Surgery Clerkship Flashcards
Cause and clinical features of air embolism
- Caused by severe chest trauma resulting in damage to the airways and vessels which cause mixing of the air and blood.
- Patients present with neurological deficits, hemoptysis, and circulatory arrest.
Telling difference between SBO and paralytic ileus:
- SBO will have “tinkling” as opposed to absent bowel sounds
- SBO will show proximal distension on plain films and distal collapse, as opposed to pan-distension in paralytic ileus
Findings on exam and imaging in perforated viscus:
- Exam will show peritonitis
- Imaging will reveal air under the diaphragm
Pathogenesis of paralytic ileus:
Not really well known, but can happen post-op or from injuries causing vertebral fractures and retroperitoneal hemorrhage.
Important causes of post-op fevers and the post-op day on which they occur:
Atelecatasis - Day 1
- “Wind” (Pneumonia) → 1-2 days post-op
- “Water” (UTI) → 3-5 days post-op
- “Walking” (DVT) → 4-6 days post op
- “Wound” (Wound infection) → 5-7 days
- “Wonder Drugs” (Drug associated) → ≥7 days
Signs of splenic injury:
Fluid (blood) in the spleno-renal space on FAST
LUQ pain
Kehr’s Sign
Left Sided Lower Rib Fractures
DVT treatment
Bridging heparin + coumadin
Coumadin tx should continue for approximately 3 months
Best treatment for acute cholecystitis:
Intial supportive care with fluids and observation
Laparoscopic cholecystectomy within 72 hours of presentation
Define “Mild TBI” and explain how to manage it:
Mild TBI is a head injury with a GCS of 13-15 and a brief LOC, vomiting, headache, or disorientation
Management = head CT; if normal then send home with clear instructions to return if any abnormalities arise
Clinical features, pathogenesis, and prevention of Bacterial Parotitis
- Presents with parotid swelling, oral purulent exudate, fever, leukocytosis
- Typically S. aureus infection of the parotid duct.
- Prevent with adequate oral hygiene and hydration of patients.
Fat necrosis:
- Similarities to breast malignancy:
- Differences from breast malignancy:
- Nipple retraction, fixed mass, calcifications, similar US findings
- Calcifications are coarse in fat necrosis–not fine; biopsy reveals fat globules and foamy histiocytes.
Nasopharyngeal Carcinoma (NPC)
Define
Clinical presentation
Risk Factors
This is an undifferentiated carcinoma of sqaumous cell origin.
Patients typically present late in the course, once the disease has already spread. There is recurrent epistaxis, sinusitis, otitis media, nasal obstruction.
Risk factors include Mediterranean or far Eastern decent; smoking; EBV infection.
Treatment for pneumothorax:
Chest tube inserted in the 2nd intercostal space on the midclavicular line
Explain directionality of trachea shift:
Trachea shifts toward the problem in (1) spontaneous PTX; (2) pneumonectomy
Trachea shifts away from the problem in (1) tension PTX; (2) traumatic PTX.
Different types of foot ulcers and their specific findings:
- Venous Insufficiency Ulcers: typically located on the medial aspect of the leg, just above the medial malleolus and associated with overlying stasis dermatitis, and chronic lower extremity edema
- Arterial Insufficiency Ulcers: Lateral aspect of the ankle or the distal digits
- Diabetic Ulcers: typcially on the sole of the foot and are painless.
Pathogenesis of diabetic foot ulcers:
Combination of:
(1) Neuropathy
(2) Microvascular insufficiency
(3) Relative immunosuppression
Etiology of whistling sound on respiration in rhinoplasty patient:
Septal Perforation
Septal cartilage has a very poor blood supply–coming completely from the overlying mucosa. Therefore minor septal trauma can cause ishemia of the underlying collagen.
Acalculous cholecystitis
Clinical Presentation
Diagnosis
Treatment
Patients will present with other severe illness, like burns, trauma, sepsis, etc. Due to the bad nature of these inciting injuries, they also commonly have paralytic ileus. Other than that they will have exactly the same symptoms as a patient with acute calculous cholecystitis if they can interact with you.
Diagnose with the various imaging studies, which should reveal dilated gall bladder, thickened wall, pericholecystic fluid, and no stones.
Can treat immediately with percutaneous drainage and supportive care and quickly move onto cholecystectomy.
Complicated Diveritculitis
Define
Treatment
This is diverticulitis that has associated obstruction, perforation, fistula, or abscess.
Treat with IV antiobiotics and drainage if an abscess, and the appropriate therapies for the other causes.
Most common and serious complication of Roux-en-Y gastric bypass surgery:
Leakage of the gastro-jejunal anastomosis
Role of steroids in Crohn’s Disease:
These are only used in patients refractory to antimicrobial (metronidazole / cipro) and anti-inflammatory drugs (5-ASA).
They are not indicated for maintenance therapy–only treatment of acute exacerbations.
Budesonide
Define
Indications
Pros and cons
This is a corticosteroid.
Used for asthma, COPD, and Crohn’s disease.
It is metabolized more rapidly than prednisone and therefore has few side effects. However it is not as potent, and therefore in Crohn’s disease it is only used in mild to moderate flare-ups–as opposed to the more severe flare-ups which are treated with prednisone.
Factors associated with disease recurrence in Crohn’s
Smoking
NSAIDs
Infliximab
Define / MOA
Indications in Crohn’s Disease
Drawbacks
This is a chimeric monoclonal antibody directed against the TNF-a receptor, and is used in inflammatory conditions such as Crohn’s.
In Crohn’s it is used in (1) patients refractory to all other medical treatments; and (2) as a first line therapy for fistulizing Crohn’s in order to stear clear of operations.
Drawbacks include: opportunistic infections and development of B-cell lymphomas.
Most common site for Crohn’s Disease:
Terminal Ileum + Cecum
Clinical Features of IBD
UC?
CD?
UC: (1) Bloody diarrhea; (2) Abdominal Pain; (3) Small frequent bowel movements; (4) rarely fever, anorexia, and weight loss; (5) Tenesmus; (6) Extra-intestinal symptoms
CD: (1) Watery diarrhea; (2) Commonly malabsorption and weight loss; (3) Abdominal pain; (4) Fever, malaise; (5) Extra-intestinal symptoms
The Extra-Intestinal Symptoms of IBD:
- Uveitis
- Erythema Nodosum (esp. CD)
- Pyoderma gangrenosum (esp. UC)
- Migratory monoarticular arthritis
- Ankylosing Spondylitis (esp. UC)
- Thrombo-embolic hypercoaguable state
- ITP
- Osteoporosis
- Gallstones (in CD due to ileal involvement)
- Sclerosing Cholangitis (UC)
Medications used for Crohn’s
- Start with 5-ASA (which is best for the colon, and inhibits prostaglandin release)
- Metronidazole + Cipro if 5-ASA fails
- Steroids if anti-microbials fail and for acute exacerbations
- Azathioprine + 6-mercaptopurine + steroids if steroids fail.
- Infliximab (anti-TNFa) if all others fail or first line for fistulas.
UC involves _____ in all cases.
the rectum
Most serious and severe complications of UC:
- Colon Cancer
- Cholangiocarcinoma
- Sclerosing Cholangitis (even with colon removed)
- Toxic Megacolon
- Iron deficiency anemia (hematochezia)
- Hemorrhage
- Electrolyte disturbances
- Strictures
- Growth Retardation
Medical Management of UC:
5-ASA is the mainstay
Prednisone for acute flares
What is going on here?
This is an “ileal J pouch” which is what is used to create a new anus for a UC patient who had their entire colon resected due to their disease.
Main indications for surgery in UC:
- Fulminant colitits / Toxic Megacolon
- Dysplasia
- Cancer
- Intractable Disease
Define fulminant colitis / Toxic Megacolon
Fulminant colitis: characterized by severe abdominal pain, fever, and sepsis which is normally caused by IC, but can also be caused by CD or pseudomembranous colitis.
Toxic Megacolon: is essentially fulminant colitis with proven dilation of the colon proven by radiographic evidence. This occurs when there is invasion of the muscularis propia by the disease.
Typical symptoms of sciatica:
Lower back pain and radicular pain shooting down the leg.
Worsened by moving around, sitting, and lifting extended leg straight up.
Improved by lying supine.
The most commonly herniated disc:
L4-L5
Followed closely by L5-S1
Cauda Equina Syndrome
Clinical presentation
Etiology
Diagnosis
Treatment
Patients present with lower back pain, accompanied by difficulty voiding urine and making bowel movements
A number of causes including: (1) herniated disc; (2) Trauma; (3) Spinal stenosis; (4) Tumor
Diagnose by MRI
Treatment with surgical decompression of nerves.
Treatment for herniated discs:
Initially conservative by resting and NSAIDs. This can resolve many disc herniations.
If no improvement or worsening then perform laminectomy.
What is this?
This is a diagram of the Kasai Procedure in which a the biliary tree is cut down flush to the liver–leaving the porta-hepatis.
A roux-en-Y procedure is then performed in which the jejunem is attached to the porta hepatitis and the distal duodenum is anastomosed to the jejunem.
Primary complications of Kasai Procedure and how they are managed:
Cholangitis - IV antibiotics against gram negatives + steroids
Cessation of Bile Flow - Steroids + Cholerectic agents
Portal HTN - liver transplant, management of related complications
Presentation of cholangitis following Kasai Procedure:
Fever
Leukocytosis
Conjugated hyperbilirubinemia
Management of biliary atresia based on age of patient:
Biliary atresia is optimally treated by Kasai procedure before patient is 120 days old.
If the patient is older than this at time of diagnosis they need to be on the list for a liver transplant.
What to do preoperatively for a patient with biliary atresia or choledochal cyst:
Perform coagulation study and appropriately administer vitamin K and FFP.
Assess anemia, and appropriately administer Cross-matched blood.
Differential diagnosis for dysphagia (break it up):
Broken down into issue swallowing solids and liquids or solids alone.
- Solids and Liquids: If only intermittent –> likely a spasm. If progressive –> achalasia, or scleroderma.
- Solids only: If intermittent –> lower esophageal ring. If progressive –> cancer or peptic ulcer.
Risk factors for SCC vs Adenocarcinoma of the esophagus
SCC: (1) EtOH; (2) Caustic material; (3) Smoking; (4) Nitrite / Nitrate containing foods.
Adenocarcinoma: (1) GERD; (2) Obesity; (3) Acid Suppression medications
Esophageal Cancer
(P / D / T)
Presents with dysphagia most commonly, and possibly other symptoms related to neoplasms like weight loss and cachexia.
Diagnose with first a barium esophagram, then a esophagogastroduodenoscopy + biopsy, and TES-US to stage depth and regional nodes, and CT or PET for distant metastasis.
Treat with chemoradiation and (1) transthoracic esophagectomy or (2) transhiatal esophagectomy for stages I-III. Stage IV can be treated palliatively with chemo.
Schatzki’s Ring
Submucosal circumferential ring in the lower esophagus often associated with hiatal hernia.
Can cause dysphagia.
Most common infections in the post transplant period and timing:
Best way to prevent:
Bacterial are most common in the first month after transplant
After that opportunistic infections are more common (CMV, Pneumosystis, aspergillous, toxoplasmosis, cryptococcus, blastomycosis).
Prevent with prophylactic trimethoprim-sulfamethoxazole
Most common anti-rejection drugs used for transplant and their specific uses and mechanisms:
Corticosteroids - used for acute rejection, works at several sites in the anti-rejection pathway.
Cyclosporin - used for more long term therapy; inhibits calcineurin and IL-2
Tacrolimus - More long term therapy; inhibits calcineurin, IL-2, IL-3, and IL-4
Sirolimus - longer term therapy; T-cell inhibitor
Mycophenolate Mofetil (MMF) - longer term therapy; inhibits B and T cell proliferation, often combined with cyclosporin.
Azathiopurine - longer term therapy; inhibits B and T cell proliferation, often combined with cyclosporin. Used when MMF doesn’t work.
OKT3 - Induction or acute rejection treatment; monoclonal Ab against CD3 receptor of T-cells
GFR cutoffs for transplant and dialysis:
20 for transplant
15 for Dialysis
Radiosensitivity of esophageal SCC
Extremely sensitive`
Chronic Allograft Nephropathy =
Refers to fibrotic changes in transplanted kidneys which are accelerated due to their allograft (non-autograft) state. This occurs years down the line.
Presents with progressive increases in serum Creatinine, protein, oliguria, and microscopic hematuria
Diagnosis is by biopsy
No treatment
Best imaging for acute osteomyelitis
Radionucleide scan with gallium or something else
Splenomegaly in ITP
Rare.
If present look for another cause of thrombocytopenia
OPSS:
P / D / T
“Overwhelming Post-Splenectomy Sepsis”
Presents as non-specific symptoms like: fever; malaise; headache; confusion. But can rapidly progress to shock and death.
Diagnosed clinically
Treatment is primarily based on prevention with administration of vaccines for encapsulated bacteria; as well as medical surveillance.
Factors predisposing to OPSS:
Children
Splenectomy for hematologic rather than traumatic disorder
ITP patient group who have best long term outcomes post-splenectomy:
Patients who respond to corticosteroids
When to give pneumococcal vaccine to splenectomy patients:
2 weeks before surgery
ITP
(P / D / M)
Present with easy bruising and bleeding, purpura and petechiae, labs revealing thrombocytopenia, and bone marrow aspirate revealing increased numbers of megakaryoctes.
Diagnosis is clinical and bone biopsy must reveal normal or increased megakaryocytes.
Management depends on the severity of the disease: asymptomatic patients with counts above 50,000 platelets require monitoring; asymptopatients with 30,000-50,000 also monitored; symptomatic patients require corticosteroids. If steroids don’t work can move onto: (1) IV immunoglobulins; (2) Plasmapheresis; (3) Chemotherapeutic agents. If none of the above work, then consider splenectomy.
Explain the grades of splenic injury:
Tumors of Spleen:
Benign: hamartomas; echinococcal cyst; hemangioma/lymphangioma
Malignant: Lymphoma; mets from lungs and breast; myeloproliferative disorders
Complications of Splenectomy
OPSS
Sub-phrenic abscess
Damage to tail of pancreas
Thrombocytosis
Left-Sided Pleural Effusion
Conditions associated with increased risk of splenic rupture:
Mononucleosis
Malaria
Blunt abdominal trauma
Splenic Abscess
Splenic Abscess
(Clinical Summary)
Presents with fever, leukocytosis, LUQ pain.
Diagnosed with US or CT
Caused by sepsis seeding, direct extension, trauma, hematoma, IV drug use
Treat with percutaneous drainage if a solitary juxtacapsular abscess; however usually treated with splenectomy.
Popliteal arteries and AAA
1/3rd of patients with a popliteal artery aneurysm will also have a AAA
ABI in diabetic patient
can be falsely elevated since the vessels may be calcified–making it seem like the pressure is higher than it is.
Size at which a AAA is surgical:
5 cm
Drug of choice for liver transplant immunosuppression
Tacrolimus
Side effects of calcineurin inhibitors (CsA and tacrolimus)
Nephrotoxicity
Diabetegenesis
(Both worse in tacrolimus since it is much more potent)
HLA matching in liver transplants:
Not as necessary as in other transplants and may even be dangerous
Mechanism of presensitization to donor antigen for hyperacute rejection:
Prior blood transfusion
Pregnancy
Prior transplant
Post Transplant Lymphoproliferative Disease (PTLD)
Clinical Summary
Patients become immunosuppressed and contract EBV infection. Leads to monoclonal B cell lymphoma.
Treatment is to stop immunosuppression or reduce it and replete immunity.
Early and Late Complications of Renal Transplant
- Early:
- Graft Thrombosis: abrupt cessation of urine output. Dx with doppler. Requires immediate surgery to reapir.
- Urine Leak: patient presents with anuria, abdominal pain, and scrotal or labial swelling. The leak is usually at the level of the UV junction.
- Delayed Graft Function: anuria or oliguria soon after surgery. Dx of exclusion once leak or thrombosis is ruled out. Patients can be placed on dialysis in the interim.
- Late:
- Uretal Stricture: Rising creatinine and hydronephrosis on US. Pyelogram can be used to diangosed. Balloon dilation to treat.
- Renal Artery Stenosis: Results in oliguria and HTN. Diagnosed by angiography, US, or MRA. Treat with angioplasty.
Prognosis of seminoma:
Great due to the high degree of sensitivity to radiation therapy
Pathologic Fracture
Clinical Summary
Fracture caused by minor trauma
Typical Causes: (1) Primary or metastatic cancer; (2) cysts; (3) Enchondroma; (4) Giant cell tumors; (5) osteomalacia; (6) osteogenesis imperfecta; (7) Scurvy; (8) Rickets; (9) Paget disease
Treat the fracture and underlying condition
Stress Fracture
(Clinical Summary)
Caused by repetitive motions.
Often pain only with activity
treat patient by telling them to rest
What is this?
Greenstick fracture
An incomplete and angulated fracture of long bones common in children due to the thick periosteal membrane
Classic triad for fat embolism
Dypnea
Petechiae
Confusion
Fat Embolism
Clinical Summary
Patients typically with a history of a serious injury, like a long bone fracture or burn.
Presents with confusion, petechiae, and dyspnea. RR is often over 30.
Studies will show snowy infiltrates on CXR, arterial hypoxemia, and fat doplets in the urine.
Mechanisms of injury for anterior and posterior shoulder dislocations and their presentations:
Anterior: patients fell on arm which was adducted and externally rotated. Present with arm on side and externally rotated–resisting internal rotation.
Posterior: patients experienced massive muscle contraction from something like an electrical shock or convulsion and perhaps fell on arm which was flexed and internally rotated. Patient presents with arm at side internally rotated.
Workup for complications of shoulder dislocations:
Axillary Artery Injury: Check radial pulse
Axillary Nerve Injury: Check motor by checking deltoid strength (abduction); check sensation on lateral aspect of arm.
2 hallmark findings in compartment syndrome of leg:
Paresthesias in digital interspace between first and second toes.
Pain out of proportion to injury findings.
Ewing Sarcoma
EPDM
2nd most common primary malignant bone tumor seen in kids aged from 5-15. Tumors are typically found on the diaphysis of long bones.
Patients present with pain worse at night, local swelling and pain, fever, malaise, leukocytosis, mild anemia, and elevated ESR.
Diagnose with lytic, onion skin lesion on radiographs
Vincristin, cyclophosphamide, actinomycin, and adriamycin and surgery are the treatments.
Symptoms suggestive of invasive / obstructive pancreatic cancer:
Jaundice
Pain
Gastric Outlet Obstruction
Trousseau’s Syndrome =
thrombophlebitis and thromboembolic syndrome associated with pancreatic cancer
Number one cause of painless rectal bleeding:
Diverticulosis
Antibiotics to use for acute diverticulitis
Flagyl
Cipro
Who requires emergent surgery for diverticulitis:
Perforation
Surgery to perform for peritonitis from diverticulitis and why this:
Hartman’s: left hemi-colectomy followed by a colostomy which will allow the inflammation to cool down before trying to anastomose to the rest of the colon
Lower GI causes of brisk blood per rectum:
AVM
Diverticulosis
Hemorrhoids
Colitis
Diagnostic tests for lower GI bleed:
CT Angio
Tagged Red blood cells
Colonoscopy if they haven’t bled for a couple of days
Most common side of colon for diverticular bleeding:
Right sided
Tumor marker for colorectal cancer:
What else can this be used for?
CA19-9
Also for adenocarcinoma of the pancreas
Tumor markers for thyroid cancer:
Medullary: CEA and Calcitonin
Papillary: CEA
Imaging follow-up protocol for colon cancer:
CT every 6 months for 3 years.
CT every year after that.
A 95 year old woman is sent to the emergency room from a nursing home with complaints of abdominal pain and distention. It is unclear, but staff at nursing home think it has been about four days since she had a bowel movement. On examination, the woman has an expressive aphasia and a right hemiparesis from a previous stroke. Her vital signs are pulse 90, blood pressure 120/80, and she is afebrile. Her abdomen is markedly distended with hyperactive bowel sounds and tympany throughout. There is no abdominal tenderness.
Rectal exam reveals large quantities of soft, brown, guaiac negative stool. KUB and upright reveal marked dilated colon consistent with obstruction.
_Study Questions: _
- What is the differential diagnosis of a large bowel obstruction?
- What test(s) would you employ to determine a specific diagnosis?
- Where can a volvulus develop and why?
- What would you see on abdominal x-rays if this patient had a volvulus?
- Outline your treatment plan for a patient with volvulus.
- How would this differ from your treatment of a patient with a colon cancer or impaction?
- What are the potential complications of a patient with large bowel obstruction if left untreated?
- Ogilve’s, cancer, strictures, IBD, volvulus
- Abdominal plain films, CT scan, thin barium or gastrograffin enema, lactate
Cause of volvulus in elderly patients:
Left colon becomes more loose and can cause things to move around.
What to think if a patient comes in with pneumonia and a lactate of 13:
patient has fulminant sepsis (double digit lactate is BAD)
Treatment for sigmoid volvulus:
Flex Sig to detorse
Next take out affected sigmoid within the same hospital stay
Better to have overriding or distracted fracture:
Overriding since ou can pull the bones and reapproximate
Ways to check bi-maleolar fractures:
Inversion-eversion
What is going on here?
What else needs to be checked?
Bilateral comminuted calcaneal fracture aka “Jumper’s Fracture”
Pelvic and spinal fractures need to be assessed–particularly the thoracolumbar junction.
2 ways to get air in soft tissues in the extremities:
Anaerobic infections
from the outside
What is going on here:
Salter Harris Type II Fracture of the radius close to the growth plate
Why is a fracture of the epiphysis worse than a fracture of the metaphysis in a child?
The cells responsible for growth are on the side of the epiphysis.
Patient population for greenstick fractures:
Why these patients?
Kids going through growth spurt (around age 13)
During the growth spurt there is a greater proportion of collagen in the bones.
What do you think is going on here?
This patient had a pathologic fracture of the humerous–most likely due to cancer in the bone.
The divots in the bone here are sites of tumors
Most common tumors of the bone:
Metastasis from breast
Multiple myeloma
What to consider with “holes in bone” in a patient over 40 yo?
Metastasis
Multiple myeloma
Treatment for SCC of the Anus:
Neoadjuvant Nigro chemoradiation protocol (90%) effective
Surgery if that doesn’t work
Source of GI bleeding in young patients:
Overwhelmingly the upper GI
How to find source of lower GI bleed that is actively bleeding:
If over 2 ml/min - perform angiogram
If under 0.5 ml/min - wait until it no longer bleeds then perform a colonoscopy
0.5 ml/min to 2 ml/min - perform tagged RBC tests
Massive upper GI bleed in stressed multiple trauma patient…
Management:
Likely from stress ulcers.
Arterial embolization to treat.
Prevention by keeping pH above 4
Only pathologic process combining severe abdominal pain with bleeding into the lumen:
Ischemic bowel processes
Mimics of acute abdomen and how to rule them out:
MI (EKG)
Lower Lobe Pneumonia (CXR)
PE (immobilized patient)
Pancreatitis (amylase)
Urinary Stones (CT)
Best dx test for urinary colick:
CT (you’re looking for stones)
Serum marker for hepatocellular carcinoma:
alpha-fetoprotein
Typical pathogenesis of pyogenic liver abscess:
Complication of acute ascending cholangitis
Organisms are typically gram negative rods and anaerobes
Treatment if gallstones are incidentally found on abdominal US or CT (asymptomatic gallstones):
None
Treatment of pancreatic pseudocysts:
Shorter than 6w or smaller than 6cm: treat conservatively and wait for spontaneous resolution.
Longer than 6w or larger than 6cm: percutaneous, endoscopic, or open drainage
Abdominal hernias which do not need to be repaired (right now)
Umbilical hernias in kids younger than 2
Sliding hiatal hernias
Digoxin Toxicity
Drug which interferes with digoxin’s renal clearance:
Signs and symptoms of digoxin toxicity:
Verapamil–not all CCBs will do this.
(1) GI symptoms–anorexia, nausea, vomiting; (2) Bidirectional ventricular tachycardias; (3) Accelerated junctional rhythms
Chronic choledocholithiasis and gall bladder carcinoma
Chronic choledocholithiasis can serve as a risk factor for the development of gall bladder carcinoma since there is constant inflammation of the gall bladder wall.
Gall bladder carcinoma is a rare disease and is more predominantly found in the Mexican and Native American populations.
Ease of diagnosis of gall bladder carcinoma:
this is extremely difficult to diagnose preoperatively
Pediatric Constipation
Diagnosis:
Causes:
Treatment:
D: this is a clinical diagnosis.
C’s: typically caused by a combination of things happening in toddlerhood, including drinking cow’s milk, potty training, and transition to school.
T: Oral Laxatives
Treatment to prevent vertical transmission of HepB to neonate:
Anti HepB Ig + HepB vaccine
Vertical transmission of HepB vs HepC:
HepB transmission occurs much more readily than HepC vertical transmission.
If the mother is HbsAg positive only the risk of transmission is about 20%. If she is both HbsAg and HbeAg positive then the rate of transmission is about 95%
HepB is typically transmitted during vaginal delivery and rarely through the placenta.
Hepatitis C vertical transmission is pretty rare, but happens more commonly if the mother has a very high viral load or is also HIV+
Clinical presentation of Chronic Mesenteric Ischemia vs Chronic Pancreatitis:
Chronic Mesenteric Ischemia: Abdominal angina with food aversion. Patients may also have symptoms related to generalized atherosclerosis.
Chronic Pancreatitis: chronic rather severe pain, with prominent malabsorptive symptoms. Patients might also have diabetes mellitus, and kidney stones.
Items needed for diagnosis of acute pancreatitis:
2 of the following:
(1) Acute onset of severe epigastric pain (usually radiating to the back)
(2) Elevated Amylase and Lipase
(3) CT findings consistent with acute pancreatitis (if amylase and lipase are normal)
Abdominal US in acute pancreatitis:
Not helpful since findings are obscured by the ileus accompanying the acute pancreatitis
Signs of increased estrogen from cirrhosis:
Spider angioma
Gynecomastia
Testicular Atrophy
Loss of hair
Treatment for asymptomatic gallstones:
None
LFTs seen in fulminant hepatitis:
Aminotransferases will decline since there aren’t really any more hepatocytes
Increased PT
Most common complication of PUD:
Hemorrhage
Normal Urine Na?
Urine Na seen in pre-renal failure (eg, hepatorenal syndrome)?
Around 20 meq/l
less than 10 meq/l
Management of cholecystitis in pregnant patients:
Perform in 2nd trimester.
If patient does not want surgery, or must wait until 2nd trimester or following gestation give ursodeoxycholic acid to help dissolve stones.
Gallstone features in Asian populations:
First off they are uncommon compared to caucasian populations
Secondly, when they do occur they are usually pigment stones
Radiographic finding in supracondylar humerous fracture:
Dual sail sign
Joint effusion causes hypodense sail shapes surrounding the fracture site.
3 areas of narrowing in esophagus
best way to visualize
CBD
Cricopharyngeus
Left main stem bronchus
Diaphragmatic Hiatus
Vertbral levels where IVC, Esophagus, and Aorta cross the diaphragm:
I (IVC) ate (T8) ten (T10) eggs (esophagus) at (aorta) noon (T12).
IVC - T8
Esophagus - T10
Aorta - T12
Signs and symptoms of achalasia
Regurgitation of food
Severe halitosis
issues swallowing both solids and liquids (remember, all weird functional issues in the esophagus will cause issues swallowing solids and liquids, whereas mechanical obstructions will cause issues mainly in swallowing solids–like meat)
Treatment of achalasia
