MIX 8 QBANK Flashcards
GB adverse effect of ceftriaxone
can cause GB SLUDGE
course of cystic artery compared to common hepatic duct
POSTERIOR
cystic artery variations
GDA
SMA
COMMON hepatic artery
Usually comes off RIGHT hepatic
primary source of bilirubin in the body
Senescent red blood cells
Whether due to aged cells or active hemolysis, hemoglobin is broken down into bilirubin and ultimately secreted into bile.
incidence of TIPS shunt stenosis
(up to 50%)
TIPS is what kind of shunt
side-to-side portosystemic shunt
nonselective shunt and completely diverts portal flow
TIPS is also effective in the treatment of medically intractable ascites
major cause of TIPS Shunt stenosis
neointimal hyperplasia
treatment of TIPS Shunt stenosis
often be resolved by balloon dilation
in some cases, by placement of a second shunt.
frequency of post-TIPS encephalopathy
(∼30%)
effectiveness of TIPS compared to endscopic tx of bleeding
TIPS more effective
effect of TIPS on pts requireing liver transplant
HELP temporize them!
does not mess with vasculature
risk factors associated with melanoma
UVA and UVB radiation congenital nevi, dysplastic nevi, xeroderma pigmentosa, family history
NOT actinic keratoses
(careful, actinic keratoses IS risk for squamous)
tx of Immediate sensory and motor deficits after creation of an arteriovenous fistula
requires immediate ligation
NOT DRIL
The DRIL (distal revascularization - interval ligation) procedure is used in patients that do not have dramatic symptoms in the immediate postoperative period
treatment of symptomatic Meckel’s diverticulum
Uncomplicated:
Diverticulectomy only
complicated:
Diverticulitis, GI bleeding, wide-based-
segmental resection
wait for obstructive symptoms to resolve?
Diagnosis of Zenker’s diverticulum
barium swallow
incision for opened Zenker’s diverticulum
left neck
when is a myotomy alone sufficient for Zenker’s
diverticulum less than 2 cm
when is diverticulo pexy performed for Zenker’s
elderly patients
LARGE diverticula to avoid complications of resection
prophylactic pre-incision antibiotics for colon surgery
second generation cephalosporin
cefoxitin
Cefotetan
or
Cefazolin and Flagyl
winded a therapeutic course of antibiotics recommended instead of just prophylactic pre-incision antibiotics for trauma
greater than 6 hours and time of injury
Signs of infection intraoperatively
symptoms of hypoglossal nerve injury
IPSILATERAL (towards the site of injury)
Tongue deviation
marginal mandibular nerve
branch of the facial nerve
“motor car”
Retraction and angle of mandible
Drooping of ipsilateral lip
site of injury from deceleration trauma of aorta
ligamentum arteriosum
just distal to subclavian
A 26-year-old female with a 3 cm heterogeneously enhancing hepatic lesion
adenoma
less than 4 cm and is asymptomatic, it does not need to be resected. If the patient is taking oral contraceptive pills (OCP), she should be advised to discontinue them.
margin for hepatic colorectal cancer metastasis
1 cm
Surgery give the best chance for cure
5 cm peripheral and centripetal enhancing hepatic lesion on CT
Cavernous hemangioma
does not need resection unless symptomatic
A 36-year-old female with a left hepatic liver lesion that has a central stellate scar
focal nodular hyperplasia
No malignant potential
Does not need resection unless symptomatic or cannot be definitively differentiated from cancer
Treatment of hepatocellular carcinoma with involvement of the portal vein
no surgery
proper location to administer an ilioinguinal nerve block?
1 cm medial and 1 cm inferior to the anterior superior iliac spine
when does carcinoid syndrome develop
small bowel ( ileum) - large portion of the liver must be replaced with carcinoid tumor for symptoms
careful, not with rectal
what our exceptions or carcinoid tumors develop more commonly with rare primary locations
organs the bypass hepatic circulation:
Ovary
Testes
Lung
these produce carcinoid syndrome without hepatic metastases
signs of air embolus
cardiovascular collapse,
dysrrhythmias,
characteristic “Mill wheel” murmur.
pulmonary artery hypertension,
elevated central venous pressure,
jugular venous distension.
most common cause of dialysis unit is now having difficulty using the fistula long term
outflow stenosis - typically intimal hyperplasia
occurs anywhere in the vein of an AV fistula
or
at the anastomosis of an AV graft
most common type of melanoma
superficial spreading
initial growth a radial-been potential for vertical
Careful, the prognosis is lentigo melanoma
most common melanoma an elderly
lentigo melanoma
best prognosis
type of melanoma with worse overall prognosis
nodular–vertical growth phase
when do type II pneumothorax began to develop
24 weeks
Careful, there is not adequate surfactant until 35 weeks
Continue develop after birth
which is more common type I or type II pneumocytes sites
type II
careful, lower surface area and a type II than type I
however, type I cover 95% of alveolar surface
enzyme that activate trypsinogen and where it is found
enterococci
Duodenum
enzymes that are secreted from the pancreas in active form
lipase
Amylase
ribonuclease
mechanism of trypsin and chemotrypsin
protein breakdown
extracolonic manifestations that will improve after colectomy for ulcerative colitis
erythema nodosum
Arthritis
Ankylosing spondylitis
Pyoderma gangrenosum
NOT PSC
treatment for primary sclerosing cholangitis
liver transplant
percentage of splenic artery aneurysms that present with year-old bleed; and percent mortality with rupture
20-30% present with abdominal pain and contained rupture and lesser sac - free rupture within 48 hours
( 20-50% rupture risk)
25% mortality with rupture
80-90% maternal and fetal mortality with rupture
treatment of splenic artery aneurysm
ligation or embolization of both the proximal and distal aspects of the aneurysm
most common side effects with pancuronium
tachycardia
coronary artery disease relative contraindication
side effects of succinylcholine
hyperkalemia with: Spinal cord injury Burn Rhabdo - including prolonged immobilization renal disease Others: Malignant hyperthermia Rhabdomyolysis Ocular hypertension Muscle pain
used for rapid sequence intubation
clearance of vecuronium
BOTH liver and kidney
with organ dysfunction is Atracurium good for and what is a side effect
minimal cardiac fracture
histamine release - vasodilated
pathophysiology of developing ascites from cirrhosis
fibrotic and parasites lead to portal hypertension
Lymphatic bed of liver and splenic neck lymph nodes began to leak into the peritoneum
This includes protein losses-hence the reason for albumin administration
mechanism of elimination of succinylcholine
pseudocholinesterase
only depolarizing agent
rapid onset and short half-life
Patient’s may be deficient in pseudocholinesterase - prolonged half-life
best prophylaxis for contrast-induced nephropathy
fluid hydration
no significant benefits of:
Mucomyst
Bicarbonate
Dopamine
With hold:
Loop diuretic
ACE inhibitor
Angiotensin II antagonists
Risk factors for contrast-induced nephropathy
multiple myeloma Proteinuria Diabetes mellitus Dehydration concomitant other nephrotoxic drugs Renal failure
what part of the kidney does contrast injure
renal tubule
Transient regional ischemia
acute cholangitis bacteria
Escherichia coli
Klebsiella
Others:
Bacteroides stridulous
Streptococcus faecalis
the tissue named vessels branches of the external iliac artery
deep circumflex iliac:
collateralizes with lateral femoral circumflex artery to the superior iliac spine also supplies collaterals to lower leg
Inferior epigastric (careful, pelvis and abdomen origin) - this vessel anastomosis with superior epigastric artery which is a branch of the internal thoracic
management of splenic abscess
IV antibiotics splenectomy-particularly of multiloculated and complex
possible IV antibiotics and CT-guided drainage-however, risky for bleeding only considered with unilocular simple abscess
time frame of intimal hyperplasia seen for graft stenosis
within 2 years of surgery
Cells involved with intimal hyperplasia
Spindle cells
Treatment of intimal hyperplasia and graft
Most effective after 6 months
balloon angioplasty using cutting balloon
early within 3 months:
Patch angioplasty
or
vein graft
what timeframe does atherosclerosis of graft usually occur
after 2 years
most common location of indirect inguinal hernia sac compared to cord structures and cremasteric muscle
deep to cremaster
Anterior and superior to spermatic cord -
hernia sac is carefully Divided off of cord structures
when can sigmoid ischemia be watched after triple-A repair regarding endoscopic findings
ischemia limited to the mucosa
Adequate perfusion
Antibiotics and bowel rest
physical symptoms of myasthenia gravis
ptosis
Diplopia
Weakness with repetitive movements
Fatigue
Percentage of myasthenia gravis patient who will have associated thymoma
only 10%!
thymectomy anyway
Percentage of patients with thymoma who will have myasthenia gravis
50%
percentage of improvement and myasthenia gravis after thymectomy
80%?
Pathway of conversion synthesis of catecholamine and adrenal medulla
Tyrosine - all starts with going in the ring L. dopamine - the dop Dopamine - gets dop Norepinephrine - starts getting adrenl Epinephrine - gets adren
only site of epinephrine production
adrenal medulla
converting norepinephrine to epinephrine
enzyme:
PNMT - final step path
steps and reducing the phimosis and possible complication
dilated with surgical clamp
Dorsal slit circumcision by urologist to temporize
paraphimosis - prepuce is trapped behind the glans-this is a urologic emergency - arterial flow continues without any risk or lymphatic congestion
treatment of paraphimosis
neurologic emergency
Emergent reduction required of pharphimosis in all circumstances
algorithm for hematochezia
NG lavage rule out upper GI
NG lavage negative colon
Bleeding intermittent and stable-colonoscopy
Brisk bleeding:
Colonoscopy not helpful can’t see anything
Localization study:
Angiography-diagnostic and potentially therapeutic-requires bleeding rate of at least 0.5 mL per minute
Pathway of oxalate kidney stones and Crohn’s
normally:
Oxalate is bound into calcium oxalate and the bound form is excreted in the stool
With Crohn’s:
steatorrhea and problems absorbing fat
the fat competes to bind calcium (leaving the oxalate free)
unbound oxalate reabsorbed by the colon and excreted by the kidney
treatment oxylate stone forming
calcium citrate
exatra calcium precipitates dietary oxalate
and citrate prevent stone formation and urine
syndrome of complete loss of adrenal function and potential cause
Waterhouse-Friderichsen syndrome is an adrenal gland hemorrhage that occurs after meningococcal sepsis infection
also described with pregnancy
lab findings with adrenal insufficiency
hyponatremia - lost aldo
HYPER kalemia -
Hypotension
fever
sometimes hypoglycemia - cortisol def
Gram negative bacteria cause of sepsis
ENDOtoxin
```
Lipid A
within lipopolysaccharide component
~~~
hemangioma CT finding
Peripheral enhancement
treatment of hemangioma
increased size
Symptoms
Kasabach-Merritt syndrome.- Consumptive heart failure
enucleation first choice
May require segment segmentectomy
NOT embolization
pressure the diagnosis portal hypertension
greater than 5
careful compared to IVC normal 0-5
portal pressure associated with esophageal variceal bleeding
–12
how is portal pressure calculated
difference between IVC and portal vein
best test to measure portal pressure and sinusoidal disease
e.g. cirrhotic
hepatic wedge
best test to measure portal pressure and pre-sinusoidal disease
EG schistosomiasis
wedge is not good-falsely low measurement
exam finding that differentiated AV fistula from pseudoaneurysm
thrill in CHF fistula
findings with popliteal entrapment
palpable pulses
Claudication with provocative activity
We progressed the paresthesias
Anatomic etiology of popliteal entrapment
develops in utero!
MEDIAL head of the gastroc
Or developmental problem popliteal artery
40-year-old smoking female string of beads on CTA left internal carotid
fibromuscular dysplasia of the carotid artery
symptoms of fibromuscular dysplasia of the carotid artery
TIA
Stroke
Disability
diagnosis of fibromuscular dysplasia of the carotid artery
ultrasound and CTA
possible angiogram
string of beads
treatment of fibromuscular dysplasia of the carotid artery
asymptomatic :
Antiplatelet therapy
Symptomatic:
Open - surgical dilation
or
angioplasty - gaining acceptance
NOT stent-redundancy kink, coil not amenable to this
most important muscles involved an active expiration
rectus Internal oblique The external oblique Transversus abdominis Internal intercostal - pull the rib cage down external intercostal
femoral hernia tissue repair
McVay (Cooper’s repair) approximate transversus abdominis aponeurosis to Cooper’s ligament
approach:
Incision ABOVE inguinal ligament
The external oblique aponeurosis split From external ring to internal ring-preserve ilioinguinal nerve
Open transversalis fascia
Hernia sac medial to the inferior epigastric vessels
Hernia sac freed from inguinal ligament
Medial:
Sutures placed pubic tubercle through transversus abdominis to Cooper’s ligament below
lateral:
Transition suture close femoral canal
Relaxing incision:
Anterior rectus sheath
treatment of fat emboli
immediate stabilization of fracture or long bones Decreases incident
supportive management:
May require intubation
Not proven:
Steroid in heparin
treatment of mesenteric obstruction and FAP patient with history of total domino proctocolectomy and ileoanal anastomosis
sulindac - anti-inflammatory medication decrease the size of desmoid tumor
LaPlace equation
tension = pressure x (radius / wall thickness)
2-year-old boy watery diarrhea, palpable mass on his right flank. elevated blood pressure and metanephrines in his urine. ataxia
nephroblastoma!
The
poor prognosticators of nephroblastoma
age or than one
Increasing neuron specific enolase
LDH
N-myc amplification
Findings that gives nephroblastoma better prognosis
hyperdilipoid
more DNA within tumor
more susceptible to chemotherapy
palliation of unresectable pancreatic cancer
at endoscopic or PERCUTANEOUS transhepatic stent
Endoscopic BETTER results of your complications
Percutaneous reserved for patients with technical issues with endoscopy
metal stent longer lasting
Gastric outlet obstruction-second portion of duodenum
Duodenal obstruction-third or fourth portion and duodenum
Biliary obstruction:
Endoscopic expandable metal stent and duodenum
Not able to stent-gastro J.
pain refractory to narcotics:
Endoscopic or percutaneous celiac plexus block
most common scenario her surgery is the approach taken to palliate pancreas cancer
undergoing laparotomy for anticipated resection and found to be unresectable
most accurate diagnosis for renovascular hypertension
angiography!
Ultrasound is screening tool to assess flow velocities
MRI made over diagnosis
indications for surgery of spontaneous pneumothorax
recurrence
Persistent leak
Incomplete expansion
High risk-high-pressure environment including air travel
Berger disease
small and medium vessels
Tobacco worsens
Usual involves more than one digit
Initial treatment tobacco cessation
ABI calculation and findings
ankle divided by brachial
higher of the 2 sides used
Dorsalis pedis and posterior tibial
Normal 1.0
claudication 0.7-0.9
Rest pain 0.4-0.7
Wound complications and gangrene/tissue lost LESS than 0.4
cholangiocarcinoma risk factors, major prognosticator
primary sclerosing cholangitis
margin status
treatment of cholangiocarcinoma
surgery only chance for cure
NO chemotherapy
classification of cholangiocarcinoma
#1 involves common hepatic duct #2 hepatic bifurcation #3 secondary hepatic ducts on one side #4 tumors involved both side secondary hepatic ducts
medial pectoral nerve
supply of both pectoralis major and pectoralis minor
lateral pectoral nerve
supplies only pectoralis major
pectoralis major more lateral
where anatomically does Zenker’s diverticulum develop
posteriorly
Transition zone between hypopharynx and esophagus-scalene triangle
Weakness near the cricopharyngeus muscle because from failure relaxation of upper esophageal sphincter
FALSE diverticulum
shortness of breath and dyspnea on exertion. A chest x-ray shows a small calcified lesion in the right upper lobe that is new from previous films. The patient reports that he was recently on a hiking trip in Ohio
histoplasmosis
treatment histoplasmosis
self limiting and do not require any further intervention!
careful, observe but These patients can have bulky mediastinal nodes that can cause compressive symptoms.
course of the thoracic duct
originates at the cysterna chyli at L1-L2
courses superiorly on the RIGHT the AORTIC hiatus.
right of midline until
CROSSES to the left at T4-T5.
empties in to the LEFT subclavian vein at the junction with the IJV
careful, not brachiocephalic
surveillance Peutz-Jegher syndrome
colonoscopy every 2 years
extracolonic cancers screening should begin at age 25
cervical and breast screening
other extracolonic cancers:
Thyroid
Lung
timing of surgery for congenital diaphragmatic hernia
not emergent
Plan for date 2-3 of life the neonate is free of significant respiratory and cardiovascular compromise
treatment of duodenal adenocarcinoma first or second portion of duodenum
Whipple resection
no chemoradiation
Treatment of duodenal adenocarcinoma third or fourth portion of duodenum
segmental resection
no chemoradiation
unstable patient esophageal perforation found to have cancer
cervical esophagostomy
gastrostomy
feeding J.
Gold standard for AV fistula access
radiocephalic wrist-Cimino
anatomic snuffbox or just above the wrist crease
that study to workup colovesicular fistula
CT scan
and demonstrate pneumaturia
but also needs colon
Endoscopy
Cystoscopy
blood supply to the pancreas
celiac
Superior mesenteric artery
Splenic artery
when is carotid endarterectomy not indicated
less than 50% stenosis
indications for carotid endarterectomy
greater than 60% stenosis even asymptomatic
size of ileal resection consistent with vitamin B12 problem
60 cm
size ileal resection at risk for bile acid malabsorption
100 cm
liver cannot compensate with increased hepatic symphysis the bile-fat is not bound with bile sufficiently causing steatorrhea
algorithm for workup of hemobilia
stable:
Endoscopy rule out other causes of upper GI bleed
Unstable high index of suspicion:
Angiography therapeutic and diagnostic
Prior to dividing the gastrohepatic ligament at the right crus, what aberrant structure may be encountered
and accessory LEFT hepatic artery originating from the left gastric artery
careful, right crus region may have a LEFT accessory hepatic artery
structures to be where of dissection around the right crus
LEFT vagus anterior
L APR
careful, right crus left anterior vagus
LEFT accessory hepatic artery and
pyoderma gangrenosum
treatment steroids
Improved with resection of inflamed bile
Associated with inflammatory bowel disease
and primary bile salts are conjugated where and by what
hepatocytes
GLYCINE
Taurine
most common bacteria the colon
Bacteroides fragilis
Other anaerobes:
lactobacillus bifidus
clostridium
Eubacterium
Aerobe: Escherichia coli- most common AEROBE Klebsiella Proteus Enterobacter enterococcus-Streptococcus faecalis careful,
what helps platelet behind the endothelium
von Willebrand factor
What helps platelet aggregate
thromboxane A2
other affect is vasoconstriction
what cross-links platelets
thrombin
converting fibrinogen to fibrin
interval, cross-linking is not aggregation
major inflammation stimulator for atherosclerosis
lipid core made from LDL
at what point is compensatory arterial dilation no longer sufficient to compensate for percentage of stenosis from plaque
40%
careful, exertional angina not seen total 75% stenosis
the role of Nissen fundoplication with Barrett’s esophagus
better than trying to maximize medical therapy
because there is continuation of reflux even if acid is controlled
relationship of aortic arch and a thoracic duct
thoracic duct runs posterior to the arch
Originates at the cisterna chyli between T10 and L3 and enters the chest through the aortic hiatus to the right of the aorta and at T5, turns left and courses posterior to the aortic arch
courses anterior to the vertebral bodies between the aorta and the azygos vein and posterior to the esophagus
mechanism of Cilostazol
Pletal
This is a phosphodiesterase III inhibitor
works on cAMP
Acts to:
inhibit smooth muscle so contraction and platelet aggregation
mechanism of action of Pentoxyfiline
increases blood cell look stability
mechanism unknown
used to treat claudication on
mechanism action of statin
HMG CoA reductase inhibitor
drugs that inhibit cyclooxygnease
ASA
nonsteroidal anti-inflammatories
mechanism of action of Plavix
irreversibly inhibited
adenosine diphosphate ADP
on platelet cell membrane
only FDA approved treatment for claudication by medication
Cilostazol phosphodiesterase 3 inhibitor - decrease smooth muscle/decreased platelet aggregation
Pentoxyfinline - red blood cell flexibility
findings of esophageal scleroderma
low amplitude
Simultaneous contractions
Normal lower esophageal pressure
careful, achalasia can have simultaneous contractions-difference is fail relaxation the lower esophageal sphincter
treatment of esophageal scleroderma
treat underlying scleroderma and secondary symptoms of esophagus improve
methotrexate and immune modulaters
diagnoses test of choice for blunt aortic dissection
TPA
aortic Aneurysm of Marfan syndrome
aortic root!
risk of dissection
defect in Ehlers-Danlos syndrome
collagen
treatment of immediate postop intracranial embolism after carotid endarterectomy
thrombolytics
inspiratory reserve volume
At the end of tidal volume inspiration
it is the maximum volume that can be inhaled from there
expiratory reserve volume
from the end of title volume exhalation
the maximum amount of air that can be exhailed from there
residual volume
volume air remaining in lungs after maximal exhalation
this includes a dead space
total lung capacity
volume in lungs after maximal inflation
inspiratory capacity
inspiratory reserve volume
AND tidal volume
functional residual capacity - definition and calculation
the volume in lungs after normal exhalation
total lung capacity minus inspiratory capacity
or
expiratory reserve volume PLUS residual volume
vital capacity
total lung capacity minus residual volume
structures of the anterior compartment of the leg
extensor pollicis longus
Extensor digitorum longus
Tibialis anterior
Peroneal tertius
deep peroneal nerve
( careful, deep peroneal nerve not so deep - anterior compartment does not have tibial nerve)
ANTERIOR tibial artery
nerve most commonly injured during lower extremity fasciotomy
superficial peroneal nerve
Superficial is at risk with - lateral incision - lies near the septum
located in the lateral compartment
described for compartment fasciotomy
medial and posterior incision to the tibia:
decompresses superficial and deep posterior
lateral incision:
Intermuscular septum
decompresses anterior and lateral compartments
defect with injury to superficial peroneal nerve
inability to evert foot
most commonly injured nerve during fasciotomy-lateral compartment
defect was injury deep peroneal ulnar
FOOT DROP
unusual to injure during fasciotomy
location of the deep peroneal nerve
ANTERIOR compartment
most commonly compressed nerve and compartment syndrome
location and defect with tibial nerve
DEEP POSTERIOR compartment
nerve and vessel and deep posterior compartment
tibial nerve
Posterior tibial artery
(careful, deep peroneal nerve is ANTERIOR compartment)
most common organism for prosthetic graft infection
staph aureus
careful, no specific infection is staph epidermidis
relationship of right hepatic artery to the common hepatic duct
right hepatic artery passes posterior to common hepatic duct as it heads towards the liver 85% of the time
relationship of right replaced hepatic artery
to portal triad and
medial aspect of Calot’s triangle
POSTERIOR to CYSTIC duct
first location of metastasis in the invasive gallbladder cancer
or cystic duct lymph nodes
largest resistance and drop in blood pressure change of any vessel
arteriols
careful, not capillaries that are downstream - because surface area is so large and extensive network branching
hereditary non-polyposis colon cancer special tumor characteristics
microsatellite instability
MLH1 MSH2 genes - these cause the:
DNA mismatch repair
Amsterdam criteria
3 or more first degree relatives colon cancer
Across 2 generations
One member diagnosed prior to the age of 50
associated with Lynch I
colon cancer
associated with Lynch II
Cancer of :
endometrial
Ovarian
Gastric
origin of the internal thoracic artery
first branch off subclavian
tissue supplied by internal thoracic artery
chest wall Breast Branches to Thymus Mediastinum The sternum
course of the internal thoracic artery
first branch off subclavian
Between the internal oblique and transverse thoracic muscles
Bifurcated sixth intercostal space
Muscular phrenic
Superior epigastric artery explanation mark
cranial nerve innervated carotid body
cranial nerve 9
Branch of glossopharyngeal
physiologic mechanism and responsive carotid body
edema receptor
Paraganglioma
Stimulated by: Hypercapnia Hypoxia Decrease pH Increase temperature Signs none Nicotine
action: Sympathetic stimulation Increased heart rate Increased vascular tone Intracerebral cortical activity
what do hepatocytes produced
bile
Synthesis proteins
Synthesis glucose
Space of Disse
interaction between hepatocyte and blood
substances are exchanged via active transport
recommended treatment for posterior knee dislocation and no flow past proximal popliteal artery on angiogram
bypass with CONTRALATERAL reverse saphenous vein
the gallbladder his mechanism of bile concentration
ATPase dependent sodium chloride transport
treatment of 2 cm common iliac occlusion
angioplasty and stent procedure of choice for all common iliac stenoses
less than 3 cm
most common time period to develop aorto enteric fistula
2-6 years
diagnostic modality that best demonstrates chance of cure and squamous cell carcinoma of the esophagus
EUS
EUS is better than PET
most important prognosticators for esophageal cancer
depth of tumor penetration and node involvement
indications on EUS the esophageal cancer his resectable
not invaded adjacent organs
Fewer than 5 enlarged lymph nodes
when should screening begin with HNPCC
colonoscopy age 20 and all polyps removed
recommend surgery for HNPCC colon cancer
total bowel colectomy with ileorectal anastomosis
or
female in no longer childbearing:
total abdominal hysterectomy and salpinco-oophorectomy
careful, FAP surgery is total abdominal proctocolectomy with ileal anal J-pouch
extent of colon resection for cancer proximal to the hepatic flexure
right hemicolectomy:
Resect ileum approximately 5 cm proximal to the ileocecal valve
anastomosis to the first third of the transverse colon
take the right branch of the middle colic artery
also takes:
Ileocolic
Right colic
mechanism action of pancreatic polypeptide
suppress:
bile secretion
gallbladder contraction
exocrine pancreatic function
treatment of superior vena cava syndrome from multiple tunneled hemodialysis catheters
balloon angioplasty - first choice
( NOT embolectomy thrombectomy)
Often requires multiple interventions
Stents for now been tried - with some success
percentage of gallstone ileus as the cause in an obstruction in patient older than 70 With no previous surgery and no hernias on exam
up to 25%!
most common site of fistula and most common site of obstruction from gallstone ileus
duodenum
terminal ileum-most narrow
epiphrenic diverticulum
pulsion diverticulum
distal esophagus
does not contain all layers of esophageal wall
traction diverticulum
all layers of esophageal wall
midesophagus
post thrombotic syndrome
23-60% of deep venous thrombosis
edema Pigmentation Calf muscle dysfunction Venous stasis ulcer Valvular incompetence Chronic venous insufficiency
fibromuscular dysplasia pathophysiology and most common site of recurrence
most common site renal artery 80%
females 40-50-year-old
Medium-size arteries
MEDIAL most common
other less common sites:
Carotid artery
Iliac artery
Vertebral artery
primary treatment of sliding hernia
type I hernia
PPI
List order of prevalent of hiatal hernia
type I #1 most common
careful, type III SECOND most common
type II third most common
structures at risk when dissecting posterior hiatal hernia sac in the mediastinum
left anterior vagus nerve
pleura, esophagus, and inferior pulmonary veins
treatment of acute cholecystitis in patients who are too high a risk to undergo surgery including child’s C.
transit hepatic cholecystostomy
even in child C.
where is the swallowing Center located
Medulla
same as breathing center
risk of major limb amputation in patient with intermittent claudication per year
1% per year
Severity of stenosis is categorized according duplex ultrasound
Less than 20% stenosis (NORMAL):
- Velocities: 150 cm/sec
- Waveform Characteristics: Spectral broadening throughout systole with no change in waveform
- Management: Rescan in 6 months
50% to 75% stenosis (MODERATE):
- Velocities: >180 cm/sec
- Waveform Characteristics: severe spectral broadening in systole with reversed-flow components
- Management: Rescan in 4-6 weeks; if lesion does not progress during two cycles of testing, increase scan interval to 3 months
Greater than 75% stenosis (SEVERE):
- Velocities: >300 cm/sec
- Waveform Characteristics: severe lumen reduction with a “flow jet”; damped distal velocity waveform
- Management: Recommend repair (urgent if average PSV 0.15)
primary functional bile acids
digestion of fat
where are bile acid conjugated
hepatocyte:
Glycine
Taurine
Colon:
Bacteria conjugate primary bile acid into:
deoxycholic acid
lithocolic acid
enzyme responsible conjugate primary bile acid
Glucoronyl transferase
non gallstone reasons to perform cholecystectomy
hydrops - Cystic duct obstruction Biliary dyskinesia porcelain gallbladder ( but less concerned than patch were calcification)
NOT ascending cholangitis
when do you start upper scope screening patients with FAP
age 20-25
OR
When colonic polyps first appear
76-year-old female presents on post operative day #14 from a left femoral-popliteal bypass graft with PTFE with acute left lower extremity pain. You suspect that the graft has thrombosed.
Which is the MOST appropriate treatment for this patient?
Thrombectomy
with intra operative angiogram
RCC that extends into the IVC
can be pulled out during the radical nephrectomy.
AAA renal dysfunction perioperatively increased in
26-42% incidence
supraceliac clamping
Increased age
preoperative hypotension
prolonged clamp time
described anatomy of right renal artery
medially below SMA L2
longer than the left as it courses POSTERIOR to inferior vena cava
posterior to renal vein
25-30% have accessory renal arteries
surgical exposure required to access right renal artery
Kocher maneuver
Take down the right colon
pigmentation pigmentation of bile
bilirubin diglucuronate
conjugated form
primary source of bilirubin
senescent red blood cells breakdown of heme heme is converted to: biliverdin biliverdin is converted to: bilirubin bilirubin is taken up by hepatocyte: conjugated by glucuronic acid
what gave his stool bile color
URObilinogen
this is because he did bilirubin from bacteria - and the amount not reabsorbed is passed in the stool
effect of nitric oxide on platelet irrigation
INHIBITS aggregation
careful, vasodilation major factor
in also: Decreases inflammatory response decreases: VACAM - 1 ICAM - 1 MCP - 1
list the order of splenic aneurysms
splenic 60%
hepatic 20%
SMA 5.5%
celiac 4%
treatment of pseudoaneurysm common femoral artery
greater than 2 cm:
Thrombin injection
open repair: greater than 5 cm with wide neck Overlying skin necrosis distal ischemia Nerve compression active bleeding
most common postoperative swelling of lower extremity bypass for chronic ischemia
lymphedema
generally improves over 2-4 months
most common bacteria to cause lymphangitis and upper extremity
Streptococcus pyogenes
careful, other cause:
Staph aureus
treatment of the iliac and femoral DVT in patient with swelling and extreme pain
thrombolysis - catheter directed
superior mesenteric artery syndrome treatment
chronic:
duodenojejunostomy
not arterial bypass
Less common surgical treatments for SMA syndrome include Roux-en-Y duodenojejunostomy, gastrojejunostomy, anterior transposition of the third portion of the duodenum, intestinal derotation, and division of the ligament of Treitz.
acute:
Medical management
Pro-motility agents such as metoclopramide may also be beneficial
etiology of superior mesenteric artery syndrome
compression of the third portion of duodenum between superior mesenteric artery and perivertebral musculature/vertebrae
If conservative treatment fails when reversed peristalsis persists,
Factors that decrease the risk of PAD
HDL,
nitrous oxide
prostacyclins
What is the MOST likely organism to be associated with a non-aneurysmal aortic infection
Salmonella
careful, STAPH is most common when associated with aneurysm
careful, STREP is most common when infection is to do bacterial endocarditis
Most likely location for non-aneurysmal aortic infection
suprarenal
postoperative intervention that had the most influence on vein graft patency
duplex ultrasound- improved patency by 15% when compared to clinical examination
Careful, Plavix is used not definitively proven for end result patency
treatment of phlegmasia cerulea dolens
catheter directed thrombolytic can improve her outcome
The alternative for this condition is surgical venous thrombectomy.
No matter which treatment is chosen, long-term anticoagulation is indicated.
Careful, thrombectomy and systemic umbilicus have poor results
Presentation of phlegmasia cerulea dolens
complication and DVT- arterial inflow can be compromised Complete occlusion of the venous system venous gangrene can develop unless flow is restored. edema and blistering with cyanosis
occasionally involve the trunk colon
symptoms of vertebral artery stenosis
dizziness Vertigo Tendinitis Dysphagia Dysarthria Ataxia
indications for treatment or vertebral artery stenosis
symptoms
lymphedema precox
primary lymphedema
Occurs after puberty
Lymphedema tarda
primary lymphedema
Recurred in women after the age of 35
relationship of nitric oxide to LDL
nitric oxide inhibitor of LDL
history of MI is what kind of perioperative risk
intermediate!
physical diagnosis of Steal syndrome AV fistula
compressed graft relieve symptoms and returns radial pulse
size of popliteal aneurysm requiring surgery
2.5 cm or greater - 30% symptoms in 3 years
ligate aneurysm as well the bypass
strong risk risk factor for AAA
smoking
other risk factors:
MMP - damage to media and elastin
hypertension-infrarenal
age - decreased the last and
Layer affected in AAA
tunica MEDIA
presentation of occlusion of superficial femoral artery
thigh is still vascularized due to patent
femoral profundus!
discoloration of the knee and distally
presentation of occlusion of the common femoral artery
cool lower extremity from 5 distally
May have waterhammer pulse or no pulse
