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Surgery > Pestana- 4. General Surgery > Flashcards

Pestana- 4. General Surgery Flashcards

1
Q

What is the best way of diagnosing GERD when the diagnosis is uncertain?

A

pH monitoring

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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

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3
Q

What is the treatment for a patient with GERD and severe dysplastic changes?

A
  • Medical therapy
  • Radiofrequency Ablation
  • Nissen fundoplication
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4
Q

What is the first line study for suspected esophageal motility problems?

A

Barium swallow

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5
Q

What provides a definitive diagnosis in a patient with suspected esophageal motility problems?

A

manometry

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6
Q

What is the typical symptom of achlasia?

A

dysphagia that is worse for liquids (needing to sit up straight after swallowing drink)

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7
Q

What is seen on x-ray with achlasia?

A

megaesophagus

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8
Q

What is the diagnostic tool for achlasia?

A

manometry

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9
Q

What is the most appealing current treatment for achlasia?

A

balloon dilatation by endoscopy

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10
Q

What is the typical symptom of esophageal cancer?

A

progression of dysphagia (meats–> other solids –> liquids –> saliva)

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11
Q

What is the typical esophageal cancer in a alcoholic black man who smokes?

A

squamous cell carcinoma

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12
Q

What is the typical esophageal cancer in a patient with long-standing GERD?

A

adenocarcinoma

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13
Q

How do you diagnose esophageal cancer?

A

1) Barium swallow

2) Endoscopy + biopsies

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14
Q

Is surgery for esophageal CA usually palliative or curative?

A

palliative

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15
Q

How do you diagnose Mallory-Weiss tear?

A

endoscopy

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16
Q

How do you treat Mallory-Weiss tears?

A

photocoagulation (during diagnostic endoscopy)

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17
Q

What is esophageal perforation after prolonged, forceful vomiting?

A

Boerhaave syndrome

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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)

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19
Q

How do you diagnose Boerhaave syndrome?

A

Contrast swallow (Gastrografin first, barium if negative)

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20
Q

What is the most common reason for esophageal perforation?

A

instrumental perforation of the esophagus (shortly after completion of endoscopy)

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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

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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

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23
Q

How do you treat low-grade lymphomatoid transformation (MALTOMA)?

A

eradication of H. pylori

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24
Q

What is the most common cause of mechanical intestinal obstruction?

A

adhesions in those who have had a prior laparotomy

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25
Q

What are symptoms of a mechanical intestinal obstruction?

A
  • 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
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26
Q

What does x-ray of a mechanical intestinal obstruction show?

A

distended loops of small bowel with air-fluid levels

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27
Q

What is the initial treatment for a patient with a mechanical intestinal obstruction?

A
  • NPO
  • NG suction
  • IV fluids
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28
Q

When do you do surgery for a mechanical intestinal obstruction?

A
  • If conservative management is unsuccessful
  • Within 24 hours in cases of complete obstruction
  • Within a few days in cases of partial obstruction
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29
Q

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?

A

strangulated obstruction

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30
Q

Other than adhesions, what is another cause of mechanical intestinal obstruction?

A

incarcerated hernia (irreducible)

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31
Q

What is carcinoid syndrome?

A

a patient who has a small bowel carcinoid tumor with liver mets

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32
Q

What are the associated symptoms of carcinoid syndrome?

A
  • Diarrhea
  • Facial flushing
  • Wheezing
  • Right sided heart valve damage (high JVP)
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33
Q

What is the diagnosis of carcinoid syndrome?

A

24 hour urinary collection for 5-hydroxyindoleacetic acid

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34
Q

Why do you need to do 24 hour urinary collection for 5-hydroxyindoleacetic acid to diagnose carcinoid syndrome?

A

the 5-hydroxyindoleacetic acid will only be high during an episodic attack or spell, so blood samples after attack will be normal

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35
Q

What is the typical initial symptom of acute appendicitis?

A

anorexia

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36
Q

How severe is the leukocytosis seen in acute appendicitis?

A

10,000-15,000 range with neutrophilia and immature forms

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37
Q

How do you diagnose acute appendicitis?

A

CT scan

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38
Q

What type of colon cancer shows up as an elderly patient with hypochromic, iron deficiency anemia (and 4+ occult blood in stool)?

A

right colon cancer

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39
Q

What is the diagnostic tool used for right colon cancer?

A

colonoscopy and biopsies

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40
Q

What is the treatment of choice for right colon cancer?

A

right hemicolectomy

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41
Q

What is the typical presentation of left colon cancer?

A

bloody bowel movements with narrow-caliber stool or constipation (this side of the colon is more narrow)

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42
Q

What is the primary diagnostic tool if you suspect left colon cancer?

A

flexible proctosigmoidoscopic exam (45 or 60cm)

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43
Q

What must be done before surgery for left sided colon cancer?

A

full colonoscopy (to r/o synchronous second primary)

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44
Q

What may be necessary if patient has a large rectal cancer?

A

re-op chemotherapy and radiation

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45
Q

Is an isolated inflammatory polyp premalignant?

A

NO

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46
Q

Is an adenomatous polyp premalignant?

A

YES

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47
Q

Is a hyperplastic polyp premalignant?

A

NO

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48
Q

Which can be cured with surgery: Crohn’s disease or CUC?

A

CUC

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49
Q

Why do you typically want to avoid surgically curing a patient of CUC?

A

surgical cure requires removal of the rectal mucosa (would need stoma or ileoanal anastomosis)

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50
Q

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?

A

toxic megacolon

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51
Q

What are the indications for surgery in CUC?

A
  • Active disease for >20 years (malignant degeneration)
  • Severe nutritional depletion
  • Multiple hospitalizations
  • Need for high dose steroids or immunosuppressants
  • Development of toxic megacolon
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52
Q

What are the indications for surgery in Crohn’s?

A

ONLY when there are complications (bleeding, stricture, fistulization)

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53
Q

What causes pseudomembranous enterocolitis?

A

overgrowth of C. difficile in patients who have been on antibiotics

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54
Q

Which class of antibiotics is currently most associated with pseudomembranous enterocolitis?

A

cephalosporins

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55
Q

How do you make the diagnosis of pseudomembranous enterocolitis?

A
  • C. diff toxin identification in stool

- Endoscopy

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56
Q

How do you treat pseudomembranous enterocolitis?

A
  • Discontinue antibiotic

- Metronidazole (vanc is alternative)

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57
Q

When is emergency colectomy warranted in pseudomembranous enterocolitis?

A
  • Disease unresponsive to treatment
  • WBC >50,000
  • Serum lactate >5
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58
Q

What new therapy is showing promise for treatment of c. difficile overgrowth/ pseudomembranous enterocolitis?

A

fecal enema

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59
Q

How do you treat internal hemorrhoids?

A

rubber band ligation

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60
Q

Who typically gets anal fissures?

A

young women

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61
Q

Where are anal fissures typically located?

A

posterior and midline

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62
Q

What is therapy for anal fissures aimed at doing?

A

relaxing a tight anal sphincter

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63
Q

What are the treatment modalities for relaxing tight anal sphincters (to treat anal fissures)?

A
  • Stool softeners
  • Topical nitroglycerin
  • CCB ointment (ex. diltiazem)
  • Local injection of botox
  • Forceful dilatation?!?!
  • Lateral internal sphincterotomy
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64
Q

How do you treat a Crohn’s fistula at the anus?

A

drainage with setons + remicade

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65
Q

What should be suspected in a febrile patient with exquisite perirectal pain that does not let him sit down to have bowel movements?

A

ischiorectal abscess

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66
Q

Where are ischiorectal abscesses usually located?

A

lateral to the anus (between the rectum and the ischial tuberosity)

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67
Q

How do you treat a patient with a ischiorectal abscess?

A

incision and drainage

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68
Q

What do you worry about in a diabetic patient with an ischiorectal abscess?

A

necrotizing soft tissue infection

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69
Q

When do fistula-in-ano develop?

A

in patients who have ischiorectal abscesses drained (tract forms between anal crypt where abscess originated and perineal skin where drainage was done)

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70
Q

What are the symptoms of fistula-in-ano?

A
  • fecal soiling

- occasional perineal discomfort

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71
Q

What does the physical exam of a patient with fistula-in-ano show?

A
  • Opening lateral to anus
  • Cordlike tract palpable
  • Discharge may be expressed
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72
Q

How do you treat fistula-in-ano?

A

fistulotomy (after ruling out tumor)

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73
Q

Who typically gets squamous cell carcinoma of the anus?

A

HIV+

Homosexuals with receptive sexual practices

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74
Q

What does squamous cell carcinoma of the anus look like?

A

fungating mass growing out of the anus

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75
Q

What is the treatment for squamous cell carcinoma of the anus?

A
  • NIgro chemoradiation protocol (5 weeks)

- Surgery (if there is residual tumor)

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76
Q

Is surgery typically required for squamous cell carcinoma of the anus?

A

NO- 90% cure rate with chemoradiation

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77
Q

What percentage of GI bleeds are upper?

A

75%

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78
Q

What is the division between upper and lower GI?

A

ligament of Treitz

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79
Q

If a GI bleed is “lower”, where is it most likely from?

A

colon or rectum

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80
Q

If a young patient has a GI bleed, is it more likely upper or lower?

A

upper

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81
Q

Vomiting blood suggests what?

A

upper GI bleed

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82
Q

What do you do if someone is vomiting blood?

A

NG tube

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83
Q

What is the next step after NG tube in patient who is vomiting blood?

A

upper GI endoscopy

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84
Q

What should the workup of a patient with melena begin with?

A

upper GI endoscopy

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85
Q

True or false: red blood per rectum is always lower GI bleed.

A

false, can be upper GI with fast transit

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86
Q

What is the first step in management of patient who is actively bleeding per rectum?

A

NG tube with aspiration of gastric contents

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87
Q

What NG tube result rules out upper GI bleed completely (so no need for upper GI endoscopy)?

A

no blood with bile-tinged (green) fluid

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88
Q

What are the 3 ways to tackle a lower GI bleed (after hemorrhoids are ruled out)?

A
  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)
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89
Q

What is the method often used to locate a GI bleed in the small bowel?

A

capsule endoscopy

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90
Q

How do you treat an older patient with h/o blood per rectum (but is now stable and not actively bleeding)?

A

upper + lower GI endoscopy

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91
Q

Blood per rectum in a child is most likely what?

A

Meckel diverticulum

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92
Q

What do you do to workup a suspected Meckel diverticulum?

A

technetium scan (look for ectopic gastric mucosa)

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93
Q

How do you avoid stress ulcers after major trauma?

A

keeping gastric pH >4

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94
Q

What is the best therapeutic option for massive upper GI bleed 2/2 stress ulcers?

A

angiographic embolization

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95
Q

What are the four main categories of acute abdominal pain causes?

A
  • Perforation
  • Obstruction
  • Inflammatory processes
  • Ischemic processes
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96
Q

What can confirm the diagnosis of perforation?

A

free air under diaphragm in upright x-ray

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97
Q

List the generalized signs of peritoneal irritation found in perforations.

A

Tenderness
Muscle guarding
Rebound
Silent abdomen

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98
Q

What is the pain like in a perf?

A

sudden
constant
generalized
very severe

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99
Q

What is the pain like in an obstruction?

A

colicky

radiating

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100
Q

How are patients’ behavior patterns different in perfs v. obstructions?

A

Perfs patients do not want to move, obstructions, patients are moving all the time to try to get comfortable

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101
Q

How does an acute abdomen caused by an inflammatory process typically present?

A

gradual onset with slow buildup (commonly 6-12 hours)

102
Q

What is the pain like in an inflammatory process?

A

Slow buildup
Constant
Ill-defined then localized
Radiating

103
Q

Other than severe abdominal pain, what till you find in ischemic processes of the bowel?

A

blood in the lumen of the gut

104
Q

What should be suspected in a child with nephrosis + ascites?

A

primary peritonitis

105
Q

What is unique about the ascitic fluid in primary peritonitis v. acute abdomen?

A

primary peritonitis will only grow a single organism

106
Q

How do you treat primary peritonitis?

A

antibiotics

107
Q

What mimics must be ruled out before performing exploratory laparotomy for acute abdomen?

A

-Primary peritonitis
-MI
-Lower lobe pneumonia
-PE
Pancreatitis
-Urinary stones

108
Q

What should you suspect in an alcoholic who develops “upper” acute abdomen within a couple of hours?

A

acute pancreatitis

109
Q

What other symptoms are associated with acute pancreatitis?

A

Constant, epigastric pain radiating through back
Nausea
Vomiting
Retching

110
Q

How do you diagnose acute pancreatitis?

A
  • Serum amylase or lipase (within 12-48 hours)

- Urinary amylase or lipase (3rd-6th days)

111
Q

What is the diagnostic tool for pancreatitis if symptoms are not clear?

112
Q

What is the treatment of acute pnacreatitis?

A

NPO
NG suction
IV fluids

113
Q

What is suspected in sudden colicky flank pain radiating to the inner thigh/scrotum (or labia) and microhematuria on UA?

A

ureteral stones

114
Q

What is the diagnostic test for ureteral stones?

115
Q

What is one of the only inflammatory processes that presents with acute abdominal pain in the LLQ?

A

acute diverticulitis

116
Q

How do you diagnose acute diverticulitis?

117
Q

How do you treat acute diverticulitis?

A

NPO
IV fluids
Antibiotics
Radiologically guided percutaneous drainage of abscess + Surgery (if it does not cool down)

118
Q

Which diverticulitis patients are eligible for elective surgery?

A

patients who have had 2+ attacks

119
Q

What should you suspect in an older patient with signs of intestinal obstruction and severe abdominal distention?

A

volvulus of the sigmoid colon

120
Q

What is used to diagnose volvulus of sigmoid?

121
Q

What is the classic x-ray in sigmoid volvulus?

A

“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
Q

How do you treat sigmoid volvulus?

A

proctosigmoidoscopic exam (with rigid instrument, leaving rectal tube in)

123
Q

How do you treat recurrent sigmoid volvulus?

A

elective sigmoid resection

124
Q

What do you suspect in a patient with a-fib or recent MI who gets acute abdomen?

A

Mesenteric ischemia (source of clot breaks off and lodges in SMA)

125
Q

If you do catch mesenteric ischemia early enough, what is the diagnosis/treatment?

A

arteriogram and embolectomy

126
Q

Who gets primary hepatoma (hepatocellular carcinoma) in the USA?

A

Patients with the following:
cirrhosis
HBV
HCV

127
Q

What is the blood marker for HCC?

A

alpha-fetoprotein

128
Q

How do you treat HCC?

A

resection (if technically possible)

129
Q

What is more common in the US, metastatic or primary cancer of the liver?

A

metastatic CA 20:1

130
Q

Hepatic adenomas are related to what medication?

131
Q

Why is emergency surgery required for hepatic adenomas?

A

they have a tendency to rupture and bleed massively in the abdomen

132
Q

Fever, leukocytosis and a tender liver are symptoms of what condition?

A

pyogenic liver abscess

133
Q

When do pyogenic liver abscesses usually arise?

A

as a complication of biliary tract disease (ex. acute ascending cholangitis)

134
Q

How do you treat pyogenic liver abscess?

A

percutaneous drainage

135
Q

If a man who is a Mexican immigrant has a liver abscess, what should you think of?

A

amebic liver abscess

136
Q

How do you diagnose amebic liver abscess?

A

serology (DO NOT wait to treat)

137
Q

How do you treat amebic liver abscesses?

A

metronidazole (if patient does not improve, may need to drain)

138
Q

What are the 3 types of jaundice?

A

hemolytic
hepatocellular
obstructive

139
Q

What type of jaundice has a bilirubin of 6 to 8 (low level) that is primarily indirect?

140
Q

True or false: you will find bile in the urine in a patient with hemolytic jaundice.

141
Q

What is the most common example of a cause of hepatocellular jaundice?

142
Q

What will lab values look like in hepatocellular jaundice?

A
  • Elevations of direct and indirect bili
  • VERY high transaminases
  • Modestly elevated alk phos
143
Q

What will lab values look like in obstructive jaundice?

A
  • Elevations of direct and indirect bili
  • Modestly elevated transaminases
  • VERY high alk phos
144
Q

What is the first step in evaluating a patient with obstructive jaundice?

A

ultrasound (look for dilation of biliary ducts)

145
Q

What will you expect the gallbladder to look like if the obstruction in obstructive jaundice is due to a stone?

A

stones located in gallbladder and the gallbladder is shrunken (NOT dilated because it is chronically irritated)

146
Q

What will you expect the gallbladder to look like if the obstruction in obstructive jaundice is due to a malignancy?

A

large, thin-walled and distended (Courvoisier-Terrier sign)

147
Q

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?

148
Q

What is the treatment for obstructive jaundice 2/2 stones?

A

ERCP with sphincterotomy and removal of common bile duct stone with cholecystectomy to follow

149
Q

How does ERCP work?

A

endoscope descends into duodenum, ampulla is cannulated, x-ray dye is injected

150
Q

How do ERCP and MRCP differ clinically?

A

ERCP requires sedation and NPO for hours before test; MRCP is noninvasive and done in fully awake patient

151
Q

Why do you choose ERCP v MRCP?

A

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
Q

What three malignancies can lead to obstructive jaundice?

A
  • Adenocarcinoma of pancreatic head
  • Adenocarcinoma of ampulla of Vater
  • Cholangiocarcinoma of common duct
153
Q

What is the order of tests that should be taken when you suspect malignancy induced obstructive jaundice?

A

CT (r/o pancreatic tumor)

MRCP (shows smaller tumors)

154
Q

How would you biopsy a large pancreatic mass that leads to obstructive jaundice?

A

CT guided percutaneous biopsy

155
Q

How would you biopsy an adenocarcinoma of the ampulla of Vater?

A

endoscopic biospy

156
Q

How would you biopsy a ductal neoplasm that leads to obstructive jaundice?

A

ERCP and brushings

157
Q

What symptoms/signs lead to you to suspect malignant obstructive jaundice specifically caused by ampullary cancers?

A

if the jaundice coincides with anemia and positive blood in the stools

158
Q

Where can a cholangiocarcinoma arise that makes it virtually inoperable?

A

within the liver at the bifurcation of the hepatic ducts

159
Q

Where is the stone in biliary colic?

A

cystic duct

160
Q

How do you treat biliary colic?

A

elective cholecystectomy

161
Q

What leads to acute cholecystitis?

A

episode of biliary colic that lasts too long (cystic duct clogged until inflammatory process develops in the obstructed gallbladder)

162
Q

What are the signs of acute cholecytstitis?

A

Pain becomes constant
Fever
Leukocytosis
RUQ pain (Murphy’s sign)

163
Q

What tests may you choose to diagnose acute cholecystitis?

A

Ultrasound (thick-walled gallbladder and pericholecystic fluid)

May get HIDA scan showing no uptake in gallbladder

164
Q

What is the pre-surgical treatment of acute cholecystitis?

A

NG suction
NPO
IV fluids
antibiotics

165
Q

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?

A

emergency percutaneous transhepatic cholecystostomy

166
Q

Where are the stones in acute ascending cholangitis?

A

common duct (PARTIAL obstruction that allows ascending infection)

167
Q

What is the key finding in acute ascending cholangitis?

A

extremely high levels of alk phos (will also see fever, chills, WBC indicative of sepsis with hyperbilirubinemia)

168
Q

What is the treatment of choice for acute ascending cholangitis?

A

IV abx and emergency decompression of common duct (ERCP) followed by cholecystectomy at a later time

169
Q

How else (other than ERCP) can you perform emergency decompression of common duct?

A
  • percutaneous transhepatic cholangiogram

- surgery (rare)

170
Q

What is going on in biliary pancreatitis?

A

stones are impacted in the distal ampulla to temporarily block both pancreatic and biliary ducts

171
Q

What is the usual progression of biliary pancreatitis?

A

stones often pass spontaneously (so you get transient episode of cholangitis with pancreatitis manifestations)

172
Q

What is the treatment for biliary pancreatitis?

A

Conservative therapy (NPO, NG, IVF) followed by elective cholecystectomy
OR
ERCP + sphincterotomy to dislodge stone

173
Q

List the 3 types of acute pancreatitis?

A

Edematous
Hemorrhagic
Suppurative (pancreatic abscess)

174
Q

What are late complications of acute pancreatitis?

A

Pancreatic pseudocyst and chronic pancreatitis

175
Q

Who gets acute edematous pancreatitis?

A

alcoholics or patients with gallstones

176
Q

What are the symptoms of acute edematous pancreatitis?

A 
Epigastric pain
Nausea
Vomiting
Retching
Tenderness and mild rebound
177
Q

What are key lab findings in acute edematous pancreatitis?

A
  • Elevated serum amylase or lipase (urine if after a couple of days)
  • Elevated hematocrit
178
Q

How do you treat acute edematous pancreatitis?

A

NPO
NG suction
IVF

179
Q

What lab findings differ between acute edematous v. hemorrhagic pancreatitis?

A

hemorrhagic pancreatitis will have lower hematocrit and the degree of amylase elevation does not correlate with severity of disease

180
Q

What are some findings in Ranson’s criteria for acute hemorrhagic pancreatitis?

A

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
Q

What leads to death in patients with acute hemorrhagic pancreatitis?

A

multiple pancreatic abscesses

182
Q

What is the major line of treatment for hemorrhagic pancreatitis?

A

ICU supportive therapy
Daily CT scans to anticipate pancreatic abscesses
Drainage of pancreatic abscesses

183
Q

What drug is used by some physicians for patients with signs of infected pancreatitis?

A

IV impenem

184
Q

What is the typical presentation of pancreatic abscess?

A

fever and leukocytosis 10 days after onset of pancreatitis

185
Q

What is the treatment for pancreatic abscess?

A

percutaneous radiological drainage

186
Q

What is a necrosectomy and what is it used to treat?

A

it is a “scooping out” of necrotic pancreas that should be performed after 4 weeks so that the dead tissue is well delineated

187
Q

How much time usually passes between pancreatitis/ pancreatic insult and pancreatic pseudocyst development?

A

around 5 weeks

188
Q

Where do pancreatic pseudocysts usually develop?

A

the lesser sac

189
Q

What type of symptoms are associated with pancreatic pseudocysts?

A

pressure symptoms (early satiety, vague discomfort)

190
Q

When should you observe a pancreatic pseudocyst?

A

if they are 6cm or smaller or that are present for

191
Q

What are the treatment options for cysts that are >6cm or older than 6 weeks?

A

Drainage (percutaneous to outside v. surgically into GI tract v. endoscopically into stomach)

192
Q

What are the symptoms of chronic pancreatitis?

A

steatorrhea
diabetes
constant epigastric pain (cannot be treated)

193
Q

What type of operations may help a sufferer of chronic pancreatitis?

A

operations to drain pancreatic duct

194
Q

What are the ONLY 2 hernias that shouldn’t be repaired?

A

-Umbilical hernias in patients

195
Q

When do you need to do emergency surgery for a hernia?

A

if it becomes irreducible

196
Q

Breast cancer favors mets to what organs?

A

brain and bone

197
Q

Abdominal adenocarcinomas favor mets to what organ?

198
Q

Sarcomas typically go to what organ?

A

lungs (spread hematogenously)

199
Q

What is the most convenient, effective and inexpensive way to biopsy breast masses?

A

US guided multiple core biopsies

200
Q

What breast masses are seen in young women and are firm, rubbery masses that move easily with palpation?

A

fibroadenomas

201
Q

What is the diagnostic tool for a fibroadenoma?

A

FNA or sonogram

202
Q

When does cystosarcoma phyllodes present?

A

late 20s (grows over many years)

203
Q

Why do you need to remove cystosarcoma phyllodes?

A

they get huge and can become malignant sarcomas

204
Q

What do you call b/l tenderness related to menstrual cycle and multiple lumps that come and go following the menstrual cycle?

A

mammary dysplasia

205
Q

What age does mammary dysplasia usually occur?

A

30s and 40s

206
Q

How do you work up mammary dysplasia with a mass?

A

aspiration with formal biopsy if mass persists/recurs

207
Q

What should you suspect if a woman in her 20s-40s has bloody nipple discharge?

A

intraductal papilloma

208
Q

What is the workup for suspected intraductal papilloma?

A

mammogram with f/u galactogram

209
Q

What is the workup for suspected intraductal papilloma?

A

mammogram with f/u galactogram

210
Q

What should be a part of incision and drainage process for breast abscesses?

A

biopsy of abscess wall

211
Q

How does treatment of breast cancer differ in pregnant v. nonpregnant women?

A
  • NO radiotherapy in pregnancy
  • NO hormonal manipulations in pregnancy
  • NO chemo in 1st trimester
212
Q

What is unique about lobular breast cancer?

A

it has a higher incidence of bilaterality

213
Q

How should you treat DCIS?

A

Total simple mamstectomy v. lumpectomy + radiation if confined to 1/4 of the breast

214
Q

What hormonal therapy is given to premenopausal women?

215
Q

What hormonal therapy is given to postmenopausal women?

A

anastrozole

216
Q

What are the most common location to find breast cancer mets in the bone?

A

vertebral pedicles of spine

217
Q

What is used to evaluate thyroid nodules?

218
Q

What type of thyroid cancer cannot be evaluated by FNA?

A

follicular (need lobectomy or larger biopsy to see if it is adenoma or malignant)

219
Q

What is the treatment for follicular cancer of the thyroid?

A

total thyroidectomy

220
Q

Where does medullary thyroid cancer originate?

A

C cells of thyroid

221
Q

What do thyroid C cells produce?

A

calcitonin

222
Q

Medullary thyroid cancer is associated with what syndrome?

A

MEN2 (look for pheo)

223
Q

Who gets anaplastic thyroid cancer?

224
Q

What is the classic presentation of hyperparathyroidism?

A

stones, bones and abdominal groans (hypercalcemia)

225
Q

What is used to identify the parathyroid gland with an adenoma before surgery?

A

sestamibi scan

226
Q

What is the initial workup for Cushing syndrome?

A

low-dose dexamethasone suppression test

227
Q

If there is no suppression with low-dose dexamethasone suppression test, what is your next step?

A

24 hour urine free cortisol

228
Q

If 24-hour urine free cortisol is elevated after no suppression with low-dose dexamethasone suppression test, what is your next step?

A

high-dose dexamethasone suppression test

229
Q

If there is suppression at high doses with dexamethasone, what is your diagnosis?

A

pituitary microadenoma

230
Q

If there is no suppression at high doses with dexamethasone, what is your diagnosis?

A

adrenal adenoma v. paraneoplastic syndrome

231
Q

What should you think of in a patient with ulcers that extend beyond the first part of the duodenum and virulent PUD?

A

Zollinger-Ellison syndrome

232
Q

What is the culprit in ZE syndrome?

A

gastrinoma

233
Q

How do you work up a gastrinoma?

A
  • Labs: gastrin and secretin

- CT with contrast

234
Q

Where are insulinomas located?

235
Q

If you suspect hypoglycemia 2/2 self administration but the c-peptide levels are wnl, what should you check for?

A

levels of sulfonylureas (induce endogenous insulin secretion)

236
Q

What is nesidioblastosis?

A

hypersecretion of insulin in the newborn

237
Q

How do you treat nesidioblastosis?

A

95% pancreatectomy

238
Q

What should you suspect if a patient has severe migratory necrolytic dermatitis, mild diabetes, anemia, glossitis and stomatitis?

A

glucagonoma

239
Q

How do you diagnose glucagonoma?

A

glucagon assay with CT to locate tumor

240
Q

What drugs may help patients with inoperable glucagonomas?

A

somatostatin and streptozocin

241
Q

What should you think of in a patient with hypokalemia and hypertension?

A

primary hyperaldo (be sure to ask about diuretics)

242
Q

What other lab anomalies are seen with primary hyperaldo?

A

modest hyperNa and metabolic alkalosis

243
Q

If you have higher aldo when upright than lying back, do you have hyperplasia or adenoma?

A

hyperplasia (this is the normal response and is not seen in adenomas)

244
Q

What are the signs of pheochromocytoma?

A

Pounding HA
Perspiration
Palpitations
Pallor

245
Q

How do you work up a possible pheo?

A

24-hour urine VMA, metanephrines or free uriary catecholamines

246
Q

What is the pretreatment for pheos?

A

alpha-blockers

247
Q

What should you suspect in a young patient with HTN of the upper extremities but normal BP in the lower extremities?

A

coarctation of aorta

248
Q

What do you expect to see on CXR in a patient with coarctation of aorta?

A

scalloping of ribs from large collateral intercostals

249
Q

What is the diagnostic tool for coarctation of the aorta?

A

spiral CT with IV dye (CT angio)

250
Q

What are the 2 things to suspect in a hypertensive patient with faint bruit over flank or upper abdomen?

A

renovascular HTN:

  • Fibromuscular dysplasia (young woman)
  • Arteriosclerotic occlusive disease (old men)
251
Q

What are diagnostic tools for renovascular HTN?

A

Duplex scanning of renal vessels

CT angiogram

252
Q

How do you treat fibromuscular dysplasia?

A

balloon dilatation and stenting

Surgery (13 decks)

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