Quick Facts Flashcards

Question

W/up of thyroid nodule found on exam or incidental imaging

Answer 1

- U/S and TSH: a. Nodule + Low TSH ➡ RAI uptake scan - hot/functioning: toxic adenoma (no cancer) ➡ thionamide, b-block + lobectomy - cold: FNA b. Nodule + Normal/High TSH ➡ FNA

Answer 2

Tx: simple mastectomy w/ SLNBx - BCT usually can’t be done b/c not enough tissue - if ER+: tamoxifen (Her2+ is rare). consider orchiectomy if metastatic. - More likely ER/PR+ than females! - Prognosis similar to W but delay in px - a/w BRCA 2/Chromosome 13. Should BRCA test if family hx

Answer 3

1. Intro-op: - convert to open, intra-op cholangio, repair OR - widely drain and send to specialty center 2. Post-op: - Perc cholangiography to define the anatomy - Control spillage: external drain +/- stent +/- PTC - Repair in 6-8 weeks

Answer 4

1. LGD: ablation OR scope q6-12m - OK for fundoplication 2. HGD: ablation + Q3m scope - fundoplication c/i 3. T1a: ablation 4. t1b (or low risk T2): upfront esophagectomy *Fundoplication does not decrease cancer risk

Answer 5

1. EGD → CTA (if stable) 2. angio embolization (no surgery) - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA

Answer 6

1. Neoadjuvant: Stage 2 and above 2. Adjuvant chemo as well for Stage 3+ (nodes) **XRT either pre or post-op (not both) **Typical course: chemo-XRT ➡ surgery ➡ chemo

Answer 7

Risks: - High risk pt: afib, MHV, recent TE event (3m) - High risk surgery: nsurg, optho, cards Tx: - bridge for high-risk patients - stop warfarin 5 days before surgery if not bridging, resume on day of surgery - Hold Noac 2 days before surgery and resume 1 day after - stop Plavix 5 days before - resume AC within 24h for low risk surgery. 48-72h for high risk surgery.

Answer 8

1. Invasive cancer- no tumor on ink 2. DCIS- 2 mm **if both in specimen, margin is no tumor on ink

Answer 9

dx: - CT: displacement of renal parenchyma (vs. Wilm's) - Can also use MIBG and VMA levels (like pheo) - Usually adrenal. Can also be neck, chest, spine - neck can px w/ horner syndrome - tissue bx to get n-myc status tx: 1. S1-2 (low risk) → surg alone 2. S3+ or n-myc+ (high risk) → chemo/XRT then XRT - need bx: chemo regimen determined by n-myc amplification

Answer 10

1. Type C - MC, 85% - Proximal esophageal atresia (blind pouch) and distal TE fistula - dx: AXR ➡ distended, gas-filled stomach, coiling tube - no UGI needed! 2. Type A: second most common, 5% - Esophageal atresia and no fistula - dx: XR: gasless abdomen, coiling tube - no UGI needed! Tx: 1. Resuscitate w/ repogle tube 2. Echo: VACTERL cardiac w/up 3. G-tube placement to decompress and feed 4. Delayed RIGHT extra-pleural thoracotomy 5. Distal ligation of TEF (if gas in abdomen, type C) **long term r/o dysphagia and GERD in almost ALL patients

Answer 11

0- redo imaging 1- negative, NTD 2- benign, NTD 3- benign, repeat q6m 4- suspicious, bx 5- highly suspicious, bx 6- confirmed, excise **discordance: perform repeat bx w/ surgical excision or core bx (if there was a correctable error)

Answer 12

1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing - >.8L wedge, >1.5L lobe, >2L pneumo - < 80% ➡ lung scan for PPO FEV1, DLCO 2. PPO FEV1, DLCO > 60% ➡ no further testing - < 60% ➡ exercise test 3. VO2 > 10 ml/min/kg ➡ OK for surgery - < 10 ➡ high risk for surgery

Answer 13

Loc: gastrinoma triangle (CBD, panc neck, 3D) Px: refractory PUD - Mostly malignant Dx: G > 1000 (off PPI) or >200 w/ secretin (off PPI) - SS Scintigraphy (dotatate scan) if can't get off PPI - MRI for regional disease Tx: Screen for MEN1 - <2 cm: enucleate w/ LADN'y - > 2cm: resect w/ LADN'y

Answer 14

1. MRI 2. EUS w/ FNA (If unclear): -Pseudocyst: high Am, low CEA -Serous cystadenoma: low Am, low CEA -MCN: low Am, high CEA (>200) -IPMN: high Am, high CEA (>200) ***High CEA > 190

Answer 15

1. Rigid proctoscopy: w/ in 2cm of anal verge (levators) 2. PE: baseline sphincter dysfxn 3. Recurrent SqCC (s/p Nigro)

Answer 16

Loc: head Px: DM, GALLSTONES (> glucagonoma), steatorrhea, block exo/endo pancreas - most malignant Dx: sx's + high fast SS Tx: resect + LADN'y + CC'y

Answer 17

Proximal landing: > 1.5 cm - diameter < 3cm Common iliac (distal landing): > 1 cm - diameter > 8 mm Neck angulation < 60 degrees External Iliac diameter> 7mm **smoking is stronger RF for AAA **extensive calc is a c/i

Answer 18

1. Sitz bath, fiber 2. topical nifedipine/nitroglycerin - nitro causes headache 3. Surgery (or botox) - Good sphincter tone: LATERAL, INTERNAL sphincterotomy - Poor tone: botox **If 2/2 crohn's dz: optimize medical management

Answer 19

1. Hemangioma: only if sxatic or KM syndrome - enucleate (or resect); angioembo if active bleed 2. FNH: NTD 3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing

Answer 20

-Dx: prenatal dx on US ➡ must confirm with MRI -Tx: 1. intubate (in delivery room) - goal O2 > 60, CO2 < 60 2. NGT +/- ECM 3. delay OR when stable

Answer 21

1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram 2. Stable: left medial visceral rotation is preferred

Answer 22

Bx: stromal overgrowth, atypia, high MI, "leaf-like" - aggressive fibroepithelial lesion - non aggressive is fibroadenoma Tx: WLE w/ 1 cm margin + XRT (if > 5cm) - can spread hematogenous to lung (more than ax nodes)

Answer 23

Indications for total thyroidectomy: - Tumor > 4cm - Tumor 1-4cm and patient preference - Distant mets or extra-thyroid disease - Nodal disease - Poorly differentiated - Prior radiation *micro-mets do not count as distant disease **if thyroid lobectomy only: tx with thyroid hormone to suppress TSH, get serial U/S to monitor

Answer 24

dx: - < 3cm: excisional bx - > 3 cm: core needle (preferred) or incisional tx: - resect w/ 2 cm marg - neoadj: rhabdomyo, Ewing, high grade, > 10 cm - adj XRT: > 5cm, high grade, recurrence, close marg - adj chemo: never

Answer 25

Infected pancreatic necrosis (WBC + gas on CT) 1. CT with gas 2. Carbapenem 3. FNA + Perc drain OR endo drain (if stomach is close to pancreas) 4. Upsize drain 5. MIS retrop necrosectomy (VARD) 6. Open necrosectomy

Answer 26

types: af, aflutter, paroxysmal SVT, WPW 1. vagal → adenosine - may unmask afib/flutter 2. HDS: BB, CCB ➡ sync cardioversion 3. HDUS ➡ sync cardioversion

Answer 27

1. Punch bx or excisional bx (if < 2cm, non-sensitive area) - MIS- 5mm margin - <1mm- 1cm - 1-2mm- 1-2cm - >2mm- 2cm 2. Clinical positive nodes (stage 3) require FNA for confirmation - negative: SLNBx - positive: completion LN dissection 3. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b) 4. If SLNBx+ (stage 3): q4m US surveillance OR completion LN dissection - LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes **MOHS can be used for in-situ disease. Need 5 mm margin.

Answer 28

c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine

Answer 29

Px: bilious emesis Dx: UGI duodenum does not cross midline - should be done in all infants with bilious emesis Tx: urgent OR (risk of malro) 1. resect Ladd’s bands 2. widen the mesentery (resect central bands) 3. counterclockwise rotation 4. place cecum in LLQ (cecopexy), duodenum in RUQ 5. appendectomy

Answer 30

1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD 2a- Parathyroid (PTC), MTC, Pheo (catecholamines); ret; AD 2b- Pheo, MTC, marfanoid/neuroma; ret; AD

Answer 31

- <30d: technical error - 1m-2y: intimal hyperplasia, (at the distal anastomosis) - >2y: progressive atherosclerotic disease

Answer 32

Dx: palpable neck mass + Ca > 14 is presumptive dx. Otherwise, dx intra-op based on gross features. - FNA is not recommended - Treat based on intra-operative gross invasion. Frozen section is not helpful. Tx: 1. Control hypercalcemia: usually > 14 - IV fluids 1st! Then bisphosphonates - cinacalcet (sensipar - ca mimetic) 2. Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT) - no chemo - usually don't perform any node dissection unless palpable nodes

Answer 33

1. Graves: IgG stimulates TSHr ➡ hyperT - BB, PTU, RAI ➡ thyroidectomy 2. TMN: chronic TSH stimulation ➡ hyperT - BB, PTU, RAI ➡ total/subtotal thyroidectomy 3. Hashimoto's: antiTPO/TG Ab ➡ hypoT - thyroxine ➡ partial thyroidectomy 4. DeQuervains/Subacute: viral URI - path: giant cells, leukocytes - NSAIDS/ASA ➡ steroids 5. Reidels: autoimmune inflammation - steroid, thyroxine ➡ surgery for compression

Answer 34

- cystic: no bx -isoech/hyperech: FNA if > 2cm -hypoech (high sus): FNA if > 1cm

Answer 35

PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks

Answer 36

1. age 2. age 1st period (earlier is worse) 3. age 1st birth (earlier is better) 4. 1d relative 5. previous bx 6. race

Answer 37

1. proximal/distal seal: immediate balloon expansion of distal/proximal attachments + stent - 1a: proximal leak - 1b: distal leak 2. back bleeding: observe. coil embolization if enlarging 3. graft defect (tear or junctional leak): immediate additional graft coverage 4. porosity- reverse anticoagulation

Answer 38

1. Carcinoid- Kulchinsky cells (enterochromaffin-like) tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable 2. GIST- cajal cells tx- resection (MC stomach), imantinib 3. Desmoid- spindle cells tx- resect if extra-abdominal. NSAID/estrogen if intra

Answer 39

Px: resistant HTN and hypokalemia 1. AM plasma aldo/renin - A/R < 20: 2nd hyperaldo - A/R > 20: primary hyperaldo ➡ 2. Confirmatory test: salt load suppression test - give salt load ➡ 24h urine aldo remains elevated 3. Discern laterality: CT scan! (>MRI) A. Unilateral: lap adrenal (consider adrenal vein sampling 1st if > 35 to r/o BAH) B. Bilateral or negative ➡ adrenal vein sampling - Lateralization: lap adrenal - No lateralization: idiopathic hyperplasia ➡ tx medically **tx HTN with spironolactone

Answer 40

dx: ↑ascitic PMN ANC > 250 (Se) and - don't require culture (Sp) - e. coli is MC (usually single organism) tx: 1. paracentesis for cx 2. abxs: - <48h/community acquired: 3GC - >48h/hospital acquired: carbapenem + MRSA coverge (dapto) 3. Albumin (survival benefit)

Answer 41

1. Resuscitate, ensure airway 2. Octreotide + antibiotics 3. Endoscopic intervention (ligation/sclerotherapy) 4. Blakemore 5. TIPS (temporized with Blakemore)

Answer 42

1. Elevate HOB 2. Chest CT with IV contrast (can skip CXR) 3. Consider bronch 4. Assess sxs A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo - no chemo/XRT unless its 2/2 cancer

Answer 43

1. Uncomplicated: lap appe 2. Septic/Unstable: immediate lap appe 3. Stable w/ abscess - < 3cm: lap appe - > 3cm: IR drain ➡ interval appe, offer scope 4. Crohn's ileitis - intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty

Answer 44

1. urine metanephrine to r/o pheo 1st 2. tx pheo 1st w/ adrenalectomy 3. Address thyroid - 2A: total thyroid + bilateral central neck by 5y - 2B: total thyroid + bilateral central neck by 1y

Answer 45

1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics) 2. Asses other lesions

Answer 46

Prognosis: - aggressive, undiff - mort ~ 100%; no tx Tx: XRT improves short-term survival +/- surg - BRAF inhibitor for chemo

Answer 47

1. T0 or T1 (submucosa) 2. < 3 cm 3. < 30% circumference 4. Palpable on DRE (<8cm from anal verge) 5. No high-risk features (poorly diff, LV invasion) **local recurrence rate is higher

Answer 48

CRC: scope q1-2y starting at 20-25 - Surgery if: CRC or endoscopically unresectable lesions - TAC with IRA w/ q1y rectum surveillance - endometrial/ovarian cancer screening

Answer 49

Dx: U/S or HIDA Tx: 1. fusiform dilation: REY-HJ 2. diverticulum: simple excision 3. choledococele: transduo excision vs. sphincteroplasty 4a. intra + extra dilation: hepatic resection + recon 4b. extra only: excision + recon 5. intra only: transplant

Answer 50

Duo atresia: newborn; bilious emesis directly after birth - a/w down syndrome -dx: AXR- double bubble with no gas distally. don't need UGI -tx: duodenoduodenostomy TEF: newborn, spit ups. can't place NG. resp sxs - dx: AXR- gasless (A), gas (C) - tx: right extra-pleural thoracotomy Pyloric stenosis: 1-3 months; NB projectile vomiting -dx: U/S- 4mm thick, 14 mm long. String sign on UGI -tx: pyloromyotomy (1-2 from duo to antrum) Intussusception: 3m-3y; currant jelly stool - dx: U/S w/ bull's eye - tx: air contrast enema Malro: 1y-5y; sudden onset bilious emesis - dx; UGI- no duo sweep (any child w/ bilious emesis) - tx: ladd's procedure

Answer 51

1a: LC only - lap chole only - excise to negative CD margin 1b: muscle involved - OPEN chole + seg 4b and 5 + portal LADN - CD margin positive: REY-HJ **high suspicion for GB Ca should also get an open chole (polyp > 2cm)

Answer 52

1. Flush ➡ glucagon x 2 2. Lap exploration A. Transcystic: stone < 1 cm, <8 stones, no CHD stones B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones 3. Open exploration: if lap exploration failed - CBD < 2 cm: trans-duo sphincteroplasty - multiple stones, CBD > 2 cm: biliary-enteric drainage. - Leave T-tube **thin CD can be dilated

Answer 53

1. FNA- hurthle cells (can be seen in other conditions) 2. Lobectomy 1st for diagnosis 3. If malig: total thyroidectomy +/- L6 nodes 4. If palpable nodes: MRND No RAI

Answer 54

Bassini: conjoint tendon to inguinal ligament (from pubic tubercle medially to internal ring laterally) - may need relaxing incision in anterior rectus sheath McVay: open the floor to ➡ conjoint tendon to cooper's/pectineal ligament. - transitional stitch from conjoint, cooper's, and femoral sheath at medial aspect of femoral vein - re-approximate the rest of the inguinal floor by suturing the conjoint tendon to the inguinal ligament - may need relaxing incision Lichtenstein: mesh to inguinal ligament and conjoint tenown Shouldice: divide the floor ➡ 4-layer tissue closure

Answer 55

Tx: 1. Resectable if: - contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor - no distant mets or organ invasion 2. Consider location - Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe - Middle ⅓: hepaticojejunostomy - Lower ⅓: Whipple 3. Chemo + transplant if unresectable

Answer 56

dx: MRI 1st! then EUS/FNA; high CEA, high amylase tx: 1. Branched - resect if >3 cm, sxs, or signs of malig (nodule) - Otherwise surveillance 2. Main duct - resect if > 1 cm or sxs (60% chance of Ca) - 5-9 mm EUS/FNA. Resect if SOMalig - < 5mm, surveillance MRIs

Answer 57

Path: outpouching SUPERIOR to cricopharyngeous Dx: UGI (don't do EGD) ➡ manometry (r/o dysmotility) Tx: open or scope approach: <2cm : myotomy alone >2cm: multiple options - consider endoscopic stapling +/- myotomy - 2-5 cm: myotomy with suspension or inversion - larger: diverticulectomy with myotomy

Answer 58

Loc: distal Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin - DRH ➡ bicarb sexn ➡ met acid - most malignant Dx: high VIP Tx: distal panc + splenectomy + LADN'y + CC'y

Answer 59

- neo-adj chemo for T2+ or N - proximal- total gastrectomy - distal- partial - 5 cm margin; 15 nodes - Can consider endoscopic mucosal resection: if < 2cm, well-differentiated, mucoa only, no LV invasion

Answer 60

indications for trx w/ HCC - Single tumor < 5cm - No more than 3 tumors each < 3 cm **Hepatectomy if compensated cirrhosis (no portal HTN), low MELD, and solitary mass < 3 cm is still preferred **5-year transplant pt survival is 65-90% indications for trx of cholangioca - cant be intrahepatic - must be unresectable, perihilar, < 3cm - no distant mets

Answer 61

Loc: throughout (B cells) Px: whipple's triad. Most benign. Dx: I/G > .4 and high C-pep - dx w/ fasting test 1st! - endoscopic U/S most sensitive for detection Tx: < 2cm encucleate, >2cm resect. - High carb diet 1st - Diazoxide if can't tolerate surgery - LADN'y if suspect malignancy

Answer 62

1. Crohn's: - Creeping fat - Skip lesions - Transmural - Cobblestoning - Granulomas - Fistulas 2. UC: - Crypt abscess - Pseudopolyps

Answer 63

Dx- EGD and Bx (Bx needed to r/o ca!) Tx-only tx if refractory to max medical management after 12 weeks. 1. lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2 2. gastric + duo; high acid ➡ antrectomy + vagotomy 3. pre pyloric: high acid ➡ antrectomy + vagotomy 4. GE junction: normal acid ➡ sub-total gastrectomy + REY

Answer 64

Emergent: 1. Steroids +/- abxs 2. Infliximab, Cyclosporine 3. No response, megacolon (> 6 cm), HDUS, or perf ➡ TAC with end-ileostomy - When stabilized can perform proctectomy and IPAA - Don't do proctectomy in emergent situations Elective: - Indications: dysplasia, cancer, refractory disease - PC w/ IPAA ** Surgery reduces: erythema nodosum, arthritis -- no effect on PSC or ank spondy

Answer 65

1. penetrating: - zone 1-3 ➡ explore 2. blunt: - zone1 ➡ explore - zone 2-3 ➡ do not explore

Answer 66

Dx: > 100 adenoma or < 100 w/ fam hx - AD; APC mutation - CA by 40 - desmoid tumors (slow growing abdominal wall mass) Tx: - sigmoidoscopy q1y at 10 (don't need colonoscopy) - EGD @ 20 or when polyps start- SB polyposis - TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen) - q1y EGD post op for duodenal cancer (MC COD after colectomy) - q1y c'scope if TAC - polyposis/high grade dysplasia @ stump → proctectomy +/- pouch - desmoid: resect. Anti-E if intra-abdominal

Answer 67

female breast, ovarian, male breast I (ch17)- 60, 40, 1 II (ch13)- 60, 10, 10 Tx: -pre-meno: offer bilateral mastectomy OR q1 MRI starting @ 25 - @ 30 annual MRI w/ mammo -post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH)

Answer 68

1. all functioning tumors 2. all > 6 cm ➡ open resection 3. if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection **DO NOT biopsy first

Answer 69

1. Adjuvent chemo: tumor > 1cm, nodal dz, triple neg - echo before for cardiotox 2. Tamoxifen/Anastrazole: 5y for HR+ tumors - Tamox for men 3. Trastuzumab- 1y for Her2/neu+ tumors - echo before for cardiotox 4. Olaparib- 1 year for triple negative/BRCA+ tumors - PARP inhibitor **Oncotype recurrence score > 26 requires adjuvant chemotherapy

Answer 70

path- CENTRAL STELLATE SCAR! dx- bright on arterial phase homogenous tx- resect if sxatic. no malignant potential.

Answer 71

1. duct > 7mm- Peustow, pancreaticojej (for large duct) 2. duct > 7mm and large head- Frey, pancreasticojej + core out head 3. duct < 7mm and large head- Berger, pancreatic head resection

Answer 72

1. Indications for total thyroidectomy: - Tumor > 4cm - Distant mets or extra-thyroid disease - Poorly differentiated - Prior radiation 2. Nodes dissection: A. Lateral neck dissection: of involved compartments if palpable or bx+ nodes B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes. - Usually not performed for follicular 3. Radio iodine indications (6w post op, want TSH high) - Only after total thyroidectomy to be effective - For high risk tumors: tumor > 1 cm, extra-thyroidal disease

Answer 73

Mammogram every 2–3 years after age 40 then yearly after 50 High-risk screening - mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative

Answer 74

eso- 15/7cm stomach- 15/5cm colon-12/5 cm rectum- 12/5 cm

Answer 75

Tx: Rutherford 1: no deficits ➡ hep gtt. imaging. eventual revasc 2a: motor intact ➡ imaging. hep gtt (motor intact, sensation). eventual revasc - if early post-op case skip the imaging 2b: any weakness, rest pain ➡ hep gtt and immediate revasc (don't image if delay in tx) - if present in prior graft perform thrombectomy 3: paralysis ➡ amputation Revasc options: 1. Endovascular: short segment, single lesion 2. Open: long segment, multiple lesions

Answer 76

path- PERIPHERAL ENHANCEMENT with continued late filling px- young women tx- if rupture, size change, or KM syndrome

Answer 77

1. dx: fluid TG > 110 2. tx: chest tube and NPO - < 1L/day: MCT diet, octreotide, TPN → 7d: thoracic duct lig (Open R chest or IR) - > 1L/day: thoracic duct ligation (Open R chest or IR) **for cancer patients: pleurodesis > ligation

Answer 78

Px: Common 2/2 B cell lymphoma - hyperU, K, Ph w/ hypoCa Path: CaPh crystal ➡ renal failure + hypoCa tx: IV hydration ➡ iHD

Answer 79

1. Dx: MC GI Sarcoma - EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC. - Bx: cajal cells. c-KIT+ - don't require bx if high suspicion 2. Tx: wedge resection (gross margin) - can be R0 or R1 resection - Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf - mitosis/hpf is most predictive of prognosis (>mets) - neoadjuvant if need to down-stage for resection - adjuvant for 3 years

Answer 80

Core needle returns ➡ - Atypical (25% of malignancy) - DH/LH - LCIS/DCIS - radial scar - papillary lesion - any atypia **lesions generally have a 15-30% chance of carcinoma in situ or invasive cancer

Answer 81

1. minimum 20% if normal liver 2. pre-op chemo/some dysfxn = 30% 3. cirrhosis = 40% -Otherwise should undergo PVE -Overt PH is a c/i to PVE

Answer 82

path- EARLY enhancement on arterial phase w/ rapid washout. well-circumscribed. **vs hemangioma: peripheral enhancement over time tx- stop OCP use. resect immediately if > 5cm, sxatic, male gender risks: 1. rupture MC 2. malig transformation

Answer 83

1. Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin (no nodes) 2. MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes 3. BCT: partial mastectomy + XRT

Answer 84

Bx: Goblet cells and columnar cells 1. No dysplasia: 4 quad every 2 cm q 3-5y 2. LGD: 4 quad every 1 cm q6m. Consider ablation. 3. HGD: ablation/endoscopic resection. 4 quad every 1 cm q3m *Fundoplication is only c/i in HGD

Answer 85

RF: HPV 16/18, STI, HIV - test for cervical ca too Dx: - Anoscopy + FNA/core bx - HIV test all patients Tx: - Nigro protocol: XRT (ing/pelvic nodes) + 5FU + MitoC - Recurrence (10-20%): q6 months to diagnose ➡ APR - Lateral to I/S groove (anal margin): tx like skin cancer

Answer 86

1. Start with conservative tx 2. Quantify output: - High output: > 500 cc/day ➡ likely OR. Start with NPO/TPN. - Low output: < 200 cc/day ➡ likely conservative. OK for PO intake. 3. If input increased with PO intake ➡ NPO and TPN 4. OR if failed after about 6 weeks

Answer 87

t1a: muscularis mucosa: endo resection t1b: SM: upfront esophagectomy (or low grade t2) t2: muscularis propria: neoadjuvant - low risk: upfront esophagectomy t3: adventitia: neoadjuvant *no serosa. Ca spread through SM lymphatics

Answer 88

1- <25% narrowing ➡ ASA 2- > 25% narrowing ➡ ASA 3- PsA ➡ ASA + IR stent 4- complete occlusion ➡ ASA only 5- transection ➡ OR if accessible. Otherwise IR. *most are not surgically accessible

Answer 89

1. Superior parathyroids: from 4th pouch - usual location: posterior to RLN. - Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath. - TE groove is MC ectopic location 2. Inferior parathyroids: from 3rd pouch (with thymus) - usual location: anterior to RLN. - Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass - thyrothymic ligament is MC ectopic location - more commonly ectopic b/c longer travel 3. 4 normal appearing galnds - supranumary PT in the thymus **Overall, thymus is MC location or ectopic gland

Answer 90

1. Head - main duct: drain + post-op ERCP + staged resection - no duct: drain 2. Tail - main duct (grade 3+): resect w/ splenectomy (unless CHILD and HDS) - no duct (grade 1-2): drain

Answer 91

Mammo: clustered calcs Tx: like ca - BCT: lumpectomy (2mm) + XRT +/- boost +/- endocrine - no SLNBx (does not metastesize) - no chemotherapy - if XRT c/i → mastectomy AND SLNBx (b/c 20% have invasive ca)

Answer 92

- does not metastasize - not w/ l’omy unless >4cm, multicentric, palpable, high grade - required w/ mastectomy b/c 20% have invasive ca

Answer 93

-2-6m: piecemeal removal -1 year: > 10 adenomas -3 years: 3+ adenomas, HGD, > 1cm, villous elements -5 years: 1-2 tubular adenomas (< 1cm) -10 years: hyperplastic polyps (<20)

Answer 94

dx: suspect if recurrent intususpeption, GI bleeds - Meckel's scan (Tc-99) is best test. Increase Se by giving pentagastrin, glucagon, h2 blocker. Not as Se in adults (atrophic gastric cells) - only detects gastric tissue (not panc) - if negative but high suspicion ➡ repeat scan - if inconclusive then proceed with abdominal exploration (not CT) tx: resection if sxs - base < 2 cm → diverticulectomy - > 2 cm or wide base → seg resection - appendectomy as well if exploratory surgery for presumed appe ended up being meckels - If incidental: resect meckel's in kids, leave in adults.

Answer 95

1. proximal ⅓ (U/P jxn and above) → primary uretero-urostomy. Other options: ileal transposition, nephrostomy 2. middle ⅓ → primary u-u (preferred) - Other options: tran uretero-urosotomy, Boari flap 3. lower ⅓ (distal to iliacs) → re-implanation +/- hitch 1. early: w/in 5 days- stent, explore, or repair - HDUS intra-op: ligate, perc neph, delayed repair (3m) 2. late: > 10 days- perc nephro and delayed repair (3m)

Answer 96

Start with lobectomy Indications for total thyroidectomy: - Tumor > 4 cm (1-4 cm, close observation or total) - Extra-thyroidal disease - Multi-centric or bilateral lesions - Previous XRT Consider ppx level 6 for high risk If thyroid lobectomy only: - Tx with thyroid hormone to suppress TSH - Get serial U/S to monitor Indications for MRND - extra thyroid extension Radio iodine indications (6w post op, want TSH high) - Consider for 1-4 cm, definitely > 4cm - Extra-thyroidal disease - Need total thyroidectomy to be effective

Answer 97

dx: dx mammo 1st ➡ U/S is enough or contrast ductogram - MCCO bloody nipple dc - only use ductogram if all other imaging is equivocal tx: excisional biopsy including the ductal segment - do central duct excision if can't ID the duct

Answer 98

most close by 2 <3cm- primary repair >3cm- mesh repair by 5 Inguinal- repair by 2 weeks if reducible - otherwise, OR then

Answer 99

1. HGD, TIS, T1a: endoscopic ablation/resection 2. T1b: upfront esophagectomy or endo ablation (if low risk) 3. T2 or N: neoadjuvant then esophagectomy - Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso 4. T4b or M: definitive chemo-XRT < 5cm from cricoP: definitive chemo-XRT > 5 cm from cricoP: esophagectomy

Answer 100

Indications: 1. Extra-eso complications: cough, aspiration, CP 2. Persistant sxs 3. C/I to antireflux meds 4. Barrett's w/out HGD 5. Strictures 6. Esophagitis C/I: 1. Cancer 2. Barrett's w/ HGD

Answer 101

Classic sxs: heart burn + regurg Alarm: 1. dysphagia (not regurgitation) 2. odynophagia (pain) 3. bleeding 4. weight loss 5. anemia *Require EGD

Answer 102

0. Avoid NGT. No neutralizing agents 1. CT scan if stable 2. Early endoscopy (AFTER CT) 3. OR if unstable. Otherwise, restart orals in 48h. *alkali- liquefaction necrosis. worse outcome *acid- coagulation necrosis

Answer 103

Dx: XR then contrast esophogography (GG then Ba) - EGD if UGI is negative but still high suspicious - don't require CT Tx- 1. abxs (fungus) 2. Cervical: open neck and place drains 3. Thoracic: L thoracotomy, extended myotomy, cover w/ 2 layers - if achalsia: contra myotomy 4. Buttress with IC muscle NG, chest tube 5. Very unstable: exclusion and diversion Selective non-op: 1. Contained perf w/ minimal signs of sepsis OR 2. Very poor operative candidate Stenting: contained perf or minimal extrav after EGD

Answer 104

- Mech: fat to carb metabolism ➡ resumption of ATP production and Insulin surg ➡ Ph influx into cells ➡ hypoPh - Px: HypoMg, Ph, K; paresthesia, confusions, RD - COD is cardiac failure

Answer 105

Left lateral decubitus position Entry port: - take into account fundal height (6cm above) - P/S @ 12 wks, half-way @ 16 weeks, umbo @ 20 weeks - 2T-3T: supra-umbo if possible otherwise LUQ or RUQ

Answer 106

7 - 8 - 4a - 2 6 - 5 - 4b - 3

Answer 107

1. Pancreatic protocol CT 2. EUS: if questionable LN or vessel involvement 3. ERCP: if jaundice or dx uncertainty - 90% sensitive for dx 4. PET/CT: selectively if suspicion for malignancy. 5. Staging scope: if suspect disseminated dz - > 3cm, high Ca 19-9, tail tumor, high weight loss/malnutrition 6. Bx: Not if resectable. Only if neo-adj chemo

Answer 108

- Dx: 1. duplex (Celiac > 200, SMA > 275) is 1st line for screening 2. CTA (>70%) for definitive dx (best test) - Tx: Sxs + stenosis of > 70% 1. Endovascular plasty/stent is 1st line. 1V SMA stenting is enough even if both celiac/SMA are inovlved 2. Open surgery: if can't tolerate endovascular - aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation

Answer 109

1. LEFT lateral decubitus and Trendelenburg (trap air in the RV) 2. Aspirate central line

Answer 110

1. Femoral: vertical incision over the artery from inguinal ligament 2. AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus medialis. I 3. BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment. 4, TP trunk: MEDIAL incision below the tibia. Divide soleus origin of the tibia

Answer 111

Location: 1. Rad/Ceph 2. Rad/Bas 3. Bra/Ceph 4. Bra/Bas 5. Prosthetic peripheral 6. Prosthetic ax-brachial 7. Prosthetic femoral **Upper extremity preferred to LE Rule of 6's: - flow > 600ml/min - diameter > 3mm before placement. > 6mm after placement - depth of 6mm **artery at least 2 mm

Answer 112

Path- Prox SC stenosis. Reversal of flow through ipsilateral vertebral to SC Tx: if V/B sxs (diplopia, vertigo, dysphagia, ataxia) 1. PTA w/ stent to SC artery 2. Carotid to SC bypass

Answer 113

1. Uncomplicated: b-blocker for impulse control, elective repair - Surveillance q3, 6, 12m. TEVAR if progression 2. Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR - Need at least 2 cm landing zone distal to L SC

Answer 114

Elective indications: - refractory to medical management - suspicion of a malignancy within an ulcer Acute indications: HDS, minimal contamination AND: 1. PUD w/ unknown h. pylori status (if known can just be tx medically) OR 2. Unable to stop NSAID therapy (NSAID ulcer)

Answer 115

Indications: bleeding, perforation, obstruction 1. Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed - can tie off the GDA if continues to bleed - no vagotomy 2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment (90% H.pylori related) - If close to pylorus: pyloroplasty (+/- truncal vagotomy) - If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy - Only do acid surgery acutely (vagotomy/drainage) if: 1. HDS, minimal contamination AND 2. PUD w /h. pylori status negative, unknown, refractory OR unable to stop NSAID therapy (NSAID ulcer) **EGD does not require bx for duodenal ulcers

Answer 116

Indications for surgery: bleeding, perforation, refractory - 8-12w of PPI + H. pylori eradication - must bx at 8 spots Approach: 1. GC, antrum, body: wedge resection 2. Lesser curve: distal gastrectomy w/ bili 3. GEJ: - bleeding: anterior gastrotomy, over-sew, send biopsy - perf: sub-total gastrectomy w/ REY reconstruction **Can't wedge lesser curve b/c prominent L gastric arcade and deformed stomach

Answer 117

1. Afferent limb obstruction: prevent with afferent limb < 20 cm - acute: convert Bil 1 or REY (STAT!) - chronic: Bacterial overgrowth: try abxs 1st (Rifaximin) . convert to REY 2. Dumping syndrome: small meals, no sugar ➡ octreotide 3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm. - pro-kinetics, bile-acid binding ➡ convert to REY with long roux 4. Post vagotomy DRH: cholestyramine (dx of exclusion) ➡ reversed jejunal segment

Answer 118

4-weeks after triple therapy: 1. Urea breath test: preferred 1st line 2. EGD + Bx: preferred if known gastric ulcer (r/o CA) 3. Fecal Ag test **Gram-, spiral-shaped

Answer 119

1. Remain in place for 3-6 weeks for tract to form 2. Cholangiogram to assess CD patency 3. Clamp tube or elective chole if surgical candidate

Answer 120

BSC: most common malignancy in USA; pearly, rolled borders, peripheral palisading; MC upper lip ca SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca - MC ca after trx Tx: - 4 mm for unaggressive: well differentiated and < 2 cm - 8 mm for aggressive: poorly differentiated, > 2cm, or Marjolin - 1 mm for MOHS - MOHS for aggressive subtypes - LADN'y for clinical positive nodes - Can consider SLNBx for high risk SqCC - Limited role for chemo/XRT

Answer 121

Dx: - LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV - CT: gas, thick fascia Bacteria profile: - MC polymicrobial -if monomicrobial, MC GAS/strep pyogenes: M protein virulence Tx: - abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage - surgery

Answer 122

1- High Ca/Low Ph: over-secretion 2- Low Ca/High Ph: CKD or VitD def (physiologic) 3- High Ca/High Ph: hyperplasia 2/2 kidney transplant **VitD def: compensatory hyperPTH 2/2 to low Ca and Ph

Answer 123

RF- trach below 4th ring OR, high pressure cuff, high innominate cross 1. Over-inflate the cuff 2. Intubate from above 3. Compress against the sternum 4. Median sternotomy 5. Ligation AND division of innominate artery 6. Buttress tracheal hole w/ muscle **aorto-enteric fistula should also be treated aggressively with operative takedown and extra-anatomic bypass

Answer 124

Px: sudden decrease in UOP weeks after trx -2/2 lymphatic leak from iliac dissection -Sirolimus is a RF Dx: US Tx: perc drain (if sxs) ➡ peritoneal window

Answer 125

1. Elevated Cr. Low UOP. 2. US: high RI is a non-specific finding - Vascular abnormality ➡ angio, stent, or surg - Lymphocele/Urinoma ➡ perc drain ➡ perit window - Negative: graft dysfunction ➡ Core needle bx

Answer 126

Dx - usually incidental/bilateral - pre-menopausal white women. mammo negative -R/o breast ca is .5% per year Tx - Lumpectomy/Excisional bx (10-20% chance of DCIS/CA) - Don't need negative margins - No SLNBx - Can use tamoxifen to prevent hormone+ cancers (even if you don't know hormone status) PPx options - Surgery - Hormonal therapy - Surveillance w/ MRI or mammo q6m

Answer 127

Dx: clinical diagnosis - rapid erythema with paeu de orange < 6 months - mammo/US first!: must have path of invasive cancer - bx: dermal lymphatic invasion is suggestive but not required Tx: 1. Neo-adjuvant - can give trastuzumab if HER2+ 2. MRM 3. XRT 4. Endocrine tx

Answer 128

Px: painful/larger w/ periods or pregnancy Dx: - imaging: well-circumcribed, coarse ca+ - bx: fibro-epithileal lesions ("aggressive" = phyllodes) Tx: - obesrve if: mobile, concordant imaging/bx - resect if: > 3cm, sxs, growth, anxiety, discordance, lesions "not further defined"

Answer 129

Dx: mammo + U/S + bx - mammo is safe Tx: 1T (13w): mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T 2-3T: lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT - chemo is safe in 2nd/3rd trimesters. XRT is not - XRT is c/i throughout preg **No blue dye!

Answer 130

1. > 5cm (T3+) 2. 4+ nodes (N2) 3. margin positive 4. skin involvement 5. inflammatory BC **if prefer recon must be delayed or used a tissue expander for immediate recon

Answer 131

Zone 1: thoracic inlet to cric ➡ median sternotomy with left neck incision Zone 2: cric to angle of mand ➡ left neck incision Zone 3: angle of mand to skull base ➡ IR

Answer 132

px: moon facies, striae 1. Initial tests: choose 1-2 - 24h urine free cortisol (most se) - late night salivary cortisol (when cortisol is lowest) - overnight 1 mg dexa suppression 2. ACT Level A. ACTH normal/high - high dose dexa suppresion - no suppression: small cell lung ca - suppressed: pituitary adenoma (Cushing's disease) (MC endogenous) B. ACTH low - CT positive: adrenal mass - CT negative: exogenous (most common)

Answer 133

Dx: neuroendocrine tumor - 24H urine HIAA - chromoA for progression (not specific, false + on PPI) - Octreotide scan if can't locate Path: +chormogranin. desmoplastic mesentery. - grade ~ Ki67 index Px: - Rectum > SI (ileum) > Appendix (MC tumor of appendix) - GI tract > pulm > GU. Rectum MC - Carcinoid Syndrome: 2/2 liver mets or large GI tumor Tx: - SS analogues (lanreotide) for sxs - < 2 cm: local excision (transanal, appendectomy, segmental) ➡ no further w/up. - > 2 cm: staging CT. formal cancer resection. - all lung carcinoids get formal resection with MLND - c/scope post-op b/c 15% have synch lesions

Answer 134

1. FNA- r/o ca 2. Bloodwork- antiTPO/TG Ab 3. Tx- thyroxine ➡ partial thyroid **MCCO hypoT and goiter in the US

Answer 135

1. PET/CT 2. PFTs 3. Bronchoscopy (can be intra-op) 4. Mediastinal eval- EBUS or mediastinoscopy

Answer 136

1. Above T6: nor-epi (b/c HoTN and brady) 2. Below T6: Phenylephrine (may worsen brady above T6) **don't normally get neuorgenic shock below T6

Answer 137

1. Median sternotomy: right 2. Left Anterolateral thoracotomy: left subclavian - trap door supraclav incision for distal access

Answer 138

Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm - hepatectomy is preferred to transplant if they are Childs A

Answer 139

A/w: - FAP (after surgery, 2nd MCCO death), Gardner syndrome Path: non calcified, fibrotic, low mit index, spindle cells Tx: - WLE for extra-abd; NSAID, anti-Estrogen (tamoxifen) if intra! - XRT if sensitive area

Answer 140

1. Dexa suppression (cortisol) 2. Urine androgens (sex hormones) 3. Plasma metanephrines (pheo) 4. aldo/rennin ratio > 30 (salts)

Answer 141

Triple phase CT: 1. Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV - EUS/FNA for tissue dx for neoadjuvant 2. Borderline- <180 SMA/celiac, reconstructable PV/SMV - EUS/FNA for tissue dx for neoadjuvant 3. Resectable - dx lap (to confirm resectability) + whipple

Answer 142

Hanley procedure: - Midline drainage incision of deep posterior space (through ano-coccygeal ligament) - Bilateral lateral counter-incisions for ischiorectal space **all external drainage

Answer 143

<30% sphincter- fistulotomy or cutting seton >30% sphincter- draining setons THEN ARAF or LIFT **Crohns patient: px w/ multiple fistulas - avoid fistolotomy. - draining setons. Can try infliximab if active infection has resolved.

Answer 144

G1- bleeding, G2- spontaneous reduce, G3- manual reduce: 1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line (office): band, sclerotherapy, coagulation - band is most effective - sclerotherapy if on blood thinners G4- can't reduce - surgical HMHD'ectomy (stapled has higher recurrence)

Answer 145

1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line: surgical HMHD'ectomy Thrombosed: incise or excision if w/in 48h

Answer 146

Criteria - bilateral HA or PV - unilateral HA with extensive contra duct Tx - no extrahepatic dz ➡ neoadj chemo-XRT + liver trx - extrahepatic dz ➡ chemo-XRT

Answer 147

1. Dissect CD to the level of the duo 2. Cholodochotomy distal to the CD/CBD junction 3. Fush, basket, or fogarty balloon the stone out 4. Close primarily, over a T-tube, or over a stent

Answer 148

Dx: fever, RUQ, and jaundice - stones > malignancy > stricture Tx: - signs of sepsis: resuscitate/abx then urgent ERCP - no sick: US/MRCP

Answer 149

1. Intra-op - <50%, not cautery: primary repair - >50%, or cautery: REY-HJ 2. Late phase - Place drain - Define anatomy w/ ERCP, PTC, or MRCP - Place PTC tube - CTA to assess for R/L HA injury - Delayed reconstruction 6-8 weeks once optimized

Answer 150

1. Sx: cc'ectomy 2. For asx: - > 18 mm: tx as GB cancer - > 10 mm: CC'y - 6-10 mm: q6m U/S for 1 year. cc'ectomy if PSC

Answer 151

1. CT w/ oral/rectal (no IV b/c will obscure bladder) (not cystoscopy, colonoscopy, or Ba enema) 2. Colonoscopy to r/o malignancy 3. Cystoscopy if suspect cancer. Retrograde cysto if CT is equivocal or operative planning Tx- resect sigmoid even if asx; Don't need to repair the bladder, just drain

Answer 152

1. R hemi- IC, RC, RBMC - cecum/asc colon 2. Extended R- IC, RC, MC - hepatic flex/prox t colon 3. L hemi- LBMC, LC - Distal TV, splenic flex, prox descending 4. Extended L- LBMC, origin of IMA - splenic flex 5. Sigmoid- IMA (hi- b4 LC, low- after LC) - dist desc/sig

Answer 153

1. Exam and CEA q3-6m x 3 years 2. Colonoscopy @ q1, 3, and 5 years - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel) 4. CT CAP q1y x 3 years - At 2 years: recurrence local or hepatic - after 2 years: hepatic more often

Answer 154

1. TRUS (avoid if > t2) or MRI- T/N stage - suspicious nodes on MRI count as clinical stage N (neo-adj) 2. CT CAP- M stage 3. C'Scope- for initial dx and sync lesion. not for T stage 4. Rigid Sig'Scope- for distance from anal verge (required! even. if c'scope done)

Answer 155

1. CRC: MC - q1y C-scope @ 20-25 - TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma - q1y scope post op 2. Endometrial: 2nd MC - q1y endometrial sampling @ 30-35 - ppx TAH-BSO after children 3. Ovarian: - q1y TVUS and Ca-125 @ 30-35 - ppx TAH-BSO after children 4. Stomach: - EGD/Bx q2-3y @ 30-35 5. Renal: transitional cell ca - q1y UA and US @ 30-35

Answer 156

Tumors that require APR: 1. < 5cm for anal verge 2. Tumor at dentate line w/ sphincter involved 3. Tumor that can't get a 1 cm distal margin w/out sphincter 4. Poor pre-surgical anorectal function (history of DRH) 5. Locally recurrent low-lying cancer **Generally follows pre-chemo location of tumor unless COMPLETE tumor response. If tumor initially involved the sphincter complex and now does not ➡ still require APR

Answer 157

1. Bridge to surgery in acute obstruction (usually with metastatic cancer) 2. Palliative measure * Usually for L-sided lesions

Answer 158

Tx: 1. Primary: oral fidox - oral vanc is 2nd line now 2. Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus - no fidox 3. Recurrence: PO fidox or vanco 4. Multiple recurrence: tapered fidox or vanco - consider fecal transplant 5. Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm)

Answer 159

Dx- CT first to rule out non-ischemic colitis or infarction; C'scope to confirm - suspect in low flow state, HoTN - CTA can't dx b/c its a microvascular disease Tx- usually supportive; OR if perf, sepsis

Answer 160

**All require bichemical testing before imaging! 1. Glucagonoma: glucagon > 1k; NME, DM, DVT (no stones vs. SS'oma) 2. Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad 3. Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1 4. VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH) 5. SSoma: High fasting SS; DM, STONES, steatorrhea *Do not perform imaging or go to the OR until biochemical diagnosis!

Answer 161

-W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA 1. Serous cystadenoma: low M/CEA, low Am; resect if sxs 2. MCN: high M/CEA, low Am; resect 3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm 4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy

Answer 162

1. Glucagonoma: distal panc w/ splenectomy + cc'y 2. Inuslinoma: enucleate 3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple 4. VIPoma: distal panc w/ splenectomy + cc'y 5. SSoma: resect w/ cc'y 6. Non functional: < 2cm observe or enucleate. > 2cm resect

Answer 163

- px: 2/2 bill2 or REYGB - watery stools, bloating, b12 deficiency - dx: d-Xylose (carb test breath test) - tx: abxs (Rifaximin) ➡ surg 2nd line

Answer 164

1. No N2 disease (stage 1-2) ➡ up-front surgery - lobectomy + MLNDx. Can consider segmentectomy. - can wedge if 2:1 margin ratio 2. N2 disease or T4 ➡ chemo-XRT first n1- ipsi bronchial/hilar nodes n2- ipsi mediatinal/subcarinal (2-9) lobe

Answer 165

1. < 8mm ➡ surveillance 2. > 8 mm ➡ PET-CT - FDG- ➡ surveillance 3. FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy) - nodal disease --> EBUS 4. No N2 dz --> Segmentectomy or lobectomy - n2 disease --> chemo

Answer 166

1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic 2. Pheo: phenoxybenzamine then BB Intra-op: - HTN crisis: Nitro gtt - Tachy arrythmia: Esmolol gtt

Answer 167

1. Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant - Consider portal vein embolization if remnant is insufficient - Consider pre-op TACE to as an adjunct 2. Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant - Transplant if candidate: UNOS criteria - Otherwise: loco-regional therapy or systemic therapy

Answer 168

1. Back-pressure < 40 2. Previous colon surgery 3. SMA stenosis 4. Inadequate left colon flow

Answer 169

1. FAP- chromosomal; APC - > 100 polyps, including small bowel (duodenum) - Surveillance: start at 10 2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM - <10 polyps in the colon - Surveillance: start at 20

Answer 170

1. Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk 2. MTC: total + bilateral L6 (usually) + T3 post op - RAI is c/i 3. Hurthle: lobectomy then total + bilateral L6 4. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes 5. PT: hemi-thyroid +/- L6 (usually not) **MRND if L6 is positive

Answer 171

1. Neuro exam: - absent brain stem reflexes - no response to stimuli 2. Apnea test: CO2 > 60 after 10 minutes - if test aborted OR CO < 60 ➡ - can't perform test if confounding factors: unstable, hypercarbia, intoxication, paralytics (unable to wean), c-spine injury 3. Confirmatory test: CTA, MRA or nuclear scan

Answer 172

1. Boerhave: XR suggestive ➡ UGI (CT controversial) 2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI 2. UGI bleed: +/- NGT ➡ EGD

Answer 173

px- failure to pass meconium dx- sweat chloride test, "soap bubble sign" on XR tx- GG then NAC enemas - surgery: ostomy for antegrade enema **Cystic fibrosis is 2nd MCCO pancreatic insufficiency (after chronic pancreatitis)

Answer 174

Nutritional requirements for average healthy adult male (70 kg) 1. 20% protein calories: 1 g protein/kg/day - burn: 1g/kg/day + 3 g/day x % BURN...(usually 2-2.5g/kg/day) 2. 30% fat calories 3. 50% carbohydrate calories

Answer 175

1. Cause: affarent limb is too long from LOTz 2. Px: acute or chronic - Acute: complete obstruction requiring emergent OR - Chronic: partial obstruction w/ bacterial overgrowth - steatorrhea, B12 deficiency. MC w/ antecolic Bili2 3. Dx: - Acute: abdominal pain with dilated afferent limb in early post op - Chronic: d-xylose breath test 4. Tx - stat OR for REY revision - Chronic: abxs --> REY/shorten the limb

Answer 176

- Pd1 inhibitors: pembrozilumab, nivolumab - CTLA inhibitors: ipilmumab - If Braf+: braf inhibitor remains 2nd line

Answer 177

1. Poor differentiation 2. Vascular/Lymphatic invasion 3. Invasion below the SM 4. < 2mm of surgical margin 5. Base involvement (Haggit 4)

Answer 178

Primary anastomosis with DLI (DIVERTI trial) or without DLI (LADIES trial) is safe except if: - HDUS - Acidosis - Acute/Chronic organ failure - I/S - Very old - Poor pre-op sphincter function

Answer 179

2-3 paracentesis/month despite Na restriction and diuretics s/e: - increase r/o encephalopathy - no change in overall survival

Answer 180

- Dx: EUS/FNA ➡ high CEA, low amylase - Location: body/tail - Spleen Preserving Distal Pancreatectomy (usually can be spleen preserving) - No follow-up is needed (no increase r/o recurrence)

Answer 181

Lesions > 2cm from primary but not beyond regional tumor basin - immunotherapy or BRAF inhibitor - only excise if feasible (few lesions)

Answer 182

px: AD; ryanodine receptor type 1 mech: huge increase in INTRAcell Ca tx: stop drug, dantrolene, Bicarb, cooling, tylenol - dantrolene: ryanodine rec antagonist

Answer 183

1. Tamoxifen: ER partial agonist - for ER/PR positive and < 70 - 5 years - s/e: dvt, endometrial ca 2. Anastrazole: reversible aromatase inhibitor - for ER/PR positive and > 70 - 5 years - s/e: MSK fractures 3. Trastuzumab: monoclonal Ab to Her2/Neu rec - for HER2 positive - 2 years - s/e: cardiotoxic

Answer 184

px: scaly, ulcerated crust of the areola dx: nipple punch bx with epidermal cells w/ clear cytoplasm and oval nuclei tx: total mastectomy (including NAC) and SLNBx - don't need ax dissection - no breast conservation - total mastectomy even if small underlying lesion

Answer 185

- Within 4 minutes of CPR for cardiac arrest - Fetus must be at least 24 weeks - Give O, Rh negative blood if needed - usually 2/2 abruption (vaginal bleeding)

Answer 186

1. EKG +/- trop - negative: can dc - positive: admit to tele (Sinus tach is abnormal) 2. Persistant arrhythmia or HoTN ➡ echo

Answer 187

Dx: CT w/ rectal contrast is best Tx: 1. Intraperitoneal ➡ colonic injury 2. Extraperitoneal ➡ primary repair w/ loop sig colostomy - if inaccessible just leave open and divert - avoid presacral drainage or distal washout

Answer 188

1. Steal: pain, diminished pulse, cold hand - Tx: DRIL (distal revasc interval ligation) - Ligate immediately artery side AVF. Bypass distal to the ligation site w/ PTFE - 2/2 to impaired compensatory mechanisms 2. IMN: pain, normal pulse, warm hand - Tx: immediate ligation - 2/2 nerve ischemia

Answer 189

Thrombus is in GSV, SSV 1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months 2. No near the jxns ➡ prophylactic AC for 45 days 3. Otherwise: surveillance **Superficial femoral vein is a DEEP vein **EHIT: heat induced thrombus after RFA - tx with AC until resolution if it involves femoral jxn and > 50% occlusion - < 50%: compress, NSAID, surveillance

Answer 190

- RFA or EVLA are 1st line - Indications for surgery instead: high ligation and vein stripping: 1. proximal/dilated and tortuous GSV 2. previous thrombophlebitis 3. vein too large (RFA > 15mm, EVLA > 8 mm) - lower extremity telangiectasias, reticular veins, and small varicose veins ➡ sclerotherapy recommended

Answer 191

- HDS: perform a cancer resection - HDUS: resect and divert - Scope in 3-6 months to r/o synch lesion **Divert if unstable, contaminated, poor nutrition, etc.

Answer 192

1. neoadjuvant 1st unless pure fetal histology and low mitotix index 2. resection 3. transplant if 4+ section involved/unresectable after chemo Good prog: < 5 yo, AFP > 100

Answer 193

Vertebral Anal Cardiac TE fistula Renal, Radial bone Limb defects

Answer 194

px: infant with bilirubinemia dx: 0. Rule out TORCH infections/neonatal hepatitis 1. HIDA with no contrast in the duo 2. Cholangiogram: look at what segments are strictured 3. perc bx (tissue dx) tx: REY-HJ vs. REY-portoenterostomy (Kasai) ➡ transplant if unsuccessful

Answer 195

- Screening scopes 8 years after onset. Scope q1-3 years thereafter. - Invisible HGD: confirm w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA - Visible HGD: 1. Resectable: endoscopic resection + serial scopes 2. Not-resectable: TC w/ IPAA - for Crohn’s can do segmental resection

Answer 196

- Adults risk starts at < 180 cm - Infants risk starts at < 75 cm - Feeds with elemental nutrition

Answer 197

- suspect when colon > 6cm - TAC w/ end ileostomy - Keep the ileocolic intact for future J pouch - Keep the SRA intact for good staple line flow - Divide rectum above the posterior peritoneal reflection at level of sacral promontory

Answer 198

A- CD stump leak: - Intraop: clip/ligate and leave drain - Postop: perc drain + ERCP plasty/stent B- Aberrant right hepatic ligation: - Only if sxs ➡ REYHJ C- Transect aberrant right hepatic: - Only if sxs ➡ REYHJ D- Lateral injury to CHD/CBD: - No devascularization and small: 1' T-tube closure - Devascularized: REY-HJ E- full transection of CHD/CBD - < 1cm or distal w/out tension: 1' T-tube closure - > 1cm OR proximal injury: REY-HJ e1- > 2cm, below confluence e2- <2cm, below confluence e3- at confluence (confluence intact) e4- at confluence (confluence separated) e5- aberrant RH duct injury w/ CBD stricture

Answer 199

1. Prior radiation 2. Radiation therapy contraindicated by pregnancy 3. Inflammatory breast cancer 4. Diffuse suspicious or malignant-appearing microcalcifications 5. Widespread disease that is multicentric 6. A positive pathologic margin after repeat re-excision MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes

Answer 200

1. Px: painless jaundice. 2. W/up: - Ca 19-9 - CT/MRI - Tissue: 1. ERCP w/ stent: brushings + in 50% (preferred if obstuctive) 2. EUS/FNA: negative bx does NOT rule out

Answer 201

- If patient is hypotensive - TAC w/ end ileostomy - If stabilized- prep 1st with 4-6L of PEG. Scope w/in 24h.

Answer 202

Stage: extent of submucosal invasion! 0- superficial to MM (no SM) 1- invasion into head 2- invasion into neck 3- invasion into stalk 4- in SM. superficial to MP. **all superficial. toMP Mx: - all sessile are 4 by definition - 4 is an indication for resection - < 4 cancer without high risk features ➡ polypectomy alone w/ follow-up scope in 3 months

Answer 203

- average risk: start at 45. Screen q 10 years. -1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.

Answer 204

dx: gg swallow then thin barium tx: - NPO, IV abxs - consider stenting - generally don't need IR drain - includes cervical and thoracic

Answer 205

1. PPI or H2 block daily x 8 weeks - BID if severe sxs, HGD, or esophagitis 2. Work-up for anti-reflux surgery - dysplasia should be eradicated prior to surgery 3. Continue surveillance - no dysplasia: q5y - LGD: q6m. ablation. - HGD: q3m. ablation or endoscopic resection.

Answer 206

1. > 4 nodes on superficial dissection 2. Positive cloquet's node 3. Enlarged ileo-obturator nodes on CT 4. Clinically palpable femoral nodes

Answer 207

1. Pregnancy 2. Diffuse micro-calcs 3. Positive pathologic margin 4. Multi-quadrant disease

Answer 208

Dx: U/S, current jelly stools, abdominal mass Tx: 1. Air contrast enema (75% effective) - surgery if unstable, perforation, mass, or completely unsuccessful on repeat U/S 2. Repeat enema 3. Observe for 4 hours if success - only 5% recur

Answer 209

Low tsh —> thyroid scint - diffuse uptake ➡ Grave's: BB, PTU, RAI ➡ total/subtotal thyroidectomy if refractory (consider lugol's solution before surgery) - focal uptake ➡ toxic adenoma: BB, PTU and lobectomy - multiple areas of increased uptake ➡ TMN ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy if refractory

Answer 210

1. FAST+, HDS ➡ OR for pericardial window ➡ extend to median sternotomy if blood found 2. FAST+, HDUS ➡ immediate median sternotomy (preferred) or ED thoracotomy (left anterolateral) - Finger compression - If failure ➡ pledgeted repair (avoid balloon/staples if possible). Horizontal mattress, permanent (prolene)

Answer 211

1. Measure lactate 2. Blood cx b4 abxs 3. Abxs after cx 4. 30 ml/cc bolus if HoTN, LA 5. Pressors for MAP >65

Answer 212

- Get diagnostic mammo - Then excisional bx (15-30% of cancer) - Like LCIS you do not need a negative margin - Finally chemo-ppx with tamoxifen **ALH and LCIS if low risk and concordant