Surgery/GI Flashcards
venous insufficiency
venous HTN –> LE edema, loss of fluid, plasma proteins, erythrocytes
- erythrocyte –> hemosiderin deposition –> stasis dermatitis (red-bronze colored legs)
- ultimately - inflammation of venules and capillaries, fibrin deposition, plt aggregation –> microvascular disease and ulcerations
- changes - 1) xerosis (dry chicken skin), 2) lipodermatosclerosis (~panniculitis aka inflammation of subQ fat) and ulcerations LE edema
- venous valvular incompetence is most common (cycle where fluid leaks out of intravascular space so kidneys retain more fluid)
- note lymphatic obstruction is an uncommon cause of edema (due to malignant obstruction, LN resection, trauma, filariasis) - affects dorsa of feet and causes marked thickening and rigidity of skin
ulcers on feet
- diabetic - microvascular disease
- arterial insufficiency - tip of toes, devoid of granulation tissue, start with Doppler (pressure gradient means that surgery may be a treatment option)
- venous stasis - will have granulation tissue
- marjolin ulcer
FOOSH
schapoid fracture - can lead to avascular necrosis and non-union of proximal pole
- tenderness in anatomic snuffbox
- xray at time of injury has low sensitivity –> get CT/MRI to confirm fracture
- immobilize wrist in thumb spica splint - and get repeat imaging in 7-10d
supracondylar fracture of humerus - kids
- brachial artery injury, medial nerve injury
- less common complications are cubitus varus deformity and compartment syndrome (volkmann ischemic contracture)
- note - mid-distal humerus fractures also risk radial injury (wrist drop)
clavicle fracture - occurs with FOOSH or direct blow to shoulder
- usu fracture of middle third of the clavicle
- tx by brace, rest, and ice
- fractures of the distal 3rd may required ORIF because of risk of non-union - careful exam because of close proximity to subclavian artery and brachial plexus
- if you hear a bruit - need to rule out vessel injury
shoulder injury - FOOSH can lead to shearing of shoulder bones
tendon injuries
penetrating injury or with extreme loading of digit (jamming a finger on a ball)
sphincter of Oddi dysfunction
can develop after any inflammatory process - surgery, pancreatitis
dyskinesia and stenosis of sphincter
- functional biliary disorder - where there is obstruction of flow through the sphincter
- recurrent episodic pain with transaminitis and alk phos elevations
- dilated common bile duct in absence of stones
opioids (morphine) cause contraction of sphincter –> precipitate sxs
manometry is the gold std dx
tx - sphincterotomy
gastritis
gastritis
bile reflux gastritis - due to incompetent pyloric sphincter (following gastric surgery)
- vomiting, heart burn, abd pain
acute erosive gastropathy: hemorrhagic lesions after exposure of gastric mucosa - ASA, cocaine, alcohol (vasoconstriction and direct mucosal injury)
acute adrenal insufficiency
due to - adrenal hemorrhage/infarct
- acute illness/injury/surgery in pt with chronic adrenal insufficiency (PAI, Addisons disease) or long-term glucocorticoid use
- pts on long-term glucocorticoid therapy will eventually develop Cushingoid features (HPA suppression can occur after 3 weeks of prednisone > 20 mg/day)
- side note - pts on <5mg/day of glucocorticoids will not need stress dosing
- for doses 5-20mg/day - get preoperative evaluation with early-morning cortisol level
- px - hypotension/shock, N&V and abd pain, weakness, fever
- hypoglycemia is also common - can cause dizziness and a wide pulse pressure (due to systolic HTN)
- tx - hydrocortisone, dexa, high-flow IVF
pts with PAI will also have mineralocorticoid deficiency - hyponatremia and hyperkalemia
“septic shock” - abx, steroid bolus - if you think someone has septic shock and they “briefly* respond to a steroid bolus –> adrenal infarct
hip/pelvis injuries
adducted and internally rotated leg - acetabular fracture with post hip dislocation
pelvic fracture - pain in low abd/groin, bruising along scrotum and perineum
- men with pelvic fractures are at high risk for posterior urethral injury - will present with blood at urethral meatus and high-riding prostate
- for suspected urethral injury - get retrograde urethrogram (contrast should enter bladder uninterrupted)
- tx with temporary urinary diversion by suprapubic catheter –> delayed urethral repair with pelvic fracture
- you can also get bladder rupture - gross hematuria and difficultly voiding - use retrograde cystogram bladder rupture
- retrograde cystogram - need post-void films to look for leaks at base of bladder
aortoiliac occlusion
Leriche syndrome
triad of 1) bilateral hip, thigh, and buttock claudication
2) impotence
3) symmetric atrophy of LE due to chronic ischemia
occurs in a men with risk factors for atheroscloersis
- pain is exercise-induced and relieved by rest
catheters and lines
CVC - used for administration of critical care medications
- IJ, subclavian
- tip in lower superior vena cava (tip placement in smaller veins predisposes to venous perforation)
- inappropriately placed catheter can also cause pneumothorax (or myocardial perf or subclavian artery puncture)
- CVC may trigger cardiac arrhythmias if inserted too far into RA
- get confirmatory CXR or portable CXR (imm) - want to see catheter tip at angle between trachea and right mainstem bronchus
pulmonary contusion
presents <24hrs after blunt thoracic trauma - often within a few min
- tachypnea, tachy, hypoxia - rales or decreased breath sounds
- CT/CXR will show patchy infiltrate not restricted by anatomic borders
- tx - pain control, pulm hygiene (neb, chest PT), supplemental O2 and vent. support
ARDS is a common complication of pulm contusion - will present 24-48hrs after trauma
- bilat, patchy infiltrates on CXR
fat embolism
long bone fractures, pancreatitis
- tachypnea (respiratory distress), tachy, hypotension, AMS (confusion, visual field defects), thrombocytopenia, petechiae
- prevention and tx - early immobilization of fracture, supportive care (mechanical vent required fro approx 50% of pts)
rib fractures
rib fractures - pain control!
- in general - surgery is rarely indicated (indications include flail chest with failure to wean from vent, refractory, deformity)
Flail chest
- when 3+ consecutive ribs are fractured in 2 places flail segment moves in during inspiration, balloons out during expiration requires large amount of trauma
- so make sure that there is no traumatic transection of aorta
- px - chest pain, tachypnea, rapid shallow breaths (splinting)
- rib fractures +/- contusion/hemothorax
- tx - pain control, supplemental O2 - PPV (+/- chest tube) for respiratory failure (due to the pulmonary contusions)
oropharyngeal infections
tonsilitis- …tender ant cervical nodes, palatal petechiae
epiglottitis
herpangina
- coxsackie A - fever, sore throat, odynophagia
mono - fever, pharyngitis, and post C-LAD
peritonsillar abscess - fever, sore throat, trismus, hot potato voice, uvular deviation region between the tonsil and the pharyngeal muscle gets infected
- most common in older adolescents and young adults - drug and etoh increases risk
- tx - needle aspiration or I&D, abx to cover group a strep and respiratory anaerobes
note - adenoids are typically enlarged in early childhood, will regress with age
GCS
GCS - for prognosis of medical conditions
eye opening
- spont - 4
- verbal command - 3
- pain - 2
- none - 1
verbal
- oriented - 5
- disoriented - 4
- inappropriate words - 3
- incomprehensible sounds - 2
- none - 1
motor
- obeys - 6
- localizes - 5
- withdraws - 4
- flexure posturing (decorticate, hold on) - 3
- extensor posturing (decerebrate, let me go) - 2
- none - 1
how to dx coma - brainstem activity, decorticate/decerebrate, impaired consciousness
nasopharyngeal carcinoma
associated with EBV - tumor expresses EBV DNA and EBV assays are often used to monitor treatment
- endemic to souther china (and Africa, middle east) - risk is higher here due to diet
- salt-cured food and genetic predisposition
tumors obstruct the nasopharynx and invade adjacent tissues –> nasal congestion, epistaxis, headache, CN palsies, otitis media
- early metastatic spread to cervical lymph nodes = non-tender neck mass
vs nasal polyposis - nasal congestion and rhinorrhea - due to recurrent bacterial sinusitis nasal polyps
- asthma, allergic rhinitis
BAT
factors increasing the likelihood of intra-abd injury - seat-belt sign, rebound, abd distention/guarding, concomitant femur fracture
work-up of BAT (almost always get a FAST)
- pos fast, hemodynamically unstable –> ex lap
- pos fast and hemodynamically stable –> CT scan of abdomen to determine need for laparotomy (will distinguish blood from urine or ascites, site of injury)
- negative fast –> serial abd exams +/- CT
- note DPL can be used if FAST is inconclusive
duodenal hematomas - most commonly occur following BAT, more commonly seen in kids (due to anatomic differences)
- occurs when BAT compresses the duodenum against the vertebral column
- blood collects between submucosal and muscular layers –> obstruction –> gastric distention 24-36hrs after injury
- dx confirmed with CT manage with NG decompression and TPN
- surgery or perc drainage if non-op management fails
spillage of blood, bowel contents, bile, pancreatic secretions into peritoneum –> acute chemical peritonitis, diffuse abd pain and guarding
- rupture of DOME of bladder will cause urine spillage into the peritoneum - because this the only part of the bladder that is intraperitoneal (also the weakest part of the bladder)
BAT –> damage to mesenteric blood supply –> delayed perf - most commonly of jejunum
small bowel perf
fever, hemodynamic instability, diminished bowel sounds
pain with impending bowel perf (small and large) = periumbilical
- ex - acute appy, mesenteric ischemia (get mesenteric angiography)
- note - visceral pain is poorly localized
nec fasc
micro - Strep pyogenes, S aureus, clostridium perfringens, polymicrobial
pathogenesis - bacteria spread through subQ tissue + deep fascia - most commonly involves extremities and perianal region
clinical - hx of trauma, erythema of skin, swelling and edema, POOP, fever and hypotension
- can also result from significant peripheral vascular disease - diabetes
tx - surgical debridement and BS abx
- if untreated - progresses to rapid discoloration of skin, purulent discharge, bullae, and necrosis
thrombophlebitis
erythema, tenderness, swelling, cord-like vein
aortic injury
consider in MVC or falls >10ft - also in rapid deceleration
- traumatic rupture of aorta - also consider if first rib, scapula, or sternum are broken (because these are very hard to break)
blunt chest trauma sxs - variable but anxiety, tachy, and hypertension are common
- get CXR! - will see mediastinal widening
- can also have tracheal deviation to R or depression of L mainstem bronchus
- CXR –> get chest CT and angiography (possibly transesophageal echo) in stable patients
other injuries in trauma
- myocardial contusion - tachy, rib fractures or sternal fracture, new bundle branch blocks or arrhythmia
- pulm contusion - opacities caused by hemorrhage in lung segments
hemoptysis
pulmonary Tb - on CXR - patchy or nodular opacity, multiple nodules, cavity in apical-posterior segments of upper lobes of lungs
- place pt in respiratory isolation
hemoptysis - rule out oropharyngeal and GI causes
- pulmonary cause
- mild/moderate - CXR, CBC, coag studies, RFTs, UA, rheum work up –> CT scan and possibly bronch
- in pts with hemoptysis and hemodynamic instability or poor gas exchange, severe dyspnea, or massive hemoptysis - FIRST intubate
- massive hemoptysis = >600 mL/day or 100 mL/hr –> bronchoscopy –> pulm arteriography if that fails –> urgent thoracotomy
- give FFP to patients with coagulopathy as the cause of hemoptysis (INR > 1.5)
DVTs and anticoagulation
factor Xa inhibitors - rivaroxaban, apixaban, fondaparinux (indirect)
- factor X activates thrombin
direct thrombin inhibitors - argatroban, bivalirudin, dabigatran
- thrombin converts fibrinogen to fibrin
provoked DVT due to surgery - 3 mo of treatment
- start on unfractionated heparin/LMWH, warfarin later that same day
- continue unfractionated heparin/LMWH for 4-5d - until INR is at 2-3
- dont use LMWH and rivaroxaban in pts with ESRD - because these are both metabolized by the kidney
stress fracture
risk factors - repetitive activities, abrupt increase in physical activity, inadequate Ca or vitamin D intake, decreased caloric intake
- female athlete triad - low caloric intake, hypomenorrhea/amenorrhea, low bone density
px - insidious onset of localized pain, point tenderness at fracture site
- XR may be negative in first 6 weeks management
- rest and analgesics (acetaminophen)
- reduce weight bearing for 4-6 wks or cast (and repeat xray in 2 wks)
- refer to ortho for fracture at high risk for malunion (anterior tibial cortex, 5th metatarsal, manage with casting or internal fixation)
medial tibial stress syndrome (shin splints) - anterior leg pain, but diffuse tenderness
- also more common in overweight individuals
pancreatic adenocarcinoma
pancreatic cancer is the 4th leading cause of cancer deaths in the US
- more common in men and AA
RF - *smoking*, hereditary pancreatitis (relatives, BRCA, PJ syndrome), chronic pancreatitis, obesity and lack of physical activity most common
sxs - B symptoms (>85%), *abdominal pain/back pain* (80%), jaundice
- others include recent onset DM, unexplained migratory superficial thrombophlebitis (Trousseau sign, most likely because the tumor releases mucins that react with plts to form thrombi)
- hepatomegaly and ascites with mets
L supraclavicular adenopathy (Virchows node) in pts with metastatic disease
labs/imaging
- cholestasis - increased alkP and direct bili
- CAA 19-9 - will tell about tumor response to chemo
- get abd US if jaundiced or CT scan if not jaundiced (ERCP /MRCP if first two fail)
- ERCP can be used in pts with cholestasis - stenting
most tumors are at the head of the pancreas - will present with jaundice, steatorrhea
- as these tumors expand –> compress pancreatic duct and common bile duct –> double duct sign
- Courvoisier sign - distended, non-tender gallbladder
jaundice can appear late if tumor is in tail or body ampullary cancer
- will present with obstructive jaundice + anemia and blood in stool
- start with scopes
volvulus
insidious sx onset in adults - ascending colon and sigmoid colon
- transition point usu in cecum or sigmoid
tx - proctosigmoid exam, leave rectal tube in
management of gallstones
RUQ pain –> US
- cholesterol gallstones - with increased estrogen or with decreased enterohepatic recycling (cholesterol saturates)
- asymptomatic - no treatment (only 20% of pts with asx gallstones will develop sxs within 15yrs)
- gallstones with biliary colic (pain is due to gallstone pressing against opening of cystic duct) - elective lap chole, possible usodeoxycholic acid in poor surgical candidates
- complicated gallstone disease (acute chole, choledocho, gallstone pancreatitis) - cholecystectomy within 72hrs
- acute chole - obstruction of cystic duct by gallstone
- note: sxs often subside in a few days with volume resuscitation, abx, and pain meds. However, early cholecystectomy has better outcomes than delayed cholecystectomy (after 7d)
- fenofibrate can contribute to gallstone formation
choledocholithiasis - stone in CBD (CBD dilation)
- RUQ pain, jaundice (due to biliary obstruction), elevated direct bili, transaminitis
- ERCP + sphincterotomy
gallstone ileus - due to biliary-enteric fistula, sxs intermittent over several days, pneumobilia (air in biliary tree) and dilated loops of bowel
- sxs are intermittent because - stone causes tumbling obstruction –> eventually lodges in ileum
- will have hyperactive bowel sounds
- confirm dx by abd CT
- tx is removal of stone and chole (at some point)
cholecystitis
acute cholecystitis - RUQ pain, fever, leukocytosis
- complications - …abscess, chronic cholecystitis
- tx - NPO, IV abx, analgesia
- lap chole shortly after hospitalization
- perform immediately in cases of perforation or gangrene emphysematous cholecystitis
- risk factors - gallstone, DM, vascular compromise (of cystic artery), immunosuppression
- px - …crepitus in abd wall adjacent to gallbladder
- dx - air-fluid levels in GB, cultures with gas-forming bac (Clostridium, E coli), unconjugated hyperbili (because of Clostridium-induced hemolysis)
- tx - emergent chole, BSAbx with clostridium coverage (ampicillin-sulbactam)
- complications - gangrene and perforation
chronic cholecystitis - porcelain gallbladder –> increased for gallbladder carcinoma
- cholecystectomy is considered
acute cholangitis
cause is biliary stasis - bile duct obstruction from gallstones, malignancy, stenosis
Charcot: 1) RUQ pain, 2) jaundice, 3) fever
Reynolds: + hypotension, AMS
significantly elevated alk phos and conjugated bili bile duct dilation on US or CT
tx - abx coverage of enteric bacteria, biliary drainage by ERCP within 24-48hrs
B12 vs folate deficiency
body has large stores of B12, minimal stores of folate - b12 storage = 3-5 yrs
both B12 and folate are involved in DNA synthesis
- deficiency will affect cells with rapid turnover
- will see macrocytic anemia, low/nl retics, pancytopenia, hyperhomocysteinemia
- also elevated MMA levels in B12 deficiency
- causes of both - malnutrition
- causes of B12 deficiency - intestinal bacterial overgrowth (competes for the B12), pernicious anemia
myelodysplasia will also have macrocytic anemia with pancytopenia - but neutrophils will by hypogranulated and hyposegmented
Beckwith-Wiedemann syndrome
c11p15 –> gene that encodes ILGF2 physical exam
- fetal macrosomia, hemihyperplasia, macroglossia rapid growth until late childhood
- omphalochele/umb hernia - will close by age 5
- monitor newborns for hypoglycemia - occurs due to fetal hyperinsulinemia
- complications - Wilms tumor, hepatoblastoma
- surveil with AFP and abd/renal US through adolescence
note - pts with isolated hemihyerplasia are at increased risk for Wilms tumor and hepatoblastoma…
pilonidal disease
age 15-30, M, obese, sedentary lifestyles
issue is an infected hair follicle in the intergluteal region –> abscess, sinus tract –> recurrent abscesses
C diff colitis
abx implicated - clinda, FQs, penicillins, and cephalosporins
- PPIs change colonic microbiome - increases risk of C diff proliferation (note the spores are acid resistant)
- C diff carriage is 8-15% and extensive proliferation is required to reach exotoxin levels that are pathogenic
get stool studies (PCR for toxin) - pt with negative studies may require sigmoidoscopy or colonoscopy with bx
- bacterial toxins –> apoptosis of colonic cells, loss of tight junctions
tx with oral metro or vanc
- mild-mod = WBC < 15K, Cr < 1.5x baseline - metro
- severe = WBC > 15K, Cr > 1.5x baseline, serum albumin <3 g/dl - oral vanc
- if pt has an ileus –> add IV metro and switch to rectal vanc
- if pt develops WBC > 20K, lactate >2.2, toxic megacolon, or severe ileus –> subtotal colectomy or diverting loop ileostomy with colonic lavage
- fidaxomicin can also be used
- note: IV vanc is not excreted into the colon (that is why it is not used)
cyclic vomiting syndrome
no symptoms in between vomiting episodes, no underlying condition
often fhx of migraines (CVS is thought to be related to abd migraine) for kids
- 2/3 will outgrow sxs in 5-10yrs
- can give sumatriptan for kids with fhx of migraines
cancer syndromes
Lynch, AD: CRC, endometrial cancer, ovarian cancer
- defect in mismatch repair gene
- early screening via colonoscopy and embx
- ppx hysterectomy and BSO at age 40
FAP: CRC, desmoids, osteomas, brain tumors
- side note - rectum is usually spared
VHL, AD: hemangioblastomas, RCC, pheo
MEN1, AD (adenomas): parathyroid adenomas, pituitary adenomas, pancreatic adenomas
MEN2, AD: medullary thyroid cancer, pheo, parathyroid hyperplasia
biliary cysts
type 1 cysts are most common - extrahepatic single cystic dilatation of the bile duct
px - triad of pain, jaundice (obstructive cholestasis), and palpable mass
- majority present at < 10 yrs, infants can present with jaundice and acholic stools
- adults present with vague epigastric pain/RUQ pain/cholangitis
dx - US, ERCP if obstruction is suspected
tx - surgical resection to relieve obstruction and prevent malignant transformation
nonalcoholic fatty liver disease
hepatic steatosis - occurs due to increased transport of FFA from adipose to liver, decreased oxidation of FF in liver, and decreased clearance of FFA from liver (decreased VLDL production)
- cause = peripheral insulin resistance –> increased peripheral lipolysis and hepatic uptake of Fas
- normally insulin decreases lipolysis in adipose cells
px - mostly asx, metabolic syndrome, AST:ALT < 1, hyperechoic texture on US
tx - diet, exercise, and bariatric surgery if BMI > 35
- safe to continue statin therapy in these patients
note on AST and ALT
- AST is in liver, heart, kidney, and skeletal muscule
- ALT is in reduced quantities in other tissues but is predominantly in liver - more specific for hepatocyte injury (and usually more elevated in liver disease, except for alcoholic liver disease)
hepatic encephalopathy
precipitating factors - drugs (sedatives, narcotics), hypovolemia, hypokalemia or metabolic alkalosis (acid-base problems), increased N load (GI bleeding), infection, TIPS
- note - UGIB will present with elevated BUN and nl Cr
tx - correct precipitating cause and decrease blood ammonia concentration (lactulose, rifaximin)
- lactulose –> metabolized to short-chain fatty acids by colonic bacteria –> acidifies colon –> ammonia becomes charged and trapped in stool
acute pancreatitis
alcohol or gallstones
- rarely drug-induced - valproate, diuretics, ACEi, IBD drugs, immunosuppressants, HIV meds, abx like metro and tet
- drug-induced pancreatitis is usually mild
- hypertriglyceridemia >1000 mg/dL (xanthomas on exam)
- infections - CMV, legionella, aspergillus
- iatrogenic - post-ERCP, ischemic/atheroembolic
dx - 2/below
- acute epigastric pain radiating to back
- (get first) amylase or lipase >3 ULN
- amylase rises 6-12hrs (remains elevated for 3-5d), lipase rises 4-8 hrs (remains elevated for 8-14d)
- (next) abnormalities in imaging
Imaging
- CT NOT required to dx pancreatitis, but it will show - swelling of pancreas, peri-pancreatic fluid, and fat-stranding
- or RUQ US if you suspect biliary pancreatitis - ALT>150 suggests biliary pancreatitis (also look at BMI, alk phos)
Treatment - SUPPORTIVE (attacks are usu self-limited, resolve in 4-7d), IVFs, NPO
- for gallstone pancreatitis - early lap chole
- ERCP if pt has cholangitis, visible CBD obstruction, or increasing LFTs - note
- ppx abx are not used (unless there is a necrotizing infection)
severe disease = pancreatitis with failure of 1 organ
- pancreatic enzymes enter vascular system, SIRS –> increased vascular permeability
- fever, tachy, hypotension
- dyspnea, tachypnea, basilar crackles
- abd tenderness or distention
- Cullens (periumbilical), Grey-Turner
- associated with: age >75, obesity, alcoholism, CRP >150 at 48hrs, rising BUN/Cr in first 48hrs, CXR with pulm infiltrates or pleural effusion, CT with necrosis and extrapancreatic inflammation
- complications - pseudocyst, peripancreatic fluid collection, necrotizing pancreatitis, ARDS, ARF, GI bleed acute hemorrhagic pancreatitis
- daily CTs to monitor for abscess development (this is a common pathway to death)
pancreatic pseudocyst
- complications - spont infection, duodenal/biliary obstruction, pseudoaneurysm (due to digestion of adjacent vessels), pancreatic ascites, pleural effusion
- no sxs - symptomatic therapy, NPO
- sig sxs, size > 6cm, older (> 6wk), infection, pseudocyst, pseudoaneurysm - endoscopic drainage
others - pancreatic abscess/necrosis, pleural effusion, ileus, ARDS
gastrinoma/ZE syndrome
80% sporadic, 20% MEN1 (check PTH, ionized ca, prolactin)
- located in duodenum or pancreas uncontrolled gastrin secretion –> parietal cell hyperplasia –> excessive production of gastric acid
px - chronic diarrhea (inactivation of pancreatic enzymes and injury to mucosal brush border) and weight loss when do you suspect a gastrinoma?
- thickened gastric folds, multiple peptic ulcers, refractory ulcers, ulcers in the jejunum (gastric acid cant be fully neutralized in the duodenum)
suspected gastrinoma
1) check serum gastrin level off PPI therapy for 1 week
- level >1000 pg/mL is diagnostic
- check gastric pH to make sure that achlorhydria (failure of gastric acid secretion is not the cause of elevated gastrin)
- <110 rules it out
- for 110-1000 pg/mL, get secretin stimulation test
- normal G cells are inhibited by secretin (but secretin will stimulate gastrinoma cells)
- last ditch effort - calcium infusion study, calcium can lead to increased serum gastrin levels in gastrinoma pts
2) EGD (ulcers and thickened gastric folds)
3) CT/MRI and somatostatin receptor scintigraphy for tumor localization
resection is the treatment of choice for primary pancreatic neuroendocrine tumors (insulinoma, glucagonoma, VIPoma)
- insulinoma - reactive hypoglycemia (after meals)…
- glucagonoma - by serum glucagon levels
- VIPoma - VIP levels, somatostatin scintigraphy to localize
- for these tumors - get CT to locate tumor
TIPS
performed when a pt has ascites that does not respond to medical therapy OR has active/recurrent variceal bleeding even after appropriate treatment with upper endoscopy
Zenkers
cause - upper esophageal sphincter dysfunction and esophageal dysmotility
dx - barium esophagram, esophageal manometry
- side note - oral contrast in a pt with a hx of aspiration is associated with a risk of pneumonitis, but do this regardless because benefits > risks
management - open/endoscopic surgery, cricopharygneal myotomy
complications - tracheal compression, ulceration with bleeding, regurgitation, and pulm aspiration
shingles
may have RUQ pain - pain may precede onset of vesicular rash
- consider shingles in pts with recent cancer (and chemo)
post-chole changes
bile is stored in upper small bowel during fasting
for the first few wks-mo - diarrhea because of insufficient bile acid absorption by terminal ileum
SBO vs ileus
SBO - hx of surgery, distention and INCreased bowel sounds (but will progress to absent bowel sounds, esp if bowel is ischemic), small bowel dilation (with no large bowel dilation)
- will have return of bowel functional temporarily post-op
- proximal v.s. mid/distal
- proximal obstructions - early vomiting, abd discomfort, abnormal contrast filling on XR
- distal - colicky abd pain, delayed vomiting, abd distention, constipation-obstipation
- simple (luminal obstruction) v.s. strangulated (loss of blood supply)
- partial v.s complete
- partial - air in colon
- complete - transition point, no air in colon
- complications - ischemia/necrosis, bowel perf
- tx - bowel rest, NG suction, IVFs
- surgical exploration when you are concerned about risk of ischemia, strangulation, and necrosis (signs are fever, hemodynamic instability, metabolic acidosis)
ileus - recent surgery - hrs-d
- hypoK –> what causes hypoK - GI losses, loops/excess aldosterone, correction of DKA (K rapidly moves into cells)
- med induced - morphine
(- pancreatitis)
- possible distension, REDuced bowel sounds - small and large bowel dilation with no transition point
- some degree of ileus occurs following most abdominal procedures, due to increased splanchnic nerve tone (peritoneal irritation) and inflammatory mediator release
- however ileus of >3-5d post-op is prolonged post-op ileus
- techniques to prevent post-op ileus - epidural anesthesia, MIS, judicious peri-op use of IVFs (minimize GI edema)
Ogilvie = paralytic ileus of the colon - massively dilated colon in elderly, sedentary post-op pts
1) fluid and electrolyte correction
2) colonoscopy to suck out air and place a long rectal tube
solid liver masses
focal nodular hyperplasia (benign) - anomalous arteries
- arterial flow and central scar on imaging
hepatic adenoma - benign epithelial tumor
- long-term OCPs, anabolic androgen use, pregnancy
- possible hemorrhage (so needle bx is not recommended) or malignant transformation
hepatic angiosarcoma - rare
- older men who have been exposed to toxins (vinyl chloride gas, arsenic compounds, thorium dioxide)
regenerative nodules - acute or chronic liver injury
HCC - B symptoms, chronic hepatitis or cirrhosis, elevated AFP
- mass often with satellite lesions
liver mets - multiple (or can be solitary, look at hx)
- most commonly secondary to GI malignancies (portal system) = colon cancer
- often silent until pressure on liver capsule or obstruction of biliary tree causes sxs
- LFTs may be normal
hydatid cysts - Echinococcus tapeworm infections
- southwest - exposure to sheep and dogs
entamoeba - tx with metro
causes of steatorrhea
pancreatic insufficiency - ..CF
bile-salt related
- Crohns, bacterial overgrowth (due to surgical blind loop or motility disorders like scleroderma), PBC, PSC, surgical resection of ileum (at least 60-100 cm)
impaired intestinal surface epithelium
- celiac disease, AIDs enteropathy, giardia
other - Whipple disease, ZES, meds
GOO
mechanical obstruction - post-prandial pain, vomiting, early satiety
- causes - malignancy, PUD, Crohns, strictures (pyloric stenosis)
- physical exam will elicit abdominal succussion splash (auscultation maneuver)
initial management - NG suction, IVFs, endoscopy for definitive dx
esophageal perf
endoscopy is the most common cause
- with severe vomiting - occurs when pt is resisting vomiting reflex
px - … Hammans sign (crunching sound on chest auscultation)
dx - CXR or CT scan will show wide mediastinum, pneumomediastinum, pneumothorax, pleural effusion (late)
- can see esophageal wall thickening, mediastinal air-fluid level on CT
- gastrin esophagram
tx - NPO, abx, IV PPI
- surgical repair (for significant leak with SIRS)
Mallory-Weiss tear associated with alcohol use and hiatal hernia
- bleeding stops spontaneously in 90% of pts
- for ongoing bleeding - endoscopic electrocoagulation or local epi injection
dysphagia
work-up
- orophargyneal dysphagia (difficulty initiating swallowing + cough, choking, nasal regurg)
- videofluoroscopic modified barium swallow (swallow study)
- stroke, dementia, oropharyngeal malignancy, NM disorder (myasthenia)
- px with aspiration pneumonia
- esophageal dysphagia
- solids + liquids –> motility disorder - 1) barium swallow, 2) manometry
- solids then progressing to liquids –> mechanical obstruction
- hx of prior radiation, caustic injury, stricture, or surgery for esophageal/larygneal cancer
- if yes barium swallow then egd
- if no –> EGD
- in general - alarm sxs –> proceed straight to EGD
achalasia - dysphagia to solids and liquids
- mild weight loss - chest pain and heartburn (many pts are initially diagnosed with GERD)
- dx by *manometry* - loss of peristalsis in the distal esophagus with lack of LES relaxation; barium esophagram
- tx - EGD to exclude malignancy, lap myotomy, pneumatic balloon dilation (other options include botox, nitrates, CCBs)
pseudoachalasia - due to esophageal cancer
- sxs are usu more rapid onset and associated with weight loss
- risk factors for squamous cell (anywhere) - tobacco, alcohol
- risk factors for adeno (distal) - Barrett’s, GERD , smoking, obesity
- classically presents with dysphagia to solids (bread, meat), chest pain, weight loss
- CXR will show narrowing of distal esophagus
- barium swallow prior to EGD for cancers - to prevent inadvertent perf
- get EGD and CT for staging
- differentiate by EGD (with bx)
- achalasia - normal mucosa, easy to pass endoscope through LES (unlike in malignancy)
globus sensation - no abnormalities on barium swallow
polymyositis - affects upper third of esophagus (striated muscle)
- also other sxs of weakness (difficulty climbing stairs)
IBD
Crohns - more women, smoking risk factor
- non-bloody diarrhea (if diarrhea is bloody, it is colitis), oral ulcers, arthritis, uveitis, scleritis, erythema nodosum, *lung disease*
- mouth to anus - rectum spared, skip lesions, perianal disease (skin tags, fistulas)
- transmural inflammation, linear mucosal ulcerations, cobblestoning, creeping fat, noncaseating granulomas
- intestinal complications - fistulas, strictures (bowel obstructions), abscesses
- treat with - 5-ASA, corticosteroids, biologics
- things on differentials - TB enteritis
UC - males, A. Jews, bimodal distribution
- mucosal and submucosal inflammation, erythema and friable mucosa
- pseudopolyps
- crypt abscesses
- other manifestations - arthritis, uveitis, episcleritis, erythema nodosum
- complications - toxic megacolon, primary sclerosing cholangitis, erythema nodosum, pyoderma gangrenosum (looks like necrotic skin infection), spondyloarthritis
- start screening for CRC 8-10 after disease dx
toxic megacolon
- inflammation limited to colonic mucosa in UC - however subset of pts have inflammation that extends to smooth muscle layers –> muscle paralysis –> colonic dilation
- usu occurs early in the disease
- will see systemic toxicity
- dx - abd xray and 3/following: temp >39, pulse >120, WBC > 10.5, anemia
- abd xray - will see dilated colon (haustra markings that dont cross the entire lumen), right colon > 6cm
- note - small bowel will look like stacked coins
- medical EMERGENCY –> colonic perf
- tx - IVFs, BS abx, bowel rest, corticosteroids, surgery if unresponsive to medical management
- DONT give opioids - because they have antimotility effects and can promote colonic perforation
PSC - frequently asx or present with chronic fatigue and pruritis
- inflammation of intra and extrahepatic bile ducts - onion skin connective tissue pattern and lymphocytic infiltration on liver bx (but this is not necessary for dx)
- pos pANCA
- ERCP/MRCP will confirm diagnosis
- complications - biliary stricture, cholangitis and cholelithiasis, cholangiocarcinoma, cholestasis (ADEK deficiency, osteoporosis), colon cancer
chronic hep C infection
elevated LFTs, hepatomegaly, increased liver echogenicity, pos HCV virus antibodies, and elevated HCV RNA
chronic HCV is frequently asx
HCV management strategies are to prevent further liver damage
- alcohol avoidance, give HAV and HBV vaccines (-instead of starting an anti-viral agent)
also evaluate these pts to determine presence of cirrhosis, etc.
- if pts have cirrhosis (shrunken liver, TCP, coagulopathy, ascites) - start diuretic
alcoholic hepatitis
anorexia, *liver pain*, jaundice, leukocytosis (predominantly neutrophils), decreased albumin if malnourished… LFTs elevated, AST:ALT 2, <300 IU/L
- GGT elevated
- ferritin - acute phase reactant, elevated
- leukocytosis
abd imaging may show fatty liver
for these pts - have them discontinue alcohol (and drug use) and repeat LFTs in 6 mo
- if transaminitis persists - then pt has chronic alcoholic liver disease
- test for hemochromatosis, viral hep, and fatty liver
for treatment of acute AH - quit drinking, supportive therapy
- prednisolone used to treat severe cases - fever, abd pain, jaundice, N&V
blood per rectum
angiodysplasia - painless GI bleeding (maroon stools), venous and low volume
- pts with anemia/gross or occult bleeding can be treated with cautery during endoscopy
- increased incidence after age 60, most common in the R colon
- more frequent in pts with advanced renal dz and vW disease (maybe because of tendency to bleed in these diseases)
- may also be more common in pts with AS - possibly due to acquired vW deficiency (turbulent valve space)
- angiodysplasia can be missed on colonoscopy - due to poor bowel prep
colon cancer - microcytic anemia
diverticulOSIS - arterial bleeding –> BRBPR, painless
- most common cause of lower GI bleeding in adults
- deformation in the colonic wall can cause weakness in associated arterial supply –> bleed
- diverticulosis is more common in sigmoid, bleeding more common in R colon
- confirmed with colonoscopy
- most cases will resolve spontaneously
- strongly associated with chronic constipation –> acute diverticular complications are lower in inds with high fiber intake
- seeds and nut = myth
ischemic colitis - abd pain –> rectal bleeding/bloody diarrhea in 24hrs
hemorrhoids - rarely cause massive bleeding
active bleeding per rectum - first exclude upper GI bleed
1) bleeding hemorrhoids - anoscopy
2) >2 mL/hr - angiogram (may allow for angiographic embolization)
3) <0.5 mL/min - wait for bleeding to stop –> colonoscopy
4) 0.5-2 - tagged red cell study
for past blood per rectum
- young - get EGD
- old - EGD and colonscopy
liver cirrhosis (alcoholic)
definitive dx? cirrhosis by liver bx
jaundice, hyperestrinism (spider angiomata, gynecomastia, loss of sexual hair, testicular atrophy, palmar erythema), ecchymosis and edema (hepatic synthetic dysfunction), portal HTN (esophageal varices, splenomegalcy, ascites, caput medusa, anorectal varices)
- cirrhosis can cause direct gonadal injury, HPA dysfunction, and increased estradiol
- liver also synthesizes thyroid-binding proteins - total T3 and T4 will be reduced (but free levels are unchanged)
- can have parotid gland enlargement - due to fatty infiltration
compensated cirrhosis - asx or non-specific sxs
- uncompensated - jaundice, prurits, upper GU bleeding, ascites, hepatic encephalopathy
if you dx someone with alcoholic liver disease - check for potential complications
- varices (EGD), HCC (screening US every 6 mo)
complications
- variceal hemorrhage - non-selective b-blockers and annual EGD
- ascites - dietary Na restriction, diuretics, paracentesis, quit drinking
- hepatic encephalopathy - id cause, lactulose
- chronic PVT presents as variceal bleeding
- acute PVT - sudden-onset abdominal pain
pts with small varices + risk factors for bleeding, or medium-large varices
- primary ppx - non-selective b-blocker = propranolol or nadalol (reduces portal blood flow and portal pressure) (or endoscopic variceal ligation in patients with contraindications)
TIPS in pts with refractory ascites or varices
acute bacterial parotitis
dehydrated post-op patients and elderly are most prone S. aureus
adequate fluid hydration and oral hygiene pre- and post-op will prevent this complication
b-blockers peri-op
peri-op b-blockers in pts with CAD decreases likelihood of myocardial ischemia peri-op
MI is due to hypotension - will usu not present with chest pain
peri-op abx
give routine for pts undergoing abdominal surgery
aortic aneurysm
thoracic aneurysm - definitive dx by *MR angio*/CT angio
- ascending - repair with surgery
- descending - repair with HTN control (ICU)
abd aneurysm is >3cm - involves all aortal layers and does not create and intimal flap or false lumen (unlike thoracic aortic aneurysms)
AAA rupture - blood can collect into adventitial layer, rupture can occur into peritoneum or retroperitonuem
- sxs - abd pain/back pain and hypotension (syncope)
- CT only in stable pts, OR for unstable pts
- AAA can rupture into retroperitoneum and create and aortocaval fistual –> venous congestion in bladder –> gross hematuria
complications following repair
- for thoracic aortic aneurysm - anterior spinal cord syndrome
- because anterior spinal artery is dependent on thoracic aorta blood, px will be *bilateral* flaccid paralysis and impaired pain/temp sensation
- late complication from AAA repair is aortoenteric fistula - duodenum..
meniscal tear
due to twisting force with the foot fixed or degeneration of meniscal cartilage (older)
- pts will generally report a popping sound, followed by acute pain
- meniscus tear = crepitus, locking, cathcing
- associated sxs - reduced extension, sensation of instability
- late knee effusion (which will become apparent after a few hours) medial meniscus injury is more common than lateral injury
dx - xray will be normal in young pts (sometimes exam will be normal, but use clinical suspicion)
–> confirm with MRI or arthroscopy
tx - mild sxs, older pts - rest, NSAIDs, and activity modification
- persistent sxs (3-4wks), impaired activity
- surgery, to reduce risk of further joint injury
knee pain/injury
ACL - forceful hyperextension of knee
- will have effusion and hemarthrosis
patellofemoral pain syndrome = chronic anterior knee pain
- pts present with pain worsened by activity or prolonged sitting (in flexion)
- may have crepitus with motion of patella, pain is reproduced during knee extension (patellofemoral compression test)
- tx - exercises to stretch and strengthen the thigh muscles
patellar tendonitis = jumpers knee - anterior knee pain and tenderness
tibial plateau fracture - pt will be unable to bear weight on that knee
patellar fracture - inability to extend knee
pes anerinus syndrome - pain and tenderness at anterior medial knee (distal to joint line)
- strongly associated with diabetes
post-op fever
immediate
- prior trauma/infection
- blood products
- mal hyperthermia (…metabolic acidosis, hypercalcemia, muscle rigidity)
- bacteremia - 30-45min classically
5Ws - atelectasis, pneumonia, UTI, DVT, wound infection, deep abscess POD1d-1wk
- nosocomial infections - S epi will be from central line, enteric orgs will be associated with foley
- VAP - after 48hrs of being on ventilator
- surgical site infection due to group A strep or clostridium
- non-infectious - MI, PE, DVT (doppler)
POD1wk-1mo
- surgical site infection due to other orgs - C diff
- drug fever - DOE, occurs 1-2 wks after mediation administration, often accompanied by rash and peripheral eosinophilia (drugs implicated are anticonvulsants, abx, allopurinol)
- PE/DVT
POD1mo and more
- viral infections (from blood products)
- infective endocarditis
- surgical site infection due to indolent orgs
- note on necrotizing SSI - DM, polymicrobial - pain, edema, or erythema spreading beyond the surgical site
- systemic signs (SIRS)
- paresthesia or anesthesia at edges of the wound
- dishwater drainage
- subQ crepitus –> EARLY surgical exploration (to prevent nec fasc)
reactions to blood products
- febrile nonhemolytic transfusion reaction - small amounts pf cytokines in PRBC bag (due to plasma or leukocyte debris) –> transient fevers, chills, malaise within 1-6hrs after transfusion
- acute hemolytic reaction
- TRALI
compartment syndrome
common features - POOP, pain on passive stretch, rapidly increasing and tense swelling, parasthesia
- uncommon - decreased sensation, motor weakness, paralysis (late), decreased distal pulses
- when will you see this? - ischemia-reperfusion syndrome
- also with lower extremity embolectomy
- circumferential eschar - constricts venous and lymphatic drainage…
- dx by compartment pressure > 30 mm HG
- if compartment pressures are improving - pts may be observed
- pts with elevated pressures and no signs of improvement –> fasciotomy
v.s an embolism - absent pulses, pallor of affected limb, lack of local swelling
v.s. DVT - vague aching pain (rather than this exquisite pain)
traumatic diaphragm injury
more common on L
some pts (esp kids) will have no sxs initially
- will px mo-yrs later with vague chest pain (due to expansion of diaphragmatic defect and herniation of abdominal organs)
CXR - abdominal contents in thorax, shifting of mediastinum
- may see NG tube in thorax
- but CT is more sensitive so get CT if CXR is unrevealing
hemothorax
each hemithorax is capable of holding up to 50% of circulating blood volume
- massive hemothorax is >1.5L or 600 mL/6hrs
- most common cause of massive hemothorax are traumatic lac to lung parenchyma, damage to intercostal or internal mammary artery
atelectasis
lobar or segmental collapse –> decreased lung volume
- decreased FRC?
- will hear decreased breath sounds in that section
post-op atelectasis - accumulation of pharyngeal secretions, tongue prolapsing into pharynx, airway tissue edema, residual anesthetic effects, splinting
- low pO2 (small-airway mucus plugging) and low pCO2 (fast shallow breathing)
- loss of lung volume
- side note - in this regard, intercostal nerve blocks have shown success in reducing post-op pulm complications
ABG - pt will be hypoxemia due to lung collapse and V/Q mismatch
- low PaO2 - pt will hyperventilate due to hypoxemia
- low PaCO2
post-op pulm complications
atelectasis, bronchospasm or exacerbation of chronic lung disease, prolonged mechanical ventilation
risk factors - age >50, emergency surgery or surgery longer than 3hrs, HF, COPD, poor general health (ASA >2)
pre-op strategies
- smoking cessation 8wks pre-op
- note on smoking - issue with ventilation = high PCO2, low FEV1 - no issue with oxygenation
- sx control of COPD (pre-op glucocorticoids)
- tx of respiratory infections prior to surgery
- pt education of pulm toilet post-op strategies - pulm toilet, epidural instead of opioids, PEEP
suspected variceal hemorrhage
1) place 2 large bore IVs - volume resus, IV octreotide (leads to splanchnic vasoconstriction and decreased portal flow), abx (ppx abx for pts with cirrhosis, to prevent SBP)
urgent endoscopic therapy with band ligation or sclerotherapy
- if no further bleeding - start b-blocker and endoscopic band ligation 1-2 wks later
- if continued bleeding - balloon tamponade (eponymed tubes) temporarily –> TIPS/shunt
- if early rebleeding - repeat endoscopic therapy –> recurrent hemorrhage –> TIPS/shunt
in approx 50% of variceal bleeding - hemorrhage ceases on its own
- in other UGIB - this rate is 90% side note - current guidelines suggest keeping hgb >9 in variceal hemorrhage
prerenal acute kidney injury
oliguria <500 mL/24hrs
decreased renal perfusion
- true volume depletion
- decreased EABV - heart failure, cirrhosis
- displacement of intravascular fluid - sepsis, pancreatitis
- renal artery stenosis - afferent arteriole vasoconstriction
- NSAIDs
features - increase in serum Cr (50% from baseline), decreased UOP
- BUN/Cr >20:1
- BUN increases because it is passively reabsorbed during the active reabsorption of Na and water
- FeNa <1%
treat by restoring renal perfusion
- give bolus of saline
AKI
b-lactam abx - cause acute interstitial nephritis
- will see WBC on UA and a skin rash if blood flow drops too much –> acute tubular necrosis
varicocle
soft scrotal mass (bag of worms) - more common on L side
- left spermatic vein drains into left renal vein (passes in between the SMA and aorta)
- can be compressed beneath SMA
- v.s. the R spermatic vein - drains directly into IVC
- R-sided varicoceles are rare and can be a sign of malignant compression or thrombosis
- can cause elevated scrotal temps –> subfertility, testicular atrophy
- US - retrograde venous flow, tortuous, anechoic tubules adjacent to testis
- dilation of pampiniform plexus veins
- tx - gonadal vein ligation - boys and young men with testicular atrophy
- scrotal support and NSAIDs - for men who dont desire children
other testicular masses
- spermatocele - painless mass at superior pole of testis
- testicular cancer- painless mass, almost always malignant
- tx by radical orchiectomy, metastatic dz responsive to radiation or platinum-based chemo
- hydrocele
burns
at home - IRRIGATION
airway - supraglottic airway is very susceptible to direct thermal injury –> edema and blistering
- subglottic airway is protected from injury by reflexive closure of vocal cords upon exposure to extremely hot air
- all burn pts should be given high-flow O2 - maintain a low threshold for intubation
increased metabolic rate - due to release of inflammatory mediators - increased basal temp, tachycardia and tachypnea, hyperglycemia
steroids are contraindicated in burn pts - steroids are diabetogenic and immunosuppresive and burn pts are already prone to metabolic derrangements and immunosuppression
infections - immediately after a severe burn - gram pos organisms dominate
- after 5d - gram negative or fungi dominate (pseudomonas, candida) - burn wound sepsis
- partial-thickness injury turns into full-thickness injury, temp changes, tachycardia, tachypnea, refractory hypotension, oliguria, unexplained hyperglycemia, TCP, and AMS
- quantitative wound culture and bx for histopathology
- treat with BS iv abx (pip/tazo, carbapenem), MRSA (vanc), MDR pseudomonal coverage (AG)
- local wound care and debridement
other things
- tetanus
- silver sulfadiazine = standard
- if thick eschar, cartilage - mafenide acetate
- triple abx near eye
acute abd/pelvic pain in women
mittelschmerz - unilateral, mid-cycle pain prior to ovulation
- pain lasts hrs-d
ectopic - what was date of last menses?
ovarian torsion - sudden-onset, severe, unilateral lower abd pain, N&V
- unilateral tender adnexal mass on examination
ruptured ovarian cyst
- sudden-onset, severe, unilateral lower abd pain immediately following strenous/sexual activity
- pelvic free fluid or hemoperitoneum
- signs of hemoperitoneum - severe, diffuse abdominal pain, pleuritic chest pain, shoulder pain, peritoneal signs
- for unstable pt with hemoperitoneum - ovarian cyst surgery
PID - fever, chills, vaginal discharge, lower abdominal pain and CMT +/- tubo-ovarian abscess
pediatric abdominal wall defects
umbilical hernia - spont resolution by age 5
- due to incomplete closure of abd muscles round umbilical ring
- most commonly associated with AA, premies, Ehlers-Danlos, Beckwith-Wiedemann, hypothyroidism
- note - spontaneous closure is less likely for hernias > 1.5cm
umbilical granuloma - appears after the umbilical cord has separated
- tx - silver nitrate
gastrochisis
- defect to the R of the cord insertion
- immediate surgery after birth - will require TPN for sometime because bowel will be angry, matted
omphalocele - umbilical cord inserts at apex of defect
- immediate surgery after brith
(acute) colonic/mesenteric ischemia
pathophys - non-occlusive, occurs in watershed areas - splenic flexure (SMA and IMA) and rectosigmoid (between sigmoid and superior rectal)
- underlying atherosclerotic disease/thrombus (…recent MI, infective endocarditis emboli) = small bowel ischemia
- low blood flow - post-AAA repair
- adverse effect can be minimize by checking sigmoid colon perfusion following placement of aortic graft
px - mod abd pain and tenderness, urge to defecate, hematochezia, diarrhea, leukocytosis, lactic acidosis (low bicarb)
- elevated amylase and phosphate
dx - CT will show colonic wall thickening and fat stranding
- mesenteric angio if dx unclear - EGD will was edematous and friable mucosa
management - IVFs and bowel rest, abx, anticoag to limit clot expansion (if pt is not actively bleeding)
- immediate operative eval if evidence of bowel infarct
- embolectomy w/ bypass or endovascular thrombolysis
- colonic resection if necrosis develops
v.s. chronic mesenteric ischemia - epigastric pain shortly after eating (blood is shunted away from intestines to feed the stomach)
- atherosclerosis - smoking, dyslipidemia
- food aversion, abdominal bruit in 50% of pts
- get CT angio
- tx - risk reduction, nutritional support, and endovascular or open surgical revascularization
ABI
claudication - no need to work-up if it does not disrupt pt’s lifestyle
for severe, disabling claudication: SBP of ankle artery (DP or PT)/SBP of brachial artery ABI should be used for initial diagnosis of PAD - high sensitivity and specificity
<0.90 - abnormal –> CT angio or MRI angio
0.91-1.30 - normal (or small vessel disease that is not amenable to surgery)
>1.30 - suggestive of calcified and uncompressible vessels
- consider additional studies
intermittent claudication –> rest pain
- rest pain = pain at night, pain relieved by gravity (dangling legs off bed), shiny atrophic skin without hair, no peripheral pulses
splenic injury
one of the most common intra-abdominal complications of BAT signs - hypotension, pleuritic CP, left abd wall bruising or tenderness, abd guarding
pts who are hemodynamically stable
- FAST –> if negative FAST –> CT for pts with high risk features
- pts with AMS - proceed directly to CT
if operative intervention is required - every effort is made to SAVE the spleen
note - if someone has mono (fever, sore throat, spleen will be enlarged), there is a greater risk of splenic injury
encapsulated bacteria - S. pneumoniae, Hib, N. meningitidis, E. Coli, Salmonella, Klebsiella, Group B streptococci
abdominal abscess
psoas abscess - fever, abd/flank pain that radiates to the groin
- abdominal pain with hip extension (psoas sign)
- risk factors - HIV, IVDA, DM, crohns disease
- can be direct (even from diverticulitis) or hematologic seeding
- get CT abd/pelvis and BC and abscess cultures
- tx - drainage, broad spectrum abx
- note psoas abscess is on the differential for fever of unknown origin
chronic radiation proctopathy
often causes bloody stools - usu presents for the first time within the first of treatment
GSW
because of diaphragm movement during inspiration and expiration
- any penetrating injury below the nipple line has the potential to involve the abdomen
- infact it is thought to involve the thorax and abdomen until proven otherwise
- for a hemodynamically unstable pt –> ex lap (even if there is no peritoneal fluid on fast exam)
- for a stable pt and fast negative - get CT
pts with suspected spinal cord injury
place urinary cath - to assess for urinary RT and prevent possible bladder injury (from acute distention)
traumatic amputation
place limb/digit in sterile, saline moistened gauze and in a plastic bag –> place the bag on ice
ganglion cyst
most common in individual 15-40 - arise due to repetitive stress and inflammation
appendicitis
Rovsing sign - RLQ pain with deep palpation of LLQ
for pts with classical presentation –> lap appy
- for pts where dx is unclear - CT or US to confirm dx
- pts with appendicitis who have had sxs for >5d usu have phlegmon with abscess (phlegmon = localized area of acute inflammation of the soft tissues)
- IV abx, bowel rest, and delayed appendectomy (6-8wks later, because presently the appendix will be inflamed, infection, friable)
- these pts will present without peritoneal signs, instead they may have pos psoas sign
mesenteric adenitis - RLQ pain, guarding, tenderness
- can be mistaken for appendicitis - get CT
C-spine trauma
scenario - fall
pre-hospital - spinal immobilization, careful helmet removal, airway oxygenation
ED - orotracheal intubaion - RSI if pt is unconscious pts who are breathing but need ventilatory support
- cervical stabilization unless it interferes with intubation
- CT Cspine - monitor for neurogenic shock
when would you get CT c-spine - basilar skull fracture, blunt neck trauma, facial fracture, CHI
airways
nasotracheal intubation - blind procedure
- contraindicated in apneic/hypopneic pts
- also contraindicated in basillar skull fracture as these fractures may have cribiform plate disruption (tube could enter brain)
subQ emphysema - fiberoptic bronchoscope
cric is FAST
- needle cric - not ideal in pts with head injury (these pts may require hyperventilation to treat intracranial HTN)
- cric has risk of CO2 retention
- surgical crich - prolonged use of cric has a high incidence of tracheal stenosis
surgical tracheostomy, formal tracheostomy
Gilbert syndrome
more common in males, most common inherited disorder of bilirubin glucuronidation AR or AD
- decreased UDP-glucuronosyltransferase activity –> increased UCB
px - intermittent mild jaundice provoked by stress
only lab abnormality will be unconjugated hyperbilirubinemia - Hgb will be normal
- NO evidence of hemolysis
tx - reassurance and supportive care
acalculous cholecystitis
critically ill hospitalized pts - severe trauma or recent surgery, prolonged fasting/TPN, critical illness (mechanical vent)
- likely due to cholestasis and gallbladder ischemia –> secondary infection
unexplained fever, leukocytosis, elevated LFTs and bili (but normal results dont exclude the dx), RUQ pain
- jaundice and RUQ pain are less common
dx
- US - will see thickened gallbladder wall with distention, pericholecystic fluid
- get HIDA or CT if needed
tx - perc cholecystostomy and chole after pt’s medical condition improves
- enteric abx coverage
complications - sepsis, death, gangrene, perf, emphysematous cholecystitis (cholecystitis with clostridium)
acute viral hepatitis
LFTs x25 ULN anorexia, N&V
B = sex
in order of appearance
1) HBsAg
2) IgM anti-HBc - same time as when clinical sxs develop and transaminitis occurs
3) window period = IgM anti-HBc, HBV DNA (lag time between disappearance of HBsAg and appearance of anti-HBs)
4) after window period, recovery phase - anti-HBs, IgG anti-HBc, anti-HBe (only time when you’ll see this), HBV DNA
- so for acute hepB infection - check for HBsAg and IgM anti-HBc
- note - HBeAg is a good level of infectivity
- get hep B virus DNA in patients with chronic hep B - to determine candidacy for anti-virals
pos HbsAg - sign of immunization
chronic carrier - pos HBsAG and IgG anti-HBc (for >6 mo)
resolved HBV infection - anti-HBs, anti-HBc
blunt GU trauma
get UA for hemodynamically stable pts –> contrast CT to id and stage renal trauma
unstable pts –> IV pyelogram –> surgery
- note - most renal injuries can be managed non-operatively
prosthetic joint infection
leukocytes count will be >1000 (but not as high as in a septic joint >50K)
<3mo onset - acute pain, wound infection or breakdown - S aureus, gram negative rods (pseudomonas), anaerobes
3-12 mo - chronic joint pain, implant loosening, sinus tract formation
- S. epi, propionibacterium, enterococci
>12 mo - acute sx in previously asx joint, recent infection at distant site (UTI)
- S. aureus, gram negative rods, b-hemolytic strep
bleeding considerations
O2 delivery doesnt become deficient until Hgb < 7g/dL
DDAVP increases factor 8 levels (indirectly) - give pre-op to patients with hemophilia A
plts >50K will provide adequate hemostasis for most procedures
hypocalcemia
- signs
- why?
tetany, seizures, LONG QT
- Chvostek sign, Trousseau sign (carpopedal spasm upon inflation of blood pressure cuff)
primary
- post-surgical - most common cause, takes a modest decrease to cause sxs
- automimmune primary hypoparathyroidism
- congenital absence of parathyroid glands (DiGeorge syndrome)
- defective Ca-sensing receptor on parathyroid glands
- non-autoimmune destruction of parathyroid gland due to infiltrative diseases (hemochromatosis, Wilson disease, neck irradiation)
secondary: insufficient Ca intake –> secondary hyperparathyroidism –> increased PTH and hyperplasia of parathyroids –> increased Ca and increased renal phosphate loss (hypophosphatemia)
tertiary: due to chronic renal disease (very increased PTH –> increased Ca)
other reasons - CYP450 inducers (phenytoin, carbamazepine, rifampin) cause vitamin D deficiency by degrading vitamin D into inactive metabolites
- kidneys convert 25-OH-D to 1,25-OH-D
- note - serum phosphorous is low in vitamin D deficiency
- precipitation of Ca with phosphate - renal failure, rhabdo, phosphate administration
PTH actions
- bone - long-term indirect action on osteoclasts –> increased Ca and phosphate
- kidney - increased Ca reabsorption and phosphate excretion
vitamin D
- increased Ca and phosphate absorption from gut and kidney
persistent hypothyroidism
can be seen post-thyroidectomy - can also see hyponatremia
complications of cardiac cath
local vascular complications at the cath site are the most common complications - bleeding
- hematoma - localized or with retroperitoneal extension (back pain)
- arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula
cholesterol emboli - s/p cardiac cath
- pts who have risk factors for aortic atherosclerosis
- signs and sxs - livedo reticularis, blue toe syndrome, AKI, pancreatitis, mesenteric ischemia
torus palatinus
benign bony growth - thought to be due to genetic and environmental factors
- more common in younger pts, women, and Asian
surgery indicated for sx pts
anterior mediastinal mass
4Ts: thymomas, teratoma, thyroid neoplasm, terrible lymphoma teratoma - Ca deposition (tooth), fat
- note - for seminoma, only bhCG will be elevated
MCL and LCL
vaLgus = applying lateral stress
MRI is the most sensitive test but reserved for pts being considered for surgical intervention
- uncomplicated MCL tears can be managed non-operatively (RICE)
melena
UPPER gi bleed - PUD, gastritis, esophagitis, Mallory-Weiss tear give anti-secretory medication (PPI)
deep neck space
retropharyngeal compartment - infection in this compartment drains to superior mediastinum
- spread to the carotid sheath –> thrombosis of IJ and deficits of CN 9-12
- extension through danger space (two fascias) –> posterior mediastinum and diaphgram
- acute necrotizing mediastinitis - fever, chest pain, dyspnea, odynophagia, requires urgent surgical intervention
paranasal sinus infection –> bone –> subdural empyema
infected molar –> Ludwig angina - bilateral cellulitis of submandibular and sublingual spaces
- AIRWAY
- infection in central face area –> cavernous sinus thrombosis - occurs due to valveless facial venous system
nasal furunculosis is potentially life threatening as it can spread to cavernous sinus
- px = diplopia, facial pain, fever
- EMERGENCY - dx with MRI, tx with early IV abx, and drain affected paranasal sinuses
acute mediastinitis
complication of cardiac surgery - due to intra-op wound contamination
px - within 14d post-op, fever, tachy, chest pain, leukocytosis, sternal wound drainage (or purulence)
- widened mediastinum
tx - surgical debridement with immediate closure and prolonged abx therapy
other things post-cardiac surgery
- afib is common - self-limited, rate control with b-blockers or amiodarone is best
- anticoagulation and/or cardioversion reserved for patients with atrial fib >24hrs post
- pericardiotomy syndrome - fever, leukocytosis, tachy, and chest pain
- autoimmune, occurs few wks following procedure where incision was made into pericardium - NSAIDs to treat (any) pericardial inflammation)
PUD
majority of duodenal ulcers are cause by H pylori infection and NSAIDs
- if H pylori is likely - start eradication triple therapy (PPI, amox, clarithro)
dx - EGD
tx - NG suction, IVFs, broad spectrum abx, **IV PPI**
- for stable pts with Hgb < 7 - give PRBC
- transfuse at Hgb <9 for pts with ACS
- for pts with active bleeding and hypovolemia - transfuse at higher Hgb levels
pericardial tamponade
acute - only takes 100-200mL to compromise hemodynamics, cardiac silhouette may appear normal
chronic processes (malignancy, renal failure) cause slow accumulation of pericardial fluid - 1-L before intrapericardial reaches a critical point
- globular cardiac silhoutte
shoulder pain
rotator cuff impingement or tendinopathy - pain with abduction, external rotation
- normal ROM, positive impingement tests
rotator cuff tear - *weakness* with external rotation, age >40
- weakness with above motions, drop arm test (drop below horizontal) - passive ROM is preserved
- FOOSH
- drop arm test - supraspinatus is commonly injured due to degeneration of tendon with age and impingement between humerus and acromion (during ABduction)
adhesive capsulitis - stiffness > pain
- can be due to rotator cuff tendinopathy, subacromial bursitis, paralytic stroke, DM, humeral head fracture
- reduction in passive and active ROM
biceps tendinopathy/rupture - anterior should pain, weakness is less common
glenohumeral osteoarthritis - trauma, gradual onset of shoulder pain
- decreased active and passive ROM
dumping syndrome
sxs - abd pain, diarrhea, nausea
- hypotension, tachycardia
- dizziness/confusion, fatigue, diaphoresis - 12-30 min after meals
common postgastrectomy - 50% of pts
- due to loss of normal action of the pyloric sphincter due to injury or surgical bypass - *rapid emptying* of hypertonic gastric contents
- causes fluid shifts from intravascular space to SI = hypotension, stimulation of autonomic reflexes, release of intestinal vasoactive polypeptides
initial management - small frequent meals
- replace simple sugars with complex carbs
- incorporate high fiber and protein-rich foods
- drink fluids in between meals (not during meals)
diverticulitis
acute diverticulitis - inflammation due to microperforation of diverticulum LLQ abd pain, fever, N&V, ileus (peritoneal irritation)
- can have urinary signs from an inflamed sigmoid colon
- dx - abd CT (oral and IV contrast)
uncomplicated (75%)
- can be managed outpatient with bowel rest, oral abx, observation
- hospitalization recommended if pt is elderly, immunosuppressed, severe comorbidities, or high fever/WBCs
complicated (25%) - abscess, perf, obstruction, or fistula formation
- fluid collection <3cm - tx with IV abx and obs
- fluid collection >3cm - CT-guided perc drainage –> surgical drainage and debridement recommended if sxs dont improve by 5d
on your differential - epiploic appendigitis
hip fracture
intracapsular - femoral neck and head
- higher risk of avascular necrosis
extracapsular - intertrochanteric, subtrochanteric
- greater need for implant devices
- requires immobilization - high risk of DVT and PE, recommend post-op anticoagulation
in general - operate asap
- may delay surgery up to *72hrs* if need to address an unstable medical comorbidity (do skeletal traction in the meantime) - need medical stability prior to operating
nutrition in alcoholics
nutritional deficiencies
scurvy - signs arise w/i 3 mo of deficiency
- follicular hemorrhage, bleeding gums, arthralgias, weakness, impaired wound healing
- vasomotor instability if severe/prolonged
- dx by serum ascorbic acid level
- tx - oral/injectable vitamin C (sxs resolve w/i days), watch for tox (abd pain, diarrhea, nausea)
sepsis treatment
1) give crystalloid (it is cheaper than albumin) - 500-1000mL boluses to achieve SBP >90
2) vasopressors - dopamine
3) IV hydrocortisone
other randoms
- hemodialysis if: uremia, fluid overload, major electrolyte abnormalities
- bicarb if severe acute acidosis (pH <7.2)
hematuria
initial hematuria (urethra issue) - urethritis, trauma (cath)
total hematuria (kidney) - renal mass, glomerulonephritis, urolithiasis, PKD, pyelo, urothelial cancer, trauma
- renal cell carcinoma - tx is surgery
terminal hematuria (bladder issue) - urothelial cancer, cystitis, urolithiasis, BPH, prostate cancer
- clots suggest bleeding in bladder or ureters (get cystoscopy)
- cancer of bladder - SMOKING
most cases of hematuria are benign - 1) CT scan, 2) cystoscopy
rhinoplasty
complications are common
- 1/4 may need revision - dissatisfaction, nasal obstruction, epistaxis
- septal hematoma (or abscess) –> septal perf - whistling noise
signs of peritonitis
guarding, rigidity, reduced bowel sounds, rebound tenderness = perforated viscus
complications - subphrenic abscess (rare)
general anesthesia
impairs to laryngeal defenses –> aspiration of gastric contents, hypoventilation
sux (rapid on/off)- depolarizing NM blocker, binds to postsynaptic AchR –> influx of Na and efflux of K –> temp paralysis
- contraindicated in crush injury - pt can be at risk for life-threatening cardiac arrhythmia due to severe hyperkalemia (use roc instead)
- side note - post-syn AchR upregulated in skeletal muscle injury (burn, disuse muscle atrophy, and denervation also have this)
etomidate - inhibits 11b-hydroxylase –> adrenal insuffiency
- elderly and critically ill are most susceptible
NO - inactivates B12, problems for pts with pre-existing B12 def
propofol - severe hypotension (due to myocardial depression)
air embolism
following major thoracic trauma acute circulatory failure (hypotension, SOB) and neuro signs (stroke type signs)
immediate management - cardiac massage
PAT
indications for urgent ex lap
- hemodynamic instability
- peritonitis
- evisceration
- blood from NG tube or on DRE
no indications for urgent ex lap –> locally explore wound and get eFAST (to asses for pneumo- and hemothorax)
penetrating neck trauma - surgical exploration IF expanding hematoma, deteriorating vital signs, or signs of esophageal/tracheal injury
- upper zone - arteriography
- base of neck - arteriography, esophagram, esophagoscopy, bronchoscopy
penetrating urologic injury is surgically explored
extremity vascular trauma
hard signs –> surgical exploration
- observed pulsatile bleeding
- bruit/thrill over the injury
- expanding hematoma
- signs of distal ischemia (absent pulses, cool extremity)
soft signs - hx of hemorrhage, diminished pulses, bony injury, neuro abnormality –> injured extremity index (<0.9 is ABnormal) –> CT/CT angio, doppler
hypovolemia
hypovolemic shock drop in blood pressure occurs when 25-30% of blood volume has been lost
if you mechanically ventilate someone in hypovolemic shock –> increase intrathoracic pressure –> collapse of venous system, loss of RV preload
spontaneous pneumothorax
primary v secondary (underlying lung disease) - small (<2cm)
- observe and supplemental O2 (enhances the speed of reabsorption!, though this is disputed and dependent on surgeons)
- large and stable - needle aspiration (stable) or chest tube (unstable)
if lung fails to re-expand (<90% expansion) and persistent air leak is present - place one-way valve, blood patch, or VATs
- recurrence - VATS pleurodesis or chemical pleurodesis
anal fissures
local trauma, IBD, malignancy - spasm of sphincter contributes to the pain and creates tension across the wound
most common at posterior anal midline
- chronic fissure may have skin tag at distal end (sentinel pile)
tx 1) high fiber, adequate fluids, stool softeners, sitz baths, topical anesthetics and vasodilators (CCBs, to reduce pressure and increase blood flow to anal sphincter)
2) surgery - lateral sphincterotomy and fissure excision
bursitis
vulnerable to acute injury or chronic repetitive pressure
- may become inflamed…
- because they are located in exposed positions
- active ROM reduced, passive nl
housemaids knee = pre-patellar bursitis
- bursitis is generally non-infectious
- however this one is commonly due to S aureus (trauma, local cellulitis) aspirate and systemic abx (if pos gram stain)
med-small artery aneurysms
1) popliteal artery aneurysm
2) femoral artery aneurysm - pulsatile mass in groin, thigh pain (due to compression of fem nerve)
- may be associated with AAA
hyperbilirubinemia in adults
Hb catabolized –> bili –> UCB + albumin –> hepatic artery
- liver: conjugation by hepatic UDG enzyme –> conjugated bilirubin conjugation happens in the liver
- deconjugation in intestine by b-glucuronidase –> 1) enterohepatic recycling of UCB, 2) excretion in feces and urine (urobilinogen)
- UCB is tightly bound to albumin - so it will NOT be renally excreted
- when you have excess UCB (hemolysis) –> more conjugation –> more excrete as urobilinogen (pos urobilinogen assay)
- hepatic dysfunction (portosystemic shunt), biliary duct obstruction, storage defects - bilirubin will build up in plasma conjugated –> check LFTs (will likely be a hepatobiliary problem because bilirubin conjugates are shunted into plasma when excretion into bile is slowed)
1) AST ALT are elevated - viral/autoimmune/toxin/drug-induced/ischemic/alcoholic hepatitis, hemochromatosis - autoimmune - pos ANA and anti-smooth muscle titers, give glucocorticoids
2) elevated alk phos (=cholestasis) - cholestasis of pregnancy, malignancy (pancreas or ampullary), cholangiocarcinoma, PBcholangitis, psc, choledocholithiasis
- get US to assess hepatic parenchyma and biliary ducts (biliary dilatation is extrahepatic cholestasis)
3) normal LFTs - Dubin-Johnson, Rotors - Dubin-Johnson - decreased bilirubin excretion in bile canaliculi
- Rotors - rare, benign, hereditary defect in hepatic secretion of conjugated bilirubin into biliary system
unconjugated - overproduction
- hemolysis (haptoglobin will be decreased)
- reduced uptake - drugs, portosystemic shunt
- conjugation defect - Gilbert’s
pattern of LFTs
- elevated alk phos, normal transaminases - inherited bilirubin disorders
- elevated transaminases, normal alk phos - liver issue
- elevated alk phos >> transaminases - intrahepatic cholestasis, biliary obstruction
small bowel follow
-through barium contrast enema
small bowel follow-through - detects stricture, obstruction, masses in the small bowel
barium enema - detects strictures or inflammation (IBD)
d-xylose test
monosaccharide - absorbed withOUT degradation by pancreatic or brush border enzymes
- absorbed in proximal small bowel
pts with proximal SI disease (celiacs) cant absorb d-xylose
false-positive D-xylose test (decreased urinary excretion, normal absorption) can be seen in pts with delayed gastric emptying or impaired GFR
- or with SIBO - because of bacterial fermentation of ingested D-xylose before it can be absorbed (rifaximin to kill bacteria)
dyspepsia
chronic, intermittent epigastric pain and postprandial discomfort causes - NSAIDs, gastric/esophageal cancer, functional dyspepsia, GERD, PUD with H pylori (demographics! India)
definitive dx by EGD - but only perform in pts >55 or with alarm sxs (weight loss, bleeding, anemia, dysphagia, persistent vomiting)
primary biliary cholangitis
immune-mediated destruction of *intrahepatic* bile ducts
often middle aged women
px with chronic fatigue, pruritis, - jaundice, hepatomegaly, cirrhosis
- xanthomas, xanthelasmas
- pos anti-mitochondrial antibody, severe hypercholesterolemia
tx - ursodeoxycholic acid delays progression, liver transplantation for advanced disease
complications - malabsorption and fat soluble vitamin deficiencies
- metabolic bone disease - osteoporosis, osteomalacia
- HCC
ascites
causes
- blood - trauma, malignancy, rarely TB
- milky - chylous, pancreatic
- turbid - infection
- straw color - benign
new onset ascites
- dx cirrhosis
- labs, imaging, abd US to evaluate for splenomegaly or HCC
- paracentesis for all pts with new-onset ascites
- liver bx only if dx is unclear
characterizing ascitic fluid
neutrophils: >250 means peritonitis (secondary or SBP)
protein - high >2.5 - CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd-Chiari, fungal
- low <2.5 - cirrhosis, nephrotic syndrome
serum ascites albumin gradient
- >1.1 indicates portal HTN - cardiac ascites, cirrhosis, Budd-Chiari
- <1.1 indicates absence of portal HTN - TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic syndrome
SBP - low grade-high grade temp (pts with cirrhosis after often hypothermic), abd pain/tenderness, AMS (connect the numbers test)
- hypotension, hypothermia, paralytic ileus (dilated loops of bowel) with severe infection
- due to bacterial translocation or hematogenous spread to liver and ascitic fluid
- ascitic fluid: PMN >250 and pos culture (often gram negatives, E coli, Klebsiella)
- tx - empiric abx (cefotaxime), FQs for SBP ppx
note - ascites separates the visceral and parietal peritoneal surfaces –> wont have peritoneal signs even with perf viscus
small portion of cirrhotics/pts with portal HTN have hepatic hydrothorax = pleural effusion due to ascites passing through defects in diaphragm
- usually on R side due to less muscular hemidiaphragm
- tx - salt restriction and diuretic administration
- can do therapeutic thoracentesis for sx pts
- DONT use chest tube - because it can result in large-volume protein, fluid, and electrolyte losses (and renal fialure)
- definitive option - liver transplant
diffuse esophageal spasm
can be precipitated by emotional stress chest
pain that is relieved by nitrates (can also give CCBs) - relax myocytes in esophagus
get esophageal manometry - will show repetitive (non-peristaltic, high-amplitude simultaneous contractions in middle and lower esophagus)
- spont or after ergonovine stimulation
- esophagram will show corkscrew pattern
- issue is dysfunction of inhibitory neurons
GERD
straight forward GERD - start empiric trial of PPI for 2 mo
- refractory sxs –> switch to different PPI or bid dosing
- persistent sxs –> consider EGD or esophageal pH monitoring
men age >50 with sxs for >5yrs or cancer risk factors (tobacco use) or alarm sxs - EGD
- either esophagitis or no esophagitis (pursue further work-up by esophageal manometry)
- alarm sxs = melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia/odynophagia
tx - lap nissen, radiofrequency ablation if there are severe dysplastic changes
Wilson disease
AR
hepatic copper accumulation –> leak from damaged hepatocytes –> deposits in BG and cornea
px - hepatic, neuro sxs (parkinsonism), psychiatric changes
decreased ceruloplasmin, increased urinary cu excretion
tx - chelators, zinc (interferes cu absorption)
- for pts with fulminant liver failure or drug-resistant disease - liver transplant
colovesical fistula
causes - diverticular disease, crohns, malignancy
dx - abd ct with oral or rectal contrast (NOT IV)
- colonoscopy to exclude malignancy
colon polyps and cancer
adenomas = neoplastic
- findings that suggest greater risk of malignant transformation
- villous features and high-grade dysplasia, large size, high number (3+), sessile
pellagra
3Ds: dermatitis (on sun exposed areas), diarrhea (+loss of appetite), dementia (+mood changes)
- note - chronic scaly rash (not hypersensitivity reaction)
niacin is synthesized from trytophan - seen in populations that subsist primarily on corn products
- can also be seen in malnourished, carcinoid syndrome, or Hartnup disease (disorder of trytophan absorption)
acute intermittent porphyria
abdominal pain, vomiting, diarrhea + neuro symptoms (agitation, paresthesia, confusion)
- may be triggered by isoniazid
- but symptoms are episodic (rather than chronic)
iron-deficiency anemia
in older patients - assume GI loss until proven otherwise
- single fecal occult blood test is not sufficient to exclude GI bleeding
- get colonoscopy and EGD - even if one fecal occult test is negative
carcinoid syndrome
neuroendocrine tumor skin flushing (85%), cutaneous telangiectasias, GI upset (secretory diarrhea), valvular lesions (R > L), bronchospasm
- other - niacin deficiency (pellagra)
dx - elevated 24hr urinary excretion of 5HIAA
- CT/MRI abd/pelvis to localize the tumor
- octreotide scan to detect mets
- echo - if there are sxs of heart disease
tx - octreotide for symptomatic pts and prior to surgery and anesthesia
- surgery for liver mets - mets to liver means that products are released directly into circulation (before being neutralized by liver)
Whipple’s disease
multi-system illness commonly seen in white men, 40-60s
GI - abd pain, diarrhea, malabsorption
- migratory polyarthropathy, chronic cough, myocardial/valvular involvement, dementia
- PAS pos material in LP
what stimulates the gallbladder to contract
fatty acids in duodenum –> stimulate endocrine cells to release CCK –> CCK causes smooth muscle contractions of the GB and relaxation of the sphincter of Oddi
vagus nerve also plays a role (hepatobiliary branches of the vagus?)
chronic pancreatitis
alcohol use, CF, ductal obstruction (malignancy, stones), autoimmune
sx - chronic epigastric pain (intermittent, pain-free interval), malabsorption, DM
- pain is relieved by sitting upright or leaning forward
CT scan - calcifications, dilated ducts, enlarged pancreas
treatment
- pain management, alcohol and smoking cessation, frequent and small meals
- enzymes based on sxs and stool fat content (sxs - bloating, diarrhea)
secretin test - measures ability of pancreatic ducts to produce bicarb
- good for diagnosing chronic pancreatitis
MALT
MALT also extranodal marginal zone B cell lymphomas
H pylori - chronic inflammation from H pylori –> stimulation of B and T cells in gastric lamina
test for H pylori
- early-stage MALT - H pylori eradication therapy (quadruple therapy) -
more advanced dz or H pylor negative tumors - radiation, immuno, or chemo
gastric adenocarcinoma
risk factors - cigarette smoking, high salt intake, consumption of N-nitroso compounds (processed foods)
- NSAIDs are protective
- H pylori is a risk factor - eradication is recommended for pts with resectable disease to reduce risk of developing second cancer
- pernicious anemia increases risk for gastric adenocarcinoma (and gastric carcinoid tumors)
pill esophagitis
pill esophagitis - tets, ASA, NSAIDs, bisphosphonates, KCl, Fe
- typical sxs are sudden-onset odynophagia and retrosternal pain
- most common in mid-esophagus (due to compression by the aortic arch or enlarged LA)
- EGD - discrete ulcers with relatively normal appearing surrounding mucosa (though dx can be made clinically)
evaluation of elevated alk phos
elevated alk phos and elevated GGT - likely biliary in origin (otherwise likely of bone origin)
- get RUQ US and AMA
- if AMA pos or abnormal hepatic parenchyma - get liver bx –> if dilated bile ducts - get ERCP
- if both normal - liver bx, ERCP, observation
pos AMA = primary biliary cholangitis
lactose intolerance
most commonly seen in Asian-Americans
colonic bacteria ferment lactose –> bloating
dx - lactose hydrogen breath test - rise in breath hydrogen level after ingestion of lactose
- indicates bacterial carbohydrate metabolism
diarrhea will have high osmotic gap due to unmetabolized lactose and organic acids
- OG = 290 - [2(stool Na + stool K)]
- stool pH will be acidic - due to fermentation products
colon cancer screening in pts with increased risk
1-2 small adenomatous polyps on colonoscopy - q5yrs
FHx of adenomatous polyps or CRC - at 40 or 10 yrs before dx of affected relative - q5yrs
IBD - UC or Crohns with colonic involvement
- 8-10 yrs post-dx
- q1-2 yrs = frequent surveillance
- prophylactic colectomy if dysplasia is identified
classic FAP (APC gene mutation) - sigmoidoscopies at age 10-12
- annual colonoscopies once colorectal adenomas are detected
- usu proctocolectomy by early 20s
HNPCC (Lynch syndrome) - age 20-25
- q1-2yrs
malignant biliary obstruction
due to malignancy - cholangiocarcinoma, pancreatic or HCC, mets
px - jaundice, pruritis, weight loss, acholic stools with dark urine
- exam - normal or RUQ mass, tenderness, or hepatomegaly
- labs - elevated direct bili, elevated alk phos and GGT, normal-elevated AST and ALT
evaluation
- abd imaging (US, CT) - MRCP or ERCP if imaging is nondiagnostic
hemochromatosis
cirrhosis, heart failure, DM, hypogonadism, arthritis
celiac disease
steatorrhea, ADEK and Fe deficiency
associated with dermatitis herpetiformis - autoimmune, on extremities
IgA, anti-TTG, and IgA anti-endomysial antibodies - however many pts with celiac disease have selective IgA deficiency!
villus atrophy on bx
postcholecystectomy syndrome
persistent abd pain or dyspepsia (nausea) post-op
can be due to - retained CBD or cystic duct stone
- bile duct injury (?)
- note that bile ducts stricture so these injuries can be devastating
- biliary dyskinesia
- pancreatitis
- PUD
- CAD
elevated alk phos, mildly abnormal serum aminotransferase, dilated CBD - 1) US, 2) ERCP
giardia
diarrhea, international travel (rural areas, developing countries, mtns), foul-smelling stools, bloating
- contaminated water, fecal-oral route
abd exam benign
get stool antigen assay - can also look for oocysts and trophozoites in stool
tx - metronidazole
- but note - short course of cipro is empiric treatment for travelers diarrhea
liver flukes
travel abroad dx - ova and parasite stool tests invade biliary tree
SIBO
bacteria from the colon are inappropriately present in the SI
- DM, jejunocolonic fistula
greasy diarrhea
pre-op risk
Cardiac
Goldman’s index
1) JVD
2) recent MI (last 6 mo)
3) PVCs, non-sinus rhythm
4) age over 70
5) emergency surgery
6) AS
7) poor medical condition
8) surgery in chest/abd
- goldmans is outdated, preferred method is assessing functional status
hepatic risk - encephalopathy, albumin ascites, bili, INR
nutritional risk - more than 20% body weight loss over couple mo (serum albumin <3, anergy, serum transferrin <200)
- 4-5 d enteric feeds will fix the issue
DKA is absolute contraindication to surgery
post-op pt becomes disoriented
consider hypoxia
DTs occur POD 2-3 - confused, hallucinations, combative
post-op urinary RT
extremely common - esp after surgery in the lower abdomen, pelvis, perineum, or groin
pt will often have dribbling - signs of overflow incontinence
straight cath at 6hrs post-op with no voiding
- indwelling foley after 2x or 3x straight caths
wound dehiscence
salmon colored fluid (peritoneal fluid)
immediate concern - evisceration
late issue - ventral hernia
symptoms of CRC
cecal - blood per rectum
rectal cancer - diarrhea (obstructed above) - 1) chemo, 2) surgery
junction of ascending and sigmoid - bloating
- note - colon cancer 1) surgery, 2) chemo
how many lymph nodes should be resected to have and adequate sample
12 minimum
embolization to leg
arterial embolization to leg (afib) –> doppler to localize
- incomplete occlusion - clot busters
- complete occlusion - Fogarty catheter to remove embolism
skin cancers
basal cell (50%) - waxy, raised, or ulcer (pearly telangiectatic papules with central ulceration)
- kills by relentless local invasion (rodent ulcer) (does not met)
- timetable is yrs
- resection - 1mm margin
squamous cell carcinoma (25%) - associated with UV light and chronically wounded, scarred, or inflamed skin
- SCC arising with burn = Marjolin ulcer
- mets to LNs
- timetable is mo
melanoma - most lethal, ABCD (>0.5 cm) E
- prognosis and management by depth, lesions beyond 4 mm have terrible prognosis
- disseminated melanoma - cant be cured, IFN improves survival time
note - ulcers should be bx at edge, other things can be completely excised
ophtho
- ambylopia
- glaucoma
- cellulitis
- retina
amblyopia - vision impairment due to interference with processing of images by brain during first 6-7yrs
- ex - strabismus
- note true strabismus is present at birth and requires corrective surgery, strabismus that arises after birth can be fixed with corrective glasses
glaucoma
- acute angle closure = emergency - painful eye, headache
- mid-dilated, nonreactive pupil, halos around lights, eye is hard as a rock, cornea is greenish hue
- often Asian female who has been watching tv for a long time (pupil dilated for a long time) -
- tx - acetazolamide, etc.
orbital cellulitis = emergency - cellulitis + pupil is dilated and fixed and limited ROM, means there is pus in orbit
- CT scan and drainage
retinal detachment - floaters in eye and flashes of light
- other clues - snowstorm, dark cloud at top of visual field
- tx with emergency laser spot welding to protect remaining retina
embolic occlusion of retinal artery - sudden loss of vision (damage becomes irr in 30 min)
- recommendation - breath into paper bag and have someone press hard on eye and release (repeatedly)
- idea is to vasodilate and shake clot into more distal location
neck mass
thryoglossal duct cyst - surgical excision involves removing cyst, track, and attaching part of hyoid bone
branchial cleft cysts - anterior edge of SCM, can have opening and blind tract onto skin
cystic hygroma - supraclavicular area + deep chest
- get CT prior to excision
enlarged LNs
recently discovered - will most likely be benign
- f/u in 3-4wks
- if persistently enlarged - have to rule out neoplasia
lymphoma - remove node, chemo tx
squamous cell carcinoma of mucosa - old men who drink, smoke and have rotten teeth, AIDS
- other pxs - persistent hoarseness, persistent painless ulcer in floor of mouth, persistent unilateral earache
- first sign will be a metastatic node in neck –> panendoscopy to look for primary
- CT to look for extent
- can do FNA, NEVER do open bx - scar will make future surgery difficult
acoustic neuroma
sensory hearing loss in one ear only, get MRI
parotid tumors
most are pleomorphic adenomas
- benign but have malignant potential
hard parotid mass, painful, facial nerve paralysis - cancer
superficial parotidectomy to excise - spares facial nerve
- in malignant tumors - take nerve
Bells palsy
treat with antivirals (and sometimes steroids)
nose bleeds
little children - epistaxis, give phenylephrine spray and local pressure
juvenile nasopharyngeal angiofibroma - surgical resection is mandatory - because it will eat away at nearby structures
cocaine use - packing
elderly and nose bleeds - posterior packing, may require surgical ligation
dizziness
inner ear - room spinning, give meclizine, promethazine, diazepam
brain - unsteady
Charcot foot
diabetic complication, rocker bottom deformity, swelling
- inflammation is the issue
pulses are fine
will have peripheral sensory neuropathy
neurosurg
TIA - IC stenosis (>70%) or ulcerated plaque at carotid bifurcation - 1) Doppler
hemorrhagic stroke - control HTN
brain bleeds - if midline shift –> surgery
- acute subdural - work on lowering ICP
- SAH - 1) CT first, 2) arteriogram to look for aneurysm
brain cancer - approx 50% from lung
elevated ICP (with a brain tumor) - tx with high dose steroids until you can surgically remove
pituitary apoplexy - steroid replacement is necessary
brain abscess - resection is required
reflex sympathetic dystrophy (formerly called CRPS?) - develops after a crushing injury
- doesnt respond to usual analgesics
- extremity is cold, cyanotic, and moist
- requires surgical sympathectomy
urology
- kidneys
- bladder
- penis/epididymis
acute epididymitis - will present with fever and pyuria
- *get doppler to rule out testicular torsion*
obstruction + infection - IV abx, immediate decompression (?)
erection longer than 4 hrs - drain blood from penis
posterior urethral valves - voiding cystourethrogram to dx, surgery/endoscopy to tx
VUR - consider in child with UTI, get voiding cystourethrogram, long term abx until child grows out of problem
low implantation of ureter - issue in girls, ureter will leak urine (constantly) into vagina
UPJ - renal/bladder system can empty normal amounts of urine, pt will present with colicky pain after a night of binge drinking…
prostate cancer - dx by transrectal needle bx
impotence due to chronic dz (arteriosclerosis) - viagra
penile fracture - rupture of corpus cavernosum (tissue around urethra) due to traumatic tear in tunica albuginea (fibrous covering around entire penis)
- crack, detumescence, variable pain, hematoma foramtion
- urologic emergency - get RUG (because urethral injury is a common complication)
- note other indications for RUG are blood at meatus, hematuria, dysuria, URT
pneumaturia
1) CT scan
2) inflammatory diverticular mass
3) sigmoidoscopy to rule out cancer
organ transplantation
hyperacute - vascular thrombosis in min, due to incompatbile ABO and lymphocytes (so pre-formed abs)
acute - 5d-3mo, organ dysfunction, get bx
- liver - usu technically problems cause an issue –> get doppler to evaluate for biliary obstruction and vascular thrombosis
- heart - routine bx (otherwise its becomes too late to intervene)
- give steroid boluses
- mediated by mononuclear macrophages and T lymphocytes (leukocytic infiltration)
chronic - yrs, insidious organ loss
- T- cell mediated (foreign mhc looks like a self mhc that is carrying an antigen) –> intimal thickening and fibrosis of graft vessels)
- no tx
- get bx - to make sure it is not a delayed and treatable case of acute rejection
repairing extremity
1) repair bone first
2) vascular - because this can be disrupted when you reduce a fracture
3) nerve
black widow spider bite
give calcium gluconate
ortho kids
Legg-Calve-Perthes disease - avascular necrosis of capital femoral epiphysis
- age 6, limping, decreased hip motion, hip (or knee) pain
- tx - by containing the femoral head in acetabulum by casting or crutches
slipped capital femoral epiphysis - 13 yo M, lanky, limping, decreased hip motion, hip/knee pain
- affected foot points in
- pin back in place
septic joint - wont move hip
- aspiration and drainage
acute hematogenous osteomyelitis
- MRI gives prompt dx
others:
bowlegs - nl till age 3
knock knee - nl till 4-8
Osgood-Schlatter - RICE
club foot - serial casting, achilles tenotomy
scoliosis - bracing is used to arrest progression, severe cases may need surgery
ortho fractures/dislocations
fractures of growth plate (kids) - ORIF
anterior shoulder dislocation - more common, “shaking hands” position
Colles - FOOSH, dorsally angulated radius fracture
Monteggia - ulnar fracture, anterior dislocation of radial head
- Galeazzi is opp
- ORIF for break, closed reduction for dislocation for both of these fractures
rupture of achilles tendon - out of shape middle aged men who subject themselves to severe strain
trigger finger, De Quervains (thumb) - steroid injection
Dupuytren - steroid or collagenase
gamekeeper thumb - injury UCL of thumb –> cast
jersey finger is opp of mallet finger
bone tumors
pathologic fracture - fracture with almost no force = mets
MM - punched out lytic lesions
sarcoma - require wide local excision and radiation &chemo, mets to lungs
giant cell tumor of bone - soap bubble appearance, eccentric lytic area
- benign, locally aggressive skeletal neoplasm seen in young adults
- tumor contains cystic and hemorrhagic lesions
osteoi osteoma - sclerotic, cortical lesion with central lucency
- nighttime pain, pain unrelated to activity, and relieved by NSAIDs
- tx - surgery
L spine
fall from height - check (L/T) spine
herniated disk - will most likely resolve
cauda equina syndrome - distended bladder (late), flaccid rectal sphincter, perineal saddle anesthesia
- condus medularis is similar - but will have EARLY urinary and fecal incontinence
gout
acute attack - indomethacin, colchicine
chronic control - allopurinol and probenicid
fistulas of GI tract
if they dont drain out directly –> sepsis
if they drain freely (pt is afebrile with no signs of peritoneal irritation) - consequences are only fluid and electrolyte loss, nutritional depletion, and erosion and digestion of belly wall
- high volume losses from high in GI tract
- tx - give enteral nutrition (past the fistula), protect abd wall
- fistula will heal on its own
anorectal disease
in all anorectal disease - rule out cancer
ischiorectal abscess - perirectal pain that prevents sitting
- watch diabetics closely - can progress to necrotizing soft tissue infection
fistula-in-ano - develops in some pts who have had an ischiorectal abscess drained
- anal crypt –> skin
- fecal soiling - r/o necrotic and draining tumor
treat with fistulotomy
SqCC of anus - bx first - tx 1) chemoradiation, 2) surgery is there is residual tumor
cancer and chemo
need systemic therapy for systemic disease - so chemo for mets
T tumor - T4 invasion of adjacent structures
N
M
thyroid
most thyroid nodules are benign but have to work all up to exclude malignancy
1) US –> 2) TSH/radionuclide scan –> 3) FNA –> …
- except follicular hot nodules are rarely malignant
- toxic multinodular goiter - TSH-independent hyperfunctioning follicular cells
thyroiditis - Hashimotos (autoimmune)
- subacute (follows viral infection)
- silent - associated with thyroid abs, can occur post-partum
- Reidels - fibrosing
neoplasia - autopsy, f-ed, pissed off, will present as a nodule (decreased I uptake in adenoma and carincoma) –> get FNA
- follicular adenoma - follicular carcinoma - FNA cant distinguish between follicular adenoma and carcinoma –> partial thyroidectomy –> total thyroidectomy if cancer
- papillary carcinoma (80%) - old lady with exposure to ionizing radiation as a child
- medullary carcinoma - C cells, aggressive –> radical surgery
- anaplastic (elderly, invades local structures…)
breast disease
have to rule out cancer ALWAYS - lymph nodes!
<30 - US
- simple breast cyst (can be quite painful)
- posterior acoustic enhancement (fluid), no echogenic debris…
- cystic fluid can reaccumulate so pt should f/u in 2-4 mo for repeat clinical breast examination
- no recurrence or sx - annual visits
screening MRI - cancer
- and use it for women with increased risk of cancer (BRCA and their relatives, genetic syndrome, hx of radiation during ages 10-30
diagnostic mammography - DONT in women < 30 (dense breast tissue prevents visualization, radiation risk)
- diagnostic to evaluate risk
- needle aspiration for breast mass
- core bx if suspicious imaging (mammogram) - for complex cysts, masses, or recurring mass
when would you image
- unilateral breast discharge, bloody or serous d/c, or palpable lump or skin changes - mammo or US accordingly
- nipple discharge that looks benign - UPT, TSH, prolactin, guaiac
fibroadenoma - FNA or sonogram
cystosarcoma phyllodes - grow over many years –> distort entire breast, dont become fixed
- core or incisional bx –> removal
mammary dysplasia (fibrocystic disease, cystic mastitis) - linked to estrogen
cyst - aspirate –> clear ok –> recurs –> get formal bx
- bloody send for cytology
- intraductal papilloma - get mammogram (though it will not show the mass)
treatment: for resectable cancer (infiltrating ductal, DCIS, small lesions away from nipple/areola)
- 1) lumpectomy, 2) radiotherapy
- otherwise - total mastectomy (no need for radiation)
- if LNs are not palpable - get sentinel node bx
- if LNs are palpable - take them out
- inoperable breast cancer - based on local extent –> give chemo
- follow every surgery with adjuvant chemo
pedi surg
esophageal atresia - rule out VACTER anomalies
imperforate anus - look for fistula nearby
- if fistula is present - can repair imperforate anus before potty training (otherwise repair immediately)
green vomiting
- double bubble - duodenal atresia, annular pancreas, malro
- if there is a normal gas pattern beyond double bubble - malro is likely (malro is diagnosed with contrast enema)
biliary atresia - 6-8 wk old babies with progressive jaundice
- normal work-up - 1) phenobarb (powerful choleretic), 2) hida scan
neuroblastoma
tracheomalacia - wheezing, stridor, dysphagia, hyperextension of neck
- vascular ring that encircles trachea and esophagus - shown on barium swallow and bronchoscopy
- surgery to divide (aortic) arches
heart murmurs
ASD - low pressure, fixed S2, hx of frequent colds
VSD (classically in membranous septum) - failure to thrive baby, loud pansystolic murmur
PDA - machine like murmur
Tet of Fallot
transposition of great vessels - need ASD or some other connection –> surgery
AS - surgical valvular stenosis, replace if gradient is more than 50 mm Hg (or other complications)
acute aortic insufficiency - endocarditis –> emergency valve replacement and abx
mitral stenosis - acute rheumatic fever
mitral regurg - holosystolic heart murmur, radiates to back and axilla
lung cancer
coin lesion 1) sputum cytology, 2) CT chest/abdomen to look for mets, 3) biopsy
- operability is based on FEV1 remaining after the surgery > 800 mL
- sufficient FEV1 –> look for mets (carinal and mediastinal mets preclude resection)
- not surgical candidate - chemo and rads
small cell = s tumors are associated with smoking, sentral, syndromes (paraneoplastic, ADH, ACTH, Eaton-Lambert)
- small cell –> chemo
non-small cell
- adenocarincoma
- squamous cell - PTHrP
- carcinoid tumor
screening guidelines - low-dose chest CT annually in pts 55-80 who have a >30-pack-yr smoking hx AND are currently smoking or quit in the past 15 yrs
heart artery disease
CAD: intervention if one or more vessels have 70% (or greater) stenosis and there is a good distal vessel
- stenting or bypass
subclavian steal syndrome - plaque at origin of subclavian–> results in retrograde flow during times of exercise
- AND posterior circulation neuro signs
salt balance
hyponatremia (<120)
- check serum Na, serum osm, UA, physical exam
- urine Na low (<20) - primary polydypsia
- urine Na high (>20) - look at volume status
- hypervolemic - cirrhosis, chf, nephrotic syndrome
- euvolemic - siadh, adrenal insufficiency, hypothyroidism
- hypovolemic - cerebral salt wasting, diarrhea, diruetics
hypernatremia (>145)
- due to net loss of free water - large wound (burn), open abd, GI tract loses, lungs (humidifier air), kidneys
- or due to net gain of sodium
K balance
insulin brings K into cells
hypokalemia
- weakness, constipation –> frank muscle necrosis –> ascending paralysis, arrhythmias are uncommon
- due to renal loss, metabolic alkalosis, diarrhea
- less often due to redistribution
hyperkalemia (5.5) - fatigue, muscle weakness, flaccid paralysis, paresthesias, cardiac excitability (can lead to heart block and vfib)
- impaired renal excretion (AKI), metabolic acidosis, rhabdo
- tx - 1) ca gluconate to stabilize heart, 2) insulin to shift K into cells, 3) excrete K (lasix, hemodialysis)
GI bugs
entamoeba histolytica - abd pain, chronic diarrhea (bloody)
peri-op MI
intraoperative hemorrhage (requiring blood transfusion) increases risk
px - lack of chest pain, possibly because of peri-op pain control
TRALI
px - fever, hypotension, pulm edema within 6 hrs of blood product administration
leukemoid reaction
leukemoid reaction - WBC > 50K, due to severe infection
- leuk alk phos - high
- mature neutrophil precursors
v. s. CML - WBC > 100K, Bcr-abl - low leuk alk phos - due to cytochemically abnormal neutrophils
- less mature neutrophli precursors, absolute basophilia
hemochromatosis
bronze diabetes, transaminitis/hepatomegaly, hypogonadism, cardiomyopathy
- MSK - arthralgia, arthropathy, chondrocalcinosis
- pts with pseudogout should be elevaluated for seocndary causes - hyperparathryoidism, hypothyroidism, hemochromatosis
- hemaochromatosis - get Fe studies, manage with serial phlebotomy
- infections - increased susceptibility to Listeria, Vibrio vulnificus, Yernsinia enterocolitica
most effective for weight loss
gastric bypass
acute liver failure
acute liver failure –> liver transplant
- jargon note - ALF is acute liver injury in a pt without cirrhosis
- triad of 1) elevated AST/ALT (1000s), 2) hepatic encephalopathy, 3) synthetic liver dysfunction (INR > 1.5)
- rising serum bili and PT - indicative of worsening ALF
- cerebral edema is a potential complication –> coma and brainstem herniation
- acute renal insufficiency is common - esp with acetaminophen (because it is directly toxic to renal tubules)
- as a note - signs of HE differentiates ALF from acute hepatitis
catheters
CA-UTI
- bacteria properties - biofilm
- avoid by clean intermittent cath - every 4-6 hrs
compare to indwelling catheters - changed monthly
- risks - increased UTI, stricture, bladder spasm
other option - suprapubic tube placement
