Casefiles 11: adrenal mass, disk herniation, PAD Flashcards
ddx of “adrenal incidentaloma”
most are?
benign functioning and nonfunctioning adrenal adenomas, adrenocortical carcinoma, and metastatic tumors
nonfunctioning adenomas, accounting for 55% to 94% of all cases.
Functioning adrenal tumors
pheochromocytoma, aldosterone-producing adenoma, and cortisol-producing adenoma
s/s of ? should be actively sought in the history and on physical examination of adrenal incidentaloma pt
excess catecholamines, aldosterone, cortisol, and androgens
history of hypertension, headaches, palpitations, profuse sweating, abdominal pain, anxiety, and prior history of malignancy
features suggestive of Cushing syndrome
The functional assessment consists of three main diseases
pheochromocytoma (metanephrine and catecholamine levels, low ACTH or DHEAS)
Conn’s syndrome
hypercortisolism (overnight 1-mg dexamethasone suppression test (DST))
What can be measured to evaluate for an aldosterone-producing adenoma (Conn syndrome) where ? is suggestive of hyperaldosteronism
Plasma aldosterone and renin activity
an aldosterone-renin ratio greater than 30
confimatory: Saline salt loading test or captopril challenge
After determining whether an adrenal mass is functioning or nonfunctioning, anatomic assessment is performed, preferably with ?
What is used for the evaluation of an adrenal mass in a patient with a known extra-adrenal cancer because of its ability to separate benign from metastatic lesions?
CT or MRI
PET scan
Imaging characteristics suggestive of adrenocortical carcinoma include ?
irregular margins, inhomogeneous density, scattered areas of decreased attenuation, local invasion
large size and enlargement over time, majority are 6 cm or greater
CT characteristics that are highly specific for adrenal adenomas are ?
Hounsfield units less than 10 during noncontrast CT and early contrast washout during a CT with intravenous contrast (defined as more than 60% contrast clearance at 10-15 minutes after contrast injection)
One/both of these CT features has extremely high negative predictive value for malignancy, and incidentalomas with these findings can be managed with observation only
Surgery is recommended for what adrenal masses?
all functioning tumors, nonfunctioning tumors 4 cm or greater, tumors that enlarge (growth of more than 0.8-1.0 cm during a 3- to 12-month period), tumors with imaging characteristics suspicious for carcinoma, or solitary adrenal metastases
The adrenal gland is a frequent site of metastasis which include ?
breast, kidney, colon, stomach, melanoma, and most commonly lung cancer
Management of patients with nonfunctioning adrenal incidentalomas smaller than 4 cm
follow-up imaging at 3 and 15 months.
A change in size greater than 1 cm may prompt adrenalectomy.
then annual H&Ps
Pheochromocytoma is a tumor that arises from the ?
“10% tumor” because ?
chromaffin cells of the adrenal medulla and secretes catecholamines.
10% are bilateral, extra-adrenal, multiple, malignant, and over 10% familial
how to localize pheos
CT or MRI
usually appears bright on a T2-weighted MRI
An iodine-131 metaiodobenzylguanidine (MIBG) scan may be obtained for confirmation or evaluation of non localized pheo
PET scan if others fail
other screening if dx pheo
CXR for mets (most common site)
EKG and ECHO: chronic catecholamine excess may cause cardiomyopathy
what should be given 1 to 2 weeks before surgery to remove pheo?
α-adrenergic–blocking agent: allows for relaxation of the constricted vascular tree and correction of the reduced plasma volume which prevents hypotension that often occurs following tumor removal
-β-adrenergic–blocking agent may be added to oppose the reflex tachycardia associated with α-blockade, but never start first due to potential precipitation of a HTN crisis related to unopposed α-receptor stimulation.
the preferred α-adrenergic antagonist is ?
phenoxybenzamine
also, α-Methyl-p-tyrosine, which is often used in combination with phenoxybenzamine, competitively inhibits tyrosine hydroxylase, the rate-limiting enzyme in catecholamine synthesis
Intraoperative medical management of pheos is critical because of the danger of ?
large fluctuations in blood pressure, heart rate, and fluids
monitor BP with art line, monitor volume with CVC and foley, IV nitroprusside for HTN control, esmolol for tachycardia
Acute hypotension may occur following excision of a pheochromocytoma related to sudden diffuse vasodilatation, so tx with ?
fluid administration, if that fails continuous IV norepinephrine
motor weaknesses associated with the affected nerve roots can also be detected with herniated disks (L4: ?; L5: ?)
anterior tibialis
extensor hallicus longus
Disc herniation at what level is most common?
L5-S1 level with S1 nerve root compression is most common (40%-50%)
then L4-L5 level herniation with L5 nerve root compression occurs in 40%
L3-L4 disc herniation with L4 nerve root compression occurs in 3% to 10%
cauda equina syndrome
Compression of the sacral nerve bundle, which forms the end of the spinal cord. Common symptoms: bladder and bowel dysfunctions, pain and/or weakness in the legs. Important to pick it up early to avoid nerve entrapment that ends up producing long-term dysfunctions
back pain red-flag symptoms
older than 50, presence of systemic symptoms such as fever, night sweats, weight loss, hx of malignancy, night pain, immune suppressed status, hx of IV drug use, failure to respond to initial treatments, prolonged corticosteroid use, diagnosis of osteoporosis, and trauma
L2 nerve root:
muscle group?
sensory dermatome?
DTR?
hip flexor
anterior medial thigh
no DTR
L3 nerve root:
muscle group?
sensory dermatome?
DTR?
quads
anterior thigh to knee
knee jerk
L4 nerve root:
muscle group?
sensory dermatome?
DTR?
anterior tibialis
medial calf and ankle
knee jerk
L5 nerve root:
muscle group?
sensory dermatome?
DTR?
extensor hallicus longus
lateral ankle to dorsum of foot
no DTR
S1 nerve root:
muscle group?
sensory dermatome?
DTR?
gastrocnemius/soleus/paroneals
plantar and lateral foot
ankle jerk
lumbar spondylosis presentation
Generalized back pain that is worse immediately after waking up; improves throughout the day; pain fluctuates with activity and is worse with extension of the spine
Spinal stenosis/neurogenic claudication presentation
Back pain with radiculopathy worsened by extension /standing; improvement with flexion, sitting
spondylolisthesis presentation
Back pain with radiation down one or both legs, exacerbated by flexion/extension
ankylosing spondylitis
More common in young males; morning stiffness, low back pain radiating to buttock that improves with exercise
conus medullaris syndrome
Same as caudal equina (Urinary retention or fecal incontinence; decreased rectal tone; saddle anesthesia) but also with UMN signs (eg, hyperreflexia, clonus)
Imaging studies should be considered in patients with “red flag” symptoms and in patients whose symptoms persist for greater than ? of conservative management. The role of imaging in these patients is to rule out ?
4 to 6 weeks
fracture, tumor, or infections
Common recommended interventions for back pain
a more effective but risky combo?
ctivity modification, rest, NSAIDs, PT
combination of oral analgesics, antidepressants, and opioids
the indications for surgical treatment for back pain include ?
identifiable anatomic nerve compression, neurologic deficits, and/or intractable pain
Surgical treatment for herniated discs involves ?
If several levels of disc spaces are involved, ? is indicated
laminectomy and removal of the protruding disc(s)
posterior spinal fusion in addition to the disc extraction
bilateral calf claudication, the locations of the arterial occlusions are most likely in the ?
superficial femoral arteries (SFAs)
One of the important initial considerations in the management of a patient with peripheral arterial disease (PAD) is to determine whether the disease falls into the category of ? or ?
intermittent claudication (IC) or critical limb ischemia (CLI)
The diagnosis of CLI is characterized by ?
ischemic rest pain lasting greater than 2 weeks in duration, and with the patient often becoming dependent on opiate analgesia for relief
ankle-brachial index (ABI) of less than 0.40
toe pressure of less than 30 mm Hg
After establishing the diagnosis of IC, the initial management should include ?
life style modifications (smoking cessation, dietary modifications, and weight loss) and pharmacological treatment to reduce his cardiovascular disease risk
risk of limb-loss for patients with IC is ?
the combined risk of mortality from cardiovascular and cerebral vascular events are ?
generally quite low (less than 5% over 5 years)
high (42% and 65% at 5 and 10 years, respectively)
Fontaine classification for PVD
I Asymptomatic
IIa Mild claudication (symptoms onset >200 m)
IIb Moderate-severe claudication (symptoms onset <200 m)
III Ischemic rest pain
IV Tissue loss or ulceration
Rutherford classification of PVD
0 I Asymptomatic
1 IIa Mild claudication*
2 IIb Moderate claudication*
3 IIb Severe claudication*
4 III Rest pain
5 IV Ischemic ulceration not exceeding the digits of the foot
6 IV Severe ischemic ulcers or frank gangrene
Statin therapy targeting the reduction of LDL levels to ?in average-risk individuals and to ? in high-risk patients with multiple other CV co-morbidities
less than 100 mg/dL
less than 70 mg/dL
What have been shown to reduce the risk of MI and strokes in patients with PAD?
Beta-blockers and ACE inhibitors
ABI values
ABI greater than 0.9 is normal; ABI less than 0.9 signifies PAD, and ABI less than 0.4 is usually associated with rest pain or tissue loss (CLI)
Anatomic assessment of patients with PAD should be reserved only for ?
imaging includes ?
individuals for whom invasive interventions are being considered
color flow duplex scan, spiral CT, MRI, and arteriography (gold standard)
patients with occlusive disease where? may complain of pain in the upper thighs and buttock regions with walking
impotence may result from occlusive disease where?
aorto-iliac
in the internal iliac arteries
Leriche syndrome
combination of buttock and thigh claudication, impotence, and diminished femoral pulses
patients with CLI often have rest pain located predominately ? and is improved or relieved with ?
other characteristics?
in the foot and toes
dependent positioning of the extremity and will have dependent rub or and elevation pallor
chronic ischemic changes of the feet and lower legs including atrophic and shiny skin and loss of leg hairs
Arterial occlusive disease can often be divided as ?
inflow disease (above the inguinal ligament) or outflow disease (below the inguinal ligament) operative and percutaneous interventions are much more successful and durable for inflow diseases
neurogenic vs vasculogenic claudication
neurogenic claudication tends to occur inconsistently with positional changes; whereas, claudication from PAD is related to insufficient blood flow to the major lower extremity muscles during exertion.
vasculogenic: a function of work load and blood supply, the symptoms are reproducible with the same amount of work load each and every time + changes in skin temperature, capillary refill, and peripheral pulses
interventions for occlusive diseases in the ? are associated with greater long-term patency than procedures performed in ?
aorta and iliac arteries
smaller vessels at the below-the-knee level
classification of aorto-iliac, femoral/popliteal occlusive disease
TASC
based on location and characteristics
helpful to determine whether open surgical approaches or endovascular approaches are best
Type A lesions (“simple lesions”) in the aorta, iliac, and femoral-popliteal have good results with ?
endovascular treatment techniques (angioplasty and stenting)
Type B lesions have good results using the ?
endovascular approaches, unless open revascularization is needed for another lesion in the same anatomic region
Type C lesions have better long-term results with ?
open revascularization techniques so endovascular approaches should be used only if the patient is at high risk for open surgery
Type D lesions have poor results with ?
endovascular treatment, therefore open surgery is the primary treatment
