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FRACS study > Pathophysiology pearls > Flashcards

Pathophysiology pearls Flashcards

1
Q

DIC

A
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2
Q

Complement activation pathways and cascade

A
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3
Q

Diagnosis of chylothorax and chylous ascites

A

Milky fluid

Presence of chylomicrons

Triglygeride greater than 2mmol/L (and often >10mmol/L)

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4
Q

Nutrition screening tool

A

MUST screening tool, 5 step process

  1. Obtain BMI
    • >20=0, 18.5-20=1, <18.5=2
  2. Percentage of unplanned weight loss
    • <5=0, 5-10=1, >10=2
  3. Disease effect
    • acute illness AND has been or likely to be poor intake >5 days
  4. Calculate score
    • 0 low risk
    • 1 medium risk- observe intake 3/7
    • 2 high risk- needs intervention
  5. Make and undertake a plan
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5
Q

What is the Fearon- Vogelstien model?

A
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6
Q

Grading and parameters of haemorrhagic shock

A
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7
Q

What is an MTP

What are the constituents

What monitoring is recommended

A

A system designed to rapidly replace blood products at an approximate 1:1:1 ratio in a patient who is exsanguinating.

  • The exact protocol differs between centres

At our centre the MTP is activated by a clinician who thinks it is warranted.

  • Additional markers for triggering the MTP include:
    • loss of half of estimated blood volume,
    • use of 10 packed red cell units, or
    • a score of 2 or more in the ABC trauma score
      • 1 point each for penetrating trauma, HR >100, SBP <90, or positive FAST

Our protocol is:

  • The first box contains
    • 2 units of RCC and 2 units of FFP
  • The second box contains
    • 4U RCC + 4U FFP + 3U cryoprecipitate
  • The third box contains
    • 4U RCC + 4U FFP + 1U platelets
  • Box Four is the same as the second box and these keep rotating.

The patient should receive 1g of TXA on arrival

The patient’s coagulation status should be continuously monitored with TEG, ROTEM, or coags as well as calcium and an ABG

Some centres use recombinant VIIa, although this is not widespread practice.

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8
Q

ABC trauma score

A

1 point each for:

  • Penetrating trauma
  • HR >100
  • SBP <90
  • Positive FAST

A score of 2 or more is an indication to commence the MTP

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9
Q

PTEN

A

Tumour suppressor gene

  • Regulates cell cycle
  • Widely expressed in most tissues

Associated conditions

  • Cowden syndrome/Cowden-like syndrome
  • Breast cancer (at least partly Cowden)
  • Lung cancer
  • Prostate cancer
  • Head and neck SCC
  • Thyroid Cancer
    • Esp follicular cancer
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10
Q

Cowden syndrome and Cowden-like syndrome

A

Autosomal dominant

These conditions are characterized by the growth of multiple hamartomas and cancers,

  • Lipomas, papillomas
  • Breast cancer
  • Thyroid cancer (follicular)
  • Endometrial cancer

Cowden syndrome and Cowden-like syndrome are considered to be part of PTEN hamartoma tumor syndrome

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11
Q

Li-Fraumeni Syndrome

A

TP53 tumour suppressor gene mutation

Risk of malignancy developing in childhood and early adulthood

  • lifetime malignancy risk of ~100%
    • Some studies have used annual whole body MRI for surveillance which is effective but trade off with high rates of incidenatalomas

Autosomal dominant

Classical cancers

  • Breast (lifetime risk 50%)
  • Soft tissue and bone sarcomas (but not Ewings)
  • Brain tumours
  • Adrenocortical carcinomas

Less common cancers:

  • Leukemias
  • Adrenocortical carcinoma
  • Pancreatic
  • Bowel
  • Many others

High association with radiation induced malignancies-

  • Avoid RTx where possible
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12
Q

Pathognomonic histology:

“Leaf like stroma”

A

Phyllodes tumour

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13
Q

Pathognomonic histology:

“Orphan Annie Eyes”

A

Papillary Thyroid Cancer

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14
Q

Pathognomonic histology:

Psammoma body

A

Arise from papillary infaction and calcification in papillary forms of cancer

  • Thyroid
    • Papillary thyroid cancer
  • Pancreas
    • Somatostatinoma
    • Glucagonoma
  • Kidney
    • Papillary RCC
  • Gynae
    • Ovarian and endometrial cancer
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15
Q

What are the phases of wound healing

A
  1. Haemostasis
  2. Inflammation
  3. Proliferation
  4. Maturation

These phases overlap significantly

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16
Q

VINDICATE

A

Vascular

Infectious/inflammatory

Neoplastic

Degenerative

Iatrogenic/Intoxication

Congenital

Autoimmune

Trauma

Endocrine/Metabolic

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17
Q

How to compose an answer to a question you do not have the answer for

In A Surgeons Gown Physicians May Make Some Progress

A

Incidence

Age

Sex

Geography

Pathogenesis/Precipitation

Macroscopic features

Microscopic features

Spread

Prognosis

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18
Q

The two hit model of tumourigenesis

A

First hit

  • Inherited germ line mutation in a gene which would otherwise suppress malignancy

Second hit

  • Sporadic mutation in the remaining functional copy of that gene in a single cell
    • Clonal expansion and tumour development
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19
Q

Peutz-Jeghers

A

GI hamartoma syndrome

STK11 mutation (aka LKB1)

Pigmented mucosal lesions

Panenteric hamartomas

Very elevated risks for gastrointestinal cancers:

  • Colorectal
  • Stomach
  • Small intestine
  • Pancreas

Also breast and ovarian cancers

  • Recommend increased/early surveilllance for these cancers
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20
Q

Hereditary diffuse gastric cancer syndrome

A

Germline cadherin 1 gene mutation (CDH1)

Susceptibility to diffuse, highly invasive gastric cancer

  • also called:
    • signet ring carcinoma
    • isolated cell-type carcinoma

Also Lobular breast cancer

  • Some pathogenic types this may be as high as 50%
  • Generally risk reducing mastectomy not warranted unless strong family history to suggest a breast cancer pathogenic variant
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21
Q

PALB2

A

Partner and localizer of BRCA2 (PALB2)

  • breast cancer susceptibility gene that encodes a BRCA2-interacting protein
  • monoallelic PALB2 pathogenic variant have a risk of breast cancer by age 70 of 33 to 58% depending on family history
    • the upper risk range can overlap with BRCA2 risks,
    • PALB2 is considered to be a moderate to high-risk gene associated with hereditary breast cancer
      • initiate annual mammography with tomography and annual breast MRI, starting at age 30 years.
      • RRM may be an appropriate option for some patients
  • Other cancers
    • Pancreatic
    • prostate cancer
    • medulloblastoma
    • ovarian
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22
Q

Tools used in recognising sepsis:

SIRS criteria

A

Not specific for sepsis but helpful in recognising the unwell patient

Four parameters

  • Pulse
    • >90
    • <50
  • Temp
    • >38
    • <35
  • WCC
    • >12
    • <4
  • Resp rate
    • >20
    • <8
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23
Q

Tools used in recognising sepsis:

qSOFA

A

Quick Sepsis Organ Failure Assessment

Three parameters scored 0-1

  • Score of 2 or more is associated with worse outcomes including mortality and is advised by several expect panels
    • It really just shows shock though and no surprises that this correlates with death in sepsis
  • Parameters are:
    • Respiratory rate ≥22/minute
    • Altered mentation
    • Systolic blood pressure ≤100 mmHg
24
Q

Tools used in recognising sepsis:

EWS

A

Should be routine practice as they are validated.

25
Q

Ki67

A

Antigen KI-67 is a nuclear protein that is associated with, and may be necessary for cellular proliferation.

  • Immunohistochemical staining can be used to detect Ki67
    • Provides information on cellular proliferation rate
26
Q

Calcium homeostasis

A
27
Q

Vitamin D synthesis and activation

A

Vitamin D synthesised in skin and absorbed from diet

  • hydroxylated at 25 position in liver
    • hydroxylated at 1 postion in kidney
      • 1,25 hydroxyvitamin D3 is the active form
28
Q

Calcium homeostasis diagram

A
29
Q

What are the functions of calcium

A

Hormone secretion

Muscle contraction

Synaptic function

Coagulation cascade

30
Q

PTH:

synthesis

half life

feedback

A

Synthesis in parathyroid chief cells

Half life of 4.5 minutes

Feedback is by ionized calcium by negative feedback

31
Q

How can the causes of hyperparathyroidism be differentiated

A

Hyperparathyroidism is the third most common endocrine disorder after DM and thyroid disorders

Primary

  • most common cause of hypercalcaemia
  • autonomous function of one or more of the glands
    • a new calcium set point is created
  • 85% have single adenoma
  • 13% have multiple gland dysfunction
    • MEN1- all glands
    • MEN2A- multiple but asymmetrical
  • 2% carcinoma (very high Ca levels)

Secondary

  • physiological secretion of PTH due to low calcium
    • usually due to vitamin D defiency in the context of renal failure

Tertiary

  • advanced form of secondary hyperparathyroidism
    • four gland hypertrophy and autonomous functioning
      • life threatening
        • usually have elevated Ca and normal PTH levels
32
Q

Symptoms of hypercalcaemia

A

Stones

  • Renal stones

Moans

  • Abdominal pain

Groans

  • Constipation

Bones

  • Osteopaenia

Psychiatric undertones

  • depression, fatigue
33
Q

Define morbid obesity

A

BMI >35 with comorbidity

or

BMI >40

34
Q

NF1

A

Also known as von Recklinghausen syndrome

NF1 gene 17q11

Manifestations

  • Neurofibromas
  • Cafe au Lait spots
  • Phaeochromocytoma
35
Q

Von Hippel-Lindau disease

A

3p25

Manifestations

  • pancreatic neuroendocrine tumours (non functional)
  • Phaeochromocytoma
  • RCC
  • Retinal and cerebellar haemangioblastomas
36
Q

What are the fat soluble vitamins

A

A

D

E

K

37
Q

Describe the physiology of B12 absorption

A

Intrinsic factor secreted by gastric parietal cells

  • cobalamin contains B12 and is released from substrate by enzymatic degradation in the duodenum and bound to intrinsic factor
    • The cobalamin-intrinsic factor complex is absorbed in the distal ileum
      • B12 is freed by transcobalamin II in terminal ileal enterocytes.
38
Q

List the causes of bowel obstruction

A

Luminal

  • bezoar
  • gallstone
  • enterolith
  • foreign body

Mural

  • tumours

Extramural

  • adhesions
  • hernias
  • carcinomatosis
  • abscesses
39
Q

Virchows triad

A

Virchow’s triad describes the three broad categories of factors that are thought to contribute to thrombosis.

  • Hypercoagulability
  • Haemodynamic changes
    • stasis, turbulence
  • Endothelial injury/dysfunction
40
Q

What is the role of secretory IgA in the gut

A

Does not opsonise or activate compliment

Prevents bacterial adherence to endothelium

  • prevents colonisation and multiplication

Neutralises bacterial toxins

41
Q

ALARM symptoms

A

Weight loss

Haematemesis

Melaena

Anaemia

Dysphagia

Odynophagia

Severe symptoms

42
Q

B symptoms

why are they called B symptoms

A

B symptoms are:

  • fever
    • >38
  • drenching sweats
    • especially night sweats
  • weight loss
    • >10% over 6/12

They are called B symptoms as per the Ann Arber staging system (A without and B with systemic symptoms

  • associated with systemic rather than local disease
  • denote a poorer prognosis
43
Q

CDH1

A

E cadherin gene

  • Rare autosomal dominant disorder
  • Marked increase in diffuse type gastric cancer and breast cancer
    • life time risks
      • women
        • 50% life time risk of gastric cancer
        • 40% lifetime risk of breast cancer
      • men
        • 56% lifetime risk of gastric cancer
        • Breast cancer risk not well defined
    • median age of gastric cancer age 38
    • risk reducing strategies including surgery for both are reasonable
      • gastrectomy generally between 20-30 years of age
44
Q

What score can be used on histology to assess the risk of malignancy in phaeochromocytoma

A

The PASS score

  • uses histological features e.g tumour necrosis, spindling, invasion etc to estimate risk of malignancy
  • there is no perfect score for phaeochromocytoma and the only definative diagnosis can be made if a metastasis occurs
45
Q

s100 histology staining

A

Marker of schwann cells and melanocytes

  • useful for evaluating nerve sheath tumors and melanoma
46
Q

What classification may be used to assess perioperative risk in cirrhosis

  • What are the parameters of the score
  • how is each parameter scored
  • what is the interpretation of the scores
  • what is the perioperative mortality by class
A

Child-Pugh score (this is a modification if the Child-Turcott score and includes INR rather than nutritional status- it is sometimes ereferred to as the Child-Turcott-Pugh score)

  • the score has been validated as a predictive tool for mortality in performing non-shunt abdominal surgery in cirrhosis
  • each parameter is scored 1-3 points
    • Albumin
      • >35
      • 28-35
      • <28
    • Bilirubin
      • <34
      • 34-51
      • >51
    • Coagulation (INR)
      • < 1.7
      • 1.7-2.2
      • >2.2
    • Distension (ascites)
      • absent
      • slight
      • moderate
    • Encephalopathy
      • absent
      • grade 1-2 (mild)
      • grade 3-4 (somnolent/disorientated to comatose)
  • the system is thus scored 5-15 points
    • Class A = 5-6 points
    • Class B = 7-9 points
    • Class C = 10+ points
  • the mortality by class is
    • A = 10%
    • B = 30%
    • C = 82%
47
Q

What is the points interpretation for the Child-Pugh score

A

Class A = 5-6 points

Class B = 7-9 points

Class C = 10+ points

48
Q

How is albumin level scored in the Child-Pugh score

A

1-3 points as is each parameter

  • >35
  • 28-35
  • <28
49
Q

How is bilirubin level scored in the Child- Pugh score

A

1-3 points as is each parameter

  • <34
  • 34-51
  • >51
50
Q

How is coagulation scored in the Child-Pugh score

A

1-3 points as is each parameter

  • < 1.7
  • 1.7-2.2
  • >2.2
51
Q

How is ascites scored in the Child-Pugh score

A

1-3 points as is each parameter

  • absent
  • slight
  • moderate
52
Q

How is encephalopathy scored in the Child- Pugh score

A

1-3 points as is each parameter

  • absent
  • grade 1-2 (mild)
  • grade 3-4 (somnolent/disorientated to comatose)
53
Q

What score may be used to predict 3 month mortality in cirrhosis and is frequently used for transplant prioritisation

  • What are the parameters
A

The New MELD score

  • initially developed to predict post TIPS mortality
    • validated as a general model for end stage liver disease
    • revised in 2016 to include sodium level as a standard variable
  • Parameters are graded as continuous variables
    • Sodium
    • Creatinine
    • INR
    • Bilirubin
54
Q

What pathway is implicated in intestinal type gastric cancer development

A

The Correa hypothesis

  • Progression from atrophic gastritis
    • through low grade dysplasia to high grade dysplasia and then malignancy
55
Q

What are the phases of clot formation

A

This is a chain of events

  • initial local vasoconstriction
  • vWF and tissue factor exposure
  • platelets activation and adherance
  • activation of the coagulation cascade
  • formation of fibrin from fibringen for clot stabilasation
  • clot maturation and remodelling under the effects of antithrombin III and thrombomodulin

FRACS study (13 decks)

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