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1
Q

Celiac artery branches

A

CHA- RGA, proper hepatic, GDA (RGE and SPD)
LGA
Splenic- LGE

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2
Q

Killians triangle (dz and borders)

A

Zenkers
Inferior constricter mm
Cricopharyngeus

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3
Q

MC esophageal perforation

MC iatrogenic perfortation

A

MC- at GE jxn (usu left) (Boerhaaves)

Iatrogenic- cricopharyngeus

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4
Q

DES vs nutcracker

A

DES- uncoordinated peristalsis

Nutcracker- coordinated high amp contractions

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5
Q

Heller myotomy incision

A

2cm stomach

6cm esophagus

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6
Q

Tx achalasia v DES v nutracker

A

Achalasia- Heller first (dilation or botox if poor sx candidate
DES/Nutracker- CCB and nitrates (long segment myotomy if uncontrolled)

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7
Q

Zenkers v epiphrenic v midesophageal- type, etiology, tx

A

Zenkers- pulsion, failed cricopharyngeal relax, divide cricopharyngeus (+/- remove diverticulum)
Epiphrenic- pulsion, motility DO, diverticulectomy and tx motility DO
Mid- full thickness, inflammatory DO (TB, malignancy), VATS and diverticulectomy

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8
Q

Esophageal CA staging

A

T1a mucosa (EMR if low grade)
T1b submucosa
T2 muscular
T3 adventitia

N1 1-2
N2 3-6
N3 >7

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9
Q

Proximal esophageal CA managmeent

A

> 5cm from cricopharyngeus- esophagectomy

<5cm from cricopharyngeus- definitive chemorads

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10
Q

Tylosis

A

palmar thickening (keratomas)- risk for esophageal SCC

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11
Q

Fanconi anemia

A

SCC esophagus
SCC H&N
pancytopenia

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12
Q

Stomach ulcer classification

A 
I lesser curve
II x2 (1 gastric and 1 prepyloric)
III prepyloric
IV GE jxn
V NSAIDs

II and III are d/t high acid output

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13
Q

Siewert classification

A

I 1-5cm above GEJ
II 1 above and 2cm below GEJ
III <2cm below GEJ

III is the worst prognosis

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14
Q

Forest classification and rebleed risk

A 
IA- brisk bleeding (80%)
IB- oozing
IIA- visible vessel (50%)
IIB- adherent clot (25%)
III- clean ulcer (<5%)
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15
Q

Early and late dumping

A

Early- 20-30min osmolar load

Late- 1-4hr insulin surge

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16
Q

Afferent loop syndrome- acute vs chronic

A

Acute- jaundice, duodenal stump blowout – > emergent surg

Chronic- bacterial overgrowth, B12 deficiency, steatorrhea –> abx, then surgery

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17
Q

CDH1 mutation

A

Autosomal dom
familial gastric cancer (also breast CA)
>18 yo –> prophylactic gastrectomy

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18
Q 
Genes:
Lynch
Juvenile polyposis
Peutz Jeugers
FAP
A

Lynch-MMR
Juvenile- SMAD4
Peutz Jeugers- STK11
FAP- APC

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19
Q

Gastric cancer staging

A 
T1a mucosa
T1b submucosa
T2 muscularis 
T3 submucosa
T4 past submucosa

N1 1-2
N2 3-6
N3 >7

Neoadju for T2 and higher or any nodes (same as esophagus)
Adju for T3 or higher or any nodes

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20
Q

gastric cancer margins, nodes

A

5cm (4cm per NCCN)

15nodes

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21
Q 
Howell Jolly- 
Pappenheimer-
Target cells
Spur cells-
Heinz-
A 
Howell Jolly- nuclear remnants 
Pappenheimer- iron deposits
Target cells- immature
Spur cells- deformed membbranes
Heinz- denatured proteins
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22
Q

highest risk for post splenectomy sepsis

A

beta thalasemia

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23
Q

TTP symptoms

A

FAT RN

fever, anemia, thrombocytopenia, renal failure, neuro changes

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24
Q

Replaced right and left hepatic a

A

Right- SMA (behind panc and CBD)

Left- left gastric (gastrohepatic lig)

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25
Rigler triad
bowel obstruction Stone on imaging Pneumobilia
26
gallbladder polyp
>6mm serial ultrasound >10mm chole Stone + polyp - chole >1.8cm suspicious for cancer
27
gallbladder cancer RF and staging
typhoid, PSC, IBD T1a lamina propria only T1b muscularis propria - radical cholecystectomy and portal LAD
28
isolate gastric varices?
splenic v thrombosis (from pancreatitis), tx w splenectomy
29
portosystemic shunts- pros and cons
splenorenal- (wont help w ascites) | portocaval- may make encephalopathy worse and may mess w transplant options
30
Pyogenic Amebic Echinococcal
Pyogenic- e coli, drain abx Amebic- serology dx, flagyl (don't drain!) Echinococal- double wall, serology dx, albendazole and excise
31
MELD vs Child Pugh
Child (liver only)- bili, albumin, PT, enceph, ascites | MELD (liver and kidney)- bili, INR, creat (>15 transplant)
32
Todani classification (and treatment)
``` 1 fusiform (hepaticoJ) 2 saccular diverticulum CBD (RNY choledochojeju) 3 intraduodenal (transduodenal excision, sphincterotomy) 4a intra and extra (hepatic resection, hepaticoJ) 4b extra only (hepaticoJ) 5 intra only (transplant) ```
33
Hemangioma v FNH v Adenoma v HCC
Hemangioma- "peripheral nodular enhancement" (peripheral to centripetal enhancement), no washout FNH- stellate scar, arterial homogenous enhancement, kupffer cell uptake Adenoma- OCP, 10% malignant, >5cm rupture...same imaging as FNH HCC- hyperdense w fast washout
34
Kasabach Merritt syndrome
Hemangioma DIC
35
MC liver cancer met
Lung
36
Liver resection percents
Healthy 20% Mild cirrhosis 30% Cirrhosis 40% Sig liver dz 50%
37
Fibrolamellar liver CA
young, better prognosis | neurotensin marker
38
Milan criteria
<5cm <3cm x3 no vascular or extra hepatic spread
39
Colorectal mets to liver- full response
resect still
40
RAAS pathway
Renin (kidney) converts angiotensinogen (liver) --> angiotensin I ACE (lung) converts angiotensin I --> II Induces aldosterone production
41
Medical treatment for hyperaldosterone 2/2 adrenal hyperplasia
Spironolactone | Eplrenone
42
Incidentaloma labs and imaging
``` cortisol (MN salivary, then 24 hr urine) catecholamines (plasma, then urine) Aldoesterone, renin DHEA (if ACC suspected) urine androgens (if ACC suspected) ``` >10 HF units <60% washout >6cm
43
adrenocortical carcinoma- chemo
mitotane
44
Pheo rule of 10%
``` extraadrenal (MC organ of zuckerkandl at aortic bifurcation) bilateral chidlren familial (VHL, MEN2, NF) malignant ```
45
Pheo imaging
CT | MIBG scan if not confirmatory
46
Stress dose steroids
20mg>3wks (none if <3weeks) | none if <5mg/day
47
MTC in MEN2 thyroidectomy?
ppx thyroidectomy at 5yo
48
pseudocyst intervention criteria
>6cm symptomatic enlarging
49
chronic pancreatitis procedures
Puestow- pancreaticoJ Beger- head resect and pancreaticoJ Frey- head excavation and pancreaticoJ
50
"fish mouth papilla"
main duct pancreatic duct
51
branch IPMN- high risk features
``` >3cm thick wall nonenhancing nodules LAD main duct >10mm abrupt main duct change ```
52
PNET- symptoms, w/u, management
PET>somatostatin scan Insulinoma- no somatostatin scan, diazoxide for med management; >2cm formal resection Gastrinoma- >1000 or secretine stim test >200 Glucagonoma- 4D (dermatitis, DM, depression, DVT) Somatostatinoma- DM, gallstones, steatorrhea VIPoma- WDHA syndrome chole if malignant (somatostatin as chemo)
53
Pancreatiic cancer genes
p53 | KRAS
54
Pancreatic cancer resectibility
resectable- no arterial contact, <180 SMV or PV borderline- <180 SMA or celiac, CHA only (no celieac or HAP), reconstructible vein nonresectable- >180 MSA or celiac
55
Pancreatic cancer chemo
FOLFIRINOX (folinic acid, 5FU, oxetecan/irenotecan, oxaliplatin)
56
dentate line- separates?
upper 2/3 from lower 1/3 of anal canal columnar (upper) vs squamous (lower) internal v external hemorrhoids
57
UC vs crohn's characteristics
UC- crypt abscesses, mucosal | Crohns- fat grandma skipped down wrecked cobbleston; transmural; erythema nodosum
58
IBD screening
8-10 years after dz onsent then q1-3 yrs 4quad bx q10cm
59
high risk colorectal cancer screening
x1 primary CRC <60yo x2 primary CRC any age - 40yo, q5y x1 primary CRC >60yo x2 secondary CRC any age - 40yo, q10y FAP 10-12yo q1y HNPCC 20-25yo, q1-2y
60
FAP v HNPCC- inheritence, gene, dz
FAP- AD, APC, duodenal polyps | HNPCC- AD, MMR, ovarian, endom, bladder, stomach
61
Amsterdam criteria
3 relatives (one is primary relative of other) 2 generations 1 CA<50yo
62
Cscope adenoma screening f/u
tubular adenoma <2x <0.5cm- 5yr tubular adenoma >3 - 3yr high risk adenoma >1cm, villous, or high grade- 3yr hyperplastic - 10yr
63
Malignant polyps- polypectomy ok?
1piece margins clear well or mod differentiation <2mm past mucosa muscularis (if sessile, no submucosal involvement)
64
colorectal cancer staging
Tis lamina propria T1 submucosa T2 muscular propria T3 serosa T3 stage 2 - rectal neoadju chemoXRT and adju chemo (xtra neoadju chemo if CRM involved b/f surg) N1 stage 3 - colon adju chemo N1 - 1-3 N2 3-6 N3 >7
65
rectal cancer margins
2cm distal and 5cm proximal
66
Neoadju and adju chemorads in CRC
Neoadju- 5000 gray, 5FU x 5 weeks | Adju- FOLFOX folinic acid, 5FU, oxaliplatin
67
EMR of colorectal cnacer
T1 <3cm or 1/3 circum Well or mod differentiation
68
APR v LAR
<5cm from anal verge --> APR
69
AIN v Anal cancer tx
AIN- imiquimoid or topical 5FU | Nigro- 5FU, mitomycin C, 3000 XRT
70
CEA anatomy (nerves)
hypoglossal (lies over bifurcation) Marginal mandibular nerve (retractor injury; lower lip chin mm) glossopharyngeal (posterior to bifurcation) vagus (lateral to ICA/CC)
71
Carotid dz pressures
125 - 50% | 230 - 80%
72
carotid repair
always patch
73
MC mortality after CEA
MI (not stroke)
74
When CEA after strokes
TIA <2 weeks moderate stroke 4-6 weeks Hemorrhagic 6-8 wks evolving symptoms - emergent
75
BIFFL
``` 1 <25% intimal narrowing 2 >25% 3 pseudoaneurysm 4 complete occlusion 5 transection or active extrav ```
76
carotid body tumors management
resection (dont bx)
77
thoracic outlet
``` 1 subclavian v 2 phrenic n 3 ant scalene 4 subclavian a 5 brachial plexus 6 middle scalene m 7 1st rib ```
78
thoracic outlet syndrome- symptoms
``` neurogenic MC paget schroeder (vein) ```
79
subclavian steal syndrome
subclavian stenosis reversal of vertebral flow d/t proximal stenosis subclavian carotid bypass (bypass distal to stenosis)
80
fasciotomies- avoid
``` superificial peroneal (lateral)- foot eversion saphenous vein (medial) ```
81
when to place lumbar drain
T8-L1 stent
82
desc thoracic aneursym fix size
5.5cm
83
when to fix aneurysms, repair
``` visceral 2cm (resect and recon) iliac a 3.5 (endovascular repair) femoral a 2.5 (resect and interposition) popliteal a 2cm (exclusion and bypass; look for AAA) ```
84
AAA repair sizes
5.5cm or >1cm/yr
85
MC AAA infection
staph aureus for mycotic and graft (#2 salmonella mycotic) (#2 e coli for graft)
86
IMA when to reimplant
<40 back pressure
87
Leriche syndrome
aortiiliac dz (smokers)- butt claudication, decr fem pulses, ED
88
May thurner syndrome (and tx)
L iliac v compression; stent
89
fistula rules
6 wks 600cc/min <6mm skin >6mm diameter
90
rutherford stages
I (viable) - basically normal IIa (threat)- no pulses, partial sensation loss IIb (threat)- slowed cap return, partial paralysis and sensation loss III (amp)- nothing
91
endoleak
I prox or distal II lumbars III limb IV porosity
92
breast nerves
``` long thoracic (serratus) winged scapula thoracodorsal (lat dorsi) weak adduction ```
93
BIRADS
``` 0 nondiag 1 negative 2 benign 3 likely benign (6mo f/u) 4 suspicious 5 highly suspicious 6 known malignant ```
94
Bethesda
1 nondx (repeat) 2 benign (repeat 12 mo) 3 AUS/FLUS (repeat FNAB or molec testing) 4 suspicious follicular (molec testing or lobectomy) 5 supsicious malig (total vs lobectomy) 6 malignant
95
phyllodes breast
WLE 1cm margins | >5 mphf maliginant concern
96
Gaile model
``` risk within 5yrs Age Menarche 1st child age Fam hx of breast CA (first degree) Past breast bx past hx of atpyical hyperplasia Race ```
97
DCIS tx
2mm margins | radiation to decr risk of local recurrence
98
breast staging
T1 <2cm T2 2-5cm T3 >5cm N1 1-3 N2 4-9 N3 >10
99
breast chemo
TAC | taxane, adramycin (doxorubicin), cyclophosphamide (mesma decr risk of hemorrhagic cystitis)
100
inflammatory breast CA
AT chemo (adriamycin, taxane) +/- rads MRM rads +/- chemo
101
pregnancy breast cancer no nos
no cyclophosphamide (AT only) no transtuzamab no blue dye
102
pregnancy breast cancer management
1st T- BCS not recommended 2nd T- node positive --> MRM or BCS +ALND (rads PP) node negative --> TM or BCS +SLN (rads PP)
103
atypical lobular hyperplasia
WLE (no neg margins needed)
104
thoracic duct course
Right --> Left (at T5) | enters into LIJ
105
Type I and II pneumocytes
I- gas exchange | II- surfactant
106
MC mediastinal tumors
MC - neurogenic tumors (posterior) | MC site = anterior (#1 is thymoma)
107
MC cause of SVC syndrome
SCC
108
Lung cancer MC met
brain
109
paraneoplastic syndromes of lung CA
Squam PTHrP | SCC- ACTH and ADH (MC)
110
MC lung tumors (adult and peds)
Adult- SCC (malignant) and hamartoma (benign) | Ped - carcinoid (malig) and hemangioma (benign)
111
PFTs
FEV1 >1.5 --> lobectomy FEV1 >2.0 --> pneumonectomy VQ scan %PPO FEV1 >40% and TLC >40% exercise testing VO2 max >15cc/kg/min
112
Vit d processing
Vit D --> OH 25 (liver) -->> 1,25 OH (kidney)
113
PTH effects
clasts --> increase Ca and Phos | Kidney --> calcium reabsorg and decr phos
114
Vit D effects Ca
gut increases ca and phos absorb
115
Parathyroidectomy indications
Incr Ca CrCl<60 Tscore <2.5 <50yo
116
palliation for parathyroid cancer
bisphos
117
parathyroid where?
MC normal location | MC ectopic = thymus
118
External pathway factors
VII | WEPT
119
AT III deficciency
heparin wont work | Give FFP first
120
factor not made in liver
VIII (endothelium)
121
TEG vs ROTEM
R time- FFP K or alpha angle - cryo Max amp - plt Lys 30 TXA Clot time - FFP MCF - FIBTEM abnormal - cryo FIBTEM normal - plt
122
alpha v beta receptors
alpha - pure vessel constriction | beta- increases heart contractility and HR
123
``` CMV and PCP tx Aspergillus C krusei C glabrata C albicans ```
``` CMV - ganciclovir PCP - bactrim Aspergillus and C krusei- voriconazole Glabrata- micafungin albicans- fluc ```
124
LCIS- management
obs only vs excise (no neg margins needed) | excisional bx to neg margins - pleomorphic or florid
125
neuroendocrine tumors- general rule re tx
<2cm - local excision(transanal excision, appy, SBR, etc) | >2cm formal resection (APR, hemicolectomy, WLE SBR)
126
GIST- margins, spread, cell type, tx, MC met
``` neg margins hematogenous intestinal cells of cajal imatinib liver ```
127
SCC skin margins
4mm margins | 6mm if high risk (>2cm, fat invasion, face/ears/scalp)
128
resp quotient
1.0 pure carb 0.8 pure protein 0.7 pure fat <0.7 starvation
129
VW dz types
i and II DDAVP | III give vWF (cryo has some vWF)
130
IPR cell types
Inflam 1-7d PMN and MAC Prolif 1-3wk fibroblasts, collagen depo III --> I Remod- crosslinking 8 weeks max strength
131
``` suprcondylar humerus fx distal radius fx anterior shoulder disloc posterior hip disloc midshaft humerus fx ```
``` supracondylar humerus- brachial a (volkmanns contracture) distal radius- median n anterior shoulder disloc- axillary n poserior hip- sciatic n midshaft humerus= radial n ```
132
Li Fraumeni syndrome
sarcoma | breast brain
133
Barretts bx
q1cm if mucosal irregularities | q2cm if none
134
DCIS margins
2mm
135
SCC margins
4mm | 6mm for high risk (>2cm, fat invasion, high risk location on face)
136
resp quotients
1.0 pure carb 0.8 pure protein 0.7 pure fat <0.7 starvation
137
vwd disease
type i and ii - DDAVP | type III vWF
138
phyllodes margins
1cm
139
surgery type and steroid dosing
minor- normal steroids moderate- 50mg IV , then 25 q8h major 100mg IV, then 50 q8h
140
meckel cell carcinoma-
carcinoid of skin
141
evar requirements
8-22mm diameter | 15-20mm lengh of CIA
142
type i vs type ii error
``` false positive (nuss is true) type II- false negative (null is false) ```
143
pancreas trauma grading
grade I and II without duct involvement
144
CBD repair injury
within 72hr
145
bismuth classification of cholangiocarcinoma
I- common hepatic duct II at bifurcation III 2nd biliary ducts 1 side IV 2 sides
146
vein stripping and high ligation reqs
>8mm or torturous
147
superior laryngeal vs RLN inn
SL- cricothyroid | RLN larynx mm
148
clinicAL trial phases
1- safe? 2- does it work 3- RCT 4- post market
149
CCK Secretin gastrin GIP
G cell antrium- secerte gastrin (gastric acid) I cells duodenum- secrete CCK (GB contraction, panc enxyame) S cells duodenum- secretin (panc bicarb) K duodenum- GIP (inhibigs gastric acid and incr insulin
150
IL1, 2, 4, 6, 8, 10
``` 1- fever, MAC 2 NK cytotoxic cells 4 B cell antibodies 6 APR (hepatic) 8 PMN chemotaxis, angio (neutrophils) 10 stops evertyhing ` ```
151
type I, II, III, IV reactions
1 IgE anaphylaxis 2 ABO, IgG, IgM 3 serum sickness 4 t cell mediated (TB, chronic rejection)
152
chromium deficiency
hyperglycemia encephalopathy nephropathy
153
copper deficiency
pancytopenia
154
zinc deficiency
wound healing
155
phos deficiency
can cause failure to wean weakness encephalopathy
156
B1 deficiency
Thiamine CM Wernickes Beri Beri
157
B6 deficiency
pyrodoxine siderblastic anemia glossitis peripheral neuropathy
158
B12 deficiency
megalobastlic anemia beffy tongue peripheral neuropathy (will not be seen w folate deficiencY)
159
Niacin deficiency
dermatitis dementia diarrhea
160
vit E deficiency
neuropathy
161
PPV
= TP/(TP+FP)
162
NPV
= TN/(TN+FN)
163
MEN 1 and 2 gene FAP gene Li fraumeni gene
MENIN RET APC p53 (sarcoma, breast, brain,, adrenals)
164
``` Venurafenlb/fabrafenib Bervacizumab Cetuximab Ipilmumab Nivolimumab Pembrolizumab ```
``` fenib- BRAF BerVacizumab- VEGF (Colon) Cetuximab (colon)- EGFR Ipilimumab CTLA4 nivo/pembrolizumab- PD1 ```
165
ptc path
psamomma bodies, ophan annie nuclei

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