Chapter 4 - General Surgery (Part 2) Flashcards
Primary hepatoma (HCC) is seen in the US only in people with ___, or those known to have had ___.
Cirrhosis; hepatitis B or C
Presentation of primary hepatoma?
Vague RUQ discomfort and weight loss
Blood marker for primary hepatoma?
Alpha-fetoprotein
Dx and Rx primary hepatoma?
CT - location and extent
Rx - resection if technically possible
What is more common - primary or metastatic cancer of the liver?
Metastatic - 20:1
Dx metastatic cancer of the liver?
CT scan if follow-up for the treated primary tumor is underway, or suspected because of rising carcinoembryonic antigen (CEA) in those who had colonic cancer
Rx metastatic cancer of the liver?
If the primary is slow growing and the mets are confined to one lobe, resection can be done. Other means of control include radioablation
Hepatic adenomas may arise as a complication of ___ and are important - why?
Birth control pills; tendency to rupture and bleed massively inside the abdomen
Dx and Rx hepatic adenoma?
Dx - CT
Rx - emergency surgery
Pyogenic liver abscess is seen most often as a complication of biliary tract disease, particularly ___. They present with fever, leukocytosis, and a tender liver.
Acute ascending cholangitis
Dx and Rx pyogenic liver abscess?
Dx - sonogram or CT scan
Rx - percutaneous drainage
Presentation of amebic abscess of the liver?
Favors men, all of whom have a “Mexico connection”
Fever, leukocytosis, tender liver
Rx amebic abscess of the liver?
Metronidazole; seldom requires drainage
Definitive dx of amebic abscess of the liver?
Serology, but because the test takes weeks to be reported, empiric Rx is started in those clinically supected. If they improve, it is continued. If not, drainage is done.
3 general causes of jaundice?
Hemolytic
Hepatocellular
Obstructive
Hemolytic jaundice is usually ___ (low or high?). All the elevated bilirubin is ___. Bile in the urine?
Low level (6 or 8, not 35 or 40); unconjugated (indirect); no bile in the urine
Work-up of hemolytic jaundice?
Find what is chewing up the red cells
Hepatocellular jaundice has elevation of ___ bilirubin, and very high levels of ___, with modest elevation of ___.
Both fractions of bilirubin; transaminases; alk phos
What is the most common cause of hepatocellular jaundice?
Hepatitis - work-up should proceed in that direction
Obstructive jaundice has elevation of ___, ___ elevation of transaminases, and ___ levels of alk phos.
Both fractions of bilirubin; modest; very high
Work-up of obstructive jaundice?
First step - sonogram, looking for dilation of the biliary ducts, as well as further clues as to the nature of the obstructive process. In obstruction caused by stones, the stone that is obstructing the common duct is seldom seen, but stones are seen in the gallbladder, which because of chronic irritation cannot dilate.
Appearance of gallbladder in malignant obstruction? Name of this sign?
Large, thin-walled distended gallbladder (Courvoisier-Terrier sign)
Next step in jaundice suspected to be caused by stones in an obese, fecund woman in her 40s with high alk phos, dilated ducts on sonogram, and non-dilated gallbladder full of stones?
ERCP to confirm the diagnosis, do sphincterotomy, and remove the common duct stone; cholecystectomy should follow
Three different cancers may be responsible for obstructive jaundice caused by a tumor and suggested by the thin-walled dilated gallbladder on U/S - what are they?
- Adenocarcinoma of the head of the pancreas
- Adenocarcinoma of the ampulla of Vater
- Cholangiocarcinoma of the common duct itself
Next steps in work-up obstructive jaundice caused by a tumor?
Significant weight loss and constant back pain suggest a large pancreatic tumor, which should be visible in a CT scan (next step). In the absence of those clues or if the CT is negative, the next step is MRCP, which can show smaller tumors that are blocking the flow of bile.
Biopsy options - CT-guided percutaneous for a large pancreatic mass, endoscopic for ampullary, ERCP and brushings for a ductal neoplasm, or endoscopic U/S for tiny tumors within the head of the pancreas
What is an ERCP?
Endoscopic retrograde cholangiopancreatogram -> invasive procedure that allows visualization and instrumentation of the biliary and pancreatic ducts
Endoscope descends into the duodenum, ampulla is cannulated, X-ray dye is injected
What is an MRCP?
Magnetic resonance cholangiopancreatogram -> completely non-invasive, done on a fully awake patient
MRCP vs. ERCP?
If all you need is a diagnostic picture, the clear choice is MRCP. But if you want to do more than look at a picture, you need ERCP (can do sphincterotomies, retrieve stones, drain pus, deploy stents, biopsy tumors, etc.)
When should ampullary cancers be suspected?
When malignant obstructive jaundice coincides with anemia and positive blood in the stools. Can bleed into the lumen like any other mucosal malignancy.
First test when ampullary cancers are supsected
Endoscopy
Pancreatic cancer is seldom cured, even when the huge ___ operation is done.
Whipple (pancreatoduodenectomy)
Why do cholangiocarcinomas that arise within the liver at the bifurcation of the hepatic ducts have a terrible prognosis?
Extremely inconvenient location
Management of asymptomatic gallstones?
Leave them alone
What causes biliary colic?
Stone temporarily occluding the cystic duct
Presentation of biliary colic?
Colicky pain in the RUQ, radiating to the right shoulder and beltlike to the back, often triggered by ingestion of fatty food, accompanied by N/V, but without signs of peritoneal irritation or systemic signs of inflammatory process. Episode is self-limited and easily aborted by anticholinergics
Dx and Rx biliary colic?
Sonogram - if gallstones, elective cholecystectomy is indicated
Presentation of acute cholecystitis?
Starts as biliary colic, stone remains at the cystic duct until an inflammatory process develops in the obstructed gallbladder
Pain becomes constant, modest fever and leukocytosis, physical findings of peritoneal irritation in the RUQ
LFTs are minimally affected
Dx acute cholecystitis?
U/S with gallstones, thick-walled gallbladder, pericholecystic fluid
Rarely, a radionuclide scan (HIDA) might be needed (would show uptake in the liver, common duct, and duodenum, but not the occluded gallbladder).
Rx acute cholecystitis?
NG suction, NPO, IV fluids, ABX to “cool down” most cases, allowing elective cholecystectomy to follow, ideally in the same admission.
If no response to cool down Rx (men, DM), emergency cholecystectomy is needed. Emergency perc transhepatic cholecystotomy may be the best temporizing option in the very sick with prohibitive surgical risk
Presentation of acute ascending cholangitis?
Stones have reached the common duct and produced partial obstruction and ascending infection
Patients are older and much sicker
Temp spikes to 104-105, chills, very high WBCs indicate sepsis
Some hyperbili
Key finding - extremely high alk phos
Rx acute ascending cholangitis?
IV ABX and emergency decompression of the common duct (ideally by ERCP, alternatively percutaneous through the liver by PTC or rarely by surgery)
Eventual cholecystectomy
Cause of biliary pancreatitis?
Seen when stones become impacted distally in the ampulla, temporarily obstructing both pancreatic and biliary ducts.
Presentation of biliary pancreatitis?
Stones often pass spontaneously, producing a mild and transitory episode of cholangitis along with the classic manifestations of pancreatitis (amylase and lipase elevation)
Dx and Rx biliary pancreatitis?
Dx - U/S (gallstones in the gallbladder) Conservative Rx (NPO, NG suction, IV fluids), allows elective cholecystectomy later
If not, ERCP and sphincterotomy may be required to dislodge the impacted stone
2 most common causes of acute pancreatitis?
Complication of gallstones or with alcohol use
Types of acute pancreatitis?
May be edematous, hemorrhagic, or suppurative (pancreatic abscess)
Late complications of acute pancreatitis?
Pancreatic pseudocyst
Chronic pancreatitis
Presentation of acute edematous pancreatitis?
Occurs in the alcoholic or patient with gallstones
Epigastric and midabdominal pain starts after a heavy meal or bout of alcohol intake, is constant, radiates straight through to the back, and is accompanied by N/V, and (after the stomach is empty), continued retching
Tenderness and mild reboud in the upper abdomen
Dx acute edematous pancreatitis?
Elevated serum amylase or lipase (early) or urinary amylase or lipase (late)
Key finding to establish the edematous nature - elevated hematocrit
Rx acute edematous pancreatitis?
Pancreatic rest (NPO, NG suction, IV fluids)
Dx acute hemorrhagic pancreatitis?
Elevated amylase/lipase
Key finding - LOWER hematocrit
What are the Ranson’s criteria for acute hemorrhagic pancreatitis?
At presentation:
Elevated WBC
Elevated blood glucose
Low serum calcium
by the next morning:
Hct even lower
Serum calcium remains low (despite calcium administration)
BUN goes up
Metabolic acidosis and low arterial PO2 eventually are evidence
Rx acute hemorrhagic pancreatitis?
Very intensive supportive therapy in the ICU
Management of pancreatic abscesses?
Drain them, if at all possible.
Monitor with daily CT scans
Carabpenems, quinolones, and metronidazole are known to penetrate infected necrotic pancreas and may be used prior to drainage
Presentation of pancreatic abscesses?
Seen on imaging or when fever and leukocytosis develop ~10 days after the onset of pancreatitis.
Rx pancreatic abscess?
Ideally perc radiological drainage; open drainage if not possible
Necrosectomy may be the best way to deal with necrotic pancreas. When should this be done and why?
Best done when the dead tissue is well-delineated, typically after 4 weeks. Material is “scooped out.” Procedure may have to be repeated until all the dead matter ha been cleared away
Presentation of pancreatic pseudocyst?
Late sequela of acute pancreatitis or of pancreatic (upper abdominal) trauma
In either case, about 5 weeks elapses between the original problem and the discovery of the pseudocyst. There is a collection of pancreatic juice outside the pancreatic ducts and pressure symptoms thereof (early satiety, vague discomfort, deep palpable mass)
Most common location of pancreatic pseudocyst?
Lesser sac
Dx and Rx pancreatic pseudocyst?
Dx with CT or sonogram
Rx depends on the size and age of the pseudocyst
-6 cm or smaller or those present for <6 weeks are not likely to have complications and can be observed for spontaneous resolution
->6cm or >6 weeks are more likely to rupture or bleed -> treat with drainage (perc to the outside, drained surgically into the GI tract, or endoscopically into the stomach)
Presentation of chronic pancreatitis?
Repeated episodes of pancreatitis (usually alcoholic) eventually develop calcified burned-out pancreas, steatorrhea, diabetes, and constant epigastric pain
Manage chronic pancreatitis?
Insulin and pancreatic enzymes for diabetes and steatorrhea; pain is resistant to most modalities of therapy. If MRCP shows specific points of obstruction and dilatation, operations that drain the pancreatic duct may help
There are 3 big families of malignant tumors, which arise from the 3 layers of the embryo - what are they?
- Epithelial tumors (ectoderm)
- Sarcomas (mesoderm)
- Adenocarcinomas (endoderm)
2 most common ways cancer metastasizes?
- Lymphatic spread to regional and more distant lymph nodes
2. Hematogenous migration to far away organs (usually liver, lung, brain, bone)
Breast cancers favor mets to what locations? Abdominal adenocarcinomas? Sarcomas?
Breast cancer -> brain and bone
Abdominal adenos -> liver
Sarcomas -> blood-borne only, lungs
In general, how is localized cancer treated?
Surgery, radiation, or both
Once there are malignant cells throughout the body, systemic therapy is needed - what three options are available?
- Chemo (most common) - drugs that target rapidly dividing cells
- Hormonal manipulations for testicular or breast cancer (tamoxifen or anastrozole)
- Immunotherapy (pembrolizumab and nivolumab are the best-known)
What is the major side effect of the following chemotherapies?
- Adriamycin
- Bleomycin
- Cyclophosphamide
- Platinum-based agents
Adriamycin -> mycocardium
Bleomycin -> pulmonary fibrosis
Cyclophosphamide -> bladder irritation
Platinum-based agents -> neurotoxic
In all breast disease, cancer must be ruled out even if the presentation suggests benign disease. The only sure way to rule out cancer is to do what?
Get tissue for the pathologist
Management of women who inherit the BRCA gene?
Early and frequent screening with MRI rather than mammogram, which are carcinogenic if repeated frequently
Past the age of 30, they should consider prophylactic bilateral mastectomies if they have the BRCA2 mutation, and that plus oophorectomies if they have the BRCA1 mutation.
Presentation of fibroadenomas?
Young women (late teens, early 20s) Firm, rubbery mass that moves easily with palpation
Dx and Rx fibroadenoma?
Dx with either FNA or sonogram
Removal is optional
Presentation of cystosarcoma phyllodes?
Late 20s
Grow over many years, become very large, replacing and distorting the entire breast, yet not invading or becoming fixed
Most are benign, but have the potential to become outright malignant sarcomas
Dx and Rx cystosarcoma phyllodes?
Dx - core or incisional biopsy (FNA not sufficient)
Removal is mandatory
Presentation of mammary dysplasia?
30s and 40s (goes away with menopause)
Bilateral tenderness related to menstrual cycle (worse in the last 2 weeks)
Multiple lumps that seem to come and go (cysts) also following the menstrual cycle
Dx and management of mammary dysplasia?
If no dominant or persistant mass - mammogram is sufficient
If persistent mass (presumably a tumor but potentially a tumor) - aspiration (not FNA - bigger needle and syringe). If clear fluid obtained and mass resolves, that’s it. If persists or recurs, formal biopsy is needed. If bloody fluid -> cytology
Presentation of intraductal papilloma?
Young women (20s-40s) with bloody nipple discharge
Dx and Rx intraductal papilloma?
Mammogram to identify other potential lesions (will not show the papilloma -> too small)
Galactogram may be diagnostic and gudies resection
Presentation of breast abscess?
Seen only in lactating women; cancer until proven otherwise in any other setting
Rx breast abscess?
I/D
Biopsy of the abscess wall should be part of the procedure
Presentation of breast cancer?
Should be suspected in any woman with a palpable breast mass
Index of suspicion increases with age
Ill-defined fixed mass, retraction of overlying skin, “orange peel” skin, recent retraction of the nipple, eczematoid lesions of the areola, reddish orange peel skin over the mass (inflammatory cancer), palpable axillary nodes
True or false - a history of trauma to the breast rules out cancer.
False
Dx and Rx breast cancer during pregnancy?
Dx exactly as if pregnancy did not exist
Rx the same way except for no radiotherapy or hormonal manipulations anytime during the pregnancy, no chemo during the first trimester. Termination of the pregnancy is not necessary.
Classic radiologic appearance of breast cancer?
Irregular spiculated mass with asymmetric density, architectural distortion, or fine microcalcifications that were not there in the previous mammogram
Rx resectable breast cancer?
Start with either of 2 operations:
- Small lesions, located far away from the nipple and areola of a large breast, are removed within only a segment of the mammary gland (lumpoectomy/segmental resection, must be followed with radiotherapy)
- Large tumors right under the nipple and areola, and occupying most of a small breast (simple total mastectomy, no subsequent radiation)
If LN not palpable, either operation must include a sentinel node biopsy. If palpable in the axilla, resect.
What is the “standard” form of breast cancer?
Infiltrating ductal carcinoma
Which type of breast cancer has a worse prognosis and needs pre-op chemo?
Inflammatory cancer
___ cannot metastasize (thus no axillary sampling needed), but it has a very high incidence of recurrence if only local excision is done. Thus, what is recommended?
Ductal carcinoma in situ; total simple mastectomy recommended for multicentric lesions throughout the breast. Many add a sentinel node biopsy because of the possibility of missing an invasive focus in multicentric disease. Lumpectomy followed by radiation is used if the lesion (or lesions) is confined to 1/4 of the breast
What determines inoperability of breast cancer? How is it treated?
Local extent (not mets); chemo +/- radiation, sometimes becomes oeprable
Who gets adjuvant systemic therapy in breast cancer?
Virtually all patients after surgery, particularly if axillary nodes are positive
Options for adjuvant systemic therapy?
Chemo in most cases, hormonal therapy added if receptor positive tumor
Premenopausal women - tamoxifen
Postmenopausal women - anastrozole
Frail old women with tumors that are not too aggressive may be offered hormonal therapy alone
HER-2+ should get trastuzumab (Herceptin) + chemo (never give alone)
What suggests possible metastasis in women with breast cancer?
Persistent headache or back pain (with areas of localized tenderness)
Dx and Rx mets from breast cancer?
Dx MRI
Brain mets can be radiated or resected
Why are axillary lymph nodes important in breast cancer?
They are a marker for the need for systemic therapy.
Most thyroid nodules are benign, but the few that are malignant must be diagnosed and treated. These can occur at any age. What is the most worrisome item in the history?
Prior exposure of the gland to radiation
True or false - thyroid cancer does not affect thyroid function.
True
First step in work-up of thyroid nodules?
Some start with U/S, which can exclude some lumps that are clearly not neoplastic
Otherwise the dx is made by FNA which indicates whether the node is benign (if so, follow-up), or has papillary, medullary, or anaplastic cancer
Which type of thyroid cancer is not easily diagnosed by FNA? What may need to be done in this setting?
Follicular cancer; lobectomy may be needed to determine if a follicular neoplasm is benign or malignant
Management of papillary cancer?
Very slow growing; extent of surgical resection is dictated by the size of the tumor or the presence of metastatic nodes
Management of follicular cancer?
Follicular cancer can take radioactive iodine if it does not have to compete with normal thyroid tissue - thus, a total thyroidectomy is always done because it permits the use of radioactive iodine in the future to identify and treat mets
Medullary cancer comes from the ___ cells that make ___.
C; calcitonin (useful for follow-up)
Management of medullary cancer?
Aggressive -> radical surgery is justified
Work-up for pheochromocytoma indicated, as they often coexist (MEN, type 2)
Management of anaplastic cancer?
Seen in old people, grows like wildfire, often all that can be done is a tracheostomy
Rx hyperthyroidism?
Radioactive iodine in most cases; very limited surgical role for patients with a “hot adenoma”
Hyperparathyroidism is most commonly identified whow?
By serendipitous discovery of high serum calcium in blood tests (rarely seen the full florid disease of stones, bones, and abdominal groans)
Asymptomatic patients become symptomatic at a rate of 20% per year
Work-up hypercalcemia?
Repeat calcium determinations
Look for low phosphorus
R/o cancer with bone mets
If findings persist, do PTH determination and interpret in light of serum calcium levels
Management of hyperparathyroidism?
Because asymptomatic patients become symptomatic at a rate of 20%/year, elective intervention is justified.
90% have a signle adenoma - removal is curative
Sestamibi scan helps locate the offending gland(s)
Intraoperative PTH assay confirms that they have been extirpated
In the few patients who have hyperplasia, transplantation of all the parathyroids to the forearm facilitates future titration to keep the disease under control
Presentation of Cushing syndrome on H&P?
Moon face, buffalo hump, supraclavicular fat pad, obese trunk with abdominal stria, thin weak extremities
Osteoporosis, DM, HTN, mental instability
Work-up of suspected Cushing syndrome?
- Overnight low-dose dexamethasone suppression test (suppression at low dosage rules out disease)
- If no suppression -> 24-hour urine-free cortisol. If elevated -> high-dose suppression test.
- Suppression at a higher dose identifies pituitary microadenoma. No suppression at either dose identifies adrenal adenoma or paraneoplastic syndrome
- Appropriate imaging (MRI for pituitary, CT for adrenal)
- Remove offending adenoma
Presentation of Zollinger-Ellison (gastrinoma)?
Virulent PUD, resistant to all usual therapy (including eradication of H. pylori) and more extensive than it should be (several ulcers rather than one, ulcers beyond first portion of duodenum)
Some with watery diarrhea
Work-up and Rx Zollinger-ellison?
Measure gastrin, do secretin test if values are equivocal.
Locate tumor with CT scan (with contrast) of pancreas and nearby areas, remove it.
Omeprazole can help with metastatic disease
Presentation of insulinoma?
CNS symptoms 2/2 hypoglycemia, always when fasting
DDx - reactive hypoglycemia - attacks after eating, self-administration of insulin
Work-up of insulinoma?
High insulin and high C-peptide (if high insulin but low C-peptide, insulin is exogenous)
Measure sulfonylurea level (attempt to defect the diagnostic value of C-peptide if administering exogenous)
CT with contrast of pancreas to locate tumor and remove it
What is nesidioblastosis?
Devastating hypersecretion of insulin in the newobrn, requires 95% pancreatectomy
Presentation of glucagonoma?
Severe migraotry necrolytic dermatitis resistant to all forms of therapy in a patient with mild diabetes, a touch of anemia, glossitis, and stomatitis
Dx and Rx glucagonoma?
Glucagon assay is diagnostic
CT to locate tumor
Resection is curative
Somatostatin and streptozocin can help those with mets, inoperable disease
