Surgical recall Flashcards
1
Q
What is the source of alkaline phosphatase?
A
Ductal epithelium (thus, elevated with ductal obstruction
2
Q
Most common liver tumor?
A
Hepatocellular carcinoma
3
Q
Imaging for liver tumor?
A
CT scan, ultrasound, A-gram
4
Q
Vinyl Chloride, arsenic, thorotrast contrast + liver
A
Angiosarcoma
5
Q
Hepatocellular adenoma risk factors
A
- ABC-Adenoma Birth Control (female)
- steroids
6
Q
Focal nodular hyperplasia histology
A
normal hapatocytes and bile ducts (adenoma with no bile ducts)
7
Q
Diagnose FNH on CT
A
central scar
8
Q
FNH treatment
A
embolization
9
Q
Kasabach-Merrit syndrome
A
Hemangioma and thrombocytopenia and fibrinogenipenia
10
Q
Risk factors for hepatocellular carcinoma
A
HepB, cirrhosis, aflatoxin (Aspergillus), hemochromatosis
11
Q
Hepatoculluar carcinoma signs/symptoms
A
- Painful haepatomegaly
- portal hypertension
- splenomegaly
12
Q
Tests for hepatocullular carcinoma
A
- US, CT, angiography, tumor marker (a-fetoprotein) elevation
- tissue diagnosis = needle biopsy with CT scan, US, or lap guidance
13
Q
most common hepatocellular carcinoma metastasis site?
A
lungs
14
Q
Bacterial abscess signs/symptoms
A
Fever, chills, RUQ pain
15
Q
you tracking on Entomeaba histolyitca?
A
yes
16
Q
What lab tests should be performed when entomoeba histolytica is suspected?
A
Indirect hemagglutinin titers, elevated LFTs.
17
Q
6 potential routes of portal-systemic collateral blood flow
A
- Umbilical vein
- Coronoary vein to esophageal venous plexuses
- Retroperitoneal veins
- Diaphragm veins
- Superior hemorrhoidal veins to middle and inferior hemorrhoidal veins and then to iliac vein
- Splenic veins to short gastric veins
18
Q
normal portal pressure?
A
19
Q
What causes pre-hepatic portal hypertension?
A
Thrombosis of portal vein/atresia of portal vein
20
Q
What causes hepatic portal hypertension?
A
Cirrhosis, cancer
21
Q
Post hepatic portal hypertension?
A
Budd-chiari thrombosis of hepatic veins
22
Q
Most common finding in patients with portal hypertension
A
Splenomegaly
23
Q
4 most common clinical findings in portal hypertension
A
- esophageal varices
- splenomegaly
- Caput medusae
- hemorrhoids
24
Q
Initial treatment of variceal bleeding
A
- Large bore IVs x 2
- Foley
- type and cross blood
- labs, correct coagulopathy (vitamin K, FFP)
- Intubation to protect from aspiration
25
Diagnostic test of choice for variceal bleeding?
Upper GI endoscopy (EGD)
26
Pharmacologic options for esophageal variceal bleeding
-Somatostain (octreotide) or IV vasopressin (and nitroglycerin, to avoid MI) to achieve vasocinstriction of the mesenteric vessels. B-blocker if still bleeding
27
Where are most bile acids absorbed?
Terminal ileum
28
What stimulates gallbladder empyting?
Cholecystokinin and vagal input
29
Source of cholecystokinin
duodenal mucosal cells
30
What inhibits cholecystokinin?
Trypsin and chymotrypsin
31
level of jaundice for bili
>2.5
32
Dark urine/clay stool =
jaundice
33
Biliary colic
- Pain from gallstones
1. RUQ, epigastrum, or right subscapular region of back.
2. lasts minutes to hours, postprandial
34
What is the initial diagnostic study of choice for evaluation of the biliary tract/gallbladder/ cholelithiasis?
Ultrasound!
35
Cholelithiasis
Gallstone formation (Female, fat, forty, fertile)
36
Calcified gallbladder
Porcelain gallbladder, do cholecystectomy.
37
When would you do asymptomatic cholecystectomy?
Sickle-cell
calcified gallbladder
child
38
choledocolithiasis management?
1. ERCP with papillotomoy and basket/balloon retrieval of stones (pre- or post-op)
2. Laparoscopic
3. Open
39
What meds can dissolve gallstone?
Ursodeoxycholic acid (Actigall), Chenodeoxycholic acid
40
ERCP complication?
Pancreatitis
41
Cholecystitis is obstruciton of _________ duct
cystic
42
Signs/sympoms of cholcystitis
UNRELENTING RUQ pain or tenderness. Fever. N/V. Murphy's sign.
43
Murphy's sign of cholcystitis
Acute pain and inspiratory arrest during RUQ palpatoin
44
labs of cholecysitis
elevated amylase, t billi slightly. alk phos/.LFT elevatoin. WBC elevation
45
US cholecystitis signs
Thickened wall >3mm. Fluid. Gallstones. Sonographic murphy's sign
46
Cholangitis
infection of biliary tract from obstruction
47
Charcot's triad of cholangitis
1. Fever/chills
2. RUQ pain
3. Jaundice
48
Reynold's pentad
1. Fever/chills
2. RUQ pain
3. Jaundice
4. altered mental status
5. Shock
49
Treatment of cholangitis
US and ocntrast (ERCP) after IV antibiotics cool them off
50
Major risk factor of sclerosing cholangitis?
Inflammatory bowel disease (usually ulcerative cholitis)
51
Beads on a string on gallbladder contrast
Sclerosing cholangitis
52
Gallstone ileus major risk factor
Women over 70
53
Diagnostic tests for gallstone ileus
- ABD X-Ray
- UGI
- Abdominal CT: Air in biliary tract, gallstone in intestine
54
Gilbert's =
Glucorynyl
55
Pancreatitis symptoms
Epigastric pain (radiates to back), nausea and vomiting
56
Signs of pancreatitis
Epigastric tenderness, diffuse abdominal tenderness, decreased bowel sounds, fever, dehydration/shock
57
Pancreatitis can cause gastric varices through
splenic vein necrosis
58
Pancreatitis chronic work up
CT, KUB, ERCP
59
Radiologic tests for gallstone pancreatitis
U/S to look for gallsotnes
| CT to look at pancreas, if symptoms are severe
60
Pancreatic cancer work up
US -> CT if US nondiagnostic
61
Greatest risk factor for pancreatic head cancer
Smoking
62
WDHA syndrome
-Pancreatic VIPoma (Vasoactive intestinal polypeptide tumor) AKA Verner-Morrison syndrome
VIP causes:
Watery diarrhea
Hypokalemia
Achlorhydria (inhibits gastric acid secretion)
63
Whipple triad of pancreatic insulinoma
1. Hypoglycemia (Glc
64
Pancreatic somatostatinoma triad
Gallstones, diabetes, steatorrhea (inhibits gallbladder contraction)
65
Pancreatic glucagonoma tumor findings
Diabetes, dermatitis
66
CRH function
Corticotropin-releasing hormone: releassed form anterior hypothalaus and causes release of ACTH from anterior pituitary
67
ACTH
released normally by anterior pituitary, which causes adrenal gland to release cortisol
68
What inhibits ACTH secretion?
Cortisol
69
Most common cause of cushings
iatrogenic (exogenous)
70
How can cortisol levels be indirectly measured over a short duration?
Urine cortisol or breakdown product of cortisol (17-OHCS) in the urine
71
Direct test of cortisol
serum cortisol
72
Initial tests for cushing's?
Electrolytes, serum cortisol, urine-free cortisol, 17-OHCS, Low dose dexamethasone suppression test
73
Low-dose dexamethasone suppression test
- Negative feedback on ACTH and thus cortisol on normal patients
- Patient's with Cushing's syndrome DO NOT suppress cortisol secretion
74
After low-dose dexamethasone suppression test, what do you do?
Check ACTH
- Low: adrenal tumor
- High or normal: ACTH dependent process, do high-dose dexamethasone
75
High dose dexamethasone suppressoin test
Suppression: Pituitary source
| No suppression: Ectopic ACTH
76
Most common sight of ectopic ACTH-producing tumor?
Oat cell tumor of lung (#2 is carcinoid)
77
What is a pheochromocytoma?
Tumor of the adrenal MEDULLA and sympathetic ganglion (from chromaffin cell lines) that produces catecholamines (noreipnephrine>epi)
78
PHEochromocyotma tria
Palps, Headache, Episodic diuresis
79
What tests should be performed for pheochromocytoma?
VanillylMandelic Acid (VMA), metanephrine, normetanephrine (all breakdown products of catechols). Urine/serum epi, NE levels
80
Most common site of pheochromocytoma?
adrenals
81
Tumor localization tests for pheo?
CT, MRI, I-MIBG, PET, Octreoscan
82
Pre-op med treatment for pheo?
incresae intravascular volume with a-blockade (phenoxybenzamine, prazosin) to allow reduction in catecholamine-induced vassoconstriction and resulting volume depletion, treatment should start as soon as diagnosis is made +/- b-blockers
83
What must be ruled out in patients with pheochromocytoma?
MEN type II
84
______ and _________ cause renin secretion from juxtaglomerular cells
Low sodium and hyperkalemia
85
What is the physiologic effect of aldosterone?
causes sodium retention for exchange of potassium in the kidney, resulting in fluid retention and increased BP
86
Sings of hyperaldosteronism?
Hypertension, headache, polyuria, weakness
87
clues of Conn's syndrome?
Hypertension, hypernatremia, hypokalemia, metabolic alkalosis
88
What commonly causes Conn's syndrome?
Adrenal adenoma or hyperplasia
89
Tests for Conn's syndrome?
CT, adrenal venous sampling, saline infusion test
90
Preop treatment of Conn's?
Spironolactone, k+ supps
91
renin levels in patients with primary aldosteronism vs secondary
normal or low
92
Addison's disease
Adrenal insufficiency with HYPERkalemia, hyponatremia
93
What is an insulinoma?
Insulin-producing tumor arising from B cells
94
Risks associated with insulinoma
Men-I syndrome (PPP = pituitary, pancreas, parathyroid tumors)
95
signs/symptoms of insulinoma?
Sympathetic nervous system symptoms resulting from hypoglycemia
-palps, diaphoresis, tremulousness, irritability, weakness
96
Labs for insulinoma
Glucose/insulin during fast. C-peptide and proinsulin (if injection of insulin is concern, as insulin injections have no proinsulin or C-peptide)
97
Diagnostic tests for insulinoma
- fasting hypoglycemia present. 72 hour fast, then check glucose and insulin every 2 hrs.
- CT, A-gram, endoscopic US
98
What is treatment of insulinoma?
Diazoxide, suppresses insulin release
99
Where is a glucagonoma located?
Tail of pancreas
100
Symtpoms of glucagonoma?
Necrotizing migratory erythema (below waist), diabetes, stomatitis
101
What is necrotizing migratory erythema?
red, often psoriatic appearing rash with serpiginous borders over the trunk and limbs
102
Lab findings for glucagonoma
hpergylcemia, high glucagon, low amino acids
103
Classic glucagonoma finding on CBC
anemia
104
Stimulation test for glucagonoma?
tolbutamide
105
Imaging for glucagonoma?
CT
106
Med treatment for necrotizing migratory erythema?
somatostatin
107
Somatostatinoma
Pancreatic tumor that secretes somatostatin: diabetes, diarrhea, dilation of gallbladder. Dx with CT. Medical treatment streptozocin
108
What is zollinger-Ellison syndrome?
Gastrinoma: non-B islet cell tumor of the pancreas (or other locale) that produces gastrin, causing gastric hypersecretion of HCl acid, resulting in GI ulcers
109
Syndrome associated with ZES
MEN-1
110
With ZES, how do yo uscreen for MEN 1?
Calcium
111
how can a ZES tumor be localized?
octreotide scan, CT
112
What tests are used to evaluate ulcers?
EGD, UGI, or both
113
High yield screening labs for MEN-1?
1. calcium
2. PTH
3. Gastrin
4. Prolactin
114
Medical treatment of ZES
H2 blockers, omeprazole, somatostatin
115
What studies can be used to evaluate a thyroid nodule?
U/S - solid or systic nodule
| FNA ->cytology I sciniscan - hot or cold nodule
116
Diagnostic test of choice for thyroid nodule?
FNA
117
Indications for I scintiscan on thyoid nodule?
multiple nondiagnostic FNAs
| Nodule with thyrotoxicosis and low TSH
118
MEN is inherited in what patter?
Autosomal dominant
119
Men I Werner's syndrome gene defect?
Chromosome 11
120
MEN I tumors
"PPP"- PA, PA, PI
Parathyroid hyperplasia
Pancreatic islet cell tumors (gastrinoma 50% insulinoma 20%)
Pituitary tumors
121
What other tumors (in addition to PPP) are associated with MEN-1?
Adrenal (30%) and thyroid (15%)
122
What is the gene defect in MEN !!A Sipple's syndrome?
RET (reT=Two)
123
Most common MEN IIA tumors?
2 = 2 MPH or miles per hour
Medullary thyroid carcinoma
Pheochromocytoma (mPH)
Hyperparathyroidism
124
All patients with MEN IIA have _________
medullary carcinoma of the thyroid
125
Screening tests for MEN IIA?
1. Calcitonin
2. Calcium
3. PTH
4. Catecholamines and metabolites (metanephrine and normetanephrine)
5. RET gene testing
126
What are most common abnormalities in MEN IIB?
"MMMP"
- Mucosal neuromas (100%) - in the nasopharynx, oropharynx, larynx, and conjunctiva
- Medullary thryoid carcinoma (85%) more aggressive than MEN IIa
- Marfinoid body habitus (IIB = TO BE marfanoid)
- Pheochromocytoma
127
Physical findings/signs of MEN IIB?
Mucosal neuromas
Marfanoid body habitus
Pes cavus/planum (large arch of foot/flatfooted)
Constipation
128
Most common GI complaint of MEN IIB?
Constipation
129
Major difference between MEN IIA/IIB?
MEN-IIA has parathyroid hyperplasia. MEN IIB has NO parathyroid hyperplasia
130
Thryoid blood supply?
1. Superior thyroid artery from external carotid
| 2. Inferior thyroid artery (branch of thyrocervical trunk)
131
What paired nerves must be identified during thyroidectomy?
Recurrent laryngeal nerves behind cricothyroid. Hoarseness if unilateral, airway obstruciton if bilateral
132
Superior laryngeal nerve cut?
Deeper and quieter voice
133
What is TRH?
Throtropin releasing hormone released from hypothalamus, causes release of TSH
134
TSH released by
Anterior pituitary
135
Most active form of thyroid hormone?
T3
136
Most common conversion site from T3 to T4?
Liver
137
Parafollicular cells secrete
Calcitonin
138
What studies are used to evaluate a thyroid nodule?
US-solid or cystic
FNA ->cytology
I scintiscan-hot or cold nodule
139
Diagnostic test of choice for thyroid nodule?
FNA
140
5 types of thyroid carcinoma?
1. Papillary - 80%
2. Follicular - 10%
3. Medullary - 5%
4. Hurthle cell - 4%
5. Anaplastic/undifferentiated carcinoma - 1-2%
141
What oncogenes are associated with thyroid cancer?
Ras gene family and RET proto oncogene
142
Papillary hiostologic findiing?
psommoma
143
Most common site of papillary adenocarcinoma metastasis?
Lung
144
Ps of papillary thryoid cancer
```
Popular (80%)
Psammoma bodies
Palpable lymph nodes
Positive I131 uptake
Positive prognosis
Postoperative I scan to find and treat metastasis
Pulmonary metastasis
```
145
Follicular carcinoma consistency
rubbery, encapsulated
146
Route of spread of follicular?
Hematogenous
147
4 Fs of follicular cancer of thyroid?
Far-away metastasis (spreads hematogenously)
Female (3 to 1)
FNA...NOT
Favorable prognosis
148
Hurthle cell tumor cell of origin
follicular cells
149
Diagnosis of hurthle?
FNA, then tissue histology
150
Hurthle metastasis?
lymphatic
151
Medullary thyroid carcinoma histology?
Amyloid (aMyloid)
152
What does a medullary thyroid carcinoma secrete?
Calcitonin (tumor marker)
153
Appropriate stimulation test for medullary thyroid carcinoma?
Pentagastrin
154
Diagnosis of medullary thyroid?
FNA
155
Ms of medullary thyroid
```
MEN II
aMyloid
Median lymph node dissection
Modified neck dissection if lateral nodes are positive
Mutation of RET proto-oncogene
Miserable I uptake
```
156
histologic findings of anaplastic carcinoma?
Giant cells, spindle cells
157
Diagnosis of anaplastic thyroid carcinoma?
FNA
158
What labs must be followed after thyroidectomy?
Calcium
159
PTU mech cs methimazole
PTU: inhibits iodione incorporation into t4/T4 AND inhibits peripheral conversion.
Methimazole: Just inhibits iodine incorporation (blocks peroxidase oxidation)
160
What medication may bring on hyperthyroidism with multinodular goiter?
Amiodarone (contains iodine)
161
Thyroiditis bacteria
Strep and staph
162
What are the features of hashimotos thyroiditis?
Firm and rubbery gland
163
What lab tests confirm Hashimotos?
Antithyroglobulin and microsomal antibodies
164
What type of cell produces parathyroid hormone?
Chief cells
165
How does PTH increase blood calcium levels?
```
Bone breakdown
GI absorption
increased resorption from kidney
excretion of phsophate by kidney
ALSO decreases serum phsophate
```
166
What does vitamin D do?
Increases intestinal absoroptoin of calcium and phosphate
167
Where is calcium absorbed?
Duodenum and jejeunum
168
Primary Hyperparathyroidism
Increased PTH secretion. High calcium, low phsophorus
169
Secondary Hyperparathyroidism
Calcium wasting from renal failure or decreased GI calcium absorption causes increased PTH. Low calcium. Rickets or osteomalacia
170
Tertiary Hyperparathyroidism
Persistent Hyperparathyroidism after correction of secondary Hyperparathyroidism. results from autonomous PTH secretion not responsive to normal negative feedback due to elevated calcium levels.
171
33 to 1 rule
Patients with primary Hyperparathyroidism have ratio of serum CL- to phophate >33
172
X-ray findings of Hyperparathyroidism?
Subperiosteal bone resorption (usually in hand/digits)
173
How is primary Hyperparathyroidism diagnosed?
Labs-elevated PTH (hypercalcemia, decrease dphsophorus, increased Cl-); urine calcium should be checked for familial hypocalciuric hypercalcemia
174
What is familial hypocalciuric hypercalcemia?
aysmptomatic hypercalcemia and low urine calciu.
175
Differential diagnosis of hypercalcemia?
```
CHIMPANZEES
Calcium overdose
Hyperparathyroidism (1,2,3)
Hyperthyroidism, Hypocalciuric hypercalcemia
Immobility/iatrogenic (thiazide)
Metastasis/milk alkali syndrome
Paget's disease (bone)
Addison's disease/acromegaly
Neoplasm (colon, lung, breast, myeloma)
Zollinger-Ellison syndrome
Excess Vitamin D
Exces vitamin A
Sarcoid
```
176
Initial treatment of hypercalcemia?
Medical-IV fluids, furosemide NOT thiazide diuretics
177
What carcinomas are associated with hypercalcemia?
BREAST, prostate, kidney, lung, pancreas, myeloma
178
Palpable neck mass, hypercalcemia, elevated PTH =????
Parathyroid carcinoma
179
Most common tumor marker of parathyroid carcinoma?
HCG
180
Diabetic ketoacidosis patient characteristics
Type I diabetic and younger age
181
Diabetic ketoacidosiss Symptoms
Less pronounced altered mentation
More rapid onset of hyperglycemic symptoms
Hyperventilation and abdominal pain common
182
DKA labs
Glucose 250-500
| Bicarb
183
Hyperosmolar hyperglycemic state patient characteristics
TII DM
| Older
184
Hyperosmolar hyperglycemic state clinical symptoms
More pronounced altered mentation
Gradual onset of hyperglycemic symptoms
Hyperventilation and abd pain less common
185
Hyperosmolar hyperglycemic state labs
```
Glucose >600
Bicarb >18
Normal anion gap
Negative or small serum ketones
Serum osmolality >320
```
186
After 2 elevated calcium levels are seen in asymptomatic patients, what is the next test?
PTH
187
Effects of excess thyroid hormone on bone
```
Increased osteoclast activity, so....
increase bone resorption
decreased bone density
Increased fracture risk
LEADS TO...
Hypercalcemia, decreased PTH secretion, decreased vitmain D conversion so decreased renal calcium absorption, leading to hypercalciuria and net calcium wasting.
```
188
Increased extracellular pH does what to calcium?
Increased pH (like alkalosis from hyperventilation in PE) causes H+ to dissacociate from albumin, allowing it to bind calcium. This mimicks hypocalcemia because it decreases ionized calcium.
189
Hashimoto's thyoiditis increases risk of what?
Thyroid lymphoma
190
Thyroid storm symptoms
- Fever as high as 40-41 C or 104-106 F
- Tachycardia, hypertension, congestive heart failure, cardiac arrhythmias (A fib)
- agitation, delirium, seizure, coma
- Goiter, lid lag, tremor, warm and moist skin
- Nausea, vomitting, diarrhea, jaundice
191
Thyroid storm treatment?
- Beta blockers (propanolol) to decrease adrenergic manifestations
- PTU followe dby iodine SSKI
- Glucocorticoids
192
Manboob testicle exam looking for ....?
Leydig cell tumor
193
Increased renin and increased aldosterone indicates ____ hyperaldosteronism?
Secondary
194
Decreased renin and increased aldosterone indicates ________ hyperaldosteronism
Primary
195
Decreased renin and decreased aldosterone indicates ______
non-aldosterone causes like congenital adrenal hyperplasia, cushing, exogenous
196
DKA management
1. 0.9% saline (NS)
2. Correct hyperglyemia with IV regular insulin
3. Pottassium correction
4. Treat precipitating factors like infections with antibiotics
197
Initial diagnosis of DKA?
Fingerstick blood glucose
198
Which MEN involves gastrin producing tumor?
1 (because of ZE syndrome)
199
Silent thyroiditis has ________ iodine uptake
Low
200
Silent thyroiditis has postive TPO like hashimotos but causes hyperthyroidism. . What type of goiter does it cause?
small, nontender
201
DeQuervain's thyroiditis
Elevated ESR and c-reactive protein, low radioiodine uptake. Likely form inflammatory process. Painful/tender goiter.
202
pancreatic body and tail tumors present with chronic pancreatitis and should be visualized with ____
CT w/ contrast
203
Trauma work up: severe blunt trauma. What happens in ER initially?
- ABCDE, IVx2 , type and cross, OGT/NGT, foley, chest tube PRN.
- X-rays: CXR, pelvic, femur (if femur fracture suspected)
204
Trauma work up: severe blunt trauma. What happens after ER management?
- Normal vital signs: Chest CT, C-spine/head CT, ABD/Pelvic CT, extremity films PRN
- Hypotension: FAST exam. + leads to OR ex lap. - leads to DPL (diagnositc peritoneal lavage).
- CT after all this
205
Upper GI bleeding is proximal to what?
Ligament of treitz
206
Coffee ground emesis is seen in what type of bleed?
Upper GI
207
Most common cause of significant UGI bleeding?
PUD (duodenal and gastric 50%)
208
Differential of UGI bleed
ADEGEM
1. Acute gastritis
2. Duodenal ulcer
3. Esophageal varices
4. Gastric ulcer
5. Esophageal
6. Mallory-Weiss tear
209
Diagnostic test of choice with UGI bleeding?
EGD
210
Labs for UGI bleed?
Chem-7, bili, LFTs, CBC, TYPE AND CROSS, PT/PTT, amylase
211
Why is BUN elevated in UGI bleed?
Because of absorption of blood by GI tract
212
Initial treatment of UGI bleed
1. IVFs, Foley
2. NGT suction
3. Water lavage (removes clots)
4. EGD: endoscopy (determine locaiton, coagulate bleeders)
213
What do you use when EGD fails to diagnose cause of UGI bleed and blood continues per NGT?
Selective mesenteric angiography
214
Treatment of PUD with H. pylori?
MOC or ACO
Metronidazole, omeprazole, clarithromycin
Ampicillin, clarithromycin, omeprazole
215
What is the duodenal ulcer classic response to food intake?
relieves pain
216
What syndrome must you always think of with duodenal ulcer?
ZES
217
What artery is involved with bleeding duodenal ulcers?
Gastroduodenal artery
218
Gastric ulcer age group
40-70
219
What is gastric ulcer response to food?
increases pain
220
What do you rule out with biopsy on EGD with gastric ulcer?
cancer
221
What diagnostic tests are indicated for perforated peptic ulcer?
X-ray, Free air under diaphragm. Labs show leukocytosis, high amylase
222
Initial treatment of perforated peptic ulcer?
NPO; NGT.
IVF/Foley
ABs/PPIs
Surgery
223
What is a Mallory-Weiss tear?
Postwretching, post-emesis longitudinal tear (submucosa and mucosa) of stomach near GE junction.
224
What causes mallory-Weiss-tear?
Increased gastric pressure, often aggravated by hiatal hernia.
225
Risk factors for mallory-weiss tear?
Alcoholism, retching, hiatal hernia
226
How is mallory weiss tear diagnosed?
EGD
227
Classic mallory weiss history
Alcoholic patient after binge drinking- first, vomit food and gastric contents, followed by forceful retching and bloody vomitus
228
Treatment for mallory-weiss tear?
Room temp water lavage, electrocautery, arterial embolizaiton, surgery
229
How are esophageal varcies diagnosed?
EGD
230
Acute medical treatment of variceal bleeding?
Lower portal pressure with somatostatin and vassopressin. Nitroglycerin prevents coronary artery vasoconstriction that may result in an MI.
231
What is boerhaave's syndrome?
Postemetic esophageal rupture
232
What causes boerhaave's syndrome?
Increased intraluminal pressure, usually caused by violent retching and vomitting.
233
boerhaave's syndrome risk factor
GERD
234
boerhaave's syndrome symptoms
pain postemesis (radiates to back, dysphagia)
235
Mackler's triad
indicates boerhaave's syndrome
1. emesis
2. Lower chest pain
3. Cervical emphysema (subQ air)
236
How is boerhaave's syndrome diagnosed?
H&P, CXR, esophogram with water soluble contrast
237
boerhaave's syndrome treatment
surgery within 24 hrs to drain mediastinum
238
What tests are used for GERD?
EGD
UGI contrast study with esophogram
24-hour acid analysis (pH probe in esophagus)
Manometry, EKG, CXR
239
What does the terminal ileum absorb?
B12, fatty acids, bile salts
240
What are the classic electrolyte/acid-base findings with proximal obstruction?
Hypovolemic, hypochloremic, hypokalemia, alkalosis
241
What is the initial management of all patients with SBO?
NPO, NGT, IVF, Foley
242
What tests can differentiate partial from complete bowel obstruction?
CT with oral contrast, small bowel follow through
243
Most common causes of SBO
ABC
1. Adhesions
2. Bulge (hernia)
3. Cancer and tumor
244
Causes of SBO
```
GIVES BAD CRAMPS
Gallstone ileus at ileocecal valve
Intussusception
Volvulus
External compression
SMA syndrome
Bezoars, Bowel wall hematoma
Abscess
diverticulitis
Crohn's
Radiation enteritis
Annular pancreas
Meckel
Peritoneal adhesions
Stricture
```
245
What lesion is associated with metastasis to the small bowel?
Melanoma
246
What is the differential diagnosis of malignant tumors of the small intestine?
1. Adenocarcinoma (50%)
2. Carcinoid (25%)
3. Lymphoma (20%)
4. sarcomas (5%)
247
Work up for small bowel tumor?
UGI with small bowel follow through, CT, enteroscopy
248
What is a Meckel's diverticulum?
remnant of omphalmesenteric duct/vitelline duct, which connects yolk sac with primitive midgut in embryo
249
When does Meckel's diverticulum usually occur?
First 2 years of life (rule of 2's)
250
How can a Meckel's diverticulum cause bleeding?
Ectopic gastric mucosa ->ulcer->bleeding
251
What heterotopic tissue type is most often found in Meckel's diverticulum?
Gatric mucosa, but duodenal, pancreatic, and colonic mucosa are also found
252
How to you scan for Meckel's diverticulum?
Scan for extopic gastric mucosa in Meckel's diverticulum; use technetium pertechnate IV, which is preferentially taken up by gastric mucosa
253
In patient's with guiac-positive stools and a negative upper-and-lower GI workup, what must be ruled out?
Small bowel tumor, evaluate with enteroclysis (small bowel contrast study)
254
What are the symptoms of carcinoid syndrome?
```
B FDR
Bronchopasm
Flushing
Diarrhea
right-sided heart failure (from valve failure)
```
255
What causes pellagra in carcinoid patients?
Decreased niacin production
256
Medical treatment for carcinoid syndrome?
Octreotide IV to block serotonin.
| Ondansetron for diarrhea alone (serotonin antagonist)
257
What does liver breakdown turn serotonin in carcinoid syndrome into?
5-HIAA (50% of patients will have elevated levels)
| 5 CAR HI pile up
258
What are associated lab findings for carcinoid syndrome
Elevated urine 5-HIAA (5-hydroxy indolacetic acid) as well as elevated urine and blood serotonin levels (take 24 hour test)
259
What stimulation test can often elevate serotonin levels and cause symptoms of carcinoid?
Pentagastrin stimulation test
260
What are the specialty radiologic (scintography) tests to localize carcinoid?
I-MIBG (M---guan)
In-octreotide
PET-scan utilizing C labeled HTP
261
What lab tests are used to monitor nutritional status?
- Prealbumin (acute changes
- Transferrin
- Albumin
- Retinol binding protein
262
Where is iron absorbed?
Duodenum
263
Where is vitamin B12 absorbed?
Terminal ileus
264
Where are bile salts absorbed?
Terminal ileum
265
Where are fat-soluble vitamins absorbed?
Terminal ileum
266
What are the signs of vitamin A deficiency?
Poor wound healing, night blindness (retinA)
267
VitaminB12/folate deficiency signs?
Megaloblastic anemia
268
Vitamin C deficiency signs?
Poor wound healing, bleeding gums
269
Vitamin K deficiency signs?
Decreasing in vitamin K dependent clotting factors (2,7,9,10, c,s), bleeding, elevated PT
270
Chromium deficiency causes ____
diabetic state
271
Zinc deficiency causes what?
Poor wound healing, alopecia, dermatitis, taste disorder
272
What does fatty acid deficiency cause?
Dry, flaky skin, alopecia
273
What is the major nutrient of the mall bowel?
Glutamine
274
What is "refeeding syndrome"?
Decreased serum K+, Mg, and phosphate after refeeding (vi TPN or enterally) a starving patient
275
What is the major nutrient of the colon?
Butyrate
276
What does intrinsic factor bind to?
B12
277
5 different types of shock
```
hypovolemic
septic
cardiogenic
neurogenic
anaphylactic
```
278
What is the best way to determine the caloric requirements of a patient on a ventilator?
metabolic chart: resting energy expendicture by measuring O2 intake and CO2 output by calorimetry
279
Signs of shock
Tachycardia, hypotension, acidosis, poor urine output, pale diaphoretic skin
280
What lab test helps asses tissue perfusion?
lactic acid, base deficit, pH from ABG
281
What type of shock can pancreatitis cause?
hypovolemic
282
What is a class I hemorrhage?
-
283
What is a class II hemorrhage?
15-30% or 750-1500 cc blood loss leading to normal systolic BP with decreased pulse pressure, tachycardia, tachypnea, anxiety
284
What is a class III hemorrhage?
30-40% or 1500-2000 cc blood loss leading to decreased systolic BP, tachycardia (>120), tachypnea (>30), confusion
285
What is a class IV hemorrhage?
(>40% or >2,000 cc blood loss leading to Decreased systolic BP, tachycardia (heart rate >140), tachypnea (>35), confused and lethargic, no urine output
286
hypovolemic Shock treatment?
1 . stop bleeding
| 2. volume: IVF (isotonic LR) then blood products
287
management of hyperkalemia
C BIG K DROP
- Calcium gluconate (cardiac stabilizer)
- Beta agonists (salbutamol nebulized or inhaled or bicarb cause temporary intracellular shift)
- Insulin
- Glucose: D5OW with insulin.
- Kayeaxelate: sodium polystyrene sulfonate (not in acute)
- Dialysis
288
If someone has a surgery and afterwards UA shows white blood cell castes, what is the most likely explanaiton?
They already had pylonephritis beforet he surgery
289
What are the 5 Ws of post-op fever in order?
1. Wonder drugs
2. Wind
3. Water
4. Walking
5. wound
290
What is likely happening when patient spikes a fever during surgery?
Malignant hyperthermia
291
What is Tx for malignant hyperthermia?
O2
Dantrolene
IV fluids
follow up with UA for myoglobinuria
292
What is prophylactic measures for malignant hyperthermia
fam Hx
293
What is the likely cause of fever when a patient gets a fever right after surgery?
Bacteremia
294
What is the likely cause of fever when a patient gets a feveron POD#1?
Atelectasis
295
What is the likely cause of fever when a patient gets a fever on POD#2?
Pneumonia
296
What is the likely cause of fever when a patient gets a fever on POD 3?
UTI
297
What is the likely cause of fever when a patient gets a fever on POD 5?
DVT/PE
298
What is the likely cause of fever when a patient gets a fever on POD 7?
Wound (cellulitis)
299
What is the likely cause of fever when a patient gets a fever on POD 10-14?
Wound (abscess)
300
What is diagnosis for post-op bactermia?
Blood culture
301
What is diagnosis for atelectasis?
CXR (- for pneumonia)
302
What is diagnosis for pneumonia?
+ CXR
303
What is diagnosis for UTI?
UA
| UC
304
What is diagnosis for post-op PE/DVT?
U/S of bilateral extremities
305
What is diagnosis for post op wound (cellulitis)?
U/S negative for abscess
306
What is post-op diagnosis for abscess?
CT
307
What is Tx for Post-op bacteremia?
Borad Abx
308
What is Tx for Post-op Pneumonia?
Broad Abx
309
What is treatment for post-op UTI?
Abx
310
What is Tx for Post-op DVT/PE?
U/S Heparin then warfarin
311
PPx for DVT?
Ambulation, heparin
312
What is treatment for wound (cellulitis) after surgeries?
Abx
313
What is treatment for abscess after surgery?
I&D, Abx
314
What is diagnosis for abscess after surgery?
CT
315
The diagnostic test of choice for blunt head trauma is always _____
CT
316
A patient has racoon eyes, battle signs (postauricular eccymosis), or oto/rhinorrhea (clear CSF), what do they have?
Fracture of basilar skull
317
How do you evaluate basilar skull fracture?
CT!
318
Acute epidural hematoma is classically caused by __________
trauma to side of head
319
Acute epidural hematoma shears what?
Middle meningeal artery
320
History of epidural hematoma
Loss of consciousness followed by lucid interval with decreasing mental function to coma. "Walk, talk, then die"
321
PE findings for epidural hematoma
-ipsilateral fixed dilated pupil and contralateral hemiparesis (caused by herniatian of uncus)
322
Diagnosis of epidural hematoma?
CT
323
Tx for epidural hematoma
Craniotomy
324
MVA, shaken baby in a young person = ___________
subdural hematoma
325
subdural hematoma history
Loss of consciousness WITHOUT lucid interval following major trauma
326
subdural hematoma TX
craniotomy, or decrease ICP with elevation, hyperventilation, and mannitol if there is no middling shaft.
327
subdural hematoma CT findings
Cresecent hematoma
328
Which patients are at risk for minor trauma that causes sharing of veins that cause slowly evolving subdural hematoma?
Elderly, demented, alcholic
329
What is history of patient with chronic subdural hematoma?
Gradually deteriorating mental function appearing as dementia, often with headache. CT wit hcrescent hematoma. Evacuation reverses effects.
330
What injury to the head can occur in angular trauma, such as spinning car suck on an angle?
Axon fibers can shear, causing blurring of grey/white matter thats seen best on MRI
331
Whats imaging modality for diffuse axonal injury?
MRI
332
What should be monitored in diffuse axonal injury?
ICP
333
What is indicated by a loss of consciousness followed by retrograde amnesia?
Concussion
334
Imaging for concussion
CT
335
Concussion treatment?
Cognitive and physical rest. Gradually ramp up activity.
336
Vitamin D deficiency causes?
Hypocalcemia, osteoporosis
337
Vitamin E deficiency causes?
Nystagmus
338
Protein deficiency causes?
Weight loss and edema
339
Calcium deficiency causes?
osteoporosis
