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284 Cards in this Set

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cardiac contraindications to elective surgery
mi < 30d, decompensated CHF, significant arrythmias (ie block, symptomatic ventricular; not afib/aflutter); severe valvular disease
how long to stop asa before surgery
1wk (vs 2d for other NSAIDs)
does hyperchol contraindicate surg?
no
what to do if concern for cardiac dz?
cardiac c/s, ecg, ?stress test (exercise vs pharma) ==> cardiac cath if unstable angina
what to do with morning insulin in diabetic on day of surgery?
INSULIN ONLINE: if glucose > 250, give 2/3 AM dose; else give 1/2 AM dose; NO ORAL HYPOGLYCEMICS
what BP greatly increases cardiovascular risk? What to do about it?
DBP > 110 -- keep pt on beta-blockers/other antihypertensives on day of surgery
how long after smoking cessation to operative risks linger?
bronchial ciliary function returns in 2d, but operative mortality high for 6wks
how to minimize operative risks in pt with respiratory pathology?
can give perioperative bronchodilators, esp for COPD
what to check in preop assessment if significant peripheral vascular disease?
cardiac function (ie stress test) because PVD a/w CAD
how does prior CABG affect periop risk if it was 6m-5y ago? >5y ago?
if 6m-5y, PROTECTIVE (?formation of collaterals?); if > 5y, graft occlusion rates are high, so stress test needed to verify efficacy
do preexisting CABG and PTCA have the same perioperative effects?
no -- PTCA has much higher failure rate ==> need cardiac w/u prior to surgery
what degree of stenosis warrants CEA?
>70%
what preop test appropriate if pt has a history of stroke?
carotid duplex
how should patients with chronic liver failure be prepped for anticipated surgery?
1) abstain from ALCOHOL for 6-12 wks prior to surg (like tobacco for smokers); 2) control ASCITES medically [k-sparing diuretics, na, h2o restriction]
what do chronic renal failure pts need to do immediately prior to surgery?
undergo dialysis to optimize electrolytes
how can renal failure cause bleeding problems? Whats the treatment?
renal failure --> uremia --> platelet dysfunction; TREATMENT: not platelets b/c they wont work ==> 1) DDAVP (causes vWF release aiding platelet aggregation); 2) DIALYSIS (decreases uremia); 3) FFP (temporarily corrects plt deficit)
how does valvular heart disease affect surgery? (elective and urgent)
BOTH: eval preop for stability/compensation with ECHO, give abx if GI/dirty case to prevent SBE; ELECTIVE: can proceed iff pt is stable and valvular disease is compensated; URGENT: need intraop monitoring (a-line, ?TEE)
what procedures need abx for SBE ppx? Which abx?
DENTAL: amox unless pcn all --> ceph/clinda/clarithro; GI: amp/gent or vanc/gent if pcn all (gent only if high risk)
what metabolic effects of golytely
NONE (no ion/h2o movement)
cloudy urine + mental status changes = what pathology? What's the tx?
urosepsis; dx with u/a + cx, tx with broad spec abx;
5ws of post-op fever
1) WIND (pneumonia, atelectasis -- mcc); 2) WATER (UTI -- 2ndmcc, d3); 3) WALKING (DVT --> ?PE); 4) WOUND (infection); 5) WONDERDRUG (
what does pus at venupuncture site suggest? How to tx?
SUPPURATIVE PHLEBITIS (infection of thrombus in IV site) --> tx by pulling line, blood cx, IV Abx, and cutting out vein to first non-infected branch
how to tx an enterocutaneous fistula?
can be treated non-operatively ==> NPO, TPN, labs; should resolve in 4-5wks; if it doesn't, need to go to OR
2 causes of HIGH post-op fever
1) ATELECTASIS (not really a big deal); 2) WOUND INFECTION w gas-producing organism (clostridium, g-negs) --> can spread quickly along fascial plane, needs to be treated quickly with wide excision, debridement, and abx
timing of healing of wound by primary intent (3)
1) RE-EPITHELIALIZATION: 2d; 2) COLLAGEN production and cross-linking: 4-6wks; 3) COMPLETE remodeling and healing: 6mos
when to use abx with wound infection
first just drain and debride non-viable tissue, apply wet-dry dressings; if cellulitis continues to spread, give abx
three levels of contamination of wounds; what kind of repair with each? When to use abx?
1) CLEAN (eg no GI/resp/GU entry): 1' intent, no abx unless FB placed; 2) CLEAN-CONTAMINATED: GI/resp/GU entered but prepped, 1' intent, YES abx; 3) CONTAMINATED (eg stool in abdomen): 2nd/3rd intent, saline dressing, requires preop abx
what are the indications for intubation (6)
1) poor RESPIRATORY EFFORT; 2) decreased MS; 3) GCS <= 8; 4) can't PROTECT airway; 5) compromised RESPIRATORY MECHANISM; 6) suspected LARYNGEAL EDEMA [inhalation burn, trauma]
tx of sucking chest wound (in order)
1) occlusive dressing; 2) chest tube
what can look like tamponade?
myocardial contusion -- causes arrythmias rather than cardiac failure; detected by ECG, confirmed by cardiac enzymes/imaging
how much blood loss with each of the classes of shock? When are changes in VS seen?
CLASS I: <15%; CLASS II: 15-30%; CLASS III: 30-40%; CLASS IV: >40%; change in VS seen around CLASS III
how to clear c-spine in a comatose patient?
only with MRI -- CANNOT CLEAR CLINICALLY
signs of fresh spinal cord injury (5)
1) PRIAPISM (often first sign); 2) loss of ANAL sphincter tone; 3) loss of VASOMOTOR tone; 4) BRADYCARDIA; 5) ILEUS
what to do with penetrating trauma below clavicle? What are you worried about?
worried about subclavian vessel injury -- notoriously hard to diagnose; if pt STABLE, do angiogram; if UNSTABLE, explore operatively
signs of aortic injury on CXR (2+)
1) widened MEDIASTINUM; 2) indistinct AORTIC KNOB; OTHERS) apical cap, tracheal deviation
in which patients do you get abdominal imaging even if there are no signs or symptomso f injury?
1) UNPROTECTED TRAUMA [eg ped, bicycle]; 2) HIGH-ENERGY TRAUMA [high speed, no restraints, large fall]; 3) HIGH-RISK pt [old, sick, immunosuppressed]
biggest concern with splenectomy
post-splenectomy sepsis
management of splenic injury
UNSTABLE --> OR; STABLE --> depends on grade of lac (I-III --> observe; IV-V --> OR); OR options include splenectomy, partial splenectomy, splenorrhaphy, angiography, embolization
management of liver lac
UNSTABLE --> OR; STABLE --> observe
whats the concern with mesenteric injury?
requires high force, so mesenteric injury usually suggests concomitant bowel injury
what test to do prior to nephrectomy?
IVP to confirm presence and functioning of contralateral kidney
management of pancreatic injury
REQUIRES EXPLORATION of panc + duo; MINOR injury --> drained and debrided; MAJOR injury (eg ductal injury) --> resection of pancreatic tissue, repair of duo
mgmt of duo hematoma
can obstruct lumen --> NPO, observe for 5-7d
what are the 3 zones of non-penetrating RP hematoma? What is their management?
I) CENTRAL: vascular territory, needs to be explored surgically [also duo and panc]; II) FLANK: usually renal, can observe if stable; III) PELVIC: observe if stable, but angiogram +/- embolization if unstable
whats the big concern with head injury? How do you minimize risk? (3)
big concern is cerebral edema --> increased ICP --> decreased CPP; MGMT: 1) elevation of head; 2) ?hyperventilation [mixed data, currently reserved for pts with impending hernia]; 3) mannitol
what two injuries can cause blown pupil?
1) tentorial herniation; 2) epidural hematoma
what is branham's sign?
a/w FISTULA; if fistula is compressed, HR drops 10 beats/min (?2/2 increased SVR?)
what effect does PEEP have on preload?
inc PEEP --> increased intrathoracic pressure --> decreased venous return --> decreased preload
what to do if strong evidence of trachea / esophageal injury?
EXPLORE
what to do if neck injury but no obvoius sign of tracheal/esophageal injury
laryngoscopy / bronchoscopy for airway; esophagoscopy / barium swallow for esophagus
what to do if pt is hoarse following neck injury? Why?
worried about airway injury, but could be nervous; --> need to explore or do laryngoscopy at minimum
what is the parkland formula?
4ml/kg/%BSA/d * weight * %BSA; 1/2 given in first 8 hrs, rest given in remaining 16hr
whats the risk with myoglobinuria? How do you fix it?
can cause ATN; tx with lots of fluids, alkanizing urine, and osmotic diuresis
protein reqs in diff pts (3 diff types)
1) NONDEPLETED: 1mg protein / kg / d; 2) DEPLETED (malnourished): less; 3) HYPERMETABOLIC: 2-2.5mg/kg/d
what is the first clinical manifestation of free fatty acid deficiency?
dry, scaly skin --> tx by administering lipids (eg soybean oil?)
empirical w/u and tx of nonspecific epigastric pain
labs, KUB, RUQ u/s to r/o cholecystitis/obstruction badness ==> then H2 blockers if negative
what to do if h2 blocker empirical tx for epigastric pain fails?
scope + biopsy to r/o ulcer dz / cancer; if normal, restart H2 blockers +/- h.pylori tx (for nonulcer dyspepsia)
mgmt of GERD
medical (h2 blockers); if fails, need surgical intervention (Nissen fundoplication)
what needs to be documented prior to Nissen for GERD?
need to show normal peristalsis by esophageal manometry to ensure normal post-op swallowing; may need 24-hr pH probe testing to confirm acid reflux if no explanation for reflux seen on manometery (eg nl LES tone)
what are the two main tests in evaluation of GERD/esophagitis?
1) MANOMETRY: measure LES pressure, show normal peristalsis in order to proceed with surgery; 2) 24-HOUR PH PROBE: confirm diagnosis of acid reflux
natural progression of GERD (3)
GERD --> esophagitis --> Barrett esophagitis --> ?cancer
tx of non-Barrett esophagitis
if MILD: med tx; if SEVERE: surg anti-reflux tx
tx of Barrett esophagitis
MILD: medical tx (85% effective) -- head up @ night, small meals, 8-12wks PPI, followed by regular surveillance scope + bx q18-24m; SEVERE: esophagectomy
types and tx of hiatal hernia (2)
TYPE I (sliding): tx like GERD (nonsurg); TYPE II (paraesophageal): repair necessary to avoid strangulation
noninvasive test for h.pylori
urea breath test
tx for h.pylori
triple therapy (usu PPI, metro, clarithro/amox; +/- bismuth, tetracycline)
types and tx of acid producing ulcers
(pyloric, duodenal, gastric types II and III): acid suppression and h.pylori tx ==> if fails (6wks), surgical tx (HSV vs vagotomy+antrectomy vs vagotomy+pyloroplasty)
preferred surgical tx of PUD
if uncomplicated, HSV (higher rate of recurrence, but fewer complications)
big difference in management of gastric vs duodenal ulcers
gastric ulcers have potential for malignancy -- REQUIRE BIOPSY (8-12 at edge of ulcer)
tx of gastric ulcers
scope, biopsy (to r/o cancer) ==> if benign: antacids, H2 blocker, +/- h.pylori tx
what to do with gastric ulcers non-resolving on medical tx? (2 diff time points)
at 12 WEEKS: repeat endoscopy, biopsy; at 18 WEEKS: ?resection; vagotomy unncessary unless type II or III ulcers (acid-related)
tx of malignant gastric ulcer (early gastric cancer)
1) STAGE -- CT/endoscopic ultrasound; 2) PARTIAL GASTRECTOMY
types of gastric cancer (2) -- which is worse?
1) INTESTINAL: gland forming, better prognosis; 2) DIFFUSE: extends into submucosa --> bad, can develop into "linitis plastica"
tx of perforated ulcer (duodenal, gastric)
1) DUODENAL: if 1st time, do graham patch; if recurrent, consider HSV/V&P; 2) GASTRIC: ALWAYS resect
how does time affect management of perforated duodenal ulcer?
if fresh perforation (<12hrs old), can do whatever; if > 12 hrs old, sepsis risk very high, so do minimum -- graham patch, peritoneal debridement, IV Abx
management of coffee-grounds emesis
h2 blocker, observation -- scope not necessary
management of bright red blood in emesis (3 scenarios)
scope --> 1) WHITE-based ulcer: not actively bleeding, NTD; 2) CLOT in ulcer: recently bleeding, do ENDOSCOPIC HEMOSTASIS; 3) ACTIVELY BLEEDING ARTERY: need to go to OR vs ENDOSCOPIC tx
what are the endoscopic treatments for a bleeding vessel?
INJECTION of epi or sclerosing agents; THERMAL coagulation; LASER therapy; SUTURING
whats different about surgical tx of bleeding duodenal vs gastric ulcers?
duodenal: can oversew vessel; gastric: NEED TO EXCISE (cancer risk)
tx of gastric varices
1) endoscopic BANDING, COAGULOPATHY correction (if cirrhosis), VASOPRESSIN/OCTREOTIDE; 2) repeat ENDOSCOPY, retry banding; 3) TIPS or balloon TAMPONADE
what coagulopathy results from liver failure (cirrhosis)? (2)
1) FACTOR DEFICIENCIES (vit K dependent factors 2, 7, 9, 10); 2) THROMBOCYTOPENIA: from splenomegaly --> sequestration
tx of mallory weiss syndrome
control vomiting --> bleeding normally stops; if not, injection vs electrocautery
what medication given for maintenance in tx of esophageal varices?
oral beta blockers
tx for gastric lymphoma
depends on stage; h.pylori eradication --> surgery --> radiation --> chemo
two main potential complications of cholecystectomy
1) injury to BILE DUCT; 2) injury to HEPATIC ARTERY
use of abx in symptomatic cholelithiasis vs acute cholecystitis
symptomatic cholecystitis: give 1dose 1hr before procedure (clean-contaminated case); acute cholecystitis: give abx preop and 24hrs postop
what are bilis with cholecystitis? What if they're higher?
usually mildly elevated: 2-3; if higher (>=4), consider CBD obstruction
tx of CBD stone
if >=3mm, need to be REMOVED; mult options, including ERCP, lapchole->IOC/exploration
how does elevated amylase affect cholecystitis management?
if transient elevation, wait for it to drop back down, then perform lap chole with IOC (likely CBD stone); if persistent elevation (acute pancreatitis), wait for pancreatitis to resolve (hydration, analgesia, etc.) and delay cholecystectomy
what do you worry about with gallbladder sx and fever? (4)
cholangitis, empyema (pus in gall bladder), pericholecystic abscess, or just acute cholecystitis
tx of empyema of gallbladder
if STABLE, IV Abx and emergent exploration/excision; if UNSTABLE, IV Abx + cholostomy tube
tx of acute cholangitis
IVF, IV Abx; U/S --> if stone, requires urgent decompression: ERCP with sphincterotomy, STONE removal
name 2 types of gallbladder emergencies
1) PALPABLE painful gallbladder --> suggests inflammation, imminent rupture; 2) EMPHYSEMATOUS gallbladder -- gas forming org in wall
what can be confused for cholangitis in patients s/p cholecystectomy? What is the tx?
biliary stricture --> tx by surgical exploration + bypass
how to w/u and manage ?biliary leak s/p cholecystectomy?
WORKUP: two main tests 1) HIDA (detect leak) and 2) U/S (detect collection); if positive, treat with ERCP and STENT to close defect; drain collection if significant
what imaging studies to use if ?pancreatic mass (3)
1) transabdominal u/s; 2) abd CT; 3) endoscopic ultrasound (best)
what do you need to know before excising a pancreatic mass? Why? (2)
1) need PATHOLOGY -- if not cancer, DON'T RESECT (high m&m with procedure); often, pathology determined intraop before resection; 2) need IMAGING to make sure no METASTASES (don't resect if mets -- not curable); also look for mets INTRAOP
what is Klatskin tumor?
cholangiocarcinoma at bifurcation of hepatic ducts
how do you w/u and tx a klatskin tumor?
WORKUP: hard to see on CT --> need to w/u using ERCP; TREATMENT: surgical resection if no mets (like panc ca); most tumors unresectable / detected after mets
what type of surgery for gallbladder cancer? Why?
OPEN cholecystectomy (NOT laparoscopic --> risk of seeding trocar sites)
what two types of gallbladder pathology predispose to gallbladder cancer?
1) POLYPS > 2cm; 2) CALCIFIED (PORCELAIN) gallbladder
how to w/u PANCREATITIS (imaging)
obstructive series imaging; CT not indicated unless complicated
tx for pancreatitis
palliative: NPO, IVF, pain meds, observation, +/- TPN
how to tx gallstone pancreatitis?
palliative tx until resolution of pancreatitis symptoms (usu 48 hrs) followed by cholecystectomy and CBD stone removal
if patient with acute pancreatitis begins to worsen and look ill, what are you worried about? How do you w/u and tx it?
severe necrotizing pancreatitis with SIRS and thirdspacing of fluid ==> need CT to look for other causes of decompensation (unlike uncomplicated pancreatitis) ==> FLUID RESUSCITATION is essential, ventilation if development of ARDS
correlation of amylase levels and pancreatitis
none
indications to intubate
ABGs (PaO2 < 60, PaCO2 > 45) and CLINICAL STATUS
tx of pancreatic abscess
aspirate and culture for Abx, then drain
specificity of amylase for pancreatitis
poor --> can be elevated in peripancreatic inflammation, eg mesenteric ischemia, volvulus, etc.
how do you tx a pancreatic pseudocyst?
manage expectantly for 6wks: NPO, IVF, TPN; if no improvement after 6 wks, need to DRAIN surgically
why wait 6 wks to operate on pancreatic pseudocyst? (2)
1) often resolve spontaneously; 2) in 6 wks, enough fibrous tissue to facilitate surgical closure
are hepatic lesions usually benign or malignant? What are common types of each?
usually BENIGN; 1) BENIGN: cystic (simple cyst) or solid (hemangioma); 2) MALIGNANT: HCC, mets, cholangiocarcinoma
what are three types of hepatic collections and their treatment?
1) SIMPLE CYST: ntd; 2) MULTILOCULATED CYST: operative steralization and excision; 3) ABSCESS: if pyogenic, IV Abx + drainage; if amebic, tx with metronidazole (no drainage)
differential of solid hepatic masses (BENIGN and MALIGNANT)
BENIGN: hemangioma, focal nodular hyperplasia, hepatic adenoma (+/-); MALIGNANT: HCC, metastatic cancer
most common solid hepatic mass
hemangioma (benign)
dx of hemangioma
RBC SCAN (inc uptake) or CT with CONTRAST (out --> in enhancement); avoid biopsy if possible --> risk of bleeding
tx of hemangioma, focal nodular hyperplasia, and hepatic adenoma
HEMANGIOMA: none (unless symptomatic); FOCAL NODULAR HYPERPLASIA: none; HEPATIC ADENOMA: resection if large/persistent (risk of rupture or development of HCC)
dx of focal nodular hyperplasia. how do you tell it's not hepatic adenoma or cancer?
often see CENTRAL STELLATE SCAR on imaging; hard to distinguish from more dangerous pathology, so BIOPSY necessary
which hepatic lesion is a/w oral contraceptive use / pregnancy?
hepatic adenoma
tx of HCC
if nonmetastatic (do CT first), SURGICAL;
tx of hepatic abscess
if PYOGENIC, small/multiple --> IV abx x 6wk; large/singular --> need to drain + abx; if AMEBIC: just metronidazole (no surg)
mgmt of small bowel obstruction
KUB, NPO, IVF, NG tube; watch for a couple days (most RESOLVE SPONTANEOUSLY). take to OR if worsened or new indications
indications to take SBO to OR (5)
1) high fever, 2) high WBC, 3) decreased pH (suggests ischemia), 4) peritonitis/local tenderness, 5) failed medical management (don't improve while observed)
definition and tx of closed loop obstruction
DEFN: inlet and outlet of loop of bowel is obstructed --> TX: OPERATE
operative mgmt of closed loop obstruction
assess viability of bowel -- if dead, cut it out; if possibly viable, two options: 1) RESECT, reanastamose; 2) CLOSE, observe, REEXPLORE in 24 hrs
how to confirm dx of SBO if question of SBO vs ileus
upper GI with SBFT
what post-op risks a/w accidental enterotomy? (2)
1) post-op LEAK; 2) small bowel FISTULA
how to w/u and manage stable pt with ?ischemic bowel
INITIALLY, need dx: 1) sigmoidoscopy (should see ischemic colon) or if negative, 2) angiography (gold standard); if no evidence of NECROSIS, medical management -- fluids, npo, abx; LATER, can do prophylactic revascularization and longterm ASA
what operative risks a/w polycythemia? how do you manage them?
polycythemia --> hypercoagulable state; need to correct prior to procedure (PHLEBOTOMY, HYDRATION)
what does bloody diarrhea suggest in ischemic bowel? mgmt?
suggests NECROSIS; do SIGMOIDOSCOPY --> if just mucosa, can manage medically; if involves full thickness, requires SURGERY
difference in etiology of colonic vs small bowel ischemia
colonic is rarely 2/2 an arterial obstruction (more likely low flow state) --> less likely to benefit from or be diagnosed by angiography
MCC of SBO in pt with crohn's disease
stricture
mgmt of fistula or stricture a/w crohns
NONOPERATIVE: NPO, TPN, bowel rest, observation; if no resolution, tx surgically
how to manage perianal problems in crohn's?
metronidazole; surgery if abscess
timeline of increased cancer risk with UC? what are the implications for surveillance frequency?
minimal inc in cancer risk for first 10 yrs, then increases steadily. after 8 yrs, need colonoscopy every 1-2yrs --> resection if severe dysplasia on biopsy
what is pouchitis? how do you treat it?
inflammation of ileal pouch after colectomy; seen in 1/3 of pts with ileal pouch; tx with metronidazole (like perianal problems in Crohn's)
tx of toxic megacolon
MEDICAL MANAGEMENT: bowel rest, decompression (NG tube), IV steroids ===> if no improvement in a few days or new findings (free air, peritonitis, fever, etc.), SURGERY
what does air in wall of colon suggest?
IMPENDING PERFORATION --> operative intervention
how to interpret pyuria in w/u of ?appendicitis
could be UTI/pyelonephritis, or peri-appendiceal ABSCESS; if not gross pyuria, could STILL BE APPENDICITIS (periappendiceal inflammation)
radiographic sign of crohn's disease
string sign
how to elicit tenderness with retrocecal appendicitis?
via RECTAL EXAM
most common ages for appendicitis
BIMODAL (25 and 65)
why is appendicitis bad in the very young and very old
very young: often present after perf; very old: present with vague, nonspecific sx
what to do if appendicitis in pregnant woman?
OPERATE (peritonitis much more dangerous than appendectomy)
what does carcinoid tumor look like? where is it found? how do you test for it?
yellow mass, often in appendix or small bowel; more common in appendix, but more likely to met from small bowel (esp ileum); check for 5-HT and 5-HIAA levels in urine
management of carcinoid tumor in appendix -- how do size and location affect management?
if >2cm or in base of appendix, need to perform RIGHT HEMICOLECTOMY; if <2cm and at tip, can get away with SIMPLE APPENDECTOMY
management of carcinoid tumor in small bowel?
RESECTION, esp of ileum and lymph nodes (high rate of metastasis to liver)
what is recommendation for screening of CRC?
if NORMAL RISK: starting at 50y, get 1) colonoscopy q10y; OR 2) sigmoidoscopy q5y and FOBT q1y
what past medical history increase recommended screening of CRC? how?
1) FAP: sigmoidoscopy q1y (will see polyps in sigmoid); 2) HNPCC: colonoscopy q1-2y (few polyps, might be in nonsigmoid); 3) ADENOMATOUS POLYP or CRC RESECTION: colonoscopy 3y after removal, then q5y, CEA q3m for CRC resection
intial tx for hemorrhoids; tx if refractory
INITIAL: sitz baths, stool softeners, increased fiber; REFRACTORY: depends on location -- internal: endoscopic banding/ligation; external: surgical excision; COLONOSCOPY/SIGMOIDOSCOPY to r/o cancer
types and tx of polyps (2)
1) PEDUNCULATED: usu can excise with snare (polypectomy) --> pathology --> cancer in stalk --> partial colectomy, else scope every 3 yrs; 2) SESSILE: excise -- <2cm endoscopically, >2cm surgically; need f/u surveillance colonoscopies
tx of colon cancer
SURGICAL RESECTION +/- adjuvant chemotherapy (5-FU, levamisole); NOT radiation
what labs to follow with colon cancer?
CEA (for recurrence) and LFTs (for liver mets)
what histology suggests poor prognosis with CRC? (3)
1) poorly differentiated; 2) mucin-producing; 3) signet-cell
potential causes of obstruction following colectomy (2 big categories)
1) LEAK: from anastamosis --> inflammatory ileus; 2) MECHANICAL: adhesions, internal hernia, obstructed anastamosis; late complications include cancer recurrance and stricture
w/u and tx of anastamotic leak
WORKUP: often see feculant matter from wound --> CT to see if drainable collection, gastrograffin enema or colonoscopy if unsure about patency of anastamosis; TREATMENT: observation (npo, ivf) --> most will close (unless distally obstructed --> operate)
how does location affect tx of rectal cancer?
if within 5cm of anal verge, need to do abdominoperineal resection (cant keep margins clean without destroying anal sphincter) --> permanent ostomy; if >5cm from anal verge, can do low anterior repair
how does rectal cancer spread? to where?
DIRECT EXTENSION (anterior structures incl bladder, ureter, prostate, seminal vesicles) and LYMPHATICS (internal iliac nodes, sacral nodes, inferior mesenteric nodes)
what to do with large, bulky rectal cancer?
PREOP RADIATION (often effective enough to not require surgery!)
tx of anal cancer
NIGRO PROTOCOL: chemo, radiation, NO SURGERY
tx of diverticulitis (depending on patient)
HEALTHY patient: liquid diet, abx x 7-10d; ELDERLY: IVF, NPO, bowel rest, IV Abx; if >1 episode or COMPLICATIONS (perf, abscess): ELECTIVE RESECTION (in 4-8 wks after colonoscopy to r/o cancer)
initial w/u of upper GI bleed
NG Lavage to make sure not upper GI bleed --> if positive, get upper endoscopy; else get anoscopy
MCC lower GI bleed
1) AVM; 2) diverticulosis
does lower GI bleed need to be admitted if bleeding stops?
YES -- need to observe and determine etiology (make sure not cancer) -- colonoscopy when stable
why not perform colonoscopy while pt is actively bleeding?
1) can't see anything; 2) higher perf risk (can't see wall)
how to stop diverticular/AVM bleeding?
vast majority stop by themselves -- just manage expectantly; if don't stop, can try colonoscopic or operate
what to do if persistent lower GI bleeding?
can try colonoscope for tx of AVM or polyps; if persistent bleeding and 4-6u of blood given, need to ID source (angiogram if stable, RBC scan if unstable) and go to OR
dx and management of sigmoid volvulus
dx by barium enema; tx: 1) "detorsing" by rigid proctoscope if STABLE, or 2) sigmoid colectomy with colostomy/anastamosis depending on patient stability
tx of cecal volvulus? how does it differ from sigmoid volvulus?
URGENT SURGERY -- detorsion, colectomy, cecopexy; (nonoperative tricks used for sigmoid volvulus don't work)
what is ogilve's syndrome, and how is it treated?
pseudobstruction, esp of cecum/rectum; if colon < 8cm, just watch; if colon > 10cm, decompress endoscopically or surgically
most common location and tx of anal fissure
mc location: posteromedial; tx: sitz baths, high fiber diet, stool softeners (like hemorrhoids)
malignancy of coin lesions in lungs
depends on age -- 50% at 50yo
characteristics of lung lesion on xray that suggest malignancy
poorly defined border, no calcifications
w/u of solitary pulm nodule found on cxr
CT --> BRONCHOSCOPY (bx lesion), MEDIASTINOSCOPY (bx nodes), ?needle biopsy
what to do with solitary pulm nodule w/u showing benign lesion? Malig lesion?
BENIGN: follow with CT in 6-12mo; MALIGNANT: stage, then resect if Stage I/II, chemo/rads if Stage III
how to stage lung cancer? Management of each stage?
STAGE I: solitary lung cancer (resection); STAGE II: lung cancer + LN in lung (resection); STAGE III: lung cancer + LN in mediastinum or elsewhere (can't resect, need to do chemo/rads)
two big categories of lung cancer; what are the differences in management?
1) SCLC -- usu presents with mets, so can't resect ==> chemo; 2) NSCLC -- often resectable +/- chemorads; usu adeno vs squamous cell (scc a/w pthrp)
how does surgical management of NSCLC differ if it invovles an airway?
if NOT involved airway, can do thoracotomy --> lobectomy; if BRONCHUS involved, need thoracotomy --> pneumonectomy (remove whole lung), can also consider "sleeve lobectomy" = lobectomy + removal of section of bronchus -- safer but harder
what are the sx of pancoast's tumor? Whats the management?
multiple sx: brachial plexus sx, horner's, pain from chest wall invasion; usu invasive at time of dx --> Tx occurs in two phases: 1) preop radiation for debulking followed by 2) surgical resection
what is the concern with hemoptysis + atalectasis? What is the management?
bronchial obstruction causing infection, decreased lung function; worrisome causes include BRONCHIAL ADENOMA: has malignant potential --> requires lobectomy
tx of mesothelioma
extrapleural pneumonectomy -- bad prognosis despite aggressive tx (<1yr)
mcc of nonresolving PTX with chest tube
techincal error: improper placement or leak at site of entry --> replace tube
what causes empyema in lung? What bugs? How to tx?
pus in pleural cavity -- occurs as a complication of pneumonia, usu from s.pneumo/gnr; tx in 3 steps: 1) Abx, 2) Drainage, 3) Reinflate lung (CT usually sufficient, but may need minithoracotomy/VATS if loculated)
how does IMA compare to other vessels for CABG?
best patency rate (90% at 10 yrs)
what are the risk of cardiopulmonary bypass?
causes a generalized inflammatory response which can lead to hemorrhagic, respiratory, and myocardial complications in postop period
in what cases does aortic valve stenosis require surgery? How do you determine patient's operative candidacy?
if SEVERE and symptomatic (angina, syncope, etc.) -- base operative candidacy on cath results, NOT age
what is the prognosis for dilaed cardiomyopathy? How do you treat it?
1/3 do better, 1/3 do worse, 1/3 stay the same; tx with beta-blockers (decreased demand) and, if necessary, heart transplant
causes of death following heart transplant (2)
1) INFECTION; 2) ATHEROSCLEROSIS (a type of chronic rejection)
name 2 types of esophageal diverticula. Where are they located? How do they form? How do you tx them?
1) ZENKER'S (above cricothyroid m.), 2) EPIPHRENIC (above LES); form 2/2 inappropriate muscle tone --> increased pressure --> force diverticulum out; sx include choking, regurgitation of unswallowed food, bad mouth odor; tx by cutting muscle + excising diverticulum
tx of achalasia
CCB + surgical release of lower esophagus (open or endoscopically)
how to tx esophageal tumors?
depends on location: lower 1/3 --> surgery; mid 1/3 --> surg vs chemo/rads; upper 1/3 --> chemorads
most common mediastinal tumors
thymoma, teratoma, lymphoma, germ cell tumor (in young pts)
three areas of mediastinum and common masses in each
SUPEROANTERIOR (thymoma, lymphoma); MIDDLE (cysts, lymphoma); POSTERIOR (neurogenic tumors, cysts)
tx of cysts in mediastinum. Why?
cysts are benign but may have inflammatory complications including fistula --> NEED TO BE REMOVED
3 big risk factors for thyroid cancer
1) hx of radiation, 2) fam hx of thyroid cancer, 3) voice/airway symptoms
how to w/u pt with neck mass + h/o radiation?
SURGERY --> further eval unnecessary
what syndrome a/w medullary thyroid cancer?
MEN 2 (RET gene mutation) -- pheochromocytoma, parathyroid cancer, thryoid cancer
w/u of thyroid nodule
FNA, U/S (NOT radioactive iodine study -- FNA is quite accurate)
how to tx thyroid cyst
aspiration; if > 4cm or recurrent, inc risk of malignancy --> excision
which type of thyroid cancer is BAD?
anaplastic / undifferentiated --> needs chemo, rads, NOT surgery (usually already too advanced)
4 types of potential surgical complications a/w thyroidectomy
1) U/L RECURRENT LARYNGEAL NERVE injury (hoarseness); 2) B/L RECURRENT LARYNGEAL NERVE injury (vocal cord paralysis); 3) EXTERNAL LARYNGEAL NERVE injury (distorted high pitched singing voice); 4) PARATHRYOID injury (hypoparthyroidism)
for which thyroid cancers do you use I_131 or TH for thryoid suppression postop?
follicular and papillary; doesn't help for medullary since that's parafollicular (c-cell) hyperplasia
mcc primary hyperparathyroidism? Whats the tx?
pituitary adenoma (carcinoma in < 2% cases) --> need to explore neck (+/- preop sestamibi imaging)
procedure for exploring primary hyperparthyroidism
If preop SESTAMIBI, can just take out the adenomatous parathryoid glands ("minimally invasive"); if NO PREOP SESTAMIBI, need to explore all 4 parathryoid glands
what if only find 3 parathryoid glands?
have to find 4th -- often intrathyroid
what does elev Ca and PTH suggest? How to tx?
primary hyperparathyroidism -- if adenoma, explore/resect; if carcinoma, radical resection
what does dec Ca and elev PTH suggest? How to tx?
secondary hyperparathyroidism (eg CRF) -- tx medically unless symptomatic (pain, fractures, ectopic calcifications, intractibile pruritis) --> SURGICAL MANAGEMENT (remove 3.5 PTH glands +/- relocation of remaining 0.5 to arm for easy accessibility)
what is a dangerous cause of hypercalcemia?
metastatic carcinoma to bone (esp breast, prostate)
what is the vicious cycle of hypercalcemia? How do you break it?
hypercalcemia --> osmotic diuresis --> dehydration --> hypercalcemia; break it by first rehydrating aggressively, followed by loop diuretic (calcium wasting), and bisphosphonates
rule of 10s with pheochromocytoma
10% malignant, 10% bilateral, 10% extra-adrenal, 10% epinephrine producing
tx of pheo
immediate tx of crisis is alpha + beta blockade (MUST HAVE BOTH) --> OCTREOTIDE SCAN to localize tumor --> ADRENALECTOMY
what is de quervain's thyroiditis? How to dx? How do you tx it?
acutely enlarged/inflamed thryoid with initial hyperthyroidism; DIAGNOSE by elev ESR, histology showing granulomas and degenerating follicles; TREAT with aspirin and analgesics, NOT SURGERY
when to operate in acute thryoiditis?
if suppurative/bacterial, need surgical drainage
tx of hashimotos
thyroid replacement, biopsy surveillance to ensure no cancer (hashimotos a/w increased risk)
how to tx gastrinoma (Zollinger Ellison syndrome)
can be sporadic or metastatic; if SPORADIC, RESECT; if METASTATIC to liver and LN, consider GASTRIC RESECTION vs HSV to prevent ulcerative complications
with which syndrome is gastrinoma associated?
MEN-1 (MENIN gene mutation); pancreatic, parathryoid, pituitary cancers
what classic triad with insulinoma?
WHIPPLE triad: 1) fasting hypoglycemia; 2) symptomatic hypoglycemia; 3) relief with glucose administration
tx of insulinoma
if sporadic, RESECT; if not, can use diazoxide (inhibitor of insulin release)
management of incidentally discovered adrenal mass
depends on size; if < 5cm, check labs for indication of malignancy (VMA, potassium, cortisol), then remove vs observe depending on outcome; if > 5cm, high risk of cancer --> wide resection + look for mets
defn of a TIA; how do you manage it?
transient neuro findings < 24 hrs usu 2/2 embolus from carotid bifurcation; MGMT: need to do duplex u/s of carotids, followed by CEA if > 70% stenosis; may need ECHO if heart murmur
when is CEA indicated?
if >70% stenosis in symptomatic patient; in asymptomatic patient, less well defined -- definitely CEA if > 80% stenosis, maybe if > 60%
what precautations needed to prevent stroke during CEA procedure?
intraop EEG monitoring, BP control
what possible complications with CEA? (3)
1) hypoglossal nerve injury; 2) mandibular branch of facial nerve injury; 3) vagus nerve injury
tx of amaurosis fugax
same as CEA: carotid duplex --> CEA if >70% stenosis
what to do if amaurosis fugax or TIA with PERSISTENT neuro findings (ie STROKE)?
OBSERVE for 2-4wks, then CEA when stable
what are the 6ps of acute arterial occlusion
Pain, Pallor, Pulselessness, Poikilothermia, Paralysis, Paresthesias (these last two happen first -- nerves most sensitive to anoxia)
how does acute arterial occlusion happen? How do you tx it?
embolus from heart (70%) or artery/aneurysm (30%); tx is REVASCULARIZATION in < 6hrs or else amputation; start with HEPARIN IMMEDIATELY --> OR for balloon catheter embolectomy
what is a dangerous finding postop with balloon catheter embolectomy for acute arterial occlusion?
COMPARTMENT SYNDROME resulting from ischemia-reperfusion injury --> edema
what are the three classifications of acute arterial occlusion? How do you know if the limb is not salvagable?
VIABLE, THREATENED, and IRREVERSIBLE (no dopplerable venous pulses, paralyzed, insensate)
what is the most common site of acute arterial occlusion?
LE, specifically common femoral artery
how do you workup intermittent claudication?
look for ulcers, skin changes, neuro deficits; TESTS include ABI (determines severity) and DOPPLER waveforms (normally triphasic)
most common site and findings with intermittent claudication
superifical femoral artery at the adductor hiatus --> loss of popliteal and pedal pulses
when to do angiogram in claudication?
ONLY as a PREOPERATIVE test (ie if you don't plan to operate, don't do an angiogram)
what is a normal ABI
>1
how to tx pt with intermittent claudication
operate only if grossly disturbing patient's lifestyle -- if with activity and mildly aggravating, treatment is EXERCISE + lifestyle modification
what does claudication + absent femoral pulse suggests? How does that change management?
suggests AORTOILIAC disease -- more progressive than distal disease, so SURGERY should be considered if sx progress
what are the tx options for aortoiliac dz? When do you pursue each? (2)
1) BYPASS: if multiple or long segments of disease; 2) PTA (angioplasty): if single, short segment
how to w/u pt with PVD and ULCER? When to tx? What options?
key is adequacy of blood supply -- if SBP > 65 (or 90 in DM), supply should be adequate for healing; if NOT, tx surgically: ANGIOGRAM to define anatomy (remember this is preop test) --> graft vs angioplasty/stent
what longterm tx do most pts with PVD receive?
ASA
what is a "trash foot" (complication of PVD repair)? How is it managed?
ischemic digit 2/2 atheroembolization --> blue, painful toe; TREATMENT is heparin and long-term anti-platelet therapy
what major risk associated with surgery in pt with vascular disease? How to workup preop?
CARDIAC DISEASE often a/w vascular dz (MI risk during op) --> need CARDIAC W/U: stresstest/thallium --> angiogram if positive with CABG/PTCA if dz; if testing negative, do operation with intraop monitoring if pt has other risk factors (sick, old)
mgmt of AAA
elective repair if > 5cm; observe if <5cm
what to watch for in postop period with AAA repair?
FLUID SHIFTS -- massive intraop thirdspacing, usually reversed by around day 3 --> massive fluid overload if not expected
three big complications associated with AAA repair
1) ISCHEMIC BOWEL -- presents with diarrhea +/- blood in first 3d, 2/2 sigmoid ischemia from IMA occlusion; 2) VASCULAR GRAFT INFECTION -- from graft seeding with skin flora, but may not present for months-years; 3) AORTOENTERIC FISTULA -- grossly bloody stool, usu from fistula between aorta and duodenum
threatment of three big complications of AAA repair
1) ISCHEMIC BOWEL -- need SIGMOIDOSCOPY to determine depth of ischemia; if SUPERFICIAL tx with bowel rest; if FULL THICKNESS, resect + colostomy; 2) VASCULAR GRAFT REPAIR -- remove graft, debride tissue, extra-anatomic bypass, long-term abx; 3) AORTOENTERIC FISTULA -- 3 steps: REMOVE graft, REPAIR GI, extra-anatomic aortic GRAFT
presentation, w/u and tx of chronic mesenteric ischemia
PRESENTS with post-prandial pain and resultant weight loss; WORKUP with angiogram (b/c of intent to operate); TREAT with surgical bypass (aorta --> vessel)
types of aortic dissection and management (3)
TYPE I: ascending only (OPERATE) TYPE II: ascending + descending (OPERATE) TYPE III: descending only (MED MGMT); control hypertension with all types
tx for DVT? How long?
anticoagulation (heparin --> warfarin) x 3-6m
what is low dose heparin (LDH) therapy?
prophlyactic heparin for high risk pts -- 5000U subq heparin q8-12hrs postop
ABG Findings in PE
dec PCO2 due to hyperventilation
what is the tx of PE?
SAME AS DVT (anticoagulation x 3-6m)
what is phlegmasia cerulea dolens? How to tx?
acute obstruction of venous outflow --> DANGEROUS (can cause sensorymotor loss and eventually gangrene) ==> URGENT TX (ANTICOAGULATION, LEG ELEVATION); VENOUS THROMBECTOMY RARELY INDICATED
indications for excision of skin lesion (4)
ABCD, ulceration, recent changes, nodularity
tx of basal cell vs squamous cell carcinoma
basal cell rarely metastatic -- just need to do local excision to clear margins; squamous cell slightly more metastatic (to LN) ==> need to do local excision + LN resection if palpable LN on exam
how to assess malignant potential of melanoma? Whats the management?
dangerous, malig potential depends on depth; TREATMENT: local resection with margins = f(depth). Lymphadenopathy = metastatic dz --> use IMMUNOTHERAPY (interferon)
tx of dysplastic nevus
excision if atypia on histo
what observable factors worsen prognosis of malignant melanoma?
ulceration, face/skin involvement
implications of lymphadenopathy for malignant melanoma
suggests metastatic dz --> use immunotherapy (interferon)
how to w/u a soft tissue sarcoma?
MRI, biopsy
causes of painful testicle (3)
ACUTE: torsion; SUBACUTE: orchitis, epididymitis
when to surgically treat hernia
if incarcerated/strangulated (URGENT); if not, essentially elective -- tx if giving patient problems
what repair in kids with inguinal hernia?
in kids, 2/2 patent processus vaginalis --> likely bilateral --> bilateral high ligation of the sac
what cancers predisposed by BRCA1 mutation? (2)
breast and ovarian
screening recommendations for breast cancer (based on level of risk)
NORMAL RISK: q1y mammo with clinical exm starting at age 40; HIGH-RISK: q1y mammo with q6m exam starting at age 30
what study should follow finding of microcalcifications on mammogram?
MAGNIFICATION mammogram --> stereotactic vs open biopsy depending on low vs high suspicion (open biopsy allows excision)
tx for DCIS
if unifocal, lumpectomy; if multifocal, simple mastectomy
when to combine radiation therapy with mastectomy?
NEVER -- no need for radiation if breast has been resected
implications and tx of LCIS
LCIS is an incidental finding on breast bx that is an INDICATOR, not PRECURSOR of malignanch --> no role for resection, only for close surveillance (q6m exam/mammo)
w/u of simple cyst in breast
aspiration --> if resolves, NTD; if bloody or persistent, need cytology --> excision
characteristics and w/u of fibrocystic dz
often multiple, bilateral, fluctuates with menstrual cycle; TREATMENT: cyst aspiration --> 3mo f/u --> bx/excision if persistent
characteristics and tx of fibroadenoma
most common lesion in young females (<25y); benign; TREATMENT: multiple, including excision, biopsy, or observation (if small)
characteristics and tx of phyloodes tumor
LARGE, BULKY mass --> excision
mgmt of bloody nipple discharge
suggests intraductal papilloma -- need surgical bx +/- excision
mgmt of clear, non-milky nipple discharge from multiple ducts
likely fibrocystic disease --> observation
how does age affect breast cancer prognosis?
younger women do worse
what types of skin changes can be seen with breast cancer? (3)
ALL ARE BAD -- ULCERS: suggest inflammatory carcinoma; PEAU D'ORANGE/EDEMA: suggests lymphatic involvement; SKIN/NIPPLE RETRACTION: suggests invasion of support structures;
what does eczematoid lesion of nipple suggest? Whats the management?
Paget's disease of the nipple, almost always a/w underlying malignancy --> mammo/PE --> mastectomy+staging if mass, biopsy nipple if not
when to do lumpectomy/simple mastectomy VS modified radical mastectomy?
depends on size of solitary tumor: if <5cm, can do lump/simplemast; if >5cm, need to do modified radical mastectomy
how to tx metastatic breast cancer?
Stages III and IV --> palliative chemo/rads/surg + hormonal tx
how does menopause change adjuvant treatment for breast cancer?
premenopausal: chemo; postmenopausal: hormonal
how to deal with local recurrence following breast surgery?
if 1st surgery was mastectomy, do local excision; if first surgery was lumpectomy, do mastectomy
what do you suspect in pt with h/o breast cancer who presents with coma?
hypercalcemia
tx for mastitis
warm compresses, antibiotics (for staph and strep)
tx of breast abscess
surgical drainage (I&D), NOT needle drainage