Truelearn Questions Flashcards
Incision for an injury to the left subclavian, left ventricle, descending aorta, left pulm artery, distal esophagus
Left posterolateral incision
If you cannot identify cystic duct, what do you do next
IOC through the infundibulum of the gallbladder
Vascular Injuries
- -Anterior tibial ligation can occur if needed
- -Brachial artery must be repaired to prevent hand ischemia
- -Primary repair or interposition graft should be done when possible
- -Injuries to both tibial arteries must be repaired to ensure there is at least a single vessel run off to the foot
- radial artery injuries can be safely lighted in pts with good ulnar flow
Pancreatic Leak
When fluid amylase levels are more than 3x higher than serum amylase levels
Embolectomy Size
Aortic Embolectomy- 6 or 7 french
Iliacs- 5 french
Femoropopliteal- 4 french
Tibial - 3 french
Reasons for Diagnostic Laparoscopsy
Gynecological evaluation
Oncalogic staging
Chronic abdominal pain
Hiatal Hernias
Type 1: most common, GE junction lies above the diaphragm (sliding hernia)
–can be treated non op with proton pump inhibitors
Type 2: paraesophageal hernia
- -ge junction is fixed and there is a true hernia sac in which the fundus of the stomach rises upward into the chest
- -should be electively repaired
Type 3: 2nd most common
Mixed hernia
GE junction lies above the diaphragm
Enlargement of the hernia allow the stomach and other organs to protrude through the hernia sac
Antidotes
Ethylene Glycol: fomepizole
Opioids: naloxone
Benzos: flumezanil
Methemoglobin: methalene blue
Hepatoblastoma
Tx with neoadjuvant chemo followed by surgrery
Gastroschesis
Abdominal wall defect located over the area where normal involution of the right umbilical vein occurs
True cause of gastroschesis is unknown
If intestine fails to return - protrusion through the umbilical ring- omphalocele
Omphalocele
By the 11th week of gestation, the midgut returns back into the abdominal cavity and undergoes normal rotation and fixation, along with closure of the umbilical ring. If the intestine fails to return, the infant is born with abdominal contents protruding directly through the umbilical ring, termed an omphalocele
Most common composition of nephrolithiasis?
Calcium Oxalate
Which of the following is the MOST common cause of this syndrome in Asia
Budd-Chiari syndrome
- venous obstruction
- at the level of the inferior vena cava, the hepatic veins, or the central veins within the liver.
The etiology of this syndrome has a geographical variation.
In the West, acute or chronic thrombosis and malignancy is the most common etiology.
In Asia, membranous webs are the major cause of obstruction of the vena cava and hepatic veins.
The most common causes of Budd-Chiari syndrome in the WEST are hypercoagulable conditions associated with polycythemia vera, paroxysmal nocturnal hemoglobinuria, myeloproliferative disorders and conditions associated with high estrogen levels such as pregnancy and use of contraceptive pills.
Bottom Line: In Asia, membranous webs are the major cause of obstruction of the vena cava and hepatic veins in patients with Budd-Chiari syndrome.
TNM staging for thyroid cancer
T1, <2 cm; T2, 2-4 cm, >4 cm; T3, >4 cm; T4a, extrathyroidal extension; T4b, invades prevertebral fascia or encases carotid artery or mediastinal vessels.
N0, no nodal involvement; N1, regional nodal metastases; N1a, metastasis to level 6 lymph nodes; N1b, metastasis to unilateral, bilateral, or contralateral cervical or superior mediastinal lymph nodes;
M0, no distant metastases; M1, distant metastases
Therefore, the patient in this scenario is T2, N1a, and M1. However, Age is the most important component of the TNM staging for well-differentiated thyroid cancer. For patients younger than 45 years, all patients are classified to either stage I or stage II regardless of the tumor size and lymph nodes involvement. Thus, this patient has stage II thyroid cancer despite the distant metastasis.
Posterior laparoscopic retroperitoneal adrenalectomy
Posterior retroperitoneal laparoscopic approach is most ideal for patients with previous abdominal surgeries and bilateral adrenal lesions.
GIST
Submucosal mass C-kit positive Spreads hematogenouslyi Lymph node dissection not indicated Just negative margins Form from interstitial cell of cajal Imatinib--tyrosine kinase inhibitor
even for complete resection, NCCN and Europeans still recommend postoperative gleevag in high risk patients (tumor bigger than 10 cm or more than 10 mitotic count per HPF
Yethere’s overall survival and recurrence-free survival benefits and they recommend at least 36 months
CAGB
Internal mammary is the best conduit
Brown recluse spider bite in children
Treat with cold compress and elevation
Whipple’s triad
Dx of insulinoma
1) neuroglycopenic symptoms
2) low blood glucose
3) relief of symptoms with glucose administration
Li-Fraumeni Syndrome
Soft tissue sarcoma (before 45)
Breast and brain neoplasms
*****p53 **
Aortoenteric fistula
First do an EGD to rule out an upper GI bleed as a cause of the bleeding
PEEP
Results in increased dead space ventilation and hypotension because of decreased preload
Magnesium
In icu pts you want magnesium to be >2
Hypomagnesemia: neuromuscular and CNS irritability, impairs parathyroid hormone excretion
appendiceal tumor:
1% of the time
Carcinoid most common
If <1cm–treat with appendectomy alone
If found to have appendiceal adenocarcinoma
–should then receivce right hemicolectomy and cytoredcuctive surgery of implants
Liver anatomy
The right and left liver are separated by the IVC and gallbladder II III IV are left liver II III are most lateral V through VIII are right liver VI and VII are more posterior Caudate is segment 1
Rectus sheath hematoma
Caused by forceful contraction of anterior abdominal wall while coughing
Roux-en-Y
Most common short term and most common overall metabolic complication is dehydration
Ovarian Torsion
Ultrasound is dx
Acute, severe, unilateral, lower abdominal pain
Intermittent
FAP
Increased risk for duodenal and periampullary polyps that harbor carcinoma
Duodenal adenocarcinoma is the leading cause of death after colorectal cancer in pts with FAP
High risk pts with multiple polyps, large polyps, villous architecture , known displasia should undergo a whipple
Entamoeba histolytica
Fecal-oral transmission
7-10 times more common in men
Spreads to the liver through portal vein
Fatty Acids
Short and medium chain fatty acids are absorbed by simple diffusion and long chain fatty acids enter a Michelle for absorption
Oral glucose challenge does what
insulin release increases and therefore insulin promotes uptake of glucose in all cells except B cells, hepatocytes and CNS cells
Glucose inhibits glycogenolysis and fatty acid breakdown
Blind loop syndrome
result after a chronic obstruction to a portion of the intestines. This causes bacterial overgrowth due to stasis within the obstructed limb. The bacteria bind with vitamin B12 and decrease its absorption into the body. Deficiencies in vitamin B12 lead to megaloblastic anemia and peripheral neuropathy.
Left hepatic artery variant
Common variant is from the left gastric artery
Common variant of common hepatic artery is from the SMA
Lymphedema
The risk of developing lymphedema one year after sentinel node biopsy and axillary dissection is 13%. The risk of developing lymphedema is 2% in sentinel node biopsy alone
Phalen’s test
Tines’ sign
Phalen’s test is a provocative test which reproduces the patient’s symptoms with the wrists firmly pressed in full flexion.
Tinel’s sign produces paresthesias in the involved digit with tapping over the carpal tunnel.
Roux Syndrome
affects a small subset of patients undergoing distal gastrectomy and roux-en-Y reconstruction. It is characterized by delayed gastric emptying in the absence of mechanical obstruction. The patient presents with epigastric pain, vomiting, and weight loss. An upper GI is often the initial test of choice but a gastric emptying study can confirm the suspicion. The test can often show delayed gastric emptying and reversed motility of the roux limb moving digested food toward instead of away from the stomach. The initial treatment of choice is a promotility agent. If that is unsuccessful, surgical intervention to reduce the size of the gastric pouch is indicated. For severe complications total gastrectomy and resection of the roux limb can be performed.
Septic Thrombophlebitis
Septic thrombophlebitis most commonly results from the insertion of intravenous catheters and needles or intravenous drug abuse. However, venous thrombi can become secondarily infected during bacteremia or if contiguous to areas of infection.
Post renal failure
Post-renal acute renal failure (ARF) is more common in the outpatient setting. Causes of post-renal ARF include prostatic hypertrophy, ureteric calculi, retroperitoneal fibrosis, pelvic tumors or papillary necrosis.
Infantile Hemangiomas (how do you handle complicated ones)
For complicated cases, peri-orbital, disfiguring, ulcerated, or involving the airway should be treated with Propranolol as a first line agent.
Lymphatic Drainage of the Thyroid Gland
What are Delphine lymph nodes
thyroid gland has intracapsular lymphatic channels that provide communication between the two lobes across the isthmus.
Within the anterior suspensory ligament is a small group of midline prelaryngeal lymph nodes known as the Delphian nodes.
The central compartment lymph nodes are classified as level VI.
The upper jugular, midjugular, and lower jugular are classified as level II, III, and IV; respectively,
whereas the posterior triangle lymph nodes are level V.
Thyroid cancers tend to involve level VI lymph node metastases before involving levels II, III, IV.
Submental (level I) and superior mediastinal (level VII) involvement is less common but can occur.
Lidocaine Toxicity
Cardiovascular Disturbances:
Widened PR, widened QRS, sinus tachy
earliest signs of an overdose or inadvertent intravascular injection are numbness or tingling of the tongue or lips, a metallic taste, light-headedness, tinnitus, or visual disturbances.
Signs of toxicity can progress to slurred speech, disorientation, and seizures
abdominal cysts
Mesenteric Cyst: cystic structure without solid components present in the small bowel mesentery unattached to the small bowel is most consistent with a mesenteric cyst.
Intestinal Duplication Cyst: Intestinal duplication may appear as a cystic structure on ultrasound but it is by definition attached to and communicates with the adjacent bowel.
Benign Liver Tumors
Hepatic Hemangioma:
- most common liver tumor
- congenital vascular malformations
- observe if asymmptomatic
Hepatic Adenomas: Hepatic adenomas are most frequently seen in women of childbearing age and are associated with oral contraceptives
- risk of bleeding
- if greater than 4 cm, should undergo resection
Focal Nodular Hyperplasia: most commonly diagnosed in female patient
- no associated with oral contraceptive use
- central scar
- no risk of malignancy, no risk of rupture, no risk of bleeding
Bariatric Surgery Weight Loss
50-60% weight loss at 2 years
Blind Loop Syndrome from an enteroenteric fistula
Strictures, diverticula, fistulas, or blind (poorly emptying) segments of intestine are anatomic lesions that cause stagnation and permit bacterial proliferation.
Blind loop syndrome results in megaloblastic anemia, malnutrition, diarrhea, and steatorrhea.
Traumatic Pancreatic Injury
Pancreatic injuries are graded based on the AAST Pancreas Organ Injury Scale
-classifies injury based on location and the presence of main pancreatic duct disruption.
Grade II injuries include hematomas that encompass more than one portion of the pancreas and lacerations <50% the total circumference. The majority of grade II injuries can be safely treated with wide drainage and hemostasis control. Excessive debridement or attempts at repair can cause injury to the main duct.
Grade I and II injuries seen on imaging can be managed non-operatively but main duct disruption must be excluded.
What is the cause of jejunal intestinal atresia
intrauterine focal mesenteric vascular accident
How do you reverse bleeding from plavix
Clopidogrel irreversibly inactivates platelets and emergent reversal of its anticoagulation effects requires platelet transfusion.
Consequence of ileocecectomy for a chron’s related stricture
Bile salts are synthesized from cholesterol within the liver where they are conjugated to either glycine or taurine to form the primary bile salts: cholic acid and chenodeoxycholic acid.
Once secreted into the bile, they pass into the duodenum and are absorbed throughout the small intestine with a predominance in the terminal ileum. The portal system returns the bile salts to the liver completing the enterohepatic circulation. This is an extremely conservative process with 95% of the circulating bile pool being recycled.
Thus, although nearly 2 to 4 grams of bile salts are dumped into the duodenum daily, only approximately 600 mg are actually excreted into the colon. Colonic bacteria act upon the primary bile salts leading to the formation of the secondary bile salts, deoxycholate and lithocholate. A small amount of this is reabsorbed passively, however, the remainder is lost in the stool.
Recirculation of these salts can be interrupted by resection of the terminal ileum as is often required in patients with complicated Crohn’s disease.
Paget-Schroeder syndrome
From compression on the subclavian vein by either a cervical rib or muscular tissue that occurs with repetitive motion seen in swimmers and baseball pitchers.
Treat with thrombotic therapy
Axillary-subclavian vein thromboses (ASVT) are classified into two forms. In primary ASVT, no clear cause for the thrombosis is readily identifiable at initial evaluation. A minority of patients have performed reptitive motions with their upper extremities resulting in damage to the subclavian vein, usually where it passes between the head of the clavicle and the first rib. This condidtion is known as venous thoracic outlet syndrome. Secondary ASVT is more common and is usually associated with an indwelling catheter or hypercoaguable state. A patient with ASVT may be asymptomatic or present with upper extremity swelling and tenderness. Duplex ultrasound can confirm the diagnosis. Anticoagulation prevents pulmonary embolism (PE) and decrease symptoms. Patients presenting like this patient, with acute symptomatic primary ASVT, may be candidates for thrombolytic therapy. A venogram is performed through a catheter placed in the basilic vein to document the extent of thrombus. A catheter is placed within the thrombus and a lytic agent infused. Heparin is also administered.. After completion of thrombolytic therapy, a follow-up venogram is performed to identify any correctable anatomic abnormalities. Following thrombolytic therapy, balloon angioplasty for residual venous narrowing and first rib resection
Breast Galactocele
Most common breast mass during lactation and may be due to mammary duct obstruction
Contents are thicker, more creamy, oily
Esophageal Perforation
an unstable patient with a free perforation during the window of opportunity, surgical intervention with débridement of devitalized tissue, primary repair, wide drainage, and contralateral myotomy (forachalasia) is indicated.
Nitrogen balance
Nitrogen balance equations are: Nitrogen balance (g) = protein intake/6.25 - (TUN + 2) Nitrogen balance (g) = protein intake/6.25 - (UUN + 2 + 3).
Mechanism of action of heparin
Heparin is an indirect thrombin inhibitor via the acceleration of anti-thrombin III activity.
TRAM flap
most commonly used pedicled myocutaneous flaps are the Transverse Rectus Abdominus Muscle (TRAM) flap and the latissimus dorsi flap. The latissimus dorsi flap is based on the thoracodorsal artery and vein as the flap’s blood supply.
Rectus Sheath Hematoma
Rectus sheath hematoma is an uncommon phenomenon commonly seen in the elderly population who are anti-coagulated without a history of trauma. Sudden contraction of the rectus muscles with coughing, sneezing, or any vigorous physical activity often times causes this condition. Given this patient’s recent respiratory infection, multiple coughing spells may have disrupted the collateralizing vessels within the rectus muscles and sheath.
Malignant Peritoneal mesothelioma
cytoreductive surgery is successful in up to 87% of cases if peritoneal carcinomatosis is caused by malignant peritoneal mesothelioma. Peritoneal carcinomatosis (PC) is the natural evolution of up to one-third of intra-abdominal malignancies, and is usually considered as the terminal stage of the disease. However, cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) could lead to lon
Where is the most common location for an extra-adrenal phenochromocytoma
organ of Zuckerkandl.
which is located anterolateral to the distal abdominal aorta between the takeoff of the inferior mesenteric artery and the aortic bifurcation. 85% of extra-adrenal pheochromocytomas are located in the retroperitoneum with a majority of these located in the organ of Zuckerkandl
Berger Operation
Surgical operations for patients with chronic pancreatitis are generally divided into four basic types: resection, drainage, combined resection and drainage, and denervation.
Choosing the correct operation is based on the different underlying anatomic and morphologic features.
The Beger operation is one of the duodenal-preserving pancreatic head resection (DPPHR) procedures. It involves transecting the pancreatic neck followed by coring-out of the pancreatic head.
This operation is typically used in patients with small duct chronic pancreatitis and a large, hypertrophic pancreatic head.
Cranial Nerves
V trigeminal: sensory in for from the facial skin, mucous membranes
VII: facial: sensory from the soft palate , middle ear, tympanic membrane, and external auditory canal
IX: glossopharyngeal: The glossopharyngeal nerve carries sensory information from the uvula, tonsil, pharynx, auditory canal, middle ear and carotid sinus bulbs.
X: The vagus nerve contains sensory, motor and parasympathetic fibers. It carries afferent sensory information from the epiglottis, larynx, trachea, bronchi, esophagus, stomach, and bowel. Vagal motor efferents innervate palatal constrictors and intrinsic laryngeal muscles. Vagal parasympathetic fibers travel from the nucleus ambiguous and dorsal motor nucleus to the heart, lungs, esophagus, stomach, mesenteric, and myenteric plexi.
Midshaft humerus fx causes what nerve injury
Radial
Injury to medical epicondyle causes what nerve injury
Ulnar
Elbow dislocation and Supracondylar fracture causes what nerve injury
Median
Anterior dislocation of shoulder causes what nerve injury
Axillary
Posterior shoulder dislocations are associated with what
Axillary artery injury
Mesenteric Cysts-Treatment
If short segment-can be excised laparoscopically
60% of the time, resection of a wedge of mesentary with associate bowel
Unroofing the cyst or marsupialization of the cyst both have high rate of recurrence. If the above wedge and bowel resection can not be visualized well laparoscopically, then an open approach is indicated.
Which of the following is an indication for parathyroidectomy in this patient population?
Surgery is indicated for all patients with symptomatic PHPT. It is also recommended for patients with asymptomatic PHPT if any of the following criteria is met: (a) age less than 50, (b) inability to participate in follow-up, (c) serum calcium level >1.0 mg/dl above the normal range, (d) urinary calcium >400 mg/24 h, (e) 30% decrease in renal function, or (f) systemic complications of PHPT such as osteoporosis, nephrocalcinosis, or a severe psychoneurologic disorder.
What is the significance of CEA and colon cancer?
CEA is measured for patients with colorectal cancer. It is not useful as a screening test. It is an independent predictor of a poor prognosis. Patients with elevated CEA preoperatively have a worse survival, higher recurrence rates, and more advanced disease than patients with a normal level.
Ransom Criteria
Parameters used to calculate Ranson score 48-hours after admission are: Hematocrit decrease >10 pt BUN increase >5 mg/dL Calcium < 8 mg/dL PaO2 < 60 mm Hg Base deficit >4 mEq/L Fluid requirement >6 L. The total score at 48 hours is added to the initial score.
Distribution of pancreatic cancers.
Insulinomnas: evenly throughout the Pancreas
Primary gastrinoma: In 70 to 90% in Passaro’s triangle, an area defined by a triangle with points located at the junction of the cystic duct and common bile duct, the second and third portion of the duodenum, and the neck and body of the pancreas.
Somatostatinoma: proximal pancreas or the pancreatoduodenal groove, with the ampulla and periampullary area as the most common site (60%).
Like VIPomas, glucagonomas are more often in the body and tail of the pancreas and tend to be large tumors with metastases.
Pyoderma Gangrenosum
Extraintestinal manifestation of IBD.
Pretibial
Impaired immune function
Manage with Steroids
Improvement in the disease once the pt undergoes colectomy
By what percentages does prophylactic bilateral salpingo-oophorectomy (BSO) reduce risk for breast cancer and ovarian cancer among women with BRCA1 and BRCA2 mutations?
Bilateral salpingo-oophorectomy reduces the risk of breast cancer by 50% and reduces the risk of ovarian cancer by 98%.
Tumor markers for yolk sac ovarian tumors
AFP
Tumor marker for different germ cell tumors including seminoma, dysgerminoma, choriocarcinoma, and embryonal carcinoma.
HCG
tumor marker for epithelial stroma tumors such as mucinous and endometrioid carcinoma and sex cord stromal tumors like granulosa cell tumor and Sertoli-Leydig cell tumor.
Inhibin
epithelial ovarian cancer tumor marker
CA-125
What physiological changes occur with aging, most of which lead to decreased function, and can put an elderly patient at an increased risk for developing pneumonia.
number of respiratory related physiological changes occur with aging and can put an elderly patient at an increased risk for developing pneumonia. Bone density decreases causing thoracic kyphosis. Transverse thoracic diameter is decreased secondary to increased rib calcification. Decreased muscle mass and elastic recoil of the lung decreases compliance. There is a decreased functional residual capacity. Cough reflex, function of the mucociliary epithelium, and response to foreign antigen are all decreased.
DVt
Virchow’s triad: stasis of blood flow, endothelial damage, and hypercoagulability
Factor V Leiden is the most common hereditary cause of VTE, representing 50% of the cases.
May thurner
occur when there is an obstruc-
tion or thrombosis of the lower left extremity venous outfl ow
as a result of compression by the overlying right iliac artery.
Pager-schrotter syndrome
Primary thrombosis of the axillary-subclavian veins is usually found in young athletes who perform sports with repetitive motion (e.g., baseball, volleyball, swimming) and is
known as effort thrombosis
Rickets
Rickets is most commonly caused by vitamin D deficiency. Symptoms include failure to thrive, scoliosis, valgus or varus deformities, wrist and ankle enlargement, and Harrison’s groove.
Complication of rubber band ligation internal hemorrhoid
Bleeding, thrombosis, infection and urinary retention are all known complications after rubber band ligation. However, pain remains the most common.
Cabg anticoagulation
Act 400-500sec
Chamberlain Procedure and understanding mediastinal sampling
Level 2 nodes are localized superior to the innominate artery and are found before level 4 or level 7 nodes during a cervical mediastinoscopy.
Level 4 nodes are localized inferior to the innominate artery.
EBUS is able to visualize superior and inferior mediastinal lymph nodes at stations 2R/2L, 4R/4L and 7, as well as stations 10, 11 and even 12.
Level 5, subaortic lymph nodes(aortopulmonary window) are lateral to the ligamentum arteriosum and are not usually accessible by EBUS.
VATS has replaced anterior mediastinostomy (Chamberlain procedure) as the procedure of choice, allowing for superior visualization, less surgical time, and providing more information about the extent of local disease.
During a Chamberlain procedure the incision is made to the left of the sternum on the 2nd or 3rd intercostal space, not the to right, and the levels 5 and 6 are sampled, in this particular patient dissection at this level is relatively contraindicated as it could lead to massive bleeding due to the history of CABG.
Bottom Line: Standard and extended mediastinoscopy along with the Chamberlain procedure are relatively contraindicated in patients with a history of neck or thoracic surgery.
TrueLearn Insight : EBUS is clearly emerging as a potential alternative to more invasive techniques in the evaluation of mediastinal and hilar lymph nodes.
Accessible nodal stations include levels 2, 3, 4, 7, 10,11 and even 12 in some cases.
MEN IIA
Medullary Carcinoma
4 gland parathyroid hyperplasia
Pheochromocytoma
Multiple endocrine neoplasia type-IIA (MEN IIA) is characterized by the presence of medullary carcinoma of thyroid, four-glands parathyroid hyperplasia, and pheochromocytoma. Patients with MEN-2A who are diagnosed with MTC should be screened for pheochromocytoma before they undergo thyroidectomy. If a patient is found to have bilateral adrenal lesions, bilateral adrenalectomy should be performed first, followed by neck exploration. Managing the hemodynamics of a patient with an untreated pheochromocytoma is extremely difficult and dangerous, owing to the labile blood pressure and heart rate due to catecholamine release. Adrenalectomy is performed after adequate pre-operative alpha blockade, followed by beta blockade. Beta blockade is NEVER initiated before alpha blockade, as this results in unopposed alpha 1 receptor mediated hypertension.
Total thyroidectomy and total parathyroidectomy with autotransplantation should be performed in one session to ensure that the total thyroidectomy does not compromise the parathyroid blood supply and also to avoid reoperation in the neck for persistent or recurrent hyperparathyroidism
Treatment of neurogenic shock
Fluid resuscitation should be the initial management of neurogenic shock. In addition, Trendelenburg positioning and the use of vasopressors can be useful in the initial management of neurogenic shock
Colonic pseudoobstruction
Neostigmine is first line - 2-2.5 mg
Keep on cardiac monitoring
Early gallbladder cancer
T1a is lamina proprietary-simple chole ok
T1b through lamina propria-need to do gallbladder bed, Portia-hepata lymphadenectomy, and port site resection
T2- 4b and 5 resection
T2 is into the muscle
T3 through muscle into the serosa
T4 is beyond
Criteria for resection of liver mets
Need 20% of the total estimated liver volume
Or need 30% if going to go through chemo
Alvarado score
4-6 - CT scan
Pilonidal disease
Wide excision off the midline
Caroli Disease–60-80%
Type 1: dilation of CBD Type 2- diverticulum of CBD Type 3- Type 4a- intra Type
ITP
1st steroids
2nd immunoglobulins
3-Wait 3 months then splenectomy
Refeeding syndrome
hypophosphatemia, hypokalemia, hypomagnesia, and vitamin deficiency.
Hypophasphatemia is the hallmark of the diagnosis and it is associated with impaired adenosine triphosphate (ATP) synthesis and subsequent muscle weakness, myocardial dysfunction and diaphragm dysfunction resulting in acute respiratory failure.
pathophysiology of refeeding syndrome is a shift from stored fat to carbohydrate metabolism with an increase in insulin levels and movement of electrolytes for use in metabolism. The best strategy to prevent refeeding syndrome is to recognize at-risk patients, such as those with eating disorders, chronic malnutrition, or alcoholism. In addition, starting tube feeding at a low rate and advancing slowly with close monitoring can help prevent this complication.
Associated with TPN
Anatomic boundaries of Zone II
Cricoid to angle of mandible
Zone 1 injury to left common carotid
Median sternotomy
CTA of a neck
Management: ASA and follow up CTA
Compartement Syndrome
Anterior compartement is the first to be affected
Interposition graft
Use the saphenous because basilic has a higher chance of
MOA of omeoprazole
H+/K+ ATPase
What is the treatment of achalsia
Pneumatic dilation–pneumatic dilation is the most effective non-surgical treatment of achalasia. Dilation works by causing “rupture” in the lower esophageal sphincter (LES). This usually is obtained through a balloon inflation across the LES tearing the muscle fibers of the sphincter. The clinical response is directly proportional to the size of the balloon used for dilation. One-year treatment success rates of pneumatic dilation is greater than 80%. However, multiple dilations are required in most patients to achieve long-term symptom control. Esophageal perforation is the main complication, with an incidence of about 2%.
Calcium channel blockers have no meaningful treatment
TNF-A
Produced by T lymphocytes and causes symptoms of septic shock and cachexia
TACE for HCC
Relative contraindications to TACE include the presence of portal vein thrombosis or cirrhosis with many Child class B and all of Child class C patients being poor candidates due to risk of hepatic decompensation. Therefore, the best results are for patients with BCLC intermediate stage.
Gallstone ileus
Gallstone ileus is managed by exploratory laparotomy with proximal enterotomy from the obstruction site with stone removal from a healthy loop of bowel. If there are signs of necrosis, that piece of bowel should be removed. Takedown of the biliary enteric fistula should be attempted with cholecystectomy only in stable patients able to tolerate the increased length of the procedure.
Acidification of the duodenum leads a hormonal response designed to buffer the pH and enhance GI motility. Somatostatin, released by D cells, acts to inhibit gastrin and pancreatic secretions
GIP, released by K cells, acts to decrease acid secretion and stimulates insulin.
Answer B: Gastrin, released by G cells, is stimulated by an alkaline environment to trigger gastric acid secretion.
Answer C: Motilin is also activated by and acidic environment, and it acts to aid in GI motility.
Answer D: Secretin, released from S cells, inhibits gastrin and stimulates bicarbonate secretion.
Primary sclerosing cholangitis
Risk factor for cholangicarcinoma
Known risk factors for cholangiocarcinoma, a rare cancer, include primary sclerosing cholangitis, choledochal cysts, ulcerative colitis, and biliary tract infection. Some industrial chemicals such as nitrosamines, dioxin, asbestos, and polychlorinated biphenyls have also been suggested as risk factors of cholangiocarcinoma. There has been also some suggestion of an increased risk of cholangiocarcinoma after transduodenal sphincteroplasty. However, it is difficult to determine if this is due to the surgical intervention or the underlying disease leading to sphincteroplasty.
Follicular thyroid cancer
Follicular thyroid carcinoma (FTC) accounts for approximately 10% to 20% of all thyroid cancers with a female predominance. Incidence begins to increase in the 5th decade of life and is often more advanced at diagnosis than papillary cancer. FNA results showing a follicular pathology still require a lobectomy to differentiate between an adenoma, follicular hyperplasia, or carcinoma. Diagnosis of carcinoma depends upon vascular invasion and capsular invasion as well as specific cellular architecture. In contrast to papillary thyroid cancer, follicular cancers are usually solitary and one third of patients with FTC have metastases via hematogenous spread at the time of diagnosis with lung and bone most often being involved. Lymph node involvement occurs in about 10% of patients. A modified radical neck dissection should be performed if there are clinically positive nodes or evidence of extrathyroid
Rest pain
On evaluation, the ABI’s will be in the range of 0.5 and arterial duplex will usually have evidence of multi-segment occlusive disease in the affected leg
The chance of major amputation with critical limb ischemia is 40%.
What modality has the highest sensitivity of detecting an insulinoma
Intra-op ultrasound
Pyogenic liver abscess
Pyogenic liver abscesses should be treated first with broad spectrum intravenous antibiotics and percutaneous drainage unless there is an underlying pathology that requires surgical attention
pyogenic liver abscess is most commonly related to biliary tract obstruction from gallstones or malignant disorders (35% of cases), and the ultrasound examination may reveal both the abscess and the dilated biliary ducts. Previously, portal pyemia from diverticulitis, ACS Surgery: Principles and Practice
19 INTRA-ABDOMINAL INFECTION — 10
b
ammatory bowel disease (IBD), or perforated appendicitis had been the most common cause; it now accounts for 20% of cases. Even less common is hematogenous spread via the hepatic artery. Approximately 20% of hepatic abscesses are cryptogenic. Ultrasonographic imaging of the liver may demonstrate lesions as small as 2 cm in the liver substance. CT, however, is superior to ultrasonography for evaluating the presence of air and abscesses as small as 0.5 cm in diam-
eter, especially near the hemidiaphragms.71 Abdominal CT is also the diagnostic modality of choice in the postoperative patient.72 ERCP and PTC are indicated only when gallstone disease or a biliary malignancy is the potential source of the abscess. Most liver abscesses occur in the right lobe: 40% are 1.5 to 5 cm in diameter, 40% are 5 to 8 cm in diameter, and 20% are greater than 8 cm in diameter.
Types of ulcers:
Type I ulcers are located on the lesser curvature and are not associated with acid secretion.
Type II ulcers are associated with high acid secretion and are located on the lesser curvature, occurring in synchrony with
duodenal ulcers.
Type III ulcers are also associated with acid
hypersecretion but occur in the prepyloric region.
Type IV ulcers are not associated with acid secretion and are located
in the cardia near the esophagogastric junction [see Figure 3].
Type V ulcers are diffuse and are related to the use of med-ications (e.g., NSAIDs) [see Acute Hemorrhagic Gastritis, below].
Surgical management of type II or type III ulcers
The surgical approach to type II or type III gastric ulcers is to perform a distal gastrectomy that includes the ulcer in the surgical resection and then a gastroduodenostomy or Billroth I reconstruction. If the duodenal involvement is more extensive and a tension free gastroduodenostomy can not be safely performed, then a Billroth II or even Roux-en-Y creation is necessary. Since conservative acid reduction therapy has failed for this patient, a vagotomy is indicated.
