Pestana Gen Surgery Flashcards
1
Q
When is surgery for GERD indicated? 3
A
for anyone with:
- long-standing symptomatic disease not controlled by medical means
- complications (ulceration, stenosis)
- severe dysplastic changes
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
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>
4
Q
diagnosis and management of achalasia?
A
- diagnosis: barium swallow + manometry
- mgmt: balloon dilation
5
Q
how does esophageal cancer present itself?
A
dysphagia initially to solids only but progresses to solids AND liquids
significant weight loss
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
7
Q
diagnosis & mgmt of esophageal cancers
A
diagnosis: barium swallow followed by endoscopic biopsy and CT scan (assesses operability)
mgmt: palliative surgery
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
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
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
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
12
Q
best treatment for gastric adenocarcinoma
A
surgery
13
Q
best treatment for gastric lymphoma
A
chemoRx or radioRx
14
Q
best treatment for MALT lymphoma (MALToma)
A
eradication of H. pylori
( 1 wk of “triple therapy” consisting of omeprazole + clarithromycin + amoxicillin)
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
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)
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
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
19
Q
mgmt of a patient with an irreducible hernia that used to be reducible
A
surgical repair
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
21
Q
how do cancers of the R colon usually present?
A
elderly
anemia (hypochromic)
(+) FOBT
22
Q
diagnosis and mgmt of R colon cancers
A
diagnosis: colonoscopy and biopsy
mgmt: R hemicolectomy
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
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
25
when is surgery indicated for chronic ulcerative colitis? 4
what does the surgery entail?
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)
26
when is emergency colectomy indicated for pseudomembrane enterocolitis?
(c. diff)
surgery indicated when
* disease that is unresponsive to standard metronidazole/vancomycin
* WBC \>50K
* serum lactate level above 5
27
∆ between external and internal hemorrhoids
**external = painful** (attributed to thrombosed hemorroids)
**internal = bleeding** after defecation
28
treatment for internal hemorrhoids
rubber band ligation
29
treatment for external hemorrhoids
surgical removal
30
who typically gets anal fissures?
young women
31
how do anal fissures typically present?
How would you conduct a proper exam?
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**
32
treatment for patients with anal fissures
stool softenders
topical NTG
botolinum toxin
forceful dilation
lateral internal sphinctertomy
Ca channel blockers (diltiazem) ointment TID for 6 weeks
33
when is perianal crohn's disease suspected?
when the area fails to heal and gets worse after surgical intervention
34
when is surgery indicated for perianal crohn's disease?
IT IS NOT! It should be avoided and the fistulas should be drained with setons while medical therapy is underway.
Remicade helps healing
35
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?
ischiorectal abscess
I&D
36
complications in patients who've had an ischiorectal abscess drained
how do these patients present?
fistula-in-ano
37
opening lateral to the anus that leaks fecal matter and occasional perineal discomfort
next best step in management?
fistula in ano
fistulotomy
38
squamous cell carcinoma of the anus is more common in which patient populations?
HIV+
homosexuals with receptive practices
39
fungating anal mass with (+) inguinal nodes felt
diagnosis and next best step in management?
squamous cell carcinoma of the anus, diagnosed with biopsy
nigrohemoradiation (5 weeks)
surgery if there is residual tumor
40
vomiting blood should denote a source within the \_\_\_\_\_\_\_\_\_
next best step in management?
upper GI (tip of nose to ligament of treitz)
upper GI endoscopy
41
patient presents with melena - next best step in management?
upper GI endoscopy
melena always indicate digested blood, thus it must originate high enough to undergo digestion
42
patient has blood per rectum. What is the FIRST diagnostic maneuver?
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
43
patient wiht blood per rectum gets an NG tube. If aspiration results in these fluid features, what is the next best step in management?
## Footnote
if blood is retreived -\>
if no blood is retreieved/fluid is white -\>
if no blood is retreieved/ fluid is bile tinged -\>
* 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
44
active bleeding per rectum (fresh red blood) - what should you always do first?
Anoscopy (rule out bleeding hemorroids)
45
active bleeding per rectum (fresh red blood) - what is the next best step in management after bleeding hemorroid is ruled out? 3
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)
46
utility of a capsule endoscopy
used when red blood per rectum is not found to be in the colon (ie source may be in the small bowel)
47
utility of a tagged red cell study
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
48
why is that when you see blood per rectum, you should not suspect that it is only from the lower GI tract?
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
49
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
upper GI endoscopy
50
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
upper + lower GI endoscopy
51
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
technectium scan - suspect MECKEL'S DIVERTICULUM
52
What should you suspect in ICU patients with massive upper GI bleeds?
next best step in management of these patients? 3
stress ulcers
endoscopy (to confirm) + angiographic embolization + PPI (maintains pH \>4)
53
4 causes of acute abdomen
perforation
obstruction
inflammatory process
ischemic process
54
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?
acute abdomen caused by perforation
upright xrays show free air under the diaphragm
emergency surgery
55
patient develops sudden onset of colicky abominal pain and moves constantly in order to try to find a position of comfort
Dx and Ddx?
acute abdomen caused by obstruction
Ddx: ureteral stone, stone in cystic or common bile duct
56
patient develops fever, leukocytosis, vague abdominal pain slowly built up over a few hours and eventually localized to a particular area
diagnosis?
acute abdomen caused by inflammatory process
57
What should you suspect in a child with nephrotic syndrome and ascites, fever, and leukocytosis?
Next best step in management?
**primary peritonitis** (would show signs of peritoneal irritation - tenderness, guading, rebound, silent abdomen)
Get **cultures** of ascitic fluid and treat with **antibiotics**
58
treatment for acute abdomen
exploratory laparatomy
(remember, acute abdomen can be caused by perforation, obstruction, inflammatory, or ischemic process)
59
rapid onset of constant upper abdominal pain in a chronic alcoholic
how to make diagnosis?
next best step in management?
acute pancreatitis
get serum or urinary amylase or lipase
NPO, IVF, NG suction to allow for bowel rest
60
acute onset of colicky flank pain with radiation to inner thigh and groin; + urgency, + frequency, + microhematuria on UA
diagnostic test?
get CT scan
ureteral stone
61
65 yo with acute onset of LLQ pain, + fever, + leukocytosis
diagnostic test and diagnosis?
next best step in management?
Acute diverticulitis
CT is diagnostic
NPO, IVF, antibiotics to allow bowel rest
62
When is surgery indicated for acute diverticulitis?
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
vovulus of the sigmoid is seen in what patient population?
how do these patients present?
management of these patients?
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
when is elective sigmoid resection ever indicated?
when there is recurrent vovulus
65
Elderly folk presents with acute abdominal pain, GI bleed, and acute sepsis. Diagnosis and rationale?
**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
acute abdomen secondary to mesenteric ischemia is seen in which patient populations? 3
management?
elderly
a-fib
recent MI
management: **arteriogram** and **embolectomy** (if early presentation)
67
vague upper RUQ discomfort and weight loss + elevated AFP
diagnosis and next best step in management?
think HCC!
get a **CT scan +** book OR for **resection**
68
How is metz to the liver treated?
resection if metz is confined to one lobe
radioablation if diffuse
69
jaundiced man from mexico should automatically trigger this diagnosis in mind
what is the next best step in management?
amebic abscess of the liver (Entamoeba histolytica)
get **serologies** but since they take a while to come back, start empiric treatment with **metronidazole**
70
25 yo F with RUQ pain with sudden onset of hypotension, tachycardia, and diaphoresis
Diagnosis? Next best step in management?
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
LFT profile of patients with hemolytic jaundice
elevated bilirubin with elevated indirect fraction + normal direct fraction (ø bile in the urine)
normal AST/ALT
normal Alk Phos
72
LFT profile of patients with hepatocellular jaundice
elevation of both indirect and direct bilirubin
high transaminases
modest elevation in alk phos
73
LFT profile of patients with obstructive jaundice
elevated direct + indirect bilirubin
modest AST/ALT elevation
very high levels of alk phos
74
patient has elevated indirect and normal direct bilirubin. What is the next best step in management?
think hemolytic jaundice
get **w/u to determine what is causing hemolysis of RBC**
75
patient has elevated indirect + direct bilirubin, high AST/ALT, and modest elevation in Alk phos. What is the next best step in management?
Think jaundice of hepatocellular origin, with hepatitis being the most common etiology.
w/u with **serologies** to determine specific type
76
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?
think obstructive jaundice, likely due to GB stones or malignancy
get **sonogram** to determine the nature of the obstructive process
77
enlarged palpable GB
courvoisier-terrier sign - usually indicative of malignancy
78
45 yo obese woman with RUQ pain
What is the diagnostic test of value? 2
next best step in management? 2
**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
ddx of obstructive jaundice 4
GB stones
adenocarcinoma of the head of the pancreas
adenocarcinoma of the ampulla of vater
cholangiocarcinoma of the common bile ducts
80
dilated GB vs non-dilated GB seen on sonogram
prognosis of either one?
**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
Patient with dilated GB seen on sonogram
next best step in management? 2
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
Patient with dilated GB seen on sonogram but CT is ngetaive
next best step in management? 1
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
when should you suspect adenocarcinoma of the ampulla of vater that is cause of jaundice?
next best step in management?
**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
surgery for pancreatic cancer
whipple
85
treatment for asymptomatic gallstones
nada
86
patient comes in with biliary colic and wants stat treatment
anticholinergics (ie scopolamine), which can relieve biliary spasms
87
patient with biliary colic has sonogram that is (+) for stones
next best step in management?
elective cholecystectomy
88
∆ btwn biliary colic and acute cholecystitis?
**_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
management of patient that presents with biliary colic 3
anticholinergics to abort colic/bilary spasms
sonogram to establish diagnosis
elective cholecystectomy
90
management of patient that presents with acute cholecystitis 5
NG suction
NPO
IVF
antibiotics
elective cholecystectomy
91
when is an percutaneous transhepatic cholecystectomy indicated for acute cholecystitis?
in patients who are very sick and have a significant surgical risk (ie patient with severe COPD)
92
∆ btwn acute cholecystitis and acute ascending cholangitis
**_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
management of acute ascending cholangitis 3
1. IV antibiotics
2. **emergency decompression via _ERCP_ or _percutaneous transhepatic cholangiogram_**
3. cholecystectomy
94
cause of patients with biliary pancreatitis
GB stones become impacted at the ampulla, temporarily obstructing both pancreatic and biliary ducts
often pass spontaneously
95
management of patients with biliary pancreatitis 4
NPO, NG suction, IVF until stone passes
elective cholecystectomy
96
management of patients with biliary pancreatitis with a large obstructing stone at the ampulla of vater
likelihood of this stone passing is nil. Proceed to **ERCP with sphincterotomy** to dislodge impacted stone
97
Acute pancreatitis can be of these 3 types
edematous
hemorrhagic
suppurative
98
labs diagnostic of edematous pancreatitis
elevated serum amylase or lipase
**_elevated_** hematocrit
99
labs diagnostic of hemorrhagic pancreatitis
starts off as the edematous form, so elevated amylase and lipase
## Footnote
**_low_ hematocrit**
100
management of patient that presents with elevated serum amylase and lipase and elevated hematocrit 3
key finding here is the elevated hematocrit, which is suggestive of **acute edematous pancreatitis**
## Footnote
**NPO, NG suction, and IVF**
101
management of patient that presents with elevated serum amylase and lipase and **decreased** hematocrit 3
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
best way to manage necrotic pancreas
**necrosectomy**
usually wait 4 weeks before debriding the necrotic tissue such that the dead tissue delineates well and mature for dissection
103
when do pancreatic abscesses form? how do patients usually present?
usually ~10 days after the onset of pancreatitis
usually presents with **persistent** fever and leukocytosis
104
late sequela of acute pancreatitis or pancreatic trauma
how do these patients usually present? diagnosed?
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
how are pancreatic pseudocysts managed?
**- observation**
**\> 6 cm** - drainage (increased likelihood of rupture/bleeding)
106
how is chronic pancreatic managed?
**insulin + pancreatic enzymes** (patients usually develop calcified pancreas, steatorrhea, diabetes, and constant epigastric pain)
107
T/F all abdominal hernias should be repaired
TRUE - avoids risk of intestinal obstruction and strangulation
108
exceptions to elective repair of abdominal hernias 2
1. patients 2-5 yo - hernias may resolve spontaenously
2. esophageal sliding hiatal hernias (not true heranis)
109
firm, rubbery mass that is mobile with palpation in a young woman
management?
fibroadenoma
get **FNA** or **sonogram** to establish diagnosis, **surgical removal** is _optional_
110
firm, rubbery mass that is mobile with palpation in a very young adolescent
management?
**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
breast mass that usually presents in the late 20s
what is the mangagement for these? 2
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
breast mass that usually present in 30s and 40s and result in bilateral breast tenderness that coincides with menstrual cycle
management?
mammary dysplasia
113
young women with bloody nipple discharge
management? 3
1. mammogram to r/o other potential lesions
2. galactogram (diagnostic and will guide resection)
3. surgical resection
114
breast abscess is seen in which subgroup of women?
management?
lactating women (infants suckling -\> introduce bacteria)
## Footnote
**biopsy and I&D**
115
palpable breast mass
suspect breast ca until proven otherwise
116
if a woman is diagnosed with breast cancer during pregnancy, is termination necessary?
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
how does breast cancer appear on mammograms?
irregular areas of increased density with fine microcalcifications
118
standard management of resectable breast cancer 2
* lumpectomy + axillary sampling/removal of sentinel nodes + post-op radiation
* radical mastectomy with axillary sampling/removal of sentinal nodes
119
management of DCIS
**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
treatment of breast cancer that has replaced/distorted significant areas of the breast
these are usually inoperable and is treated with chemoRx +/- radiation
121
when and in whom is adjuvant systemic therapy indicated in breast cancer?
after surgery in virtually ALL patients, esp. if axillary LN are (+)
tamoxifen = premenopausal women
anastrozole = post-menopausal women
122
What are the adjuvant systemic therapy used to treat breast cancer?
tamoxifen = premenopausal women
anastrozole = post-menopausal women
123
woman with breast cancer s/p mastectomy presents with persistant HA or localized back pain
management?
**suggests metz**
**MRI** of the brain
brain metz is **radiated** or **resected**
124
euthyroid patient is found to have a thyroid nodule
next best step in management?
FNA
if benign -\> follow but ø intervention is necessary
if malignant/indeterminate -\> lobectomy
125
when is a total thyroidectomy ever indicated in patients with thyroid nodules?
when FNA shows evidence of **follicular** **cancer**
126
hyperthyroid patient is found to have a nodule
how to diagnose? 3
next best step in management?
**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
Labs of a healthy patient show a high serum Ca. He is otherwise asymptomatic and denies use of supplements
diagnostic tests?
management?
determine PTH levels
elective surgical removal is justified because asymptomatic patients become symptomatic at a rate of 20%/year
128
Your old patient now comes in with Cushing features. What is the next diagnostic test?
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
∆ btwn Zollingers and H. pylori?
* **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
patient presents with PUD that is resistant to antibiotics and PPI
diagnostic tests 3 and management 2?
Diagnostic
* **fasting gastrin levels**
* **secretin test** - increases gastrin (normally inhibits release of gastrin)
* **CT** to locate tumor
Management
* **Surgical removal**
* **PPI**
131
Patient comes in with hypoglycemic + CNS symptoms
first step in diagnosis? 3
next best step in management? 2
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
What is nesidioblastosis?
how are these patients managed?
hypersecretion of insulin in newborns
95% pancreatectomy
133
How do patients with glucagonoma present?
* severe migratory necrolytic dermatitis that is resistant to all forms of therapy
* mild diabetes
* IDA (glossitis, stomatitis)
134
4 indications for surgical hypertension
* Primary hyperaldosteronism
* Pheochromocytoma
* Coarctation of aorta
* RAS (secondary to fibromuscular dysplasia or arteriosclerotic occlusive disease)
135
How do patients with primary hyperaldosteronism present?
next diagnostic steps and management
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
How does postural changes help determine etiology of hyperaldosteronism and help guide treatment?
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
woman comes in with a classic presentation of pheochromocytoma.
Next step in diagnosis and management?
**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
child comes in with a classic presentation of aortic coarctation
next best step in diagnsois and management?
Diagnostic:
* CXR - rib scalloping (due to erosion from large collateral intercostals)
* **Spiral CT scan** (aka CT angio) - diagnostic
Management: surigcal correction
139
HTN of renal etiology 2
* fibromuscular dysplasia in young women
* arteriosclerotic occlusive disease in old men
140
management of HTN secondary to fibromuscular dysplasia in young women
balloon dilation + stenting
141
management of HTN secondary to arteriosclerotic occlusive disease in old men
controversial since these men have shorter life expectancy from other manifestations of arteriosclerosis
