Pearls Flashcards
(38 cards)
First step in treatment of colonic pseudo obstruction?
Second step?
First step: conservative measures with NPO, IVF, rectal tube
Second step: 2mg neostigmine over 3 min in a monitored bed with atropine ready in case of bradycardia
Repair of an umbilical hernia should be differed until what age?
5years old
Treatment for colonic volvulus?
NPO, NGT, IVF, Abx, Foley
Then rigid or flexible sigmoidoscopy to de-torse a sigmoid volvulus. Leave a tube while bowel prepping for OR
Treatment for radiation injury to small or large bowel
Low residual diet that is low fat, lactose and gluten free. Steroids, IVF, and abx may be helpful. Sucralfate enemas are the most effective medical therapy
Nonoperative techniques to lowering intracranial pressure?
Raise head of bed, Mannitol, hyperventilation, sedation and paralysis
Amsterdam criteria for HNPCC?
3-2-1, 50-25-5
3 relatives with HNPCC related cancers, 2 successive generations, one relative under 50 years old, start colonoscopy at 25 or 5 years before age of relative at diagnosis
Screening and treatment for Familial adenomatous polyposis (FAP)?
Colonoscopy and EGD starting at age 12. Routine CT abdomen every 12 months as well given possibility of retroperitoneal Desmond tumors.
Colectomy deferred until 17 or 18 unless polyps appear earlier. Prophylactic total colectomy with ileorectal anastomosis should be performed once polyps appear. Will still need surveillance of rectum every 5 years
Screening and treatment for HNPCC?
Colonoscopy starting at 25 or 5 years younger than age of youngest relative at diagnosis.
Surgery once cancer or adenomas with satellite instability are found or if patient cannot adhere to surveillance. Total abdominal colectomy with ileorectal anastomosis or total proctocolectomy with ileal pouch anal anastomosis are the options. Hysterectomy indicated in female patients who have finished child bearing.
What is Nigro protocol?
4 weeks of 5-FU, mitomycin C, and radiation (3000-4800 rads)
If inguinal nodes are positive then they are included in radiation field
6 weeks of rest
Re-evaluate and re-biopsy
If negative then start surveillance (proctoscopy with biopsy every 3 months for 2 years, then every 6 months for 3 years, then annually)
If positive then give second dose of chemorads
6 weeks of rest
Re-evaluate and re-biopsy
If positive then APR
Treatment for anal squamous carcinoma and adenocarcinoma?
Squamous carcinoma: nigro protocol
Adenocarcinoma: if not invading sphincters then WLE, if invading sphincters then nigro protocol
If focal nodular hyperplasia is suspected diagnosis of liver lesion, what tests to order?
Triple phase CT abdomen will show contrast-enhanced central scar and spoke wheel appearance.
Confirm with sulfur-colloid nuclear medicine scan which will show a cold module
Which two tumor markers differentiate between primary malignant and metastatic liver lesions?
Primary hepatocellular carcinoma: Elevated AFP
Metastatic lesion: elevated CEA
What do malignant liver lesions look like on triple phase CT?
Look hypervascular on arterial phase but washes out quickly and look hypovascular on venous phase
Treatments of liver cyst caused by entamoeba histolytica and echinococcus?
Entamoeba histolytica: flagyl followed by chloroquine if no improvement in first 3 days
Echinococcus: Antihelminthics (albendaxole, mebendazole) and surgery
How are the diagnoses of a hydatid cyst and amoebic cyst confirmed?
Hydatid: Serology tests such as ELISA or immunoblotting can be 80-100% sensitive
Amoebic: Microscopic identification of cysts and trophozoites in the stool
Management of ascitis?
Medical treatment for hepatic encephalopathy?
Ascitis: low sodium diet, spironolactone, lasix, therapeutic paracentesis, TIPS
Encephalopathy: rule out other causes (UTI etc), restrict protein in diet to 1 gm/kg/day, lactulose, oral neomycin can reduce nitrogen producing bacteria
What are the 5 components of the Child’s-Pugh score?
Albumin, bilirubin, INR, Ascites, encephalopathy
Treatment for bleeding esophageal varices?
Start octreotide, vasopressin, and PPI drips. EGD with banding (sclerotherapy second line option)
If fails then place minnesota tube x48 hrs
If fails then perform TIPS
Management of asymptomatic pancreatic pseudocyst?
Management of symptomatic management pseudocyst?
Asymptomatic: observe for 6 weeks and then repeat CT. If stable or decreases in size then continue to observe. If increases in size, especially above 6cm then treat like symptomatic pseudocyst.
Symptomatic: Do ERCP to determine if pseudocyst communicates with pancreatic duct. If no communication then place percutaneous drain (send fluid for amylase, CEA, mucin, and CA 19-9). If communication then surgical drainage.
What is the preoperative therapy before thyroidectomy for conditions causing hyperthyroidism?
Preop PTU for 2 weeks, Lugols solution for 10 days, and propranolol
What is the medical prep to optimize patient for adrenalectomy for pheochromocytoma?
Phenoxybenzamine 10mg PO TID given until patient has orthostatic hypotension. Propranolol if patient remains tachycardic.
In the OR nitroprusside, esmolol, neosynephrine, and lidocaine drips must all be available
What is the medical management of aldosteronoma leading up to surgery?
Spironolactone and potassium supplementation to correct hypokalemia, and verapamil or lisinopril to treat hypertension.
What gastrin level is diagnostic for Zollinger Ellison syndrome? What level is diagnostic after a secretin stimulation test?
Gastrin > 1000 or gastrin > 200 checked in 5 min intervals for first 30 min after secretin stimulation test. Patient must be off PPI for 7 days prior to testing.
What is treatment of unresectable gastrinoma?
ZAP-5 Zanosar (streptozosin) Adriamycin (doxorubicin) PPI 5-FU
Pyloromyotomy and vagotomy is also an option
