Chapter 4: General Surgery Flashcards
1
Q
How do you diagnose GERD when it’s ambiguous?
A
pH monitoring
2
Q
When do you do surgery for GERD?
A
if complications have developed:
- ulceration
- stenosis
3
Q
What’s the usual procedure that’s done for GERD?
A
Nissen fundoplication
4
Q
Clinical pattern of motility problems?
A
crushing pain with swallowing in uncoordinated massive contraction
5
Q
Pattern of dysphagia in achalasia?
A
solids are swallowed w less difficulty than liquids
6
Q
How do you diagnose achalasia?
A
- barium swallow
2. manometry (diagnostic)
7
Q
Most common treatment for achalasia?
A
balloon dilation by endoscopy
8
Q
Presentation of cancer of esophagus?
A
- dysphagia starting with meat–> then other solids –> soft foods –> liquids–> saliva
- significant weight loss
9
Q
Types of esophageal cancer?
A
- squamous cell carcinoma: seen in male smokers and drinkers
- adenocarcinoma: long-acting GERD
10
Q
What should you do before endoscopy in diagnosing esophageal cancer to avoid inadvertent perforation?
A
barium swallow
11
Q
How can you assess operability in esophageal cancer?
A
CT scan
12
Q
Typical management for esophageal cancer?
A
palliative, most cases aren’t good for surgery
13
Q
Diagnosis and treatment of mallory-weiss tear?
A
endoscopy and photocoagulation respectively
14
Q
Sx of Boerhaave Syndrome
A
- prolonged, forceful vomiting
- continuous, severe epigastric pain + low sternal pain of sudden onset
- fever
- leukocytosis
15
Q
Dx of Boerhaave Syndrome?
A
Contrast swallow:
- Gastrografin
- Barium
16
Q
Tx of Boerhaave Syndrome?
A
surgical repair
17
Q
Sx of gastric adenocarcinoma?
A
anorexia weight loss vague epigastric distress early satiety occasional hematemesis
18
Q
Gastric adenocarcinoma diagnosis and treatment?
A
Dx: endoscopy and biopsies, CT to assess operability
Tx: surgery
19
Q
Sx and diagnosis Gastric lymphoma?
A
similar to gastric adenocarcinoma
20
Q
Gastric lymphoma tx?
A
surgery if you fear perforation as the tumor melts away
low-grade MALTOMAs can be reversed by eradicating H. pylori
21
Q
initial treatment of mechanical small bowel obstruction?
A
NPO
NG suction
IV fluids
22
Q
How long do you wait for resolution of complete sbos?
A
24 hs
23
Q
how long do you wait before surgically treating a partial sob?
A
a few days
24
Q
Difference bw bowel obstruction and strangulated obstruction?
A
strangulated= sbo sx + fever, leukocytosis, constant pain, signs of peritoneal irritation, and full-blown peritonitis and sepsis
25
Treatment for strangulated obstruction?
emergency surgery
26
Incarcerated hernia vs strangulated obstruction?
incarcerated hernia= irreducible hernia that used to be reducible
27
Carcinoid syndrome:
=small bowel carcinoid tumor with liver metastases
2. diarrhea
3. flushing of the face
4. wheezing
5. right-sided heart valve damage (look for prominent JVP)
28
What will be prominent in 24h urine collection of people with carcinoid syndrome?
5-hydroxyindoleacetic acid
29
Sx of anorexia?
1. vague periumbilical pain
2. sharp, severe, constant pain localized to the right lower quadrant of the abdomen
3. tenderness, guarding, rebound in the right lower quadrant of the abdomen (not elsewhere in the belly)
4. modest fever
5. leukocytosis: 10,000-15,000 range
6. neutrophilia and immature forms
30
What do you use to diagnose acute appendicitis when you're not 100% certain of the diagnosis?
CT scan
31
Cancer of the Right Colon Sx:
1. anemia (hypochromic, Fe defic) in elderly
2. 4+ stools for occult blood
3. Dx: colonoscopies and biopsies
32
Tx for right colon cancer?
right hemicolectomy
33
Cancer of the left colon Sx:
1. bloody bm (blood coats outside of stool)
| 2. constipation + stools of narrow caliber
34
Dx of left colon cancer?
1. flexible proctosigmoidoscopic exam (45-60 cm)
| 2. biopsies
35
What must you do before surgery of left colon cancer?
full colonoscopy to r/o synchronous second primary
36
Tx of left colon cancer?
1. surgery
| 2. pre-op chemotherapy + radiation for large rectal cancers
37
Colonic Polyps: descending order of probability of malignant degeneration
1. familial polyposis (and variants such as Gardners)
2. familial multiple inflammatory polyps
3. villous adenoma
4. adenomatous polyp
38
Non-malignant colonic polyps:
1. Juvenile
2. Peutz-Jeghers
3. isolated inflammatory
4. hyperplastic
39
Chronic ulcerative colitis (CUC) Tx:
medically managed
40
Chronic ulcerative colitis indications for surgery?
1. disease present for longer than 20 years (high incidence of malignant degeneration)
2. severe interference w nutritional status
3. multiple hospitalizations
4. need for high-dose steroids or immunosuppressants
5. development of toxic megacolon (abdominal pain, fever, leukocytosis, epigastric tenderness, massively distended transverse colon on x-ray w gas wi wall of colon)
41
Definitive surgical treatment of chronic ulcerative colitis?
remove affected colon + all of the rectal mucosa (always involved)
42
Current most common abx that causes pseudomembranous enterocolitis?
cephalosporins
43
How to dx C-diff?
identify toxin in the stool
| stool cultures too long, pseudomembrane not always seen on endoscopy
44
C-diff Tx of choice:
metronidazole
| vancomycin (alternate)
45
What presentation in C diff requires emergency colectomy?
form that's unresponsive to treatment
wbc >50,000
lactate >5
46
How to r/o cancer in all anorectal diseases?
proper physical exam (including proctosigmoidoscopic exam)
47
Internal hemorrhoids:
typically bleed when they're internal
treat w rubber-band ligation
can become painful or itchy if they prolapse
48
External hemorrhoids;
typically hurt
| surgery if conservative treatment fails
49
Who usually gets anal fissure? Sx?
young women
exquisite pain w defecation
blood streaks the stools
(may need to do physical exam under anesthesia to see fissure)
50
Typical location of anal fissure?
posterior midline
51
Cause of anal fissure? Tx?
```
tight sphincter
Tx:
1. stool softener
2. topical nitroglycerin
3. local injection of bolulinum toxin
4. forceful dilation
5. lateral internal sphincterotomy
6. calcium channel blocker (diltiazem ointment 2% TID) for 6 weeks: 80-90% success rate
```
52
Sign of Crohn's disease?
fissure, fistula, or small ulceration that fails to heal and gets worse after surgical intervention *this area typically heals really well bc of excellent blood supply)
53
Should you do surgery on Crohn disease of anus?
NO!
| if fisula is present: drain w setons while medical therapy is underway + remicade helps healing
54
Ischiorectal abscess sx:
1. febrile
2. exquisite perirectal pain that can't sit down or have a bm
3. classic findings of abscess: rumor, dolor, cal or, tumor (lateral to the anus bw the rectum and ischial tuberosity)
55
Tx of ischiorectal abscess?
Incision and Drain
make sure to do physical exam for cancer first!
In diabetics, watch for horrible necrotizing soft tissue infection
56
Fistula-in-ano
seen in some its who have had an ischiorectal abscess drained
- epithelial migration from the anal crypts (where abscess originated)
- epithelial migration from the perineal skin (where the drainage was done) form permanent tract
57
Fistula-in-ano presentation:
1. pts complain of fecal soiling + occasional perineal discomfort
2. Physical exam: opening lateral to the anus w cordlike tract and discharge that is expressed
58
Tx of fistula-in-ano?
r/o necrotic and draining tumor
| treat with fistulotomy
59
Who gets squamous cell carcinoma of the anus?
HIV+ individuals
| homoseuals w receptive sexual practices
60
Squamous cell carcinoma of the anus presentation + Dx?
fungating mass that grows out of the anus
metastatic inguinal lymph nodes felt
Dx with biopsy
61
Tx for squamous cell carcinoma of the anus?
Nigro chemoradiation protocol (5 weeks protocol has 90% success rate) + surgery (if residual tumor is there)
62
What proportion of GI bleeding originates from the upper GI tract?
3/4 cases
| upper gi= from tip of nose to the ligament of Treitz
63
Where does the remaining 1/4 of cases of GI bleeding come from?
colon or rectum
| very few originate from the jejunum and ileum
64
Etiology of GI bleeding that originates from the colon?
1. angiodysplasia
2. polyps
3. diverticulosis
4. cancer
* *all are diseases of old people**
65
Young person w GI bleeding, where is it coming from?
most likely the upper GI
66
Old person w GI bleeding, where is it coming from?
anywhere ("equal opportunity")
67
Vomiting blood: where is it coming from?
```
upper GI (tip of nose to ligament of treitz)
-same is true when blood is recovered by NG tube in pt who shows up w bleeding from rectum
```
68
Red blood per rectum work-up:
* *could come from anywhere in the GI tract (even upper GI bc could have transited too fast to be digested) **
1. pass an NG tube and aspirate gastric contents
- -> if blood--> means it's an upper source
- -> if non-bilious--> can exclude territory from tip of nose to pylorus (duodenum could still be a source) --> do upper GI endoscopy --> if no blood and fluid is green (bile tinged), then entire upper GI has been excluded
69
Active bleeding per rectum when upper GI is excluded?
1. Anoscopy first: to exclude bleeding hemorrhoids
* *** colonoscopy NOT helpful in active bleeding (incoming blood obscures the field)
- -Two directions to go after r/o hemorrhoids--
* *One**
a. look at rate of bleeding: if >2ml/min (1 unit of blood every 4 hrs) --> do angiogram which can find source and allow for hagiographic embolization
b. if bleeding is wait until bleeding stops and then do colonoscopy
c. for in-between cases--> do a tagged red-cell study (really slow study though)-> see if blood puddles somewhere--> can possibly do an angiogram then or if the tagged red cells don't show up can plan a colonoscopy
d. if bleeding is not found to be in the colon--> do capsule endoscopy to localize the spot in the small bowel
70
Blood per rectum in a child:
Meckel diverticulum
| 1. do technetium scan first to look for ectopic gastric mucosa
71
Massive upper GI bleeding in stressed or polytrauma or complicated post-op pt? Dx? Tx? Px?
probably stress ulcers
- Dx: use endoscopy to confirm
- Tx: angiographic embolization
- Px: maintain gastric pH above 4
72
Acute abdomen: Perforation
1. sudden onset
2. constant, generalized, severe
3. reluctant to move, very protective of abdomen
4. signs of peritoneal irritation (tenderness, guarding, rebound)
5. Dx: free air under the diaphragm in upright x-ray is confirmatory
73
Most common cause of perforation?
peptic ulcer perforation
74
Acute abdomen: obstruction
1. sudden colicky pain
2. pt moves constantly looking for a comfortable position
3. few physical exam findings of peritoneal irritation limited to affected areas
75
Acute abdomen: inflammatory process
1. gradual onset and slow buildup ( couple of hours at least- more commonly 6-10-12 hrs)
2. constant, ill-defined (at first) --> eventually locates to area where problem is
3. physical findings of peritoneal irritation in affected area
4. systemic signs : fever and leukocytosis (except in pancreatitis)
76
Ischemic bowel:
severe pain + blood in the lumen of gut
77
Primary peritionitis:
Child: has nephrosis or ascitis
Adult: w ascitis who has "mild" generalized acute abdomen + equivocal physical exam findings + fever + leukocytosis
Culutre of ascitis fluid: yields a single organism
78
Treatment for primary peritonitis?
antibiotics, not surgery
79
Tx for generalized acute abdomen?
1. Ex lap: no need to have a specific diagnosis
2. If doesn't look like primary peritonitis only need to r/o those things that mimic acute abdomen or things that don't require surgery:
a. MI (EKG)
b. lower lobe pneumonia (chest x-ray)
c. pulmonary embolism (immobilized pt)
d. pancreatitis (amylase)
e. urinary stones (CT scan of abdomen)
80
Acute pancreatitis presentation:
```
alcoholic w "upper' acute abdomen
1. constant, epigastric pain
2. radiates straight through to back
3. nausea + vomiting + retching
Physical exam:
1. modest findings in upper abdomen
2. Dx: serum or urinary amylase or lipase (12-48h for serum, urinary from 3-6th day)
OR if diagnosis is not clear, do CT
```
81
Tx for acute pancreatitis:
1. NPO
2. NG suction
3. IV fluids
82
Ureteral stones:
1. sudden onset colicky flank pain
2. radiates to inner thigh and scrotum (or labia)
3. urinary urgency and frequency
4. microhematuria in UA
5. CT is best diagnostic test
83
Acute diverticulitis:
1.acute abdominal pain in left lower quadrant (the fallopians and ovaries are other potential sources in women)
2. middle-aged or beyond pt
3. fever
4. leukocytosis
5. peritoneal irritation in the LLQ on physical exam
6. palpable tender mass sometimes in LLQ
Dx: CT scan
84
Acute diverticulitis Tx:
1. NPO
2. IV fluids
3. Abx
4. emergency surgery in ones that don't resolve with the above
- - radiologically guided percutaneous drainage of abscess precedes resection
5. elective surgery if had at least two or more attacks
85
Volvulus of the sigmoid:
1. in old people
2. signs of obstruction + severe and distention
Dx: x-rays ( air-fluid levels, very distended colon, huge air-filled loop in right upper quadrant that tapers down toward the LLQ with shape of "parrot's beac"
86
Tx of volvulus of sigmoid?
proctosigmoidoscopic exam w old rigid instrument resolves problem
- leave rectal tube in
- elective sigmoid resection for recurrent cases
87
Mesenteric ischemia?
1. most common in elderly + a fib pt + recent MI (latter two are source of clot that breaks off & lodges in SMA)
2. in very old, presentation is more subtle and often diagnosis is made late when there's blood in the bowel lumen and acidosis and sepsis have already developed
3. arteriogram and embolectomy can save the day in early cases
88
What is primary hepatoma?
HCC
89
HCC presentation:
1. vague RUQ discomfort
2. weight loss
3. Dx: alpha-fetoprotein is the specific serum marker
4. Dx: CT scan shows location and extent
5. Tx: resection if possible
90
Metastatic cancer of the liver:
outnumbers primary cancer of liver in US 20:1
1. suspect when see a rise in carcinoembryonic antigen (CA) in those who had colon cancer
2. Tx: if primary is slow-growing and mets are confined to one lobe--> resection is done OR radio ablation
91
Hepatic Adenoma:
1. can arise as OCPs complication
2. tend to rupture and bleed massively in abdomen
3 . Dx: CT
4. Tx: emergency surgery
92
Pyogenic liver abscess:
most often biliary tract disease complication (esp. acute ascending cholangitis)
1. Presentation: fever, leukocytosis, tender liver
2. Dx: US or CT
3. percutaneous drainage required
93
Amebic abscess of liver
1. most commonin me with a "mexico connection)
2. presents and diagnosed similarly to pyogenic liver abscess
3. Tx: empiric metronidazole; seldom requires drainage
4. Dx: serology (ameba doesn't grow in pus)...takes two weeks for test to be reported though
5. if pt doesn't improve w metronidazole drainage is done
94
Hemolytic anemia:
1. low bilirubin: 6-8
| 2. all is unconjugated (indirect), no elevation of the direct, conjugated
95
Hepatocellular jaundice
1. high direct AND indirect bilirubin
2. very high transaminases
3. modestly elevated alk phos
HEPATITIS is most common cause
96
Obstructive Jaundice:
1. high direct AND indirect bilirubin
2. modestly high transaminases
3. very high alk phos
Dx: US to look for dilation of biliary ducts; can't usually see stone obstructing the CBD which can't dilate bc of chronic irritation, can see stone in the gallbladder
97
Malignant obstructive jaundice:
**Courvoisier-Terrier sign** :large, thin-walled, distended gall-bladder
98
Obstructive jaundice caused by stones:
1. obese, fecund woman in forties
2. high alkaline phosphatase
3. dilated ducts on sonogram
4. non-dilated gallbladder
99
Tx for obstructive jaundice caused by stones:
1. ERCP to confirm diagnosis + sphincterotomy (remove the common duct stone)
2. then follow with cholecystectomy
100
Obstructive jaundice caused by tumor etiology:
1. maybe adenocarcinoma of the head of the pancreas
2. adenocarcinoma of the Ampulla of Vaster
3. Cholangiocarcinoma of the CBD itself
101
Obstructive jaundice due to tumor presentation:
1. dilated gallbladder on sonogram first sign
2. then do CT scan (can usually see pancreatic cancers)
- --if negative--> do ERCP (can show ampullary cancers or cancers of the bile duct that are too small for CT
3. percutaneous biopsy next
102
Ampullary cancers:
suspect when you have:
malignant obstructive jaundice + anemia + positive blood in stool
- 40% cure
Dx: endoscopy is first test bc of its location
103
Pancreatic cancer:
seldom cured even when huge Whipple (pancreatoduodenectomy is done)
104
Most common populations to get gallstone problems?
mexican americans and native americans
105
What do you do about Asx gallstones?
leave them alone
106
biliary colic Sx:
1. colicky pain in RUQ
2. radiates to right shoulder
3. band like
4. nausea + vomiting
6. following fatty meal ingestion
7. NO signs of peritoneal irritation
8. NO systemic signs of inflammation
9. self-limited episode: lasts 10-20-30 mins
107
Easy way to stop biliary colic sx?
anticholinergic
108
Management of biliary colic?
if gallstones seen on sonogram-> elective cholecystectomy
109
Acute cholecystitis sx:
1. biliary colic + stones stay in the cystic duct
2. get inflammatory process: fever + leukocytosis
3. peritoneal irritation in RUQ
4. LFTs minimally affected
5. Diagnostic test: sonogram
110
Signs of acute cholecystitis on sonogram:
1. gallstones
2. thickened gallbladder
3. pericholecystic fluid
111
Test for cholecystitis?
radionuclide HIDA scan:
| would show uptake in the liver, common duct, duodenum, but NOT the gallbladder
112
Management of cholecystitis?
To "cool down" gallbladder:
1. NPO
2. NG
3. abx
4. IV fluids
then--> cholecystectomy
113
What if patients don't respond to gallbladder "cool down"
emergency cholecystectomy
114
What if you can't do cholecystectomy due to surgical risk?
emergency percutaneous transhepatic cholecystostomy
115
Acute ascending cholangitis? what is it? who gets it?
1. stones reached the common duct producing partial obstruction and ascending infection
2. typically older pts
116
Cholangitis Sx:
1. Temp spike to 104-105 F
2. chills
3. very high WBC--> means there's sepsis
4. some hyperbilirubinemia
5. Key finding: high levels of alk phos!
117
Cholangitis Tx:
1. IV fluids
2. Emergency decompression of CBD via:
a. ERCP
b. percutaneous transhepatic cholangiogram (PTC)
c. surgery (rarely)
3. eventually cholecystectomy
118
Obstructive jaundice w/o ascending cholangitis? cause?
complete rather than partial biliary stone obstruction
119
Biliary pancreatitis? Cause?
1. stones impacted distally in the ampulla
| 2. temporarily obstructs pancreatic + biliary duct
120
Biliary pancreatitis Sx? Dx?
1. stones often pass spontaneously so get:
2. brief, mild cholangitis
3. elevated amylase or lipase (classic pancreatitis)
4. Dx: sonogram shows gallstones
121
Biliary pancreatitis Tx?
1. NPO
2. NG suction
3. IV fluids
...improvement in sx...
4. Then cholecystectomy later
5. if no improvement--> ERCP and sphincterotomy needed to dislodge stone
122
Acute pancreatitis types?
1. edematous
2. hemorrhagic
3. supprative
123
Acute edematous pancreatitis sx;
1. epigastric and miabdominal pain after heavy meal or bout of alcoholic intake
2. constant
3. radiates straight through to the back
4. nausea + vomiting + retching
5. tenderness and mild rebound in the upper abdomen
5. high serum or urinary amylase/lipase
6. * elevated hematocrit identifies edematous nature
124
Acute hemorrhagic pancreatitis:
1. starts like edematous pancreatitis
2. But also have low hematocrit (degree of amylase elevation doesn't correlate with severity of disease)
3. elevated WBC
4. elevated blood glucose
5. low serum calcium
Day 2
1. hematocrit even lower
2. serum calcium stays low
3. BUN goes up
4. metabolic acidosis
5. low PaO2
125
Tx of acute pancreatitis:
```
intensive supportive therapy
IV imipenem (or meropenem in those wo seizure disorder) in its with signs of infected pancreatitis
```
126
Common final pathway for death from acute pancreatitis?
multiple pancreatic abscesses
| -anticipate and drain them early
127
What imaging study should you get daily in acute pancreatitis?
CT scan to look for abscesses
128
What is necrosectomy?
1. removal of necrotic pancreas
2. usually best to wait as long as possible for necrotic tissue to delineate well (usually wait at least 4 weeks before deriding dead pancreatic tissue)
129
How long does it take for pancreatic pseudocyst to develop?
5 weeks
| sx: early satiety, vague discomfort, deep palpable mass
130
Tx of pancreatic pseudocyst?
```
cysts t likely to have complications and will probably resolve spontaneously
3 ways to drain a pseudocyst:
1. drainage percutaneously
2. drainage surgically into GI
3. drainage endoscopically into stomach
```
131
Sx of chronic pancreatitis?
1. steatorrhea (can give pancreatic enzymes)
2. diabetes (can give insulin)
3. constant epigastric pain (not responsive to most modalities of therapy)
132
Tx of chronic pancreatis?
if ERCP shows specific its of obstruction and dilation, can do operations to drain the pancreatic duct
133
Management of hernias?
all should be electively repaired to avoid risk of obstruction and strangulation eXCEPT:
1. pts younger than 2-5 years old (these typically close on their own)
2. esophageal sliding hiatal hernia (not a "true" hernia)
134
What must you rule out in all breast disease?
cancer! even if presentation suggests benign disease
135
How do you rule out cancer of breast definitively?
tissue biopsy analyzed by pathologist
136
What's the best correlate for the odds of breast cancer?
age:
- unknown in teens
- rare in young women
- quite possible in middle aged women
- very likely in elderly
137
Can mammography diagnose breast cancer?
NO
| it's an adjunct to physical exam (can catch masses that are missed by palpation and vice versa)
138
At what age should mammograms be started?
Age 40 (earlier if there's a family history)
- not done before age 20 (breasts too dense)
- not done during lactation (all you see is milk)
- CAN do them during pregnancy
139
Fibroadenomas? age?
1. young women: late teens, early 20s
2. firm, rubbery moves easily with palpation
3. do FNA or sonogram to establish diagnosis
140
Giant juvenile fibroadenomas? age? Tx?
1. seen in very young adolescents
2. associated with very rapid growth
Tx: remove to avoid deformity and distortion of breast
141
Cystosarcoma phyllodes? age? Dx? Tx?
1. late 20s
2. very large, replace and distort entire breast but don't invade or become fixed
3. most are benign w malignant potential
Dx: core or incisional biopsy necessary (FNA INSUFFICIENT)
Tx: mandatory removal
142
Mammary dysplasia
1. 30-40s
2. bilateral tenderness related to menstrual cycle (worse in last 2 weeks)
3. multiple lumps that come and go (cysts) that also follow the menstrual cycle
4. Dx: If no dominant or persistent mass, only need mammogram
Dx: If there's a persistent mass, do aspiration (NOT FNA, something with a bigger needle and drying) --> if clear fluid + mass goes away --> no further action
--if mass persists after aspiration--> formal biopsy needed
--if bloody fluid--> send fluid off to cytology
143
Intraductal papilloma age? Dx?
1. young women 20-40s w bloody nipple discharge
2. Dx: mammogram to identify other potential lesions, won't show papilloma though bc they're too small
* galactogram is diagnostic and guides surgical resection*
144
Breast abscess: population? Tx?
1. only seen in lactating women (if in non-lacatating woman, then it's cancer until proven otherwise)
2. I&D
3. biopsy of abscess wall needed, too
145
Breast cancer indicators?
1. age
2. ill-defined fixed mass
3. retraction of overlying skin
4. "orange peel" skin
5. recent retraction of nipple
6. eczematoid lesions of the areola
7. reddish orange-peel skin over the mass (inflammatory cancer)
8. palpable axillary nodes
146
Does a history of trauma rule out breast cancer?
NO
147
Breast cancer during pregnancy? Dx? Tx?
Dx: exact same as if not pregnant
Tx: same treatment but NO radiation and NO chemo during FIRST trimester, NO need to terminate pregnancy
148
Tx of resectable breast cancer?
1. lumpectomy + axillary sampling + post-op radiation (only for small lumps not near nipple or areola) OR modified radical mastectomy with axillary sampling
149
Infiltrating ductal carcinoma:
1. standard form of breast cancer
150
Breast cancer with the worst prognosis and need for pre-op chemo?
inflammatory infiltrating ductal cancer
151
other variants of infiltrating ductal carcinoma?
1. lobular
2. medullary
3. mucinous
152
Variant of infiltrating ductal breast carcinoma that has a high incidence of bilaterally?
lobular
153
Which breast cancer can't metastasize?
ductal carcinoma in situ (thus don't need axillary sampling)
154
Ductal carcinoma in situ prognosis?
1. doesn't metastasize
2. high incidence of recurrence if only local excision is done though
3. total simple mastectomy is recommended if multi centric lesion throughout breast
4. lumpectomy + radiation if lesion is confined to 1/4th the breast
155
Treatment for inoperable cancer of the breast?
1. chemotherapy + radiation maybe
156
How is inoperably of breast cancer assessed?
local extent, not metastases
157
Who gets adjuvant systemic therapy in breast cancer?
virtually all pts if axillary nodes are positive
chemo + hormonal therapy if tumor is receptor positive
a. tamoxifen for premenopausal
b. anastazole for post-menopausal
158
What does persistent headache or back pain in women who recently had breast cancer indicate?
metastases to:
1. brain
2. vertebral pedicle
159
Thyroid nodule in euthyroid patient management:
1. FNA--> if benign, follow but don't intervene
2. FNA-> if malignant or indeterminant--> thyroid lobectomy --> hisotological frozen section
3. total thyroidectomy should be performed in follicular cancers
160
Lab values in hyperthyroid "hot nodules" & Tx
TSH: low
T4: high
Treatment: radioactive iodine
161
What can help locate parathyroid adenoma prior to surgery?
sestamibi scan
162
Sx of cushing?
1. round, ruddy, hairy face
2. buffalo hump
3. supraclavicular fat pads
4. obese trunk w abdominal stria
5. thin, weak extremities
6. osteoporosis
7. diabetes
8. hypertension
9. mental instability
163
Dx for cushing?
overnight low-dose dexamethasone suppression test
1. suppression at low dosage r/o the disease
2. if no suppression --> 24 h urine free cortisol --> if elevated--> do high-dose suppression test (if then suppressed, then there's a pituitary micro adenoma)
- no suppression at either dosage identifies adrenal adenoma (or paraneoplastic syndrome)
OR
1. measure 24h free cortisol (cushing its have levels 3-4x higher than normal)
2. measure corticotropin to differentiate pituatary adenoma or adrenal adenoma
164
What imaging modality detects pituatary adenoma?
MRI
165
What imaging modality detects adrenal adenoma?
CT
166
Zollinger-Ellison (gastrinoma)
1. virulent peptic ulcer disease
2. resistant to ALL usual therapy (including eradication of H pylori)
3. several ulcers rather than just one
4. ulcers extend beyond first part of the duodenum
5. watery diarrhea
167
Dx zollinger-ellison?
1. measure gastrin
2. measure secretin
3. locate tumor w CT scan of the pancreas and nearby areas
168
Tx of zollinger-ellison?
1. remove it tumor
| 2. omeprazole helps with metastatic disease in Zollinger-Ellison
169
Insulinoma sx?
1. CNS sx always when the person is fasting bc of low blood sugar
2. high insulin
3. high C-peptide
170
Differential Dx in insulinoma?
1. reactive hypoglycemia ( attacks occur after eating)
2. self-administration of insulin: high serum insulin, low serum C-peptide
* *some pts use sulfonylureas to induce endogenous insulin secretion to raise C-peptide levels...so measure levels of sulfonylureas also in work-up
171
Nesidioblastosis? what is it? Tx?
insidious disease of hyper secretion of insulin in the newborn
Tx: 95% pancreatectomy
172
Glucagonoma Sx?
```
1. severe migratory necrolytic dermatitis (resistant to all forms of therapy)
pt has:
1. mild diabetes
2. slight anemia
3. glossitis
4. stomatitis
```
173
Diagnosis of glucagonoma?
1. glucagon assay diagnostic
| 2. use CT scan to locate tumor
174
Tx of glucagonoma?
1. resection is curative
| 2. somatostatin and streptzocin help those with metastatic, inoperable disease
175
Primary Hyperaldosteronism causes? Sx?
```
Causes:
1. adrenal adenoma
2. adrenal hyperaldosteronism
Sx:
1. hypokalemia
2. hyperension
3. usually female pts.
4. modest hypernatremia
5. metabolic alkalosis
6. high aldosterone
7. low renin
```
176
Unique presentation of hyperaldosteronism due to hyperplasia?
postural changes:
| 1. more aldosterone when upright than lying down
177
Management of hyperplasia vs adenoma in hyperaldosteronism?
hyperplasia: medically treat
adenoma: surgical removal
178
Typical pheochromocytoma pt?
1. thin
2. hyperactive
3. attacks of pounding headache
4. perspiration
5. palpitations
6. pallor
179
Dx of pheochromocytoma:
1. 24h urinary vanillylmandelic acid (VMA) levels --can give false positive
2. metanephrines (more SPECIFIC)
3. or free urinary catecholamines
4. do CT of adrenals or radionuclide study to look for extra adrenal sites
180
What must you give the pheo patient before surgery?
alpha-blockers
181
Coarctation of aorta presentation?
1. young pt with hypertension in arms
2. normal/low pressure or no clinical pulses in lower extremities
3. scallopin got the ribs on chest X-ray (from collaterals)
182
Diagnostic test for coarctation of aorta?
1. Spiral Ct scan enhances with IV dye (CT angio)
183
Cure for coarctation of aorta?
Surgical correction
184
Renovascular hypertension pt population?
1. young women w fibromuscular dysplasia
| 2. old men with arteriosclerotic occlusive disease
185
Dx of renovascular ht?
1. faint bruit over flank or upper abdomen
2. Duplex scanning of renal vessels
3. CT angio
186
Tx of renovascular ht?
balloon dilation and stenting
