Stupid crap I can never remember Flashcards
screening intervals for Barrett’s esophagus
what’s low risk? how often?
what’s high risk? how often?
how often for high risk with low grade dysplasia?
low risk: less than 3cm, no dysplasia. every 2 years
high risk: more than 3cm or circumferential. every year
high risk with low grade dysplasia: every 6 months
high risk, high grade: q3 months, EMR
flumanezil to treat what?
what is the dose? how much can you give?
to treat benzo toxicity
0.2mg IV loading dose over 30 seconds then up to 3mg
felon vs. paronychia
felon: infection of the fingertip pulp. needs midline incision. lateral incision can hurt nerve bundle
paronychia: infection of the skin fold around the nail bed. needs lateral incision
Merkel cell carcinoma:
CK-20? TTF-1?
sentinel node?
adjuvant radiation? chemo?
Merkel cell is CK-20 (+), TTF-1 (-)
small cell carcinoma of the lung is CK-20 (+), TTF-1 (+)
Yes. do sentinel node
yes radiation. no chemo
lentigo maligna vs. acral lentiginous melanoma
what is the most common non-skin melanoma?
leitgo maligna is usually in older patients. LEAST AGGRESSIVE melanoma. rare in dark skin ppl
Acral lentiginous: nails, toes. most common subtype in dark skin ppl
most common non-skin melanoma: eye melanoma
apocrine vs. eccrine gland
apocrine empties into hair follicles. blockage of this causes hidradenitis
eccrine empties into pores on the skin
borders of superficial inguinal node dissection?
location and significance of cloquet’s node?
borders of the deep inguinal lymphadenectomy?
5cm above the inguinal ligament superiorly
adductor longus medially
sartorius laterally
cloquet’s node is below the inguinal ligament and medial to femoral vein. if (+) then do a deep node dissection
bifurcation of the common iliac artery into the external and internal iliac arteries. The caudal limit is the inguinal ligament.
what primary tumor metastasizes to the skin the most?
breast goes to the skin most frequently
hidradenitis staging differences
Hurley I: multiple abscess, NO SINUS tracts. most patients present with this
Hurley II: recurrent abscesses with sinus tracts, multiple separated lesions
Hurley III: diffuse involvement. multiple connected sinuses
melanoma. (+) sentinel node but pt doesnt want node dissection. how do you surveil?
based on MSLT II okay to not do completion node dissection.
ultrasound of the nodal basin every 4 months for the first 2 years then every 6 months for the next 3 years
margin for squamous cell cancer
low risk: 4mm
high risk (tumor depth > 2mm, moderately differentiated, size > 2cm): 10mm
dermatofibrosarcoma protuberans. you do a margin negative WLE. are you done? what should you look for in pathology and do what if pathology shows this?
look for fibrosarcomatous changes in pathology. if this is present, then CT chest needs to be obtained
mechanism of resistance to beta-lactam antibiotics found in MRSA?
alteration of the antibiotic target site.
Methicillin resistance in MRSA is mediated by horizontal transfer of the mecA gene. This gene encodes penicillin-binding protein 2a, which has low affinity for beta-lactams, in contrast to the other types of penicillin-binding proteins. The low binding affinity of beta-lactams renders the antibiotic ineffective in its action at that target site
which immunosuppressant causes these side effects?
- GI bleed, pancytopenia
- Thrombocytopenia and poor wound healing
- GI bleed, pancytopenia: mycophenolate
mycophenolate also has 50% diarrhea incidence - Thrombocytopenia and poor wound healing: rapamune (sirolimus)
difference between
- physician assisted dying
- voluntary active euthanasia
- Passive euthanasia
- rule of double effect
- physician assisted dying: when a physician prescribes a lethal dose of a medication for a patient to administer himself
- voluntary active euthanasia: when a physician knowingly administers a lethal medication to a patient per his request to end his life
- passive euthanasia: withdrawal of care
- rule of double effect: palliative medication given specifically to alleviate symptoms and it foreseeably, though unintentionally, hastens a patient’s death
pts should quit smoking how many weeks before surgery?
what DLCO and FEV1 is needed to be able to undergo pneumonectomy?
4 weeks
DLCO > 60%, FEV1 > 60% for pneumonectomy
who needs a screening CT for lung cancer?
what to do with 8mm ground-glass opacity?
all patients aged 55 to 80 with at least a 30 pack-year smoking history who either currently smoke or have quit in the past 15 years
lesions <1cm can be followed with follow-up CT
risk of transmitting hep C from needle stick?
HIV?
- 8% for hep C
0. 3% for HIV
how does cetuximab work?
decreases production of EGFR by binding it on both normal and tumor cells. inhibits the binding of EGF and other ligands. it inhibits the phosphorylation of kinases
ipilimumab blocks what?
pembrolizumab blocks what?
nivolumab?
ipilimumab: CTLA-4
pembrolizumab (keytruda): PD1
nivolumab: PD1
screening for HNPCC
colonoscopies every 1-3 years starting age 20-25
annual transvaginal ultrasound starting 20-25
undescended testicle
- risk of testicular cancer compared to normal population?
- is the contralateral normal testicle also at risk for developing cancer?
- risk of cancer in undescended tesis in the abdomen vs. inguinal canal?
- most common type of cancer in testicle after orchiopexy vs. unrepaired undescended?
- does earlier orchiopexy reduce risk?
- about 2-8 times more
- contralateral testes is not at increased risk
- if in the abdomen, 4-5x higher risk than inguinal
- uncorrected undescended testis: seminoma
- after orchiopexy: non-seminoma
- yes, preadolescent repair results in decreased risk of cancer
most common tumor found in meckel??
carcinoid
hernia repair.
this nerve lies superiorly in the canal and passes through the external oblique aponeurosis superior to the external ring
this nerve travels beneath the inguinal ligament and does not enter the inguinal canal
this nerve runs within the spermatic cord and supplies the cremaster muscle
iliohypogastric nerve lies superiorly in the canal and passes through the external oblique aponeurosis superior to the external ring
femoral branch of the genitofemoral nerve travels beneath the inguinal ligament and does not enter the inguinal canal
genital branch of the genitofemoral nerve runs within the spermatic cord and supplies the cremaster muscle
what is Amyand hernia
what is Littre hernia
Amyand: Appendix
Littre: Meckel diverticulum
peds. gasless abdomen. procedure of choice?
what are the TE fistula types
gasless abdomen means long gap esophageal atresia. needs G-tube to let kid grow over time (type A or type B)
type A: atresia. no fistula type B: atresia. proximal fistula type C: atresia, distal fistula type D: both proximal and distal fistula type H: H
liver CT: enhancement of the lesion on arterial phase followed by washout on delayed phase
delayed washout is pathognomonic for HCC. Hepatic adenomas have a variable CT appearance that overlaps with that of HCC, because both lesions enhance on arterial phase. However, hepatic adenomas do not typically demonstrate delayed washout.
esophageal CA found on endoscopy. best way to assess locoregional disease? PET CT or MRI?
PET CT of the chest
should mesh be used for large hiatal hernia repairs?
short term outcomes are better but it doesn’t matter long term based on 3 different RCTs
normal esopahgus is lined by what type of epithelium?
normal stomach is lined by what epithelium?
stratified squamous epitheliu
stomach is lined by simple columnar epithelium
most common anterior mediastinum tumor?
middle?
posterior?
anterior: thymoma. myasthesnia gravis
middle: lymphoma
posterior: neurogenic tumors
pt with Zenker’s diverticulum has cervical stenosis and can’t extend neck. treatment option?
when is it okay to do myotomy alone vs. diverticulectomy?
can’t do endoscopy because can’t extend neck
straight up open diverticulectomy with myotomy
> 5cm definitely do diverticulectomy
<2cm myotomy alone may be sufficient
medication protective against radiation enteritis?
ACE inhibitors
pt with billroth II has diarrhea, oily stools, malnutrition due to bacterial overgrowth.
what kind of diet helps? what kind of anemia?
what test can diagnose bacterial overgrowth?
treatment?
Medium-chain triglyceride diets
Pernicious anemia (vitamin B12 deficiency) is common
d-xylose test (carbohydrate breath test) . Metabolism of carbohydrate substrates from bacteria leads to the production of hydrogen and/or methane, which is detected in the breath.
treatment: rifaximin, 14 days
for surveillance after distal gastrectomy for cancer, what do you do?
EGD every 6 months for the first 2 years then yearly for up to 5 years?
CTCAP every 6 months for the first 2 years then yearly for up to 5 years?
CTCAP every 6 months for the first 2 years then yearly for up to 5 years
a girl swallows a nickel coin. when do you need to do EGD to get it out?
can she go home?
if no signs of obstruction she can go home.
endoscopic retrieval should be performed if the coin remains in the gastric lumen for more than 3 to 4 weeks.
GIST
who needs neoadjuvant imatinib?
for adjuvant gleevec how long to treat? 1 year? 3 years?
> 5cm or >5 mitoses
for high risk GIST, treat for >3 years
what is amifostine?
what is misopristol?
what is mifepristone?
Amifostine is a radioprotectant that, when converted to its active form, binds free radicals to prevent cellular damage. dont’ use this first for radiation enteritis
misopristol is a synthetic prostaglandin E analogue. It can prevent stomach ulcers caused by anti-inflammatories
mifepristone is a progesterone blocker used to end pregnancy up to 10 weeks. can also control high blood sugar in patients with Cushing syndrome who have type 2 diabetes and have failed surgery or are not candidates for surgery
does highly selective vagotomy cut posterior nerve of Latarjet?
does selective vagotomy cut Latarjet?
what happens to liquid phase gastric emptying after truncal vagotomy vs. highly selective?
highly selective: no it preserves Latarjet, both posterior and anterior. no need for drainage procedure. it does cut the criminal nerve of grassi (posterior)
Selective: yes it cuts anterior and posterior latarjet nerves. Denervates pylorus. Needs drainage procedure
truncal vagotomy accelerates liquid phase gastric emptying
what do chief cells secrete?
what do parietal cells secrete?
intrinsic factor is secreted by what?
antrum procuces what?
chief cells: pepsin
parietal cells: acid, intrinsic factor
antrum makes mucous and gastric (from g cells)
which is more common after ileostomy reversal? SBO or SSI?
when you’re doing an ileostomy reversal through the peri-ostomy incision, you encounter an intra-abdominal abscess adjacent to the ostomy site. what do you do?
SBO is more common. 7%
if abscess encountered, leave the ostomy in place and drain the abscess operatively. if reversed, risk of leak, fistula at the closure site
Which of the following primary neoplasms of the small intestine has the best long-term prognosis?
A. Lymphoma of the terminal ileum
B. Neuroendocrine tumor (NET) of the ileum with regional lymph node metastases
C. Adenocarcinoma of the duodenum
D. Gastrointestinal stromal tumor (GIST) of the jejunum measuring 8 cm and with a high mitotic rate
E. NET of the duodenum with regional lymph node metastases
Neuroendocrine tumors (NETs) of the duodenum are rare tumors. Even in the presence of regional lymph node metastases and even when treated with simple endoscopic excision as opposed to radical surgical resection, they exhibit an excellent prognosis (100% disease-specific survival)
Primary lymphomas of the small bowel have a 5-year survival rate of approximately 50% to 60%
Although patients with NETs of the ileum with regional lymph node (and even liver) metastases can live for many years because of the often indolent biology of these tumors, the 5-year survival of such patients is still only on the order of 60% to 70%
Adenocarcinomas of the duodenum exhibit the best prognosis of all small bowel adenocarcinomas (likely because of the fact that they tend to be diagnosed at an earlier stage), but the 5-year survival of these tumors is only on the order of 50%
Despite the existence of highly effective targeted therapies (tyrosine kinase inhibitors such as imatinib and sunitinib) for gastrointestinal stromal tumors (GISTs), this is a very high-risk GIST; it is large, arises from the small bowel, and has a high mitotic rate. As such, even if this tumor has a favorable mutation in the c-kit gene and thus is responsive to tyrosine kinase inhibitor therapy, the 5-year survival of this patient is unlikely to exceed 80%.
what is an abnormal gastric emptying study?
what % of radiotracer remaining in the stomach at 2hr vs. 4 hr?
2hr: if >60% remains
4hr: if >10% remains
what’s the difference between afferent loop syndrome vs. blind loop syndrome?
between antecolic and retrocolic Billroth II which one has a higher incidence of blind loop syndrome?
what is efferent loop syndrome?
afferent loop syndrome: severe postprandial pain, nonbilious vomiting. it’s due to afferent loop obstruction in patients who underwent gastric bypass
blind loop syndrome: bacterial overgrowth, chronic malnutrition, B12 deficiency. treat with medium chain triglyceride diet. no abx
Antecolic Billroth II is the worst. Retrocolic is preferred.
efferent loop syndrome is gastric outlet obstruction due to hernia or kinking. usually within 1st month post-op
what length of stricture is classified as:
short segment
medium segment
long segment
and which strictureplasty do you use?
what do you do for Crohn’s stricture of isolated 2cm?
short segment: 5-7cm Heinecke-Mikulicz
medium segment: 10-15cm Finney
long segment: >15cm Michelassi
2cm is too short and suspicious. do resection to r/o maglinancy
What agent has been shown to significantly decrease the severity of nausea and vomiting and patient discomfort in patients with MBO?
octreotide
when do they need repeat endoscopy?
- pt with mallory weiss tear, now better and recovered, ready to be discharge
- gastric cancer pt s/p distal gastrectomy
- after complete healing of caustic ingestion
- mallory weiss: no follow-up endoscopy needed
- gastric cancer pts need surveillance CTs, not endoscopy
- caustic ingestion: 15 years after injury (malignant transformation takes about a decade)
for GIST:
difference between stage IA vs. IB
what makes stage II?
IIIA vs. IIIB?
GIST has (+) lymph nodes. what stage is it?
IA: <5cm, low mitotic rate
IB: 5-10cm, low mitotic rate
II: <5cm + high mitotic rate
>10cm + low mitotic rate
IIIA: 5-10cm, high mitotic rate
IIIB: >10cm, high mitotic rate
Stage IV tumors are those of any size with either lymph node metastasis or distant metastasis, or both. any positive nodes: stage IV
use of GLP-1 analogue (exenatide)
vs.
GLP-2 analogue (teduglutide)
GLP-1 (exenatide): management of hyperglycemia in diabetics
GLP-2 (teduglutide): management of short bowel
blood supply for:
- cervical esophagus
- thoracic esophagus
- abdominal esophagus
- cervical: inferior thyroid
- thoracic: bronchial arteries + directly from aorta
- abdominal: left gastric + inferior phrenic
PNET that is
- usually in the pancreatic tail
- usually in the pancreatic head
which type is most common in MEN1?
most common PNET in general?
tail: glucagonoma, VIPoma
head: somatostatinoma
most common in MEN1: gastrinoma
most common in general: insulinoma
Perforated appendix with abscess
- failure rate of non-op management
- complication rate of interval appendectomy
- risk of recurrent appendicitis
- in pts > 40 what needs to be done after initial mngmt? For what reason?
- What is the incidence of appendiceal tumor in ALL pts with appendicitis?
- what are the odds of concurrent malignancy in pts >40
for UNCOMPLICATED appendicitis,
- readmission rate?
- length of hospital stay?
- complication rate/pain duration?
- cost?
- failure rate of non-op management: ~5%
- complication rate of interval appendectomy: 2-23%
- risk of recurrent appendicitis: ~8%
- in pts > 40 Colonoscopy needs to be done after initial management. To rule out malignancy
- in ALL pts with appendicitis, tumor rate is ~2%
- 15% concurrent malignancy
for uncomplicated appendicitis
- readmission rate is higher in conservative management (up to 1/3 recur)
- longer stay for non-op management
- no difference in complication rate/pain duration
- higher cost with surgery
rivaroxaban
apixaban
dabigatran
Pra(DA)xa: (DA)bigatran. (D)irect thrombin inhibitor
i(DA)rucimab (praxbind) or dialysis
Eliquis: apixaban. Xa inhibitor
PCC
least renal clearance (use in renal pts)
Xarelto: rivaroxiban. Xa inhibitor
PCC
TEG numbers
LY30 > 3%
alpha angle < 53
R time > 10
amplitutde < 50
LY30: TXA
angle: fibrinogen
amplitude: platelet
time: FFP
Where is the dissection plane for carotid endarterectomy to remove the plaque?
What layers of the artery are left behind after the endarterectomy?
Should you extend your arteriotomy to external carotid to remove residual plaque?
Acceptable stroke rate?
Between intima and media.
Deep layers of the media and adventitia are left behind to prevent aneurysm
Don’t extend arteriotomy to external carotid. Complicated patch
<6% is acceptable stroke rate
management of symptomatic pancreatic pseudocyst:
- pseudocyst in communication with the main pancreatic duct and with otherwise normal pancreatic duct anatomy
- pseudocyst without communication to the pancreatic duct
- if cyst well adherent to the posterior stomach or duodenum
- if not adhered to posterior stomach wall or duodenum
- tail of the pancreas
- ERCP guided sphincterotomy, or transpapillary stent
- endoscopic cystgastrostomy
- cystgastrostomy or cystduodenostomy
- open/lap roux-en-y cystenterostomy
- tail: distal panc may be better
only approved systemic therapy for metastatic PNET?
streptozocin
resect both primary and liver met if possible
can use somatostatin for glucagonoma
insulinoma: when is enucleation not okay
> 2cm or close to main duct (then needs radical resection)
if multiple AND <2cm, enucleate each
what % of remaining liver do you need in healthy person?
cirrhotic?
when to do portal vein embolization?
healthy: needs 20%
cirrhotic: needs 40%
do portal vein embolization for FLR < 25%
trauma pt. retained hemothorax after chest tube. next step?
get a CT first. don’t place another chest tube.
then will likely need VATS
when to start aspirin after splenectomy
who gets prophylactic daily augmentin
plt > 1000 x10^6
children <10 for 6 months after splenectomy to prevent OPSI
plt 600k can be watched
gallbladder polyp is most likely to be what kind?
risk factors for malignancy?
cholesterol polyp
risk factor for malignancy: stones are also present, >1cm, sessile
breast cancer s/p lumphectomy. years later local recurrence. treatment?
breast cancer s/p mastectomy. years lateral local recurrence. treatment?
lumpectomy: salvage modified radical mastectomy
mastectomy: mammogram, CT, LFT, brain MRI
resect with 1cm margin
salvage chemo xrt
hernias and PD catheters?
fix hernias before if possible but concomitant repair is okay
postpartum thyroiditis. when does it happen
what antibodies do they have?
4-8 months after delivery and may last up to 9 –12 months
anti-thyroid antibodies (anti-thyroid peroxidase, anti-thyroglobulin)
Most women will regain normal thyroid function within 12-18 months after the onset of symptoms. However, approximately 20% of those that go into a hypothyroid phase will remain hypothyroid.
in hepatorenal, what’s the serum sodium level?
urine osm? urine sodium?
median survival for type I vs. type II?
in hepatorenal they keep absorbing sodium. this pulls more water in than sodium, resulting in hyponatremia.
so serum sodium will be low (only because there’s more water than sodium)
low urine sodium
urine osm is higher than serum
type I: 2 weeks
type II: 6 months
how to treat auto-peep
decrease the respiratory rate
decrease the I:E ratio (more expiration time, less inspiration time)
decrease the tidal volume
absent vas defereans
chloride sweat test. CF
UC flare. biopsy shows active UC, atypia and mild dysplasia. next step?
medical treatment + repeat colonoscopy/biopsy
surgery would be indicated if the patient fails to respond to medical therapy, or if high-grade dysplasia is seen on the repeat colonoscopy with biopsy
criteria for adjuvant therapy after colon cancer resection?
anything > T3
any node
any met
what diameter defines “toxic megacolon” for cecum and colon
cecum: 12cm
colon: 6cm
pt with locally advanced anal SCC has complete response to nigro. what should the surveillance be?
what if there is evidence of persistent disease?
CTCAP or PET annually for the first 3 years
if persistent disease, restage with PET + salvage APR
surveillance guideline for FAP
start annual colonoscopy at age 10-12 then colectomy when polyp burden > 20
rectal cancer MRI vs. US
MRI can define the extent of involvement of the mesorectal fascia, whereas ERUS does not
US is better at:
- T staging (but it gets worse with higher T stages). especially accurate for T0, T1
- ruling out nodal involvement than diagnosing it
GI bleed. planning for colonoscopy. what’s the time frame that this needs to be done? <12 hrs? <24 hrs?
Within 24 hours, if bowel “prep” yields clear, liquid stool
Several studies have compared urgent (< 8 or 12 hours from presentation) colonoscopy versus elective colonoscopy (24-90 hours from presentation). In patients who are hemodynamically stable without ongoing transfusion requirement, urgent colonoscopy did not result in reduced mortality but did shorten length of stay and time to hemostasis
what type of study?
get people with disease and try to find what they were exposed to
will this study measure odds ratio or relative risk?
case control
risk cannot be determined in a case-control study. Odds ratio is what you get
odds of the disease given an exposure divided by the odds of the disease given no exposure
what is an intention to treat analysis?
in a randomized controlled trial
ignores noncompliance, withdrawal, and crossover and therefore produces a conservative estimate of the effect of the treatment on the outcome
what analysis do you need to use for survival analysis?
Cox proportional hazard analysis
what type of study can report relative risk?
cohort study and randomized clinical trials can both report relative risk.
what type of study is cohort study in terms of exposure and disease?
find everyone who had the EXPOSURE
then see if they got the disease or not. you can get relative risk from this
case control study is when you find everyone who has the DISEASE and then try to look at their exposure
what’s the difference between linear regression vs. logistic regression?
linear regression: comparing how multiple variables are associated with a CONTINUOUS variable
logistic regression: comparing how multiple variables are associated with a CATEGORICAL variable
