QE COPY

Question 1

Dx of Fibrolamellar HCC

Answer 1

-Labs: normal AFP and elevated neurotensin (vs. FNH)

-Imaging: well-circumscribed w/ central scar. Similar to FNH

Question 2

Hemodynamic parameters:
- HMHG shock
- Septic shock
- Neurogenic shock
- Cardiogenic shock

Answer 2

1. HMHG: low CI, high SVR, low wedge
   - SCV02 < 75
2. Septic: high CI!, low SVR, low wedge
   - SCV02 > 75 (poor O2 extraction)
3. Neurogenic: low/normal CI, low SVR, low wedge
   - At or above t4 ➡ decreased CI
   - Bradycardia and HoTN
   - SCV02 < 75
4. Cardiogenic: low CI, high SVR, high wedge
   - SCV02 < 75

Question 3

Pheo w/up:

Answer 3

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

Question 4

Mucinous cystic neoplasm - dx and tx

Answer 4

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

Question 5

Tx pelvic fx

Answer 5

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

Question 6

STSG vs. FTSG
- survival
- cosmesis
- contraction

Answer 6

1. STSG: epi + part dermis
   - higher survival/less resistant
   - worse cosmesis
   - more 2’ contxn. (don’t use over joints)
2. FTSG: epi + full dermis
   - lower survival/more resistant
   - better cosmesis
   - more 1’ contxn

Question 7

F5 Leiden Mechanism

Answer 7

• acts w/ Xa to convert prothrombin to thrombin
• protein C/S acts by inhibiting factor 5 and 8
• mutated factor 5 can’t be inactivated by protein C/S (protein C resistance)

Question 8

Dx and Localize a gastrinoma

Answer 8

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

Question 9

Tx pseudocyst/WON

Answer 9

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)

Question 10

Post trx lymphoproliferative disorder - path, px, and tx

Answer 10

Path- EBV positive B cell proliferation

Px- B sxs (fever, fatigue, weight loss) and abdominal mass (lymphoma)
- may cause lymphoma, abdominal mass (SBO)
- hyper Ca, high LDH

Tx- reduce IS, rituximab-CHOP

Question 11

Tx of Thrombosed external HMHD

Answer 11

1. w/in 48h - excision
2. after 48h - medically manage

Question 12

Free water deficit - calculation and use

Answer 12

TBW x [(Na-140)/140]
TBW = weight x .6 (men) or .5 (women)

Used for hyperNa

Question 13

Order of contents in thoracic outlet

Answer 13

1. Subclavian VEIN
2. Phrenic NERVE
3. Anterior scalene MUSCLE
4. Subclavian ARTERY
5. Brachial plexus NERVE
6. Middle scalene MUSCLE

Question 14

Corrected Ca

Answer 14

[ (4 - albumin) x .8] + Ca

**always falsely low (not high)
**hyperventilation leads to hypoCa
- alkalosis increases binding affinity of Ca to Albumin (No H+ to distract)

Question 15

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

Answer 15

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.

Question 16

Indications to tx ICA stenosis and sxs

Answer 16

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

Question 17

EBV associated with

Answer 17

1. B cell lymphoma (Burkitt)
   - swelling at the jaw
2. n/ph cancer
3. PTLD
4. Gastric ca

Question 18

Medications for hyperthyroidism - MOA and s/e

Answer 18

1. PTU: thyroperoxidase and de-iodinase inhibitor
   - s/e: aplastic anemia, agranulocytosis. OK for preggo.
2. Methimazole: thyroperoxidase inhibitor
   - s/e: cretinism, aplastic anemia and agranulocytosis

Question 19

Mechanism:
VWF
Fibrin

Answer 19

• VWF: binds GP1b on PLTs and attaches them to endothelium
• Fibrin: Links Gp2b/3a to form PLT plug

Question 20

MRSA tx

Answer 20

1. Vancomycin, Linezolid (best)
2. Clind, bactrim, and doxy have partial coverage
3. Ceftaroline (new 5G cephalosporin)
4. Muporicin for skin burn

***mecA gene encodes for altered penicillin binding protein giving methicillim resistance

Question 21

Neostigmine

Answer 21

MOA: AChE inhibitor

Use: reversal of non-depol muscle relaxants

Question 22

Bethesda criteria for thyroid

Answer 22

**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

Question 23

Achalasia - Px, Dx, Path and Tx

Answer 23

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.

Question 24

Ab reactions: px, path, tx, ppx
1. Non-hemolytic
2. Hemolytic

Answer 24

1. Non-hemolytic: fever after 1hr
   - cytokine from donor leukocytes
   - tx w/ epi, antihistamine, steroids
   - ppx w/ leukoreduced blood
2. Hemolytic: fever, HoTN/shock
   - recipient Ab attack donor leukocytes/RBC (abo mm)
   - tx w/ fluid bolus
   - ppx w/ preventing clerical error (ABO mm)

Question 25

Cowden's mutation and cancers

Answer 25

Mutation: pten Ca: breast, thyroid ca, hamartomas, endometrial

Question 26

Drainage of gonadal veins

Answer 26

1. Right- IVC 2. Left- Left renal vein

Question 27

Tx Medullary thyroid cancer

Answer 27

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)

Question 28

Tx for hyponatermia

Answer 28

1. Acute w/ any sx's or severe (<110): hypertonic saline bolus 2. Chronic and asxatic: free water restriction - give hypertonic saline if < 110 3. Hyper or euovolemic: free water restriction 4. Hypovolemic: can give NS or LR (no 3% unless sxs!) **rapid correction leads to CPM - "from low to high your pons will die"

Question 29

Ulcers: - Marginal - Cameron - Marjolin ulcer - Cushing's ulcer

Answer 29

- Marginal: REYGB at GJ anastomosis - Cameron: on lesser curve of large hiatal hernia - Marjolin ulcer: chronic wound - Cushing's ulcer: elevated ICP

Question 30

Radial scar- Dx and Tx

Answer 30

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)

Question 31

preA vs. Albumin

Answer 31

1. Prealbumin: >15; t1/2 is 1-2 days; good post-op marker 2. Albumin: >3.5; t1/2 is 21 days; good pre-op marker

Question 32

Tx pop aneurysm

Answer 32

>2cm- ligation and bypass <2cm- observation; avoid stents

Question 33

Tx for ectopic pregnancy

Answer 33

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

Question 34

Hyperkalemia EKG Hypokalemia EKG

Answer 34

- hyperK: peaked T wave, eventual SINE - hypoK: flat T waves, U waves

Question 35

HS reactions

Answer 35

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

Question 36

Tx of thyroid ca in pregnancy

Answer 36

- 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)

Question 37

Mastodynia tx

Answer 37

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

Question 38

Tx mucinous neoplasm of the appendix

Answer 38

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

Question 39

GCS eye opening

Answer 39

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

Question 40

Torsades

Answer 40

- "polymorphic ventricular tachycardia" - 2/2 hypoK, hypoCa, hypoMg, macrolides

Question 41

Normal values: CVP, WP, SVR, CI

Answer 41

- CVP 2-6 - WP 4-12 - SVR 700-1500 - CI 2.5-4

Question 42

When to excise burns

Answer 42

- < 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)

Question 43

TTP - Path, Px, Tx

Answer 43

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

Question 44

LE angio

Answer 44

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

Question 45

Liver lesions on arterial phase: HCC Mets Adenoma Hemangioma FNH

Answer 45

- 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

Question 46

Methanol and Ethylene glycol toxicity - Px and Tx

Answer 46

Px: profound AG metabolic acidosis - oxalate stones → renal failure Tx: NaB + fomipazole (ADH inhibitor) - consider iHD

Question 47

Ureter anatomy

Answer 47

Runs under the vas/uterine arteries  Runs over the iliacs

Question 48

Elective surgery after stent

Answer 48

1. ASA lifelong 2. Plavix - BMS: 1 month - DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)

Question 49

UE Injuries: 1. supracondylar humerus 2. DRF 3. Mid shaft 4. ant shoulder disloc 5. post shoulder disloc

Answer 49

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

Question 50

Teg interpretation: R time K time a angle MA LY 30

Answer 50

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%

Question 51

DeMeester score

Answer 51

Score: pH <4 , changes in position, duration, # of episodes > 14.7 is positive

Question 52

Standard Deviations

Answer 52

1, 2, and 3 SD = 67%, 95%, and 99.7% of the data

Question 53

s/e of ileal conduit

Answer 53

Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)

Question 54

Angiodysplasia of the colon - Dx and Tx

Answer 54

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

Question 55

Stewart-Treves syndrome - px, dx, tx

Answer 55

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)

Question 56

Tx for gallstone ileus

Answer 56

Stable and healthy- stone removal and take down fistula Unstable, old/frail- stone removal only!

Question 57

Sorafenib

Answer 57

Tyrosine kinase inhibitor Tx of HCC

Question 58

Stricturoplasties - Heineke s’plasty - Finney s’plasty - Side2Side isoperistaltic s’plasty

Answer 58

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

Question 59

Dx and tx of gastroparesis

Answer 59

Dx: Scintigraphy gastric emptying Tx: - Metoclopramide (Reglan): dopa antagonist - gastric pacemaker or pyloroplasty - feeding tube - TPN

Question 60

Burn degrees

Answer 60

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

Question 61

Tx and Survival Benefit of ARDS

Answer 61

- TV at 4-6 ml/kg - Permissive hypercapnia - Proven benefit: prone, lung protection, paralyze -P/F < 100 = severe

Question 62

Interleukins 1, 2, 4, 5, 10 C5-9

Answer 62

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

Question 63

Glucagonoma - loc, px, dx, tx

Answer 63

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

Question 64

Aminocaproic acid vs. streptokinase

Answer 64

ACA: Plasmin inhibitor - Use: DIC, excess tpa Streptokinase/Urokinase/TPA: plasmin activator - bust clot

Question 65

s/e of carb, protein, and lipid

Answer 65

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)

Question 66

Dx, Bx, and Tx actinic keratosis

Answer 66

- Dx: red, crusty, weeping lesion - Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ) - Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)

Question 67

Hirschsprung surgeries - Duhamel - Soave - Swenson

Answer 67

- 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.

Question 68

z11 trial implications

Answer 68

- 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

Question 69

Hard signs of vascular injury

Answer 69

shock expanding hematoma pulsatile bleed thrill/bruit absent pulse ischemia If negative ➡ ABI...if positive ➡ CTA (to localize)

Question 70

Polyps that require surgery instead of endoscopic resection

Answer 70

1. Submucosal invasion > 1mm 2. Poorly differentiated 3. <1 mm margin 4. LV invasion 5. Tumor budding 6. Taken piecemeal

Question 71

Iron deficiency sxs

Answer 71

anemia, glossitis, brittle nails, cardiomegaly

Question 72

T staging indications for neoadjuvant - eso - stomach - colon - rectal - lung

Answer 72

- eso: T2 (MP) - stomach: t2 (MP) - colon: t4b (adjacent organs) - rectal: t3 (through MP) - lung: n2 nodes

Question 73

Atlanta classification pancreatits

Answer 73

1. Interstitial: <4w- acute peripanc collection >4w pseudocyst 2. Necrotic: <4w- acute necrotic collection >4w- walled of necrosis

Question 74

Fuel for: - SB - LB

Answer 74

- SB: glutamine - LB: short-chain fatty acids (acetate, butyrate). Directly absorbed by intestinal epithelium w/out lipolysis

Question 75

Motilin

Answer 75

Motilin – released by intestinal cells of gut; acts. on smooth muscle to↑ intestinal motility (erythromycin acts on this smooth muscle receptor)

Question 76

Screening in IBD patients

Answer 76

- 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

Question 77

NEC - px and tx

Answer 77

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.

Question 78

W/up of thyroid nodule found on exam or incidental imaging

Answer 78

- 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

Question 79

Tx male breast ca

Answer 79

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

Question 80

Nutcracker eso - manometery and tx

Answer 80

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

Question 81

General principles - repair of Bile Duct Injury

Answer 81

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

Question 82

Eso dysplasia tx

Answer 82

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

Question 83

Superior epigastrics Inferior epigastrics

Answer 83

SE: runs between rectus and posterior rectus sheath; branch of int mammary IE: runs between rectus and transversalis fascia; branch of EI

Question 84

When to intubate burn patients

Answer 84

- hypoxia, hypercarbia, severe upper airway edema - If stable/GCS > 8 and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling

Question 85

Tx hemobilia after trauma

Answer 85

1. EGD → CTA (if stable) 2. angio embolization (no surgery) - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA

Question 86

Paget Von Schroetter syndrome - path, px, tx

Answer 86

Path: narrowing of SC/Ax vein 2/2 mech compression Px: acute swelling Tx: catheter-directed thrombolysis before anything else (NOT open thrombectomy)

Question 87

Tx of AT3 def

Answer 87

Tx- recombinant at3 or FFP followed by heparin then warfarin

Question 88

Vitamin C mechanism and deficiency

Answer 88

Mech: - hydroxylation of lysine and proline - type 3 collagen cross-linking Def: Scurvy - gingivitis, wound healing, rough skin

Question 89

Indications for chemotherapy for rectal cancer

Answer 89

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

Question 90

Periop anticoagulation - risks and tx

Answer 90

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.

Question 91

What is not suppressed by high dose dexa

Answer 91

Adrenal mass Ectopic mass (small cell cancer) **dexa is strongest steroid (hydrocort is weakest)

Question 92

Metabolic alkalosis - chloride responsiveness

Answer 92

1. Cl responsive (Ur Cl < 20) - temporary loss, replaceable - vomiting 2. Cl resistant (Ur Cl > 20) - hormonal, continuous loss - conn’s, steroids, hyperaldosterone

Question 93

Heller myotomy margins and fibers

Answer 93

6 cm proximal, 2 cm distal - Esophagus: vertical fibers first (outside), then circular (inside)

Question 94

Margin for invasives cancer vs. dcis

Answer 94

1. Invasive cancer- no tumor on ink 2. DCIS- 2 mm **if both in specimen, margin is no tumor on ink

Question 95

ITP- path, dx and tx

Answer 95

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

Question 96

Staph species causing graft infection

Answer 96

G+/aerobe/clusters coag+ → staph aureus - MC early graft infections coag- → staph epidermidis - MC late graft infection 2/2 biofim

Question 97

Cryptorchidism tx

Answer 97

- wait until 6 month old - if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma - risk of ca higher in both testes.

Question 98

Sarcoma grade

Answer 98

1. differentiation 2. mitotic coun 3. necrosis ** more important than size, nodal/distal mets for prognosis

Question 99

Neuroblastoma dx and tx

Answer 99

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

Question 100

Gastrin - MOA and stimulation

Answer 100

- 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

Question 101

Esophagus blood supply

Answer 101

1. Cervical- inf thyroid 2. Thoracic- aortic branches (bronchial arteries) 3. Abd- left gastric/inferior phrenic

Question 102

- CBD and PD on ERCP - Blood supply of CBD

Answer 102

- 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'

Question 103

Tx urethral injury

Answer 103

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

Question 104

TEF - MC types. dx and tx

Answer 104

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

Question 105

Tx of Ogilvie's

Answer 105

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

Question 106

Px and Tx of prolactinoma

Answer 106

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

Question 107

Pros/Cons: - Sevoflurane - Isoflurane - Halothane - NO

Answer 107

- 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.

Question 108

Atropine MOA

Answer 108

- competitive inhibitor of ACh at muscarinic receptor - liver metabolism

Question 109

FMD- Dx, Path and Tx

Answer 109

Dx: string of beads on angiogram Path: fibroplasia, thickened media, collagen formation Tx: angio + balloon (no stent)

Question 110

MEN1/MEN2 genes

Answer 110

MEN1: MENIN gene, TSGene MEN2: RET gene, receptor TK protein, proto-oncogene

Question 111

Birads score

Answer 111

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)

Question 112

MOA, use, s/e of antifungals: Fluconazole Voriconazole Micafungin Amphotericin

Answer 112

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)

Question 113

Recurrent laryngeal nerve + aberrant anatomy

Answer 113

- 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

Question 114

PFTs for lung resection

Answer 114

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

Question 115

Origins of medullary thyroid cancer

Answer 115

- 4th pharyngeal arch releases NCC which form parafollicular C cells

Question 116

Gastrinoma - loc, px, dx, tx

Answer 116

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

Question 117

qSOFA score

Answer 117

1. AMS (<15) 2. RR > 22 3. SBP < 100

Question 118

MC Benign and Malignant H/N tumors - tx

Answer 118

1. Benign: Pleomorphic adenoma - Tx: superficial parotidectomy even if asx 2. Malignant: mucoepidermoid carcinoma tx - Tx: total parotidectomy (facial nerve preservation) + MRND + XRT

Question 119

Tx frostbite

Answer 119

- Frostnip: rapid moist/pool re-warming - 2d: clear/milky blister- drain - 3d: HMHG blister- leave intact - 4d: bone- prostacyclin/TPA, amputate

Question 120

Tx of Pilonidal cyst

Answer 120

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)

Question 121

Tx TCPenia

Answer 121

<10k if asx <20k if septic, chemo/rads, RF’s <50K if elective surgery

Question 122

Dx and Tx annular pancreas

Answer 122

Dx: UGI with double bubble at 2D Tx: - neonates: duo-duo (mobile duo) - adults: duo-jej

Question 123

Production and function: - TNFa - IF-gamma

Answer 123

TNF-a: produced by PMNs, mphages -cachexia, inflammation IF-gamma: produced by T lymphos - activate PMNs, mphages

Question 124

W/up of pancreatic cystic neoplasms: Pseudocyst Serous cystadenoma MCN IPMN

Answer 124

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

Question 125

Propofol - MOA, pros and cons

Answer 125

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

Question 126

Enterohepatic circulation

Answer 126

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

Question 127

Dx and Tx CO poisoning

Answer 127

- 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

Question 128

Indication for APR

Answer 128

1. Rigid proctoscopy: w/ in 2cm of anal verge (levators) 2. PE: baseline sphincter dysfxn 3. Recurrent SqCC (s/p Nigro)

Question 129

Cancer associations: - CEA - AFP - CA 19-9 - CA 125 - Beta-HCG - PSA - NSE - BRCA I and II - Chromogranin A - Ret oncogene - KRAS

Answer 129

- 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)

Question 130

Types of esophagectomy compared

Answer 130

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)

Question 131

Somatostatinoma - loc, px, dx, tx

Answer 131

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

Question 132

Etomidate - Pros and Cons

Answer 132

Induction agent Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e Cons- adrenocortical suppression

Question 133

W/up and Tx testicular mass: - Seminoma - Non-seminomatous

Answer 133

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

Question 134

Liver collection dx and tx: 1. Pyo 2. Amoebic 3. Echino 4. Fungal

Answer 134

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

Question 135

EVAR specs: - Proximal landing - Common iliac (distal landing) - Neck angulation - External Iliac

Answer 135

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

Question 136

Tx of anal fissure

Answer 136

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

Question 137

Lynch genes and gene funtions

Answer 137

Genes: - MLH1 - MSH2, MSH6 - PMS2 - EPCAM Fxn: DNA MM repair gene causing microsatellite instability

Question 138

Condyloma types

Answer 138

1. acuminatum- HPV (6, 11- warts; 16, 18- Cancer) 2. lata- syphilis

Question 139

Tx of liver lesions: 1. Hemangioma 2. FNH 3. Adenoma

Answer 139

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

Question 140

Dx and Tx congential DPGM hernia

Answer 140

-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

Question 141

Stages of empyema formation

Answer 141

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

Question 142

Vertebral artery occlusion px

Answer 142

posterior circulation sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia

Question 143

5T's of cyanosis

Answer 143

1. TOF 2. Transposition of GVs 3. Truncus art 4. Tricuspid atresia 5. TAPVC

Question 144

DES - Manno and Tx

Answer 144

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

Question 145

Supraceliac aortic control

Answer 145

1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram 2. Stable: left medial visceral rotation is preferred

Question 146

Mondor disease - px and tx

Answer 146

px- tender, “cord-like” structure tx- NSAIDs

Question 147

Dx and Tx Phyllodes

Answer 147

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)

Question 148

Replaced R and L hepatic

Answer 148

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

Question 149

Effective for enteroccous

Answer 149

Ampicillin/Amoxacillin Vancomycin Zosyn (Resistant to all cephalosporins)

Question 150

Loss in excess weight for each surgery

Answer 150

REYGB- 75% SG- 60% Lap band- 50%

Question 151

Acid/Base of Ng suctioning

Answer 151

HypoCl, HypoK metabolic alk - Mech: Loose HCl and fluid ➡ turn on RAA system Retain Na/Excrete acid (paradoxic acidurea)

Question 152

Indications for total thyroidectomy (pap and follicular)

Answer 152

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

Question 153

Soft tissue sarcoma - dx and tx

Answer 153

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

Question 154

Step up approach

Answer 154

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

Question 155

CN11 - nerve, location, muscle/injury

Answer 155

- nerve: spinal accessory nerve - location: exit jugular foramen (post triangle) - injury: SCM and trapezius. no shoulder shrug, winged scap!

Question 156

1. Central cord syndrome 2. Anterior cord syndrome

Answer 156

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

Question 157

Types and Tx SVT

Answer 157

types: af, aflutter, paroxysmal SVT, WPW 1. vagal → adenosine - may unmask afib/flutter 2. HDS: BB, CCB ➡ sync cardioversion 3. HDUS ➡ sync cardioversion

Question 158

Von Hippel Lindau - mechanism and surveillance

Answer 158

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

Question 159

Melanoma w/up and tx

Answer 159

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.

Question 160

Steps of rapid sequence intubation

Answer 160

c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine

Question 161

PSC vs. PBC - assocaited and tx

Answer 161

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

Question 162

CPP

Answer 162

MAP - ICP normal CPP > 60 Normal ICP  < 20 - would prefer low MAP with CPP of 60 then higher MAP for brain bleed

Question 163

Draining peri-rectal abscess

Answer 163

1. Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles) 2. Supralevator abscesses need to be drained trans-rectally

Question 164

Px, Dx and Tx malrotation

Answer 164

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

Question 165

Epidural hematoma - shape, vessels, px

Answer 165

Shape: Biconvex. DOES NOT suture lines Vessel: MMA Px: lucid interval. Ipsilateral blown pupil is early sign - (vs. subarachnoid thunderclap, worst HA)

Question 166

MEN syndromes

Answer 166

1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD 2a- Parathyroid (PTC), MTC, Pheo (catecholamines); ret; AD 2b- Pheo, MTC, marfanoid/neuroma; ret; AD

Question 167

Nitrogen balance

Answer 167

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

Question 168

Periop Warfarin

Answer 168

stop 5 days before Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6+

Question 169

Management of PE

Answer 169

1. no RH strain → acoag 2. RH strain → IR catheter 3. RH strain + HDUS → systemic tPA

Question 170

Methemoglobinemia - px, dx and tx

Answer 170

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)

Question 171

Layers of colon/rectum

Answer 171

1. mucosa 2. sub-mucosa (strength layer) 3. muscularis propria 4. serosa

Question 172

LE vascular trauma

Answer 172

- small: patch plasty - large: contralateral GSV (must maintain venous system b/c deep vein may be injured) - limited time/unstable: shunt

Question 173

Tx for DVT

Answer 173

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

Question 174

Loop diuretics vs. Ca sparing diuretics

Answer 174

- loop: furosemide - Ca sparing: thiazides (can cause gynecomastia)

Question 175

MALT lymphoma dx and tx

Answer 175

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)

Question 176

lower extremity bypass graft failure depends on temporal relation to the surgery.

Answer 176

- <30d: technical error - 1m-2y: intimal hyperplasia, (at the distal anastomosis) - >2y: progressive atherosclerotic disease

Question 177

Dx and Tx Parathyroid ca

Answer 177

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

Question 178

Tx infected pseudocyst

Answer 178

aspirate/gram stain to dx → drainage (internal, external, endoscopic)

Question 179

Tx melanoma of anal canal

Answer 179

Tx: - WLE (1 cm). No SLNBx - APR if sphincter involved, LADN, or > 4mm - No chemo-XRT **5y-S is 20% w/ R0 **WLE = APR

Question 180

Kaposi's sarcoma - cause and px

Answer 180

- Case: HSV8 - Px: Violet/brown papules

Question 181

Mechanism and Tx of thyroid dz: 1. Graves 2. TMN 3. Hashimoto's 4. DeQuervains/Subacute 5. Reidels

Answer 181

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

Question 182

Sonograph FNA recs

Answer 182

- cystic: no bx -isoech/hyperech: FNA if > 2cm -hypoech (high sus): FNA if > 1cm

Question 183

Tx anal incontinence

Answer 183

1. 1st line: fiber/bulking, exercises 2. Refractory: endoanal U/S - defect: overlapping sphincteroplasty - no defect or refractory: sacral modulator

Question 184

s/e of burn topical treatments: - silver nitrate - silver sulfadiazene - mafenide - bacitracin

Answer 184

- 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

Question 185

Triple therapy

Answer 185

PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks

Question 186

APC gene

Answer 186

- chromosome 5 - 1st mutn in adenoma to carcinoma - mc mutation in colon ca - a/w FAP

Question 187

Contents of post triangle

Answer 187

1. CN 11 2. subclavian artery 3. EJV 4. brachial plexus trunks

Question 188

Gail model

Answer 188

1. age 2. age 1st period (earlier is worse) 3. age 1st birth (earlier is better) 4. 1d relative 5. previous bx 6. race

Question 189

Associated orthopedic injuries: 1. post hip disloc’n 2. post knee disloc’n 3. DRF 4. Supracondylar humerus fx 5. Anterior shoulder disloc'n

Answer 189

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

Question 190

Dobutamine

Answer 190

B1 at low dose - inotropy B2 at high dose - vasodilation

Question 191

types of endoleak and tx

Answer 191

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

Question 192

Carcinoid vs. GIST vs. Desmoid- cells and tx

Answer 192

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

Question 193

Meckel's Diverticulum Pathophys

Answer 193

- Anti-mesenteric border of SB - 2/2 peristant viteline duct - pancreatic and gastric tissue  - 2 feet from IC valve

Question 194

VRE coverage

Answer 194

Linezolid, Dapto - Amp if not amp resistant

Question 195

MOA: - Milrinone - Midodrine

Answer 195

Milrinine- PD inhibitor, contractility with vasodilation - c/i in renal failure Midodrine- a1 agonist

Question 196

Hyperaldosterone w/up

Answer 196

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

Question 197

Dx and Tx of SBP

Answer 197

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)

Question 198

HLA test

Answer 198

- Tissue typing - Donor organ: carries Ag (on WBC) - Recipient body: carried Ab - Recipient serum with donor wbc

Question 199

Tx acute variceal HMHG

Answer 199

1. Resuscitate, ensure airway 2. Octreotide + antibiotics 3. Endoscopic intervention (ligation/sclerotherapy) 4. Blakemore 5. TIPS (temporized with Blakemore)

Question 200

Tx SVC syndrome tx

Answer 200

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

Question 201

Crystalloid and colloid for trauma kids

Answer 201

Crystalloid: 20cc/kg PRBC: 10cc/kg

Question 202

Melanoma characteristics: - superficial spreading - lentigo - nodular - acral

Answer 202

- superficial spreading: MC - lentigo: sun exposed, best prog - nodular: worst prog - acral: AA **thickness is most indicative of prognosis

Question 203

Tx appendicitis

Answer 203

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

Question 204

Tx MEN2A/B

Answer 204

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

Question 205

Tx MEN1

Answer 205

1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics) 2. Asses other lesions

Question 206

Prog and Tx anaplastic thyroid ca

Answer 206

Prognosis: - aggressive, undiff - mort ~ 100%; no tx Tx: XRT improves short-term survival +/- surg - BRAF inhibitor for chemo

Question 207

GI Hormone Release and action: - Glucagon - Insulin

Answer 207

Glucagon: alpha cells of pancreas - glycogenolysis, gluconeogenesis Insulin – beta cells of the pancreas - cellular glucose uptake; promotes protein synthesis

Question 208

Criteria for transanal excision of adenocarcinoma

Answer 208

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

Question 209

Merkel cell ca - dx, histo, and tx

Answer 209

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)

Question 210

Breast abscess tx

Answer 210

- 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

Question 211

5 steps to LADDS procedure

Answer 211

1. Resect Ladd’s bands 2. Widen the mesentery 3. Counterclockwise rotation 4. Cecum in LLQ (cecopexy), place duodenum in RUQ 5. Appendectomy

Question 212

HNPCC screening and treatment

Answer 212

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

Question 213

Dx and Tx choledochal cyst

Answer 213

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

Question 214

Vit D vs. PTH

Answer 214

Vit D: increase Ca and Ph PTH: increase Ca and decrease Ph

Question 215

Arterial content

Answer 215

(1.34 x Hb x Sa02) + (.003 x PaO2)

Question 216

Px, Dx, and Tx: Duo atresia TEF Pyloric stenosis Intussusception Malro

Answer 216

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

Question 217

Cori cycle

Answer 217

- recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production - requires alanine - provides 40% of glu when starving

Question 218

Tx of GB cancer

Answer 218

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)

Question 219

Layers of mucosa

Answer 219

Epithelium Lamino Propria Muscularis mucosa

Question 220

Stage 3 breast cancer and tx

Answer 220

3a: 4 to 9 nodes ➡ +/- neoadj 3b: chest wall (not pec wall) or breast skin ➡ +/- neoadj 3c: supra clavicular nodes ➡ neoadj required

Question 221

Tx of CBD stone intra-operatively

Answer 221

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

Question 222

W/up Hurthle Cell Cancer

Answer 222

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

Question 223

Conduit after esophagectomy

Answer 223

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)

Question 224

Cancer Markers: Ca 125 bHCG AFP Inhibin

Answer 224

Ca 125- epithelial bHCG- choriocarcinoma AFP- germ cell/endodermal/yolk sac Inhibin- granulosa/sex-cord

Question 225

Tx of High grade AIN/bowen’s disease of anal margin

Answer 225

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

Question 226

Types of rejection - px, path, and tx

Answer 226

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)

Question 227

Dx and Tx DPGM injury

Answer 227

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)

Question 228

Hypocalcemia vs. Hypercalcemia - sxs and ekg

Answer 228

1. HypoCa: tingling, chvostek/trousseau sign - EKG: qt prolongation 2. HyperCa: stones, bones, groans, overtones, DI - EKG: shortened QT

Question 229

Calcitonin

Answer 229

Parafollicular C cells Inhibits osteoclast resorption Increases Ph excretion

Question 230

Crohn's drugs MOA: - Azathioprine/6-MP - Sulfasalazine/5-ASA - Infliximab

Answer 230

- Azathioprine/6-MP: inhibit DNA synthesis - Sulfasalazine/5-ASA: COX/LOX inhibitor - Infliximab: monoclonal Ab to TNF; moderate Crohns, recurrent perianal fistula!

Question 231

GI Hormone Release and action: Gastrin Somatostatin CCK Secretin VIP

Answer 231

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

Question 232

Anal canal Dentate line Anal verge Anal margin

Answer 232

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

Question 233

Px, Dx, Tx Galactocele

Answer 233

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)!

Question 234

Stages of graft healing

Answer 234

1. imbibition (direct diffusion) 2. inosculation (cap beds meet) 3. revascularization

Question 235

Hernia repairs: Bassini McVay Lichtenstein Shouldice

Answer 235

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

Question 236

EBUS accesible nodes:

Answer 236

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

Question 237

Order of cells in healing

Answer 237

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

Question 238

Hemophilia A

Answer 238

f8 deficiency, SLR MC inherited disorder tx- DDAVP (mild), f8 concentrate (severe)

Question 239

Adenoid cystic carcinoma - px and tx

Answer 239

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

Question 240

Tx for cholangiocarcinoma

Answer 240

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

Question 241

acid and alkali burns - px

Answer 241

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

Question 242

IPMN - dx and tx

Answer 242

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

Question 243

Tx PDA

Answer 243

to close- indomethacin to open- PGE1

Question 244

Airway management anatomy

Answer 244

Anatomy: 1. Elective trach: between 2nd and 3rd trach rings 2. Crich: CT membrane between thyroid cart and cric - Thyroid ➡ cricoid ➡ rings

Question 245

Dopamine dosing and s/e

Answer 245

low: d1/2-ago (renal dose) medium: B-ago (heart) high: A-ago (vaso) **s/e: high UOP. difficult to titrate. tachyarrythmias

Question 246

Parkland formula

Answer 246

- 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

Question 247

Who needs stress dose steroids and how to dose

Answer 247

>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

Question 248

Path, Dx and Tx of Zenkers

Answer 248

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

Question 249

Tx SIADH

Answer 249

Acute – vaptan, demeclocycline Chronic – fluid restriction, diuresis

Question 250

Spinal vs. Epidural

Answer 250

Spinal- below l1/l2; SA space; fast; n/m block Epidural- any level; epidural space; slow; no block

Question 251

VIPoma - loc, px, dx, tx

Answer 251

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

Question 252

Gastric CA tx - chemo, margins, nodes

Answer 252

- 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

Question 253

DDAVP/Vasopressin - production and effect

Answer 253

- Made in SON of HT. Stored PP - Cause endothelium to release f8 and vWF

Question 254

Milan criteria

Answer 254

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

Question 255

Posterior and anterior vagal trunk branches Vagotomies

Answer 255

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

Question 256

Insulinoma - loc, px, dx, tx

Answer 256

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

Question 257

Dx and Tx fat necrosis

Answer 257

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

Question 258

Px, Dx and Tx Pancreatic divisum

Answer 258

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)

Question 259

Indications for neoadjuvant therapy eso cancer

Answer 259

- high grade t1b or T2 and above OR any nodal involvement - Also get XRT

Question 260

Marfans vs. Ehlers-Danlos

Answer 260

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``

Question 261

Bladder ca - dx and tx

Answer 261

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

Question 262

Tx tracheal inj

Answer 262

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

Question 263

Specific to Crohn's and UC

Answer 263

1. Crohn's: - Creeping fat - Skip lesions - Transmural - Cobblestoning - Granulomas - Fistulas 2. UC: - Crypt abscess - Pseudopolyps

Question 264

Uremic PLT dysfunction - px, dx, tx

Answer 264

Px- 2/2 renal disease. dx- normal coags. elevated BT only. tx- ddavp

Question 265

Escharotomy indications

Answer 265

- 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

Question 266

Gastric ulcers: elective classification and management

Answer 266

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

Question 267

Emergent vs. Elective UC Tx

Answer 267

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

Question 268

Kasabach-Merritt Syndrome

Answer 268

- hemangioma + thrombocytopenia - usually infants - resect!

Question 269

Peutz-Jeghers - px and screening

Answer 269

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

Question 270

Omphalocele

Answer 270

- 2/2 failure of umbo ring closure - 11th week gut returns to abdominal cavity - normal bowel (protected) - Other congenital defect are more common

Question 271

Cryo contents and uses

Answer 271

- Contents: VWF, f8, fibrinogen - Uses: 1. VWD 2. Fibrinogen def 3. Hemophilia A

Question 272

Zone injuries and management

Answer 272

1. penetrating: - zone 1-3 --> explore 2. blunt: - zone1 --> explore - zone 2-3 --> do not explore

Question 273

TOS tx

Answer 273

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

Question 274

FAP - Dx and Tx

Answer 274

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

Question 275

BRCA risks and tx

Answer 275

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!

Question 276

When to operate on adrenal mass

Answer 276

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

Question 277

Adjuvent chemo for breast ca

Answer 277

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

Question 278

FNH - path, dx and tx

Answer 278

path- CENTRAL STELLATE SCAR! dx- bright on arterial phase homogenous tx- resect if sxatic. no malignant potential.

Question 279

Secretin vs. CCK

Answer 279

Both released by duo S cells ➡ Secretin- duct cells ➡ bicarb I cells ➡ CCK- acinar cells ➡ enzymes

Question 280

Pancreas drainage procedures

Answer 280

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

Question 281

Tx papillary/follicar thyroid cancer

Answer 281

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

Question 282

Heparin - MOA and measurement

Answer 282

MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin Measurement: - PTT - ACT: better intra-op if high doses of hep given

Question 283

Screening guidelines for breast ca

Answer 283

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

Question 284

Tx SDH

Answer 284

1. Nonop: HDS, <10 mm, <5 mm shift 2. Evacuate: > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP

Question 285

Central venous O2 vs. mixed venous O2

Answer 285

Mixed venous: from PA Central venous: from SVC only (estimation of mixed)

Question 286

Reversals: - BB - CCB - Tylenol - Benzos - CN/Nitroprusside - Vecuronium/Rocuronium - Ethylene glycol - Methemoglobinemia

Answer 286

- 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

Question 287

Orientation of portal triad

Answer 287

Bile duct lateral Hepatic artery medial Portal vein posterior

Question 288

Px an tx: Cryoptococcus Coccidiomycosis Histoplasmosis Mucormycosis

Answer 288

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

Question 289

LN harvest/margin eso stomach colon rectum

Answer 289

eso- 15/7cm stomach- 15/5cm colon-12/5 cm rectum- 12/5 cm

Question 290

Succinylcholine - MOA, s/e, c/i

Answer 290

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

Question 291

Breast nerve - muscle and actions: - Thoracodorsal - Intercosto-brachial - Lateral petoral - Medial pectoral - Long thoracic (medial)

Answer 291

- 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

Question 292

Cohort study vs. Case control

Answer 292

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

Question 293

Tx acute limb ischemia

Answer 293

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

Question 294

Papillary cystadenoma (Warthin tumor) - px, tx

Answer 294

Px: benign tumor of salivary gland - often BILATERAL and 2/2 smoking - Slow growing Tx: complete resection with uninvolved margins even if ASx

Question 295

Hemangioma - path, px, and tx

Answer 295

path- PERIPHERAL ENHANCEMENT with continued late filling px- young women tx- if rupture, size change, or KM syndrome

Question 296

Pancreatic ducts

Answer 296

Wirsung- major, lies inferior Santorini- minor, lies superior

Question 297

Gluconeogenesis precursors

Answer 297

lactate , pyruvate, AA (alanine, glutamine)

Question 298

Sirolimus - MOA, s/e

Answer 298

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

Question 299

Tx of rectal prolpase

Answer 299

- 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

Question 300

Li Fraumeni - gene, mechanism, and px

Answer 300

- 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

Question 301

Chylothorax dx and tx

Answer 301

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

Question 302

Tumor lysis syndrome - px, path and tx

Answer 302

Px: Common 2/2 B cell lymphoma - hyperU, K, Ph w/ hypoCa Path: CaPh crystal ➡ renal failure + hypoCa tx: IV hydration ➡ iHD

Question 303

CRC T and N stages

Answer 303

t1- SM t2- MP t3- xMP/subserosa t4- invade n1- 1-3, n2- >=4

Question 304

Rectovaginal fistula tx

Answer 304

wait 3-6m low- endorectal advancement flap high- abdominal approach

Question 305

Schiatzki's Ring - Path and Tx

Answer 305

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

Question 306

NNT

Answer 306

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

Question 307

Tx childhood GI disease: - Pyloric stenosis - Intussusception - Duo atresia - TEF - Malro

Answer 307

- Pyloric stenosis: pyloromyotomy - Intussusception: air contrast enema (air > water) - Duo atresia: DD or DJ - TEF: right extrapleural thoracotomy - Malro: LADDS proc

Question 308

Pancreatic fistula - dx and tx

Answer 308

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)

Question 309

Max dose of lido and bupiv and tx of OD

Answer 309

lido = 5mg/kg (7 w/ epi) bupiv = 2.5 mg/kg (3 w/ epi) tx- lipid emulsion

Question 310

Epi, Dx and Tx Aspergillosis

Answer 310

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)

Question 311

Dx and Tx of GIST

Answer 311

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

Question 312

Vitamin K - MOA and def

Answer 312

MOA: gamma CARBOXYLATION (not decarb) of GLUTAMATE on 2, 7, 9, 10, c, s Px of def: coagulopathy, suspect if obstructive jaundice

Question 313

Rectum: 1. Arterial supply 2. Venous drainage

Answer 313

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)

Question 314

Kcal per macronutrient Total kcal req

Answer 314

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

Question 315

Hinchey

Answer 315

1- pericolic abscess 2- pelvic abscess 3- purulent 4- feculent

Question 316

Contents of ant triangle of neck

Answer 316

- Carotid sheath, anca cervicalis, CN 12 (hypoglossal) - Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular - Facial vein is the gateway

Question 317

Px and Tx for Leriche syndrome

Answer 317

px: diminished femoral pulse, butt claudication, ED - younger than infra-inguinal vascular dz patient tx: aortobifemoral bypass

Question 318

Benign lesions that require excisional bx

Answer 318

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

Question 319

Future Liver Remnant requirements and indications for PVE

Answer 319

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

Question 320

type 1 vs. type 2 error

Answer 320

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"

Question 321

hepatic adenoma - imaging, tx, and risks

Answer 321

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

Question 322

Types of mastectomy

Answer 322

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

Question 323

Pyoderma gangrenosum and erythema nodosum - px and tx

Answer 323

- Pyoderma: pre-tibial ulcer - Erythema Nodosum: pre-tibial erythematous plauque - both associated w/ IBD - both RESOLVE after resection - tx: steroids

Question 324

anion gap - equation and causes Cases of NAGMA

Answer 324

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

Question 325

MOA reglan and erythromcyin

Answer 325

- reglan: dopamine antagonist - erythromycin: motlin receptor agonist causing SM contraction

Question 326

Modality and staging for eso cancer (T and N)

Answer 326

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+

Question 327

Barrett’s eso surveillance (progress to cancer)

Answer 327

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

Question 328

HNPCC vs. Lynch S Dx and Screening

Answer 328

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

Question 329

Serum osmolarity

Answer 329

Osm = 2xNa + Glu/18 + urea/2.8

Question 330

Superior laryngeal nerve (external branch) - fxn, injury, and tx

Answer 330

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

Question 331

GCS motor

Answer 331

6- obeys commands 5- localized 4- w/draws 3- flexion (decort) - 'flex your core' 2- extension (decErebrate) 1- none

Question 332

LeFort fxs

Answer 332

I- palate II- nose and palate III- entire face

Question 333

Human bite tx and organism

Answer 333

tx: amox/clavulanate (augmentin) - requires I&D if joint appears septic (pain w/ passive motion) **MC for human bites- eikenella

Question 334

MCCO healthcare infection: - HAP/VAP - central line infection - SSI - UTI - GI infection - SBP - Cholangitis - NSTI - ICU infection - Fungal infection - Graft infection - Lymphangitis

Answer 334

- 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

Question 335

Tx of trx of great vessels

Answer 335

1st give PGE1 → ballon atrial septostomy

Question 336

RF, Dx and Tx SqCC of anal canal

Answer 336

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

Question 337

TOF - defects and tx

Answer 337

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

Question 338

Cutoff for low risk lung nodules not requiring follow-up

Answer 338

1. 6mm ➡ NTD 2. 6-8 mm ➡ q6-12m CT 3. > 8mm - low risk pt- q3m CT - high risk pt- bx or resection

Question 339

Light's criteria

Answer 339

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;

Question 340

Treatment of colo-cutaenous fistula

Answer 340

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 

Question 341

Most abundant bacteria in the colon

Answer 341

Bacteroides fragiles (anaerobe)

Question 342

T staging for esophageal cancer

Answer 342

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

Question 343

Exposing the pancreas: head, body, tail and order of operations in trauma

Answer 343

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

Question 344

Thoracic duct course

Answer 344

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

Question 345

Stomach vs. Duo ulcer px

Answer 345

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

Question 346

Effective for Pseudomonas

Answer 346

1. Zosyn 2. 3/4G cephalosporin (ceftriaxone, cefepime) 3. Aminoglycodies (genta, tobra) 4. Flouroquinolones (cipro) 5. Meropenem/Imipenem  **Not linezolid (good for G+/MRSA)

Question 347

most common organism in burn wound infection most common viral burn wound infection

Answer 347

- Pseudomonas (< 10^5 organisms – not a burn wound infection) - HSV

Question 348

Cuff size for kids

Answer 348

age/4 + 4

Question 349

Grading and tx of BCVI

Answer 349

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

Question 350

Ectopic parathyroids

Answer 350

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

Question 351

Trauma to the pancreas

Answer 351

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

Question 352

MOA and s/e of trx meds - Tacro - Cyclosporine - Sirolimus

Answer 352

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

Question 353

Interossei and lumbrical innervation

Answer 353

palmar- ulnar n, adduct dorsal- ulnar n, abduct lumbricals- median (1-2)/ulnar (3-4)

Question 354

MOA and S/e of tamoxifen

Answer 354

MOA: competitive E inhibitor in breast; weak agonist in uterus/liver S/e: - dvt/pe - endometrial cancer - cant take with SSRI (CYP inhibitors)

Question 355

DCIS mammo and tx

Answer 355

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)

Question 356

DCIS SLNBx

Answer 356

- does not metastasize - not w/ l’omy unless >4cm, multicentric, palpable, high grade - required w/ mastectomy b/c 20% have invasive ca

Question 357

Dx and Tx of Cystadenoma

Answer 357

low CEA, low Amylase tx- resect if sxs

Question 358

Post polypectomy screening

Answer 358

-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)

Question 359

Encapsulate organisms and empiric tx

Answer 359

-Organism: “Shin” 1. Strep pneumo (MC) 2. Neisseria 3. Haemophilus - Empiric tx: vanc + 3GC

Question 360

Casues of increased ET CO2

Answer 360

Increased muscle activity (shivering) Increased metabolism (sepsis, fever, malignany hyperT) Increased CO Decreased minute ventilation

Question 361

Dx and Tx of Meckels

Answer 361

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.

Question 362

Products of posterior pituitary

Answer 362

"PAO in the POST" ADH, Oxytocin 2/2 direct stem from neurosecretory cell

Question 363

Hereditary pancreatitis - dx and tx

Answer 363

dx - PRSS1 trypsinogen mut'n - AD tx: none - smoking cessation is important **different from AI pancreatitis (IgG+)

Question 364

Cilostazol - MOA and use

Answer 364

MOA- PDi, inhibits PLT aggregation tx for periph claudication - c/i in any degree of HF (PDi)

Question 365

Esophagus and Trachea access

Answer 365

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

Question 366

Ureter injuries

Answer 366

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)

Question 367

Vitamin D processing

Answer 367

7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3

Question 368

Tx papillary/follicar thyroid ca

Answer 368

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

Question 369

Tx Odontoid fx

Answer 369

1: upper D, stable, non-op 2: base of D, unstable, worst, +/- surg - may require intubation 3: c2 vert, usually no OR

Question 370

GCS verbal

Answer 370

5- normal 4- confused 3- inappropriate words 2- incomprehensible 1- none

Question 371

MELD vs. CTP

Answer 371

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

Question 372

Intraductal papilloma dx and tx

Answer 372

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

Question 373

Tx Umbo and Inguinal hernia in child

Answer 373

most close by 2 <3cm- primary repair >3cm- mesh repair by 5 Inguinal- repair by 2 weeks if reducible - otherwise, OR then

Question 374

Gastroschisis - px and tx

Answer 374

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

Question 375

Mineral def: -Zn -Sel -Chromium -Copper -B1 -B3

Answer 375

-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)

Question 376

UES vs LES muscles

Answer 376

UES- cricopharyngeus; higher resting pressure (70) LES- lower resting pressure (15)

Question 377

Stiewert-Stein Class and Tx

Answer 377

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

Question 378

Esophageal CA tx

Answer 378

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

Question 379

Indications and C/I to anti-reflux surgery

Answer 379

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

Question 380

Classic and Alarm sxs for GERD

Answer 380

Classic sxs: heart burn + regurg Alarm: 1. dysphagia (not regurgitation) 2. odynophagia (pain) 3. bleeding 4. weight loss 5. anemia *Require EGD

Question 381

Tx of Leiomyoma

Answer 381

1. sxs or > 4cm- enucleate 2. < 4cm- observe 3. >8cm or circumferential- esophagectomy Approach: Cervical- L Mid eso- R Distal eso- L

Question 382

Required for staging esophageal CA

Answer 382

1. CT of chest, abdomen- M 2. Whole-body PET scan- M 3. EUS- T and N stage

Question 383

Caustic injury w/up

Answer 383

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

Question 384

Steps of Heller myotomy

Answer 384

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

Question 385

How to mobilize the stomach for intra-thoracic anastamosis

Answer 385

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

Question 386

Epiphrenic divertciulum

Answer 386

Loc: distal eso. R > L. Pulsion Tx: only if sxs. - L diverticulectomy w/ contra myotomy

Question 387

Dx and Tx of Eso perf

Answer 387

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

Question 388

FeNa equation and interpretation

Answer 388

(U Na/S Na) / (U Cr / S Cr) * 100 <1% = Pre-renal >1% = Intrinsic >4% = Post-renal

Question 389

Refeeding Syndrome - mech and px

Answer 389

- 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

Question 390

pH relation to pCO2

Answer 390

10 mmHg increase in pCO2 = .08 decrease in pH

Question 391

Tx of DI

Answer 391

1. Central- DDAVP 2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ

Question 392

W/up and Tx of endometrial CA

Answer 392

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

Question 393

Pregnant lap appe

Answer 393

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

Question 394

Px, Dx and Tx of ovarian torsion

Answer 394

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

Question 395

Monitor and reverse TPA

Answer 395

Fibrinogen level (<100 = r/o bleeding) Reverse: a-CA

Question 396

Cause and Tx of Warfarin skin necrosis

Answer 396

Cause: protein C def (not S!) Tx: Stop Coumadin Give vitamin K Start hep gtt or argatroban

Question 397

Intrinsic vs. Extrinsic Pathways

Answer 397

Intrinsic: 8, 9, 11, 12 Extrinsic: 7 (shortest t 1/2), Tissue factor Common: 1, 2, 5, 10

Question 398

Reversal of NOACs: Apixaban Rivoroxaban Dabigatran

Answer 398

Apixaban: andexanet Rivoroxaban: andexanet Dabigatran: idarucizumab (+iHD)

Question 399

VWD dx and tx

Answer 399

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

Question 400

Tx of hepatic encephalopathy

Answer 400

0. Correct precipitating cause 1. Lactulose (goal 2-3 stools/day) 2. Rifaximin 3. Neomycin

Question 401

PEP: 1. HIV 2. HBV 3. HCV

Answer 401

1. HIV: 4wks of anti-retroviral combo 2. HBV: HBIG + Vaccine 3. HCV: No recommendations.

Question 402

Segmental liver anatomy

Answer 402

7 - 8 - 4a - 2 6 - 5 - 4b - 3

Question 403

Dx and Tx of Budd-Chiari Syndrome

Answer 403

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

Question 404

Tx of Isolated Gastric Varices

Answer 404

2/2 chronic pancreatitis induced splenic vein thrombosis tx- Splenectomy

Question 405

Effects of pneumoperitoneum

Answer 405

Increase preload initially, then decrease Increase afterload. Decrease CO Increased PCO2. Decrease FRC Decrease renal function

Question 406

Pancreas blood supply and anatomy

Answer 406

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

Question 407

Indication for ERCP w/ GB dz

Answer 407

1. Bili > 4 2. CBD stone on U/S 3. CBD > 6 mm and Billi > 2 4. Ascending cholangitis

Question 408

Autoimmune pancreatitis - px, dx, tx

Answer 408

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

Question 409

W/up of pancreatic cancer

Answer 409

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

Question 410

Tx of acute mesenteric ischemia

Answer 410

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

Question 411

Dx and Tx of chronic mesenteric ischemia

Answer 411

- 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

Question 412

Tx of renovascular stenosis

Answer 412

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

Question 413

Open SMA embolectomy

Answer 413

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

Question 414

Tx of air embolism

Answer 414

1. LEFT lateral decubitus and Trendelenburg (trap air in the RV) 2. Aspirate central line

Question 415

Timing of endarterectomy after a stroke

Answer 415

1. Non-disabling stroke or TIA: 2d-2w 2. Big stroke: no consensus

Question 416

When to consider ppx fasciotomy + steps

Answer 416

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

Question 417

Femoral embolectomy

Answer 417

- 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

Question 418

Exposure of LE arteries: 1. Femoral 2. AK Pop 3. BK Pop 4. TP Trunk

Answer 418

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

Question 419

Preference for peripheral fistula

Answer 419

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

Question 420

SC Steal syndrome - path and tx

Answer 420

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

Question 421

Tx of type B dissection

Answer 421

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

Question 422

Tx of splenic aneurysm

Answer 422

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

Question 423

Tx of aneurysms - splenic - renal - iliac - femoral - pop

Answer 423

- splenic: > 2cm or sxs ➡ embolize - iliac: > 3 cm ➡ covered stent - femoral: > 2.5 cm ➡ covered stent - pop: > 2 cm ➡ exclusion and bypass

Question 424

Tx of psuedoaneurysm

Answer 424

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,

Question 425

Nerve injuries during CEA: - Recurrent laryngeal - Marginal mandibular - Hypoglossal nerve - G/Ph nerve - Superior laryngeal - Accessory

Answer 425

- 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

Question 426

Tx of Type A dissection

Answer 426

- Treat with immediate surgery - Put patient on bypass - Median sternotomy

Question 427

May-Thurner Syndrome

Answer 427

Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine tx- venogram, thrombolysis and stenting

Question 428

W/up of non-variceal UGI bleed (M/W tear)

Answer 428

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

Question 429

Surgical indications for acid reduction surgery

Answer 429

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)

Question 430

Acute surgical options for duodenal ulcer disease

Answer 430

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

Question 431

Tx of gastric ulcer disease

Answer 431

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

Question 432

Tx of Complications after Billroth 2: - Afferent limb obstruction - Dumping syndrome - Alk reflux - Post-vag DRH

Answer 432

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

Question 433

How to confirm H. pylori eradication

Answer 433

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

Question 434

Primary fuel source in fasting state

Answer 434

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

Question 435

Dx and Tx of rectus sheath hematoma

Answer 435

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

Question 436

Removal of perc chole tube

Answer 436

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

Question 437

Essential fatty acids and deficiency px

Answer 437

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

Question 438

RQ interpretation (metabolic cart)

Answer 438

CO2/O2 < .7 = underfeeding/starving .7 = pure fat .8 = pure protein .8-.9 = desired 1 = pure carb >1 = overfeeding

Question 439

BSC vs. SqCC - dx and tx

Answer 439

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

Question 440

Dx and Tx of Nec Fac

Answer 440

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

Question 441

Dx and Tx of pancoast tumor

Answer 441

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

Question 442

Types of hyperPTH

Answer 442

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

Question 443

Dx and Tx of Ewing Sarcoma

Answer 443

Dx: "onion skin" in diaphysis - pelvis is MC location Tx: chemotherapy (1st line) + surgery or XRT

Question 444

Pulmonary sequestration

Answer 444

No bronchial commmunication 1. Intra-lobar: MC; blood from aorta; pulmonary veins 2. Extra-lobar: systemic arteries and veins Tx- lobectomy or segmentectomy

Question 445

Lung anatomy: R vs. L

Answer 445

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

Question 446

RF and Tx of T/I fistua

Answer 446

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

Question 447

Indications for pleurodesis

Answer 447

- Air Leak > 5 days - Recurrent (even if contra-side) - High risk occupation (scuba, pilot)

Question 448

Px, dx and tx Lymphocele

Answer 448

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

Question 449

Px, Dx, Tx of RAS and thrombosis after kidney transplant

Answer 449

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)

Question 450

W/up and Causes of low UOP after kidney trx

Answer 450

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

Question 451

Inflow and outflow for pancreas transplant

Answer 451

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

Question 452

w/up of kidney graft dysfunction

Answer 452

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

Question 453

Post transplant hepatic artery vs. PV thrombosis

Answer 453

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

Question 454

GVHD - px, path, dx, tx

Answer 454

-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

Question 455

Tx of testicular torsion

Answer 455

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

Question 456

Dx and Tx of RCC

Answer 456

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

Question 457

Types of hydrocele and Tx

Answer 457

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

Question 458

Dx and Tx of LCIS

Answer 458

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

Question 459

Dx and Tx of inflammatory breast ca

Answer 459

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

Question 460

Fibroadenoma - px, dx, tx

Answer 460

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"

Question 461

Tx of breast ca in preg

Answer 461

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!

Question 462

Indications for post-mastectomy radiation

Answer 462

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

Question 463

Bolus fluid and blood in children

Answer 463

Fluid: 20cc/kg Blood: 10cc/kg

Question 464

Repair aortic trauma

Answer 464

Access usually with Mattox maneuver If < 50% closure primary with polypropylene suture If > 50% perform a PTFE patch

Question 465

Small bowel trauma

Answer 465

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

Question 466

Access to neck zones

Answer 466

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

Question 467

Causes of R-shift/decrease affinity on Oxy-Hb curve

Answer 467

2,3 DPG Elevated temp Higher paCO2 Acidosis

Question 468

Shock class

Answer 468

1. No VS changes 2. Tachycardia 3. Hypotension and combative 4. No UOP and obtunded

Question 469

Ketamine MOA, s/e and c/i

Answer 469

MOA: NMDA glutamate ANTAgonist, s/e: tachycardia, hallucinations c/i: - MI (b/c SNS activity/cardiac demand) - Space occupying brain lesion

Question 470

SCIP Quality Measures

Answer 470

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

Question 471

Insulin peri-op

Answer 471

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

Question 472

Frey Syndrome

Answer 472

- Gustatory sweating - 2/2 auriculotemporal nerve - Suspect after parotidectomy for H/N tumor - tx with anti-persiperant

Question 473

Dx and Tx: 1. TG duct cyst 2. Brachial cleft cyst 3. Cystic hygroma

Answer 473

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)

Question 474

STITCH trial

Answer 474

5 mm bites every 5 mm

Question 475

Tx of parastomal hernia

Answer 475

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

Question 476

Tx of hiatal hernia

Answer 476

Type 1- asx: NTD; sxatic: PPI; Surgery if refractory Type 2-4: surgery even if asx

Question 477

Dx and Tx Ischemic Orchitis

Answer 477

dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5 tx- NSAID and pain meds. Orchiectomy is last resort.

Question 478

MCCO Cushing syndrome

Answer 478

1. Exogenous steroids 2. ACTH pituitary adenoma (Cushing disease) 3. Cortisol secreting adrenal adenoma 4. ACC

Question 479

Dx and Tx of Addison's

Answer 479

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

Question 480

Px and W/up of Hypercortisolism (Cushing's syndrome)

Answer 480

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)

Question 481

Dx, Path and Px, and Tx of carcinoid tumors

Answer 481

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

Question 482

Tx of mesenteric vein thrombosis

Answer 482

1. AC 2. Surgery if peritonitis or failure to improve - can also consider endovascular thrombolytics 3. 2nd look operation 24-48 hours

Question 483

Tx of Grave's disease

Answer 483

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

Question 484

W/up of Hashimoto's disease

Answer 484

1. FNA- r/o ca 2. Bloodwork- antiTPO/TG Ab 3. Tx- thyroxine ➡ partial thyroid **MCCO hypoT and goiter in the US

Question 485

Tetanus ppx

Answer 485

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

Question 486

Px, Dx and Tx of CMV colitis

Answer 486

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

Question 487

Standard w/up for lung ca

Answer 487

1. PET/CT 2. PFTs 3. Bronchoscopy (can be intra-op) 4. Mediastinal eval- EBUS or mediastinoscopy

Question 488

Bronchiolitis obliterans

Answer 488

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)

Question 489

Pressor for neurogenic shock

Answer 489

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

Question 490

Vitamin A

Answer 490

- wound healing especially in steroid patients - def: night blindness, dry eyes

Question 491

PPV and NPV

Answer 491

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

Question 492

Pearson's R Value

Answer 492

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

Question 493

Phases of clinical trail

Answer 493

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

Question 494

Subclavien exposures

Answer 494

1. Median sternotomy: right 2. Left Anterolateral thoracotomy: left subclavian - trap door supraclav incision for distal access

Question 495

Indications for hepatectomy instead of liver trx in HCC patient who meets Milan criteria

Answer 495

Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm - hepatectomy is preferred to transplant if they are Childs A

Question 496

SMA embolus vs. thormbosis px

Answer 496

Embolus- lodges after the middle colic. Jejunal sparring Thrombus- at ostium; pan-bowel

Question 497

Desmoid Tumor - associations, path and tx

Answer 497

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

Question 498

Serologic work-up for adrenocortical mass

Answer 498

1. Dexa suppression (cortisol) 2. Urine androgens (sex hormones) 3. Plasma metanephrines (pheo) 4. aldo/rennin ratio > 30 (salts)

Question 499

Px, Dx and Tx endometriosis

Answer 499

Px- cyclic pain, pain with sex Dx- dx laparoscopy Tx- 1. Medical therapy 2. Surgery if unresponsive. Ablation if young.

Question 500

MCCO primary hyper-aldosteronism and tx

Answer 500

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

Question 501

Respectability of pancreatic tumor and next step

Answer 501

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

Question 502

Tx of horseshoe abscess

Answer 502

Hanley procedure: - Midline drainage incision of deep posterior space (through ano-coccygeal ligament) - Bilateral lateral counter-incisions for ischiorectal space **all external drainage

Question 503

Tx of anorectal fistula

Answer 503

<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.

Question 504

Tx of Internal HMHDs

Answer 504

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)

Question 505

Tx of External HMHDS

Answer 505

1st line: sitz, stool softener, bowel reg, fiber, fluids 2nd line: surgical HMHD'ectomy Thrombosed: incise or excision if w/in 48h

Question 506

Paget's disease of the anus (px and tx)

Answer 506

Px: intractable pruritis, eczematoid rash Tx: scope (r/o malignancy) - dc topical agents - perianal punch bx + WLE

Question 507

Unresectable cholangiocarcinoma

Answer 507

Criteria - bilateral HA or PV - unilateral HA with extensive contra duct Tx - no extrahepatic dz ➡ neoadj chemo-XRT + liver trx - extrahepatic dz ➡ chemo-XRT

Question 508

Bismuth classification and tx

Answer 508

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

Question 509

Lap CBD exploration

Answer 509

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

Question 510

Px and Tx of Chalangitis

Answer 510

Dx: fever, RUQ, and jaundice - stones > malignancy > stricture Tx: - signs of sepsis: resuscitate/abx then urgent ERCP - no sick: US/MRCP

Question 511

Px and Tx of Sphincter of Oddi dysfunction

Answer 511

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

Question 512

Ideal setting for stone formation

Answer 512

Low bile salts Low lecithin High cholestersol

Question 513

Mirizzi syndrome tx

Answer 513

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

Question 514

Types of GB polyp

Answer 514

1. Cholesterolosis: MC; CE mphages in LP; benign 2. Adenomyomatosis: benign 3. Adenoma: malignant; >1cm is RF for CA (resect)

Question 515

Tx strategy for CBD transections

Answer 515

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

Question 516

Management of GB polyps

Answer 516

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

Question 517

PSC screening guidelines

Answer 517

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)

Question 518

Dx and Tx of Colovesicular Fistula

Answer 518

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

Question 519

Colon cancer and arterial resection

Answer 519

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

Question 520

Colon CA surveillance after curative resection

Answer 520

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

Question 521

Staging w/up of rectal cancer

Answer 521

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)

Question 522

Tx of refractory Crohn's pan-colitis

Answer 522

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

Question 523

Tx of cecal volvulus

Answer 523

Stable- R hemi and primary mosis (no pexy) Unstable- R hemi with end ileostomy

Question 524

Dx of Juvenile polyposis

Answer 524

Dx: 5+ polyps or any polyps w/ family hx - SMAD4+ Non-adenomatous polyps ~ hamartomas

Question 525

Tx of Lynch Syndrome

Answer 525

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

Question 526

APR vs. LAR

Answer 526

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

Question 527

Polyposis syndromes: -Muir-Torre -Gardner -Turcot -P/J -Cowden -JuP

Answer 527

-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

Question 528

Indications for colonic stent

Answer 528

1. Bridge to surgery in acute obstruction (usually with metastatic cancer) 2. Palliative measure * Usually for L-sided lesions

Question 529

Gram, Tx and Virulence of C. diff

Answer 529

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

Question 530

Dx and Tx of ischemic colitis

Answer 530

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

Question 531

Dx and Sx of PNETs 1. Glucagonoma 2. Inuslinoma 3. Gastrinoma 4. VIPoma 5. SSoma

Answer 531

**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!

Question 532

Dx and Tx of Pancreatic cysts: 1. Serous cystadenoma 2. MCN 3. IPMN 4. Psuedocyst

Answer 532

-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

Question 533

Tx of PNETs: 1. Glucagonoma 2. Inuslinoma 3. Gastrinoma 4. VIPoma 5. SSoma 6. Non functional

Answer 533

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

Question 534

Perform splenectomy for distal panc PNET?

Answer 534

No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm

Question 535

Arterial anatomy of the celiac trunk

Answer 535

1. CHA: gives off GDA then R gastric - GDA gives of SPDA and R gastroepi 2. Splenic: gives off short gastrics and L gastroepi

Question 536

ECG findings of PE

Answer 536

Sinus tach is MC S1Q3T3 pattern w/ TWI

Question 537

Dx and Tx of Pulmonary Blastoma

Answer 537

MC primary lung tumor in children Dx- air/fluid filled cystic lesions. Looks like pneumo. Tx- Surgical resection +/- chemo-XRT

Question 538

lead vs length time bias

Answer 538

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.

Question 539

Brown-Sequard

Answer 539

Ipsi loss of motor Contra loss of pain/temp

Question 540

Dx of biliary dyskinesia

Answer 540

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)

Question 541

Emergent ariway in a child

Answer 541

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

Question 542

Tx of peptic stricture 2/2 GERD

Answer 542

1. Serial dilations 2. PPI 3. Consider stenting - Surgery is last resort (in contrast to achalasia)

Question 543

Exposure to bronchial tree in trauma

Answer 543

Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)

Question 544

CREST Trial

Answer 544

- Carotid stenting has higher incidence of stroke - CEA has high incidence of MI - Composite end-point of stroke, death, MI was the same

Question 545

Px, Dx and Tx of Bacterial Overgrowth

Answer 545

- px: 2/2 bill2 or REYGB - watery stools, bloating, b12 deficiency - dx: d-Xylose (carb test breath test) - tx: abxs (Rifaximin) ➡ surg 2nd line

Question 546

Inguinal hernia nerves + MC injuries

Answer 546

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

Question 547

HRS- Path, Px and Tx

Answer 547

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

Question 548

Treatment of lung ca

Answer 548

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

Question 549

Lung ca w/up

Answer 549

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

Question 550

Steps of hiatal hernia repair

Answer 550

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

Question 551

Pre-op and intra-op regiments for aldosteronoma and pheo

Answer 551

1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic 2. Pheo: phenoxybenzamine then BB Intra-op: - HTN crisis: Nitro gtt - Tachy arrythmia: Esmolol gtt

Question 552

Tx of HCC

Answer 552

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

Question 553

When to re-implant the IMA in EVAR

Answer 553

1. Back-pressure < 40 2. Previous colon surgery 3. SMA stenosis 4. Inadequate left colon flow

Question 554

Lynch vs FAP Screening

Answer 554

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

Question 555

Surgical Tx of thyroid/PT cancers 1. Papillary/Follicular 2. MTC 3. Hurthle 4. Anaplastic 5. PT

Answer 555

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

Question 556

Confirmation of brain death

Answer 556

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

Question 557

Bleeding during mesh fixation, inguinal hernia

Answer 557

1. Open: sewing mesh onto EO --> femoral vein 2. TEP: tacking mesh medially --> corona mortis (obturator branch)

Question 558

Tx of H/N tumors 1. Mucoepidermoid 2. Adenoid cystic 3. Pleomorphic adenoma 4. Warthin/Papillary cystadenoma

Answer 558

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

Question 559

W/up of UGI bleed/perf: 1. Boerhave 2. Traumatic esophogeal perf 2. UGI bleed

Answer 559

1. Boerhave: XR suggestive ➡ UGI (CT controversial) 2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI 2. UGI bleed: +/- NGT ➡ EGD

Question 560

Tx of Cellular vs. Ab Rejection

Answer 560

1. Cellular: - mild: steroids (inhibit COX2) - severe: TG 2. Ab: - Plasmaphoresis (clear Ab) - IVIG (so body thinks there are still ab) - Rituximab (CD20 Ab)

Question 561

IS for transplant - induction and maintenance

Answer 561

Induction: choose 1 1. Thymoglobulin - polyclonal Ab (potent) 2. Basiliximab - IL2 inhibitor (mild) Maintenance 1. Tacrolimus 2. MMF 3. Prednisone 4. Sirolimus

Question 562

Transplant ABX ppx

Answer 562

1. Bactrim- PCP, toxo gondi, listeria, nocardia 2. Diflucan- antifungal 3. Valganciclovir- CMV

Question 563

Transplant cross-matching

Answer 563

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

Question 564

MAC

Answer 564

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

Question 565

CDH1

Answer 565

High r/o gastric ca ppx gastrectomy by age 40

Question 566

px, dx, and tx of meconium ileus

Answer 566

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)

Question 567

Congenital thoracic disorders - px and tx 1. Pulm sequestration 2. Cystic adenoid malformation 3. Congenital lobar emphysema 4. CDH

Answer 567

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.

Question 568

1. Ig crosses the placenta 2. Ig in brast milk 3. Ig first responder

Answer 568

1. IgG (small, y-shape) 2. IgA (two y's with joined tails) 3. IgM (pentad)

Question 569

Nutrition requirements per day 1. Protein 2. Fat 3. Carb

Answer 569

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

Question 570

Wilcoxon test

Answer 570

Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed - ex: patient satisfaction before and after an intervention (1-5)

Question 571

COX proportion hazard modeling

Answer 571

Like a regression model but for survival analysis Allow you to control for different factors

Question 572

Changes to VS and labs with preggo

Answer 572

- Increased HR, increased SV - Decreased SVR, Decreased BP - Dilutional anemia. More PRBC but also more water. Requires more blood loss for HoTN

Question 573

Afferent limb syndrome - cause, px, dx, tx

Answer 573

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

Question 574

Medical tx for melanoma

Answer 574

- Pd1 inhibitors: pembrozilumab, nivolumab - CTLA inhibitors: ipilmumab - If Braf+: braf inhibitor remains 2nd line

Question 575

MC benign/malignant thoracic tumors in adults/children

Answer 575

Adults - benign: hamartoma (popcorn calcification) - malignant: sqcc Children - benign: hemangioma - malignant: carcinoid

Question 576

Tx of Rhabdomyosarcoma

Answer 576

MC soft tissue tumor in children tx: surgery + SLNBx - consider neo-adjuvent if unresectable - post-op chemo-XRT (very radiosensitive)

Question 577

C/i to covering the left subclavian artery

Answer 577

1. Aberrant or Dominant left vertebral a. 2. Previous CABG using LIMA (cardiac ischemia) 3. LUE AVF

Question 578

Mesothelioma - px, dx, tx

Answer 578

px- asbestos exposure (shipyard) dx- CT then tissue dx tx- surgery, XRT, systemic chemotherapy, HIPEC

Question 579

Marginal ulcer - dx and tx

Answer 579

S/p REY GB On the jejunal side Dx- EGD Tx- PPI + sucralfate + stop smoking + avoid NSAID +/- tx H. pylori (if present)

Question 580

Hipec is most effective for which cancers? (5ys) c/i

Answer 580

1. Appendix (75%) 2. Mesothelioma (45%) **c/i: extra-peritoneal dz

Question 581

Tx of HPV precursors in the anus

Answer 581

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

Question 582

Tx of rectal carcinoid

Answer 582

<1 cm - endoscopic removal 1-2 cm- full thickness excision > 2cm- LAR or APR **Invasion into muscularis/LN involvement- require TME

Question 583

Polypectomy criteria that require formal resection

Answer 583

1. Poor differentiation 2. Vascular/Lymphatic invasion 3. Invasion below the SM 4. < 2mm of surgical margin 5. Base involvement (Haggit 4)

Question 584

Cancer screening in FAP

Answer 584

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

Question 585

Staging Melanoma and MC mets

Answer 585

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

Question 586

Perforated diverticulitis tx

Answer 586

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

Question 587

Zenker location

Answer 587

- Killian's triangle - Inferior to pharyngeal constrictor (thyropharygneous) - Superior to cricopharyngeous

Question 588

Tx for reflux after heller

Answer 588

Lifetime PPI DO NOT convert to a Nissen b/c baseline achalasia

Question 589

Narrowest portions of the eso

Answer 589

1. Criciopharyngeous 2. AA/Left mainstem bronchus 3. Hiatus

Question 590

Sxs of vagus injury after hiatal repair

Answer 590

- Gastroparesis - Delayed gastric emptying - Reflux - DRH - normal UGI!

Question 591

Required w/up before anti-reflux surgery

Answer 591

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

Question 592

Deficiency of fat soluble vitamins

Answer 592

A- xeropthalmia D- hypoca, hypoPh E- hemolytic anemia K- elevated INR **suspect with any fat malabsorption

Question 593

Na deficit

Answer 593

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

Question 594

Lung cancer paraneoplastic syndromes

Answer 594

Squamous cell- PTHrP Adenoca- hypertrophic osteodystrophy Small cell- SIADH

Question 595

Lithium toxicity

Answer 595

HyperCa, hypocalcuria HyperMg Elevated PTH, normal Ph **gastric bypass can elevate Li levels

Question 596

Ferritin

Answer 596

Main storage protein of Iron Low in iron def anemia High in anemia of chronic dz (acute phase rxn)

Question 597

Sheehan syndrome

Answer 597

Hypopituitarism (anterior pit) 2/2 gland necrosis from HoTN Usually px w/ hypoNa

Question 598

Tx for STI: 1. Chlamydia 2. Gonorrhea 3. Trich/BV

Answer 598

1. Chlamydia: doxy 2. Gonorrhea: CTX 3. Trich/BV: flagyl

Question 599

HIT - path, dx, and tx

Answer 599

path: IgG to PF4 dx: 50% PLT fall ➡ Ser release assay tx: stop SQH. start fondaparinox, argatroban - use bivalirudin is liver/cirhotic patients

Question 600

Hormone and production: - CCK - Gastrin - Glucagon - Histamine - Insulin - Motilin - Secretin - SS

Answer 600

- 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

Question 601

Steps of hepatectomy

Answer 601

1. Mobilize ligaments 2. CC'y and cannulate CD 3. Isolate vessels 4. Ligate HA ➡ PV ➡ HV 5. Divide parenchyma

Question 602

Tx of HCC

Answer 602

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

Question 603

Indication and s/e for TIPS

Answer 603

2-3 paracentesis/month despite Na restriction and diuretics s/e: - increase r/o encephalopathy - no change in overall survival

Question 604

kwashiorkor vs. marasmus

Answer 604

kwashiorkor - moderate calorie intake; inadequate protein - large belly. normal weight. marasmus - insufficient calorie and protein - simian face. low weight.

Question 605

Absorption of glucose, galactose, fructose

Answer 605

glucose: Na-dependent secondary active transport galactose: Na-dependent secondary active transport fructose: Na-independent facilitated diffusion

Question 606

Tx of MCN

Answer 606

- 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)

Question 607

S/e of protamine

Answer 607

- Hypotension, Bradycardia - Administer slowly: 1 mg per 100 units of insulin - Has partial reversal on lovenox - No renal/liver adjustment required

Question 608

Dermatofibrosarcoma protuberans - px, histo, tx

Answer 608

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`

Question 609

In transit melanoma tx

Answer 609

Lesions > 2cm from primary but not beyond regional tumor basin - immunotherapy or BRAF inhibitor - only excise if feasible (few lesions)

Question 610

Pressure wound staging

Answer 610

1- non-blanching erythema 2- dermis 3- full-thickness subcutaenous 4- muscle, bone fascia

Question 611

Post-splenectomy blood smear + best way to ID

Answer 611

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

Question 612

Gastro-gastric fistula - px, dx, and tx

Answer 612

Px- weight gain, reflux years after a bypass Dx- UGI or CT with oral contrast Tx- observation, resection of the involved segment

Question 613

ERCP with REY anatomy

Answer 613

1. Laparoscopic-assisted ERCP or ERCP through a gastrostomy 2. Double balloon endoscopy

Question 614

Posterior Mediastinal Mass - dx and tx

Answer 614

dx: neurogenic- schwannoma, neurofibroma - CT then MRI. Bx not needed tx: all require resection (even if asx) **lymphoma if middle **thymoma if anterior

Question 615

Lung ca resectability

Answer 615

- carina/contra trachea involvement is still resectable ➡ sleeve pneumonectomy - SVC involvement can still be resectable - c/i: N3 disease ➡ contralateral mediastinal LN involvement

Question 616

Internal thoracic (mammary) anatomy

Answer 616

- 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

Question 617

Management of lung abscess

Answer 617

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

Question 618

Prostate ca - px, dx

Answer 618

Px- asx or abnormal PSA Dx: - Transrectal U/S guided bx - 12 samples - Gleason score 1-5

Question 619

CAH - px's

Answer 619

"salt and sex" 21: most common; sex - dx: high 17 levels 17: salt 11: salt and sex

Question 620

Amide vs. ester

Answer 620

amide- two "i's"; plasma cholinesterase metab; ester- one "i"; liver metab; PABA analogue --> allergic reactions

Question 621

Px, Mech, Tx of Malignant Hyperthermia

Answer 621

px: AD; ryanodine receptor type 1 mech: huge increase in INTRAcell Ca tx: stop drug, dantrolene, Bicarb, cooling, tylenol - dantrolene: ryanodine rec antagonist

Question 622

Dx adrenal insufficiency in the ICU

Answer 622

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)

Question 623

Breast cancer endocrine chemo: MOA, tx duration/indications, s/e: 1. Tamoxifen 2. Anastrazole 3. Trastuzumab

Answer 623

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

Question 624

Paget's disease of the breast

Answer 624

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

Question 625

Indications for transcutaneous pacing

Answer 625

- Symptomatic sinus bradycarias - Mobitz II (2nd degree) AV block - 3rd degree AV block - New L or R BBB **If transcutaneous is unsuccessful ➡ transvenous

Question 626

Types of AV block

Answer 626

- 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

Question 627

Digoxin - MOA and S/e

Answer 627

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

Question 628

Indications for emergent C-section in preggo trauma

Answer 628

- 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)

Question 629

Management of penetrating coronary artery injury

Answer 629

- LAD is MC - Primary repair is preferred - If too much loss of length then CABG - Do not ligate

Question 630

Tx of blunt cardiac injury

Answer 630

1. EKG +/- trop - negative: can dc - positive: admit to tele (Sinus tach is abnormal) 2. Persistant arrhythmia or HoTN ➡ echo

Question 631

Dx and Tx of rectal injuries

Answer 631

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

Question 632

Tx of gastric trauma

Answer 632

- 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

Question 633

SC artery control

Answer 633

Right: median sternotomy Left: - anterior thoracotomy: proximal control - supraclavicular incision: distal control - can connect with sternotomy for "trap door"

Question 634

Central vs. Peripheral DI - cause and tx

Answer 634

1. Central: disrupted ADH synthesis ➡ responds to DDAVP 2. Peripheral: genetic or Li induced defective ADH receptor ➡ low salt diet, amiloride

Question 635

Px and Tx of Steal syndrome vs. IMN

Answer 635

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

Question 636

Tx of superficial venous thrombosis

Answer 636

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

Question 637

Tx of varicose veins

Answer 637

- 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

Question 638

Sensory nerves of the foot

Answer 638

- Dosal: superfial peroneal n. - 1st webspace: deep peroneal n. (is deeper) - Medial: saphenous n. - Lateral: sural n.

Question 639

Tx of perforated colon ca

Answer 639

- 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.

Question 640

Contents of cord structures

Answer 640

- Cremasterics (vessels, muscle, lymphatics) - GB of GF - Testicular artery and veins - Vas deferens - Processus vaginalis **round ligament in women

Question 641

Levels of evidence

Answer 641

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

Question 642

Tx and prognosticators of hepatoblastoma

Answer 642

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

Question 643

VACTERL defects

Answer 643

Vertebral Anal Cardiac TE fistula Renal, Radial bone Limb defects

Question 644

Biliary atresia - px, dx, and tx

Answer 644

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

Question 645

Catelcholamine synthesis

Answer 645

Tyrosine ➡ L-dopa ➡ dopamine ➡ NE ➡ adrenal PNMT ➡ Epi

Question 646

BK Virus- rf, px, and tx

Answer 646

rf's- high IS, pulse steroids px- hematuria, nephritis after kidney trx tx- decrease IS, cysto/possible stent

Question 647

Strategies to decrease SSI

Answer 647

- 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

Question 648

Aminoglycosides - MOA, coverage, s/e

Answer 648

MOA- inhibit 30s; bacteriocidal Coverage- GNRS, pseudomonas s/e- nephrotoxic, ototoxic

Question 649

Tx of thyroid storm

Answer 649

1. PTU or methimazole 2. Steroids **No alpha/beta blockade

Question 650

Polypsos syndromes: px and gene mutations - MutY - FAP - Peutz-Jeghers - Juvenile polyposis - Lynch/HNPCC - Cowden

Answer 650

- 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

Question 651

Tx of dysplasia with IBD (UC and Crohn's)

Answer 651

- 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

Question 652

Indications for surgery of brain bleeds: 1. Epidural 2. SDH 3. Intraparenchymal

Answer 652

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

Question 653

Indications for trx of cholangioca

Answer 653

- cant be intrahepatic (prognosis is too poor) - must be unresectable, perihilar, < 3cm - no distant mets

Question 654

Short gut syndrome - risk/length + feeds

Answer 654

- Adults risk starts at < 180 cm - Infants risk starts at < 75 cm - Feeds with elemental nutrition

Question 655

Tx of toxic megacolon

Answer 655

- 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

Question 656

Repair of bile duct injuries based on Strasburg class

Answer 656

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

Question 657

Indications for MRM

Answer 657

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

Question 658

p450 inducers and inhibitors

Answer 658

CRAP GPs spend all day on SICKFACES.com. Inducers: Rifampicin Alcohol Phenytoin Sulphonylureas Inhibitors: Sodium valproate Isoniazid Fluconazole Grapefruit juice Sulfonamides Ciprofloxacin Omeprazole Metronidazole

Question 659

Pseudomyxoma peritonei - dx and tx

Answer 659

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

Question 660

Condyloma acuminata - tx

Answer 660

1. Imiquimod, Podophyllotoxin, Sinecatechins 2. Cryo, acetic acid, surgery, laser 3. Podophylin, 5-FU

Question 661

Px and w/up of cholangioca

Answer 661

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

Question 662

RF's for cholangioca

Answer 662

- PSC - UC - Choledochal cyst - Biliary tract infection

Question 663

Hypothermia classes

Answer 663

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

Question 664

Emergent management of lower GI bleed of unknown origin

Answer 664

- If patient is hypotensive - TAC w/ end ileostomy - If stabilized- prep 1st with 4-6L of PEG. Scope w/in 24h.

Question 665

Haggit stage and management

Answer 665

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

Question 666

Path, Dx and Tx of rectocele

Answer 666

Path- bulging of rectum into vagina Dx- bimanual exam reveal large bulge in posterior vagina Tx- transvaginal plication of vaginal muscularis +/- mesh

Question 667

ERAS protocol of CRC

Answer 667

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

Question 668

Dx and Tx of slow transit constipation

Answer 668

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

Question 669

Impediments to fistula closure

Answer 669

1. Foreign body 2. Radiation 3. Inflammation/Infection 4. Epithelialization 5. Neoplasia 6. Distal obstruction

Question 670

NCCM CRC screening

Answer 670

- average risk: start at 45. Screen q 10 years. -1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.

Question 671

Tx of sigmoid volvulus

Answer 671

1. Colonoscopic detorsion 2. Sigmoid resection DURING the admission

Question 672

Colon/Rectum Transitions

Answer 672

- Colon: has taenia/above reflection - Rectum: no taenia/below reflection

Question 673

Dx and Tx of contained esophageal perforation

Answer 673

dx: gg swallow then thin barium tx: - NPO, IV abxs - consider stenting - generally don't need IR drain - includes cervical and thoracic

Question 674

Tx of Barrett's

Answer 674

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.

Question 675

Tx of TOA

Answer 675

1. Abxs first - unless rupture or HDUS 2. Drainage/Surgery if failure

Question 676

Types of collagen and life cycle

Answer 676

- 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

Question 677

Tx of eso varices

Answer 677

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

Question 678

Branched chain AA - importance and use

Answer 678

- leucine, isoleucine, valine - metabolized by the muscle instead of liver - use to feed liver impaired patients

Question 679

Peroneal nerve injury

Answer 679

1. Superficial: inability to evert. numbness at dorsum (except 1st web space) 2. Deep: foot drop. numbness of first web space

Question 680

Px and Tx of Pancreatic Lymphoma

Answer 680

Px- pancreatic head mass with LADN. Normal Ca 19-9. Constitutional sxs Tx- chemo only

Question 681

Indications for MOHS

Answer 681

- 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

Question 682

Indications for deep inguinal LN dissection for melanoma and operative considerations

Answer 682

1. > 4 nodes on superficial dissection 2. Positive cloquet's node 3. Enlarged ileo-obturator nodes on CT 4. Clinically palpable femoral nodes

Question 683

Pernicious anemia - pathophysiology

Answer 683

- IF secreted by parietal cells - improves absorption of b12 in the TI - post gastrectomy can get megaloblastic anemia

Question 684

Tx of Bronchial Carcinoid

Answer 684

Surgical resection with complete LADN - usually lobectomy

Question 685

Immunotherapy agents and use by target: - PD-1 - EGFR - CTLA4 - RET - Aromatase - HER2

Answer 685

- 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

Question 686

Histoplasmosis - px, dx, tx

Answer 686

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

Question 687

MOA and s/e of trx meds - MMF - Basiliximab - Azathioprine

Answer 687

MMF: purine (T cell) inhibitor - GI sxs, myelosuppression, anemia Basilixamab: il2 inhibitor - GI sxs Azathioprine: purine (T cell) inhibitor - myelosuppression, marrow suppression, pulm fibrosis

Question 688

Meperadine (demerol) - MOA and s/e

Answer 688

MOA: mu agonist s/e: seizures - 2/2 to metabolite normeperadine - worse with renal impariment

Question 689

s/e of local anesthetic and opioid epidural

Answer 689

Bupivocaine: HoTN Morphine: respiratory depression

Question 690

Absolute c/i to BCT

Answer 690

1. Pregnancy 2. Diffuse micro-calcs 3. Positive pathologic margin 4. Multi-quadrant disease

Question 691

Tx of Lymphedema s/p breast surgery

Answer 691

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

Question 692

Most common recon after mastectomy with blood supply

Answer 692

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

Question 693

Pressor receptors: - NE - Epi - Phenyl - Vaso

Answer 693

- NE: alpha1 > beta1 - Epi: beta1 > alpha 1, some beta 2 - Phenyl: all alpha1 - V1 stimualtor

Question 694

Effects of hypovolemia on RAA

Answer 694

- 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

Question 695

Nerves in triangle of pain

Answer 695

medial-to-lateral: 1. GB of GF 2. FB of GF 3. Femoral 4. Anterior femoral cutaneous 5. Lateral femoral cutaneous (MC injured)

Question 696

Phase of cell cycle

Answer 696

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

Question 697

WAGR Syndrome - chrom anomaly and px

Answer 697

Chrom: deletion of short arm of chrome 11 Px: Wilm's tumor Aniridia- absent iris GU anomalies- cryptorchidism, hypospadia, streak ovary Retardation

Question 698

Dx and Tx of pediatric Intussusception

Answer 698

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

Question 699

Tx of duodenal ulcer

Answer 699

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

Question 700

Tx of small bowel polyps

Answer 700

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

Question 701

Causes of thyrotoxicosis on RAI and tx

Answer 701

- 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

Question 702

Management of penetrating cardiac injury

Answer 702

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)

Question 703

CXR of aortic trauma

Answer 703

1. Widened mediastinum 2. Apical cap 3. Displacement of trachea 4. Depression of L mainstem bronchus *suggest injury at ligamentum arteriosum

Question 704

Polycystic kidney disease a/w

Answer 704

- HTN - Hepatic cysts - Head (Intracranial) aneurysms

Question 705

Tx of thrombophlebitis and catheter releated DVT

Answer 705

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

Question 706

Indications for iHD

Answer 706

1. GFR < 6 and asx 2. GFR < 15 with sxs - absolute: uremic pericarditis, pleuritis, encephalopathy - relative: AEIOU

Question 707

MOA of abxs: (cell wall, protein, or DNA inhibitor) - cell wall - protein 30S - prostein 50S - DNA synthesis

Answer 707

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)

Question 708

Abx ppx for suspected colonic injury

Answer 708

- ancef, cefoxitin, or cefotetan + flagyl - unasyn - pen allergic: clinda or vanc + gent, cipro, levo, aztrenoam

Question 709

Guidelines to prevent SSI

Answer 709

- 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

Question 710

QI strategies - six sigma - teamSTEPPS - SBAR - re-AIM - PDSA

Answer 710

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.

Question 711

Requirements for SBP ppx

Answer 711

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

Question 712

Tx of appendix carcinoid

Answer 712

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

Question 713

MCCO acute liver failure

Answer 713

1. US: tylenol 2. Worldwide: viral hepatitis (Hep B)

Question 714

LA class for esophagitis

Answer 714

A- mucosal breaks <5 mm B- mucosal breaks >5 mm C- mucosal breaks spanning 2 folds, <75% circ D- mucosal breaks >75% circumference

Question 715

Scleroderma manometry

Answer 715

- absent peristalsis - normal/low LES pressure **contrast to achalasia: aperistalsis and high LES pressure

Question 716

Immuno-nutrition

Answer 716

1. arginine 2. omega-3 FA - a/w less infections, shorter LOS

Question 717

Renal arterial anatomy

Answer 717

- Renals come off just under the SMA at L2 - SMA hugs the left renal vein - Renal arteries run behind the veins and the IVC

Question 718

Belsey IV fundoplication

Answer 718

- Thoracic approach with anterior 270-degree wrap - Bailout after failed abdominal approaches

Question 719

How to access cervical esophagus for esophagectomy

Answer 719

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

Question 720

Most important prognosticator of survival in stage IV (liver mets) colon cancer

Answer 720

- response to neoadjuvant chemo - not size. or node status (its already disseminated)

Question 721

MC location of small bowel lymphoma

Answer 721

Ileum (has most lymphoid tissue)

Question 722

SMA exposure options for bypass

Answer 722

1. Anteior: base of transverse mesocolom 2. Lateral: mobilize 4D and LOTz

Question 723

Consequences of ileal resection

Answer 723

- megaloblastic anemia - fat malabsorption/ADEK def - cholesterol stones (EH circulation) - oxalate stones (ca binds fat instead of Ox)

Question 724

BPD for weight loss surgery

Answer 724

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)

Question 725

MC Vit def after REYGB and sxs

Answer 725

1. Vit D- bone dz, hypoCa 2. Vit A- night blind 3. Folate- skin changes 4. Iron- anemia 5. Thiamine- encephalopathy

Question 726

Surviving Sepsis 1-hour bundle

Answer 726

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

Question 727

Immuno-nutrition and benefits

Answer 727

1. arginine 2. omega-3 FA - a/w less infections, shorter LOS

Question 728

S/e of Amiodarone

Answer 728

1. Pulmonary dysfunction: tx w/ steroids 2. Thyroid dysfunction: tx w/ steroids or thionamides

Question 729

Virulence of G+ and G- bacteria

Answer 729

G+: exotoxins G-: endotoxins (lipid A)

Question 730

Tx of atypical ductal hyperplasia (ADH)

Answer 730

- 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

Question 731

Axilla boundaries

Answer 731

medial- pec minor lateral- lat dorsi superior- ax vein posterior- subscap

Question 732

Histology of pap thyroid ca

Answer 732

- Pale cytoplasm - Prominent nucleoli (orphan annie) - Psammoma bodies - Large/crowded nuclei

Question 733

Adrenal blood supply

Answer 733

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

Question 734

Advantages of robotic surgery

Answer 734

-7 degrees of freedom

Question 735

Damage control trauma to visceral vessels

Answer 735

Celiac- ligate SMA- shunt or repair IMA- ligate

Question 736

Lap band imaging

Answer 736

- 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

Question 737

Melanoma indications for SLNBx

Answer 737

> 1mm < 1mm w/ ulceration or > 1 mm2 mitoses

Question 738

Causes for AV fistula failure to mature

Answer 738

1. venous branches (doesn't fill enough) 2. fistula is too deep (can't pop out)

Question 739

CEA operative pearls

Answer 739

- 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

Question 740

Tx of aortoenteric fistula

Answer 740

Fistula takedown, prior graft revmoval (if s/p evar) and extra-anatomic bypass

Question 741

U/S findings for thyroid nodule suspicious of cancer

Answer 741

1. Unclear boundary of solid component 2. Irregular shape 3. Calcs 4. Hypoechoic

Question 742

Indications for ICP monitor

Answer 742

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

Question 743

Submental triangle - boundaries and contents

Answer 743

Boundaries: - Anterior bellies of digastric - Hyoid bone - Symphysis menti - Mylohyoid is floor Contents: - Contents: mylohyoid nerve, anterior jugular veins

Question 744

Morphine equivalents of narcs

Answer 744

5 IV morphine = - .7 IV HM - .05 IV fentanyl 15 PO morphine = - 3 PO HM - 10 POD Oxy

Question 745

FRC

Answer 745

FRC = RV + ERV - TV not included - Increases with age - Decrease with obesity, pneumoperitoneum