Case Files Flashcards
What is the work up for possible breast cancer?
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
Surgical approach to breast cancer
Breast conservation therapy - partial mastectomy with lymph node sample and post-surgical local radiation
If large … may choose neoadjuvant chemo and then therapy
ALND v. SLNB For Breast Cancer
SLNB»_space; ALND in terms of mortality
Injection of radiotracer at primary tumor then remove node with most dye
Systemic Therapy Options for Breast Cancer (4)
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
BPH Symptom Workup
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
What are the extra-esophageal complications of GERD?
laryngitis, reactive airway disease, recurrent pneumonia, pulmonary fibrosis
Work-up for surgical anti-reflux procedure
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)
Indications for surgical anti-reflux
still symptomatic despite highest dose PPIs
Boerhaave Syndrome
Spontaneous esophageal perforation (classically after increased abdominal pressure from vomiting repeatedly)
Why is esophageal perforation a surgical emergency? What is the most common cause?
Causes pneumomediastinum
Most often iatrogenic -during endoscopic procedures
DELAY IN DIAGNOSIS INC MORBIDITY AND MORTALITY
What is the clinical progression of esophageal perforation?
Immediate chest pain
SubQ emphysema 1 hr later
Pleural effusion
Fever/ Leuks from sepsis from mediastinum inflammation
Death esp if diagnosed >24 hr later
Diagnosis and Tx Esophageal Perforation
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
4 Types of Melanoma
Superficial spreading (most common)
nodular sclerosing (aggressive early vertical growth)
Lentigo maligna
Acral lentiginous - also aggressive vertical and more common in blacks
Melanoma Management
Initial biopsy
If pos then go back and do wide local excision
Also ID sentinel nodes and extract any positive
Anti-reflux Procedure
Nissen fundoplification - wrap fundus around GE junction
TURP
Transurethral resection of prostate
Scope that chips away at prostate from within prostatic urethra
Monitor PSA levels after
SBO Presentation
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
What is your major concern in SBO?
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
Causes of SBO in kids v adults
Kids - hernia, malrotation, meconium ileus, Meckel diverticulum, intussusception, intestinal atresia
Adults - adhesions, Chron, gallstone ileus, tumor
Non-operative v Operative Tx of SBO
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
Carpal Tunnel Causes
Edema esp worse at night in tunnel - DM, myxedema, hyperthyroid, acromegaly, pregnancy
Others - lipoma in canal, autoimmune, hematoma, bone abnormalities
Women > men 3:1
Non-operative v Operative Management of Carpal Tunnel
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)
Reasons why carpal tunnel would not be relieved by surgery?
Already advance hypotrophy
Neuropathy from DM
Misdiagnosis - compression of median at medial epicondyle or compression of ulnar instead
Biliary colic
Acute cholecystitis
Chronic cholecystitis
Choledocolithiasis
Biliary pancreatitis
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
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)
Charcot Triad
Means cholangitis or inflammation of bile ducts
1 - fever
2 - jaundice
3- RUQ pain
Treatment is antibiotics and ERCP to decompress
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)
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)
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)
How can you stop the bleeding in Upper GI Bleed?
Endoscopic thermotherapy, electrocoagulation, ethanol or epi injection, sclerosing agents if esophageal varices
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
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)
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
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
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
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
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
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)
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
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
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
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
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)
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
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
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
Mesenteric adenitis
Viral illness leading to inflammation of small bowel mesentery
Can also see RLQ pain esp in kids
Self limited - no antibiotics
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
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
R v L sided colon cancer symptoms
R tend to bleed so iron deficiency anemia
L tend to cause dec stool caliber and diarrhea
When to respect polyp/ cancer instead of polypectomy?
Once it has penetrated the submucosa
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
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)
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
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
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
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
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
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
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
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)
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
HCC and Colorectal Tumor Markers
HCC - AFP and ferritin
Colon- CEA
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
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
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)
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
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
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
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
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
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)
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
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
Gastric v Duodenal Ulcers
Gastric - should biopsy to exclude malignancy
Duodenal - no risk malignancy
When should gastric/duodenal ulcers be operated on?
- persist despite 3 mo meds
- recur within 1 yr initial healing
- obstruction
- perforation
- hemorrhage
