Gen surg 2/22/17 Flashcards
3 general types of pain
somatic (problem with tissue, eg skin, can pinpoint)
visceral (no pain receptors, hijack nerves associated w skin dermatome of embryological origin
neuropathic (problem with nerve… burning pins and needles tingling)
why kick in nuts hurts in abdlomen
testicles start in abdomen
visceral pain referred to dermatome of embryologic origin
colicky abdlominal pain think…
obstructive
hurts w peristalsis
(cholelithiasis, nephrolithiasis)
-writhing, no comfortable position
obstructive visceral pain
describe
colicky
(hurts w peristalsis)
(cholelithiasis, nephrolithiasis)
-writhing, no comfortable position
types of abdominal pain
and descriptions
obstructive - colicky (w peristalsis), writhing no comfortable position (chole nephro lithiasis)
inflammatory - constant, no comfortable position, fev leuk (cholecystitis pyelonephritis)
perforated - sick as shit, constant, motionless (peritoneal irritants settle and desensitize if motionless) free air on xr (pud cancer penetrating trauma)
ischemic - pain out of proportion to exam (tons of pain, little tenderness) bloody bms, sepsis (CAD Afib mesenteric ischemia)
referred…
RUQ pain anatomic structures
lung
diaphragm
liver
gallbladder
LUQ pain anatomic structures
lung
diaphragm
spleen
RLQ pain anatomic structures
kidneys ureters
ovaries testes
colon (appendix)
LLQ pain anatomic structures
kidneys ureters
ovaries testes
colon (sigmoid diverticulitis)
cirrhotic ascitic patient gets peritonitis
how
diagnose
treat
sbp spontaneous bacterial peritonitis in ascetic patient for whatever reason - fluid sitting there with low flow great for bacteria
diagnostic paracentesis - cx (low yield) and WBC (250 polys makes dx)
ceftriaxone, or fluoroquinolone if low serum protein or prior sbp (a peritonitic pt who does NOT need surgery) .. unless evident that viscous has perforated (multiple organisms in paracentesis)
tf
cirrhosis is contraindication to ex lap
t
high risk of death, do everything to avoid operating on cirrhotic pt (but must operate if perforated viscus)
tf
ruq us for cirrhotic ascetic peritonitic
f
diagnostic paracentesis to cx (low yield) and wbc (^250 polys diagnostic)
clinical pancreatitis - nausea vomiting epigastric pain to back after alcohol binge not remitting
next step
lipase
(just dx before tx)
then ivf npo ngt
air under diaphragm
what does it mean
ruptured hollow viscus, peritonitis, acute abdomen
all mean EX LAP
treatment for severe bleeding gastric ulcer
intravenous omeprazole
permits ulcer healing
tf
gastric ulcers can perforate
t
rebound, guarding, motionless, diaphoretic, pale, toxic appearing
next step
ex lap (acute abdomen gets ex lap)
endoscopy of ruptured peptic ulcer for…
DONT do it! insufflation will make worse
tf
perfed ulcers bleed
f
perfed ulcers perf
bleeding ulcers bleed
bowel obstruction on ct
distended abdomen and multiple loops of bowel with air-fluid levels
Multiple air fluid levels and obstipation are indicative of
bowel obstruction
tf
localized peritoneal signs are consistent with diverticulitis
t
eg llq pain when palpated on r,
rebound tenderness on ll1 when released on r
dx diverticulitis
CT w IV contrast
typical abx for diverticulitis
cipro/flagyl
gnrs/anaerobes
risk of perforating active diverticulitis on colonoscopy
huge
don’t do it till 2-6 wks resolved
elevated lactic acid means
tissue is dying somewhere
measure of poor perfusion
best test and first test in emergency situation where lactate is elevated and aterial occlusion is most likely, how to dx
mesentery angiography
ct ab can see
free air
stones
masses (poorly)
dilated bowel
w con can see
-arterial and venous thrombosis in addition
work up thyroid nodule
get tsh, RAIU vs US
- if TSH low, prob low risk hot nodule, double check w RAIU scan,
- –if hot hyperfunctioning nodule, resect
- –if cold nonfunctioning, us + FNA, if cancer surgery, if non cancer q6mo checks us, if equivocal FNA again or a few months down the line
if TSH high prob nonfuncitoning not good
-us-
if ^1cm it is large get FNA if cancer operate if not q6mo checks ish
if v1cm small can check up q6mos w us
what does gastrin do
tell parietal cells to make acid
gastrinoma path pres dx tx
pud not improved w ppi
(gastrin just telling parietal cells to make too much acid)
virulent ulcers, diarrhea (it’s a stimulant…)
- gastrin level (off ppi’s!) slightly elevated into triple digits
- secretin stim test (secretin should turn off parietal cells, does not work on gastrinoma) inc gastrin when secretin given
- if positive secretin stim test or way elevated gastrin 4 digits off the bat get secretin receptor scintography or CT scan (something to localize)
and cut out - because can cause transform into malignant gastric cancer
insulinoma path pt dx tx
tumor secreting insulin
hypoglycemia (diaphoresis
presynchope, tachycardia)
elevated insulin
c-peptide elevated
sulfonylurea screen
ct scan```
sx of hypoglycemia
diaphoresis
presynchope
tachycardia
glucagonoma path pres dx tx
- gulcagon
- MIGRATORY NECROLYTIC NONTOXIC DERMATIITS
- glucagon level
- CT scan to localize
resect
migratory necrolytic nontoxic dermatitis think
glucagonoma
get glucagon level
get ct
resect
primary hyperparathyroidism
pres
dx
tx
^Ca vPhos ^PTH
bone pain
eventually osteofibrosis cystica
sestamibi scan identifies hyperfunctioning gland
- you go cut it out
- but f/u postop hypocalcemia (perioral tingling, treusseau’s sign (elb flex wrist prone flex w bp cuff), chvostic sign (failure of facial nerver reflex to dull over time)
- give IV calcemia till remaining parathyroid glands wake up (were atrophic and suppressed by hyperfunctioning gland)
secondary hyperparathyroidism is a product of
ckd
so not the one surgeons operate on, they remove primary hyperparathyroidism
how does PTH affect
calcium
phosphorus
Ca goes up
resorbs bone
absorbs from gut
resorbs from kidney
Phos goes down resorbs bone absorbs from gut EXCRETES from KIDNEY -kidney always wins
perioroal tingling and trousseau sign after parathyroidectomy
next step
give IV ca gluconate
(don’t wait to draw ionized calcium level, but get those routinely going forward till other parathyroid glands wake up and get homeostatic calcium)
how does hyperventilation cause hypocalcemia
respiratory acid H+ blown off frees up binding sites on albumin Ca++ binds ionized calcium drops can become symptomatic (perioral tingling, chvostek, trousseau sign)
treat follicular thyroid cancer
thyroidectomy
radioactive iodine
(acts just like parenchyma so will take up thyroid)
treat anaplastic thyroid cancer
rapidly fatal, occurs in elderly
external beam radiation
tf
thyroid lobectomy for follicular thyroid cancer
f
thyroidectomy and radioactive iodine
(because difficult to differentiate follicular thyroid cancer from normal thyroid, need to get whole thing out)
how much t3 vs t4 does the thyroid make
and which is more metabolically active
17x more t4 than t3
t3 is 5x more metabolically active
thyrotoxicosis vs hyperthyroid
thyrotoxicosis is a general term for too much thyroid hormone
hyperthyroid is thyrotoxicosis specifically coming from the thyroid gland
general function of thyroid hormone
movement metabolism mentation
first test for hyperthyroid
best test
tsh, free t4 (low, high… unless rare central hyperthyroid from pituitary… then both high)
RAIU scan
graves - diffuse enlarged toxic
thyroiditis - cold not making t4 during hyperthyroid inflammatory spilling
multinodular goiter - multille hot nodules suppressing the rest
toxic adenoma - single hot nodule suppressing the rest
factitious - cold from exogenous t4
struma ovarii - cold from ovarian t4
how does RAIU scan work
uptakes radioactive iodine wherever thyroid hormone is made
graves disease path pres dx tx
-autoimmune tsh receptor stimulating antibodies
-hyperthyroid - tachyc maybe afib diarrhea heat intolerance inc DTRs weight loss
exopthalmos pretibial myxedema from antibody deposition
-tsh free t4 as with any hyperthyroid down up
raiu diffusely enlarged and hyperactive
thyroid stimulating antibody test
-unlike other hyperthyroid responds well to thionamides (ptu - blocks thyroxine-triiodothyronine conversion in periph, or methimazole - blocks oxygenation of iodine therby th synthesis in thyroid gland)
radioactive iodine and surgery
(but watch out if exophthalmos and pretibial myxedema because rai may make worse… then needs steroids and surgery nit rai and surgery)
thyroiditis path pres appearance on RAIU scan prognosis
-inflammation of thyroid gland
-spills t4 for transient hyperthyroidism
painful thyroiditis = dequervains subacute granulomatous or infectious thyroiditis
painless thyroiditis = usually hashimoto’s or otherwise autoimmune
-RAIU cold because not making new t4 during inlammatory period
-return of function vs shrivel up and die loss of function (hashimoto’s)
multinodular goiter vs toxic adenoma
multiple small toxic thyroid nodules
single large toxic nodule
easy to see on RAIU scan because active nodules suppress tsh amd activity of the rest of the gland
factitious disorder vs struma ovarii
taking exogenous t4 eg healthcare worker with access trying to lose weight
vs toxic thyroid nodule on ovary
so if female and suspect factitious, get raiu scan of pelvis to r/o struma ovarii
thyroid storm
sx
tx
afib/shock (not just hyperthy tachy)
hypotensive (too tachy)
ams
fever ^104
storm cloud cold ivf and cold blankets to reduce temp and hopefully hypotension
lightning bolt beta block (propanolol), ptu methimazole thionamides, steroids to further reduce peripheral conversion of t4 to t3
treat hyperthyroid
can use thionamides ptu or methimazole to control, may lit graves in remission, but most will need removal instead of lifeling medical management
rai for multinodular goiter and toxic adenoma and struma ovarii
rai for graves too, but can do thyroidectomy eg if exophthalmos severe… but can pretreat with steroids to reduce exacerbation of exophthalmos w rai…
ride thyroiditis out i think w supportive care… stop exogenous t4 if factitious
thionamides
moa
use
ptu - blocks thyroxine-triiodothyronine conversion in periph
methimazole - blocks oxygenation of iodine therby th synthesis in thyroid gland
medical mgmt of graves can put in remission, but most graves will need thyroidecotmy and other hyperthyroidism will need rai ablation
hypothyroidism path pres dx tx
-iatrogenic (thyroidectomy for graves, rai for toxic nodules, struma ovarii) hashimotos (autoimmune thyroiditis transient hyperthyroid then shrivel and die) other causes -- don't really matter, dx ant tx the same -bradycardia constipation cold intolerant dec DTRs weight gain -tsh free t4 (high low... unless rare pituitary cause both low) anti-TPO antibody to dx hashimotos -levithyroxine... give what they don't got if subclinical (high tsh but no sx).. treat (give levothyroxine) if tsh ^10
myxedema coma path pres dx tx
-severe hypothyroidism
(aka the opposite of thyroid storm)
-coma, hypothermia, hypotension
-warm ivf, Normal blankets (warm blankets in hypothermia could cause peripheral vasodilation and hemodynamic collapse), get tsh free t4 (high low), give IV T4 and if necessary IV T3
2 keys to remember in rai tx for graves
- likely to develop hypothyroidism as whole gland is uptaking
- likely to worsen ophthalmolathy so can pretreat with steroids
how to distinguish thyroiditis from factitious (both are cold on RAIU)
thyroglobulin
- high in thyroiditis because spilling with th
- low in factitious because exogenous t4 circumvents thyroglobulin formation
beta blocker for thyroid storm only or for hyperthyroid too?
give for hyperthyroid too, while geting to controlling otu or methimazole or getting to definitive rai or thyroidectomy
sestamibi scan vs raiu scan
sestamibi… nuclear imaging thay identifies ECTOPIC PARATHYROID tissue in body… not thyroid…
normal range tsh
normal range T4 thyroxine
.5-6 tsh
4.6-12 t4
often the first temporizing treatment for hyperthyroidism as diagnosis is being worked up
beta blocker (propanolol)
eurhyroid sick syndrome path pres dx tx
just from being sick, not a thyroid disorder, slightly low but not critically low t4 and tsh eg in an icu patient who had these labd drawn to rule out myxedema coma or hypothyroidism otherwise (those would look like low t4 high tsh)
rT3 (high) … because the enzyme that breaks t4 into t3 into t2 and rt3 to t2 to clear them is inhibited in sickness espec in hypoxia or ischemia… thus rT3 can help distinguish euthyroid sick syndrome from central hypothyroidism (from pit)
no levothyroxine necessary – only if deemed hypothyroid or myxedema coma (then iv t4 or if necessary t3)
bruit over neck in setting of hyperthyroid suggests…
graves
diffuse active enlargement
why is it called myxedema coma
myxedema just a synonym for hypothyroidism here
different and confusing use of word vs dermatologic pretibial myxedema in graves hyperthyroidism
warm blankets for hypothermia?
no
can cause peripheral vasodilation and hemodynamic collapse
use normal blankets
pressors for hypotension bradycardia in myxedema coma?
careful
will need iv t4, simultaneous pressors can cause arrhythmia
prefer warm ivf, normal blankets, iv t4 should get her hemodynamics up
dequervains
hashimotos
silent lymphocytic thyroiditis
how to differentiate
all have similar labs and raiu
dequervains is painful
hashimotos has anti-tsh receptor antibodies
silent lymphoxytic is like hashimotos wothout antibodies
medically manage hyperthyroidism in pregnancy
Ptu in Pregnancy
not such a hard and fast rule anymore, but choose ptu over methimazole if faced with the choice
if peritoneal signs…
go to the OR
peritoneal signs
involuntary guarding
(bump bed)
rebound tenderness
(tap at nontender point, pain at tender point)
tf
local peritonitis without systemic signs is possible
t
can have physical exam involuntary guarding and rebound tenderness without fever and leukocytosis and toxic appearance
obstipation
fecal impaction hardened stool stuck in lower colon and rectum from chronic constipation
ligament of Trietz
aka “suspensory muscle of duodenum”
thin muscle connecting the junction between the duodenum, jejunum, and duodenojejunal flexure to connective tissue surrounding the superior mesenteric artery and coeliac artery. Most often connects to both the third and fourth parts of the duodenum, as well as the duodenojejunal flexure, although the attachment is quite variable.
marks formal division between first and second parts of the small intestine, the duodenum and the jejunum. Difference between the upper and lower gastrointestinal tracts,
SBO path pres dx tx
-most commonly ADHESIONS in pt w surgical hx, HERNIAS in pt without surgical hx
-COLICKY (peristaltic) abdominal pain
flatus and bm’s to OBSTIPATION
brorborygmi to SILENT
abdominal distension
-upright KUB (air-fluid levels)
CT w PO contrast (small contrast makes to colon partially obstructive, none makes it complete obstruction)
-WATCH and wait w NGT SUCTION, IVF, MONITORING (eg K+ repletion as needed) if PARTIALly obstructed
SURGERY if COMPLETE obstruction, if no improvement in 3 DAYSconservative for partial, f partial becomes PERITONEAL sign positive
4 types of hernias by geography
direct inguinal - adult men, through transversalis (not inguinal canal), but inguinal region
indirect - baby boys, through inguinal ring into scrotum
femoral - females (FEMoral HERnia), under inguinal ligament into thigh
ventral - iatrogenic (eg postop)
4 types of hernias by severity
tx
reducible - elective surgery
irreducible - elective surgery
incarcerated - urgent surgery
incarcerated w peritoneal signs - emergent surgery
why does our appendix exist
to get blocked by a fecolith and give us appendicitis… has no helpful purpose
why do we perform appendectomies
if appendix bursts can be life threatening
McBurney’s point
1/3 distance from ASIS to umbilicus
appendiceal pain localizes here after period of non-specific periumbilical pain
appendicitis path pres dx tx
fecolith block, inflammation
periumbilical pain localizes to McBurney’s point 1/3 distance ASIS to umbilicus (pathognomonic), maybe anorexia n/v, peritoneal signs if late
clinical dx, may get ct in 15 minutes it takes surgeon to get to ED
appendectomy
carcinoid tumor of the small intestine path pres dx tx
-neuroendocrine serotonin secreting tumor, only symptomatic if mets to liver because liver breaks down serotonin
-serotonin flushing wheezing diarrhea
R sided cardiac fibrosis (because lung breaks down serotonin too)
- check urine for 5-HIAA (breakdown product of serotonin)
- CT scan, resect
where is serotonin broken down
liver and lungs
if you see 5-HIAA in an answer choice
look for carinoid tumor because that is an easy question to get
GI bleed common causes
epistaxis (bloody nose, not true gi bleed)
PUD *most common GERD upper GI cancer varices Mallory-Weiss / Boerhaave upper GI AVM dielafoy congenital lesion
diverticular bleed *most common
hemorrhoids *most common
lower GI cancer
lower GI AVM
vocabulary of GI bleeds on presentation and do they mean upper or lower
hematemesis - upper
melena - more likely upper but not always
hematochezia - more likely lower but not always
define upper vs lower GI
above ligament of Treitz
(duodenum and above)
below ligament of Treitz
(jejunum and below)
GI bleed diagnostic workup
regardless of source
2 large bore ivs, ivf, ivppi, type cross transfuse, call gi, octreotide, ceftriaxone, egd, colo vs arteriogram embolization vs tagged rbc scan vs pill-cam endoscopy
-stabilize - 2 large bore (18 guage) peripheral (short better than long central) IVs for rapid infusion/transfusion
IVF IVPPI (will help most common cause of upper, PUD… will not hurt lower)
type and cross, transfuse as necessary
call GI
-octreotide if cirrhotic (SS analogue… reduces portal pressure and variceal hemorrhages)
-ceftriaxone to ppx for spontaneous bacterial peritonitis
EGD - will find upper GI bleed, blood will not obscure like colonoscopy
if EGD negative, thinking lower GI bleed
- colonoscopy if bleeding has stopped (can’t visualize through active bleed)
- arteriogram to ID bleed and embolize if bleed brisk
- tagged RBC scan if bleed moderately brisk
- pill-cam endoscopy if all else negative
tf
NG tube lavage part of diagnostic workup for GI bleed
not diagnostic workup
but prognostic
-if positive for blood can repeat to see if bleeding has stopped
but 30% of upper GI bleeds negative on ng tube lavage
- so prefer EGDfor upper GI bleed
- colonoscopy (not actively bleeding), arteriogram and embolization (brisk bleed), tagged RBC scan (moderate bleed), pill-cam endoscopy (all else fails to dx) for lower GI bleed
esophageal varices path pres dx tx
portal htn (liver failure) – engorgement of portosystemic shunts vasculature
vomiting, bleeding (not self-limiting, can be fatal), hematemesis, melena ?
NGT pos for blood
EGD definitive dx by visualizaion
octreotide (decreases portal pressure)
endoscopic cautery, banding, baoon tamponade
TIPS
low dose propanolol can shrink varices
TIPS
why is it called that
transjugular intrahepatic portosystemic shunt
transjugular because IR entry via jugular vein
sheath and guidewire passed to hepatic vein, path to intrahepatic portal vein created
mallory weiss tear path pres dx tx
tear in GE junction mucosa from vomiting
one-time vomiters eg drinking binge, hematemesis, usualy self-limiting
EGD if pt presents w active bleeding
Boerhaave syndrome path pres dx tx
transmural tear in GE junction
like sick Mallory-Weiss - alcoholic or bulimic career vomiter w hematemesis, fever, leukocytosis, esophageal crepitus
Hamman’s Crunch - crepitus w each heartbeat - pneumomediastinum
gastrografin swallow (water soluble, less harsh on mediastinum)
barium swallow
EGD
emergent surgery
Doeulafoy's lesion path pres dx tx
anatomic variant of superficial artery in cardia of stomach (esophageal inlet)
sudden massive upper GI bleed from easy erosion by gastritis or ulcer
GIB workup - 2 large bore ivs, ivf, ivppi, type cross transfuse, call gi, octreotide, ceftriaxone, EGD
subtotal gastrectomy
cardia of stomach
first portion of stomach… esophageal inlet
esophagitis can it cause gi bleeds common causes dx tx
can cause GI bleed -- especially as progresses to cancer GERD #1 (antacid...) CMV, HERPES (gancyclovir, foscarnet) Candida (nystatin) HIV (HAART)
via EGD bx, culture
gastritis / peptic ulcers path pres dx tx
1 cause of upper GI bleed
NSAIDs - multiple shallow ulcers
malignant - heaped up margins, necrotic core
acid-induced - can erode into blood vessels
EGD
PPIs, resection
colitis as cause of GI bleed
pres
dx
tx
bloody diarrhea
biopsy via EGD tp dx
stool cx to r/o infectious cause
control w steroidds
diverticular hemorrhage path pres dx? tx
more L than R rupture of arteriole at dome of diverticulum massive lower GI bled, hematochezia dx? resection, cautery
cancer as casue of GI bleed
basic path pres dx tx
UGIB in stomach or esophagus LGIB in colon endoscopy w biopsy to dx stage w PET CT resect or chemo,radiation
mesenteric ischemia path pres dx tx
"gut attack" "heart attack of gut" from atherosclerosis or afib prandial-induced "intestinal angina" consequent weight loss pain out of proportion with exam (very late, perfed if exam positive or blood in stool)
angiogram
resection
ischemic colitis
path
pres
dx
ischemia at watershed areas of colon during hypotension
pain, self-limiting bleed
colonoscopy (can do as bleed self-limiting)
ischemic colitis vs mesenteric ischemia
ischemia from hypotension
vs ischemia from afib thromboembolism or atherosclerosis - “intestinal angina” with prandial food digestive workout
LFTs in viral vs etoh hepatitis
Viral Hepatitis (AST and ALT in the 1000s)
EtOH Hepatitis (AST:ALT > 1.5)
When do you operate on a hernia
Almost all the time -Unless surgery contraindicated eg childs-pugh class c cirrhotic or new heart failure from heart attack)
Even if not incarcerated or strangulated, will not heal on own and may become incarcerated etc, so operate electively when pt younger and healthier and better able to tolerate
-Unless umbilical hernia v2yo can spontaneously resolve gradually
TF
Senna and docusate for SBO
F
Senna motilizes
Docusate bulks
Not what you want for SBO, want bowel rest
Appendicitis localized to mcburney, peritonitic
Abx? CT?
emergent surgery
If waiting for surgeon to show up can give abx and get ct to strengthen workup in meantime but these are not the “next best step” answer
What is a small bowel series
Drink contrast, take series of xrays to see how far it gets
What is a fleet enema used for
Treat constipation or fecal impaction
Before or after digital disimpaction
When to think sbo is complete and in need of surgery
- fails 3 days ish of conservative npo, ngt intermittent suction, ivf
- becomes peritoneal, toxic, bowel sounds go silent
Barium enema evaluates what section of GI
Large bowel
Right sided valvular fibrosis
Diarrhea
Hot flashes/flushing
Next step?
Intestinal Carcinoid
Get Urinary 5-HIAA (serotonin metabolite)
GI serotonin 5-ht secreting tumor that is not symptomatic till mets to liver because serotonin metabolized by liver
R sided valvular fibrosis only because serotonin metabolized by lungs too
Why do boards love carcinoid tumor?
Cancer of intestines
Mets to liver
Affects heart and lungs
Diagnosed with urinary test
Where can Carcinoid tumor occur and how does that change how it affects the heart?
Intestinal carcinoid – R sided valvular fibrosis, once mets to liver (serotonin metabolized by liver and lungs)
Lung carcinoid – L sided valvular fibrosis
If there is an acute abdomen
You operate
Ex lap time
5 things the test is probably getting at with tumultuous ICU course
ARDS nutrition deficiency (low alb low vit K) Polyneuropathy (weak) ICU delirium (ams) Stress ulcers (sudden upper GI bleed)
TF
Everyone should get PPI for ppx of stress ulcers
F
If give to everyone, inc c.diff more than dec peptic ulcers
but DO give PPI ppx to ICU pts on steroids, ventiliated, or in intracranial pressure to avoid sudden UGIB from stress ulcer
what is a Cushing’s ulcer
peptic ulcer that results from increased ICP intracranial pressure
TF
hypotension often leads to gastric necrosis
F
stomach is a central organ, good blood supply (6 sources, great collaterals, can ligate multiple and still perfuse)
... hypotension can cause kidney ischemia (ATN) hepatic ischemia (hepatic necrosis) gut ischemia (mesenteric ischemia)
but rarely stomach ischemia or UGIB upper GI bleed
TF
corticosteroids can reduce risk of UGIB upper gi bleed in acute pancreatitis pt in ICU
F
corticosteroids are risk for peptic ulcer development – eg stress ulcer in ICU
TF
NG tube for UGIB
Fish
not unless ongoing emesis or SBO
-get upper endoscopy -diagnostic and therapeutic can intervene if find something
What is a Blakemore tube and when is it used
Tamponades bleeding varices to prevent death as a temporizing measure, bridge to definitive therapy - eg TIPS for definitive decompresion of varices in cirrhosis
UGIB in cirrhotic think first on ddx…
esophageal varices
the only type of GI Bleeding that will kill someone in hours
esophageal varices
esophageal varices found on EGD, next step
endoscopic variceal banding
-you are in there, varices the only UGIB that will kill you in hours, go ahead and fix it
initial stabilization of any urgent GI Bleed pt should get…
2 large bore IVs type and cross GI consult for endoscopy PPI infusion octreotide if cirrhotic
why should cirrhotic with UGIB get octreotide
slows portal flow, dec variceal bleeding… but pt still needs endoscopy and esophageal banding
TF
Nadolol for UGIB pt, hypotensive, to control rate and myocardial ischemia
F
blunting HR in UGIB will likely cause further hypotension
if there is a GIB… next step…
place 2 large bore IVs
when is BRBPR consistent w UGIB
when Massive UGIB
what does biliary contents on NG tube lavage tell you in patient with large blood loss per rectum
you are getting down to ligament of Treitz (biliary contents)
so no need for EGD, bleed is distal to where you can get – get mesenteric angiography
– i any other situation (not Briskly bleeding, NG tube sample not Perfect…) you Would get an EGD, because negative NG tube lavage turns up positive for UGIB in 30% of pts
when brisk GI bleed known not of upper-source (NGT lavage negative for blood but positive for bile in brisk bleed), what is the next diagnostic step
mesenteric angiography (requires IR, but the only way to prevent ex lap from here)
GI bleed ongoing but not brisk, pt stable, test to get
tagged red blood scan
why is tagged red blood scan not good in unstable pt
because will need to sit in radiology for a while
when is colonoscopy the answer for GI bleed
if bleeding slow or stopped, before resorting to pill-cam endoscopy
(can’t see anything in pipe of red if actively bleeding too much)
when to resort to pill-cam endoscopy for GI bleed
when little to no bleeding… when slight ongoing bleeding likely distal to ligament of treitz but proximal to ileocecal valve, when no other source has been found on other tests
(colonoscopy negative, EGD negative… red blood cell scan negative?)
highest risk factor for thyroid nodule being cancer
radiation head/neck
risk factors for thyroid nodule being cancer
#1 Radiation head/neck Personal hx cancer Family hx cancer Hoarseness (nodule growing into recurrent laryngeal vs airway itself, not good) Young age v20 Old age ^60
physical exam findings of thyroid nodule concerning for cancer
Fixed Firm Hard Non-tender Lymphadenopathy
findings on US concerning for thyroid nodule being cancer
Solid Hypoechogenic Size ^2cm (will Always bx ^2cm... for some types, will bx ^1cm as well) Microcalcifications Irregular borders
findings on
history
physical
US concerning that thyroid nodule is cancer
Radiation To Neck, hx/fh cancer, hoarseness, v20 ^60
fixed firm hard Non-tender LAN
Solid hypoechoic ^2cm (^1cm sometimes) Microcalcifications Irregular borders
thyroid nodule
1st thing to do
TSH
-if hyperfunctioning, low chance it is malignant
aka low TSH is low risk of cancer
f/u w RAIU scan – if confirmed hot nodule, low risk for malignancy, just treat hyperthyroidism (RAI, surg, meds… depending on ID of nodule)
cold nodule on RAIU scan, next step
US - FNA… you are going to biopsy a cold nodule whatever US shows, but will check out w US in course of biopsy…
thyroid nodule, TSH normal or elevated, next step
US (this is a high risk nodule)
if ^1cm, that is big, FNA (unless negative for like every other risk factor)
if v1cm, repeat US in 6-12mos, (unless positive for like every other risk factor)
risk factors head/neck rad, hx/fh cancer, hoarseness, v20 ^60, fixed firm hard non-tender LAN, solid hypoechoic microcalcifications irregular borders
next step for thyroid nodule after FNA
FNA shows…
cancer - surgery
not cancer - US in 6-12 mos
equivocal - repeat FNA, maybe just cut out nodule to check it out, maybe molecular studies or repeat RAIU
workup a thyroid nodule
hx, pe, us for risk factors
TSH
-If TSH low, prob hot, low risk, get RAIU to confirm, if hot, treat (RAI, surg, meds depending)
if cold, US and FNA
-if TSH normal or high, high risk, FNA if ^1cm (unless risk factors like all negative), f/u US 6-12 mos if v1cm (unless risk factors like all positive)
FNA shows cancer - take it out
no cancer - f/u US 6-12 mos
equivocal - repeat FNA, or cut it out, or RAIU
4 types of thyroid cancers
Papillary
Follicular
Medullary
Anaplastic
4 types of thyroid cancers
high yield dx, tx
Papillary
-most common, 85% of thyroid cancers, radiation is risk, Orphan Annie nuclei – resect
Follicular
-best one to have, looks like normal thyroid, spreads hematogenously – but susceptible to RAI ablation
Medullary
-Parafollicular C-cells calcitonin secreting, MEN2A MEN2B syndromes, RET Oncogene assoc, Pheochromocytoma assoc
Anaplastic
-worst one to have, locally invasive, elderly, rapidly fatal (grows fast chokes out trachea and esophagus)
*Think they are all eu or hypoactive nodules…
when to get RAIU for thyroid nodule
if TSH low, probably hyperfunctioning nodule, want to confirm
if TSH normal or high the nodule is high risk, skip RAIU go straight to US, Bx if Size ^1cm + risks, f/u US if v1cm no risks, RAIU if FNA equivocal (or just resect, or repeat FNA)
type of thyroid most associated with radiation therapy
papillary thyroid cancer
thyroid nodule is ^2 cm and apparently hot, w low TSH and hyperthyroid sx
next step?
RAIU
(next step for hot nodule evidenced by low TSH… only reflex bx ^1cm nodule if eu or cold and get US for size)
when RAIU hot toxic then resect RAI ablate or medicate
if RAIU cold eu FNA
when to get MRI for hyperthyroid
pretty much never
can consider MRI of pituitary if TSH and T4 BOTH elevated, or BOTH depressed eg panhypopituitarism… but these rare and unlikely to present with only thyroid symptoms
how does palpation hint at thyroid nodule size
subcentimeter nodules usually not palpable
when to get CT scan for thyroid nodule
not usually needed
may get to search for mets or extra-thyroid extension of tumor RIGHT-BEFORE-SURGERY if ever
Treat follilcular thyroid cancer
consider size
take lymph nodes?
total thyroidectomy plus postop RAI
TF
can enuncleate a smal follicular thyroid tumor
F
can’t tell normal thyroid from follicular thyroid cancer, TOTAL THYROIDECTOMY AND RAI
when is a full neck dissection indicated for thyroid cancer
when papillary, medullary, or anaplastic with lymph nodes or extra-thyroid extension
NOT for follicular - RAI can get to where it is, no need to dissect, just do total thyroidectomy and RAI
when do you do thyroidectomy with radiation therapy
for invasive thyroid tumor such as anaplastic thyroid cancer
when is nodulectomy an option for thyroid nodule
toxic goiter
Toxic thyroid nodule means
produced T4
