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surgery: pestana shelf > Pestana Gen Surgery > Flashcards

Pestana Gen Surgery Flashcards

1
Q

When is surgery for GERD indicated? 3

A

for anyone with:

  1. long-standing symptomatic disease not controlled by medical means
  2. complications (ulceration, stenosis)
  3. severe dysplastic changes
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2
Q

what type of surgery is appropriate for GERD? 2

A
  • Laparoscopic Nissen Fundoplication (LNF) - if patient has symptomatic disease not controlled by medical means or developed complications (ulceration+stenosis)
  • LNF + radiofrequency ablation if there are severe dysplastic changes
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3
Q

how does achalasia usually present?

A

since it is a motility issue, there is dysphagia for liquids AND solids

<span>(dysphagia initially to solids w/ progression to involve liquids -> think mechanical obstruction, i.e. cancer)</span>

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4
Q

diagnosis and management of achalasia?

A
  • diagnosis: barium swallow + manometry
  • mgmt: balloon dilation
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5
Q

how does esophageal cancer present itself?

A

dysphagia initially to solids only but progresses to solids AND liquids

significant weight loss

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6
Q

what are 2 types of esophageal cancers and in what patient population do you normally see them in?

A
  • squamous cell carcinoma - men with hx of smoking + EtOH
  • adenocarcinoma - long-standing GERD
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7
Q

diagnosis & mgmt of esophageal cancers

A

diagnosis: barium swallow followed by endoscopic biopsy and CT scan (assesses operability)
mgmt: palliative surgery

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8
Q

Patient with prolonged, forceful vomiting eventually starts to vomit bright red blood. Diagnosis and management?

A

diagnosis: mallory weiss tear
mgmt: endoscopy + laser photocoagulation

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9
Q

Patient with prolonged, forceful vomiting suddenly develops epigastric pain, fever, and leukocytosis. Diagnosis and management?

A

diagnosis: boerhaave syndrome
mgmt: contrast swallow followed by emergency surgical repair

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10
Q

shortly after an endoscopy procedure, a patient develops sub-cutaneous emphysema in the lower neck. Diagnosis and management?

A

diagnosis: iatrogenic perforation of the esophagus
mgmt: contrast study + prompt repair

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11
Q

diagnosis and management of an elderly patient who presents with anorexia, weight loss, intermittent hematemesis, and early satiety

A

gastric adenocarcinoma or lymphoma

mgmt: endoscopic biopsy w/ CT to assess operability

if adenocarcinoma –> surgery

if lymphoma –> chemoRx + radioRx

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12
Q

best treatment for gastric adenocarcinoma

A

surgery

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13
Q

best treatment for gastric lymphoma

A

chemoRx or radioRx

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14
Q

best treatment for MALT lymphoma (MALToma)

A

eradication of H. pylori

( 1 wk of “triple therapy” consisting of omeprazole + clarithromycin + amoxicillin)

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15
Q

patient with a prior history of laparoscopic appendectomy presents with colicky abdominal pain with progerssive abdominal distension, protracted vomiting, and absence of BM/flatulence.

What should you think of? How would you confirm your suspicion?

A

mechanical intestinal obstruction

Xray -> distended loops of small bowel with air-fluid levels

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16
Q

mgmt of patient with SBO 3

A

NPO, NG suction, and IVF with hopes for spontaneous resolution and watching for early signs of strangulation (fever, leukocytosis, constant pain, signs of peritoneal irritation, peritonitis, sepsis)

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17
Q

when is surgery indicated for a patient with SBO? 3

A

1) conservative mgmt is unsuccessful
2) within 24h of complete obstruction
3) within a few days in partial obstruction

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18
Q

5 indications that a patient with SBO has a compromised blood supply (ie strangulated obstruction).

how are these patients managed?

A

fever

leukocytosis

constant pain

signs of peritoneal irritation/peritonitis

sepsis

mgmt: emergency surgery

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19
Q

mgmt of a patient with an irreducible hernia that used to be reducible

A

surgical repair

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20
Q

Carcinoid syndrome

how do these patients present? how to make the diagnosis?

A

seen in patients with small bowel carcinoid tumor with liver metz

diarrhea, facial flushing, wheezing, R valvular damage

dx: 24 hour urinary collection for 5-hydroxyindolacetic acid

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21
Q

how do cancers of the R colon usually present?

A

elderly

anemia (hypochromic)

(+) FOBT

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22
Q

diagnosis and mgmt of R colon cancers

A

diagnosis: colonoscopy and biopsy
mgmt: R hemicolectomy

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23
Q

how do cancers of the L colon usually present?

A

bloody bowel movements such that blood coats the outisde of the stool

stools are of narrow caliber

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24
Q

diagnosis and mgmt of L colon cancers

A
  • diagnosis: flexible proctosigmoidoscopic exam + biopsy
  • prior to surgery:
    • full colonoscopy (to r/o a second primary) and CT scan (assess operability)
    • chemoRx and radiation Rx necessary for large rectal cancers
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25
Q

when is surgery indicated for chronic ulcerative colitis? 4

what does the surgery entail?

A
  1. disease >20 years
  2. severe nutritional deficits
  3. multiple hospitalizations
  4. need for high-dose steroids or immunosuppressants
  5. development of toxic megacolon

surgery entails removing all of the affected colon, including all of the rectal mucosa (which is always involved)

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26
Q

when is emergency colectomy indicated for pseudomembrane enterocolitis?

A

(c. diff)

surgery indicated when

  • disease that is unresponsive to standard metronidazole/vancomycin
  • WBC >50K
  • serum lactate level above 5
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27
Q

∆ between external and internal hemorrhoids

A

external = painful (attributed to thrombosed hemorroids)

internal = bleeding after defecation

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28
Q

treatment for internal hemorrhoids

A

rubber band ligation

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29
Q

treatment for external hemorrhoids

A

surgical removal

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30
Q

who typically gets anal fissures?

A

young women

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31
Q

how do anal fissures typically present?

How would you conduct a proper exam?

A

blood streaked stools

exquisite pain with defecation

bowel movements are avoided due to pain (thus perpetuating the situation).

pain may be so intense that they may refuse a proper exam of the area, and therefore exam may be need to be done under anesthesia

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32
Q

treatment for patients with anal fissures

A

stool softenders

topical NTG

botolinum toxin

forceful dilation

lateral internal sphinctertomy

Ca channel blockers (diltiazem) ointment TID for 6 weeks

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33
Q

when is perianal crohn’s disease suspected?

A

when the area fails to heal and gets worse after surgical intervention

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34
Q

when is surgery indicated for perianal crohn’s disease?

A

IT IS NOT! It should be avoided and the fistulas should be drained with setons while medical therapy is underway.

Remicade helps healing

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35
Q

febrile, exquisite perirectal pain to the point where the patient can’t sit down or have bowel movements.

physical exam shows a perianal abscess lateral to the anus (btwn rectum and ischial tuberosity)

next best step in management?

A

ischiorectal abscess

I&D

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36
Q

complications in patients who’ve had an ischiorectal abscess drained

how do these patients present?

A

fistula-in-ano

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37
Q

opening lateral to the anus that leaks fecal matter and occasional perineal discomfort

next best step in management?

A

fistula in ano

fistulotomy

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38
Q

squamous cell carcinoma of the anus is more common in which patient populations?

A

HIV+

homosexuals with receptive practices

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39
Q

fungating anal mass with (+) inguinal nodes felt

diagnosis and next best step in management?

A

squamous cell carcinoma of the anus, diagnosed with biopsy

nigrohemoradiation (5 weeks)

surgery if there is residual tumor

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40
Q

vomiting blood should denote a source within the _________

next best step in management?

A

upper GI (tip of nose to ligament of treitz)

upper GI endoscopy

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41
Q

patient presents with melena - next best step in management?

A

upper GI endoscopy

melena always indicate digested blood, thus it must originate high enough to undergo digestion

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42
Q

patient has blood per rectum. What is the FIRST diagnostic maneuver?

A

Aspirate gastric contents with an NG tube and if:

  • if blood is retreived -> upper GI source is established -> follow-up with upper GI endoscopy
  • if no blood is retreieved/fluid is white -> duodenal is potential source -> get upper GI endoscopy
  • if no blood is retreieved/ fluid is bile tinged -> upper GI is excluded -> no need for an upper GI endoscopy
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43
Q

patient wiht blood per rectum gets an NG tube. If aspiration results in these fluid features, what is the next best step in management?

if blood is retreived ->
if no blood is retreieved/fluid is white ->
if no blood is retreieved/ fluid is bile tinged ->

A
  • if blood is retreived -> upper GI source is established -> follow-up with upper GI endoscopy
  • if no blood is retreieved/fluid is white -> duodenal is potential source -> get upper GI endoscopy
  • if no blood is retreieved/ fluid is bile tinged -> upper GI is excluded -> no need for an upper GI endoscopy
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44
Q

active bleeding per rectum (fresh red blood) - what should you always do first?

A

Anoscopy (rule out bleeding hemorroids)

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45
Q

active bleeding per rectum (fresh red blood) - what is the next best step in management after bleeding hemorroid is ruled out? 3

A

Angiogram - finds the source and allow for angiographic embolization

or

tagged red-cell study if the bleeding isn’t too fast or too slow

or

capsule endoscopy (used when bleeding is not found to be in the colon)

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46
Q

utility of a capsule endoscopy

A

used when red blood per rectum is not found to be in the colon (ie source may be in the small bowel)

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47
Q

utility of a tagged red cell study

A

can localize to the site of a bleed in the colon but the caveat is that by the time the patient is finished, the patient may no longer be bleeding

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48
Q

why is that when you see blood per rectum, you should not suspect that it is only from the lower GI tract?

A

it can come from anywhere in the GI tract (including upper GI) as it may have transited too fast through the colon to be digested

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49
Q

next best step in management of a young patient with a recent history of blood per rectum, but not actively bleeding at the time of presentation

A

upper GI endoscopy

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50
Q

next best step in management of an elderly patient with a recent history of blood per rectum, but not actively bleeding at the time of presentation

A

upper + lower GI endoscopy

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51
Q

next best step in management of a child patient with a recent history of blood per rectum, but not actively bleeding at the time of presentation

A

technectium scan - suspect MECKEL’S DIVERTICULUM

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52
Q

What should you suspect in ICU patients with massive upper GI bleeds?

next best step in management of these patients? 3

A

stress ulcers

endoscopy (to confirm) + angiographic embolization + PPI (maintains pH >4)

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53
Q

4 causes of acute abdomen

A

perforation

obstruction

inflammatory process

ischemic process

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54
Q

Patient with long history of PUD suddenly becomes very reluctant to move and is very protective of his abdomen. Physical exam shows generalized signs of peritoneal irritation (tenderness, muscle guarding, rebound, and silent adomen)

Diagnosis? How is it confirmed?

Next best step in management?

A

acute abdomen caused by perforation

upright xrays show free air under the diaphragm

emergency surgery

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55
Q

patient develops sudden onset of colicky abominal pain and moves constantly in order to try to find a position of comfort

Dx and Ddx?

A

acute abdomen caused by obstruction

Ddx: ureteral stone, stone in cystic or common bile duct

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56
Q

patient develops fever, leukocytosis, vague abdominal pain slowly built up over a few hours and eventually localized to a particular area

diagnosis?

A

acute abdomen caused by inflammatory process

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57
Q

What should you suspect in a child with nephrotic syndrome and ascites, fever, and leukocytosis?

Next best step in management?

A

primary peritonitis (would show signs of peritoneal irritation - tenderness, guading, rebound, silent abdomen)

Get cultures of ascitic fluid and treat with antibiotics

58
Q

treatment for acute abdomen

A

exploratory laparatomy

(remember, acute abdomen can be caused by perforation, obstruction, inflammatory, or ischemic process)

59
Q

rapid onset of constant upper abdominal pain in a chronic alcoholic

how to make diagnosis?

next best step in management?

A

acute pancreatitis

get serum or urinary amylase or lipase

NPO, IVF, NG suction to allow for bowel rest

60
Q

acute onset of colicky flank pain with radiation to inner thigh and groin; + urgency, + frequency, + microhematuria on UA

diagnostic test?

A

get CT scan

ureteral stone

61
Q

65 yo with acute onset of LLQ pain, + fever, + leukocytosis

diagnostic test and diagnosis?

next best step in management?

A

Acute diverticulitis

CT is diagnostic

NPO, IVF, antibiotics to allow bowel rest

62
Q

When is surgery indicated for acute diverticulitis?

A

when patients continue to be febrile and have persistent leukocytosis despite NPO, IVF and antibiotics

elective surgery indicated for those who has had >2 attacks

63
Q

vovulus of the sigmoid is seen in what patient population?

how do these patients present?

management of these patients?

A

old folks

present with signs of intestinal obstruction - severe abdominal distension, xrays that show air-fluid levels, “parrot’s beak”

proctosigmoidoscopic exam (with a rigid instrument) followed by rectal tube

64
Q

when is elective sigmoid resection ever indicated?

A

when there is recurrent vovulus

65
Q

Elderly folk presents with acute abdominal pain, GI bleed, and acute sepsis. Diagnosis and rationale?

A

acute abdomen secondary to mesenteric ischemia

Elderly folks tend not to mount impressive acute abdomens and the diagnosis is often made late, when there is blood in bowel lumen, acidosis, and sepsis

66
Q

acute abdomen secondary to mesenteric ischemia is seen in which patient populations? 3

management?

A

elderly

a-fib

recent MI

management: arteriogram and embolectomy (if early presentation)

67
Q

vague upper RUQ discomfort and weight loss + elevated AFP

diagnosis and next best step in management?

A

think HCC!

get a CT scan + book OR for resection

68
Q

How is metz to the liver treated?

A

resection if metz is confined to one lobe

radioablation if diffuse

69
Q

jaundiced man from mexico should automatically trigger this diagnosis in mind

what is the next best step in management?

A

amebic abscess of the liver (Entamoeba histolytica)

get serologies but since they take a while to come back, start empiric treatment with metronidazole

70
Q

25 yo F with RUQ pain with sudden onset of hypotension, tachycardia, and diaphoresis

Diagnosis? Next best step in management?

A

consider hepatic adenomas, which is a complication of birth control pills (she is of the age group that would use it

Emergency schedule is indicated - these have a tendency to rupture and bleed massively, leading to to hypotension, tachycardia, and diaphoresis

71
Q

LFT profile of patients with hemolytic jaundice

A

elevated bilirubin with elevated indirect fraction + normal direct fraction (ø bile in the urine)

normal AST/ALT

normal Alk Phos

72
Q

LFT profile of patients with hepatocellular jaundice

A

elevation of both indirect and direct bilirubin

high transaminases

modest elevation in alk phos

73
Q

LFT profile of patients with obstructive jaundice

A

elevated direct + indirect bilirubin

modest AST/ALT elevation

very high levels of alk phos

74
Q

patient has elevated indirect and normal direct bilirubin. What is the next best step in management?

A

think hemolytic jaundice

get w/u to determine what is causing hemolysis of RBC

75
Q

patient has elevated indirect + direct bilirubin, high AST/ALT, and modest elevation in Alk phos. What is the next best step in management?

A

Think jaundice of hepatocellular origin, with hepatitis being the most common etiology.

w/u with serologies to determine specific type

76
Q

patient has elevated indirect and direct bilirubin, with modest elevation in AST/ALT and very high levels of alk phos. What is the next best step in management?

A

think obstructive jaundice, likely due to GB stones or malignancy

get sonogram to determine the nature of the obstructive process

77
Q

enlarged palpable GB

A

courvoisier-terrier sign - usually indicative of malignancy

78
Q

45 yo obese woman with RUQ pain

What is the diagnostic test of value? 2

next best step in management? 2

A

biliary tract disease, likely attributed to stones in the CBD

get sonogram - dilated ducts + non-dilated GB full of stones

Alkalkine phosphatase is also elevated

next steps: ERCP to confirm diagnsois, do sphinctertomy, and extract CBD stone. Cholecystectomy should follow

79
Q

ddx of obstructive jaundice 4

A

GB stones

adenocarcinoma of the head of the pancreas

adenocarcinoma of the ampulla of vater

cholangiocarcinoma of the common bile ducts

80
Q

dilated GB vs non-dilated GB seen on sonogram

prognosis of either one?

A

dilated GB = BAD! “bad ass dilation” - should make one think of malignancy

shrunken, fibrotic (non-dilated) GB = OK! - should make one think of stones because the stones can cause chronic irritation and inflammation, which can result in a shruken fibrotic GB

81
Q

Patient with dilated GB seen on sonogram

next best step in management? 2

A

dilated GB = BAD! “bad ass dilation” - should make one think of malignancy

get CT + percutaneous biopsy - pancreatic cancers that have produced obstructive jaundice are often large enough to be seen on CT

82
Q

Patient with dilated GB seen on sonogram but CT is ngetaive

next best step in management? 1

A

get MRCP - will usually show tumors that were too small to show up on the CT (small ampullary tumors, cholangiocarcinomas, small pancreatic tumors pushing on the ducts from the outside)

83
Q

when should you suspect adenocarcinoma of the ampulla of vater that is cause of jaundice?

next best step in management?

A

jaundice + anemia + FOBT, since ampullary cancers can bleed into the lumen like any other mucosal malignancy while obstructing biliary flow

get endoscopy to biopsy the ampullary cancer

84
Q

surgery for pancreatic cancer

A

whipple

85
Q

treatment for asymptomatic gallstones

A

nada

86
Q

patient comes in with biliary colic and wants stat treatment

A

anticholinergics (ie scopolamine), which can relieve biliary spasms

87
Q

patient with biliary colic has sonogram that is (+) for stones

next best step in management?

A

elective cholecystectomy

88
Q

∆ btwn biliary colic and acute cholecystitis?

A

biliary colic - colicky pain, ø signs of peritoneal irritation or systemic signs of inflammatory process

acute cholecystitis - constant pain, (+) signs of peritoneal irritation or systemic signs of inflammatory (fever/leukocystosis) process

  • stone remains at the cystic duct until an inflammatory process develops
89
Q

management of patient that presents with biliary colic 3

A

anticholinergics to abort colic/bilary spasms

sonogram to establish diagnosis

elective cholecystectomy

90
Q

management of patient that presents with acute cholecystitis 5

A

NG suction

NPO

IVF

antibiotics

elective cholecystectomy

91
Q

when is an percutaneous transhepatic cholecystectomy indicated for acute cholecystitis?

A

in patients who are very sick and have a significant surgical risk (ie patient with severe COPD)

92
Q

∆ btwn acute cholecystitis and acute ascending cholangitis

A

BOTH present with constant pain, (+) signs of peritoneal irritation or systemic signs of inflammatory (fever, leukocystosis) process, but acute ascending cholangitis also presents with extremely high levels of alkaline phosphatase

93
Q

management of acute ascending cholangitis 3

A
  1. IV antibiotics
  2. emergency decompression via ERCP or percutaneous transhepatic cholangiogram
  3. cholecystectomy
94
Q

cause of patients with biliary pancreatitis

A

GB stones become impacted at the ampulla, temporarily obstructing both pancreatic and biliary ducts

often pass spontaneously

95
Q

management of patients with biliary pancreatitis 4

A

NPO, NG suction, IVF until stone passes

elective cholecystectomy

96
Q

management of patients with biliary pancreatitis with a large obstructing stone at the ampulla of vater

A

likelihood of this stone passing is nil. Proceed to ERCP with sphincterotomy to dislodge impacted stone

97
Q

Acute pancreatitis can be of these 3 types

A

edematous

hemorrhagic

suppurative

98
Q

labs diagnostic of edematous pancreatitis

A

elevated serum amylase or lipase

elevated hematocrit

99
Q

labs diagnostic of hemorrhagic pancreatitis

A

starts off as the edematous form, so elevated amylase and lipase

low hematocrit

100
Q

management of patient that presents with elevated serum amylase and lipase and elevated hematocrit 3

A

key finding here is the elevated hematocrit, which is suggestive of acute edematous pancreatitis

NPO, NG suction, and IVF

101
Q

management of patient that presents with elevated serum amylase and lipase and decreased hematocrit 3

A

key finding here is that the hematocrit is decreased, which is suggestive of acute hemorrhagic pancreatitis

intensive supportive therapy (ICU)

anticipate abscess formation and subsequent drainage

IV imipenem or meropenem (if pt has seizure d/o)

102
Q

best way to manage necrotic pancreas

A

necrosectomy

usually wait 4 weeks before debriding the necrotic tissue such that the dead tissue delineates well and mature for dissection

103
Q

when do pancreatic abscesses form? how do patients usually present?

A

usually ~10 days after the onset of pancreatitis

usually presents with persistent fever and leukocytosis

104
Q

late sequela of acute pancreatitis or pancreatic trauma

how do these patients usually present? diagnosed?

A

pancreatic pseudocyst

usually the cyst is just outside the pancreatic ducts, resulting in “pressure-like” sx (early satiety, vague discomfort, palpable mass)

CT or sono is diagnostic

105
Q

how are pancreatic pseudocysts managed?

A

- observation

> 6 cm - drainage (increased likelihood of rupture/bleeding)

106
Q

how is chronic pancreatic managed?

A

insulin + pancreatic enzymes (patients usually develop calcified pancreas, steatorrhea, diabetes, and constant epigastric pain)

107
Q

T/F all abdominal hernias should be repaired

A

TRUE - avoids risk of intestinal obstruction and strangulation

108
Q

exceptions to elective repair of abdominal hernias 2

A
  1. patients 2-5 yo - hernias may resolve spontaenously
  2. esophageal sliding hiatal hernias (not true heranis)
109
Q

firm, rubbery mass that is mobile with palpation in a young woman

management?

A

fibroadenoma

get FNA or sonogram to establish diagnosis, surgical removal is optional

110
Q

firm, rubbery mass that is mobile with palpation in a very young adolescent

management?

A

fibroadenoma (variant of fibroadenoma w/ incr. stromal cellularity)

get FNA or sonogram to establish diagnosis, surgical removal is recommended to avoid deformity and distortion of the breast

111
Q

breast mass that usually presents in the late 20s

what is the mangagement for these? 2

A

cystosarcoma phylloides - most are benign but some have the potential to become malignant sarcomas, and therefore a core/incisional biopsy and subsequent removal is mandatory

112
Q

breast mass that usually present in 30s and 40s and result in bilateral breast tenderness that coincides with menstrual cycle

management?

A

mammary dysplasia

113
Q

young women with bloody nipple discharge

management? 3

A
  1. mammogram to r/o other potential lesions
  2. galactogram (diagnostic and will guide resection)
  3. surgical resection
114
Q

breast abscess is seen in which subgroup of women?

management?

A

lactating women (infants suckling -> introduce bacteria)

biopsy and I&D

115
Q

palpable breast mass

A

suspect breast ca until proven otherwise

116
Q

if a woman is diagnosed with breast cancer during pregnancy, is termination necessary?

A

NO, it is treated the same way (lumpectomy or radical mastectomy w/ axillary sampling) except:

  • ø radioTx during the entire pregnancy
  • ø chemoRx during the first trimester
117
Q

how does breast cancer appear on mammograms?

A

irregular areas of increased density with fine microcalcifications

118
Q

standard management of resectable breast cancer 2

A
  • lumpectomy + axillary sampling/removal of sentinel nodes + post-op radiation
  • radical mastectomy with axillary sampling/removal of sentinal nodes
119
Q

management of DCIS

A

total simple mastectomy

(local excision = NOT recommended since there is a very high incidence of recurrence, esp if there are multicentric lesions which increases risk of missing an invasive foci)

120
Q

treatment of breast cancer that has replaced/distorted significant areas of the breast

A

these are usually inoperable and is treated with chemoRx +/- radiation

121
Q

when and in whom is adjuvant systemic therapy indicated in breast cancer?

A

after surgery in virtually ALL patients, esp. if axillary LN are (+)

tamoxifen = premenopausal women

anastrozole = post-menopausal women

122
Q

What are the adjuvant systemic therapy used to treat breast cancer?

A

tamoxifen = premenopausal women

anastrozole = post-menopausal women

123
Q

woman with breast cancer s/p mastectomy presents with persistant HA or localized back pain

management?

A

suggests metz

MRI of the brain

brain metz is radiated or resected

124
Q

euthyroid patient is found to have a thyroid nodule

next best step in management?

A

FNA

if benign -> follow but ø intervention is necessary

if malignant/indeterminate -> lobectomy

125
Q

when is a total thyroidectomy ever indicated in patients with thyroid nodules?

A

when FNA shows evidence of follicular cancer

126
Q

hyperthyroid patient is found to have a nodule

how to diagnose? 3

next best step in management?

A

Diagnosis

  • Thyrotropin-releasing hormone (TRH) assay - TSH will be low
  • Thyroxine assay - T4 will be high
  • Nuclear scan - will determine if the nodule is the source of excess T4

Treatment

  • radioactive iodine
  • surgical excision of affected lobe
127
Q

Labs of a healthy patient show a high serum Ca. He is otherwise asymptomatic and denies use of supplements

diagnostic tests?

management?

A

determine PTH levels

elective surgical removal is justified because asymptomatic patients become symptomatic at a rate of 20%/year

128
Q

Your old patient now comes in with Cushing features. What is the next diagnostic test?

A

start with O/N low-dose dex suppression test

if ø suppression -> 24 hr urine cortisol

if high Ucortisol -> high dose dex suppression test

if suppression -> pituitary microadenoma

if ø suppression -> adrenal adenoma/paraneoplastic

129
Q

∆ btwn Zollingers and H. pylori?

A
  • Zollingers is PUD that is resistant to standard treatment, is more extensive (>1 ulcer, extends beyond first part of duodenum)
  • H. pylori responds to antibiotics + PPI, usually has 1 ulcer at pyloric antrum or in the duodenum
130
Q

patient presents with PUD that is resistant to antibiotics and PPI

diagnostic tests 3 and management 2?

A

Diagnostic

  • fasting gastrin levels
  • secretin test - increases gastrin (normally inhibits release of gastrin)
  • CT to locate tumor

Management

  • Surgical removal
  • PPI
131
Q

Patient comes in with hypoglycemic + CNS symptoms

first step in diagnosis? 3

next best step in management? 2

A

plasma assay for insulin + C-peptide + sulfonylurea

  • C-peptide
    • low in patients who are taking exogenous insulin
    • high in patients with insulinoma
  • Sulfonylurea induces endogenous insulin secretion and defeats the diagnostic value of C-peptide, often used by medically sophisticated patients

if determined to be an endgenous insulinoma, get CT scan to locate tumor and surgically remove it

132
Q

What is nesidioblastosis?

how are these patients managed?

A

hypersecretion of insulin in newborns

95% pancreatectomy

133
Q

How do patients with glucagonoma present?

A
  • severe migratory necrolytic dermatitis that is resistant to all forms of therapy
  • mild diabetes
  • IDA (glossitis, stomatitis)
134
Q

4 indications for surgical hypertension

A
  • Primary hyperaldosteronism
  • Pheochromocytoma
  • Coarctation of aorta
  • RAS (secondary to fibromuscular dysplasia or arteriosclerotic occlusive disease)
135
Q

How do patients with primary hyperaldosteronism present?

next diagnostic steps and management

A

HTN + hypokalemia + metabolic alkalosis + modest hypernatremia

Diagnostic tests

  • Aldosterone levels = high
  • Renin levels = low
  • postural change; if patient is upright and there is
    • more aldosterone -> think hyperplasia (medically treated)
    • no change in aldosterone -> diagnostic of adenoma (get adrenal CT with surgical removal)
136
Q

How does postural changes help determine etiology of hyperaldosteronism and help guide treatment?

A

postural change; if patient is upright and there is

  • more aldosterone -> think hyperplasia, which is medically treated
  • no change in aldosterone -> diagnostic of adenoma, which should be followed up with adrenal CT and subsequent surgical removal
137
Q

woman comes in with a classic presentation of pheochromocytoma.

Next step in diagnosis and management?

A

Diagnosis

  • 24hr urine VMA, metanephrines, or catecholamines
  • CT of adrenals (tumors are usually large)
  • radionuclide studies (to assess extra-adrenal sites)

Management

  • surgery + alpha blockers PRIOR to surgery
138
Q

child comes in with a classic presentation of aortic coarctation

next best step in diagnsois and management?

A

Diagnostic:

  • CXR - rib scalloping (due to erosion from large collateral intercostals)
  • Spiral CT scan (aka CT angio) - diagnostic

Management: surigcal correction

139
Q

HTN of renal etiology 2

A
  • fibromuscular dysplasia in young women
  • arteriosclerotic occlusive disease in old men
140
Q

management of HTN secondary to fibromuscular dysplasia in young women

A

balloon dilation + stenting

141
Q

management of HTN secondary to arteriosclerotic occlusive disease in old men

A

controversial since these men have shorter life expectancy from other manifestations of arteriosclerosis

surgery: pestana shelf (14 decks)

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