ABSITE 2023 Flashcards
Dx of Fibrolamellar HCC
-Labs: normal AFP and elevated neurotensin (vs. FNH)
-Imaging: well-circumscribed w/ central scar. Similar to FNH
Hemodynamic parameters:
- Septic shock
- Neurogenic shock
- Cardiogenic shock
- Septic: high CI, low SVR, +/- wedge
- Neurogenic: high CI, low SVR, low wedge
- Cardiogenic: low CI, high SVR, high wedge
Pheo w/up:
- Spot plasma or urine metanephrine (sensitive)
- 24-urine metanephrine (specific)
- CT (> MRI)
- MIBG (if suspect multi-focal)
Mucinous cystic neoplasm - dx and tx
- dx: EUS-FNA w/ high CEA (>190), low Amylase
- tx: resect
Tx pelvic fx
- Binder
- Angio OR packing w/ fixation (especially if IR n/a)
- Early external fixation
- refractory bleed after angio → packing + fixation
**MC source is presacral venous plexus
STSG vs. FTSG
- survival
- cosmesis
- contraction
- STSG: epi + part dermis
- higher survival/less resistant
- worse cosmesis
- more 2’ contxn. (don’t use over joints) - FTSG: epi + full dermis
- lower survival/more resistant
- better cosmesis
- more 1’ contxn
F5 Leiden Mechanism
- 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 (protein C resistance)
Dx and Localize a gastrinoma
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
Tx pseudocyst/WON
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)
Post trx lymphoproliferative disorder - path, px, and tx
Path- EBV positive B cell proliferation
Px- B sxs (fever, fatigue, weight loss)
- may cause lymphoma, abdominal mass (SBO)
- hyper Ca, high LDH
Tx- reduce IS, rituximab-CHOP
Tx of Thrombosed external HMHD
- w/in 48h - excision
- after 48h - medically manage
Free water deficit - calculation and use
TBW x [(Na-140)/140]
TBW = weight x .6 (men) or .5 (women)
Used for hyperNa
Order of contents in thoracic outlet
- Subclavian VEIN
- Phrenic NERVE
- Anterior scalene MUSCLE
- Subclavian ARTERY
- Brachial plexus NERVE
- Middle scalene MUSCLE
Corrected Ca
serum Ca + [ (4 - patient’s albumin) x .8]
**always falsely low (not high)
Tx of pancreatitis masses
1. WON sterile
2. WON infected
3. Pseudocyst
4. Infected pseudocyst
- WON sterile: conservatively
- WON infected: step-up approach
- Pseudocyst: tx if sxs (infxn, obstruction, pain)
- 4-6w → internal drain → cyst-enterostomy - Infected pseudocyst: drainage (internal, external, endoscopic). Endoscopic preferred.
Indications to tx ICA stenosis and sxs
- Asx: > 60%
- Sxs: > 50% (>125 cm/s)
- Sxs: contralateral motor/sensory sxs, ipsi vision sxs
EBV associated with
- B cell lymphoma (Burkitt)
- n/ph cancer
- PTLD
Medications for hyperthyroidism - MOA and s/e
- PTU: thyroperoxidase and de-iodinase inhibitor
- s/e: aplastic anemia, agranulocytosis. OK for preggo. - Methimazole: thyroperoxidase inhibitor
- s/e: cretinism, aplastic anemia and agranulocytosis
Mechanism:
VWF
Fibrin
- VWF: binds GP1b on PLTs and attaches them to endothelium
- Fibrin: Links Gp2b/3a to form PLT plug
MRSA tx
- Vancomycin, Linezolid (best)
- Clind, bactrim, and doxy have partial coverage
- Ceftaroline (new 5G cephalosporin)
- Muporicin for skin burn
***mecA gene encodes for altered penicillin binding protein giving methicillim resistance
Neostigmine
MOA: AChE inhibitor
Use: reversal of non-depol muscle relaxants
Bethesda criteria for thyroid
**1 cm is cutoff to get an FNA
- Non-diagnostic → repeat FNA
- Benign → follow-up
- Undetermined significance → repeat FNA or lobectomy
- Follicular neoplasm → lobectomy
- Suspicious for malignancy → lobectomy vs. thyroidectomy
- Malignant → thyroidectomy
Achalasia - Dx, Path and Tx
Dx:
- no peristalsis
- high LES pressure > 15 (vs. scleroderma, low)
- incomplete relaxation
Path: injured ganglion cells
Tx: only motility disorder w/ upfront surgery
- myotomy (6 eso, 2 stomch) is 1st line (avoid Nissen).
- botox or dilation if high risk.
Ab reactions: px, tx, ppx
1. Non-hemolytic
2. Hemolytic
- Non-hemolytic: fever after 1hr; cytokine from donor leukocytes
- tx w/ epi, antihistamine, steroids
- ppx w/ leukoreduced blood - Hemolytic: fever, HoTN, bleeding; recipient Ab attack donor leukocytes/RBC (abo mm)
- tx w/ fluid bolus
- ppx w/ preventing clerical error (ABO mm)
Cowden’s mutation and cancers
Mutation: pten
Ca: breast, thyroid ca, hamartomas, endometrial
Umbo ligs remnants:
- Round
- Median
- Medial
- Omph/M
- Round: umbo vein
- Median: urachus
- Medial: umbo artery
- Omph/M: vitelline duct (Meckel’s)
Octreotide - MOA
- Somatostatin analogue
- Inhibits exocrine function of pancreas and CCK release
Drainage of gonadal veins
- Right- IVC
- Left- Left renal vein
Tx Medullary thyroid cancer
- TOTAL thyroidectomy
- > 1 cm or bilobar: central/level 6 dissection
- Lateral neck dissection on that side if central+
- Start T4 postop. Monitor w/ calcitonin AND CEA
- RAI is c/i! (C cell origin)
Tx for hyponatermia
- Acute w/ any sx’s or severe (<110): hypertonic saline bolus
- Chronic and asxatic: free water restriction
- give hypertonic saline if < 110 - Hyper or euovolemic: free water restriction
- Hypovolemic: can give NS or LR (no 3% unless sxs!)
Ulcers:
- Marginal
- Cameron
- Marjolin ulcer
- Cushing’s ulcer
- Marginal: REYGB at GJ anastomosis
- Cameron: on lesser curve of large hiatal hernia
- Marjolin ulcer: chronic wound
- Cushing’s ulcer: elevated ICP
Radial scar- Dx and Tx
- Dx:
- Mammo: spiculated mass with central sclerosis (lucency) and surrounding distortion
- Histo: fibroelastic core w/ entrapped ducts - Tx: core bx ➡ excisional bx (to r/o ca)
preA vs. Albumin
- Prealbumin: >15; t1/2 is 1-2 days; good post-op marker
- Albumin: >3.5; t1/2 is 21 days; good pre-op marker
Tx pop aneurysm
> 2cm- ligation and bypass
<2cm- observation; avoid stents
Tx for ectopic pregnancy
- Stable ➡ methotrexate or salpingotomy
- MTX: absolute c/i if the patient is breast-feeding - Unstable, free fluid, ongoing pain/bleeding ➡ salpingectomy
Hyperkalemia EKG
Hypokalemia EKG
- hyperK: peaked T wave, eventual SINE
- hypoK: flat T waves, U waves
HS reactions
- IgE allergic rxn; anaphylaxis; tx w/ epi
- Ab rxn; AIHA
- immune cx; serum sickness, hep’s
- delayed; t-cell; dermatitis, PPD
- auto-immune
Tx of thyroid ca in pregnancy
- Well differentiated: surgery post-partum
- Postpone until 2T if advanced (MTC, nodes, mets)
- Anaplastic requires immediate surgery in any trimester
- RAI is c/i (during pregnany. andw/ breastfeeding)
Mastodynia tx
- OCP/NSAIDS
- non-cyclic and >30 OR cyclic + mass ➡ mammo
Tx mucinous neoplasm of the appendix
- Confined to appendix: appe only (no LADN’y)
- must have negative margin
- scope in 6w to r/o sync lesions - Involving base, ruptured, or +margin: R hemi +/- LADN
- Peritoneal dissemination: perc bx
- if appendicitis: remove ruptured segment + directed peritoneal bx
- no appendicitis: postpone appe until cytoreductive surgery
- no hipec/cancer operation until staged
**need post-op scope to r/o synchronous lesions
GCS eye opening
4- spon
3- to voice
2- to pain
1- none
Torsades
“polymorphic ventricular tachycardia”
2/2 hypoK, hypoCa, hypoMg
all cause qt prolongation
Normal values: CVP, WP, SVR, CI
- CVP 2-6
- WP 4-12
- SVR 700-1500
- CI 2.5-4
When to excise burns
- < 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)
TTP - Path, Px, Tx
Path- def in ADAMtS13
Px- fever, anemia, TCP purpura, renal dz, neuro sx (FATRN)
Tx- plasmapheresis → splenectomy if failed
LE angio
AT comes off first and goes lateral
TP trunk- PT behind tibia, peroneal behind fibula
Liver lesions on arterial phase:
HCC
Mets
Adenoma
Hemangioma
FNH
HCC: rapid enhancement. rapid 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
Methanol and Ethylene glycol toxicity - Px and Tx
Px: profound AG metabolic acidosis
- oxalate stones → renal failure
Tx: NaB + fomipazole (ADH inhibitor)
- consider iHD
Ureter anatomy
Runs under the vas/uterine arteries
Runs over the iliacs
Elective surgery after stent
- ASA lifelong
- Plavix
- BMS: 1 month
- DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)
UE Injuries:
1. supracondylar humerus
2. DRF
3. Mid shaft
4. ant shoulder disloc
5. post shoulder disloc
- supracondylar humerus- brachial artery
- DRF- median nerve
- Mid shaft- radial nerve
- ant shoulder disloc- ax. nerve
- post shoulder disloc- ax. artery
Teg interpretation:
R time
K time
a angle
MA
LY 30
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%
DeMeester score
Score: pH <4 , changes in position, duration, # of episodes
> 14.7 is positive
Standard Deviations
1, 2, and 3 SD = 67%, 95%, and 99.7% of the data
s/e of ileal conduit
Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)
Angiodysplasia of the colon - Dx and Tx
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
Stewart-Treves syndrome - px, dx, tx
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)
Tx for gallstone ileus
Stable and healthy- stone removal and take down fistula
Unstable, old/frail- stone removal only!
Sorafenib
Tyrosine kinase inhibitor
Tx of HCC
Stricturoplasties
- Heineke s’plasty
- Finney s’plasty
- Side2Side isoperistaltic s’plasty
- Heineke: <10cm; open long and close transversely
- Finney: > 10cm; segment folded on itself and common wall created
- Side2Side isoperistaltic (Michellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together
Dx and tx of gastroparesis
Dx: Scintigraphy gastric emptying
Tx:
- Metoclopramide (Reglan): dopa antagonist
- gastric pacemaker or pyloroplasty
- feeding tube
- TPN
Burn degrees
1D: epidermis
2D superficial: pap dermis, painful, hair follicles intact; blanches
- don’t need grafting
2D deep: retic dermis, decreased sensation; loss of hair follicles, no blanch
- need skin grafts
3D burn: subcutaneous fat, leathery
4D: fat/muscle/bone; surg
Tx and Survival Benefit of ARDS
- TV at 4-6 ml/kg
- Permissive hypercapnia
- Proven benefit: prone, lung protection, paralyze
-P/F < 100 = severe
Interleukins 1, 2, 4, 5, 10
IL1: fever
IL2: T cell proliferation
IL4: B cell proliferation
IL5: eosinophil growth, asthma, allergic rxns
IL 10: anti-inflammatory
Glucagonoma - loc, px, dx, tx
Loc: distal (a cells)
Px: dermatitis, DRH, DM, nec mig erythema
- most malignant
- no stones (vs. SS’oma)
Dx: gluc > 1000
Tx: distal panc + splenectomy + LADN’y + CC’y
Aminocaproic acid - MOA and use
MOA: Plasmin inhibitor
Use: DIC, excess tpa
s/e of carb, protein, and lipid
- carb: immunosuppression, resp failure
- lipid: pro inflammatory
- protein: false neurotransmitters, rise in ammonia/urea
- can worsen hepatic encephalopathy (use branched chain AA instead of aromatic AA)
Dx, Bx, and Tx actinic keratosis
- Dx: red, crusty, weeping lesion
- Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
- Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)
Hirschsprung surgeries
- Duhamel
- Soave
- Swenson
- Duhamel: agang stump in place/gang colon pulled behind; end-to-side mosis; neo-rectum; lowest stricture rate
- Soave: pull-through; “reverse alte”; remove M/SM; pull through within an aganglionic CUFF; least dissection
- Swenson: original; aganglionic segment resected to sigmoid colon; pull-through with end-to-end anastomosis- colon x rectum.
z11 trial implications
- 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
Hard signs of vascular injury
shock
expanding hematoma
pulsatile bleed
thrill/bruit
absent pulse
ischemia
If negative ➡ ABI…if positive ➡ CTA (to localize)
Polyps that require surgery instead of endoscopic resection
- Submucosal invasion > 1mm
- Poorly differentiated
- <1 mm margin
- LV invasion
- Tumor budding
- Taken piecemeal
Iron deficiency sxs
anemia, glossitis, brittle nails, cardiomegaly
T staging indications for neoadjuvant
- eso
- stomach
- colon
- rectal
- lung
- eso: select t1b (SM) or T2 (MP)
- stomach: t2 (MP)
- colon: t4b (adjacent organs)
- rectal: t3 (through MP)
- lung: n2 nodes
Atlanta classification pancreatits
- Interstitial:
<4w- acute peripanc collection
>4w pseudocyst - Necrotic:
<4w- acute necrotic collection
>4w- walled of necrosis
Fuel for:
- SB
- LB
- SB: glutamine
- LB: short-chain fatty acids (acetate, butyrate). Directly absorbed by intestinal epithelium w/out lipolysis
Motilin
Motilin – released by intestinal cells of gut; ↑ intestinal motility (erythromycin acts on this receptor)
Screening in IBD patients
- 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 can consider endoscopic resection with close surveillance
NEC - px and tx
Px: bloody stools after 1st feed
- prematurity is biggest RF
tx:
- resuscitation, ngt, abx (no surgery) x 7-10 day (50% success)
-surgery (50%): resect all non-viable segments. create stoma.
W/up of thyroid nodule found on exam or incidental imaging
- U/S and TSH:
a. Nodule + Low TSH ➡ RAI uptake scan - hot/functioning: toxic adenoma (no cancer) ➡ thionamide, b-block + lobectomy
- cold: FNA
b. Nodule + Normal/High TSH ➡ FNA
Tx male breast ca
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
Nutcracker eso - manometery and tx
- Mano:
high amplitude/long peristalsis
normal LES pressure
normal relaxation - Tx: (identical to DES)
1. PPI, CCB, TCA
2. Long segment myotomy if refractory
General principles - repair of Bile Duct Injury
- Intro-op:
- convert to open, intra-op cholangio, repair OR
- widely drain and send to specialty center - Post-op:
- Perc cholangiography to define the anatomy
- Control spillage: external drain +/- stent +/- PTC
- Repair in 6-8 weeks
Eso dysplasia tx
- LGD: scope q6-12m
- OK for fundoplication - HGD: ablation + Q3m scope
- fundoplication c/i - T1a: ablation
- t1b (or low risk T2): upfront esophagectomy
*Fundoplication does not decrease cancer risk
Superior epigastrics
Inferior epigastrics
SE: runs between rectus and posterior rectus sheath; branch of int mammary
IE: runs between rectus and transversalis fascia; branch of EI
When to intubate burn patients
- hypoxia, hypercarbia, severe upper airway edema
- If stable/GCS > 8 and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling
Tx hemobilia after trauma
- EGD → CTA (if stable)
- angio embolization (no surgery)
- catheterize the celiac artery first ➡ R/L hepatic ➡ SMA
Paget Von Schroetter syndrome - path, px, tx
Path- narrowing of SC/Ax vein 2/2 mech compression
Px- acute swelling
Tx- catheter-directed thrombolysis before anything else (NOT open thrombectomy)
Tx of AT3 def
Tx- recombinant at3 or FFP followed by heparin then warfarin
Vitamin C mechanism
- hydroxylation of lysine and proline
- type 3 collagen cross-linking
Indications for chemotherapy for rectal cancer
- Neoadjuvant:
Stage 2 and above
Stage 2: at least t3 (crossing muscularis prop) or any n (stage 3) - Adjuvant chemo as well for Stage 3+ (nodes)
**XRT either pre or post-op (not both)
Periop anticoagulation - risks and tx
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
What is not suppressed by high dose dexa
Adrenal mass
Ectopic mass (small cell cancer)
Metabolic alkalosis - chloride responsiveness
- Cl responsive (Ur Cl < 20)
- temporary loss, replaceable
- vomiting - Cl resistant (Ur Cl > 20)
- hormonal, continuous loss
- conn’s, steroids, hyperaldosterone
Heller myotomy margins and fibers
6 cm proximal, 2 cm distal
- Esophagus: vertical fibers first (outside), then circular (inside)
Margin for invasives cancer vs. dcis
- Invasive cancer- no tumor on ink
- DCIS- 2 mm
**if both in specimen, margin is no tumor on ink
ITP- path, dx and tx
- path: IgG against gp 2b/3a
- dx: of exclusion- increased megakaryocytes, petechia, TCPenia
- tx:steroids → IVIG 2nd line → splenectomy
- do not tx unless PLT < 30k
- spleen is source of Ab’s
Staph species causing graft infection
G+/aerobe/clusters
coag+ → staph aureus
- MC early graft infections)
coag- → staph epidermidis
- MC late graft infection 2/2 biofim
Cryptorchidism tx
- wait until 6 month old
- if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma
- risk of ca higher in both testes.
Sarcoma stage and grade
- Grade ~ differentiation, mitotic count, and necrosis
– more important than size, nodal/distal mets for prognosis - Stage
Stage 1- G1 w/ any T stage
Stage 2- G2/3 and T1
Stage 3- G2/3 and T2+
Stage 4- N+
Neuroblastoma dx and tx
dx:
- CT: displacement of renal parenchyma (vs. Wilm’s).
- usually adrenal. Can also be neck, chest, spine
- neck can px w/ horner syndrome
tx:
- S1-2 (low risk) → surg alone
- S3+ (high risk) → surg + chemo/XRT
Gastrin - MOA and stimulation
- MOA: G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ H/K exchange (ATP) ➡ HCl (+ intrinsic factor)
- Stimulation: ACh, beta ago, AA
- Inhibition: acid, SS, secretin, CCK
Esophagus blood supply
- Cervical- inf thyroid
- Thoracic- aortic branches (bronchial arteries)
- Abd- left gastric/inferior phrenic
- CBD and PD on ERCP
- Blood supply of CBD
- CBD at 11’. Blood supply 9’ and 3’.
- PD at 2’
Tx urethral injury
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
TEF - MC types. dx and tx
- Type MC, 85%
- Proximal esophageal atresia (blind pouch) and distal TE fistula
- dx: AXR ➡ distended, gas-filled stomach, coiling tube
- no UGI needed! - Type A: second most common, 5%
- Esophageal atresia and no fistula
- dx: XR: gasless abdomen, coiling tube
- no UGI needed!
Tx:
1. Resuscitate w/ repogle tube
2. Echo: VACTERL cardiac w/up
3. G-tube placement to decompress and feed
4. Delayed right extra-pleural thoracotomy
5. Distal ligation of TEF (if gas in abdomen, type C)
**long term r/o dysphagia and GERD
Tx of Ogilvie’s
- CT or scope to confirm dx. R/o obstruction.
2 supportive, dc narcotics, ng tube, neostigmine
- if > 10cm ➡ scope decompression and neostigmine
- failure ➡ OR
Px and Tx of prolactinoma
Px: bitemporal hemianopsia, galactorrhea, amenorrhea, ED, osteopenia
Tx:
1. Bromocriptine or carbegoline (both dopa agonists)
- bromo is safe in pregnancy
2. Surgery only if tx failure
Pros/Cons:
- Sevoflurane
- Isoflurane
- Halothane
- NO
- 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.
Atropine MOA
- competitive inhibitor of ACh at muscarinic receptor
- liver metabolism
FMD- Dx and Tx
Dx: string of beads on angiogram
Tx: angio + balloon (no stent)
MEN1/MEN2 genes
MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene
Birads score
0- redo imaging
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)
MOA, use, s/e of antifungals:
Fluconazole
Voriconazole
Micafungin
Amphotericin
- Fluconazole: ergosterol synth inhibitor
- Non-systemic candida (yeast infection, c. albicans)
- s/e: liver toxic, GI upset - Voriconazole: ergosterol synth inhibitor
- aspergillosis, C. krusei
- s/e: visual changes, psychosis - Micafungin: echinocandin; inhibit glucan production
- invasive/disseminated candidiasis (c. glabrata)
- s/e: TCPenia - Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access)
- invasive mucor or cryptococcal meningitis
- s/e: nephrotoxic, hypoK
Recurrent laryngeal nerve + aberrant anatomy
- motor: larynx except cricothyroid
- sensory: larynx below the cords
- injury: hoarseness, airway compromise, permanent ADduction —> bilateral may need a trach
Aberrant anatomy:
- NR right a/w: arteria lusoria ➡ absent innominate + right SC takes off from left aortic arch
- NR left a/w R sided arch
PFTs for lung resection
- Preop FEV1 and DLCO predicted > 80% ➡ no further testing
- >.8L wedge, >1.5L lobe, >2L pneumo
- < 80% ➡ lung scan for PPO FEV1, DLCO - PPO FEV1, DLCO > 60% ➡ no further testing
- < 60% ➡ exercise test - VO2 > 10 ml/min/kg ➡ OK for surgery
- < 10 ➡ high risk for surgery
Origins of medullary thyroid cancer
- 4th pharyngeal arch releases NCC which form parafollicular C cells
Gastrinoma - loc, px, dx, tx
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
qSOFA score
- AMS (<15)
- RR > 22
- SBP < 100
MC Benign and Malignant H/N tumors - tx
- Benign: Pleomorphic adenoma
- Tx: superficial parotidectomy even if asx - Malignant: mucoepidermoid carcinoma tx
- Tx: total parotidectomy (facial nerve preservation) + MRND + XRT
Tx frostbite
- Frostnip: rapid moist/pool re-warming
- 2d: clear/milky blister- drain
- 3d: HMHG blister- leave intact
- 4d: bone- prostacyclin/TPA, amputate
Tx of Pilonidal cyst
- ASx: NTD
- Acute abscess: drain only
- Chronic cyst: offer surgery if effecting QOL
- marsupialization and leave open: lower recurrence
- primary closure: faster healing. Off midline- less complication (preferred)
MCCO Cancer
Male- prostate, lung, CRC
- death: lung, prostate, CRC
Women- breast, lung , CRC
- death: lung, breast, CRC
Tx TCPenia
<10k if asx
<20k if septic, chemo/rads, RF’s
<50K if elective surgery
Tx annular pancreas
neonates- duododuodenostomy (mobile duo)
adults- duodenojejunostomy
Production and function:
- TNFa
- IF-gamma
TNF-a: produced by PMNs, mphages
-cachexia, inflammation
IF-gamma: produced by T lymphos
- activate PMNs, mphages
W/up of pancreatic cystic neoplasms:
Pseudocyst
Serous cystadenoma
MCN
IPMN
- MRI
- 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
Propofol - MOA, pros and cons
MOA: GABA-A agonist
Pros
- rapid distribution and on/off
- decreases ICP, anti-emetic
Cons
- s/e: hypotension, resp depression, meta acid
- no analgesia
- liver metabolism
Enterohepatic circulation
Primary bile salts → hepatocytes → conjugated BS:
- 80% conjugated ➡ active ileum absorbed
- 20% deconjugated by bacteria ➡ passive colon absorbed
- 5% out in stool
Dx and Tx CO poisoning
- Suspect in burn patient with neuro/cards sxs
Tx:
1. 100% O2 w/ facemask or intubation (not hi flo)
- Hyperbaric O2 if C-Hb > 25%
- Intubate if comatose, severe acidosis
Indication for APR
- Rigid proctoscopy: w/ in 2cm of anal verge (levators)
- PE: baseline sphincter dysfxn
- Recurrent SqCC (s/p Nigro)
Cancer associations:
- CEA
- AFP
- CA 19-9
- CA 125
- Beta-HCG
- PSA
- NSE
- BRCA I and II
- Chromogranin A
- Ret oncogene
- 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
Types of esophagectomy compared
- 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 - 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 - McKeown: abdominal + L neck
- anastomosis: cervical
***Gastric conduit supply- R gastroepiploic (off GDA/CHA)
Somatostatinoma - loc, px, dx, tx
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
Etomidate - Pros and Cons
Induction agent
Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e
Cons- adrenocortical suppression
W/up and Tx testicular mass:
- Seminoma
- Non-seminomatous
- PE
- Ultrasound
- AFP, HCG, LDH
- Seminoma: no AFP!`
- Non-seminoma: high AFP, HCG, LDH - Inguinal orchiectomy: any patient with solid testicular mass
- Based on path/markers decide:
- Seminoma: XRT
- Non-seminomatous: retroperitoneal node dissection
**ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection
Liver collection dx and tx:
1. Pyo
2. Amoebic
3. Echino
4. Fungal
- Pyogenic: after cholangitis (MC) or div’s;
- drain and abx (+mica if fungal) - Amoebic: after mexico trip (or aMazon).
- dx w/ serology/hemagglutination 1st
- metronidazole (no drain) - Echinococcal: wall Ca+ and sub-cysts
- albendazole and resect/PAIR - Fungal: 2/2 chemo/neutropenia
- perc drain + micafungin
EVAR specs:
- Proximal landing
- Common iliac (distal landing)
- Neck angulation
- External Iliac
Proximal landing: > 1.5 cm
- diameter < 3cm
Common iliac (distal landing): > 1 cm
- diameter > 8 mm
Neck angulation < 60 degrees
External Iliac diameter> 7mm
Tx of anal fissure
- Sitz bath, fiber
- topical nifedipine/nitroglycerin
- Surgery (or botox)
- Good sphincter tone: LATERAL, INTERNAL sphincterotomy
- Poor tone: botox
**If 2/2 crohn’s dz: optimize medical management
Lynch genes and gene funtions
Genes:
- MLH1
- MSH2, MSH6
- PMS2
- EPCAM
Fxn:
DNA MM repair gene causing microsatellite instability
Condyloma types
- acuminatum- HPV (6, 11- warts; 16, 18- Cancer)
- lata- syphilis
Tx of liver lesions:
1. Hemangioma
2. FNH
3. Adenoma
- Hemangioma: only if sxatic or KM syndrome
- enucleate (or resect); angioembo if active bleed - FNH: NTD
- Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing
REY limbs
Roux- 75 to 150 cm
BP- 15 to 50 cm
Dx and Tx congential DPGM hernia
-Dx: prenatal dx on US
-Tx:
1. intubate (in delivery rm)
2. NGT +/- ECMO
3. delay OR when stable
Indications for neoadjuvant therapy for stomach cancer
Any T2 lesion or LN involvement
T2: growth into the muscularis propria
Stages of empyema formation
- Exudative ➡ drainage or VATS (1-7 days)
- Fibrinopurulent ➡ VATS (7-21 days)
- Organizing ➡ thoracotomy (21+)
**VATS between days 3-7
- Preferred over 2nd CT placement or fibrinolytic therapy
Vertebral artery occlusion px
posterior circulation
sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia
5T’s of cyanosis
- TOF
- Transposition of GVs
- Truncus art
- Tricuspid atresia
- TAPVC
DES - Manno and Tx
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
Supraceliac aortic control
- HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram
- Stable: left medial visceral rotation is preferred
Mondor disease - px and tx
px- tender, “cord-like” structure
tx- NSAIDs
Dx and Tx Phyllodes
Bx: stromal overgrowth, atypia, high MI, “leaf-like”
- aggressive fibroepithelial lesion
- non aggressive is fibroadenoma
Tx: WLE w/ 1 cm margin
- can spread hematogenous to lung
Replaced Rand L hepatic
Right- SMA (behind pancreas and CBD)
Left- left gastric (in gastrohepatic ligament)
Effective for enteroccous
Ampicillin/Amoxacillin
Vancomycin
Zosyn
(Resistant to all cephalosporins)
Loss in excess weight for each surgery
REYGB- 75%
SG- 60%
Lap band- 50%
Acid/Base of Ng suctioning
HypoCl, HypoK metabolic alk
- Mech: Loose HCl and fluid ➡ turn on RAA system
Retain Na/Excrete acid (paradoxic acidurea)
Indications for total thyroidectomy (pap and follicular)
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
**if thyroid lobectomy only: tx with thyroid hormone to suppress TSH, get serial U/S to monitor
Soft tissue sarcoma - dx and tx
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
Step up approach
Infected pancreatic necrosis (WBC + gas on CT)
- Carbanem
- FNA
- Perc drain OR endo drain (if stomach is close to pancreas)
- Upsize drain
- Video, Lap, or Endo assisted retrop necrosectomy
- Lap/open necrosectomy
CN11 - nerve, location, muscle/injury
- nerve: spinal accessory nerve
- location: exit jugular foramen (post triangle)
- injury: SCM and trapezius. no shoulder shrug
- Central cord syndrome
- Anterior cord syndrome
- Central cord: loss of pain, temp, motor
- motor UE> LE loss (vs. anterior syndrome)
- hyperextension in the setting of SS - Anterior cord: loss of pain, temp, motor
- below the level of the lesion
- ASA injury or anterior cord compression
Types and Tx SVT
types: af, aflutter, paroxysmal SVT, WPW
- vagal → adenosine
- may unmask afib/flutter - HDS: BB, CCB ➡ sync cardioversion
- HDUS ➡ sync cardioversion
Von Hippel Lindau - mechanism and surveillance
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
Melanoma w/up and tx
- Punch bx or excisional bx (if small, non-sensitive area)
- MIS- 5mm margin
- <1mm- 1cm
- 1-2mm- 1-2cm
- >2mm- 2cm - Clinical positive nodes (stage 3) require FNA for confirmation
- negative: SLNBx
- positive: completion LN dissection - SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
- 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.
Steps of rapid sequence intubation
c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine
PSC vs. PBC - assocaited and tx
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: trx, cholesty., UDCA
- meds generally don’t help
CPP
MAP - ICP
normal CPP > 60
Normal ICP < 20
- would prefer low MAP with CPP of 60 then higher MAP for brain bleed
Draining peri-rectal abscess
- Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles)
- Supralevator abscesses need to be drained trans-rectally
Px, Dx and Tx malrotation
Px: bilious emesis
Dx: UGI duodenum does not cross midline
- should be done in all infants with bilious emesis
Tx: urgent OR (risk of malro)
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
Epidural hematoma - shape, vessels, px
Shape: Biconvex. DOES NOT suture lines
Vessel: MMA
Px: lucid interval. Ipsilateral blown pupil is early sign
- (vs. subarachnoid thunderclap, worst HA)
MEN syndromes
1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD
2a- Parathyroid (PTC),MTC, Pheo (catecholamines); ret; AD
2b- Pheo, MTC, marfanoid/neuroma; ret; AD
Nitrogen balance
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
Periop Warfarin
stop 5 days before
Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6
Management of PE
- no RH strain → acoag
- RH strain → IR catheter
- RH strain + HDUS → systemic tPA
Methemoglobinemia - px, dx and tx
Px: nitrites, Hurricane spray, fertilizers, g6PD def, seretonergic drugs
- Fe2+ to Fe3+ impairing O2 binding
Dx: blood gas measurement and pulse ox says 85%
- MethHb level > 20%
Tx: methylene blue or vitamin C (for g6pd or ser)
Layers of colon/rectum
- mucosa
- sub-mucosa (strength layer)
- muscularis propria
- serosa
LE vascular trauma
- small: patch plasty
- large: contralateral GSV (must maintain venous system b/c deep vein may be injured)
- limited time/unstable: shunt
Tx Post dural puncture headache
after epidural
tx with blood patch
Tx for DVT
- unprovoked: malignancy, inherited ➡ indefinite
- 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
Loop diuretics vs. Ca sparing diuretics
- loop: furosemide
- Ca sparing: thiazides
MALT lymphoma dx and tx
Dx: EGD + bx
- usually in the stomach
- CD20+, lympho infiltration
- associated w/ h. Pylori.
Tx:
- Low grade: triple therapy (eradicate HP)
- High grade: chemo and XRT (CHOP) +/- rituximab (CD20)
lower extremity bypass graft failure depends on temporal relation to the surgery.
- <30d: technical error
- 1m-2y: intimal hyperplasia, (at the distal anastomosis)
- > 2y: progressive atherosclerotic disease
Dx and Tx Parathyroid ca
Dx: palpable neck mass + Ca > 14 is presumptive dx. Otherwise, dx intra-op based on gross features.
- FNA is not recommended
- Treat based on intra-operative gross invasion. Frozen section is not helpful.
Tx:
1. Control hypercalcemia: usually > 14
- IV fluids 1st! Then bisphosphonates
- cinacalcet (sensipar - ca mimetic)
- Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT)
- no chemo
- usually don’t perform any node dissection unless palpable nodes
Tx infected pseudocyst
aspirate/gram stain to dx → drainage (internal, external, endoscopic)
Tx melanoma of anal canal
Tx:
- WLE (1 cm). No SLNBx
- APR if sphincter involved, LADN, or > 4mm
- No chemo-XRT
**5y-S is 20% w/ R0
**WLE = APR
Kaposi’s sarcoma - cause and px
- Case: HSV8
- Px: Violet/brown papules
Mechanism and Tx of thyroid dz:
1. Graves
2. TMN
3. Hashimoto’s
4. DeQuervains/Subacute
5. Reidels
- Graves: IgG stimulates TSHr ➡ hyperT
- BB, PTU, RAI ➡ thyroidectomy - TMN: chronic TSH stimulation ➡ hyperT
- BB, PTU, RAI ➡ total/subtotal thyroidectomy - Hashimoto’s: antiTPO/TG Ab ➡ hypoT
- thyroxine ➡ partial thyroidectomy - DeQuervains/Subacute: viral URI
- NSAIDS/ASA ➡ steroids - Reidels: autoimmune inflammation
- steroid, thyroxine ➡ extensive fibrosis often need surgery for compression
Sonograph FNA recs
- cystic: no bx
-isoech/hyperech: FNA if > 2cm
-hypoech (high sus): FNA if > 1cm
Tx anal incontinence
- 1st line: fiber/bulking, exercises
- Refractory: endoanal U/S
- defect: overlapping sphincteroplasty
- no defect or refractory: sacral modulator
s/e of burn topical treatments:
- silver nitrate
- silver sulfadiazene
- mafenide
- bacitracin
- Silver nitrate: electrolytes disturbance (no sulfa)
- Silver sulfa: neutropenia, sulfa (covers pseudo)
- Mafenide: met acidosis (CA inhibitor), sulfa (covers pseudo and eschar)
- Bacitracin: G+; nephrotoxic
Triple therapy
PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks
APC gene
- chromosome 5
- 1st mutn in adenoma to carcinoma
- mc mutation in colon ca
- a/w FAP
Contents of post triangle
- CN 11
- subclavian artery
- EJV
- brachial plexus trunks
Gail model
- age
- age 1st period (earlier is worse)
- age 1st birth (earlier is better)
- 1d relative
- previous bx
- race
Associated orthopedic injuries:
1. post hip disloc’n
2. post knee disloc’n
3. DRF
4. Supracondylar humerus fx
5. Anterior shoulder disloc’n
- post hip disloc’n: sciatic nerve (peroneal branch)
- post knee disloc’n: popliteal atery
- DRF: median nerve
- Supracondylar humerus fx: brachial artery
- Anterior shoulder disloc’n: axillary nerve
Dobutamine
B1 at low dose
- inotropy
B2 at high dose
- vasodilation
types of endoleak and tx
- proximal/distal seal: immediate balloon expansion of distal/proximal attachments + stent
- 1a: proximal leak
- 1b: distal leak - back bleeding: observe. coil embolization if enlarging
- graft defect (tear or junctional leak): immediate additional graft coverage
- porosity- reverse anticoagulation
Carcinoid vs. GIST vs. Desmoid- cells and tx
- Carcinoid- Kulchinsky cells (enterochromaffin-like)
tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable - GIST- cajal cells
tx- resection, imantinib - Desmoid- spindle cells
tx- resect if extra-abdominal. NSAID/estrogen if intra
Meckel’s Diverticulum Pathophys
- Anti-mesenteric border of SB
- 2/2 peristant viteline duct
- pancreatic and gastric tissue
- 2 feet from IC valve
VRE coverage
Synercid, linezolid
MOA:
- Milrinone
- Midodrine
Milrinine- PD inhibitor, contractility with vasodilation
- c/i in renal failure
Midodrine- a1 agonist
Hyperaldosterone w/up
Px: resistant HTN and hypokalemia
- AM plasma aldo AND plasma renin
- A/R < 20: 2nd hyperaldo
- A/R > 20: primary hyperaldo ➡ - Confirmatory test: salt load suppression test
- give salt load ➡ 24h urine aldo remains elevated - 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
**tx HTN with spironolactone
Dx and Tx of SBP
dx- ↑ascitic PMN (Se) and + culture (Sp); e. coli is MC (usually single organism)
tx- 3GC abx AND albumin (survival benefits)
HLA test
- Tissue typing
- Donor organ: carries Ag (on WBC)
- Recipient body: carried Ab
Recipient serum with donor wbc
Tx acute variceal HMHG
- Resuscitate, ensure airway
- Octreotide + antibiotics
- Endoscopic intervention (ligation/sclerotherapy)
- Blakemore
- TIPS (temporized with Blakemore)
Tx SVC syndrome tx
- Elevate HOB
- Chest CT with IV contrast (can skip CXR)
- Consider bronch
- Assess sxs
A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting
B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo
Crystalloid and colloid for trauma kids
Crystalloid: 20cc/kg
PRBC: 10cc/kg
Melanoma characteristics:
- superficial spreading
- lentigo
- nodular
- acral
- superficial spreading: MC
- lentigo: sun exposed, best prog
- nodular: worst prog
- acral: AA
**thickness is most indicative of prognosis
Tx appendicitis
- Uncomplicated: lap appe
- Septic/Unstable: immediate lap appe
- Stable w/ abscess
- < 3cm: lap appe
- > 3cm: IR drain ➡ interval appe, offer scope - Crohn’s ileitis
- intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty
Tx MEN2A/B
- urine metanephrine to r/o pheo 1st
- tx pheo 1st w/ adrenalectomy
- Address thyroid
- 2A: total thyroid + bilateral central neck by 5y
- 2B: total thyroid + bilateral central neck by 1y
Tx MEN1
- HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
- Asses other lesions
Prog and Tx anaplastic thyroid ca
Prognosis:
- aggressive, undiff
- mort ~ 100%; no tx
Tx: XRT improves short-term survival +/- surg
- BRAF inhibitor for chemo
GI Hormone Release and action:
- Glucagon
- Insulin
Glucagon: alpha cells of pancreas
- glycogenolysis, gluconeogenesis
Insulin – beta cells of the pancreas
- cellular glucose uptake; promotes protein synthesis
Criteria for transanal excision of adenocarcinoma
- T0 or T1 (submucosa)
- < 3 cm
- < 30% circumference
- Palpable on DRE (<8cm from anal verge)
- No high-risk features (poorly diff, LV invasion)
**local recurrence rate is higher
Merkel cell ca - dx, histo, and tx
Dx:
-rare neuroendocrine tumor of the skin
-purple raised; looks like BCC w/out rolled edge
- CK20+
Tx:
-Tx: surgical excision + SLNBx! + XRT (very sensitive)
Breast abscess tx
US aspiration BEFORE I/D if refractory
Bx if > 2 weeks to r/o ca
5 steps to LADDS procedure
- Resect Ladd’s bands
- Widen the mesentery
- Counterclockwise rotation
- Cecum in LLQ (cecopexy), place duodenum in RUQ
- Appendectomy
HNPCC screening and treatment
- CRC: scope q1-2y starting at 20-25
- Surgery if:CRC or endoscopically unresectable lesions
- TAC with IRA w/ q1y rectum surveillance - Endometrial ca
- childbearing: endometrial sampling q1y
- after children: TAH-BSO - Ovarian ca: annual pelvic exam and TVUS
Dx and Tx choledochal cyst
Dx: U/S or HIDA
Tx:
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
5. intra only: transplant
Vit D vs. PTH
Vit D: increase Ca and Ph
PTH: increase Ca and decrease Ph
Arterial content
(1.34 x Hb x Sa02) + (.003 x PaO2)
Px, Dx, and Tx:
Duo atresia
TEF
Pyloric stenosis
Intussusception
Malro
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
Cori cycle
- recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production
- requires alanine
- provides 40% of glu when starving
Tx of GB cancer
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)
Layers of mucosa
Epithelium
Lamino Propria
Muscularis mucosa
Stage 3 breast cancer and tx
3a: 4 to 9 nodes ➡ +/- neoadj
3b: chest wall (not pec wall) or breast skin ➡ +/- neoadj
3c: supra clavicular nodes ➡ neoadj required
Tx of CBD stone intra-operatively
- Flush ➡ glucagon x 2
- Lap exploration
A. Transcystic: stone < 1 cm, <8 stones, no CHD stones
B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones - Open exploration: if lap exploration failed
- CBD < 2 cm: trans-duo sphincteroplasty
- multiple stones, CBD > 2 cm: biliary-enteric drainage.
- Leave T-tube
W/up Hurthle Cell Cancer
- FNA- hurthle cells (can be seen in other conditions)
- Lobectomy 1st for diagnosis
- If malig: total thyroidectomy +/- L6 nodes
- If palpable nodes: MRND
No RAI
Conduit after esophagectomy
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)
Cancer Markers:
Ca 125
bHCG
AFP
Inhibin
Ca 125- epithelial
bHCG- choriocarcinoma
AFP- germ cell/endodermal/yolk sac
Inhibin- granulosa/sex-cord
Tx of High grade AIN/bowen’s disease of anal margin
- Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin
- otherwse: cryo, curettage, 5-FU, laser - Lifetime surveillance even if tx!
- Bowen disease = SqCC in situ = high grade AIN
- Actinic keratosis is precursor
*vs. pagers disease- excision
Types of rejection - px, path, and tx
- hyper-acute: w/in 1 hour
- path: ABO Ab (t2 HS)
- px: mottled organ
- tx: remove organ - acute cellular: days-weeks; change in organ function
- path: B or T (t4 HS)
- px kidney: lymphocytic infiltration, tubulitis
- px liver: endothelitis, portal triad lymphocytosis
- tx: increase IS or pulse steroids ➡ IVIG - chronic: months-years
- path: B or T (t4 HS)
- px kidney: interstitial fibrosis, tubular atrophy
- px liver: bile duct atrophy
- px heart: vasculopathy and atherosclerosis; 1/2 @ 10y
- px lung: bronchiolitis obliterans; 1/2 @ 5y
- tx: increase IS or re-trx (no good options)
Dx and Tx DPGM injury
Dx: CXR ➡ CT ➡ diagnostic scope if inconclusive
Tx: repair is always recommended
- Abdominal approach
- Debride devitlized tissue
- Repair with non-absorbable suture
- If too large can close primarily can use mesh or tissue flap (if contamination)
Strep species
G+/aerobe/chains
a hemo- pneumo, viridans
b hemo- GAS(pyo)/GBS(aga)
non hemo- enterococci
Hypocalcemia vs. Hypercalcemia - sxs and ekg
- HypoCa: tingling, chvostek/trousseau sign
- EKG: qt prolongation - HyperCa: stones, bones, groans, overtones, DI
- EKG: shortened QT
Calcitonin
Parafollicular C cells
Inhibits osteoclast resorption
Increases Ph excretion
Types of Shunts
- Total: porto-caval, meso-caval
- Relieves bleeding and ascites
- More hepatic encephalopathy - Partial: distal spleno-renal
- Relives bleeding only
Crohn’s drugs MOA:
- Azathioprine/6-MP
- Sulfasalazine/5-ASA
- Infliximab
- Azathioprine/6-MP: inhibit DNA synthesis
- Sulfasalazine/5-ASA: COX/LOX inhibitor
- Infliximab: monoclonal Ab to TNF; moderate Crohns, recurrent perianal fistula!
GI Hormone Release and action:
Gastrin
Somatostatin
CCK
Secretin
VIP
- Gastrin - G cells in antrum
- ↑ HCl, IF, and pepsinogen - Somatostatin – D cells in pancreas
- inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output - CCK – I cells of duodenum
- gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells) - Secretin – S cells of duodenum
- ↑ pancreatic/GB bi release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release - VIP – pancreas and gut
- ↑ intestinal secretion (water and electrolytes) and motility
Anal canal
Dentate line
Anal verge
Anal margin
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
Px, Dx, Tx Galactocele
Px: breast mass that looks like abscess w/ no infectious signs
Dx/tx: u/s ➡ aspiration shows milky debris
- continue bfeeding
- no abxs (unless infected)!
Stages of graft healing
- imbibition (direct diffusion)
- inosculation (cap beds meet)
- revascularization
Hernia repairs:
Bassini
McVay
Lichtenstein
Shouldice
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
EBUS accesible nodes:
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
Order of cells in healing
- Hemostasis: PMNs (24-48h)
- PMNs: remove necrotic tissue, release ROS’s - Inflammatory: monocytes/macrophages (48-96h)
- mphage: growth factors, angiogenesis, cell proliferation
- chronic wounds arrest in this stage - Proliferative: fibroblasts (3d+)
- fblasts: collagen production and secretion - Maturation: fibroblasts (10d)
- myofibroblasts for wound contraction
Hemophilia A
f8 deficiency, SLR
MC inherited disorder
tx- DDAVP (mild), f8 concentrate (severe)
Adenoid cystic carcinoma - px and tx
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
Tx for cholangiocarcinoma
Tx:
1. Resectable if:
- contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor
- no distant mets or organ invasion
- Consider location
- Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
- Middle ⅓: hepaticojejunostomy
- Lower ⅓: pancreaticoduodenectomy (Whipple) - Consider chemo + transplant if unresectable
acid and alkali burns - px
- Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis
- Acid burns (battery acid) produce coagulation necrosis
- copious water irrigation as soon as possible
- cagluc if HF acid
IPMN - dx and tx
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
Tx PDA
to close- indomethacin
to open- PGE1
Airway management anatomy
Anatomy:
1. Elective trach: between 2nd and 3rd trach rings
2. Crich: CT membrane between thyroid cart and cric
- try direct scope intubation first
- Thyroid cart ➡ cricoid cart ➡ rings
Indications:
- Avoid nasotracheal intubation w/ basal skill fractures - hemotympanum, CSF rhinorrhea/otorrhea
- Nasotracheal intubation good for unstable c-spine fx
Dopamine dosing and s/e
low- d1/2 ago (renal dose)
medium- B ago
high- A ago
**s/e: high UOP. difficult to titrate. tachyarrythmias
Parkland formula
- 4 x weight x TBSA
- Use 2 for “modified Brooke formula”
- 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
Who needs stress dose steroids and how to dose
> 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
Dx and Tx of Zenkers
Dx- UGI (don’t do EGD) –> manometry (r/o dysmotility)
Tx- open or scope approach:
<2cm : myotomy alone
>2cm: multiple options
- consider endoscopic stapling +/- myotomy
- 2-5 cm: myotomy with suspension or inversion
- larger: diverticulectomy with myotomy
Tx SIADH
Acute – vaptan, demeclocycline
Chronic – fluid restriction, diuresis
Spinal vs. Epidural
Spinal- below l1/l2; SA space; fast; n/m block
Epidural- any level; epidural space; slow; no block
VIPoma - loc, px, dx, tx
Loc: distal
Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin
- most malignant
Dx: high VIP
Tx: distal panc + splenectomy + LADN’y + CC’y
Gastric CA tx - chemo, margins, nodes
- 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
DDAVP/Vasopressin - production and effect
Made in SON of HT. Stored PP.
Cause endothelium to release f8 and vWF
Milan criteria
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
Posterior and anterior vagal trunk branches
Vagotomies
Right ➡ Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet
Left ➡ Anterior trunk- hepatic branch, ant laterjet
- Truncal vagotomy: transect ant/post @ distal eso
- removes lesser curve and pylorus nerve
- need pyloroplasty. high r/o dumping syndrome - Highly selective: transect @ crow’s ft, preserve laterjet
- removes innervation to lesser curvature
- preserves pylorus → no drainage procedure
- lowest morbidity
Insulinoma - loc, px, dx, tx
Loc: throughout (B cells)
Px: whipple’s triad. Most benign.
Dx: I/G > .4 and high C-pep
- endoscopic U/S most sensitive for detection
Tx: < 2cm encucleate, >2cm resect.
- High carb diet 1st
- Diazoxide if can’t tolerate surgery
- LADN’y if suspect malignancy
Dx and Tx fat necrosis
- dx: oil cyst w/ Ca+ rim
- smooth, circumscribed lesion - tx:
no trauma- bx
trauma- watch
Px and Tx Pancreatic divisum
Px: chronic pancreatitis episodes
Tx:
- Only tx if sxs
- ERCP sph’otomy of MINOR papilla (Santorini/Superior)
- Refractory: resect HOP (duo preserving)
Indications for neoadjuvant therapy eso cancer
- high grade t1b or T2 and above OR any nodal involvement
- Also get XRT
Marfans vs. Ehlers-Danlos
- Marfans- Fibrillin-1 defect (elastin);
- AD; mitral regurg, aortic root dilation, lens defect, arachnodactyly - Ehlers Danlos- t3 collagen defect
- hyper elastic skin, hypermobile joints, aortic root dilation
**Both need CTA of aorta to r/o aortic root``
Bladder ca - dx and tx
px- hematuria in a smoker
dx- CT urogram 1st (bladder, kidney, or ureter ca)
- T1a- no muscle/including LP
tx- transuretehral resexn (TURBT) + mitoM + BCG - T2a- muscle/beyond LP
tx- cystectomy + LND + chemo - T3- fat/nodes
tx- neoadjuvant
Tx tracheal inj
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)
Specific to Crohn’s and UC
- Crohn’s:
- Creeping fat
- Skip lesions
- Transmural
- Cobblestoning
- Granulomas
- Fistulas - UC:
- Crypt abscess
- Pseudopolyps
Uremic PLT dysfunction - px, dx, tx
Px- 2/2 renal disease.
dx- normal coags. elevated BT only.
tx- ddavp
Escharotomy indications
- Circumferential deep burns
- Neuro-vascular sxs
- Problems ventilating torso burns
**Perform within 4–6 hours
**Usually bedside
**May need fasciotomy AFTER
Gastric ulcers: elective classification and management
Dx- EGD and Bx (Bx needed to r/o ca!)
Tx-only tx if refractory to max medical management after 12 weeks.
- lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2
- gastric + duo; high acid ➡ antrectomy + vagotomy
- pre pyloric: high acid ➡ antrectomy + vagotomy
- GE junction: normal acid ➡ sub-total gastrectomy + REY
Emergent vs. Elective UC Tx
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
Kasabach-Merritt Syndrome
- hemangioma + thrombocytopenia
- usually infants
- resect!
Peutz-Jeghers - px and screening
Px- intestinal hamartomas (intususpeption), 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
Omphalocele
- 2/2 failure of umbo ring closure
- 11th week gut returns to abdominal cavity
- normal bowel (protected)
- Other congenital defect are more common
Cryo contents and uses
- Contents: VWF, f8, fibrinogen
- Uses:
1. VWD
2. Fibrinogen def
3. Hemophilia A
Zone injuries and management
- penetrating:
- zone 1-3 –> explore - blunt:
- zone1 –> explore
- zone 2-3 –> do not explore
TOS tx
- neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
- venous- catheter-directed thrombolysis → surgical decompression
- arterial- C7/1r resection, subc artery resection/reconstruction
FAP - Dx and Tx
Dx: > 100 adenoma or < 100 w/ fam hx
- AD; APC mutation
- 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- SB polyposis
- TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen)
- q1y EGD post op for duodenal cancer (MC COD)
- q1y c’scope if TAC
- polyposis/high grade dysplasia @ stump → proctectomy +/- pouch
- desmoid: resect. Anti-E if intra-abdominal
BRCA risks and tx
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!
When to operate on adrenal mass
- all functioning tumors
- all > 6 cm ➡ open resection
- if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection
**DO NOT biopsy first
Adjuvent chemo for breast ca
- Adjuvent chemo: tumor > 1cm, nodal dz, triple neg
- echo before for cardiotox - Tamoxifen/Anastrazole: 5y for HR+ tumors
- Tamox for men - Trastuzumab- 1y for Her2/neu+ tumors
- echo before for cardiotox
FNH - path, dx and tx
path- CENTRAL STELLATE SCAR!
dx- bright on arterial phase homogenous
tx- resect if sxatic. no malignant potential.
Secretin vs. CCK
Both released by duo
S cells ➡ Secretin- duct cells ➡ bicarb
I cells ➡ CCK- acinar cells ➡ enzymes
Pancreas drainage procedures
- duct > 7mm- Peustow, pancreaticojej (for large duct)
- duct > 7mm and large head- Frey, pancreasticojej + core out head
- duct < 7mm and large head- Berger, pancreatic head resection
Tx papillary/follicar thyroid can
- Indications for total thyroidectomy:
- Tumor > 4cm
- Distant mets or extra-thyroid disease
- Poorly differentiated
- Prior radiation - 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 - 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
Heparin - MOA and measurement
MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin
Measurement:
- PTT
- ACT: better intra-op if high doses of hep given
