Cases 1-15 Flashcards
Acute onset chest pain after vomiting
- also expect?
Boerhaave syndrome - spontaneous esophageal perforation
Also expect: subQ emphysema + left-sided effusion
Need vomiting so think: alcohol binge, eating bad food, etc.
Most spontaneous esophageal ruptures occur where?
Distal 1/3 of esophagus
Most esophageal perforations are due to?
Iatrogenic causes, especially endoscopy
Best initial diagnostic test to confirm esophageal rupture?
Water-soluble contrast esophagogram
(gastrografin esophagogram)
How do you mangage Boerhaave syndrome?
ABC’s - manage airway, breathing, circulation
Place left chest tube
Fluid resuscitation
Broad-spectrum antibiotics
Water-soluble contrast study of the esophagus
Pneumomediastinum w/ abdominal pain and 4 hours later, fever + leukocytosis
Spontaneous esophageal perforation (Boerhaave)
Why do you need to have a high clinical suspicion for esophageal rupture?
Duration between the event and corrective surgery determines outcome. Infection and sepsis result from diagnostic or treatment delay.
Left-sided effusion + acute chest pain…what is your next question?
Have you been vomiting? If so = spontaneous esophageal perforation
33 yo Female painless breast mass slowly enlarging x3 months
Hard, nontender 3cm mass in upper outer quadrant of left breast. Left axilla w/o abnormalities.
Next step?
Obtain tissue for diagnosis
If malignancy confirmed, proceed w/ staging
(which should include bilateral mammography)
Two options for breast cancer malignant treatment
- ) Surgery first, then adjuvant therapy
2. ) Systemic chemotherapy to first shrink the tumor, then local surgical therapy (called neoadjuvant)
Tests to order to work-up breast cancer
Core Needle biopsy (not FNA)
Bilateral mammography
CBC, Liver function, CXR
If pt desires breast conservative therapy (BCT), what treatment route?
Neoadjuvant therapy (chemo to shrink then surgery) Use MRI to determine if BCT is a good option
FNA
- describe
- limitations
Fine needle aspiration - small-gauge needle under vacuum for cytologic analysis
Can identify cancer cells but CANNOT differentiate invasive from in situ cancers
Core needle biopsy
Large-bore 10-14 gauge needle biopsy
Provided histologic diagnosis
How search for mets in breast cancer?
PET + brain MRI
positron emission tomography
Level 1 & 2 axillary node dissection ALND vs.
Sentinal lymph node biopsy SLNB
SLNB: remove nodes w/ high blue dye/radioactivity (satisfactory staging + less morbidity than ALND)
When SLN is + for mets, complete level 1&2 dissection of axilla preferred
When add systemic therapy in breast cancer?
Stage III, or IV – known metastatic diseases
- surgery followed by chemo
- chemo to shrink then surgery
Stage II recurrence with local resection alone = 30-44%
- so majority of stage II pt’s are offered chemo
When use trastuzumab?
Breast cancer tumors that overexpress HER2/neu receptors
- receptor antagonist
aka Herceptin
When use aromatase inhibitors?
Breast cancer tumors that are Estrogen-receptor positive
- get survival benefit
- low SE’s
- especially used in post-menopausal women
38yo F, painless 1cm right breast mass
No dimpling, no adenopathy
FNA reveals malignant cells
What is best next step? Why?
Core needle biopsy of mass
- determine histology of tumor
- assess receptor status
- assess tumor biology of the cancer
60yo F, breast-conserving surgery for 0.3cm tumor
Axillary LN negative
What do? Radiation? Observation? Chemotherapy? Radical mastectomy?
Radiation therapy to affected breast will reduce local recurrence rate from 30% with just local resection to 9% with surgery + radiation.
Chemotherapy may or may not be indicated in postmenopausal woman w/ early breast CA
Radical mastectomy is rarely indicated
62yo painful enlargement of right breast. Warmth, redness, and right axilla non-tender adenopathy. Next best step?
Observation - assume it’s breast cancer so don’t go down the road of antibiotics assuming it’s just inflammation.
Pt has T2N2 ER+ HER/2neu negative invasive ductal carcinoma w/ 2 mets to liver. Treatment? A. Aromatase inhibitor B. Trastuzumab C. Radiation to liver D. Liver resection
A. aromatase inhibitor - due to the ER+ tumor
Radiation - liver is highly susceptible to radiation injury
Could add systemic chemotherapy w/ Taxotere (Docetaxel)
48yo M burning epigastric & substernal pain daily x 4 mo
Worse when lies down and after meals
Early morning wheezing + hoarseness x several months
PPI for 12 weeks = partial resolution of symptoms
Diagnosis? Mechanisms?
GERD + silent aspiration + pharyngitis
Diminished LES tone/function
Impaired esophageal clearance
Excess gastric acidity
Diminished gastric emptying
Complications assoc w/ GERD?
Peptic stricture (narrowing/tightening)
Barrett esophagus
Extraesophageal complications
Hoarseness + wheezing in setting of GERD?
Atypical symptoms
- think silent aspiration + pharyngeal reflux
Suspected GERD, but lack of response to PPI. What next?
Endoscopy to rule out other pathology as PPI’s provides symptom relief in 95% of GERD pt’s.
Surgical therapy may be indicated such as Nissen fundoplication
Which better for GERD? PPI? H2 blockers?
H2 okay for mild reflux
PPI’s are far more effective for GERD
GERD…Barrett Esophagus…
…esophageal adenocarcinoma
Hiatal hernia & GERD
When LES is abnormally located in chest (as w/ hiatal hernia), the antireflux mechanism may be compromised at the gastroesophageal junction.
Mainstay treatment for GERD?
PPI - acid suppression
High dose PPI often required for severe/refractory symptoms
51yo F 6mo hx substernal chest pain + vague upper abdominal discomfort. Antacid therapy provides minimal relief. Negative upper endoscopy. Next best step?
Cardiac workup - cardiac disease would be most concerning disease so rule this out first.
24yo on PPI for long-standing GERD. What are indications for surgical intervention?
- Inability to tolerate PPI’s
- Pt’s desire to discontinue medication
- Incomplete relief of symptoms despite max dose of PPI therapy
Long-standing GERD symptoms or
GERD symptoms refractory to medical treatment
Indications for diagnostic endoscopy
What is one of the most reliable clinical indicators of GERD?
Response to PPI
What is most reliable objective indicator of GERD?
24-hour pH monitoring
Numbness in 3 fingers, pain wakes her at night
Thumb especially affected; drops objects
Median nerve compression at wrist leading to paresthesias of radial 3 fingers +/- hand weakness
Carpal Tunnel Syndrome
What is incised in carpal tunnel release surgery?
Transverse carpal ligament
How reproduce carpal tunnel pain?
Tinel sign = percuss medial nerve at wrist
Or gravity induced wrist flexion
Who is affected by carpal tunnel?
Women 3x > men
Diabetes, hyperthyroid, pregnancy, myxedema, acromegaly, autoimmune
Why carpal tunnel worse at night?
Edema
Tenosynovitis
Imaging for Carpal Tunnel?
CT and MRI are rarely needed
MR has greatest sensitivity & specificity
Radiographs to detect arthritis or fractures
Electrophysiologic studies may be helpful
Treatment for Carpal Tunnel?
Conservative: splints esp at night + NSAIDs
Local steroid injections 80-90% effective
(but symptoms return)
Intractable symptoms = surgery
Carpal tunnel surgery
Complete division of transverse carpal ligament extending distally from ulnar side of medial nerve.
Post-Op: splint wrist in slight extension for 2 weeks
30yo numbness & tingling of right thumb + index finger
Pain at night; Tinel sign +
Nighttime splint; 3 months later, symptoms worse
Electrophysiologic study results = equivocal
Best next step?
MRI of wrist.
When clinical present but EMG are equivocal, MRI can assist in diagnosis.
No imaging is routinely needed in evaluation of CTS normally
Most prevalent symptoms of GERD
Heartburn, regurgitation, dysphagia, epigastric pain
worse when lying down
How do we diagnose GERD?
Clinically; proven w/ response to PPI/H2
What are some common H2 antagonists?
Ranitidine, Cimetidine, Famotidine, Nizatidine
block the action of histamine at the histamine H2 receptors of the parietal cells in the stomach
Regurgitation vs. Vomiting
Regurg is passive
Vomit is muscle driven
FDA warnings on PPI’s
Increased C. diff
Increased osteoporosis & long bone fracture
Reduces effects of clopidogrel/plavix
(also kidney, early onset Alzheimer’s)
Treatment for GERD if meds aren’t appropriate/working?
First, prove it’s GERD: further diagnostics
Endoscopy, 24 hour esophageal pH, manometry, esophagram/upper GI; and biopsy
Then fundoplication (nissen = 360 fundus wrap)
(>90% successful)
How treat H. pylori?
PPI + amoxacillin + clarithromycin
alternatives: metro (flagyl), tetracycline, levoflox
