GENERAL - Surgical HTN

Question 1

A woman is found to have HTN. Her labs show hypokalemia, mild hypernatremia, and metabolic alkalosis. She takes no diuretics.

1. Likely diagnosis
2. Dx
3. Tx

Answer 1

1. Primary hyperaldosteronism
   - hypokalemia in hypertensive (usually female) patient not on diuretics
   - also modest hypernatremia and met alk
2. Dx:
   Aldosterone levels high, Renin levels low
   Appropriate response to postural changes (more aldosterone when upright than laying down) indicates hyperplasia.
   Lack of response to postural changes indicates adenoma.
3. Tx:
   Hyperplasia –> medical tx
   Adenoma –> Surgical removal after adrenal CT to localize

Question 2

A thin woman has been having attacks of pounding headaches, sweating, palpitations, and pallor. She is extremely jittery. Her doctor is lucky enough to witness one of these attacks, during which her BP is found to be extremely high.

1. Likely diagnosis
2. Dx
3. Tx

Answer 2

1. Pheochromocytoma
   - thin, hyperactive woman with attacks of pounding HA, perspiration, palpitations, pallor, and extremenly high BP
   - usually subsides when seen–> hard to dx
   - occasionally sustained HTN –> easier to dx
2. Dx
   1st, 24hr urinary…
   —vanillylmandelic acid (VMA) (easy, but false+),
   —metanephrines (more specific),
   —or free urinary catecholamines
   Then, CT scan of adrenals, or radionucleotide studies to look for extraadrenal sites
   —tumors usually large
3. Tx
   Pre-op alpha blockers
   Surgery

Question 3

A young boy presents with hypertension. On exam, it is found he has no pulses in his legs. Further investigation shows hypertension in his arms but hypotension in his legs. CXR shows scalloping of the ribs.

1. Likely diagnosis
2. Dx
3. Tx

Answer 3

1. Coarctation of the aorta
   - usually young patient
   - hypertension in arms + normal/low low pressure or no clinical pulses in legs
2. Dx
   CXR: rib scalloping (erosion from large collateral intercostal arteries)
   Spiral CT w/IV dye (CT angio) diagnostic
3. Tx: Surgical correction cures

Question 4

A young woman with PMHx of TIAs has HTN that is resistant to all treatments. Her FHx includes her mother and aunt who both had strokes as young ages. On exam, a faint bruit is appreciated over her upper abdomen.

1. Likely diagnoses
2. Dx
3. Tx

Answer 4

1. Renovascular disease 2/2 Fibromuscular dysplasia
   Renovascular dz:
   –refractory hypertension
   –faint bruit over flank/abdomen
   Fibromuscular dysplasia:
   –dz of medium arteries (renal, cerebrovascular, limbs, coronary, pulmonary, aorta, mesenteric…)
   –young women
   –FHx of stroke at young age
   –Personal Hx of TIA, stroke, refractory HTN (renal), sentinel bleed/aneurysm, ischemic bowel, claudication
2. Dx:
   Duplex scanning of renal vessels
   CT angio
3. Tx:
   Balloon dilation & stenting

Question 5

An old man with PMHx of claudication and gangrene of several toes presents due to refractory HTN. An faint bruit is heard over his flank.

1. Likely diagnosis
2. Dx
3. Tx

Answer 5

1. Renovascular disease 2/2 arterio-sclerotic occlusive dz
   - -refractory hypertension
   - -faint bruit over flank/abdomen
   - -often old men
2. Dx:
   Duplex scanning of renal vessels
   CT angio
3. Tx:
   Balloon dilation & stenting
   *controversial in old men, depending on life expectancy from other manifestations of ateriosclerosis