General surgery Flashcards

Question

Which arteries supply the pancreas?

Answer 1

* Pancreatic branches of splenic * Pancreaticoduodenals

Answer 2

Superior mesenteric branches: jejunal, ileal, ileocolic

Answer 3

1. Superior mesenteric branches: right colic, middle colic 2. Inferior mesenteric branches: left colic, sigmoid, superior rectal

Answer 4

Key tests for specific diagnosises: * LFTs * Amylase/ lipase * urinalyss * ß-HCG * troponin * ABG/VBG Key tests for or preparation: * FBC, UECs, Glucose * CXR + ECG * PT/INR and aPTT

Answer 5

* Hepatobiliary * Biliary colic * Cholecystitis * Cholangitis * CBD obstruction (stone, tumor) * Hepatitis * Budd-Chiari * Hepatic abscess/mass * Right subphrenic abscess * Gastrointestinal * Pancreatitis * Presentation of gastric, duodenal, or pancreatic pathology * Hepatic flexure pathology (CRC, subcostal incisional hernia) * Genitourinary * Nephrolithiasis * Pyelonephritis * Renal: mass, ischemia, trauma * Cardiopulmonary * RLL pneumonia * Effusion/empyema * CHF (causing hepatic congestion and R pleural effusion) * MI * Pericarditis * Pleuritis * Miscellaneous * Herpes zoster * Trauma * Costochondritis

Answer 6

* Cardiac * Aortic dissection/ruptured AAA * MI * Pericarditis * Gastrointestinal * Gastritis * GORD/oesophagitis * PUD * Pancreatitis * Mallory-Weiss tear

Answer 7

* Pancreatic * Pancreatitis (acute vs. chronic) * Pancreatic pseudocyst * Pancreatic tumors * Gastrointestinal * Gastritis * PUD * Splenic flexure pathology (e.g. CRC, ischemia) * Splenic * Splenic infarct/abscess * Splenomegaly * Splenic rupture * Splenic aneurysm * Cardiopulmonary (see RUQ and Epigastric) * Genitourinary (see RUQ)

Answer 8

* Gastrointestinal * Peritonitis * Early appendicitis, perforated appendicitis * Mesenteric ischemia * Gastroenteritis/colitis * Constipation * Bowel obstruction * Pancreatitis * Inflammatory bowel disease * Irritable bowel syndrome * Ogilvie’s syndrome * Cardiovascular/Hematological * Aortic dissection/ruptured AAA * Sickle cell crisis * Genitourinary/Gynecological * Perforated ectopic pregnancy * PID * Acute urinary retention * Endocrinological * Carcinoid syndrome * Diabetic ketoacidosis * Addisonian crisis * Hypercalcemia * Other * Lead poisoning * Tertiary syphilis

Answer 9

* Gastrointestinal * Appendicitis * Crohn’s disease * Tuberculosis of the ileocecal junction * Cecal tumor * Intussusception * Mesenteric lymphadenitis (Yersinia) * Cecal diverticulitis * Cecal volvulus * Hernia: femoral, spigelian, inguinal obstruction, Amyand’s (and resulting cecal distention) * Gynecological * See ‘suprapubic’ * Genitourinary * See ‘suprapubic’ * Extraperitoneal * Abdominal wall hematoma/abscess * Psoas abscess

Answer 10

* Gastrointestinal (see RLQ/LLQ) * Acute appendicitis * IBD * Gynecological * Ectopic pregnancy * PID * Endometriosis * Threatened/incomplete abortion * Hydrosalpinx/salpingitis * Ovarian torsion * Hemorrhagic fibroid * Tubo-ovarian abscess * Gynecological tumors * Genitourinary * Cystitis (infectious, hemorrhagic) * Hydroureter/urinary colic * Epididymitis * Testicular torsion * Acute urinary retention * Extraperitoneal * Rectus sheath hematoma

Answer 11

* Gastrointestinal * Diverticulitis * Diverticulosis * Colon/sigmoid/rectal cancer * Fecal impaction * Proctitis (ulcerative colitis, infectious; i.e. gonococcus or chlamydia) * Sigmoid volvulus * Hernia * Gynecological * See ‘suprapubic’ * Genitourinary * See ‘suprapubic’ * Extraperitoneal * Abdominal wall hematoma/abscess * Psoas abscess

Answer 12

Right shoulder or scapula

Answer 13

periumbilical to right lower quadrant

Answer 14

to back or flank

Answer 15

RLQ (via right paracolic gutter)

Answer 16

* failure of medical management * exsanguinating hemorrhage: hemodynamic instability despite vigorous resuscitation * recurrent hemorrhage after initial stabilization procedures (up to two attempts of endoscopic control) * hypovolemic shock * prolonged bleeding with transfusion requirement \>4 units * bleeding at rate \>1 unit/8 h

Answer 17

* Hepatocellular: Elevated bilirubin + elevated ALT/AST * Cholestatic: Elevated bilirubin + elevated ALP/GGT ± duct dilatation upon biliary U/S * Hemolysis: ↓ haptoglobin ↑ LDH

Answer 18

* respiratory: atelectasis, pneumonia, pulmonary embolus (PE), ARDS, asthma, pleural effusion * cardiac: MI, arrhythmia, CHF * Inadequate pain control

Answer 19

ATELECTASIS * comprises 90% of post-operative pulmonary complications Clinical Features * low-grade fever on POD #1, tachycardia, crackles, decreased breath sounds, bronchial breathing, tachypnea Risk Factors * COPD, smoking, obesity, elderly persons * upper abdominal/thoracic surgery, oversedation, significant post-operative pain, poor inspiratory effort Treatment * pre-operative prophylaxis * smoking cessation (best if \>8 wk pre-operative) * provide incentive spirometer and instruct how to use * post-operative prophylaxis * incentive spirometry, deep breathing exercise, chest physiotherapy, intermittent positive- pressure breathing * selective NGT decompression after abdominal surgery * short-acting neuromuscular blocking agents * minimize use of respiratory depressive drug, good pain control, early ambulation

Answer 20

PNEUMONIA/PNEUMONITIS * may be secondary to aspiration of gastric contents during anesthetic induction or extubation, causing a chemical pneumonitis Risk Factors * aspiration: general anesthetic, decreased LOC, GERD, full stomach, bowel/gastric outlet obstruction + non-functioning NGT, pregnancy, seizure disorder * non-aspiration: atelectasis, immobility, pre-existing respiratory disease Clinical Features * productive cough, fever * tachycardia, cyanosis, respiratory failure, decreased LOC * CXR: pulmonary infiltrate Treatment * prophylaxis: see atelectasis prophylaxis, pre-operative NBM/NGT, rapid sequence anesthetic induction * immediate removal of debris and fluid from airway * consider endotracheal intubation and flexible bronchoscopic aspiration * IV antibiotics to cover oral nosocomial aerobes and anaerobes (e.g. ceftriaxone, metronidazole)

Answer 21

Clinical Features * unilateral leg swelling and pain (DVT as a source of PE), sudden onset shortness of breath, tachycardia, fever * most commonly POD #8-10, but can occur anytime post-operatively Treatment * IV heparin, long-term warfarin (INR = 2-3) for 3 mo * Greenfield (IVC) filter if contraindications to anticoagulation or develops a complication while on anticoagulation * prophylaxis: subcutaneous heparin (5,000 U bid) or LMWH, compression stockings (TED™ Hose)

Answer 22

Etiology * cardiogenic vs. noncardiogenic * circulatory overload: excess volume replacement, LV failure, shift of fluid from peripheral to pulmonary vascular bed, negative airway pressure, alveolar injury due to toxins (e.g. ARDS) * more common with pre-existing cardiac disease * negative pressure pulmonary edema due to inspiratory efforts against a closed glottis upon awakening from general anesthesia Clinical Features * SOB, crackles at lung bases, CXR abnormal Treatment (LMNOP) * Lasix (furosemide) * Morphine (decreases symptoms of dyspnea, venodilator and afterload reduction) * Nitrates (venodilator) * Oxygen + non-invasive ventilation * Position (sit patient up)

Answer 23

Clinical Features * dyspnea, cyanosis, evidence of obstructive lung disease * earliest manifestations – tachypnea and hypoxemia (RR \>25, pO 2 \<60) * pulmonary edema, unexplained decrease in SaO 2 Treatment * ABCs, O 2 , ± intubation * bronchodilators, diuretics to treat CHF * adequate blood pressure to maintain pulmonary perfusion * if these measures fail to keep PaO 2 \>60, consider ARDS

Answer 24

Incidence * surgery increases risk of MI * incidence * 0.5% in previously asymptomatic men \>50 yr old * 40-fold increase in men \>50 yr old with previous MI Risk Factors * pre-operative HTN, CHF * previous MI (highest risk ≤6 mo, but risk never returns to baseline) * increased age * intraoperative hypotension * operations \>3 h * angina Clinical Features * majority of cases on day of operation or POD #3-4 (shifting of third space fluid back into intravascular compartment) * often silent without chest pain, may only present with new-onset CHF (dyspnea), arrhythmias, hypotension

Answer 25

Defect in abdominal wall causing abnomral protrusion of intra-abdominal contents.

Answer 26

* M:F = 9:1 * lifetime risk of developing a hernia: males 20-25%, females 2% * frequency of occurrence: 50% indirect inguinal, 25% direct inguinal, 8-10% incisional (ventral), 5% femoral, 3-8% umbilical * most common surgical disease of males

Answer 27

* activities which increase intra-abdominal pressure * obesity, chronic cough, asthma, COPD, pregnancy, constipation, bladder outlet obstruction, ascites, heavy lifting * congenital abnormality (e.g. patent processus vaginalis, indirect inguinal hernia) * previous hernia repair, especially if complicated by wound infection * loss of tissue strength and elasticity (e.g. hiatus hernia, aging, repetitive stress)

Answer 28

* mass of variable size * tenderness worse at end of day, relieved with supine position or with reduction * abdominal fullness, vomiting, constipation * transmits palpable impulse with coughing or straining

Answer 29

* physical examination usually sufficient * ultrasound ± CT (CT required for obturator hernias, internal abdominal hernias and Spigelian and/or femoral hernias in obese patients)

Answer 30

* complete: hernia sac and contents protrude through defect * incomplete: partial protrusion through the defect * internal hernia: sac herniating into or involving intra-abdominal structure * external hernia: sac protrudes completely through abdominal wall * strangulated hernia: vascular supply of protruded viscus is compromised (ischemia) * requires emergency repair * incarcerated hernia: irreducible hernia, not necessarily strangulated * Richter’s hernia: only part of bowel circumference (usually anti-mesenteric border) is incarcerated or strangulated so may not be obstructed * a strangulated Richter’s hernia may self-reduce and thus be overlooked, leaving a gangrenous segment at risk of perforation in the absence of obstructive symptoms * sliding hernia: part of wall of hernia sac formed by retroperitoneal structure (usually colon)

Answer 31

* groin * indirect and direct inguinal, femoral * pantaloon: combined direct and indirect hernias, peritoneum draped over inferior epigastric vessels * epigastric: defect in linea alba above umbilicus * incisional: ventral hernia at site of wound closure, may be secondary to wound infection * other: Littre’s (involving Meckel’s), Amyand’s (containing appendix), lumbar, obturator, peristomal, umbilical, Spigelian (ventral hernia through linea semilunaris), Grynfeltt-Lesshaft hernia (superior lumbar hernia), Petit's hernia (inferior lumbar triangle)

Answer 32

* incarceration * strangulation * small, new hernias more likely to strangulate * femoral \>\> indirect inguinal \> direct inguinal * intense pain followed by tenderness * intestinal obstruction, gangrenous bowel, sepsis * surgical emergency * DO NOT attempt to manually reduce hernia if septic or if contents of hernial sac gangrenous * will cause closed loop SBO – and EMERGENCY

Answer 33

* surgical treatment (herniorrhaphy) is only to prevent strangulation and evisceration, for symptomatic relief, for cosmesis; if asymptomatic can delay surgery * repair may be done open or laparoscopic and may use mesh for tension-free closure * most repairs are now done using tension-free techniques – a plug in the hernial defect and a patch over it or patch alone * observation is acceptable for small asymptomatic inguinal hernias

Answer 34

* recurrence (15-20%) * risk factors: recurrent hernia, age \>50, smoking, BMI \>25, poor pre-operative functional status (ASA ≥3), associated medical conditions: type 2 DM, hyperlipidemia, immunosuppression, any comorbid conditions increasing intra abdominal pressure * less common with mesh/"tension-free" repair * scrotal haematoma (3%) * painful scrotal swelling from compromised venous return of testes * deep bleeding: may enter retroperitoneal space and not be initially apparent * difficulty voiding * nerve entrapment * ilioinguinal (causes numbness of inner thigh or lateral scrotum) * genital branch of genitofemoral (in spermatic cord) * stenosis/occlusion of femoral vein * acute leg swelling * ischemic colitis

Answer 35

* Through Hesselbach’s triangle * Medial to inferior epigastric artery * Usually does not descend into scrotal sac

Answer 36

* Originates in deep inguinal ring * Lateral to inferior epigastric artery * Often descends into scrotal sac (or labia majora)

Answer 37

* Into femoral canal, below inguinal ligament but may override it * Medial to femoral vein within femoral canal

Answer 38

1. vas deferens 2. testicular artery/veins, 3. genital branch of genitofemoral nerve, 4. lymphatics 5. cremaster muscle, 6. ± hernia sac

Answer 39

Common risks: * troublepassing urine due to spasm of bladder sphincter * swelling of testicle and scrotum * damage to local structures: vas deferens * Chronic pain at site of surgery * Bleeding * seroma formation * Atelectasis, pneumonia * Wound infection * DVT/PE *

Answer 40

General: * Infection * Bleeding * Atelectasis * Pneumonia * Wound infection * MI and stroke * DVT/PE * Death Specific: * Damage to surrounding structures: blood vessels, bile duct, and other organs * Gas in abdo causing heart and lung issues * may need to convert to open surgery * Stone may be found outside of gallbladder, spill from gallbladder into abdo cavity or be left in bile duct - needing further treatment * Clips and ties may come off * Abnormal wound healing - keloid scars, wound dehesence * Hernia at wound site * Adhesions * symtpoms pre surgery may not resolve * Allergy to injected contrast

Answer 41

* imbalance of cholesterol and its solubilizing agents (bile salts and lecithin) * excessive hepatic cholesterol secretion → bile salts and lecithin are “overloaded” → supersaturated cholesterol can precipitate and form gallstones * cholesterol stones (80%), pigment stones (20%)

Answer 42

* cholesterol stones * obesity, age \<50 * estrogens: female, multiparity, OCPs * Ethnicity: Caucasian \> Black * terminal ileal resection or disease (e.g. Crohn’s disease) * impaired gallbladder emptying: starvation, TPN, DM * rapid weight loss: rapid cholesterol mobilization and biliary stasis * pigment stones (contain calcium bilirubinate) * cirrhosis * chronic hemolysis * biliary stasis (strictures, dilation, biliary infection) * protective factors: statins, vitamin C, coffee, exercise

Answer 43

* asymptomatic (80%) * most do NOT require treatment * consider cholecystectomy if: increased risk of malignancy (choledochal cysts, Caroli’s disease, porcelain or calcified gallbladder), sickle cell disease, pediatric patient, bariatric surgery, immunosuppression * biliary colic (10-25%) * cholecystitis * choledocholithiasis (8-15%) * cholangitis * gallstone pancreatitis * gallstone ileus (0.3-0.5%) * other: empyema of the gallbladder, liver abscess, gallbladder perforation with bile peritonitis

Answer 44

* Labs * CBC, LFTs, amylase and lipase * U/S – diagnostic procedure of choice * image for signs of inflammation, obstruction, localization of stones * 95% specific for detecting stones * signs: gallbladder wall thickening \>4 mm, edema (double-wall sign), gallbladder sludge, pericholecystic fluid, sonographic Murphy’s sign * ERCP * visualization of upper GI tract, ampullary region, biliary and pancreatic ducts * method for treatment of CBD stones in periampullary region * complications: traumatic pancreatitis (1-2%), pancreatic or biliary sepsis * MRCP * same information gained as ERCP but non-invasive * cannot be used for therapeutic purposes * PTC * injection of contrast via needle passed through hepatic parenchyma * useful for proximal bile duct lesions or when ERCP fails or not available * requires prophylactic antibiotics * contraindications: coagulopathy, ascites, peri/intrahepatic sepsis, disease of right lower lung or pleura * complications: bile peritonitis, chylothorax, pneumothorax, sepsis, hemobilia * HIDA scan * used less commonly * radioisotope technetium-99 injected into a vein is excreted in high concentrations into bile, allowing visualization of the biliary tree * does not visualize stones; diagnosis by seeing occluded cystic duct or CBD

Answer 45

* Symptomatic cholelithiasis with or without complications * Asymptomatic cholelithiasis in patients who are at increased risk of gallbladder carcinoma or gallstone complications * Acalculous cholecystitis * Gallbladder polyps \>0.5 cm * Procelain gallbladder

Answer 46

* RUQ or epigastric pain which radiates to the back * Colicky pain but can be dull and constant * Dyspepsia, flatulence * Food intolerance particualrly to fats * Alteration in bowel frequency * N/V

Answer 47

* Common * appendicitis * perforated peptic ulcer * acute pancreatitis * Uncommon * Acute pyelonephritis * myocardial infarction * pneumoina - right lower lobe

Answer 48

* luminal obstruction g bacterial overgrowth → inflammation/swelling → increased pressure → localized ischemia → gangrene/perforation → localized abscess (walled off by omentum) or peritonitis * aetiology * children or young adult: hyperplasia of lymphoid follicles, initiated by infection * adult: fibrosis/stricture, fecolith, obstructing neoplasm * other causes: parasites, foreign body

Answer 49

Tenderness 1/3 the distance from the ASIS to the umbilicus on the right side

Answer 50

* most reliable feature is progression of signs and symptoms * low grade fever (38ºC), rises if perforation * abdominal pain then anorexia, N/V * classic pattern: pain initially periumbilical; constant, dull, poorly localized, then well localized pain over McBurney’s point * due to progression of disease from visceral irritation (causing referred pain from structures of the embryonic midgut, including the appendix) to irritation of parietal structures * McBurney’s sign * signs * inferior appendix: McBurney’s sign (see sidebar GS28), Rovsing’s sign (palpation pressure to left abdomen causes McBurney’s point tenderness). McBurney’s sign is present whenever the opening of the appendix at the cecum is directly under McBurney’s point; therefore McBurney’s sign is present even when the appendix is in different locations * retrocecal appendix: psoas sign (pain on flexion of hip against resistance or passive hyperextension of hip) * pelvic appendix: obturator sign (flexion then external or internal rotation about right hip causes pain) * complications * perforation (especially if \>24 h duration) * abscess, phlegmon

Answer 51

* laboratory * mild leukocytosis with left shift (may have normal WBC counts) * higher leukocyte count with perforation * β-hCG to rule out ectopic pregnancy * urinalysis * imaging * ultrasound: may visualize appendix, but also helps rule out gynecological causes – overall accuracy 90-94%, can rule in but cannot rule out appendicitis (if \>0.2 in, SENS/SPEC/NPV/PPV 98%) * upright CXR, AXR: usually nonspecific – free air if perforated (rarely), calcified fecolith, loss of psoas shadow, RLQ ileus * CT scan: thick wall, appendicolith, inflammatory changes – overall accuracy 94-100%, optimal investigation

Answer 52

* hydrate, correct electrolyte abnormalities * surgery (gold standard, 20% mortality with perforation especially in elderly) + antibiotic coverage * if localized abscess (palpable mass or large phlegmon on imaging and often pain \>4-5 d), consider radiologic drainage + antibiotics x 14 d ± interval appendectomy in 6 wk (controversial) * appendectomy * laparoscopic vs. open * complications: spillage of bowel contents, pelvic abscess, enterocutaneous fistula * perioperative antibiotics: * cefazolin + metronidazole (no post-operative antibiotic unless perforated) * other choices: 2nd/3rd generation cephalosporin for aerobic gut organisms * colonoscopy in the elderly to rule out other etiology (neoplasm)

Answer 53

* _Inferior appendix_: McBurney’s sign), Rovsing’s sign (palpation pressure to left abdomen causes McBurney’s point tenderness). McBurney’s sign is present whenever the opening of the appendix at the cecum is directly under McBurney’s point; therefore McBurney’s sign is present even when the appendix is in different locations * _Retrocecal appendix:_ psoas sign (pain on extension of hip against resistance or passive hyperextension of hip * _Pelvic appendix_: obturator sign (extension then external or internal rotation about right hip causes pain). * Relavent so that appropriate surgical planning can be made, this will change incision points depending on where the appendix is located.

Answer 54

* Appendix is a midgut structure therefore arterial supply is from a branch of the superior mesenteric artery. * The appendicular artery branches off the ileocolic artery and runs through the appendix mesentery to supply the appendix

Answer 55

* General: * Infection, bleeding, converting to open * Atelectasis and pneumonia * MI/ stroke * DVT /PE * Death * Specific: * Damage to local vessels and organs * May need to conver to open surgery * Hernia developement in surgical scars * Deep bleeding into the abdo cavity - needing blood transfusion or fluid replacement. * surgical drainage of abscess that can occur after surgery * wound dehescience * abnormal scaring * adhesions

Answer 56

* Intraluminal: * Intussusception * gallstones * Intramural: * Crohns * Raditation strictures * Adenocarcinoma * Extramural: * adhesions * incarcerated hernia * peritoneal carinomatosis

Answer 57

* consider whether complete or partial obstruction, ongoing or impending strangulation, location and cause * SBO with history of abdomen/pelvic surgery → conservative management (NGT decompression, GI rest, serial abdominal exams) → surgery if no resolution in 48-72 h or complications * complete SBO, strangulation → urgent surgery after stabilizing patient with fluid resuscitation * SBO with no previous surgery and no evidence of carcinomatosis → operate * trial of medical management may be indicated in Crohn’s, recurrent SBO, carcinomatosis * special case: early post-operative SBO (within 30 d of abdominal surgery) – prolonged trial of conservative therapy may be appropriate, surgery is reserved for complications such as strangulation

Answer 58

* Intraluminal * Constipation * Intramural: * Adenocarcinoma * Diverticulitis * IBD stricture * Radiation stricture * Extramural * Volvulus * Adhesions

Answer 59

* open loop (10-20%) * incompetent ileocecal valve allows relief of colonic pressure as contents reflux into ileum, therefore clinical presentation similar to SBO * closed loop (80-90%) (dangerous) * competent ileocecal valve, resulting in proximal and distal occlusions * massive colonic distention → increased pressure in cecum → bowel wall ischemia → necrosis → perforation

Answer 60

* disruption of the normal flow of intestinal contents leading to proximal dilatation and distal decompression * may take 12-24 h to decompress, therefore passage of feces and flatus may occur after the onset of obstruction * bowel ischemia may occur if blood supply is strangulated or if bowel wall inflammation leads to venous congestion * bowel wall edema and disruption of normal bowel absorptive function can lead to increased intraluminal fluid and transudative fluid loss into peritoneal cavity, electrolyte disturbances

Answer 61

* prior abdominal or pelvic surgery * abdominal wall or groin hernia * history of malignancy * prior radiation

Answer 62

* strangulating obstruction (10% of bowel obstructions) = surgical emergency * cramping pain turns to continuous ache, hematemesis, melena (if infarction) * fever, leukocytosis, tachycardia * peritoneal signs, early shock * Intestinal Ischemia * other * perforation: secondary to ischemia and luminal distention * septicemia * hypovolemia (due to third spacing)

Answer 63

* Bloods: * UECs, FBC, LFT, coags * Amylase/ lipase * ABG/VBG * group and hold * Imaging * Upright CXR or left lateral decubitus to rule out free air, usually seen under the right hemidiaphragm * abdominal x-ray (3 views) to determine SBO vs. LBO vs. ileus * if ischemic bowel look for: free air, pneumatosis, thickened bowel wall, air in portal vein, dilated small and large bowels, thickened or hose-like haustra (normally finger-like projections) * CT: provides information on level of obstruction, severity, cause – important to rule out closed loop obstruction, especially in the elderly

Answer 64

* stabilize vitals, fluid and electrolyte resuscitation * NGT to relieve vomiting, prevent aspiration, and decompress small bowel by prevention of further distention by swallowed air * Foley catheter to monitor ins/outs

Answer 65

* surgical correction of obstruction (usually requires resection + temporary diverting colostomy) * volvulus requires sigmoidoscopic or endoscopic decompression followed by operative reduction if unsuccessful * if successful, consider sigmoid resection on same admission * cecal volvulus can be a true volvulus or a cecal ‘bascule’ (cecum folds anteriorly to the ascending colon producing a flap valve occlusion to cecal emptying) – both need surgical treatment

Answer 66

* General: * infection, bleeding, scaring * atelectasis and pneumonia * MI and stroke * DVT/PE * Death * Specific: * Damage to local organs and vessels that may need further surgery * Paralytic bowel - causes N/V. Usual this is temporary * WOund infection/UTI/ Abdo infection * May need to form a stoma if unable to join bowel * Stoma specific issues: * blood supply to stoma fails * excess fluid loss * stoma prolapse * parastomal hernia * local skin irritation * Erectile dysfunction * Thickened, red, painful scar * Diarrhoea * adhesions - causing obstruction * Death

Answer 67

* polyp: protuberance into the lumen of normally flat colonic mucosa * sessile (flat) or pedunculated (on a stalk)

Answer 68

* 50% in the rectosigmoid region, 50% are multiple * usually asymptomatic, do not typically bleed, tenesmus, intestinal obstruction, mucus * usually detected during routine endoscopy or familial/high risk screening

Answer 69

* non-neoplastic * hyperplastic: most common non-neoplastic polyp * mucosal polyps: small \<0.2 in, no clinical significance * inflammatory pseudopolyps: associated with IBD, no malignant potential * submucosal polyps: lymphoid aggregates, lipomas, leiomyomas, carcinoids * neoplastic * hamartomas: juvenile polyps (large bowel), Peutz-Jegher syndrome (small bowel) * malignant risk due to associated adenomas (large bowel) * low malignant potential → most spontaneously regress or autoamputate * adenomas: premalignant, often carcinoma in situ: * some may contain invasive carcinoma (“malignant polyp” – 3-9%): invasion into muscularis * malignant potential: villous \> tubulovillous \> tubular

Answer 70

* colonoscopy is the gold standard for diagnosis and treatment of colonic polyps * CT colonography: increasing in availability; patients still require bowel prep and will require colonoscopy if polyps are identified * other: flexible sigmoidoscopy if polyps are detected, proceed to colonoscopy for examination of entire bowel and biopsy * Polyps sent to path for ID

Answer 71

* Autosomal dominant inheritance, mutation in adenomatous polyposis coli (APC) gene on chromosome 5q21. * hundreds to thousands of colorectal adenomas usually by age 20 (by 40s in attenuated FAP) * extracolonic manifestations * carcinoma of small bowel (i.e. polyps in colon), bile duct, pancreas, stomach, thyroid, adrenal, small bowel * congenital hypertrophy of retinal pigment epithelium presents early in life in 2/3 of patients; 97% sensitivity * virtually 100% lifetime risk of colon cancer (because of number of polyps) * Variants: * Gardner’s syndrome: FAP + extraintestinal lesions (sebaceous cysts, osteomas, desmoid tumors) * Turcot syndrome: FAP + CNS tumors (childhood cerebellar medulloblastoma)

Answer 72

* genetic testing (80-95% sensitive, 99-100% specific) * if no polyposis found: annual flexible sigmoidoscopy from puberty to age 50, then routine screening * if polyposis or APC gene mutation found: annual colonoscopy and consider surgery, consider upper endoscopy to evaluate for periampullary tumors

Answer 73

* surgery indicated by age 17-20 * total proctocolectomy with ileostomy or total colectomy with ileorectal anastomosis * doxorubicin-based chemotherapy * NSAIDs for intra-abdominal desmoids

Answer 74

* Pathogenesis * autosomal dominant inheritance, mutation in a DNA mismatch repair gene (MSH2, MSH6, MLH1) resulting in microsatellite genomic instability and subsequent mutations * microsatellite instability account for approximately 15% of all colorectal cancers * Clinical Features * early age of onset, right \> left colon, synchronous and metachronous lesions * mean age of cancer presentation is 44 yr, lifetime risk 70-80% (M\>F) * HNPCC I: hereditary site-specific colon cancer * HNPCC II: cancer family syndrome – high rates of extracolonic tumors (endometrial, ovarian, hepatobiliary, small bowel)

Answer 75

* Amsterdam Criteria * 3 or more relatives with verified Lynch syndrome associated cancers, and 1 must be 1st degree relative of the other 2 * 2 or more generations involved * 1 case must be diagnosed before 50 yr old * FAP is excluded * genetic testing (80% sensitive) – colonoscopy mandatory even if negative * refer for genetic screening individuals who fulfill EITHER the Amsterdam Criteria (as above) OR the revised Bethesda Criteria * colonoscopy (starting age 20) annually * surveillance for extracolonic lesions

Answer 76

Total colectomy and ileorectal anastomosis with annual proctoscopy

Answer 77

Colon cancer

Answer 78

4th most common cancer (after lung, prostate, and breast), 2nd most common cause of cancer death

Answer 79

* most patients have no specific risk factors * age \>50 (dominant risk factor in sporadic cases), mean age is 70 * genetic: FAP, HNPCC, family history of CRC * colonic conditions * adenomatous polyps (especially if \>1 cm, villous, multiple) * IBD (especially UC: risk is 1-2%/yr if UC \>10 yr) * previous colorectal cancer (also gonadal or breast) * diet (increased fat, red meat, decreased fiber) and smoking * DM and acromegaly (insulin and IGF-1 are growth factors for colonic mucosal cells)

Answer 80

* often asymptomatic * haematochezia/melena, abdominal pain, change in bowel habits (e.g. overflow diarrhoea, secondary to constipation) * others: weakness, anemia, weight loss, palpable mass, obstruction * 20% patients have distant metastatic disease at time of presentation * spread * direct extension, lymphatic, hematogenous (liver most common, lung, bone, brain; tumor of distal rectum → IVC g lungs) * peritoneal seeding: ovary, Blumer’s shelf (pelvic cul-de-sac)

Answer 81

* colonoscopy (best), look for synchronous lesions (3-5% of patients); alternative: air contrast barium enema (“apple core” lesion) + sigmoidoscopy * if a patient is FOBT +ve, or has microcytic anemia or has a change in bowel habits, do colonoscopy * laboratory: FBC, urinalysis, liver enzymes, liver function tests, carcinogenic embryonic antigen (CEA) (pre-operative for baseline, \>5 ng/mL have worse prognosis) * staging: CT chest/abdomen/pelvis; bone scan, CT head only if lesions suspected * rectal cancer: pelvic MRI or endorectal ultrasound to determine T and N stage

Answer 82

* colon cancer * wide surgical resection of lesion and regional lymphatic drainage; usually colectomy with primary anastomosis * curative: wide resection of lesion (2 in margins) with nodes and mesentery * palliative: if distant spread, local control for hemorrhage or obstruction * care is taken to not spread tumor by unnecessary palpation * cancer-bearing portion of colon is removed according to vascular distribution of segment * adjuvant chemotherapy (5-FU or oral capecitabine with oxaliplatin) can be considered for stages II or III * rectal cancer * choice of operation depends on individual case; types of operations * low anterior resection of rectum (LAR): curative procedure of choice if adequate distal margins; uses technique of total mesorectal excision * abdominoperineal resection of rectum (APR): if adequate distal margins cannot be obtained; involves the removal of distal sigmoid colon, rectum, and anus – permanent end colostomy required * local excision: for select T1 lesions only * palliative procedures: electrocoagulation or laser photocoagulation for unresectable cancers for symptom relief * adjuvant therapy * combined neoadjuvant chemoradiation therapy followed by post-operative adjuvant chemotherapy for stages II and III

Answer 83

* Benign * Fibrocystic changes * Fibroepithelial lesions (fibroadenoma most common; benign phyllodes also) * Fat necrosis * Papilloma/papillomatosis * Galactocele * Duct ectasia * Ductal/lobular hyperplasia * Sclerosing adenosis * Lipoma * Neurofibroma * Granulomatous mastitis (e.g. TB, granulomatosis with polyangiitis, sarcoidosis) * Abscess * Silicone implant * Malignant * Breast cancer (likely invasive, DCIS rarely forms a breast mass) * Malignant phyllodes * Angiosarcoma (rare)

Answer 84

* most common benign breast tumor in women \<30 yr * risk of subsequent breast cancer is increased only if fibroadenoma is complex, there is adjacent atypia, or a strong family history of breast cancer * clinical features * nodules: smooth, rubbery, discrete, well-circumscribed, non-tender, mobile, hormone-dependent * unlike cysts, needle aspiration yields no fluid * Investigations * core or excisional biopsy required * U/S and FNA alone cannot differentiate fibroadenoma from Phyllodes tumor * treatment * generally conservative: serial observation * consider excision if size 2-3 cm and growing on serial U/S (q6mo x 2 yr is usual follow-up), if symptomatic, formed after age 35, or patient preference

Answer 85

* also known as chronic cystic mastitis, mammary dysplasia * benign breast condition characterized by fibrous and cystic changes in the breast * no increased risk of breast cancer * age 30 to menopause (and after if HRT used) * clinical features * breast pain, focal areas of nodularity or cysts often in the upper outer quadrant, frequently bilateral, mobile, varies with menstrual cycle, nipple discharge (straw-like, brown, or green) * treatment * evaluation of breast mass and reassurance * if \>40 yr old: mammography every 3 yr * no strong evidence for avoidance of xanthine-containing products (coffee, tea, chocolate, cola) * analgesia (ibuprofen, ASA) * for severe symptoms: OCP, danazol, bromocriptine

Answer 86

* solitary intraductal benign polyp * present as nipple discharge (most common cause of spontaneous, unilateral, bloody nipple discharge), breast mass, nodule on U/S * can harbor areas of atypia or DCIS * treatment: excision of involved duct to ensure no atypia

Answer 87

* **gender (99% female)** * **age (80% \>40 yr)** * important risk factors are prior history of breast cancer and/or prior breast biopsy (regardless of pathology) * 1st degree relative with breast cancer (greater risk if relative was premenopausal) * increased risk with high breast density, nulliparity, first pregnancy \>30 yr, menarche \<12 yr, menopause \>55 yr * decreased risk with lactation, early menopause, early childbirth * radiation exposure (e.g. mantle radiation for Hodgkin’s disease) * \>5 yr HRT

Answer 88

* mammography * indication * screening, women aged 50-74 every 2 years. * findings indicative of malignancy * mass that is poorly defined, spiculated border * microcalcifications * architectural distortion * interval mammographic changes * normal mammogram does not rule out suspicion of cancer based on clinical findings * other radiographic studies * U/S: differentiate between cystic and solid * MRI: high sensitivity, low specificity * galactogram/ductogram (for nipple discharge): identifies lesions in ducts * metastatic workup as indicated (usually after surgery or if clinical suspicion of metastatic disease): bone scan, abdominal U/S, CXR (or CT chest/abdomen/pelvis), CT head (only if specific neurological symptoms)

Answer 89

* needle aspiration: for palpable cystic lesions; send fluid for cytology if blood or cyst does not completely resolve * U/S or mammography guided core needle biopsy (most common) * fine needle aspiration (FNA): for palpable solid masses; need experienced practitioner for adequate sampling * excisional biopsy: only performed as second choice to core needle biopsy; should not be done for diagnosis if possible

Answer 90

* consider testing for BRCA1/2 if: * patient diagnosed with breast AND ovarian cancer * strong family history of breast/ovarian cancer * family history of male breast cancer * young patient (\<35 yr) * bilateral breast cancer in patients \<50 yr

Answer 91

* clinical * tumor size by palpation, mammogram * nodal involvement by palpation * metastasis by physical exam, CXR, and abdominal U/S (or CT chest/abdomen/pelvis), bone scan (usually done post-operative if node-positive disease) * pathological * tumor size * grade: modified Bloom and Richardson score (I to III) – histologic, nuclear, and mitotic grade * number of axillary nodes positive for malignancy out of total nodes resected, extranodal extension, sentinel node positive/negative * oestrogen receptor (ER) + progesterone receptor (PR) testing * Her2Neu receptor testing * margins: negative, \<1 mm, positive * lymphovascular invasion (LVI) * extensive in situ component (EIC): DCIS in surrounding tissue * involvement of dermal lymphatics (inflammatory) – automatically Stage IIIb

Answer 92

* Non-invasive: cannot penetrate basement membrane * ductal carcinoma in situ (DCIS) * Lobular carcinoma in situ (LCIS) * Invasive: * Invasive ductal carcinoma (most common 80%) * Invasive lobular carcinoma (8-15%) * Pagets disease (1-3%) * Inflammatory carcinoma (1-4%) * male breast cancer (\<1%) * Sarcomas: rare * Lymphmoa: rare * Other: papillary, medullary, mucinous, tubular cancers

Answer 93

* Breast conserving surgery: lumpectomy with wide local excision * for treatment of stage I and II disease * must be combined with radiation for survival equivalent to mastectomy * contraindications * high risk of local recurrence: extensive malignant-type calcifications on mammogram, multifocal primary tumors, or failure to obtain tumor-free margins after re-excision * contraindications to radiation therapy (pregnancy, previous radiation, collagen vascular disease) * large tumor size relative to breast * mastectomy * radical mastectomy (rarely done anymore): removes all breast tissue, skin, pectoralis muscle, axillary nodes * modified radical mastectomy (MRM): removes all breast tissue, skin, and axillary nodes * simple mastectomy: removes all breast tissue and skin * breast reconstruction * axillary lymph node dissection (ALND) * performed if SLNB is positive or nodes are clinically concerning * risk of arm lymphedema (10-15%), decreased arm sensation, shoulder pain * sentinel lymph node biopsy (SLNB) * technetium-99 ± blue dye injected at tumor site prior to surgery to identify sentinel node(s) * intraoperative frozen section * proceed with ALND if positive * 5% false negative rate

Answer 94

* radiation * indications * decrease risk of local recurrence; almost always used after BCS, sometimes after mastectomy (if \>4 nodes positive or tumor \>5 cm) * inoperable locally advanced cancer * axillary nodal radiation may be added if nodal involvement * hormonal * indications * ER positive plus node-positive or high-risk node-negative * palliation for metastases * tamoxifen if premenopausal or aromatase inhibitors (e.g. anastrozole) * ovarian ablation (e.g. goserelin/GnRH agonist, oophorectomy), progestins (e.g. megestro acetate), androgens (e.g. fluoxymesterone) are other options * chemotherapy * indications * ER negative plus node-positive or high-risk node-negative * ER positive and young age * stage I disease at high risk of recurrence (high grade, lymphovascular invasion) * palliation for metastatic disease

Answer 95

bone \> lungs \> pleura \> liver \> brain

Answer 96

* indications: thyroid cancer, symptomatic thyroid mass or goiter, medically refractory Graves’ or hyperthyroidism * contraindications: uncontrolled severe hyperthyroidism (i.e. Graves’) due to risk of intraoperative or post-operative thyroid storm

Answer 97

* thyroid U/S for thyroid nodules * FNA for large nodules * U/S of the neck for lesions suspicious for papillary or medullary thyroid cancer * CT neck useful to rule out extension, vocal cord function

Answer 98

* hypocalcemia secondary to hypoparathyroidism * recurrent/superior laryngeal nerve injury * neck haematoma * infection * thyrotoxic storm

Answer 99

* General * Infection, bleeding * Atalectasis and pneumonia * MI/stroke * DVT/PE * Death * Specific * Haematoma * Recurrent laryngeal nerve damage resulting in hoarseness, if damaged enough may need respiratory support for life * parathyroids removed * Will need TFT and thyroid supplementation * Keloid scar

Answer 100

* Papillary 70-75% * Follicular 10% * Medullary 3-5% * Anaplastic \<5% * Lymphoma \<1%

Answer 101

* Orphan Annie nuclei * Psammoma bodies * Papillary architecture

Answer 102

* Popular (most common) * Palpable lymph nodes * Positive I 131 uptake * Positive prognosis * Post-operative I¹³¹ scan to guide treatments

Answer 103

* Small tumors: Near total thyroidectomy or lobectomy * Diffuse/bilateral: Total thyroidectomy ± post-operative I¹³¹ treatment

Answer 104

* Far away mets * Female (3:1) * NOT FNA (cannot be diagnosed by FNA) * Favorable prognosis

Answer 105

* Small tumors: Near total thyroidectomy/lobectomy/ isthmectomy * Large/diffuse tumors: Total thyroidectomy

Answer 106

* Amyloid * May secrete calcitonin, prostaglandins, ACTH, serotonin, kallikrein, or bradykinin

Answer 107

* **M**ultiple endocrine neoplasia (**M**EN IIa or IIb) * a**M**yloid * **M**edian node dissection

Answer 108

* Total thyroidectomy * Median lymph node dissection if lateral cervical nodes +ve * Modified neck dissection * Post-operative thyroxine * Tracheostomy * Screen asymptomatic relatives

Answer 109

* all patients with thyroid nodules require evaluation of serum TSH and ultrasound * any nodule \>5 mm with suspicious sonographic features (particularly microcalcifications) should undergo FNA * any nodule \>1 cm should undergo FNA * when performing repeat FNA on initially non-diagnostic nodules, U/S-guided FNA should be employed * nuclear scanning has minimal value in the investigation of the thyroid nodule

Answer 110

* Dyspnea or stridor (positional vs. non-positional) * Hoarseness or dysphonia * Otalgia * Non-healing oral ulcer * Dysphagia * Haemoptysis, haematemesis

Answer 111

* lung tumors can be classified as primary or secondary, benign or malignant, endobronchial or parenchymal * bronchogenic carcinoma (epithelial lung tumors) are the most common type of primary lung tumor (other types make up less than 1%) * small cell lung cancer (SCLC) * non-small-cell lung cancer (NSCLC) * squamous cell carcinoma: arise from the proximal respiratory epithelium * adenocarcinoma: incidence is increasing; most common subtype in nonsmokers – bronchoalveolar carcinoma: grows along the alveolar wall in the periphery; may arise at sites of previous lung scarring * large cell undifferentiated cancer: diagnosis of exclusion * benign epithelial lung tumors can be classified as papillomas or adenomas

Answer 112

* cigarette smoking: the relative risk of developing lung cancer is 10-30 times higher for smokers than for non-smokers * other risk factors include: * cigar, pipe smoking * second-hand smoke * asbestos without smoking (relative risk is 5) * asbestos with smoking (relative risk is 92) * metals (e.g. chromium, arsenic, nickel) * radon gas * ionizing radiation * genetics

Answer 113

* cough (75%): beware of chronic cough that changes in character * dyspnea (60%) * chest pain (45%) * haemoptysis (35%) * other pain (25%) * clubbing (21%) * constitutional symptoms: anorexia, weight loss, fever, anemia

Answer 114

* lung, hilum, mediastinum, pleura: pleural effusion, atelectasis, wheezing * pericardium: pericarditis, pericardial tamponade * oesophageal compression: dysphagia * phrenic nerve: paralyzed diaphragm * recurrent laryngeal nerve: hoarseness * superior vena cava syndrome * obstruction of SVC causing neck and facial swelling, as well as dyspnea and cough * other symptoms: hoarseness, tongue swelling, epistaxis, and haemoptysis * physical findings: dilated neck veins, increased number of collateral veins covering the anterior chest wall, cyanosis, edema of the face, arms, and chest, Pemberton’s sign (facial flushing, cyanosis, and distension of neck veins upon raising both arms above head) * milder symptoms if obstruction is above the azygos vein * lung apex (Pancoast tumor): Horner’s syndrome, brachial plexus palsy (most commonly C8 and T1 nerve roots) * rib and vertebrae: erosion * distant metastasis to brain, bone, liver, adrenals

Answer 115

* initial diagnosis * imaging: CXR, CT chest + upper abdomen, PET scan, bone scan * cytology: sputum * biopsy: bronchoscopy, EBUS, CT-guided percutaneous needle biopsy, mediastinoscopy * staging workup * TMN staging system: T – primary tumor (size); N – regional lymph nodes; M – distant metastasis * blood work: electrolytes, LFTs, calcium, ALP * imaging: CXR, CT thorax and upper abdomen, bone scan, neuroimaging * invasive: bronchoscopy (EBUS), mediastinoscopy, mediastinotomy, thoracotomy * screen adenocarcinoma for EGFR mutations

Answer 116

* options include surgery, radiotherapy, chemotherapy, and palliative care for end-stage disease * surgery not usually performed for SCLC since it is generally non-curable * contraindications for surgery * spread to contralateral lymph nodes or distant sites * patients with potentially resectable disease must undergo mediastinal node sampling since CT thorax is not accurate in 20-40% of cases * poor pulmonary status (e.g. unable to tolerate resection of lung) * chemotherapy (used in combination with other treatments) * common agents: etoposide, platinum agents (e.g. cisplatinum), ifosfamide, vincristine, anthracyclines, paclitaxel, irinotecan, gefitinib (an endothelial growth factor receptor inhibitor) * complications * acute: tumor lysis syndrome, infection, bleeding, myelosuppression, hemorrhagic cystitis (cyclophosphamide), cardiotoxicity (doxorubicin), renal toxicity (cisplatin), peripheral neuropathy (vincristine) * chronic: neurologic damage, leukemia, additional primary neoplasms

Answer 117

Cholangitis * (RUQ) pain * rigors * jaundice

Answer 118

* 95% left-sided in patients of Western countries, 75% right-sided in Asian populations

Answer 119

* lifestyle: low-fiber diet (predispose to motility abnormalities and higher intraluminal pressure) inactivity, obesity * muscle wall weakness from aging and illness (e.g. Ehler-Danlos, Marfan’s)

Answer 120

* erosion of the wall by increased intraluminal pressure or inspissated food particles → inflammation and focal necrosis g micro or macroscopic perforation * usually mild inflammation with perforation walled off by pericolic fat and mesentery; abscess, fistula, or obstruction can ensue * poor containment results in free perforation and peritonitis

Answer 121

* depend on severity of inflammation and whether or not complications are present; hence ranges from asymptomatic to generalized peritonitis * LLQ pain/tenderness (2/3 of patients) often for several days before admission * constipation, diarrhea, N/V, urinary symptoms (with adjacent inflammation) * complications (25% of cases) * abscess: palpable tender abdominal mass * fistula: colovesical (most common), coloenteric, colovaginal, colocutaneous * colonic obstruction: due to scarring from repeated inflammation * perforation: generalized peritonitis (feculent vs. purulent) * recurrent attacks rarely lead to peritonitis * low-grade fever, mild leukocytosis common, occult or gross blood in stool rarely coexist with acute diverticulitis

Answer 122

* AXR, upright CXR * localized diverticulitis (ileus, thickened wall, SBO, partial colonic obstruction) * free air may be seen in 30% with perforation and generalized peritonitis * CT scan (test of choice): very useful for assessment of severity and prognosis; this is usually done with rectal contrast * 97% sensitive, 99% specific * increased soft tissue density within pericolic fat secondary to inflammation, diverticula secondary to inflammation, bowel wall thickening, soft tissue mass (pericolic fluid, abscesses), fistula * 10% of diverticulitis cannot be distinguished from carcinoma * elective evaluations: establish extent of disease and rule out other diagnoses (polyps, malignancy) after resolution of acute episode * colonoscopy or barium enema and flexible sigmoidoscopy

Answer 123

* uncomplicated: conservative management * outpatient: clear fluids only until improvement and antibiotics * hospitalize: if severe presentation, inability to tolerate oral intake, significant comorbidities, fail to improve outpatient management * treat with NPO, IVF, IV antibiotics (e.g. IV metronidazole, ampicillin, gentamicin) * indications for surgery * unstable patient with peritonitis * Hinchey stage 3-4 * after 1 attack if immunosuppressed * consider after 2 or more attacks, recent trend is toward conservative management of recurrent mild/moderate attacks * complications: generalized peritonitis, free air, abscess, fistula, obstruction, hemorrhage, inability to rule out colon cancer on endoscopy, or failure of medical management * surgical procedures * for emergency or complex cases: Hartmann procedure: colon resection + colostomy and rectal stump g colostomy reversal in 3-6 mo * elective cases or minimal contamination of the abdominal cavity: consider colon resection + primary anastomosis

Answer 124

states that in the presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones. This sign implicates possible malignancy of the gallbladder or pancreas

Answer 125

Carcinoid tumours are a type of neuroendocrine tumour that can occur in a number of locations. Carcinoid tumours arise from enterochromaffin (argentaffin) cells that can be found throughout the gastrointestinal tract as well as other organs (e.g. lung). In general, they are slow growing tumours but are nevertheless capable of metastasizing.

Answer 126

* Can be variable, dependent on the location: * carcinoid tumours involving the jejunum and ileum can be large at presentation but are usually found incidentally * rectal carcinoids may cause pain * gastrointestinal tract carcinoid can present as vague abdominal pain * carcinoid syndrome: in 8% of patients with a carcinoid tumour

Answer 127

* Diarrhoea * Flushing with hypotension * Telangectasia * Bronchospasm.

Answer 128

* gastrointestinal tract carcinoid (60-85% of all carcinoids) * small bowel: ~40% of gastrointestinal carcinoids, mostly in the terminal ileum * rectum (~22.5%) * colon (~15%) * appendix (~10%) * stomach (~7.5%) * pancreas (~7.5%) * carcinoid tumours of the lung (~25% of all carcinoids) * bronchial carcinoid * peripheral pulmonary carcinoid tumours * primary hepatic carcinoid * ovarian carcinoid: accounts for 0.5% of carcinoid tumours and 0.3% of ovarian tumours * thymic carcinoid

Answer 129

* Secretes: * 5 hydroxytryptamine (5-HT) * bradykinin * histamine * substance P * prostaglandins * Markers * 5-HIAA (5-hydroxyindoleacetic acid): usually suggests a functioning carcinoid tumour * chromogranin A (CgA): considered a valuable tool in the diagnosis of neuroendocrine neoplasia in general.

Answer 130

* Cardiac valve lesions resulting in heart failure.