Gren Surg Georgetown 3/4/17 Flashcards
what is pneumatosis intestinalis
gas cysts in the bowel wall
Cellcept generic category MOA uses contraindications BBW BW
mycophenolate
immunosuppresant
# cytostatic to B and T lymphos by inhib IMPDH inosine monophosphate dehydrogenase, thereby inhibiting guanosine nucleotide sythesis and proliferation
-renal, cardiac, hepatic transplants
-off-label refractory autoimmune hepatitis, lupus nephritis, myasthenia gravis, psoriasis
CI drug hypersensitivity, allergy to polysorbate 80…
BBW inc infection risk
BW inc lymphoma and skin malignancy risk
Prograf generic category MOA uses contraindications BBW BW
tacrolimus immunosuppressant (calcineurin inhibitor) inhib T lympho activation by binding to FKBP-12 protein and complexing with calcineurin dependent proteins to inhibit calcineurin phosphatase activity (basically, calcineurin activates T cells and tacrolimus blocks that) -prevent transplant rejection -GVHD, uveitis CI hsn to formulation BBW - inc infection BW - lymphoma, skin malignancy inc risk
define incisura of stomach
angle made by lesser curvature and antrum (pyloric antrum)
3 things that tell stomach to make acid
vagal input
gastrin
histamine
what to worry about when reducing say 50% of abdominal contents chronically externalized eg into the scrotum
loss of domain
must re-expand abdomen sufficiently before reducing contents
father of surgical outcomes measuring for quality improvement
ernest codman
surgeon in boston
blood supply to breast
-internal thoracic - from subclavian
(aka internal mammary)
-perforators from intercostals (from aorta running around posteriorly
-lateral thoracic - from axillary, continuation of subclavian
lymphatic drainage of breast
75% to axillary nodes
some to internal mamary nodes
levels of axillary lymph nodes
I - lat/inf to pec minor
II - post to pec minor
III - medial ot pec minor
what happens if you cut the long thoracic nerve
scapular winging
lost serratus anterior
what happens if you cut the thoracodorsal nerve
lose abduction ^90deg… climbing wall, combing hair
lost latissumus dorsi
how are long thoracic and thoracodorsal nerves orientated to each other
parallel down side
long thoracic to serratus anterior more ant
thoracodorsal to lat mor post
what happens if you cut the intercostobrachial nerve
lose sensation to medial arm
-second intercostal nerve does not divide like others into ant and post branches, just called the intercostobrachial nerve and crosses axilla into the medial side of the arm
what happens if you cut the lateral pectoral nerve
some pec weakenss
nerves of the axilla
watch out for them in breast surgery
Long thoracic to serratus ant
thoracodorsal to lat
intercostobrachial to med arm
lateral pectoral to pec
overview of breast exam
upright and supine
arm over head or pressing on waist to move pec
inspection palpation discharge axilla cervical supraclavicular infraclavicular
(nodules and nodes)
2 mammography views
axial
MLO medial-lateral oblique
(to see axillary tail, make sure you see pec so you know you have seen all of axillary tail)
do breasts become more or less dense with age
less - less milk producing
usually
characterize benign breast calcifications on mammography
scattered
large
monomorphic
characterize cancerous calcifications on mammography
clustered
pleomorphic
unstable over time
what is breast tomosynthesis
multiple slices like CT for better detection of invasive breast cancer
less compression because better resolution
first test for palpable breast mass or mass on mammography (not calcifications)
breast ultrasound
dense mass will shadow
cyst will enhance posteriorly
when to get breast MRI
screen HIGH RISK pts
eval KNOWN BREAST CANCER - eg for neoadjuvant chemo to eval response
SETTLE other equivocal tests
read breast MRI
- round, not enhancing
- peripheral enhancement, irregular edge
- very irregular, spiculated, enhancing, edema, satellite masses
-round, not enhancing FIBROADENOMA -peripheral enhancement, irregular edge BREAST CANCER WITH CENTRAL NECROSIS -very irregular, spiculated, enhancing, edema, satellite masses VERY BAD BREAST CANCER
BI-RADS
0 Incomplete assessment
1 Negative; routine mammo in 1 year
2 Benign finding; routine mammo in 1 year
3 Suspicious abnormality; short-term follow-up
4 Suspicious abnormality; biopsy, risk of malignancy 35-65%
5 Highly suggestive of malignancy, 95%
6 Known malignancy
who gets a screening mammogram
40-44yo - debated
45-55 - annually… debated
55-75 - every other year
75+ every other year if life expectancy ^10y
BRCA 1 or 2+ - biannual CBE q6mos starting 25yo or 10y prior to earliest age of onset in family
- alternate MRI & mammo (mammo only if ^30)
- screen for ovarian ca w US and CA-125 beginning age 35
how to biopsy breast mass
mammographically detected - stereotactic core needle bx
ultrasound detected - us guided core needle biopsy
MRI detected - MRI guided core needle biopsy… correlated to MRI, NOT LIVE… because can’t use metal needle in mri…
what is a stereotactic biopsy
use of xrays in MULTIPLE PLANES (2 views at least) to guide biopsy
% of breast cancer
sporadic
familial
hereditary
sporadic 70%
familial 20% (fam hx)
hereditary 10% (gen mut ID’d)
most impressive known risk factor for breast cancer
and what is the relative incidence of breast and ovarian
BRCA1 BRCA2
breast cancer
12% non-mut women get breast cancer in life
60% BRCA1 get by age 70
45% BRCA2 get by age 70
ovarian cancer
1.3% non-mut women get in life
50% BRCA1 get by age 70
20% BRCA2 get by age 70
who to refer for genetic testing for breast cancer
ashkenazi jew
1st degree fh breast cancer v50yo
2x+ 1st or 2nd degree fh breast cancer any age
fh male breast cancer
hx ovarian cancer in pt or 1st or 2nd degree relative
how much breast cancer is epithelial
how much ductal vs lobular
95% epithelial
more ductal than lobular
most common breast cancer and how is it detected usually
25% DCIS
usually found via clustered microcalcifications on mammography
XRT stands for..
xray therapy
radiotherapy
radation therapy
RT
treatment options for breast cancer
mastectomy with sentinal lymph node biopsy
breast conservation (limited resection) with XRT (ranges from intraop to 5-6 wks duration postop..)
endocrine therapy (ER/PR +)
chemo (age size grade nodes receptors mets)
what is Paget’s disease of the nipple and what should your reflex be
DCIS of nipple
get detailed breast imaging because 97% assoc w underlying breast cancer
radical mastectomy
vs
modified radical mastectomy
radical - take breast, pec major, lymph node levels I-III
modified radical - just take breast and lymph nodes I and II… we now know taking the pec and III is not necessary so don’t perform full radical anymore
tf
nipple preserving mastectomy preserves sensation
f
just cosmetic preservation
tf
most mastectomies don’t need radiation
t
usually adjuvant XRT for breast sparing resection not mastectomy
when can nipple sparing mastectomy be performed
ppx surgery
tumors away from the nipple
how is the sentinel lymph node identified
blue dye
and radioisotope
tf
if sentinel node is negative there is no need for axillary dissection for breast cancer
t
3 aromatase inhibitors
anastrozole
letrozole
examastane
tamoxifen vs anostrozole
demographic for use
side effects
tamoxifen for premenopauseal, ER antag in breast but ag elsewhere… so inc endometrial ca, dvt/pe, hot flashes, vaginal bleeding, etc
anostrozole aromatase inhib… for postmenopausal… no endometrial ca DVT hot flashes bleeding… but inc bone fractures and bone pain msk pain
pronounce the orange thing in breast cancer
-and what does it signify
“Poh di-oranj”
-inflammatory breast cancer… from lymphatic infiltration and obstruction, swelling, ligaments of cooper intact
tf
must rule out mets in locally advanced breast cancer
t
bone (ER+ espec)
liver brain (triple neg epec)
lung
tf
imaging to screen brain for breast cancer mets
f diplopia headache dizziness clinically apparent, no need for imaging
tf
vegan diet is cholesterol free
t
no animals = no livers = no cholesterol = cholesterol free
WHY are gallstones assoc w forty fat female fertile
because they change cholesterol metabolism, and change can precipitate stones
what makes gallbladder contract
cck
what causes acute cholecystitis
and how do you treat
block of cystic duct (GB to CBD)
cholecystectomy
complete the sentence
“pus under pressure….”
makes you sick; general surgeons drain pus”
Charcot’s triad for an abdominal thingy
Raynaud’s pentad for…
cholangitis
fever RUQ pain jaundice
hypotension and AMS
(dec urine too)
septic shock
(inflammatory mediators should be sent out by the liver, but it gets overwhelmed)
SO act on charcot’s triad to avoid raynaud’s pentad
safety of ERCP in charcot’s pentad vs Raynaud’s triad
if Raynaud’s pentad (fever RUQ pain jaundice HYPOTENSION AMS)
sign liver overwhelmed by inflammatory mediators… ERCP involves injection of dye to make sure in bile duct not pancreatic duct… can force a bolus of inflammatory mediators into body and kill pt via shock)
this disease is like MS of the liver
how so
how to treat
PSC
primary sclerosing cholangitis
multiple scleroses at different times and spaces - beads on a string
treat with steroids for immunosupression, consider UC association…
treat cholangiits
iv abx IVF NPO
ERCP to remove stone / blockage
cholecystectomy once recovered to prevent more stones from causing
PBC
alternate names
antibody test
treat
primary biliary cirrhosis primary biliary cholangitis AMA anti-mitochondrial antibody UDCA ursodeoxcholic acid (dec bile secretion for stones but inclear why it helps in PBC..) staroids... chemo.... transplant
segments of liver
7 8 | 4a 2
6 5 | 4b 3
describe the branches of the hepatic duct backward form common hepatic duct from 6 oclock clockwise
R hepatic duct
inferior branch to 6 and 7
superior branch to 5 and 8
-but branch to 5 hooks over 67 common branch and 5 is proximal right lower segment
Left hepatic duft
brances to 4….
branches to 2 superiorly and 3 inferiorly
pt w afib, how to manage anticoagulation for surgery
d/c warfarin 5 days prior
bridge w lovenox till 24hrs prior
if lovenox CI because CKD, bridge w heparin
3 common indications for warfarin therapy
afib
dvt
mechanical valve
what is the difference between subq and iv heparin inpatient…
sq for ppx
iv for therapeutic – also nice that you can turn off/on on a dime eg for limb patient w frequent surgery
pt npo for surgery… how to manage insulin
continue long acting at 1/2 dose (still blood sugar from glycogenolysis, cortisol stress response…)
don’t take short acting obviously that is only with meals and the pt is npo
mnemonic for communicating sensitive news
SPIKES
- setting (turn off beeper, have kleenex available, ask for privacy unless pt prefers otherwise)
- perception
- invitation
- knowledge (send shot across bow fist .. e.g. it’s not what we hoped for…)
- empathy
- summary
air pressures for laparoscopy vs thorascopy
15mmhg for lap
v5mmhg for thora because higher will compress vena cava
what did the iron lung do
provided negative pressure for breathing when the chest was open, eg kids with TB
Ranson criteria
Hour 0 age ^55 wbc ^16 glucose ^200 LDH ^350 AST ^250
Hour 48 hematocrit v 10 points BUN ^ 5 ponts Ca v8 PaO2 v60 base deficit ^4 fluid sequestration ^6L
1-3 mild pancreatitis... like 10% mort 4+ significantly inc mortality (purpose to predict mortality risk from acute pancreatitis) say 4-7 30% mort ^7 0% mort
explain glucose in Ranson criteria
glucose^200
marker of acute inflammation (stress)
also, pancratitis can’t secrete insulin
explain age in Ranson criteria
^55yo
less able to withstand a code… just more accumulated physiologic insults to heart vs a younger person who can withstand a code better
why is it called the pancreas
pan (all)
creas (flesh)
feeds all flesh
digests all flesh
conceptually define pancreatitis
inflammation damaging body as collateral in trying to prevent pancreatic enzymes from eating the body
explain wbc in Ranson criteria
wbc^16
inflammation, not infection
explain AST in Ranson criteria
AST^250
first pass effect of inflammatory cytokines, liver gets overwhelmed, can’t digest them fast enough, gets damaged
-not just biliary back up, that would make alk phos elevated…
explain LDH in Ranson criteria
LDH^250
marker of cell lysis
(there are 5 subtypes of LDH… 1 is cardiac specific… the others are just systemic inflammatory markers)
explain Ca in Ranson criteria
pancreatic lipase converts TAGs to FFAs
leaks into peripancreatic fat in pancreatitis
FFAs are divalent anions
bind readily to available divalent cations - Calcium Ca++
= fat saponification
looks like buckshot on imaging
explain hct in Ranson criteria
v10 points (NOT 10%... not 4 points... 10 percentage points) bleeding from splenic artery or gastroduodenal artery, or gastric varix from splenic vein thrombus)
take straight to IR for embolizaiton if hemorrhagic artery…. splenectomy to treat upper GI bleed from gastric varix from splenic vein thrombosis from pancreatitis
explain O2 in Ranson criteria
PaO2v60
from ARDS from inflammatory cytokines… getting into lungs…?
“3” fluid spaces of body
relative sizes
1st space intracellular
2nd space intravascular and intra-CSF and intra-synovial etc
3rd space extra both… interstitial
1st space intracellular is 2/3 TBW
3rd space is smallest… like 1/3 of remaining 1/3 so like 1/9 TBW
explain BUN in Ranson criteria
dehydration
from third spacing
from inflammatory craziness
so kidney retaining urea for countercurrent multiplier
explain base deficit in Ranson criteria
eg HCO2 v 4
from lactic acidosis… from shunting centrally… according to Jackson
explain fluid sequestration Ranson criteria
from 3rd spacing from inflammation
treat acute pancreatitis
ride out the storm
batton down the hatches
supportive care
diagnose pancreatitis
classic pain pattern
elevated lipase
cross sectional imaging shows inflammation
need 2/3 of above to dx
what kind of CT to get for diverticulitis
CT w PO contrast
-don’t get PO for diverticular or other GI BLEED, will obscure therapeutic options aka IR intervention
which attack is usually the worst in diverticulits
the first one
is diverticulitis usually from true or false diverticula
false diverticula (mucosa thru muscular wall at vasa recta…. not true full thickness mucosa and muscle balooning out - that is congenital usually)
pathogenesis of appendicitis vs diverticulitis
appy - obstruction of apendiceal orifice eg by fecolith, and engorgement of lymphatics…
diverticulitis - micro perforations…
why doesn’t diverticulitis extend to the rectum
because teniae coli coalesce into full circumference outer longitudinal muscle layer at rectum… no muscular wall weakness for microperfs
how many lower gastrointestinal bleeds are from diverticulum
~40%
from ruptured vasa recta
tf
upper gi bleed is never bright red per rectum
f
can be, if a very brisk bleed
how to continually assess airway in trauma pt
interview
get history, keep them talking
5 areas hemorrhage can cause shock
chest peritoneum retroperitoneum thighs floor
large enough
GCS
4eye spont verb pain none
5verbal oriented confused inappropriate incomprehensible none
6motor obeys localizes withdraws decorticate decerebrate none
how many IVs to start in trauma pt
2 large bore peripheral IVs
avoid obviously injured extremity if possible
infusion rate of 1L crystalloid fluids
wide open 30min
pressure bag 15min
level one infuser 5 min
top 5 causes of shock in trauma pt
bleeding bleeding bleeding bleeding bleeding
4 types of shock
hypovolemic
septic
cardiogenic
neurogenic
classes of hemorrhage
0-15% blood loss
15-30% blood loss
30-40% blood loss
^40% blood loss
class I II III IV think tennis scoring 15 30 40
signs and symptoms, treatment of class I hemorrhage
v15% (750cc) loss
-minimal clinical signs
not even tachy above 100
no measurable bp, pulse, respiratory change… like anna kournakova looks striking doesn’t pack a punch
-No iVF needed, blood restored by natural compensatory mechanisms within 25hrs
signs and symptoms, treatment of class II hemorrhage
15-30% (750cc-1.5L) loss
- inc cc - inc pvr, tachy hr^100, dec pulse pressure, tachypnea 20-30, subtle cns anxiety fright hostility, mild dec urine output
- stabilize with crystalloid, may eventually require transfusion
signs and symptoms, treatment of class III hemorrhage
30-40% (1.5-2L) loss
tachy hr^120, tachypnea 30-40, hypOtensive, cns sig anxious combative, marked urine dec
-colloid and blood resuscitation, stop source of hemorrhage
signs and symptoms, treatment of class IV hemorrhage
^40% 2L blood loos
- life-threatening, marked tachy hr^140, marked tachypnea ^40, dec systolic BP, very narrow pulse pressure or unattainable diastolic bp, negligible urine output, depressed mental status, cold pale
- rapid transfusion, immediate surgery… 50% loss means loss of consciousness pulse and blood pressure
basics of treating any significant bleed
stop bleeding
replace volume lost
resolve base deficit
normalize lactate
lethal triad of trauma
acidosis makes hypothermic (by dec heart performance…) makes coagulopathic
blood volume is what % of body weight
7%
so ~5L in 70kg person
guidelines for volume resuscitation in trauma
1L crystalloid
2 units blood for adults
10cc/kg for kids
start with O (+ because - rare and expensive not always available) uncrossmatched
give type specific or crossmatched bloodwhen available
highest GCS score when intubated
11t
4 eyes
6 motor
1(t) verbal because intubated
highes GCS score when paralyzed
3pt
lowest score is 3
nonresponsive eyes verbal motor
intubated
why is it called a tension pneumo
because HYPOTENSION
