General Flashcards
Bacteria and viruses associated with acalculous cholecystitis?
CMV
EBV
Salmonella
Brucellus
Best individual lab for choledocholithiasis?
Bili >3
69/88% sen/spec
sizes that matter for CBD stone?
<3 very unlikely
>10= 90%
If stone seen with US it is 100% specific. Just bad sensitivity at 18-74
percent of pancreatitis from ERCP?
3.5%
Ways to stratify patients with CBD stones?
High, moderate or low
based on american society of gastroentestinal endoscopy
Treatment of gallstone panc?
ERCP and early cholecystectomy
- labs do NOT need to normalize just patients pain needs to improve
Riglers triad?
Pneumobilia
Bowel obstruction
Stone seen on imaging
- dx gallstone ileus
Where is a bravo probe placed?
5cm above LES
What is the advantages of impedance monitoring rather than pH probe?
- Detection of reflux regardless of pH (bile reflux)
- Detection of reflug regardless of Solute (food, gas, air, liquid)
- Detection of height of reflux
- Detection of reflux even if on PPI’s or antireflux meds
Bad demeester score?
- 97 is 95th percentile
- positional and subjective as well as objective
What chemokine causes cachexia?
TNF-a
What lab value is measured to monitor tPA or catheter directed therapy for arterial clot? What levels of this predict bleeding?
Fibrinogen
<150 mg/dl
Risk of major and minor bleeding with CDT?
8.8% for major
44% for minor
What does acral and lentigo mean?
Peripheral body part
freckle or dark spot
Most common melanoma? Most aggressive? least aggressive? MC mets?
Superficial spreading
Nodular–> blue lesions, vertical growth first
Lentigo maligna–> radial growth before deep growth
Lungs
difference between modified brooke formula and parklands formula?
2cc/hr vs 4cc/hr xTSBA x Weight kg’s
- leads to less fluid overload. Titrate to 0.5-1cc/hr/kg UOP
- Both only 2nd and 3rd degree burns
- need to have >10%, 15%TSBA burned in peds, adults respectively
Zinc deficiency leads to what symptoms?
FTT
Impaired wound healing
Skin rash
What soft tissue cancer is associated with Spindle cells and CD-34?
Dermatofibrosarcoma
- characteristically laterally extension–> thus high risk for local recurrence
What causes erythema and warmth of breast in inflammatory breast cancer? also known as?
Invasion of cancer into dermal lymphatics leading to swelling, erythema and warmth of breast
- Peau d’orange
Treatment for inflammatory breast cancer?
Neoadjuntive chemo
Modified radial mastectomy
Rads
Most common site of iatrogenic Esophageal perf? how about boaerhave’s?
At level of crycopharyngeus muscle
Left site of distal esophagus
HPV strains associate with warts?
6, 11
1= foot warts
2= hand warts
HPV strains associated with Cancer?
16,18,31,33,45
Differences between condyloma accuminata and lata?
First is from HPV looks like cauliflower
2nd is syphyllis is white and flat
voltage of high voltage electrical injury?
> 1000V
What is a Peustow’s procedure and indications?
Longitudinal pancreticojejunostomy
- for dilated pancreatic ducts throughout with inflammatory mass at head
- Duct needs to be greater than 6-8mm wides for this
What is a Frey procedure?
Longitudinal pancreticojejunostomy with pancreatic head core out
- one loop of jejunum brought up for large PJ
- for small masses of pancreatic head with main duct dilation
What is a Bern procedure?
resection of pancreatic head with Roux-en-y PJ
- for large pancreatic head masses without main duct dilation
- dont resect completely to portal vein
- only one mosis
Beger procedure?
Similar to Bern but more aggressive
- BEGER is longer then BERN and thus more aggressive
- has two mosis’es
Morgagni hernia location?
congenital diaphragmatic hernia located anterior-medially
Bochdeleck hernia?
Posterior-lateral hernia of congenital diaphragm
- much more common than Morgagni
Malignant hyperthermia ion involved and pathophys?
Calcium
- sustained release of CA2+ from SR leading to prolonged muscle activation and contraction
- inhaled halogens
- Succ and suxamethonium
Medullary thyroid carcinoma is made of which cells? Releases what?
Neural crest cells
- releases Calcitonin from C- cells
What is the cause of Lymphoma after an organ transplant?
Post transplant lymphoproliferative disorder
- increases production of B-cells
- predisposes one to Lymphoma after a organ transplant
What are some purine synthesis inhibitors?
Azathiaprine (Imuran)
mycofenolate mofetil (cellcept)
- inhibits iosine monophosphate dehydrogenase and stops production of B cells
What are the pryrmidine inhibitors?
Leflunomide
teraflunomide
- for RA and psoriatic arthritis
What does cyclosporine inhibit?
INF-gamma
- IL 2, 3, 4
Mechanism of action of steroids?
Inhibits cytokine gene transcription of macrophages and decreases release of IL-1,6 and TNF-a
- also inhibits release of cytokines from T-cells which decreases response to B-cells and macrophages
Zenkers diverticuli true to false?
False
- means that mucosa and submucosa herniate through muscle wall
Traction diverticuli? MC location in esophagus?
From LAD pulling on esophagus
- true divertculum
- all the layers
- mid-esophagus
Mechanism of ESRD and hypocalcemia?
Kids not as responsive to PTH and thus pee out more Calicum
- increase PTH leads to more bone breakdown which releases phosphates and calcium
- Decreased activation of Vitamin D 1,25 type
- this vitamin helps increased intestinal absorption of Calcium
Common side effect of silver nitrate?
Low electrolytes
- specifically hyponatremia
- Methemoglobinemia
Side effects of sulfamulon (mefenide sodium/acetate)
Systemically absorbed and thus metabolic acidosis
- inhibits carbonic anhydrase
Side effects of silvadene (silver sulfadiazine)?
Neutropenia and thrombocytopenia
What is phimosis and paraphimosis?
inability to retract foreskin past glans of penis
- If this foreskin gets stuck retracted–> constrictions venous and lymphatic outflow with arterial inflow–> significant edema and urological emergency
predominant cellular source of TNF-a?
Macrophages
Treatment for anal melanoma?
WLE vs APR
- does not respond to immuno/chemo/rads therapy
MOA of tacrolimus? MC side effect?
Calcinuerin inhibitor- similar to cyclosporin in inhibiting Cytokines but more potent against IL-2
- Neurotoxic leads to headaches, seizures, tremors and confusion
MC side effect of mycophenolate?
GI related–> diarrhea
MC side effect of azathioprine?
Bone marrow suppression
MC long term complication of J-pouch after total proctocolectomy for UC?
Pouchitis
- up to 50% of patients
Pathophys of hepatorenal syndrome?
renal artery vasocontriction in setting of splanchnic and systemic vasodialtion
MOA of hepatorenal syndrome?
- Activation of Renin angiotesinogen system from HoTN
- increase sympathetics from HoTN and increase intrahepatic sinosidal pressure
- increase release of arginine vasopressin
- reduced hepatic clearance of vasodilators
Who is at greatest risk of post splenectomy sepsis syndrome?
Children before age 3. ideally wait until child is about 5
- if taking out spleen for hematological or malignancy
Types of le fort fractures?
1- Horizontal through maxilla
- Pyrymidal involving nasal bone, orbit and maxilla
- Complete craniofacial seperation (lateral fracture of orbit)
- all have pterygoid plate fx involvement
Types of internal hernia locations after Roux-en-y?
three of them
- Petersen’s–> between transverse mesocolon and roux limb mesentery
- Opening in transverse mesentery
- mesenteric opening at the biliopancreatic limb
Which product of blood that is donated cannot transmit viruses?
Albumin
What are the causes of chloride wasting metabolic alkalosis?
Diarrhea
Massive vomiting
chloride riding diuretics
What are the causes of chloride resistant alkalosis?
Conn syndrome 2' hyperparathryoidism Cushing Little syndrome Bartter syndrome exogenous corticoids
What supplies 3 segments of esophagus?
Cervical–> inferior thyroid (thyrocervical trunk from subclavian)
Thoracic- aorta
Abdominal- LEFT gastric
most common site for colonoscopy perf?
Sigmoid-70%
Most common instrument left in abdomen?
Mallable
ovarian tumors assocciated with Lactate dehydrogenase?
Dysgerminomas
Ovarian tumors associated with CA-125?
Epithelial
Ovarian tumors associated with B-hcg?
Germ cell, Embyronic, chorio
Ovrian tumors associated with A-fp?
all else
- yolk sac, embryonal, tertatomas, mixed germ, polyembryonal
Contraindications to liver transplant?
Cant handle surgery- cardiac pulmonary
- also recent intracranial bleed
- extrahepatic malig
mc quick treatment for anal incontinence from obstetric trauma?
Wrap around sphincteroplasty
- mobilizing and identifying the sphincter and reapproximate without tension
stage I and II rectal cancer treatment?
Surgery followed by chemo/xrt
Stage III rectal cancer tx?
Neoadjuvant chemo/xrt
surgery
followed by adjuvant chemo
Hypomagnesium usually resembles which other low electrolyte and why?
Hypocalcium
- magnesium is needed to release PTH
- they have similar neuromuscular disturbances
- eye twitches, irritability, muscle spasms, fatigue
most common mutation associated with pancreatic tumors?
K-ras- 80-100% if them
p53 only 75%
- the later is a tumor suppressor and the firrst is an oncogene
MOA of milronone and amrinone?
Phosphodiesterase inhibitors which leads to increase in cAMP which increases CA uptake by SR which causes increase in ionotropic effects of cardiac tissue
also leads to vascular smooth muscle relaxation
Myeloproliferative disorders are commonly associated with?
Budd-chiari syndrome
- thrombosis of hepatic veins
What is efferent loop syndrome?
After roux-en-y or billroth type surgeries
- abdominal pain, bilious vomiting, nausea
- typically in 1st month
- kinking of efferent limb typically behind the GJ anastomamosis
- tx: surgery
What is afferent loop syndrome/
Typically from it being too long
- acute or chronic
- abdominal pain and vomiting
Tx: shorten loop
Primary fuel source when NPO for enterocytes?
GLutamine
When not NPO its medium chain fatty acids
Primary fuel source for colon cells?
Short chain fatty acids
Fungal liver abscess mc species?
- candida
- aspergillus
- cryptococcus
What is Nodular lymphoid hyperplasia?
Numerous polyps in rectum, colon and small bowel
- associated with immocompromised individuals
- HIV, malignancy, hematoproliferative disorders
- no surgery needed–> seek cause
MC primary cardiac tumor in children?
Rhabdomyomas
- cardiac- watch and wait. take out only if causing outlet obstruction
- multiple
- > 50% associated with tuberous sclerosis
- Not malignant
Bilateral mobile rubbery masses in older? male
Likely gynecomastia
- watch and wait
- happens to neonates, adolescence and older gentlemen
- US if under 25 or unilateral
mneomonic for abnormal uterine bleeding?
PALM-COEIN Polyp Adenomyosis leiomyoma malig Coagulopathy Ovulatory dysfunction Endometrial iatrogenic
MC reason for hysterectomy ?
Fibroids–> leiomyoma
Days prior to surgery do we need to stop NOAC?
2 days
- 5 days for warfarin
Calculation for serum osmarlarity?
2x Sodium + 2x K+ +Glucose/18 + BUN/2.8
what type of lymphoma does Celiac put you at risk for?
T-cell
Steps needed prior to lung resection for lung cancer?
PET/CT
EUS for mediastinum eval
Bronch intraop
Pulmonary function tests
Familial hypocalciuric hypercalcemia?
inativated calcium sensing receptor
- leads to hypocalciuria, hypercalcemia and normal vitamin D levels.
When does male gynecomastia get concerning? 3 things? Needs further eval.
- Pre puberty or post puberty before elderly
- Size >4cm
- present for greater than a year
When does DCIS need SLNB?
High grade features >4cm multicentric disease palpable disease or needing mastectomy
Difference between multifocal breast disease and multicentric?
Focal is different areas
- Centric is multiple quadrant involvement
seven characteristics of Gail model?
- Age
- Age of first menarche
- Age of first child
- Family history (1st degree relatives with BC)
- Number of Past breast biopsies
- Past bx showing atypical ductal hyperplasia
- race/ethnicity
Pregnancy available treatments? specific to each trimester.
first: only surgery (MRM). No chemo. No rads
early 2nd. surgery (MRM) and select chemo
late 2nd: can get most chemo, can do SLNB but no blue dye, surgery
3rd: same as late 2
- rads only after delivery
- first and early 2nd need MRM because you cant do SLNB
Characteristis that stratisfy Phyloides?
number of mitotic events
cellularity
margins
Can patient with prior rads get SLNB?
no
Classic NCCN guidelines for SNLB?
clinical stage invasive T1-3 with clinically negative nodes
percent of malignancy from blood nipple discharge based on age?
<40- 3%
>60 30%
- 3 and 30
