Pestana Chap 4 - General Surgery

Question 1

When the diagnosis of GERD is uncertain, what test should be done?

Answer 1

pH monitoring is best to establish the presence of reflux and its correlation with the symptoms

Question 2

What is the typical case of GERD?

Answer 2

An overweight individual that complains of burning retrosternal pain and “heartburn” that is brought about by bending over, wearing tight clothing, or lying flat in bed at night; and relieved by the ingestion of antacids or OTC H2 blockers

Question 3

What is the concern with longstanding GERD?

Answer 3

The concern is the damage that might have been done to the lower esophagus (peptic esophagitis) and the possible development of Barrett esophagus

Question 4

What is the indicated test for longstanding GERD?

Answer 4

Indicated tests:

1) Endoscopy
2) Biopsies

Question 5

When is surgery appropriate for GERD? When is surgery necessary for GERD? When is surgery imperative for GERD?

Answer 5

Surgery for GERD:

1) Is appropriate for longstanding symptomatic disease that cannot be controlled by medical means
2) Is necessary in anyone who has developed complications (ulceration, stenosis)
3) Is imperative if there are severe dysplastic changes

Question 6

What is the usual surgical procedure for GERD? How is it performed? What should be added to Nissen if severe dysplastic changes are present?

Answer 6

1) Laparoscopic Nissen fundoplication
2) In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, all the way 360 degrees around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm
3) Radiofrequency ablation should be added to Nissen if severe dysplastic changes are present

Question 7

What are two common recognizable clinical patterns found with esophageal motility problems?

Answer 7

1) Crushing pain with swallowing in uncoordinated massive contraction
2) Suggestive pattern of dysphagia seen in achalasia, where solids are swallowed with less difficulty than liquids

Question 8

What is the first test done for an esophageal motility problem? What is the test for definitive diagnosis?

Answer 8

1) Barium swallow is typically done first

2) Manometry studies are used for the definitive diagnosis

Question 9

Is achalasia more common in men or in women?

Answer 9

Achalsia is seen more commonly in women

Question 10

What are common clinical pearls of achalasia?

Answer 10

1) There is dysphagia that is worse for liquids
2) The patient eventually learns that sitting up straight and waiting allows the weight of the column of liquid to overcome the sphincter
3) There is occasional regurgitation of undigested food

Question 11

In a patient with achalasia, what will be seen on X-rays?

Answer 11

Megaesophagus

Question 12

What is the diagnostic test for achalasia?

Answer 12

Manometry is diagnostic

Question 13

What is the most appealing current treatment for achalasia?

Answer 13

The most appealing current treatment is balloon dilitation done by endoscopy

Question 14

What is the classic clinical presentation of cancer of the esophagus?

Answer 14

1) There is a classic progression of dysphagia starting with meat, then other solids, then soft foods, eventually liquids, and finally (in several months) saliva
2) Significant weight loss is always seen

Question 15

Who most commonly develops squamous cell carcinoma of the esophagus?

Answer 15

Squamous cell carcinoma of the esophagus is seen in men with a history of smoking and drinking (blacks have high incidence)

Question 16

Who most commonly develops adenocarcinoma of the esophagus?

Answer 16

Adenocarcinoma of the esophagus is seen in people with long-standing gastroesophageal reflux

Question 17

What diagnostic test establishes the diagnosis of cancer of the esophagus? What must precede this test to help prevent inadvertent perforation of the esophagus?

Answer 17

Diagnosis for both squamous cell and adenocarcinoma of the esophagus is established with endoscopy and biopsies, but barium swallow must precede the endoscopy to help prevent inadvertent perforation

Question 18

What is the function of performing a CT scan in patients with esophageal cancer? What is the function of surgery in esophageal cancer?

Answer 18

1) CT scan assesses operability of the esophagus

2) Most cases can only get palliative (rather than curative) surgery

Question 19

When does a Mallory-Weiss tear occur? What is a sign of a Mallory-Weiss tear?

Answer 19

1) Mallory-Weiss tear occurs after prolonged, forceful vomiting
2) Eventually, bright red blood comes up

Question 20

How is a Mallory-Weiss tear diagnosed? How is it treated?

Answer 20

Endoscopy establishes diagnosis and allows photocoagulation (laser)

Question 21

How does Boerhaave syndrome begin? What is the clinical presentation of Boerhaave syndrome?

Answer 21

1) Boerhaave syndrome starts with prolonged, forceful vomiting leading to esophageal perforation
2) There is continuous, severe, wrenching epigastric and low sternal pain of sudden onset, soon followed by fever, leukocytosis, and a very sick-looking patient

Question 22

How is diagnosis of Boerhaave made? How is it treated?

Answer 22

1) Contrast swallow (Gastrografin first, barium if negative) is diagnostic
2) Emergency surgical repair should follow
3) Delay in diagnosis and treatment has grave consequences

Question 23

What is the most common reason for esophageal perforation?

Answer 23

Instrumental perforation of the esophagus is by far the most common reason for esophageal perforation

Question 24

How does intrumental perforation of the esophagus present? How is it treated?

Answer 24

1) Shortly after completion of endoscopy, symptoms as described for Boerhaave syndrome (continuous, severe, wrenching epigastric and low sternal pain of sudden onset, soon followed by fever, leukocytosis, and a very sick-looking patient) will develop. There may be emphysema in the lower neck (virtually diagnostic in this setting)
2) Contrast studies and prompt repair are imperative

Question 25

In what age group is gastric adenocarcinoma more common?

Answer 25

Gastric adenocarcinoma is more common in the elderly

Question 26

What is the common presentation of gastric adenocarcinoma?

Answer 26

There is anorexia, weight loss, and vague epigastric distress or early satiety. Ocassionally there is hematemesis

Question 27

How is gastric adenocarcinoma diagnosed? What is the function of CT scan in gastric adenocarcinoma? What is the best therapy?

Answer 27

1) Endoscopy and biopsies are diagnostic
2) CT scan helps assess operability
3) Surgery is the best therapy

Question 28

How common is gastric lymphoma in relation to gastric adenocarcinoma and how does it present?

Answer 28

1) Gastric lymphoma is nowadays almost as common as gastric adenocarcinoma
2) Presentation and diagnosis are similar (There is anorexia, weight loss, and vague epigastric distress or early satiety. Ocassionally there is hematemesis)

Question 29

What is the treatment for gastric lymphoma? How can low-grade lymphomatoid transformation (Maltoma) be reversed?

Answer 29

1) Treatment is based on chemotherapy or radiotherapy
2) Surgery is done if perforation is feared as the tumor melts away
3) Low-grade lymphomatoid transformation (Maltoma) can be reversed by eradication of H.pylori

Question 30

What is the typical cause of mechanical intestinal obstruction? How does it present? What can be heard on auscultation early on?

Answer 30

1) Mechanical intestinal obstruction is typically caused by adhesions in those who have had a prior laparotomy
2) There is colicky abdominal pain and protracted vomiting, progressive abdominal distention (if it is a low obstruction), and no passage of gas or feces
3) Early on, high-pitched bowel sounds coincide with the colicky pain (after a few days there is silence)

Question 31

What do X-rays of a mechanical intestinal obstruction show?

Answer 31

X-rays show distended loops of small bowel, with air-fluid levels

Question 32

How is mechanical intestinal obstruction treated?

Answer 32

1) Treatment starts with NPO, NG suction, and IV fluids, hoping for spontaneous resolution, while watching for early signs of strangulation
2) Surgery is done if conservative management is unsuccessful, within 24 hours in cases of complete obstruction or within a few days in cases of partial obstruction

Question 33

How does a strangulated obstruction present? How is it treated?

Answer 33

1) Strangulated obstruction (compromised blood supply) starts as a mechanical intestinal obstruction does (There is colicky abdominal pain and protracted vomiting, progressive abdominal distention (if it is a low obstruction), and no passage of gas or feces), but eventually the patient develops fever, leukocytosis, constant pain, signs of peritoneal irritation, and ultimately full-blown peritonitis and sepsis
2) Emergency surgery is required

Question 34

How does mechanical intestinal obstruction caused by an incarcerated hernia present? How is it treated?

Answer 34

1) Mechanical intestinal obstruction caused by an incarcerated hernia presents with colicky abdominal pain and protracted vomiting, progressive abdominal distention (if it is a low obstruction), and no passage of gas or feces, but can eventually lead to strangulation in which the patient develops fever, leukocytosis, constant pain, signs of peritoneal irritation, and ultimately full-blown peritonitis and sepsis
2) Physical exam however, shows the irreducible hernia that used to be reducible
3) Because we can effectively eliminate the hernia (we cannot effectively eliminate adhesions), all of these undergo surgical repair, but the timing varies: emergently after proper rehydration in those who appear to be strangulated; electively in those who can be reduced manually and have viable bowel

Question 35

Which patients present with carcinoid syndrome? How does this syndrome present?

Answer 35

1) Carcinoid syndrome is seen in patients with a small bowel carcinoid tumor with liver metastasis
2) The syndrome includes diarrhea, flushing of the face, wheezing, and right-sided heart valvular damage (look for prominent jugular venous pulse)

Question 36

How is carcinoid syndrome diagnosed?

Answer 36

24-hour urinary collection for 5-hydroxyindoleacetic acid provides the diagnosis. (Hint: Whenever syndromes produce episodic attacks or spells, the offending agent will be at high concentrations in the blood only at the time of the attack. A blood sample taken afterward will be normal. Thus, a 24-hour urinary collection is more likely to provide the diagnosis)

Question 37

What is the classic picture of acute appendicitis? What is found on physical exam and labs? What is the treatment?

Answer 37

1) The classic picture of acute appendicitis begins with anorexia, followed by vague periumbilical pain that several hours later becomes sharp, severe, constant, and localized to the right lower quadrant of the abdomen
2) Tenderness, guarding, and rebound are found to the right and below the umbilicus (not elsewhere in the belly)
3) There is modest fever and leukocytosis in the 10,000-15,000 range, with neutrophilia and immature forms
4) Emergency appendectomy should follow

Question 38

How do doubtful presentations of acute appendicitis present? How are they diagnosed?

Answer 38

1) Doubtful presentations that could be acute appendicitis include any that do not have all the classic findings
2) CT scan has become the standard diagnostic modality for those cases

Question 39

How does cancer of the right colon present? In what age group does it present? Is there occult blood? What tests are diagnostic? What is the treatment of choice?

Answer 39

1) Cancer of the right colon typically shows up with anemia (hypochromic, iron deficiency) in the right age group (elderly), for no good reason
2) Stools will be 4+ for occult blood
3) Colonoscopy and biopsies are diagnostic
4) Surgery (right hemicolectomy) is treatment of choice

Question 40

How does cancer of the left colon present? What are the first diagnostic studies done? What needs to be done before surgical treatment? What is the function of CT scan in cancer of the left colon?

Answer 40

1) Cancer of the left colon typically shows with bloody bowel movements. Blood coats the outside of the stool, there may be constipation, and stools may have narrow caliber
2) Flexible proctosigmoidoscopic exam (45 or 60 cm) and biopsies are usually the first diagnostic study
3) Before surgery is done, full colonoscopy is needed to rule out synchronous second primary. Pre-op chemotherapy and radiation may be needed for large rectal cancers
4) CT scan helps assess operability and extent

Question 41

Can colonic polyps be premalignant? If so, what is the descending order of probability for malignant degeneration? Which polyps are not premalignant?

Answer 41

1) Yes, colonic polyps may be premalignant
2) In descending order of probability for malignant degeneration are familial polyposis (and variants such as Gardner), familial multiple inflammatory polyps, villous adenoma, and adenomatous polyp
3) Poylps that are not premalignant include juvenile, Peutz-Jeghers, isolated inflammatory, and hyperplastic

Question 42

What kind of diarrhea do Crohn’s disease and chronic ulcerative colitis (CUC) produce? When is Crohn’s disease treated surgically? When is CUC treated surgically?

Answer 42

1) Crohn’s disease and CUC produce severe diarrhea with blood and mucus
2) Crohn’s disease and CUC can happen in multiple GI locations, and thus cannot be cured by surgical resection. Crohn’s disease is surgically treated only when there are complications such as bleeding, stricture, or fistulization
3) CUC can be surgically cured but is avoided because it always requires removal of the rectal mucosa, raising the need for a stoma or an ileoanal anastomosis. Indications for surgery in CUC include active disease for more than 20 years (malignant degeneration), severe nutritional depletion, multiple hospitalizations, need for high-dose steroids or immunosuppressants, or development of toxic megacolon (fever, leukocytosis, abdominal pain and tenderness, and massively dilated colon with gas within the wall)

Question 43

How is pseudomembranous enterocolitis caused? What are symptoms? How is the diagnosis best made? What is the treatment of choice?

Answer 43

1) Pseudomembranous enterocolitis is caused by overgrowth of Clostridium difficile in patients who have been on antibiotics. Any antibiotic can do it. Clindamycin was the first one described, and, currently, cephalosporins are the most common cause
2) There is profuse, watery diarrhea, crampy abdominal pain, fever, and leukocytosis
3) The diagnosis is best made by identifying the toxin in the stool. Stool cultures take too long, and the pseudomembranes are not always seen on endoscopy. The culpable antibiotic should be discontinued, and no antidiarrheals should be used
4) Metronidazole is the treatment of choice, with vancomycin serving as an alternate. A virulent form of the disease, unresponsive to treatment, with a WBC above 50,000 and serum lactate above 5, requires emergency colectomy

Question 44

What is a recently reported effective cure for the overgrowth of C. diff?

Answer 44

Fecal enema has been recently reported as a very effective cure for the overgrowth of C. diff. It makes sense that restoring normal bowel flora would help in this situation

Question 45

What should be ruled out in all anorectal disease and how is it done?

Answer 45

In all anorectal disease cancer should be ruled out by proper physical exam (including proctosigmoidoscopic exam), even though the clinical presentation may suggest a specific benign process

Question 46

Which type of hemorrhoid bleeds? Which type is painful?

Answer 46

1) Hemorrhoids typically bleed when they are internal (can be treated with rubber band ligation), or hurt when they are external may need surgery if conservative treatment fails)
2) Internal hemorrhoids can become painful and produce itching if they are prolapsed

Question 47

Who commonly develops an anal fissure? How does it present? What is believed to cause and perpetuate the problem? What is the choice of therapy?

Answer 47

1) Anal fissures happen to young women
2) They have exquisite pain with defecation and blood streaks covering the stools. The fear of pain is so intense that they avoid bowel movements (and get constipated) and sometimes refuse proper physical examination of the area. Exam may need to be done under anesthesia (the fissure is usually posterior, in the midline)
3) A tight sphincter is believed to cause and perpetuate the problem, thus therapy is directed at relaxing it: stool softeners, topical nitroglycerin, local injection of botulinum toxin, forceful diltation or lateral internal sphincterotomy
4) Calcium channel blockers such as diltiazem ointment 2% TID topically for 6 weeks have had an 80-90% success rate, as compared to only 50% success for botulinum toxin

Question 48

How does anorectal Crohn’s disease present? How is it treated?

Answer 48

1) Crohn’s disease often affects the anal area. It starts with a fissure, fistula, or small ulceration, but the diagnosis should be suspected when the area fails to heal and gets worse after surgical interventions (the anal area typically heals very well because it has excellent blood supply-failure to do so means Crohn’s disease)
2) Surgery, in fact, should not be done in Crohn’s disease of the anus. A fistula, if present, could be drained with setons while medical therapy is underway. Remicade (infliximab) helps healing

Question 49

How does an ischiorectal (perirectal) abscess present?

Answer 49

1) Ischiorectal abscess (perirectal abscess) is very common
2) Patient is febrile, with exquisite perirectal pain that does not let him sit down or have bowel movements
3) Physical exam shows all the classic findings of an abscess (rubor, dolor, calor, and tumor) lateral to the anus, between the rectum and the ischial tuberosity

Question 50

How is a ischiorectal (perirectal) abscess treated and what should be ruled out during the procedure? What should one look out for after treatment if the patient is severely diabetic?

Answer 50

1) Incision and drainage are needed, and cancer should be ruled out by proper examination during the procedure
2) If a patient is severely diabetic, horrible necrotizing soft tissue infection may follow: watch him closely

Question 51

How can a fistula-in-ano form?

Answer 51

1) Fistula-in-ano develops in some patients who have had an ischiorectal abscess drained
2) Epithelial migration from the anal crypts (where the abscess originated) and from the perineal skin (where the drainage was done) form a permanent tract

Question 52

What do patients complain of with a fistula-in-ano? What does physical exam show?

Answer 52

1) Patient reports fecal soiling and occasional perineal discomfort
2) Physical exam shows opening (or openings) lateral to the anus, a cordlike tract may be felt, and discharge may be expressed

Question 53

What should you rule out when a fistula-in-ano may be present? How is a fistula-in-ano treated?

Answer 53

1) Rule out necrotic and draining tumor

2) Treat with fistulotomy

Question 54

Who more commonly develops squamous cell carcinoma of the anus?

Answer 54

Squamous cell carcinoma of the anus is more common in HIV+, and in homosexuals with receptive sexual practices

Question 55

How does squamous cell carcinoma of the anus present? What additional finding can be palpated on physical exam commonly?

Answer 55

1) A fungating mass grows out of the anus

2) Metastatic inguinal nodes are often felt

Question 56

How is squamous cell carcinoma of the anus diagnosed? How is it treated?

Answer 56

1) Diagnose with biopsy
2) Treatment starts with Nigro chemoradiation protocol, followed by surgery if there is residual tumor
3) Currently the 5-week chemo-radiation protocol has a 90% success rate, so surgery rarely is required

Question 57

What is Nigro chemoradiation protocol?

Answer 57

Nigro protocol is the pre-operative use of chemotherapy with 5-fluorouracil and mitomycin and medical radiation for squamous cell carcinomas of the anal canal of less than 5 cm, followed by surgical excision if necessary

Question 58

Where do most GI bleeds originate from? Where do the remaining GI bleeds originate from?

Answer 58

1) General statistics of GI bleeding show that 3 of 4 cases originate in the upper GI tract (from the tip of the nose to the ligament of Treitz)
2) 1 of 4 originates in the colon or rectum, and very few arise from the jejunum of ileum

Question 59

What are causes of GI bleeding arising from the colon? Where are GI bleeds most commonly seen in younger patients as compared to older patients?

Answer 59

1) GI bleeding arising from the colon comes from angiodysplasia, polyps, diverticulosis, or cancer, all of which are diseases of old people. Even hemorrhoids become more common with age
2) Thus, when a young patient has GI bleeding, the odds are overwhelming that is comes from the upper GI tract. When an old patient bleeds, it could be from anywhere (an “equal opportunity bleeder”), as the upper GI is the most common source overall (3/4), but age makes that old patient a good candidate for lower GI bleeding. Statistics are helpful when the bleeding is per rectum, but they are not needed when patients vomit blood

Question 60

When a patient vomits blood, where does it originate from? What about when blood is recovered by NG tube? If blood is recovered from an NG tube, what is the next best diagnostic test? What should you first check before conducting this diagnostic test?

Answer 60

1) Vomiting blood always denotes a source within the upper GI (tip of the nose to the ligament of Treitz)
2) The same is true when blood is recovered by NG tube in a patient who shows up with bleeding per rectum
3) The best next diagnostic test in that setting is upper GI endoscopy
4) Be sure to look at the mouth and nose first

Question 61

What does melena (black, tarry stools) indicate? How should you begin workup for melena?

Answer 61

1) Melena always indicates digested blood, thus it must originate high enough to undergo digestion
2) Start workup with upper GI endoscopy

Question 62

Where does red blood per rectum originate from? What series of steps should first be done to determine if the origin of actively bleeding red blood per rectum is from an upper GI bleed?

Answer 62

1) Red blood per rectum could come from anywhere in the GI tract (including upper GI, as it may have transited too fast to be digested)
2) The first diagnostic maneuver if the patient is actively bleeding at the time is to pass an NG tube and aspirate gastric contents. If blood is retrieved, an upper source has been established (follow with upper endoscopy). If no blood is retrieved and the fluid is white (no bile), the territory from the tip of the nose to the pylorus has been excluded, but the duodenum is still a potential source. Upper GI endoscopy should follow. If no blood is recovered and the fluid is green (bile tinged), the entire upper GI (tip of the nose to the ligament of Treitz) has been excluded, and there is no need for an upper GI endoscopy

Question 63

When upper GI bleed has been excluded, how should active bleeding per rectum be worked up?

Answer 63

1) Active bleeding per rectum, when upper GI has been excluded, is more difficult to work up
2) Bleeding hemorrhoids should always be excluded first (anoscopy), but colonoscopy is not helpful during active bleeding (the oncoming blood obscures the field)
3) There are two ways to go after the hemorrhoids have been excluded. Some practitioners proceed according to the estimated rate of bleeding. If it exceeds 2 mL/min (1 unit of blood every 4 hours), they do an angiogram, which has a very good chance of finding the source and may allow for angiographic embolization. If the bleeding is less than 0.5 mL/min, they wait until the bleeding stops and then do a colonoscopy. For the cases in-between, they may do a tagged red-cell study. If the tagged blood puddles somewhere, an angiogram may be productive. The curse of the tagged red cell study is that it is a slow test. By the time it’s finished, the patient is often no longer bleeding, and the subsequent angiogram is useless. In that case, at least there is some idea if the puddling is on the right or the left and could thus guide a potential “blind” hemicolectomy in the future. If the tagged red cells do not show up on the scan, a subsequent colonoscopy is planned. Some practitioners always begin with the tagged red-cell study, regardless of the estimated rate of bleeding
4) With increasing frequency in clinical practice, when bleeding is not found to be in the colon, capsule endoscopy is done to localize the spot in the small bowel, once the patient is stable.

Question 64

How should workup be started for a patient with a recent history of blood per rectum, but no active bleeding at the time of presentation?

Answer 64

Patients with a recent history of blood per rectum, but not actively bleeding at the time of presentation, should start workup with upper GI endoscopy if they are young (overwhelming odds); but if they are old they need both an upper and a lower GI endoscopy (at the same session)

Question 65

What is the most common cause of blood per rectum in a child? How should you start the work up of this condition?

Answer 65

1) Blood per rectum in a child should be from Meckel diverticulum
2) Start workup with technetium scan, looking for the ectopic gastric mucosa

Question 66

What is the most likely cause of massive upper GI bleeding in the stressed, multiple trauma, or complicated post-op patient?

Answer 66

Stress ulcers

Question 67

What are stress ulcers? Where are they found?

Answer 67

1) A stress ulcer is a single or multiple mucosal defect which can become complicated by upper gastrointestinal bleeding during the physiologic stress of serious illness
2) Ordinary peptic ulcers are found commonly in the gastric antrum and the duodenum whereas stress ulcers are found commonly in fundic mucosa and can be located anywhere within the stomach and proximal duodenum

Question 68

How do you confirm the diagnosis of a suspected stress ulcer?

Answer 68

Endoscopy

Question 69

What is the best therapeutic option for a stress ulcer? How can a stress ulcer be avoided?

Answer 69

1) Angiographic embolization

2) Stress ulcers should be avoided by maintaining the gastric pH above 4

Question 70

What are categorical processes that can cause acute abdominal pain?

Answer 70

1) Perforation
2) Obstruction
3) Inflammatory or ischemic processes

Question 71

How does acute abdominal pain caused by perforation present? What is the confirmatory diagnosis?

Answer 71

1) Acute abdominal pain caused by perforation has sudden onset and is constant, generalized, and very severe
2) The patient is reluctant to move, and very protective of his abdomen
3) Except in the very old or very sick, impressive generalized signs of peritoneal irritation are found (tenderness, muscle guarding, rebound, silent abdomen)
4) If present, free air under the diaphragm in upright x-rays confirms the diagnosis

Question 72

What is the most common example of acute abdominal pain caused by perforation? What is the treatment of acute abdominal pain caused by perforation?

Answer 72

1) Perforated peptic ulcer is the most common example

2) Emergency surgery is needed

Question 73

How does acute abdominal pain caused by obstruction of a duct (ureter, cystic, or common) present?

Answer 73

1) Acute abdominal pain caused by obstruction of a narrow duct (ureter, cystic, or common) has sudden onset of very severe colicky pain, with typical location and radiation according to source
2) The patient moves constantly, seeking a position of comfort
3) There are few physical findings, and they are limited to the area where the process is

Question 74

How does acute abdominal pain caused by inflammatory process present? What are the physical exam and lab findings?

Answer 74

1) Acute abdominal pain caused by inflammatory process has gradual onset and slow buildup (at the very least a couple of hours, more commonly 6 or 10 or 12 hours), it is constant, starts as ill-defined, eventually locates to the area where the problem is, and often has typical radiation patterns
2) There are physical findings of peritoneal irritation in the affected area, and (except for pancreatitis) systemic signs such as fever and leukocytosis

Question 75

What is a characteristic feature of ischemic processes of acute abdominal pain?

Answer 75

Ischemic processes affecting the bowel are the only ones that combine severe abdominal pain with blood in the lumen of the gut

Question 76

When should primary peritonitis be suspected in a patient? What will cultures of the ascitic fluid reveal? How is primary peritonitis treated?

Answer 76

1) Primary peritonitis should be suspected in the child with nephrosis and ascites, or the adult with ascites who has a “mild” generalized acute abdomen with equivocal physical findings, and perhaps some fever and leukocytosis
2) Cultures of the ascitic fluid will yield a single organism (in garden-variety acute abdomens, a multiplicity of organisms grow)
3) Treat with antibiotics, not with surgery

Question 77

What is the treatment for a generalized acute abdomen? What conditions that mimic a generalized acute abdomen should be ruled out before treatment and what tests can be done to rule these conditions out?

Answer 77

1) The treatment for a generalized acute abdomen is exploratory laparotomy, with no need to have a specific diagnosis as to the exact nature of the process
2) If it does not look like primary peritonitis (one of the exceptions), we only need to rule out things that may mimic an acute abdomen-myocardial ischemia (EKG, tropnins), lower lobe pneumonia (chest x-ray), PE (immobilized patient)-or things that specifically do not require surgery-pancreatitis (amylase or lipase) and urinary stones (CT scan of abdomen)

Question 78

When should acute pancreatitis be most suspected? What is the classic picture of acute pancreatitis?

Answer 78

1) Acute pancreatitis should be suspected in the alcoholic who develops an “upper” acute abdomen
2) The classic picture has rapid onset for an inflammatory process (a couple of hours), and the pain is constant, epigastric, radiating straight through to the back, with nausea, vomiting, and retching
3) Physical findings are relatively modest, found in the upper abdomen

Question 79

How is acute pancreatitis diagnosed? What if the diagnosis is unclear?

Answer 79

1) Diagnose with serum or urinary amylase or lipase (serum from 12 to 48 hours, urinary from third to sixth day)
2) CT if diagnosis is unclear

Question 80

How is acute pancreatitis treated?

Answer 80

Treat with NPO, NG suction, IV fluids

Question 81

In what patients should biliary tract disease be suspected?

Answer 81

Biliary tract disease should be suspected in the fat woman in her forties who has “fifty-five children,” and who develops right upper quadrant abdominal pain

Question 82

How do ureteral stones present? What will be found on urinalysis? What is the best diagnostic test?

Answer 82

1) Ureteral stones produce sudden onset of colicky flank pain radiating to inner thigh and scrotum (or labia), sometimes with other urinary symptoms like urgency and frequency; and with microhematuria in the urinalysis
2) CT scan is the best diagnostic test

Question 83

What is one of the very few inflammatory processes giving acute abdominal pain in the left lower quadrant? What is the common age group for the this condition? What is the common presentation for this condition?

Answer 83

1) Acute diverticulitis is one of the very few inflammatory processes giving acute abdominal pain in the left lower quadrant (in women the tube and ovary are other potential sources)
2) Patient is middle-age or beyond
3) There is fever, leukocytosis, physical findings of peritoneal irritation in the left lower quadrant, and sometimes a palpable tender mass

Question 84

What is the diagnostic test for acute diverticulitis? How is it first treated? If initial treatment does not work, what is the next treatment option? In the presence of an abscess, what can be done? Who is eligible for elective surgery?

Answer 84

1) CT is diagnostic
2) Start treatment with NPO, IV fluids, antibiotics. Most will cool down
3) Emergency surgery is needed for those who do not
4) Radiologically guided percutaneous drainage of abscess may precede resection
5) Elective surgery for those who have had at least two or more attacks

Question 85

Volvulus of the sigmoid is commonly seen in what age group? What are two clinical signs of volvulus of the sigmoid?

Answer 85

1) Old people

2) Intestinal obstruction and severe abdominal distention

Question 86

What is the diagnostic test for volvulus of the sigmoid? How can it be treated? What is recommended for recurrent cases?

Answer 86

1) X-rays are diagnostic, as they show air-fluid levels in the small bowel, very distended colon, and a huge air-filled loop in the right upper quadrant that tapers down toward the left lower quadrant with the shape of a “parrot’s beak”
2) Proctosigmoidoscopic exam with the old rigid instrument resolves the acute problem. Rectal tube is left in
3) Recurrent cases need elective sigmoid resection

Question 87

Mesenteric ischemia is commonly seen in what age group? What is the real key to development of mesenteric ischemia?

Answer 87

1) Mesenteric ischemia is seen predominantly in the elderly
2) The real key is the development of an acute abdomen in someone with atrial fibrillation or a recent MI (the source of the clot that breaks off and lodges in the superior mesenteric artery)

Question 88

Why is the diagnosis of mesenteric ischemia often made late? What diagnostic test may save the day in a very early case of mesenteric ischemia?

Answer 88

1) Because the very old do not mount impressive acute abdomens, often the diagnosis is made late, when there is blood in the bowel lumen (the only condition that mixes acute pain with GI bleeding) and acidosis and sepsis have developed
2) In very early cases, arteriogram and embolectomy might save the day

Question 89

In the United States, primary hepatoma (hepatocellular carcinoma) is only seen in patients with what conditions?

Answer 89

Primary hepatoma (hepatocellular carcinoma) is seen in the United States only in people with cirrhosis, or those known to have had hepatitis B or C

Question 90

How does primary hepatoma present? What is the specific blood marker? What test will show the location and extent of the hepatoma? What treatment can be done if possible?

Answer 90

1) Patients develop vague right upper-quadrant discomfort and weight loss
2) The specific blood marker is alpha-fetoprotein
3) CT scan will show location and extent
4) Resection is done if technically possible

Question 91

Is there more metastatic or primary cancer of the liver? How much more?

Answer 91

Metastatic cancer of the liver outnumbers primary cancer of the liver in the United States by 20:1

Question 92

How is metastatic cancer of the liver found?

Answer 92

They are found by CT scan if follow-up for the treated primary tumor is under way, or suspected because of rising carcinoembryonic antigen (CEA) in those who had colonic cancer

Question 93

How is metastatic cancer of the liver typically treated? What is another way to control the cancer?

Answer 93

1) If the primary is slow growing and the metastases are confined to one lobe, resection can be done
2) Other means of control include radioablation

Question 94

How do hepatic adenomas arise? Why are they important to identify?

Answer 94

1) Hepatic adenomas may arise as a complication of birth control pills
2) They are important because they have a tendency to rupture and bleed massively inside the abdomen

Question 95

What is the diagnostic test for hepatic adenoma? How is it treated?

Answer 95

1) CT scan is diagnostic

2) Emergency surgery is required

Question 96

Pyogenic liver abscess is often a complication of what condition? How do patients present?

Answer 96

1) Pyogenic liver abscess is seen most often as a complication of biliary tract disease, particularly acute ascending cholangitis
2) Patients develop fever, leukocytosis, and a tender liver

Question 97

How is a pyogenic liver abscess diagnosed? How is it treated?

Answer 97

1) Sonogram or CT scan are diagnostic

2) Percutaneous drainage is required

Question 98

Who most often develops amebic abscess of the liver? How does an amebic abscess of the liver present?

Answer 98

1) Amebic abscess of the liver favors men, all of whom have a “Mexico connection.” (It is very common there and seen here in immigrants)
2) It presents very similarly to a pyogenic liver abscess (Patients develop fever, leukocytosis, and a tender liver)

Question 99

How is an amebic abscess of the liver diagnosed? How is it treated?

Answer 99

1) Definitive diagnosis is given by serology (the ameba does not grow in the pus)
2) Because the serological diagnostic test takes weeks to be reported, empiric treatment is started in those clinically suspected. The treatment is generally metronidazole, seldom requiring drainage. If they improve, it is continued-if not, drainage is done

Question 100

What are three classifications of jaundice?

Answer 100

1) Hemolytic
2) Hepatocellular
3) Obstructive

Question 101

How elevated is the bilirubin in a hemolytic jaundice? What type of bilirubin is elevated? Is there any bile in the urine? What should workup determine?

Answer 101

1) Hemolytic jaundice is usually low level (bilirubin of 6 or 8, but not 35 or 40)
2) All the elevated bilirubin is unconjugated (indirect), with no elevation of the direct, conjugated fraction
3) There is no bile in the urine
4) Workup should determine what is chewing up the red cells

Question 102

What labs are typically elevated in hepatocellular jaundice? What is the most common example of a cause of hepatocellular jaundice?

Answer 102

1) Hepatocellular jaundice has elevation of both fractions of bilirubin and very high levels of transaminases, with modest elevation of alkaline phosphatase
2) Hepatitis is the most common example, and workup should proceed in that direction (serologies to determine specific type)

Question 103

What labs are typically elevated in obstructive jaundice? What is the first step in your workup of obstructive jaundice?

Answer 103

1) Obstructive jaundice has elevations of both fractions of bilirubin, modest elevation of transaminases, and very high levels of alkaline phosphatase
2) First step in the workup is a sonogram, looking for dilatation of the biliary ducts, as well as further clues as to the nature of the obstructive process

Question 104

In obstructive jaundice caused by stones, where are stones commonly seen? In malignant obstruction, what structure will often be identified and what is this sign called?

Answer 104

1) In obstruction caused by stones, the stone that is obstructing the common duct is seldom seen, but stones are seen in the gallbladder, which because of chronic irritation cannot dilate
2) In malignant obstruction, a large, thin-walled, distended gallbladder is often identified (Courvoisier-Terrier sign)

Question 105

In who should we suspect obstructive jaundice caused by stones? What specific lab will be elevated? What will be seen on ultrasound?

Answer 105

Obstructive jaundice caused by stones should be suspected in the obese, fecund woman in her forties who has high alkaline phosphatase, dilated ducts on sonogram, and nondilated gallbladder full of stones

Question 106

What should be done if obstructive jaundice is suspected?

Answer 106

The next move is to endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis, do sphincterotomy, and remove the common duct stone. Cholecystectomy should follow

Question 107

What is an ERCP? How is it done? How long does it usually take

Answer 107

1) An endoscopic retrograde cholangiopancreatogram (ERCP) is an invasive procedure that allows visualization and instrumentation of the biliary and pancreatic ducts
2) An endoscope descends into the duodenum, the ampulla is cannulated, and x-ray dye is injected
3) Although experts can do the ERCP in less than an hour, the need for sedation makes ERCP an all-day affair: nothing by mouth for several hours prior to the test; then the procedure itself; perhaps a bit of discomfort (gagging) if the sedation is light; and then a recovery period, after which the patient needs a ride home

Question 108

What is an MRCP?

Answer 108

1) A newer study, magnetic resonance cholangiopancreatogram (MRCP) is completely noninvasive and is done on a fully awake patient
2) Every now and then it’s necessary to hold breathing for about 10 seconds at a time, and the whole thing is over in roughly 10 minutes. No gagging, no limitations, Simple. And the pictures thus produced are gorgeous: detailed views of both ducts and the surrounding parenchyma

Question 109

When should you choose an ERCP vs a MRCP?

Answer 109

1) Obviously, if all you need is a diagnostic picture, the clear choice is MRCP. But if you want to do more than look at a picture, you will need the ERCP. With the latter you can do sphincerotomies, retrieve stones, drain pus, deploy stents, biopsy tumors, and so on. Introduced as a diagnostic study only, ERCP has evolved into an instrument for therapy-which MRCP cannot do
2) Sometimes a progressive sequence will make sense: Get your diagnosis and make your plans with the 10-minute, noninvasive test (MRCP). They, if the findings call for manipulations, schedule the all-day affair (ERCP)

Question 110

When is obstructive jaundice caused by tumor suggested? What are the different cancers that may be responsible?

Answer 110

1) Obstructive jaundice caused by tumor is suggested by the thin-walled, dilated gallbladder in the sonogram
2) The different cancers that may be responsible are adenocarcinoma of the head of the pancreas, adenocarcinoma of the ampulla of Vater, or cholangiocarcinoma of the common duct itself

Question 111

In the presence of obstructive jaundice caused by tumor, what signs/symptoms are suggestive of a large pancreatic tumor? How should the tumor be diagnosed? What if symptoms are negative or if a CT scan is negative?

Answer 111

1) Significant weight loss and constant back pain suggest a large pancreatic tumor, which should be visible in a CT scan-the next test to run
2) In the absence of those clues or if the CT scan is negative, the next step is MRCP, which can show smaller tumors that are blocking the flow of bile thanks to strategic location-a cholangiocarcinoma, an ampullary cancer, or a small pancreatic malignancy abutting the intrapancreatic portion of the common duct

Question 112

What options are available for a biopsy of a tumor causing obstructive jaundice?

Answer 112

1) CT-guided percutaneous for a large pancreatic mass
2) Endoscopic for ampullary
3) ERCP and brushings for a ductal neoplasm
4) Endoscopic ultrasound for tiny tumors within the head of the pancreas

Question 113

When are ampullary cancers suspected as a cause of obstructive jaundice? What test should be done first for diagnosis and why?

Answer 113

1) Ampullary cancers may be suspected when malignant obstructive jaundice coincides with anemia and positive blood in the stools
2) Ampullary cancer can bleed into the lumen like any other mucosal malignancy, at the same time that it can obstruct biliary flow by virtue of its location. Given that combination, endoscopy should be the first test

Question 114

Is pancreatic cancer usually cured? Do ampullary cancer and cancer of the lower end of the common duct have a better prognosis?

Answer 114

1) Pancreatic cancer is seldom cured, even when the huge Whipple operation (pancreatoduodenectomy) is done
2) Ampullary cancer and cancer of the lower end of the common duct have a much better prognosis (about 40% cure)

Question 115

When do cholangiocarcinomas in a certain location have terrible prognosis? Can a margin-free resection commonly be done?

Answer 115

1) Cholangiocarcinomas that arise within the liver at the bifurcation of the hepatic ducts have terrible prognosis by virtue of their extremely inconvenient location
2) They can be beautifully shown by magnetic resonance cholangiopancreatography (MRCP), but achieving margin-free resection is almost impossible

Question 116

What is responsible for the vast majority of biliary tract pathology? Who commonly develops this condition?

Answer 116

1) Gallstones
2) Although the obese woman in her forties is the “textbook” victim, incidence increases with age so that eventually they are common in everybody, particularly Mexican Americans and Native

Question 117

How are asymptomatic gallstones treated?

Answer 117

Asymptomatic gallstones are left alone

Question 118

When does biliary colic occur? How does it present?

Answer 118

1) Biliary colic occurs when a stone temporarily occludes the cystic duct
2) There is colicky pain in the right upper quadrant, radiating to the right shoulder and beltlike to the back, often triggered by ingestion of fatty food, accompanied by nausea and vomiting but without signs of peritoneal irritation or systemic signs of inflammatory process

Question 119

How long does an episode of biliary colic usually last if untreated? How can it be treated? How are gallstones diagnosed? What is biliary colic cured?

Answer 119

1) The episode is self-limited (10, 20, maybe 30 minutes) or easily aborted by anticholinergics
2) Sonogram establishes diagnosis of gallstones
3) Elective cholecystectomy if sonogram is establishes the diagnosis

Question 120

What pathophysiology differentiates biliary colic from acute cholecystitis? What differs on physical exam and labs?

Answer 120

1) Acute cholecystitis starts as a biliary colic, but the stone remains at the cystic duct until an inflammatory process develops in the obstructed gallbladder
2) Pain becomes constant, there is modest fever and leukocytosis, and there are physical findings of peritoneal irritation in the right upper quadrant
3) Liver function tests are minimally affected

Question 121

What is the diagnostic test for acute cholecystitis? If this test is negative and acute cholecystitis is still suspected, what other test should be done?

Answer 121

1) Sonogram is diagnostic in most cases (gallstones, thick-walled gallbladder, and pericholecystic fluid)
2) Rarely, a radionuclide scan (HIDA) might be needed (would show uptake in the liver, common duct, and duodenum, but not in the occluded gallbladder)

Question 122

What is the initial treatment of acute cholecystitis?

Answer 122

NG suction, NPO, IV fluids, and antibiotics “cool down” most cases, allowing elective cholecystectomy to follow

Question 123

When is cholecystectomy usually done on a patient with acute cholecystitis? When is it emergent? What is the best treatment option if a patient is very ill, but has prohibitive surgical risk?

Answer 123

1) Physicians typically endeavor to do cholecystectomy in the same hospital admission, as an urgent case, though it is not a “middle of the night” true emergency
2) If the patient does not respond (men and diabetics often do not), emergency cholecystectomy is needed
3) Emergency percutaneous transhepatic cholecystostomy may be the best temporizing option in the very sick with prohibitive surgical risk

Question 124

What is acute ascending cholangitis?

Answer 124

Acute ascending cholangitis is a far more deadly disease than acute cholecystitis, in which stones have reached the common duct producing partial obstruction and ascending infection

Question 125

Are patients with acute ascending cholangitis usually younger or older? Are they sicker than patients with acute cholecystitis? What is acute ascending cholangitis?

Answer 125

1) Patients are often older and sicker
2) Acute ascending cholangitis is a far more deadly disease, in which stones have reached the common duct producing partial obstruction and ascending infection

Question 126

What findings indicate sepsis for acute ascending cholangitis?

Answer 126

Temperature spikes to 104-105F, with chills, and very high white blood cell (WBC) count

Question 127

What is the key lab finding for acute ascending cholangitis? What is an additional lab finding that is present?

Answer 127

1) Extremely high levels of alkaline phosphatase

2) There is some hyperbilirubinemia

Question 128

What are lifesaving therapies for acute ascending cholangitis? What procedure must follows?

Answer 128

1) IV antibiotics & Emergency decompression of the common duct (ideally by ERCP, alternatively percutaneous through the liver by percutaneous transhepatic cholangiogram [PTC], or rarely by surgery)
2) Eventually cholecystectomy has to follow

Question 129

What is the pathophysiology of biliary pancreatitis?

Answer 129

Biliary pancreatitis is seen when stones become impacted distally in the ampulla, temporarily obstructing both pancreatic and biliary ducts

Question 130

What is the fate of the stones in biliary pancreatitis? What labs are elevated? What test confirms the diagnosis in the presence of these labs and symptoms?

Answer 130

1) The stones often pass spontaneously, producing a mild and transitory episode of cholangitis along with the classic manifestations of pancreatitis (elevated amylase or lipase)
2) Sonogram confirms gallstones in the gallbladder

Question 131

How is biliary pancreatitis treated conservatively? What happens if conservative treatment fails?

Answer 131

1) Conservative treatment (NPO, NG suction, IV fluids) usually leads to improvement, allowing elective cholecystectomy to be done later
2) If not, ERCP and sphincterotomy may be required to dislodge the impacted stone

Question 132

Acute pancreatitis is typically a complication of what two things?

Answer 132

1) Gallstones

2) Alcoholism

Question 133

What are the different classifications of acute pancreatitis?

Answer 133

1) Edematous
2) Hemorrhagic
3) Suppurative (pancreatic abscess)

Question 134

What are two late complications of acute pancreatitis?

Answer 134

1) Pancreatic pseudocyst

2) Chronic pancreatitis

Question 135

In which patients does acute edematous pancreatitis usually occur in? How does it present?

Answer 135

1) Alcoholics or in patients with gallstones
2) Epigastric and midabdominal pain starts after a heavy meal or bout of alcoholic intake, is constant, radiates straight through to the back, and is accompanied by nausea, vomiting and (after the stomach is empty) continued retching

Question 136

For a patient with acute edematous pancreatitis, what finding is found on physical exam? What elevated lab values are diagnostic? How does resolution occur?

Answer 136

1) There is tenderness and mild rebound in the upper abdomen
2) Elevated serum amylase or lipase (early on) or urinary amylase or lipase (after a couple of days) are diagnostic, and a key finding to establish the edematous nature is an elevated hematocrit
3) Resolution usually follows a few days of pancreatic rest (NPO, NG suction, IV fluids)

Question 137

How does acute hemorrhagic pancreatitis differ from acute edematous pancreatitis? What are some other initial characteristic parts of acute hemorrhagic pancreatitis? What about the next morning?

Answer 137

1) Acute hemorrhagic pancreatitis is a much more deadly disease. It starts as the edematous form does, but an early laboratory clue is lower hematocrit (the degree of amylase elevation does not correlate with the severity of the disease)
2) Other findings have been catalogued (Ranson’s criteria), and they include at the time of presentation elevated WBC count, elevated blood glucose, and low serum calcium
3) By the next morning, the hematocrit is even lower, the serum calcium remains low (in spite of calcium administration), the blood urea nitrogen (BUN) goes up, and metabolic acidosis and low arterial PO2 eventually are evident

Question 138

Once acute hemorrhagic pancreatitis progresses, what is the treatment option?

Answer 138

Prognosis at that time is bad, and very intensive supportive therapy is needed (in the ICU)

Question 139

What is the final common pathway for death in acute hemorrhagic pancreatitis and what can be done about this?

Answer 139

1) A common final pathway for death is the development of multiple pancreatic abscesses
2) Try to anticipate them and drain them, if at all possible
3) Daily CT scans are recommended

Question 140

What antibiotic can be used by physicians in patients with signs of infected pancreatitis?

Answer 140

Intravenous imipenem (or meropenem in those with a seizure disorder) is used by some physicians in patients with signs of infected pancreatitis

Question 141

How does a pancreatic abscess come to surgical attention? How is it treated?

Answer 141

1) Pancreatic abscesses come to surgical attention via imaging studies, or when fever and leukocytosis develop about 10 days after the onset of pancreatitis
2) Ideally percutaneous radiological drainage should be performed. Because that is not always possible, open drainage may be required

Question 142

What is the best way to deal with necrotic pancreas? When is it best to do this procedure? How is this procedure done?

Answer 142

1) Necrosectomy
2) This operation is best done when the dead tissue is well delineated, typically after 4 weeks
3) The material is “scooped out” and may have to be repeated until all the dead matter has been cleared away

Question 143

What is pancreatic pseudocyst a complication of? When does it usually arise? What is the classic presentation?

Answer 143

1) Pancreatic pseudocyst can be a late sequela of acute pancreatitis or of pancreatic (upper abdominal) trauma
2) In either case about 5 weeks elapses between the original problem and the discovery of the pseudocyst
3) There is a collection of pancreatic juice outside the pancreatic ducts (most commonly in the lesser sac) and the pressure symptoms thereof (early satiety, vague discomfrot, a deep palpable mass)

Question 144

What test is diagnostic of pancreatic pseudocyst? What determines whether or not the pseudocyst requires treatment? What is the treatment?

Answer 144

1) CT or sonogram will be diagnostic
2) Treatment is dictated by the size and age of the pseudocyst. Cysts 6 cm or smaller, or those that have been present for less than 6 weeks are not likely to have complications and can be observed for spontaneous resolution. Bigger (>6 cm) or older cysts (>6 wk) are more likely to rupture or bleed, and they need to be treated
3) Treatment involved drainage of the cyst. The cyst can be drained percutaneously to the outside, drained surgically into the gastrointestinal tract, or drained endoscopically into the stomach

Question 145

What develops in patients with repeated episodes of chronic pancreatitis?

Answer 145

People who have repeated episodes of pancreatitis (usually alcoholic) eventually develop calcified burned-out pancreas, steatorrhea, diabetes, and constant epigastric pain, which is why chronic pancreatitis is a devastating disease

Question 146

What part of chronic pancreatitis is manageable and what part is usually not?

Answer 146

The diabetes and steatorrhea can be controlled with insulin and pancreatic enzymes, but the pain is resistant to most modalities of therapy and it wrecks sufferers’ lives

Question 147

What can be done to help chronic pancreatitis if MRCP shows specific points of obstruction and dilatation?

Answer 147

Operations that drain the pancreatic duct may help

Question 148

Why should all abdominal hernias be electively repaired? What are exceptions to this? When is abdominal hernia repair emergent?

Answer 148

1) All abdominal hernias should be electively repaired to avoid the risk of intestinal obstruction and strangulation
2) Exceptions include umbilical hernias in patients younger than 2 to 5 years of age (they may close by themselves) and esophageal sliding (para-esophageal) hiatal hernias (which are not “true” hernias)
3) Hernias that become irreducible need emergency surgery to prevent strangulation. Those that have been irreducible for years need elective repair only

Question 149

What are the 3 big families of malignant tumors?

Answer 149

There are 3 big families of malignant tumors, which arise from the 3 layers of the embryo:

1) Epithelial tumors, which come from the ectoderm
2) Sarcomas, which originate in mesodermal tissue
3) Adenocarcinomas, which grow from the endoderm

Question 150

What makes a cancer, cancer?

Answer 150

Its ability to metastasize

Question 151

How does cancer metastasize? Where does it usually metastasize to?

Answer 151

1) Lymphatic spread to regional and more distant lymph nodes
2) Hematogenous migration to far-away organs
3) Hematogenously to the liver, lung, brain, and bone

Question 152

How do epithelial tumors and adenocarcinomas typically spread?

Answer 152

Both through lymphatics and hematogenously

Question 153

Where do breast malignancies generally metastasize to?

Answer 153

Brain and bone

Question 154

Where do abdominal adenocarcinomas generally metastasize to?

Answer 154

Liver

Question 155

How do sarcomas metastasize and where do they generally metastasize to?

Answer 155

1) Sarcomas typically ignore the lymph nodes and go only blood-borne
2) Lungs

Question 156

What is the most common cause of death from cancer?

Answer 156

Primary tumors can kill if they are strategically located where they interfere with a vital function, but more cancer deaths come from metastatic spread, or systemic disease

Question 157

What is a requirement for local therapy to be able to cure cancer? What are the two therapies?

Answer 157

1) Local therapy can cure cancers only if they have not yet metastasized
2) Surgery and radiation

Question 158

Once cancer has metastasized, what are treatments focused on? What is the treatment is a cancer has metastasized?

Answer 158

1) Once cancer cells have migrated, treatments are only palliate, not curative. We cannot surgically resect and throw away the entire body; neither can we radiate someone from head to toe
2) We need systemic therapy for systemic disease: chemotherapy and (for some tumors) hormonal manipulations

Question 159

What negative effects do chemotherapy drugs have on the body and how do they have these effects?

Answer 159

Chemotherapy drugs target rapidly dividing cells and thus share some common side effects: They damage bone marrow, the lining of the GI tract, and hair follicles

Question 160

What is a specific negative effect of: 1) Adriamycin, 2) Bleomycin, 3) Cyclophosphamide, and 4) Platinum-based agents?

Answer 160

1) Myocardial damage
2) Pulmonary fibrosis
3) Hemorrhagic cystitis
4) Neurotoxicity

Question 161

What tumors occur almost exclusively in children?

Answer 161

Primary malignant tumors of bone occur almost exclusively in children

Question 162

What must be ruled out in all breast disease? How can this be done?

Answer 162

1) In all breast disease, cancer must be ruled out even if the presentation suggests benign disease
2) The only sure way to rule out cancer is to get tissue for the pathologist

Question 163

What demographic factor correlates best with the odds for breast cancer?

Answer 163

1) Age correlates best with the odds for breast cancer: virtually unknown in the teens, rare in young women, quite possible by middle age, and very likely in the elderly
2) The much-quoted statement “One of every 8 women in the US will develop breast cancer” is true only for those who have reached the age of 85

Question 164

Is breast cancer usually more benign or aggressive when it arises in young women?

Answer 164

Aggressive

Question 165

Mammography is an adjunct to what test that a physician can perform? How does it help?

Answer 165

1) Mammography is not a substitute for tissue diagnosis, but an adjunct to physical examination
2) Breast masses that may be missed by palpation may be seen in x-rays, and vice versa

Question 166

When should mammography screening begin?

Answer 166

As a regular screening exam, mammography should be started at age 40 (earlier if there is family history)

Question 167

When is mammography not done?

Answer 167

Mammograms are not done before age 20 (breast is too dense) or during lactation (all you see is milk), but they can be done if needed during pregnancy

Question 168

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

Answer 168

Mammographically or sonographically guided multiple core biopsies have become the most convenient, effective, and inexpensive way to biopsy breast masses, whether they are palpable or are discovered by screening mammogram

Question 169

How old are patients usually who present with fibroadenomas? How do fibroadenomas present?

Answer 169

Fibroadenomas are seen in young women (late teens, early twenties) as a firm, rubbery mass that moves easily with palpation

Question 170

How is diagnosis of fibroadenoma established? Should a fibroadenoma be removed?

Answer 170

1) Either fine-needle aspiration (FNA) or sonogram is sufficient to establish diagnosis
2) Removal is optional (most women want them out, and we are happy to oblige)

Question 171

How old are patients usually who present with cystosarcoma phyllodes? What do these masses do over time? Can they become malignant?

Answer 171

1) Cystosarcoma phyllodes is seen in the late 20s
2) They grow over many years, becoming very large, replacing and distorting the entire breast, yet not invading or becoming fixed
3) Most are benign, but they have potential to become outright malignant sarcomas

Question 172

How are cystosarcoma phyllodes diagnosed? Do they need to be removed?

Answer 172

1) Core or incisional biopsy is needed (FNA is not sufficient)
2) Removal is mandatory

Question 173

How old are patients usually who present with mammary dysplasia (fibrocystic disease, cystic mastitis)? How does it present?

Answer 173

Mammary dysplasia (fibrocystic disease, cystic mastitis) is seen in the thirties and forties (goes away with menopause), with bilateral tenderness related to menstrual cycle (worse in the last 2 weeks) and multiple lumps that seem to come and go (they are cysts) also following the menstrual cycle

Question 174

When is only mammogram needed for diagnosis of mammary dysplasia and when are further steps required? What are the further steps, if needed?

Answer 174

1) If there is no “dominant” or persistent mass, mammogram is all that is needed, but if there is a persistent mass (presumably a cyst but potentially a tumor), further steps are required
2) Aspiration is done (not FNA, but aspiration with a bigger needle and syringe). If clear fluid is obtained and the mass goes away, that’s it. If the mass persists or recurs after aspiration, formal biopsy is required. If bloody fluid is aspirated, it should be sent for cytology

Question 175

How old are patients usually who present with intraductal papilloma? How does it present?

Answer 175

Intraductal papilloma is seen in young women (twenties to forties) with bloody nipple discharge

Question 176

What is needed to workup intraductal papilloma?

Answer 176

1) Mammogram is needed to identify other potential lesions, but it will not show the papilloma (they are tiny)
2) Galactogram may be diagnostic and guides surgical resection

Question 177

What is a galactogram?

Answer 177

Ductography (also called galactography or ductogalactography) is a special type of contrast enhanced mammography used for imaging the breast ducts. Ductography can aid in diagnosing the cause of an abnormal nipple discharge and is valuable in diagnosing intraductal papillomas and other conditions

Question 178

Which women develop a breast abscess? What is needed for treatment?

Answer 178

1) Breast abscess is only seen in lactating women (what appears to be a breast abscess at other times is cancer until proven otherwise)
2) Incision and drainage is needed, but biopsy of the abscess wall should be part of the procedure

Question 179

What should be suspected in any woman with a palpable breast mass? How does the index of this suspicion change with age?

Answer 179

Breast cancer should be suspected in any woman with a palpable breast mass, and the index of suspicion goes up with the patient’s age

Question 180

Aside from patient’s age, what are other strong indicators of breast cancer? Does a history of trauma rule out cancer?

Answer 180

1) Ill-defined fixed mass
2) Retraction of overlying skin
3) “Orange peel” skin
4) Recent retraction of the nipple
5) Eczematoid lesions of the areola
6) Reddish orange peel skin over the mass (inflammatory cancer)
7) Palpable axillary nodes
8) No

Question 181

How is breast cancer diagnosed during pregnancy? Is termination of pregnancy necessary to treat breast cancer?

Answer 181

1) Breast cancer during pregnancy is diagnosed exactly as if pregnancy did not exist and is treated the same way except for: no radiotherapy or hormonal manipulations at any time during the pregnancy, and no chemotherapy during the first trimester
2) No, it is not necessary

Question 182

What is the radiological appearance of breast cancer?

Answer 182

The radiological appearance of breast cancer is an irregular, spiculated mass with asymmetric density, architectural distortion, or fine microcalcifications that were not there in the previous mammogram

Question 183

What is the treatment of resectable breast cancer? What is the workup of lymph nodes in the presence of breast cancer?

Answer 183

Treatment of resectable breast cancer starts with either of two operations:

1) Small lesions, located far away from the nipple and areola of a large breast, are removed within only a segment of the mammary gland. The operation is called a lumpectomy, or segmental resection, and it must be followed by radiotherapy
2) Large tumors lying right under the nipple and areola, and occupying most of a small breast, require a simple total mastectomy and do not need subsequent radiation
3) If lymph nodes are not palpable in the axilla, either operation must include a sentinel node biopsy. If enlarged lymph nodes are palpable in the axilla, they are resected

Question 184

What is the standard form of breast cancer? What is the only variant with much worse prognosis? What are other variants and what is their prognosis and treatment method?

Answer 184

1) Infiltrating ductal carcinoma is the standard form of breast cancer
2) Inflammatory cancer is the only variant with much worse prognosis (and the need for pre-op chemotherapy)
3) Other variants (lobular, medullary, mucinous) have slightly better prognosis and are treated the same way as the standard infiltrating ductal. Lobular has higher incidence of bilaterality, but not high enough to justify bilateral mastectomy

Question 185

Can ductal carcinoma in situ (DCIS) metastasize? Does it have a high incidence of recurrence? What is the treatment if is confined to one quarter of the breast?

Answer 185

1) Ductal carcinoma in situ cannot metastasize (thus no axillary sampling is needed) but has very high incidence of recurrence if only local excision is done
2) Lumpectomy followed by radiation is used is the lesion (or lesions) is confined to one quarter of the breast

Question 186

When is total simple mastectomy recommended for DCIS? What do many practitioners follow this up with and why?

Answer 186

Total simple mastectomy is recommended for multicentric lesions throughout the breast; because of the possibility of missing an invasive focus in multicentric disease, many practitioners add a sentinal node biopsy in those

Question 187

How is inoperable cancer of the breast treated? What is inoperability based on?

Answer 187

1) Inoperable cancer of the breast is treated with chemotherapy (may also add radiation), and sometimes it is rendered operable
2) Inoperability is based on local extent (not metastases)

Question 188

When should adjuvant systemic therapy follow surgery in breast cancer treatment? When is chemotherapy used and when is hormonal therapy added?

Answer 188

1) Adjuvant systemic therapy should follow surgery in virtually all patients, particularly if axillary nodes are positive
2) Chemotherapy is used in most cases, and hormonal therapy is added if the tumor is receptor positive

Question 189

What type of breast cancer hormonal therapy do premenopausal women receive if given? Postmenopausal women? In what patients is hormonal therapy given alone for breast cancer?

Answer 189

1) Premenopausal women receive tamoxifen
2) Postmenopausal women receive anastrozole
3) Frail, old women with tumors that are not too aggressive may be offered hormonal therapy alone

Question 190

What finding suggests metastasis in women who recently had breast cancer?

Answer 190

Persistent headache or back pain (with areas of localized tenderness) in women who recently had breast cancer suggests metastasis

Question 191

What is a diagnostic test for breast cancer metastasis? How can brain metastases be treated? What is the favorite location in the spine for breast cancer to metastasize to?

Answer 191

1) MRIs are diagnostic
2) Brain metastases can be radiated or resected
3) The vertebral pedicles are the favorite location in the spine

Question 192

For breast cancer, what are infiltrated axillary nodes a marker of? What does removing these lymph nodes help with?

Answer 192

1) Cancer infiltrated axillary nodes tell us that systemic therapy is needed
2) If we choose to clean out an axilla that is full of cancer, we are only debulking. We are making the job of chemo and hormonal therapy a little easier by reducing the number of cells they have to kill

Question 193

Are most thyroid nodules benign or malignant? At what age do they occur? Does thyroid cancer affect thyroid function?

Answer 193

1) Most thyroid nodules are benign, but the few that are malignant must be diagnosed and treated
2) These can occur at any age
3) As a rule, thyroid cancer does not affect thyroid function

Question 194

How is the diagnosis made for thyroid cancer? What if the node is benign? What are the different types of thyroid cancer that can be diagnosed by FNA?

Answer 194

The diagnosis is typically made by fine needle aspiration (FNA), which is most cases indicates whetehr the node is benign (if so, follow up) or has papillary, medullary, or anaplastic cancer

Question 195

Which type of thyroid cancer cannot be easily diagnosed by FNA and what may be needed to be done next?

Answer 195

Follicular cancer is not easily diagnosed by FNA, and a lobectomy may be needed to determine if a follicular neoplasm is benign (adenoma) or malignant

Question 196

Is papillary thyroid cancer slow or fast growing? What dictates the extent of surgical resection?

Answer 196

1) Papillary cancer is very slow growing

2) The extent of surgical resection is dictated by the size of the tumor or the presence of metastatic nodes

Question 197

What is an advantage of doing a total thyroidectomy in the presence of follicular cancer?

Answer 197

1) Follicular cancer has rudimentary function: It can take radioactive iodine if it does not have to compete with normal thyroid tissue
2) Thus, a total thyroidectomy is always done for follicular cancer, because doing so permits use of radioactive iodine in the future to identify and treat any potential metastasis

Question 198

What cell type does medullary cancer of the thyroid develop from? How is it treated and why? Workup for what other condition is indicated in the presence of medullary thyroid cancer?

Answer 198

1) Medullary cancer comes from the C cells that make calcitonin (useful for follow-up)
2) It is aggressive, and radical surgery is justified
3) Workup for pheochromocytoma is indicated, as they often coexist (MEN, type 2)

Question 199

Anaplastic cancer of the thyroid is seen in young or old people? How quickly does it grow and what can be done?

Answer 199

1) Anaplastic cancer is seen in old people

2) It grows like wildfire, and often all that can be done for the patient is a tracheostomy

Question 200

What is hyperthyroidism treated with in most cases?

Answer 200

Hyperthyroidism is treated with radioactive iodine in most cases. There is a very limited role for surgery on patients who have a “hot adenoma”

Question 201

How is hyperparathyroidism most commonly found? What should be done next?

Answer 201

1) Hyperparathyroidism is most commonly found by serendipitous discovery of high serum calcium in blood tests (rarely seen in the full florid “disease of stones, bones, and abdominal groans”)
2) Repeat calcium determinations, look for low phosphorus, and rule out cancer with bone metastases. If findings persist, do parathyroid hormone (PTH) determination (and interpret in light of serum calcium levels)

Question 202

How frequently do asymptomatic patients with hyperparathyroidism become symptomatic? What is therefore justified to do?

Answer 202

1) Asymptomatic patients become symptomatic at a rate of 20% per year
2) Thus elective intervention is justified

Question 203

What percent of patients with hyperparathyroidism have single adenoma? Is removal curative? What test can be done to help locate the adenoma before surgery?

Answer 203

1) 90%

2) Removal is curative (sestamibi scan may help locate the culprit gland before surgery)

Question 204

How can Cushing syndrome be identified? What conditions are present?

Answer 204

1) Cushing can be identified at a glance by looking at the picture of a lovely young woman next to a picture of a “monster” who is the same lady a couple of years later. The “monster” has a round, ruddy, hairy face, buffalo hump, supraclavicular fat pads, obese trunk with abdominal stria, and thin weak extremities
2) Osteoporosis, diabetes, hypertension, and mental instability are also present

Question 205

What does workup of Cushing syndrome begin with? What does a negative test indicate?

Answer 205

1) Workup starts with an overnight low-dose dexamethasone suppression test
2) Suppression at low dosage rules out the disease (she is just a fat hairy lady)

Question 206

If dexamethasone suppression test is positive (no suppression), what is the next step in diagnosing Cushing syndrome? What if this test is elevated?

Answer 206

1) 24-hour urine-free cortisol is measured

2) If elevated, we go to a high-dose suppression test

Question 207

What does suppression at a higher dose dexamethasone indicate for Cushing syndrome? No suppression? Once the causal site is identified, what are the final steps?

Answer 207

1) Suppression at a higher dose identifies pituitary microadenoma
2) No suppression at either dosage identifies adrenal adenoma (or paraneoplastic syndrome)
3) Do appropriate imaging studies (MRI for pituitary, CT scan for adrenal) and remove the offending adenoma

Question 208

What diagnostic algorithm does the Mayo Clinic advocate that differs from the high-dose suppression test + imaging studies?

Answer 208

24-hour urinary collection for free cortisol levels (patients with this disease have levels 3 to 4 times the normal) is followed by measurement of corticotropin to differentiate pituitary adenomas from adrenal adenomas

Question 209

What is Zollinger-Ellison syndrome?

Answer 209

Zollinger-Ellison (gastrinoma) shows up as virulent peptic ulcer disease, resistant to all usual therapy (including eradication of Helicobacter pylori) and more extensive than it should be (several ulcers rather than one, ulcers extending beyond first portion of the duodenum)

Question 210

What symptom do some patients with Zollinger-Ellison syndrome present with? How should you workup and treat suspected Zollinger-Ellison syndrome?

Answer 210

1) Some patients have watery diarrhea
2) Measure gastrin and do secretin test if values are equivocal
3) Locate the tumor with CT scan (with contrast) of the pancreas and nearby areas
4) Remove it
5) Omeprazole helps those with metastatic disease

Question 211

Why and when does an insulinoma produce CNS symptoms?

Answer 211

Insulinoma produces CNS symptoms because of low blood sugar, always when the patient is fasting

Question 212

What is the differential diagnosis of insulinoma with?

Answer 212

Differential diagnosis is with reactive hypoglycemia (attacks occur after eating) and with self-administration of insulin

Question 213

How can you determine if someone has hypoglycemia induced by self-administration of insulin?

Answer 213

Patients have reason to be familiar with insulin (some connection with the medical profession, or with a diabetic patient), and in plasma assays they have high insulin but low C-peptide. In insulinoma, both are high

Question 214

What imaging should be done to identify an insulinoma? What should be done once the tumor is located?

Answer 214

1) CT (with contrast) of pancreas is done to locate tumor

2) Remove it

Question 215

In a patient with suspected insulinoma, levels of what drug aside from insulin needs to be measured in the workup?

Answer 215

Some medically sophisticated patients are using sulfonylureas to induce endogenous insulin secretion, and defeat the diagnostic value of C-peptide. Levels of those drugs need to be measured in the workup

Question 216

What is nesidioblastosis?

Answer 216

Nesidioblastosis is a devastating hypersecretion of insulin in the newborn, requiring 95% pancreatectomy

Question 217

How does a glucagonoma present?

Answer 217

Glucagonoma produces severe migratory necrolytic dermatitis, resistant to all forms of therapy, in a patient with mild diabetes, a touch of anemia, glossitis, and stomatitis

Question 218

What is a diagnostic test for glucagonoma? What test is used to locate the tumor? Is resection curative?

Answer 218

1) Glucagon assay is diagnostic
2) CT scan is used to locate tumor
3) Resection is curative

Question 219

What can help in patients with metastatic, inoperable glucagonoma?

Answer 219

Somatostatin and streptozocin can help those with metastatic, inoperable disease

Question 220

What can primary hyperaldosteronism be caused by? What is the key finding in both cases? What are some other findings?

Answer 220

1) Primary hyperaldosteronism can be caused by an adenoma or by hyperplasia
2) In both cases the key finding is hypokalemia in a hypertensive (usually female) patient who is not on diuretics
3) Other findings include modest hypernatremia and metabolic alkalosis

Question 221

Are levels of aldosterone high or low in primary hyperaldosteronism? Renin?

Answer 221

Aldosterone levels are high, whereas renin levels are low

Question 222

How can response to postural changes help in the diagnosis of etiology of primary hyperaldosteronism?

Answer 222

Appropriate response to postural changes (more aldosterone when upright than when lying down) suggests hyperplasia (which is treated medically), whereas lack of response (or inappropriate response) is diagnostic of adenoma

Question 223

How is adrenal adenoma identified? Can surgical removal provide cure?

Answer 223

1) Adrenal CT scans localize it

2) Yes

Question 224

In which patients is pheochromocytoma typically seen in? Why can diagnosis be frustrating?

Answer 224

1) Pheochromocytoma is typically seen in thin, hyperactive women who have attacks of pounding headache, perspiration, palpitations, and pallor (at which time they have extremely high blood pressure)
2) By the time patients are seen, the attack has subsided and the pressure may be normal, leading to a very frustrating lack of diagnosis. Patients who have sustained hypertension are easier to diagnose

Question 225

How should workup of pheochromocytoma begin? What should be done next? Are tumors usually small or large? What is required prior to surgery?

Answer 225

1) Start workup with 24-hour urinary determination of vanillylmandelic acid (VMA-easy to do, but may give false positives), metanephrines (more specific), or free urinary catecholamines
2) Follow with CT scan of adrenal glands or radionuclide studies if looking for extraadrenal sites
3) Tumors are usually large
4) Surgery requires careful pharmacologic preparation with alpha-blockers

Question 226

How do patients with coarctation of the aorta typically present? What does CXR show? What is the diagnostic test? Is surgical correction curative?

Answer 226

1) Coarctation of the aorta may be recognized at any age, but patients typically are young and have hypertension in the arms, with normal pressure (or low pressure, or no clinical pulses) in the lower extremities
2) Chest x-ray shows scalloping of the ribs (erosion from large collateral intercostals)
3) Spiral CT scan enhanced with intravenous dye (CT angio) is usually diagnostic
4) Yes, surgical correction is curative

Question 227

In which two groups do you usually see renovascular hypertension? What do you see in both groups that suggests the diagnosis?

Answer 227

1) Young women with fibromuscular dysplasia
2) Old men with arteriosclerotic occlusive disease
3) In both groups hypertension is resistant to the usual medications, and a telltale faint bruit over the flank or upper abdomen suggests the diagnosis

Question 228

What is the workup of renovascular hypertension? What is therapy and when is it used?

Answer 228

1) Workup is multifactorial, but duplex scanning of the renal vessels and CT angio have prominent roles
2) Therapy is imperative in the young women, usually balloon dilatation and stenting; but it is much more controversial in the old men who may have short life expectancy from the other manifestations of the arteriosclerosis