Old deck Flashcards
(457 cards)
<p>Tx of SIADH</p>
<p>fluid restriction</p>
<p>demeclocycline or vaptans (adh inhibitor)</p>
<p>Portal vein thrombosis tx</p>
<p>Control HMHG with variceal ligation</p>
<p>Anticoagulate once bleeding controlled</p>
<p>Consider distal spleno-renal shunt</p>
<p>MRSA tx</p>
<p>vancomycin</p>
<p>if vanc resistant then linezolid</p>
<p>VWF</p>
<p>binds GP1b on PLTs and attaches them to endothelium</p>
<p>Margin for invasives cancer vs. dcis</p>
<p>invasive cancer- gross negative</p>
<p>dcis- 1 to 2 mm</p>
<p>Interleukins 1, 2, 4</p>
<p>IL1: fever</p>
<p>IL2: T cell prolif and Ig production</p>
<p>IL4: T/B cell maturation</p>
<p>Ovarian tumor markers:</p>
<p>AFP</p>
<p>CEA</p>
<p>HCG</p>
<p>LDH</p>
<p>Ca 125</p>
<p>Inhibin</p>
<p>AFP: yolk sac tumor, endodermal sinus</p>
<p>CEA: mucinous ovarian tumor</p>
<p>HCG: ovarian choriocarcinoma, embryonal carcinoma</p>
<p>LDH: dysgerminoma</p>
<p>Ca 125: epithelial ovarian tumors</p>
<p>Inhibin: granulosa cell tumor</p>
<p>Hormones that increase LES pressure</p>
<p>Gastrin</p>
<p>Motilin</p>
<p>Origin of med thyroid cancer</p>
<p>4th pharyngeal arch NCC --> parafollicular C cells</p>
<p>Gardner syndrome</p>
<p>epidermal cysts, GI polyposis, osteomas</p>
<p>Indidcations for operative treatment of eso perf</p>
<ul> <li>early postemetic perforation</li> <li>hemodynamic instability</li> <li>intra-abdominal perforation</li> <li>extravasations of contrast into adjacent body cavities</li> <li>presence of underlying malignancy, obstruction or stricture</li></ul>
<p>place jejunostomy tube for feeding after. don't place gastric tube (conduit)</p>
<p>Uremic PLT dysfunction</p>
<p>2/2 renal disease</p>
<p>reversible dysfunction</p>
<p>tx- ddavp</p>
<p>B12 def</p>
<p>megalo anemia, neuropathy</p>
<p>Traction vs. Pulsion Diverticulum</p>
<p>traction- inflammation; all 3 layers; mid eso</p>
<p>pulsion- pressure; 2 layers; above circoph.</p>
<p>Positioning for indirect laryngoscopy</p>
<p>sitting upright with a straight back, leaning slightly toward you with chin pointing upward (“sniffing position”)</p>
<p>Kcal per macronutrient</p>
<p>protein = 4 kcal/g</p>
<p>dextrose = 3 kcal/g</p>
<p>lipid = 9kcal/g</p>
<p>carb = 4 kcal/g</p>
<p>p53</p>
<p>TSG on Ch17</p>
<p>cell cycle regulation and apoptosis</p>
<p>Rule of 9s</p>
<p>Each arm 9</p>
<p>Each leg 18</p>
<p>Ant belly 18, Post belly 18</p>
<p>Each hand 1</p>
<p>Ant face 4.5, Post face 4.5</p>
<p>Genitals 1</p>
<p>EBV associated with</p>
<p>B cell lymphome (Burkitt)</p>
<p>n/ph cancer</p>
<p>FRC</p>
<p>Volume of the lung after normal tidal expiration</p>
<p>Cisatracurium</p>
<p>non-depolarizing</p>
<p>cleared by Hoffman degradation</p>
<p>use in pts w/ renal and hepatic disease</p>
<p>tacro</p>
<p>MOA: calcineurin inhibitor (binds fK)</p>
<p>s/e- nephrotoxic, p. neuropathy, allopecia</p>
<p>SD</p>
<p>1, 2, and 3 SD = 67%, 95%, and 99.7% of the data</p>
<p>Intraductal papilloma</p>
<p>MCCO bloody nipple d/c</p>
<p>tx w/ duct excision</p>
<p>no increased r/o ca</p>
Blood supply to esophagus
Upper 3rd- inferior thryoid artery
Middle 3rd- thoracic aorta
Lower 3rd- left gastric
Pleomorphic adenoma
MC benign H/N tumor
middle aged woman
slow growing; t2 bright
Tx: superficial parotidectomy even if asx
Rule of 6s
flow > 600/min
diameter > 6mm (after placement)
depth of 6mm
Comparing pressors
Norepi: alpha1 > alpha2, beta1
Epi: beta1, alpha1 > beta2, alpha2
Phenylephrine: alpha1 > alpha2 (no beta)
MCCO of spontaneous bacterial peritonitis
E. Coli
Max dose of lido and bupiv
lido = 5mg/kg (7 w/ epi)
bupiv = 2.5 mg/kg
tx- lipid emulsion
Lamivudine
rTranscriptase inhibitor
Tx for hep B at low doses; HIV at high doses
Wound healing order of entry
plts → PMNs → macrophages → fibroblast → keratinocytes
5Ts of cyanosis
- TOF
- Transposition of GVs
- Truncus art
- Tricuspid atresia
- TAPVC
Pain after inguinal hernia repair
Ilioinguinal nerve
Injured at external ring. Lies anterior to cord
tx- local injection
Staging adrenal cancer
s1- <5cm
s2- >5cm
s3- n1 or t3
s4- mets
location of vagus nerve
LARPleft anterior, right posterior to esophagus
Dopamine dosing
low- d1/2 ago (renal dose)
medium- B ago
high- A ago
LIPID A
Gram negative bacteria (Klebsiella)
lipopolysaccharide layer endotoxin → septic shock
Beta lactamase inhibitors
Sulbactam/Tazobactam
Clavulanic acid
Contents of ant triangle
Carotid sheath, anca cervicalis, CN 12 (hypoglossal)
Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular
- facial vein is the gateway
BRCA risks
female breast, ovarian, male breast
I- 60, 40, 1
II- 60, 10, 10
Women with BRCA breast CA have the same prognosis stage for stage as non-BRCA breast CA
Kasabach-Merritt Syndrome:
hemangioma + thrombocytopenia
usually infants
resect!
Traumatic renal artery thrombosis
Unilateral- anticoagulation
Bilateral- OR or IR stent
Adenoid cystic carcinoma
MC minor salivary gland tumor (SM gland)
propensity for perineural invasion
Remains quiescent for years then metastasizes aggressively
SLNBx for melanoma
< .75 mm none
> .75 to 1 mm w/ ulceration, mitosis, invasion
Hernia repairs:
Bassini
McVay
Lichtenstein
Bassini: CT to IL
McVay: CT to cooper's
Lichtenstein: mesh
Casues of increased ETCO2
Increased muscle activity (shivering)
Increased metabolism (sepsis, fever, malignany hyperT)
Increased CO
Decreased minute ventilation
Acute cellular rejection
T cell mediated
path: portal cellular infiltrate + endotheliitis
tx: pulse steroids → consider thymo
Phyllodes tumor
“sarcoma of the breast”
tx- en bloc resection
hematog spread- chemo/LN dissection unnneccesary
Birads 0
More imaging: mammogram or targeted US
Mediastinal tumors
Anterior: lymphoma MC in children, thymoma MC in adults
Middle: lymphoma MC
Posterior: neurologic MC
Vitamin C
hydroxylation of lysine and proline
type 3 collagen cross-linking
Staph virulence factors
- protein A: binds Fc component of IgG, forcing variable region to face away from bacterium
- Enterotoxins: intestines
- Toxic shock syndrome toxin-1 (TSST-1): superantigen. binds MHC II and T-cell receptor
- Coagulase: converts fibrinogen to fibrin clot
- Exfolatins: skin-exfoliating toxins
CN11
spinal accessory nerve
exit jugulars foramen
innervates SCM and trapezius goes along post triangle
Tx of SVC syndrome
Angio stenting and steroids for sxatic relief
Urgent chemo/rads therapy
Silvadene, mafenide, silver nitrate s/e
Silvadene: s/e- neutropenia, hypersensitivity, kernicterus (avoid in preg)
Mafenide: psuedomonas coverage s/e- met acidosis
Silver Nitrate: s/e- hypoNatremia
Indications for radioiodine thereapy
2-4 cm mass
vascular invasion
anti-Tg Ab
TG < 5
Hemophilia A
f8 DEFICIENCY SLR
MC inherited disorder
tx- DESMOPRESSIN (mild), f8 concentrate (severe)
Strongest layer of bowel
SM
Contents of post triangle
CN 11 subclavian artery
EJV
brachial plexus trunks
Paget-Schroetter syndrome
Exercise induced thrombosis of subclavian/axillary VEIN
Tx- catheter directed thrombolysis
NEC
Bloody stools after 1st feed
dx- pneumatosis
tx- resuscitation, abx; OR if free air, clinical deterioration
Fibroadenoma
cyclical pain
dx- US guided core bx
only excise if discordance with biopsy!
Pancuronium
non-depol
eliminated by kidney and liver
Location of superior sympathetic block
- 3 to 5 cm in length
- on the longus capitus muscle
- anterior to the transverse process of the second, third, and rarely the fourth cervical vertebrae
Order of contents in thoracic outlet
vein (SC)
phrenic
muscle (scalene)
artery (SC)
nerve (br plexus)
Insulinoma
Loc: throughout
Px: whipple's triad
tx- < 2cm encucleate, >2cm resect
GCS verbal
5- normal
4- confused
3- inappropriate words
2- incomprehensible
1- none
Plasmin
Degrades f5, 8, fibrinogen, and fibrin
TXA2
vasoconstrictors
released by PLTs
Pseudocyst
encapsulated
lack epithelial lining
>5cm requires drainage
Sevoflurane
fast, less laryngospasm, less pungent
good for mask induction
Fibrin
Links Gp2b/3a to form PLT plug
NOAC reversak
Dabigatran (pradaxa)- Idarucizumab, iHD
Apixaban- PCC (partial)
Rivoroxaban- PCC (partial)
Indications for post op radio-iodine
2-4 cm
vascular invasion
anti-Tg Ab
TG<5
PEAK and TROUGH
PEAK- amount
TROUGH- frequency
Desmoid tumor
Locally aggressive with no portential for mets
Tx with resection and chemo
MC vitamind def after REY GB
B12
Ulcers:
Marginal
Cameron
Marjolin ulcer
Cushing's ulcer
Marginal- REYGB at GJ anastomosis
Cameron- on lesser curve of large hiatal hernia
Marjolin ulcer- chronic wound
Cushing's ulcer- elevated ICP
Products of posterior pituitary
"PAO in the POST"
ADH, Oxytocin
2/2 direct stem from neurosecretory cell
Stage 3 breast cancer and tx
3a- 4 to 9 nodes --> consider neoadj for BCT
3b- chest wall (not pec wall) or breast skin --> neoadj required
3c- supra clavicular nodes --> neoadj required
Tx of GIST
Resection w/ gross margin
No LN dissection
Add imatinib (TK inhibitor) if >5m/50HPF
Non-cyanotic heart defects
ASD
VSD
coarctation
Bevacizumab
recombinant humanized monoclonal antibody that blocks angiogenesis by inhibiting VEGF-A
c/i to BCT
multicentric
inflammatory ca
c/i to radiation
AT3 Functions
Inhibits thrombin2. Inhibits f9, 10, 11
Ranson's criteria on admission
"GA Law"
- Glu > 200
- age > 55
- LDH > 350
- AST > 250
- WBC > 16
Cholangiocarcinoma types
1- below confluence
2- at confluence
3- R or L hep duct
4- R and L hep duct
5- multicentric
Glycogen
stores depleted after 24-48h of starvation
MOST found in skeletal muscle, rest in the liver
Types of esophogectomy
Transhiatal- laparotomy and cervical incision/anast
Ivor Lewis- thoracic incisions/anast
type 3 choledochocal cyst
choledochocele
tx- transduodenal marsupialization or excision
Treatment of colo-cutaenous fistula
- Start with conservative tx
- High output: > 500 cc/day --> likely OR
- Low Output: < 200 cc/dayt --> likely conservative
- OR if failed after about 6 weeks
CPP
MAP - ICP
normal CPP > 60
Normal ICP < 20
hyperventilation to 35 decreases CO2 causing vascoconstriction and decreasing ICP
Accessible nodal stations w/ EBUS
2, 3, 4, 7, 10, 11, 12
tx of Meckels
tx- resection if sxs.
- if appendicits leave Meckel's alone
- If no appendicitis take out the Meckel's
Only consider taking out incidentally found asx Meckel's in young/healthy pt
if bleeding, inflamed or tumor at base --> segmental resection
Hypocalcemia
tingling
chvostek/trousseau sign
EKG- qt prolongation
Angiodysplasia of the colon
2nd MC CO gi bleed (vs. div's)
Usually found in cecum and ascending colon
Effective for enteroccous
Ampicillin/Amoxacillin
Vancomycin
Timentin/Zosyn
(Resistant to all cephalosporins)
Lateral to medial femoral anatomy
Femoral nerve
Femoral artery
Femoral vein
Empty space (hernia)
Lacunar ligament
Superficial ring
Gastrin
G cells of antrum signal EC cells --> His --> Parietal cell --> HCl
Stimulated by ACh, beta ago, AA
Tx for gallstone ileus
Stable and healthy- stone removal and take down fistula
Unstable- stone removal only!
septic shock
high CI, low SVR, +/- wedge
Normal SBP in a neonate
60-90
How to reach D2 during EGD
right rotation and manipulate the up/down control knob
S/e of tamoxifen
dvt/pe
uterine cancer
Best test for resectability and staging of eso cancer
Resectability- ct
Staging- US
Specific to UC
Crypt abscess
Psuedopolyps
LeFort fxs
I- palate
II- nose and palate
III- entire face
Epoteitn
stimulated by HYPOXIA produced by kidney fibroblasts
Liver is major producer of EPO in fetus
Cutoff for low risk lung nodules not requiring follow-up
6mm
Best opioid to use for AKI
- methadone and fentanyl/sufentanil
- hydromorphone or oxycodone are used with caution
morphine and codeine are avoided
Anti-staph Penicillins
Oxacillin
Methicillin
Nafcillin
Bile concentration
Sodium chloride channels actively transport salt across the epithelium efficiently and water follows passively in response to the resultant osmotic force
Warthin tumor/Papillary cystadenoma
benign tumor of salivary gland
often BILATERAL and 2/2 smoking
Tx- complete resection with uninvolved margins even if ASx
Hurthle cell
Usually benign
MUST do lobectomy to diagnose
tx- total thyroid if malignant. XRT effective.
Neostigmine
reversal of non-depol muscle relaxantsAChE inhibitor
Imaging associated with benign adrenal mass
< 10HU
Rapid washout
< 4cm
ITP
px- petechiae and megakaryotcytes
tx- steroids (IVIG 2nd line)
- do not tx unless PLT < 30k or 20k in low risk
Paired vs. unparied t test
Paired- compares study subjects at 2 different times (paired observations of the same subject)
Unparied- compares two different subjects
Respiratory quotient
CO2 produced / O2 consumed
>1 → carb is major nutrient
.7 → lipids major nutrient
Absolute c/i to spinal anesthesia
Infection at the site
Hypovolemia
Allergy
Increased ICP
Parkland formula
4 x weight x TBSA 1st 1/2 in 1st 8h
2nd half next 16
Steps of rapid sequence intubation
c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine
Where to find superior and inferior PD during a whipple
Superior: pancreatic head
Inferior: uncinate process
Tx of Barrett's
low grade dysplasia: repeat scope/bx in 6m
high grade dysplasia: endoscopic mucosal resection
cyclosporine
MOA: calcineurin inhibitor
s/e- 100x less potent then tacro, nephrotoxic, hypertrichosis, gum hyperplasia
Effective for VRE
Synercid
Linezolid
Kaposi's sarcoma
HSV8
Violet/brown papules
T and N staging eso cancer
- t1a- LP and MM
- t1b- SM
- t2- MP
- t3- adventitia
- t4a- resectable structures
- t4b- unresectable structures
n1: 1-2 nodes
n2: 3-6 nodes
n3: 7+
CRC T and N
t1- SM
t2- MP
t3- xMP/subserosa
t4- invade
n1- 1-3, n2- >=4
Triple therapy
PP1 + 2 antibioticsabxs: amoxicillin, metronidazole, tetracycline, clarithromycin
Chole docho in REY bypass pt
w/ GB --> lap chole with CBD exploration --> ERCP through remnant stomach
w/out GB --> ERCP with double balloon endoscopt --> ERCP throught remnant stomach
bile salt circulation
- conjugate in hepatocytes into gly/taurine
- secreted into bile
- 80% reabsorbed in ileuim ACTIVELY
- 20% DECONJUGATED by bacteria
- deconjugated salts absorbed in colon PASSIVELY
- 6. 5% is excreted
Howship-Romburg Sign
Pain in medial thigh with internal rotation and extension
Suggests an obtruator hernia
MS vs. ED
MS- Fibrillin defect (elastin); AD, tall, aortic root dilation, lens defect, arachnodactyly
ED- t1, t3 , t5 collagen defect; hyper elastic skin, hypermobile joints
Most abundant bacteria in the colon
Bacteroides fragiles
Liver lesions on arterial phase:
- HCC
- Mets
- Adenoma
- Hemangioma
- FNH
- HCC- Homogeneous enhancement
- Mets- Hypoattenuation
- Adenoma- Heterogeneous enhancement
- Hemangioma- Periph enhancing
- FNH- Centrifugal enhancing
Number of lung segments
R-10
L-8
confounding
a variable that influences both the dependent variable and independent variable causing a spurious association
Epidural hematoma
Biconvex
MMA
DOES NOT suture lines
Bethesda criteria for thyroid
10 mm is cutoff to get an FNA
- Non-diagnostic → repeat FNA
- Benign → follow-up
- Undetermined significance → repeat FNA
- Suspicious for follicular neoplasm → lobectomy, repeat FNA, or genetic testing (no core needle)
- Suspicious for malignancy → lobectomy vs. thyroidectomy
- Malignant → thyroidectomy
Effective for P/A/S
Ticarcillin (+ticarcillin), Piperacillin (+Zosyn)
3/4G cephalosporin (ceftriaxone, cefepime)
Aminoglycodies (genta, tobra)
Flouroquinolones
Meropenem/Imipenem
HNPCC and criteria
HNPCC pts who fulfill Amsterdam clinical criteria for Lynch syndrome
Criteria:
- 3 relatives (one 1st deg) w/ Lynch syndrome-associated cancer (CRC, endometrial, small bowel, ureter/renal)
- 2 successive generations
- 1 < 50 yo
MALT lymphoma
associated w/ h. Pylori.
Tx:
- Low grade: triple therapy
- High grade: chemo and XRT (CHOP) +/- rituximab
MCCO chylous ascites
malignancy
Gastroschisis
GastRoschisis to the Right of midline
rare defects...EXCEPTION- instestinal atResia
Tx of AT3 def
Heparin does not work!
Tx- recombinant at3 or FFP followed by heparin then warfarin
Indications to tx ICA stenosis
if Asx, only tx if > 60
if sx, tx if > 50
sxs- contralateral motor/sensory sxs, ipsi vision sxs
STSG vs. FTSG
STSG- epi + part dermis; worse cosmesis; more contracture! (don't use over joints)
FTSG- epi + dermis; lower survival; more resistant; hypertrophic scar formation; more sensation
ASA
irreversible inhibitor of PG metabolism in PLTs
2/2 cox acetylation
7-days of PLT dysfunction
Tx for beta blocker overdose
glucagon
Products of anterior pituitary
TSH, ACTH, FSH/LH, GH, Pro
neurosecretory cell stimulates hypothalamus which lets go of releasing hormone
Rapid coumadin reversal
PCC
Pyoderma gangrenosum
associated w/ IBD
RESOLVES after resection
pre-tibial
tx- steroids
Central cord syndrome
loss of pain, temp, motor
motor UE> LE loss (vs. anterior syndrome)
Scope schedule after Crohn's dx
10 years after dx then every year to r/o dysplasia
TNFa
produced by macrophages
causes cachexia
Beckwith Wiedmann Syndrome
3m-2yAssociated with hepatoblastoma and wilm's tumor
type 1 choledochocal cyst
fusiform dilationtx- excision w/ REY H-J
Cryo
vWF, f8, fibrinogen
Breslow depth
t1: < 1mm → .5-1 cm margin
t2: 1-2 mm → 1-2 cm margin
t3: > 2 mm → 2 cm margin
Best test to dx gastroparesis
Scintigraphic gastric emptying
Atlanta classification pancreatits
1. Interstitial:
- <4w- acute peripanc collection,
- >4w psuedocys
t2. Necrotic:
- <4w- acute necrotic collection
- >4w- walled of necrosis
FFP
All factors, Protein C and S, AT3
Child's Pugh Score
Billirubin, Albumin, INR, Ascites, Encephalopathy
ARDS ratio
P/F
- mild- 200 to 300
- moderate 100-200
- severe < 100
Orientation of portal triad
Bile duct lateral
Hepatic artery medial
Portal vein posterior
Schiatzki's Ring
Associated with hiatal hernia
Tx- only if sxatic. dilation and PPI; do not resect
MOA reglan and erythromcyin
reglan: dopamine antagonist
erythromycin: motlin receptor agonist causing SM contraction
indications to bx a neck mass
confirm FNA or core needle with excisional biopsy!
- >1.5 cm
- enlarged node without signs of infection
- persistence after trial of antibiotics and observation >2-4 wks
- increasing size of mass
Peri-op anti-PLT agents
Clopidogrel (plavix): hold 5-7 days before elective surgery
ASA: continue through the surgery
neurogenic shock
high CI, low SVR, low wedge
Indications for iHD
GFR 10-15 for sxatic
GFR < 5 for asymptomatic
Sxs = AEIOU (acid, lytes, intox, olverload, uremia)
Breast Cancer in pregnancy
1T- MRM. Chemo is not OK.
2T/3T- consider BCT. Modfied radio-isotope. Chemo is OK. Post delivery radiation.
Who needs stress dose steroids
>20 mg of steroids for > 3 weeks
Frey syndrome
gustatory sweating s/p parotidectomy
Layers of colon/rectum
1. mucosa
2. sub-mucosa
3. muscularis propria
4. serosa
FNH
path- CENTRAL STELLATE SCAR!; bright on arterial phase homogenous
tx- resect if sxatic. no malignant potential.
TOF
Most common cyanotic defect
VSD, PS, OA, RVH
tx- beta blocker; surgery at 3-6m
Omphalocele
2/2 failure of umbo ring closure 11th week gut returns to abdominal cavity
normal bowel (protected)
Other congenital defect are more common
Hard signs of vascular injury
shock
expanding hematoma
pulsatile bleed
thrill/bruit
absent pulse
ischemia
Primary lymphoid organ vs. secondary
Primary: generate cells i.e. liver, bone, thymus
Secondary: maintain cells i.e. nodes, spleen, MALT
Tx of liver lesions:
Hemangioma
FNH
Adenoma
- Hemangioma: only if sxatic or KM syndrome
- FNH: NTD
- Adenoma: < 4cm w/out OCP response or > 4cm
s/e of silver nitrate, silver sulfadiazene, mafenide
Silver nitrate- eletrolytes disturbace (no sulfa)
Silver sulfadizene- neutropenia, sulfa
Mafenide- met acidosis, sulfa
Tx of complete CBD transection
REY HJ has better long term outcome than primary repair
Indications for neoadjuvant therapy for stomach cancer
Any T2 lesion or LN involvement
T2: growth into the muscularis propria
Number of LN needed for gastric vs. CRC
gastric- 15CRC- 12
Thyroid ima
supplies medial aspect of both lobes of the thyroidcome off the innominate/brachiocephalic
long chain vs. medium chain TG
LC- absorbed by lymphatics
MC- absorbed into blood
Fuel for SB and LB
SB- glutamine
LB- SCFA
Torsades
2/2 hypoK, hypoCa, hypoMg
all cause qt prolongation
Carcinoid vs. GIST origin and tx
- carcinoid- Kulchinsky cells (enterochromaffin-like)
- < 2cm --> appendectomy
- > 2cm --> R hemi
- chemo if unresectable
- GIST- cajal cells
- tx- resection
- imantinib
Thoracic duct course
originates at L1-L2 @ c. chyli
cross from R to L at T4-5
empties into L SC/IJ jxn
TOF anomalies
- Over-riding aorta
- RV hypertrophy
- VSD
- RV obstruction
Sevoflurane
rapid induction, less laryngospasm, less pungent
good for mask induction
s/e- expensive, liver metabolism
Inidications for neoadjuvant chemotherapy for rectal cancer
Stage 2 and above
Stage 2: at least t3 (crossing musc prop) or any n (stage 3)
Screening guidelines for breast ca
annual screening at age 40
DDAVP
Cause endothelium to release f8 and vWF
Iron def
anemia, glossitis, brittle nails, cardiomegaly
Types of vagotomy
Highly selective: only removes innervation to lesser curvature
- preserves pylorus → no drainage procedure
Truncal vagotomy: removes lesser curve and pylorus nerves (upstream)
- need pyloroplasty. high r/o dumping syndrome
Vitamin K
gamma CARBOXYLATION (not decarb) of GLUTAMATE on 2, 7, 9, 10, c, s
Spigelian hernia
found along semilunar line lateral to rectus
all should be repaired
Ethylene glycol toxicity
metabolized in the liveroxalate stones → renal failureanion gap met acid
type 4 choledochocal cyst
extra/intra dilations
tx- excision w/ REH H-J
Hyperacute rejection mechanism
Host IgG towards class 1 MHC
PPV, NPV
PPV = of the people who test positive how many have the disease
NPV = of the people who test negative how many do not have the disease
Isoflurane
good for neurosurgery; no increase in ICP
Indications for neoadjuvant therapy eso cancer
t1b and above OR
any nodal involvement
MCCO healthcare infection:
- HAP
- central line infection
- SSI
- UTI
- GI infection
- HAP: staph
- central line infection- candida
- SSI- staph
- UTI- e. Coli
- GI infection- c. diff
Peutz-Jeghers
AD
Px- intestinal hamartomas, pigmented oral mucosa
Start screening at 25; scope q2 years
T and N staging for gastric cancer
t1- SM
t2- MP
t3- xMP/subserosa
t4- invade
n1: 1-2, n2: 3-6, n3: >7
MC uni-microbial CO nec fasc
Clostridium perfringens
gas gangrene
anaerobic
Calcitonin
Parafollicular C cells Inhibits osteoclast resorption
Increases Ph excretion
Halothane
Slow onset/offset.
Least pungent (children)
s/e:- highest cards depression and arrhythmia
- halothane hepatitis
types of endoleak and tx
1- proximal or distal seal --> emergent!
2- back bleeding
3- graft defect (tear or overlap leak) --> emergent!
4- porosity
ASD
L to R shunt
Ostium primum (down syndrome) and secundum
Paradoxical emboli
Repair at 1-2y
Atropine
competitive inhibitor of ACh at muscarinic receptor liver metabolism
Zinc def
skin rash, impaired wound healing, testicular atrophy
Hepatitis seromarkers
Vaccinated: surface Ab POSITIVE
Resolved Hb infection: surface Ab POSITIVE and core Ab POSITIVE
Active infection: surface Ag, surface Ab, and core Ab ALL POSITIVE
MCCO Cancer
Male- prostate, lung, CRC
- lung, prostate, CRC
Women- breast, lung , CRC
- death: lung, breast, CRC
Hereditary pancreatitis
PRSS1 trypsinogen mut'n
AD
smoking cessation is important
type 2 choledochocal cyst
cystic diverticula
tx- excision w/ primary closure (NOT a REY)
Reversals:
- BB
- Tylenol
- Benzos
- CN/Nitroprusside
- Vecuronium/Rocuronium
- Ethylene glycol
- Methemoglobinemia
- BB overdose: fluids/atropine → glucagon
- Tylenol: NAC
- Benzos: flumazenil
- CN/Nitroprusside: sodium thiosulfate, amyl nitrite
- Vecuronium/Rocuronium: sugammadex
- Ethylene glycol: femopizole and bicarb OR ethanol; iHD
- Methemoglobinemia: methylene blue
TASC classifcation
TASC a and b usually get endovascular repair
A- < 3cm
B- 3-10 cm
Superior laryngeal nerve
motor to cricothyroidinjury: high pitch
Lipopolysaccharide
cell wall of GN bacteria endotoxin
activates complements cascade → sepsis
Tylenol metabolsim
- Glucuronidation (45-55%)
- Sulfation (sulfate conjugation) (20–30%)
- N-hydroxylation and dehydration, then glutathione conjugation, (less than 15%)
- hepatic cytochrome P450 enzyme system
- NAPQI
F5 Leiden
resistance to protein C and S
acts w/ Xa to converts fibrinogen to fibrin
Paget Von Schroetter syndrome
narrowing of SC/Ax vein 2/2 mech compression
px- acute swelling
Tx- catheter directed thrombolysis (NOT open thrombectomy)
Lung fissures
Oblique fissure: aka major fissure; separates upper lobe from lower lobe +/- middle
Horizontal fissure: aka minor fissure; only on the R; separates upper lobe from middle lobe
Treatment of Merkel Cell
excision
highly radiosensitive. radiate if > 2cm
SLNBx
Mucoepidermoid carcinoma
MC malignant H/N tumor
Staging GB cancer
1a- LP --> just cc'ectomy
1b- MM --> cc'ectomy, hepatic/ LN/duct resection
t2- perimuscular CT
t3- organs
Copper def
pancytopenia, myelopathy, pigmentation change
CRC staging
stage 1- t1 to t2, n0
stage 2- t3 to t4, n0
stage 3- node involvement
stage 4- m1
sirolimus
MOA: mTOR inhibitor
s/e- lymphocele, wound complications
- lymphcele can cause mesenteric mass and SBO
benefit- less nephrotoxic
DES
unorganized peristalisis
normal LES pressure
normal relaxation
Selenium def
cardiomyopathy, hypothyroid
Clinical trial phase
1- determine safe dosing and route
2- evaluate effectiveness and side effects
3- determine if better than alternatives
4- follow individuals for s/e's
Echinoccocus
Hydatid cyst
tx w/ mebendazole
Heparin
accelerates AT3 activity and INDIRECTLY inhibits thrombin
hepatic adenoma
path- EARLY HETEROGENEOUS enhancement on A phase w/ rapid washout
tx- stop OCP use. resect if > 5cm or sxatic
Specific to Crohn's disease
Cobblestoning
Granulomas
Transmural Fistulas
Free water deficit
TBW x [(Na-140)/140]
TBW = weight x .6 (men) or .5 (women)
Spinal vs. Epidural
Spinal- below l1/l2; SA space; fast; n/m block
Epidural- any level; epidural space; slow; no block
Tx SIADH
Chronic – Tx: fluid restriction and diuresis
Acute – Tx: conivaptan, tolvaptan
Rocuronium
non-depol
rapid onset; best for short procedures
eliminated by liver only
type 1 vs. type 2 error
type 1: false positive
type 2: false negative
power = 1 - type2
Periop DM management
Oral agents:
- hold ON THE MORNING of surgery.
- Resume after surgery (EXCEPT for metformin)
Rapid IV agents:
- withhold while NPO and use with a sliding scale
Intermediate/Long acting:
- give normal dose the night before
- Give ½ dose the morning of surgery
Pump: keep a basal insulin infusion on the day of surgery - use pump to correct levels as needed
T staging indications for neoadjuvant
- eso
- stomach
- colon
- rectal
- eso: t1b (SM)
- stomach: t2 (MP)
- colon: t4b (adjacent organs)
- rectal: t3 (through MP)
Ureter injuries
proximal ⅓ → primary ureterourostomy
middle ⅓ → primary or tran uretero urosotomy
lower ⅓ → re-implanation +/- hitch
Hot vs. cold nodules
Hot- surgery or iodine ablation --> unlikely cancer
Cold- FNA --> may be cancer
Post splenectomy ppx
"SHiN"
PPV23 + haemophilus influenzae TYPE B + meningococcal polysaccharide
Electively- 2 weeks before
Emergently- PPV23 directly postop, other two given 2 w post op
Milan criteria
indications for trx w/ HCC
- Single tumor < 5cm
- No more than 3 tumors each < 3 cm
5-year transplant pt survival is 65-90%
Isoflurane
Good for neurosurgery
Pungent (not used for induction)
Hyperkalemia EKG
peaked T wave
Dexmedetomidine
Mech- CNS alpha2 ago
Not an induction agent. Good for intubated pts
Anesthesia and analgesia
s/e- bradycardia
MC aortic infections
aneurysmal- staph
non-aneurysm- salmonella
febrile transfusion rxn
RECIPIENTS Ab attack DONOR leukocytes
Tx of breast CA in preg
partial mastectomy + radiation after preg OR full mastectomy
trastuzumab is c/i
Octreotide
Somatostatin analogue
Inhibits exocrine function of pancreas and CCK release
Tx for chronic pancreatitis
Latent error
2/2 condition of system being removed
evident after a “perfect storm”
Specific to Crohn's
Creeping fat
Skip lesions
Transmural
Polyps that require surgery instead of endoscopic resection
Submucosal invasion > 1mm
Poorly differentiated
<1 mm margin
Lymphovascular invasion
Tumor budding
Sessile polyp (if you can't get it all)
Blood supply of pancreas
Head: superior PD and inferior PD
Body/tail: splenic
Mondor disease
tender, “cord-like” structure
tx- NSAIDs
Criteria for transanal excision of adenocarcinoma
T0 or T1 (submucosa)
< 3 cm
< 30% circumference
Palpable on DRE (<8cm from anal verge)
Meckel's Diverticulum
Anti-mesenteric border of SB
2/2 peristant viteline duct
pancreatic and gastric tissue
Acetazolamide
Inhbitis carbonic anhydrase
Interferes with bicarb resorbtion causing non-AG metabolic acidosis
hypovolemic shock
low CI, high SVR, low wedge
Tx for hemobilia
angioembolization
PFTs for lung resection
FEV1 >1.5L lobe, >2L pneumo --> OK for surgery
If not: lung scan
PPO FEV1 > .8L (>40%)
PPO DLCO > 10 ml/min/mmHg (>40%)
If not: exercise test
VO2 > 10 ml/min/kg --> OK for surgery
Succinylcholine
ONLY depolarizing
short half life and rapid onset (RSI)
degraded by plasma CE
s/e: rhabdo, ocular HTN, malig hyperthermia, hyperK
c/i: spinal cord injury, renal failure, large burns
dcis vs. lcis
- dcis: excisional bx
- 1mm margin
- no SLN unless mastectomy
- lcis: excisional bx
- margin for LCIS --> no further intervention. consider hormone tx or ppx mastectomy
- margin positive for DCIS/invasive ca --> surgery
Sarcoma T and N staging
T1- <5 cm
T2- > 5cm
N1- regional nodes
Etomidate
Fewer hemodynamic changes
Fast acting
Fewest cards s/e
s/e- adrenocortical suppresion w/ cont infusion
basiliximab
MOA: IL2 inhibitor
Midodrine
a1 agonist
Li Fraumeni
p53 mutation
breast ca + soft tissue sarcoma
Tx of Ogilvie's
supportive, dc narcotics, ng tube, neostigmine
if > 10cm --> scope decompression and neostimgine
- failure --> OR
MCCO cauti
1. e. coli
2. enterococcus
3. candida
cardiogenic
low CI, high SVR, high wedge
GCS eye opening
4- spon
3- to voice
2- to pain
1- none
Dysplasia of any grade in the GI tract
polypectomy will suffice
need to re-scope in 3m if high grade or sessile
if there is SM invasion --> surgical resection
Markers:
Ca 125
bHCG
AFP
Inhibin
Ca 125- epithelial
bHCG- choriocarcinoma
AFP- germ cell/endodermal/yolk sac
Inhibin- granulosa/sex-cord
Inguinal hernia nerves
Ilioinguinal- MC in open repair; runs ant/top of cord; under EO
Iliohypogastric
GB of GF
Lateral femoral cutaneous- MC in lap repair; injured laterally
Axis of gastric volvulus
- Organoaxial: rotate around the long/vertical axis
- Mesenteroaxial: rotate around wide/horizontal axis
neostigmine
MOA: increased PS activity (AChE-I)
tx for ogilvie's
MONITORED SETTING w/ atropine b/c high r/o BRADYCARDIA
b4 r/o mech obsxn 1st or r/o perf b/c of enhanced motility and pressure
Somatostatinoma
Loc: head
Px: DM, gallstones, steatorrhea, block exo/endo pancreas
Tx of prolactinoma
if sxatic or macroadenoma
- bromocriptine or carbegoline (both dopa agonists)
- bromo is safe in pregnancy
surgery if failure
Sub-acute thyroiditis
Recent viral URI
tx- NSAIDs/steroids
Variceal bleeding 2/2 pancreatits
Splenic vein thrombosis
tx- splenectomy
VW disease
1- low quantity. tx- desmo and cryo
2- low quality: tx- only cryo
3- complete absence: tx- cryo and desmo
dx- ristocetin test or measure vWF level
Loss in excess weight for each surgery
REYGB- 75%
SG- 60%
Lap band- 50%
Gastric ulcers
1- lesser curve/antrum; normal acid
2- gastric + duo; high acid
3- pre pyloric: high acid
4- GE junction: normal acid
Modified radical mastectomy
mastectomy with ALND (level 1 and 2 only) w/ sparing of pectoralis
layers of the eso
- Mucosa
- epithelium
- LP
- MM
- Sub-mucosa (lots of lyphatics!)
- MP
- Adventitia
NO serosa!
Duration of treatment - tamoxifen and trastuzumab
Tamoxifen- 5y
Trastuzumab- 1y
F11 def
r/o bleeding w/ surgery
tx- FFP (not f11 concentrate!)
Margin for LE sarcoma
2cm
Somatostatin
D cells in stomach, duo and panc
Shuts off insulin, glucagon, and gastrin
Stimulated by acid
Stimulation of CCK release
fatty acids and amino acids in the chyme entering the duodenum
CCK-releasing protein
ACh
Order of potency of steroids
- HC
- Pred
- Methylpred
- Dexameth
Cowden's
pten mutation
breast ca + thyroid ca + hamartomas
long thoracic nerve vs. thoracodorsal nerve
LTN → serratus --> winged scap
TD → LD --> difficult shoulder ADduction/Int rotation
PLT count trx threhold
Stable and non-bleeding --> < 10K
Stable and non-bleeding with temp > 38 --> < 20k
Surgical pt < 50k
<20K spontaneous bleeds
NNT`
NNT = 1/absolute risk reduction (ARR)
ARR = event rate in intervention group - rate in null group
half-life acoags:
war
hep
noac
war - 36h
hep 90m
noac- 12h
3.5 half lives to ss
Achalasia
no peristalsis
high LES pressure
incomplete relaxation
MEN syndromes
1- panc, pit, PT
2a- PT, MTC, pheo
2b- pheo, MTC, marfanoid/neuromas
Tx of cholangiocarcinoma
1. Upper 3rd- duct resection w/ partial hepatectomy
2. Middle 3rd- bile duct resection + LADN
3. Lower 3rd- Whipple
*Locally advanced/unresectable- transplant
Types of Shunts
- Total: porto-caval, meso-caval
- Relieves bleeding and ascites
- More hepatic encephalopathy
- Partial: distal spleno-renal
- Relives bleeding only
Glucagonoma
Loc: distal
Px: dermatitis, DRH, DM, nec mig erythema
MELD
- Bili
- INR
- Creatinine
Pancreatic ducts
Wirsung- major, lies inferior
Santorini- minor, lies superior
Hypokalemia EKG
qt prolongation
Entamoeba histo
MExico
tx with MEtronidazole (no OR!)
NO rim enhancement (vs. amoebic abscess)
dx- EIA (assay)
Group A strep
strep pyogenes
suspect if gas and bullae
Imatinib
competitive inhibitor of TK
tx for GIST
Tx of ovarian vein thrombosis
Anticoagulation
Abx if septic sxs
Pyogenic abscess
MC- biliary dz and bile obstruction; e. Coli and kleb
tx- perc drainage is 1st line!
clostridium
anaerobic, GPR
MC CO emphysematous cholecystitis
MC CO gas gangrene
tx- PCN, clinda 2nd line
Light's criteria
- PL protein/serum Pr >.5
- PL LDH/serum LDH > .6
- PL LDH > 2/3 ULN
Tx of psuedocyst
<6cm and <6w --> conservative
>6cm and >6w --> drain if sxatic (perc cath, endoscopic methods, or surgery)
Arterial content
(1.34 x Hb x Sa02) + (.003 x PaO2)
tx of eso cancer by t stage
t1a- mucosal resection
t1b- esophagectomy
t2- esophagectomy
t3- esophagectomy
t4a- esophagectomy
t4b- chemo/rads
cervical- chemo/rads
FAP screening and treatment
- Scopes annually starting at 10-12y
- life-long screening for APC carriers.
- Can stop at 40 if not APC carrier
Indications for colectomy
- Suspected colorectal cancer
- Severe symptoms
- High-grade dysplasia
- Multiple adenomas larger than 6 mm
- Marked increases in polyp number on consecutive exams
- Inability to adequately survey the colon because of multiple diminutive polyps
Stewart-Treves syndrome
post mastectomy lymphangiosarcoma
rare and highly malignant
Tx- wide local excision w/ 3-6 cm margin
Fibrinogen
binds gp2b/3a receptors to link PLTs together
Ranson's criteria at 48 h
"C and Hobbs"
- Ca < 8
- HCT down > 10 pts
- O2 < 60
- Base deficit > 4
- BUN > 5
- Sequestration of fluids > 6L
Hemangioma
path- PERIPHERAL ENHANCEMENT
tx- if rupture, size change, or KM syndrome
Drainage of gonadal veins
R- IVC
L- L renal vein
T staging for HCC
T1: any size without vascular invasion
T2: < 5 cm with vascular invasion
T3: > 5 cm with vascular invasion
T4: invade adjacent organs
Indications of breast MRI
- high risk women
- occult breast cancer
T staging for esophageal cancer
t1a- muscularis mucosa
t1b- SM
t2- muscularis propria
t3- adventitia
*no serosa
Halothane
cheapest
effective at low concentration
s/e- ventricular arrhythmia, hepatic necrosis
Stress induced gastritis
Stress elevated ACh
ACh --> parietal cells --> ATPase H+ secretion
Grading of splenic injury
1- <1 cm,
2- 1-5 cm,
3- > 5cm,
4- segment/hilar vessels,
5- shattered
Return to activity → injury grade + 2; so grade 2 would be 4 weeks
Tx of Zenkers
<2cm: circopharyngeal myotomy
2-5 cm: myotomy +/- diverticulectomy
>5cm: myotomy + diverticulectomy
Liver collection tx
Pyo-
Amoebic-
Echino-
Pyogenic- drain and abx
Amoebic- metronidazole
Echinococcal- albendazole and resect
AT3 def
AD
non-vit K dependent protease for 10a potentiated by heparin
tx- FFP
Fibrolamellar HCC
well circumscribed w/ central scar similar to FNH
normal AFP and elevated neurotensin (Vs. FNH)
Warfarin
competitive inhibitor of epoxide reductase (vit K activator)
Human bite tx
amox/clavulanate (augmentin)
MC for human bites- eikenella
Variceal bleeding after distal pancreatectomy
Gastric varices
NNT
1/ARR
ARR = risk w/ tx - risk w/ placebo
Surveilance schedule for FAP, HNPCC
FAP- start at 10
HNPCC- start at 20
preA vs. Albumin
Prealbumin: t1/2 is 1-2 days; best marker for short-term nutritional status
Albumin: t1/2 is 21 days; biomarker of long term nutrition; pre op assessment
Cause of:
graves
TMN
Hashimoto's
DeQuervains
graves- IgG against TSHr
TMN- hyperplasia 2/2 low grade TSH stimulation
Hashimoto's- antiTG abs (cell-med and humoral)
DeQuervains- viral URI
Mechanical valve periop
restart coumadin in 12-24h and bridge w/ heparin or lovenox
Vitamin D processing
7-DHC + sunlight --> d3
liver --> 25-d3
kindey --> 1,25-d3
Requirements for lung surgery
- FEV1 > 1.5L (lobectomy), > 2L pneumonectomy
- pppo FEV1 > 40%
- ppo DLCO > 40%
- VO2max > 15
TRAM flap
SUPERIOR epigastric arterycan use ipsi or contra muscle
Normal values: CVP, WP, SVR, CI
CVP 2-6
WP 4-12
SVR 700-1500
CI 2.5-4
Loop diuretics vs. Ca sparing diuretics
loop- furosemide
Ca sparing- thiazides
Indications for chemo with breast cancer
> 1cm
Cx positive nodes
Triple negative
Poor oncotype
TLV
TLV = RV + ERV + TV + IRV
FRC = RV + ERV
IC = TV + IRV
VIPoma
Loc: distal
Px: watery DRH, hypoK, achlorhydria, inhibits gastrin
Types of rejection
hyperacute- preformed IgG against donor; t2HS
acute- T and B cell resposne to MHC; t4HS
graft vs. host- graft T-cells attach host; t4HS
Neoinitmal hyperplasia
- proliferation and migration of vascular smooth muscle cells primarily in the tunica intima, resulting in the thickening of arterial walls and decreased arterial lumen space.
- cause of restonisis after CEA
Benign lesions that require excisional bx
- Atypical DH/LH
- LCIS/DCIS
- radial scar
- papillary lesion
- any atypia
MC nerve injury Br/Bac fistula
medial brachial cutaneous n.
Pyloric stenosis
px- hypochloremic, hypokalemic metabolic alkalosis
dx- US
tx- pyloromyotomy
Treatment of SVT
Vagal maneuvers or adenosine
Fuel for colonocytes
SCFA (acetate, butyrate, propionate)
Tx for hyponatermia
Acute sxatic: hypertonic saline
Hypervolemia: hypertonic saline
Euvolemic and asxatic: free water restriction
Hypovolemic: volume resuscitate w/ LR or NS
Zone injuries
penetrating:
- zone 1-3 --> explore
blunt:
- zone1 --> explore
- zone 2-3 --> do not explore
Wiskott-Aldrich Syndrome
X-linked
TCPenia + combined b/t cell def + eczema
hot vs cold nodules
hot- surgery or iodine ablation
cold- FNA
TTP
path- def in ADAMtS13
px- TCP purpura, neuro sx, kidney dz, hemo anemia, fever
tx- plasmapheresis → splenectomy if failed
Layers of mucosa
Epithelium
Lamino Propria
Muscularis mucosa
What is not suppressed by high dose dexa
Adrenal mass
Ectopic mass (small cell cancer)
MOA of tacro, cyclosporine, sirolimus, mmf, basiliximab
tacro- calcineurin inhibitor
cyclosporine- calcineurin inhibitor
sirolimus- mTor inhibitor
mmf- cell cycle inhibitor
basilixamab- il2 inhibitor
Enzymes secreted in their active form from pancreas
Amylase/Lipase
Ribonuclease/Deoxyribonuclease
Gastrinoma
Loc: gastrinoma triangle (CBD, panic neck, 3D)
Px: refractory PUD, gastrin > 200 on sec stim test
dx of colovag and colovesic fistula
colovag: tampon test
colovesic: CT scan
SCIP guidelines
- Ppx abx 1 hour before incision (vanc can be 2hr)
- DC abx 24h after end time
- 48h for cardiac surgery
- Cardiac pt should have glucose should be < 200 on POD1 and 2
- Shaving is inappropriate; should clip hair
- Remove foley on POD1 or 2
- Maintain normothermia (=> than 36)
- Recieve BB 1 day prior to surgery through POD2
- VTE prophy within 24h of end time
Milrinone
PD inhibitor
contractility with vasodilation
great for pulmonary hypertension
HNPCC inheritance - Amsterdam criteria
AD
Defect in MLH/MSH
- 3x relatives
- 2x generations
- 1x < 50y
Richter's hernia
protrusion and/or strangulation of part of the intestine's anti-mesenteric border
Plasmin
degrades fibrin and fibrinogen
activated by urokinase and streptokinase
HNPCC screening and treatment
- scope q1-2y starting at 20-25
- Surgery if: CRC or endoscopically unresectable
- TAC with IRA and surveillance rectum
- prophylactic hysterectomy and BSO offered at the time of colectomy
- Other screens:
- Annual pelvic exam, endometrial bx, TVUS
- Upper endoscopy with bx of antrum. treatment of H. pylori infection
- Annual urinalysis
- Annual skin/neuro exams
Melanoma types
superficial spreading- MC
lentigo- sun exposed, best prog
nodular- worst prog
Replaced R and L hepatic
R- SMA
L- left gastric
RQ of fat, carb, and protein
Carb = 1
Protein = .8
Fat = .7
RR vs. OR
RR: of those who were exposed how many got the dz/of those who were not exposed how many got the dz
- considers total population. good for prospective
OR: odds of exposure in cases / odds of exposure in controls
(a/c) / (b/d)
- good for retrospective
Encapsulate organisms
Strep pneumo (MC)
Neisseria
Haemophilus
MMF
MOA: cell cycle inhibitor
Immunonutrients
Glutamine
Arginine
Omega-3 FA
Gail model
age
age 1st period
age 1st birth
1d relative
previous bx
race
When to operate on adrenal mass
all functioning tumors
all > 6 cm --> open resection (no lap)
if < 6cm with suspicious features (>10HU, slow w/out) --> open resection (no lap)
if bilateral --> tx medically w/spironolactone
Origins of medullary thyroid cancer
4th pharyngeal arch releases NCC which form parafollicular C cells
Bile Acids
750 cc/day secreted
Primary bile acids- cholic, chenodeoxycholic
Secondary bile acids- deoxycholic, lithocholic
primary bile acids produced by the liver then undergo deconjugation in the gut by bacteria.
Component separation
External oblique fascia
VHL
up regulation of vegf
hyper vascular tumors
Felty syndrome
rheumatoid arthritis, splenomegaly, granulocytopenia
Merkel cell ca
rare neuroendocrine tumor of the skin
looks like BCC w/out rolled edges
highly radiosensitive
Tx- surgical excision + SLNBx + XRT
Aminocaproic acid
Plasmin inhibitor
Use: DIC, excess tpa
Secretin vs. CCK
Both released by duo
S cells --> Secretin- duct cells --> bicarb
I cells --> CCK- acinar cells --> enzymes
Nutcracker eso
high amplitude/long peristalsis
normal LES pressure
normal relaxation
Ectopic parathyroids
superior parathyroids is the tracheoesophageal groove and retroesophageal region.
inferior parathyroids- anterior mediastinum, thymus, thyroid gland
421 rule for mIVF
4 ml/kg/hr for 1st 10 kg
+2 for next 10-20
+1 for every kg above 20
Inidications for non-op managemement of eso perf
- early diagnosis or delayed diagnosis with contained leak
- not in the abdomen
- contained perforation in the mediastinum
- content of the perf drain back to the esophagus
- perforation does not involve neoplasm or obstruction of the esophagus
- absence of sepsis
Treatment of GB polyp
Sxatic --> resect
High risk or > 6mm --> resect
Low risk --> EUS
> 18 mm --> open cholecystectomy, partial liver resection, and possible lymph node dissection
Gallbladder polyps that are not resected should be followed-up with serial ultrasound examinations
Se, Sp
Sensitivity = of the people who have the disease how many test positive
Specific = of the people who don’t have the disease how many test negative
z11 trial implications
If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK
Splenic vein thrombosis
If variceal bleeding tx with splenectomy
Cervical neoplasia
CIN1- tx infection, close f/up
CIN2- cryo or leep
CIN3- cryo or leep
McVay repair
Hernia repair without mesh
Approximates TAA to cooper's ligament
GCS motor
6- obeys commands
5- localized
4- w/draws
3- flexion (decort)
2- extension (decerebrate)
1- none
Minimum negative margin for BCC
4 mm for unaggressive
8 mm for aggressive tumors
CO2 vs. NO2 for pneumoperitoneum
CO2 advantage
- doesn't combust. less expensive.
CO2 disadvantage
- acidosis, long elimination, sympathomimetic
Mattox maneuver
"L --> Mattox"
move left structures to the right
exposure left sided vasculatre
explore aorta and L renal vein
Propofol
Rapid distribution and on/off
s/e- hypotension, resp depression, meta acid
metabolism- liver
Pancreas drainage procedures
Peustow- pancreaticojej (for large duct)
Frey- pancreasticojej + core out head
Berger- pancreatic head resection (for large head)
Recurrent laryngeal nerve
motor to larynx excluding circothryoidinjury: hoarsness, airway compromise
Cryo used to treat?
1. VWD
2. Fibrinogen def
3. Hemophilia A
Tx for DVT
unprovoked: no RF --> 3-6m acoag
provoked: RF --> 3m
open thrombectomy --> last resort for threatened limb loss secondary to extensive DVT and phlegmasia
Contents of FFP and Cryo
FFP: all clotting factors; f5 and 8 decrease over time
Cryo: VWF, f8, fibrinogen
Ureter anatomy
Runs under the vas/uterine arteries
Runs over the iliacs
Trauma to the pancreas
head
- main duct: drain w/ staged resection
- tail: drain
tail
- main duct: drain
- tail: resect w/ splenectomy (unless child)
Central venous O2 vs. mixed venous O2
Mixed venous: from PA
Central venous: from SVC only (estimation of mixed)
Exposing the pancreas
- Head: kocherize
- Body: incise gastrocolic ligament --> lesser sac
- Tail: mobilize spleen
Cuff size for kids
age/4 + 4
Crystalloid and colloid for trauma kids
Crystalloid: 20cc/kg
PRBC: 10cc/kg
qSOFA score
AMS (<15)
RR > 22
SBP < 100
Nitrogen balance
Nitrogen Balance =
Protein intake (grams)/6.25 - (UUN + 4 grams)
UUN = grams of nitrogen excreted in the urine over a 24 hour period
4 = stool and insensible losses
s/e of carb, protein, and lipid
carb- immunosuppression, resp failure
lipid- pro inflammatory
protein- false neurotransmitters, rise in ammonia/urea
Serum osm calculation
2xNa + Glu/18 + BUN/2.8
Corrected Ca
For every 1 drop in albumin below 4, serum Ca drops by .8
Acid/Base of Ng suctioning
HypoCl, HypoK metabolic alk
Loose HCl and fluid
Turn on RAA system
Retain Na/Excrete acid (paradoxic acidurea)
Acetazolamide
MOA: Ca inhibitor
Causes kidneys to excrete bicarb causing a metabolic acidosis
Ileal conduit
Hyperchloremic metabolic acidosis
(urine high in Cl is exchanged for bicarb which is excreted)
MC ST sarcoma and dx and tx
MC- malignant fibrous histiosarcoma then liposarcoma
dx- core needle then -->
- <4cm: excisional
- >4cm: long. incisional
tx- resection. post op xrt if > 5cm. pre op if > 10cm. doxorubicin.
Penecillins evolution
- Penicillin: strep
- Methicillin, Oxacillin, Nafcillin: staph
- Ampicillin, Amoxacillin: enteroccocus
- Unasyn/Augmentin: GNRs (not psuedo)
- Ticarcilin/Piperazillin: pseudomonas
peri-op anti-PLT therapy in pt with stent/PCI
- No CV dz: stop ASA 7-10 days before surgery. Restart after 24-72h depending on bleeding in surgery
- Known CV dz
- Elective surgery: delay surgery until after optimal time
- Emergent surgert: c/w DAPT unless high bleeding risk
Dual antiplatelet therapy duration: post-pone elective operations
- two weeks after simple dilatation
- six weeks after bare-metal stents
- 12 months after drug-eluting stent
Acute cholangitis
Dx: U/S showing dilation > 7mm w/ jaundice, fever, RUQ pain
Tx:
- Mild and responding to abx: ERCP w/in 72h
- Severe and non responding: ERCP w/in 24h
Relative c/i to componenet separation
- Extensive destruction of the components of the abdominal wall
- Compromise of the superior epigastric artery and/or deep inferior epigastric artery,
- Contaminated operative field
- Smoking, COPD, DM, ascites
Stimulates pancreas from the jejunum
CCK
Secretein
GIP
MYH gene
MYH associated polyposis
AR!
Cryoptococcus vs. Coccidiomycosis
Crypto- CNS sxs in AIDs pt; tx- amphotericin
Coccidio- pulm sxs in the southwest; tx- amphotericin
hypokalemia on EKG
ST depression.
T wave inversion
Prominent U waves
Long QU interval
Rectal cancer work-up
- complete scope: look for synch lesion
- CT CAP: mets
- T staging: rectal US (early stage), MRI (late stage)
REY GB with choledocho
Trans-gastric ERCP
or double balloon endoscopy
dx of ischemic colitis
endoscopy (although CT should be your first test)
SIADH tx
acute- vaptans
chronic- h2o restriction, diuresis
Breast abscess that fails to resolve after 2 weeks
Excisional bx to rule out inflammatory cancer
Sarcoma prognosis by grade
1-
Tx for ectopic pregnancy
Stable – methotrexate or salpingotomy
Unstable – salpingectomy
Tx ARDS
TV at 4-6 ml/kg
Permissive hypercapnia
P/E < 200 --> high PEEP
P/E < 300 --> prone, nm blockade,
Pitfalls of hiatal hernia repair
- Left gastric artery along right crus
- Abberant left hepatic artery in the gastrohepatic ligament
- vagus nerve
MEN genes
1- MENIN
2- RET
Dx of:
Insulinoma:
Gastrinoma:
Glucagonoma:
VIPoma:
Somatostatinoma:
Dx of:
Insulinoma: insulin to glucose ratio > 0.4 after fasting; ↑ C peptide and proinsulin
Gastrinoma: serum gastrin > 1000 or SS test
Glucagonoma: gasting glucagon level
VIPoma: high VIP and dx of exclusion
Somatostatinoma: fastin somatostatin level
Incidentally found Meckel's
- Child and young adult- resection of the normal-appearing Meckel's diverticulum
- healthy, young adults (<50 years of age)- resection of the normal-appearing Meckel's diverticulum if there is a palpable abnormality or longer than 2 cm
- >50 years of age, and patients with significant comorbidities- not resecting
Chemo drh
loperamide --> octreotide
consider c. diff testing if copious or resistant
Choledochol cyst epidemiology
females and asians
15% get cholagioncarcinoma
Tx of desmoid tumors
Women, benign but locally invasive; ↑ recurrences
Gardner’s syndrome
Painless mass
Tx: wide local excision if possible; if involving significant small bowel mesentery, excision may not be indicated → often not completely resectable
Medical Tx: sulindac and tamoxifen
