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131 Cards in this Set
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Arsenic sources
resistors |
* As5+ - competitive substitution of arsenate for inorganic phosphate during synthesis of ATP
* As3+ - binds to and inhibit enzymes with sulfhydryl groups (SH) e.g. pyruvate dehydrogenase |
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Arsenic kinetics
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the liver, kidneys, heart and lung (soft tissues and highly profused )
Hair and nails (rich in sulfur) *********crosses the placenta |
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S & S
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• Acute and subacute doses of inorganic As induce vasodilation ® occult edema (healthy weight gain)
• Long-term exposure ® ****gangrene of extremities (black foot disease) ****hypotension cns: stocking and glove distribution like Guillan Barre garlic odor to breathe kidney cass liver - • fatty infiltration**** ( A WAY TO DISTINGUISH FROM OTHER METALS***), Mee's lines ( all heavy metal tox ) - transverse lines |
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Tx for arsenic
(also used for gold, lead, mercury ) |
Dimercaprol (every 4-12 hours ) IV
oral penicillamine if exposed to the gas -- need to do chelation therapy |
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Lead sources
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usually kids playing with toys (made in china)
also pottery and amuntion |
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lead pharmacokinetics
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• ****Lead absorption in low Ca2+ iron deficiency and could be linked to DMT.
lead competes with calciu, so.. • A high PO42- in-take ® skeletal lead storage and ¯ soft tissue concentrations. • Vitamin D tends to lead bone deposition ******Milky vomit ( PbCl precipitate) Black stool : PbS |
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acutelead poisoning
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Lead Cholic ***** classic
CNS - paresthsia *********wrist dropa nd foot drop are pathneumonic |
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tx for GI lead symptoms
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• Not morphine , give calcium glucaronate
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enzymnes that lead inhibits
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ferrochelatase
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lead complications
and Tx |
seizures ( diazapam and phenytoin )
need chelation therapy |
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mercury uses
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used as an electrode and fungaside ( Iraq)
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kinetics mercury
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inorganic salts- hardly cross the placenta and BBB
organomercuralis - crosses the BBB, liver - conj to glutathione |
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mercury tx
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organic mercury - poor affinity for chelating agents
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iron tox
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iron pills -- kids
greater than 3.5 mg /liter - give deforox s & s: abdominal pain ******hemoraggic gastroenteritis |
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Pancreas Divisum
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Most common clinically significant congenital anomaly of pancreas (3-10%).
Failure of fetal duct of dorsal and ventral pancreatic primordia to fuse. |
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Pancreas Divisum results
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As a result, the bulk of the pancreas drains through the dorsal pancreatic duct and the minor papilla (the duct of Santorini).
Relative stenosis caused by bulk of pancreatic secretions passing through minor papilla predisposes patients to development of recurrent, and ***chronic pancreatitis. |
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ectopic pancreas
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Ectopic pancreatic tissue can be found in the stomach, duodenum, or jejunum in about 2% of postmortem exams.
Normal Exocrine glands cells can be activated and cause a GI bleed |
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cystic fibrosis and pancreas
recessive |
Lungs- hyperconcentrated, viscid secretions.
Pancreas- decrease bicarbonate secretion. Skin- increase NaCl in sweat. -digital clubbing -meconium ileus |
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Medications associated with Acute Pancreatitis
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Sulfa-containing drugs (bactrim, sulfasalazine)
6-Mercaptopurine, azathioprine Valproic acid Tetracycline, metronidazole Pentamidine Didanosine Diuretics (furosemide, thiazides) NSAIDs (salicylates, sulindac) |
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acute abdomen
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Ruptured appendicitis.
Perforated peptic ulcer. Acute cholecystitis. Mesenteric ischemia. Ectopic preg – check HcG - N/V – make sure not preg Pelvic exam |
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Acute pancreatitis labs
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Amylase
Marked elevation in first 24 hours Lipase Rises after 72 to 96 hours Hypocalcemia Results from precipitation of calcium soaps in the fat necrosis. Poor prognostic sign. ***AGRESSIVE FLUIDS ***** |
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chronic pancreatitis
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alcohol and fibrosis
tx: pain management |
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Cystic Neoplasms
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Tumor markers- CEA, CA19-9
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what cystic neoplasm can become malignant ?
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****Mucinous cystic neoplasms
Almost always arise in women. Can be benign, borderline malignant or malignant. Usually arise in body or tail. Present as painless, slow-growing masses. Cystic spaces are filled with thick mucin. |
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pseudocyst
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alcohol-yes (only one)
hx of pancreatitis - yes evenly located no malignant potential |
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Mucinos CN
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no hx of alcohol abuse
located in body/tail |
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PAINLESS JAUNDICE
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PANCREATIC CARCINOMA**********
molecularcarcinogenesis K-RAS: -most frequently altered oncogene in pancreatic cancer. -activated in 80-90% of cases. p16: -most frequently inactivated tumor suppressor gene. -inactivated in 95% of cases ***Migratory thrombophlebitis (Trousseau sign). – painful Less than 15% are resectable at the time of diagnosis. |
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Peds
presents with an atresia - big time distention of upper gut .. |
something else going on
no air is distal guy Seen with Down’s, cystic fibrosis, etc. Distention and no air in rectum NG tube with contrast a lot of cystic fibrosis malrotation is common emergency if obstructed |
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Meconium ileus ***
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always associated with cystic fibrosis
sick within first 24 hours of life fistulas : can occur anywhere when baby feeds - will have a frothy , bubbly secretion ,, breast milks ends up in lungs , and end up blowing bubbles .. use barium -- it layers out gastrogracin causes a pneumonitis |
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Hirschsprungs
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1/5,000
20% of neonatal obstructions Obstruction to obstipation dx: biopsy , but can also test pressures using manometry have to resect bad section and anast. |
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Diaphragmatic hernia
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baby in severe distress
***FLAT abodomen *** left sided hernia, right side protected by liver abdominal contents ends up in left chest left lung does nto develop well high mortality |
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intestinal obstructions
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N/V
big belly anyway , can be hard to tell they cant tell u where it hurts u have to be able to find it hernias : meckels , intussusception **** currant jelly stools --bowel is telescoping , needs surg right away can be seen on ultra sound meckel's |
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hernia
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incarcerated - is an emergency
otherwise will have to do a bowel ressection if its an inguinal hernia- always check other side umbillical hernia -- not uncommon --- incomplete closure of fascia -- unless huge u can wait , and frequently will close on its own |
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Meckels
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more common in males
ileal - 100 cm from valve and 2 types of tissue gastric tissue ulcerates H-pylori is harbored here |
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reflux in PEDS
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becomes a prob when failure to thrive
feeds and reflux constantly change type of feeding elevate head of crib ***DO NOT INDUCE VOMITTING **** b/c it burns coming back up also CHEMICAL BURNS - common cause of strictures in kids back of throat MILK TO NEUTRRALIZE BLEACH *** POSION CONTROL BEFORE AMBULANCE --- WILL STRICTURE ENTIRE ESOPHAGUS drano--keep a tract --- to dilate again POISON CONTROL ****** saving a life stroy - battery acid |
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pyloric stenosis --- *****
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string sign on X-ray - looks like a strong -- stomach full of barium , very tight
duodenum that is normal an old tx -- force feed.. and open pylorus ... most projectile vomit mostly male |
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peptic ulcer disease
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over -diagnosed
not very common if its real , usually before age 6 very rare.. tx: H pylori , just like an adult more common in families |
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foreign bodies
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if object gets to stomach - it will pass , if bigger than 5 cm , and has a sharp point , take it out, or it will stick
small intestine , can turn a sharp object around , blunt side down **** |
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recurring abdominal pain
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hard to dx
pain starts after an illness but it does not resolve hurts all over family anxiety |
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what's wrong kid
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have them draw - like a pic of family
and then ask them questions they will tell you what is wrong kid was upset , dad would nt come home -- safe, wearing seatbelt |
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Diarrhea
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rise in C Diff and colitis
presenting symptom is C diff g200 gm in 24 hoursreater than 3 types : osmotic , fluid changes Giardia fairly common , and have outbreaks |
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Intractable diarrhea of infancy
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infection not picking up on
4-12 weeks of age failure to thrive tests all negative need aggressive hyperalimentation |
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Chronic nonspecific diarrhea
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greater than 2 weeks of loose stools
rarely weight loss resolves spontaneously |
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Appendicitis
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*****Classic triad
RLQ pain Fever Leukocytes in kids, RLQ pain not as severe |
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Necrotizing Enterocolitis
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premature baby - sig hypoxia
free air from a perforation Premature infants Stress and hypoxia Pneumatosis intestinalis-air in bowel wall, can be seen anywhere in bowel Free performation |
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Henoch-Schonlein Purpura
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type III purpora
Abdominal pain Later develop rash (urticaria/purpura) Prednisone for severe attacks looks like crohns |
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IBD
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blooding diarrhea, and abdominall pain
take a p-anca -- if positive in UC C Diff is first presentation PSC --- primary sclerosing cholangitis most of these kids are anemic ulcerative colitis -- sent for an x-ray ---- lead pipe colon ******* thick wall, very straight colon -- no folds classic for UC x-ray shown ... lead pipe colon **** ****crypt abcesses most of the biopsies are not pathologic |
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Crohn's disease
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****Transmural enterocolitis
these kids are sicker.... mouth to anus growth retardation skip lesion ( not a whole lead pipe ) worse symtoms need to give B12 intractable pain ----indication for surg dont want a 15 year old addicted to narcotics -- will affect schoo, everything |
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Colon ---
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prob with elimination
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liver diseas
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jaundice
Conjugated Hyperbilirubinemia Dubin-Johnson Syndrome Mild jaundice < 6 Liver biopsy characeristic dark brown color black liver |
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physiologic jaundice
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*****bili > 10mg never normal in first 24 hours= SERIOUS PROBLEM
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Unconjugated Hyperbilirubinemia
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Gilbert’s
Chronic intermittent bili rise - scheduled to go to surg --- need to measure unconjugated ---related to fasting --- |
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Unconjugated Hyperbilirubinemia
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not as common
Crigler-Najjar : glucuronyl transferase Type I – severe and deadly Type II--insidious -- higher billirubin |
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Reye’s Syndrome
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Encephalopathy, liver failure
Chicken pox or influenza +/- ASA |
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Alpha 1-antitrypsin deficiency
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20% of all liver disease in children
autosomal recessive HSmegaly, jaundice, failure to thrive peds: stage if u make it out of that , will end up with emphasema , if u survive that - will end up with with cirrosis of liver will need liver and lung combined transplant |
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Wilson’s disease
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patient who had it , pimped you
what do you know about it ? Hepatolenticular degeneration Copper metabolism disorder Cirrhosis in children KAYSER-FLEISCHER RINGS in cornea Low ceruloplasmin, increased urinary copper ***Treat early to prevent need for transplant |
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blunt trauma
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most common is MVC - 48%
car is going 75 mph , u are going 75 mph --you hit something --- and declerate to zero |
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hypotensive on arrival
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blunt abdominal trauma
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Blunt Abdominal Trauma Pattern of Injury
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Spleen (most common: 40-55%)
Liver (35-45%) Retroperitoneal hematoma (15%) |
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chance fracture
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lumbar compression fx
lap belt --forward flexion of spine but anytime u see a chance , think abdominal innj --- force going that way |
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shock
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first sign will be tachy
HR > 100 Systolic BP < 100 mmHg * < 25% > 110 mmHg * 25-33% ~ 100 mm Hg * > 33% < 100 mm Hg |
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• 35 - 44% of patients admitted with hypotension will have HR <100.
why ? |
blockers
b) youth, conditioning c) elderly |
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perfusion
how to measure |
By maintaining adequate urine output, you are ensuring adequate perfusion of the heart and brain:
***adult……0.5 -1.0 cc/kg/hr child……1-1.5 cc /kg/hr infant….. 1.5 - 2.0 cc / kg/hr also , can look at ABGs |
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Trauma Bay Management General Resuscitation Algorithm
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Bolus of 1 L crystalloid, if no response…...
• Bolus second L crystalloid, if no response or a transient response Bolus of 1 L crystalloid, if no response…... • Bolus second L crystalloid, if no response or a transient response |
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chem panal
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LFT ,s
asses for hematuria |
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imagining
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CXR ****
pelvis Lac-c-spine treating all trauma patients like they have a c-spine issue |
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spiral CT
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oral contrast takes several hours to get a good image
vessel injury requires contrast CT - for solid organ inj limitstions : can miss diaphram inj , pnacreatic |
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indications for abd CT
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needs to be HD stable
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ultrasound
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ideal for HD unstable ******
sensitive tech compromised with obesity |
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5 potential places for hemorrhage
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External
2) Hemithorax 3) ******Retroperitoneum (usually pelvis) 4) Abdomen 5) Extremities 3-4 6) pelvis - 4-5 |
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what makes a positive DPL
Diagnostic Peritoneal Lavage) |
RBC’s > 100,000 -WBC’s > 500
-particulate matter |
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most common transfusion related complication ?
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Hep C
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Sickle cell disease
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spleen withers away ---- makes ig G
Can’t opsonize , encapsulated bugs |
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Abdominal Boundaries
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Superior …………Nipple line
• Inferior………… Inguinal ligaments • Lateral ……….... Midaxillary line Depends where diaphram is at the time of injury |
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Penetrating Abdominal Trauma Pattern of Injury
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liver - 40 %
small bowel - 30% |
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Kerr's sign
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Grade 5 spleen inj
IVC – full of contrast Kerr’s sign --- spleen enlarges and irritates diaphram Left arm pain Chestpain .. |
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cheese puffs
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document !!!!!!!!!!
everything |
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3 classifications :
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Pakella sign : legs crossed , and reading paper
3 groups sick as hell fine or needs work up look at them before they come to exam room ...vitals will be telling of pain |
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peritonitis
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you bump their bed, they grimace
colicky "when you were driving , when u hit a bump -- peritoneal signs rebound have to do a rectal exam , and check blood in stool testicular pain that radiates to abdomen have to deliniate ,btw GI and genitourinary ultrasound in pelvic |
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melena
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black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.
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MEN I
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parathyroid tumors
pituitary tumors pnacreatic tumors - like Zollinger-Ellison , VIPomas chrom 11 mutation |
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MEN etiology
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genetic ? or developmental -- neural crest cells affected
with mutation - 2 hits required , first in germ cell line and second in somatic cell line |
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screening for MEN I
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parathyroid most commonly involved
will see *****hypercalcemia check : calcium, PTH, Phos **** |
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MEA type I symptoms of pancreatic involvment
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peptic ulcer disease , and hypoglycemia (due to insulin secreting tumor ) ****but
if an RN presents with low sugars, she is self - medicating with insulin |
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other Symptoms of pancreatic involvement...
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Hyperglycemia, dermatitis, anemia, wt. loss
glucagon-producing pancreatic tumors ******Water diarrhea and hypokalemia VIP producing tumors |
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Anterior Pituitary Tumors
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Adenoma
2/3 of all patients Cushing’s syndrome Acromegaly Hyperprolactinemia |
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MEA type I and GI tract
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Carcinoid tumors in 5-9%
possibly due to gastrinoma Extrapancreatic gastrinoma gastrinoma triangle-good surg pimp queston |
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MEA type IIA
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associated with pheo
and with thyroid CA |
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screening for MEA type II
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calcitonin secreting
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thyroid involvement in MEA type IIA
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true MEA IIa is
bilateral multicentric diffuse or nodular hyperplasia of C-cells symptoms 2nd-3rd decade Calcitonin used for screening sporactic and is a medually carcinoma |
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if high calcitonin
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need to resect thyroid
it is a carcinoma |
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parathyroid involvement with MEA type IIA
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only 20% of MEA IIA
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adrenal involvement
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is serious if not treated early
hypertensive crisis***200/150 cardiac dysrhythmia |
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pheo
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no screening, second most common lesion in MEA type II
challenging surgical removal |
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MEA IIB
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Marfanoid habitus
neurofibromatosis , VonRecklenhausen's association |
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family member with MEN II
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get a calcitonin level ******
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why does esophageal cancer spread easier ?
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****one of only 2 organs that do not have a serosa – bare – nothing surrounding it
Same for pancreas – serosa – helps precent the spread of cancer |
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Barrett's esophagus
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glandular metaplasia with goblet cells formed in distal esophagus due to acid inj
complications : strictures, ulceration , inc risk for distal adenocarcinoma |
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predisposing conditons for esophageal cancer
squamous type ******* adeno *** |
being black
Achalasia Celiac sprue Lye stricture Plummer-Vinson syndrome Head and neck cancer Tylosis ***Barrett's |
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adenocarcinoma
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much more common in men , and whites , distal esophagous , questionable association with smoking and alcohol
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squamous cell carcinoma
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blacks , associted with drinking, smoking
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why wieght loss with cancer in esohagus ?
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difficulty swallowing!!
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exsanguinate
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total blood loss , bleeding out
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tx for lipoma
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dont cut it out !!!!
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Linitis plastica
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diffuse infiltration of malignant cells to the stomach
stomach will not peristalse signet ring cells infiltrate stomach wall produces krukenberg tumors to the ovaries *** somewhat easy to miss on path slides, looks flat .. |
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findings for gastric adenocarcinoma
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weight loss , epigastric pain , mets to Virchow's node
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dx for gastric cancers
endoscopy is gold standard tumor markers ? |
dont mean jack shit for gastric
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risk factors for pancreatic cancer
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age, diabetes *** , chronic pancreatitis
not realted to EtOH or coffee **** hereditary is super rare *** |
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although painless jaundice = pancreatic cancer ...
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90% of patients do have pain
relieved by bending forward |
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tumor markers..
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should not be used for screening , except... alpha -fetoprotein
imaging.. can do ultrasound first, although CT is goldstandard ... ultrasound.. bowel in the way ? |
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double duct sign
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* The double duct sign is a finding seen at magnetic resonance (MR) cholangiopancreatography and consists of simultaneous dilatation of the common bile and pancreatic ducts.
* This sign can also be seen with other modalities such as endoscopic retrograde cholangiopancreatography, computed tomography, and ultrasonography. * The simultaneous dilatation of the common bile duct (in the intrapancreatic segment) and the pancreatic duct occurs with biductal narrowing. * The narrowing is generally secondary to contiguous obstruction or encasement of the common bile and main pancreatic ducts by a pancreatic head tumor. * The two most common causes of the double duct sign are carcinoma of the head of the pancreas and carcinoma of the ampulla of Vater. |
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tx for pancreatic cancer
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surgery !!!!!
whipple chemo and radiation not going to heal |
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small bowel cancer
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associated with FAP
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carcinoid tumor seen with ..
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mets
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metastatic lesions in small bowel , where from ?
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skin, cervix, lung, breast, kidney
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*****Cacinoid syndrome
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Usually only with liver mets
Features flushing diarrhea abdominal pain valve disease Serotonin producing symptoms 5-HIAA used for diagnosis |
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location in small bowel where most malignant carcinoid growth is found ?
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ileum
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adenocarcinoma S and S
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Abdominal pain
Anemia and weight loss Jaundice if periampullary Advanced stage at diagnosis Survival < 6 months |
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carcinoid clinical course
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Metastasis occurs in 1/3
size of tumor is the key < 1 cm only 6% risk |
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desmoplastic rxn
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scarring of whole abdominal cavity
surgery is key |
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frank bleeding
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Frank bleeding is a type of bleeding that can form in the stool. As opposed to "black tarry stool" that is digested stool, frank blood is bright red probably caused by a hemorrhoid or anal fissures. This blood is on the surface of the stool, not digested.
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lymphoma
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clubbing of fingers
palpable mass |
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Leimyosarcoma
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Unusual to have symptoms before age 50
Melena or frank bleeding Symptoms present for more than 1 year -most have a palpable mass |
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three major factors for progression of colorectal adenoma
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# of polyps , size , histo
villous polyp is worst |
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Pneumoperitoneum, tells you ?
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free air in peritoneal cavity
perforated bowel |
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imaging , how to tell if large or small bowel ?
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septations going all the way across in small bowel
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what causes hepatomegaly ?
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ALCOHOL USE
CHF HEPATITIS TUMOR (METATSTASIS) STEATOSIS |
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MR CHOLANGIOPANCREATOGRAPHY
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NON INVASIVE
TAKES ADVANTAGE OF LONG T2 |
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HIDA SCAN
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NORMAL GALLBLADDER SHOWS PROGRESSIVE ACCUMULATION OF RADIONUCLIDE ACTIVITY OVER 30 MINUTES TO 1 HOUR.
CONSIDERED POSITIVE WITH NORMAL ACTIVITY IN LIVER AND BOWEL WITH NO ACTIVITY AT 4 HOURS MAY BE CONSIDERED POSITIVE AT 1 HOUR IF ****MORPHINE UTILIZED . (spasm of sphincter of odi) |
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duodenal lesions
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In fourth portion most are malignant
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most common pancreatic congential lesion
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Annular pancreas
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