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326 Cards in this Set

  • Front
  • Back
What is the first step in work-up for thyroid nodule?
FNA
What is the cause of Grave's disease?
TSI (anti-TSH-receptor IgG)
What is the best medical management of Grave's disease?
MMI or PTU
What is the best definitive therapy for Grave's disease?
Radioablation (I131)
"What is the treatment of Grave's in a pregnant, allergic patient?"
Thyroidectomy
What is the biggest post-surgical complication of thyroidectomy?
Transient hypocalcemia
What is the biggest long-term complication of thyroidectomy?
Hypothyroidism
What are the treatments of thyroid storm?
"SSKI (Lugol's), MMI, beta-block"
"What is the diagnosis -- hyperthyroid symptoms, no exopthalmos or pretibial myxedema"
Toxic adenoma
What is the most common carcinoma of the thyroid? How does it spread?
Papillary. Lymph nodes (Palpable - P)
What is the second most common carcinoma of the thyroid? How does it spread? Catch to diagnosis?
Follicular. Blood. Can't use FNA (penetrates capsule).
What is the best medical treatment for metastatic thyroid cancer?
I131
What must be done in addition to excision for medullary thyroid cancer?
Lymph node dissection.
How can medullary thyroid cancer be followed?
Calcitonin levels.
What gene is blamed for medullary thyroid cancer?
RET
What is the most common cause of hypercalcemia in non-hospitalized pt? Hospitalized?
Hyperparathyroidism. Malignancy.
How can the cause of hyperparathyroidism be localized? Treatment?
Sestamibi scan. Parathyroidectomy.
What is the treatment of SECONDARY hyperparathyroidism?
Treat underlying problem… then parathyroidectomy of 3.5 glands.
"2 first treatments for dangerously high, acute hypercalcemia."
Large amount of peripheral IVF's + loop diuretic.
What is Cushing's DISEASE?
Pituitary adenoma producing ACTH
How can you diagnose Cushing's syndrome? How does Cushing's DISEASE differ?
"Dex-suppression test (not with low-dose, suppressed with high doses). Disease has high ACTH"
What is Conn's disease? What are some signs/symptoms?
"Primary hyperaldosteronism. HTN, hypokalemia, low renin levels."
What is the rule of 10's? What syndrome is this part of?
"Pheochromocytoma -- Familial, bilateral, malignant, children, extra-adrenal. MEN-2A/2B"
How can you make the diagnosis of pheochromocytoma?
Plasma-free metanephrines OR urinary metanephrine + normetanephrine + VMA
How are pt's treated medically before surgery for pheochromocytoma?
"Alpha-block --> beta-block (THIS ORDER), large amounts of fluid"
What is the treatment of an incidentaloma of the adrenal?
"If less than 3cm, check for Conn's, Cushing's, or pheochromocytoma with K levels, dex-suppression, catacholamines. Then CXR and CT scan to look for other tumors. If nothing, F/U CT in 6 months. If >3cm, remove because possible adrenal carcinoma."
What is MEN-1? MEN-2A? MEN-2B?
"Parathyroid (remove 3.5 glands), pituitary (PRL), pancreas (ZE, insulinoma, VIP). Thyroid (medullary), parathyroid, pheo. Same as 2A with MARFANOID habitus."
What is deficient in hereditary spherocytosis? Inheritance? Treatment?
Spectrin/ankyrin. Autosomal dominant. Splenectomy.
What is the primary treatment of ITP? What if non-responsive? What is the best indicator of long-term prognosis?
Steroids/immunosuppressives. Splenectomy if non-responsive or refractory to therapy. Initial response to steroid treatment.
"For a patient needing platelet transfusion during splenectomy for ITP, what is the ideal time to give?"
When spleen has been removed.
"What is a common physiologic response to splenectomy? At what level is it treated, and what is the treatment?"
"Thrombocytosis. >1E6, aspirin."
How long before splenectomy should pt's be immunized. What immunizations?
"~2 weeks. HIB, Pneumococcus, Meningococcus."
What is the most common post-op complication of splenectomy?
Atelectasis.
What is an easy way to screen whether splenectomy has been successful? What if it's not?
"Peripheral smear for spherocytes, Howell-Jolly, Acanthocytes, Target cells. Probably have accessory spleen."
What are some risk factors for breast cancer?
"Family history (esp. pre-menopausal), early menarche, late menopause, nullparous, radiation, BRCA, previous biopsy."
Signs of BRCA-1?
Breast + ovarian CA
Signs of BRCA-2?
Breast + male breast CA
What is the typical screening for breast CA?
"Yearly breast exam at 20, yearly mammography at 40"
What is the best radiographic test for palpable breast lesions? What if they are very fibrous?
US. Use MRI.
A pt shows up with microcalcifications associated with a breast mass. What is the next step? Follow-up?
"Core biopsy. If benign, f/u 6 months with mammogram."
What is the treatment for fibroadenoma?
"Biopsy, 6 month f/u, excise of growth"
How are brest cysts diagnosed? Treatment?
US. Asipration if painful/complex -- cytology if complex or bloody asiprate.
What is the most common cause of bloody nipple discharge? Treatment?
Intraductal papilloma. Subareolar duct excision.
What is the treatment of a breast abscess?
"US, I&D, abx, stop breast-feeding and pump."
"Non-lactating woman with red, painful, swollen breast. Treatment?"
"Inflammatory breast cancer. Chemo, THEN mastectomy."
Patient with 'eczema' of the nipple. Next step?
Paget's disease of the breast. Nipple biopsy.
Pt with isolated breast lump needs treatment. Most important prognostic indicator?
Lumpectomy + radiation = mastectomy. Lymph node involvement.
What is the surgery performed in an isolated breast lump with no palpable nodes? What if this is positive?
"Lumpectomy + sentinal node dissection. If sentinel node positive, must dissect axillary nodes too."
What patients with breast cancer get chemo? Who gets tamoxifen? What is its side effect?
Node+ or premenopausal. ER+. Blood clots.
What are some complications of axillary node dissection?
"Lymphedema, winged scapula (long thoracic nerve), numbness (intercostobrachial nerve), no adduction (thoracodorsal nerve)."
What are the 2 most common BENIGN liver tumors? Best visualization?
Hemangiomas and FNH. Arteriography.
Woman using OCPs has spot noticed on her liver. When to remove?
Hepatic adenoma. Resect always because RISK of rupture.
When should hemangiomas of the liver be removed?
If symptomatic or extrememely large.
What is the catch-word for FNH of the liver?
CENTRAL SCAR
What is the treatment of metastasis to the liver?
"Resection if <5, radioablation if >5"
What is the treatment of cystic neoplasms of the liver?
"RESECTION if thick walls, calcifications, or septated."
How are hydatid cysts of the liver diagnosed? What should NEVER be done? Treatment?
"Serology. Aspiration. Albendazole, maybe resection."
What is the treatment of liver pus?
"Drainage, insertion of drain, and abx."
A pt has a abscess that has 'anchovy paste' leaking from it. Treatment?
Amoebic abscess. Flagyl.
What is the medical treatment of symptomatic portal hypertension (ascites)? Surgical?
"Beta-block, salt/fluid restriction, lasix + spironolactone. TIPS"
What is the cause of hepatic encephalopathy? Treatment?
High ammonia levels. Protein restriction + lactulose.
What is the treatment for an acute variceal bleed?
Fluid resuscitation + somatostatin + EGD (sclerotherapy)
What is the treatment for a variceal bleed that has been treated once with EGD but recurs?
Fluid resuscitation + somatostatin + EGD (sclerotherapy)
What is the treatment for variceal bleeds that recur a 3rd time?
TIPS after baloon tamponade.
What are the 2 simple indications for liver transplant?
ESLD or fulminant liver failure.
What is the base cause of gallstone formation?
Supersaturation of cholesterol.
What is biliary colic?
Intermittent abdominal pain caused by transient obstruction of cystic duct.
How does acute cholecystitis differ from biliary colic?
Persistent pain caused by impacted cystic duct.
What is the triad for cholangitis?
"Jaundice, RUQ pain, fever/leukocytosis."
"What is the treatment for acute cholecystitis? What if the patient is septic, or too unstable for surgery?"
Lap chole. Percutaneously drain/decompress.
What is the best diagnostic test for biliary disease?
RUQ US
What diagnostic test for biliary disease can be done for an equivocal RUQ US?
HIDA scan (cholecystitis = non-filling of gallbladder)
What is the usual bug in infected acute cholecystitis?
E. coli.
What is the treatment for choledocholithiasis?
"ERCP FIRST, then lap chole."
What is the treatment for gallstone pancreatitis?
NPO + IVFs + analgesia --> possible ERCP --> lap chole when cleared up
Pt presents with evidence of SBO with air in the biliary tract.
Gallstone ileus.
What does a porcelain gallbladder mean?
REMOVE IT -- high incidence of malignancy
What is the treatment of gallbladder cancer?
"Lap chole. If invasion to liver, wedge resection of liver."
What is the treatment of cholangiocarcinoma of the hepatic bifurcation?
Only palliative stenting
Pt has painless jaundice and palpable gallbladder.
Carvosier's sign -- periampullary cancer.
What is pancreatic divisum?
Non-fusion of ventral and dorsal pancreas -- cause of chronic pancreatitis.
2 most common causes of acute pancreatitis.
Alcohol and gallstones.
Most common cause of mechanical pancreatitis.
Gallstones.
Pt has signs of pancreatitis and results of aspiration show necrotic tissue.
Surgical debridement.
When and how should a pancreatic pseudocyst be treated?
After 6 weeks for wall thickening. Ostomy to nearest structure.
When is surgical intervention required for chronic pancreatitis? Procedure?
"Intractable pain. Peustow (pancreaticojejunostomy) if chain-o-lakes, resection of no stricture."
What is the biggest risk factor for pancreatic CA?
Smoking.
What is the most common location of pancreatic CA?
Head of pancreas.
What is the most common cause of death after resection of pancreatic CA?
Recurrence of CA.
What is the most common cause of islet cell tumor?
Non-functioning!
How can ZE syndrome be diagnosed? What should be the next step?
High gastrin levels or rise in gastrin with secretin. Check for MEN-1 syndrome.
What cells do glucagonomas come from?
Alpha cells.
What is the best number to assess nutritional status?
Prealbumin (or albumin)
What is the number for normal protein requirment? What states raise it?
"1.5mg/kg/dy. Burns, sepsis, etc."
What is the normal calorie need?
~30kcal/kg/dy
What drives the catabolic state during stressful situations?
"Cortisol, cytokines, glucagon."
Why does muscle wasting occur?
The liver uses alanine for gluconeogenesis.
What is the normal RQ ratio? What makes it too high? What is the RQ ratio of fat?
0.8. All carb diet. Fat = 0.7
What kind of nutrition should be given to a patient with hypercholremic metabolic acidosis?
Lipids.
Pt has diarrhea with tube feeds.
"Dumping syndrome -- high osmotic load causes pull of water, high sugar, high insulin, then low sugar. Decrease feeds, make more feeds, decrease lipids."
What amino acid can both decrease sepsis and increase wound healing?
Arginine.
What is the nutritional treatment of a patient with post-op ileus?
NGT + 3% amino acids + extra glucose.
What type of hiatal hernia has high incidence of GERD? Diagnosis?
Sliding (type 1). Barium esophogram + EGD.
What type of hiatal hernia requires surgical treatment? Diagnosis?
"Paraesophageal (type 2). Requires EGD, but may suspect with CXR (air behind heart, or NGT above diaphragm)"
What exactly is achalasia? Diagnosis? Treatment options?
"Non-relaxation of LES with dysfunctional peristalsis. Barium swallow (bird's beak) + manometry + EGD. Dilatation, medical, then Heller myotomy."
What is the most common esophageal diverticulum? Cause? Treatment?
Zencker's. Non-relaxation of cricopharyngeus. Ligation of diverticulum + myotomy of cricopharyngeus.
What is a diverticulum in middle of esophagus called? Cause?
Traction diverticulum. Mediastinal inflammation.
What is the diagnosis in a pt with esophageal dysmotility + very smooth wall esophagus on barium swallow?
Scleroderma.
3 risk factors for squamous cell CA of esophagus? Adenocarcinoma?
"Smoking, drinking, nitrosamines. Barrett's."
What is the treatment of squamous cell CA of the esophagus?
"Ivor-Lewis procedure IF NO NODES. Otherwise, palliative care (e.g. stenting)."
What is the biggest cause of esophageal perforation?
"Iatrogenic (e.g. dilation, EGD)."
"Pt with severe mediastinal pain after retching, air/fluid levels in left chest and pneumomediastinum."
"Boerhaave's syndrome -- diagnose with GASTROGRAFFIN, then early repair and drainage."
What is the best way to evaluate the esophagus after ingesting a caustic agent?
EGD.
What types of ulcers are caused by acid hypersecretion?
Types 2 and 3.
What is the first step in evaluation of suspected ucler disease?
EGD and multiple biopsies.
What is the treatment of H. pylori?
Triple therapy for 2 weeks -- PPI + amoxicillin/clarythromycin/metronidazole. F/U in 6 weeks with fecal testing or breath testing + EGD.
What are some surgical indications for peptic ulcers?
"Persistent ulcers despite triple therapy, obstruction, perforation, penetration, bleeding."
What is the surgical procedure for peptic ulcer disease?
Antrectomy + selective vagotomy + Billroth-I/II.
What procedure must be performed if a patient receives TRUNCAL vagotomy?
Pyloroplasty.
"After vagotomy, what is the likely cause of persistent ulcer disease?"
"Criminal nerve of Grassi, branch of R Vagus."
Pt s/p antrectomy + vagotomy has diarrhea and sweating/shaking after meals.
"Dumping syndrome -- decrease carbs, increase fluids, increase number of feedings and decrease amount."
Pt s/p Billroth-I has persistent gastritis.
Alkaline reflux gastritis -- revise to Billroth-II.
What is the most common source of ulcer bleeds?
Gastroduodenal artery.
What is the indication for surgery from variceal bleeds? What if not a good surgical candidate?
Only after 2 tries of EGD. Can do angiography with embolization.
What is the quickest screening method for suspected abdominal perforation?
Upright or LEFT lateral decubitus films -- looking for free air under diaphragm or behind liver.
What is the surgical treatment of a perforated peptic ulcer? What if the patient has chronic ulcer disease?
"Oversewing + Graham's patch. If chronic disease, antrectomy + selective vagotomy."
What is the staging work-up for gastric cancer?
"CXR, CT-abdomen/pelvis, laparoscopy + peritoneal washings."
What is the treatment for GIST? Recurrence?
Resection. Imatinib.
What is the most common type of FUNCTIONAL iselt-cell tumor? What syndrome is it associated with?
Gastrinoma (ZE syndrome). Think of MEN-I.
What are 2 medical treatments of metastatic ZE?
PPI + octreotide.
What hormone signals hunger? From where? Satiety?
"Ghrelin, from stomach. Leptin, from adipocytes."
What are the indications for bariatric surgery?
Morbid obesity (BMI>40) or BMI>35 with comorbidities.
What is the best surgical option of bariatric surgery? What else should be done during procedure? Why? Complications?
"Roux-en-Y. Chole, weight loss precipitates stone formation. Anastamotic leak, DVT."
What structure is Meckel's diverticulum derived from?
Ompthalomesenteric duct (Vitelline).
What is the Rule of 2's?
"Meckel's diverticulum -- 2 feet from ileocecal valve, by 2 years old, 2:1 M:F, 2 inches in length, 2 types of tissue (gastric/pancreatic)."
Should Meckel's be removed if found incidentally?
NO.
What is a good treatment for perianal fistulas from Crohn's disease?
Remicade.
What is the most common presentation of Crohn's disease? Location?
Abdominal pain. RLQ (ileocecal).
What is the most common BENIGN small bowel tumor?
Leiomyoma.
What is the most common malignancy of the small bowel?
Adenocarcinoma.
What is the most common site of carcinoids? What is the treatment?
Appendix. Appendectomy if less than 2cm.
What does the carcinoid syndrome suggest?
Suggests metastasis to or past the liver (but also could be high level of 5HT).
What is the main cause of small bowel obstruction?
Abdominal adhesions.
How can ileus and obstruction be differentiated on film?
"Ileus will still have dilated loops and slow follow-through, but air will reach distal colon and rectum."
What is a good medical treatment for VIPoma?
Somatostatin.
When should a pt with familial polyposis be followed after EGD?
6 months with repeat
What is the most common cause of massive lower GI bleed?
Diverticulosis.
What is the treatment of uncomplicated diverticulitis? When is surgery required?
"Bowel rest, abx, IVFs. 2nd incident, less than 40-50, immunocompromised."
What is the surgical procedure for perforated diverticulitis?
Hartmann's procedure (sigmoidectomy + proximal colostomy + Hartmann's pouch).
What is the surgical procedure for FAP? What other syndrome has the same procedure?
Total proctocolectomy + ileal-anal pull-through. UC.
What is the most likely cause of occult anemia?
Right-sided colon cancers.
What is the main presenting symptom in left-sided colon cancers?
Bowel obstruction.
What is the procedure if you find liver spots during a colectomy for colon cancer?
"Biopsy the spots. If mets, can resect 2 months later if <5."
What is the most important prognostic indicator for colon cancer?
Lymph node involvement.
What is the treatment for rectal cancer?
Resection + chemoradiation for ALL tumors (high recurrence).
"Pt presents with obstructive symptoms, abdominal films show U-loop. Treatment?"
Sigmoid volvulus. Decompress with sigmoidoscopy. IVFs and bowel prep. Then resect when clean.
What is Ogilvie's syndrome?
Ileus without obstruction. Treat with NGT and bowel rest.
What is the treatment of 1st and 2nd degree hemorrhoids?
Bulking agents.
What is the treatment of 3rd degree hemorrhoids?
Rubber banding
What is the treatment of 4th degree hemorrhoids?
These are incarcerated -- must surgically resect.
What is the treatment of perianal abscesses?
I&D in the OR.
What is Goodsall's rule? What is the treatment of fistula-in-ano?
"Perianal fistulas anterior will open at the pectinate line at a straight radial line, and those posterior will open at the midline in a curved line. Surgical unroofing."
"A patient had severe pain when pooping, and noticed some BRB on the TP. What other physical finding is associated? Treatment?"
"Anal fissure. Skin tags. Bulking, Sitz baths, sphincterotomy."
What is the first step in work-up for thyroid nodule?
FNA
What is the cause of Grave's disease?
TSI (anti-TSH-receptor IgG)
What is the best medical management of Grave's disease?
MMI or PTU
What is the best definitive therapy for Grave's disease?
Radioablation (I131)
"What is the treatment of Grave's in a pregnant, allergic patient?"
Thyroidectomy
What is the biggest post-surgical complication of thyroidectomy?
Transient hypocalcemia
What is the biggest long-term complication of thyroidectomy?
Hypothyroidism
What are the treatments of thyroid storm?
"SSKI (Lugol's), MMI, beta-block"
"What is the diagnosis -- hyperthyroid symptoms, no exopthalmos or pretibial myxedema"
Toxic adenoma
What is the most common carcinoma of the thyroid? How does it spread?
Papillary. Lymph nodes (Palpable - P)
What is the second most common carcinoma of the thyroid? How does it spread? Catch to diagnosis?
Follicular. Blood. Can't use FNA (penetrates capsule).
What is the best medical treatment for metastatic thyroid cancer?
I131
What must be done in addition to excision for medullary thyroid cancer?
Lymph node dissection.
How can medullary thyroid cancer be followed?
Calcitonin levels.
What gene is blamed for medullary thyroid cancer?
RET
What is the most common cause of hypercalcemia in non-hospitalized pt? Hospitalized?
Hyperparathyroidism. Malignancy.
How can the cause of hyperparathyroidism be localized? Treatment?
Sestamibi scan. Parathyroidectomy.
What is the treatment of SECONDARY hyperparathyroidism?
Treat underlying problem… then parathyroidectomy of 3.5 glands.
"2 first treatments for dangerously high, acute hypercalcemia."
Large amount of peripheral IVF's + loop diuretic.
What is Cushing's DISEASE?
Pituitary adenoma producing ACTH
How can you diagnose Cushing's syndrome? How does Cushing's DISEASE differ?
"Dex-suppression test (not with low-dose, suppressed with high doses). Disease has high ACTH"
What is Conn's disease? What are some signs/symptoms?
"Primary hyperaldosteronism. HTN, hypokalemia, low renin levels."
What is the rule of 10's? What syndrome is this part of?
"Pheochromocytoma -- Familial, bilateral, malignant, children, extra-adrenal. MEN-2A/2B"
How can you make the diagnosis of pheochromocytoma?
Plasma-free metanephrines OR urinary metanephrine + normetanephrine + VMA
How are pt's treated medically before surgery for pheochromocytoma?
"Alpha-block --> beta-block (THIS ORDER), large amounts of fluid"
What is the treatment of an incidentaloma of the adrenal?
"If less than 3cm, check for Conn's, Cushing's, or pheochromocytoma with K levels, dex-suppression, catacholamines. Then CXR and CT scan to look for other tumors. If nothing, F/U CT in 6 months. If >3cm, remove because possible adrenal carcinoma."
What is MEN-1? MEN-2A? MEN-2B?
"Parathyroid (remove 3.5 glands), pituitary (PRL), pancreas (ZE, insulinoma, VIP). Thyroid (medullary), parathyroid, pheo. Same as 2A with MARFANOID habitus."
What is deficient in hereditary spherocytosis? Inheritance? Treatment?
Spectrin/ankyrin. Autosomal dominant. Splenectomy.
What is the primary treatment of ITP? What if non-responsive? What is the best indicator of long-term prognosis?
Steroids/immunosuppressives. Splenectomy if non-responsive or refractory to therapy. Initial response to steroid treatment.
"For a patient needing platelet transfusion during splenectomy for ITP, what is the ideal time to give?"
When spleen has been removed.
"What is a common physiologic response to splenectomy? At what level is it treated, and what is the treatment?"
"Thrombocytosis. >1E6, aspirin."
How long before splenectomy should pt's be immunized. What immunizations?
"~2 weeks. HIB, Pneumococcus, Meningococcus."
What is the most common post-op complication of splenectomy?
Atelectasis.
What is an easy way to screen whether splenectomy has been successful? What if it's not?
"Peripheral smear for spherocytes, Howell-Jolly, Acanthocytes, Target cells. Probably have accessory spleen."
What are some risk factors for breast cancer?
"Family history (esp. pre-menopausal), early menarche, late menopause, nullparous, radiation, BRCA, previous biopsy."
Signs of BRCA-1?
Breast + ovarian CA
Signs of BRCA-2?
Breast + male breast CA
What is the typical screening for breast CA?
"Yearly breast exam at 20, yearly mammography at 40"
What is the best radiographic test for palpable breast lesions? What if they are very fibrous?
US. Use MRI.
A pt shows up with microcalcifications associated with a breast mass. What is the next step? Follow-up?
"Core biopsy. If benign, f/u 6 months with mammogram."
What is the treatment for fibroadenoma?
"Biopsy, 6 month f/u, excise of growth"
How are brest cysts diagnosed? Treatment?
US. Asipration if painful/complex -- cytology if complex or bloody asiprate.
What is the most common cause of bloody nipple discharge? Treatment?
Intraductal papilloma. Subareolar duct excision.
What is the treatment of a breast abscess?
"US, I&D, abx, stop breast-feeding and pump."
"Non-lactating woman with red, painful, swollen breast. Treatment?"
"Inflammatory breast cancer. Chemo, THEN mastectomy."
Patient with 'eczema' of the nipple. Next step?
Paget's disease of the breast. Nipple biopsy.
Pt with isolated breast lump needs treatment. Most important prognostic indicator?
Lumpectomy + radiation = mastectomy. Lymph node involvement.
What is the surgery performed in an isolated breast lump with no palpable nodes? What if this is positive?
"Lumpectomy + sentinal node dissection. If sentinel node positive, must dissect axillary nodes too."
What patients with breast cancer get chemo? Who gets tamoxifen? What is its side effect?
Node+ or premenopausal. ER+. Blood clots.
What are some complications of axillary node dissection?
"Lymphedema, winged scapula (long thoracic nerve), numbness (intercostobrachial nerve), no adduction (thoracodorsal nerve)."
What are the 2 most common BENIGN liver tumors? Best visualization?
Hemangiomas and FNH. Arteriography.
Woman using OCPs has spot noticed on her liver. When to remove?
Hepatic adenoma. Resect always because RISK of rupture.
When should hemangiomas of the liver be removed?
If symptomatic or extrememely large.
What is the catch-word for FNH of the liver?
CENTRAL SCAR
What is the treatment of metastasis to the liver?
"Resection if <5, radioablation if >5"
What is the treatment of cystic neoplasms of the liver?
"RESECTION if thick walls, calcifications, or septated."
How are hydatid cysts of the liver diagnosed? What should NEVER be done? Treatment?
"Serology. Aspiration. Albendazole, maybe resection."
What is the treatment of liver pus?
"Drainage, insertion of drain, and abx."
A pt has a abscess that has 'anchovy paste' leaking from it. Treatment?
Amoebic abscess. Flagyl.
What is the medical treatment of symptomatic portal hypertension (ascites)? Surgical?
"Beta-block, salt/fluid restriction, lasix + spironolactone. TIPS"
What is the cause of hepatic encephalopathy? Treatment?
High ammonia levels. Protein restriction + lactulose.
What is the treatment for an acute variceal bleed?
Fluid resuscitation + somatostatin + EGD (sclerotherapy)
What is the treatment for a variceal bleed that has been treated once with EGD but recurs?
Fluid resuscitation + somatostatin + EGD (sclerotherapy)
What is the treatment for variceal bleeds that recur a 3rd time?
TIPS after baloon tamponade.
What are the 2 simple indications for liver transplant?
ESLD or fulminant liver failure.
What is the base cause of gallstone formation?
Supersaturation of cholesterol.
What is biliary colic?
Intermittent abdominal pain caused by transient obstruction of cystic duct.
How does acute cholecystitis differ from biliary colic?
Persistent pain caused by impacted cystic duct.
What is the triad for cholangitis?
"Jaundice, RUQ pain, fever/leukocytosis."
"What is the treatment for acute cholecystitis? What if the patient is septic, or too unstable for surgery?"
Lap chole. Percutaneously drain/decompress.
What is the best diagnostic test for biliary disease?
RUQ US
What diagnostic test for biliary disease can be done for an equivocal RUQ US?
HIDA scan (cholecystitis = non-filling of gallbladder)
What is the usual bug in infected acute cholecystitis?
E. coli.
What is the treatment for choledocholithiasis?
"ERCP FIRST, then lap chole."
What is the treatment for gallstone pancreatitis?
NPO + IVFs + analgesia --> possible ERCP --> lap chole when cleared up
Pt presents with evidence of SBO with air in the biliary tract.
Gallstone ileus.
What does a porcelain gallbladder mean?
REMOVE IT -- high incidence of malignancy
What is the treatment of gallbladder cancer?
"Lap chole. If invasion to liver, wedge resection of liver."
What is the treatment of cholangiocarcinoma of the hepatic bifurcation?
Only palliative stenting
Pt has painless jaundice and palpable gallbladder.
Carvosier's sign -- periampullary cancer.
What is pancreatic divisum?
Non-fusion of ventral and dorsal pancreas -- cause of chronic pancreatitis.
2 most common causes of acute pancreatitis.
Alcohol and gallstones.
Most common cause of mechanical pancreatitis.
Gallstones.
Pt has signs of pancreatitis and results of aspiration show necrotic tissue.
Surgical debridement.
When and how should a pancreatic pseudocyst be treated?
After 6 weeks for wall thickening. Ostomy to nearest structure.
When is surgical intervention required for chronic pancreatitis? Procedure?
"Intractable pain. Peustow (pancreaticojejunostomy) if chain-o-lakes, resection of no stricture."
What is the biggest risk factor for pancreatic CA?
Smoking.
What is the most common location of pancreatic CA?
Head of pancreas.
What is the most common cause of death after resection of pancreatic CA?
Recurrence of CA.
What is the most common cause of islet cell tumor?
Non-functioning!
How can ZE syndrome be diagnosed? What should be the next step?
High gastrin levels or rise in gastrin with secretin. Check for MEN-1 syndrome.
What cells do glucagonomas come from?
Alpha cells.
What is the best number to assess nutritional status?
Prealbumin (or albumin)
What is the number for normal protein requirment? What states raise it?
"1.5mg/kg/dy. Burns, sepsis, etc."
What is the normal calorie need?
~30kcal/kg/dy
What drives the catabolic state during stressful situations?
"Cortisol, cytokines, glucagon."
Why does muscle wasting occur?
The liver uses alanine for gluconeogenesis.
What is the normal RQ ratio? What makes it too high? What is the RQ ratio of fat?
0.8. All carb diet. Fat = 0.7
What kind of nutrition should be given to a patient with hypercholremic metabolic acidosis?
Lipids.
Pt has diarrhea with tube feeds.
"Dumping syndrome -- high osmotic load causes pull of water, high sugar, high insulin, then low sugar. Decrease feeds, make more feeds, decrease lipids."
What amino acid can both decrease sepsis and increase wound healing?
Arginine.
What is the nutritional treatment of a patient with post-op ileus?
NGT + 3% amino acids + extra glucose.
What type of hiatal hernia has high incidence of GERD? Diagnosis?
Sliding (type 1). Barium esophogram + EGD.
What type of hiatal hernia requires surgical treatment? Diagnosis?
"Paraesophageal (type 2). Requires EGD, but may suspect with CXR (air behind heart, or NGT above diaphragm)"
What exactly is achalasia? Diagnosis? Treatment options?
"Non-relaxation of LES with dysfunctional peristalsis. Barium swallow (bird's beak) + manometry + EGD. Dilatation, medical, then Heller myotomy."
What is the most common esophageal diverticulum? Cause? Treatment?
Zencker's. Non-relaxation of cricopharyngeus. Ligation of diverticulum + myotomy of cricopharyngeus.
What is a diverticulum in middle of esophagus called? Cause?
Traction diverticulum. Mediastinal inflammation.
What is the diagnosis in a pt with esophageal dysmotility + very smooth wall esophagus on barium swallow?
Scleroderma.
3 risk factors for squamous cell CA of esophagus? Adenocarcinoma?
"Smoking, drinking, nitrosamines. Barrett's."
What is the treatment of squamous cell CA of the esophagus?
"Ivor-Lewis procedure IF NO NODES. Otherwise, palliative care (e.g. stenting)."
What is the biggest cause of esophageal perforation?
"Iatrogenic (e.g. dilation, EGD)."
"Pt with severe mediastinal pain after retching, air/fluid levels in left chest and pneumomediastinum."
"Boerhaave's syndrome -- diagnose with GASTROGRAFFIN, then early repair and drainage."
What is the best way to evaluate the esophagus after ingesting a caustic agent?
EGD.
What types of ulcers are caused by acid hypersecretion?
Types 2 and 3.
What is the first step in evaluation of suspected ucler disease?
EGD and multiple biopsies.
What is the treatment of H. pylori?
Triple therapy for 2 weeks -- PPI + amoxicillin/clarythromycin/metronidazole. F/U in 6 weeks with fecal testing or breath testing + EGD.
What are some surgical indications for peptic ulcers?
"Persistent ulcers despite triple therapy, obstruction, perforation, penetration, bleeding."
What is the surgical procedure for peptic ulcer disease?
Antrectomy + selective vagotomy + Billroth-I/II.
What procedure must be performed if a patient receives TRUNCAL vagotomy?
Pyloroplasty.
"After vagotomy, what is the likely cause of persistent ulcer disease?"
"Criminal nerve of Grassi, branch of R Vagus."
Pt s/p antrectomy + vagotomy has diarrhea and sweating/shaking after meals.
"Dumping syndrome -- decrease carbs, increase fluids, increase number of feedings and decrease amount."
Pt s/p Billroth-I has persistent gastritis.
Alkaline reflux gastritis -- revise to Billroth-II.
What is the most common source of ulcer bleeds?
Gastroduodenal artery.
What is the indication for surgery from variceal bleeds? What if not a good surgical candidate?
Only after 2 tries of EGD. Can do angiography with embolization.
What is the quickest screening method for suspected abdominal perforation?
Upright or LEFT lateral decubitus films -- looking for free air under diaphragm or behind liver.
What is the surgical treatment of a perforated peptic ulcer? What if the patient has chronic ulcer disease?
"Oversewing + Graham's patch. If chronic disease, antrectomy + selective vagotomy."
What is the staging work-up for gastric cancer?
"CXR, CT-abdomen/pelvis, laparoscopy + peritoneal washings."
What is the treatment for GIST? Recurrence?
Resection. Imatinib.
What is the most common type of FUNCTIONAL iselt-cell tumor? What syndrome is it associated with?
Gastrinoma (ZE syndrome). Think of MEN-I.
What are 2 medical treatments of metastatic ZE?
PPI + octreotide.
What hormone signals hunger? From where? Satiety?
"Ghrelin, from stomach. Leptin, from adipocytes."
What are the indications for bariatric surgery?
Morbid obesity (BMI>40) or BMI>35 with comorbidities.
What is the best surgical option of bariatric surgery? What else should be done during procedure? Why? Complications?
"Roux-en-Y. Chole, weight loss precipitates stone formation. Anastamotic leak, DVT."
What structure is Meckel's diverticulum derived from?
Ompthalomesenteric duct (Vitelline).
What is the Rule of 2's?
"Meckel's diverticulum -- 2 feet from ileocecal valve, by 2 years old, 2:1 M:F, 2 inches in length, 2 types of tissue (gastric/pancreatic)."
Should Meckel's be removed if found incidentally?
NO.
What is a good treatment for perianal fistulas from Crohn's disease?
Remicade.
What is the most common presentation of Crohn's disease? Location?
Abdominal pain. RLQ (ileocecal).
What is the most common BENIGN small bowel tumor?
Leiomyoma.
What is the most common malignancy of the small bowel?
Adenocarcinoma.
What is the most common site of carcinoids? What is the treatment?
Appendix. Appendectomy if less than 2cm.
What does the carcinoid syndrome suggest?
Suggests metastasis to or past the liver (but also could be high level of 5HT).
What is the main cause of small bowel obstruction?
Abdominal adhesions.
How can ileus and obstruction be differentiated on film?
"Ileus will still have dilated loops and slow follow-through, but air will reach distal colon and rectum."
What is a good medical treatment for VIPoma?
Somatostatin.
When should a pt with familial polyposis be followed after EGD?
6 months with repeat
What is the most common cause of massive lower GI bleed?
Diverticulosis.
What is the treatment of uncomplicated diverticulitis? When is surgery required?
"Bowel rest, abx, IVFs. 2nd incident, less than 40-50, immunocompromised."
What is the surgical procedure for perforated diverticulitis?
Hartmann's procedure (sigmoidectomy + proximal colostomy + Hartmann's pouch).
What is the surgical procedure for FAP? What other syndrome has the same procedure?
Total proctocolectomy + ileal-anal pull-through. UC.
What is the most likely cause of occult anemia?
Right-sided colon cancers.
What is the main presenting symptom in left-sided colon cancers?
Bowel obstruction.
What is the procedure if you find liver spots during a colectomy for colon cancer?
"Biopsy the spots. If mets, can resect 2 months later if <5."
What is the most important prognostic indicator for colon cancer?
Lymph node involvement.
What is the treatment for rectal cancer?
Resection + chemoradiation for ALL tumors (high recurrence).
"Pt presents with obstructive symptoms, abdominal films show U-loop. Treatment?"
Sigmoid volvulus. Decompress with sigmoidoscopy. IVFs and bowel prep. Then resect when clean.
What is Ogilvie's syndrome?
Ileus without obstruction. Treat with NGT and bowel rest.
What is the treatment of 1st and 2nd degree hemorrhoids?
Bulking agents.
What is the treatment of 3rd degree hemorrhoids?
Rubber banding
What is the treatment of 4th degree hemorrhoids?
These are incarcerated -- must surgically resect.
What is the treatment of perianal abscesses?
I&D in the OR.
What is Goodsall's rule? What is the treatment of fistula-in-ano?
"Perianal fistulas anterior will open at the pectinate line at a straight radial line, and those posterior will open at the midline in a curved line. Surgical unroofing."
"A patient had severe pain when pooping, and noticed some BRB on the TP. What other physical finding is associated? Treatment?"
"Anal fissure. Skin tags. Bulking, Sitz baths, sphincterotomy."