Genel Cerrahi 4 Flashcards

Question

Info abt etiology of stomach cancer?

Answer 1

H pylori infection!, M> W, 50+, asian/ pacific islander, smoking, obesity, type A blood, family history of gastric cancer, previous stomach surgery, pernicious anemia, menetrier disease, inherited cancer syndromes (hereditary diffuse gastric cancer, Lynch syndrome, FAP, BRCA1 and 2 genes). --> increase the risk Diet: smoked food, salted fish, meat, pickled vegetables increase the risk. But, A and C vitamins that are antioxidant reduce the risk.

Answer 2

%95 adenocarcinoma %4 lymphoma %1 leimyosarcoma (GIST- malignant gastrointestinal stromal tumors) Rare: carcinoid, angiosarcoma, scc Metastasis from: colon/ pancreas, melanoma/ breast

Answer 3

Diffüz mide kanseri; daha fazla metastatik özelliğe sahip kanserler olup, hızlı progresyon ve kötü prognoza sahiptir. Mide duvarını daha fazla invaze eder, bazen de distal özofagus ve duodenuma da invaze olur, bazen de linitis plastikaya (leather bottle appereance) neden olur. İntestinal kanserler gibi, H. pylori ile indüklenebilir. Cell cohesion is absent: individual cells infiltrate and thicken stomach wall without forming a discrete/ayrık mass, younger patients, very bad prognosis, thickened gastric wall. Cardia. Genetic. W> M

Answer 4

Cohesive neoplastic cells form glandlike tubular structures. Frequently ulcerative. Antrum. Environmental. M> W

Answer 5

Advanced disease: indigestion, nausea, dysphagia, early satiety, anorexia, weight loss Weight loss, nausea, vomiting --> tumors of pylorus Dysphagia, early satiety--> diffuse lesions originating in cardia. Upper abdominal discomfort--> extensive tumor -

Answer 6

All are late events. Palpable stomach with succussion/ gastric splash, hepatomegaly, virchow nodes (sol), sister mary joseph nodes (umblicus), irish nodes (sol aksilla), malignant ascites, weight loss, pallor from bleeding and anemia (parantezdeki yerlerden emin değilim)

Answer 7

AKA gastric splash, is a sloshing sound heard through a stethoscope during sudden movement of the patient on abdominal auscultation. It reflects the presence of gas and fluid in an obstructed organ, as in gastric outlet obstruction.

Answer 8

Pleural effusion, peritoneal effusion, gastric outlet obstruction, GE obstruction, small bowel obstruction, bleeding, jaundice, cachexia (Sadece daha fazla kalori almakla durdurulamayan kilo ve kas kaybı) Unusual clinical features: migratory thromboplebitis, microangiopathic hemolytic anemia

Answer 9

screening--> Double contrast barium study, diagnostic endoscopy, serum tumor markers Local assessment--> upper GI endoscopy, endoscopic usg Assessment for distal disease--> X ray, CT, MRI

Answer 10

CBC identifies anemia (might be due to bleeding, liver dysfunction, poor nutrition) %30 of the patients have anemia Electrolytes and liver function tests (AFP, Ca19-9 vs çok spesifik olmasalar da takip için önemliler)

Answer 11

Surgery, perioperative chemotherapy, neoadjuvant chemotherapy, adjuvant chemotherapy, intraperitoneal chemotherapy, adjuvant radiotherapy, intraoperative radiotherapy

Answer 12

Endoscopic mucosal resection, Endoscopic submucosal dissection, Endoscopic laser ablation, limited surgical resection, gastrectomy

Answer 13

Partial gastrectomy > total gastrectomy Gastric preserving r0 can minimize the risk of specific sequelae of total gastrectomy: Early satiety, weight loss, B12 supplementation need

Answer 14

90% of cases occurs after age 50. Third leading cause of cancer in the US Second leading cause of cancer death Average lifetime risk for developing this cancer is 6% Women are more likely to have right sided colonic adenomas

Answer 15

95%+ colonic polyps are hyperplastic or adenomatous. Although these two types have some distinctive features on gross appearance, they cannot be reliably distinguished endoscopically

Answer 16

Yarıdan fazlası: Sporadic, tesadüfi. Familial risk cases: %10- 30 Lynch syndrome: hereditary nonpolyposis colorectal cancer, 2-3% Familial adenomatous polyps: <1% Hamartomatous polyposis syndromes: <0.1

Answer 17

increase: Lack of physical activity, consumption of red meat, obesity, cigarette smoking, alcohol use decrease: MVI containing folic acid, ASA and other NSAID’s, Post menopausal HRT, Ca supplementation, Selenium, Consumption of fruits, vegetables and fiber

Answer 18

Age >50 yrs High fat, low fiber diet IBS – Chronic ulcerative colitis and Crohn’s disease Familial adenomatous polyposis (FAP) Heriditary nonpolyposis colorecal cancer (HNPCC) Hamartomatous polyposis syndromes Peutz-Jeghers syndrome Juvenile polyposis Family history – Colorectal adenomas, Colorectal cancer Personal history of Colorectal adenomas, Ureterosigmoidostomy, Breast, Ovarian and Uterine cancers

Answer 19

Depends on tumor location: Proximal (right sided) lesions present with symptoms caused by anemia – fatigue, weight loss, shortness of breath, lightheadedness, mahagony feces caused by occult bleeding Distal (left sided) lesions present with symptoms of obstruction, changes in BM pattern, postprandial colicky abdominal pain, hematochezia (dışkıda parlak kan ve mukus)

Answer 20

Abdominal pain 44% (obstraksiyona sebep olması ile olur) Change in bowel habit 43% Hematochezia or melena (proksimal) 40% Weakness 20% Anemia without other gastrointestinal symptoms 11% Weight loss 6% Some patients have more than one abnormality 15 to 20% of patients have distant metastatic disease at the time of presentation

Answer 21

Postmenopozal kadınlarda ve erkeklerde kansızlık olursa gis malignitesi düşün!

Answer 22

Most human CRCs are thought to arise from adenomatous polyps Early carcinomas are frequently seen within large adenomatous polyps, and areas of adenomatous change can often be found surrounding human CRCs. Adenomas and carcinomas are found in similar distributions throughout the large bowel, and adenomas are typically observed 10 to 15 years prior to the onset of cancer in both sporadic and familial cases. In animal models, adenomas develop before carcinomas, and carcinomas develop exclusively in adenomatous tissue. The ability to reduce the incidence of CRC through removal of polyps has been shown in controlled trials in humans Hangisinde polip kansere dönüşebilir bilemeyiz. O nedenle polipleri çıkarmamız lazım.

Answer 23

hereditary nonpolyposis colorectal cancer. Polyposis olmayan ailesel CRC. MLH1 ve MSH2 genleri mutasyonu. Amsterdam kriteri ile ölçeriz. 3-2-1 kuralı: 3 affected members, 2 generations, 1 under age 50 Dışarıdan anlaşılmaz lynch sendromu.

Answer 24

For average risk ppl 50+: FOBT (Fecal occult blood test, dışkıda gizli kan testi.) --> antikoagülan kullananlarda yanlış poziif çıkabilir. every year. Flexible sigmoidoscopy every 5 years Colonoscopy every ten years.

Answer 25

A first-degree relative who has had colorectal cancer or an adenomatous polyp --> <40y FAP family history--> Begin at puberty! Annual Sigmoidoscopy, 5 yılda bir colonoscopy Lynch--> 21y Adenomatous polyp history, crc history, ibd history hepsi screening yaşını erkene çeker.

Answer 26

Ulcerative colitis--> There is an association between chronic uc and colonic neoplasia. Pancolitis confers a 5- to 15-fold increase in risk. UC ters köşe yapabilir dikkat etmek lazım. Crohn disease--> Crohn disease is associated with a similar risk of colon malignancy as extensive ulcerative colitis Most guidelines recommend surveillance when one-third or more of the colonic mucosa is involved.

Answer 27

Directly measures hemoglobin in the stool Advantages: *Dietary and medication restrictions are not needed, *Does not require bowel preparation, *Requires only one sample rather than three days of samples as for guaiac-based fecal occult blood testing Multitarget stool DNA tests with FIT sadece FITden çok daha sensitif bir CRC teşhis yoludur.

Answer 28

Digital rectal exam--> çok iyi tanı koydurur. Sigmoidoscopy. Colonoscopy. Virtual colonoscopy – CT colonoscopy. CT--> staging. Transrectal ultrasound (TRUS)--> RECTAL carcinoma staging. MRI--> metastasis detection. Laparotomy--> metastasis detection.

Answer 29

Carcinoembryonic antigen (CEA) Carbohydrate antigen (CA) 19 9, CA 50, and CA 195 Have a low diagnostic ability to detect primary CRC overlap with benign disease low sensitivity for early stage disease

Answer 30

Crohn’s colitis. Diverticulosis. Endometriosis. Solitary rectal ulcer. Lipoma. Tuberculosis. Amebiasis. Cytomegalovirus. Fungal infection. Extrensic lesion. Arterio-venous malformations. Adenomatous polyps: Premalignant neoplasm, Morphological types are tubular, tubulovillous, villous Ischemic colitis. Infarcted colon. Megacolon. Hemorrhoids

Answer 31

Adenocarcinoma (en çok kolon kaynaklı tümör) Lymphoma Carcinoid tumor Kaposi’s sarcoma Prostate cancer

Answer 32

UC--> Sadece mukoza Crohn--> Tüm bağırsak duvarı, transmural

Answer 33

Rectum--> Akciğer metastazı Colon--> Karaciğer met

Answer 34

Adenomatous polyps: Premalignant neoplasm, Morphological types are tubular (80%), tubulovillous (15%), villous (5%). Villous ve tubovillous daha yüksek kanser ihtimali. Polipten sadece biyopsi almak yetmez hepsini çıkarmak lazımdır. Adenomas are the most prevalent neoplastic polyps in the colon (2/3 of all polyps) 30-50% synchronous adenoma. Prevalence is 25-30% at age 50 years

Answer 35

Surgical excision: Local excision, for palliative treatment or simple polyp removal. Only treatment for localized colon cancer. Resection should include the regional mesenteric lymph nodes along the course of major mesenteric vessels and along the vascular arcades (intermediate and central nodes) as well as those adjacent to the colon along its mesocolic border. Chemotherapy-Radiation therapy For systemic chemotherapy: 5-FU has been the mainstay of systemic chemotherapy for CRC. Capecitabine. Irinotecan (Camptosar), Oxaliplatin (Eloxatin), Bevacizumab, Cetuximab

Answer 36

Synchronous colon cancer--> occur in 3 to 5% of patients with CRC and have the same prognosis as a solitary cancer. Signet ring cell carcinomas--> are aggressive while the Medullary adenocarcinoma subtype has a relatively favorable prognosis Mucinous carcinomas--> accounts for approximately 11 to 17% of all CRCs, they are often right sided, and they may have a poor responsiveness to upfront (neoadjuvant) chemoradiotherapy and adjuvant chemotherapy

Answer 37

*Circumferential resection margin (CRM) involvement is one of most important predictive factors for both local and distant recurrence as well as survival *The presence of «Extramural non-nodal tumor deposits» is a strong adverse prognostic feature *Lymphovascular invasion is a negative prognostic factor *Perineural invasion is a negative prognostic factor *Host immune response is a positive prognostic factor *Peritumoral fibrosis is a negative prognostic factor *bowel obstruction or perforation is a negative prognostic factor *CEA> 5 is a negative prognostic factor

Answer 38

Enlargement of the thyroid gland is called "goiter." The thyroid gland can grow during puberty and pregnancy. Such enlargements are referred to as "physiological enlargements" and are not considered a disease.

Answer 39

Abnormal tissue formation within the thyroid gland. If multiple nodules are present in the patient, this is referred to as «multinodular goiter».

Answer 40

Graves' Disease (Toxic Diffuse Goiter)* (MOST COMMON) Toxic Multinodular Goiter* Plummer's Disease = Toxic Adenoma*: Excessive hormone secretion from a "hot" nodule in the thyroid gland Thyroid Inflammations (Thyroiditis) Excessive Thyroid Hormone Intake: Overuse of LT4

Answer 41

Weight loss Muscle weakness Trembling hands Difficulty sleeping Palpitations Thinning and hair loss Thinning, moist skin with excessive sweating Increased bowel movements, sometimes diarrhea Irritability Irregular menstruation Heat intolerance Bone loss (osteoporosis)

Answer 42

If T4 and T3 levels are high and TSH is low, a diagnosis of hyperthyroidism is made.

Answer 43

Medication Therapy Definitive Treatment: Radioactive Iodine Therapy or Surgery

Answer 44

AKA toxic diffuse goiter Hyperthyroidism cause Autoimmune TSH Receptor Antibody (TRAb): Stimulates the thyroid gland, causing excessive hormone production. Patients with this condition develop goiter and eye protrusion (ophthalmopathy). The majority of patients with hyperthyroidism (70-80%) have Graves' disease.

Answer 45

In all patients with hyperthyroidism, medication therapy is initiated to normalize the elevated thyroid hormone levels. *Propylthiouracil tablets *Methymazole tablets Follow-up every two months One year of medication therapy (İşe yaramazsa kesin çözümlere yani radioactive iodine ve ameliyata başvururuz)

Answer 46

Pregnancy Planning: Patients planning to become pregnant within 6 months. Symptomatic Compression: Presence of a large goiter (>80g) causing symptoms. Low Radioactive Iodine Uptake Malignant/Suspicious Nodules: Presence of nodules that are suspected to be malignant. Nodules >4 cm Failure of Other Treatments: When other treatments are unsuccessful or not tolerated.

Answer 47

Severe Comorbidities Terminal Cancer Patients Mentally Retarded Patients Bedridden Patients Inaccessibility to a Low-Complication-Rate Surgeon Pregnancy: Optimal in the second trimester, but there is a 4.5-5.5% risk of preterm birth. (In the first trimester, anesthetics may have teratogenic effects. In the third trimester, there is an increased risk of premature labor.)

Answer 48

Total thyroidectomy RAI (?) (Radioacitve iodine neden ? anlamadım. Google rai nin de işe yaradığını söylüyor?)

Answer 49

Excessive hormone secretion from a "hot" nodule in the thyroid gland

Answer 50

RAI/Surgery If there are no other nodules present: Lobectomy

Answer 51

Thyroid nodules are abnormal tissues that form within the thyroid gland, differing from normal thyroid tissue. Prevalence: 50-70% Malignancy Risk: 5-15%

Answer 52

Most patients with nodular goiter do not exhibit any symptoms. However, there may be a noticeable swelling in the neck. If there is bleeding into the nodule, pain may occur. If the nodule grows significantly, it can cause pressure symptoms, leading to difficulty breathing or swallowing.

Answer 53

Exposure to Ionizing Radiation: Previous exposure increases the risk of thyroid cancer. Development of Hoarseness: A change in voice can indicate invasion of surrounding structures. Family History: A family history of thyroid cancer or other endocrine tumors may raise suspicion.

Answer 54

1)Rapidly Growing Nodules: Nodules that increase in size quickly may raise concern for malignancy. 2) Associated Cervical Lymphadenopathy (LAP): The presence of lymphadenopathy in the neck can suggest metastasis or aggressive behavior. 3) Hard and Fixed Nodules: Nodules that feel very firm and are fixed to surrounding tissues may be more likely to be malignant.

Answer 55

Thyroid Hormones: Presence of hyperthyroidism or hypothyroidism. Thyroid Scintigraphy: Performed in patients with low TSH levels. Whether a nodule is "hot" (functioning) or "cold" (non-functioning). Thyroid US In detecting different types of thyroid nodules; Very sensitive and specific. Ultrasound-Guided Fine-Needle Aspiration Biopsy (FNAB)

Answer 56

Papillary TC (70-80%): The most common type; typically has a good prognosis. Follicular TC (5-10%): Less common than papillary, can be more aggressive. Hurthle Cell Carcinoma (3-5%): A variant of follicular cancer; often considered more aggressive. . Medullary TC (5-10%): Arises from parafollicular C cells; can be associated with genetic syndromes. Anaplastic TC (3%): A rare and aggressive form; has a poor prognosis. Other Types Lymphoma: Primary thyroid lymphoma is rare but can occur Metastatic Cancer:

Answer 57

Well--> Papillary TC, Follicular TC, Hurthle Cell Carcinoma Poor--> Medullary TC, Anaplastic TC

Answer 58

70-80% The most common type; typically has a good prognosis. 30-40 years F:M / 3:1 Caucasian race mostly Best prognosis among differentiated thyroid cancers long, indolent course with low mortality rates

Answer 59

Typically, capsule-free and measures 2-3 cm in diameter Exhibits infiltration into thyroid tissue, as well as calcification, necrosis, and cystic changes Characterized by stromal calcifications --> psammoma bodies In approximately 10% of cases, there is invasion of the thyroid capsule and extension into surrounding tissues

Answer 60

*Multifocality: Microscopic cancer foci may be present in the contralateral lobe in 30-82% of cases. *Cervical metastasis: Can reach to 40-90% of patients. *Involvement can be found in various lymph node levels, including: Level VI (central compartment), Levels II-IV (lateral neck), Level VII (upper mediastinal region)

Answer 61

Distant Metastasis: Initially occurs in 1% of cases, increasing to 10% in advanced stages. Most commonly metastasizes to the lungs and bone tissue. In younger patients (under 20 years), metastases tend to remain stable, whereas in older patients (over 50 years), the disease may exhibit a more aggressive course. 10-Year Survival Rate: Approximately 85-90%.

Answer 62

(Mini bir tanım yapabilirsin istersen) Papillary Microcarcinoma (<1 cm): For papillary microcarcinomas, active surveillance is often recommended, especially if there are no aggressive features or significant risk factors. This may involve regular ultrasound monitoring and clinical evaluations rather than immediate surgical intervention.

Answer 63

5-10% Less common than papillary, can be more aggressive. F: M = 2: 1 40 years More frequently seen in regions with iodine deficiency and endemic goiter. Can be associated with hyperthyroidism in some cases.

Answer 64

Typically presents as a solitary, encapsulated nodule measuring 2-4 cm. Multifocal disease is rare compared to other thyroid cancers Distinguished from benign adenomas by the presence of vascular and capsular invasion

Answer 65

Hematogenous spread can occur, leading to distant metastasis. There is a false-negative rate of approximately 62% in fine-needle aspiration biopsy (FNAB), which can complicate the diagnosis.

Answer 66

3-5% A variant of follicular cancer; often considered more aggressive. Composed of capsulated, follicular cell groups that predominantly exhibit Hurthle (oncocytic) cell characteristics (at least 75%). Typically, less differentiated and more aggressive compared to other types of thyroid cancer.

Answer 67

Has a tendency for cervical and distant metastasis. Contains TSH receptors and produces thyroglobulin, which can be used as a tumor marker in monitoring the disease. Frequently presents as multifocal and bilateral in location. Approximately 20% of all Hurthle cell neoplasms are malignant. Exhibits a two-fold increased likelihood of pulmonary metastasis compared to patients with follicular carcinoma.

Answer 68

Total Thyroidectomy (and Central Neck Dissection) Radioactive Iodine (RAI) Therapy Hormonal Replacement Therapy - TSH Suppression Follow-up with Thyroglobulin Measurement

Answer 69

5-10% Arises from the parafollicular C cells of the thyroid gland, which are responsible for producing calcitonin. This type of thyroid cancer is distinct from well-differentiated thyroid cancers (like papillary and follicular thyroid carcinoma).

Answer 70

Can be associated with genetic syndromes, such as Multiple Endocrine Neoplasia (MEN) type 2. It can be sporadic or hereditary, and it tends to have a different clinical behavior, often presenting with lymph node metastasis and potentially distant metastases at the time of diagnosis. The diagnosis is made by measuring serum calcitonin levels and performing imaging studies, with management involving surgical removal of the thyroid and affected lymph nodes.

Answer 71

3% A rare and aggressive form; has a poor prognosis. Considered one of the most aggressive solid organ cancers. The average survival rate after diagnosis is typically around 6 months due to its rapid progression and poor response to treatment.

Answer 72

Total Thyroidectomy Near-Total Thyroidectomy Thyroid Lobectomy Central Neck Dissection Lateral Neck Dissection

Answer 73

Wound (Bleeding, Hematoma, Seroma, Infection) Nerves (EBSLN: Voice fatigue, Difficulty sustaining high-pitched sounds. RLN: Unilateral --> Loss of voice. Bilateral -->Tracheostomy) Parathyroid glands (Symptoms: Numbness, Restlessness and irritability, Carpopedal spasm (known as "Trousseau's sign" or "obstetrician's hand" posture), Hypocalcemic tetany Hypocalcemia, mostly temporary but rarely permanent.) Other surrounding structures

Answer 74

For Tetany / Carpopedal Spasm Administer IV Calcium Gluconate slowly with EKG monitoring to observe for any cardiac effects. Dosage: 1-4 ampoules of Calcium Gluconate diluted in 150 cc of 5% Dex solution, infused over 1-4 hours. Oral Therapy Calcium Tablets: 1 gram of elemental calcium (up to 5 tablets per day) ±Active Vitamin D Tablets: Supplemented as needed to support calcium absorption and maintain serum levels.

Answer 75

*Embriyolojik, anatomik, histolojik ve fonksiyonel olarak 2 farklı bezdir *Böbreklerin üst polü üzerinde yer alırlar *Retroperitoneal yerleşim yaparlar *T11-12 hizası * Perirenal yağ dokusundan daha koyu sarı renklidir.

Answer 76

1.İnferior frenik arter- superior adrenal a. 2.Aorta – (sağ) middle adrenal a. 3.Renal arter – inferior adrenal a.

Answer 77

1. Sağ sürrenal ven oldukça kısadır (0.5 cm) ve direkt olarak v.cava inferiora dökülür. 2. Sol adrenal ven ise sol renal vene dökülür (bazen VCI)

Answer 78

2 pleksus: 1.Kapsül 2.Medulla Her iki pleksus paraaortik, subdiafragmatik ve renal nodlara dökülür. O yüzden malign olaylarda bu lenf nodu grupları metastaz açısından kontrol edilmelidir.

Answer 79

Medulla - nöroendokrin transduser. Çöliak ve renal pleksusdan gelen preganglionik splansinik inervasyon; epinefrin ve norepinefrin salgılanır Korteks- sadece vazomotor innervasyon; direkt innervasyon yok

Answer 80

*İnce fibröz bir kapsül ile sarılı iki ayrı tabakakadan, korteks ve medulladan oluşur. *Korteks açık sarı renkte, medulla kırmızı-kahverengi karışımı renklidir. *Korteks medulladan 3-4 kat kalındır: %70-80 korteks, % 10-20 medulla

Answer 81

Korteksin dıştan içe 3 tabakası 1.Zona glomeruloza (%15) - aldosteron 2.Zona fasikulata (%75) - kortizol 3.Zona retikülaris (%10) - androjenler

Answer 82

Aldosteron↑: Hiperaldosteronizm Kortizol↑: Cushing Sendrom Testosteron↑: Virilizasyon Send.

Answer 83

✓Mezoderm kökenli ✓Ürogenital çıkıntı ✓5. hft: sölomik mezotel proliferasyonu ✓7. hft: “Fetal korteks” oluşumu (T6-12) ✓5. ay: 2. Mezotel proliferasyonu dalgası ✓“Esas korteks” oluşumu Doğum sonrası: Adrenal /böbrek oranı düşer. Dejenere fetal korteks çevresinde esas korteks oluşur. *Kapsül ve öncü Z. Glomerulosa oluşumu *Doğumda Z. Glomeruloza ve Z. Fasciculata *Z. Reticularis 1-3 yaşına kadar oluşur

Answer 84

Bezin ağırlığın % 10’unu oluşturur. Kromaffin hücreler: –epinefrin ya da norepinefrin %80 %20 Meduller hipersekresyon: FEOKROMOSİTOMA (genelde benign, nadir bir lezyon)

Answer 85

*Nöroektoderm kökenli *5. haftada paraaortik ve paravertebral bölgelerdeki nöral crest hücrelerinden kökenli *Nöral tüp apeksinden dorsal aortaya göç başlar *Nöroblast veya adrenal primordia dönüşüm *Fonksiyonel ekstraadrenal kromaffin hücrelerin oluşumu

Answer 86

*BT: duyarlılık % 90 * ALTIN STANDART *Ultrasonografi: Duyarlılık %70. Gebeler, yenidoğan ve çocuklarda daha yararlı *MRG: T1 sekans normal dokuları, T2 ise benign-malign ayrımında yararlı *Adrenal sintigrafi: I-131 MIBG ve I-123 MIBG ile adrenal bez dışı feokromasitoma yerleşimi tanısı. Test 3-7 gün sürer ve görüntüleme BT den iyi değildir. *Direkt grafiler: genelde yararsızdır.

Answer 87

Fonksiyonel olarak aktif kitle ve malignite şüphesi. *Fonksiyonel olarak aktif kitle: –Aldosteronoma, –Cushing adenomu, –Virilizan veya feminizan adrenal TM (Konjenital adrenal hiperplazi), –Feokromositoma *Malignite veya şüphesi: –İnsidentolama (> 4-5 cm veya büyüyen), –Adrenokortikal kanser, –İzole Adrenal metastazlar + Tek taraflı adenom alsak da diğer tarafı atrofiye gitmiş olabilir ondan dıştan hormon lazımdır, bir de, bezin tamamını alıyoruz.

Answer 88

Aşırı aldosteron salınımıdır. Hipokalemi ve ödem olmaksızın hipertansiyon ile karakterizedir.

Answer 89

Primer-Conn Sendromu (↑Aldosteron, ↓PRA--> plasma renin activity) –Adenom (Aldosteronoma) % 60-70 –İdiyopatik bilateral adrenal hiperplazi % 30-40 –Adrenal karsinom <%1 Sekonder (↑Aldosteron, ↑PRA) –Renal arter stenozu –Konjestif kalp yetmeziği –Siroz –Normal gebelik

Answer 90

Asemptomatik veya minimal şikayetlerle seyreder genelde. Hipertansiyon: –Devamlı, orta derece, diastolik, tedaviye dirençli, –Baş ağrısı, –Retinopati Hipokalemi (karpopedal spazm, parestezi): –Kas zayıflığı ve kramplar, –Polidipsi, –Poliüri ve noktüri

Answer 91

Hipokalemi: <3.2 mEq/l (Normal %40) –<3.0 m Eq/lt diuretik tedavisi –K desteğine rağmen İdrar K+ atılımı (>30 mEq/gün) P.Aldosteron >15 ng/dl; Kortizol normal Plazma Renin aktivitesi < 3 ng/ml –Aldosteron/PRA *> 25-30 primer *< 15 sekonder Na yükleme testi

Answer 92

Daha ciddi ve dirençli hipertansiyon Daha derin hipokalemi (< 3.0 mEq/dl) Plazma aldosteron düzeyi (> 25 mg/dl) İdrar aldosteron düzeyleri (30 µg/24 gün) Daha genç hasta (<50 yaş) İSE ADENOM LEHİNE (Daha kötümser bir durum varsa adenomdur denebilir)

Answer 93

BT: 0.5-2.0 cm çaplı (tek taraflı) –1 cm (%90) –3 mm ince kesit çekim MRG- gebelikte Selektif adrenal venöz örnekleme!! –Duyarlılık % 95-100; Özgüllük %90 –Adenom-hiperplazi ayrımı –Komplikasyon % 1 Adrenal sintigrafi –NP-59 (sıcak nodül tutulumu) (düzenle, yanlış değil ama bazı şeyler silinebilir)

Answer 94

Adenom saptanamaması Bilateral kitle saptanması Hiperplazi saptanması Nasıl yapılır: Transfemoral adrenal v. kateter, oradan ACTH verilmesi sonrası her iki AV ve IVC örneklemesi

Answer 95

*Adrenokortikal korizol hipersekresyonuna bağlı obezite, amonere, hirşutizm, hipertansiyon, diabet, mor çizgiler vb semptomların görüldüğü bir hastalıktır. *Etiyolojiden bağımsızdır. (bu ne demek anlamadım.) *Pituiter adenoma bağlı ise Cushing hastalığı adını alır. *Ektopik acth salgılayan tümörler de cushing sendromuna yol açabilirler. Hatta, olguların % 50'sinden fazlasını Akciğer tümörleri yapar. Diğer ACTH salgılayan tümörler; timoma, pankreatik islet hücreli tümör ve tiroidin medüller kanseridir. Cushing hastalığı = primer, Cushing sendromu = hepsi EN ÇOK DIŞARIDAN KORTİZON ALIMI İLE OLUR

Answer 96

10 / milyon populasyon Erişkinler K/E: 8 Sporadik ama bazen MEN 1 bileşeni olur Eksojen: En sık neden iyatrojenik-steroid tedavileri Pituiter adenom, adrenal adenom, ektopik ACTH salgılayan TMler sebep oalbilir.

Answer 97

ACTH bağımlı: –Cushing hastalığı (%70), –Ektopik ACTH sendromu (%10) ACTH bağımsız: –Primer Adrenal Adenom (%10), –Adrenal Karsinom (%5), –Adrenal Hiperplazi (<1%)

Answer 98

20-40 yaş K>E 1/100.000 HT olgularında % 0.2 %80-90 tek taraflı- diğer bez atrofik Diğer bez fonksiyonel olarak baskıda (kortizol desteği lazım olur!) +Şişmanlık 95%, Hipertansiyon 85%, Diyabet 80%, Adet bozukluğu ve İmpotans 75%, Hirsutizm ve akne 70% Mor strialar, hiperpigmentasyon 70% Ekstremitelerde kas atrofisi 65% Kötü yara iyileşmesi 55% Osteoporoz 55% Psikiyatrik bozukluklar 50% Ödem ve Hipokalemik alkaloz 40% Bufalo boyun, trunkal obezite, kırmızılaşma

Answer 99

24 saatlik idrarda serbest kortizol (>100 µg/dl) Gecelik Deksametazon testi Plazma ACTH düzeyi (ACTH bağımlılığını gösterir) Yüksek doz Deksametazon Testi (Ektopik ACTH ve Cushing hastalık ayrımı)

Answer 100

Virilizan sendromlar Feminizan sendromlar Malignant karakterli olma ihtimali yüksek, görece nadir tümörlerdir. Cerrahi oldukça endikedir.

Answer 101

Histolojik benign-malign ayrımı yok Androgen precursor fazlalığı –Testosterone ve 5α –dihydrotestosterone –DHEA, DHEA-S, Androstenedione İdrar ve plasmada 17-ketosteroid bulunmasıdır. Kadınlarda daha çok overyen kökenli Şüpheli olguda 3x1 mg Dex/5 gün test: Adrenal – overyen köken ayrımı % 100 Malignite % 80!! Adrenalektomi gereklidir!!

Answer 102

Erkekler--> Erkeklerde ilerlemiş durumda saptanabilir Kadınlar--> Hirsutizm, Amonere, Infertilite, Maskulinizasyon (–Kas kütle artışı, –Ses kalınlaşması, –Temporal kelleşme) Çocuklar--> Hızlı büyüme, Prematür kıllanma, Akne, Erken genital gelişme, Ses kalınlaşmas

Answer 103

Son derece nadir, genellikle benign Adrenal veya testiküler lezyon 20-50 yaş arası erkeklerde en sık İdrarda 17-ketosteroid ve estrogen Erkeklerde; bilateral jinekomasti, impotans ve testis atrofisi Kadınlarda; adet düzensizlikleri, disfonksiyonel veya postmenapozal kanama Çocuklarda; erken puberte Adrenalektomi gereklidir

Answer 104

Adrenal steroidogenezde hormon eksikliği 21-hidroksilaz enzim eksikliği en sık -–> %90 Steroid eksikliği ACTH salınımını artırarak adrenal androjen ve kortikosteroid prekursor düzeyini artırır Tedavi öncelikle hormon replasmanı –Steroid ve mineralokortikoid –İyatrojenik Cushing sendrom riski Bilateral lap. adrenalektomi 2. seçenektir

Answer 105

Feokromositoma + % 10’luk Tümör” olarak geçer: Multifokal veya Bilateral Ekstraadrenal yerleşim (erişkin) Çocuk Malign Familiyal-herediter Nadir 1-2/100.000 veya 2-8/milyon Hipertansif krizler: –% 0.5 HT nedeni Sporadik (%80-90), familial veya multipl endokrin neoplazilerin bir parçası Sempatik ganglion zinciri boyunca veya Kromaffin hücrelerin bulunduğu her yerde Sağ taraf daha fazla ( %90 ?) Idrarda metanefrin görürsek akla feokromositoma getirmeliyiz!

Answer 106

Adrenalde % 10, adrenal dışı % 30 Yavaş büyüme ve ciddi hipertansiyon En sık akciğer, kemik ve yumuşak dokulara metastaz 5 yıllık yaşam süresi % 44 Benign-malign ayırımları zor, sadec çevreye invasyon ve uzak organ metastazları ile anlarız. BT MRG Adrenal sintigrafi -–>Ekstraadrenal yerleşim

Answer 107

Adrenaloma Tesadüfen ve radyolojik olarak saptanma: Malignite evrelemesi sırasında saptanan adrenal kitleler hariç Anamnez, fizik muayene ve laboratuar bulguları sonrası non-fonksiyonel görünen: % 20 subklinik hormon disfonksiyonu M= F, Yaşla birlikte görülme sıklığı artar

Answer 108

Non fonksiyonel: Non-fonksiyonel adenom, Hiperplazi, Myelolipoma, Ganglionöroma, Adrenal kist, Hematom Fonksiyonel: Aldosteronoma, Subklinik Cushing, Feokromasitoma (kortisol K+) Malign: Adrenal kortikal karsinom, Metastatik lezyonlar, Diğer nadir durumlar Hepsinde adrenalektomiye gidebiliyoruz ama non fonksiyoneller benign ise takip de edebiliriz.

Answer 109

Minimal hormonal değerlendirme: –24 saatlik idrarda metanefrin düzeyi, –24 saatlik idrarda serbest kortizol düzeyi veya 1 mg gecelik deksametazon supresyon testi, –Serum K takibi

Answer 110

1.Boyut: 4cmden büyükse malignite riski çok!: Adrenalektemi!!! 2.Radyoloji: BT gold, belki MR sonra 3.Histoloji

Answer 111

Tüm kanserler içinde % 0.2 ölüm nedeni (nadir), 2. en saldırgan endokrin tümör: –Erken lokal invazyon ve metastaz, –%20-40 metastatik, –5 yıllık yaşam % 19-35 (Ort. 3.1) Adrenal met. ve feo > 6 cm ve 100-5000 g <5 yaş ve 40-50’li yaşlarda daha sık Kadınlarda 1.5-2 kat daha sık Sporadik Adenomdan patolojik ayırımı zor Fonksiyonel veya nonfonksiyonel % 75 ilerlemiş dönemde tanı konmakta Erken cerrahi girişim

Answer 112

1.Büyük kitle sendromu (%30) Yan ağrısı, ateş, kilo kaybı, IVK basısı Örtülü hormonal bozukluk 1.Kitleye eşlik eden hipersekresyon (%60) Hiperkortikolizm (%30), virilizasyon (%22), feminizasyon (%10), hiperaldosteronizm (%2.5), karışık (%35) 1.İnsidentaloma (%10) <1.5 cm ve hormon salgılamayan nadir

Answer 113

USG, BT veya MRG –Heterojen görünüm –Düzensiz yüzey –Komşu lenfadenopatiler –Lokal invazyon –Uzak met. bulgusu

Answer 114

–% 72 akciğer –% 55 karaciğer –% 33 peritona –% 24 kemik –% 15 karşı adrenal bez –% 10 beyin

Answer 115

Adrenalektomi Cerrahi sonrası 5 yıllık sağ kalım: –Tam eksizyonda <% 50, –Tam olmayanlarda 1 yıl Adjuvan Mitotan uygulaması endokrin semptomları kontol eder ama yaşam süresini etkilemez Radyoterapi- kemik met. için

Answer 116

Akciğer, meme, böbrek, prostat ve melanoma Adrenalektomi genelde yararsız –İzole bir tutulum ise olabilir –Genellikle disemine yayılım ile saptanır İİAB gerekli –Feo ekarte edildikten sonra

Answer 117

1.İleri derecedeki vaskülaritesi 2.Yakın komşulukları; IVC, pankreas, dalak 3.Kontrolsüz katekolamin salınımı 4.Derin yerleşim nedeniyle büyük kesi gereği Laparoskopik adrenalektomi gold standard

Answer 118

Anal Fissure Hemorrhoidal Disease Anal Abscess Anal Fistula Pilonidal Disease

Answer 119

Starts with a tear to the anoderm. Recurring anal pain. Internal anal sphincter spasm. Restricted blood flow to the fissure. 90% located in the posterior midline. Kısacası anüsün yakınındaki derinin yırtılması.

Answer 120

Primary--> Local trauma, Constipation, Diarrhea, Vaginal delivery, Anal sex Secondary--> Crohn disease, Granulomatous diseases, Malignancy, Communicable diseases

Answer 121

Anal pain. Anal bleeding <8 weeks --> acute, >8 weeks --> chronic +Diff diagnosis: Hemorrhoids, Perianal ulcers, Anal fistula

Answer 122

Crohn--> Gastroenterology reference. If not due to crohn--> Four weeks of medical therapy (all of them): topical nifedipine, topical analgesic, stool softener, sitz bath, fiber. If the symptoms continue, 4 wk more. If still do, endoscopy. After endoscopy: colorectal surgery or second line medical therapy + alternate topical vasodilator. CR surgery if risky for incontinence--> botox, anal advancement flap If not--> lateral internal sphincterotomy.

Answer 123

A surgical procedure done for anal fissure treatment.

Answer 124

When defecating, feces forces the hemorrhoidal plexus. Abnormal dilatation of the veins of the internal hemorrhoidal venous plexus might cause it. Deterioration of the connective tissue that anchors hemorrhoids.

Answer 125

Advanced age, diarrhea, pregnancy, pelvic tumors, prolonged sitting, straining (zorlama), chronic constipation + Hematochezia, pain associated with thrombosed hemorrhoid, perianal pruritus, fecal soilage (akıntı)

Answer 126

4 level var. 1--> Hemorrhoid with vascular engorgement bulging into anal canal without prolapse. 2--> Hemorrhoid prolapses with straining but reduces spontaneously 3--> Hem. prolapses beyond the dentate line with straining and is only reducible by manual pressure 4--> Grossly evident prolapse of hemorrhoid tissue that is non reducible: chronic inflammatory changes.

Answer 127

4 level var. 1--> Painless bleeding. Medical. 2--> Painless bleeding + perianal itching. Med. 3--> Painless bleeding + perianal itching + swelling + staining or soilage with mucus or feces. Med. 4--> Painful bleeding + swelling + staining or soilage with mucus or feces. Surgery.

Answer 128

İnspection of anal verge, digital rectal exam, anoscopy, endoscopic evaluation

Answer 129

Conservative--> sitz bath, diet, topical analgesic and steroids, venoactive agents such as flavonoids and calcium dobesilate, for 123 Office- based procedures--> rubber band ligation. Sclerotherapy. Infrared coagulation. Electrocautery, laser photocoagulation. Cyrosurgery. for 123 Surgical treatment--> Conventional hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidectomy

Answer 130

Originates from an infected anal crypt gland 8 – 10 anal crypt glands within the anal canal Anal crypt gland becomes obstructed with debris Permits bacterial growth and abscess formation Some abscesses traverse distally in the intersphincteric groove into the perianal skin Others follow the path of least resistance to other spaces (intersphincteric, ischiorectal, supralevator)

Answer 131

Ischiorectal abscess, crypt of morgagni, interspinchteric abscess, supralevator abscess, subcutaneous/ perianal.

Answer 132

Cryptoglandular abscess Crohn disease Obstetric injury Radiation proctitis Rectal foreign bodies Infectious diseases Malignancy

Answer 133

Nonhealing anorectal abscess Perianal drainage Pruritus

Answer 134

Physical Examination--> Inspection Fistula probe Imaging Studies Pelvic MR EUS