q

Tx of Lynch Syndrome

A
  1. CRC: q1y C-scope @ 20-25; TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma. q1y scope post op (metachronous CA)
  2. Endometrial: q1y endometrial sampling @ 30-35; ppx TAH-BSO after children
  3. Ovarian: q1y TVUS and Ca-125 @ 30-35; ppx TAH-BSO after children
  4. Stomach: EGD/Bx q2-3y @ 30-35
  5. Renal: q1y UA and US @ 30-35
645
Q

Tx of FAP

A 
q1y scope @ 10-12y
Tx- TAC w/ IRA or PC w/ IPAA (rectum involved)
Colectomy if:
- suspected CRC
- severe sxs/gi bleeding
- HGD or multiple adenomas > 6 mm 
- marked increase in poylp number
- inability to survey colon
Surveillance of pouch/rectal cuff post op q1y
646
Q

APR vs. LAR

A

Tumors that require APR:

  1. < 5cm for anal verge
  2. Tumor at dentate line w/ sphincter involved
  3. Tumor that can’t get a 1 cm distal margin w/out sphincter
  4. Poor pre-surgical anorectal function
  5. Locally recurrent low-lying cancer
647
Q

Polyposis syndromes:

  • Muir-Torre
  • Gardner
  • Turcot
  • P/J
  • Cowden
  • JuP
A
  • Muir-Torre: MLH/MSH; sebaceous gland tumor
  • Gardner: APC; desmoid tumors, osteomas, epidermal cysts/lipomas
  • Turcot: APC; Malignant CNS tumors
  • P/J: STK; myocutameous pigmentation
  • Cowden: PTEN; Hamartoma polyps, endometrial/breast/thyroid CA
  • JuP: SMAD4; epistaxis, AVM, telangiectasia
648
Q

Indications for colonic stent

A
  1. Bridge to surgery in acute obstruction
  2. Palliative measure
    * Usually for L-sided lesions
649
Q

Tx of ureter injury after sigmoidectomy

A
  1. <7 days and healthy: re-explore and fix primarily

2. >7 days or poor candidate: perc neph tube, stent; fix in 6-12 wks

650
Q

Dx/Tx of slow transit constipation

A

Dx- nuclear medicine colonic transit or radiopaque marker
Tx-
1. Laxative, fiber, pelvic floor exercise
2. TAC w/ IRA (Not TPC w/ IPAA)

651
Q

Tx of C. diff

A
  1. Primary: oral vanco or fidox
  2. Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus
  3. 1st-2nd recurrence: tapered vanco or fidox
  4. Multiple recurrence: consider fecal transplant
  5. Total colectomy if sepsis or toxic megacolon (colon > 6 cm, cecum > 10 cm)
652
Q

Dx and Tx of ischemic colitis

A

Dx- CT first to rule out non-ischemic colitis or infarction; C’scope to confirm
- suspect in low flow state, HoTN
Tx- usually supportive; OR if perf, sepsis

653
Q

Dx and Sx of PNETs

  1. Glucagonoma
  2. Inuslinoma
  3. Gastrinoma
  4. VIPoma
  5. SSoma
A
  1. Glucagonoma: glucagona > 1k; NME, DM, DVT
  2. Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad
  3. Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1
  4. VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH)
  5. SSoma: High fasting SS; DM, stones, steatorrhea

*Do not perform imaging or go to the OR until biochemical diagnosis!

654
Q

Dx and Tx of Pancreatic cysts:

  1. Serous cystadenoma
  2. MCN
  3. IPMN
  4. Psuedocyst
A
  • W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA
    1. Serous cystadenoma: low M/CEA, low Am; resect if sxs
    2. MCN: high M/CEA, low Am; resect
    3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm
    4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy
655
Q

Tx of PNETs:

  1. Glucagonoma
  2. Inuslinoma
  3. Gastrinoma
  4. VIPoma
  5. SSoma
A
  1. Glucagonoma: distal panc w/ splenectomy + cc’y
  2. Inuslinoma: enucleate
  3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple
  4. VIPoma: distal panc w/ splenectomy + cc’y
  5. SSoma: resect w/ cc’y
656
Q

Perform splenectomy for distal panc PNET?

A

No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm

657
Q

Steps to Whipple

A
  1. Inspect. Frozen any lesions. Abort if +
  2. Mobilize hepatic flexure. Expose 3D/4D
  3. Kocherize duo and HOP to LOT
  4. Palpate the SMA posteriorly from aortic origin
  5. CC’y. CHD divided above CD entry
  6. Dissect down the portal vein towards the pancreas developing plane. Ligate R gastric then GDA (branch of common hepatic)
  7. PV turns into SMV behind the pancreas (where pancreatic vein joins). Create plane between SMV/pancreas
  8. Divide the stomach at the antrum and duo 2cm past the pylorus
  9. 2 index fingers are sea-sawed behind the duo and pancreas and in front for PV/SMV, developing a the plane. Transect pancreas using cautery.
  10. Retract the pancreatic head lateral and PV/SMV medial. Ligate venous tributaries to PV/SMV.
  11. Perform P-J (2-layer, end to side)
  12. Perform H-J (1-layer) distal to P-J
  13. G-J: Billroth 2 (2-layer, end to side)
658
Q

Arterial anatomy of the celiac trunk

A
  1. CHA: gives off GDA then R gastric
    - GDA gives of SPDA and R gastroepi
  2. Splenic: gives off short gastrics and L gastroepi
659
Q

ECG findings of PE

A

Sinus tach is MC

S1Q3T3 pattern w/ TWI

660
Q

Dx and Tx of Pulmonary Blastoma

A

MC primary lung tumor in children
Dx- air/fluid filled cystic lesions. Looks like pneumo.
Tx- Surgical resection +/- chemo-XRT

661
Q

Length time bias vs. lead time bias

A
  1. Length time: screening by its very nature will pick up more indolent disease
  2. Lead time: asymptomatic disease is caught earlier by screening, “starting the clock” sooner
662
Q

Brown-Sequard

A

Ipsi loss of motor

Contra loss of pain/temp

663
Q

Dx of biliary dyskinesia

A

Suspect if GB w/ normal US and EGD

Dx- HIDA scan w/ EF < 35%

664
Q

Px and Tx of epididymitis

A

Px- scrotal pain and pyuria usually 2/2 STD

Tx- IM CTX and oral azithromycin (STD tx)

665
Q

Tx of GB perf in acalculous chole

A

Early CC’y and IV abxs

Avoid perc chole drain even if very sick

666
Q

Dx and Tx of obturator hernia

A

Dx- groin pain that improves w/ flexion and bulge
- DO NOT need CT scan for diagnosis
Tx- urgent operative exploration (don’t wait for CT eve if stable)

667
Q

Emergent ariway in a child

A
  1. Try ETT placement with a miller blade

2. Needle cric is preferred over open if < 12

668
Q

Tx of peptic stricture 2/2 GERD

A
  1. Serial dilations
  2. PPI
  3. Consider stenting
    . Surgery is last resort (in contrast to achalasia)
669
Q

Exposure to bronchial tree in trauma

A

Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)

670
Q

CREST Trial

A
  • Carotid stenting has higher incidence of stroke
  • CEA has high incidence of MI
  • Composite end-point of stroke, death, MI was the same
671
Q

Dx and Tx of Bacterial Overgrowth

A
  • px: 2/2 bill2 or REYGB
  • – watery stools, bloating, b12 deficiency
  • dx: d-Xylose test to
  • tx: abxs –> surg 2nd line
672
Q

Inguinal hernia nerves

A
  1. Ilioinguinal: under to EO
  2. Ilio-hypogastric: supero/medial to the ilio-inguinal. Passes EO superior to the external ring
  3. GB of GF: runs within the spermatic cord
673
Q

Types of HRS

A

Type 1: rapidly progressive RF. May respond to diuretics.

Type 2: slowly progressive renal failure. Ascites refractory to diuretics. Better prognosis.

674
Q

Treatment of lung ca

A
  1. No N2 disease (stage 1-2) –> up-front surgery
  2. N2 disease or T4 –> chemo-XRT first

n1- ipsi bronchial/hilar nodes
n2- ipsi mediatinal/subcarinal (2-9)

t1- <3cm
t2- >3cm
t3- >5cm OR invading pleura, chest wall, phrenic n, pericardium OR nodule in same lobe
t4- >7cm OR invading DPGM, mediastinum, heart, great vessels, trachea, RLN, esophagus, vert body, carina. OR different ipsi lobe

675
Q

Lung ca w/up

A
  1. < 8mm ➡ surveillance
  2. > 8 mm ➡ PET-CT
    - FDG- ➡ surveillance
  3. FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy)
    - nodal disease –> EBUS
  4. No N2 dz –> Segmentectomy or lobectomy
    - n2 disease –> chemo
676
Q

Ingested foreign body w/up

A
  1. Abdominal XR!

2. High risk: button batery,

677
Q

Steps of hiatal hernia repair

A
  1. Complete dissection of hernia sac from mediastinum
    - avoid vagus nerve
    - can divide short gastrics to aid in mobilization
  2. At least 3 cm of esophagus into the abdomen!
    - - Colis gastroplasty if insufficient
  3. Close the hiatus with sutures or mesh (posterior and inferior)
    - - mesh has better short term outcomes only
678
Q

Pre-op regiments for aldosteronoma and pheo

A
  1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic
  2. Pheo: phenoxybenzamine then BB
679
Q

Window to the great vssels

A

innominate vein

680
Q

Tx of HCC

A
  1. Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant
    - Consider portal vein embolization if remnant is insufficient
    - Consider pre-op TACE to as an adjunct
  2. Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant
    - Transplant if candidate: UNOS criteria
    - Otherwise: loco-regional therapy or systemic therapy
681
Q

When to re-implant the IMA in EVAR

A
  1. Back-pressure < 40
  2. Previous colon surgery
  3. SMA stenosis
  4. Inadequate left colon flow
682
Q

Lynch vs FAP Screening

A
  1. FAP- chromosomal; APC
    - > 100 polyps, including duo
    - Surveillance: start at 10
  2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM
    - <10 polyps in the colon
    - Surveillance: start at 20
683
Q

Surgical Tx of thyroid/PT cancers

  1. Papillary/Follicular
  2. MTC
  3. Hurthle
  4. Anaplastic
  5. PT
A
  1. Papillary: lobectomy +/- total + consider ppx L6 for high risk
  2. Follicular: lobectomy +/- total (criteria)
    - no node dissection unless cx+
  3. MTC: total + bilateral L6
  4. Hurthle: lobectomy then total + bilateral L6
  5. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes
  6. PT: hemi-thyroid + L6 (usually)

**MRND if L6 is positive

684
Q

Confirmation of brain death

A
  1. Neuro exam:
    - absent brain stem reflexes
    - no response to stimuli
  2. Apnea test: CO2 > 60
685
Q

Bleeding during mesh fixation, inguinal hernia

A
  1. Open: sewing mesh onto EO –> femoral vein

2. TEP: tacking mesh medially –> corona mortis (obturator branch)

686
Q

Tx of H/N tumors

A
  1. Mucoepidermoid: MC malignant
    - total parotid + ppx MRND + XRT
  2. Adenoid cystic: malignant
    - total parotid + ppx MRND + XRT
  3. Pleomorphic adenoma: MC benign
    - superficial parotidectomy
  4. Warthin/Papillary cystadenoma
    - superficial parotidectomy
687
Q

W/up of UGI bleed/perf:

  1. Boerhave
  2. Traumatic esophogeal perf
  3. UGI bleed
A
  1. Boerhave: XR suggestive ➡ UGI (CT controversial)
  2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI
  3. UGI bleed: +/- NGT ➡ EGD
688
Q

Tx of Cellular vs. Ab Rejection

A
  1. Cellular:
    - mild: steroids
    - severe: TG
  2. Ab:
    - Plasmaphoresis (clear Ab)
    - IVIG (so body thinks there are still ab)
    - Rituximab (CD20 Ab)
689
Q

IS for transplant

A

Induction: choose 1

  1. Thymoglobulin - polyclonal Ab (potent)
  2. Basiliximab - IL2 inhibitor (mild)

Maintenance

  1. Tacrolimus
  2. MMF
  3. Prednisone
  4. Sirolimus
690
Q

Transplant ABX ppx

A
  1. Bactrim- PCP, toxo gondi, listeria, nocardia
  2. Diflucan- antifungal
  3. Valganciclovir- CMV
691
Q

Transplant cross-matching

A
  1. ABO Incompatibility
    - A, B, O Ab
  2. Cross-match: recipient serum X donor lymphocytes
    - preformed HLA Ab (A, B, DR). DR is most important.
  • *Livers don’t need a cross-match
  • *Can give A2 donors to O recipients
  • *Donor: Ags are important (WBC)
  • *Recipient: Abs are important
692
Q

MAC

A

Low MAC = lipid soluble
High MAC = water soluble
- NO has highest MAC

693
Q

CDH1

A

High r/o gastric ca

ppx gastrectomy by age 40

694
Q

px, dx, and tx of meconium ileus

A

px- failure to pass meconium
dx- sweat chloride test
tx- GG then NAC enemas
- surgery: ostomy for antegrade enema

695
Q

Congenital thoracic disorders - px and tx

  1. Pulm sequestration
  2. Cystic adenoid malformation
  3. Congenital lobar emphysema
  4. CDH
A
  1. Pulm sequestration: infection w/ abnormal CXR
    - tx: resection
  2. Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree
    - tx: lobectomy
  3. Congenital lobar emphysema: XR looks like tension PTX
    - tx: lobectomy
  4. CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior
    - a/w pulm HTN, NTD, malrotation
    - tx: intubate +/- ECMO. Delayed repair.
696
Q

Ig crosses the placement

A

IgG

697
Q

Nutrition requirements per day

  1. Protein
  2. Fat
  3. Carb
A

Nutritional requirements for average healthy adult male (70 kg)

  1. 20% protein calories - 1 g protein/kg/day
    - burn: 1g/kg/day + 3 g/day x % BURN
  2. 30% fat calories
  3. 50% carbohydrate calories
698
Q

Wilcoxon test

A

Compare PAIRED ordinal variables between two groups

- ex: patient satisfaction before and after an intervention (1-5)

699
Q

COX proportion hazard modeling

A

Like a regression model but for survival analysis

Allow you to control for different factors

700
Q

Changes to VS with preggo

A

Increased HR
increased SV
Decreased SVR
Decreased BP

701
Q

Afferent limb syndrome

A
  • AKA bacterial overgrowth
  • px: steatorrhea, b12 deficiency
  • -MC w/ antecolic Bili2
  • Dx: d-xylose breath test
  • tx: abxs –> REY/shorten the limb
702
Q

Medical tx for melanoma

A

Pd1 inhibitors- pembrozilumab, nivolumab

If Braf+: braf inhibitor remains 2nd line

703
Q

MC benign/malignant thoracic tumors in adults/children

A

Adults

  • benign: hamartoma
  • malignant: sqcc

Children

  • benign: hemangioma
  • malignant: carcinoid
704
Q

Tx of Rhabdomyosarcoma

A

MC soft tissue tumor in children

tx- chemo + XRT + surgery

ABSITE 2021 (1 decks)

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