All Flashcards
Celiac artery branches
CHA- RGA, proper hepatic, GDA (RGE and SPD)
LGA
Splenic- LGE
Killians triangle (dz and borders)
Zenkers
Inferior constricter mm
Cricopharyngeus
MC esophageal perforation
MC iatrogenic perfortation
MC- at GE jxn (usu left) (Boerhaaves)
Iatrogenic- cricopharyngeus
DES vs nutcracker
DES- uncoordinated peristalsis
Nutcracker- coordinated high amp contractions
Heller myotomy incision
2cm stomach
6cm esophagus
Tx achalasia v DES v nutracker
Achalasia- Heller first (dilation or botox if poor sx candidate
DES/Nutracker- CCB and nitrates (long segment myotomy if uncontrolled)
Zenkers v epiphrenic v midesophageal- type, etiology, tx
Zenkers- pulsion, failed cricopharyngeal relax, divide cricopharyngeus (+/- remove diverticulum)
Epiphrenic- pulsion, motility DO, diverticulectomy and tx motility DO
Mid- full thickness, inflammatory DO (TB, malignancy), VATS and diverticulectomy
Esophageal CA staging
T1a mucosa (EMR if low grade)
T1b submucosa
T2 muscular
T3 adventitia
N1 1-2
N2 3-6
N3 >7
Proximal esophageal CA managmeent
> 5cm from cricopharyngeus- esophagectomy
<5cm from cricopharyngeus- definitive chemorads
Tylosis
palmar thickening (keratomas)- risk for esophageal SCC
Fanconi anemia
SCC esophagus
SCC H&N
pancytopenia
Stomach ulcer classification
I lesser curve II x2 (1 gastric and 1 prepyloric) III prepyloric IV GE jxn V NSAIDs
II and III are d/t high acid output
Siewert classification
I 1-5cm above GEJ
II 1 above and 2cm below GEJ
III <2cm below GEJ
III is the worst prognosis
Forest classification and rebleed risk
IA- brisk bleeding (80%) IB- oozing IIA- visible vessel (50%) IIB- adherent clot (25%) III- clean ulcer (<5%)
Early and late dumping
Early- 20-30min osmolar load
Late- 1-4hr insulin surge
Afferent loop syndrome- acute vs chronic
Acute- jaundice, duodenal stump blowout – > emergent surg
Chronic- bacterial overgrowth, B12 deficiency, steatorrhea –> abx, then surgery
CDH1 mutation
Autosomal dom
familial gastric cancer (also breast CA)
>18 yo –> prophylactic gastrectomy
Genes: Lynch Juvenile polyposis Peutz Jeugers FAP
Lynch-MMR
Juvenile- SMAD4
Peutz Jeugers- STK11
FAP- APC
Gastric cancer staging
T1a mucosa T1b submucosa T2 muscularis T3 submucosa T4 past submucosa
N1 1-2
N2 3-6
N3 >7
Neoadju for T2 and higher or any nodes (same as esophagus)
Adju for T3 or higher or any nodes
gastric cancer margins, nodes
5cm (4cm per NCCN)
15nodes
Howell Jolly- Pappenheimer- Target cells Spur cells- Heinz-
Howell Jolly- nuclear remnants Pappenheimer- iron deposits Target cells- immature Spur cells- deformed membbranes Heinz- denatured proteins
highest risk for post splenectomy sepsis
beta thalasemia
TTP symptoms
FAT RN
fever, anemia, thrombocytopenia, renal failure, neuro changes
Replaced right and left hepatic a
Right- SMA (behind panc and CBD)
Left- left gastric (gastrohepatic lig)
Rigler triad
bowel obstruction
Stone on imaging
Pneumobilia
gallbladder polyp
> 6mm serial ultrasound
10mm chole
Stone + polyp - chole
1.8cm suspicious for cancer
gallbladder cancer RF and staging
typhoid, PSC, IBD
T1a lamina propria only
T1b muscularis propria - radical cholecystectomy and portal LAD
isolate gastric varices?
splenic v thrombosis (from pancreatitis), tx w splenectomy
portosystemic shunts- pros and cons
splenorenal- (wont help w ascites)
portocaval- may make encephalopathy worse and may mess w transplant options
Pyogenic
Amebic
Echinococcal
Pyogenic- e coli, drain abx
Amebic- serology dx, flagyl (don’t drain!)
Echinococal- double wall, serology dx, albendazole and excise
MELD vs Child Pugh
Child (liver only)- bili, albumin, PT, enceph, ascites
MELD (liver and kidney)- bili, INR, creat (>15 transplant)
Todani classification (and treatment)
1 fusiform (hepaticoJ) 2 saccular diverticulum CBD (RNY choledochojeju) 3 intraduodenal (transduodenal excision, sphincterotomy) 4a intra and extra (hepatic resection, hepaticoJ) 4b extra only (hepaticoJ) 5 intra only (transplant)
Hemangioma v FNH v Adenoma v HCC
Hemangioma- “peripheral nodular enhancement” (peripheral to centripetal enhancement), no washout
FNH- stellate scar, arterial homogenous enhancement, kupffer cell uptake
Adenoma- OCP, 10% malignant, >5cm rupture…same imaging as FNH
HCC- hyperdense w fast washout
Kasabach Merritt syndrome
Hemangioma DIC
MC liver cancer met
Lung
Liver resection percents
Healthy 20%
Mild cirrhosis 30%
Cirrhosis 40%
Sig liver dz 50%
Fibrolamellar liver CA
young, better prognosis
neurotensin marker
Milan criteria
<5cm
<3cm x3
no vascular or extra hepatic spread
Colorectal mets to liver- full response
resect still
RAAS pathway
Renin (kidney) converts angiotensinogen (liver) –> angiotensin I
ACE (lung) converts angiotensin I –> II
Induces aldosterone production
Medical treatment for hyperaldosterone 2/2 adrenal hyperplasia
Spironolactone
Eplrenone
Incidentaloma labs and imaging
cortisol (MN salivary, then 24 hr urine) catecholamines (plasma, then urine) Aldoesterone, renin DHEA (if ACC suspected) urine androgens (if ACC suspected)
> 10 HF units
<60% washout
6cm
adrenocortical carcinoma- chemo
mitotane
Pheo rule of 10%
extraadrenal (MC organ of zuckerkandl at aortic bifurcation) bilateral chidlren familial (VHL, MEN2, NF) malignant
Pheo imaging
CT
MIBG scan if not confirmatory
Stress dose steroids
20mg>3wks (none if <3weeks)
none if <5mg/day
MTC in MEN2 thyroidectomy?
ppx thyroidectomy at 5yo
pseudocyst intervention criteria
> 6cm
symptomatic
enlarging
chronic pancreatitis procedures
Puestow- pancreaticoJ
Beger- head resect and pancreaticoJ
Frey- head excavation and pancreaticoJ
“fish mouth papilla”
main duct pancreatic duct
branch IPMN- high risk features
>3cm thick wall nonenhancing nodules LAD main duct >10mm abrupt main duct change
PNET- symptoms, w/u, management
PET>somatostatin scan
Insulinoma- no somatostatin scan, diazoxide for med management; >2cm formal resection
Gastrinoma- >1000 or secretine stim test >200
Glucagonoma- 4D (dermatitis, DM, depression, DVT)
Somatostatinoma- DM, gallstones, steatorrhea
VIPoma- WDHA syndrome
chole if malignant (somatostatin as chemo)
Pancreatiic cancer genes
p53
KRAS
Pancreatic cancer resectibility
resectable- no arterial contact, <180 SMV or PV
borderline- <180 SMA or celiac, CHA only (no celieac or HAP), reconstructible vein
nonresectable- >180 MSA or celiac
Pancreatic cancer chemo
FOLFIRINOX (folinic acid, 5FU, oxetecan/irenotecan, oxaliplatin)
dentate line- separates?
upper 2/3 from lower 1/3 of anal canal
columnar (upper) vs squamous (lower)
internal v external hemorrhoids
UC vs crohn’s characteristics
UC- crypt abscesses, mucosal
Crohns- fat grandma skipped down wrecked cobbleston; transmural; erythema nodosum
IBD screening
8-10 years after dz onsent
then q1-3 yrs
4quad bx q10cm
high risk colorectal cancer screening
x1 primary CRC <60yo
x2 primary CRC any age - 40yo, q5y
x1 primary CRC >60yo
x2 secondary CRC any age - 40yo, q10y
FAP 10-12yo q1y
HNPCC 20-25yo, q1-2y
FAP v HNPCC- inheritence, gene, dz
FAP- AD, APC, duodenal polyps
HNPCC- AD, MMR, ovarian, endom, bladder, stomach
Amsterdam criteria
3 relatives (one is primary relative of other)
2 generations
1 CA<50yo
Cscope adenoma screening f/u
tubular adenoma <2x <0.5cm- 5yr
tubular adenoma >3 - 3yr
high risk adenoma >1cm, villous, or high grade- 3yr
hyperplastic - 10yr
Malignant polyps- polypectomy ok?
1piece
margins clear
well or mod differentiation
<2mm past mucosa muscularis (if sessile, no submucosal involvement)
colorectal cancer staging
Tis lamina propria
T1 submucosa
T2 muscular propria
T3 serosa
T3 stage 2 - rectal neoadju chemoXRT and adju chemo (xtra neoadju chemo if CRM involved b/f surg)
N1 stage 3 - colon adju chemo
N1 - 1-3
N2 3-6
N3 >7
rectal cancer margins
2cm distal and 5cm proximal
Neoadju and adju chemorads in CRC
Neoadju- 5000 gray, 5FU x 5 weeks
Adju- FOLFOX folinic acid, 5FU, oxaliplatin
EMR of colorectal cnacer
T1
<3cm or 1/3 circum
Well or mod differentiation
APR v LAR
<5cm from anal verge –> APR
AIN v Anal cancer tx
AIN- imiquimoid or topical 5FU
Nigro- 5FU, mitomycin C, 3000 XRT
CEA anatomy (nerves)
hypoglossal (lies over bifurcation)
Marginal mandibular nerve (retractor injury; lower lip chin mm)
glossopharyngeal (posterior to bifurcation)
vagus (lateral to ICA/CC)
Carotid dz pressures
125 - 50%
230 - 80%
carotid repair
always patch
MC mortality after CEA
MI (not stroke)
When CEA after strokes
TIA <2 weeks
moderate stroke 4-6 weeks
Hemorrhagic 6-8 wks
evolving symptoms - emergent
BIFFL
1 <25% intimal narrowing 2 >25% 3 pseudoaneurysm 4 complete occlusion 5 transection or active extrav
carotid body tumors management
resection (dont bx)
thoracic outlet
1 subclavian v 2 phrenic n 3 ant scalene 4 subclavian a 5 brachial plexus 6 middle scalene m 7 1st rib
thoracic outlet syndrome- symptoms
neurogenic MC paget schroeder (vein)
subclavian steal syndrome
subclavian stenosis
reversal of vertebral flow d/t proximal stenosis
subclavian carotid bypass (bypass distal to stenosis)
fasciotomies- avoid
superificial peroneal (lateral)- foot eversion saphenous vein (medial)
when to place lumbar drain
T8-L1 stent
desc thoracic aneursym fix size
5.5cm
when to fix aneurysms, repair
visceral 2cm (resect and recon) iliac a 3.5 (endovascular repair) femoral a 2.5 (resect and interposition) popliteal a 2cm (exclusion and bypass; look for AAA)
AAA repair sizes
5.5cm or >1cm/yr
MC AAA infection
staph aureus for mycotic and graft
(#2 salmonella mycotic)
(#2 e coli for graft)
IMA when to reimplant
<40 back pressure
Leriche syndrome
aortiiliac dz (smokers)- butt claudication, decr fem pulses, ED
May thurner syndrome (and tx)
L iliac v compression; stent
fistula rules
6 wks
600cc/min
<6mm skin
>6mm diameter
rutherford stages
I (viable) - basically normal
IIa (threat)- no pulses, partial sensation loss
IIb (threat)- slowed cap return, partial paralysis and sensation loss
III (amp)- nothing
endoleak
I prox or distal
II lumbars
III limb
IV porosity
breast nerves
long thoracic (serratus) winged scapula thoracodorsal (lat dorsi) weak adduction
BIRADS
0 nondiag 1 negative 2 benign 3 likely benign (6mo f/u) 4 suspicious 5 highly suspicious 6 known malignant
Bethesda
1 nondx (repeat)
2 benign (repeat 12 mo)
3 AUS/FLUS (repeat FNAB or molec testing)
4 suspicious follicular (molec testing or lobectomy)
5 supsicious malig (total vs lobectomy)
6 malignant
phyllodes breast
WLE 1cm margins
>5 mphf maliginant concern
Gaile model
risk within 5yrs Age Menarche 1st child age Fam hx of breast CA (first degree) Past breast bx past hx of atpyical hyperplasia Race
DCIS tx
2mm margins
radiation to decr risk of local recurrence
breast staging
T1 <2cm
T2 2-5cm
T3 >5cm
N1 1-3
N2 4-9
N3 >10
breast chemo
TAC
taxane, adramycin (doxorubicin), cyclophosphamide (mesma decr risk of hemorrhagic cystitis)
inflammatory breast CA
AT chemo (adriamycin, taxane) +/- rads
MRM
rads +/- chemo
pregnancy breast cancer no nos
no cyclophosphamide (AT only)
no transtuzamab
no blue dye
pregnancy breast cancer management
1st T- BCS not recommended
2nd T- node positive –> MRM or BCS +ALND (rads PP)
node negative –> TM or BCS +SLN (rads PP)
atypical lobular hyperplasia
WLE (no neg margins needed)
thoracic duct course
Right –> Left (at T5)
enters into LIJ
Type I and II pneumocytes
I- gas exchange
II- surfactant
MC mediastinal tumors
MC - neurogenic tumors (posterior)
MC site = anterior (#1 is thymoma)
MC cause of SVC syndrome
SCC
Lung cancer MC met
brain
paraneoplastic syndromes of lung CA
Squam PTHrP
SCC- ACTH and ADH (MC)
MC lung tumors (adult and peds)
Adult- SCC (malignant) and hamartoma (benign)
Ped - carcinoid (malig) and hemangioma (benign)
PFTs
FEV1 >1.5 –> lobectomy
FEV1 >2.0 –> pneumonectomy
VQ scan %PPO FEV1 >40% and TLC >40%
exercise testing VO2 max >15cc/kg/min
Vit d processing
Vit D –> OH 25 (liver) –» 1,25 OH (kidney)
PTH effects
clasts –> increase Ca and Phos
Kidney –> calcium reabsorg and decr phos
Vit D effects Ca
gut increases ca and phos absorb
Parathyroidectomy indications
Incr Ca
CrCl<60
Tscore <2.5
<50yo
palliation for parathyroid cancer
bisphos
parathyroid where?
MC normal location
MC ectopic = thymus
External pathway factors
VII
WEPT
AT III deficciency
heparin wont work
Give FFP first
factor not made in liver
VIII (endothelium)
TEG vs ROTEM
R time- FFP
K or alpha angle - cryo
Max amp - plt
Lys 30 TXA
Clot time - FFP
MCF - FIBTEM abnormal - cryo
FIBTEM normal - plt
alpha v beta receptors
alpha - pure vessel constriction
beta- increases heart contractility and HR
CMV and PCP tx Aspergillus C krusei C glabrata C albicans
CMV - ganciclovir PCP - bactrim Aspergillus and C krusei- voriconazole Glabrata- micafungin albicans- fluc
LCIS- management
obs only vs excise (no neg margins needed)
excisional bx to neg margins - pleomorphic or florid
neuroendocrine tumors- general rule re tx
<2cm - local excision(transanal excision, appy, SBR, etc)
>2cm formal resection (APR, hemicolectomy, WLE SBR)
GIST- margins, spread, cell type, tx, MC met
neg margins hematogenous intestinal cells of cajal imatinib liver
SCC skin margins
4mm margins
6mm if high risk (>2cm, fat invasion, face/ears/scalp)
resp quotient
1.0 pure carb
0.8 pure protein
0.7 pure fat
<0.7 starvation
VW dz types
i and II DDAVP
III give vWF (cryo has some vWF)
IPR cell types
Inflam 1-7d PMN and MAC
Prolif 1-3wk fibroblasts, collagen depo III –> I
Remod- crosslinking
8 weeks max strength
suprcondylar humerus fx distal radius fx anterior shoulder disloc posterior hip disloc midshaft humerus fx
supracondylar humerus- brachial a (volkmanns contracture) distal radius- median n anterior shoulder disloc- axillary n poserior hip- sciatic n midshaft humerus= radial n
Li Fraumeni syndrome
sarcoma
breast brain
Barretts bx
q1cm if mucosal irregularities
q2cm if none
DCIS margins
2mm
SCC margins
4mm
6mm for high risk (>2cm, fat invasion, high risk location on face)
resp quotients
1.0 pure carb
0.8 pure protein
0.7 pure fat
<0.7 starvation
vwd disease
type i and ii - DDAVP
type III vWF
phyllodes margins
1cm
surgery type and steroid dosing
minor- normal steroids
moderate- 50mg IV , then 25 q8h
major 100mg IV, then 50 q8h
meckel cell carcinoma-
carcinoid of skin
evar requirements
8-22mm diameter
15-20mm lengh of CIA
type i vs type ii error
false positive (nuss is true) type II- false negative (null is false)
pancreas trauma grading
grade I and II without duct involvement
CBD repair injury
within 72hr
bismuth classification of cholangiocarcinoma
I- common hepatic duct
II at bifurcation
III 2nd biliary ducts 1 side
IV 2 sides
vein stripping and high ligation reqs
> 8mm or torturous
superior laryngeal vs RLN inn
SL- cricothyroid
RLN larynx mm
clinicAL trial phases
1- safe?
2- does it work
3- RCT
4- post market
CCK
Secretin
gastrin
GIP
G cell antrium- secerte gastrin (gastric acid)
I cells duodenum- secrete CCK (GB contraction, panc enxyame)
S cells duodenum- secretin (panc bicarb)
K duodenum- GIP (inhibigs gastric acid and incr insulin
IL1, 2, 4, 6, 8, 10
1- fever, MAC 2 NK cytotoxic cells 4 B cell antibodies 6 APR (hepatic) 8 PMN chemotaxis, angio (neutrophils) 10 stops evertyhing `
type I, II, III, IV reactions
1 IgE anaphylaxis
2 ABO, IgG, IgM
3 serum sickness
4 t cell mediated (TB, chronic rejection)
chromium deficiency
hyperglycemia
encephalopathy
nephropathy
copper deficiency
pancytopenia
zinc deficiency
wound healing
phos deficiency
can cause failure to wean
weakness
encephalopathy
B1 deficiency
Thiamine
CM
Wernickes
Beri Beri
B6 deficiency
pyrodoxine
siderblastic anemia
glossitis
peripheral neuropathy
B12 deficiency
megalobastlic anemia
beffy tongue
peripheral neuropathy (will not be seen w folate deficiencY)
Niacin deficiency
dermatitis
dementia
diarrhea
vit E deficiency
neuropathy
PPV
= TP/(TP+FP)
NPV
= TN/(TN+FN)
MEN 1 and 2 gene
FAP gene
Li fraumeni gene
MENIN
RET
APC
p53 (sarcoma, breast, brain,, adrenals)
Venurafenlb/fabrafenib Bervacizumab Cetuximab Ipilmumab Nivolimumab Pembrolizumab
fenib- BRAF BerVacizumab- VEGF (Colon) Cetuximab (colon)- EGFR Ipilimumab CTLA4 nivo/pembrolizumab- PD1
ptc path
psamomma bodies, ophan annie nuclei
