Pestana- 4. General Surgery Flashcards
1
Q
What is the best way of diagnosing GERD when the diagnosis is uncertain?
A
pH monitoring
2
Q
What should be performed in a patient with longstanding GERD where you are concerned for potential peptic esophagitis or Barrett esophagus?
A
Endoscopy and biopsies
3
Q
What is the treatment for a patient with GERD and severe dysplastic changes?
A
- Medical therapy
- Radiofrequency Ablation
- Nissen fundoplication
4
Q
What is the first line study for suspected esophageal motility problems?
A
Barium swallow
5
Q
What provides a definitive diagnosis in a patient with suspected esophageal motility problems?
A
manometry
6
Q
What is the typical symptom of achlasia?
A
dysphagia that is worse for liquids (needing to sit up straight after swallowing drink)
7
Q
What is seen on x-ray with achlasia?
A
megaesophagus
8
Q
What is the diagnostic tool for achlasia?
A
manometry
9
Q
What is the most appealing current treatment for achlasia?
A
balloon dilatation by endoscopy
10
Q
What is the typical symptom of esophageal cancer?
A
progression of dysphagia (meats–> other solids –> liquids –> saliva)
11
Q
What is the typical esophageal cancer in a alcoholic black man who smokes?
A
squamous cell carcinoma
12
Q
What is the typical esophageal cancer in a patient with long-standing GERD?
A
adenocarcinoma
13
Q
How do you diagnose esophageal cancer?
A
1) Barium swallow
2) Endoscopy + biopsies
14
Q
Is surgery for esophageal CA usually palliative or curative?
A
palliative
15
Q
How do you diagnose Mallory-Weiss tear?
A
endoscopy
16
Q
How do you treat Mallory-Weiss tears?
A
photocoagulation (during diagnostic endoscopy)
17
Q
What is esophageal perforation after prolonged, forceful vomiting?
A
Boerhaave syndrome
18
Q
What are the symptoms of Boerhaave syndrome?
A
Continuous, severe, wrenching epigastric/low sternal pain of sudden onset (with fever, leukocytosis, and sick looking patient)
19
Q
How do you diagnose Boerhaave syndrome?
A
Contrast swallow (Gastrografin first, barium if negative)
20
Q
What is the most common reason for esophageal perforation?
A
instrumental perforation of the esophagus (shortly after completion of endoscopy)
21
Q
What should you suspect in an elderly patient with anorexia, weight loss, early satiety, vague epigastric distress and occasional hematemesis?
A
gastric adenocarcinoma
22
Q
When do you treat a gastric lymphoma with surgery (rather than chemo or radiotherapy)?
A
if perforation of stomach is feared as tumor melts away
23
Q
How do you treat low-grade lymphomatoid transformation (MALTOMA)?
A
eradication of H. pylori
24
Q
What is the most common cause of mechanical intestinal obstruction?
A
adhesions in those who have had a prior laparotomy
25
What are symptoms of a mechanical intestinal obstruction?
- Colicky abdominal pain
- Protracted vomiting
- Progressive abdominal distention (if it is low)
- NO passage of gas or feces
- High pitched bowel sounds --> no bowel sounds
26
What does x-ray of a mechanical intestinal obstruction show?
distended loops of small bowel with air-fluid levels
27
What is the initial treatment for a patient with a mechanical intestinal obstruction?
- NPO
- NG suction
- IV fluids
28
When do you do surgery for a mechanical intestinal obstruction?
- If conservative management is unsuccessful
- Within 24 hours in cases of complete obstruction
- Within a few days in cases of partial obstruction
29
What should you be concerned about in you patient with a mechanical intestinal obstruction who develops fever, leukocytosis, constant pain, signs of peritoneal irritation and ultimately full-blown peritonitis and sepsis?
strangulated obstruction
30
Other than adhesions, what is another cause of mechanical intestinal obstruction?
incarcerated hernia (irreducible)
31
What is carcinoid syndrome?
a patient who has a small bowel carcinoid tumor with liver mets
32
What are the associated symptoms of carcinoid syndrome?
- Diarrhea
- Facial flushing
- Wheezing
- Right sided heart valve damage (high JVP)
33
What is the diagnosis of carcinoid syndrome?
24 hour urinary collection for 5-hydroxyindoleacetic acid
34
Why do you need to do 24 hour urinary collection for 5-hydroxyindoleacetic acid to diagnose carcinoid syndrome?
the 5-hydroxyindoleacetic acid will only be high during an episodic attack or spell, so blood samples after attack will be normal
35
What is the typical initial symptom of acute appendicitis?
anorexia
36
How severe is the leukocytosis seen in acute appendicitis?
10,000-15,000 range with neutrophilia and immature forms
37
How do you diagnose acute appendicitis?
CT scan
38
What type of colon cancer shows up as an elderly patient with hypochromic, iron deficiency anemia (and 4+ occult blood in stool)?
right colon cancer
39
What is the diagnostic tool used for right colon cancer?
colonoscopy and biopsies
40
What is the treatment of choice for right colon cancer?
right hemicolectomy
41
What is the typical presentation of left colon cancer?
bloody bowel movements with narrow-caliber stool or constipation (this side of the colon is more narrow)
42
What is the primary diagnostic tool if you suspect left colon cancer?
flexible proctosigmoidoscopic exam (45 or 60cm)
43
What must be done before surgery for left sided colon cancer?
full colonoscopy (to r/o synchronous second primary)
44
What may be necessary if patient has a large rectal cancer?
re-op chemotherapy and radiation
45
Is an isolated inflammatory polyp premalignant?
NO
46
Is an adenomatous polyp premalignant?
YES
47
Is a hyperplastic polyp premalignant?
NO
48
Which can be cured with surgery: Crohn's disease or CUC?
CUC
49
Why do you typically want to avoid surgically curing a patient of CUC?
surgical cure requires removal of the rectal mucosa (would need stoma or ileoanal anastomosis)
50
What do you expect in a patient with CUC who develops fever, leukocytosis, abdominal pain and tenderness with massively dilated colon with gas in the wall?
toxic megacolon
51
What are the indications for surgery in CUC?
- Active disease for >20 years (malignant degeneration)
- Severe nutritional depletion
- Multiple hospitalizations
- Need for high dose steroids or immunosuppressants
- Development of toxic megacolon
52
What are the indications for surgery in Crohn's?
ONLY when there are complications (bleeding, stricture, fistulization)
53
What causes pseudomembranous enterocolitis?
overgrowth of C. difficile in patients who have been on antibiotics
54
Which class of antibiotics is currently most associated with pseudomembranous enterocolitis?
cephalosporins
55
How do you make the diagnosis of pseudomembranous enterocolitis?
- C. diff toxin identification in stool
| - Endoscopy
56
How do you treat pseudomembranous enterocolitis?
- Discontinue antibiotic
| - Metronidazole (vanc is alternative)
57
When is emergency colectomy warranted in pseudomembranous enterocolitis?
- Disease unresponsive to treatment
- WBC >50,000
- Serum lactate >5
58
What new therapy is showing promise for treatment of c. difficile overgrowth/ pseudomembranous enterocolitis?
fecal enema
59
How do you treat internal hemorrhoids?
rubber band ligation
60
Who typically gets anal fissures?
young women
61
Where are anal fissures typically located?
posterior and midline
62
What is therapy for anal fissures aimed at doing?
relaxing a tight anal sphincter
63
What are the treatment modalities for relaxing tight anal sphincters (to treat anal fissures)?
- Stool softeners
- Topical nitroglycerin
- CCB ointment (ex. diltiazem)
- Local injection of botox
- Forceful dilatation?!?!
- Lateral internal sphincterotomy
64
How do you treat a Crohn's fistula at the anus?
drainage with setons + remicade
65
What should be suspected in a febrile patient with exquisite perirectal pain that does not let him sit down to have bowel movements?
ischiorectal abscess
66
Where are ischiorectal abscesses usually located?
lateral to the anus (between the rectum and the ischial tuberosity)
67
How do you treat a patient with a ischiorectal abscess?
incision and drainage
68
What do you worry about in a diabetic patient with an ischiorectal abscess?
necrotizing soft tissue infection
69
When do fistula-in-ano develop?
in patients who have ischiorectal abscesses drained (tract forms between anal crypt where abscess originated and perineal skin where drainage was done)
70
What are the symptoms of fistula-in-ano?
- fecal soiling
| - occasional perineal discomfort
71
What does the physical exam of a patient with fistula-in-ano show?
- Opening lateral to anus
- Cordlike tract palpable
- Discharge may be expressed
72
How do you treat fistula-in-ano?
fistulotomy (after ruling out tumor)
73
Who typically gets squamous cell carcinoma of the anus?
HIV+
| Homosexuals with receptive sexual practices
74
What does squamous cell carcinoma of the anus look like?
fungating mass growing out of the anus
75
What is the treatment for squamous cell carcinoma of the anus?
- NIgro chemoradiation protocol (5 weeks)
| - Surgery (if there is residual tumor)
76
Is surgery typically required for squamous cell carcinoma of the anus?
NO- 90% cure rate with chemoradiation
77
What percentage of GI bleeds are upper?
75%
78
What is the division between upper and lower GI?
ligament of Treitz
79
If a GI bleed is "lower", where is it most likely from?
colon or rectum
80
If a young patient has a GI bleed, is it more likely upper or lower?
upper
81
Vomiting blood suggests what?
upper GI bleed
82
What do you do if someone is vomiting blood?
NG tube
83
What is the next step after NG tube in patient who is vomiting blood?
upper GI endoscopy
84
What should the workup of a patient with melena begin with?
upper GI endoscopy
85
True or false: red blood per rectum is always lower GI bleed.
false, can be upper GI with fast transit
86
What is the first step in management of patient who is actively bleeding per rectum?
NG tube with aspiration of gastric contents
87
What NG tube result rules out upper GI bleed completely (so no need for upper GI endoscopy)?
no blood with bile-tinged (green) fluid
88
What are the 3 ways to tackle a lower GI bleed (after hemorrhoids are ruled out)?
1. If >2 mL/min bleeding--> angiogram to allow for angiographic embolization
2. If wait until bleeding stops and do colonoscopy
3. If bleeding is in between --> tagged RBC study (if puddling, do angiogram; if no buddling, do colonoscopy)
89
What is the method often used to locate a GI bleed in the small bowel?
capsule endoscopy
90
How do you treat an older patient with h/o blood per rectum (but is now stable and not actively bleeding)?
upper + lower GI endoscopy
91
Blood per rectum in a child is most likely what?
Meckel diverticulum
92
What do you do to workup a suspected Meckel diverticulum?
technetium scan (look for ectopic gastric mucosa)
93
How do you avoid stress ulcers after major trauma?
keeping gastric pH >4
94
What is the best therapeutic option for massive upper GI bleed 2/2 stress ulcers?
angiographic embolization
95
What are the four main categories of acute abdominal pain causes?
- Perforation
- Obstruction
- Inflammatory processes
- Ischemic processes
96
What can confirm the diagnosis of perforation?
free air under diaphragm in upright x-ray
97
List the generalized signs of peritoneal irritation found in perforations.
Tenderness
Muscle guarding
Rebound
Silent abdomen
98
What is the pain like in a perf?
sudden
constant
generalized
very severe
99
What is the pain like in an obstruction?
colicky
| radiating
100
How are patients' behavior patterns different in perfs v. obstructions?
Perfs patients do not want to move, obstructions, patients are moving all the time to try to get comfortable
101
How does an acute abdomen caused by an inflammatory process typically present?
gradual onset with slow buildup (commonly 6-12 hours)
102
What is the pain like in an inflammatory process?
Slow buildup
Constant
Ill-defined then localized
Radiating
103
Other than severe abdominal pain, what till you find in ischemic processes of the bowel?
blood in the lumen of the gut
104
What should be suspected in a child with nephrosis + ascites?
primary peritonitis
105
What is unique about the ascitic fluid in primary peritonitis v. acute abdomen?
primary peritonitis will only grow a single organism
106
How do you treat primary peritonitis?
antibiotics
107
What mimics must be ruled out before performing exploratory laparotomy for acute abdomen?
-Primary peritonitis
-MI
-Lower lobe pneumonia
-PE
Pancreatitis
-Urinary stones
108
What should you suspect in an alcoholic who develops "upper" acute abdomen within a couple of hours?
acute pancreatitis
109
What other symptoms are associated with acute pancreatitis?
Constant, epigastric pain radiating through back
Nausea
Vomiting
Retching
110
How do you diagnose acute pancreatitis?
- Serum amylase or lipase (within 12-48 hours)
| - Urinary amylase or lipase (3rd-6th days)
111
What is the diagnostic tool for pancreatitis if symptoms are not clear?
CT
112
What is the treatment of acute pnacreatitis?
NPO
NG suction
IV fluids
113
What is suspected in sudden colicky flank pain radiating to the inner thigh/scrotum (or labia) and microhematuria on UA?
ureteral stones
114
What is the diagnostic test for ureteral stones?
CT
115
What is one of the only inflammatory processes that presents with acute abdominal pain in the LLQ?
acute diverticulitis
116
How do you diagnose acute diverticulitis?
CT
117
How do you treat acute diverticulitis?
NPO
IV fluids
Antibiotics
Radiologically guided percutaneous drainage of abscess + Surgery (if it does not cool down)
118
Which diverticulitis patients are eligible for elective surgery?
patients who have had 2+ attacks
119
What should you suspect in an older patient with signs of intestinal obstruction and severe abdominal distention?
volvulus of the sigmoid colon
120
What is used to diagnose volvulus of sigmoid?
x-ray
121
What is the classic x-ray in sigmoid volvulus?
"parrot's beak" (huge air-filled loop in RUQ that tapers down toward LLQ with the shape of a beak) + air fluid levels in small bowel
122
How do you treat sigmoid volvulus?
proctosigmoidoscopic exam (with rigid instrument, leaving rectal tube in)
123
How do you treat recurrent sigmoid volvulus?
elective sigmoid resection
124
What do you suspect in a patient with a-fib or recent MI who gets acute abdomen?
Mesenteric ischemia (source of clot breaks off and lodges in SMA)
125
If you do catch mesenteric ischemia early enough, what is the diagnosis/treatment?
arteriogram and embolectomy
126
Who gets primary hepatoma (hepatocellular carcinoma) in the USA?
Patients with the following:
cirrhosis
HBV
HCV
127
What is the blood marker for HCC?
alpha-fetoprotein
128
How do you treat HCC?
resection (if technically possible)
129
What is more common in the US, metastatic or primary cancer of the liver?
metastatic CA 20:1
130
Hepatic adenomas are related to what medication?
OCPs
131
Why is emergency surgery required for hepatic adenomas?
they have a tendency to rupture and bleed massively in the abdomen
132
Fever, leukocytosis and a tender liver are symptoms of what condition?
pyogenic liver abscess
133
When do pyogenic liver abscesses usually arise?
as a complication of biliary tract disease (ex. acute ascending cholangitis)
134
How do you treat pyogenic liver abscess?
percutaneous drainage
135
If a man who is a Mexican immigrant has a liver abscess, what should you think of?
amebic liver abscess
136
How do you diagnose amebic liver abscess?
serology (DO NOT wait to treat)
137
How do you treat amebic liver abscesses?
metronidazole (if patient does not improve, may need to drain)
138
What are the 3 types of jaundice?
hemolytic
hepatocellular
obstructive
139
What type of jaundice has a bilirubin of 6 to 8 (low level) that is primarily indirect?
hemolytic
140
True or false: you will find bile in the urine in a patient with hemolytic jaundice.
false
141
What is the most common example of a cause of hepatocellular jaundice?
hepatitis
142
What will lab values look like in hepatocellular jaundice?
- Elevations of direct and indirect bili
- VERY high transaminases
- Modestly elevated alk phos
143
What will lab values look like in obstructive jaundice?
- Elevations of direct and indirect bili
- Modestly elevated transaminases
- VERY high alk phos
144
What is the first step in evaluating a patient with obstructive jaundice?
ultrasound (look for dilation of biliary ducts)
145
What will you expect the gallbladder to look like if the obstruction in obstructive jaundice is due to a stone?
stones located in gallbladder and the gallbladder is shrunken (NOT dilated because it is chronically irritated)
146
What will you expect the gallbladder to look like if the obstruction in obstructive jaundice is due to a malignancy?
large, thin-walled and distended (Courvoisier-Terrier sign)
147
If you suspect obstructive jaundice 2/2 stones (fat, forty, fertile, dilated ducts on US and nondilated gallbladder full of stones), what is the confirmatory diagnostic test?
ERCP
148
What is the treatment for obstructive jaundice 2/2 stones?
ERCP with sphincterotomy and removal of common bile duct stone with cholecystectomy to follow
149
How does ERCP work?
endoscope descends into duodenum, ampulla is cannulated, x-ray dye is injected
150
How do ERCP and MRCP differ clinically?
ERCP requires sedation and NPO for hours before test; MRCP is noninvasive and done in fully awake patient
151
Why do you choose ERCP v MRCP?
MRCP gives better pictures, but you cannot do sphincterotomies, retrieve stones, deploy stents, biopsy tumors, etc with MRCP (ERCP is more therapeutic, MRCP is more diagnostic)
152
What three malignancies can lead to obstructive jaundice?
- Adenocarcinoma of pancreatic head
- Adenocarcinoma of ampulla of Vater
- Cholangiocarcinoma of common duct
153
What is the order of tests that should be taken when you suspect malignancy induced obstructive jaundice?
CT (r/o pancreatic tumor)
| MRCP (shows smaller tumors)
154
How would you biopsy a large pancreatic mass that leads to obstructive jaundice?
CT guided percutaneous biopsy
155
How would you biopsy an adenocarcinoma of the ampulla of Vater?
endoscopic biospy
156
How would you biopsy a ductal neoplasm that leads to obstructive jaundice?
ERCP and brushings
157
What symptoms/signs lead to you to suspect malignant obstructive jaundice specifically caused by ampullary cancers?
if the jaundice coincides with anemia and positive blood in the stools
158
Where can a cholangiocarcinoma arise that makes it virtually inoperable?
within the liver at the bifurcation of the hepatic ducts
159
Where is the stone in biliary colic?
cystic duct
160
How do you treat biliary colic?
elective cholecystectomy
161
What leads to acute cholecystitis?
episode of biliary colic that lasts too long (cystic duct clogged until inflammatory process develops in the obstructed gallbladder)
162
What are the signs of acute cholecytstitis?
Pain becomes constant
Fever
Leukocytosis
RUQ pain (Murphy's sign)
163
What tests may you choose to diagnose acute cholecystitis?
Ultrasound (thick-walled gallbladder and pericholecystic fluid)
May get HIDA scan showing no uptake in gallbladder
164
What is the pre-surgical treatment of acute cholecystitis?
NG suction
NPO
IV fluids
antibiotics
165
What is the emergency option for patients with acute cholecystitis, not responsive to NG, NOP, IVF, and abx who is very sick with prohibitive surgical risk?
emergency percutaneous transhepatic cholecystostomy
166
Where are the stones in acute ascending cholangitis?
common duct (PARTIAL obstruction that allows ascending infection)
167
What is the key finding in acute ascending cholangitis?
extremely high levels of alk phos (will also see fever, chills, WBC indicative of sepsis with hyperbilirubinemia)
168
What is the treatment of choice for acute ascending cholangitis?
IV abx and emergency decompression of common duct (ERCP) followed by cholecystectomy at a later time
169
How else (other than ERCP) can you perform emergency decompression of common duct?
- percutaneous transhepatic cholangiogram
| - surgery (rare)
170
What is going on in biliary pancreatitis?
stones are impacted in the distal ampulla to temporarily block both pancreatic and biliary ducts
171
What is the usual progression of biliary pancreatitis?
stones often pass spontaneously (so you get transient episode of cholangitis with pancreatitis manifestations)
172
What is the treatment for biliary pancreatitis?
Conservative therapy (NPO, NG, IVF) followed by elective cholecystectomy
OR
ERCP + sphincterotomy to dislodge stone
173
List the 3 types of acute pancreatitis?
Edematous
Hemorrhagic
Suppurative (pancreatic abscess)
174
What are late complications of acute pancreatitis?
Pancreatic pseudocyst and chronic pancreatitis
175
Who gets acute edematous pancreatitis?
alcoholics or patients with gallstones
176
What are the symptoms of acute edematous pancreatitis?
```
Epigastric pain
Nausea
Vomiting
Retching
Tenderness and mild rebound
```
177
What are key lab findings in acute edematous pancreatitis?
- Elevated serum amylase or lipase (urine if after a couple of days)
- Elevated hematocrit
178
How do you treat acute edematous pancreatitis?
NPO
NG suction
IVF
179
What lab findings differ between acute edematous v. hemorrhagic pancreatitis?
hemorrhagic pancreatitis will have lower hematocrit and the degree of amylase elevation does not correlate with severity of disease
180
What are some findings in Ranson's criteria for acute hemorrhagic pancreatitis?
At time of presentation:
High WBC count
High blood glucose
Low serum calcium
Next morning:
Even lower Hct
Serum calcium remains low despite replacement
BUN increases
Ultimately:
Metabolic acidosis
Low arterial PO2
181
What leads to death in patients with acute hemorrhagic pancreatitis?
multiple pancreatic abscesses
182
What is the major line of treatment for hemorrhagic pancreatitis?
ICU supportive therapy
Daily CT scans to anticipate pancreatic abscesses
Drainage of pancreatic abscesses
183
What drug is used by some physicians for patients with signs of infected pancreatitis?
IV impenem
184
What is the typical presentation of pancreatic abscess?
fever and leukocytosis 10 days after onset of pancreatitis
185
What is the treatment for pancreatic abscess?
percutaneous radiological drainage
186
What is a necrosectomy and what is it used to treat?
it is a "scooping out" of necrotic pancreas that should be performed after 4 weeks so that the dead tissue is well delineated
187
How much time usually passes between pancreatitis/ pancreatic insult and pancreatic pseudocyst development?
around 5 weeks
188
Where do pancreatic pseudocysts usually develop?
the lesser sac
189
What type of symptoms are associated with pancreatic pseudocysts?
pressure symptoms (early satiety, vague discomfort)
190
When should you observe a pancreatic pseudocyst?
if they are 6cm or smaller or that are present for
191
What are the treatment options for cysts that are >6cm or older than 6 weeks?
Drainage (percutaneous to outside v. surgically into GI tract v. endoscopically into stomach)
192
What are the symptoms of chronic pancreatitis?
steatorrhea
diabetes
constant epigastric pain (cannot be treated)
193
What type of operations may help a sufferer of chronic pancreatitis?
operations to drain pancreatic duct
194
What are the ONLY 2 hernias that shouldn't be repaired?
-Umbilical hernias in patients
195
When do you need to do emergency surgery for a hernia?
if it becomes irreducible
196
Breast cancer favors mets to what organs?
brain and bone
197
Abdominal adenocarcinomas favor mets to what organ?
liver
198
Sarcomas typically go to what organ?
lungs (spread hematogenously)
199
What is the most convenient, effective and inexpensive way to biopsy breast masses?
US guided multiple core biopsies
200
What breast masses are seen in young women and are firm, rubbery masses that move easily with palpation?
fibroadenomas
201
What is the diagnostic tool for a fibroadenoma?
FNA or sonogram
202
When does cystosarcoma phyllodes present?
late 20s (grows over many years)
203
Why do you need to remove cystosarcoma phyllodes?
they get huge and can become malignant sarcomas
204
What do you call b/l tenderness related to menstrual cycle and multiple lumps that come and go following the menstrual cycle?
mammary dysplasia
205
What age does mammary dysplasia usually occur?
30s and 40s
206
How do you work up mammary dysplasia with a mass?
aspiration with formal biopsy if mass persists/recurs
207
What should you suspect if a woman in her 20s-40s has bloody nipple discharge?
intraductal papilloma
208
What is the workup for suspected intraductal papilloma?
mammogram with f/u galactogram
209
What is the workup for suspected intraductal papilloma?
mammogram with f/u galactogram
210
What should be a part of incision and drainage process for breast abscesses?
biopsy of abscess wall
211
How does treatment of breast cancer differ in pregnant v. nonpregnant women?
- NO radiotherapy in pregnancy
- NO hormonal manipulations in pregnancy
- NO chemo in 1st trimester
212
What is unique about lobular breast cancer?
it has a higher incidence of bilaterality
213
How should you treat DCIS?
Total simple mamstectomy v. lumpectomy + radiation if confined to 1/4 of the breast
214
What hormonal therapy is given to premenopausal women?
tamoxifen
215
What hormonal therapy is given to postmenopausal women?
anastrozole
216
What are the most common location to find breast cancer mets in the bone?
vertebral pedicles of spine
217
What is used to evaluate thyroid nodules?
FNA
218
What type of thyroid cancer cannot be evaluated by FNA?
follicular (need lobectomy or larger biopsy to see if it is adenoma or malignant)
219
What is the treatment for follicular cancer of the thyroid?
total thyroidectomy
220
Where does medullary thyroid cancer originate?
C cells of thyroid
221
What do thyroid C cells produce?
calcitonin
222
Medullary thyroid cancer is associated with what syndrome?
MEN2 (look for pheo)
223
Who gets anaplastic thyroid cancer?
elderly
224
What is the classic presentation of hyperparathyroidism?
stones, bones and abdominal groans (hypercalcemia)
225
What is used to identify the parathyroid gland with an adenoma before surgery?
sestamibi scan
226
What is the initial workup for Cushing syndrome?
low-dose dexamethasone suppression test
227
If there is no suppression with low-dose dexamethasone suppression test, what is your next step?
24 hour urine free cortisol
228
If 24-hour urine free cortisol is elevated after no suppression with low-dose dexamethasone suppression test, what is your next step?
high-dose dexamethasone suppression test
229
If there is suppression at high doses with dexamethasone, what is your diagnosis?
pituitary microadenoma
230
If there is no suppression at high doses with dexamethasone, what is your diagnosis?
adrenal adenoma v. paraneoplastic syndrome
231
What should you think of in a patient with ulcers that extend beyond the first part of the duodenum and virulent PUD?
Zollinger-Ellison syndrome
232
What is the culprit in ZE syndrome?
gastrinoma
233
How do you work up a gastrinoma?
- Labs: gastrin and secretin
| - CT with contrast
234
Where are insulinomas located?
pancreas
235
If you suspect hypoglycemia 2/2 self administration but the c-peptide levels are wnl, what should you check for?
levels of sulfonylureas (induce endogenous insulin secretion)
236
What is nesidioblastosis?
hypersecretion of insulin in the newborn
237
How do you treat nesidioblastosis?
95% pancreatectomy
238
What should you suspect if a patient has severe migratory necrolytic dermatitis, mild diabetes, anemia, glossitis and stomatitis?
glucagonoma
239
How do you diagnose glucagonoma?
glucagon assay with CT to locate tumor
240
What drugs may help patients with inoperable glucagonomas?
somatostatin and streptozocin
241
What should you think of in a patient with hypokalemia and hypertension?
primary hyperaldo (be sure to ask about diuretics)
242
What other lab anomalies are seen with primary hyperaldo?
modest hyperNa and metabolic alkalosis
243
If you have higher aldo when upright than lying back, do you have hyperplasia or adenoma?
hyperplasia (this is the normal response and is not seen in adenomas)
244
What are the signs of pheochromocytoma?
Pounding HA
Perspiration
Palpitations
Pallor
245
How do you work up a possible pheo?
24-hour urine VMA, metanephrines or free uriary catecholamines
246
What is the pretreatment for pheos?
alpha-blockers
247
What should you suspect in a young patient with HTN of the upper extremities but normal BP in the lower extremities?
coarctation of aorta
248
What do you expect to see on CXR in a patient with coarctation of aorta?
scalloping of ribs from large collateral intercostals
249
What is the diagnostic tool for coarctation of the aorta?
spiral CT with IV dye (CT angio)
250
What are the 2 things to suspect in a hypertensive patient with faint bruit over flank or upper abdomen?
renovascular HTN:
- Fibromuscular dysplasia (young woman)
- Arteriosclerotic occlusive disease (old men)
251
What are diagnostic tools for renovascular HTN?
Duplex scanning of renal vessels
| CT angiogram
252
How do you treat fibromuscular dysplasia?
balloon dilatation and stenting
