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surgery > Gen surg 2/22/17 > Flashcards

Gen surg 2/22/17 Flashcards

1
Q

3 general types of pain

A

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)

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2
Q

why kick in nuts hurts in abdlomen

A

testicles start in abdomen

visceral pain referred to dermatome of embryologic origin

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3
Q

colicky abdlominal pain think…

A

obstructive
hurts w peristalsis
(cholelithiasis, nephrolithiasis)
-writhing, no comfortable position

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4
Q

obstructive visceral pain

describe

A

colicky
(hurts w peristalsis)
(cholelithiasis, nephrolithiasis)
-writhing, no comfortable position

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5
Q

types of abdominal pain

and descriptions

A

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…

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6
Q

RUQ pain anatomic structures

A

lung
diaphragm
liver
gallbladder

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7
Q

LUQ pain anatomic structures

A

lung
diaphragm
spleen

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8
Q

RLQ pain anatomic structures

A

kidneys ureters
ovaries testes
colon (appendix)

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9
Q

LLQ pain anatomic structures

A

kidneys ureters
ovaries testes
colon (sigmoid diverticulitis)

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10
Q

cirrhotic ascitic patient gets peritonitis
how
diagnose
treat

A

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)

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11
Q

tf

cirrhosis is contraindication to ex lap

A

t

high risk of death, do everything to avoid operating on cirrhotic pt (but must operate if perforated viscus)

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12
Q

tf

ruq us for cirrhotic ascetic peritonitic

A

f

diagnostic paracentesis to cx (low yield) and wbc (^250 polys diagnostic)

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13
Q

clinical pancreatitis - nausea vomiting epigastric pain to back after alcohol binge not remitting

next step

A

lipase
(just dx before tx)

then ivf npo ngt

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14
Q

air under diaphragm

what does it mean

A

ruptured hollow viscus, peritonitis, acute abdomen

all mean EX LAP

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15
Q

treatment for severe bleeding gastric ulcer

A

intravenous omeprazole

permits ulcer healing

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16
Q

tf

gastric ulcers can perforate

A

t

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17
Q

rebound, guarding, motionless, diaphoretic, pale, toxic appearing

next step

A 
ex lap
(acute abdomen gets ex lap)
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18
Q

endoscopy of ruptured peptic ulcer for…

A

DONT do it! insufflation will make worse

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19
Q

tf

perfed ulcers bleed

A

f
perfed ulcers perf
bleeding ulcers bleed

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20
Q

bowel obstruction on ct

A

distended abdomen and multiple loops of bowel with air-fluid levels

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21
Q

Multiple air fluid levels and obstipation are indicative of

A

bowel obstruction

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22
Q

tf

localized peritoneal signs are consistent with diverticulitis

A

t
eg llq pain when palpated on r,
rebound tenderness on ll1 when released on r

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23
Q

dx diverticulitis

A

CT w IV contrast

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24
Q

typical abx for diverticulitis

A

cipro/flagyl

gnrs/anaerobes

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25
Q

risk of perforating active diverticulitis on colonoscopy

A

huge

don’t do it till 2-6 wks resolved

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26
Q

elevated lactic acid means

A

tissue is dying somewhere

measure of poor perfusion

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27
Q

best test and first test in emergency situation where lactate is elevated and aterial occlusion is most likely, how to dx

A

mesentery angiography

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28
Q

ct ab can see

A

free air
stones
masses (poorly)
dilated bowel

w con can see
-arterial and venous thrombosis in addition

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29
Q

work up thyroid nodule

A

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

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30
Q

what does gastrin do

A

tell parietal cells to make acid

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31
Q 
gastrinoma
path
pres
dx
tx
A

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

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32
Q 
insulinoma
path
pt
dx
tx
A

tumor secreting insulin
hypoglycemia (diaphoresis
presynchope, tachycardia)

elevated insulin
c-peptide elevated
sulfonylurea screen
ct scan```

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33
Q

sx of hypoglycemia

A

diaphoresis
presynchope
tachycardia

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34
Q 
glucagonoma
path
pres
dx
tx
A
  • gulcagon
  • MIGRATORY NECROLYTIC NONTOXIC DERMATIITS
  • glucagon level
  • CT scan to localize

resect

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35
Q

migratory necrolytic nontoxic dermatitis think

A

glucagonoma
get glucagon level
get ct
resect

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36
Q

primary hyperparathyroidism
pres
dx
tx

A

^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)
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37
Q

secondary hyperparathyroidism is a product of

A

ckd

so not the one surgeons operate on, they remove primary hyperparathyroidism

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38
Q

how does PTH affect
calcium
phosphorus

A

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
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39
Q

perioroal tingling and trousseau sign after parathyroidectomy
next step

A

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)

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40
Q

how does hyperventilation cause hypocalcemia

A 
respiratory acid H+ blown off
frees up binding sites on albumin
Ca++ binds
ionized calcium drops
can become symptomatic (perioral tingling, chvostek, trousseau sign)
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41
Q

treat follicular thyroid cancer

A

thyroidectomy
radioactive iodine

(acts just like parenchyma so will take up thyroid)

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42
Q

treat anaplastic thyroid cancer

rapidly fatal, occurs in elderly

A

external beam radiation

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43
Q

tf

thyroid lobectomy for follicular thyroid cancer

A

f
thyroidectomy and radioactive iodine

(because difficult to differentiate follicular thyroid cancer from normal thyroid, need to get whole thing out)

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44
Q

how much t3 vs t4 does the thyroid make

and which is more metabolically active

A

17x more t4 than t3

t3 is 5x more metabolically active

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45
Q

thyrotoxicosis vs hyperthyroid

A

thyrotoxicosis is a general term for too much thyroid hormone

hyperthyroid is thyrotoxicosis specifically coming from the thyroid gland

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46
Q

general function of thyroid hormone

A

movement metabolism mentation

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47
Q

first test for hyperthyroid

best test

A

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

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48
Q

how does RAIU scan work

A

uptakes radioactive iodine wherever thyroid hormone is made

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49
Q 
graves disease
path
pres
dx
tx
A

-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)

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50
Q 
thyroiditis
path
pres
appearance on RAIU scan
prognosis
A

-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)

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51
Q

multinodular goiter vs toxic adenoma

A

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

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52
Q

factitious disorder vs struma ovarii

A

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

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53
Q

thyroid storm
sx
tx

A

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

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54
Q

treat hyperthyroid

A

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

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55
Q

thionamides
moa
use

A

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

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56
Q 
hypothyroidism
path
pres
dx
tx
A 
-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
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57
Q 
myxedema coma
path
pres
dx
tx
A

-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

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58
Q

2 keys to remember in rai tx for graves

A
  • likely to develop hypothyroidism as whole gland is uptaking
  • likely to worsen ophthalmolathy so can pretreat with steroids
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59
Q

how to distinguish thyroiditis from factitious (both are cold on RAIU)

A

thyroglobulin

  • high in thyroiditis because spilling with th
  • low in factitious because exogenous t4 circumvents thyroglobulin formation
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60
Q

beta blocker for thyroid storm only or for hyperthyroid too?

A

give for hyperthyroid too, while geting to controlling otu or methimazole or getting to definitive rai or thyroidectomy

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61
Q

sestamibi scan vs raiu scan

A

sestamibi… nuclear imaging thay identifies ECTOPIC PARATHYROID tissue in body… not thyroid…

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62
Q

normal range tsh

normal range T4 thyroxine

A

.5-6 tsh

4.6-12 t4

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63
Q

often the first temporizing treatment for hyperthyroidism as diagnosis is being worked up

A

beta blocker (propanolol)

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64
Q 
eurhyroid sick syndrome
path
pres
dx
tx
A

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)

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65
Q

bruit over neck in setting of hyperthyroid suggests…

A

graves

diffuse active enlargement

66
Q

why is it called myxedema coma

A

myxedema just a synonym for hypothyroidism here

different and confusing use of word vs dermatologic pretibial myxedema in graves hyperthyroidism

67
Q

warm blankets for hypothermia?

A

no
can cause peripheral vasodilation and hemodynamic collapse
use normal blankets

68
Q

pressors for hypotension bradycardia in myxedema coma?

A

careful
will need iv t4, simultaneous pressors can cause arrhythmia

prefer warm ivf, normal blankets, iv t4 should get her hemodynamics up

69
Q

dequervains
hashimotos
silent lymphocytic thyroiditis

how to differentiate

A

all have similar labs and raiu

dequervains is painful

hashimotos has anti-tsh receptor antibodies

silent lymphoxytic is like hashimotos wothout antibodies

70
Q

medically manage hyperthyroidism in pregnancy

A

Ptu in Pregnancy

not such a hard and fast rule anymore, but choose ptu over methimazole if faced with the choice

71
Q

if peritoneal signs…

A

go to the OR

72
Q

peritoneal signs

A

involuntary guarding
(bump bed)
rebound tenderness
(tap at nontender point, pain at tender point)

73
Q

tf

local peritonitis without systemic signs is possible

A

t

can have physical exam involuntary guarding and rebound tenderness without fever and leukocytosis and toxic appearance

74
Q

obstipation

A

fecal impaction hardened stool stuck in lower colon and rectum from chronic constipation

75
Q

ligament of Trietz

A

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,

76
Q 
SBO
path
pres
dx
tx
A

-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

77
Q

4 types of hernias by geography

A

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)

78
Q

4 types of hernias by severity

tx

A

reducible - elective surgery
irreducible - elective surgery
incarcerated - urgent surgery
incarcerated w peritoneal signs - emergent surgery

79
Q

why does our appendix exist

A

to get blocked by a fecolith and give us appendicitis… has no helpful purpose

80
Q

why do we perform appendectomies

A

if appendix bursts can be life threatening

81
Q

McBurney’s point

A

1/3 distance from ASIS to umbilicus

appendiceal pain localizes here after period of non-specific periumbilical pain

82
Q 
appendicitis
path
pres
dx
tx
A

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

83
Q 
carcinoid tumor of the small intestine
path
pres
dx
tx
A

-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
84
Q

where is serotonin broken down

A

liver and lungs

85
Q

if you see 5-HIAA in an answer choice

A

look for carinoid tumor because that is an easy question to get

86
Q

GI bleed common causes

A

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

87
Q

vocabulary of GI bleeds on presentation and do they mean upper or lower

A

hematemesis - upper
melena - more likely upper but not always
hematochezia - more likely lower but not always

88
Q

define upper vs lower GI

A

above ligament of Treitz
(duodenum and above)

below ligament of Treitz
(jejunum and below)

89
Q

GI bleed diagnostic workup

A

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
90
Q

tf

NG tube lavage part of diagnostic workup for GI bleed

A

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
91
Q 
esophageal varices
path
pres
dx
tx
A

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

92
Q

TIPS

why is it called that

A

transjugular intrahepatic portosystemic shunt
transjugular because IR entry via jugular vein
sheath and guidewire passed to hepatic vein, path to intrahepatic portal vein created

93
Q 
mallory weiss tear
path
pres
dx
tx
A

tear in GE junction mucosa from vomiting
one-time vomiters eg drinking binge, hematemesis, usualy self-limiting
EGD if pt presents w active bleeding

94
Q 
Boerhaave syndrome
path
pres
dx
tx
A

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

95
Q 
Doeulafoy's lesion
path
pres
dx
tx
A

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

96
Q

cardia of stomach

A

first portion of stomach… esophageal inlet

97
Q 
esophagitis
can it cause gi bleeds
common causes
dx
tx
A 
can cause GI bleed -- especially as progresses to cancer
GERD #1 (antacid...)
CMV, HERPES (gancyclovir, foscarnet)
Candida (nystatin)
HIV (HAART)

via EGD bx, culture

98
Q 
gastritis / peptic ulcers
path
pres
dx
tx
A

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

99
Q

colitis as cause of GI bleed
pres
dx
tx

A

bloody diarrhea
biopsy via EGD tp dx
stool cx to r/o infectious cause
control w steroidds

100
Q 
diverticular hemorrhage
path
pres
dx?
tx
A 
more L than R
rupture of arteriole at dome of diverticulum
massive lower GI bled, hematochezia
dx?
resection, cautery
101
Q

cancer as casue of GI bleed

basic path pres dx tx

A 
UGIB in stomach or esophagus
LGIB in colon
endoscopy w biopsy to dx
stage w PET CT
resect or chemo,radiation
102
Q 
mesenteric ischemia
path
pres
dx
tx
A 
"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

103
Q

ischemic colitis
path
pres
dx

A

ischemia at watershed areas of colon during hypotension

pain, self-limiting bleed

colonoscopy (can do as bleed self-limiting)

104
Q

ischemic colitis vs mesenteric ischemia

A

ischemia from hypotension

vs ischemia from afib thromboembolism or atherosclerosis - “intestinal angina” with prandial food digestive workout

105
Q

LFTs in viral vs etoh hepatitis

A

Viral Hepatitis (AST and ALT in the 1000s)

EtOH Hepatitis (AST:ALT > 1.5)

106
Q

When do you operate on a hernia

A 
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

107
Q

TF

Senna and docusate for SBO

A

F
Senna motilizes
Docusate bulks

Not what you want for SBO, want bowel rest

108
Q

Appendicitis localized to mcburney, peritonitic

Abx? CT?

A

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

109
Q

What is a small bowel series

A

Drink contrast, take series of xrays to see how far it gets

110
Q

What is a fleet enema used for

A

Treat constipation or fecal impaction

Before or after digital disimpaction

111
Q

When to think sbo is complete and in need of surgery

A
  • fails 3 days ish of conservative npo, ngt intermittent suction, ivf
  • becomes peritoneal, toxic, bowel sounds go silent
112
Q

Barium enema evaluates what section of GI

A

Large bowel

113
Q

Right sided valvular fibrosis
Diarrhea
Hot flashes/flushing

Next step?

A

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

114
Q

Why do boards love carcinoid tumor?

A

Cancer of intestines
Mets to liver
Affects heart and lungs
Diagnosed with urinary test

115
Q

Where can Carcinoid tumor occur and how does that change how it affects the heart?

A

Intestinal carcinoid – R sided valvular fibrosis, once mets to liver (serotonin metabolized by liver and lungs)

Lung carcinoid – L sided valvular fibrosis

116
Q

If there is an acute abdomen

A

You operate

Ex lap time

117
Q

5 things the test is probably getting at with tumultuous ICU course

A 
ARDS
nutrition deficiency (low alb low vit  K)
Polyneuropathy (weak)
ICU delirium (ams)
Stress ulcers (sudden upper GI bleed)
118
Q

TF

Everyone should get PPI for ppx of stress ulcers

A

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

119
Q

what is a Cushing’s ulcer

A

peptic ulcer that results from increased ICP intracranial pressure

120
Q

TF

hypotension often leads to gastric necrosis

A

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

121
Q

TF

corticosteroids can reduce risk of UGIB upper gi bleed in acute pancreatitis pt in ICU

A

F

corticosteroids are risk for peptic ulcer development – eg stress ulcer in ICU

122
Q

TF

NG tube for UGIB

A

Fish
not unless ongoing emesis or SBO
-get upper endoscopy -diagnostic and therapeutic can intervene if find something

123
Q

What is a Blakemore tube and when is it used

A

Tamponades bleeding varices to prevent death as a temporizing measure, bridge to definitive therapy - eg TIPS for definitive decompresion of varices in cirrhosis

124
Q

UGIB in cirrhotic think first on ddx…

A

esophageal varices

125
Q

the only type of GI Bleeding that will kill someone in hours

A

esophageal varices

126
Q

esophageal varices found on EGD, next step

A

endoscopic variceal banding

-you are in there, varices the only UGIB that will kill you in hours, go ahead and fix it

127
Q

initial stabilization of any urgent GI Bleed pt should get…

A 
2 large bore IVs
type and cross
GI consult for endoscopy
PPI infusion
octreotide if cirrhotic
128
Q

why should cirrhotic with UGIB get octreotide

A

slows portal flow, dec variceal bleeding… but pt still needs endoscopy and esophageal banding

129
Q

TF

Nadolol for UGIB pt, hypotensive, to control rate and myocardial ischemia

A

F

blunting HR in UGIB will likely cause further hypotension

130
Q

if there is a GIB… next step…

A

place 2 large bore IVs

131
Q

when is BRBPR consistent w UGIB

A

when Massive UGIB

132
Q

what does biliary contents on NG tube lavage tell you in patient with large blood loss per rectum

A

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

133
Q

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

A

mesenteric angiography (requires IR, but the only way to prevent ex lap from here)

134
Q

GI bleed ongoing but not brisk, pt stable, test to get

A

tagged red blood scan

135
Q

why is tagged red blood scan not good in unstable pt

A

because will need to sit in radiology for a while

136
Q

when is colonoscopy the answer for GI bleed

A

if bleeding slow or stopped, before resorting to pill-cam endoscopy
(can’t see anything in pipe of red if actively bleeding too much)

137
Q

when to resort to pill-cam endoscopy for GI bleed

A

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?)

138
Q

highest risk factor for thyroid nodule being cancer

A

radiation head/neck

139
Q

risk factors for thyroid nodule being cancer

A 
#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
140
Q

physical exam findings of thyroid nodule concerning for cancer

A 
Fixed
Firm
Hard
Non-tender
Lymphadenopathy
141
Q

findings on US concerning for thyroid nodule being cancer

A 
Solid
Hypoechogenic
Size ^2cm (will Always bx ^2cm... for some types, will bx ^1cm as well)
Microcalcifications
Irregular borders
142
Q

findings on
history
physical
US concerning that thyroid nodule is cancer

A

Radiation To Neck, hx/fh cancer, hoarseness, v20 ^60

fixed firm hard Non-tender LAN

Solid hypoechoic ^2cm (^1cm sometimes) Microcalcifications Irregular borders

143
Q

thyroid nodule

1st thing to do

A

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)

144
Q

cold nodule on RAIU scan, next step

A

US - FNA… you are going to biopsy a cold nodule whatever US shows, but will check out w US in course of biopsy…

145
Q

thyroid nodule, TSH normal or elevated, next step

A

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

146
Q

next step for thyroid nodule after FNA

A

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

147
Q

workup a thyroid nodule

A

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

148
Q

4 types of thyroid cancers

A

Papillary
Follicular
Medullary
Anaplastic

149
Q

4 types of thyroid cancers

high yield dx, tx

A

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…

150
Q

when to get RAIU for thyroid nodule

A

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)

151
Q

type of thyroid most associated with radiation therapy

A

papillary thyroid cancer

152
Q

thyroid nodule is ^2 cm and apparently hot, w low TSH and hyperthyroid sx

next step?

A

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

153
Q

when to get MRI for hyperthyroid

A

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

154
Q

how does palpation hint at thyroid nodule size

A

subcentimeter nodules usually not palpable

155
Q

when to get CT scan for thyroid nodule

A

not usually needed

may get to search for mets or extra-thyroid extension of tumor RIGHT-BEFORE-SURGERY if ever

156
Q

Treat follilcular thyroid cancer
consider size
take lymph nodes?

A

total thyroidectomy plus postop RAI

157
Q

TF

can enuncleate a smal follicular thyroid tumor

A

F

can’t tell normal thyroid from follicular thyroid cancer, TOTAL THYROIDECTOMY AND RAI

158
Q

when is a full neck dissection indicated for thyroid cancer

A

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

159
Q

when do you do thyroidectomy with radiation therapy

A

for invasive thyroid tumor such as anaplastic thyroid cancer

160
Q

when is nodulectomy an option for thyroid nodule

A

toxic goiter

161
Q

Toxic thyroid nodule means

A

produced T4

surgery (22 decks)

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