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1
Q

Pheo w/up:

A
  1. Spot plasma or urine metanephrine (sensitive)
  2. 24-urine metanephrine (specific)
  3. CT (> MRI)
  4. MIBG (if suspect multi-focal)
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2
Q

Mucinous cystic neoplasm - dx and tx

A
  • dx: EUS-FNA w/ high CEA (>190), low Amylase
  • tx: resect
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3
Q

Tx pelvic fx

A
  1. Binder
  2. Angio OR packing w/ fixation (especially if IR n/a)
  3. Early external fixation
    - refractory bleed after angio → packing + fixation

**MC source is presacral venous plexus

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4
Q

Dx and Localize a gastrinoma

A

Dx:
1. Off PPI: G > 1000 or >200 w/ secretin stimlation
2. Can’t get off PPI: SS Scintigraphy

Localize:
1. Triphasic CT/MRI
2. SS Scintography (Dotatate PET/CT)
3. Endoscopic US
4. Selective intra arterial Ca
5. OR: Intra-Op US, transduodenal palpation, duodenotomy, palpate HOP

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5
Q

Tx pseudocyst/WON

A

Dx: US or CT
- if can’t r/o cystic neoplasm on imaging must get EUS-FNA

Tx: drain if persistent sxs. Wait 4-6 weeks for the wall to mature
- near stomach/duo, > 6cm: endoscopic cystogastrostomy/duodenostomy
- open or lap cysto-enterostomy (usually jejunostomy if not abutting duo or stomach)

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6
Q

Tx of pancreatitis masses
1. WON sterile
2. WON infected
3. Pseudocyst
4. Infected pseudocyst

A
  1. WON sterile: conservatively
  2. WON infected: step-up approach
  3. Pseudocyst: tx if sxs (infxn, obstruction, pain)
    - 4-6w → internal drain → cyst-enterostomy
  4. Infected pseudocyst: drainage (internal, external, endoscopic). Endoscopic preferred.
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7
Q

Indications to tx ICA stenosis and sxs

A
  1. Asx: > 60%
  2. Sxs: > 50% (>125 cm/s)
    - Sxs: contralateral motor/sensory sxs, ipsi vision sxs
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8
Q

Bethesda criteria for thyroid

A

**1 cm is cutoff to get an FNA

  1. Non-diagnostic → repeat FNA
  2. Benign → follow-up
  3. Undetermined significance → repeat FNA or lobectomy
  4. Follicular neoplasm → lobectomy
  5. Suspicious for malignancy → lobectomy vs. thyroidectomy
  6. Malignant → thyroidectomy
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9
Q

Achalasia - Px, Dx, Path and Tx

A

Px: dysphagia (to solid and liquid) is MC sx

Dx:
- no peristalsis
- high LES pressure > 15 (vs. scleroderma, low)
- incomplete relaxation

Path: injured ganglion cells

Tx: only motility disorder w/ upfront surgery
- myotomy (6 eso, 2 stomch) is 1st line (avoid Nissen).
- botox or dilation if high risk.

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10
Q

Tx Medullary thyroid cancer

A
  1. TOTAL thyroidectomy
  2. > 1 cm or bilobar: bilateral central/level 6 dissection
  3. Lateral neck dissection on that side if central+
  4. Start T4 postop. Monitor w/ calcitonin AND CEA
    - RAI is c/i! (C cell origin)
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11
Q

Radial scar- Dx and Tx

A
  1. Dx: aka comlpex sclerosing lesion
    - Mammo: spiculated mass with central sclerosis (lucency) and surrounding distortion
    - Histo: fibroelastic core w/ entrapped ducts
    Gross: white center (central scar)
  2. Tx: core bx ➡ excisional bx (to r/o ca)
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12
Q

Tx for ectopic pregnancy

A
  1. Stable ➡ methotrexate or salpingotomy
    - MTX: absolute c/i if the patient is breast-feeding
  2. Unstable, free fluid, ongoing pain/bleeding ➡ salpingectomy
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13
Q

Hyperkalemia EKG
Hypokalemia EKG

A
  • hyperK: peaked T wave, eventual SINE
  • hypoK: flat T waves, U waves
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14
Q

HS reactions

A
  1. IgE allergic rxn; anaphylaxis; tx w/ epi
  2. Ab rxn; AIHA
  3. immune cx; serum sickness, hep’s
  4. delayed; t-cell; dermatitis, PPD
  5. auto-immune
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15
Q

Tx of thyroid ca in pregnancy

A
  • Well differentiated: surgery post-partum
  • Postpone until 2T if advanced (MTC, nodes, mets)
  • Anaplastic requires immediate surgery in any trimester
  • RAI is c/i (during pregnancy and w/ breastfeeding)
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16
Q

Mastodynia tx

A
  1. Cyclic: OCP/NSAIDS
    - sxs improve after menses
  2. non-cyclic and >30 OR cyclic + mass ➡ mammo
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17
Q

Tx mucinous neoplasm of the appendix

A
  1. Confined to appendix: appe only (no LADN’y)
    - must have negative margin
    - scope in 6w to r/o sync lesions
  2. Involving base, ruptured, or +margin: R hemi +/- LADN
  3. Peritoneal dissemination: perc bx
    - if appendicitis: remove ruptured segment + directed peritoneal bx
    - no appendicitis: postpone appe until cytoreductive surgery
    - no hipec/cancer operation until staged

**need post-op scope to r/o synchronous lesions

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18
Q

GCS eye opening

A

4- spon
3- to voice
2- to pain
1- none

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19
Q

Torsades

A
  • “polymorphic ventricular tachycardia”
  • 2/2 hypoK, hypoCa, hypoMg, macrolides
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20
Q

Normal values: CVP, WP, SVR, CI

A
  • CVP 2-6
  • WP 4-12
  • SVR 700-1500
  • CI 2.5-4
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21
Q

When to excise burns

A
  • < 72 hours but not until after appropriate fluid resuscitation
  • Used for deep 2nd-, 3rd-, and some 4th-degree burns
  • Viability is based on punctate bleeding (#1), color, and texture after removal (use dermatome)
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22
Q

TTP - Path, Px, Tx

A

Path- def in ADAMtS13
Px- fever, anemia, TCP purpura, renal dz, neuro sx (FATRN)
Tx- plasmapheresis ➡ steroids ➡ splenectomy

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23
Q

LE angio

A

AT comes off first and goes lateral
TP trunk- PT behind tibia, peroneal behind fibula

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24
Q

Liver lesions on arterial phase:
HCC
Mets
Adenoma
Hemangioma
FNH

A
  • HCC: rapid enhancement. rapid w/out. “hot” on nuclear imaging
  • Mets: Hypoattenuation
  • Adenoma: rapid enhancement. rapid w/out. “cold” on nuclear imaging. gado/eovist not retained
  • Hemangioma: peripheral nodular enhancement. delay: centripetal fill-in (no early washout!)
  • FNH: Centrifugal enhancing. w/out except for scar enhancement. take up sulfer colloid and gado/eovist
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25
Methanol and Ethylene glycol toxicity - Px and Tx
Px: profound AG metabolic acidosis - oxalate stones → renal failure Tx: NaB + fomipazole (ADH inhibitor) - consider iHD
26
Ureter anatomy
Runs under the vas/uterine arteries  Runs over the iliacs
27
Elective surgery after stent
1. ASA lifelong 2. Plavix - BMS: 1 month - DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)
28
UE Injuries: 1. supracondylar humerus 2. DRF 3. Mid shaft 4. ant shoulder disloc 5. post shoulder disloc
1. supracondylar humerus- brachial artery 2. DRF- median nerve 3. Mid shaft- radial nerve 4. ant shoulder disloc- ax. nerve 5. post shoulder disloc- ax. artery
29
Teg interpretation: R time K time a angle MA LY 30
R time- FFP K time- cryo a angle- cryo MA- PLTs LY 30- TXA Rule of 6's: R > 6 minutes alpha angle > 60 degrees MA < 60 mm LY30 > 6%
30
DeMeester score
Score: pH <4 , changes in position, duration, # of episodes > 14.7 is positive
31
Standard Deviations
1, 2, and 3 SD = 67%, 95%, and 99.7% of the data
32
s/e of ileal conduit
Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)
33
Angiodysplasia of the colon - Dx and Tx
Dx: usually found in cecum and ascending colon -2nd MC CO gi bleed (vs. div's) - MC CO right colon bleeding - MC CO bleeding > 65 yo Tx: if bleeding or iron deficiency 1. Endoscopic 2. Surgery if refractory
34
Stewart-Treves syndrome - px, dx, tx
Px: post-mastectomy lymphangiosarcoma (bruises) - 2/2 chronic lymphedema; 10 years from surgery Dx: incisional bx Tx: wide local excision w/ 3-6 cm margin + chemotherapy - often requires arm amputation - don't need to stage nodes (hematog spread)
35
Tx for gallstone ileus
Stable and healthy- stone removal and take down fistula Unstable, old/frail- stone removal only!
36
Sorafenib
Tyrosine kinase inhibitor Tx of HCC
37
Stricturoplasties - Heineke s’plasty - Finney s’plasty - Side2Side isoperistaltic s’plasty
1. Heineke: <10cm; open long and close transversely 2. Finney: > 10cm; segment folded on itself and common wall created 3. Side2Side isoperistaltic (Michellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together **Bleeding is MC complication
38
Dx and tx of gastroparesis
Dx: Scintigraphy gastric emptying Tx: - Metoclopramide (Reglan): dopa antagonist - gastric pacemaker or pyloroplasty - feeding tube - TPN
39
Burn degrees
1D: epidermis 2D superficial: pap dermis, painful, hair follicles intact; blanches - don't need grafting 2D deep: retic dermis, decreased sensation; loss of hair follicles, no blanch - need skin grafts 3D burn: subcutaneous fat, leathery 4D: fat/muscle/bone; surg
40
Tx and Survival Benefit of ARDS
- TV at 4-6 ml/kg - Permissive hypercapnia - Proven benefit: prone, lung protection, paralyze -P/F < 100 = severe
41
Interleukins 1, 2, 4, 5, 10 C5-9
IL1: fever, wound healing IL2: T cell proliferation IL4: B cell proliferation. abxs allergic rxs IL5: eosinophil growth, asthma, allergic rxns IL 10: anti-inflammatory C5-9: MAC ➡ cell lysis
42
Glucagonoma - loc, px, dx, tx
Loc: distal (a cells) Px: dermatitis, DRH, DM, nec mig erythema - most malignant - no stones (vs. SS'oma) Dx: gluc > 1000 Tx: distal panc + splenectomy + LADN'y + CC'y
43
Aminocaproic acid vs. streptokinase
ACA: Plasmin inhibitor - Use: DIC, excess tpa Streptokinase/Urokinase/TPA: plasmin activator - bust clot
44
s/e of carb, protein, and lipid
1. carb: immunosuppression, resp failure 2. lipid: pro inflammatory 3. protein: false neurotransmitters, rise in ammonia/urea - can worsen hepatic encephalopathy (use branched chain AA instead of aromatic AA)
45
Dx, Bx, and Tx actinic keratosis
- Dx: red, crusty, weeping lesion - Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ) - Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)
46
Hirschsprung surgeries - Duhamel - Soave - Swenson
- Duhamel: agang stump in place/gang colon pulled behind; end-to-side mosis; neo-rectum; lowest stricture rate - Soave: pull-through; “reverse alte”; remove M/SM; pull through within an aganglionic CUFF; least dissection - Swenson: original; aganglionic segment resected to sigmoid colon; pull-through with end-to-end anastomosis- colon x rectum.
47
z11 trial implications
- If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK - if >70, t1, ER+ and SNLBx neg ➡ can consider no XRT after lumpectomy
48
Hard signs of vascular injury
shock expanding hematoma pulsatile bleed thrill/bruit absent pulse ischemia If negative ➡ ABI...if positive ➡ CTA (to localize)
49
Polyps that require surgery instead of endoscopic resection
1. Submucosal invasion > 1mm 2. Poorly differentiated 3. <1 mm margin 4. LV invasion 5. Tumor budding 6. Taken piecemeal
50
Iron deficiency sxs
anemia, glossitis, brittle nails, cardiomegaly
51
T staging indications for neoadjuvant - eso - stomach - colon - rectal - lung
- eso: T2 (MP) - stomach: t2 (MP) - colon: t4b (adjacent organs) - rectal: t3 (through MP) - lung: n2 nodes
52
Atlanta classification pancreatits
1. Interstitial: <4w- acute peripanc collection >4w pseudocyst 2. Necrotic: <4w- acute necrotic collection >4w- walled of necrosis
53
Fuel for: - SB - LB
- SB: glutamine - LB: short-chain fatty acids (acetate, butyrate). Directly absorbed by intestinal epithelium w/out lipolysis
54
Motilin
Motilin – released by intestinal cells of gut; acts. on smooth muscle to↑ intestinal motility (erythromycin acts on this smooth muscle receptor)
55
Screening in IBD patients
- Start 8 years after sx onset - 2-4 random bx every 10 cm throughout the colon + suspicious areas Repeat schedule: - normal: q1-3 years - PSC, stricture, or dysplasia w/out colectomy: q1 year Any dysplasia usually gets a colectomy - if resectable can consider endoscopic resection with close surveillance
56
NEC - px and tx
Px: bloody stools after 1st feed - prematurity is biggest RF tx: - resuscitation, ngt, abx (no surgery) x 7-10 day (50% success) -surgery (50%): resect all non-viable segments. create stoma.
57
W/up of thyroid nodule found on exam or incidental imaging
- U/S and TSH: a. Nodule + Low TSH ➡ RAI uptake scan - hot/functioning: toxic adenoma (no cancer) ➡ thionamide, b-block + lobectomy - cold: FNA b. Nodule + Normal/High TSH ➡ FNA
58
Tx male breast ca
Tx: simple mastectomy w/ SLNBx - BCT usually can’t be done b/c not enough tissue - if ER+: tamoxifen (Her2+ is rare). consider orchiectomy if metastatic. - More likely ER/PR+ than females! - Prognosis similar to W but delay in px - a/w BRCA 2/Chromosome 13. Should BRCA test if family hx
59
Nutcracker eso - manometery and tx
Mano: - high amplitude (> 180 mmHg)/long peristalsis (>6 sec) - normal LES pressure - normal relaxation  Tx: (identical to DES) 1. PPI, CCB, TCA 2. Long segment myotomy if refractory
60
General principles - repair of Bile Duct Injury
1. Intro-op: - convert to open, intra-op cholangio, repair OR - widely drain and send to specialty center 2. Post-op: - Perc cholangiography to define the anatomy - Control spillage: external drain +/- stent +/- PTC - Repair in 6-8 weeks
61
Eso dysplasia tx
1. LGD: ablation OR scope q6-12m - OK for fundoplication 2. HGD: ablation + Q3m scope - fundoplication c/i 3. T1a: ablation 4. t1b (or low risk T2): upfront esophagectomy *Fundoplication does not decrease cancer risk
62
Superior epigastrics Inferior epigastrics
SE: runs between rectus and posterior rectus sheath; branch of int mammary IE: runs between rectus and transversalis fascia; branch of EI
63
When to intubate burn patients
- hypoxia, hypercarbia, severe upper airway edema - If stable/GCS > 8 and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling
64
Tx hemobilia after trauma
1. EGD → CTA (if stable) 2. angio embolization (no surgery) - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA
65
Paget Von Schroetter syndrome - path, px, tx
Path: narrowing of SC/Ax vein 2/2 mech compression Px: acute swelling Tx: catheter-directed thrombolysis before anything else (NOT open thrombectomy)
66
Tx of AT3 def
Tx- recombinant at3 or FFP followed by heparin then warfarin
67
Vitamin C mechanism and deficiency
Mech: - hydroxylation of lysine and proline - type 3 collagen cross-linking Def: Scurvy - gingivitis, wound healing, rough skin
68
Indications for chemotherapy for rectal cancer
1. Neoadjuvant: Stage 2 and above Stage 2: at least t3 (crossing muscularis prop) or any n (stage 3) 2. Adjuvant chemo as well for Stage 3+ (nodes) **XRT either pre or post-op (not both) **Typical course: chemo-XRT ➡ surgery ➡ chemo
69
Periop anticoagulation - risks and tx
Risks: - High risk pt: afib, MHV, recent TE event (3m) - High risk surgery: nsurg, optho, cards Tx: - bridge for high-risk patients - stop warfarin 5 days before surgery if not bridging, resume on day of surgery - Hold Noac 2 days before surgery and resume 1 day after - stop Plavix 5 days before - resume AC within 24h for low risk surgery. 48-72h for high risk surgery.
70
What is not suppressed by high dose dexa
Adrenal mass Ectopic mass (small cell cancer) **dexa is strongest steroid (hydrocort is weakest)
71
Metabolic alkalosis - chloride responsiveness
1. Cl responsive (Ur Cl < 20) - temporary loss, replaceable - vomiting 2. Cl resistant (Ur Cl > 20) - hormonal, continuous loss - conn’s, steroids, hyperaldosterone
72
Heller myotomy margins and fibers
6 cm proximal, 2 cm distal - Esophagus: vertical fibers first (outside), then circular (inside)
73
Margin for invasives cancer vs. dcis
1. Invasive cancer- no tumor on ink 2. DCIS- 2 mm **if both in specimen, margin is no tumor on ink
74
ITP- path, dx and tx
1. path: IgG against gp 2b/3a 2. dx: of exclusion- increased megakaryocytes, petechia, TCPenia - smear: normal with low PLTs 3. tx: only if PLT < 30K! steroids → IVIG 2nd line → splenectomy - spleen is source of Ab's
75
Staph species causing graft infection
G+/aerobe/clusters coag+ → staph aureus - MC early graft infections coag- → staph epidermidis - MC late graft infection 2/2 biofim
76
Cryptorchidism tx
- wait until 6 month old - if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma - risk of ca higher in both testes.
77
Sarcoma grade
1. differentiation 2. mitotic coun 3. necrosis ** more important than size, nodal/distal mets for prognosis
78
Neuroblastoma dx and tx
dx: - CT: displacement of renal parenchyma (vs. Wilm's) - Can also use MIBG and VMA levels (like pheo) - Usually adrenal. Can also be neck, chest, spine - neck can px w/ horner syndrome - tissue bx to get n-myc status tx: 1. S1-2 (low risk) → surg alone 2. S3+ or n-myc+ (high risk) → chemo/XRT then XRT - need bx: chemo regimen determined by n-myc amplification
79
Gastrin - MOA and stimulation
- MOA: G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ H/K exchange (ATP) ➡ HCl (+ intrinsic factor) - Stimulation: ACh, beta ago, AA - Inhibition: acid, SS, secretin, CCK
80
Esophagus blood supply
1. Cervical- inf thyroid 2. Thoracic- aortic branches (bronchial arteries) 3. Abd- left gastric/inferior phrenic
81
- CBD and PD on ERCP - Blood supply of CBD
- CBD at 11'. PD at 2’ - Ampulla is between them (they both feed into it) - Blood supply 9' and 3'. - perform sphincterotomy by cutting from 11' to 2'
82
Tx urethral injury
Grade: 1/2- contusion/stretch ➡ foley 3- part disruption ➡ foley +/- cystostomy/repair 4/5-complete disruption ➡ cystostomy + delayed repair - can try urethral cath with cysto assistance - must get a CTAP to r/o concomitant injuries that would require delayed repair
83
TEF - MC types. dx and tx
1. Type C - MC, 85% - Proximal esophageal atresia (blind pouch) and distal TE fistula - dx: AXR ➡ distended, gas-filled stomach, coiling tube - no UGI needed! 2. Type A: second most common, 5% - Esophageal atresia and no fistula - dx: XR: gasless abdomen, coiling tube - no UGI needed! Tx: 1. Resuscitate w/ repogle tube 2. Echo: VACTERL cardiac w/up 3. G-tube placement to decompress and feed 4. Delayed RIGHT extra-pleural thoracotomy 5. Distal ligation of TEF (if gas in abdomen, type C) **long term r/o dysphagia and GERD in almost ALL patients
84
Tx of Ogilvie's
1. CT or scope to confirm dx. R/o obstruction. 2 supportive, dc narcotics, ng tube, neostigmine 3. if > 10cm ➡ scope decompression and neostigmine 4. failure ➡ OR
85
Px and Tx of prolactinoma
Px: bitemporal hemianopsia, galactorrhea, amenorrhea, ED, osteopenia Tx: 1. Bromocriptine or carbegoline (both dopa agonists) - bromo is safe in pregnancy 2. Surgery only if tx failure
86
Pros/Cons: - Sevoflurane - Isoflurane - Halothane - NO
- Sevo: rapid induction, less pungent. Good for kids. - Isoflurane: good for neurosurgery; no increase in ICP - Halothane: slow onset/offset, cards depression, hepatitis. - NO: least cardiac depression b/c sympathomimetic. c/i in SBO. Highest MAC.
87
Atropine MOA
- competitive inhibitor of ACh at muscarinic receptor - liver metabolism
88
FMD- Dx, Path and Tx
Dx: string of beads on angiogram Path: fibroplasia, thickened media, collagen formation Tx: angio + balloon (no stent)
89
MEN1/MEN2 genes
MEN1: MENIN gene, TSGene MEN2: RET gene, receptor TK protein, proto-oncogene
90
Birads score
0- redo imaging 1- negative, NTD 2- benign, NTD 3- benign, repeat q6m 4- suspicious, bx 5- highly suspicious, bx 6- confirmed, excise **discordance: perform repeat bx w/ surgical excision or core bx (if there was a correctable error)
91
MOA, use, s/e of antifungals: Fluconazole Voriconazole Micafungin Amphotericin
1. Fluconazole: ergosterol synth inhibitor - Non-systemic candida (yeast infection, c. albicans) - s/e: liver toxic, GI upset 2. Voriconazole: ergosterol synth inhibitor - aspergillosis - s/e: visual changes, psychosis 3. Micafungin: echinocandin; inhibit glucan - invasive/disseminated candidiasis - s/e: TCPenia 4. Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access) - invasive mucor, cryptococcal meningitis - s/e: nephrotoxic, electrolytes (hypoK)
92
Recurrent laryngeal nerve + aberrant anatomy
- motor: larynx except cricothyroid - sensory: larynx below the cords - injury: hoarseness, airway compromise, permanent ADduction —> bilateral may need a trach Aberrant anatomy: - NR right a/w: arteria lusoria ➡ absent innominate + right SC takes off from left aortic arch - NR left a/w R sided arch - inferior PT is anterior to RLN. Superior PT is posterior to RLN
93
PFTs for lung resection
1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing - >.8L wedge, >1.5L lobe, >2L pneumo - < 80% ➡ lung scan for PPO FEV1, DLCO 2. PPO FEV1, DLCO > 60% ➡ no further testing - < 60% ➡ exercise test 3. VO2 > 10 ml/min/kg ➡ OK for surgery - < 10 ➡ high risk for surgery
94
Origins of medullary thyroid cancer
- 4th pharyngeal arch releases NCC which form parafollicular C cells
95
Gastrinoma - loc, px, dx, tx
Loc: gastrinoma triangle (CBD, panc neck, 3D) Px: refractory PUD - Mostly malignant Dx: G > 1000 (off PPI) or >200 w/ secretin (off PPI) - SS Scintigraphy (dotatate scan) if can't get off PPI - MRI for regional disease Tx: Screen for MEN1 - <2 cm: enucleate w/ LADN'y - > 2cm: resect w/ LADN'y
96
qSOFA score
1. AMS (<15) 2. RR > 22 3. SBP < 100
97
MC Benign and Malignant H/N tumors - tx
1. Benign: Pleomorphic adenoma - Tx: superficial parotidectomy even if asx 2. Malignant: mucoepidermoid carcinoma tx - Tx: total parotidectomy (facial nerve preservation) + MRND + XRT
98
Tx frostbite
- Frostnip: rapid moist/pool re-warming - 2d: clear/milky blister- drain - 3d: HMHG blister- leave intact - 4d: bone- prostacyclin/TPA, amputate
99
Tx of Pilonidal cyst
1. ASx: NTD 2. Acute abscess: drain only 3. Chronic cyst: offer surgery if effecting QOL - marsupialization and leave open: lower recurrence - primary closure: faster healing. Off midline- less complication (preferred)
100
Tx TCPenia
<10k if asx <20k if septic, chemo/rads, RF’s <50K if elective surgery
101
Dx and Tx annular pancreas
Dx: UGI with double bubble at 2D Tx: - neonates: duo-duo (mobile duo) - adults: duo-jej
102
Production and function: - TNFa - IF-gamma
TNF-a: produced by PMNs, mphages -cachexia, inflammation IF-gamma: produced by T lymphos - activate PMNs, mphages
103
W/up of pancreatic cystic neoplasms: Pseudocyst Serous cystadenoma MCN IPMN
1. MRI 2. EUS w/ FNA (If unclear): -Pseudocyst: high Am, low CEA -Serous cystadenoma: low Am, low CEA -MCN: low Am, high CEA (>200) -IPMN: high Am, high CEA (>200) ***High CEA > 190
104
Propofol - MOA, pros and cons
MOA: GABA-A agonist Pros - rapid distribution and on/off - decreases ICP, anti-emetic Cons - s/e: hypotension, resp depression, meta acid - no analgesia - liver metabolism - prop infusion syndrome: metabolic acid + rhabdo
105
Enterohepatic circulation
Primary bile salts - cholic acid, cheno-cholic acid (C's) → hepatocytes → conjugated BS: 1. 80% conjugated ➡ active ileum absorbed 2. 20% deconjugated by bacteria ➡ passive colon absorbed 3. 5% out in stool
106
Dx and Tx CO poisoning
- Suspect in burn patient with neuro/cards sxs Tx: 1. 100% O2 w/ facemask or intubation (not hi flo) - Hyperbaric O2 if C-Hb > 25% 2. Intubate if comatose, severe acidosis
107
Indication for APR
1. Rigid proctoscopy: w/ in 2cm of anal verge (levators) 2. PE: baseline sphincter dysfxn 3. Recurrent SqCC (s/p Nigro)
108
Cancer associations: - CEA - AFP - CA 19-9 - CA 125 - Beta-HCG - PSA - NSE - BRCA I and II - Chromogranin A - Ret oncogene - KRAS
- CEA: colon CA - AFP: liver CA - CA 19-9: pancreatic CA - CA 125: ovarian CA - Beta-HCG: testicular CA, choriocarcinoma - PSA: prostate CA - NSE: small cell lung CA, neuroblastoma - BRCA I and II: breast CA - Chromogranin A: carcinoid tumor - Ret oncogene: medullary thyroid CA - KRAS: pancreatic CA (MC genetic mutation)
109
Types of esophagectomy compared
1. Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy - anastomosis: thoracic - theoretically more thorough oncologic resection - less overall leak rate - may be better in more fit patients 2. Transhiatal: abdominal + L neck - anastomosis: cervical - theoretically less chance of mediastinal leak, shorter operation BUT more overall leak rate - may be better if old/frail and distal esophagus tumors 3. McKeown: abdominal + L neck - anastomosis: cervical ***Gastric conduit supply- R gastroepiploic (off GDA/CHA)
110
Somatostatinoma - loc, px, dx, tx
Loc: head Px: DM, GALLSTONES (> glucagonoma), steatorrhea, block exo/endo pancreas - most malignant Dx: sx's + high fast SS Tx: resect + LADN'y + CC'y
111
Etomidate - Pros and Cons
Induction agent Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e Cons- adrenocortical suppression
112
W/up and Tx testicular mass: - Seminoma - Non-seminomatous
1. PE 2. Ultrasound 3. AFP, HCG, LDH - Seminoma: no AFP! (most common) - Non-seminoma: high AFP, HCG, LDH 4. Inguinal orchiectomy: any patient with solid testicular mass 5. Based on path/tumor markers decide: - Seminoma: XRT or chemo - Non-seminomatous: retroperitoneal node dissection **ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection
113
Liver collection dx and tx: 1. Pyo 2. Amoebic 3. Echino 4. Fungal
1. Pyogenic: after cholangitis (MC) or div's (via portal vein); - drain and abx (+mica if fungal) 2. Amoebic: after mexico trip (or aMazon). - dx w/ serology/hemagglutination 1st - metronidazole (no drain) 3. Echinococcal: wall Ca+ and sub-cysts - albendazole and resect/PAIR 4. Fungal: 2/2 chemo/neutropenia - perc drain + micafungin
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EVAR specs: - Proximal landing - Common iliac (distal landing) - Neck angulation - External Iliac
Proximal landing: > 1.5 cm - diameter < 3cm Common iliac (distal landing): > 1 cm - diameter > 8 mm Neck angulation < 60 degrees External Iliac diameter> 7mm **smoking is stronger RF for AAA **extensive calc is a c/i
115
Tx of anal fissure
1. Sitz bath, fiber 2. topical nifedipine/nitroglycerin - nitro causes headache 3. Surgery (or botox) - Good sphincter tone: LATERAL, INTERNAL sphincterotomy - Poor tone: botox **If 2/2 crohn's dz: optimize medical management
116
Lynch genes and gene funtions
Genes: - MLH1 - MSH2, MSH6 - PMS2 - EPCAM Fxn: DNA MM repair gene causing microsatellite instability
117
Condyloma types
1. acuminatum- HPV (6, 11- warts; 16, 18- Cancer) 2. lata- syphilis
118
Tx of liver lesions: 1. Hemangioma 2. FNH 3. Adenoma
1. Hemangioma: only if sxatic or KM syndrome - enucleate (or resect); angioembo if active bleed 2. FNH: NTD 3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male,  or growing
119
Dx and Tx congential DPGM hernia
-Dx: prenatal dx on US ➡ must confirm with MRI -Tx: 1. intubate (in delivery room) - goal O2 > 60, CO2 < 60 2. NGT +/- ECM 3. delay OR when stable
120
Stages of empyema formation
1. Exudative ➡ drainage or VATS (1-7 days) 2. Fibrinopurulent ➡ VATS (7-21 days) 3. Organizing ➡ thoracotomy (21+) **VATS between days 3-7 - Preferred over 2nd CT placement or fibrinolytic therapy
121
Vertebral artery occlusion px
posterior circulation sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia
122
5T's of cyanosis
1. TOF 2. Transposition of GVs 3. Truncus art 4. Tricuspid atresia 5. TAPVC
123
DES - Manno and Tx
Manno: - unorganized peristalisis - normal LES pressure - normal relaxation  Tx: 1. CCB (+TCA if chest pain) 2. Botox injection (endoscopic) 3. Last resort: long segment myotomy
124
Supraceliac aortic control
1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram 2. Stable: left medial visceral rotation is preferred
125
Mondor disease - px and tx
px- tender, “cord-like” structure tx- NSAIDs
126
Dx and Tx Phyllodes
Bx: stromal overgrowth, atypia, high MI, "leaf-like" - aggressive fibroepithelial lesion - non aggressive is fibroadenoma Tx: WLE w/ 1 cm margin + XRT (if > 5cm) - can spread hematogenous to lung (more than ax nodes)
127
Replaced R and L hepatic
Right: - SMA (behind pancreas and CBD) - found behind CD during a chole Left: left gastric (in gastrohepatic ligament) - found medial to portal triad - injured during paraeso hernia
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Effective for enteroccous
Ampicillin/Amoxacillin Vancomycin Zosyn (Resistant to all cephalosporins)
129
Loss in excess weight for each surgery
REYGB- 75% SG- 60% Lap band- 50%
130
Acid/Base of Ng suctioning
HypoCl, HypoK metabolic alk - Mech: Loose HCl and fluid ➡ turn on RAA system Retain Na/Excrete acid (paradoxic acidurea)
131
Indications for total thyroidectomy (pap and follicular)
Indications for total thyroidectomy: - Tumor > 4cm - Tumor 1-4cm and patient preference - Distant mets or extra-thyroid disease - Nodal disease - Poorly differentiated - Prior radiation *micro-mets do not count as distant disease **if thyroid lobectomy only: tx with thyroid hormone to suppress TSH, get serial U/S to monitor
132
Soft tissue sarcoma - dx and tx
dx: - < 3cm: excisional bx - > 3 cm: core needle (preferred) or incisional tx: - resect w/ 2 cm marg - neoadj: rhabdomyo, Ewing, high grade, > 10 cm - adj XRT: > 5cm, high grade, recurrence, close marg - adj chemo: never
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Step up approach
Infected pancreatic necrosis (WBC + gas on CT) 1. CT with gas 2. Carbapenem 3. FNA + Perc drain OR endo drain (if stomach is close to pancreas) 4. Upsize drain 5. MIS retrop necrosectomy (VARD) 6. Open necrosectomy
134
CN11 - nerve, location, muscle/injury
- nerve: spinal accessory nerve - location: exit jugular foramen (post triangle) - injury: SCM and trapezius. no shoulder shrug, winged scap!
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1. Central cord syndrome 2. Anterior cord syndrome
1. Central cord: loss of pain, temp, motor - motor UE> LE loss (vs. anterior syndrome) - hyperextension in the setting of SS 2. Anterior cord: loss of pain, temp, motor - below the level of the lesion - ASA injury or anterior cord compression
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Types and Tx SVT
types: af, aflutter, paroxysmal SVT, WPW 1. vagal → adenosine - may unmask afib/flutter 2. HDS: BB, CCB ➡ sync cardioversion 3. HDUS ➡ sync cardioversion
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Von Hippel Lindau - mechanism and surveillance
VHL gene - upreg. of VEGF 1. Brain/retinal hemangioblastoma- q2y brain MRI 2. Clear cell RCC- q1y US/MRI of abdomen 3. Pheochromocytoma- yearly metanephrines
138
Melanoma w/up and tx
1. Punch bx or excisional bx (if < 2cm, non-sensitive area) - MIS- 5mm margin - <1mm- 1cm - 1-2mm- 1-2cm - >2mm- 2cm 2. Clinical positive nodes (stage 3) require FNA for confirmation - negative: SLNBx - positive: completion LN dissection 3. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b) 4. If SLNBx+ (stage 3): q4m US surveillance OR completion LN dissection - LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes **MOHS can be used for in-situ disease. Need 5 mm margin.
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Steps of rapid sequence intubation
c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine
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PSC vs. PBC - assocaited and tx
PSC: Male; intra/extra hepatic; onion fibrosis; chain of lakes - a/w Ulcerative colitis, cholangioca PBC: Female; intra hepatic; granulomas; +AMA - a/w Sjogren, RA tx: trx, cholesty., UDCA - meds generally don't help
141
CPP
MAP - ICP normal CPP > 60 Normal ICP  < 20 - would prefer low MAP with CPP of 60 then higher MAP for brain bleed
142
Draining peri-rectal abscess
1. Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles) 2. Supralevator abscesses need to be drained trans-rectally
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Px, Dx and Tx malrotation
Px: bilious emesis Dx: UGI duodenum does not cross midline - should be done in all infants with bilious emesis Tx: urgent OR (risk of malro) 1. resect Ladd’s bands 2. widen the mesentery (resect central bands) 3. counterclockwise rotation 4. place cecum in LLQ (cecopexy), duodenum in RUQ 5. appendectomy
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Epidural hematoma - shape, vessels, px
Shape: Biconvex. DOES NOT suture lines Vessel: MMA Px: lucid interval. Ipsilateral blown pupil is early sign - (vs. subarachnoid thunderclap, worst HA)
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MEN syndromes
1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD 2a- Parathyroid (PTC), MTC, Pheo (catecholamines); ret; AD 2b- Pheo, MTC, marfanoid/neuroma; ret; AD
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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 Recommended protein = 1.5g/kg/day Nitrogen = protein intake/6.25 **muscle is greatest site of protein turnover
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Periop Warfarin
stop 5 days before Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6+
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Management of PE
1. no RH strain → acoag 2. RH strain → IR catheter 3. RH strain + HDUS → systemic tPA
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Methemoglobinemia - px, dx and tx
Px: nitrites, Hurricane spray, fertilizers, g6PD def, serotonergic drugs, benzocaine spray - Fe2+ to Fe3+ impairing O2 binding Dx: blood gas measurement and pulse ox says 85% - MethHb level > 20% Tx: methylene blue or vitamin C (for g6pd or ser)
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Layers of colon/rectum
1. mucosa 2. sub-mucosa (strength layer) 3. muscularis propria 4. serosa
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LE vascular trauma
- small: patch plasty - large: contralateral GSV (must maintain venous system b/c deep vein may be injured) - limited time/unstable: shunt
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Tx for DVT
1. unprovoked: malignancy, inherited ➡ indefinite 2. provoked: surgery, travel, preg, OCP, immbility ➡ 3m Special cases: - ileofemoral: cather directed thrombolysis - open thrombectomy ➡ extensive (ileofemoral) DVT OR phlegmasia - Superficial femoral vein is a DVT - Pregnant ➡ use Lovenox. NOAC and Coumadin are c/i
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Loop diuretics vs. Ca sparing diuretics
- loop: furosemide - Ca sparing: thiazides (can cause gynecomastia)
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MALT lymphoma dx and tx
Dx: EGD + bx - usually in the stomach - CD20+, lympho infiltration - associated w/ h. Pylori. - non-hogkins (worse prognosis) Tx: - Low grade: triple therapy (eradicate HP) - High grade: chemo and XRT (CHOP) +/- rituximab (CD20)
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lower extremity bypass graft failure depends on temporal relation to the surgery.
- <30d: technical error - 1m-2y: intimal hyperplasia, (at the distal anastomosis) - >2y: progressive atherosclerotic disease
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Dx and Tx Parathyroid ca
Dx: palpable neck mass + Ca > 14 is presumptive dx. Otherwise, dx intra-op based on gross features. - FNA is not recommended - Treat based on intra-operative gross invasion. Frozen section is not helpful. Tx: 1. Control hypercalcemia: usually > 14 - IV fluids 1st! Then bisphosphonates - cinacalcet (sensipar - ca mimetic) 2. Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT) - no chemo - usually don't perform any node dissection unless palpable nodes
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Tx infected pseudocyst
aspirate/gram stain to dx → drainage (internal, external, endoscopic)
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Tx melanoma of anal canal
Tx: - WLE (1 cm). No SLNBx - APR if sphincter involved, LADN, or > 4mm - No chemo-XRT **5y-S is 20% w/ R0 **WLE = APR
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Kaposi's sarcoma - cause and px
- Case: HSV8 - Px: Violet/brown papules
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Mechanism and Tx of thyroid dz: 1. Graves 2. TMN 3. Hashimoto's 4. DeQuervains/Subacute 5. Reidels
1. Graves: IgG stimulates TSHr ➡ hyperT - BB, PTU, RAI ➡ thyroidectomy 2. TMN: chronic TSH stimulation ➡ hyperT - BB, PTU, RAI ➡ total/subtotal thyroidectomy 3. Hashimoto's: antiTPO/TG Ab ➡ hypoT - thyroxine ➡ partial thyroidectomy 4. DeQuervains/Subacute: viral URI - path: giant cells, leukocytes - NSAIDS/ASA ➡ steroids 5. Reidels: autoimmune inflammation - steroid, thyroxine ➡ surgery for compression
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Sonograph FNA recs
- cystic: no bx -isoech/hyperech: FNA if > 2cm -hypoech (high sus): FNA if > 1cm
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Tx anal incontinence
1. 1st line: fiber/bulking, exercises 2. Refractory: endoanal U/S - defect: overlapping sphincteroplasty - no defect or refractory: sacral modulator
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s/e of burn topical treatments: - silver nitrate - silver sulfadiazene - mafenide - bacitracin
- Silver nitrate: electrolytes disturbance (no sulfa) - Silver sulfa: neutropenia, sulfa (covers pseudo) - Mafenide: met acidosis (CA inhibitor), sulfa (covers pseudo and eschar) - Bacitracin: G+; nephrotoxic
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Triple therapy
PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks
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APC gene
- chromosome 5 - 1st mutn in adenoma to carcinoma - mc mutation in colon ca - a/w FAP
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Contents of post triangle
1. CN 11 2. subclavian artery 3. EJV 4. brachial plexus trunks
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Gail model
1. age 2. age 1st period (earlier is worse) 3. age 1st birth (earlier is better) 4. 1d relative 5. previous bx 6. race
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Associated orthopedic injuries: 1. post hip disloc’n 2. post knee disloc’n 3. DRF 4. Supracondylar humerus fx 5. Anterior shoulder disloc'n
1. post hip disloc’n: sciatic nerve (peroneal branch) 2. post knee disloc’n: popliteal atery 3. DRF: median nerve 4. Supracondylar humerus fx: brachial artery 5. Anterior shoulder disloc'n: axillary nerve
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Dobutamine
B1 at low dose - inotropy B2 at high dose - vasodilation
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types of endoleak and tx
1. proximal/distal seal: immediate balloon expansion of distal/proximal attachments + stent - 1a: proximal leak - 1b: distal leak 2. back bleeding: observe. coil embolization if enlarging 3. graft defect (tear or junctional leak): immediate additional graft coverage 4. porosity- reverse anticoagulation
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Carcinoid vs. GIST vs. Desmoid- cells and tx
1. Carcinoid- Kulchinsky cells (enterochromaffin-like) tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable 2. GIST- cajal cells tx- resection (MC stomach), imantinib   3. Desmoid- spindle cells tx- resect if extra-abdominal. NSAID/estrogen if intra
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Meckel's Diverticulum Pathophys
- Anti-mesenteric border of SB - 2/2 peristant viteline duct - pancreatic and gastric tissue  - 2 feet from IC valve
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VRE coverage
Linezolid, Dapto - Amp if not amp resistant
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MOA: - Milrinone - Midodrine
Milrinine- PD inhibitor, contractility with vasodilation - c/i in renal failure Midodrine- a1 agonist
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Hyperaldosterone w/up
Px: resistant HTN and hypokalemia 1. AM plasma aldo/renin - A/R < 20: 2nd hyperaldo - A/R > 20: primary hyperaldo ➡ 2. Confirmatory test: salt load suppression test - give salt load ➡ 24h urine aldo remains elevated 3. Discern laterality: CT scan! (>MRI) A. Unilateral: lap adrenal (consider adrenal vein sampling 1st if > 35 to r/o BAH) B. Bilateral or negative ➡ adrenal vein sampling - Lateralization: lap adrenal - No lateralization: idiopathic hyperplasia ➡ tx medically **tx HTN with spironolactone
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Dx and Tx of SBP
dx: ↑ascitic PMN ANC > 250 (Se) and - don't require culture (Sp) - e. coli is MC (usually single organism) tx: 1. paracentesis for cx 2. abxs: - <48h/community acquired: 3GC - >48h/hospital acquired: carbapenem + MRSA coverge (dapto) 3. Albumin (survival benefit)
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HLA test
- Tissue typing - Donor organ: carries Ag (on WBC) - Recipient body: carried Ab - Recipient serum with donor wbc
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Tx acute variceal HMHG
1. Resuscitate, ensure airway 2. Octreotide + antibiotics 3. Endoscopic intervention (ligation/sclerotherapy) 4. Blakemore 5. TIPS (temporized with Blakemore)
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Tx SVC syndrome tx
1. Elevate HOB 2. Chest CT with IV contrast (can skip CXR) 3. Consider bronch 4. Assess sxs A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo - no chemo/XRT unless its 2/2 cancer
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Crystalloid and colloid for trauma kids
Crystalloid: 20cc/kg PRBC: 10cc/kg
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Melanoma characteristics: - superficial spreading - lentigo - nodular - acral
- superficial spreading: MC - lentigo: sun exposed, best prog - nodular: worst prog - acral: AA **thickness is most indicative of prognosis
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Tx appendicitis
1. Uncomplicated: lap appe 2. Septic/Unstable: immediate lap appe 3. Stable w/ abscess - < 3cm: lap appe - > 3cm: IR drain ➡ interval appe, offer scope 4. Crohn's ileitis - intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty
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Tx MEN2A/B
1. urine metanephrine to r/o pheo 1st 2. tx pheo 1st w/ adrenalectomy 3. Address thyroid - 2A: total thyroid + bilateral central neck by 5y - 2B: total thyroid + bilateral central neck by 1y
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Tx MEN1
1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics) 2. Asses other lesions
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Prog and Tx anaplastic thyroid ca
Prognosis: - aggressive, undiff - mort ~ 100%; no tx Tx: XRT improves short-term survival +/- surg - BRAF inhibitor for chemo
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GI Hormone Release and action: - Glucagon - Insulin
Glucagon: alpha cells of pancreas - glycogenolysis, gluconeogenesis Insulin – beta cells of the pancreas - cellular glucose uptake; promotes protein synthesis
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Criteria for transanal excision of adenocarcinoma
1. T0 or T1 (submucosa) 2. < 3 cm 3. < 30% circumference 4. Palpable on DRE (<8cm from anal verge) 5. No high-risk features (poorly diff, LV invasion) **local recurrence rate is higher
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Merkel cell ca - dx, histo, and tx
Dx: -rare neuroendocrine tumor of the skin -purple raised; looks like BCC w/out rolled edge - CK20+. TTF- (vs. small cell ca of the lung, TTF+) Tx: -Tx: surgical excision + SLNBx! + XRT (very sensitive)
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Breast abscess tx
- US aspiration BEFORE I/D if refractory - Bx if > 2 weeks to r/o ca - abxs to cover staph if systemic sxs. Consider MRSA coverage if RFs
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5 steps to LADDS procedure
1. Resect Ladd’s bands 2. Widen the mesentery 3. Counterclockwise rotation 4. Cecum in LLQ (cecopexy), place duodenum in RUQ 5. Appendectomy
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HNPCC screening and treatment
1. CRC: scope q1-2y starting at 20-25 - Surgery if: CRC or endoscopically unresectable lesions - TAC with IRA w/ q1y rectum surveillance 2. Endometrial ca - childbearing: endometrial sampling q1y - after children: TAH-BSO 3. Ovarian ca: annual pelvic exam and TVUS
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Dx and Tx choledochal cyst
Dx: U/S or HIDA Tx: 1. fusiform dilation: REY-HJ 2. diverticulum: simple excision 3. choledococele: transduo excision vs. sphincteroplasty 4a. intra + extra dilation: hepatic resection + recon 4b. extra only: excision + recon 5. intra only: transplant
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Vit D vs. PTH
Vit D: increase Ca and Ph PTH: increase Ca and decrease Ph
194
Arterial content
(1.34 x Hb x Sa02) + (.003 x PaO2)
195
Px, Dx, and Tx: Duo atresia TEF Pyloric stenosis Intussusception Malro
Duo atresia: newborn; bilious emesis directly after birth - a/w down syndrome -dx: AXR- double bubble with no gas distally. don't need UGI -tx: duodenoduodenostomy TEF: newborn, spit ups. can't place NG. resp sxs - dx: AXR- gasless (A), gas (C) - tx: right extra-pleural thoracotomy Pyloric stenosis: 1-3 months; NB projectile vomiting -dx: U/S- 4mm thick, 14 mm long. String sign on UGI -tx: pyloromyotomy (1-2 from duo to antrum) Intussusception: 3m-3y; currant jelly stool - dx: U/S w/ bull's eye - tx: air contrast enema Malro: 1y-5y; sudden onset bilious emesis - dx; UGI- no duo sweep (any child w/ bilious emesis) - tx: ladd's procedure
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Cori cycle
- recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production - requires alanine - provides 40% of glu when starving
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Tx of GB cancer
1a: LC only - lap chole only - excise to negative CD margin 1b: muscle involved - OPEN chole + seg 4b and 5 + portal LADN - CD margin positive: REY-HJ **high suspicion for GB Ca should also get an open chole (polyp > 2cm)
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Layers of mucosa
Epithelium Lamino Propria Muscularis mucosa
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Stage 3 breast cancer and tx
3a: 4 to 9 nodes ➡ +/- neoadj 3b: chest wall (not pec wall) or breast skin ➡ +/- neoadj 3c: supra clavicular nodes ➡ neoadj required
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Tx of CBD stone intra-operatively
1. Flush ➡ glucagon x 2 2. Lap exploration A. Transcystic: stone < 1 cm, <8 stones, no CHD stones B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones 3. Open exploration: if lap exploration failed - CBD < 2 cm: trans-duo sphincteroplasty - multiple stones, CBD > 2 cm: biliary-enteric drainage. - Leave T-tube **thin CD can be dilated
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W/up Hurthle Cell Cancer
1. FNA- hurthle cells (can be seen in other conditions) 2. Lobectomy 1st for diagnosis 3. If malig: total thyroidectomy +/- L6 nodes 4. If palpable nodes: MRND No RAI
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Conduit after esophagectomy
Stomach and Right gastroepiploic - if out abort and discuss conduit options at a later time (don't go for colon or jejunum b/c needs to be prepped)
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Cancer Markers: Ca 125 bHCG AFP Inhibin
Ca 125- epithelial bHCG- choriocarcinoma AFP- germ cell/endodermal/yolk sac Inhibin- granulosa/sex-cord
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Tx of High grade AIN/bowen’s disease of anal margin
1. Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin - otherwse: cryo, curettage, 5-FU, laser 2. Lifetime surveillance even if tx! - Bowen disease = SqCC in situ = high grade AIN - Actinic keratosis is precursor *vs. pagets disease- excision
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Types of rejection - px, path, and tx
1. hyper-acute: w/in 1 hour - path: ABO Ab (t2 HS) - px: mottled organ - tx: remove organ 2. acute cellular: days-weeks; change in organ function - path: B or T (t4 HS) - px kidney: lymphocytic infiltration, tubulitis - px liver: endothelitis, portal triad lymphocytosis - tx: increase IS or pulse steroids ➡ IVIG 3. chronic: months-years - path: B or T (t4 HS) - px kidney: interstitial fibrosis, tubular atrophy - px liver: bile duct atrophy - px heart: vasculopathy and atherosclerosis; 1/2 @ 10y - px lung: bronchiolitis obliterans; 1/2 @ 5y - tx: increase IS or re-trx (no good options)
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Dx and Tx DPGM injury
Dx: CXR ➡ CT ➡ diagnostic scope if inconclusive Tx: repair is always recommended - Abdominal approach - Debride devitlized tissue - Repair with non-absorbable suture - If too large can close primarily can use mesh or tissue flap (if contamination)
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Hypocalcemia vs. Hypercalcemia - sxs and ekg
1. HypoCa: tingling, chvostek/trousseau sign - EKG: qt prolongation 2. HyperCa: stones, bones, groans, overtones, DI - EKG: shortened QT
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Calcitonin
Parafollicular C cells Inhibits osteoclast resorption Increases Ph excretion
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Crohn's drugs MOA: - Azathioprine/6-MP - Sulfasalazine/5-ASA - Infliximab
- Azathioprine/6-MP: inhibit DNA synthesis - Sulfasalazine/5-ASA: COX/LOX inhibitor - Infliximab: monoclonal Ab to TNF; moderate Crohns, recurrent perianal fistula!
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GI Hormone Release and action: Gastrin Somatostatin CCK Secretin VIP
1. Gastrin - G cells in antrum - ↑ HCl, IF, and pepsinogen 2. Somatostatin – D cells in pancreas - inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output 3. CCK – I cells of duodenum - gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells) 4. Secretin – S cells of duodenum - ↑ pancreatic/GB bi release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release 5. VIP – pancreas and gut - ↑ intestinal secretion (water and electrolytes) and motility
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Anal canal Dentate line Anal verge Anal margin
Anal canal- from levators to verge Dentate line- w/in the canal; columnar/sq. jxn Anal verge- sqamous/myoc. jxn Anal Margin- 5-6 cm from the anal verge
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Px, Dx, Tx Galactocele
Px: breast mass that looks like abscess w/ no infectious signs Dx/tx: u/s ➡ aspiration shows milky debris - continue bfeeding - no abxs (unless infected)!
213
Stages of graft healing
1. imbibition (direct diffusion) 2. inosculation (cap beds meet) 3. revascularization
214
Hernia repairs: Bassini McVay Lichtenstein Shouldice
Bassini: conjoint tendon to inguinal ligament (from pubic tubercle medially to internal ring laterally) - may need relaxing incision in anterior rectus sheath McVay: open the floor to ➡ conjoint tendon to cooper's/pectineal ligament. - transitional stitch from conjoint, cooper's, and femoral sheath at medial aspect of femoral vein - re-approximate the rest of the inguinal floor by suturing the conjoint tendon to the inguinal ligament - may need relaxing incision Lichtenstein: mesh to inguinal ligament and conjoint tenown Shouldice: divide the floor ➡ 4-layer tissue closure
215
EBUS accesible nodes:
2, 3, 4, 7, 10, 11, 12 - innominate seperates level 3, 4 - 4: carinal - 7: sub-carinal - 10: R/L hilar -n2 nodes: 1-9 -n1 nodes: 10-14 - cannot sample 5, 6 (sub-aortic/AP window) ➡ chamberlain procedure (Parasternal mediastinotomy) - 8 (para-eso), 9 (IPL) ➡ EUS or VATS
216
Order of cells in healing
1. Hemostasis: PMNs - 24-48h - PMNs: remove necrotic tissue 2. Inflammatory: monocytes/macrophages - 48-96h - mphage: growth factors, angiogenesis, cell proliferation - chronic wounds 3. Proliferative: fibroblasts - 3 days+ - fblasts: collagen production 4. Maturation: fibroblasts -10 days+ - myofibroblasts for wound contraction PMN (24-48h) ➡ MPhages (48-96h) ➡ Fblast (3d) ➡ MFblast
217
Hemophilia A
f8 deficiency, SLR MC inherited disorder tx- DDAVP (mild), f8 concentrate (severe)
218
Adenoid cystic carcinoma - px and tx
Px: MC minor salivary gland tumor (Sub-Mand gland @ Palate) - Spread along nerves - Remains quiescent for years then metastasizes Tx: Total parotidectomy w/ facial nerve preservation + MRND + XRT - don't aggressively resect b/c very XRT responsive
219
Tx for cholangiocarcinoma
Tx: 1. Resectable if: - contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor - no distant mets or organ invasion 2. Consider location - Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe - Middle ⅓: hepaticojejunostomy - Lower ⅓: Whipple 3. Chemo + transplant if unresectable
220
acid and alkali burns - px
1. Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis 2. Acid burns (battery acid) produce coagulation necrosis - copious water irrigation as soon as possible - cagluc if HF acid
221
IPMN - dx and tx
dx: MRI 1st! then EUS/FNA; high CEA, high amylase tx: 1. Branched - resect if >3 cm, sxs, or signs of malig (nodule) - Otherwise surveillance 2. Main duct - resect if > 1 cm or sxs (60% chance of Ca) - 5-9 mm EUS/FNA. Resect if SOMalig - < 5mm, surveillance MRIs
222
Tx PDA
to close- indomethacin to open- PGE1
223
Airway management anatomy
Anatomy: 1. Elective trach: between 2nd and 3rd trach rings 2. Crich: CT membrane between thyroid cart and cric - Thyroid ➡ cricoid ➡ rings
224
Dopamine dosing and s/e
low: d1/2-ago (renal dose) medium: B-ago (heart) high: A-ago (vaso) **s/e: high UOP. difficult to titrate. tachyarrythmias
225
Parkland formula
- 4 x weight x TBSA - Use 2 for "modified Brooke formula" - 1st 1/2 in 1st 8h - 2nd half next 16 arm = 9, leg = 18, each torso = 18, head = 9, each hand = 1, genitals = 1 UOP: .5-1 cc/hr. 1-2 cc/hr if child < 30 kg
226
Who needs stress dose steroids and how to dose
>20 mg of steroids for > 3 weeks Surgery: continue regular dose the day of surgery + 1. Low risk (inguinal hernia): just continue regular dose day of surgery 2. Moderate risk: 50 mg HC pre-proc. Then 25q8 x 3 3. High risk: 100 mg HC pre-proc. Then 50q8 x 3
227
Path, Dx and Tx of Zenkers
Path: outpouching SUPERIOR to cricopharyngeous Dx: UGI (don't do EGD) ➡ manometry (r/o dysmotility) Tx: open or scope approach: <2cm : myotomy alone >2cm: multiple options - consider endoscopic stapling +/- myotomy - 2-5 cm: myotomy with suspension or inversion - larger: diverticulectomy with myotomy
228
Tx SIADH
Acute – vaptan, demeclocycline Chronic – fluid restriction, diuresis
229
Spinal vs. Epidural
Spinal- below l1/l2; SA space; fast; n/m block Epidural- any level; epidural space; slow; no block
230
VIPoma - loc, px, dx, tx
Loc: distal Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin - DRH ➡ bicarb sexn ➡ met acid - most malignant Dx: high VIP Tx: distal panc + splenectomy + LADN'y + CC'y
231
Gastric CA tx - chemo, margins, nodes
- neo-adj chemo for T2+ or N - proximal- total gastrectomy - distal- partial - 5 cm margin; 15 nodes - Can consider endoscopic mucosal resection: if < 2cm, well-differentiated, mucoa only, no LV invasion
232
DDAVP/Vasopressin - production and effect
- Made in SON of HT. Stored PP - Cause endothelium to release f8 and vWF
233
Milan criteria
indications for trx w/ HCC - Single tumor < 5cm - No more than 3 tumors each < 3 cm **Hepatectomy if compensated cirrhosis (no portal HTN), low MELD, and solitary mass < 3 cm is still preferred **5-year transplant pt survival is 65-90% indications for trx of cholangioca - cant be intrahepatic - must be unresectable, perihilar, < 3cm - no distant mets
234
Posterior and anterior vagal trunk branches Vagotomies
Right ➡ Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet Left ➡ Anterior trunk- Liver (hepatic branch) and ant Laterjet (L's) 1. Truncal vagotomy: transect ant/post @ distal eso - removes lesser curve and pylorus nerve - selective: resect at ant/post Laterjet - need pyloroplasty. high r/o dumping syndrome 2. Highly selective: transect @ crow’s ft, preserve laterjet - removes innervation to lesser curvature - preserves pylorus → no drainage procedure - lowest morbidity
235
Insulinoma - loc, px, dx, tx
Loc: throughout (B cells) Px: whipple's triad. Most benign. Dx: I/G > .4 and high C-pep - dx w/ fasting test 1st! - endoscopic U/S most sensitive for detection Tx: < 2cm encucleate, >2cm resect. - High carb diet 1st - Diazoxide if can't tolerate surgery  - LADN'y if suspect malignancy
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Dx and Tx fat necrosis
1. dx: breast oil cyst w/ Ca+ rim - smooth, circumscribed lesion outlined in white (course, egg-shell calcs) - suspect post-op 2. tx: no trauma- bx trauma- watch
237
Px, Dx and Tx Pancreatic divisum
Px: child with chronic pancreatitis episodes Dx: secretin-enhanced MRCP Tx: - Only tx if sxs - ERCP sph’otomy of MINOR papilla (Santorini/Superior) - Refractory: resect HOP (duo preserving)
238
Indications for neoadjuvant therapy eso cancer
- high grade t1b or T2 and above OR any nodal involvement - Also get XRT
239
Marfans vs. Ehlers-Danlos
1. Marfans- Fibrillin-1 defect (elastin); - AD; mitral regurg, aortic root dilation, lens defect, arachnodactyly 2. Ehlers Danlos- t3 collagen defect - hyper elastic skin, hypermobile joints, aortic root dilation **Both need CTA of aorta to r/o aortic root``
240
Bladder ca - dx and tx
px- hematuria in a smoker dx- CT urogram 1st (bladder, kidney, or ureter ca) 1. T1a- no muscle/including LP tx- transuretehral resexn (TURBT) + mitoM + BCG 2. T2a- muscle/beyond LP tx- cystectomy + LND + chemo 3. T3- fat/nodes tx- neoadjuvant
241
Tx tracheal inj
Small ➡ absorbable in 1 LAYER w/ strap buttress - 2 layer leads to tracheal stenosis - primary repair up to 5-6 rings - bilateral injury ➡ bilateral SCM incisions and join ("U" incision) Large and above 3rd ring → tracheostomy through the defect - avoid below 3rd ring (TI fistula) Access: distal 1/3, right main, proximal L main ➡ right postero-lateral thoracotomy
242
Specific to Crohn's and UC
1. Crohn's: - Creeping fat - Skip lesions - Transmural - Cobblestoning - Granulomas - Fistulas 2. UC: - Crypt abscess - Pseudopolyps
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Uremic PLT dysfunction - px, dx, tx
Px- 2/2 renal disease. dx- normal coags. elevated BT only. tx- ddavp
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Escharotomy indications
- Circumferential deep burns - Neuro-vascular sxs - Problems ventilating torso burns - Go down to fascia but don't divide the fascia **Perform within 4–6 hours **Usually bedside **May need fasciotomy AFTER
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Gastric ulcers: elective classification and management
Dx- EGD and Bx (Bx needed to r/o ca!) Tx-only tx if refractory to max medical management after 12 weeks. 1. lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2 2. gastric + duo; high acid ➡ antrectomy + vagotomy 3. pre pyloric: high acid ➡ antrectomy + vagotomy 4. GE junction: normal acid ➡ sub-total gastrectomy + REY
246
Emergent vs. Elective UC Tx
Emergent: 1. Steroids +/- abxs 2. Infliximab, Cyclosporine 3. No response, megacolon (> 6 cm), HDUS, or perf ➡ TAC with end-ileostomy - When stabilized can perform proctectomy and IPAA - Don't do proctectomy in emergent situations Elective: - Indications: dysplasia, cancer, refractory disease - PC w/ IPAA ** Surgery reduces: erythema nodosum, arthritis -- no effect on PSC or ank spondy
247
Kasabach-Merritt Syndrome
- hemangioma + thrombocytopenia - usually infants - resect!
248
Peutz-Jeghers - px and screening
Px- intestinal hamartomas (intususpeption), pigmented oral mucosa, polyposis - Cancers: GI tract, breast, pancreatic - AD, STK11 mutation Screening - Scope @ 25y then q2 years b/c high r/o GI/pancreas ca
249
Omphalocele
- 2/2 failure of umbo ring closure - 11th week gut returns to abdominal cavity - normal bowel (protected) - Other congenital defect are more common
250
Cryo contents and uses
- Contents: VWF, f8, fibrinogen - Uses: 1. VWD 2. Fibrinogen def 3. Hemophilia A
251
Zone injuries and management
1. penetrating: - zone 1-3 --> explore 2. blunt: - zone1 --> explore - zone 2-3 --> do not explore
252
TOS tx
1. neurogenic PT: PT --> rib resection, scalenectomy, BPlex dissection 2. venous- catheter-directed thrombolysis → surgical decompression 3. arterial- C7/1r resection, subc artery resection/reconstruction
253
FAP - Dx and Tx
Dx: > 100 adenoma or < 100 w/ fam hx - AD; APC mutation - CA by 40 - desmoid tumors (slow growing abdominal wall mass) Tx: - sigmoidoscopy q1y at 10 (don't need colonoscopy) - EGD @ 20 or when polyps start- SB polyposis - TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen) - q1y EGD post op for duodenal cancer (MC COD after colectomy) - q1y c'scope if TAC - polyposis/high grade dysplasia @ stump → proctectomy +/- pouch - desmoid: resect. Anti-E if intra-abdominal
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BRCA risks and tx
female breast, ovarian, male breast I (ch17)- 60, 40, 1 II (ch13)- 60, 10, 10 Tx: -pre-meno: offer bilateral mastectomy OR q1 MRI starting @ 25 - @ 30 annual MRI w/ mammo -post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH) **SOO decrease r/o OVARIAN Ca (80%) for BRCA1/2 AND breast Ca for BRCA2 only (50%) **No TAH!
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When to operate on adrenal mass
1. all functioning tumors 2. all > 6 cm ➡ open resection 3. if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection **DO NOT biopsy first
256
Adjuvent chemo for breast ca
1. Adjuvent chemo: tumor > 1cm, nodal dz, triple neg - echo before for cardiotox 2. Tamoxifen/Anastrazole: 5y for HR+ tumors - Tamox for men 3. Trastuzumab- 1y for Her2/neu+ tumors - echo before for cardiotox 4. Olaparib- 1 year for triple negative/BRCA+ tumors - PARP inhibitor **Oncotype recurrence score > 26 requires adjuvant chemotherapy
257
FNH - path, dx and tx
path- CENTRAL STELLATE SCAR! dx- bright on arterial phase homogenous tx- resect if sxatic. no malignant potential.
258
Secretin vs. CCK
Both released by duo S cells ➡ Secretin- duct cells ➡ bicarb I cells ➡ CCK- acinar cells ➡ enzymes
259
Pancreas drainage procedures
1. duct > 7mm- Peustow, pancreaticojej (for large duct) 2. duct > 7mm and large head- Frey, pancreasticojej + core out head 3. duct < 7mm and large head- Berger, pancreatic head resection
260
Tx papillary/follicar thyroid cancer
1. Indications for total thyroidectomy: - Tumor > 4cm - Distant mets or extra-thyroid disease - Poorly differentiated - Prior radiation 2. Nodes dissection: A. Lateral neck dissection: of involved compartments if palpable or bx+ nodes B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes. - Usually not performed for follicular 3. Radio iodine indications (6w post op, want TSH high) - Only after total thyroidectomy to be effective - For high risk tumors: tumor > 1 cm, extra-thyroidal disease
261
Heparin - MOA and measurement
MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin Measurement: - PTT - ACT: better intra-op if high doses of hep given
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Screening guidelines for breast ca
Mammogram every 2–3 years after age 40 then yearly after 50 High-risk screening - mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative
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Tx SDH
1. Nonop: HDS, <10 mm, <5 mm shift 2. Evacuate: > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP
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Central venous O2 vs. mixed venous O2
Mixed venous: from PA Central venous: from SVC only (estimation of mixed)
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Reversals: - BB - CCB - Tylenol - Benzos - CN/Nitroprusside - Vecuronium/Rocuronium - Ethylene glycol - Methemoglobinemia
- BB overdose: fluids/atropine → glucagon - CCB: Ca + Insulin + Atropine + Pressor - Tylenol: NAC - Benzos: flumazenil (.2mg IV) - CN/Nitroprusside: sodium thiosulfate, amyl nitrite - Vecuronium/Rocuronium: sugammadex - Ethylene glycol: femopizole and bicarb OR ethanol; iHD - Methemoglobinemia: methylene blue
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Orientation of portal triad
Bile duct lateral Hepatic artery medial Portal vein posterior
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Px an tx: Cryoptococcus Coccidiomycosis Histoplasmosis Mucormycosis
1. Crypto- CNS sxs in AIDs pt tx- amphotericin 2. Coccidio- pulm sxs in the southwest tx- amphotericin 3. Histo- pulm sxs in ohio river valley tx- itraconazole → ampho B (only if sxs) 4. Mucormycosis- burns/trauma w/ bloody cough tx- emergent debride, ampho
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LN harvest/margin eso stomach colon rectum
eso- 15/7cm stomach- 15/5cm colon-12/5 cm rectum- 12/5 cm
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Succinylcholine - MOA, s/e, c/i
MOA: ONLY depolarizing. degraded by plasma CE - Short half-life and rapid onset (RSI) - Used for "full stomach" s/e: rhabdo, hyperK, M/H, bradycardia c/i: spinal cord injury, renal failure, large burns tx of M/H: stop drug, dantrolene, Bicarb, cooling, tylenol
270
Breast nerve - muscle and actions: - Thoracodorsal - Intercosto-brachial - Lateral petoral - Medial pectoral - Long thoracic (medial)
- Thoracodorsal (lateral): Lat Dorsi, ADduct/extension/IR - Intercosto-brachial: hypesthesia - Lateral petoral: p major, arm flexion - Medial pectoral: p major/minor, ADduct/extension/IR - Long thoracic (medial): SA, wing scap **Wing scap: LTN or spinal accessory nerve
271
Cohort study vs. Case control
Cohort: prosepective; exposed vs. non-exposed RR- [a/a+b]/[c/c+d] Case control: retrospective; diseased vs. non-diseased OR- (a/b)/(c/d) - good initial study to show an association
272
Tx acute limb ischemia
Tx: Rutherford 1: no deficits ➡ hep gtt. imaging. eventual revasc 2a: motor intact ➡ imaging. hep gtt (motor intact, sensation). eventual revasc - if early post-op case skip the imaging 2b: any weakness, rest pain ➡ hep gtt and immediate revasc (don't image if delay in tx) - if present in prior graft perform thrombectomy 3: paralysis ➡ amputation Revasc options: 1. Endovascular: short segment, single lesion 2. Open: long segment, multiple lesions
273
Papillary cystadenoma (Warthin tumor) - px, tx
Px: benign tumor of salivary gland - often BILATERAL and 2/2 smoking - Slow growing Tx: complete resection with uninvolved margins even if ASx
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Hemangioma - path, px, and tx
path- PERIPHERAL ENHANCEMENT with continued late filling px- young women tx- if rupture, size change, or KM syndrome
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Pancreatic ducts
Wirsung- major, lies inferior Santorini- minor, lies superior
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Gluconeogenesis precursors
lactate , pyruvate, AA (alanine, glutamine)
277
Sirolimus - MOA, s/e
MOA: mTOR (rapamycin) inhibitor - Less nephrotoxic - Alternative to tacro intolerance s/e: - lymphocele (w/ obstruction) - wound complications/poor wound healing: held or switched to tacro before hernia repairs
278
Tx of rectal prolpase
- Not past the verge: biofeedback, fiber -Many comorbidities or acute presentation: Altemeir (perineal rectosigmoid'y) -Prolpase < 50cm with comorbidities: Delorme (muscle plication) -Young/healthy and elective: rectopexy +/- resection
279
Li Fraumeni - gene, mechanism, and px
- gene: p53 mutation; TSG on Ch17; AD inheritance - mech: cell cycle regulation at G1/S to promote apoptosis in DNA damaged cells - px: breast ca + sarcoma b4 45
280
Chylothorax dx and tx
1. dx: fluid TG > 110 2. tx: chest tube and NPO - < 1L/day: MCT diet, octreotide, TPN → 7d: thoracic duct lig (Open R chest or IR) - > 1L/day: thoracic duct ligation (Open R chest or IR) **for cancer patients: pleurodesis > ligation
281
Tumor lysis syndrome - px, path and tx
Px: Common 2/2 B cell lymphoma - hyperU, K, Ph w/ hypoCa Path: CaPh crystal ➡ renal failure + hypoCa tx: IV hydration ➡ iHD
282
CRC T and N stages
t1- SM t2- MP t3- xMP/subserosa t4- invade n1- 1-3, n2- >=4
283
Rectovaginal fistula tx
wait 3-6m low- endorectal advancement flap high- abdominal approach
284
Schiatzki's Ring - Path and Tx
Path: - Associated with hiatal hernia. 2/2 GERD. - Usually distal eso - Mucosal process. No muscle involved - Protective against Barret's Tx: only if sxatic. 1. Bx first to r/o eosino esoph's - if esosino esoph's: medical therapy first 2. Dilation and PPI 3. Steroids, endoscopic resection
285
NNT
NNT = 1/absolute risk reduction (ARR) - ARR = event rate in intervention group - rate in control group - RR = event rate in intervention / rate in null group - RRR = (rate control - rate experimental) / rate control
286
Tx childhood GI disease: - Pyloric stenosis - Intussusception - Duo atresia - TEF - Malro
- Pyloric stenosis: pyloromyotomy - Intussusception: air contrast enema (air > water) - Duo atresia: DD or DJ - TEF: right extrapleural thoracotomy - Malro: LADDS proc
287
Pancreatic fistula - dx and tx
dx: drain amylase 3x serum amylase at 3 weeks - considered a "biochemical leak" if leakage is cx insignificant - amylase clears faster than lipase tx: - NPO, TPN or N-J feeding x 4-6 wks - octreotide if high output (>200/day). Does not increase healing rate or closure. Does decrease output. - consider ERCP w/ stent after 6 weeks (vs. biloma which can be ERCP/stented early)
288
Max dose of lido and bupiv and tx of OD
lido = 5mg/kg (7 w/ epi) bupiv = 2.5 mg/kg (3 w/ epi) tx- lipid emulsion
289
Epi, Dx and Tx Aspergillosis
Epi: - MC fungal infection in IC patient - Histoplasmosis is MC fungal infection overall (itraconazole) Dx: +gallactomannan Ab/Ag detection, PCR, microscopy, cx or path - can cause pneumonioa, lung abscess, brain abscess Tx: - aspergilloma: resect - aspergillosis: voriconazole (inhibits ergosterol)
290
Dx and Tx of GIST
1. Dx: MC GI Sarcoma - EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC. - Bx: cajal cells. c-KIT+ - don't require bx if high suspicion 2. Tx: wedge resection (gross margin) - can be R0 or R1 resection - Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf - mitosis/hpf is most predictive of prognosis (>mets) - neoadjuvant if need to down-stage for resection - adjuvant for 3 years
291
Vitamin K - MOA and def
MOA: gamma CARBOXYLATION (not decarb) of GLUTAMATE on 2, 7, 9, 10, c, s Px of def: coagulopathy, suspect if obstructive jaundice
292
Rectum: 1. Arterial supply 2. Venous drainage
1. Arterial supply: - IMA to superior rectal a. - II to middle rectal a - II to internal pudendal a. to inferior rectal a. 2. Venous drainage- - SRV ➡ IMV ➡ PV (portal) - MRV/IRV ➡ internal pudendal ➡ internal iliac (systemic)
293
Kcal per macronutrient Total kcal req
1. protein = 4 kcal/g 2. dextrose = 3.4 kcal/g 3. lipid = 9 kcal/g 4. carb = 4 kcal/g total req = 25-30 kcal/kg - use ideal body weight if BMI > 25 - 50% carb, 30% fat, 20% protein
294
Hinchey
1- pericolic abscess 2- pelvic abscess 3- purulent 4- feculent
295
Contents of ant triangle of neck
- Carotid sheath, anca cervicalis, CN 12 (hypoglossal) - Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular - Facial vein is the gateway
296
Px and Tx for Leriche syndrome
px: diminished femoral pulse, butt claudication, ED - younger than infra-inguinal vascular dz patient tx: aortobifemoral bypass
297
Benign lesions that require excisional bx
Core needle returns ➡ - Atypical (25% of malignancy) - DH/LH - LCIS/DCIS - radial scar - papillary lesion - any atypia **lesions generally have a 15-30% chance of carcinoma in situ or invasive cancer
298
Future Liver Remnant requirements and indications for PVE
1. minimum 20% if normal liver 2. pre-op chemo/some dysfxn = 30% 3. cirrhosis = 40% -Otherwise should undergo PVE -Overt PH is a c/i to PVE
299
type 1 vs. type 2 error
type 1: false positive - say something is true (reject the null) when it's not - alpha = prob of type 1 error. Set at .05 - minimize by decreasing stat significance type 2: false negative - say something is false (do not reject the null, accept H0) when it's true - beta = prob of type 2 error. Set at .2 - minimize by increasing sample size/power **power = 1 - type 2 **reject the null = "a difference exists"
300
hepatic adenoma - imaging, tx, and risks
path- EARLY enhancement on arterial phase w/ rapid washout. well-circumscribed. **vs hemangioma: peripheral enhancement over time tx- stop OCP use. resect immediately if > 5cm, sxatic, male gender risks: 1. rupture MC 2. malig transformation
301
Types of mastectomy
1. Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin (no nodes) 2. MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes 3. BCT: partial mastectomy + XRT
302
Pyoderma gangrenosum and erythema nodosum - px and tx
- Pyoderma: pre-tibial ulcer - Erythema Nodosum: pre-tibial erythematous plauque - both associated w/ IBD - both RESOLVE after resection - tx: steroids
303
anion gap - equation and causes Cases of NAGMA
Na - (Cl+Bic) NaCl = non-AG, increased Cl, metabolic acidosis AGMA: Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, LA, Ethanol/Glycol, Salicylates NAGMA: normal saline, DRH, fistula, ureteral conduit, RTA
304
MOA reglan and erythromcyin
- reglan: dopamine antagonist - erythromycin: motlin receptor agonist causing SM contraction
305
Modality and staging for eso cancer (T and N)
If CT and PET: no distance disease ➡ Endoscopic U/S for T and N: t1a- LP and MM t1b- SM (where it spreads) t2- MP t3- adventitia t4a- resectable structures t4b- unresectable structures n1: 1-2 nodes, n2: 3-6 node, sn3: 7+
306
Barrett’s eso surveillance (progress to cancer)
Bx: Goblet cells and columnar cells 1. No dysplasia: 4 quad every 2 cm q 3-5y - 1 cm if mucosal irregularities - Ca .1%/y 2. LGD: 4 quad every 1 cm q6m. Consider ablation. - Ca .5%/year 3. HGD: ablation/endoscopic resection. 4 quad every 1 cm q3m - Ca 5%/year *Fundoplication is only c/i in HGD *No screening if asx
307
HNPCC vs. Lynch S Dx and Screening
HNPCC: fulfill amsterdam criteria - 3+ relatives with Lynch syndrome-associated cancers (CRC, endometrium, small bowel, ureter, renal) - 2 generations - 1 ca dx < 50 yo Lynch syndrome: refers to mutation in DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) or the EPCAM gene. - should test in all with new onset CRC
308
Serum osmolarity
Osm = 2xNa + Glu/18 + urea/2.8
309
Superior laryngeal nerve (external branch) - fxn, injury, and tx
fxn: motor to cricothyroid injury: trouble w/ high pitch, voice remins clear - cord looks normal on laryngoscopy tx: none **MC nerve injury w/ a total thyroid
310
GCS motor
6- obeys commands 5- localized 4- w/draws 3- flexion (decort) - 'flex your core' 2- extension (decErebrate) 1- none
311
LeFort fxs
I- palate II- nose and palate III- entire face
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Human bite tx and organism
tx: amox/clavulanate (augmentin) - requires I&D if joint appears septic (pain w/ passive motion) **MC for human bites- eikenella
313
MCCO healthcare infection: - HAP/VAP - central line infection - SSI - UTI - GI infection - SBP - Cholangitis - NSTI - ICU infection - Fungal infection - Graft infection - Lymphangitis
- HAP/VAP: staph aureus (pseudomonas #2) - central line infection: coag negative staph (staph epi) - SSI: staph aureus - UTI: e. coli - GI infection: c. diff - SBP: e. coli - Cholangitis: e. coli - NSTI: polymicrobial - ICU infection: VAP - Fungal infection: hitsto (asperg if I/C) - Graft infection: staph aureus (early), staph epi (late) - Lymphangitis: strep pyogenes
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Tx of trx of great vessels
1st give PGE1 → ballon atrial septostomy
315
RF, Dx and Tx SqCC of anal canal
RF: HPV 16/18, STI, HIV - test for cervical ca too Dx: - Anoscopy + FNA/core bx - HIV test all patients Tx: - Nigro protocol: XRT (ing/pelvic nodes) + 5FU + MitoC - Recurrence (10-20%): q6 months to diagnose ➡ APR - Lateral to I/S groove (anal margin): tx like skin cancer
316
TOF - defects and tx
Most common cyanotic defect 1. VSD 2. Pulmonary outflow obstruction 3. Over-riding aorta 4. RVH (2/2 RV outflow obstruction w/ harsh murmur) tx- beta blocker; surgery at 3-6m
317
Cutoff for low risk lung nodules not requiring follow-up
1. 6mm ➡ NTD 2. 6-8 mm ➡ q6-12m CT 3. > 8mm - low risk pt- q3m CT - high risk pt- bx or resection
318
Light's criteria
Exudate if: PL protein/serum Pr >.5 PL LDH/serum LDH > .6 PL LDH > 2/3 ULN - Exudate: capillary damage from inflammation, neoplasm, trauma - Transudate: change in oncotic pressure;
319
Treatment of colo-cutaenous fistula
1. Start with conservative tx 2. Quantify output: - High output: > 500 cc/day ➡ likely OR. Start with NPO/TPN. - Low output: < 200 cc/day ➡ likely conservative. OK for PO intake. 3. If input increased with PO intake ➡ NPO and TPN 4. OR if failed after about 6 weeks 
320
Most abundant bacteria in the colon
Bacteroides fragiles (anaerobe)
321
T staging for esophageal cancer
t1a: muscularis mucosa: endo resection t1b: SM: upfront esophagectomy (or low grade t2) t2: muscularis propria: neoadjuvant - low risk: upfront esophagectomy t3: adventitia: neoadjuvant *no serosa. Ca spread through SM lymphatics
322
Exposing the pancreas: head, body, tail and order of operations in trauma
Head: kocherize Body: incise gastrocolic ligament ➡ lesser sac Tail: mobilize spleen Trauma: 1. R medial visceral rotation 2. Kocher 3. Divide GC ligament/enter LS 4. Complete Kattel 5. Mobilize LOT
323
Thoracic duct course
1. originates at L1-L2 @ c. chyli 2. cross from R to L at T4-5 3. empties into L SC/IJ jxn **Carries chylomicrons and LCFA
324
Stomach vs. Duo ulcer px
1. Stomach ulcer: pain right after meal - 75% H. pylori, 25% NSAIDS/ASA 2. Duo ulcer: pain 2-3h after meal - 90% H. pylori, 10% NSAIDS/ASA **NSAID/ASA: decrease mucosal mucus secretion and bicarb secretion
325
Effective for Pseudomonas
1. Zosyn 2. 3/4G cephalosporin (ceftriaxone, cefepime) 3. Aminoglycodies (genta, tobra) 4. Flouroquinolones (cipro) 5. Meropenem/Imipenem  **Not linezolid (good for G+/MRSA)
326
most common organism in burn wound infection most common viral burn wound infection
- Pseudomonas (< 10^5 organisms – not a burn wound infection) - HSV
327
Cuff size for kids
age/4 + 4
328
Grading and tx of BCVI
1- <25% narrowing ➡ ASA 2- > 25% narrowing ➡ ASA 3- PsA ➡ ASA + IR stent 4- complete occlusion ➡ ASA only 5- transection ➡ OR if accessible. Otherwise IR. *most are not surgically accessible
329
Ectopic parathyroids
1. Superior parathyroids: from 4th pouch - usual location: posterior to RLN. - Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath. - TE groove is MC ectopic location 2. Inferior parathyroids: from 3rd pouch (with thymus) - usual location: anterior to RLN. - Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass - thyrothymic ligament is MC ectopic location - more commonly ectopic b/c longer travel 3. 4 normal appearing galnds - supranumary PT in the thymus **Overall, thymus is MC location or ectopic gland
330
Trauma to the pancreas
1. Head - main duct: drain + post-op ERCP + staged resection - no duct: drain 2. Tail - main duct (grade 3+): resect w/ splenectomy (unless CHILD and HDS) - no duct (grade 1-2): drain
331
MOA and s/e of trx meds - Tacro - Cyclosporine - Sirolimus
Tacro: calcineurin inhibitor; bind fK ➡ calcineurin ➡ block IL2 - 100x more potent than cyclosporine - neuro sxs (tremor), GI sxs - nephrotox, hepatotoxic - DM - alopecia Cyclosporine: calcineurin inhibitor; bind cyclophillin ➡ calcineurin ➡ block IL2 - nephrotox, hepatotox, neuro sxs - gingival hyperplasia, hypertrichosis - cycled in bile, gallstones Sirolimus: bind fK ➡ mTor inhibitor (IL2 inhibitor) - impaired wound healing - interstitial lung disease - lymphocele
332
Interossei and lumbrical innervation
palmar- ulnar n, adduct dorsal- ulnar n, abduct lumbricals- median (1-2)/ulnar (3-4)
333
MOA and S/e of tamoxifen
MOA: competitive E inhibitor in breast; weak agonist in uterus/liver S/e: - dvt/pe - endometrial cancer - cant take with SSRI (CYP inhibitors)
334
DCIS mammo and tx
Mammo: clustered calcs Tx: like ca - BCT: lumpectomy (2mm) + XRT +/- boost +/- endocrine - no SLNBx (does not metastesize) - no chemotherapy - if XRT c/i → mastectomy AND SLNBx (b/c 20% have invasive ca)
335
DCIS SLNBx
- does not metastasize - not w/ l’omy unless >4cm, multicentric, palpable, high grade - required w/ mastectomy b/c 20% have invasive ca
336
Dx and Tx of Cystadenoma
low CEA, low Amylase tx- resect if sxs
337
Post polypectomy screening
-2-6m: piecemeal removal -1 year: > 10 adenomas -3 years: 3+ adenomas, HGD, > 1cm, villous elements -5 years: 1-2 tubular adenomas (< 1cm) -10 years: hyperplastic polyps (<20)
338
Encapsulate organisms and empiric tx
-Organism: “Shin” 1. Strep pneumo (MC) 2. Neisseria 3. Haemophilus - Empiric tx: vanc + 3GC
339
Casues of increased ET CO2
Increased muscle activity (shivering) Increased metabolism (sepsis, fever, malignany hyperT) Increased CO Decreased minute ventilation
340
Dx and Tx of Meckels
dx: suspect if recurrent intususpeption, GI bleeds - Meckel's scan (Tc-99) is best test. Increase Se by giving pentagastrin, glucagon, h2 blocker. Not as Se in adults (atrophic gastric cells) - only detects gastric tissue (not panc) - if negative but high suspicion ➡ repeat scan - if inconclusive then proceed with abdominal exploration (not CT) tx: resection if sxs - base < 2 cm → diverticulectomy - > 2 cm or wide base → seg resection - appendectomy as well if exploratory surgery for presumed appe ended up being meckels - If incidental: resect meckel's in kids, leave in adults.
341
Products of posterior pituitary
"PAO in the POST" ADH, Oxytocin 2/2 direct stem from neurosecretory cell
342
Hereditary pancreatitis - dx and tx
dx - PRSS1 trypsinogen mut'n - AD tx: none - smoking cessation is important **different from AI pancreatitis (IgG+)
343
Cilostazol - MOA and use
MOA- PDi, inhibits PLT aggregation tx for periph claudication - c/i in any degree of HF (PDi)
344
Esophagus and Trachea access
Proximal eso- L cervical Mid eso/prox thoracic eso- R P/L thoracotomy Distal eso- L thoractomy Cervical trachea: collar incision Carina/Either main-stem bronch: RIGHT P/L thoracotomy Aorta: L thoracotomy **for trauma do A/L thoracotomy b/c decub is not safe in unstable patient and want access to the heart
345
Ureter injuries
1. proximal ⅓ (U/P jxn and above) → primary uretero-urostomy. Other options: ileal transposition, nephrostomy 2. middle ⅓ → primary u-u (preferred) - Other options: tran uretero-urosotomy, Boari flap 3. lower ⅓ (distal to iliacs) → re-implanation +/- hitch 1. early: w/in 5 days- stent, explore, or repair - HDUS intra-op: ligate, perc neph, delayed repair (3m) 2. late: > 10 days- perc nephro and delayed repair (3m)
346
Vitamin D processing
7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3
347
Tx papillary/follicar thyroid ca
Start with lobectomy Indications for total thyroidectomy: - Tumor > 4 cm (1-4 cm, close observation or total) - Extra-thyroidal disease - Multi-centric or bilateral lesions - Previous XRT Consider ppx level 6 for high risk If thyroid lobectomy only: - Tx with thyroid hormone to suppress TSH - Get serial U/S to monitor Indications for MRND - extra thyroid extension Radio iodine indications (6w post op, want TSH high) - Consider for 1-4 cm, definitely > 4cm - Extra-thyroidal disease - Need total thyroidectomy to be effective
348
Tx Odontoid fx
1: upper D, stable, non-op 2: base of D, unstable, worst, +/- surg - may require intubation 3: c2 vert, usually no OR
349
GCS verbal
5- normal 4- confused 3- inappropriate words 2- incomprehensible 1- none
350
MELD vs. CTP
Meld: 1. Bili 2. INR 3. Creatinine  - designed for mortality over 3 months after TIPS - At least 15 for trx - HCC gets automatic score of 22 CTP: Billirubin, Albumin, INR, Ascites, Encephalopathy
351
Intraductal papilloma dx and tx
dx: dx mammo 1st ➡ U/S is enough or contrast ductogram - MCCO bloody nipple dc - only use ductogram if all other imaging is equivocal tx: excisional biopsy including the ductal segment - do central duct excision if can't ID the duct
352
Tx Umbo and Inguinal hernia in child
most close by 2 <3cm- primary repair >3cm- mesh repair by 5 Inguinal- repair by 2 weeks if reducible - otherwise, OR then
353
Gastroschisis - px and tx
Px: - GastRoschisis to the Right of midline - rare defects...EXCEPTION- instestinal atResia Tx: - cover bowel after delivery - stabilize and attempt primary closure (80%) - for larger defects, place silo for delayed closure - post op: ICU, TPN, assess for short gut
354
Mineral def: -Zn -Sel -Chromium -Copper -B1 -B3
-Zn: wound heal/skin, night blind -Sel: cardiomyopathy -Chromium: hyperglycemia -Copper: micro anemia -B1 (thiamine): wernicke’s encephalopathy, p. Neuropathy, gap acidosis (lactate) -B3 (niacin): pellagra (DRH, dementia, dermatitis)
355
UES vs LES muscles
UES- cricopharyngeus; higher resting pressure (70) LES- lower resting pressure (15)
356
Stiewert-Stein Class and Tx
Relation to GEJ: 1. 1-5 cm above: eso ca - esophagectomy and prox gastrectomy (Ivor lewis) 2. 1 cm above-2 cm below: eso ca - esophagectomy and prox gastrectomy (Ivor lewis) 3. 2-5 cm below GEJ: gastric ca - total gastrectomy *Require 5 cm eso margin, 4 cm gastric margin, 15 nodes for eso CA
357
Esophageal CA tx
1. HGD, TIS, T1a: endoscopic ablation/resection 2. T1b: upfront esophagectomy or endo ablation (if low risk) 3. T2 or N: neoadjuvant then esophagectomy - Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso 4. T4b or M: definitive chemo-XRT < 5cm from cricoP: definitive chemo-XRT > 5 cm from cricoP: esophagectomy
358
Indications and C/I to anti-reflux surgery
Indications: 1. Extra-eso complications: cough, aspiration, CP 2. Persistant sxs 3. C/I to antireflux meds 4. Barrett's w/out HGD 5. Strictures 6. Esophagitis C/I: 1. Cancer 2. Barrett's w/ HGD
359
Classic and Alarm sxs for GERD
Classic sxs: heart burn + regurg Alarm: 1. dysphagia (not regurgitation) 2. odynophagia (pain) 3. bleeding 4. weight loss 5. anemia *Require EGD
360
Tx of Leiomyoma
1. sxs or > 4cm- enucleate 2. < 4cm- observe 3. >8cm or circumferential- esophagectomy Approach: Cervical- L Mid eso- R Distal eso- L
361
Required for staging esophageal CA
1. CT of chest, abdomen- M 2. Whole-body PET scan- M 3. EUS- T and N stage
362
Caustic injury w/up
0. Avoid NGT. No neutralizing agents 1. CT scan if stable 2. Early endoscopy (AFTER CT) 3. OR if unstable. Otherwise, restart orals in 48h. *alkali- liquefaction necrosis. worse outcome *acid- coagulation necrosis
363
Steps of Heller myotomy
1. Divide G-H ligament 2. ID R crus and posterior vagus 3. ID L crus and anterior vagus 4. Divid short gastric vessels 5. Expose GEJ (excise eso fat pad) 6. Myotomy (6 eso, 2 stomach) - outer long 1st - inner circular 2nd 7. Partial wrap
364
How to mobilize the stomach for intra-thoracic anastamosis
1. Divide G-H ligament 2. Transect the L gastric. Keep the R gastric. ---- Lesser Curve Mobilized---- 3. Transect gastro-colic until prox duo. Avoid R gastro-epiploic! 4. Extend gastro-colic to take the L gastro-epiploic, short gastric vessels, and gastrophrenic vessels ---- Grater Curve Mobilized ---- To gain extra length: 1. Kocher maneuver 2. Divide the R gastric artery Greater omentum = gastro-colic + gastroc-splenic + gastro-phrenic ligaments
365
Epiphrenic divertciulum
Loc: distal eso. R > L. Pulsion Tx: only if sxs. - L diverticulectomy w/ contra myotomy
366
Dx and Tx of Eso perf
Dx: XR then contrast esophogography (GG then Ba) - EGD if UGI is negative but still high suspicious - don't require CT Tx- 1. abxs (fungus) 2. Cervical: open neck and place drains 3. Thoracic: L thoracotomy, extended myotomy, cover w/ 2 layers - if achalsia: contra myotomy 4. Buttress with IC muscle NG, chest tube 5. Very unstable: exclusion and diversion Selective non-op: 1. Contained perf w/ minimal signs of sepsis OR 2. Very poor operative candidate Stenting: contained perf or minimal extrav after EGD
367
FeNa equation and interpretation
(U Na/S Na) / (U Cr / S Cr) * 100 <1% = Pre-renal >1% = Intrinsic >4% = Post-renal
368
Refeeding Syndrome - mech and px
- Mech: fat to carb metabolism ➡ resumption of ATP production and Insulin surg ➡ Ph influx into cells ➡ hypoPh - Px: HypoMg, Ph, K; paresthesia, confusions, RD - COD is cardiac failure
369
pH relation to pCO2
10 mmHg increase in pCO2 = .08 decrease in pH
370
Tx of DI
1. Central- DDAVP 2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ
371
W/up and Tx of endometrial CA
W/up: Post-meno w/ bleeding ➡ TVUS ➡ endo bx Tx: Hysterectomy, bilateral SO, peritoneal w/out, LN sampling - Required for Tx AND staging! - XRT if high risk - Chemo if mets
372
Pregnant lap appe
Left lateral decubitus position Entry port: - take into account fundal height (6cm above) - P/S @ 12 wks, half-way @ 16 weeks, umbo @ 20 weeks - 2T-3T: supra-umbo if possible otherwise LUQ or RUQ
373
Px, Dx and Tx of ovarian torsion
Px: Sudden pain + adnexal mass w/out bleeding - prior similar episdoes Dx: pelvic US with doppler Tx: - Lap detorsion - Oopherectomy only if- necrosis, cancer, recurrent
374
Monitor and reverse TPA
Fibrinogen level (<100 = r/o bleeding) Reverse: a-CA
375
Cause and Tx of Warfarin skin necrosis
Cause: protein C def (not S!) Tx: Stop Coumadin Give vitamin K Start hep gtt or argatroban
376
Intrinsic vs. Extrinsic Pathways
Intrinsic: 8, 9, 11, 12 Extrinsic: 7 (shortest t 1/2), Tissue factor Common: 1, 2, 5, 10
377
Reversal of NOACs: Apixaban Rivoroxaban Dabigatran
Apixaban: andexanet Rivoroxaban: andexanet Dabigatran: idarucizumab (+iHD)
378
VWD dx and tx
dx: normal PLTs. Abnormal BT, PTT - ristocetin test or measure vWF level tx: 1. type 1: not enough; ddavp ➡ cryo - MC congenital bleeding disorder 2. type 2: qualitative; VWF/f8 concentrate, cryo - DDAVP for some subtypes 3. type 3: VWF/f8 concentrate, cryo **only type 1 (and some type 2 subtypes) can use DDAVP
379
Tx of hepatic encephalopathy
0. Correct precipitating cause 1. Lactulose (goal 2-3 stools/day) 2. Rifaximin 3. Neomycin
380
PEP: 1. HIV 2. HBV 3. HCV
1. HIV: 4wks of anti-retroviral combo 2. HBV: HBIG + Vaccine 3. HCV: No recommendations.
381
Segmental liver anatomy
7 - 8 - 4a - 2 6 - 5 - 4b - 3
382
Dx and Tx of Budd-Chiari Syndrome
Dx: doppler (usually 2/2 to p. vera) Tx: 1. Lifelong AC 2. < 4 weeks: thrombolytics 3. > 4 weeks: angioplasty/stenting 4. Refractory: TIPS, transplant, surgical shunt
383
Tx of Isolated Gastric Varices
2/2 chronic pancreatitis induced splenic vein thrombosis tx- Splenectomy
384
Effects of pneumoperitoneum
Increase preload initially, then decrease Increase afterload. Decrease CO Increased PCO2. Decrease FRC Decrease renal function
385
Pancreas blood supply and anatomy
Head- Superior PD (Off GDA, off CHA, off CeT) and Inferior PD (off SMA) Body/Tail- Branches of the splenic artery Head- right of SMA (SMV is right of SMA also) Uncinate- hugs the SMV and SMA Neck- over the SMA Body/tail- left of SMA
386
Indication for ERCP w/ GB dz
1. Bili > 4 2. CBD stone on U/S 3. CBD > 6 mm and Billi > 2 4. Ascending cholangitis
387
Autoimmune pancreatitis - px, dx, tx
Px: pancreatitis w/ normal Lipase and LFTs Dx: IgG+, biopsy to prove. - CT: dilated w/ no Calcs. "sausage" appearance. - Brush biliary tree if concern for malignancy - different from hereditary pancreatitis (PRSS1 mut'n) Tx: 0. Bx first! 1. ERCP if stricutre: r/o ca, relieve obstruction 2. Steroids
388
W/up of pancreatic cancer
1. Pancreatic protocol CT 2. EUS: if questionable LN or vessel involvement 3. ERCP: if jaundice or dx uncertainty - 90% sensitive for dx 4. PET/CT: selectively if suspicion for malignancy. 5. Staging scope: if suspect disseminated dz - > 3cm, high Ca 19-9, tail tumor, high weight loss/malnutrition 6. Bx: Not if resectable. Only if neo-adj chemo
389
Tx of acute mesenteric ischemia
Thrombotic: at origin of SMA; prox. jejunum to transverse colon - smokers Embolic: distal SMA; jejunal sparring - embolism (usually from left atrial appendage) 1. IVF, abxs, AC 2. Emergent revascularization - peritonitis: ex lap to evaluate bowel, open embolectomy - consider endovascular if specialized center, no peritonitis, and low suspicioun for necrotic bowel
390
Dx and Tx of chronic mesenteric ischemia
- Dx: 1. duplex (Celiac > 200, SMA > 275) is 1st line for screening 2. CTA (>70%) for definitive dx (best test) - Tx: Sxs + stenosis of > 70% 1. Endovascular plasty/stent is 1st line. 1V SMA stenting is enough even if both celiac/SMA are inovlved 2. Open surgery: if can't tolerate endovascular - aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation
391
Tx of renovascular stenosis
1. BB 2. ACEi: unless 1 kidney or bilateral dz - efferent dil'n can worsen kidney dz 2. PTA: perc trans-luminal angio +/- stent (or open revascularization) - only if refractory to meds! 3. Nephrectomy **CORAL trial: PTA is not better than maximum medical therapy
392
Open SMA embolectomy
1. Lift transverse mesocolon 2. Trace MCA. Palpate the SMA at root of mesentery along inferior margin of pancreas 3. Incise peritoneum and dissect down to the artery (left of the SMV) 4. Therapeutic heparinize 5. Proximal and distal control 6. Transverse arteriotomy PROXIMAL to middle colic origin 7. 2 or 3 Fogarty balloon passed proximal and distal 8. Close arteriotomy with interrupted proline
393
Tx of air embolism
1. LEFT lateral decubitus and Trendelenburg (trap air in the RV) 2. Aspirate central line
394
Timing of endarterectomy after a stroke
1. Non-disabling stroke or TIA: 2d-2w 2. Big stroke: no consensus
395
When to consider ppx fasciotomy + steps
6+ hours of warm ischemia Steps: - lateral incision: between tibia and fibula ➡ open anterior and lateral compartment - medial incision: 1 finger posterior to tibia ➡ open fascia over the gastric ➡ peel soleus off of the tibia ➡ open deep posterior fascia
396
Femoral embolectomy
- Longitudinal incision over the groin - Expose femoral common, SFA, and profunda - Control with vessel loops - Ensure ACT > 250 - 4-5F fogarty proximal, then distal to SFA and profunda (2x clean pass for each) - Infuse hep saline - Close arteriotomy w/ interuppted prolene
397
Exposure of LE arteries: 1. Femoral 2. AK Pop 3. BK Pop 4. TP Trunk
1. Femoral: vertical incision over the artery from inguinal ligament 2. AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus lateralis. I 3. BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment. 4, TP trunk: MEDIAL incision below the tibia. Divide soleus origin of the tibia
398
Preference for peripheral fistula
Location: 1. Rad/Ceph 2. Rad/Bas 3. Bra/Ceph 4. Bra/Bas 5. Prosthetic peripheral 6. Prosthetic ax-brachial 7. Prosthetic femoral **Upper extremity preferred to LE Rule of 6's: - flow > 600/min - diameter > 3mm before placement. > 6mm after placement - depth of 6mm **artery at least 2 mm
399
SC Steal syndrome - path and tx
Path- Prox SC stenosis. Reversal of flow through ipsilateral vertebral to SC Tx: if V/B sxs (diplopia, vertigo, dysphagia, ataxia) 1. PTA w/ stent to SC artery 2. Carotid to SC bypass
400
Tx of type B dissection
1. Uncomplicated: b-blocker for impulse control, elective repair - Surveillance q3, 6, 12m. TEVAR if progression 2. Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR - Need at least 2 cm landing zone distal to L SC
401
Tx of splenic aneurysm
1. > 2cm, sxatic, or fertile age female - embolize distal AND proximal (back bleeding from short gastric) - trauma/rupture situation may require splenectomy 2. Otherwise, monitor
402
Tx of aneurysms - splenic - renal - iliac - femoral - pop
- splenic: > 2cm or sxs ➡ embolize - iliac: > 3 cm ➡ covered stent - femoral: > 2.5 cm ➡ covered stent - pop: > 2 cm ➡ exclusion and bypass
403
Tx of psuedoaneurysm
tx: < 2cm observe > 2cm: - skinny neck: thrombin injection - wide neck: operative intervention Surgery for complicated disease: - infxn (cellulitis) - skin necrosis, skin changes - neuro deficit, AMS - HDUS, pulsatile,
404
Nerve injuries during CEA: - Recurrent laryngeal - Marginal mandibular - Hypoglossal nerve - G/Ph nerve - Superior laryngeal - Accessory
- Recurrent laryngeal: MC cranial nerve; 2/2 clamping; hoarseness - Marginal mandibular: excessive retraction and angle of jaw; Ipsilateral lip palsy - Hypoglossal nerve: ipsilateral tongue deviation - G/Ph nerve: from high dissection; difficult swallowing - Superior laryngeal: high-pitch - Accessory: failure to shrug shoulders
405
Tx of Type A dissection
- Treat with immediate surgery - Put patient on bypass - Median sternotomy
406
May-Thurner Syndrome
Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine tx- venogram, thrombolysis and stenting
407
W/up of non-variceal UGI bleed (M/W tear)
1. NGT+ ➡ EGD w/in 24h- clips, coags, banding, sclerose 2. NGT-: - HDUS: IR angio (must be brisk) - HDS- C'scope/consider RBC scan, surgery
408
Surgical indications for acid reduction surgery
Elective indications: - refractory to medical management - suspicion of a malignancy within an ulcer Acute indications: HDS, minimal contamination AND: 1. PUD w/ unknown h. pylori status (if known can just be tx medically) OR 2. Unable to stop NSAID therapy (NSAID ulcer)
409
Acute surgical options for duodenal ulcer disease
Indications: bleeding, perforation, obstruction 1. Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed - can tie off the GDA if continues to bleed - no vagotomy 2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment (90% H.pylori related) - If close to pylorus: pyloroplasty (+/- truncal vagotomy) - If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy 3. Obstruction: NGT, resuscitation, anti-secretory ➡ EGD w/ balloon dilation ➡ antrectomy - Only do acid surgery acutely (vagotomy/drainage) if: 1. HDS, minimal contamination AND 2. PUD w /h. pylori status negative, unknown, refractory OR unable to stop NSAID therapy (NSAID ulcer) **EGD does not require bx for duodenal ulcers
410
Tx of gastric ulcer disease
Indications for surgery: bleeding, perforation, refractory - 8-12w of PPI + H. pylori eradication - must bx at 8 spots Approach: 1. GC, antrum, body: wedge resection 2. Lesser curve: distal gastrectomy w/ bili 3. GEJ: - bleeding: anterior gastrotomy, over-sew, send biopsy - perf: sub-total gastrectomy w/ REY reconstruction **Can't wedge lesser curve b/c prominent L gastric arcade and deformed stomach
411
Tx of Complications after Billroth 2: - Afferent limb obstruction - Dumping syndrome - Alk reflux - Post-vag DRH
1. Afferent limb obstruction: prevent with afferent limb < 20 cm - acute: convert Bil 1 or REY (STAT!) - chronic: Bacterial overgrowth: try abxs 1st (Rifaximin) . convert to REY 2. Dumping syndrome: small meals, no sugar ➡ octreotide 3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm. - pro-kinetics, bile-acid binding ➡ convert to REY with long roux 4. Post vagotomy DRH: cholestyramine (dx of exclusion) ➡ reversed jejunal segment
412
How to confirm H. pylori eradication
4-weeks after triple therapy: 1. Urea breath test: preferred 1st line 2. EGD + Bx: preferred if known gastric ulcer (r/o CA) 3. Fecal Ag test **Gram-, spiral-shaped
413
Primary fuel source in fasting state
1. 1st 4 hours: exogenous glucose 2. 4h-1d: Liver glycogen 3. 1d-1w: gluconeogenesis phase (alanine from muscle) 4. 1w+: protein-sparing phase - FA/Ketones are used everywhere - RBCs use glucose only
414
Dx and Tx of rectus sheath hematoma
Dx- mass unchanged with contraction Tx- CTA if HDS. OR if unstable: 1. Observation- no active bleed 2. IR- if active bleeding or T3 (pre-vesicle space) 3. OR- if HDUS or skin necrosis **can also consider IR if HDUS
415
Removal of perc chole tube
1. Remain in place for 3-6 weeks for tract to form 2. Cholangiogram to assess CD patency 3. Clamp tube or elective chole if surgical candidate
416
Essential fatty acids and deficiency px
1. Linoleic acid- omega-6 (Cis, Unsturated) - inflammatory 2. α-linolenic acid- omega-3 (Cis, Unsturated) - anti-inflammatory Deficiency: waxy skin, dermatitis, hair loss, TCP
417
RQ interpretation (metabolic cart)
CO2/O2 < .7 = underfeeding/starving .7 = pure fat .8 = pure protein .8-.9 = desired 1 = pure carb >1 = overfeeding
418
BSC vs. SqCC - dx and tx
BSC: most common malignancy in USA; pearly, rolled borders, peripheral palisading; MC upper lip ca SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca - MC ca after trx Tx: - 4 mm for unaggressive: well differentiated and < 2 cm - 8 mm for aggressive: poorly differentiated, > 2cm, or Marjolin - 1 mm for MOHS - MOHS for aggressive subtypes - LADN'y for clinical positive nodes - Can consider SLNBx for high risk SqCC - Limited role for chemo/XRT
419
Dx and Tx of Nec Fac
Dx: - LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV - CT: gas, thick fascia Bacteria profile: - MC polymicrobial -if monomicrobial, MC GAS/strep pyogenes: M protein virulence Tx: - abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage - surgery
420
Dx and Tx of pancoast tumor
Dx: - Perc bx: usually sqcc - Mediastinoscopy (or EBUS) Tx: - Induction chemo-XRT - surgical evaluation - c/i to surgery: extra-thoracic mets, n2 disease, brachial plexus above T1, >50% vertebral body, eso/trachea involvement - vascular involvement is not c/i
421
Types of hyperPTH
1- High Ca/Low Ph: over-secretion 2- Low Ca/High Ph: CKD or VitD def (physiologic) 3- High Ca/High Ph: hyperplasia 2/2 kidney transplant **VitD def: compensatory hyperPTH 2/2 to low Ca and Ph
422
Dx and Tx of Ewing Sarcoma
Dx: "onion skin" in diaphysis - pelvis is MC location Tx: chemotherapy (1st line) + surgery or XRT
423
Pulmonary sequestration
No bronchial commmunication 1. Intra-lobar: MC; blood from aorta; pulmonary veins 2. Extra-lobar: systemic arteries and veins Tx- lobectomy or segmentectomy
424
Lung anatomy: R vs. L
Right: - oblique/major fissure: separates lower from middle/upper - horizontal/minor: separates middle from upper - main bronchus 90-degrees; 2 bronchi Left: - oblique/major fissure; 1 bronchus
425
RF and Tx of T/I fistua
RF- trach below 4th ring OR, high pressure cuff, high innominate cross 1. Over-inflate the cuff 2. Intubate from above 3. Compress against the sternum 4. Median sternotomy 5. Ligation AND division of innominate artery 6. Buttress tracheal hole w/ muscle **aorto-enteric fistula should also be treated aggressively with operative takedown and extra-anatomic bypass
426
Indications for pleurodesis
- Air Leak > 5 days - Recurrent (even if contra-side) - High risk occupation (scuba, pilot)
427
Px, dx and tx Lymphocele
Px: sudden decrease in UOP weeks after trx -2/2 lymphatic leak from iliac dissection -Sirolimus is a RF Dx: US Tx: perc drain (if sxs) ➡ peritoneal window
428
Px, Dx, Tx of RAS and thrombosis after kidney transplant
1. Thrombosis: sudden cessation of UOP immediately post op -Dx: U/S -Tx: nephrectomy unless small branch 2. Stenosis: refractory HTN and elevated Cr - Dx: US (vel > 180, 70%) - Tx: perc angio/stent **No pain with arterial issue (pain = venous issue)
429
W/up and Causes of low UOP after kidney trx
w/up: 1. doppler U/S: check vasc/urteter mosis, bladder outlet obstruction 2. empiric fluid bolus Causes 1. Immediate: arterial thrombosis- nephrectomy 2. Weeks: lymphocele- open/lap peritoneal window 3. Months: polymovirus (BK)- nephrostomy + reconstruction
430
Inflow and outflow for pancreas transplant
1. Inflow: iliac vessels (kidney- left, pancreas- right) --donor SMA and splenic artery are connected with donor iliac artery Y graft to be plugged into the right iliiac 2. Outflow: iliac vessels --donor SMV/splenic vein are already connected. Plugged into R iliac vein (or SMV/PV) **Duo can be connected to SB or bladder
431
w/up of kidney graft dysfunction
1. Elevated Cr. Low UOP. 2. US: high RI is a non-specific finding - Vascular abnormality ➡ angio, stent, or surg - Lymphocele/Urinoma ➡ perc drain ➡ perit window - Negative: graft dysfunction ➡ Core needle bx
432
Post transplant hepatic artery vs. PV thrombosis
1. HA thrombosis: MC - Early: FHF ➡ thrombectomy OR re-trx - Late (months): abscess, strictures ➡ temporize, re-trx - Stenosis: angio and stent 2. PV thrombosis: rare - Early: FHF ➡ thrombectomy or re-trx - Late (months): encephalopathy, varices ➡ AC - Stenosis: angio and stent
433
GVHD - px, path, dx, tx
-Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx -Path: DONOR T cells morph into Th cells; target host -Dx: bx -Tx: steroids + IS
434
Tx of testicular torsion
1. Surgical de-torsion of involved testes - If doubtful viability: <10 keep, >10yo orchiectomy 2. Exploration and fixation of uninvolved testis as well! **don't delay OR for U/S if suspicion is high
435
Dx and Tx of RCC
Dx: triple phase CT (don't need tissue bx unless mets) - do cystoscopy after CT Tx: Upfront Radical nephrectomy + LND +/- chemo +/- XRT - TK inhibitor is 1st line chemo - Simultaneous thrombectomy if IVC thrombus
436
Types of hydrocele and Tx
1. Communicating: children. 2/2 patent processus - <2yo: conservative, observe - >2yo: surgical excision of processus 2. Non-communicating: adults. 2/2 secretions not connected to peritoneum - dont tx if asx. tx w/ excision **can dx on PE (transillumination). DO NOT need U/S
437
Dx and Tx of LCIS
Dx - usually incidental/bilateral - pre-menopausal white women. mammo negative -R/o breast ca is .5% per year Tx - Lumpectomy/Excisional bx (10-20% chance of DCIS/CA) - Don't need negative margins - No SLNBx - Can use tamoxifen to prevent hormone+ cancers (even if you don't know hormone status) PPx options - Surgery - Hormonal therapy - Surveillance w/ MRI or mammo q6m
438
Dx and Tx of inflammatory breast ca
Dx: clinical diagnosis - rapid erythema with paeu de orange < 6 months - mammo/US first!: must have path of invasive cancer - bx: dermal lymphatic invasion is suggestive but not required Tx: 1. Neo-adjuvant - can give trastuzumab if HER2+ 2. MRM 3. XRT 4. Endocrine tx
439
Fibroadenoma - px, dx, tx
Px: painful/larger w/ periods or pregnancy Dx: - imaging: well-circumcribed, coarse ca+ - bx: fibro-epithileal lesions ("aggressive" = phyllodes) Tx: - obesrve if: mobile, concordant imaging/bx - resect if: > 3cm, sxs, growth, anxiety, discordance, lesions "not further defined"
440
Tx of breast ca in preg
Dx: mammo + U/S + bx - mammo is safe Tx: 1T (13w): mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T 2-3T: lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT - chemo is safe in 2nd/3rd trimesters. XRT is not - XRT is c/i throughout preg **No blue dye!
441
Indications for post-mastectomy radiation
1. > 5cm (T3+) 2. 4+ nodes (N2) 3. + margin 4. skin involvement 5. inflammatory BC **if prefer recon must be delayed or used a tissue expander for immediate recon
442
Bolus fluid and blood in children
Fluid: 20cc/kg Blood: 10cc/kg
443
Repair aortic trauma
Access usually with Mattox maneuver If < 50% closure primary with polypropylene suture If > 50% perform a PTFE patch
444
Small bowel trauma
1. Serosal tear: interrupted, non-absorbable 2. <50%: 1 or 2 layer closure 3. >50%: resection and anastaoisis 4. Multiple short segments: resection and anastamoisis
445
Access to neck zones
Zone 1: thoracic inlet to cric ➡ median sternotomy with left neck incision Zone 2: cric to angle of mand ➡ left neck incision Zone 3: angle of mand to skull base ➡ IR
446
Causes of R-shift/decrease affinity on Oxy-Hb curve
2,3 DPG Elevated temp Higher paCO2 Acidosis
447
Shock class
1. No VS changes 2. Tachycardia 3. Hypotension and combative 4. No UOP and obtunded
448
Ketamine MOA, s/e and c/i
MOA: NMDA glutamate ANTAgonist, s/e: tachycardia, hallucinations c/i: - MI (b/c SNS activity/cardiac demand) - Space occupying brain lesion
449
SCIP Quality Measures
1. abx 1h prior to incision (for approrpaite pts) - include G negative coverage for GI procedures 2. abx dc w/in 24h 3. appropriate hair removal 4. controlled 6am glucose in cards pts 5. dc foley on POD1-2 6. normothermia
450
Insulin peri-op
On morning of surgery: - Don't take oral hypo-glycemics - Don't take short-acting insulin - Take 1/2 of long-acting insulin **Insulin pump should be converted to insulin gtt for emergency surgery
451
Frey Syndrome
- Gustatory sweating - 2/2 auriculotemporal nerve - Suspect after parotidectomy for H/N tumor - tx with anti-persiperant
452
Dx and Tx: 1. TG duct cyst 2. Brachial cleft cyst 3. Cystic hygroma
1. TG duct: midline through hytoid bone; sistrunk procedure - if infected tx w/ abxs first 2. Brachial cleft: anterior SCM; resection - 2nd cleft cyst MC (mid/lower neck) 3. Cystic hygroma: posterior triangle; resection (avoid infection)
453
STITCH trial
5 mm bites every 5 mm
454
Tx of parastomal hernia
1. ASx- can observe 2. Sxs- sugarbaker is preferred - keyhole is alternative - do not relocate - Only repair for obstruction or strangulation - LB herniates more than SB
455
Tx of hiatal hernia
Type 1- asx: NTD; sxatic: PPI; Surgery if refractory Type 2-4: surgery even if asx
456
Dx and Tx Ischemic Orchitis
dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5 tx- NSAID and pain meds. Orchiectomy is last resort.
457
MCCO Cushing syndrome
1. Exogenous steroids 2. ACTH pituitary adenoma (Cushing disease) 3. Cortisol secreting adrenal adenoma 4. ACC
458
Dx and Tx of Addison's
Cause- AI attack of adrenal cx Labs- hypoNa, hyperK Dx: cosyntropin stim test - cortisol remains low - deceased cortisol and aldo with high ACTH Tx- steroids
459
Px and W/up of Hypercortisolism (Cushing's syndrome)
px: moon facies, striae 1. Initial tests: choose 1-2 - 24h urine free cortisol (most se) - late night salivary cortisol (when cortisol is lowest) - overnight 1 mg dexa suppression 2. ACT Level A. ACTH normal/high - high dose dexa suppresion - no suppression: small cell lung ca - suppressed: pituitary adenoma (Cushing's disease) (MC endogenous) B. ACTH low - CT positive: adrenal mass - CT negative: exogenous (most common)
460
Dx, Path and Px, and Tx of carcinoid tumors
Dx: neuroendocrine tumor - 24H urine HIAA - chromoA for progression (not specific, false + on PPI) - Octreotide scan if can't locate Path: +chormogranin. desmoplastic mesentery. - grade ~ Ki67 index Px: - Rectum > SI (ileum) > Appendix (MC tumor of appendix) - GI tract > pulm > GU. Rectum MC - Carcinoid Syndrome: 2/2 liver mets or large GI tumor Tx: - SS analogues (lanreotide) for sxs - < 2 cm: local excision (transanal, appendectomy, segmental) ➡ no further w/up. - > 2 cm: staging CT. formal cancer resection. - all lung carcinoids get formal resection with MLND - c/scope post-op b/c 15% have synch lesions
461
Tx of mesenteric vein thrombosis
1. AC 2. Surgery if peritonitis or failure to improve - can also consider endovascular thrombolytics 3. 2nd look operation 24-48 hours
462
Tx of Grave's disease
1. Beta blocker 2. Methimazole. PTU if preggo 3. RAI once euthyroid: worsens opthalmopathy and c/i in pregnancy/breast-feeding 4. Surgery if refractory, opthalmotaphy, compressive sxs, RAI and methimazole/PTU c/i - consider lugol's solution pre-op (only for Grave's) **Preggo: beta blocker, PTU. Avoid RAI. Surgery if can't tolerate PTU
463
W/up of Hashimoto's disease
1. FNA- r/o ca 2. Bloodwork- antiTPO/TG Ab 3. Tx- thyroxine ➡ partial thyroid **MCCO hypoT and goiter in the US
464
Tetanus ppx
1. Full immunized (>= 3 toxoid doses) - clean/minor: toxoid vaccine if dose >= 10 years - dirty or > 1cm: toxoid vaccine if dose >= 5 years 2. Unknown or not fully immunized - clean/minor: toxoid vaccine - dirty or > 1 cm: toxoid vaccine + Ig
465
Px, Dx and Tx of CMV colitis
Px: colitis, retinitis, hepatitis (can effect any organ system) Dx: - usual CD4 < 50 - PCR is unreliable b/c does not prove end-organ disease (can be falsely negative) - must scope and bx: Cowdry bodies, punched out ulcers Tx: gancylovir (valgan is oral form) - initiate HAART - opthalmic exam to r/o retinitis
466
Standard w/up for lung ca
1. PET/CT 2. PFTs 3. Bronchoscopy (can be intra-op) 4. Mediastinal eval- EBUS or mediastinoscopy
467
Bronchiolitis obliterans
MCCO long term lung trx failure 2/2 bronchiole inflammation Px- serial decline in PFTs. Normal tacro. CT- ILD Dx- of exclusion Tx- steroids (inhibit COX2), IS, reTrx (very poor outcomes)
468
Pressor for neurogenic shock
1. Above T6: nor-epi (b/c HoTN and brady) 2. Below T6: Phenylephrine (may worsen brady above T6) **don't normally get neuorgenic shock below T6
469
Vitamin A
- wound healing especially in steroid patients - def: night blindness, dry eyes
470
PPV and NPV
PPV = of those who test + how many have the dz NPV = of those who test - how many do not have the dz Increasing prevalence = increase PPV and decrease NPV Increasing survival = increasing prevalence
471
Pearson's R Value
Correlation coeff between -1 and 1 1 = very strong positive (direct proportion) > .7 = strong positive 0 = no correlation - .7 = strong negative Do not determine causation
472
Phases of clinical trail
1. Safety in a small group of humans 2. Effectiveness and side effects 3. RCT compared to standard of care 4. Long term safety and monitoring
473
Subclavien exposures
1. Median sternotomy: right 2. Left Anterolateral thoracotomy: left subclavian - trap door supraclav incision for distal access
474
Indications for hepatectomy instead of liver trx in HCC patient who meets Milan criteria
Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm - hepatectomy is preferred to transplant if they are Childs A
475
SMA embolus vs. thormbosis px
Embolus- lodges after the middle colic. Jejunal sparring Thrombus- at ostium; pan-bowel
476
Desmoid Tumor - associations, path and tx
A/w: - FAP (after surgery, 2nd MCCO death), Gardner syndrome Path: non calcified, fibrotic, low mit index, spindle cells Tx: - WLE for extra-abd; NSAID, anti-Estrogen (tamoxifen) if intra! - XRT if sensitive area
477
Serologic work-up for adrenocortical mass
1. Dexa suppression (cortisol) 2. Urine androgens (sex hormones) 3. Plasma metanephrines (pheo) 4. aldo/rennin ratio > 30 (salts)
478
Px, Dx and Tx endometriosis
Px- cyclic pain, pain with sex Dx- dx laparoscopy Tx- 1. Medical therapy 2. Surgery if unresponsive. Ablation if young.
479
MCCO primary hyper-aldosteronism and tx
1. Idiopathic bilateral adrenal hyperplasia (60%)- medical 2. Adrenal adenoma (Conn's syndrome)- lap adrenal 3. Adrenal adenoca- open adrenal + mitotane * Can use adrenal vein sampling to distinguish
480
Respectability of pancreatic tumor and next step
Triple phase CT: 1. Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV - EUS/FNA for tissue dx for neoadjuvant 2. Borderline- <180 SMA/celiac, reconstructable PV/SMV - EUS/FNA for tissue dx for neoadjuvant 3. Resectable - dx lap (to confirm resectability) + whipple
481
Tx of horseshoe abscess
Hanley procedure: - Midline drainage incision of deep posterior space (through ano-coccygeal ligament) - Bilateral lateral counter-incisions for ischiorectal space **all external drainage
482
Tx of anorectal fistula
<30% sphincter- fistulotomy or cutting seton >30% sphincter- draining setons THEN ARAF or LIFT **Crohns patient: px w/ multiple fistulas - avoid fistolotomy. - draining setons. Can try infliximab if active infection has resolved.
483
Tx of Internal HMHDs
G1- bleeding, G2- spontaneous reduce, G3- manual reduce: 1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line (office): band, sclerotherapy, coagulation - band is most effective - sclerotherapy if on blood thinners G4- can't reduce - surgical HMHD'ectomy (stapled has higher recurrence)
484
Tx of External HMHDS
1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line: surgical HMHD'ectomy Thrombosed: incise or excision if w/in 48h
485
Paget's disease of the anus (px and tx)
Px: intractable pruritis, eczematoid rash Tx: scope (r/o malignancy) - dc topical agents - perianal punch bx + WLE
486
Unresectable cholangiocarcinoma
Criteria - bilateral HA or PV - unilateral HA with extensive contra duct Tx - no extrahepatic dz ➡ neoadj chemo-XRT + liver trx - extrahepatic dz ➡ chemo-XRT
487
Bismuth classification and tx
For hilar cholangioca. Only t4 unresectable. 1: CH duct- REYHJ + LADN +/- lobectomy 2: bifurcation- REYHJ + LADN +/- lobectomy 3: R or L HD- REYHJ + LADN + lobectomy 4: Both ducts- chemo-XRT + liver trx
488
Lap CBD exploration
1. Dissect CD to the level of the duo 2. Cholodochotomy distal to the CD/CBD junction 3. Fush, basket, or fogarty balloon the stone out 4. Close primarily, over a T-tube, or over a stent
489
Px and Tx of Chalangitis
Dx: fever, RUQ, and jaundice - stones > malignancy > stricture Tx: - signs of sepsis: resuscitate/abx then urgent ERCP - no sick: US/MRCP
490
Px and Tx of Sphincter of Oddi dysfunction
Px: Biliary pain with normal RUQ U/S after years lap chole Dx: mannometry (no MRCP or CT 1st) Tx: endoscopic sphincterotomy at 11' (CCB usually ineffective) - CBD at 11', PD at 1-3' - h/o REY: open transduo sphincterotomy
491
Ideal setting for stone formation
Low bile salts Low lecithin High cholestersol
492
Mirizzi syndrome tx
px- GB neck/CD stone compresses CHD types: 1: no fistula- cholecystectomy 2: < 1/3 circ- CC'ectomy + CBD repair w/ T-T 3: < 2/3 circ- CC'ectomy + REY-HJ 4: full circ- CC'ectomy+ REY-HJ
493
Types of GB polyp
1. Cholesterolosis: MC; CE mphages in LP; benign 2. Adenomyomatosis: benign 3. Adenoma: malignant; >1cm is RF for CA (resect)
494
Tx strategy for CBD transections
1. Intra-op - <50%, not cautery: primary repair - >50%, or cautery: REY-HJ 2. Late phase - Place drain - Define anatomy w/ ERCP, PTC, or MRCP - Place PTC tube - CTA to assess for R/L HA injury - Delayed reconstruction 6-8 weeks once optimized
495
Management of GB polyps
1. Sx: cc'ectomy 2. For asx: - > 18 mm: tx as GB cancer - > 10 mm: CC'y - 6-10 mm: q6m U/S for 1 year. cc'ectomy if PSC
496
PSC screening guidelines
1. Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9 2. GB CA: US q6-12m 3. CRC: colonscopy q1-2 years (regardless of UC)
497
Dx and Tx of Colovesicular Fistula
1. CT w/ oral/rectal (no IV b/c will obscure bladder) (not cystoscopy, colonoscopy, or Ba enema) 2. Colonoscopy to r/o malignancy 3. Cystoscopy if suspect cancer. Retrograde cysto if CT is equivocal or operative planning Tx- resect sigmoid even if asx; Don't need to repair the bladder, just drain
498
Colon cancer and arterial resection
1. R hemi- IC, RC, RBMC - cecum/asc colon 2. Extended R- IC, RC, MC - hepatic flex/prox t colon 3. L hemi- LBMC, LC - Distal TV, splenic flex, prox descending 4. Extended L- LBMC, origin of IMA - splenic flex 5. Sigmoid- IMA (hi- b4 LC, low- after LC) - dist desc/sig
499
Colon CA surveillance after curative resection
1. Exam and CEA q3-6m x 3 years 2. Colonoscopy @ q1, 3, and 5 years - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel) 4. CT CAP q1y x 3 years - At 2 years: recurrence local or hepatic - after 2 years: hepatic more often
500
Staging w/up of rectal cancer
1. TRUS (avoid if > t2) or MRI- T/N stage - suspicious nodes on MRI count as clinical stage N (neo-adj) 2. CT CAP- M stage 3. C'Scope- for initial dx and sync lesion. not for T stage 4. Rigid Sig'Scope- for distance from anal verge (required! even. if c'scope done)
501
Tx of refractory Crohn's pan-colitis
1. Segmental colitis- partial colectomy 2. Rectal sparing pan-colitis- TAC w/ IRA 3. Pan-colitis w/ rectum- PC w/ end ileostomy - IPAA whether w/ or w/out loop should NOT be done on Crohn's b/c r/o pouchitis
502
Tx of cecal volvulus
Stable- R hemi and primary mosis (no pexy) Unstable- R hemi with end ileostomy
503
Dx of Juvenile polyposis
Dx: 5+ polyps or any polyps w/ family hx - SMAD4+ Non-adenomatous polyps ~ hamartomas
504
Tx of Lynch Syndrome
1. CRC: MC - q1y C-scope @ 20-25 - TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma - q1y scope post op 2. Endometrial: 2nd MC - q1y endometrial sampling @ 30-35 - ppx TAH-BSO after children 3. Ovarian: - q1y TVUS and Ca-125 @ 30-35 - ppx TAH-BSO after children 4. Stomach: - EGD/Bx q2-3y @ 30-35 5. Renal: transitional cell ca - q1y UA and US @ 30-35
505
APR vs. LAR
Tumors that require APR: 1. < 5cm for anal verge 2. Tumor at dentate line w/ sphincter involved 3. Tumor that can't get a 1 cm distal margin w/out sphincter 4. Poor pre-surgical anorectal function (history of DRH) 5. Locally recurrent low-lying cancer **Generally follows pre-chemo location of tumor unless COMPLETE tumor response. If tumor initially involved the sphincter complex and now does not ➡ still require APR
506
Polyposis syndromes: -Muir-Torre -Gardner -Turcot -P/J -Cowden -JuP
-Muir-Torre: MLH/MSH; sebaceous gland tumor -Gardner: APC; desmoid tumors, osteomas, epidermal cysts/lipomas -Turcot: APC; Malignant CNS tumors -P/J: STK; myocutameous pigmentation -Cowden: PTEN; Hamartoma polyps, endometrial/breast/thyroid CA -JuP: SMAD4; epistaxis, AVM, telangiectasia
507
Indications for colonic stent
1. Bridge to surgery in acute obstruction (usually with metastatic cancer) 2. Palliative measure * Usually for L-sided lesions
508
Gram, Tx and Virulence of C. diff
Gram: G+ bacillus, anaerobic Tx: 1. Primary: oral fidox - oral vanc is 2nd line now 2. Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus - no fidox 3. Recurrence: PO fidox or vanco 4. Multiple recurrence: tapered fidox or vanco - consider fecal transplant 5. Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm) Virulence: - Toxin A: intestinal necrosis - Toxin B: cytotoxin
509
Dx and Tx of ischemic colitis
Dx- CT first to rule out non-ischemic colitis or infarction; C'scope to confirm - suspect in low flow state, HoTN - CTA can't dx b/c its a microvascular disease Tx- usually supportive; OR if perf, sepsis
510
Dx and Sx of PNETs 1. Glucagonoma 2. Inuslinoma 3. Gastrinoma 4. VIPoma 5. SSoma
**All require bichemical testing before imaging! 1. Glucagonoma: glucagon > 1k; NME, DM, DVT (no stones vs. SS'oma) 2. Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad 3. Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1 4. VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH) 5. SSoma: High fasting SS; DM, STONES, steatorrhea *Do not perform imaging or go to the OR until biochemical diagnosis!
511
Dx and Tx of Pancreatic cysts: 1. Serous cystadenoma 2. MCN 3. IPMN 4. Psuedocyst
-W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA 1. Serous cystadenoma: low M/CEA, low Am; resect if sxs 2. MCN: high M/CEA, low Am; resect 3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm 4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy
512
Tx of PNETs: 1. Glucagonoma 2. Inuslinoma 3. Gastrinoma 4. VIPoma 5. SSoma 6. Non functional
1. Glucagonoma: distal panc w/ splenectomy + cc'y 2. Inuslinoma: enucleate 3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple 4. VIPoma: distal panc w/ splenectomy + cc'y 5. SSoma: resect w/ cc'y 6. Non functional: < 2cm observe or enucleate. > 2cm resect
513
Perform splenectomy for distal panc PNET?
No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm
514
Arterial anatomy of the celiac trunk
1. CHA: gives off GDA then R gastric - GDA gives of SPDA and R gastroepi 2. Splenic: gives off short gastrics and L gastroepi
515
ECG findings of PE
Sinus tach is MC S1Q3T3 pattern w/ TWI
516
Dx and Tx of Pulmonary Blastoma
MC primary lung tumor in children Dx- air/fluid filled cystic lesions. Looks like pneumo. Tx- Surgical resection +/- chemo-XRT
517
lead vs length time bias
Lead-time bias is due to early detection. Remember the "d" in lead is for early detection. Length-time bias is due to slow cases being detected more often simply because they are slowly progressing/indolent. Remember the "g" in length is for slowly progressing.
518
Brown-Sequard
Ipsi loss of motor Contra loss of pain/temp
519
Dx of biliary dyskinesia
Suspect if GB w/ normal US and EGD Dx- HIDA scan w/ EF < 35% (c/i in pregnancy) Good responders if classic sxs (n/v, RUQ pain, w/ fatty meals)
520
Emergent ariway in a child
1. Try ETT placement with a miller blade 2. Needle cric is preferred over open if < 12 yo - use cuffed tubes for everyone except newborns
521
Tx of peptic stricture 2/2 GERD
1. Serial dilations 2. PPI 3. Consider stenting - Surgery is last resort (in contrast to achalasia)
522
Exposure to bronchial tree in trauma
Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)
523
CREST Trial
- Carotid stenting has higher incidence of stroke - CEA has high incidence of MI - Composite end-point of stroke, death, MI was the same
524
Px, Dx and Tx of Bacterial Overgrowth
- px: 2/2 bill2 or REYGB - watery stools, bloating, b12 deficiency - dx: d-Xylose (carb test breath test) - tx: abxs (Rifaximin) ➡ surg 2nd line
525
Inguinal hernia nerves + MC injuries
1. Ilioinguinal: under to EO, anterior to cord - sensation to medial thigh 2. Ilio-hypogastric: supero/medial to the ilio-inguinal. Between EO and IO - sensation to lower abdomen 3. GB of GF: runs within the spermatic cord, posterior to the cord structures - sensation to scrotum MC injuries: - Open repair: II, GB of GF - Lap repair: lateral femoral cutaneous, GF **Iliac vein inured when sewing mesh to shelving edge
526
HRS- Path, Px and Tx
Path: liver failure ➡ sinusoidal portal HTN ➡ increase CO and splanchnic dilation (compensatory)➡ HoTN ➡ turn on RAA system ➡ renal constriction Px: - albumin + vasoconstrictive agents (terlipressin) - TIPS - transplant
527
Treatment of lung ca
1. No N2 disease (stage 1-2) ➡ up-front surgery - lobectomy + MLNDx. Can consider segmentectomy. - can wedge if 2:1 margin ratio 2. N2 disease or T4 ➡ chemo-XRT first n1- ipsi bronchial/hilar nodes n2- ipsi mediatinal/subcarinal (2-9) t1- <3cm t2- >3cm t3- >5cm OR invading pleura, chest wall, phrenic n, pericardium OR nodule in same lobe t4- >7cm OR invading DPGM, mediastinum, heart, great vessels, trachea, RLN, esophagus, vert body, carina. OR different lobe
528
Lung ca w/up
1. < 8mm ➡ surveillance 2. > 8 mm ➡ PET-CT - FDG- ➡ surveillance 3. FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy) - nodal disease --> EBUS 4. No N2 dz --> Segmentectomy or lobectomy - n2 disease --> chemo
529
Steps of hiatal hernia repair
1. Complete dissection of hernia sac from mediastinum - look for replaced L hepatic and hepatic branch of vagus near pars flaccida - avoid vagus nerve - divide short gastrics to aid in mobilization 2. At least 3 cm of esophagus into the abdomen! -- Colis gastroplasty if insufficient 3. Close the hiatus with sutures or mesh (posterior and inferior) -- mesh has better short term outcomes only -- RELAXING incision if can't reapproximate
530
Pre-op and intra-op regiments for aldosteronoma and pheo
1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic 2. Pheo: phenoxybenzamine then BB Intra-op: - HTN crisis: Nitro gtt - Tachy arrythmia: Esmolol gtt
531
Tx of HCC
1. Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant - Consider portal vein embolization if remnant is insufficient - Consider pre-op TACE to as an adjunct 2. Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant - Transplant if candidate: UNOS criteria - Otherwise: loco-regional therapy or systemic therapy
532
When to re-implant the IMA in EVAR
1. Back-pressure < 40 2. Previous colon surgery 3. SMA stenosis 4. Inadequate left colon flow
533
Lynch vs FAP Screening
1. FAP- chromosomal; APC - > 100 polyps, including small bowel (duodenum) - Surveillance: start at 10 2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM - <10 polyps in the colon - Surveillance: start at 20
534
Surgical Tx of thyroid/PT cancers 1. Papillary/Follicular 2. MTC 3. Hurthle 4. Anaplastic 5. PT
1. Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk 2. MTC: total + bilateral L6 (usually) + T3 post op - RAI is c/i 3. Hurthle: lobectomy then total + bilateral L6 4. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes 5. PT: hemi-thyroid +/- L6 (usually not) **MRND if L6 is positive
535
Confirmation of brain death
1. Neuro exam: - absent brain stem reflexes - no response to stimuli 2. Apnea test: CO2 > 60 after 10 minutes - if test aborted OR CO < 60 ➡ - can't perform test if confounding factors: unstable, hypercarbia, intoxication, paralytics (unable to wean), c-spine injury 3. Confirmatory test: CTA, MRA or nuclear scan
536
Bleeding during mesh fixation, inguinal hernia
1. Open: sewing mesh onto EO --> femoral vein 2. TEP: tacking mesh medially --> corona mortis (obturator branch)
537
Tx of H/N tumors 1. Mucoepidermoid 2. Adenoid cystic 3. Pleomorphic adenoma 4. Warthin/Papillary cystadenoma
1. Mucoepidermoid: MC malignant - total parotid + ppx MRND + XRT 2. Adenoid cystic: malignant - total parotid + ppx MRND + XRT 3. Pleomorphic adenoma: MC benign - superficial parotidectomy 4. Warthin/Papillary cystadenoma - superficial parotidectomy **Use modified Blair incision for these tumors
538
W/up of UGI bleed/perf: 1. Boerhave 2. Traumatic esophogeal perf 2. UGI bleed
1. Boerhave: XR suggestive ➡ UGI (CT controversial) 2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI 2. UGI bleed: +/- NGT ➡ EGD
539
Tx of Cellular vs. Ab Rejection
1. Cellular: - mild: steroids (inhibit COX2) - severe: TG 2. Ab: - Plasmaphoresis (clear Ab) - IVIG (so body thinks there are still ab) - Rituximab (CD20 Ab)
540
IS for transplant - induction and maintenance
Induction: choose 1 1. Thymoglobulin - polyclonal Ab (potent) 2. Basiliximab - IL2 inhibitor (mild) Maintenance 1. Tacrolimus 2. MMF 3. Prednisone 4. Sirolimus
541
Transplant ABX ppx
1. Bactrim- PCP, toxo gondi, listeria, nocardia 2. Diflucan- antifungal 3. Valganciclovir- CMV
542
Transplant cross-matching
1. ABO Incompatibility - A, B, O Ab 2. Cross-match: recipient serum X donor lymphocytes - preformed HLA Ab (A, B, DR). DR is most important. **Livers don't need a cross-match **Can give A2 donors to O recipients **Donor: Ags are important (WBC) **Recipient: Abs are important
543
MAC
MAC = minimum alveolar [] to prevent movement in 50% of people Low MAC = lipid soluble High MAC = water soluble - NO has highest MAC Factors that decrease MAC: older age, met acidosis, hypothermia, anemia, pregnancy - require less anesthesia
544
CDH1
High r/o gastric ca ppx gastrectomy by age 40
545
px, dx, and tx of meconium ileus
px- failure to pass meconium dx- sweat chloride test, "soap bubble sign" on XR tx- GG then NAC enemas - surgery: ostomy for antegrade enema **Cystic fibrosis is 2nd MCCO pancreatic insufficiency (after chronic pancreatitis)
546
Congenital thoracic disorders - px and tx 1. Pulm sequestration 2. Cystic adenoid malformation 3. Congenital lobar emphysema 4. CDH
1. Pulm sequestration: infection w/ abnormal CXR - tx: resection 2. Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree - tx: lobectomy 3. Congenital lobar emphysema: XR looks like tension PTX - tx: lobectomy 4. CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior - a/w pulm HTN, NTD, malrotation - tx: intubate +/- ECMO. Delayed repair.
547
1. Ig crosses the placenta 2. Ig in brast milk 3. Ig first responder
1. IgG (small, y-shape) 2. IgA (two y's with joined tails) 3. IgM (pentad)
548
Nutrition requirements per day 1. Protein 2. Fat 3. Carb
Nutritional requirements for average healthy adult male (70 kg) 1. 20% protein calories: 1 g protein/kg/day - burn: 1g/kg/day + 3 g/day x % BURN...(usually 2-2.5g/kg/day) 2. 30% fat calories 3. 50% carbohydrate calories
549
Wilcoxon test
Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed - ex: patient satisfaction before and after an intervention (1-5)
550
COX proportion hazard modeling
Like a regression model but for survival analysis Allow you to control for different factors
551
Changes to VS and labs with preggo
- Increased HR, increased SV - Decreased SVR, Decreased BP - Dilutional anemia. More PRBC but also more water. Requires more blood loss for HoTN
552
Afferent limb syndrome - cause, px, dx, tx
1. Cause: affarent limb is too long from LOTz 2. Px: acute or chronic - Acute: complete obstruction requiring emergent OR - Chronic: partial obstruction w/ bacterial overgrowth - steatorrhea, B12 deficiency. MC w/ antecolic Bili2 3. Dx: - Acute: abdominal pain with dilated afferent limb in early post op - Chronic: d-xylose breath test 4. Tx - stat OR for REY revision - Chronic: abxs --> REY/shorten the limb
553
Medical tx for melanoma
- Pd1 inhibitors: pembrozilumab, nivolumab - CTLA inhibitors: ipilmumab - If Braf+: braf inhibitor remains 2nd line
554
MC benign/malignant thoracic tumors in adults/children
Adults - benign: hamartoma (popcorn calcification) - malignant: sqcc Children - benign: hemangioma - malignant: carcinoid
555
Tx of Rhabdomyosarcoma
MC soft tissue tumor in children tx: surgery + SLNBx - consider neo-adjuvent if unresectable - post-op chemo-XRT (very radiosensitive)
556
C/i to covering the left subclavian artery
1. Aberrant or Dominant left vertebral a. 2. Previous CABG using LIMA (cardiac ischemia) 3. LUE AVF
557
Mesothelioma - px, dx, tx
px- asbestos exposure (shipyard) dx- CT then tissue dx tx- surgery, XRT, systemic chemotherapy, HIPEC
558
Marginal ulcer - dx and tx
S/p REY GB On the jejunal side Dx- EGD Tx- PPI + sucralfate + stop smoking + avoid NSAID +/- tx H. pylori (if present)
559
Hipec is most effective for which cancers? (5ys) c/i
1. Appendix (75%) 2. Mesothelioma (45%) **c/i: extra-peritoneal dz
560
Tx of HPV precursors in the anus
1. Condyloma in low risk patient: simple anoscopy (internal extent defined) and ablate 2. High risk pt: homosexual, HIV, women w/ +pap ➡ anal cytology/anal pap ➡ high resolution anoscopy, - Condyloma: ablate - AIN1: observe/annual screen - High grade: AIN2, AIN3 ➡ ablate - All patients: give HPV vaccine - LSIL/HSIL ➡ high resolution anoscopy
561
Tx of rectal carcinoid
<1 cm - endoscopic removal 1-2 cm- full thickness excision > 2cm- LAR or APR **Invasion into muscularis/LN involvement- require TME
562
Polypectomy criteria that require formal resection
1. Poor differentiation 2. Vascular/Lymphatic invasion 3. Invasion below the SM 4. < 2mm of surgical margin 5. Base involvement (Haggit 4)
563
Cancer screening in FAP
1. CRC- q1-2y c'scope starting at 10 2. Duo/Stomach ca- EGD at 20 or when polyps occur 3. Pap thyroid ca- thyroid U/S q2-5y at 18 4. Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs
564
Staging Melanoma and MC mets
Staging: -Stage 1-2: Don't need staging CT CAP - Stage 3+: Consider CT CAP or PET/CT - Stage 4: MRI brain + PET/CT MC Mets: 1. Lungs 2. Small bowel! - suspect if multiple isolated small bowel masses 3. Colon
565
Perforated diverticulitis tx
Primary anastomosis with DLI (DIVERTI trial) or without DLI (LADIES trial) is safe except if: - HDUS - Acidosis - Acute/Chronic organ failure - I/S - Very old - Poor pre-op sphincter function
566
Zenker location
- Killian's triangle - Inferior to pharyngeal constrictor (thyropharygneous) - Superior to cricopharyngeous
567
Tx for reflux after heller
Lifetime PPI DO NOT convert to a Nissen b/c baseline achalasia
568
Narrowest portions of the eso
1. Criciopharyngeous 2. AA/Left mainstem bronchus 3. Hiatus
569
Sxs of vagus injury after hiatal repair
- Gastroparesis - Delayed gastric emptying - Reflux - DRH - normal UGI!
570
Required w/up before anti-reflux surgery
1. EGD- r/o ca 2. 24h pH- prove reflux 3. Esophagram- r/o motility disorder (DES, eso web) 4. Manometry- r/o other motility disorders
571
Deficiency of fat soluble vitamins
A- xeropthalmia D- hypoca, hypoPh E- hemolytic anemia K- elevated INR **suspect with any fat malabsorption
572
Na deficit
NAD - "no denominator" (140 - current Na) * TBW TBW = .6 or .5 x (weight in kg) .9NS = 154 mEq per liter 3%NS = 514 mEq per liter replete 6 mEq/24 hours
573
Lung cancer paraneoplastic syndromes
Squamous cell- PTHrP Adenoca- hypertrophic osteodystrophy Small cell- SIADH
574
Lithium toxicity
HyperCa, hypocalcuria HyperMg Elevated PTH, normal Ph **gastric bypass can elevate Li levels
575
Ferritin
Main storage protein of Iron Low in iron def anemia High in anemia of chronic dz (acute phase rxn)
576
Sheehan syndrome
Hypopituitarism (anterior pit) 2/2 gland necrosis from HoTN Usually px w/ hypoNa
577
Tx for STI: 1. Chlamydia 2. Gonorrhea 3. Trich/BV
1. Chlamydia: doxy 2. Gonorrhea: CTX 3. Trich/BV: flagyl
578
HIT - path, dx, and tx
path: IgG to PF4 dx: 50% PLT fall ➡ Ser release assay tx: stop SQH. start fondaparinox, argatroban - use bivalirudin is liver/cirhotic patients
579
Hormone and production: - CCK - Gastrin - Glucagon - Histamine - Insulin - Motilin - Secretin - SS
- CCK: I cell, SI - Gastrin: G cells, antrum and duo - Glucagon: alpha cells, pancreas - Histamine: ECL cells, stomach - Insulin: beta cells, pancreas - Motilin: Mo cells, SI - Secretin: S cells, SI - SS: delta cells, pancreas
580
Steps of hepatectomy
1. Mobilize ligaments 2. CC'y and cannulate CD 3. Isolate vessels 4. Ligate HA ➡ PV ➡ HV 5. Divide parenchyma
581
Tx of HCC
1. Trx: tumor < 5cm or 3+ tumors < 3cm 2. Resection: early stage, preserved liver function 3. RFA: early-stage BUT poor OR candidate 4. TACE: intermediate stage disease 5. Sorafenib: advanced/Unresectable
582
Indication and s/e for TIPS
2-3 paracentesis/month despite Na restriction and diuretics s/e: - increase r/o encephalopathy - no change in overall survival
583
kwashiorkor vs. marasmus
kwashiorkor - moderate calorie intake; inadequate protein - large belly. normal weight. marasmus - insufficient calorie and protein - simian face. low weight.
584
Absorption of glucose, galactose, fructose
glucose: Na-dependent secondary active transport galactose: Na-dependent secondary active transport fructose: Na-independent facilitated diffusion
585
Tx of MCN
- Dx: EUS/FNA ➡ high CEA, low amylase - Location: body/tail - Spleen Preserving Distal Pancreatectomy (usually can be spleen preserving) - No follow-up is needed (no increase r/o recurrence)
586
S/e of protamine
- Hypotension, Bradycardia - Administer slowly: 1 mg per 100 units of insulin - Has partial reversal on lovenox - No renal/liver adjustment required
587
Dermatofibrosarcoma protuberans - px, histo, tx
px: flesh-colored sarcoma resembling a keloid - inovles dermis and subcutaenous tissue. No epidermis. dx: - excisional bx if < 3 cm - core/incision if > 3 cm - histo: spindle cells, +cd34, +Vimentin tx: - imatinib to down-stage if needed - en block resection w/ 2-4 cm margin`
588
In transit melanoma tx
Lesions > 2cm from primary but not beyond regional tumor basin - immunotherapy or BRAF inhibitor - only excise if feasible (few lesions)
589
Pressure wound staging
1- non-blanching erythema 2- dermis 3- full-thickness subcutaenous 4- muscle, bone fascia
590
Post-splenectomy blood smear + best way to ID
H-J bodies and Target cells - If absent: accessory spleen (usually in hilum or tail of the pancreas) - HJ bodies: nuclear remnant (purple spot in cytoplasm) - Target cells (codocyte): deformed RBC with excess membrane ID accessory spleen: peripheral smear ➡ radionucleotide tech sulfur colloid scan
591
Gastro-gastric fistula - px, dx, and tx
Px- weight gain, reflux years after a bypass Dx- UGI or CT with oral contrast Tx- observation, resection of the involved segment
592
ERCP with REY anatomy
1. Laparoscopic-assisted ERCP or ERCP through a gastrostomy 2. Double balloon endoscopy
593
Posterior Mediastinal Mass - dx and tx
dx: neurogenic- schwannoma, neurofibroma - CT then MRI. Bx not needed tx: all require resection (even if asx) **lymphoma if middle **thymoma if anterior
594
Lung ca resectability
- carina/contra trachea involvement is still resectable ➡ sleeve pneumonectomy - SVC involvement can still be resectable - c/i: N3 disease ➡ contralateral mediastinal LN involvement
595
Internal thoracic (mammary) anatomy
- 1st branch off the subcalvien - supplies anterior chest wall, breast - bifurcates to form superior epigastric and m/phrenic - gold standard for LAD bypass - can ID during clambshell thoracotomy
596
Management of lung abscess
1. Abxs 1st. No drain if < 4 cm 2. Cath drainage: > 4 cm or failure of abxs - perc (peripheral) or bronch (central) 3. Surgical resections Indications for surgery: - failed medical tx - BP fistula - hemoptysis - suspect cancer - empyema
597
Prostate ca - px, dx
Px- asx or abnormal PSA Dx: - Transrectal U/S guided bx - 12 samples - Gleason score 1-5
598
CAH - px's
"salt and sex" 21: most common; sex - dx: high 17 levels 17: salt 11: salt and sex
599
Amide vs. ester
amide- two "i's"; plasma cholinesterase metab; ester- one "i"; liver metab; PABA analogue --> allergic reactions
600
Px, Mech, Tx of Malignant Hyperthermia
px: AD; ryanodine receptor type 1 mech: huge increase in INTRAcell Ca tx: stop drug, dantrolene, Bicarb, cooling, tylenol - dantrolene: ryanodine rec antagonist
601
Dx adrenal insufficiency in the ICU
1. Early morning salivary or serum cortisol (screen when cortisol is highest) - vs. cushing's which requires PM cortisol (when cortisol is lowest) 2. High dose cosyntropin (ACTH) stim: give 250 ug and measure serum cortisol (positive if < 18) Tx- Resuscitation. IV dex 4 q24 or HC 100 q8 **dexa is strongest steroid (hydrocort is weakest)
602
Breast cancer endocrine chemo: MOA, tx duration/indications, s/e: 1. Tamoxifen 2. Anastrazole 3. Trastuzumab
1. Tamoxifen: ER partial agonist - for ER/PR positive and < 70 - 5 years - s/e: dvt, endometrial ca 2. Anastrazole: reversible aromatase inhibitor - for ER/PR positive and > 70 - 5 years - s/e: MSK fractures 3. Trastuzumab: monoclonal Ab to Her2/Neu rec - for HER2 positive - 2 years - s/e: cardiotoxic
603
Paget's disease of the breast
px: scaly, ulcerated crust of the areola dx: nipple punch bx with epidermal cells w/ clear cytoplasm and oval nuclei tx: total mastectomy (including NAC) and SLNBx - don't need ax dissection - no breast conservation - total mastectomy even if small underlying lesion
604
Indications for transcutaneous pacing
- Symptomatic sinus bradycarias - Mobitz II (2nd degree) AV block - 3rd degree AV block - New L or R BBB **If transcutaneous is unsuccessful ➡ transvenous
605
Types of AV block
- 1d- PR > 200 ➡ no tx if asx - 2d Mobitz 1- progressive PR prolongation, then dropped beat ➡ no tx if asx - 2nd Mobitz 2- random dropped beat. normal PR ➡ atropine and pacing - 3rd degree- A and V pump independently ➡ atropine and pacing
606
Digoxin - MOA and S/e
MOA: inhibits N/K ATPase. Stimulated PSNS - increased contractility (Ca rushes in) - slows AV node conduction S/e: - fatal arrythmia (especially in the setting of hypoK) - beware of patients with n/v (hypoK met alk) - keep K > 4
607
Indications for emergent C-section in preggo trauma
- Within 4 minutes of CPR for cardiac arrest - Fetus must be at least 24 weeks - Give O, Rh negative blood if needed - usually 2/2 abruption (vaginal bleeding)
608
Management of penetrating coronary artery injury
- LAD is MC - Primary repair is preferred - If too much loss of length then CABG - Do not ligate
609
Tx of blunt cardiac injury
1. EKG +/- trop - negative: can dc - positive: admit to tele (Sinus tach is abnormal) 2. Persistant arrhythmia or HoTN ➡ echo
610
Dx and Tx of rectal injuries
Dx: CT w/ rectal contrast is best Tx: 1. Intraperitoneal ➡ colonic injury 2. Extraperitoneal ➡ primary repair w/ loop sig colostomy - if inaccessible just leave open and divert - avoid presacral drainage or distal washout
611
Tx of gastric trauma
- mobilize to see extent of injury - most commonly primary repair - if large along the greater curve can wedge staple - if very extensive can resect and reconstruct w/ REY or Billroth
612
SC artery control
Right: median sternotomy Left: - anterior thoracotomy: proximal control - supraclavicular incision: distal control - can connect with sternotomy for "trap door"
613
Central vs. Peripheral DI - cause and tx
1. Central: disrupted ADH synthesis ➡ responds to DDAVP 2. Peripheral: genetic or Li induced defective ADH receptor ➡ low salt diet, amiloride
614
Px and Tx of Steal syndrome vs. IMN
1. Steal: pain, diminished pulse, cold hand - Tx: DRIL (distal revasc interval ligation) - Ligate immediately distal to AVF. Bypass distal to the ligation site. - 2/2 to impaired compensatory mechanisms 2. IMN: pain, normal pulse, warm hand - Tx: immediate ligation - 2/2 nerve ischemia
615
Tx of superficial venous thrombosis
Thrombus is in GSV, SSV 1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months 2. No near the jxns ➡ prophylactic AC for 45 days 3. Otherwise: surveillance **Superficial femoral vein is a DEEP vein **EHIT: heat induced thrombus after RFA - tx with AC until resolution if it involves femoral jxn and > 50% occlusion - < 50%: compress, NSAID, surveillance
616
Tx of varicose veins
- RFA or EVLA are 1st line - Indications for surgery instead: high ligation and vein stripping: 1. proximal/dilated and tortuous GSV 2. previous thrombophlebitis 3. vein too large (RFA > 15mm, EVLA > 8 mm) - lower extremity telangiectasias, reticular veins, and small varicose veins ➡ sclerotherapy recommended
617
Sensory nerves of the foot
- Dosal: superfial peroneal n. - 1st webspace: deep peroneal n. (is deeper) - Medial: saphenous n. - Lateral: sural n.
618
Tx of perforated colon ca
- HDS: perform a cancer resection - HDUS: resect and divert - Scope in 3-6 months to r/o synch lesion **Divert if unstable, contaminated, poor nutrition, etc.
619
Contents of cord structures
- Cremasterics (vessels, muscle, lymphatics) - GB of GF - Testicular artery and veins - Vas deferens - Processus vaginalis **round ligament in women
620
Levels of evidence
1- RCT or SR of RCT 2- Cohort study or SR of cohort studies 3- Case-control or SR of case-control 4- Case series 5- Expert opinion
621
Tx and prognosticators of hepatoblastoma
1. neoadjuvant 1st unless pure fetal histology and low mitotix index 2. resection 3. transplant if 4+ section involved/unresectable after chemo Good prog: < 5 yo, AFP > 100
622
VACTERL defects
Vertebral Anal Cardiac TE fistula Renal, Radial bone Limb defects
623
Biliary atresia - px, dx, and tx
px: infant with bilirubinemia dx: 0. Rule out TORCH infections/neonatal hepatitis 1. HIDA with no contrast in the duo 2. Cholangiogram: look at what segments are strictured 3. perc bx (tissue dx) tx: REY-HJ vs. REY-portoenterostomy (Kasai) ➡ transplant if unsuccessful
624
Catelcholamine synthesis
Tyrosine ➡ L-dopa ➡ dopamine ➡ NE ➡ adrenal PNMT ➡ Epi
625
BK Virus- rf, px, and tx
rf's- high IS, pulse steroids px- hematuria, nephritis after kidney trx tx- decrease IS, cysto/possible stent
626
Strategies to decrease SSI
- stop smoking 4-6 weeks b4 surgery - mechanical and abx prep before elective colectomy - perioperative glucose < 200 - clippers > razors - abxs 1h b4 incision; 2h for vanc or FQ - normothermia - closing tray for colorectal cases
627
Aminoglycosides - MOA, coverage, s/e
MOA- inhibit 30s; bacteriocidal Coverage- GNRS, pseudomonas s/e- nephrotoxic, ototoxic
628
Tx of thyroid storm
1. PTU or methimazole 2. Steroids **No alpha/beta blockade
629
Polypsos syndromes: px and gene mutations - MutY - FAP - Peutz-Jeghers - Juvenile polyposis - Lynch/HNPCC - Cowden
- MutY: 10 R sided adenomas ➡ MUTYH - FAP: 100s of adenomas + desmoid ➡ APC - Peutz-Jeghers: hamartomas + skin lesions ➡ STK11 - Juvenile polyposis: hamartomoas + telangiectasias ➡ SMAD4 - Lynch/HNPCC: L sided adenomas ➡ MLH1, MSH2, MSH6, PMS2 - Cowden: hamartomas + breast/thyroid ➡ PTEN
630
Tx of dysplasia with IBD (UC and Crohn's)
- Screening scopes 8 years after onset. Scope q1-3 years thereafter. - Invisible HGD: confirm w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA - Visible HGD: 1. Resectable: endoscopic resection + serial scopes 2. Not-resectable: TC w/ IPAA - for Crohn’s can do segmental resection
631
Indications for surgery of brain bleeds: 1. Epidural 2. SDH 3. Intraparenchymal
Indications for surgery of brain bleeds: 1. Epidural: > 1.5 cm or > 5 mm shift 2. SDH: > 1 cm or > 5 mm shift 3. Intra-parenchymal: > 5mm shift
632
Indications for trx of cholangioca
- cant be intrahepatic (prognosis is too poor) - must be unresectable, perihilar, < 3cm - no distant mets
633
Short gut syndrome - risk/length + feeds
- Adults risk starts at < 180 cm - Infants risk starts at < 75 cm - Feeds with elemental nutrition
634
Tx of toxic megacolon
- suspect when colon > 6cm - TAC w/ end ileostomy - Keep the ileocolic intact for future J pouch - Keep the SRA intact for good staple line flow - Divide rectum above the posterior peritoneal reflection at level of sacral promontory
635
Repair of bile duct injuries based on Strasburg class
A- CD stump leak: - Intraop: clip/ligate and leave drain - Postop: perc drain + ERCP plasty/stent B- Aberrant right hepatic ligation: - Only if sxs ➡ REYHJ C- Transect aberrant right hepatic: - Only if sxs ➡ REYHJ D- Lateral injury to CHD/CBD: - No devascularization and small: 1' T-tube closure - Devascularized: REY-HJ E- full transection of CHD/CBD - < 1cm or distal w/out tension: 1' T-tube closure - > 1cm OR proximal injury: REY-HJ e1- > 2cm, below confluence e2- <2cm, below confluence e3- at confluence (confluence intact) e4- at confluence (confluence separated) e5- aberrant RH duct injury w/ CBD stricture
636
Indications for MRM
1. Prior radiation 2. Radiation therapy contraindicated by pregnancy 3. Inflammatory breast cancer 4. Diffuse suspicious or malignant-appearing microcalcifications 5. Widespread disease that is multicentric 6. A positive pathologic margin after repeat re-excision MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes
637
p450 inducers and inhibitors
CRAP GPs spend all day on SICKFACES.com. Inducers: Rifampicin Alcohol Phenytoin Sulphonylureas Inhibitors: Sodium valproate Isoniazid Fluconazole Grapefruit juice Sulfonamides Ciprofloxacin Omeprazole Metronidazole
638
Pseudomyxoma peritonei - dx and tx
dx: CT and histopathology - mc at the appendix tx: - ex lap in acute setting to resolve obstruction - cytoreductive surgery + HIPEC - don't do palliative feeding tube without tissue dx/staging
639
Condyloma acuminata - tx
1. Imiquimod, Podophyllotoxin, Sinecatechins 2. Cryo, acetic acid, surgery, laser 3. Podophylin, 5-FU
640
Px and w/up of cholangioca
1. Px: painless jaundice. 2. W/up: - Ca 19-9 - CT/MRI - Tissue: 1. ERCP w/ stent: brushings + in 50% (preferred if obstuctive) 2. EUS/FNA: negative bx does NOT rule out
641
RF's for cholangioca
- PSC - UC - Choledochal cyst - Biliary tract infection
642
Hypothermia classes
1.Mild: 90-94; mild MS change 2. Moderate: 84-89; afib, HoTN 3. Severe: 84-70; Osborne waves, coma 4. Profound: <70; no vitals
643
Emergent management of lower GI bleed of unknown origin
- If patient is hypotensive - TAC w/ end ileostomy - If stabilized- prep 1st with 4-6L of PEG. Scope w/in 24h.
644
Haggit stage and management
Stage: extent of submucosal invasion! 0- superficial to MM (no SM) 1- invasion into head 2- invasion into neck 3- invasion into stalk 4- in SM. superficial to MP. **all superficial. toMP Mx: - all sessile are 4 by definition - 4 is an indication for resection - < 4 cancer without high risk features ➡ polypectomy alone w/ follow-up scope in 3 months
645
Path, Dx and Tx of rectocele
Path- bulging of rectum into vagina Dx- bimanual exam reveal large bulge in posterior vagina Tx- transvaginal plication of vaginal muscularis +/- mesh
646
ERAS protocol of CRC
1. CLD 2h preop 2. Preop gabapentin and tylenol 3. Thoracic epidural or TAP block 4. Pre-op entereg + 7 days post-op 5. Scope patch 6. Non-opiate 7. Normothermia, good O2, glycemic control, skin preop 8. Net zero fluids 9. Avoid draina nd prolonged foley 10. Dc w/in 3 days
647
Dx and Tx of slow transit constipation
Dx: nuclear study or radio-opaque marker Tx: 1. Medical management 2. TAC with IRA is most effective - pelvic floor dysfunction must be addressed prior to surgery
648
Impediments to fistula closure
1. Foreign body 2. Radiation 3. Inflammation/Infection 4. Epithelialization 5. Neoplasia 6. Distal obstruction
649
NCCM CRC screening
- average risk: start at 45. Screen q 10 years. -1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.
650
Tx of sigmoid volvulus
1. Colonoscopic detorsion 2. Sigmoid resection DURING the admission
651
Colon/Rectum Transitions
- Colon: has taenia/above reflection - Rectum: no taenia/below reflection
652
Dx and Tx of contained esophageal perforation
dx: gg swallow then thin barium tx: - NPO, IV abxs - consider stenting - generally don't need IR drain - includes cervical and thoracic
653
Tx of Barrett's
1. PPI or H2 block daily x 8 weeks - BID if severe sxs, HGD, or esophagitis 2. Work-up for anti-reflux surgery - dysplasia should be eradicated prior to surgery 3. Continue surveillance - no dysplasia: q5y - LGD: q6m. ablation. - HGD: q3m. ablation or endoscopic resection.
654
Tx of TOA
1. Abxs first - unless rupture or HDUS 2. Drainage/Surgery if failure
655
Types of collagen and life cycle
- type 1: most abundant. scar tissue. predominate after 8 weeks of wound healing. - type 3: 1st 2-3 weeks of wounds healing. weaker. **Collagen deposition peaks at 3 weeks. Degradation starts then
656
Tx of eso varices
1. > 5mm or < 5mm w/ red spots - Tx: beta blocker or banding ➡ TIPS 2. < 5 mm: repeat scope in 1-2 years **bleed rate 10%/year w/ 20% mortality
657
Branched chain AA - importance and use
- leucine, isoleucine, valine - metabolized by the muscle instead of liver - use to feed liver impaired patients
658
Peroneal nerve injury
1. Superficial: inability to evert. numbness at dorsum (except 1st web space) 2. Deep: foot drop. numbness of first web space
659
Px and Tx of Pancreatic Lymphoma
Px- pancreatic head mass with LADN. Normal Ca 19-9. Constitutional sxs Tx- chemo only
660
Indications for MOHS
- Cancers: SqCC, BSC, melanoma in-situ Location: face, genitalia, hand/foot - Size: > 6mm on high-risk area - High risk subtype: morphaeform, dibrosing, sclerosing, infiltrating, micronodular - High risk features: Ill defined borders, peri-neural invasion, prior radiation, immunosuppression
661
Indications for deep inguinal LN dissection for melanoma and operative considerations
1. > 4 nodes on superficial dissection 2. Positive cloquet's node 3. Enlarged ileo-obturator nodes on CT 4. Clinically palpable femoral nodes
662
Pernicious anemia - pathophysiology
- IF secreted by parietal cells - improves absorption of b12 in the TI - post gastrectomy can get megaloblastic anemia
663
Tx of Bronchial Carcinoid
Surgical resection with complete LADN - usually lobectomy
664
Immunotherapy agents and use by target: - PD-1 - EGFR - CTLA4 - RET - Aromatase - HER2
- PD-1: pembrolizumab; melanoma (1st line); NSC lung ca, - EGFR: cetuximab; KRAS NEGATIVE colon ca - CTLA4: ipilimumab; melanoma (2nd option) - RET: selpercatinib; MTC (MEN) - Aromatase: anastrazole; ER+ breast ca - HER2: trastuzumab; HER2+ breast ca
665
Histoplasmosis - px, dx, tx
Px: pulm sxs in ohio river valley - MC mycosis in the overall - SVC syndrome if fibrosis CT: fibrosing mediastinitis Bx: oval budding yeasts Tx: only if sxs - itraconazole → ampho B - stent if fibrosis
666
MOA and s/e of trx meds - MMF - Basiliximab - Azathioprine
MMF: purine (T cell) inhibitor - GI sxs, myelosuppression, anemia Basilixamab: il2 inhibitor - GI sxs Azathioprine: purine (T cell) inhibitor - myelosuppression, marrow suppression, pulm fibrosis
667
Meperadine (demerol) - MOA and s/e
MOA: mu agonist s/e: seizures - 2/2 to metabolite normeperadine - worse with renal impariment
668
s/e of local anesthetic and opioid epidural
Bupivocaine: HoTN Morphine: respiratory depression
669
Absolute c/i to BCT
1. Pregnancy 2. Diffuse micro-calcs 3. Positive pathologic margin 4. Multi-quadrant disease
670
Tx of Lymphedema s/p breast surgery
Stage 1: pitting edema, no fibrosis - compression garment Stage 2: fibrosis - complete decongestive therapy Stage 3: severe fibrosis, elephantiasis - pneumatic compression **venous insufficiency does NOT cause lymphedema
671
Most common recon after mastectomy with blood supply
Pedicled: - TRAM: superior epigastric. use rectus. - Lat dorsi: thoracodorsal Free: - DIEP flap: deep IE vessels. lower abdominal skin. Rectus spared. **delayed autologous flap is preferred over implant if XRT is expected
672
Pressor receptors: - NE - Epi - Phenyl - Vaso
- NE: alpha1 > beta1 - Epi: beta1 > alpha 1, some beta 2 - Phenyl: all alpha1 - V1 stimualtor
673
Effects of hypovolemia on RAA
- constrict the efferent arteriole to promoted blood to kidney - increase ADH secretion - JG cells sense low Na and release renin - absorb water/na and excrete K/H
674
Nerves in triangle of pain
medial-to-lateral: 1. GB of GF 2. FB of GF 3. Femoral 4. Anterior femoral cutaneous 5. Lateral femoral cutaneous (MC injured)
675
Phase of cell cycle
G1: longest. self regulation. go to G0 if irregular. - p53 regulated G1/S transition S: DNA replication G2: 2nd check-point M: mitosis/cell division - most XRT sensitive
676
WAGR Syndrome - chrom anomaly and px
Chrom: deletion of short arm of chrome 11 Px: Wilm's tumor Aniridia- absent iris GU anomalies- cryptorchidism, hypospadia, streak ovary Retardation
677
Dx and Tx of pediatric Intussusception
Dx: U/S, current jelly stools, abdominal mass Tx: 1. Air contrast enema (75% effective) - surgery if unstable, perforation, mass, or completely unsuccessful on repeat U/S 2. Repeat enema 3. Observe for 4 hours if success - only 5% recur
678
Tx of duodenal ulcer
1. 1-2 cm: simple closure 2. 2+ cm: graham patch repair 3. >4 cm: resection and reconstruction - thal patch, pyloric exclusion, G-J 4. >4 cm unstable: controlled fistula via drain through defect, pyloric exclusion, G-J with REY or Billroth 2 - consider drainage procedure if HDS and unlikely. to comply with PPI or developed ulcer on PPI
679
Tx of small bowel polyps
Tx: bx all SB lesions - excision of adenomas or all sx'atic tumors - < 3 cm: endoscopic resection - > 3cm: surgical resection (trans-duodenal polypectomy, segmental resection). Whipple if peri-ampullary and worrisome features. - routine surveillance for recurrence
680
Causes of thyrotoxicosis on RAI and tx
- diffuse uptake ➡ Grave's: BB, PTU, RAI ➡ total/subtotal thyroidectomy if refractory (consider lugol's solution before surgery) - focal uptake ➡ toxic adenoma: BB, PTU and lobectomy - multiple areas of increased uptake ➡ TMN ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy if refractory
681
Management of penetrating cardiac injury
1. FAST+, HDS ➡ OR for pericardial window ➡ extend to median sternotomy if blood found 2. FAST+, HDUS ➡ immediate median sternotomy (preferred) or ED thoracotomy (left anterolateral) - Finger compression - If failure ➡ pledgeted repair (avoid balloon/staples if possible). Horizontal mattress, permanent (prolene)
682
CXR of aortic trauma
1. Widened mediastinum 2. Apical cap 3. Displacement of trachea 4. Depression of L mainstem bronchus *suggest injury at ligamentum arteriosum
683
Polycystic kidney disease a/w
- HTN - Hepatic cysts - Head (Intracranial) aneurysms
684
Tx of thrombophlebitis and catheter releated DVT
Thrombophlebitis: 1. Superficial veins: dc the IV, warm compress, NSAIDS - abxs if you suspect infection - surgery if failure of abxs or septic 2. Deep veins: abxs + AC x 2-3 weeks ➡ thrombectomy and vein excision only if refractory (high morbidity) Catheter-related DVT: - anticoagulation - catheter can remain in place if functional, needed, and not infected
685
Indications for iHD
1. GFR < 6 and asx 2. GFR < 15 with sxs - absolute: uremic pericarditis, pleuritis, encephalopathy - relative: AEIOU
686
MOA of abxs: (cell wall, protein, or DNA inhibitor) - cell wall - protein 30S - prostein 50S - DNA synthesis
MOA of abxs: - cell wall: PCN, cephalsporin, vanc - protein 30s: AG (gent), tetracyclines (doxy) - protein 50s: macrolide (azithro), clinda, linezolid - dna synthesis: quinolones (gyrase), bactrim (folate), flagyl (free radicals)
687
Abx ppx for suspected colonic injury
- ancef, cefoxitin, or cefotetan + flagyl - unasyn - pen allergic: clinda or vanc + gent, cipro, levo, aztrenoam
688
Guidelines to prevent SSI
- make albumin > 3.5 - stop smoking 4-6 weeks pre op - mechanical and PO prep before colectomy - glucose 110-200 - use clipper over blade - give abxs w/in 1h (2h for vanc/FQ) - closing tray for colons - keep patient warm
689
QI strategies - six sigma - teamSTEPPS - SBAR - re-AIM - PDSA
QI strategies: - six sigma: improve quality by covering all variables to measurable parameters - teamSTEPPS: optimize teamwork through leadership, communication, mutual support, situation monitoring - SBAR: communication tool for team safety. situation, background, assessment, recommendation - re-AIM: strategy to reach targeted population of evidence-based practice. reach, effectiveness, adoption, implementation, maintain - PDSA: test a change. plan, do study, act.
690
Requirements for SBP ppx
Cirrhotic w/: 1. GI bleed 2. Low protein ascites 3. Hx of SBP 4. Cr > 1.2 5. Billi > 3, C/P > 9 6. Na < 130
691
Tx of appendix carcinoid
1. >2cm or at base: R hemi 2. high risk (high MI, KI > 2%, mixed histology, LV invasion meso invasion): R hemi 3. Otherwise: appe only **require c'scope post-op b/c 15% have synch lesions
692
MCCO acute liver failure
1. US: tylenol 2. Worldwide: viral hepatitis (Hep B)
693
LA class for esophagitis
A- mucosal breaks <5 mm B- mucosal breaks >5 mm C- mucosal breaks spanning 2 folds, <75% circ D- mucosal breaks >75% circumference
694
Scleroderma manometry
- absent peristalsis - normal/low LES pressure **contrast to achalasia: aperistalsis and high LES pressure
695
Immuno-nutrition
1. arginine 2. omega-3 FA - a/w less infections, shorter LOS
696
Renal arterial anatomy
- Renals come off just under the SMA at L2 - SMA hugs the left renal vein - Renal arteries run behind the veins and the IVC
697
Belsey IV fundoplication
- Thoracic approach with anterior 270-degree wrap - Bailout after failed abdominal approaches
698
How to access cervical esophagus for esophagectomy
1. Anterior to SCM. Divide platysma 2. Divide omohyoid, strap muscles 3. Retract carotid structures laterally 4. Ligate middle thyroid vein and inferior thyroid artery
699
Most important prognosticator of survival in stage IV (liver mets) colon cancer
- response to neoadjuvant chemo - not size. or node status (its already disseminated)
700
MC location of small bowel lymphoma
Ileum (has most lymphoid tissue)
701
SMA exposure options for bypass
1. Anteior: base of transverse mesocolom 2. Lateral: mobilize 4D and LOTz
702
Consequences of ileal resection
- megaloblastic anemia - fat malabsorption/ADEK def - cholesterol stones (EH circulation) - oxalate stones (ca binds fat instead of Ox)
703
BPD for weight loss surgery
1. BPD/DS: prevent marginal ulcers and dumping syndrome (keep pylorus) - sleeve - resect TI 100 cm from ICV - roux limb end-to-end to duo 2. BPD: good for weight loss but high ulcer/dumping syndrome - resect stomach - ileum to stomach (250 cm from ICV) - more distal ileum to BP limb (100 cm from ICV)
704
MC Vit def after REYGB and sxs
1. Vit D- bone dz, hypoCa 2. Vit A- night blind 3. Folate- skin changes 4. Iron- anemia 5. Thiamine- encephalopathy
705
Surviving Sepsis 1-hour bundle
1. Measure lactate 2. Blood cx b4 abxs 3. Abxs after cx 4. 30 ml/cc bolus if HoTN, LA 5. Pressors for MAP >65
706
Immuno-nutrition and benefits
1. arginine 2. omega-3 FA - a/w less infections, shorter LOS
707
S/e of Amiodarone
1. Pulmonary dysfunction: tx w/ steroids 2. Thyroid dysfunction: tx w/ steroids or thionamides
708
Virulence of G+ and G- bacteria
G+: exotoxins G-: endotoxins (lipid A)
709
Tx of atypical ductal hyperplasia (ADH)
- Get diagnostic mammo - Then excisional bx (15-30% of cancer) - Like LCIS you do not need a negative margin - Finally chemo-ppx with tamoxifen **ALH and LCIS if low risk and concordant
710
Axilla boundaries
medial- pec minor lateral- lat dorsi superior- ax vein posterior- subscap
711
Histology of pap thyroid ca
- Pale cytoplasm - Prominent nucleoli (orphan annie) - Psammoma bodies - Large/crowded nuclei
712
Adrenal blood supply
Artery: R and L the same - Superior a: from inf phrenic - Middle a: from aorta - Inferior a: from renal a Vein - L adrenal vein: into L renal v - R adrenal vein: into IVC
713
Advantages of robotic surgery
-7 degrees of freedom
714
Damage control trauma to visceral vessels
Celiac- ligate SMA- shunt or repair IMA- ligate
715
Lap band imaging
- Band should be at 45-degree angle - Too much contrast past the band means its underfilled - Fundus above means slipped band - Band melding with lumen of the stomach: erosion
716
Melanoma indications for SLNBx
> 1mm < 1mm w/ ulceration or > 1 mm2 mitoses
717
Causes for AV fistula failure to mature
1. venous branches (doesn't fill enough) 2. fistula is too deep (can't pop out)
718
CEA operative pearls
- take out plaque between media and adventitia - pull out plaque transversely - acute deficit post op: get an U/S 1. thrombus/initimal flap: re-explore 2. normal U/S ➡ cerebral angio
719
Tx of aortoenteric fistula
Fistula takedown, prior graft revmoval (if s/p evar) and extra-anatomic bypass
720
U/S findings for thyroid nodule suspicious of cancer
1. Unclear boundary of solid component 2. Irregular shape 3. Calcs 4. Hypoechoic
721
Indications for ICP monitor
1. GCS <=8 with abnormal head CT 2. GCS <=8 with normal head CT and 2 of the following: - age > 40 - abnormal posturing - hx of HoTN
722
Submental triangle - boundaries and contents
Boundaries: - Anterior bellies of digastric - Hyoid bone - Symphysis menti - Mylohyoid is floor Contents: - Contents: mylohyoid nerve, anterior jugular veins
723
Morphine equivalents of narcs
5 IV morphine = - .7 IV HM - .05 IV fentanyl 15 PO morphine = - 3 PO HM - 10 POD Oxy
724
FRC
FRC = RV + ERV - TV not included - Increases with age - Decrease with obesity, pneumoperitoneum

2. QE (3 decks)

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