gen surg 12/30/16 Flashcards
1
Q
presentation of acute mesenteric ischemia
A
periumbilical abdominal pain (sudden onset, poorly localized (visceral), often severe, with nausea amd vomiting)
pain out of proportion to exam (severe pain but minimal diffuse tenderness, early)
hematochezia (late), also localized pain peritoneal signs and sepsis if infarct develops
2
Q
lab findings in acute mesenteric ischemia
A
leukocytosis
amylase and lipase elevated
metabolic acidosis (lactate)
3
Q
diagnose acute mesenteric ischemia
A
ct preferred to mr angiography
mesenteric angiography if still unclear
4
Q
pres
labs
dx
mesenteric ischemia
A
periumbilical abdominal pain (sudden onset, poorly localized (visceral), often severe, with nausea amd vomiting)
pain out of proportion to exam (severe pain but minimal diffuse tenderness, early)
hematochezia (late), also localized pain peritoneal signs and sepsis if infarct develops
leukocytosis
amylase and lipase elevated
metabolic acidosis (lactate)
hemoglobin elevated (hemoconcentration)
ct preferred to mr angiography
mesenteric angiography if still unclear
5
Q
most common causes of acute mesenteric ischemia
A
cardiac embolism (afib, valvular dz/vegetations, cv aneurysm
thrombosis (pad, low cardiac output state)
6
Q
acalculous cholecystitis
pres
A
usually in critically ill hospitalized pt
jaundice, urq pain and/or mass
7
Q
tf
urge to defecate is common with acute mesenteric ischemia
A
t
8
Q
tf
acute severe abdominal pain in alc wdrwl
A
f restlessness diaphoresis tachycardia seizures hallucinations ams
acute severe ab pain less likely
9
Q
presenation of abdominal abscess
A
subacute fever focal tenderness weight loss
10
Q
bowel sounds in opioid wdrwl
A
increases
gi sx, flu-like sx, sns sx (mydriasis, agitation, anxiety)
11
Q
postop pt w fev leuk parotid inflammation think…
how to prevent…
A
acute bacterial parotitis
(most common in dehydrated postop pts amd elderly)
prevent w hydration and oral hygiene
12
Q
most common bug in acute bacterial parotitis
A
staph aureus
13
Q
tf
incentive spirometry had been shown to reduce postop pulmonary complications by 50%
A
t
uworld 2016
14
Q
why are beta blocker used perioperatively
A
to reduce the risk of ischemia
15
Q
tf
perioperative abx for routine abdominal surg
A
t
16
Q
who gets “polysaccharide vaccine” and what does it prevent?
A
pts ^65yo
strep pneumo
17
Q
acute bacterial parotitis
pres
prev
tx
A
parotid pain aggravated by chewing
fev leuk tender swollen erythematous parotid common
hydration and oral hygiene
tx staph aureus usually
18
Q
normal total bilirubin
A
.1-1 mg/dl
19
Q
chronic mesenteric ischemia aka
A
intestinal angina
20
Q
intestinal angina aka
A
chrinic mesenteric ischemia
21
Q
etiology of sphincter of oddi dysfunction
A
any inflammatory process
(post surgical, pancreatitis, etc…)
opioid analgesics can cause sphimcter contraction and precipitate sx
22
Q
sphincter of oddi dysfunction define pres dx tx
A
dyskinesia or stenosis blocking bile flow
recurrent episodic ruq or epigastric pain
ast alt all phos ele
us dilated bile duct no stones
MANOMETRY gold standard
sphincterotomy usually
23
Q
bile reflux gastritis
pathogenesis
pres
A
incompetent pyloric sphincter (eg postop gastric surg) duod can reflux into stomach and esophagus
vom, freq heartburn, ab pain
24
Q
define choledocholythiasis
A
gallstones in common bile duct
25
chronic mesenteric ischemia
| pres
"intestinal angina"
| dull post prandial epigastric pain due to atherosclerotic narrowing
26
dx ibs
ab pain bowel habit change (diarrhea vs constipation) etc
| ro other dxs (infection, lactose intolerance...)
27
lab tests and imagimg studies to dx ibs
none
ab pain bowel habit change (diarrhea vs constipation) etc
ro other dxs (infection, lactose intolerance...)
28
normal hb
12-16 f
| 13.5-17.5 m
29
blunt abdominal trauma
left sided ab pain
anemia
think...
splenic injury
30
blunt abdominal trauma with evidence of hemorrhage must think...
splenic injury
31
presentation of splenic injury after blunt abdominal trauma
```
hypotension
pleuritic chest pain
left abdominal wall bruising
luq tenderness
guarding
referred left shoulder pain from hemorrhage irritating left hemidiaphragm, worse w inspiration (kehr's sign)
```
32
workup for suspected splenic injury after blunt abdominal trauma
cbc for anemia
FAST focused assessment w sonography for trauma, for hemodynamically unstable (eg sbpv90) or stable and alert, ct if fast normal
if not alert can consider straight to ct
33
manage splenic injury after blunt abdominal trauma
hemodynamically unstable, fast positive, or ct positive - operate (repair preferred to removal and immunize against encapsulated bact)
hemo stable, fast neg, ct neg or minimal splenic inj - non-op serial exams and close obs
between, mgmt may vary
34
splenic inj after blunt ab trauma
pres
dx
tx
hypotension, pleuritic chest pain, left abdominal wall bruising, luq tenderness, guarding
referred left shoulder pain
cbc
fast focused assessment w sonography for trauma
ct if fast normal
op (repair preferred to removal and immunize against encapsulated bact) if hemo unstable or imaging positive
conservative serial exams and close obs if stable and imaging negative or minimal splenic inj on ct
gray between...
35
```
tf
bp 113/71
hr 116
hb 11.8
in 25 yo m w blunt abdominal trauma is sufficient to warrant concern for hemorrhage
```
t
male hb nl 13.5-17.5
suspect splenic inj w blunt ab trauma
36
when is peritoneal lavage used in diagnosis of splenic injury
hemodynamically unstable w equivocal fast (focused assessment w sonography for trauma) or emergency us or ct unavailalable
(used to be used more before good us and ct available)
37
when is urgent exploratory laparotomy performed for pt after blunt abdominal trauma
hemodynamically unstable w positive fast (focused assessment w sonography for trauma)
or stable with significant injury on ct ab
38
presentations of colon cancer
asymptomatic screen (colonoscopy)
postmenopausal / man w iron deficiency anemia
change in stool caliber
alternating bowel habits (d/c)
weight loss
39
colon cancer found on colonoscopy... next steps
ct scan to stage
chemo (eg folfox or folfiri)
radiation
40
what is folfox
folinic acid (leucovorin) - supplies cofactor blocked by mtx or here enhances activity of 5fu by stabilizing 5-dUMP binding to thymidylate synthetase, depleting thymidine triphosphate needed for dna synth
f 5fu fluorouracil (pyrimidine antimetabolite)
ox oxaliplatin (alkylating)
41
what is folfiri
folinic acid (leucovorin) - supplies cofactor blocked by mtx or here enhances activity of 5fu by stabilizing 5-dUMP binding to thymidylate synthetase, depleting thymidine triphosphate needed for dna synth
f 5fu fluorouracil (pyrimidine antimetabolite)
irinotecan (binds topo I /DNA complex preventing religation of cleaved DNA strand... s-phase cell death
42
treat FAP
familial adenomatosis polyposis
-prophylactic cholectomy
otherwise tons of polyps, premalignant by age 18, malignant by 28, dead by 38...
43
good vs bad colonic polyps
good
-pedunculated, small, tubular
bad
-sessile, large, villous
44
how long to repeat colonoscopy
normal - 10 years
polyp - 5 years
cis carcinoma in situ - 3 years
dysplasia - 1 year
(worse it soudns, sooner back)
45
ulcerative colitis
deep vs superficial
continuous vs skip
tx
superficial
continuous
medical tx... but 8 years post diagnosis malignant conversion likely so consider q1y screens and prophylactic colectomy
46
crohn's dz
deep vs superficial
continuous vs skip
transmural (fistula forming, fecal soiling)
| skip
47
how will surgeon treat crohn's dz
may symptomatically remove fistulas (transmural thickness lesions)
but mostly medically managed
(ppx colectomy for ulcerative colitis not crohn's)
48
hemorrhoids
which type bleed
which type hurt
internal bleed don't hurt
| external hurt itch don't bleed
49
dx hemorrhoid
gross visual - external
| anoscopy - may be needed for internal
50
treat hemorrhoids
creams (preparation h)
sitz baths...
internal - band
external - resect (v50% anal circumference to reduce chance of scarring and stricture)
51
what is a sitz bath
sitz bath is a warm, shallow bath that cleanses the perineum, which is the space between the rectum and the vulva or scrotum. A sitz bath can be used for everyday personal hygiene. It can also provide relief from pain or itching in the genital area
52
presentation of ulcerative colitis
bloody bowel movements
| weight loss
53
where will colon cancer cause constipation vs bleeding
right - bleeding (stool loose enough to squeeze by)
left - constipation (stool dry and gets blocked up)
54
```
anal fissure
path
pres
dx
tx
```
tight sphincter... constipation... tears with passage of big lump... scars smaller
pain on defecation that lasts for hours (longer than defecation pain vs relief w IBD...)
grossly visualize / clinical dx
```
nitroglycerin paste to try to relax
botulinum
topical lidocaine (numbs and loosens)
sitz baths
(good idea to soften stool in addition..)
lateral internal sphincterotomy
```
55
LEEP procedure stands for...
loop electrosurgical excision procedure
- removes abnormal tissue by cutting away with thin wire loop carrying electrical current
- -eg for cervical cancer
56
2 big cancers colorectal surgeons will treat
colon cancer
| anal cancer
57
```
anal cancer
path
pres
dx
tx
```
anoreceptive sex - hpv - scc
msm (screen for HIV), mass... brbpr
anal pap, bx
chemo and radiation (nIgro protocol)
58
```
pilonidal cyst
path
pres
dx
tx
```
abscessed hair follicle
(hair follicle grows into cyst?... infects it...)
congenital dz
hairy butt
clinical dx - find the cyst
incision and drainage First
then resect
59
nigro protocol treats
anal cancer
(hpv - scc)
((nigro = chemo and radiation))
NOT cervical cancer
60
hhv8 assoc w this cancer
kaposi sarcoma
61
common complications of haart
pancreatitis
| dyslipidemia
62
pathogenesis of anal fissure in elderly
not moving, eating much, generally incapacitated.... constipation
...now straining tears a fissure...
...now defecation associated with pain so hold it in.... more constipation...
63
tf
| it is reasonable to screen msm w pap smears
t
anal pap smears
for anal scc caused by hpv caused by anoreceptive sex
64
define cholelithiasis
gallstones
| in gall bladder
65
```
cholelithiasis
define
path
pres
dx
tx
```
gallstones (in gall bladder)
-mixed (cholesterol) Green - fat forty fertile female fNative American
-pigmented (hemolysis) Black
-colicky abdominal pain (when gb contracts on stones) ruq radiating to shoulder, worse w fatty foods
-RUQ US
-ELECTIVE cholecystectomy
ursodeoxycholic acid if not a surgical candidate
66
in GENERAL, when is US a helpful test
when soft tissues of different densities - e.g. soft tissue vs fluid
e.g. spongy liver (solid ish) vs gallbladder (liquid)
67
```
cholecystitis
define
path
pres
dx
tx
```
-inflammed gallbladder
-gallstone blocking cystic duct (gb to cbd)
-- pericholycystic fluid, thickened wall, gallstones
-Constant pain(blocked... inflamed (not colicky - that is cholelithiasis gallstones In gallbladder only hurt when gallbladder contracts for food espec fatty food)... Murphy sign positive, Iinflammation so Febrile and Leukocytotic
-RUQ US - pericholycystic fluid, thickened wall, gallstones
---HIDA scan (if ruq us equivocal but still suspicious) shows no gallbladder as cystic duct blocked by stone not patent
-NPO IVF IVabx, URGENT cholecystectomy (w/in 72 hours before gb perfs or inflammation makes impossible to visualize well for surg)
cholecystostomy if not a surgical candidate
68
RUQ US in cholecystitis
pericholycystic fluid
thickened wall
gallstones (although rarely see Obstructing stone itself in cystic duct
69
HIDA scan
stands for
use
aka
```
hepatobiliary iminodiacetic acid scan
--of liver, gb, biliary tree, small intestine
cholescintigraphy
hepatobiliary scintigraphy
hepatobilliary scan
```
70
how does HIDA scan work
Technetium labeled hepatic iminodiacetic acid (HIDA) is injected intravenously and is then taken up selectively by hepatocytes and excreted into bile
-to visualize liver, gb, biliary tree, small intestine
71
```
choledocolithiasis
define
path
pres
dx
tx
```
gallstone in CBD common bile duct
Obstructive Painful jaundice, transaminitis, amylase, lipase up (if gallstone pancrea) Murphy pos, mild fever and leukocytosis
-RUQ US
MRCP if equivocal
-npo IVF abx (cipro/flagyl or amp-gent/flagyl for gnr/anaerobe coverage) - ERCP urgently to get stone, w later cholecystectomy
f/u Bull-Valve... stone blocks, jaundice, transaminitis, pain... unlblocks, goes away allows vs obstructs flow alternately... if turns out was choledocholithiasis w stone that passed spontaneously can watch and wait w serial LFTs, w elective cholecystectomy down the road, ercp if recurs
72
```
cholangitis
define
path
dx
tx
```
inflammation of biliary tree
-gallstone stasis in cbd w infection (gut GNRs and anaerbes
-RUQ pain, PAINFUIL jaundice, fever
(charcot's triad)
add hypotension and AMS (raynaud's pentad)
-RUQ US - obstruction..
-IVF (septic)
IVabx (cipro/flagyl or amp-gent/flagyl for gnrs and anaerobes)
NPO
ON WAY to EMERGENT ERCP to get stone out and cholecystectomy now or later
73
charcot's triad
RUQ pain,
jaundice
fever
(for cholangitis)
74
raynauds pentad
RUQ pain,
jaundice
fever (charcot's triad)
w hypotension and AMS (raynaud's pentad)
75
tf
| use zosyn for cholangitis
f
...even though sen in hosp, easy, convenient
(overcoverage (strep, pseudomonas), only need enteric GNRs and anaeriobes -- cipro/flagyl or amp-gent/flagyl)
76
name different gallstone pathologies according to location
cholelithiasis (in gb)
cholecystitis (in cystic duct)
choledocolithiasis (in cbd)
cholangitis (in cbd w infaction/inflammation)
77
tf
| ascending cholangitis can cause pyogenic abscess in liver
t
| if ascends far enough an infectios (eg in setting of choledocolithiasis or cholangitis
78
```
path
pres
dx
tx
pyogenic abscess of liver in cholangitis
```
choledocolithiasis causes cholangitis,
ascends into liver - pyogenic abscess
-IV abx for cholangitis switched to PO for home, returns 2 days later febrile and leukocytotic (abscess reveals when IV abx stopped... iv abx partially treat and po abx do less)
-RUQ US
-percutaneous drainage (will give iv abx too but insufficient to cure)
79
treat echinococcus cyst
```
resect it
(risk cyst rupture and anaphylaxis if try percutaneous drain)
```
80
for what kind of abscess do yo give metronidazole alone
entamoeba histolytica abscess
| make sure to draw titer before giving abx
81
when to get MRCP before ERCP
for choledocolithiasis (stone in cbd) - causing PAINLESS JAUNDICE
NOT for cholangitis (inflammed cbd)
--go straight to ERCP
82
when to do percutaneous drainage or ex lap for cholangitis
can consider if ERCP fails or is not possible...
83
mexico plus liver abscess ...
```
entamoeba histolytica
(gets into biliary tree and embeds in liver forming abscess)
-treat with metronidazole (one abscess you don't drain!)
```
84
tf
| aspirate entamoeba histolytica liver abscess prior to starting metronidazole
f
draw a titer first (blood titer?)
no aspiration
just metronidazole
85
tf
| resect entamoeba histolytica liver abscess
f
resect echinococcus cyst (may rupture and spill into anaphylaxis if try to aspirate)
metronidazole for entamoeba histolytica abscess (no drainage necessary)
86
tf
| you can culture and amoeba
f
87
why might sickle cell be relevant in a gallbladder patient
risk for pigmented gallstones (hemolysis)
88
what characteristics of lumph nodes on exam suggest breast cancer
firm fixed axillary nodes
89
risks for breast cancer
estrogen exposure
-early menarche late menopause, nulliparity, hormone replacement therapy (not ocp's, lower than endogenous exposure?)
chest radiation for lymphoma
brca1/2 genes (and fh otherwise)
90
screen for breast cancer
mammogram start age 50 q2yrs (uspstf... 2017) - best answer
per clinical societies, can consider start age 40 q1y
MRI for high risk only (brca1/2, chest radiation for lymphoma, very positive family history maybe)
not self exams -- too sensitive, false positives, morbidity and cost of workup
likewise no clinical breast exams for screening
91
best test for breast cancer screening
MRI
but very costly, reserved for high risk only (brca1/2, chest radiation for lymphoma, very positive family history maybe)
otherwise mammogram screening is standard
start age 50 q2yrs (uspstf... 2017) - best answer
per clinical societies, can consider start age 40 q1y
92
screening vs diagnostic mammogram
pt asymptomatic
vs has lump or obvious cancer
93
diagnose breast cancer
positive mammogram
core biopsy
if v30yo, us shows
mass - prob ca get core bx
or cyst -- fna shows blood
get core biopsy?
94
ddx breast cyst by fna
bloody - prob cancer, get core bx?
pus - abscess
fluid - benign
95
breast lump in woman v30yo how to proceed
monitor over 1-2 more menstrual cycles
if persists, us
mass (may be cancer, get core bx)
cyst - fna - if bloody, may be cancer, get core biopsy?
if resolves w menstrual cycling or fluid cyst on fna, don't worry any further
96
which is more effective local tx for breast cancer
mastectomy w axillary ln dissection
or
lumpectomy w axillary ln dissection and radiation
similar efficacy
aka lumpectomy plus radiation = mastectomy
get sentinal ln bx and depending acillary ln dissection with both
97
what to get before axillary lymph node dissection for breast cancer
positive sentinel node bx
otherwise morbidity of lymphedema not worth it
98
typical non-targeted chemo regimen for breast cancer
doxo
cyclo
pacli
doxorubicin/danorubicin
(get periodic echo to check for dose dependent irreversible chf)
cyclophosphomide
paclitaxel
99
targeted therapies for breast cancer
traztuzumab if her2neu positive (watch non dose-dependent reversible chf w echos)
tamoxifen or raloxifen (SERMs) if ER PR positive and premenopausal
aromatase inhibitors (anastrozole) if ER PR positive and postmenopausal
100
difference between chf side effect from
doxo/danorubicin
vs
traztuzumab
doxodano dose-dependent, irreversible... so periodic echos to monitor, stopping will halt progression but not reverse
traztu non dose-dependent, reversible... so monitor w echos and will likely recover if stopped
101
manage brca1/2 positive pt
prophylactic bilateral mastectomy and salpingoopherectomy
or else annual mri and mammogram to screen
102
tamoxifen vs raloxifen
| key differences
tamoxifen stronger efficacy but se's dvt and endometrial cancer
(breast er antag but endometrial er ag)
raloxifen weaker efficacy but not the se's
103
neoadjuvant vs adjuvant chemo for breast cancer
define the difference
neoadjuvant for higher grade to shrink before surgery
adjuvant after to supress mets... after surgery
104
is her2neu posotivity better or worse for breast cancer prognosis?
worse
even though succeptible to traztuzumab targeted therapy
105
when are serms and aromatase inhibitors combined for tx of breast cancer?
never
eg never raloxifene plus anastrozole
ramoxifen raloxifene for er pr pos pre menopausal
anastrozole for er pr pos post menopausal
106
doxorubicin and danorubicin belong to this class of drugs
anthracyclines
107
woman on doxorubicin and traztuzumab among others for systemic tx of breast cancer, gets heart failure after 2 rounds of chemo, which drug is responsible?
traztuzumab
-dose-independent, reversible chf... so can get early and unpredictably after few doses
doxo dano dose-dependent, non reversible... get more chf w more doses
108
biggest side effect of cyclophosphamide
hemorrhagic cystitis
109
paclitaxel side effects
| and how to mitigate
typical chemo hair loss diarrhea nausea vomiting
dexamethasone
ondansetron (or other setrons)
110
what kind of lymphoma is most often the reason for chest radiation and increasing risk of breast cancer?
hodgkin lymphoma
111
tf
| pet ct and ct ab pelv to stage breast cancer
f
sentinal ln bx
if pos followed by axillary ln dissection
to stage breast cancer and determine tx, because w breast ca, ct usually positive only when mets already obvious... by h and p?
but most other cancers ct is used to stage
112
pancreatitis
pres
dx
tx
-epigastric andominal pain boring to back
worse w spine ext ab stretched
nausea vomiting
-lipase better than amylase-p even,
ct if enzymes equivocal and strong suspicion, or if get sick as shit, hypotensive, septic w fevers and leuko, or early satiety weight loss w cont abdominal pain
ruq us next day after starting mgmt, and triglycerides to eval for risks (alcohol, gallstones, hypertriglyceridemia)
- npo ivf pain mgmt
- if soon hours to days sick as shit hypotensive think necrotizing, icu, necrosectomy, imipenem if infection on fna
- if days to weeks later fev leuko septic think abscess abx i and d
- if early satiety weight loss think pseudocyst (v6wk6cm wait and watch uncomplicated, ^6wk6cm drain complicated)
-if chronic pancreatitis may need pain mgmt enzymes endo and exo etc but surgery not really and option taking out pancreas just makes worse
113
top risk factors for pancreatitis
alcohol, gallstones, hypertriglyceridemia, medication side effects
trinidadian scorpions and black widows
etc
114
when to get ct for pancreatitis
not usually
can usually dx by h and p amd lipase better than amylase
ct if enzymes equivocal and strong suspicion, or if get sick as shit, hypotensive; septic w fevers and leuko; or early satiety weight loss w cont abdominal pain
115
when surg for pancreatitis
when complocated
- npo ivf pain mgmt
- if soon hours to days sick as shit hypotensive think necrotizing, icu, necrosectomy, imipenem if infection on fna
- if days to weeks later fev leuko septic think abscess abx i and d
- if early satiety weight loss think pseudocyst (v6wk6cm wait and watch uncomplicated, ^6wk6cm drain complicated)
-if chronic pancreatitis may need pain mgmt enzymes endo and exo etc but surgery not really and option taking out pancreas just makes worse
116
pancreatic pseudocyst
| define
circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue, typically located in the lesser sac of the abdomen. usually complications of pancreatitis, although in children they frequently occur following abdominal trauma
-classically occur 1-2 weeks after pancreatitis, can cause early satiety and palpable mass, no fev or leuk
117
presentation of necrotizing pancreatitis
| and tx
occurs within 2 days of pancreatitis
climbing hb (hemoconcentration)
falling calcium (saponification)
ards (inflammation)
hypotension (fluid collection 3rd spacing)
maybe fev leuk
tx w imipenem if infection on fna, necrosectomy
118
hemorrhagic pancreatitis
pres
tx
```
pretty sick within 2 days of pancreatitis
hypotension
anemia not hemoconc like necrotizing
no fev leuk
tx supportive care
```
119
chronic pancreatitis
time course
tx
years after acute episode
more likely w more past bouts of acute pancreatitis
may need pain mgmt enzymes endo and exo etc but surgery not really an option taking out pancreas just makes worse
120
pancreatic adenocarcinoma
| pres
usually no sx
may cause weight loss, painless jaundice, clay colored stools
may precipitate acute pancreatitis
ct scan shows mass, usually on pancreatic head if symptomatic
no fev leuk
-usually mets by the time found
121
define uncomplicated pancreatitis and treatment
```
normal vitals and labs (aside from lipase 3x uln)
just pain sx
pain mgmt
npo for bowel/pancreatic rest
ivf
```
122
how to diff hemorrhagic from necrotizing pancreatitis
anemia vs hemoconcentration
123
when cefipime for pancreatitis
when necrotizing and infection on fna
| -can give iv cefipime or a carbapenem like imipenem
124
goal of ct for pancreatitis
to assess complications
not routinely used for uncomplicated pancreatitis
125
pancreatic pseudocyst
pres
tx
early satiety and weight loss
2 plus wks after pancreatitis
ct ab demonstrates
if v6cm6wks repeat ct at 6 wks to check for resolution
if ^6cm6wks drain it (ct guided drainage or endoscopic cystogastrostomy)
126
when endoscopic us w biopsy of pancreas
assess multiple smaller pseudocysts or ro cancer
127
when is radical pancreatectomy the answer
never
(per med ed)
can resect pieces... pseudocysts ot necrosis... taking the whole thing out just makes things worse... don't even do for chronic pancreatitis
128
normal lipase and amylase
lipase 0-160
amylase 23-85, as high as 140
may depend on specific lab a bit
129
pt going into ards from necrotizing pancreatitis
| go
intubate and peep
central access for pressors
then ct for extent of nec
fna - iv meropenem if infected
(iv vanc/piptazo if hap)
130
what does ards from pancreatitis look like on cxr
bilateral pulmonary edema
131
lipase level in chronic pancreatitis
often normal
132
sign of
| failure of exocrine and endocrine pancreatic function
diabetes
steatorrhea
pancreatic calcifications
133
sticky stools difficult to flush in context of pancreatitis suggests
steatorrhea from failed pancreatic exocrine function
134
dx chronic pancreatitis
clinical
| supported w ct for calcification and shrinking of pancreas
135
when is mrcp w ercp the tx for pancreatitis
maybe for cheonic pancreatitis to see if can stent a duct open
but evidence not great yet, alc cessation and lain control is still best answer on test
136
when endoscopic us for pancreatitis
after ct demonstrates accessible lesions of concern
| to assess smaller pseudocysts or rule out cancer
137
tf
| get amylase and lipase for chronic pancreatitis
f
will be normal in chronic
(may be high if acute on chronic)
138
when to get abdominal us of pancreas
not usually,
poor for visualizing pancreas
endoscopic us better but invasive, only for eg accessible lesions on ct - characterize smaller pseudocysts, ro cancer
139
writhing inability to get comfortable in pain suggests
obstruction or inflammation
140
classic presentation of nephrolithiasis
flank pain radiating to groin, no mass, hematuria
141
define obstipation
severe or complete constipation
142
classic presentation sbo
| imaging
colicky abdominal pain
distension
obstipation
xr w dilated loops of bowel
143
suspect kidney stone
| next step? IVF? urine microscopy?
noncon CT AP
(because can eval size of stone and impact on ureters (hydroureter/hydronephrosis...)
can use US eg if pregnant and see hyrdro from obstructing stone
144
50 F RUQ P and TTP nausea slight leuk, lft's normal
3 ddx
2 studies
3 compx
*cholecystitis, pud, pancreatitis
RUQ us, HIDA scan
gallstone ileus
acute pancreatitis
Mirizzi syndrome (gallstone impacted on cystic duct or neck of gb compressing cbd or chd -- obstruction, jaundice
