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Surgery Clerkship - Pestana > Chapter 4 - General Surgery (Part 2) > Flashcards

Chapter 4 - General Surgery (Part 2) Flashcards

1
Q

Primary hepatoma (HCC) is seen in the US only in people with ___, or those known to have had ___.

A

Cirrhosis; hepatitis B or C

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2
Q

Presentation of primary hepatoma?

A

Vague RUQ discomfort and weight loss

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3
Q

Blood marker for primary hepatoma?

A

Alpha-fetoprotein

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4
Q

Dx and Rx primary hepatoma?

A

CT - location and extent

Rx - resection if technically possible

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5
Q

What is more common - primary or metastatic cancer of the liver?

A

Metastatic - 20:1

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6
Q

Dx metastatic cancer of the liver?

A

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

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7
Q

Rx metastatic cancer of the liver?

A

If the primary is slow growing and the mets are confined to one lobe, resection can be done. Other means of control include radioablation

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8
Q

Hepatic adenomas may arise as a complication of ___ and are important - why?

A

Birth control pills; tendency to rupture and bleed massively inside the abdomen

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9
Q

Dx and Rx hepatic adenoma?

A

Dx - CT

Rx - emergency surgery

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10
Q

Pyogenic liver abscess is seen most often as a complication of biliary tract disease, particularly ___. They present with fever, leukocytosis, and a tender liver.

A

Acute ascending cholangitis

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11
Q

Dx and Rx pyogenic liver abscess?

A

Dx - sonogram or CT scan

Rx - percutaneous drainage

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12
Q

Presentation of amebic abscess of the liver?

A

Favors men, all of whom have a “Mexico connection”

Fever, leukocytosis, tender liver

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13
Q

Rx amebic abscess of the liver?

A

Metronidazole; seldom requires drainage

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14
Q

Definitive dx of amebic abscess of the liver?

A

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.

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15
Q

3 general causes of jaundice?

A

Hemolytic
Hepatocellular
Obstructive

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16
Q

Hemolytic jaundice is usually ___ (low or high?). All the elevated bilirubin is ___. Bile in the urine?

A

Low level (6 or 8, not 35 or 40); unconjugated (indirect); no bile in the urine

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17
Q

Work-up of hemolytic jaundice?

A

Find what is chewing up the red cells

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18
Q

Hepatocellular jaundice has elevation of ___ bilirubin, and very high levels of ___, with modest elevation of ___.

A

Both fractions of bilirubin; transaminases; alk phos

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19
Q

What is the most common cause of hepatocellular jaundice?

A

Hepatitis - work-up should proceed in that direction

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20
Q

Obstructive jaundice has elevation of ___, ___ elevation of transaminases, and ___ levels of alk phos.

A

Both fractions of bilirubin; modest; very high

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21
Q

Work-up of obstructive jaundice?

A

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.

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22
Q

Appearance of gallbladder in malignant obstruction? Name of this sign?

A

Large, thin-walled distended gallbladder (Courvoisier-Terrier sign)

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23
Q

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?

A

ERCP to confirm the diagnosis, do sphincterotomy, and remove the common duct stone; cholecystectomy should follow

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24
Q

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?

A
  1. Adenocarcinoma of the head of the pancreas
  2. Adenocarcinoma of the ampulla of Vater
  3. Cholangiocarcinoma of the common duct itself
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25
Q

Next steps in work-up obstructive jaundice caused by a tumor?

A

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

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26
Q

What is an ERCP?

A

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

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27
Q

What is an MRCP?

A

Magnetic resonance cholangiopancreatogram -> completely non-invasive, done on a fully awake patient

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28
Q

MRCP vs. ERCP?

A

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.)

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29
Q

When should ampullary cancers be suspected?

A

When malignant obstructive jaundice coincides with anemia and positive blood in the stools. Can bleed into the lumen like any other mucosal malignancy.

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30
Q

First test when ampullary cancers are supsected

A

Endoscopy

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31
Q

Pancreatic cancer is seldom cured, even when the huge ___ operation is done.

A

Whipple (pancreatoduodenectomy)

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32
Q

Why do cholangiocarcinomas that arise within the liver at the bifurcation of the hepatic ducts have a terrible prognosis?

A

Extremely inconvenient location

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33
Q

Management of asymptomatic gallstones?

A

Leave them alone

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34
Q

What causes biliary colic?

A

Stone temporarily occluding the cystic duct

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35
Q

Presentation of biliary colic?

A

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

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36
Q

Dx and Rx biliary colic?

A

Sonogram - if gallstones, elective cholecystectomy is indicated

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37
Q

Presentation of acute cholecystitis?

A

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

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38
Q

Dx acute cholecystitis?

A

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).

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39
Q

Rx acute cholecystitis?

A

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

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40
Q

Presentation of acute ascending cholangitis?

A

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

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41
Q

Rx acute ascending cholangitis?

A

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

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42
Q

Cause of biliary pancreatitis?

A

Seen when stones become impacted distally in the ampulla, temporarily obstructing both pancreatic and biliary ducts.

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43
Q

Presentation of biliary pancreatitis?

A

Stones often pass spontaneously, producing a mild and transitory episode of cholangitis along with the classic manifestations of pancreatitis (amylase and lipase elevation)

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44
Q

Dx and Rx biliary pancreatitis?

A 
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

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45
Q

2 most common causes of acute pancreatitis?

A

Complication of gallstones or with alcohol use

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46
Q

Types of acute pancreatitis?

A

May be edematous, hemorrhagic, or suppurative (pancreatic abscess)

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47
Q

Late complications of acute pancreatitis?

A

Pancreatic pseudocyst

Chronic pancreatitis

48
Q

Presentation of acute edematous pancreatitis?

A

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

49
Q

Dx acute edematous pancreatitis?

A

Elevated serum amylase or lipase (early) or urinary amylase or lipase (late)

Key finding to establish the edematous nature - elevated hematocrit

50
Q

Rx acute edematous pancreatitis?

A

Pancreatic rest (NPO, NG suction, IV fluids)

51
Q

Dx acute hemorrhagic pancreatitis?

A

Elevated amylase/lipase

Key finding - LOWER hematocrit

52
Q

What are the Ranson’s criteria for acute hemorrhagic pancreatitis?

A

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

53
Q

Rx acute hemorrhagic pancreatitis?

A

Very intensive supportive therapy in the ICU

54
Q

Management of pancreatic abscesses?

A

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

55
Q

Presentation of pancreatic abscesses?

A

Seen on imaging or when fever and leukocytosis develop ~10 days after the onset of pancreatitis.

56
Q

Rx pancreatic abscess?

A

Ideally perc radiological drainage; open drainage if not possible

57
Q

Necrosectomy may be the best way to deal with necrotic pancreas. When should this be done and why?

A

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

58
Q

Presentation of pancreatic pseudocyst?

A

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)

59
Q

Most common location of pancreatic pseudocyst?

A

Lesser sac

60
Q

Dx and Rx pancreatic pseudocyst?

A

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)

61
Q

Presentation of chronic pancreatitis?

A

Repeated episodes of pancreatitis (usually alcoholic) eventually develop calcified burned-out pancreas, steatorrhea, diabetes, and constant epigastric pain

62
Q

Manage chronic pancreatitis?

A

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

63
Q

There are 3 big families of malignant tumors, which arise from the 3 layers of the embryo - what are they?

A
  1. Epithelial tumors (ectoderm)
  2. Sarcomas (mesoderm)
  3. Adenocarcinomas (endoderm)
64
Q

2 most common ways cancer metastasizes?

A
  1. Lymphatic spread to regional and more distant lymph nodes

2. Hematogenous migration to far away organs (usually liver, lung, brain, bone)

65
Q

Breast cancers favor mets to what locations? Abdominal adenocarcinomas? Sarcomas?

A

Breast cancer -> brain and bone
Abdominal adenos -> liver
Sarcomas -> blood-borne only, lungs

66
Q

In general, how is localized cancer treated?

A

Surgery, radiation, or both

67
Q

Once there are malignant cells throughout the body, systemic therapy is needed - what three options are available?

A
  1. Chemo (most common) - drugs that target rapidly dividing cells
  2. Hormonal manipulations for testicular or breast cancer (tamoxifen or anastrozole)
  3. Immunotherapy (pembrolizumab and nivolumab are the best-known)
68
Q

What is the major side effect of the following chemotherapies?

  • Adriamycin
  • Bleomycin
  • Cyclophosphamide
  • Platinum-based agents
A

Adriamycin -> mycocardium
Bleomycin -> pulmonary fibrosis
Cyclophosphamide -> bladder irritation
Platinum-based agents -> neurotoxic

69
Q

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?

A

Get tissue for the pathologist

70
Q

Management of women who inherit the BRCA gene?

A

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.

71
Q

Presentation of fibroadenomas?

A 
Young women (late teens, early 20s)
Firm, rubbery mass that moves easily with palpation
72
Q

Dx and Rx fibroadenoma?

A

Dx with either FNA or sonogram

Removal is optional

73
Q

Presentation of cystosarcoma phyllodes?

A

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

74
Q

Dx and Rx cystosarcoma phyllodes?

A

Dx - core or incisional biopsy (FNA not sufficient)

Removal is mandatory

75
Q

Presentation of mammary dysplasia?

A

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

76
Q

Dx and management of mammary dysplasia?

A

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

77
Q

Presentation of intraductal papilloma?

A

Young women (20s-40s) with bloody nipple discharge

78
Q

Dx and Rx intraductal papilloma?

A

Mammogram to identify other potential lesions (will not show the papilloma -> too small)
Galactogram may be diagnostic and gudies resection

79
Q

Presentation of breast abscess?

A

Seen only in lactating women; cancer until proven otherwise in any other setting

80
Q

Rx breast abscess?

A

I/D

Biopsy of the abscess wall should be part of the procedure

81
Q

Presentation of breast cancer?

A

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

82
Q

True or false - a history of trauma to the breast rules out cancer.

A

False

83
Q

Dx and Rx breast cancer during pregnancy?

A

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.

84
Q

Classic radiologic appearance of breast cancer?

A

Irregular spiculated mass with asymmetric density, architectural distortion, or fine microcalcifications that were not there in the previous mammogram

85
Q

Rx resectable breast cancer?

A

Start with either of 2 operations:

  1. 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)
  2. 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.

86
Q

What is the “standard” form of breast cancer?

A

Infiltrating ductal carcinoma

87
Q

Which type of breast cancer has a worse prognosis and needs pre-op chemo?

A

Inflammatory cancer

88
Q

___ 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?

A

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

89
Q

What determines inoperability of breast cancer? How is it treated?

A

Local extent (not mets); chemo +/- radiation, sometimes becomes oeprable

90
Q

Who gets adjuvant systemic therapy in breast cancer?

A

Virtually all patients after surgery, particularly if axillary nodes are positive

91
Q

Options for adjuvant systemic therapy?

A

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)

92
Q

What suggests possible metastasis in women with breast cancer?

A

Persistent headache or back pain (with areas of localized tenderness)

93
Q

Dx and Rx mets from breast cancer?

A

Dx MRI

Brain mets can be radiated or resected

94
Q

Why are axillary lymph nodes important in breast cancer?

A

They are a marker for the need for systemic therapy.

95
Q

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?

A

Prior exposure of the gland to radiation

96
Q

True or false - thyroid cancer does not affect thyroid function.

A

True

97
Q

First step in work-up of thyroid nodules?

A

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

98
Q

Which type of thyroid cancer is not easily diagnosed by FNA? What may need to be done in this setting?

A

Follicular cancer; lobectomy may be needed to determine if a follicular neoplasm is benign or malignant

99
Q

Management of papillary cancer?

A

Very slow growing; extent of surgical resection is dictated by the size of the tumor or the presence of metastatic nodes

100
Q

Management of follicular cancer?

A

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

101
Q

Medullary cancer comes from the ___ cells that make ___.

A

C; calcitonin (useful for follow-up)

102
Q

Management of medullary cancer?

A

Aggressive -> radical surgery is justified

Work-up for pheochromocytoma indicated, as they often coexist (MEN, type 2)

103
Q

Management of anaplastic cancer?

A

Seen in old people, grows like wildfire, often all that can be done is a tracheostomy

104
Q

Rx hyperthyroidism?

A

Radioactive iodine in most cases; very limited surgical role for patients with a “hot adenoma”

105
Q

Hyperparathyroidism is most commonly identified whow?

A

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

106
Q

Work-up hypercalcemia?

A

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

107
Q

Management of hyperparathyroidism?

A

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

108
Q

Presentation of Cushing syndrome on H&P?

A

Moon face, buffalo hump, supraclavicular fat pad, obese trunk with abdominal stria, thin weak extremities

Osteoporosis, DM, HTN, mental instability

109
Q

Work-up of suspected Cushing syndrome?

A
  1. Overnight low-dose dexamethasone suppression test (suppression at low dosage rules out disease)
  2. If no suppression -> 24-hour urine-free cortisol. If elevated -> high-dose suppression test.
  3. Suppression at a higher dose identifies pituitary microadenoma. No suppression at either dose identifies adrenal adenoma or paraneoplastic syndrome
  4. Appropriate imaging (MRI for pituitary, CT for adrenal)
  5. Remove offending adenoma
110
Q

Presentation of Zollinger-Ellison (gastrinoma)?

A

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

111
Q

Work-up and Rx Zollinger-ellison?

A

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

112
Q

Presentation of insulinoma?

A

CNS symptoms 2/2 hypoglycemia, always when fasting

DDx - reactive hypoglycemia - attacks after eating, self-administration of insulin

113
Q

Work-up of insulinoma?

A

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

114
Q

What is nesidioblastosis?

A

Devastating hypersecretion of insulin in the newobrn, requires 95% pancreatectomy

115
Q

Presentation of glucagonoma?

A

Severe migraotry necrolytic dermatitis resistant to all forms of therapy in a patient with mild diabetes, a touch of anemia, glossitis, and stomatitis

116
Q

Dx and Rx glucagonoma?

A

Glucagon assay is diagnostic
CT to locate tumor
Resection is curative

Somatostatin and streptozocin can help those with mets, inoperable disease

Surgery Clerkship - Pestana (17 decks)

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