LOOKED UP REVIEWS Flashcards
algorithm for gastrinoma workup: initial, labs values, imaging
initial:
fasting serum gastrin level 72 hours off PPIs
(not definitive diagnosis)
Baseline gastrin level nondiagnostic
All patient’s require secretary stimulation test to confirm:
Most widely used level 200
Recent recommendations 110-120
Imaging:
Somatostatin scintigraphy greater sensitivity than all conventional studies combined
EUS high-sensitivity for detection of pancreatic gastrinoma
Not good for duodenal gastrinoma (even intraop)
If cannot find gastrinoma:
Hepatic vein sampling with calcium stimulation
arcuate line of the abdomen, other names, relationships to rectus, internal oblique, transversus, external landmarks, epigastric vessels,
also called linea semicircularis or Douglas’ line
Horizontal lower limit of the posterior (lateral) layer of the rectus sheath
(Above you have two layers of fascia to close)
1/3 of the distance from the umbilicus to the pubic crest
where the inferior epigastric vessels perforate the rectus abdominis.
Inferior to the arcuate line, the internal oblique and transversus abdominis aponeuroses merge and pass superficial (i.e. anteriorly) to the rectus muscle.
The linea semilunaris
a curved tendinous line placed one on either side of the rectus abdominis boarding the lateral edges of the rectus muscle
Acinic cell carcinoma of the parotid treatment
malignant
“En bloc surgical resection”-does not include facial nerve if no invasion
superficial parotidectomy with radiation and mass confined to superficial parotid
total parotidectomy deep lobe involved
radiation used when: unclear margin- partial parotidectomy to spare facial nerve High-grade Neural invasion Invasion of surrounding structures Metastatic
small bowel lymphoma most common type and site
Most common non-Hodgkin’s:
diffuse
B cell
MALT lymphoma
most common site of non-Hodgkin’s:
Ileum-large immune component
in children younger than 10 years, lympomas are the most common intestinal neoplasm
most common GI site of lymphoma
stomach
Second most-small bowel
risk factors for small bowel lymphoma
celiac - Non-Hodgkin’s T-cell lymphoma
HIV-aggressive B-cell lymphoma
H. pylori-MALT
diagnosis small bowel lymphoma
CT scan
Tissue biopsy
treatment small bowel lymphoma, early stage, symptomatic, cell type tx is
local early stage:
surgical resection all gross disease prevents perforation/obstruction (Cam)
in the absence of symptoms:
may respond to chemotherapy without the need for surgery (Sab)!
B cell lymphomas:
more chemosensitive have high remission rates with or without surgery.
T cell lymphomas:
traditionally more resistant to therapy and will progress to symptoms of obstruction or perforation if not resected.
resection is indicated:
at any onset of symptoms regardless of type
because progression to life-threatening hemorrhage or perforation with worse prognosis
Advanced disseminated:
Surgery only for tissue biopsy and possibly pale eating complications
Chemotherapy-test for diffuse large cell
Anaplastic resistant to chemotherapy and
most common site of GIST tumor in small bowel
duodenum (2nd portion) to- this is from H. pylori risk factor in stomach/duodenum
careful, lymphomas most common ileum
diagnosis gist tumor and small bowel
NO biopsy
CT scan abdomen pelvis
Smooth well-circumscribed exophytic growth
Large tumor-central necrosis/hemorrhage
Treatment of GIST tumor small bowel
localized disease:
complete gross resection With intact capsule
en bloc resection of involved organs
Involved periampullary tumors:
May require Whipple
NO lymphadenectomy -
metatarsal metastasis to liver
marginal resectable tumors:
Neoadjuvant Imatinib
adjuvant for:
incomplete resection
Recurrent disease
Metastatic disease
von Willebrand disease mechanism
deficient von Willebrand factor
Cannot link platelets on collagen on endothelium
treatment of von Willebrand’s 1, 2, 3
II: Low circulating level DDAVP Conjugated estrogens von Willebrand factor Cryoprecipitate
II:
Qualitative - may not work to give DDAVP because of defective present von Willebrand factor
von Willebrand factor
Cryoprecipitate
III: Complete absence of production Associated with low factor a level severe bleeding - like hemophilia A. DDAVP will not work
unresectable pancreatic cancer
Vascular- circumferential encasement or invasion or inclusion of: Portal vein Superior mesenteric vein Superior mesenteric artery
exception may be made for venous structure- SMV, portal vein
advanced disease: Extension beyond pancreas capsule and the retroperitoneum Neural Nodes outside direct field of resection: Pubic access Superior mesenteric artery Hepatoduodenal ligament frank metastases: Liver Peritoneal
careful, pancreatic metastases to not undergo meniscectomy peek and shreek
blood products associated with TRALI and mechanism
RBC
Platelet
Plasma!
the DONOR antibodies of attach host leukocyte
Workup of a patient with suspected Cushing’s syndrome includes
24-hour urine cortisol, late evening salivary cortisol, ACTH level, high dose dexamethasone suppression test, MRI head, CT chest/abdomen/pelvis, inferior petrosal sinus sampling.
treatment of melanoma
in situ:
0.5-1 cm excision
less than 1 mm:
1 cm excision
1 and greater mm:
2 cm excision!
1-2 mm - 1 cm margin maybe acceptable if greater excision would cause significant morbidity
sentinel node: 1 millimeter or greater ulceration Regression Absence of clinical note
basal cell carcinoma margin
low risk: 4-5 mm less than 2 cm trunk/extremities Head and neck less than 1 cm Less than 6 mm- face, feet, hands
High-risk: 1 cm size greater than 6 mm Recurrent Immunocompromised Radiation field Sclerosing Micronodular Perineural invasion
squamous cell carcinoma skin margin
same his basal
low risk: 4-5 mm less than 2 cm trunk/extremities Head and neck less than 1 cm Less than 6 mm- face, feet, hands
High-risk: 1 cm Recurrent Immunocompromised Radiation field Sclerosing Micronodular Perineural invasion
also: Poorly differentiated Adenoid Adenosquamous Desmoplastic
most common skin cancer and
Basal cell
second most common skin cancer
squamous cell
Merkel cell carcinoma skin, risk factors, Workup, treatment
immunocompromise
polyomavirus
CT scan
Excision down to fascia or pericranium:
1.5-2 cm margin
sentinel node or no dissection
adjuvant radiation
chemotherapy for regional or distant metastases
dermatofibroma sarcoma protuberans
30-40-year-old
Wide excision with frozen section
3 cm margin
Or
Mohs
radiation for colon
Less than 1 cm margin
Involved margin
Or cannot reexcised
treatment of Kaposi’s sarcoma the skin workup, treatment
chest x-ray and fecal occult rules out systemic solid organ
optimize antiretrovirals and immune status
Initial treatment for local disease:
Chemotherapy-vinblastine
or
Radiation
systemic disease
Doxorubicin
angiosarcoma Skin
head and neck elderly
treatment:
2 cm margin used to require his free flap
Adjuvant:
Postoperative radiation
metastases to the lungs
advanced disease on presentation: the
chemotherapy
Central DI will presentation and treatment
traumatic brain injury.
aantidiuretic hormone (ADH) synthesis is disrupted due to injury of the hypothalamus or pituitary
leads to an inability to concentrate urine and a decrease in the urine osmolarity.
cause excessive urine output,
can be treated with desmopressin.
ADH replacement in the form of desmopressin.
Peripheral DI
defect in the ADH receptors at the level of the kidney.
will not respond to desmopressin
most common organism in pathogenic liver abscess
gallbladder source :
Escherichia coli
Klebsiella
Other organisms: Staphylococcus Streptococcus Enterococcus (careful, different than Enterobacter) Bacteroides
esophageal perforation workup
chest x-ray:
hydropneumothorax
barium swallow for chest
Gastrografin for abdomen
most perforations:
Above the GE junction on LEFT
endoscopy if swallow negative
or if surgery planned
Boerhaave syndrome Mechanism
disruption of normal vomiting reflux that because the sphincter relaxation
Increase intrathoracic esophageal pressure
findings consistent with mucosal injury the esophagus
blood
Because the hematoma
Flap
Esophagus difficult to insufflate
treatment of esophageal perforation
stabilize:
No NG tube and a management decision planned
contained perforation:
N.p.o., antibiotics, observation
temporary endoluminal stent may be placed and removed 6-12 weeks
with followup swallow or scope
unstable patient with contained perforation:
Stent may be entertained
unstable patient with free perforation: Surgery Upper two thirds: rglht thoracotomy lower one third: left thoracotomy GE junction: Left thoracotomy / upper midline abdominal
cannot identify perforation:
Drainage
inflammation Without distal obstruction: primary repair Muscle flap Drainage J-tube
inflammation with distal obstruction: resection/exclusion esophagostomy drainage J-tube G-tube
no inflammation with distal obstruction: resection RECONSTRUCTION drainage J-tube
no inflammation no obstruction:
Primary repair
Muscle flap
Drainagel
4 underlying conditions that mandates esophagectomy even without inflammation with free perforation of the esophagus
End-stage achalasia - Megaesophagus
cancer - resectable
caustic injury
severe peptic stricture
management of small cervical perforation
drainage only-difficult to locate
surgical landmarks the finding esophagus into thirds
carina and above - fourth intercostal space right
Mid esophageal perforation-sixth intercostal space right
lower esophageal - seventh intercostal space left
most narrow portions of the esophagus at risk for perforation
cricopharyngeus muscle is the narrowest point of the gastrointestinal tract
aortic arch - left mainstem bronchus and aorta abut the esophagus, the bronchoaortic constriction at the level of the fourth thoracic vertebra
diaphragmatic constriction
recommendations antibiotic prophylaxis for children after splenectomy
prophylaxis with penicillin is routinely practiced in children, at least during the first 2 postsplenectomy
Sab
and test results for TTP versus ITP
negative for TTP
Careful, positive for ITP
management of Hodgkin’s lymphoma
NO staging splenectomy
Treatment chemotherapy
Splenectomy if:
Thrombocytopenia symptoms of splenomegaly l
findings and staging theof Hodgkin’s lymphoma
Reed-Sternberg cells: disease or B cells
staging:
1 single node
2 chest/mediastinum - can be bilateral
3 both sides the diaphragm
4 extranodal involvement (careful, spleen counts this lymph node)
bone marrow count is metastasis to
LEpstein-Barr virus
ITP and children
usually self-limiting
Associated with previous infectious illness
Observation short-term medical therapy
IVIG his risk of intracranial hemorrhage when platelet counts below 20,000 short term prednisone
Splenectomy reserved if thrombocytopenia greater than one year
Fails medical management
Severe thrombocytopenia
life-threatening bleed presentation
treatment of ITP medical
is glucocorticoid administration (typically, prednisone
less than 50,000/mm3 and symptoms such as mucous membrane bleeding, high-risk conditions (e.g., active lifestyle, hypertension, peptic ulcer disease)
20,000 to 30,000/mm3, even without symptoms,
IV immunoglobulin is important for the treatment of acute bleeding, in pregnancy, or for patients being prepared for operation, including splenectomy.
Platelet transfusion is indicated only for those who experience severe hemorrhage.
treatment ITP surgical
severe thrombocytopenia, with counts less than 10,000 for 6 weeks or longer,
thrombocytopenia refractory to glucocorticoid treatment,
require toxic doses of steroid to achieve remission
severe thrombocytopenia, with counts less than 10,000/mm3 for 6 weeks or longer, those with thrombocytopenia refractory to glucocorticoid treatment, or those who require toxic doses of steroid to achieve remission, the treatment of choice is to proceed to splenectomy.
pregnant in the second trimester of pregnancy who have also failed steroid treatment or IV Ig therapy with platelet counts less than 10,000/mm3 without symptoms
or
less than 30,000/mm3 with bleeding problems
hereditary spherocytosis
Splenectomy is indicated in cases of severe anemia with these conditions, except hereditary xerocytosis, which results in only mild anemia of limited clinical significance.
normalization of the erythrocyte morphology does not occur
Splenectomy should be delayed until the age of 5 years to preserve immunologic function of the spleen and reduce the risk of OPSI.
Diagnosis is made by examination of a peripheral blood smear, increased reticulocyte count, increased osmotic fragility, and a negative Coombs’ test.
treatment of Hereditary elliptocytosis, hereditary pyropoikilocytosis, hereditary xerocytosis, and hereditary hydrocytosis
Splenectomy is indicated in cases of severe anemia with these conditions,
except hereditary xerocytosis, which results in only mild anemia of limited clinical significance.
treatment of G6PD deficiency
Primary treatment, therefore, is avoidance of exacerbation
splenectomy is rarely indicated. T
his X-linked condition is typically seen in people of African, Middle Eastern, or Mediterranean ancestry. Hemolytic anemia in these patients most often occurs after infection or exposure to certain foods, medications, or chemicals. cerbation of the condition.
when his splenectomy indicated for sickle cell and thalassemia
Hypersplenism and acute splenic sequestration are life-threatening disorders in children with thalassemia and sickle cell disease. I
Resuscitation with hydration and transfusion may be followed by splenectomy in these patients.
Hypersplenism and acute splenic sequestration presentation of sickle cell thalassemia
apid splenic enlargement, which results in severe pain and may require multiple blood transfusions. Patients with acute splenic sequestration crisis present with severe anemia, splenomegaly, and an acute bone marrow response, with erythrocytosis.
Splenic abscesses with sickle cell anemia
fever, abdominal pain, and a tender enlarged spleen.
leukocytosis, as well as thrombocytosis and Howell-Jolly bodies indicating a functional asplenia.
Salmonella and Enterobacter spp. and other enteric organisms are commonly seen in those with a splenic abscess.
resuscitation and may require urgent splenectomy
management of Hodgkin’s lymphoma when is staging laparotomy indicated
rarely
Staging laparotomy remains appropriate for select patients:
arly clinical disease stages (IA or IIA) in whom abdominal staging will significantly alter therapeutic management.
treatment of Hodgkin’s lymphoma
Early-stage Hodgkin’s
RADIATION cured therapy alone.
advance disease:
Chemotherapy
relapse
intra-abdominal involvement
B symptoms
when is splenectomy indicated for non-Hodgkin’s lymphoma
consider first-line treatment if splenic marginal zone lymphoma-indolent B-cell lymphoma-old her presentation-usually isolated spleen
and for
massive splenomegaly leading to
abdominal pain,
early satiety,
fullness.
It may also be indicated for:
anemia,
neutropenia,
thrombocytopenia associated with hypersplenism.
treatment for leukemia of the spleen
chemotherapy
Splenectomy rarely indicated- Pancytopenia Refractory to medical therapy Splenic rupture Severe bleeding from thrombocytopenia
splenic chronic lymphocytic leukemia
B cell
50-year-old plus
Bone marrow transplantation currently offers the only known cure for CLL. Splenectomy is indicated for patients with refractory splenomegaly and pancytopenia, which results in improvements in blood counts in 60% to 70% of patients.[21] the
splenectomy and symptomatic
including thrombocytopenia
splenectomy a worse outcome if advanced and refractory to medical management
chronic myelogenous leukemia spleen
first line treatment is Imatinib Gleevec! - transplantation less common.
splenectomy if hypersplenism - but not survival benefit in an early chronic phase or before bone transplant
primary myelofibrosis myeloid metaplasia
hyperplasia of normal myeloid precursor cells with pulmonary fibrosis and extramedullary hematopoiesis
risk factor radiation toxic industrial chemicals
Splenectomy for colon
Symptoms including hemolysis, transfusions, splenic infarctions, portal hypertension, refractory variceal hemorrhage
Caution-substantial risk of morbidity and mortality
Splenectomy also considered for delineation
Treatment of splenic abscesses
depends on whether the abscess is unilocular or multilocular.
Unilocular abscesses are often amenable to percutaneous drainage, along with antibiotics,[29] with success rates reported at 75% to 90% for unilocular lesions. Multilocular lesions, however, are usually treated with splenectomy, drainage of the left upper quadrant, and antibiotics
wandering spleen
choosing splenopexy or splenectomy.[32]
