Thoracics Flashcards
what is GERD
when significant symptoms or tissue changes occur with heartburn, with 2 or more episodes per week and extraluminal symptoms like dysphagia
normally there is the LES and 2 cm of intraabdominal esophagus beneath the diaphgram at the angle of His –> there is esophageal motility and the antacid effect of saliva
typical symptoms of GERD
heart burn
water brash (sour taste)
triggers (lying down, alcohol, spicy/fatty food, chocolate, caffeine etc)
atypical symptoms of GERD
chest pain
regurg
respiratory sx
belching
alarm symptoms of GERD
weight loss
dysphagia
hematemesis/melena/anemia
tests used in evaluating GERD
barium esophagram
where do you find a hiatal hernia
at junction between esophagus and stomach
what 4 tests should you consider before doing anti-reflux surgery for GERD
- gold standard to confirm GERD is 24 hour pH monitoring–> pH probe inserted to GE junction, left in for 24 hours as patient goes home with diary of symptoms–> gives a DeMeester score
- Upper GI endoscopy –> identify anatomy, hiatus hernia, esophagitis, Barrett’s
- UGI contrast study–> confirm anatomy, hiatus hernia, visualize swallowing/reflux
- esophageal manometry–> measures pressures in the esophagus, rules out motility disorders
define barrett’s esophagus
intestinal metaplasia of the esophagus–> squamous to intestinal columnar
*associated with risk of malignancy
risk factors for barretts esophagus
chronic reflux
hiatus hernia
motility disorders
obesity
how do you characterize dysphagia?
- solids? liquids?
- progressive?
- painful?
- weight loss?
- cervico-thoracic versus oropharygneal
what is cervico-thoracic dysphagia
related to food getting stuck in the thoracic esophagus
what is orophayngeal dysphagia
initiation of swallowing, choking or coughing, associated with neuromuscular diseases, strokes
what do you order to evaluate dysphagia?
esophagastroscopy
what type of esophageal cancer is associated with chronic GERD
adenocarcinoma
what type of esophageal cancer is associated with achalasia
SCC
typically mid-esophageal in location
what is achalasia
failure of LES opening when you eat, causing back up of food in esophagus
how do you stage esophageal cancer
TNM
T–tumour size and location into wall
N–nodal involvement and number of nodes involved
M–distant mets
how do you treat esophageal cancer
surgery, chemo, radiation
surgery–> usually entails esophagectomy–> often multiple approaches and different cavities
may have pre or postop chemo with or without radiation
investigate with CT/PET, endoscopic U/S, biopsy
what is the overall survival rate of lung cancer
less than 10%
lung ca is often asymptomatic early, and patients usually present with metastatic disease (usually what brings up symptoms)
beware of new resp symptoms in smokers, this may represent lung ca
most common symptoms of lung ca? next most common?
cough–75%
dyspnea–50%
symptoms of lung ca
cough dyspnea wheeze hemoptysis pneumonia extrapulmonary--> invasion of nearby structures--> chest pain, dysphagia etc...
list 4 examples of conditions associated with paraneoplastic syndromes
- increased cortisol secretion from small cell lung cancer (ACTH secretion)
- hyponatremia–> SIADH
- hypercalcemia–> PTH related peptide secretion
- bone manifestations
what is the best investigation for lung ca
CXR
there are some worrisome imaging characteristics (also on CT)
what signs do you look for on CXR that suggest lung cancer
- spiculation –> looks like a star
- thick walled cavitation
- lack of calcification (though eccentric asymmetric calcification is also worrying
- growth over time
what tests should you order to image lung cancer
CXR
CT chest
(PET)
what info does CT chest give you RE: lung ca
anatomic info
info about lymph node involvement or mets
may give histologic info too
any patient with suspected lung ca should have one to determine if they are a surgical candidate along with PET scan
when do you do chemo and radiation instead of surgery for lung ca
if N2 nodes are positive
define a solitary lung nodule
(solid on CT)
less than 3 cm is nodule
more than 3cm is mass
what are the most common cancers to metastasize to the lung
breast
colon
sarcoma
list the types of lung cancer
non small cell lung cancer–> adenocarcinoma, SCC, large cell carcinoma
small cell lung cancer
carcinoid
sarcoma
how do you stage lung cancer
TNM staging
T1–> less than 3cm, peripheral
T2–> 2-7 cm, invades the main airway, extends into periphery/visceral pleura
T3–> larger than 7 cm, invades chest wall or main bronchus or phrenic nerve or pericardium or there are two modules in the same lobe that are both cancerous (regardless of size)
T4–> invasion of essentially unresectable organs (trachea, great vessels, heart, esophagus)–> 2 nodules in different lobes that are both cancerous is automatically T4
location is more important than number
where does lung cancer met to
contralateral lung
brain
bone
etc
who is a good candidate for surgery for lung ca
must be possible to resect with acceptable morbidity and have limited enough disease that surgery will provide improved outcomes, alone or with chemo/radiation
patient must be able to undergo the operation with an acceptable risk of complications
what are the principles of surgery for lung ca
- gross resection of all tumour
- free resection of margins
- systemic assessment of metastatic deposits
what is the surgical treatment for lung ca
LOBECTOMY is standard of care for stage 1 and 2
but some patients may not be able to have a lobectomy because of limited lung function–> can do removal of tumour with negative margin (wide resection) instead but this tends to have lower survival and greater return of disease
segmentectomy has better outcomes oncologically with more preservation of lung function
pneumonectomy with removal of entire lung if it is not isolated to single lobe
how do you assess a patient for lung ca operability
pulm function–
- PFTs with FEV1 etc
- exercise testing (i.e 6 minute walk test)
cardiac function–
- baseline ECG
- stress testing
- echo
- coronary angiography
when do you use chemo and radiation to treat lung ca
used if surgery is contraindicated or advanced
radiation is about equivalent to wedge therapy
what is the most common outpatient GI complaint
GERD
what is the normal esophageal reflux barrier
LES–> diaphragm, intraabdominal esophagus, angle of His
stomach reservoir
esophageal motility
antacid effect of saliva
how would you manage GERD initially
lifestyle mods (elevate head of bed, avoid eating late at night) and trial daily PPI
what syndrome is associated with esophageal SCC
plummer-vinson syndrome
achalasia
where is esophageal adenocarcinoma usually found in the esophagus
distal
where is esophageal SCC usually found in the esophagus
mid esophagus
how do you assess esophageal cancer resectability
PET
CT
endoscopic U/S
what are the stages of esophageal cancer
T1–invades mucosa
T2–invades muscularis
T3–invades adventitia
T4–invades adjacent structures
define Ivor lewis esophagectomy
laparotomy plus right thoracotomy
define transhiatal esophagectomy
laparotomy plus cervical incision
define left thoracoabdominal esophagectomy
single incision through left chest and abdomen
define McKeown esophagectomy
right thoracotomy and left cervical incision laparotomy
what is the most common chemo regime for esophageal cancer
cisplatin or carboplatin
paclitaxel
5-fluoruracil
what is the most common chemo regime for esophageal cancer
cisplatin or carboplatin
paclitaxel
5-fluoruracil
symptoms of myasthesia gravis
progressive muscle weakness that gets worse throughout the day
associated with diplopia, blurred vision, occasional dyspnea and dysphonia
what is myasthenia gravis
autoimmune disorder with antibodies targeting neuromuscular junction and resulting in neuromuscular weakness
what blood test is used to evaluation myasthenia gravis
anti-AChR (acetylcholine receptor) antibody test
how do you work someone up for myasthenia gravis
anti-AChR antibody test
edrophonium testing (Ach mimetic that can improve symptoms temporarily
electromyography
CT for eval for associated conditions like thymic malignancy
what cancer is associated with myasthenia gravis
thymus
ddx of anterior mediastinal mass
thymic tumor/thymoma
teratoma/germ cell tumours
thyroid goiter
terrible lymphoma
workup for mediastinal mass
workup:
look at anti-AChR antibody, CBC, tumour markers
AFP and beta HCG–> elevations are diagnostic of non-seminomatous germ cell tumour
LDH–>for lymphoma
biopsy indicated if advanced tumour stage or large bulky disease likely needing adjuvant chemo, LAD, suspicion for seminomatous germ cell tumour
medical management of myasthenia gravis
- cholinesterase inhibitor (pyridostigmine)
- corticosteroids (anti-inflammatories)
- maybe IVIG
- surgery?
when to do surgery in the case of myasthenia gravis/thymoma
for severe symptoms that may or may not be refrectory to medical management
removal of thymic gland if indicated
is surgery indicated for non-seminomatous germ cell tumours
sometimes, though are sensitive to chemo
biopsy no required
how do you treat a thymoma
stage I-IIb–> thymectomy
stage III completely resected–> thymectomy with or without chemo
stage III incompletely resected–> thymectomy plus chemo plus radiation
stage IV–> chemo plus or minus radiation
why do patients with myasthenia gravis have associations with thymomas
thymus gland has role in immune system and in MG it stays large and abnormal into adulthood via lymphoid hyperplasia
why do patients with myasthenia gravis have associations with thymomas
thymus gland has role in immune system and in MG it stays large and abnormal into adulthood via lymphoid hyperplasia
what might you see on CXR in a pleural effusion
blurred costophrenic angle
what might you see on CXR in a pleural effusion
blurred costophrenic angle
what is the worldwide numer 1 cause of cancer deaths
lung ca
what is the number 1 risk factor for lung ca
smoking
what % die from lung ca within 2 years of dx
80%
what % of solitary pulmonary nodules on CXR are malignant
70%
ddx of benign pulmonary nodules
granuloma
hamartoma
bronchial adenoma
chondroma
ddx of benign pulmonary nodules
granuloma
hamartoma
bronchial adenoma
chondroma
AFP tumor marker for?
non seminomatous germ cell tumour
what is the most common cause of pleural effusion
increased capillary intravascular pressure (from increased intravascular volume or obstruction)
- -venous obstruction
- -cardiac failure
- -hypervolemia
second most common–> increased intrapleural oncotic pressure
- -malignancy
- -inflammatory or infectious cause
can also be due to–>
- -decreased capillary oncotic pressure
- -decreased intrapleural hydrostatic pressure
what is the most common cause of pleural effusion
increased capillary intravascular pressure (from increased intravascular volume or obstruction)
- -venous obstruction
- -cardiac failure
- -hypervolemia
second most common–> increased intrapleural oncotic pressure
- -malignancy
- -inflammatory or infectious cause
can also be due to–>
- -decreased capillary oncotic pressure
- -decreased intrapleural hydrostatic pressure
define transudate
imbalance in the pleural forces (hydrostatic and oncotic pressures) allows watery fluid to leak into the pleural space
from decreased intrapleural hydrostatic pressure, intravascular oncotic pressure or increase in intravascular hydrostatic pressure
define exudate
a disease process causes protein, pus or other oncotic material to enter the pleural space which draws out fluid from the capillary bed
what determines transudative or exudative
lights criteria
what tests should you perform on pleural fluid
- glucose and pH–> both low in infection
- cell count
- cytology (positive indicates malignancy)
- gram stain
- amylase (high in esophageal perforation)
- triglycerides/chylomicrons (high in chylothorax)
what should you order in all patients with a pleural effusion
thoracocentesis
what are indications for drainage of a parapneumonic effusion
- symptomatic–> uncontrolled sepsis, dyspnea etc
- asymptomatic –> large pleural effusion (more than 50% of hemithorax), positive gram stain of bacterial culture on pleural fluid analysis, frank pus
- relative indications–> thickened pleura, loculated pleural effusion
define simple parapneumonic effusion
free flowing serious fluid with negative culture
only need drainage if symptomatic
define complicated pleural effusion
loculated
empyema
drainage sometimes indicated
what condition is often associated with bloody pleural effusion
malignancy
can also be caused by trauma/iatrogenic, TB, sometimes PE
what is the mechanism of bloody pleural effusion in malignancy
increased interstitial oncotic pressure due to malignant cells
most common cause for malignant pleural effusion in males is lung cancer–> in females it is breast, uterine and ovarian cancer
what is malignant mesothelioma
primary cancer of the pleura
main risk factor is asbestos exposure but smoking multiplies this risk
uniformly poor outcomes
treatment includes removal of the pleura with or without some lung removal–> radiotherapy commonly performed
how do you manage malignant pleural effusion
repeated drainage
pleurodesis–> intentional scarification of the pleural surfaces (chemical or mechanical)
tunneled indwelling pleural catheter
with what conditions do we associated transudative pleural effusion
beign disease
usually associated with chornic end organ disease like CKD, cirrhosis
treatment is treatment of underlying organ dysfunction
why do we care about parapneumonic effusions
high risk for progressing to empyema–> draining should be performed when indicated
what are the three phases of empyema and their treatment
- phase I–> exudative with minimal pleural reaction–> drain
- phase II–> fibrinopurulent with heavy fibrin deposits on the pleural surfaces–> drain or surgery
- phase III–> organizing with thick peel on the pleural surfaces–> surgery almost always indicated
