ABSITE 2022 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

Hemodynamic 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 (sensitive)
  2. 24-urine metanephrine (specific)
  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. Early external fixation
    - refractory bleed after angio → packing + fixation

**MC source is presacral venous plexus

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6
Q

STSG vs. FTSG
- survival
- cosmesis
- contraction

A
  1. STSG: epi + part dermis
    - higher survival/less resistant
    - worse cosmesis
    - more 2’ contxn. (don’t use over joints)
    - ideal use: large wounds (trunk, extremities)
    - harvest: thigh, buttock, belly
  2. FTSG: epi + full dermis
    - lower survival/more resistant
    - better cosmesis
    - more 1’ contxn
    - ideal use: small, cosmesis, functional area (joints, sacral decub)
    - harvest: groin, behind ear, neck
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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

Dx and Localize a 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: drain if persistent sxs. Wait 4-6 weeks for the wall to mature
- near stomach/duo, > 6cm: endoscopic cystogastrostomy/duodenostomy
- open or lap cysto-enterostomy (usually jejunostomy if not abutting duo or stomach)

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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 → cyst-enterostomy
  4. Infected pseudocyst: drainage (internal, external, endoscopic). Endoscopic preferred.
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16
Q

Indications to tx ICA stenosis

A
  1. Asx: > 60%
  2. Sxs: > 50% (>125 cm/s)
    - Sxs: contralateral motor/sensory sxs, ipsi vision sxs
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17
Q

EBV associated with

A
  1. B cell lymphoma (Burkitt)
  2. n/ph cancer
  3. PTLD
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18
Q

Medications for hyperthyroidism - MOA and s/e

A
  1. PTU: thyroperoxidase and de-iodinase inhibitor
    - s/e: aplastic anemia, agranulocytosis. OK for preggo.
  2. Methimazole: thyroperoxidase inhibitor
    - s/e: cretinism, aplastic anemia and agranulocytosis
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19
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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20
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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21
Q

Neostigmine

A

MOA: AChE inhibitor

Use: reversal of non-depol muscle relaxants

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22
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 or lobectomy
  4. Follicular neoplasm → lobectomy
  5. Suspicious for malignancy → lobectomy vs. thyroidectomy
  6. Malignant → thyroidectomy
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23
Q

Achalasia - Dx and Tx

A

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

Tx: only motility disorder w/ upfront surgery
- myotomy (6 eso, 2 stomch) is 1st line (avoid Nissen).
- botox or dilation if high risk.

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24
Q

Ab reactions:
1. Non-hemolytic
2. Hemolytic

A
  1. Non-hemolytic: fever after 60 minutes; cytokine from donor leukocytes
    - tx w/ epi, antihistamine, steroids
    - ppx w/ leukoreduced blood
  2. Hemolytic: fever, HoTN, bleeding; recipient Ab attack donor leukocytes/RBC
    - delay px from Ab to Rh, duffy, and Kell Ag
    - tx w/ fluid bolus
    - ppx w/ preventing clerical error (ABO mm)
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25
Q

Cowden’s mutation and cancers

A

Mutation: pten
Ca: breast, thyroid ca, hamartomas, endometrial

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26
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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27
Q

Octreotide - MOA

A
  • Somatostatin analogue
  • Inhibits exocrine function of pancreas and CCK release
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28
Q

Drainage of gonadal veins

A
  1. Right- IVC
  2. Left- Left renal vein
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29
Q

Tx Medullary thyroid cancer

A
  1. TOTAL thyroidectomy
  2. Bilateral central/level 6 dissection - if > 1cm or < 1cm w/ bilobar disease
  3. Lateral neck dissection on that side if central+
  4. Start T4 postop. Monitor w/ calcitonin AND CEA
    - RAI is c/i! (C cell origin)
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30
Q

Tx for hyponatermia

A
  1. Acute w/ any sx’s: hypertonic saline bolus
  2. Chronic and asxatic: free water restriction
  3. Hyper or euovolemic: free water restriction
  4. Hypovolemic: can give NS or LR (no 3% unless sxs!)
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31
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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32
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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33
Q

Radial scar- Dx and Tx

A
  1. Dx:
    - Mammo: spiculated mass with central sclerosis (lucency) and surrounding distortion
    - Histo: fibroelastic core w/ entrapped ducts
  2. Tx: core bx ➡ excisional bx (to r/o ca)
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34
Q

preA vs. Albumin

A
  1. Prealbumin: >15; t1/2 is 1-2 days; good post-op marker
  2. Albumin: >3.5; t1/2 is 21 days; good pre-op marker
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35
Q

Tx pop aneurysm

A

> 2cm- ligation and bypass
<2cm- observation; avoid stents

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36
Q

Tx for ectopic pregnancy

A
  1. Stable, HCG < 5k, no cardiac activity ➡ methotrexate
    - MTX: absolute c/i if the patient is breast-feeding
  2. Stable, otherwise ➡ salpingotomy
  3. Unstable, free fluid, ongoing pain/bleeding ➡ salpingectomy
    - loose future fertility
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37
Q

Hyperkalemia EKG
Hypokalemia EKG

A
  • hyperK: peaked T wave, eventual SINE
  • hypoK: QT prolongation, U waves
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38
Q

HS reactions

A

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

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39
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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40
Q

Mastodynia tx

A
  1. OCP/NSAIDS
  2. non-cyclic and >30 OR cyclic + mass ➡ mammo
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41
Q

Tx mucinous neoplasm of the appendix

A
  1. Confined to appendix: appe only (no LADN’y)
    - must have negative margin
    - scope in 6w to r/o sync lesions
  2. Involving the base, ruptured, or +margin: usually R hemicolectomy +/- LADN’y
  3. Peritoneal dissemination: can dx with perc bx
    - if appendicitis: just remove ruptured segment + directed peritoneal bx
    - if no appendicitis can postpone appe until cytoreductive surgery
    - do not do hipec/cancer operation until properly staged

**need post-op scope to r/o synchronous lesions

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42
Q

GCS eye opening

A

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

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43
Q

Torsades

A

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

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44
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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45
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)
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46
Q

TTP - Path, Px, Tx

A

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

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47
Q

LE angio

A

AT comes off first and goes lateral
TP trunk- PT behind tibia, peroneal behind fibula

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48
Q

Liver lesions on arterial phase:
HCC
Mets
Adenoma
Hemangioma
FNH

A

HCC: rapid enhancement. rapid w/out. Pseudocapsule on w/out. “hot” on nuclear imaging

Mets: Hypoattenuation

Adenoma: rapid enhancement. rapid w/out. “cold” on nuclear imaging

Hemangioma: peripheral nodular enhancement. delay: centripetal fill-in

FNH: Centrifugal enhancing. w/out except for scar enhancement. take up sulfer colloid

**If unclear, MRI can distinguish benign from malig

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49
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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50
Q

Ureter anatomy

A

Runs under the vas/uterine arteries
Runs over the iliacs

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51
Q

Elective surgery after stent

A
  1. ASA lifelong
  2. Plavix
    - BMS: 1 month
    - DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)

**Postpone elective surgery until these times
**If surgery is needed (i.e. cancer) wait at least 1m for DES

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52
Q

UE Injuries:
1. supracondylar humerus
2. DRF
3. Mid shaft
4. ant shoulder disloc
5. post shoulder disloc

A
  1. supracondylar humerus- brachial artery
  2. DRF- median nerve
  3. Mid shaft- radial nerve
  4. ant shoulder disloc- ax. nerve
  5. post shoulder disloc- ax. artery
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53
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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54
Q

DeMeester score and indications

A

Score: 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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55
Q

Standard Deviations

A

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

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56
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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57
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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58
Q

Stewart-Treves syndrome - px, dx, tx

A

Px: post-mastectomy lymphangiosarcoma
- 2/2 chronic lymphedema
- rare and highly malignant

Dx: incisional bx

Tx: wide local excision (total mastectomy) w/ 3-6 cm margin + chemotherapy
- don’t need to stage nodes (hematog spread)

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59
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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60
Q

Sorafenib

A

Tyrosine kinase inhibitor
Tx of HCC

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61
Q

Stricturoplasties
- Heineke s’plasty
- Finney s’plasty
- Side2Side isoperistaltic s’plasty

A
  1. Heineke: <10cm; open long and close transversely
  2. Finney: > 10cm; segment folded on itself and common wall created
  3. Side2Side isoperistaltic (Michellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together
  • can’t be performed in proximal duo (would require G-J bypass)
  • perform resection instead if this is first episode
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62
Q

Best test to dx gastroparesis

A

Scintigraphic gastric emptying

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63
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; no blanch

3D burn: subcutaneous fat, leathery

4D: fat/muscle/bone; surg

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64
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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65
Q

Interleukins 1, 2, 4, 5, 10

A

IL1: fever
IL2: CD4 T cell proliferation
IL4: B cell proliferation
IL5: eosinophil growth, asthma, allergic rxns
IL 10: anti-inflammatory

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66
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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67
Q

Aminocaproic acid - MOA and use

A

MOA: Plasmin inhibitor
Use: DIC, excess tpa

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68
Q

s/e of carb, protein, and lipid

A
  1. carb: immunosuppression, resp failure
  2. lipid: pro inflammatory
  3. protein: false neurotransmitters, rise in ammonia/urea
    - can worsen hepatic encephalopathy (use branched chain AA instead of aromatic AA)
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69
Q

Dx, Bx, and Tx actinic keratosis

A
  • Dx: red, crusty, weeping lesion
  • Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
  • Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)
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70
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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71
Q

z11 trial implications

A
  • If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK
  • if >70, t1, ER+ and SNLBx neg ➡ can consider no XRT after lumpectomy
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72
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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73
Q

Polyps that require surgery instead of endoscopic resection

A
  1. Submucosal invasion > 1mm
  2. Poorly differentiated
  3. <1 mm margin
  4. LV invasion
  5. Tumor budding
  6. Taken piecemeal
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74
Q

Iron deficiency sxs

A

anemia, glossitis, brittle nails, cardiomegaly

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75
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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76
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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77
Q

Fuel for:
- SB
- LB

A
  • SB: glutamine
  • LB: SCFA (acetate, butyrate)
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78
Q

Motilin

A

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

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79
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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80
Q

NEC - px and tx

A

Bloody stools after 1st feed
tx- resuscitation, abx (no surgery)

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81
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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82
Q

Tx male breast ca

A

Tx: simple mastectomy w/ SLNBx
- BCT usually can’t be done b/c not enough tissue
- if ER+: tamoxifen (Her2+ is rare). consider orchiectomy if metastatic.
- Prognosis similar to W but delay in px
- a/w BRCA 2/Chromosome 13

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83
Q

Nutcracker eso - manometery and tx

A
  • Mano:
    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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84
Q

MC etiology of ESRD leading to kidney trx

A
  1. DM, 2. HTN, 3. PCKD
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85
Q

General principles - 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
    - Repair in 6-8 weeks
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86
Q

Eso dysplasia tx

A
  1. LGD- scope q6-12m lifetime (even if fundoplication)-
    - OK for fundoplication
  2. HGD- ablation + Q3m scope
    - fundoplication c/i
  3. T1a- ablation
  4. t1b (or low risk T2)- esophagectomy

*Fundoplication does not decrease cancer risk

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87
Q

Superior epigastrics
Inferior epigastrics

A

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

IE: runs between rectus and transversalis fascia; branch of EI

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88
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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89
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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90
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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91
Q

Tx of AT3 def

A

Tx- recombinant at3 or FFP followed by heparin then warfarin

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92
Q

Vitamin C mechanism

A
  • hydroxylation of lysine and proline
  • type 3 collagen cross-linking
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93
Q

Indications for chemotherapy for rectal cancer

A
  1. Neoadjuvant:
    Stage 2 and above
    Stage 2: at least t3 (crossing muscularis prop) or any n (stage 3)
  2. Adjuvant chemo as well for Stage 3+ (nodes)

**XRT either pre or post-op (not both)

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94
Q

Periop anticoagulation - risks and tx

A

Risks:
- High risk pt: afib, MHV, recent TE event (3m)
- High risk surgery: nsurg, optho, cards

Tx:
- 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 (Dabigatran require CrCl 1st to determine days to hold)
- continue ASA for low/moderate risk
- stop Plavix 5 days before

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95
Q

What is not suppressed by high dose dexa

A

Adrenal mass
Ectopic mass (small cell cancer)

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96
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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97
Q

Heller myotomy margins and fibers

A

6 cm proximal, 2 cm distal
- Esophagus: vertical fibers first (outside), then circular (inside)

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98
Q

Margin for invasives cancer vs. dcis

A
  1. Invasive cancer- no tumor on ink
  2. DCIS- 2 mm

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

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99
Q

ITP- dx and tx

A
  1. dx: of exclusion- increased megakaryocytes, petechia, TCPenia
  2. tx:steroids → IVIG 2nd line → splenectomy
    - do not tx unless PLT < 30k or 20k in low risk
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100
Q

Staph species

A

G+/aerobe/clusters
coag+ → staph aureus
coag- → staph epidermidis

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101
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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102
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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103
Q

Neuroblastoma dx and tx

A

dx:
- CT: displacement of renal parenchyma (vs. Wilm’s).
- usually adrenal. Can also find in the neck, chest, spine,

tx:
- S1-2 (low risk) → surg alone
- S3+ (high risk) → surg + chemo/XRT

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104
Q

Gastrin - MOA and stimulation

A
  • MOA: G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ H/K exchange (ATP) ➡ HCl (+ intrinsic factor)
  • Stimulation: ACh, beta ago, AA
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105
Q

Innervation to internal and external anal sphincter

A
  1. Internal: superior rectal and hypogastric plexus (sns/psns)
  2. External: Internal pudendal nerve
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106
Q

Esophagus blood supply

A
  1. Cervical- inf thyroid
  2. Thoracic- aortic branches
  3. Abd- left gastric/inferior phrenic
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107
Q
  • CBD and PD on ERCP
  • Blood supply of CBD
A
  • CBD at 11’. Blood supply 9’ and 3’.
  • PD at 1’ to 3’
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108
Q

Tx urethral injury

A

Grade:
1/2- contusion/stretch ➡ foley
3- part disruption ➡ foley +/- cystostomy/repair
4/5-complete disruption ➡ cystostomy + delayed repair

  • can try urethral cath with cysto assistance
  • must get a CTAP to r/o concomitant injuries that would require delayed repair
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109
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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110
Q

Tx of Ogilvie’s

A
  1. CT or scope to confirm dx. R/o obstruction.

2 supportive, dc narcotics, ng tube, neostigmine

  1. if > 10cm ➡ scope decompression and neostigmine
  2. failure ➡ OR
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111
Q

Px and Tx of prolactinoma

A

Px: bitemporal hemianopsia, galactorrhea, amenorrhea, ED, osteopenia

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

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112
Q

Pros/Cons:
- Sevoflurane
- Isoflurane
- Halothane
- NO

A
  • Sevo: rapid induction, less pungent. Good for kids.
  • Isoflurane: good for neurosurgery; no increase in ICP
  • Halothane: slow onset/offset, cards depression, hepatitis.
  • NO: least cardiac depression b/c sympathomimetic. c/i in SBO. Highest MAC.
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113
Q

Atropine MOA

A
  • competitive inhibitor of ACh at muscarinic receptor
  • liver metabolism
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114
Q

FMD- Dx and Tx

A

Dx: string of beads on angiogram
Tx: angio + balloon (no stent)

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115
Q

MEN1/MEN2 genes

A

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

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116
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

**discordance: perform repeat bx w/ surgical excision or core bx (if there was a correctable error)

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117
Q

MOA, use, s/e of antifungals:
Fluconazole
Voriconazole
Micafungin
Amphotericin

A
  1. Fluconazole: ergosterol synth inhibitor
    - Non-systemic candida (yeast infection, c. albicans)
    - s/e: liver toxic, GI upset
  2. Voriconazole: ergosterol synth inhibitor
    - aspergillosis, C. krusei
    - s/e: visual changes, psychosis
  3. Micafungin: echinocandin; inhibit glucan production
    - invasive/disseminated candidiasis (c. glabrata)
    - s/e: TCPenia
  4. Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access)
    - invasive mucor or cryptococcal meningitis
    - s/e: nephrotoxic, hypoK
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118
Q

Recurrent laryngeal nerve + aberrant anatomy

A

motor to larynx except circothryoid
injury: hoarsness, airway compromise, cord paralysis (permanent ADduction)
- If bilateral may need a trach

Normal anatomy:
- Superior PT runs posterior
- Inferior PT runs anteriorly

Abbarent anatomy:
- NR right a/w: arteria lusoria ➡ absent innominate + right SC takes off from left aortic arch + travers retr-eso
- NR left a/w R sided arch

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119
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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120
Q

Origins of medullary thyroid cancer

A
  • 4th pharyngeal arch releases NCC which form parafollicular C cells
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121
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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122
Q

qSOFA score

A
  1. AMS (<15)
  2. RR > 22
  3. SBP < 100
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123
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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124
Q

Tx frostbite

A
  • Frostnip: rapid moist/pool re-warming
  • 2d: clear/milky blister- drain
  • 3d: HMHG blister- leave intact
  • 4d: bone- prostacyclin/TPA, amputate
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125
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 complication (preferred)
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126
Q

MCCO Cancer

A

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

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

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127
Q

Tx TCPenia

A

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

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128
Q

Tx annular pancreas

A

neonates- duododuodenostomy (mobile duo)
adults- duodenojejunostomy

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129
Q

Production and function:
- TNFa
- IF-gamma

A

TNF-a: produced by PMNs, mphes
-cachexia, inflammation

IF-gamma: produced by T lymphos
- activate PMNs, mphages

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130
Q

W/up of pancreatic cystic neoplasms:
Pseudocyst
Serous cystadenoma
MCN
IPMN

A
  1. MRI
  2. EUS w/ FNA (If unclear):

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

***High CEA > 190

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131
Q

Propofol - pros and cons

A

Pros
- rapid distribution and on/off
- decreases ICP

Cons
- s/e: hypotension, resp depression, meta acid
- no analgesia
- liver metabolism

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132
Q

Enterohepatic circulation

A

Liver → primary bile salts → 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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133
Q

Tx CO poisoning

A
  1. 100% O2 w/ facemask or intubation (not hi flo)
    - Hyperbaric O2 if C-Hb > 25%
  2. intubate if comatose, severe acidosis
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134
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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135
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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136
Q

Types of esophagectomy compared

A
  1. Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy
    - anastomosis: thoracic
    - theoretically more thorough oncologic resection
    - less overall leak rate
    - may be better in more fit patients
  2. Transhiatal: abdominal + L neck
    - anastomosis: cervical
    - theoretically less chance of mediastinal leak, shorter operation BUT more overall leak rate
    - 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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137
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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138
Q

Etomidate - Pros and Cons

A

Induction agent

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

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139
Q

W/up and Tx testicular ca:
- Seminoma
- Non-seminomatous

A
  1. AFP, HCG, LDH
    - Seminoma: no AFP!`
    - Non-seminoma: high 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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140
Q

Liver collection dx and tx:
1. Pyo
2. Amoebic
3. Echino

A
  1. Pyogenic: after div’s;
    - drain and abx (+mica if fungal)
  2. Amoebic: after mexico trip (or aMazon)
    - metronidazole (no drain)
  3. Echinococcal: wall Ca+ and sub-cysts
    - albendazole and resect/PAIR
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141
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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142
Q

EVAR specs:
- Proximal landing
- Common iliac (distal landing)
- Neck angulation
- External Iliac

A

Proximal landing: > 1.5 cm
- diameter < 3cm

Common iliac (distal landing): > 1 cm
- diameter > 8 mm

Neck angulation < 60 degrees

External Iliac diameter> 7mm

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143
Q

Tx of anal fissure

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

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

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144
Q

Lynch genes and gene funtions

A

MLH1, MSH2, MSH6, PMS2, EPCAM
DNA MM repair gene causing microsatellite instability

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145
Q

Condyloma types

A
  1. acuminatum- HPV (6, 11- benign; 16, 18- Cancer)
  2. lata- syphilis
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146
Q

Tx of liver lesions:
1. Hemangioma
2. FNH
3. Adenoma

A
  1. Hemangioma: only if sxatic or KM syndrome
    - enucleate (or resect); angioembo if active bleed
  2. FNH: NTD
  3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing
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147
Q

REY limbs

A

Roux- 75 to 150 cm
BP- 15 to 50 cm

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148
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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149
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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150
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 fibrinolytic therapy

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151
Q

Vertebral artery occlusion px

A

posterior circulation
sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia

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152
Q

5T’s of cyanosis

A
  1. TOF
  2. Transposition of GVs
  3. Truncus art
  4. Tricuspid atresia
  5. TAPVC
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153
Q

DES - Manno and Tx

A

Manno:
- 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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154
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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155
Q

Mondor disease - px and tx

A

px- tender, “cord-like” structure
tx- NSAIDs

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156
Q

Dx and Tx Phyllodes

A

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

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

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157
Q

Replaced Rand L hepatic

A

Right- SMA (behind pancreas and CBD)

Left- left gastric (in gastrohepatic ligament)

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158
Q

Effective for enteroccous

A

Ampicillin/Amoxacillin
Vancomycin
Zosyn
(Resistant to all cephalosporins)

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159
Q

Loss in excess weight for each surgery

A

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

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160
Q

Acid/Base of Ng suctioning

A

HypoCl, HypoK metabolic alk
- Mech: Loose HCl and fluid ➡ turn on RAA system
Retain Na/Excrete acid (paradoxic acidurea)

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161
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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162
Q

Soft tissue sarcoma - dx and tx

A

dx:
- < 3cm: excisional bx
- > 3 cm: core needle (preferred) or incisional

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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163
Q

Step up approach

A

Infected pancreatic necrosis (WBC + gas on CT)

  1. Carbanem
  2. FNA
  3. Perc drain OR endo drain (if stomach is close to pancreas)
  4. Upsize drain
  5. Video, Lap, or Endo assisted retrop necrosectomy
  6. Lap/open necrosectomy
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164
Q

CN11

A

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

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165
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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166
Q

Types and 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 cardioversion
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167
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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168
Q

Melanoma w/up and tx

A
  1. Punch bx or excisional bx (if small, non-sensitive area)
    - MIS- 5mm margin
    - <1mm- 1cm
    - 1-2mm- 1-2cm
    - >2mm- 2cm
  2. Clinical positive nodes (stage 3) require FNA for confirmation
    - negative: SLNBx
    - positive: completion LN dissection
  3. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
  4. If SLNBx+ (stage 3): q4m US surveillance OR completion LN dissection
  • LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes

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

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169
Q

Steps of rapid sequence intubation

A

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

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170
Q

PSC vs. PBC - assocaited and tx

A

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

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

tx both- trx, cholesty., UDCA

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171
Q

CPP

A

MAP - ICP
normal CPP > 60
Normal ICP < 20

  • would prefer low MAP with CPP of 60 then higher MAP for brain bleed
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172
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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173
Q

Px, 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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174
Q

Epidural hematoma

A

Biconvex
MMA
DOES NOT suture lines

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175
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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176
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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177
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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178
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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179
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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180
Q

Methemoglobinemia - px, dx and tx

A

Px: nitrites, Hurricaine spray, fertilizers
- Fe2+ to Fe3+ impairing O2 binding
- G6PD def or serotonergic drugs

  • Dx: blood gas measurement and pulse ox says 85%
  • Tx: vitamin C (for g6pd or ser) or methylene blue
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181
Q

Layers of colon/rectum

A
  1. mucosa
  2. sub-mucosa (strongest)
  3. muscularis propria
  4. serosa
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182
Q

LE vascular trauma

A
  • small: patch plasty
  • large: contralateral GSV (must maintain venous system b/c deep vein may be injured)
  • limited time/unstable: shunt
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183
Q

Tx Post dural puncture headache

A

after epidural
tx with blood patch

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184
Q

Tx for DVT

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

Special cases:
- ileofemoral: cather directed thrombolysis
- open thrombectomy ➡ extensive (ileofemoral) DVT OR phlegmasia
- Superficial femoral vein is a DVT
- Pregnant ➡ use Lovenox. NOAC and Coumadin are c/i

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185
Q

Loop diuretics vs. Ca sparing diuretics

A
  • loop: furosemide
  • Ca sparing: thiazides
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186
Q

MALT lymphoma dx and tx

A

Dx: EGD + bx
- CD20+, lympho infiltration
- associated w/ h. Pylori.

Tx:
- Low grade: triple therapy (eradicate HP)
- High grade: chemo and XRT (CHOP) +/- rituximab (CD20)

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187
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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188
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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189
Q

Tx infected pseudocyst

A

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

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190
Q

Tx melanoma of anal canal

A

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

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

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191
Q

Kaposi’s sarcoma - cause and px

A
  • Case: HSV8
  • Px: Violet/brown papules
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192
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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193
Q

Sonograph FNA recs

A
  • cystic: no bx

-isoech/hyperech: FNA if > 2cm

-hypoech (high sus): FNA if > 1cm

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194
Q

Tx anal incontinence

A
  1. 1st line: fiber/bulking, exercises
  2. Refractory: endoanal U/S
    - defect: overlapping sphincteroplasty
    - no defect or refractory: sacral modulator
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195
Q

s/e of burn topical treatments:
- silver nitrate
- silver sulfadiazene
- mafenide
- bacitracin

A
  • Silver nitrate: electrolytes disturbance (no sulfa)
  • Silver sulfadizene: neutropenia, sulfa (covers pseudo)
  • Mafenide: met acidosis, sulfa (covers pseudo and eschar)
  • Bacitracin: G+; nephrotoxic
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196
Q

Triple therapy

A

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

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197
Q

APC gene

A
  • chromosome 5
  • 1st mutn in adenoma to carcinoma
  • mc mutation in colon ca
  • a/w FAP
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198
Q

Contents of post triangle

A
  1. CN 11
  2. subclavian artery
  3. EJV
  4. brachial plexus trunks
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199
Q

Gail model

A
  1. age
  2. age 1st period (earlier is worse)
  3. age 1st birth (earlier is better)
  4. 1d relative
  5. previous bx
  6. race
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200
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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201
Q

Dobutamine

A

B1 at low dose
- inotropy

B2 at high dose
- vasodilation

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202
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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203
Q

Carcinoid vs. GIST vs. Desmoid- cells and tx

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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204
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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205
Q

VRE coverage

A

Synercid, linezolid

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206
Q

MOA:
- Milrinone
- Midodrine

A

Milrinine- PD inhibitor, contractility with vasodilation
- c/i in renal failure

Midodrine- a1 agonist

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207
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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208
Q

Tx and Dx of SBP

A

dx- ↑ascitic PMN and + culture; e. coli is MC
tx- 3GC abx AND albumin (survival benefits)

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209
Q

HLA test

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

Recipient serum with donor wbc

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210
Q

Tx acute variceal HMHG

A
  1. Octreotide + antibiotics
  2. Endoscopic intervention (ligation/sclerotherapy)
  3. Blakemore
  4. TIPS
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211
Q

Tx SVC syndrome tx

A
  1. Elevate HOB
  2. CXR and CTA
  3. Consider bronch
  4. Assess sxs
    A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting
    B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo
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212
Q

Crystalloid and colloid for trauma kids

A

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

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213
Q

Melanoma characteristics:
- superficial spreading
- lentigo
- nodular
- acral

A
  • superficial spreading: MC
  • lentigo: sun exposed, best prog
  • nodular: worst prog
  • acral: AA

**thickness is most indicative of prognosis

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214
Q

Tx appendicitis

A
  1. Uncomplicated: lap appe
  2. Septic/Unstable: immediate lap appe
  3. Stable w/ abscess
    - < 3cm: lap appe
    - > 3cm: IR drain ➡ interval appe
  4. Phlegmon:
    - ileocecal resection likely: abx trial 1st
    - ileocecal resection unlikely: lap appe
  5. Crohn’s ileitis
    - intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty

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

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215
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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216
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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217
Q

Prog and Tx anaplastic thyroid ca

A

Prognosis:
- aggressive, undiff
- mort ~ 100%; no tx

Tx: XRT improves short-term survival +/- surg
- BRAF inhibitor for chemo

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218
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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219
Q

Criteria for transanal excision of adenocarcinoma

A
  1. T0 or T1 (submucosa)
  2. < 3 cm
  3. < 30% circumference
  4. Palpable on DRE (<8cm from anal verge)
  5. No high-risk features (poorly diff, LV invasion)

**local recurrence rate is higher

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220
Q

Merkel cell ca - dx, histo, and tx

A

Dx:
-rare neuroendocrine tumor of the skin
-purple raised; looks like BCC w/out rolled edge
- CK20+

Tx:
-highly radiosensitive
-Tx (like melanoma): surgical excision + SLNBx! + XRT

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221
Q

Breast abscess tx

A

US aspiration BEFORE I/D if refractory
Bx if > 2 weeks to r/o ca

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222
Q

5 steps to LADDS procedure

A
  1. Resect Ladd’s bands
  2. Widen the mesentery
  3. Counterclockwise rotation
  4. Cecum in LLQ (cecopexy), place duodenum in RUQ
  5. Appendectomy
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223
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 ➡ MEtronidazole…surgery if refractory
  2. 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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224
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
    - after children: TAH-BSO
  3. Ovarian ca: annual pelvic exam and TVUS
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225
Q

Tx choledochal cyst

A
  1. fusiform dilation: REY-HJ
  2. diverticulum: simple excision
  3. choledococele: transduo excision vs. sphincteroplasty
    4a. intra + extra dilation: hepatic resection + recon
    4b. extra only: excision + recon
  4. intra only: transplant
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226
Q

Vit D vs. PTH

A

Vit D: increase Ca and Ph
PTH: increase Ca and decrease Ph

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227
Q

Arterial content

A

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

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228
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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229
Q

Cori cycle

A
  • recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production
  • requires alanine
  • provides 40% of glu when starving
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230
Q

Tx of GB cancer

A

1a: LC only
- lap chole only
- excise to negative CD margin
1b: muscle involved
- OPEN chole + seg 4b and 5 + portal LADN
- CD margin positive: REY-HJ

**high suspicion for GB Ca should also get an open chole (polyp > 2cm)

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231
Q

Layers of mucosa

A

Epithelium
Lamino Propria
Muscularis mucosa

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232
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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233
Q

Tx of CBD stone intra-operatively

A
  1. Flush ➡ glucagon x 2
  2. Lap exploration
    A. Transcystic: stone < 1 cm, <8 stones, CHD > 4 mm, no CHD stones, normal anatomy
    B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones
  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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234
Q

W/up Hurthle Cell Cancer

A
  1. FNA- hurthle cells (can be seen in other conditions)
  2. Lobectomy 1st for diagnosis
  3. If malig: total thyroidectomy +/- L6 nodes
  4. If palpable nodes: MRND

No RAI

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235
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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236
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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237
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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238
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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239
Q

Tx DPGM injury

A
  • All left sided and most right sided should be repaired
  • Abdominal approach
  • Debride devitlized tissue
  • Repair with non-absorbable suture
  • If too large can close primarily can use mesh or tissue flap (if contamination)
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240
Q

Tx of liver abscess:
- fungal
- hydatid cyst
- amoebic
- pyogenic

A
  • fungal: perc drain + micafungin (ampho is 2nd line); usually 2/2 chemo/neutropenia
  • hydatid cyst: albendazole qwks +/- PAIR
  • amoebic: metronidazole
  • pyogenic: DRAIN! and Abxs (even if multi-loculated)
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241
Q

Strep species

A

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

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242
Q

Hypocalcemia vs. Hypercalcemia - sxs and ekg

A
  1. HypoCa: tingling, chvostek/trousseau sign
    - EKG: qt prolongation
  2. HyperCa: stones, bones, groans, overtones, DI
    - EKG: shortened QT
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243
Q

Calcitonin

A

Parafollicular C cells
Inhibits osteoclast resorption
Increases Ph excretion

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244
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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245
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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246
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 pancreas
    - 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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247
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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248
Q

Px, Dx, Tx Galactocele

A

Px: breast mass that looks like abscess w/ no infectious signs

Dx/tx: u/s ➡ aspiration; continue bfeeding

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249
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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250
Q

Stages of graft healing

A
  1. imbibition (direct diffusion)
  2. inosculation (cap beds meet)
  3. revascularization
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251
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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252
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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253
Q

Order of cells in healing

A
  1. Hemostasis: PMNs (24-48h)
    - PMNs: remove necrotic tissue, release ROS’s
  2. Inflammatory: monocytes/macrophages (48-96h)
    - mphage: growth factors, angiogenesis, cell proliferation
    - chronic wounds arrest in this stage
  3. Proliferative: fibroblasts (3d+)
    - fblasts: collagen production and secretion
  4. Maturation: fibroblasts (10d)
    - myofibroblasts for wound contraction
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254
Q

Hemophilia A

A

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

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255
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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256
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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257
Q

acid and alkali burns - px

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
    - cagluc if HF acid
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258
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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259
Q

Tx PDA

A

to close- indomethacin
to open- PGE1

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260
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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261
Q

Dopamine dosing and s/e

A

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

**s/e: high UOP. difficult to titrate. tachyarrythmias

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262
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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263
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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264
Q

Tx of Zenkers

A

Dx- UGI (don’t do EGD)
Tx- open or scope approach:

  • small (1 cm) symptomatic pouches are very likely well suited to myotomy alone
  • moderate-sized diverticula (1 to 4 cm) are best treated by myotomy with suspension or inversion
  • larger pouches probably warrant diverticulectomy with myotomy
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265
Q

Tx SIADH

A

Acute – vaptan, demeclocycline
Chronic – fluid restriction, diuresis

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266
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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267
Q

VIPoma - loc, px, dx, tx

A

Loc: distal

Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin
- most malignant

Dx: high VIP

Tx: distal panc + splenectomy + LADN’y + CC’y

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268
Q

Gastric CA tx

A
  • neo-adj chemo for T2+ or N
  • proximal- total gastrectomy
  • distal- partial
  • 5 cm margin; 15 nodes
  • Can consider endoscopic mucosal resection: if < 2cm, well-differentiated, mucoa only, no LV invasion
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269
Q

DDAVP/Vasopressin - production and effect

A

Made in SON of HT. Stored PP.
Cause endothelium to release f8 and vWF

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270
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%

indications for trx of cholangioca
- cant be intrahepatic
- must be unresectable, perihilar, < 3cm
- no distant mets

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271
Q

Posterior and anterior vagal trunk branches
Vagotomies

A

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

Left ➡ Anterior trunk- hepatic branch, ant laterjet

  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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272
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

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273
Q

Dx and Tx fat necrosis

A
  1. dx- oil cyst w/ Ca+ rim
  2. tx:
    no trauma- bx
    trauma- watch
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274
Q

Tx Pancreatic divisum

A
  • Only tx if sxs
  • ERCP sph’otomy of MINOR papilla (Santorini/Superior)
  • Refractors: resect HOP (duo preserving)
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275
Q

Indications for neoadjuvant therapy eso cancer

A
  • high grade t1b or T2 and above OR any nodal involvement
  • Also get XRT
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276
Q

Marfans vs. Ehlers-Danlos

A
  1. Marfans- Fibrillin-1 defect (elastin);
    - AD; mitral regurg, aortic root dilation, lens defect, arachnodactyly
  2. Ehlers Danlos- t3 collagen defect
    - hyper elastic skin, hypermobile joints, aortic root dilation

**Both need CTA of aorta to r/o aortic root``

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277
Q

Bladder ca - dx and tx

A

px- hematuria in a smoker
dx- CT urogram 1st (bladder, kidney, or ureter ca)

  1. T1a- no muscle
    tx- endoscopic resexn + BCG/mitoM
  2. T2a- muscle/beyond LP
    tx- cystectomy + chemo + LND
  3. T3- fat/nodes)
    tx- neoadjuvant
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278
Q

Tx tracheal inj

A

Small ➡ absorbable in 1 LAYER w/ strap buttress
- 2 layer leads to tracheal stenosis
- primary repair up to 5-6 rings
- bilateral injury ➡ bilateral SCM incisions and join (“U” incision)

Large and above 3rd ring → tracheostomy through the defect
- avoid below 3rd ring (TI fistula)

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279
Q

Specific to Crohn’s and UC

A
  1. Crohn’s:
    - Creeping fat
    - Skip lesions
    - Transmural
    - Cobblestoning
    - Granulomas
    - Fistulas
  2. UC:
    - Crypt abscess
    - Pseudopolyps
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280
Q

Uremic PLT dysfunction - px, dx, tx

A

Px- 2/2 renal disease.
dx- normal coags. elevated BT only.
tx- ddavp

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281
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

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282
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
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283
Q

Emergent vs. Elective UC Tx

A

Emergent:
1. Steroids +/- abxs
2. Infliximab, Cyclosporine
3. No response, megacolon (> 6 cm), HDUS, or perf ➡ TAC with end-ileostomy
- When stabilized can perform 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

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284
Q

Kasabach-Merritt Syndrome

A
  • hemangioma + thrombocytopenia
  • usually infants
  • resect!
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285
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

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286
Q

Peutz-Jeghers - px and screening

A

Px- intestinal hamartomas, pigmented oral mucosa, polyposis
- Cancers: GI tract, breast, pancreatic
- AD, STK11 mutation

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

287
Q

Acute hemolytic trx reaction vs. non-hemolytic - path and tx

A
  1. Hemolytic: rapid RBC destruction by host IgM/IgG
    - +direct coomb’s. ABO incompatibility
    - px: flushing, bleeding
    - tx: stop trx. Fluids.
  2. non-hemolytic: cytokines from donor WBC
    - px: fever and rash (no bleeding)
    - tx: antihistamine, epi, steroids
288
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
289
Q

Cryo contents and uses

A
  • Contents: VWF, f8, fibrinogen
  • Uses:
    1. VWD
    2. Fibrinogen def
    3. Hemophilia A
290
Q

Zone injuries and management

A
  1. penetrating:
    - zone 1-3 –> explore
  2. blunt:
    - zone1 –> explore
    - zone 2-3 –> do not explore
291
Q

TOS tx

A
  1. neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
  2. venous- catheter-directed thrombolysis → surgical decompression
  3. arterial- C7/1r resection, subc artery resection/reconstruction
292
Q

FAP - Dx and Tx

A

AD; APC mutation
Dx: > 100 adenoma or < 100 w/ fam hx
- CA by 40
- desmoid tumors (slow growing abdominal wall mass)

Tx:
- sigmoidoscopy q1y at 10 (don’t need colonoscopy)
- EGD @ 20 or when polyps start
- 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
- desmoid: resect. Anti-E if intra-abdominal

293
Q

BRCA risks and tx

A

female breast, ovarian, male breast
I (ch17)- 60, 40, 1
II (ch13)- 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!

294
Q

When to operate on adrenal mass

A
  1. all functioning tumors
  2. all > 6 cm ➡ open resection
  3. if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection

**DO NOT biopsy first

295
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

296
Q

Adjuvent chemo for breast ca

A
  1. Adjuvent chemo: tumor > 1cm, nodal dz, triple neg
    - 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
297
Q

FNH - path, dx and tx

A

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

298
Q

Secretin vs. CCK

A

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

299
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
300
Q

Tx papillary/follicar thyroid can

A
  1. Indications for total thyroidectomy:
    - Tumor > 4cm
    - Tumor 1-4cm and patient preference
    - Distant mets or extra-thyroid disease
    - Poorly differentiated
    - Prior radiation
  2. Nodes dissection:
    A. 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
    - For high risk tumors: tumor > 1 cm, extra-thyroidal disease
301
Q

Heparin - MOA and measurement

A

MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin

Measurement:
- PTT
- ACT: better intra-op if high doses of hep given

302
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

303
Q

Tx SDH

A
  1. Nonop: HDS, <10 mm, <5 mm shift
  2. Evacuate: > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP
304
Q

Central venous O2 vs. mixed venous O2

A

Mixed venous: from PA
Central venous: from SVC only (estimation of mixed)

305
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
306
Q

Orientation of portal triad

A

Bile duct lateral
Hepatic artery medial
Portal vein posterior

307
Q

Px and tx:
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
308
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)
309
Q

LN harvest/margin
eso
stomach
colon
rectum

A

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

310
Q

Succinylcholine - MOA, s/e, c/i

A

MOA: ONLY depolarizing. degraded by plasma CE
- Short half-life and rapid onset (RSI)
- Used for “full stomach”

s/e: rhabdo, hyperK, M/H, bradycardia
c/i: spinal cord injury, renal failure, large burns

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

311
Q

Breast nerve - muscle and actions:
- Thoracodorsal
- Intercosto-brachial
- Lateral petoral
- Medial pectoral
- Long thoracic (medial)

A
  • Thoracodorsal (lateral): Lat Dorsi, ADduct/extension/IR
  • Intercosto-brachial: hypesthesia
  • Lateral petoral: p major, arm flexion
  • Medial pectoral: p major/minor, ADduct/extension/IR
  • Long thoracic (medial): SA, wing scap
312
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)
- good initial study to show an association

313
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

314
Q

Papillary cystadenoma (Warthin tumor) - px, tx

A

Px: benign tumor of salivary gland
- often BILATERAL and 2/2 smoking
- Slow growing

Tx: complete resection with uninvolved margins even if ASx

315
Q

Hemangioma - path, px, and tx

A

path- PERIPHERAL ENHANCEMENT
px- young women
tx- if rupture, size change, or KM syndrome

316
Q

Pancreatic ducts

A

Wirsung- major, lies inferior
Santorini- minor, lies superior

317
Q

Gluconeoenesis precursors

A

lactate , pyruvate, AA

318
Q

Sirolimus - MOA, s/e

A

MOA: mTOR inhibitor
- Less nephrotoxic

s/e:
- lymphocele (w/ obstruction)
- wound complications/poor wound healing: held or switched to tacro before hernia repairs

319
Q

Tx of rectal prolpase

A

Not past the verge- biofeedback, fiber

Many comorbidities or acute presentation- Altemeir (perineal rectosigmoid’y)

Prolpase < 50cm- Delorme (plication)

Young/healthy and elective- rectopexy +/- resection

320
Q

Li Fraumeni - gene, mechanism, and px

A
  • gene: p53 mutation; TSG on Ch17; AD inheritance
  • mech: cell cycle regulation and apoptosis
  • px: breast ca + sarcoma b4 45
321
Q

Chylothorax dx and tx

A
  1. dx: fluid TG > 110
  2. 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)
322
Q

Chemotherapy indications for breast ca

A
  • Tumors >1cm
  • Positive nodes
  • Triple negative tumors
323
Q

Tumor lysis syndrome - px, path and tx

A

Px: Common 2/2 B cell lymphoma
- hyperU, K, Ph w/ hypoCa

Path: CaPh crystal ➡ renal failure + hypoCa

tx: IV hydration ➡ iHD

324
Q

CRC T and N stages

A

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

325
Q

Rectovaginal fistula tx

A

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

326
Q

Schiatzki’s Ring - Tx

A

Associated with hiatal hernia
Tx- only if sxatic. dilation only and PPI

327
Q

NNT

A

NNT = 1/absolute risk reduction (ARR)
- ARR = event rate in intervention group - rate in control group
- RR = event rate in intervention / rate in null group
- RRR = (rate control - rate experimental) / rate control

328
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
329
Q

Pancreatic fistula - dx and tx

A

dx: drain amylase 3x serumo amylase

tx:
- NPO, TPN x 4-6 wks
- remove drain if amylase and output decrease
- enteral nutrition can stimulate output
- octreotide may decrease output but does not accelerate healing
- consider ERCP w/ stent after 6 weeks

330
Q

Max dose of lido and bupiv
Tx of OD

A

lido = 5mg/kg (7 w/ epi)
bupiv = 2.5 mg/kg (3 w/ epi)

tx- lipid emulsion

**epi can help ID intravascular access b/c quick changes in heart dynamics
**local anesthetic can cause hypotension in an epidural

331
Q

Tx Aspergillosis

A
  • aspergilloma: resect
  • aspergillosis: voriconazole

**MC fungal infxn in IC patient

332
Q

Dx and Tx of GIST

A
  1. Dx- MC GI Sarcoma
    - EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC.
    - Bx: cajal cells. c-KIT+
    - don’t require bx if high suspicion
  2. Tx- wedge resection (gross margin)
    - can be R0 or R1 resection
    - Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf
    - neoadjuvant if need to down-stage for resection
    - adjuvant for 3 years
333
Q

Vitamin K - MOA and def

A

MOA: gamma CARBOXYLATION (not decarb) ofGLUTAMATE on 2, 7, 9, 10, c, s

Px of def: coagulopathy, suspect if obstructive jaundice

334
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)
335
Q

Kcal per macronutrient
Total kcal req

A
  1. protein = 4 kcal/g
  2. dextrose = 3.4 kcal/g
  3. lipid = 9kcal/g
  4. carb = 4 kcal/g

total req = 25-30 kcal/kg
- use ideal body weight if BMI > 25
- 50% carb, 30% fat, 20% protein

336
Q

Hinchey

A

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

337
Q

Contents of ant triangle of neck

A
  • Carotid sheath, anca cervicalis, CN 12 (hypoglossal)
  • Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular
  • Facial vein is the gateway
338
Q

Tx for Leriche syndrome

A

aortobifemoral bypass

339
Q

Benign lesions that require excisional bx

A

Core need returns ➡
- Atypical
- DH/LH
- LCIS/DCIS
- radial scar
- papillary lesion
- any atypia

**can use sterotactic needle bx if mass in visible on mammo but otherwise difficult to find

340
Q

Future Liver Remnant requirements

A
  • minimum 20% if normal liver
  • pre-op chemo/some dysfxn = 30%
  • cirrhosis = 40%
341
Q

type 1 vs. type 2 error

A

type 1: false positive
- say something is true (reject the null) when it’s not
- alpha = prob of type 1 error. Set at .05
- minimize by decreasing stat significance

type 2: false negative
- say something is false (do not reject the null) when it’s true
- beta = prob of type 2 error. Set at .2
- minimize by increasing sample size/power

**power = 1 - type 2
**reject the null = “a difference exists”

342
Q

hepatic adenoma - imaging, tx, and risks

A

path- EARLY enhancement on arterial phase w/ rapid washout. well-circumscribed.
**vs hemangioma: peripheral enhancement over time

tx- stop OCP use.
resect immediately if > 5cm, sxatic, male gender

risks:
1. rupture MC
2. malig transformation

343
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
344
Q

Pyoderma gangrenosum - px and tx

A

px: associated w/ IBD
- RESOLVES after resection
- pre-tibial

tx: steroids

345
Q

anion gap - equation and causes

A

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

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

346
Q

MOA reglan and erythromcyin

A
  • reglan: dopamine antagonist
  • erythromycin: motlin receptor agonist causing SM contraction
347
Q

Modality and staging for eso cancer (T and N)

A

If CT and PET: no distance disease ➡

Endoscopic U/S for T and N:
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+

348
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
*No screening if asx

349
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.

350
Q

Serum osmolarity

A

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

351
Q

Superior laryngeal nerve (external branch) - fxn, injury, and tx

A

fxn: motor to cricothyroid

injury: trouble w/ high pitch, voice remins clear
- cord looks normal on laryngoscopy

tx: none

**MC nerve injury w/ a total thyroid

352
Q

GCS motor

A

6- obeys commands
5- localized
4- w/draws
3- flexion (decort) - ‘flex your core’
2- extension (decErebrate)
1- none

353
Q

LeFort fxs

A

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

354
Q

Human bite tx and organism

A
  • tx: amox/clavulanate (augmentin)
  • MC for human bites- eikenella
355
Q

tx flank wound

A

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

356
Q

Indics and steps for ED thoracoytom

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
357
Q

TRALI

A

DONOR Ab attacks recipient WBC

358
Q

MCCO healthcare infection:
- HAP
- central line infection
- SSI
- UTI
- GI infection
- SBP
- Cholangitis
- 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
  • Cholangitis: e. coli
  • NSTI: polymicrobial
  • ICU infection: VAP
359
Q

Tx of trx of great vessels

A

1st give PGE1 → ballon atrial septostomy

360
Q

Tx SqCC of anal canal

A

Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC
Recurrence (10-20%)- must wait at least 6 month to diagnose. APR

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

361
Q

TOF - defects and tx

A

Most common cyanotic defect
1. VSD
2. Pulmonary outflow obstruction
3. Over-riding aorta
4. RVH (2/2 RV outflow obstruction w/ harsh murmur)

tx- beta blocker; surgery at 3-6m

362
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
363
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
364
Q

Light’s criteria

A

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

  • Exudate: capillary damage from inflammation, neoplasm, trauma
  • Transudate: change in oncotic pressure;
365
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
366
Q

Most abundant bacteria in the colon

A

Bacteroides fragiles

367
Q

T staging for esophageal cancer

A

t1a- muscularis mucosa: endo resection
t1b- SM: upfront esophagectomy (low grade t2)
t2- muscularis propria: neoadjuvant
t3- adventitia: neoadjuvant
*no serosa. Ca spread through SM lymphatics

368
Q

Exposing the pancreas: head, body, tail

A

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

369
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

**Carries chylomicrons and LCFA

370
Q

Stomach vs. Duo ulcer px

A
  1. Stomach ulcer: pain right after meal
    - 75% H. pylori, 25% NSAIDS/ASA
  2. Duo ulcer: pain 2-3h after meal
    - 90% H. pylori, 10% NSAIDS/ASA

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

371
Q

Effective for Pseudomonas

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

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

372
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
373
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

**VARD can be c/b pseudoaneurysm of GDA/splenic artery requiring angioembo

374
Q

Cuff size for kids

A

age/4 + 4

375
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

376
Q

Ectopic parathyroids

A
  1. Superior parathyroids
    - usual location: Posterior to RLN.
    - Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath.
    - TE groove is MC ectopic location
  2. Inferior parathyroids
    - usual location: Anterior to RLN.
    - Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass
    - thyrothymic ligament is MC ectopic location
  3. 4 normal appearing galnds
    - supranumary PT in the thymus

**Overall, thymus is MC location or ectopic gland

377
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 CHILD and HDS)
    - no duct (grade 1-2): drain
378
Q

S/e and medications of trx meds
- Tacro
- Cyclosporine
- Sirolimus
- MMF
- Basiliximab
- Azathioprine

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, gallstones
- cycled in bile

Sirolimus: bind fK –> mTor inhibitor (IL2 inhibitor)
- impaired wound healing, interstitial lung disease
- lymphocele

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

Basilixamab: il2 inhibitor
- GI sxs

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

379
Q

Interossei and lumbrical innervation

A

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

380
Q

S/e of tamoxifen

A
  • dvt/pe
  • endometrial cancer
  • cant take with SSRI (CYP inhibitors)
381
Q

DCIS tx

A

BCT: 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)

382
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
383
Q

Dx and Tx of Cystadenoma

A

low CEA, low Amylase
tx- resect if sxs

384
Q

Post polypectomy screening

A

-2-6m: piecemeal removal

-1 year: > 10 adenomas

-3 years: 3+ adenomas, HGD, > 1cm, villous elements

-5 years: 1-2 tubular adenomas (< 1cm)

-10 years: hyperplastic polyps (<20)

385
Q

Encapsulate organisms

A

Strep pneumo (MC)
Neisseria
Haemophilus
“Shin”

386
Q

Casues of increased ET CO2

A

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

387
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

388
Q

Products of posterior pituitart

A

“PAO in the POST”
ADH, Oxytocin
2/2 direct stem from neurosecretory cell

389
Q

Hereditary pancreatitis

A

PRSS1 trypsinogen mut’n
AD
smoking cessation is important

390
Q

Cilostazol - MOA and use

A

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

391
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 bronch: RIGHT P/L thoracotomy
Aorta: L thoracotomy

392
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
393
Q

Vitamin D processing

A

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

394
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

395
Q

Tx for hemobilia

A

angioembolization

396
Q

Tx Odontoid fx

A

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

397
Q

GCS verbal

A

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

398
Q

MELD vs. CTP

A

Meld:
1. Bili
2. INR
3. Creatinine
- designed for mortality over 3 months after TIPS
- At least 15 for trx
- HCC gets automatic score of 22

CTP: Billirubin, Albumin, INR, Ascites, Encephalopathy

399
Q

Intraductal papilloma dx and tx

A

MCCO bloody nipple dc
dx- dx mammo 1st ➡ contrast ductogram
tx- complete excisional biopsy including the ductal segment

400
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

401
Q

Gastroschisis

A

GastRoschisis to the Right of midline
rare defects…EXCEPTION- instestinal atResia

402
Q

Mineral def:
-Zn
-Sel
-Chromium
-Copper
-B1
-B3

A

-Zn: wound heal/skin, night blind
-Sel: cardiomyopathy
-Chromium: hyperglycemia
-Copper: micro anemia
-B1 (thiamine): wernicke’s encephalopathy, p. Neuropathy, gap acidosis (lactate)
-B3 (niacin): pellagra (DRH, demetnia, dermatitis)

403
Q

MC aortic infections

A

aneurysmal- staph
non-aneurysm- salmonella

404
Q

Effective for VRE

A

Linezolid

405
Q

Predictors of good outcome after reflux surgery

A
  1. Typical sxs
  2. DeMeester Score > 14.72
  3. Improvement w/ acid suppression
406
Q

UES vs LES

A

UES- cricopharyngeus; higher resting pressure (70)
LES- lower resting pressure (15)

407
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

408
Q

Esophageal CA tx

A
  1. HGD, TIS, T1a: endoscopic ablation/resection
  2. T1b: upfront esophagectomy or endo ablation (if low risk)
  3. T2 or N: neoadjuvant then esophagectomy
    - Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso
  4. T4b or M: definitive chemo-XRT

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

409
Q

C/I and indications to anti-reflux surgery

A

C/I:
1. Cancer
2. Barrett’s w/ HGD

Indications:
1. Extra-eso complications: cough, aspiration, CP
2. Persistant sxs
3. C/i to antireflux meds
4. Barrett’s w/out HGD
5. Strictures

410
Q

Classic and Alarm sxs for GERD

A

Classic sxs: heart burn + regurg

Alarm:
1. dysphagia (not regurgitation)
2. odynophagia
3. bleeding
4. weight loss
5. anemia
*Require EGD

411
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

412
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
413
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

414
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. Partial wrap
415
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

416
Q

Epiphrenic divertciulum

A

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

417
Q

Dx and Tx of Eso perf

A

Dx- XR then contrast esophogography (GG then Ba)
- EGD if UGI is negative but still high suspicioun

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 w/ minimal signs of sepsis
OR
2. Very poor operative candidate

Stenting: contained perf or minimal extrav after EGD

418
Q

FeNa interpretation

A

<1% = Pre-renal
>1% = Intrinsic
>4% = Post-renal

419
Q

Refeeding Syndrome - mech and px

A
  • Mech: fat to carb metabolism ➡ resumption of ATP production causes Ph influx into cells ➡ hypoPh
  • Px: HypoMg, Ph, K; paresthesia, confusions, RD
  • COD is cardiac failure
420
Q

pH relation to pCO2

A

10 mmHg increase in pCO2 = .08 decrease in pH

421
Q

Tx of DI

A
  1. Central- DDAVP
  2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ
422
Q

W/up and Tx of endometrial CA

A

W/up: Post-meno bleeding ➡ TVUS ➡ endo bx

Tx: Hysterectomy, bilateral SO, peritoneal w/out, LN sampling
- Required for Tx AND staging!

423
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

424
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, cancer, recurrent
425
Q

Monitor and reverse TPA

A

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

426
Q

Cause and Tx of Warfarin skin necrosis

A

Cause: protein C def (not S!)
Tx:
Stop Coumadin
Give vitamin K
Start hep gtt or argatroban

427
Q

Intrinsic vs. Extrinsic Pathways

A

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

428
Q

Reversal of NOACs:
Apixaban
Rivoroxaban
Dabigatran

A

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

429
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

430
Q

Tx of hepatic encephalopathy

A
  1. Correct precipitating cause
  2. Lactulose (goal 2-3 stools/day)
  3. Rifaximin
  4. Neomycin
431
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.
432
Q

Segmental liver anatomy

A

7 - 8 - 4a - 2
6 - 5 - 4b - 3

433
Q

Dx and Tx of Budd-Chiari Syndrome

A

Dx: doppler (usually 2/2 to p. vera)
Tx:
1. Lifelong AC
2. < 4 weeks: thrombolytics
3. > 4 weeks: angioplasty/stenting
4. Refractory: TIPS, transplant, surgical shunt

434
Q

Tx of Isolated Gastric Varices

A

2/2 chronic pancreatitis induced splenic vein thrombosis
tx- Splenectomy

435
Q

Effects of pneumoperitoneum

A

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

436
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

437
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

438
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
439
Q

Autoimmune pancreatitis - px, dx, tx

A

Px: pancreatitis w/ normal Lipase and LFTs
Dx: elevated IgG, biopsy to prove.
- CT: dilated w/ no Calcs. “sausage” appearance.
- Brush biliary tree if concern for malignancy
Tx:
0. Bx first!
1. ERCP if stricutre: r/o ca, relieve obstruction
2. Steroids

440
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
441
Q

Tx of acute mesenteric ischemia

A

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

Embolic: distal SMA; jejunal sparring
- embolism

  1. no peritonitis- endovascular embolectomy
  2. peritonitis- ex lap to evaluate bowel, embolectomy/bypass
442
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
443
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 (or open revascularization)
  4. Nephrectomy

**CORAL trial: PTA is not better than maximum medical theraphy

444
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
445
Q

Tx of air embolism

A
  1. LEFT lateral decubitus and Trendelenburg (trap air in the RV)
  2. Aspirate central line
446
Q

Timing of endarterectomy after a stroke

A
  1. Non-disabling stroke or TIA: 2d-2w
  2. Big stroke: no consensus
447
Q

When to consider ppx fasciotomy + steps

A

6+ hours of warm ischemia

Steps:
- lateral incision: between tibia and fibula ➡ open anterior and lateral compartment
- medial incision: 1 finger posterior to tibia ➡ open fascia over the gastric ➡ peel soleus off of the tibia ➡ open deep posterior fascia

448
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
449
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.
450
Q

Preference for peripheral fistula

A

Location:
1. Rad/Ceph
2. Rad/Bas
3. Bra/Ceph
4. Bra/Bas
5. Prosthetic peripheral
6. Prosthetic ax-brachial
7. Prosthetic femoral

**Upper extremity preferred to LE

Rule of 6’s:
- flow > 600/min
- diameter > 3mm before placement. > 6mm after placement
- depth of 6mm

451
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

452
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
    - Need at least 2 cm landing zone distal to L SC
453
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
454
Q

Tx of aneurysms
- splenic
- renal
- iliac
- femoral
- pop

A
  • splenic: > 2cm or sxs ➡ embolize
  • iliac: > 3 cm ➡ covered stent
  • femoral: > 2.5 cm ➡ covered stent
  • pop: > 2 cm ➡ exclusion and bypass
455
Q

Tx of psuedoaneurysm

A

tx:
< 2cm observe
> 2cm:
- skinny neck: thrombin injection
- wide neck: operative intervention

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

456
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
457
Q

Tx of Type A dissection

A
  • Treat with immediate surgery
  • Put patient on bypass
  • Median sternotomy
458
Q

May-Thurner Syndrome

A

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

tx- venogram, thrombolysis and stenting

459
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
460
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)

461
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
    - no vagotomy
  2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment (90% H.pylori related)
    - 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:
    1. HDS, minimal contamination AND
    2. PUD w /h. pylori status negative, unknown, refractory OR unable to stop NSAID therapy (NSAID ulcer)

**EGD does not require bx for duodenal ulcers

462
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

463
Q

Tx of Complications after Billroth 2:
- Afferent limb obstruction
- Dumping syndrome
- Alk reflux

A
  1. Afferent limb obstruction: prevent with afferent limb < 20 cm
    - acute: convert Bil 1 or REY (STAT!)
    - chronic: Bacterial overgrowth: try abxs 1st (Rifaximin)
    . convert to REY
  2. Dumping syndrome: small meals, no sugar –> octreotide
  3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm.
    - pro-kinetics, bile-acid binding ➡ convert to REY with long roux
464
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
465
Q

Primary fuel source in fasting state

A
  1. 1st 4 hours: exogenous glucose
  2. 4h-1d: Liver glycogen
  3. 1d-1w: gluconeogenesis phase
  4. 1w+: protein-sparing phase
    - FA/Ketones are used everywhere
    - Only RBCs use glucose
466
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

467
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
468
Q

Essential fatty acids and immuno-nutrition

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

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

469
Q

RQ interpretation (metabolic cart)

A

CO2/O2

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

470
Q

BSC vs. SqCC - dx and tx

A

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

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

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

471
Q

Dx. Bacteria, and Tx of Nec Fac

A

Dx:
- LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV
- CT: gas, thick fascia

Bacteria profile:
- MC polymicrobial
-if monomicrobial, MC GAS/strep pyogenes: M protein virulence

Tx:
- abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage
- surgery

472
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, >50% vertebral body, eso/trachea involvement
    - vascular involvement is not c/i
473
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

474
Q

Dx and Tx of Ewing Sarcoma

A

Dx- “onion skin” in diaphysis
Tx- chemotherapy (1st line) + surgery or XRT

475
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

476
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

477
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

**aorto-enteric fistula should also be treated aggressively with operative takedown and extra-anatomic bypass

478
Q

Indications for pleurodesis

A
  • Air Leak > 5 days
  • Recurrent (even if contra-side)
  • High risk occupation (scuba, pilot)
479
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

480
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)

481
Q

W/up and Causes of low UOP after kidney trx

A

w/up:
1. doppler U/S: check vasc/urteter mosis, bladder outlet obstruction
2. empiric fluid bolus

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

482
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

483
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
484
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
485
Q

GVHD - px, path, dx, tx

A

-Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx

-Path: DONOR T cells morph into Th cells; target host

-Dx: bx

-Tx: steroids + IS

486
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

487
Q

Dx and Tx of RCC

A

Dx: triple phase CT (don’t need tissue bx unless mets)
- do cystoscopy after CT

Tx: Upfront Radical nephrectomy + LND +/- chemo +/- XRT
- TK inhibitor is 1st line chemo
- Simultaneous thrombectomy if IVC thrombus

488
Q

Types of hydrocele and Tx

A
  1. Communicating: 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.
489
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
- Can use tamoxifen if to prevent hormone+ cancers in the future

PPx
- Surgery can be done for prophylaxis
- Can get hormonal therapy
- Surveillance w/ MRI or mammo q6m

490
Q

Dx and Tx of inflammatory breast ca

A

Dx: skin punch bx ➡ dermal lymphatic invasion

Tx:
1. Neo-adjuvant
2. MRM
3. XRT
4. Endocrine tx

491
Q

Fibroadenoma - px, dx, tx

A

Px: painful/larger w/ periods or pregnancy

Dx:
- imaging: well-circumcribed; coarse ca+
- bx: fibro-epithileal lesions (if “aggressive” concern for phyllodes)

Tx:
-can obesrve if: mobile, concordant imaging/bx
-resect if: > 3cm, sxs, growth, anxiety, discordance
- fibroepithelial lesion that is not further defined should be excised for definitive classification (vs. phylodes)

492
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
- chemo is safe in 2nd/3rd trimesters. XRT is not
- XRT is c/i throughout preg

493
Q

Indications for post-mastectomy radiation

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

**if prefer recon must be delayed or used a tissue expander for immediate recon

494
Q

Bolus fluid and blood in children

A

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

495
Q

Repair aortic trauma

A

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

496
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
497
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

498
Q

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

A

2,3 DPG
Elevated temp
Higher paCO2
Acidosis

499
Q

Shock class

A
  1. No VS changes
  2. Tachycardia
  3. Hypotension and combative
  4. No UOP and obtunded
500
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

501
Q

Ketamine c/i

A
  1. MI (b/c increases SNS activtiy and cardiac demand)
  2. Space occupying brain lesion
502
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

**Bowel prep a/w increased r/o infection

503
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

504
Q

Frey Syndrome

A

Gustatory sweating
2/2 auriculotemporal nerve

505
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)
506
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
507
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

508
Q

STITCH trial

A

5 mm bites every 5 mm

509
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
510
Q

Tx of hiatal hernia

A

Type 1- asx: NTD; sxatic: PPI; Surgery if refractory
Type 2-4: surgery even if asx

511
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.

512
Q

MCCO Cushing syndrome

A
  1. Exogenous steroids
  2. ACTH pituitary adenoma
  3. Cortisol secreting adrenal adenoma
  4. ACC
513
Q

Dx and Tx of Addison’s

A

Cause- AI attack of adrenal cx
Labs- hypoNa, hyperK
Dx: cosyntropin stim test - cortisol remains low
- deceased cortisol and aldo with high ACTH
Tx- steroids

514
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

515
Q

Dx, Path and Distribution of carcinoid tumors

A

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

Path: +chormogranin

Distribution:
1. Rectum
2. SI (ileum)
3. Appendix
4. Colon

516
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
517
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

518
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 and goiter in the US

519
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
520
Q

Dx and Tx of CMV colitis

A

Dx
- usual CD4 < 50
- PCR is unreliable b/c does not prove end-organ disease (can be falsely negative)
- must scope and bx: Cowdry bodies, punched out ulcers

Tx: gancylovir
- initiate HAART
- opthalmic exam to r/o retinitis

521
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
522
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)

523
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)
524
Q

Vitamin A

A
  • wound healing especially in steroid patients
  • def: night blindness
525
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

526
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

527
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
528
Q

Subclavien exposures

A
  1. Median sternotomy: right
  2. Left Anterolateral thoracotomy: left subclavian
    - trap door supraclav incision for distal access
529
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

530
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.
531
Q

SMA embolus vs. thormbosis

A

Embolus- lodges after the middle colic. Jejunal sparring
Thrombus- at ostium; pan-bowel

532
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
533
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 (tamoxifen) if intra!
- XRT if sensitive area

534
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)
535
Q

Dx and Tx endometriosis

A

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

536
Q

MCCO primary hyper-aldosteronism and tx

A
  1. Idiopathic 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
537
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

538
Q

Respectability of pancreatic tumor and next step

A

Triple phase CT:

  1. Unresctable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable pv/smv
    - EUS/FNA for tissue dx for neoadjuvant
  2. Borderline- <180 SMA/celiac
    - EUS/FNA for tissue dx for neoadjuvant
  3. Resectable
    - dx lap (to confirm resectability) + whipple
539
Q

Tx of horseshoe abscess

A

Hanley procedure:
- Midline drainage incision of deep posterior space (through ano-coccygeal ligament)
- Bilateral lateral counter-incisions for ischiorectal space
**all external drainage

540
Q

Tx of anorectal fistula

A

<30% sphincter- fistulotomy or cutting seton
>30% sphincter- draining setons THEN ARAF or LIFT

**Crohns patient: px w/ multiple fistulas
- avoid fistolotomy.
- draining setons.
Can try infliximab if active infection has resolved.

541
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 (office): band, sclerotherapy, coagulation
- band is most effective
- sclerotherapy if on blood thinners

G4- can’t reduce
- surgical HMHD’ectomy

542
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

543
Q

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

A

Px: intractable pruritis, eczematoid rash
Tx: scope (r/o malignancy)
- dc topical agents
- perianal punch bx + WLE

544
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) –> no further w/up
> 2 cm- formal cancer resection (APR, R hemi-colectomy, cancer resection WITH mesentery)

545
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

546
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

547
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
548
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

549
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

550
Q

Ideal setting for stone formation

A

Low bile salts
Low lecithin
High cholestersol

551
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

552
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)
553
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
554
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)
555
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

556
Q

PSC screening guidelines

A
  1. Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9
  2. GB CA: US q6-12m
  3. CRC: colonscopy q1-2 years (regardless of UC)
557
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
558
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
559
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

560
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
561
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
562
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
563
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
564
Q

Tx of cecal volvulus

A

Stable- R hemi and primary mosis (no pexy)
Unstable- R hemi with end ileostomy

565
Q

Dx of Juvenile polyposis

A

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

566
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
567
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

568
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

569
Q

Indications for colonic stent

A
  1. Bridge to surgery in acute obstruction
  2. Palliative measure
    * Usually for L-sided lesions
570
Q

Gram, Tx and Virulence of C. diff

A

Gram: G+ bacillus, anaerobic

Tx:
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. Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm)

Virulence:
- Toxin A: intestinal necrosis
- Toxin B: cytotoxin

571
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
- CTA can’t dx b/c its a microvascular disease
Tx- usually supportive; OR if perf, sepsis

572
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!

573
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

574
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
575
Q

Perform splenectomy for distal panc PNET?

A

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

576
Q

Steps to Whipple`

A
  • Inspect. Frozen any lesions. Abort if +
  • Obtain plane between pancreatic neck and PV. If cannot then abort!
  • Cattel: expose 3D/4D, SMV/SMA (don’t need to take down base of mesentery unless 4D lesion)
  • Kocherize duo: expose portal triad
  • Enter lesser sac from gastrocolic lig
  • Ligate the R gastric and GDA (ensure common hepatic flow first)
  • Follow R gastroepiploic vein to the SMV
  • Dissect SMV off inferior border of pancreas
  • CC’y. Divide CHD.
  • Antrectomy 2cm past the pylorus
  • Pancreatectomy at level of PV
  • Retract the pancreatic head lateral and PV/SMV medial. Ligate venous tributaries to PV/SMV and PDA.
  • Perform P-J (2-layer, end to side)
  • Perform H-J (1-layer) distal to P-J
  • G-J: Billroth 2 (2-layer, end to side)

**No definite margin, just R0 resection
**LN harvest not necessary

577
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
578
Q

ECG findings of PE

A

Sinus tach is MC
S1Q3T3 pattern w/ TWI

579
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

580
Q

lead vs length time bias

A

Lead-time bias is due to early detection. Remember the “d” in lead is for early detection.

Length-time bias is due to slow cases being detected more often simply because they are slowly progressing. Remember the “g” in length is for slowly progressing.

581
Q

Brown-Sequard

A

Ipsi loss of motor
Contra loss of pain/temp

582
Q

Dx of biliary dyskinesia

A

Suspect if GB w/ normal US and EGD
Dx- HIDA scan w/ EF < 35% (c/i in pregnancy)
Good responders if classic sxs (n/v, RUQ pain, w/ fatty meals)

583
Q

Emergent ariway in a child

A
  1. Try ETT placement with a miller blade
  2. Needle cric is preferred over open if < 12
  • use cuffed tubes for everyone except newborns
584
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)
585
Q

Exposure to bronchial tree in trauma

A

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

586
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
587
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 (Rifaximin) ➡ surg 2nd line
588
Q

Inguinal hernia nerves + MC injuries

A
  1. Ilioinguinal: under to EO
  2. Ilio-hypogastric: supero/medial to the ilio-inguinal. Between EO and IO
  3. GB of GF: runs within the spermatic cord, under the cord structures

MC injuries:
- Open repair: II, GB of GF
- Lap repair: lateral femoral cutaneous, GF

589
Q

HRS- Path, Px and Tx

A

Path: liver failure ➡ sinusoidal portal HTN ➡ increase CO and splanchnic dilation (compensatory)➡ HoTN ➡ turn on RAA system ➡ renal constriction

Px:
- albumin + vasoconstrictive agents (terlipressin)
- TIPS
- transplant

590
Q

Treatment of lung ca

A
  1. No N2 disease (stage 1-2) ➡ up-front surgery
    - lobectomy + MLNDx. Can consider segmentectomy.
    - can wedge if 2:1 margin ratio
  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

591
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
592
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
    – RELAXING incision if can’t reapproximate
593
Q

Pre-op regiments for aldosteronoma and pheo

A
  1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic
  2. Pheo: phenoxybenzamine then BB
594
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
595
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
596
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
597
Q

Surgical Tx of thyroid/PT cancers
1. Papillary/Follicular
2. MTC
3. Hurthle
4. Anaplastic
5. PT

A
  1. Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk
  2. MTC: total + bilateral L6 + T3 post op
    - RAI is c/i
  3. Hurthle: lobectomy then total + bilateral L6
  4. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes
  5. PT: hemi-thyroid + L6 (usually)

**MRND if L6 is positive

598
Q

Confirmation of brain death

A
  1. Neuro exam:
    - absent brain stem reflexes
    - no response to stimuli
  2. Apnea test: CO2 > 60 after 10 minutes
    - if test aborted OR CO < 60 ➡
  3. Confirmatory test: CTA, MRA or nuclear scan
599
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)
600
Q

Tx of H/N tumors

  1. Mucoepidermoid
  2. Adenoid cystic
  3. Pleomorphic adenoma
  4. Warthin/Papillary cystadenoma
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
601
Q

W/up of UGI bleed/perf:
1. Boerhave
2. Traumatic esophogeal perf
2. UGI bleed

A
  1. Boerhave: XR suggestive ➡ UGI (CT controversial)
  2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI
  3. UGI bleed: +/- NGT ➡ EGD
602
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)
603
Q

IS for transplant - induction and maintenance

A

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

Maintenance
1. Tacrolimus
2. MMF
3. Prednisone
4. Sirolimus

604
Q

Transplant ABX ppx

A
  1. Bactrim- PCP, toxo gondi, listeria, nocardia
  2. Diflucan- antifungal
  3. Valganciclovir- CMV
605
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

606
Q

MAC

A

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

607
Q

CDH1

A

High r/o gastric ca
ppx gastrectomy by age 40

608
Q

px, dx, and tx of meconium ileus

A

px- failure to pass meconium
dx- sweat chloride test, “soap bubble sign” on XR
tx- GG then NAC enemas
- surgery: ostomy for antegrade enema

609
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.
610
Q
  1. Ig crosses the placenta
  2. Ig in brast milk
  3. Ig first responder
A
  1. IgG (small, y-shape)
  2. IgA (two y’s with joined tails)
  3. IgM (pentad)
611
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…(usually 2-2.5g/kg/day)
  2. 30% fat calories
  3. 50% carbohydrate calories
612
Q

Wilcoxon test

A

Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed
- ex: patient satisfaction before and after an intervention (1-5)

613
Q

COX proportion hazard modeling

A

Like a regression model but for survival analysis
Allow you to control for different factors

614
Q

Changes to VS with preggo

A

Increased HR
increased SV
Decreased SVR
Decreased BP

615
Q

Afferent limb syndrome - cause, px, dx, tx

A
  1. Cause: affarent limb is too long from LOTz
  2. Px: acute or chronic
    - Acute: complete obstruction requiring emergent OR
    - Chronic: partial obstruction w/ bacterial overgrowth
    - steatorrhea, B12 deficiency. MC w/ antecolic Bili2
  3. Dx:
    - Acute: abdominal pain with dilated afferent limb in early post op
    - Chronic: d-xylose breath test
  4. Tx
    - stat OR for REY revision
    - Chronic: abxs –> REY/shorten the limb
616
Q

Medical tx for melanoma

A
  • Pd1 inhibitors: pembrozilumab, nivolumab + Anti-CTLA-4 Ab: ipilmumab
  • If Braf+: braf inhibitor remains 2nd line
617
Q

MC benign/malignant thoracic tumors in adults/children

A

Adults
- benign: hamartoma (popcorn calcification)
- malignant: sqcc

Children
- benign: hemangioma
- malignant: carcinoid

618
Q

Tx of Rhabdomyosarcoma

A

MC soft tissue tumor in children
tx: surgery + SLNBx
- consider neo-adjuvent if unresectable
- post-op chemo-XRT (very radiosensitive)

619
Q

C/i to covering the left subclavian artery

A
  1. Aberrant or Dominant left vertebral a.
  2. Previous CABG using LIMA (cardiac ischemia)
  3. LUE AVF
620
Q

Mesothelioma - px, dx

A

px- asbestos exposure (shipyard)
dx- CT then tissue dx
tx- surgery, XRT, systemic chemotherapy, HIPEC

621
Q

Marginal ulcer - dx and tx

A

S/p REY GB
On the jejunal side
Dx- EGD
Tx- PPI + sucralfate + stop smoking + avoid NSAID +/- tx H. pylori (if present)

622
Q

Hipec is most effective for which cancers? (5ys)

A
  1. Appendix (75%)
  2. Mesothelioma (45%)
623
Q

HPV precursors in the anus

A

Low grade: condyloma, AIN1
High grade: AIN2, AIN3 –> should treat

All patients: give HPV vaccine
- High risk pt: homosexual, HIV, women w/ +pap –> screen with anal cytology or anal pap smears

624
Q

Tx of CBD injury

A
  1. Early (during chole): primary repair (<50%) or H-J (>50%)
  2. Late (>72 hours)
    - define anatomy: MRCP, ERPC, or perc cholangio
    - control sepsis: abxs, drain collections
    - establish biliary drainage: PTC (complete transection) or ERCP w/ stent
    - CTA to r/o vascular injury
    - delayed repair (6-8 w) when optimized
625
Q

Tx of rectal carcinoid

A

<1 cm - endoscopic removal
1-2 cm- full thickness excision
> 2cm- LAR or APR

**Invasion into muscularis/LN involvement- require TME

626
Q

Polypectomy criteria that require formal resection

A
  1. Poor differentiation
  2. Vascular/Lymphatic invasion
  3. Invasion below the SM
  4. < 2mm of surgical margin
  5. Base involvement (Haggit 4)
627
Q

Cancer screening in FAP

A
  1. CRC- q1-2y c’scope starting at 10
  2. Duo/Stomach ca- EGD at 20 or when polyps occur
  3. Pap thyroid ca- thyroid U/S q2-5y at 18
  4. Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs
628
Q

Dx/Tx of Carcinoid syndrome

A

More common with liver mets (liver otherwise inactivates portal vein chemicals)
- liver mets more common form small bowel

Sxs: flushing, telangiectasia, DRH, bronchospasm

Tx: SS analogues (octreotide)
- liver resection/embolization for palliative,

629
Q

Staging Melanoma - MC mets

A

-Don’t need staging CT CAP for stage 1 or 2 disease
- Stage 3+: CBC, LDH, CXR. Consider CT CAP or PET/CT
- Stage 4: MRI brain + labs + PET/CT

  1. Lungs
  2. Small bowel!
  3. Colon
630
Q

High tie vs. Low tie of IMA

A

High tie: ligate IMA @ origin
- risk of hitting the hypogastric plexus
- risk of worse perfusion

Low tie: tie after the L colic branch takes off (turns into SRA)
- theoretically less lymph nodes

631
Q

Perforated diverticulitis tx

A

Primary anastomosis with DLI (DIVERTI trial) or without DLI (LADIES trial) is safe except if:
- HDUS
- Acidosis
- Acute/Chronic organ failure
- I/S
- Very old
- Poor pre-op sphincter function

632
Q

Zenker location

A

Killian’s triangle
Inferior to pharyngeal constrictor (thyropharygneous)
Superior to cricopharyngeous

633
Q

Tx for reflux after heller

A

Lifetime PPI
DO NOT convert to a Nissen b/c baseline achalasia

634
Q

Narrowest portions of the eso

A
  1. Criciopharyngeous
  2. AA/Left mainstem bronchus
  3. Hiatus
635
Q

Sxs of vagus injury after hiatal repair

A

Gastroparesis
Delayed gastric emptying
Reflux
DRH

636
Q

Required w/up before anti-reflux surgery

A
  1. EGD- r/o ca
  2. 24h pH- prove reflux
  3. Esophagram- r/o motility disorder (DES, eso web)
  4. Manometry- r/o other motility disorders
637
Q

Deficiency of fat soluble vitamins

A

A- xeropthalmia
D- hypoca, hypoPh
E- hemolytic anemia
K- elevated INR

**suspect with any fat malabsorption

638
Q

Na deficit

A

NAD - “no denominator”
(140 - current Na) * TBW
TBW = .6 or .5 x (weight in kg)

.9NS = 154 mEq per liter
3%NS = 514 mEq per liter

replete 6 mEq/24 hours

639
Q

Lung cancer paraneoplastic syndromes

A

Squamous cell- PTHrP
Adenoca- hypertrophic osteodystrophy
Small cell- SIADH

640
Q

Lithium toxicity

A

HyperCa, hypocalcuria
HyperMg
Elevated PTH, normal Ph

**gastric bypass can elevate Li levels

641
Q

Ferritin

A

Main storage protein of Iron
Low in iron def anemia
High in anemia of chronic dz (acute phase rxn)

642
Q

Sheehan syndrome

A

Hypopituitarism (anterior pit) 2/2 gland necrosis from HoTN
Usually px w/ hypoNa

643
Q

Tx for STI:
1. Chlamydia
2. Gonorrhea
3. Trich/BV

A
  1. Chlamydia: doxy
  2. Gonorrhea: CTX
  3. Trich/BV: flagyl
644
Q

HIT - path, dx, and tx

A

path- IgG to PF4
dx- 50% PLT fall –> Ser release assay
tx- stop SQH. start fondaparinox (active SQH subunit)

645
Q

Delayed trx reactions

A

Px: 30d after transfusion w/ fevers and pain
Path: Ab to minor Ag’s –> duffy, kell, Rh
Tx: supportive

646
Q

Hormone and production:
- CCK
- Gastrin
- Glucagon
- Histamine
- Insulin
- Motilin
- Secretin
- SS

A
  • CCK: I cell, SI
  • Gastrin: G cells, antrum and duo
  • Glucagon: alpha cells, pancreas
  • Histamine: ECL cells, stomach
  • Insulin: beta cells, pancreas
  • Motilin: Mo cells, SI
  • Secretin: S cells, SI
  • SS: delta cells, pancreas
647
Q

Steps of hepatectomy

A
  1. Mobilize ligaments
  2. CC’y and cannulate CD
  3. Isolate vessels
  4. Ligate HA ➡ PV ➡ HV
  5. Divide parenchyma
648
Q

Tx of HCC

A
  1. Trx: tumor < 5cm or 3+ tumors < 3cm
  2. Resection: early stage, preserved liver function
  3. RFA: early-stage BUT poor OR candidate
  4. TACE: intermediate stage disease
  5. Sorafenib: advanced/Unresectable
649
Q

Indication and s/e for TIPS

A

2-3 paracentesis/month despite Na restriction and diuretics

s/e:
- increase r/o encephalopathy
- no change in overall survival

650
Q

kwashiorkor vs. marasmus

A

kwashiorkor
- moderate calorie intake; inadequate protein
- large belly

marasmus
- insufficient calorie and protein
- simian face

651
Q

Absorption of glucose, galactose, fructose

A

glucose: Na-dependent secondary active transport
galactose: Na-dependent secondary active transport
fructose: Na-independent facilitated diffusion

652
Q

Tx of MCN

A
  • Dx: EUS/FNA ➡ high CEA, low amylase
  • Location: body/tail
  • Distal pancreatectomy (usually can be spleen preserving)
  • No follow-up is needed (no increase r/o recurrence)
653
Q

S/e of protamine

A
  • Hypotension, Bradycardia
  • Administer slowly: 1 mg per 100 units of insulin
  • Has partial reversal on lovenox
654
Q

Dermatofibrosarcoma protuberans - px, histo, tx

A

Px- flesh-colored sarcoma resembling a keloid
Histo- spindle cells, +cd34, +Vimentin
Tx
- imatinib to down-stage if needed
- en block resection w/ 2-4 cm margin`

655
Q

In transit melanoma tx

A

Lesions > 2cm from primary but not beyond regional tumor basin
- immunotherapy or BRAF inhibitor
- only excise if feasible (few lesions)

656
Q

Pressure wound staging

A

1- non-blanching erythema
2- dermis
3- full-thickness subcutaenous
4- muscle, bone fascia

657
Q

Post-splenectomy blood smear + best way to ID

A

H-J bodies and Target cells
- If absent: accessory spleen (usually in hilum or tail of the pancreas)
- HJ bodies: nuclear remnant (purple spot in cytoplasm)
- Target cells (codocyte): deformed RBC with excess membrane

ID: peripheral smear ➡ radionucleotide scan

658
Q

Splenic vasculature ligaments

A

Gastrosplenic ➡ short gastrics
Splenorenal: ➡ splenic artery

659
Q

Obstruction from duo ulcer - causes, tx

A

causes: 1. H pylori, 2. Nsaid
tx:
1. Hydration, NGT, PPI
2. H pylori testing and tx
3. EGD and bx (r/o cancer)
4. Balloon dilation!
5. Definitive operation: vagotomy + antrectomy + B1/2

660
Q

Gastro-gastric fistula - px, dx, and tx

A

Px- weight gain, reflux years after a bypass
Dx- UGI or CT with oral contrast
Tx- observation, resection of the involved segment

661
Q

ERCP with REY anatomy

A
  1. Laparoscopic-assisted ERCP or ERCP through a gastrostomy
  2. Double balloon endoscopy
662
Q

Posterior Mediastinal Mass - dx and tx

A

dx: neurogenic- schwannoma, neurofibroma
- CT then MRI. Bx not needed

tx: all require resection (even if asx)

663
Q

Lung ca resectability

A
  • carina/contra trachea involvement is still resectable ➡ sleeve pneumonectomy
  • SVC involvement can still be resectable
  • c/i: N3 disease ➡ contralateral mediastinal LN involvement
664
Q

Internal thoracic (mammary) anatomy

A
  • 1st branch off the SC
  • supplies anterior chest wall, breast
  • bifurcates to form superior epigastric and m/phrenic
  • gold standard for LAD bypass
665
Q

Management of lung abscess

A
  1. Abxs
  2. Cath drainage: perc (peripheral) or bronch (central)
  3. Surgical resections

Indications for surgery:
- failed medical tx
- BP fistula
- hemoptysis
- suspect cancer
- empyema

666
Q

Prostate ca - px, dx

A

Px- asx or abnormal PSA

Dx:
- Transrectal U/S guided bx - 12 samples
- Gleason score 1-5

667
Q

CAH - px’s

A

“salt and sex”

21: most common; sex
- dx: high 17 levels
17: salt
11: salt and sex

668
Q

Amide vs. ester

A

amide- two “i’s”; plasma cholinesterase metab;
ester- one “i”; liver metab; PABA analogue –> allergic reactions

669
Q

Px and Tx of Malignant Hyperthermia

A

px: AD; ryanodine receptor type 1

tx: stop drug, dantrolene, Bicarb, cooling, tylenol
- dantrolene: ryanodine rec antagonist

670
Q

Dx adrenal insufficiency in the ICU

A
  1. Early morning salivary or serum cortisol (screen)
  2. High dose cosyntropin stim: give 250 ug and measure serum cortisol (positive if < 18)

Tx- Resuscitation. IV dex 4 q24 or HC 100 q8

671
Q

Breast cancer endocrine chemo: MOA, tx duration/indications:
1. Tamoxifen
2. Anastrazole
3. Trastuzumab

A
  1. Tamoxifen: ER partial agonist
    - for ER/PR positive and < 70
    - 5 years
  2. Anastrazole: reversible aromatase inhibitor
    - for ER/PR positive and > 70
    - 5 years
  3. Trastuzumab: monoclonal Ab to Her2/Neu rec
    - for HER2 positive
    - 2 years
672
Q

Gynecomastia - px, dx, tx

A

px
- bilateral or unilateral tender mass
- RF meds: digoxin, thiazides, estrogen
- RF illnesses: cirrhosis, renal failure

dx- us w/ hypoechoic mass

tx: observation; surgery for cosmetic reasons or pain

673
Q

Paget’s disease of the breast

A

px: scaly, ulcerated crust of the areola

dx: nipple punch bx with clear cytoplasm w/ ovtal nuclei

tx: total mastectomy (including NAC) and SNLBx
- no breast conservation
- total mastectomy even if small underlying lesion

674
Q

Indications for transcutaneous pacing

A
  • Symptomatic sinus bradycarias
  • Mobitz II (2nd degree) AV block
  • 3rd degree AV block
  • New L or R BBB

**If transcutaneous is unsuccessful ➡ transvenous

675
Q

Types of AV block

A
  • 1d- PR > 200 ➡ no tx if asx
  • 2d Mobitz 1- progressive PR prolongation, then dropped beat ➡ no tx if asx
  • 2nd Mobitz 2- random dropped beat. normal PR ➡ atropine and pacing
  • 3rd degree- A and V pump independently ➡ atropine and pacing
676
Q

w/up and tx of cholangitis

A
  • W/up: labs ➡ RUQ US
  • Tx: IV abxs ➡ urgent/emergent ERCP

**applies for cholangioca as well

677
Q

Digoxin - MOA and S/e

A

MOA- inhibits N/K ATPase. Stimulated PSNS
- increased contractility (Ca rushes in)
- slows AV node conduction

S/e:
- fatal arrythmia (especially in the setting of hypoK)
- beware of patients with n/v (hypoK met alk)

678
Q

Indications for emergent C-section in preggo trauma

A
  • Within 4 minutes of CPR for cardiac arrest
  • Fetus must be at least 24 weeks
  • Give O, Rh negative blood if needed
679
Q

Management of penetrating coronary artery injury

A
  • LAD is MC
  • Primary repair is preferred
  • If too much loss of length then CABG
  • Do not ligate
680
Q

Tx of blunt cardiac injury

A
  1. EKG +/- trop
    - negative: can dc
    - positive: admit to tele
  2. Persistant arrhythmia or HoTN ➡ echo
681
Q

Dx and Tx of rectal injuries

A

Dx: CT w/ rectal contrast is best

Tx:
1. Intraperitoneal ➡ colonic injury
2. Extraperitoneal ➡ primary repair w/ loop sig colostomy
- if inaccessible just leave open and divert
- avoid presacral drainage or distal washout

682
Q

Tx of gastric trauma

A
  • mobilize to see extent of injury
  • most commonly primary repair
  • if large along the greater curve can wedge staple
  • if very extensive can resect and reconstruct w/ REY or Billroth
683
Q

SC artery control

A

Right: median sternotomy

Left:
- anterior thoracotomy: proximal control
- supraclavicular incision: distal control
- can connect with sternotomy for “trap door”

684
Q

Central vs. Peripheral DI - cause and tx

A
  1. Central: disrupted ADH synthesis ➡ responds to DDAVP
  2. Peripheral: genetic or Li induced defective ADH receptor ➡ low salt diet, amiloride
685
Q

Px and Tx of Steal syndrome

A

Px: pain and diminished pulse after AV fistula

Tx: DRIL (distal revasc interval ligation)
- bypass the fistula. Ligate the artery distal to the fistula.

686
Q

Tx of superficial venous thrombosis

A

Thrombus is in GSV, SSV

  1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months
  2. No near the jxns ➡ prophylactic AC for 45 days
  3. Otherwise: surveillance

**Superficial femoral vein is a DEEP vein

687
Q

Tx of varicose veins

A
  • RFA or EVLA are 1st line
  • Indications for surgery instead: high ligation and vein stripping:
    1. proximal/dilated and tortuous GSV
    2. previous thrombophlebitis
    3. vein too large (RFA > 15mm, EVLA > 8 mm)
  • lower extremity telangiectasias, reticular veins, and small varicose veins ➡ sclerotherapy recommended
688
Q

Tx of peripheral pseudoaneurysm

A

< 3 cm ➡ observe
> 3 cm ➡ endovasc thrombin
> 3 cm + infection or neuro def ➡ OR

689
Q

Sensory nerves of the foot

A
  • Dosal: superfial peroneal n.
  • 1st webspace: deep peroneal n. (is deeper)
  • Medial: saphenous n.
  • Lateral: sural n.
690
Q

Layers of EUS

A
  1. superficial mucosa (white)
  2. deep mucosa (dark)
  3. SM (white)
  4. MP (dark)
  5. Adventitia (white)
691
Q

Tx of perforated colon ca

A
  • HDS: perform a cancer resection
  • HDUS: resect and divert
  • Scope in 3-6 months to r/o synch lesion

**Divert if unstable, contaminated, poor nutrition, etc.

692
Q

Contents of cord structures

A
  • Cremasterics (vessels, muscle, lymphatics)
  • GB of GF
  • Testicular artery and veins
  • Vas deferens
  • Processus vaginalis

**round ligament in women

693
Q

Arachidonic acid pathways

A

AA ➡
1. LOX ➡ leukotrienes ➡ bronchoconstriction, PLT aggregation, capillary permeability

  1. COX ➡
    - prostaglandins ➡ vasodilation
    - thromboxanes ➡ vasoconstriction
694
Q

Levels of evidence

A

1- RCT or SR of RCT
2- Cohort study or SR of cohort studies
3- Case-control or SR of case-control
4- Case series
5- Expert opinion

695
Q

Tx of hepatoblastoma

A
  • neoadjuvant if: hepatic v/portal v. involvement, extrahepatic, multifocal, tumor rupture, caudate involved, LNs, distance mets
  • otherwise upfront surgery if resectable
  • transplant if 4+ section involved/unresectable after chemo
696
Q

VACTERL defects

A

Vertebral
Anal
Cardiac
TE fistula
Renal, Radial bone
Limb defects

697
Q

Biliary atresia - px, dx, and tx

A

px: infant with bilirubinemia

dx: HIDA with no contrast in the duo ➡ perc bx

tx- REY-HJ vs. Kasai ➡ transplant if unsuccessful

698
Q

Catelcholamine synthesis

A

Tyrosine ➡ L-dopa ➡ dopamine ➡ NE ➡ PNMT ➡ Epi

699
Q

BK Virus- rf, px, and tx

A

rf’s- high IS, pulse steroids

px- hematuria, nephritis after kidney trx

tx- decrease IS, cysto/possible stent

700
Q

Strategies to decrease SSI

A
  • stop smoking 4-6 weeks b4 surgery
  • mechanical and abx prep before elective colectomy
  • perioperative glucose < 200
  • clippers > razors
  • abxs 1h b4 incision; 2h for vanc or FQ
  • normothermia
  • closing tray for colorectal cases
701
Q

Aminoglycosides - MOA, coverage, s/e

A

MOA- inhibit 30s; bacteriocidal

Coverage- GNRS, pseudomonas

s/e- nephrotoxic, ototoxic

702
Q

Tx of thyroid storm

A
  1. PTU or methimazole
  2. Steroids

**No alpha/beta blockade

703
Q

Polypsos syndromes: px and gene mutations
- MutY
- FAP
- Peutz-Jeghers
- Juvenile polyposis
- Lynch/HNPCC
- Cowden

A
  • MutY: 10 R sided adenomas ➡ MUTYH
  • FAP: 100s of adenomas + desmoid ➡ APC
  • Peutz-Jeghers: hamartomas + skin lesions ➡ STK11
  • Juvenile polyposis: hamartomoas + telangiectasias ➡ SMAD4
  • Lynch/HNPCC: L sided adenomas ➡ MLH1, MSH2, MSH6, PMS2
  • Cowden: hamartomas + breast/thyroid ➡ PTEN
704
Q

High-grade dysplasia with IBD (UC and Crohn’s)Indicachymal

A

Screening scopes 8 years after onset

  • Invisible HGD: repeat w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA
  • Visible HGD:
    1. Resectable: endoscopic resection + serial scopes
    2. Not-presectable: TC w/ IPAA
  • for Crohn’s can do segmental resection
705
Q

Indications for surgery of brain bleeds:
1. Epidural
2. SDH
3. Intraparenchymal

A

Indications for surgery of brain bleeds:
1. Epidural: > 1.5 cm or > 5 mm shift
2. SDH: > 1 cm or > 5 mm shift
3. Intra-parenchymal: > 5mm shift

706
Q

Tx of lung abscess

A
  1. Abxs x 7-10 days
  2. Perc drain if peripheral. Bronchoscopic if central.
  3. Surgery if: B/P fistula, empyema, bleeding
707
Q

indications for trx of cholangioca

A
  • cant be intrahepatic (prognosis is too poor)
  • must be unresectable, perihilar, < 3cm
  • no distant mets
708
Q

Short guy syndrome - risk/length

A
  • Adults risk starts at < 180 cm
  • Infants risk starts at < 75 cm
709
Q

Operative considerations for toxic megacolon

A
  • TAC w/ end ileostomy
  • Keep the ileocolic intact for future J pouch
  • Keep the SRA intact for good staple line flow
  • Divide rectum above the posterior peritoneal reflection at level of sacral promontory
710
Q

Repair of bile duct injuries based on Strasburg class

A

A- CD stump leak:
- Intraop: clip/ligate and leave drain
- Postop: perc drain + ERCP plasty/stent

B- Aberrant right hepatic ligation:
- Only if sxs ➡ REYHJ

C- Transect aberrant right hepatic:
- Only if sxs ➡ REYHJ

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

711
Q

Indications for MRM

A
  1. Prior radiation
  2. Radiation therapy contraindicated by pregnancy
  3. Inflammatory breast cancer
  4. Diffuse suspicious or malignant-appearing microcalcifications
  5. Widespread disease that is multicentric
  6. A positive pathologic margin after repeat re-excision

MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes

712
Q

p450 inducers and inhibitors

A

CRAP GPs spend all day on SICKFACES.com.

Inducers:
Carbemazepines
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas

Inhibitors:
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole

713
Q

Options for choledocholithiasis after REY

A
  • double balloon, single balloon or spiral ERCP
  • percutaneous endoscopic ERCP (through remnant)
  • laparoscopic assisted ERCP (through remnant)
  • laparoscopic or open CBD exploration (transcystic or choledochotomy)
714
Q

Tx of thrombophlebitis

A
  1. Superficial veins: abxs +/- surgery
    - surgery if: purulence, infection beyond vessel wall, failure of abxs
  2. Deep veins: abxs + AC x 2-3 weeks ➡ thrombectomy and vein excision