Case Files Flashcards
1
Q
What is the work up for possible breast cancer?
A
1- CONFIRM CANCER
Fine needle biopsy (cells) but core needle biopsy shows actual histology
Bilateral mammography
2- METS
CBC, chest X-ray and LFTs
3- Stage III METS
Brain MRI, bone scan, PET, abdominal CT
2
Q
Surgical approach to breast cancer
A
Breast conservation therapy - partial mastectomy with lymph node sample and post-surgical local radiation
If large … may choose neoadjuvant chemo and then therapy
3
Q
ALND v. SLNB For Breast Cancer
A
SLNB»_space; ALND in terms of mortality
Injection of radiotracer at primary tumor then remove node with most dye
4
Q
Systemic Therapy Options for Breast Cancer (4)
A
Stage II usually get systemic chemo - FAC or AC with docetaxel
Anti-estrogen for 5 yrs if estrogen or progesterone receptor positive
Aromatase inhibitors in post menopausal women with ER positive
Trastuzumab
5
Q
BPH Symptom Workup
A
Check creatinine to make sure there is proper renal function
Urinalysis to rule out UTI as cause of symptoms (may coexist)
PSA
DRE
Rule out neuro cause - neuro exam
6
Q
What are the extra-esophageal complications of GERD?
A
laryngitis, reactive airway disease, recurrent pneumonia, pulmonary fibrosis
7
Q
Work-up for surgical anti-reflux procedure
A
Endoscopy (is there erosion or Barrett)
Manometry for LES tone
24 hr pH probe test (do symptoms occur when pH is highest)
barium esophagography (look at where GE junction is and look for obstruction)
8
Q
Indications for surgical anti-reflux
A
still symptomatic despite highest dose PPIs
9
Q
Boerhaave Syndrome
A
Spontaneous esophageal perforation (classically after increased abdominal pressure from vomiting repeatedly)
10
Q
Why is esophageal perforation a surgical emergency? What is the most common cause?
A
Causes pneumomediastinum
Most often iatrogenic -during endoscopic procedures
DELAY IN DIAGNOSIS INC MORBIDITY AND MORTALITY
11
Q
What is the clinical progression of esophageal perforation?
A
Immediate chest pain
SubQ emphysema 1 hr later
Pleural effusion
Fever/ Leuks from sepsis from mediastinum inflammation
Death esp if diagnosed >24 hr later
12
Q
Diagnosis and Tx Esophageal Perforation
A
Diagnose w water soluble esophogram (not barium in case of leak)
Either non-op (abx, CT guided drainage) or operative repair depending on severity scale
13
Q
4 Types of Melanoma
A
Superficial spreading (most common)
nodular sclerosing (aggressive early vertical growth)
Lentigo maligna
Acral lentiginous - also aggressive vertical and more common in blacks
14
Q
Melanoma Management
A
Initial biopsy
If pos then go back and do wide local excision
Also ID sentinel nodes and extract any positive
15
Q
Anti-reflux Procedure
A
Nissen fundoplification - wrap fundus around GE junction
16
Q
TURP
A
Transurethral resection of prostate
Scope that chips away at prostate from within prostatic urethra
Monitor PSA levels after
17
Q
SBO Presentation
A
Vomiting or not able to pass gas or BM
Complications/strangulated if there is pain (dilated bowel leads to venous congestion and thus dec perfusion and necrosis) or other signs like fever, high WBC, high amylase, tachy
X-rays - dilated bowel or air-fluid level
CT- thick bowel wall with less enhancement and free fluid
PEOPLE CAN STILL HAVE BM AND HAVE OBSTRUCTION
Labs -elevated amylase or high anion gap lactic acidosis with high lactate
18
Q
What is your major concern in SBO?
A
Dec intravascular volume (lose volume into lumen, bowel wall and peritoneum) - need IV
esp if operating because anesthesia in setting of low volume can lead to hypotension
NG tube and foley
19
Q
Causes of SBO in kids v adults
A
Kids - hernia, malrotation, meconium ileus, Meckel diverticulum, intussusception, intestinal atresia
Adults - adhesions, Chron, gallstone ileus, tumor
20
Q
Non-operative v Operative Tx of SBO
A
If uncomplicated try non-operative - NPO, place NG tube to decompress, monitor fluid status/labs/imaging
SHOULD SEE IMPROVEMENT IN 6-24 HRS
If complicated operate - give abx and do exploratory laparotomy (ID obstruction, cut any adhesions and remove any ischemic bowel)
THOSE WITH CLOSED LOOP ALWAYS OPERATE RIGHT AWAY
21
Q
Carpal Tunnel Causes
A
Edema esp worse at night in tunnel - DM, myxedema, hyperthyroid, acromegaly, pregnancy
Others - lipoma in canal, autoimmune, hematoma, bone abnormalities
Women > men 3:1
22
Q
Non-operative v Operative Management of Carpal Tunnel
A
Always try non-operative first - splints and NSAIDs/ steroid injections
Operate if intractable symptoms not helped by splints and meds (divide transverse carpal ligament with a tourniquet and local anesthetic then extensions splints for 2 wks)
23
Q
Reasons why carpal tunnel would not be relieved by surgery?
A
Already advance hypotrophy
Neuropathy from DM
Misdiagnosis - compression of median at medial epicondyle or compression of ulnar instead
24
Q
Biliary colic
Acute cholecystitis
Chronic cholecystitis
Choledocolithiasis
Biliary pancreatitis
A
Colic - postprandial pain less than 6 hr without fever or lab abnormalities - due to gallstones
Acute - persistent RUQ pain and Gb tenderness, gallstone on US, may have fever or high white count
Chronic - persistent RUQ pain but THICK gb as well as stones on US
Choledocholithiasis - postprandial pain because CBD dilated and plugged by gallstones, inc LFTs
Biliary pancreatitis - persistent epigastric and back pain, stone in gb and CBD dilation on US, elevated LFTs and amylase
25
Biliary Scintigraphy (HIDA)
ERCP
HIDA -radiotracer goes from liver to gb to duodenum normally but if gb is not visualized then cholecystitis
ERCP- use scope to cannulate the common bile duct and inject contrast (can also cut sphincter into duodenum to release bile duct stones)
26
Charcot Triad
Means cholangitis or inflammation of bile ducts
1 - fever
2 - jaundice
3- RUQ pain
Treatment is antibiotics and ERCP to decompress
27
Treatment of Cholecystitis
Give abx
Perform gb removal during that hospital stay but only if you have objective evidence that symptoms are related to gallbladder ( thickening on US, HIDA)
28
Causes of Upper GI Bleed
Variceal (20%)
Non-variceal (80%) - gastric or duodenal ulcers, gastric erosions, gastric cancer (more often occult/chronic blood loss), Mallory Weiss tears in gastric mucosa from coughing or vomiting, AV Malformations, Dieulafoy erosions (rare bleeding from submucosal artery in stomach)
29
Steps in Managing Upper GI Bleed
1- ABCs (fluid resuscitation and incubate if needed)
2- NG tube and irrigate until clear gastric aspirate
3- diagnose (via endoscope)
4- treat underlying cause (stop NSAIDs, give PPIs for ulcers, COX2 selectives)
30
How can you stop the bleeding in Upper GI Bleed?
Endoscopic thermotherapy, electrocoagulation, ethanol or epi injection, sclerosing agents if esophageal varices
31
When to perform surgery for Upper GI bleed?
Complicated peptic ulcer disease with massive, persistent or recurrent Upper GI hemorrhage
Or if ulcer is non-healing or > 3 cm
** may also do angiography and arterial embolization with foam, springs or clot to stop Bleed
32
Risks of rebleed (8)
Shock on admission
Prior bleed needing transfusion
Hemoglobin < 8
Needing > 5 units packed red cells
Continued blood in NG tube aspirate
Visible vessel or oozing blood in ulcer base on endoscope
Adherent clot at ulcer base
Location of ulcer - near large artery
Age associated with inc mortality but not rebleed (> 60)
33
Upper v lower GI bleeds
Upper- above ligament of Treitz - coffee ground or bloody emesis, tar colored stools (melena - when bacteria degrades hemoglobin from blood in tract for 14+ hours)
Lower - below ligament- maroon stools (mix of fecal material and blood)
Can put in NG tube and if no bloody aspirate then likely lower GI
34
Causes of lower GI bleed by age
Kids - IBS, Meckel, polyp
20 to 60 yo - diverticulosis, neoplasm, IBS
> 60 yo - diverticulosis, angiodysplasia (dilated submucosal veins esp in cecum), neoplasm
35
Ways to localize lower GI bleed
Tagged RBC scan - tag w technetium and see where it localizes
CT with contrast
Me sent Eric angiography - superior and inferior mesenteric (can then inject vasopressin or gel foam)
Video capsule endoscopy - swallow camera (rare)
Rigid procto-sigmoidoscopy OR colonoscopy (can give epi injection for angiodysplasia)
Ex lap only as last resort
** colonoscopy is most specific and preferred
36
Relative risk of breast cancer for various benign breast lesions
No risk - adenosine, apocrine metaplasia, ductal ectasia, fibroadenoma, fibrosis, mild hyperplasia, mastitis
1.5-2X - moderate or severe ductal hyperplasia, papillomatosis
5X - atypical duct all hyperplasia
10X - lobular carcinoma in situ or atypical ductal hyperplasia with family hx
37
BI-RADS Classifiation
Category 0- breast imaging assessment incomplete
1- negative so just routine screening
2- benign findings so just routine screening
3- probably benign but short term imaging follow up in 6 months
4- suspicious abnormality so biopsy ( a is low, b is intermediate, c is moderate concern )
5- highly suggestive of malignancy
6- known biopsy proven malignancy
38
Breast cancer screening for high risk individuals
LCIS - annual mammogram and consider raloxifene
BRCA or family hx- annual mammogram at 25 yo, or 5-10 yrs before first relative case THEN MRI at 30 and consider raloxifene (may consider prophylactic mastectomy)
39
Mammography
Meant to detect non-palpable breast mass
Not as sensitive in women less than 30 due to possible dense fibrocystic change
Less sensitive for lobular carcinoma
10% false positive and 10% false negative rates
40
Immediate management of closed head injury
ABCs- give blood and intubation
Controlled hyperventilation to cause vasoconstriction in vessels to the brain - this will decrease blood pooling in the brain and thus reduce intracranial pressure
Mannitol- decrease volume of blood and edema in brain
***For ICP to remain constant ... inc blood must result in dec CSF or brain tissue
GCS calculated
CT to determine type of bleed
41
GCS
```
Eye opening -
4- spontaneous
3- to speech
2- to pain
1 - none
```
```
Best motor response
6- obeys commands
5- localizes pain
4- withdraws to pain
3- decorticate posture (flex)
2- decerebrate posture (extend)
1- no response
```
```
Verbal response
5- oriented
4- confused conversation
3- inappropriate words
2- incomprehensible sounds
1- none
```
TBI CLASSIFICATION BY SCORE
13-15 mild
9-12 moderate
<9 severe
42
Physical exam signs of closed head injury
Dilation of one pupil with sluggish response to light may mean temporal lobe herniation - compresses cranial Nerve 3 on ipsilateral side of bleed
43
Approach to penetration abdominal trauma
1 - ABCs - airway, breath sounds, pulses
2 - imaging (FAST ultrasound really good for pericardial fluid, chest X-ray to look at lungs)
3 - secondary survey aka abdominal exam
4 - observation for 24 hrs if asymptomatic, local wound exploration with local anesthetic, diagnostic peritoneal lavage, CT, diagnostic laparoscopy (good for diaphragm injury)
44
Indications for exploratory laparotomy
If peritoneal lavage shows RBCs, WBCs, fecal content
If CT shows peritoneal penetration, free fluid or air in peritoneum, hollow organ penetration
If wound exploration shows anterior fascia has been penetrated
45
Atypical appendicitis
Only half of patients have typical presentation
Atypical = more pelvic location (do US because this is best to rule our pelvic pathology and then CT can find appendix)
Incomplete rotation of appendix in embryo can lead to variable location
46
Alvarado Score
Point for ea...
```
RLQ pain
RLQ rebound tenderness
RLQ tenderness
Anorexia
Nausea or vomiting
Fever
High WBC
Left shift
```
0-4 low probability appendicitis (observe)
5-6 compatible - do CT
7-8 probable - do CT
9-10 high probability - appendectomy
47
Mesenteric adenitis
Viral illness leading to inflammation of small bowel mesentery
Can also see RLQ pain esp in kids
Self limited - no antibiotics
48
Appendicitis pathology- clinical correlates
Luminal obstruction (lymph nodes or fecolith) - poorly localized pain and nausea
Inflammation - more localized pain
Perforation - pain may improve but more systemically toxic
49
Bowel prep
Polyethylene glycol for laxative to clear fecal material
Broad spectrum non- absorbable antibiotic to dec bacteria in colon in case of spilling of colonic contents
50
R v L sided colon cancer symptoms
R tend to bleed so iron deficiency anemia
L tend to cause dec stool caliber and diarrhea
51
When to respect polyp/ cancer instead of polypectomy?
Once it has penetrated the submucosa
52
2 rectal cancer surgery types
Low anterior resection - if above anal sphincter muscles, can do anastomoses
Abdominoperineal resection - respect anal canal including sphincter complex, need colostomy bag
53
Colonoscopy recommendations
Every 10 yrs starting at age 50
If remove polyp > 1 cm then repeat in 3 yrs ... if that is clear then every 5 yrs
FAP relatives - start at 10 yo and repeat every 1-2 yrs until 40 then every 3 yrs (also do Upper endoscopy for duodenal polyps)
54
Colon cancer treatment by stage
Stage 1 or 2 - resect
Stage 3- resect then systemic chemo (or radiation if rectal)
Stage 4- just systemic chemo
55
Post- op acute respiratory insufficiency
Causes - aspiration, pneumonia (painful breathing means pt is not cleaning airway as well), PE, direct parenchyma injury, ARDS, atelectasis from anesthesia, carcinogenic pulmonary edema
Approach - ABCs before diagnosis (non rebreather mask or intubation)
Pathophysiology - inflammation and endothelial damage - fluid leaves capillaries, dec lung compliance and volume, also less type 1 pneumocytes and less surfactant
56
Phases of wound healing and factors that impair it
1- inflammatory - few days of sterilization and growth factor secretion
2- proliferation - deposit fibrin- fibrinogen matrix and collagen
3- remodeling - capillary regression and collagen cross linking leads to increased strength
Factors - infection, vitamin c deficiency, vitamin b6 deficiency, vitamin a deficiency, lack of oxygenation, DM, corticosteroids
57
When to operate on incisional hernia
Evisceration, enterocutaneous fistula, uncontrolled sepsis
Presents as serous peritoneal fluid from wound or billions contents from wound if fistula
***higher rate of recurrence and infection than inguinal hernia repair
58
Possible causes of post-op fever
Surgical site infection- superficial if not involving fascia and deep if involves fascia (deep get CT)
Microbial peritonitis from spill of gut bacteria into peritoneum from perforation
Intra-abdominal abscess - fibrin and omen them contain the fluid
along with small bowel ileus
Hospital- acquired (uti, pneumonia, iv)
Drugs reaction, endocrinopathy, SIRS, transfusion reaction
59
Treatment of intrabdominal infection
Stop source (aka if appendix perforation then remove appendix) and antibiotics
Generally aminoglycoside, fluroquinolone, cephalosporin + metro or clindamycin (mainly gram negative and anaerobes)
If less severe use single agent like cefoxitin, ceftriaxone, ampicillin- sulbactam
If abscess then can do CT guided drainage
60
Short Bowel Syndrome
Loss of small bowel absorption from resection or functional dec (radiation, IBS) leading to nutrition deficiency, diarrhea, electrolyte problems
If only 80-90 cm will have transient diarrhea and malabsorption
If less than 60 cm then permanent TPN
In adults - chron or mesenteric infarction
In kids - necrotizing enterocolitis or midgut volvulus
Extent depends on ... what part is affected (ileum and jejunem worse), absence of valves, length removed, underlying pathology
Bowel eventually adapts - inc villi height, inc surface area, inc wall thickness
61
SBS Treatment
Nutritional support - have to decide between TPN and enteral nutrition (enteral preferred otherwise bowel atrophy)
Medical - PPIs, octreotide, clonidine, loperamide (dec secretions and motility) and cholestryamine if bile acid malabsorption
Surgical - small bowel transplant, insertion of valves, bowel elongation (only if very bad and cannot maintain nutrition)
62
Differential for liver mass and best imaging for each
Hemangioma - most common but benign, do not biopsy because rupture, use angiography or CT (early contrast enhancement with peripheral outlining)
Focal hyperplasia -common and benign, reproductive age women, angiography is best or central scar seen on CT
Adenoma - associated with oral contraceptives, can become metastatic and can hemorrhage so often removed, may need to biopsy
HCC - lap US and must biopsy to confirm
Mets to liver - most often from colon, CT/MRI/lap US and must biopsy, resection unless already late stage
63
HCC and Colorectal Tumor Markers
HCC - AFP and ferritin
Colon- CEA
64
4 common anorectal complaints
1- fissure - superficial tear often w skin tag, hypertrophic anal papilla and inc sphincter tone (MOST COMMON IN POSTERIOR ANODERM)
2- hemorrhoids - purple or blue enlarged soft masses
3- abscess, painful, pus, fever
4- fistula - draining sinus from anal canal to perineum resulting from ulcer, pus/erythema/ fluctuant
65
Hemorrhoid grading and tx
I - prominent on inspection but asymptomatic or painless - change diet
II- prolapse but reduce on own, may bleed or itch - diet, band ligation, infrared coagulation
III- need manual reduction, prolapse and bleed - band ligation or hemorrhoidectomy
IV- not reducible, severe pain - hemorrhoidectomy
66
Tx of anal fissures v. Fistula
Fissure - sitz bath, stool softener, suppositories, bulking agents, nitroglycerin cream (vasodilator)
** if chronic then botulinum toxin injections and last resort is lateral internal sphincterectomy
Fistula - fistulotomy if superficial or seton if involves sphincter (plastic or silicone loop thru fistula)
67
Goodsall rule for anal fistula
Fistula exiting posterior to lines between ischial spines will be curvilinear
Fistula exiting anterior to line between ischial spines will be radial or straight - directly to dentate line
68
2 types esophageal cancer
Squamous cell - upper esophagus, burns, alcohol, smoke, nitrites (dec in US) - benefit from radiation
Adenocarcinoma - lower esophagus, western diet and PPIs (inc in US) - benefit from chemo then surgical resection unless too advanced
69
Palliative care for advanced esophageal adenocarcinoma
Main goal = treat dysphagia to inc quality of life
Endoscopic stent - fast relief but may obstruct
Laser destruction of mass - good if exophytic
Intraluminal radiation/brachytherapy - delayed but higher quality
Palliative chemo
70
Transthoracic v. Transhiatal Esophagectomy
Thransthoracic - r chest and ab incisions - anastomose in thorax - inc risk pulmonary complications
Hiatal - cervical and ab incisions - anastomose in neck
71
Revised Cardiac Risk Index
1 pt for each ...
- ischemic heart disease
- CHF
- cerebral vascular disease
- high risk surgery (thoracic, abdominal, vascular, major ortho)
- insulin dep DM
- creatinine>2
Class I - 0 points
Class II - 1 point
Class III- 2 points
Class IV - 3+ points
Class III or IV benefit from beta blocker use before operation
72
Dobutamine stress test
High dose dobutamine IV then look for symptoms or wall motion abnormalities on echo
HIGH SENSITIVITY (low false neg rate) but low specificity (not all positive will have a perioperative MI)
73
Steps to Pre-op cardiac risk assessment
1- is it emergent surgery? Then just optimize pt
2- have they undergone coronary revascularization in last 5 yrs? If asymptotic since then no more tests needed
3- have they had cardiac eval in last 2 yrs? Then skip
4- do they have unstable coronary syndrome ? If yes then postpone operation
5- do they have intermediate risk factors? (Mild angina, prior MI, compensated CHF, DM) if yes - consider functional capacity and risk of operation itself
6- okay if moderate/excellent function and intermediate risk operation BUT further testing if low function and high risk operation
7- good to go if moderate clinical risks (age, odd rhythm, abnormal ekg, hx stroke, uncontrolled systemic HTN), moderate to excellent function and non-cardiac surgery
8- risk of cardiac pre-op intervention must be weighed against risk of operation itself
74
Types of Gastric Ulcers
I- lesser curve, low acid secretion (most common)
II- lesser curve, high acid secretion, duodenal ulcers (more hemorrhage and perforation)
III - pre-pyloric, high acid secretion (more hemorrhage and perforation)
IV- high on lesser curve near GE junction, low acid secretion (elderly)
V- associated w NSAIDs
75
Gastric v Duodenal Ulcers
Gastric - should biopsy to exclude malignancy
Duodenal - no risk malignancy
76
When should gastric/duodenal ulcers be operated on?
- persist despite 3 mo meds
- recur within 1 yr initial healing
- obstruction
- perforation
- hemorrhage
77
H pylori Eradication
Triple therapy for 1-2 wks, twice daily, no bismuth
OAC -omeprazole, amox, clarithromycin
OAM - metro
OCM
78
Possible progression of acute pancreatitis
Initial - N&V, pain to back and systemic inflammation symptoms (monitor for end organ damage, fluid resuscitation and CT)
Few days later - pancreatic necrosis --> fluid around pancreas walled off by surrounding structures (give abx)
Secondary infection (bowel bacteria) --> abscess formation (wks) OR pseudocyst as fibrin forms around debris and fluid (percutaneous drainage)
IF DETERIORATE QUICKLY W/ NECROSIS - operate
79
Ranson Criteria
For pancreatitis - determines severity / prognosis
```
On admission ...
WBC > 16
Glucose > 200
Age > 55
AST > 250
LDH > 350
```
```
48 hrs later ...
HCT falls 10%
Calcium < 8
BUN inc > 5
Fluid requirement > 6 L
Alkalosis / PO2 < 60
```
3+ means severe
AMYLASE AND LIPASE WITH SYMPTOMS SIGNIFIES DISEASE BUT NOT SEVERITY
80
Presentation of Mesenteric Ischemia
Carotid / femoral bruits (or other atherosclerosis)
Massive wt loss b/c "food fear" - pain w/ eating b/c inc blood demand by GI (mesenteric angina)
Bowel goes from dusky --> necrotic
SURGICAL EMERGENCY IF ACUTE
81
Causes of Mesenteric Ischemia
Most common chronic cause = atherosclerosis (2/3 arteries w/ sig pathology in 3rd)
Most common acute cause = embolism (esp distal main SMA) - embolectomy and remove any ischemic bowel
** can give catheter thrombolytics if no evidence of ischemia to attempt to lyse embolism
Less common acute = low flow in critically ill or those on pressors, mesenteric venous thrombosis, external compression of celiac by diaphragm (MEDIAN ARCUATE LIGAMENT SYNDROME)
** can give dobutamine to inc flow
82
Hinchey Classification of Diverticulitis
I - pericolic abscess confined by colonic mesentery
II - local pelvic abscess from perforation of pericolic abscess
III - generalized peritonitis from free perforation of pericolic abscess or perforation of pelvic anscess
IV - fecal perionitis from free perfortation of diverticuitis
**types II, III and IV considered complicated and require immediate surgical mgt or percutaneous drainage
83
Tx of Diverticulitis by Severity
Uncomplicated - give abx/hydration/observe, if 4+ episodes or immune-compromised pt then do sigmoid resection w/ anastomosis
Abscess - percutaneous drainage (CT) then later surgery OR surgical exploration if cannot drain
If peritonitis - surgery
Fistula - resect colon and repair affect organs
84
Common Diverticulosis Fistulas
**MOST COMMON CAUSE OF GI FISTULA)
Sigmoid - bladder
Sigmoid - vagina
Sigmoid - skin
Sigmoid - other bowel portion
85
Presentation of Diverticulitis and Its Complications
LUQ pain (usually sigmoid in USA)
Complications - peritonitis, abscess formation, bowel obstruction, fistulas
86
Howship-Romberg Sign
obturator neuralgia produced by nerve compression by an obturator hernia
produced by thigh extension, adduction and medial rotation
87
Littre Hernia
Richter Hernia
Spigelian Hernia
Sliding Hernia
Littre - contain Meckel diverticulum or appendix
Richter - contains bowel wall but does not obstruct lumen
Spigelian - lateral to rectus sheath at semilunar line
Sliding - one wall of hernia is made of abdominal organ
88
Hesselbach Triangle and Other Hernia Anatomy
Triangle = epigastrics, rectus ,uscles medially and inguinal ligament
Triangle is closed anteriorly by peritoneum and transversalis fascia
Cooper ligament = pubic tubercle to femoral vessels (often suture to this ligament)
89
Hernia Complications / When to Operate
- Sudden onset of pain from known hernia --> incarceration --> strangulation (OPERATE)
- Bowel obstruction (N&V and no BM) OPERATE
IV fluid resuscitation and electrolytes b/f operating
**otherwise, can watch and wait if asymptomatic
90
Medical v Surgical Therapy for Crohns
Medical- maintenance with metro or 5-ASA, immune modulators as disease progresses (AZA, 6-MP, cyclosporine A, infliximab/ TNF-alpha blockers
Corticosteroids for flares NOT maintenance
Surgery - usually only for strictures or refractory disease or if cannot tolerate medication side effects (strictoplasty where you cut longitudinally and reconnect pieces transversely OR resection)
91
What is the major concern for surgical intervention in Crohns?
Short bowel syndrome - leading to need for permanent TPN
92
Megacolon (presentation and tx)
Present - sepsis, fever, abdominal pain
Seen in UC, Crohns and pseudomembranous colitis
Esp in cecum
Give IV resuscitation and antibiotics
Then if do not improve with meds ... colectomy
Defined by colon distention> 6 cm
93
UC Indications for Surgery
Fulminant colitis / toxic megacolon unresponsive to meds
Dysplasia/cancer - risk depends on duration and length of bowel involved
Operation options - colectomy or total proctocolectomy + ostomy or anastomoses (still cancer risk in rectum if not removed and if no ostomy then may have multiple BMs per day)
Surgery does not get rid of extra-abdominal problems like ankylosis get spondylitis or uveitis
94
Initial Assessment of Burn Victims
A- intubated if oropharynx if dry, red, blistered esp because smoke injury can cause airway edema
C- volume resuscitation because burns increase fluid losses (prostaglandins, TA2, ROS inc capillary permeability)
If <15% total body area ... oral
If >15% total body area ... IV LR 4/kg/% and give half in first 8 hrs then half in next 16 hrs
If closed space fire also check COHgb
95
Rule of Nines in Burn Injuries
Front of head and neck - 4.5% adult 9% infant
Back of head and neck - 4.5% adult and 9% infant
Front torso and back torso - ea 18%
Front or back of one arm- 4.5% ea
Front or back of one leg - 9% ea adult or 7% ea infant
96
How do you assess the adequacy of volume resuscitation in burn victims?
Measure urine output
.5 cc / kg/ hr in adults
.5-1 cc in kids
1-2 cc in infants
** average of 2-3 hours then make adjustments
97
Burn depth/ degree
First degree - epidermis - red and pain so give lotion and NSAIDs
Second degree - epidermis into dermis - pink, swelling, blisters, very painful - excuse and graft if deep
Third degree - all the way thru dermis - white or dark, leathery, painless- excise and graft
98
Temporary Wound Coverings for Burns (4)
Silver sulfadiazine - does not penetrate eschar so do not use if infected, sulfa allergy
Sulfamylon- painful with application and can cause metabolic acidosis by inhibiting carbonic anhydrase
Silver nitrate - turns area black, also does not penetrate eschar, may leach Na and Cl
Pigskin- can be used on flat, clean wounds - growth factors
99
Burn complications
Coagulation, complement, capillary leak
Delirium
Pneumonia or respiratory failure
May have myocardial depression at first requiring inotropics to maintain perfusion
Stomach and duodenal ulcers from dec splanchnic flow, a calculus cholecystitis
ATN from dec blood supply and myoglobinuria
Infection
Corneal abrasions
100
When can someone be treated outpatient for burns v need to go to burn center
Outpatient - less than 10% partial thickness or 2% full thickness or 5% in kids/ elderly
Center - kids less than 10 or adults older than 50 with >10% full thickness, any age if >20%, if involves face, hands, genitalia
101
Classification of Lower Extremity Peripheral Vascular Disease
I - no symptoms, ABI .8-1
II- claudication w exertion, ABI .41-.8 - lifestyle maybe intervene
III- pain at rest and pallor w elevation, ABI .2-.4 - bypass
IV - ulceration, ABI
102
ABI
Doppler ratio of systolic ankle pressure / systolic brachial pressure
Normal >.95
Intermittent disease .5-.95
Severe -less than .5
103
What determines outcomes of grafting for peripheral vascular occlusive disease ?
Length of stenosis, number of individual stenosis portions
Better if proximal, short, focal, non- calcified and concentric
104
Differential for Claudication
Neurogenic lumbar stenosis - esp if positional changes, use pulses and capillary refill to rule out
DM - neuropathy can also confound ischemic rest pain and delay diagnosis OR cause inc infection and tissue loss
105
What injuries are associated with blunt chest trauma and how to diagnose/ deal with each?
Pneumothorax - see in chest X-ray- chest tube or needle decompression (if does not improve may be major tracheobronchial injury)
Hemothorax - chest tube and possible exploration
Cardiac tamponade - decompression with needle or open, see pericardial fluid on FAST US
Blunt cardiac injury - inotropes and operative repair if cardiac rupture
Air emboli
Injury to great vessels - explore/ repair endovascularly
Rib fractures - manage pain - seen on chest X-ray (upper 2 ribs most associated with vessel injury)
Pulmonary contusion - from hemorrhage into parenchyma - seen on chest X-ray or CT, supportive care
Traumatic Aortic rupture - if see wide mediastinum on chest X-RAY you suspect it and do CT ANGIO OR TEE , urgent surgical repair (endovascular >>> open)
106
Diagnostic Algorithm for PE
If hemodynamically stable and leg swelling ... do duplex (US and doppler in leg) ...if pos then treat BUT if neg move on to CT angio
If hemodynamically stable but no leg swelling ... go right to CT angio ... if pos then treat
If UNSTABLE do echo ... if RV dysfunction then treat but if no dysfunction then consider other dx
107
V/Q Scan v. CT angio v. Pulmonary Angio
V/Q - must interpret results in light of clinical suspicion (AKA if high clinical suspicion then still may be PE even if scan is negative)
CT angio - 64-93% sensitive, more sensitive the more central the clot is (not as sensitive if sub-segmental artery occlusion)
Pulmonary angio - gold std (96% accurate) but time delay and high procedural complication risk
108
When to use different DVT therapies
Unfractionated heparin - risk hep induced thrombocytopenia (IgG)
LMW Heparin (subQ) - less risk HIT
TPA - only if ileofemoral DVT, R heart dysfunction and if no major surgery or closed head injury in last 10 days
IVC Filter - recurrent DVTs despite prophylaxis, contraindication to meds or complications from meds
109
Indications for Pulmonary Artery Catheter Embolectomy
Retrieve clot thru median sternotomy using cario bypass
Indications - massive PE w/ hemodynamic instability and hypoxia and thrombolytic therapy is contraindicated
Associated w/ 30-60% mortality
110
How do soft tissue sarcomas present? How do you diagnose them?
Present - firm mass, non-tender, no redness/skin changes, no inciting event, noticeable growth in wks to months
(may be tender and red if massive tumor growth leads to tumor necrosis)
Diagnosis - fine needle or core needle biopsy (NOT EXCISION)
111
Where are extremity STS's most likely to metastasize to? What about retroperitoneal STS's?
Extremity - LUNGS (do CT of lung)
Retroperitoneal - generally more likely to have local recurrence than met but if met then liver/lungs
112
Risk Factors for Sarcomas
Genetics - Neurofibromatosis (nerve sarcomas, paraganglionomas), Li-Fraumeni (p53 mutation), retinoblastoma (Rb), Gardner Syndrome (along w/ colon polyps)
Prior radiation, lymphedema, chemicals/chemo
113
STS Tx
1- wide local excision w/ > 2 cm neg margins
2- follow w /radiation in high risk pts (may also consider chemo but weight toxic risks)
114
GISTs
From interstitial cells of Cajal in GI tract
Overexpress c-KIT protooncogene (tyrosine kinase)
Asymptomatic - incidental findings in stomach and SI - may have GI bleed
Tx - complete resection followed by imatinib if high risk (may give neo-adjuvant imatinib if large tumor)
115
Work up for thyroid nodules
ONLY DONE IF NODULE > 1 CM
Does pt have hyper-thyroid symptoms?
If yes - do TSH (low TSH confirms hyperfunctioning nodule - usually benign - medical tx)
If no - do TSH and fine needle aspiration (normal/high TSH suggests hypofunctioning nodule which is way more likely to be carcinoma)
FNA results ...
- If malignant --> surgery
- If cellular (follicular or Hurthle cells) look at TSH and if high/normal --> surgery
- If non-diagnostic REPEAT FNA
- If benign f/u
116
Main Questions to Ask When Pt Has Thyroid Nodule
Hyper/hypothyroid symptoms
Compressive symptoms - dyspnea, choking, coughing, dysphagia, hoarseness
Prior neck radiation
Family hx
117
Thyroid Nodule Surgery
Near total thyroidectomy or lobectomy depending on extent
May use post-op radioactive iodine ablation
Compression of adjacent esophagus, trachea, recurrent laryngeal nerve is indication for surgery
In more aggressive medullary thyroid cancer may also do central LN dissection (internal jugular vein laterally, hyoid superiorly and suprasternal notch inferiorly)
118
MEN 2A & MEN2B
MEN2A - medullary thyroid cancer (more aggressive), pheochromocytoma, hyperparathyroidism
MEN2B - medullary thyroid cancer, pheochromocytoma, GI neuromas
119
Causes/Risks of Primary v. Secondary Pneumothorax
Primary - rupture of sub-pleural pulmonary bleb; 15-35 yo men, esp if tall and thin, esp if smoker
Secondary - acquired process, often in older pts (>50), malignancy, COPD, CF, Tb, sarcoidosis, PJP
Risk inc w/ ea recurrent pneumothorax ... 30% after 1, 50% after 2, 80 % after 3
120
Tx of Pneumothorax
Initially - chest tube / chest thoracostomy
If lung does not re-expand ... reposition or replace tube
If persistent air leak > 3 days despite tube or lung still does not re-expand ... address underlying problem (Tb, CF, etc)
Surgical indications - persistent air leak > 3 days or no re-expansion OR if lung re-expands but there us recurrence, bilateral pneumothorax, live in remote area, scuba diver/pilot
Surgery = VATS or open bleb resection and mechanical pleurodesis (cause inflammation b/n pleural layers so they stick together)
121
Tension Pneumothorax
Open Pneumothorax
Flail Chest
Tension - air can enter pleural space but not exit
Open - injury to full chest wall, air is sucked directly into chest wall rather than thru trachea - must cover hole
Flail chest - mult rib injury so chest moves in on inspiration instead - less air moves in w/ breath - worry about direct lung injury by ribs too
122
Physical Exam for Pneumothorax
Tachypnea
Agitation or somnolence b/c hypoxic
Dec breath sounds, trachea deviates away, hyper-resonant on side of air
123
When should you repair a AAA?
Recommended at 5.5 cm in male and 5.0 cm in females (related to size b/c ... Wall Tension = radius squared/ wall thickness)
Must weigh risk of rupture v risk operation (cardio, pulm, renal risks, systemic disease)
Risk of rupture is .6%/yr if less than 5 cm, 5-10%/yr at 5 cm and 10-20% . yr if 6 cm so may not operate if elderly and poor quality of life
ALWAYS REPAIR IF RUPTURED - do immediate open lap b/f imaging if suspect rupture (back pain, hypotension, pulsatile epigastric mass)
124
How do you manage asymptomatic AAA?
If less than 5/5.5 cm then do annual US
125
Operative Options for AAA
Open - inc morbidity/ mortality (most commonly cardiac - AAA associated w/ atherosclerosis in 95% cases)
EVAR (endovascular) - used if medical complications, hostile abdomen, downside if need for post-op imaging every 3-6 mo to check for endoleaks
126
Endoleaks from AAA EVAR
Type IA - around proximal aortic neck
Type Ib - retrograde from iliack artery
Type II -MOST COMMON - retrograde from IMA or lumbar artery into aneurysm sac
Type III - leak at endograft overlap sites OR from graft itself
Type IV - cont leak thru graft material w/o definitive opening
127
Where are AAA's most commonly located?
Infrarenal (90%)
128
What does a lactate measurement indicate?
Lactate = end -product of anaerobic metabolism so represents dec oxygen delivery
129
Reasons for Post-operative Shock / How to Address Ea
Hypovolemic - hemorrhage in surgery or ongoing, dehydration, bleeding due to coagulopathy (do PT, PTT)
**if bleed then use blood products not just IV
Distributive - sepsis (infection - give abx), neurogenic (damage to cervical or upper thoracic - loss of autonomic tone), anaphylaxis (epi) , meds (anesthesia can be vasodilators)
**for distributive - epi, NE, phenylephrine, vasopressin
Cardiac - cardiomyopathy (ECHO, may need dobutamine), acute coronary syndrome, OR external compression by cardiac tamponade (do pericardialcentesis), PE, tension pneumothorax (insert chest tube)
Mixed - COMBO
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How to determine if your fluid resuscitation is working in post-operative shock
Foley cath - prod light urine (may be falsely elevated in diabetic)
Central Venous Cath - measures venous return to heart
A line - meas BP constantly
Serial HgB meas
Serial ABG (look for trends in lactate levels - acidosis)
131
HgB in Operative Bleeds
Early hemoglobin meas may not reflect active hemorrhage
HgB represents a % so the person is bleeding WHOLE blood so % stays same
Dilution effect from crystalloid IV resuscitation will then make later HgB values lower
132
How much isotonic crystalloid solution remains in intravascular space at equilibrium?
1/3
AKA if person looses 1 L blood then must replace w/ 3 L crystalloid infusion
133
Hypotension in a Polytrauma Pt
BLEEDING assumed until all poss source of blood loss are ruled out
Spaces for major blood loss - external (floor), pleural space, intraperitoneal, retroperitoneal, pelvic and soft tissue
Do chest and pelvic Xray, FAST US, peritoneal lavage
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FAST US
4 views - sub-xiphoid, RUQ, LUQ and pelvis
Good at ID intraperitoneal fluid and pericardial fluid
135
Differential for Nipple D/c (9)
1- Pregnancy - reproductive age; can occur 2+ yrs after breastfeeding
2- Infection / Mastitis / Abscess - purulent w/ red nipple and duct ectasia (elastin loss) - gram stain, CBC, drain, abx
3- Pituitary Adenoma --> galactorrhea, get prolactin level and MRI
4- Meds --> galactorrhea (phenothiazines, oral contraceptives, TCAs, reserpine, metoclopramide, alpha-methylphenylalanine)
5- Hypothyroid --> galactorrhea
6- Fibrocystic change - usually yellow, brown or green, related to menstruation, nodular breast - US, mammogram, biopsy if really worried (NO INC RISK ON OWN)
7- Intraductal papilloma - unilateral, serous or bloody - US and subareolar biopsy to confirm (NO RISK ON OWN)
8- Diffuse Papillomatosis - further from nipple, not bloody- may need to excise mult ducts (INC CANCER RISK)
9- Carcinoma - bloody, serous or no d/c - nipple inversion or abnormal skin changes, mass - biopsy
**generally bilateral is physiological or endocrine and unilateral is ductal problem or carcinoma
136
Ductogram
Inject contrast dye into ducts to look for filling defects (intraductal papilloma) OR abrupt cut-off, irregular filling defects, external compression of ducts (carcinoma)
Used instead of cytology b/c high false neg and false pos
If positive ductogram finding then biopsy
137
Scoring System to Stratify Stroke Risk in Symptomatic Carotid Artery Disease
- Age > 60 = 1 pt
- BP > 140/90 = 1 pt
- Unilateral weakness = 2 pts
- Speech impairment w/o weakness = 1 pt
- TIA > 60 min = 2 pts
- TIA 10-59 min = 1 pt
- DM = 1 pit
0-3 - 1.2% risk stroke in 7 days
4-5 - 5.9% risk stroke in 7 days
5-6 - 11.7% risk stroke in 7 days
138
How to determine degree of carotid stenosis
Duplex US first (operator dep)
Confirm w/ MRI angio or CT angio to guide tx
139
Medical and Surgical Intervention for Carotid Stenosis
Meds - statin, dipyridamole (anti-aggregation), smoking cessation, BP control
Surgery if ... >70% and symptomatic
Carotid endarterectomy v. stenting (stenting preferred in high risk pts b/c less early post-op mortality)
Timing - perform 2 wks after TIA in symptomatic carotid first then repair other carotid if needed once recovered
140
5 Most Common Sites of Lung Cancer Mets
Contralateral lung / uninvolved ipsilateral lung
Liver
Adrenals
Bone
Brain
141
Small Cell Lung Cancer Presentation
Usually advanced at presentation
Classify as limited to chest, extensive or extra-thoracic
Paraneoplastic - Eaton-Lambert, hypercalcemia, Cushing, SIADH and paraneoplastic cerebellar degeneration
142
Tx Non-Small Cell and Small Cell Lung Cancer
Early stage non small cell - surgery (must have enough pulmonary function reserve - 40% FEV1/FVC post-op and no smoking 2 wks)
Later stage non small cell and small cell - chemo +/- radiation
Can resect mets in lung if primary cancer is under control, there are no other mets, pt has enough pulmonary reserve and met is in a resectable location in lung
143
Diagnostic Modalities for Lung Nodule
Look at old CXRs - if new likely cancer but if old/unchanged likely infection
CT first to get idea then decide on next modality dep on location of nodule and other factors
PET, sputum cytology, transthoracic FNA, bronchoscopic biopsy, surgical resection
144
Whipple Procedure (+ contraindications)
Resect duodenum, head of pancreas, common bile duct and sometimes distal stomach
Majority of pts are unresectable at time of dx
Contraindications - ascites, SMA involvement
145
Presentation of Pancreas Cancer
MOST COMMONLY IN HEAD OF PANCREAS
Obstructive, painless jaundice (inc direct bilirubin)
DM
Wt loss
Ab pain
Gastric outlet obstruction
146
Medical and Palliative Therapy for Pancreatic Cancer
Post-whipple chemo - gemcitabine (inc sensitivity to radiation too)
endoscopic biliary stent placement to relieve obstructive jaundice (can also do percutaneous placement if needed)
147
Hyperparathyroid Labs
High PTH
High Ca
Low phos and high Cl- (Cl:phos > 33:1) - b/c more bicarb excreted so more Cl- reabsorbed to maintain charge neutrality w/ Na
148
What is the most common complication of hyperparathyroidism? Others?
Kidney stones (Ca++)
Others - bone pain, osteoporosis, polyuria, constipation, lethary/delusions, muscle fatigue, HTN/LVH/valve calcification, etc
Main inc risk of premature death due to cardio complications
Hypercalcemic crisis (> 15) - altered mental status
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Indications for Parathyroidectomy
```
< 50 yo
Serum Ca > 11.5
24 hr urine Ca > 400 mg
Bone mineral density < 2 SD from norm
Kidney stones
OR dec creatinine clearance > 30% w/o other cause (dec kidney function)
```
ASYMPTOMATIC OR SYMPTOMATIC (b/c such high cardio complications)
150
Differential for Incidental Adrenal Mass (how to distinguish)
- Non-functioning adenoma (MAJORITY)
- pheochromocytoma (24 hr vanillylmandelic acid)
- aldosterone producing adenoma (aldo and renin labs)
- cortisol producing adenoma (Cushing signs and dexa suppression test)
- ganglioneuroma
- adrenocortical carcinoma
- mets
- Hematoma, lipoma or cyst (can distinguish on CT)
151
How is CT used to differentiate adrenal masses?
Inc risk carcinoma if ... irregular margins, non-homo density, local invasion, LARGE
Less risk carcinoma if ... Hounsfield units < 10 & early contrast washout (> 60% contrast cleared in 10-15 min)
152
Indications for Surgical Resection of Adrenal Mass
- all functioning tumors
- non-functioning > 4 cm
- Tumors < 4 cm but enlarging more than .8-1 cm in 3-12 month period (so if f/u w/ pt yr later and notice huge growth - operate)
- imaging characteristics of carcinoma
- solitary adrenal mets (LUNG MOST COMMON)
153
Pheochromocytoma Management
10% rule - bilateral, extra0adrenal, mult, malignant or familial
Present - headache, palpitations, sweating
Dx - 24 hr urine or serum free metanephrine
Localize - CT or MRI or iodine-131 metaiodobenzylguanidine scan (MOST SPECIFIC)
Pre-op - alpha blocker 1-2 wks before surgery then beta blocker (do not want sudden hypotension once remove and beta blocker dec reflex tachy but also do not want un-opposed beta block)
Worry about BP fluctuation - use A line in operating room
Follow-up meas of free metanephrine levels at 1 month and 1/yr after
154
When is FNA biopsy of adrenal mass indicated?
Only if think it is met b/c this is only time that a pos biopsy result would change management
155
Radical Orchiectomy
make inguinal incision over spermatic cord and take testicle / epididymis / cord at internal ring
do not incise scrotum itself
156
Seminoma v Non-seminoma
AFP abd beta-HCG associated w/ non-seminoma (can use level to monitor tx response)
Seminoma very responsive to radiation
157
Definition of ESRD
GFR < 15
158
Signs and tx of acute graft rejection in kidney transplant
Fever, malaise, HTN, oliguria, inc creatinine
Tenderness and swelling over implanted kidney
Usually in wks to months
Give high dose steroids
159
Post-transplant immune suppression meds
Steroids
Cyclosporine - inhibits calcineurin - nephrotoxic
Tacrolimus - calcineurin inhibitor- more nephrotoxic and insulin resistance
Sirolimus - T cell inhibitor - less nephrotoxic but thrombocytopenia
Mycophenolate mofetil
160
Timing of post-transplant infections
First month - bacterial
Later - opportunistic (CMV, PJP, aspergillosis, toxo, crypto, blasto, nocardia
161
Chronic allograft nephropathy
Fibrotic change and accelerated loss of renal function
Takes yrs
Seen as progressive inc in creatinine, protein in urine and hematuria
Confirm w biopsy and no treatment
162
Neuropathic v Vasopathic Diabetic Foot Ulcers
Neuro- pressure and weight bearing areas, sufficient oxygen so less likely to have infection with anaerobes
Vaso - at tips of digits, low oxygen so anaerobes
163
Charcot Foot
Bone and joint destruction not infection
Acutely - soft tissue swelling, erythema and warmth
Leads to remodeling
164
Presentation / Dx of Osteomyelitis in Diabetic Foot
Deep ulcer, high WBCs, pain
X-rays may not show acute changes but radionuclide scan w gallium will
Surgical drainage and debriedment
165
Presentation of Necrotizing Soft Tissue Infection
- pain beyond area of erythema
- on debridement there is separation of subQ tissue and underlying fascia b/c microvascular thrombosis --> necrosis
- systemic signs - high fever, tachy, mental confusion
- signs of end organ dysfunction due to sepsis (ARDS, AKI, liver problems)
166
General Approach to Necrotizing Soft Tissue Infection
- I&D as soon as poss
- Abx (start broad then narrow w/ results from debridement)
- supportive care for poss end organ damage
167
4 Specific Subtypes of Necrotizing Soft Tissue Infection
1- Vibrio - from water exposure - ceftazadime + quinolone/tetracycline
2- Mixed gram neg and anaerobes - progression of perirectal infection OR complication of GI surgery
3- Clostridial species - gas gangrene - swelling / crepitus - PCN
4- Related to drug abuse - Clostridial or other gram pos anaerobes - "skin popping" - inject below fascia so infection is in muscle below fascia - sepsis/exotoxins - PCN/clindamycin/vancomycin
168
What is associated w/ neonatal ab mass and polyhydramnios in utero?
neonatal bowel obstruction
169
Wilms Tumor v Neuroblastoma in Kids
Wilms - asymptomatic upper abdomen or flank mass in child 1-4 yo; may have hematuria
Neuroblastoma - most common retroperitoneal mass in kids > 1 yo (SOLID and CALCIFIED on imaging); present as symptomatic w/ failure to thrive
170
Wilms Tumor Tx
Resection followed by chemo (vincristine, dactinomycin, doxorubicin, cyclophosphamide)
May use radiation if spillage of tumor pre or peri-operatively
171
What is the most common cause of an enlarged renal mass in a neonate?
hydronephrosis
172
Roux-en-Y
Gastric Banding
Roux-en-Y: connect proximal stomach to jejunem then distal duodenum to jejunem (for bile)
Banding: adjustable band around upper stomach w/ subQ port so you can adjust lumen size by saline
173
Inidications for Bariatric Surgery
unsuccessful attempt at supervised wt loss (diet, exercise, meds)
BMI of at least 35-40 w/ co-morbidity OR at least 40 if no co-morbidities
18-60 yo
Psych stability enough for post-op changes
174
What co-morbidities of obesity are improved by surgery?
Cured of type 2 DM
improved sleep apnea
Dec HTN correlated w/ wt loss
Dec TGs and LDL
175
BMI Calculation
BMI = (# lbs x 704) / (ht in inches) ^2
BMI = # kg / (ht in meters) ^2
176
Complications of Roux-En-Y
Marginal ulcers
Anemia
Osteoporosis
Vit def
Tx - supplemental Ca, iron, Vit B12
177
Surgical Tx of ITP and Indications
Splenectomy - spleen is making anti-platelet IgG
Initially try steroids (resolves 50-75% cases) but splenectomy if ... do not respond to steroids OR need high dose steroids OR require chronic steroid therapy > 1 yr
Usually spontaneously regresses in kids
178
Overwhelming Post-splenectomy Sepsis
RARE
High mortality - so look for early signs (malaise, nausea, headache, confusion)
Usually w/in 2 yrs splenectomy
Organisms = ENCAPSULATED (strep pneumo, H flu B, N meningitidis) - vaccines
More common in kids and more common if splenectomy was for a primary heme disorder (as opposed to trauma)
179
At what platelet count is intervention for ITP needed?
Can just observe if asymptomatic and above 50,000
Treat if < 30 - 50,000
180
What group of patients are more likely to achieve remission w/ splenectomy?
Those whose ITP responded to steroids
181
Differential Diagnosis of Back Pain
Fracture
Joint subluxation
Tumors of bone, joint or meninges
abscess
Arachnoiditis
ankylosing spondylitis
RA
aortic occlusion
peripheral neuropathies
prolapsed lumbar nucleus polposus
182
Typical Presentation of Prolapsed Lumbar Disc (+most common nerves involved)
Pain down posterior or lateral leg
Inc pain by straining, bending, sitting, straight leg test or dorsiflexion
Pain better w/ lying flat
Most common = L4-L5 then L5-S1
183
Cauda Equina Syndrome
Compression of sacral nerve bundle --> bowel and bladder symptoms +/- pain and weakness in legs
Surgery ASAP to avoid permanent damage
184
Conservative v Surgical Tx Prolapsed Disc
Cons - bed rest, heat or ice, NSAIDs, muscle relaxants, PT
Surgery - ID which disc w/ MRI then laminectomy w/ removal of protruding disc; may do fusion if several discs involved
Indications for Surgery - acute disabling neuro deficit like bowel or bladder problem, intractable severe pain
185
When is neonatal jaundice considered pathologic? Mechanisms?
If persists after 2 wks old
Mechanisms - biliary obstruction, inc HgB load, iver dysfunction
186
Differential for Persistent Neonatal Jaundice and Associated Testing / Tx
IF UNCONJ...
- Hemolytic disease (Coomb's positive) - phototherapy or transfusions
- Metabolic disease
- Physiological - phototherapy (makes it soluble)
IF CONJUGATED ...
- Biliary atresia (US, HIDA, liver bx, intraoperative cholangiogram) - do surgery
- Choledocal cyst - (feel ab mass, US, HIDA) - surgery
- Biliary Hypoplasia / Alagille syndrome - (US, HIDA, liver bx, intraoperative cholangiogram, WOULD SEE OTHER ABNORMALITIES) - choleretics to inc bile production by liver
- SBS - give enteral feeding
- Blockage by thick bile (seen in CF) - US and intraoperative cholangiogram to dx and treat
- Sepsis/ infection/ TORCH (screen and blood cx) - disease specific tx
187
Surgical Mgt Biliary Atresia (including complications and timing)
PORTOENTEROSTOMY (Kasai Procedure)
1- do intraoperative cholangiogram (confirmed dx if no bile into duodenum)
2- dissect extrahepatic ducts up to the portal plate and transect
3- attach a limb of jejunem to the portal plate (now biliary ductules will drain into jejunem
Complications = most common is cholangitis (fevers, WBCs, jaundice so give abx and steroids), cessation of bile flow, portal HTN
Only 20% survive into adulthood w/o need for liver transplant
Timing - must be done by 8 wks old (12 wks max)
188
Surgical Mgt of Choledochal Cyst
1- Excise cyst
2- attach limb of jejunem to bifrucation of hepatic duct (hepatico-jejunostomy)
EXCELLENT PROGNOSIS
189
Differential for Anterior Mediastinal Mass
Thymoma - resect + chemo/radiation if stage III or IV
Lymphoma - associated w/ lymphadenopathy - open biopsy to confirm then chemo / radiation
Germ cell tumor - seminoma or non-seminoma; get AFP and bHCG labs and open biopsy - radiation for seminoma and chemo for non-seminoma
Teratoma - resect
Parathyroid adenoma - see hyperparathyroid labs, CT, sestamibi scan - resect
Lipoma, hemangion, cyst - CT or MRI - resect if symptomatic
190
Osserman MG Severity Classification
Class I - ocular (diplopia, ptosis)
Class IIA - generalized musc weakness, no resp prob
Class IIB - more bulbar than IIA
Class III - rapid onset bulbar and generalized weakness including resp weakness
Class IV - severe generalized weakness and progressive symptoms
Class V - muscle atrophy requiring ventilation
191
Thymoma Staging / Prognosis
I - completely encapsulated w/o invasion
II - macro invasion to fat or pleura or micro invasion thru capsule
III - macro invasion to adjacent structures (great vessels, lung, pericardium)
IV - extrathoracic mets
STAGING IS DONE AT TIME OF RESECTION
