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159 Cards in this Set

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Describe the difference between:
Epidermal Burns
Partial-Thickness Burns
Full-Thickness Burns
Epidermal- 1st degree, involve only the epidermis. Dermal capilaries dilated,-> red, painful, blanching areas. No blistering. Only need supportive care (pain control, fluids, neosporin cream). No scar tissue

Partial thickness (2nd degree). into but not through the dermis. vary in appearance and significance. Superficial are reddened, blister, painful. dead tissue (eschar) forms over it. 10-14 days to heal.
Deep partial thicknes sinjuries- coag necrosis of the upper dermis-> dry, leathery, no erythema, wounds are waxy white. can heal on it's own. Vary in pain. scars (best Rx is removal and grafting)

Full Thickness- 3rd degree. all layers destroyed. covered w/ dry, avascular coagulum. no nerves. any color. can cause tourniquet, when derm proteins come togeter. small ones heal by contraction, larger= skin graft
what is the initial care of the burn pt?
stop the burn. Burns produce tissue damage for minutes to hours after the initial burn occurs; douse w/ water, smother, roll. liquids must be cooled immediately. chemicals diluted.

ABCs- Inhalation injury- CO, pulm edema, swelling of airway. Circulation- look for edema, constricting burns.

Resuscitation- large bore IVs, foley.

2ndry survey- heatd to toe.
What is the parkland formula?
algorithm for burns. Isotonic crystaalloid fluid. (lactated Ringers) determined by burn size and body weight.

4 ml Lactated Ringers x body weight x % TBSA burned
1st 8 hrs= 1/2 calculated total
2nd 8 hrs= 1/4 calculated total
3rd 8 hrs= 1/4 calculated total.

urin > 30 ml/hr in adults, 1-2 ml/hr/kg in kids is a good indicatior.
When does a burn requre referral to a burn center?
-Partial and full > 10% of anyone <10 >50 y/o.
-Partial and full > 20% of anyone 10-50.
Full thickness > 5% of any age.
Any burn involving face, hands, groin, feet, perineum or major joints.
Electric burns
Chemical burns
Inhalation injury
Preexisting medical problems.
Burns and trauma
Pediatric burns
Special care: social needs.
What are the three types of inhalation injury?
CO poisoning
- immediate after exposure. replaces O on Hb. Pt have cherry red color; neuro dysfunction. suspect in anyone unconcious at the scene. Rx- high flow O2.

Upper-airway obstruction- presents up to 24 hrs post burn. Gasses damage the pharynx-> edema, swelling, obstruction. Suspect in pts w/ burns of the mouth, nose, or pharynx. hoase voice, coough, stridor. Rx- intubate, high-flow O2. cogh, suction, clear secretions.

Pulmonary injury- can by immediate, but can occur days after. Smoke w/ chemicals (formaldehyde, formic and hydrochloric acid, acrolein. They cause bronchiectasis, hypoxemia-> pneumonia. Patients present w/ hypoxia, resp distress, infiltrates on CXR. Hx of prolonged exposure. Burns on face, nose, lips. Crowing rspiractions, bronchorrea, tachypnea. Rx- early intubatoin. high-flow, 02. pulmonary toilet. Pneumonia sought.
What is the rule of 9s?
head- 9%
arm- 9%
Trunk- 18%
legs 18%
Groin- 1%
when can a burn not be managed outpatient?
superficial partial > 15% or worse for adults
kids > 10%
circumferential burns
what can be used for wound infection?
mafenide acetate
silver sulfadiazine for G-s.. Psuedomonas, staph and strep are culprits.

early burn excision and grafting is importent. regular debridement should occure bid.
what are the sequencial steps of wound healing?
substrate phase- lag phase. PMNs, macros. PMNs 48 hrs. Macros after 24 hrs. TGF-Beta-> prolif of fibroblasts and IL-1. continues until skin closure.

Proliferative phase. constant. begins when skin covers wound. collagen develops in the wound. (raised scar, red, hard. fibroblast is primary cell.

Maturation phase- remodeling, collagen cross-linking. Scar flattens. less prominent. more pale and supple. (9 montsh)
What is Primary, Secondary, Tertiary healing?
1ry- wound closed by direct approximation of the wound edges.
2ry- spontaneous wound closure. wound left open, allowed to heal. bimodal (contraction and epithelialization)
what is a gut suture?
sheep intestine, biologic, last 7-10 days. absorbed. Not used for skin closure.
What are polyglycolic acid sutures?
Dexon, Vicryl
Absorbable. Absorbed by hydrolysis. Good for reapproximation o ftissue below the skin surface. braided, not good for skin.
What are synthetic sutures?
nylon. monofilament. not broken down or absorbed. used for skin closure.
what is the course of wound healing with stitches?
swelling in first 24-48 hrs.
excessive tension -> ischemia of the wound edge and inflammation.
What's the deal with pelvic fractures?
What important vessels, nerves are nearby?
What are the two major consequences?
What are the goals of surgery?
What are some other organs damaged?
what are signs of an open fractures.
Anatomy: ileacs, lumbosacral plexus.
massive blood loss, multiorgan system.

sugery goals: tamponade bleeding, confer sitting stability

can have bladder, urethra injury. (requires retrograde urethrogram) Blood in rectum/vagina can mean open fracture.
Talar neck fractures
WHy are they bad?
when do they occur?
what are the different types?
What are the treatments?
bad because it is a joint, weight bearing. improper resetting can cause arthritis.
Occur when slamming on the break in an accident
type I- nondisplaced
type II- displaced with subtalar
Type III- displaced with subtalar and ankle.
Type IV- also talonavicular joint
nondisplaced- short cast, 8-12 wks.
displaced- closed reduction or open; if closed works, then short cast, 8-12 wks.
If open, then all fragments should be removed. avoid fusion.
What is the most common presentation of Crohn's disease?
triad ab pain, diarrhea, weight loss. symps gradual in onset, progress in characteristic waxing and waning fashion
- ab pain is most common symp; non-bloody diarrhea.
- perianal involvement including abscesses, fistulas, and fissures
- extraintestinal manifestations more common in pts w/ colonic involvement than w/ small bowel disease. pyoderma, gangrenosum, conjuctivitis, arthritis
- loss of bodyweight, hypoporteinemia, malabsorption.
What ar ethe complications of Crohn's that may require surgical therapy?
Surgery is Palliative.
Terminal ileitis; with Yersinia infection-> appendicitis

rule out skip leasions intraoperatively, note negative margins. denote decreased change for recurrence.

Small bowel obstruction, fistula, anal complications, cobblestoning, granulomas, increased mucus secretion.
- Extraintestinal manifestations: aphthous ulcers, pyoderma, gangrenosum, iritis, erythema nodosum, sclerosing cholangitis, arthritis (ankylosing spondylitis), clubbing of fingers, kidney (amyloid deposits)
What is the diagnostic approach to a pt w/ signs and symps of Crohn's
colonoscopy w/ biopsy (transmural, dysplasia), barium enema (skip lesions), UGI w/ small bowel follow through (skip lesions), stool culture (bleeding is rare)
Crohn's vs UC-
Rx and complications
pre-malignant potential
- transmural
- segmental involvement
- no rectum
- thickeend bowel wall
- small bowel involved
- fistulas
- anal complications
- no toxic megacolon
- cobblestoning
- narrow, deeply penetrating ulcers
- granulomas common
- mucus secretion increased

- mucosal disease
- diffuse involvement
- rectum invovled
- normal bowwel wall
- no small bowel
- no fistulas
- no anal complications
- toxic megacolon
- no bleeding
- curative surgery
- pseudopolyps
- shallow wide ulcers
- rare granulomas
- mucus secretion decreased
What is the role of surgery in UC with:
toxic megacolon
perf and bleeding
refractory to meds, needs surge
What is the role of surgery in Crohn's w/:
needs surge
What is the non-op Rx of UC and Crohn's?
UC- loperamide to slow gut transit; sulfasalazine as anti-inflamm; steroids

Crohn's- metronidazol for abcess, 6-MP, MTX, and cyclosporin; roids, sulfasalazine, loperamide
What si teh clinical findings of diverticular disease of the colon?
Diverticulosis- recurrent ab pain, LLQ, changes in bowel habits, bleeding, constipation, diarrhea, alternating constipation, diarrhea; PEX unremarkable- mild tenderness in LLQ, fever, leukocytosis absent, XR may show segmental spasm and luminal narrowing, endoscope may show openings of diverticula.

Diverticulitis: LLQ in subacute onset, changes in bowel habits, palpable mass, fever, localized or generalized if perf occurs. tenderness, guarding, cicatricial.
- diverticular perforation can cause abscesses, fistulas, obstructions
- AxR, barium enema (not in acute), contrast enema, upright CXR (pneumoperitoneum)
What are the 5 complications of diverticular disease adn when is surgery indicated?
Infection- Rx- resection, 1ry anastamosis
Perforation- immediate resection of the diseased colon. temporary diverting colostomy and hartmann procedure. 1ry anastomosis in a second stage.
Bleeding- elective resection of diseased colon, 1ry anastomosis.
Fistulization: closure of fistula, resection of sigmoid colon w/ 1ry anastomosis.
Obstruction- immediate resection, temporary diverting colostomy, hartmann procedure, 1ry anastomosis
Abscess- ct-guided drainage, Hartmann's operation in the face of undrained abscess.
What sit eh DDX of LLQ?
Divertiquilitis, sigmoid volvulus, perforated colon, colon CA, UTI, small bowel obstruction, IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gyne, PID, mittleshmerz, ovarian cyst, fibroid degeneration, endometriosis, gynecological tumor, fallopian torsion
What is the medical/surgical management of LLQ pain?
initial- NPO, IVF, hemodynamic monitoring, NGT, foleyDx- CBC, blood tests, coag, chem 10, abg, urinalysis, BHCG, LFTs, amylase, CXR, AXR, US, CT, contrast studies, pyelogram, angiography, endoscopy

Surgery- perforation, obstruction, intractability, unresolvable bleeding, abscess, fistula.
What sit eh DDx of massive rectal bleeding?
diverticulosis, upper GI, hemorrhoidal from portal hypertension, ulcer, angiodysplasia, varices, cancer, IBD
What is the initial management of massive rectal bleed?
transfusion of 4 unites of blood.
IVF, crystalloid- lactated ringers, blood, foley , NGT, Vital signs, CBC, coags, CVP or pulm artery monitoring in unstable pt.
What is done for Dx of bleed?
NGT to rule out upper GI source, rectal to rule out hemorrhoidal, flex sig for lwoer colon, angiography, colonoscopy
What is the Rx for rectal bleed?
70% of diverticular bleed stop, 70% of bleeding is caused by diverticulosis. Continued bleeding is indication for resection. Upper GI bleed w/ sclerotherapy or electrocautery or DDAVP. Embolization or resection, treat angiodysplasia and hemorrhoids w/ surgical resection, treat carcinoma w/ surgical resection, Rx IBD w/ steroids, sulfasalazine or surgical resection if sever probs.
What are the recs for colon cancer screening?
10 years before age of onset in relative, or every 5 years after 50;
FAP- puberty
HPNCC- 21 y/o
What is the typical presentation for Colon Cancer of the right colon?
Right Colon- occult blood loss, Fe defecient anemia, obstruction is rare; palpable right lower ab mass

CA in general- anorexia, fatigue, weight loss, change in bowel habits, anemia, rectal bleeding,

risk factors including >50 y/o, hereditary polyposis syndromes and adenomatous polyps and previous colorectal cancer and IBD and FHx

Virchow's node, blumer's shelf
what is the staging for colon cancer?
T0- no tumor
Tis- Insitue, intraepithelial
T1- invades submucosa
T2- invades muscularis propria
T3- invades muscularis propria into subserosa or into nonperitonealized pericolic or perirectal tissues
T4- invades directly into other organs or structures or perforates visceral peritoneum

N1- mets in 1-3 pericoloc nodes
N2- mets to > 4 pericolic nodes
N3- mets to any node along vasc trunk or >1 apical node.

Other prognostic factors- CEA, lesion size, depth of invatsion

TNM1- T1-2
TNM2- T3-4
TNM3- any T, N1-3
TNM4- any T, any N, M1
What are the risks for Colon Ca?
diagnosing HNPCC- 2 generations, <50 cancer, 3 relatives

risk factors including >50 y/o, hereditary polyposis syndromes and adenomatous polyps and previous colorectal cancer and IBD and FHx

meat diet, geography
what are the common sites of mets for colon cancer?
lung, liver, bone, brain
what are teh features of a polyp that suggest malignant potential?
- tubular adenoma- pedunculated (rounded and attached to mucosa by a long, thin neck); 7% malig
- tubulovillous adenoma- pedunculated- 20% malig
- villous adenoma- commonly sessile (flat, intimately attached to mucosa), 33% malig; greatest potentential is >3cm

inflammatory polyps- IBD; not malignant

Hamartomas and polyps in Peutz-Jeghers- low malignent, usually regress.
What is the typical presentation for Colon Cancer of the left colon?
CA in left/sigmoid colon: annular and invasive. obstruction and macroscopic rectal bleeding, rectal cancers cause rectal bleeding, obstruction/diarrhea/constipation, tenesmus in advanced stages (blood streaking in stool)

CA in general- anorexia, fatigue, weight loss, change in bowel habits, anemia, rectal bleeding,

risk factors including >50 y/o, hereditary polyposis syndromes and adenomatous polyps and previous colorectal cancer and IBD and FHx
What is the typical presentation for Colon Cancer of the rectum?
rectal bleeding, obstruction and alternating diarrhea, constipation; tenesmus for advanced disease
How do you screen for colon cancer?
fecal blood
flex sig- every 5 years
colonoscopy- most sensitive (every 10)
barium enema
Familial adenomatous polyposis?
half of off spring, beginning in teens
hundreds of polyps
if untreated-> cancer
younger age than sporadic
mult tumors
proximal colon
What are teh signs and symps of acute appendicitis?
periumbilical pain, may have nausea, vomit, anorexia; spreads to RLQ.
Low grade fever; left shift WBCs
- rebound tenderness, guarding, pain on palpation of McBurney's point

Rovsing's sign, positive psoas, obturator.
What is the DDx of acute appendicitis?
Gastroenteritis- nausea/vomiting precedes pain, diarrhea

Salpingitis, ovarian cyst, tuboovarian abscess, PID, torsion of ovary, ectopic;

Pneumonia of RLL oro RML
Pyelonephritis, kidney stone, UTI
meckel's diverticulum
How are other diseases differentiated from appendicitis?
GE- nausea vomiting precedes pain
women- ultrasound
Penumonia- CXR
Pyelo- UTI; hematuria, pyuria
cecal diverticulitis- elderly colonoscopy, barium enema
Meckels- young kids, painless lower GI; w/o ab pain and obstruction
Crohn's- ab pain, diarrhea, weight loss, perianal involvement, barium enema
what is the workup for appendicitis?
increased WBC >10,000 w/ left shift
UA- rule out UTI
CXR- rule out pneumonia
CT- if needed to show dilated thickened lumen
US- for women
Barium enema- rarely done for rule out of diverticulitis
What is the Rx for appendicitis?
Preop prep- rehydrate, Abtics
- nonperfed appendicitis.- prompt appendectomy w/in 24hrs;
- perfed- if symps > 24hrs, prompt appendectomy- drain and culture pus, post-op abtics for 5-7 days.
What are teh signs and symps of acute appendicitis?
periumbilical pain, may have nausea, vomit, anorexia; spreads to RLQ.
Low grade fever; left shift WBCs
- rebound tenderness, guarding, pain on palpation of McBurney's point

Rovsing's sign, positive psoas, obturator.
What is the DDx of acute appendicitis?
Gastroenteritis- nausea/vomiting precedes pain, diarrhea

Salpingitis, ovarian cyst, tuboovarian abscess, PID, torsion of ovary, ectopic;

Pneumonia of RLL oro RML
Pyelonephritis, kidney stone, UTI
meckel's diverticulum
How are other diseases differentiated from appendicitis?
GE- nausea vomiting precedes pain
women- ultrasound
Penumonia- CXR
Pyelo- UTI; hematuria, pyuria
cecal diverticulitis- elderly colonoscopy, barium enema
Meckels- young kids, painless lower GI; w/o ab pain and obstruction
Crohn's- ab pain, diarrhea, weight loss, perianal involvement, barium enema
what is the workup for appendicitis?
increased WBC >10,000 w/ left shift
UA- rule out UTI
CXR- rule out pneumonia
CT- if needed to show dilated thickened lumen
US- for women
Barium enema- rarely done for rule out of diverticulitis
What is the Rx for appendicitis?
Preop prep- rehydrate, Abtics
- nonperfed appendicitis.- prompt appendectomy w/in 24hrs;
- perfed- if symps > 24hrs, prompt appendectomy- drain and culture pus, post-op abtics for 5-7 days.
what are the common etiologies, signs and symps of small intestic mechanical obstruction?
adhesions, bulge, cancer

others- gallstone ileus, intussusception, volvulus, external compresion, SMA syndrome, Bezoars, Bowel wall hematoma, abscesses, diverticulitis, Crohn's, Rads, annular pancreas, meckel's diverticulum, peritoneal adhesions. Stricture.

Signs and symps- ab discomfort, cramping pain, nausea, ab distension, bilious, high-pitched bowel sounds, stool and flatus may be present. hypovolemia, may be present from 3rd spacing into the lumen; AXR, scars, hernia
What are teh complications of small bowel obstruction (fluids and elytes), vasc compromise, and sepsis?
hypovolemic; hypochloremic, hypokalemia, alkalosis
What are the labs and XR for teh Dx of small bowel?
Type and screen
symps of w/ paralytic ileus? vs. obstruction?
mech- bowel distal empties (high pitched sounds, obstruction. Not in paralytic ileus.
Oglivies- form of paralytic ileus- massive dilation of the colon w/o obstruction in severly ill pts. Hapens in recent surge, infxn, neuro or cardiopulm disorders, metabolic disturbances.

r/o hernia.
What are the signs of strangulation w/ bowel ischemia?
fever, tachycard, peritoneal signs, leukocytosis
What are the signs and symps of LBO?
Hx of changed bowel habits or constipation, no stool or flatus, small caliber or blood streaked stools
- colicky, suprapubic pain
- N/V
- distention
- hypovolemia
- no leukocytosis
- differentiate between partial and total

Dx- air fluid levels; distended large/small bowel
distal decompression

worry about
closed loops- volvulus
cecal diameter- enlarged- rupture
toxic megacolon- rupture
pneumatosis intestinalis- air in bowel wall- ischemia
air in bortal system- infx or necrotic tissue in bowel
What are 4 causes of colonic obstruction and frequency
adenocarcinoma- 65%
scarring- 20%
volvulus- 5%
- inflamm dz, tumor, bodies, fecal impaction; rare adhesive bands
What is the Dx workup for LBO?
(a) Abdominal series
(i) Multiple air-fluid levels
(ii) Distended large/small bowel
(iii) Distal decompression
(iv) Causes for concern:
1. closed loops – volvulus
2. cecal diameter >10-12 cm - rupture
3. toxic megacolon – rupture
4. pneumatosis intestinalis (air in bowel wall) – ass. with ischemia
5. air in portal system – infxn or necrotic tissue in bowel
what is the inital preop managment of:
Volvulus- elderly, immobile, adhesions, pregs, laxative abuse; pain, constipation, distension; strangulated- sever pain, rapid distension, obstipation; Dx- films; water soluble contrast enema; sigmoidoscopy-> can be therapeutic; DO NOT GIVE BARIUM

Impaction- if total-> emergent; if partial- laxative

Cancer- change in habit, Fe anemia, or bleading-> DRE- occult blood, flex sig, barium enema (NOT in total obstruction); if total- surgery
what are the signs and symps of a perforation?
malaise, tachy, decreased bowel sounds.
what is the DDx for a perforated viscous?
gastric/duodenal ulcer
what si the Hx that would help differentiate the DDx for a perforation?
Appendicitis- high grade fever, diffuse, intense pain, increased WBC
Diverticulitis- microperf- swelling in colon wall, adjacent tissues.
what is the steps for Rx and Dx of perforated viscous?
abd xray, endoscopy, colonoscopy.

surgery, to close and irrigate the cavity.
what are 4 etiologies of pancreatitis?

(iatrogenic ERCP, meds, ascaris lumbricoides, opisthorchis sinesis, coxsackie, mumps, hyperCa, scorpion)
what is the clinical presentation of a patient w/ pancreatitis?
ab pain- unrelenting
IDDM in 1/3
- retroperitoneal hemorrhage of the flank; umbilicus, inguinal ligament
what are indications for surgery in acute pancreatitis?
necrosis, infection
what are 5 early and late complications of acute pancreatitis?
early- hyperglycemia, hypocalcemia, renal failure
resp insufficiency- diaphragm elevation; fluid overload, pulm thromboemboli, antisurfactant release.
coagulopathy, hemorrhage
paralytic ileus
sterile peripancreatic fluid collection
thrombosis of splenic vein-> esophageal varices.

Late: necrosis of gland, infections, hemorrhage, pseudocyst formation
What are teh criteria used to predict the prognosis of acute pancreatitis?
Ranson's > 3 is risk for compicated pancreatitis and need for surgery:
1- less than 24 hrs:
WBC >16
LDH >350
AST > 250
Gcose> 200

Less than 48 Hrs:
- Fluid sequestration > 6L
Base Deficit > 4
pO2 < 60
Hct decrease > 10%
Ca < 8
BUN up > 5
what are 4 potential outcomes of chronic pancreratitis?
scarring and fibrosis of pancreas
insufficiency- malabsorp- enzymes decrease to 10% normal, fat and protein not obsorbed; DM from islet cell destruction
Chronic ab pain and recurrent bouts of acute pancreatitis
Increased risk for pancreatic cancer
what is the Dx and Rx for chronic pancratitis?
Dx- CT scan can show gland enlargement, atrophy, calcifications, masses, pseudocysts, nflammation, and extensions beyond the pancreas

Medical- low-fat diet, no alcohol, enzyme and insulin.
how are pancreatic pseudocysts formed; what are 5 symps and signs of pseudocysts?
complication of pancreatitis: fluid collection in the peripancreatic area. ductal disruption and gland autolysis; Enzymatic fluid collects and builds up; walled off. can become fibrotic.

Symps- epigastric pain, fever, weight loss, obstruction, N/V, jaundice
what is the Dx approach to someone w/ a pancreatic pseudocyst?
Dx- US, CT
What is the natural Hx of untreated pancreatic pseudocyst and medical and surgical options for Rx a pt w/ pancreatic pseudocyst?
> 5 cm resolve
> 5 cm 25% resolve, 75% require drainage; should be allowed to mature for 6 wks.

Meidcal- pain control
Surgical- Image guided drainage (30-40% failure rate
Cystgastrostomy- lower failure and recurrance
Endoscopic cystogastrostomy or cystenterostomy- newer
what is the non-op Rx for pancreatitis?
non-op- NG tube, fluids, intubate, Abtics, ERCP for sphincterotomy
What are the surgical indications in chronic pancreatitis?
refractory, disabling disease
concer of malignancy
biliary obstruction
complications of pseudocysts- obstruction, splenic argery pseudoaneurysm, splenic vein thrombosis
What are the operative techniques for pancreatitis?
Drainage: duval procedure: retrograde drainage w/ distal resection and end-to-end pancreaticojejunostomy; modified Peustow procedure: side-to-side pancreaticojejunostomy w/ partial pancreatic head resection

Resection: Distal pancreatectomy- trauma
modified whipple: for inflammed mass of head
Total pancreatectomy- rarely indicated for diffuse chronic pancreatitis w/ nondilated pancreatic duct
Hematemesis: vomit of blood; upper GI bleed, proximal GI tract; proximal to ligament of Trietz

Hematochezia- bright red blood per rectum: lower Gi blled; distal to Treitz, mostly colon

Melena: black Tarry stools; > 100 ml of blood enters the gut. Upper GI blled; proximal to ligament of Trietz

Stool Guaiac: detects peroxidase activity of hemoglobin
Differentiate acute and chronic gastro bleed presentations
Acute: presents with hematemesis, melena, or hematochezia; Upper GI is in 85% of acute. lower is 10-15% of patis. Small bowel is 1-5%

Chronic GI bleed- slow or intermittent bleed. occult blood. present with anemia or fatigue
differentiate bleeding from upper and lower GI sources
upper- hematemesis, melena, syncope, shock, fatigue, coffee ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, hypovolemisa
- hematochezia can occur because blood is cathartic; indicates vigorous rate of bleeding

Lower- hematochezia, w/ or w/out ab pain, melena, anorexia, fatigue, syncope, SOB, shock
Given a patient w/ hemorrhage what is the priority of steps for the following:
- general systemic eval
- correction of hypovolemia
- verification of bleeding
- management of traige (surgery vs. studies)
Upper GI- general: Hx, PE, NGT aspirate, ab XR, EGD, Chem 7, CBC, type and cross, PT/PTT, amylase

Correction of hypovolemia- IVFs, foley

verification of bleeding: NGT, endoscopy

Management: surgery for refractory or recurrent bleeding and site known

Dx: EGD, Selective mesenteric angiography

Lower GI: Hx, PE, NGT (rule out upper GI), labs: CBC, Chem 7, PT/PTT, type and cross)
Correction of Hypovolemia: IVFs, lacted ringers, packed RBCs;
Verification of bleeding NGT aspiration: if + blood, EGD, if bile, EGD or anoscopy; if anoscopy negative and massive bleed-> angiogram. If slow bleed, colonoscopy.

Triag: 10 percent need emergent surgery. If bleeding site is known and massive bleed continues-> resect bowel
exploratory laparotomy if uknown.
what aer the most common causes of upper and lower GI bleeds for:
16 and above
birth to 2y/o
Upper GI
Adults- duodenal ulcer, gastric ulcer, acute gastritis, esophageal varices, mallory-Weiss tear

Infant- Gastritis, esophagitis, gastric ulcer, duodenal ulcer, eophageal varices, foreign body, epistaxis, coagulopathy, vascular malformation, cyst

Lower GI:
Adult- diverticulosis, vascular ectasia, colon cancer, hemorrhoids, trauma, hereditary hemorrhagic telangiectasia, intussusception, volvulus, ishcemic

Infant- upper GI bleed, anal fissures, necrotizing enterocolitis. midgut volvulus, intusseption
what are the criteria for surgery in GI hemorrhage?
upper- refractory or recurrent bleed and site unknown

lower- bleeding site is known and massive recurrent bleeding continues, segmental resection of bowel.
What are the symptoms and signs of a pancreatic tumor in the head of the pancreas?
adenocarcinoma- 90% of neoplasms. Risks age, smoking;

can have jaundice, apin- posterior epigastric region, radiating to the back. constant;
Courvoisiers sign: palpable non-tender gallbladder- sing of malignancy, not cholelithiasis
What are the signs and symps of a pancreatic tumor at the tail
asymptomatic, or pain and weight loss
what is the Dx workup and lab findings for tumor of the head of the pancreas?
US- biliary dilation and liver lesions; does not show pancreatic lesions well.

CT- detail of periampullary region, shows biliary dilation, liver mets and tumor invasion
rarely angio is done
preop biopsy is not indicated unless surgery is not planned
What is the Rx for pancreatic tumor?
surgical, Chemo and Rads don't work.
- determine resectability by CT or ECRP- unresectable: liver mets, ascites, vasc invasion, general regional or systemic spread
- prior to surgery, coag dz should be corrected
- sugre begins laparoscopically to determine respectability w/ minimal invasiveness.

Whipple- pancreaticoduodenectomy for head; resection of the distal CBD, duodenum, and head of the pancreas.
- following resection, continuity is restored w/ choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy
- complications include leakage of the pancreaticojejunostomy (20%)

Lesion of the tail-> distal pancreatectomy

Unresectable disease- Palliation w/ minimally invasive technique- billiary stenting, gastrojejunostomy for gastric outlet obstruction
what are the symps suggestive of esophageal malignancy?
Dysphagia, weight loss
(chest pain, back pain, hoarseness, symps of mets
What is the plan for Dx eval of a patient w/ esophageal tumor?
Upper GI localizes tumor
EGD obtains biopsy and assesses resection
Full Mets workup (CXR, bone scan, CT, LfTs
What is the prognosis for pancreatic adenocarcinoma
- Patients who have resection have a median survival of 12 mos; pts w/ unresectable disease have a med survival of 6 mos.
- Pts w/o lymph notde mets at dx have 5 yr survivial of 25-30%
What are the signs of an insulinoma?
palpitations, tremulousness @ tachy from whipple triad
Whipple's Triad: fasting, fasting blood sugar < 50, relief of Sx w/ eating

Patients are treated by psychiatrists due to bizarre behavior.
Dx- abnl high serum insulin
What is the preop eval of an insulinoma?
angio- hypervasc lesions in 50%
CT- insulinoma in < 50%
best means of identification is careful surgical exposure of the pancreas & exploration via palpation
- intraop US is used to confirm the findings
what is the Rx for an insulinoma?
enucleation of tumor w/o major resection

Medical- Stretozotocin and diazoxide- limited efficacy
What si the presentation of a gastrinoma?
Delta cells
ZES is the Syndrome of sever PUD from this. Jxn of 2nd and 3rd portions of the duodenum & SMA as the cross under the pancreatic neck.
- part of MEN-> multicentric lesions
- otherwise solitary
- most are malignant but histo - hard.
- usually it is a clinical determination based on the detection of mets

Presentation- ulcers in distal duodenum or jejunom, recurrent duodenal ulcers, profuse watery diarrhea, large gastric rugal folds
- elevations of fasting serum gastrin > 750 pg/dl are common, not diagnostic

Diagnosis: secretin-stim test.
What is the Rx for a gastrinoma?
Imaging- CT and US are used
angiography-> vascular blush in 75%

Surgical removal is inddicated if the lesion can be localized
- may involve enucleation or wider pancreatic resection, depending on the lesion
- intra OP US is useful for localization
- surgery often involves intraop duodenal transillumination w/ endoscopy
- Gastrectomy- rarely indicated- if unresectable, pts can tx PUD with PPIs.
What is the Rx for esophageal maliganancy
Rx- total thoracic esophagectomy with gastric pull-up or colon interposition; chemo/rads
Stage I- 80% survival- lamina propria, submucosa
Stage II (33%)- IIa- invades muscularis propria or adventitia
IIb: invases muscularis progria w/ positive regional nodes
III- (15%)- a- tumor invades adventitial and positive nodes or Tumor invades adjacent structures, independant of nodes
Stage IV- (0%)- mets
what is the management for an anal fistula?
abnl communication between anus and level of the dentate line and perirectal skin through the bed of a previous abscess- can cause recurrent abscess

- symps- drainage of pus and stool from skin
recurrent abscess
diaber rash due to drainage and itching

- determine path of fistula- Goodall's rule: fistulas originating ant to transverse line through anus course straight and exit ant.
- Post fistulas- curved

-> fisulotomy- probe to identify tract, unroof fistula, allow fistula to heal by 2ry intention
Woond care- sitz baths, dressing changes, stool softeners; staged fistulotomy w/ seton stictch if fistula runs through phincteric structures.- avoid incontinence
What is than anal fissure and what is the presentation
tear in lining of anal canal below dentate line. post midline for both sexes, women can get ant tears.
- cause: constipation, diarrhea, disease- crohn's, STD, malignancies, leukemia
- pain w/ bowel movement
- minimal rectal bleeding
- tear in anal skin
extreme pain w/ rectal exam

Triad- skin tag, internal sphincteric fibers, hypertorphied anal papilla at the level of the dentate line
how do you treat an anal fissure?
Treat the diarrhea, constipation.
bulk laxatives or stool softeners
high fiber
non-narcotic analgesic
sitz baths
- lateral internal sphincterotomy to relieve spansm and pain.
What is the anatomy of the hemorrhoid, what are the 4 grades encountered clinically?
Venous plexi of the rectum or anus
left lateral, right ant. right posterior

1st degree- bulge in anal canal- no prolapsse
2nd degree- protrude w/ defecation: reduces spontaneously
3rd degree- protrudes w/ defecation, must be reduced manually
4th degree- cannot be reduced
what are teh differences between internal and external hemorrhoids?
internal- painless bleeding, w/ bowel movement
External- constant pain when thrombosed, no grading system
what are the etiological factors and predisposing conditions in development of hemorrhoids?
constipation, straining
increased pelvic pressure- ascites, tumor
portal HTN
What are the prinicples of management of pts w/ symptomatic external and internal hemorrhoids, incluidng roles of non-op and op management?
asymptomatic- bulk forming agents to avoid constipation
high fiber, water diet
topical roids, sitz bath

surgery when internal hemorrhoids are 2nd, 3rd degree. Rubber band ligation. Infrared coagulation;
4th degree- hemorrhoidectomy
Thrombosed external hemorrhoids- resolve over 7-10 days, if early, excise under local anesthesia. If later, conservative Rx w/ Sitz baths.
What is teh role of anal crypts in perianal infection?
obstruction of glands can cause abscess. Glands secrete at teh crypts. (columns of Morgagni)
what are the symps and PEX of perianal infections?
perianal pain, swelling, redness
loss of function
DRE reveals peranal or rectal submucosal mass
What are th etypes of perianal infections?
Ischiorectal (below levator ani, outside external sphincter
supralevator abscess (above the levator ani muscles, between internal and external sphincter)

Perianal, ischiorectal are most common
What is the Rx for perianal abscess?
I and D
abtics w/ I and D for those w/ DM, chemo pts, leukemia, AIDS, Heart Valve
Stool softeners, sitz baths hygiene
check for fistula
What are the recs for screening mammography?
45 and up
what are the common risk factors for benign breast diseae and breast cancers?
family history
atypical hyperplasia
personal Hx of breast Ca
increased egen- early menarche, nulliparity, egen replacement
what are teh Dx modalities and what is the diquence for a breast mass; with nipple discharge?
Breast Mass
- Mammogram
- US
- Aspiration- cyst vs. solid
- if slid- FNA; incisional, excisional biopsy
- if cyst- screening mammography

Nipple Discharge- bloody- intraductal papilloma
other: cysts, ductal ectasia
What is teh Rx for fibroadenoma and fibrocystic disease?
Fibroadenoma- surgery
fibrocystic Dz- aspiration, FNA if necessary
What are the tpes of breast cancer?
- non-invasive: ductal CIS, loblular CIS

Invasive: infiltrating ductal Ca; infiltrating lobular, Paget's Inflamm breast carcinoma

Non-epithelial- angiosarcoma, malignant cystosarcoma phyllodes, 1ry stromal sarcomas
What is the Rx for local, regional and systemic breast cancer and describe wehn each is indicated?
Ductal CIS
- lumpectomy w/ rads
- mastectomy

Small invasive tumors
- modified radical mastectomy- simple mastectomy w/ axillary dissection
- lumpectomy w/ axillary dissection and 6 wks of rads

- local exicision of nipple-areola complex

Chemo- tumors > 1cm

Hormonal- Tamoxifen- Egen Receptor+
- post menopauseal women
What is the staging for breast cancer?
Stage 1- tumor < 2 cm
Stage 2a- tumor < 2 cm, mobile nodes. or between 2-5, no nodes
Stage 2b- tumor >2cm, mobile axillary; >5cm, no nodes
Stage 3a- tumor > 5cm, mobile axilalry; any size, fixxed axillary
Stage 3b- skin edema, chest wall invasion/fixation, inflamm cancer, breast skin ulceration, breast skin satellite mets, any tumor + ipsi internal mammary LNs
Stage 4- distant mets
What is a hiatal hernia and what is its relationship to esophagitis?
Paraesophageal- Type II: hernaition of all or part of stomach through the esophageal hiatus w/o displacement of the gastroesophageal junction
Sliding esophageal hiatal hernia- Type I: both teh stomach and the GE junction herniate into the thorax- 90%

Causes reflux becasu GE junction causes loss of the normal intraab pressure to comptency of the LES.
what are the symps to reflux esophagitis? What procedures can Diagnose?
substernal pain, heartburn, dysphagia, odynophagia (pain on swallowing), regurgitation, nausea, belching, or hoarseness (reflux of gastric juice into lower esophagus)

Dx- pH probe in LE
- EGD shows esophagitis
- manometry shows decreased LES
- barium swallow
Medical vs. surgical managment of esphageal reflux?
85% treated w/ medicine- PPIs, H2 blockers, antacids, metoclopramide, omeprazole, head elevation after meals, small meals, no food prior to sleeping

15% require surgery for persistent symptoms despite adequate medical treatment
what is the most common anti-reflux operative procedure?
Nissen fundoplication- involves wrapping the fundus aroudn the LES and suturing it in place. Maintains LES intra-abdominal
What are teh common esophageal diverticula, tehir location, their symptomatology and pathogenesis?
Proximal 3rd- Cervical and Zenker's diverticula- closely related to dysfunction of the cricopharyngeal muscle; located between the oblique fibers of the thryopharyngeal muscel and the more horizontal fibers of the cricopharyngeus
- pulsion diverticula- mech of development
- Pts w/ symptomatic Zenker's diverticula have regurgitation of recently swallowed food or pills, choking, or a putrid breath odor

- traction diverticula and not related to intrinsic abnlty in esophageal motility; mediastinal inflammation or histoplasmosis; -> scar-> contraction.
- Pts w/ traction are asymptomatic

Distal 3rd
- pulsion diverticula- bad EG junction; chronic stricture from acid reflux, antireflux procedures, achalasia or others.
What is dysphagia, odynophagia, pyrosis, and globus hystericus?
Dysphagia- difficulty swallowing
odynophagia- pain swallowing
pyrosis- substernal pain or burning sensation (heartburn)
globus hystericus: difficulty in swallowing; sensation of ball in throat. (conversion disorder)
What is teh pathophys and symps of achalasia?
Failure of LES to relax, loss of esophageal peristalsis
- Neuro- ganglionic degeneration of Auerbach's and/or vagus; infections
- Chagas

Symps- dysphagia of solids and liquids, followed by regurgitation; dysphagia for liquids is worse.
What are the management options of achalasia?
Balloon dilation of LES
Meds of reflux vs. Belsey mark IV 270 degree fundoplication
Myotomy of the LE and LES
What is the DDx of dysphagia? How would you evaluate?
Tumor, Gerd, achalasia

Hx and PEX
Posteroant and lateral chest xray
contrast studies w/ barium
CT scan of chest- esophagus IRT and others
- esophagoscopy
- manometry
Describe the anatomic and developmental differences between indirect and direct inguinal hernias?
Indirect: bowel, omentum, or other protrude through the abdominal wall due to a patent processus vaginalis. Congennital lesion; Similar to hydroceles. indirect cause a bulge in teh groin w/ increased ab pressure. laterally to inf epigastric fessesl. Most common, occur more on the R.

Direct- proceeds through the post inguinal wall, medial to inferior epigastric vessels. Aquired, not congenital. Older men. bulge in groin.
Name 3 clinical conditions which predispose the development of inguinal hernias
Increased intraab pressure- rectal, colon cancer
Abnl congenital anatomic route, open processus
What is the frequency of indirect, direct and femoral hernias by age and sex
Men: 40% direct, 50% indirect, 10% femoral;
Women: 70% indirect, 30% femoral
Children: 100% indirect
what is a sliding hernia, incarcerated hernia, strangulated hernia, Hesseblach's Triangle?
Sliding hernia: sac formed by wall of a viscus
incarcerated: swollen or fixed w/in sac; may cause intestinal obstruction
strangulated: incarcerated hernia w/ ischemia;

Hesselbach's triangle: inguinal ligament, inferior epigastric, lateral border of the rectus sheath. (floor is internal oblique and transverses abdominis
what is the clinical presentation, distinctive features, and surgical treatment of femoral hernia?
aquired, no hernia sac. Short medial attachment of the transverses abdominus muscle. onto cooper's ligament. enlarged femoral ring. Patients present w/ bulge onto ant thigh and likely to become incarcerated.
What are teh prinicples of management of a patient w/ an incarcerated inguinal hernia?
Gentle attempts at manual reduction;
Surgically, reduce abdominal viscus to abdominal cavity
close the processus vaginalis
- return structural integrity to the ab wall
Differentiate etiology, natural history, complications and Rx of umblical hernia in the infant and adult
etiology: incomplete umbilical closure allowing omentum or bowel to protrude through. Can happen even in adulds- umbilcal scar can be stressed, and seal is weakend.

Omphalocele: incomplete closure of the ab wall during development.
Gastroschisis: more severe failure of abdominal wall closure; herniates into amniotic cavity and has no sac; no covering.

Infants- no problems unless incarcerated; some resolve spontaneously. In adults these need to be treated becasue of the high likelihood of strangulation and incardceration due to fully formed walls of linea alba.

Rx- reduce ab contents- establisch continuity of the abdominal wall.
Whata re the four factors contributing to development of incisional hernia?
infection in wound
orientation of the incision
suture materials
technical details
What are the two most common types of inguinal hernia repair and indications for their use?
Bassini- use sutures to approximate the freflection of the inguinal ligament to the transversus- smaller direct/indirect hernias
McVay- transversus aponeuroses sewn to Cooper's ligament and the ant femoral sheath. for larger direct/indirect hernias.
What is Richter's hernia, pantaloon hernia, spigellian hernia?
Richter's- any site and is characterized by incarceration or strangulation of only a portion of the circumference of the bowel; symps of obstruction may be absent despite gangrene.

Pantaloon hernia- combo of indirect and direct hernia

Spigellian- cephalad to the inf epigastric vessesl and through the semicircular line.
What aer teh diseases associated with hypercalcemia?
parathyroid adenoma, parathyroid hyperplasia, parathyroid carcinoma

malignancy- ectopic PTH production or lytic mets

Vit D, Vit A intox, sarcoid, MM, hyperthyroid, thiazide or Li toxicity, milk-alkali syndrome
What si the workup of a patient with hypercalcemia?
Total serum Ca, PTH, renal function
HyperPTH w/ serum Ca and PTH elevated, and normal renal function.
- Elevated levels of serum phosphate suggest 2ry hyperparathyroidism
What is the difference between 1ry, 2ry, and 3ry hyperparathyroidism. Surgery?
1ry- parathyroid adenoma, hyperplasia, carcinoma
Adenoma- single, 1 of four clands, firm, fixed mass, pale/white, thick fibrous capsule; treated surgically, resection is curative. Resection may include ipsi thyroid lobectomy and regional lymph node resection. Hyperplasia- Enlargement < 2cm; surgical excision of 3 glands and and some remove all 4; (autotransplant into forearm)

2ry hypreparathyroid- chronically low Ca-> increased hyperPTH. Usually in CRF.
- impaired GFR-> P retension and low Ca-> increase PTH-> hyperplasia of gland-> when GFR is too low, PTH can't compensate, Serum P and PTH levels increase and Ca falls_> abnl calcificaion of tissues-> fractures, tendon ruptues; Rx- renal transplant.

3ry hyperPTH
- chrnoically stimmed hyperplastic glands of 2ry- glands become autonomous producers of PTH. Correction of Ca does not decrease PTH-> eventual hyperCa, bone disease, soft tiissue.
what ar ethe complicatiosn of parathyroid surgery?
persitent hyperCa (if adenoma is not found)
- hypoparathyroid- if all is damaged
- recurrent laryngeal nerve injury
- risk of complication is greater w/ reoperation
what si the Rx of a hyperCa crisis?
IV saline for dehydration
Diuretics for Renal Ca excretion
meds to inhib bone resorp
Rx for underlying disorder
what are the most common causes, symps and signs of hypoparathyroidism and pseudohypoparathyroidism?
Hypoparathyroid- cause- surgical- transient
- DiGeorge- functional lack of PTH from chronic hypomagnesium
Signs- numbness/tingling of circumoral area, fingers, and toes; anxiety confusion; advanced- tetany, hyperventilation, seizure, heart block; Rx- vit D and Ca

- familial disesase w/ target tissue resistance to PTH- pts remain hypocalcemic. Replace Vit D and Ca
What are the MEN syndromes involving the parathyroid?
MEN-1- Cr 11; AD
Parathyroid hyprplasia- almost 100% after 50.
Pancreatic islet cell tumors- gastrinoma, insulinoma, VIPoma, glucagonoma, somatostatinoma
Dx- high levels of hormone. (glucagonoma- red, scaly, pruritic rash (necrolytic migratory erythema); (VIPoma: secretory diarrhea w/ dehydration, hypochloremia, hypercalcemia) Rx- excision;
Pituitary- PRLoma (treat with bromocriptine) Carcinoids

MEN-IIa- AD; Cr 10
Parathyroid, medullary thyroid cancer
What are teh signs and symps of hyperCa
stones, bones, moans, ab groans, psychogenic overtones.

Renal calculi, painful resoprtion of bone, fatigure, depression, confusion, peptic ulcers, pancreatitis

irriversible skeletal damage, kidney damage via hypercalciuria and renal calculi
early stages, pts may have few symps
What is teh DDx for a thyroid nodule? What is the workup?
presenting symps- pain, pressure, hoarseness, choking, swallowing, difficulty breathing.

toxic adenoma
papillary carcinoma
follicular carcinoma
medullary carcinoma
anaplastic carcinoma
goiter, hashimotos,

PEX, TSH and free T4.
What are the risk factors for carcinoma of the thyroid gland?
rads in childhood.

poor prognosis in males, > 50, 1ry tumor > 4 cm, poor differentiation. Mets.

papillary most common, good prognosis. solution: lobectomy

Follicular- 10-20%, total thyroidectomy needed.
What are teh common presenting symps and physical findings of a pt w/ a thyroid carcinoma?
pain, pressure, hoarseness, choking, swallowing, difficulty breathing.

can be active.
what is the role of surge in treating hyperthyroid adn the role of radioactive agents?
medical blockade- injection of iodide. can inhibit, B blocker can ameliorate symps. Tionamides (PTU and methimazole- interfere with synt and peripheral conversion.

2/3rds need more
radioiodine ablation- I131; hypothyroid in 50-70%. safe, effective. no injury to parathyroids.
surgical resection- effective, no radioactivity, rapid control. injury to nerves, parathyroids. preggers. allergic to iodine, refuse radioiodine. poor compliance
What is the presentation and treatment for a thyroid storm?
thyrotoxic crisis, acute life-threatening hypermetabolic state. Fever, tachy, HTN, neuro and GI abnlties. HTN may be followed by CHF. Kids.

ICU, O2, ventilatory support, IV fluids. Dextrose IV fluids. Correct Elyte abnlties, treat arrythmia, control hyperthermia- ice packs and cooling blanket, acetaminophen. antiadrenergic drugs. correct the hyperthiroid, PTU.
what are the MEN that involve the thyroid?
2a and b
What are teh indications for CABG?
stable angina that is unresponsive to medical therapy
Unstable angina
double or triple vessel disease w/ decreased LV fxn
Concommitant CABG for patients who undergo surgery for complications of MI or those who undero elective valve replacement w/ crititcal vessel occlusion
What are teh risk factors for operative mortality in Cardiothoracic surgery?
poor ventricular fxn
>70 y/o
Hx of MI
Chronic renal failure
What is the cardiac risk assessment for non-cardiac surgery
Hx, Px, Labs, CXR
- low risk- surgery
high risk- noninvasive cardiac- exercise, echo, nuc.
low- surgery
high- hemodynamics, cardiac cath-> low surger, medium- modify risk factors, Rx pre-existing disease; intense peri-op monitory
Very high risk-> non-oerable, less extensive resection
What is the Dx plan for pulm nodule
Hx- seek previous xrays
- old lesion- follow
- new lesion/changed or no previous x-ray-> CT, hih CT or benign morph- follow every 3 months. Suspicious- low CT, percutaneous biopsy, transbronchial biopsy
- malignant or indefinite- thoracotomy
- benign, Rx

Multiple nodules requires more investigation
What is the role of PFTs in assessing morbidity in pulmonary resection
FEV1 helps identify pts who cannot tolerate pulm resection
FEV1> 800-1000 ml needed to avoid chronic resp insufficiency after surgery
Diffusion of CO helps to evaluate alveolar-capillary membrane and it's fxn.
Pneumothorax, how do you diagnose?
Hx of chest pain or pressure.
Px of decreased breath sounds on ascultation, tympany on percussion
Dx confirmed by CXR
How do you treat a pneumothorax?
symptomatic pneumothorax requires a chest tube
Surge consists of closure and exclusion of ruptured bleb or any other large blebs w/ surgical staplers and mechanical pleurodesis (creation of fibrous adhesion between the visceral and parietal layers of the pleura by rubbing parietal pleura w/ dry gauze to create inflammatory rxn coupled w/ complete lung expansion. Obliterate pleural space and prevent recurrence.

Thoracoscopy - exclusion of blebs, lysis of adhesions, and sclerosis
Mitral valve disease?
stenosis- rheumatic valvulitis, scarring and fusion of leaflets. Scarring of chordae tendinae, shrinking of subvalvular apparatus.
Rugurge- rheumatic, myxomatous degen of mitral leaflets, preivous MI or endocarditis
Aortic valve disease
stenosis of progressive narrowing of bicuspid, senile degen and calcification

Regurge- aortic annular dilation, scarring from valvulitis from rheumatic heart, valvular damage from endocarditis
What is the differences between mechanical and bioprosthetic heart valves?
mechanical- durable, obstrucion in small, calcification w/ age, dialysis, coumadin

Bioprothetic- durable, thromboembolsim
How do we choose bioprosthetic vs. mechanical?
mechanical- lifetime
age < 70- mechanical unless they can't use anticoag
w/ pts w/ less than 10 yrs-> bioprosthesis

Women- bioprostheiss- (can't take coumadin)
Xenograft- no need