First Aid for Surgery

Crohn’s disease: risk factors (8)
Jewish descent
Urban dwelling
15-40 or 50-80y/o
Family history
Diet high in refined sugar
Crohn’s: signs and symptoms (8)
Diarrhea, weight loss, fever, crampy abdominal pain, GI bleeding (usually occult), perianal disease (1/3), symptoms of perforation or fistula
Crohn’s: diagnosis (4)
Physical exam: perianal skin tags, sinus tracts, abdominal mass, aphthous ulcers
Colonoscopy: skip lesions, cobblestone appearance
Barium enema
Radiographic evidence of Crohn’s (5)
Nodular contour of bowel
Narrowed lumen with sinuses and clefts
Linear ulcers
Asymmetrical involvement of bowel wall
String sign
Medical treatment of Crohn’s (4)
Aminosalicylates (sulfasalazine, 5-ASA)
Immune modulators (azathioprine, cyclosporine, mercaptopurine)
Indications of surgery in Crohn’s (6)
Obstruction, abscess, fistula, perforation, perianal disease, cancer
Double-contrast study that involves passing a tube into the proximal small intestine and injecting barium and methylcellulose. Detects tumors missed on conventional imaging.
Extended enteroscopy
Similar to enteroclysis but involves advancement of enteroscope via peristalsis. Detects tumors missed in enteroclysis.
Benign neoplasms of small intestine: signs and symptoms (5)
Intermittent obstruction
Occult bleeding
Palpable abdominal mass
Abdominal pain
Risk factors for neoplasms of small intestine (7)
Red meat & salt-cured foods
Peutz-Jeghers syndrome (hamartomatous polyps)
Crohn’s (adenocarcinoma)
Garder syndrome (adenoma)
Familial adenomatous polyposis (adenoma)
Celiac disease (lymphoma, carcinoma)
Immunodeficiency / autoimmune disease (lymphoma)
Adenocarcinoma of small intestine: risk factors, signs and symptoms, location
25-50% primary small bowel malignancies
Risk factors: Crohn’s
Signs: obstruction, bleeding, mass
Location: duodenum, ileum
Carcinoid malignancy in small intestine: signs, location
40% primary small bowel malignancies
Signs: often asymptomatic, obstruction, carcinoid syndrome
Location: ileum
Lymphoma in small intestine: risk factors (3), signs (6), location (1)
Risk factors: celiac disease, immunosuppression, autoimmune disease
Signs: fatigue, weight loss, obstruction, pain, mass, bleeding
Location: ileum
Sarcoma in small intestine: signs (3), location (3)
Signs: obstruction, pain, bleeding
Location: ileum, jejunum, Meckel’s diverticulum
Neuroendocrine tumor in small intestine: signs (2), location
Signs: mass, hormone-specific symptoms
Location: proximal small intestine
Metastasis to small intestine: origin (6), signs (2)
Origin: melanoma, cervical, colon, breast, lung, ovarian
Signs: obstruction, bleeding
Carcinoid tumor
Slow-growing malignant tumor of enterochromaffin cell origin in GI tract or respiratory tract
Carcinoid tumor: epidemiology
Peak incidence 50-70y/o
>90% in GI system (mostly appendix & ileum)
Carcinoid tumor: signs and symptoms (6)
Often asymptomatic
Abdominal pain, obstruction, rectal bleeding, weight loss
10% of patients have carcinoid syndrome
Carcinoid syndrome
Seen in 10% of patients with carcinoid tumor, usually after metastasis to liver. Tumor produces serotonin, bradykinin, or tryptophan, which enter the systemic circulation, causing cutaneous flushing, diarrhea, valvular lesions, and bronchoconstriction.
Carcinoid tumor: diagnosis
5-HIAA or 5-HTP in 24-hr urine
Small bowel series, enteroclysis, or extended enteroscopy
Often found incidentally during surgery for something else
Carcinoid tumor: treatment
Medical: serotonin antagonist (cyproheptadine) or somatostatin analogue (octreotide) for carcinoid syndrome
Surgical: appendectomy for appendiceal tumor <2cm, right hemicolectomy for appendiceal tumor >2cm, tumor resection for small intestinal carcinoid
GI fistula: risk factors (4)
Previous abdominal surgery (most common)
Diverticular disease
Colon cancer
GI fistula: signs and symptoms
Fever & leukocytosis if there is an abscess
Enterocutaneous fistula: drainage of bowel contents from skin
Entero-enteric fistula: diarrhea
Enterovesicular fistula: pneumaturia & UTI
GI fistula: treatment (4)
Somatostatin to decrease loss of volume & electrolytes
Bowel rest
IV antibiotics
Resection if no improvement after 6 weeks
Factors that keep a GI fistula tract open (FRIEND)
Foreign body
Distal obstruction
Types of small bowel obstruction (2)
Open loop: flow is blocked but proximal decompression possible
Closed loop: inflow and outflow both blocked, e.g. incarcerated hernia, torsion, adhesions, volvulus
Mechanical causes of small bowel obstruction (11)
Intraluminal: gallstone, foreign body, intussusception
Intramural: Crohn’s, lymphoma, radiation enteritis
Extrinsic: adhesion (1), hernia (2), cancer (3), abscess, congenital
Functional causes of small bowel obstruction (paralytic ileus) (7)
Medications (opiates, anticholinergics)
Retroperitoneal hematoma
Small bowel obstruction: signs and symptoms (5)
Colicky abdominal pain
High-pitched bowel sounds
Abdominal distention
Small bowel obstruction: diagnosis
Supine & upright AXR
CT scan if AXR is non-diagnostic
Small bowel obstruction: treatment
Medical: IV hydration, NPO, NG decompression
Surgical: exploratory laparotomy to find & fix cause
Typical symptoms of left-sided colon cancer
Change in bowel habits (small-caliber stools)
Weight loss & anorexia
Typical symptoms of right-sided colon cancer
Microcytic anemia
Weight loss & anorexia
Main functions of colon & rectum (2)
Absorption of water & electrolytes from stool
Storage of feces
Types of colonic contractions (3)
1. Retrograde: slow transit of luminal contents, increasing absorption
2. Segmental: localized simultaneous contractions of longitudinal & circular muscle
3. Mass movement: contractions of long segments lasting 30s ~3-4x per day (after waking up or eating)
Ability to pass flatus, but inability to pass stool
Inability to pass flatus or stool
Irritable bowel syndrome: signs & symptoms
Altered bowel function (constipation, diarrhea) occurring intermittently over a prolonged period of time +/- abdominal pain
Irritable bowel syndrome: treatment
Reassurance & education
Medical treatment for anxiety / depression
<3 stools/week while on a high-fiber diet
May be acute (<3m) or chronic (>3m)
Constipation: causes (6)
Diet: too little fluid or fiber
Lack of physical activity
Medications: opiates, anticholinergics
Medical illness: IBS, diabetes, hypothyroidism
Neurologic disease: Parkinson’s, MS
Postvagotomy diarrhea: mechanism & treatment
Mechanism: denervation of extrahepatic biliary tree & small intestine leads to rapid transit of unconjugated bile salts into colon –> poor water absorption –> diarrhea.
Treatment: cholestyramine or surgical reversal of a segment of small intestine to prolong transit time
>3 loose stools/day
Diarrhea: diagnosis (3)
Check stool for enteric pathogens or C. difficile toxin
Check stool for WBCs: IBD, infectious colitis
Check stool for RBCs: ischemia, infasive infectious diarrhea, cancer
Fecal incontinence: etiology (4)
Anal sphincter trauma: childbirth, iatrogenic, s/p fistulotomy for abscess or perianal fistula
Fecal impaction
Pudendal nerve injury
Fecal incontinence: diagnosis (4)
Anal manometry: detects resting & squeeze pressures of internal & external sphincters
Endoanal U/S: more accurate, detects occult lesions
Pelvic floor EMG: differentiates between anatomic & neurogenic causes
Pudendal nerve terminal motor latency testing: predicts success of surgical repair
Pseudomembranous colitis: etiology
Overgrowth of C. difficile, usually after use of antibiotics (clindamycin, ampicillin, cephalosporins)
Pseudomembranous colitis: treatment
Stop antibiotic
PO / IV metronidazole or PO vancomycin
Actinomyces colitis: signs & symptoms (5)
Weight loss
Night sweats
Draining fistulas
Abdominal mass
Usually follows appendectomy
Actinomyces colitis: diagnosis
“Sunburst” pattern of sulfur granules on hisopathology
Actinomyces colitis: treatment
Surgical drainage
Tetracycline or penicillin
Neutropenic colitis: definition
Diffuse mucosal ulceration and invasive infection with enteric organisms
Neutropenic colitis: signs & symptoms (5)
Abdominal pain and/or partial small bowel obstruction
Neutrophils <100/mL
Radiation-induced colitis during XRT: signs (6), diagnosis (2), etiology (3), treatment (2)
Signs & symptoms: nausea, vomiting, cramps, diarrhea, tenesmus, rectal bleeding
Diagnosis: AXR, barium enema
Etiology: mucosal edema, hyperemia, acute ulceration
Treatment: treat symptoms, decrease XRT dose
Radiation-induced colitis weeks/years later: signs (5), diagnosis (2), etiology (6), treatment (5)
Signs & symptoms: tenesmus, bleeding, abscess, rectal fistula, increased BMs
Diagnosis: barium enema, CT scan
Etiology: submucosal arteriolar vasculitis, microvascular thrombosis, wall thickening, mucosal ulceration, strictures, perforation
Treatment: stool softener, topical 5-ASA, corticosteroid enema, dilatation of stricture, proximal colostomy to repair rectovaginal fistula
Ischemic colitis: definition
Acute or chronic intestinal ischemia due to decreased intestinal perfusion or thromboembolism in IMA. Most often affects the splenic flexure.
Ischemic colitis: risk factors (7)
Old age (>60yrs)
s/p AAA repair
Coronary artery disease
Adhesions s/p abdominal surgery
Obstructive lesion in colon
Ischemic colitis: signs & symptoms (5)
Mild lower abdominal pain, insidious in onset
Rectal bleeding
Increased WBC
Peritoneal signs
Ischemic colitis: treatment (3)
Mild: observe
Moderate (fever, increased WBC): IV abx
Severe (peritoneal signs): exploratory laparotomy + colostomy
Ulcerative colitis: risk factors (8)
Jewish descent
Urban dwelling
Age 15-40 or 50-80
Family history
Diet: refined sugar
Medications: NSAIDs, OCPs
Nicotine DECREASES risk
Ulcerative colitis: 2 characteristic presentations
Insidious recurrent abdominal pain, anorexia, weight loss, mild diarrhea
Acute onset of BLOODY diarrhea, abdominal pain +/- tenesmus, vomiting, fever
Ulcerative colitis: diagnosis (2)
Endoscopy + pathologic evaluation of biopsies
Barium enema (lead pipe appearance)
Crohn’s: complications (4)
Perianal disease
Ulcerative colitis: complications (3)
Crohn’s: pathology
Inflammation involves ALL bowel wall layers, which may lead to fistula & abscess formation. Rectal sparing in 50% of patients.
Ulcerative colitis: pathology
Inflammation ONLY involves mucosa, leading to exudate of pus, blood and mucus from the “crypt abscess.” It ALWAYS starts in the rectum, and about 1/3 don’t progress further than that.
Ulcerative colitis: treatment
Mild/moderate: 5-ASA, corticosteroids (PO or PR)
Severe: IV steroids
Proctitis: topical steroids
Refractory disease or perforation: immunosuppression, proctocolectomy, or diverting loop colostomy
Diverticular disease
Herniation of mucosa & submucosa through muscular layers of bowel wall at sites where arterioles penetrate, on mesenteric side of colon
Diverticular disease: risk factors (2)
Old age (>70yrs)
Low-fiber diet
Diverticulosis: signs & symptoms (3)
80% asymptomatic
MAY cause recurrent intermittent LLQ pain & tenderness after meals and relieved by flatus or defecation
LLQ rope-like mass palpable on exam
Massive & rapid lower GI bleeding
Diverticulitis: signs & symptoms (7)
Persistent abdominal pain that is first diffuse and then becomes localized to LLQ and/or pelvis with peritoneal signs
Nausea / vomiting
Change in bowel habits
Elevated WBC
Diverticulitis: diagnosis
Elevated WBC
AXR: ileus, distention, free intraperitoneal air
CT: pericolonic inflammation +/- abscess formation
Treatment of severe diverticulitis with perforation
Surgical drainage & diverting colostomy, followed by colonic reanastomosis 2-3 months later
Causes of lower GI bleed (6)
Ischemic colitis
Anticoagulation treatment
Angiodysplasia: signs & symptoms (3)
Slow lower GI bleeding from cecum & ascending colon
Melena and/or hematochezia
Repeated muscular contractions –> chronic intermittent obstruction of submucosal veins –> dilated venules with incompetent precapillary sphincters –> arteriovenous communication
Disruption of arteriole ad dome or antimesenteric neck of diverticulum, most commonly on mucosal side –> blood goes into bowel lumen
Lower GI bleeding: diagnosis (4)
1. NG lavage to rule out upper GI bleeding
2. Colonoscopy
3. Bleeding scan with Tc-sulfur colloid (>0.5ml/mn)
4. Angiography (>1ml/mn) to detect angiodysplasia
Lower GI bleeding: treatment (4)
1. Resuscitation
2. If site is identified: octreotide, embolization, vasoconstriction with epinephrine, vasodestruction with alcohol or Na, coagulation with heat
3. If bleeding is refractory or massive: segmental colectomy
4. If site is not identified: total abdominal colectomy + ileostomy
Large bowel obstruction: signs & symptoms (5)
Abdominal distention
Cramping abdominal pain
Nausea / vomiting
High-pitched bowel sounds
Large bowel obstruction: most common causes (3)
1. adenocarcinoma
2. scarring after diverticulosis
3. volvulus
Large bowel obstruction: diagnosis (3)
1. History of 8-12hrs of obstipation (flatus indicates PARTIAL obstruction)
2. Supine AND upright AXR: distended proximal colon, air-fluid levels, no distal rectal air
3. Barium enema: distinguishes between ileus & partial obstruction
Large bowel obstruction: treatment (4)
1. correct fluid & electrolyte abnormalities
2. decompress intestines with NG tube
3. broad-spectrum IV antibiotics
4. surgery to relieve obstruction
Ogilvie syndrome (pseudo-obstruction)
Massive colonic dilation without evidence of mechanical obstruction, due to imbalance between parasympathetic & sympathetic control of intestinal motility.
Ogilvie syndrome: risk factors (8)
Older age
Severe acute illness / infection
Recent surgery or trauma
Metabolic disturbances
Ogilvie syndrome: signs & symptoms (3)
Abdominal distention
Mild abdominal pain
Decreased / absent bowel sounds
Ogilvie syndrome: diagnosis (3)
AXR: massive colonic distention
CXR: free air under diaphragm
Enema or colonoscopy: to exclude mechanical cause for obstruction
Ogilvie syndrome: treatment (6)
1. Decompress with NG & rectal tubes
2. Correct electroly abnormalities
3. Stop narcotics, anticholinergics, etc.
4. Turn patient frequently
5. Neostigmine (AChE inhibitor) to decompress bowel
6. Exploratory laparotomy with cecostomy or loop colostomy if cecal diameter >11cm or patient has peritoneal signs
Rotation of intestine around its mesenteric axis, usually in sigmoid colon or cecum, leading to large bowel obstruction
Volvulus: risk factors (2)
Age >65
Hypermobile cecum after incomplete fixation in utero
Volvulus: diagnosis (2)
AXR: dilated sigmoid colon or cecum with “kidney bean” appearance
Barium enema: “bird’s beak” at areas of colonic narrowing
Cecal volvulus: treatment
Right hemicolectomy (if vascular compromise) or cecopexy (suture right colon to parietal peritoneum)
Sigmoid volvulus: treatment (3)
1. Sigmoidoscopy & rectal tube insertion to decompress
2. Emergent laparotomy: if sigmoidoscopy fails, or if you suspect perforation or strangulation
3. Elective resection later, to prevent recurrence
Histologic types of colorectal polyps (5)
Inflammatory (pseudopolyp): seen in UC
Lymphoid: mucosal bumps containing intramucosal lymphoid tissue; NO malignant potential
Hyperplastic: overgrowth of normal tissue; NO malignant potential
Adenomatous: premalignant; may be tubular, tubulovillous or villous
Hamartomatous: normal tissue in abnormal configuration
Indications for colonoscopic resection of a polyp (5)
Well or moderately well differentiated
No venous or lymphatic invasion
Invades only into stalk
Margins are negative
Familial polyposis coli (FAP)
Autosomal dominant mutation on chromosome 5 –> polyps develop at 20-40yrs –> colon cancer inevitable if colectomy is not performed
Gardner’s syndrome
Autosomal dominant
Many colonic polyps, osteomas, epidermal cysts and fibromas
Colon cancer is inevitable without surgery
Turcot’s syndrome
Autosomal recessive
Multiple adenomatous colonic polyps and CNS tumors
Cronkite-Canada syndrome
GI polyposis, alopecia, nail dystrophy, and hyperpigmentation
Very low malignant potential
Peutz-Jeghers syndrome
Autosomal dominant
Hamartomatous polyps of entire GI tract
Melanotic pigmentation of face, lips, oral mucosa, palms
Increase risk of pancreas, breast, lung, ovary, uterus cancers
HNPCC (Lynch syndrome)
Autosomal dominant
High risk of right-sided colon cancer
High risk of adenocarcinoma of uterus, ovary, cervix, breast
Diagnosis of colon cancer
Flexible sigmoidoscopy or colonoscopy
Barium enema
Diagnosis of rectal cancer
Proctoscopy or colonoscopy
Barium enema
Transrectal ultrasound, CT, or MRI to assess invasion
Dukes system for colon cancer
A: limited to wall
B: through wall of bowel, but not to lymph nodes
C: metastatic to regional lymph nodes
D: distant metastases
Operative management of CRC in cecum
Right hemicolectomy
Operative management of CRC in right colon
Right hemicolectomy
Operative management of CRC in proximal or mid-transverse colon
Extended right hemicolectomy (entire transverse colon + splenic flexure)
Operative management of CRC in splenic flexure or left colon
Left hemicolectomy
Operative management of CRC in sigmoid colon
Sigmoid colectomy
Operative management of CRC in proximal rectum
Low anterior resection
For tumors >4cm from anal verge
Operative management of CRC in distal rectum
Abdominal-perineal resection: resection of rectum, total mesorectal excision, closure of anus
Prolapse of submucosal veins in left lateral, right anterior & right posterior quadrants of the anal canal
Risk factors for hemorrhoids (5)
Excessive diarrhea
Increased pelvic pressure (ascites, tumor)
Portal hypertension
Internal hemorrhoids
Hemorrhoids covered by columnar mucosa, above dentate line
External hemorrhoids
Hemorrhoids covered by squamous mucosa, below dentate line
Grading system for internal hemorrhoids
I: protrudes into lumen without prolapse –> bleeding –> treat via non-resectional measures
II: prolapse with straining, spontaneous return –> bleeding & feel prolapse –> non-resectional measures
III: prolapse that requires manual reduction –> bleeding, prolapse, mucus, pruritis –> non-resectional measures or excision
IV: prolapse can’t be reduced –> bleeding, prolapse, mucus, pruritis, pain –> excision
Anal fissure: signs & symptoms (5)
Pain with defecation
Bright red blood on TP
Increased rectal tone
Extreme pain on DRE
Visible tear
Anal fissure: treatment (5)
Sitz baths
Fiber supplements
Increased fluid intake
Lateral internal sphincterotomy (last resort)
Forceful anal dilation (last resort)
Anorectal abscess: risk factors (7)
History of recent surgery or trauma
History of CRC
Previous anorectal abscess
Anorectal abscess: signs & symptoms (4)
Sudden onset rectal pain
Fever, chills, malaise
Perianal swelling with erythema & warmth
Anal fistula
Abnormal connection between the epithelialised surface of the anal canal and perianal skin
Risk factors for anal fistula (6)
History of ischiorectal abscess
Foreign body
Treatment of anal fistula
Intraoperative unroofing of entire fistula tract. Loop heavy suture through tract to keep it patent for drainage & to stimulate fibrosis.
Pilonidal disease
Cystic inflammation at or near the cranial edge of the gluteal cleft, usually seen in young men. Presents as an abscess or a draining sinus with pain at the top of the gluteal cleft.
Anal cancer: risk factors (6)
Multiple sexual partners
Anal intercourse
Anal squamous cell carcinoma: treatment
Radiation + chemotherapy
Surgery only in case of recurrence
Treatment of anal margin tumors (except SCC)
Wide local excition +/- radiation +/- chemo
80% successful without abdominal-perineal resection if tumor is small & not deeply invasive
Anal canal tumors (epidermoid, melanoma)
Chemo (5-FU & mitomycin C) + radiation
Abdominal-perineal resection if follow-up biopsy shows residual tumor
Causes of obstruction of appendix lumen (5)
Lymphoid hyperplasia
Foreign objects: seeds, barium from previous x-ray
Stricture: e.g. tumor
Parasites: esp. Ascaris
Typical symptoms of appendicitis (4)
Abdominal pain followed by vomiting
Pain that is initially diffuse and epigastric or periumbilical, and then localizes to RUQ
Typical signs of appendicitis (5)
Direct rebound tenderness at McBurney’s point
Rovsing’s sign: pain in RLQ during palpation of LLQ
Ilipsoas sign: pelvic pain upon extension of right thigh
Obturator sign: pelvic pain upon internal rotation of right thigh
Dunphy’s sign: increased pain with coughing
Location of somatic pain of appendicitis according to anatomic location
Long tip: LLQ pain
Retrocecal: flank or back pain
Pelvic: suprapubic pain
Retroileal: testiclar pain
Malrotation: perplexing pattern or pain
Appendicitis: CT findings (4)
>6mm dilation of appendix
Appendiceal thickening
Periappendiceal streaking (densities in perimesenteric fat)
Appendicitis: ultrasound findings
Enlarged (>6mm) noncompressible appendix
False positives: dilated fallopian tube, inspissated stool (looks like appendicolith), obesity (fat prevents compression of appendix)
False negatives: inflammation only in tip, retrocecal appendix, large appendix (looks like small bowel), perforation (allows compression of appendix)
Mucinous appendiceal tumor
Rupture leads to pseudomyxoma peritonei, bowel obstruction, and perforation
Associated with migratory thrombophlebitis
Hepatoduodenal ligament
Contains common bile duct, portal vein, proper hepatic artery
Forms anterior boundary of epiploic foramen of Winslow
Connects greater and lesser peritoneal cavities
Pringle maneuver
Compression of the hepatoduodenal ligament
Performed to control bleeding from the liver
Sphincterotomy (papillotomy)
Cut through sphincter of Oddi to allow stones to pass from CBD to duodenum. Performed during ERCP.
Kocher incision
Incision at right costal margin during open cholecystectomy
Endoscope into duodenum –> introduce catheter into ampulla of Vater –> inject contrast into CBD and/or pancreatic duct.
Percutaneous transhepatic cholangiography (PTHC)
Pass needle through skin & subcutaneous tissue –> into hepatic parenchyma –> advance into peripheral bile duct –> inject contrast medium. Complements ERCP.
Jaundice: signs (10)
Yellow skin and sclera
RUQ tenderness
Dark urine
Clay-colored stool
Bilirubin >2.5
Obstructive jaundice: signs (4)
Dark urine
Clay-colored stool
Elevated alkaline phosphatase
Prehapatic hyperbilirubinemia: causes & bilirubin levels
Causes: hemolysis, Gilbert’s disease, Crigler-Najjar syndrome
Direct bilirubin: normal
Indirect bilirubin: high
Hepatic hyperbilirubinemia: causes & bilirubin levels
Causes: alcoholic cirrhosis, acute hepatitis, primary biliary cirrhosis
Direct bilirubin: high
Indirect bilirubin: high
Posthepatic hyperbilirubinemia: causes & bilirubin levels
Causes: gallstones, tumor
Direct bilirubin: high
Indirect bilirubin: normal
Pyogenic hepatic abscess: etiology (3), risk factors (6), treatment
Etiology: E. coli, Klebsiella, Proteus
Risk factors: sepsis, biliary or portal vein infection, perforated infected gallbladder, cholangitis, diverticulitis, liver cancer / metastases
Treatment: U/S or CT-guided percutaneous drainage + IV abx
Amebic hepatic abscess: etiology, appearance, risk factors (4), treatment
Etiology: Entamoeba histolytica
Appearance: “anchovy paste”
Risk factors: Central American origin, gay men, institutionalized pts, alcoholism
Treatment: IV metronidazole
Hepatic abscess: signs & symptoms (8)
Fever, chills, RUQ pain, jaundice, sepsis, weight loss
Elevated LFTs
Hepatic abscess: diagnosis
Ultrasound or CT scan
Hydatid cyst: definition, risk factors, symptoms, diagnosis, treatment
Definition: solitary cyst on right lobe of liver, caused by Echinococcus multilocularis or granulosus
Risk factors: exposure to dogs, sheep, cattle, wolves, cats, foreign travel
Symptoms: usually asymptomatic, but may have HSM
Diagnosis: incidental calcifications on U/S, CT or AXR; eosinophilia; serology
Treatment: albendazole or mebendazole
Nonparasytic hepatic cysts: definintion, signs, diagnosis, treatment
Definition: benign congenital cysts in parenchyma of right lobe of liver, associated with polycystic kidney disease
Signs: usually asymptomatic but large cysts can cause abdominal pain, bleeding & infection
Diagnosis: incidentally on U/S or CT
Treatment: excise if large & symptomatic
Cavernous liver hemangioma: definition, signs, diagnosis, treatment
Definition: benign vascular tumor in right posterior segment of liver
Signs: usually asymptomatic but may cause pain, mass or hepatomegaly
Diagnosis: incidentally; do NOT biopsy
Treatment: observe or resect if symptomatic
Liver hamartoma: definition, signs, diagnosis, treatment
Definition: benign focal lesion containing normal tissue that has differentiated abnormally
Signs: usually asymptomatic but may cause RUQ pain or fullness
Diagnosis: incidentally
Treatment: surgical excision
Liver adenoma: definition, risk factors, signs, diagnosis, treatment
Definition: benign proliferation of hepatocytes
Risk factors: OCPs, anabolic steroids, glycogen storage disease
Signs: abdominal mass & pain, bleeding, may be asymptomatic
Diagnosis: U/S + needle biopsy
Treatment: surgical excision
Focal nodular hyperplasia (FNH): definition, risk factors, signs, diagnosis, treatment
Definition: benign hepatic tumor arising from hepatocytes & bile ducts, with characteristic “central scar” on pathology
Risk factors: OCPs
Signs: usually asymptomatic, but may cause abdominal pain or RUQ mass
Diagnosis: incidentally on U/S or CT; use Tc-99 study to differentiate from adenoma
Treatment: resect if patient is symptomatic
Hepatocellular carcinoma: risk factors (8)
Aflatoxins (in peanuts)
Liver flukes (trematodes)
Alpha-1-antitrypsin deficiency
Anabolic steroids
Hepatocellular carcinoma: signs & symptoms (9)
Weight loss
Dull pain in RUQ or epigastrium
Nontender hepatomegaly
Bruit over liver, due to high vascularity of tumor
Hepatocellular carcinoma: diagnosis
Increased alkaline phosphatase, AST, ALT, GGT, DCP
CT scan or U/S
Hepatocellular carcinoma: treatment
Surgical resection with >1cm margin
Most common origin of liver metastases
Lung, breast, colon
Child-Pugh score
Classification that estimates hepatic reserve in patients with liver failure. Accounts for bilirubin, albumin, ascites, neurologic deficits, prothrombin time.
Causes of portal hypertension: prehepatic, intrahepatic, and posthepatic
Prehepatic: congenital atresia, cyanosis, portal vein thrombosis
Intrahepatic: cirrhosis; fibrosis from hemochromatosis, Wilson’s disease, or congenital fibrosis
Posthepatic: hepatic vein thrombosis (Budd-Chiari syndrome), hypercoagulable state, lymphoreticular malignancy
Budd-Chiari syndrome
Occlusion of hepatic veins (e.g. due to thrombosis or external compression) causes abdominal pain, ascites and hepatomegaly
Portal hypertension: signs & symptoms (9)
Palmar erythema
Spider angiomata
Collateral blood flow: esophageal varices, hemorrhoids, caput medusa, retroperitoneal varices
Truncal obesity & wasted extremities
Asterixis (flapping hand tremor)
Hepatic encephalopathy
Portal hypertension: diagnosis
Doppler ultrasound
Portal hypertension: treatment
Splenorenal shunt: connects splenic vein to left renal vein in patients with bleeding from esophageal varices
End-to-side shunt: connects end of portal vein to side of IVC
Side-to-side shunt: connects side of portal vein to side of IVC
Portocaval H graft: synthetic graft from portal vein to IVC
Mesocaval H graft: synthetic graft from SMV to IVC
Hepatic encephalopathy
Toxins normally cleared by the liver stay in the circulation and enter the CNS. The toxins may be ammonia, GABA, mercaptens or short-chain fatty acids.
Hepatic encephalopathy: precipitating factors
Spontaneous bacterial peritonitis
Depletion of K, Mg or other electrolytes
Drugs normally cleared by liver (opiates, sedatives)
GI bleed
Excess dietary protein
Hepatic encephalopathy: signs & symptoms: (4)
Altered consciousness
Lethargy / coma
Normal EEG
Hepatic encephalopathy: diagnosis
Elevated serum ammonia (level does NOT correlate with degree of encephalopathy)
Altered mental status
Hepatic encephalopathy: treatment
Lactulose + neomycin to reduce intestinal absorption
Liver dialysis
Low albumin production by the failing liver causes low oncotic pressure + increased hydrostatic pressure in hepatic circulation + Na / fluid retention by the kidneys –> causes fluid to be lost in the peritoneal cavity.
Ascites: treatment
Reduce sodium intake
Potassium-sparing diuretic: spironolactone
Abdominal paracentesis: don’t remove too much, otherwise intravascular fluid may be drawn into peritoneal cavity, causing hypovolemic shock
LaVeen shunt (peritoneal-jugular shunt): may increase hepatic encephalopathy
Esophageal varices: diagnosis
Ruptured esophageal varices: treatment (7)
Endoscopic sclerotherapy
Balloon tamponade (Sengstaken-Blakemore tube)
Transjugular intrahepatic portocaval shunt (TIPS)
Intraoperative placement of portocaval shunt
Liver transplant
Calot’s triangle
Made up of inferior border of liver, common hepatic duct, and cystic duct. Cystic artery runs through it. Right hepatic duct is adjacent to cystic duct and may be injured during cholecystectomy.
Hartman’s pouch
Infundibulum of gallbladder
Cholelithiasis: risk factors (10)
Fat (hyperlipidemia, obesity)
Fertile (premenopausal, pregnant, OCPs)
Flatulent (IBD, ileal resection)
F-Hb (sickle cell disease)
Native American
Western diet
Gallstones: composition
85% made primarily of cholesterol
15% pigmented
15% have enough calcium to be radiopaque
Mirizzi’s syndrome
External compression of common hepatic duct by a gallstone impacted in the cystic duct
Cholelithiasis: signs & symptoms
Biliary colic: severe RUQ pain radiating to back, epigastrium or LUQ that is worse after eating fatty foods
Cholelithiasis: diagnosis
AXR: finds 15% of gallstones
Ultrasound: acoustic shadow (“headlight”) & gravity-dependent movement of gallstones when patient moves
Cholelithiasis: treatment
Asymptomatic: no treatment, EXCEPT if patient is a child or has a porcelain gallbladder (higher risk of carcinoma), sickle cell anemia, or a stone >2-3cm
Symptomatic: laparoscopic cholecystectomy OR medical treatment with chenodeoxycholic acid or ursodeoxycholic acid (dissolve cholesterol stones)
Acute calculous cholecystitis: signs & symptoms (4)
Severe RUQ tenderness & guarding lasting >3hrs
Nausea & vomiting
Murphy’s sign
Acute calculous cholecystitis: diagnosis (3)
Labs: leukocytosis +/- elevated alk phos, LFTs, amylase, bilirubin
Ultrasound: inflamed gallbladder wall (>4mm), pericholecystic fluid & stones in gallbladder, sonographic Murphy’s sign
HIDA scan: inject Technetium-99m-labeled iminodiacetic acid into hepatocytes –> gallbladder is NOT visualized within 1hr
Acute calculuous cholecystitis: treatment (5)
IV fluids
IV antibiotics
IV analgesia
Cholecystectomy within 24-48hrs
Emphysematous cholecystitis: definition, risk factors, diagnosis
Definition: rare form of cholecystitis caused by gas-forming bacteria and often resulting in perforation of the gallbladder
Risk factors: affects elderly diabetic men
Diagnosis: gas within gallbladder in AXR or CT scan
Acalculous cholecystitis: cause and risk factors (5)
Cause: biliary stasis
Risk factors: ICU patients with multiorgan system failure, trauma, burns, sepsis, TPN
Acalculous cholecystitis: diagnosis
Labs: leukocytosis +/- elevated alk phos, LFTs, amylase, bilirubin
Ultrasound: biliary sludge & inflammation
HIDA scan: confirms diagnosis
Cholecystitis: complications
Acalculous cholecystitis: treatment
Urgent cholecystectomy
Choledocholithiasis: signs & symptoms (4)
Epigastric or RUQ pain & tenderness
Recurrent attacks of acute pancreatitis
Choledocholithiasis: diagnosis (4)
Labs: increased alk phos, LFTs, total bilirubin, direct bilirubin
ERCP: gold standard
Endoscopic ultrasound: less invasive than ERCP
Transabdominal ultrasound: less sensitive than endoscopic
Choledocholithiasis: treatment (2)
ERCP: endoscopic sphincterotomy & retrieval of CBD stones
If ERCP fails, remove stones surgically & place T-tube so bile can drain surgically
Acute ascending cholangitis: signs & symptoms
Charcot’s triad: RUQ pain, fever, jaundice
Reynold’s pentad: RUQ pain, fever, jaundice, CNS symptoms, septic shock
Nausea / vomiting
Common causes of common bile duct obstruction (SINGE)
Iatrogenic: ERCP, PTHC, biliary stent placement
Extrinsic compression: pancreatic pseudocyst, pancreatitis
Acute ascending cholangitis: diagnosis (4)
Labs: increased WBC, bilirubin, alk phos, LFTs
Ultrasound: dilation of common & intrahepatic bile ducts
ERCP or PTHC: definitive diagnosis
Bile cultures: usually enteric gram negatives & enterococci
Acute ascending cholangitis: treatment (3)
NPO, IV fluids, IV abx
ERCP or PTHC to decompress bile duct if patient is in shock
If ERCP/PTHC fails, intraoperative decompression with T-tube placement
Sclerosing cholangitis
Chronic progressive inflammation of biliary tree, causing strictures and ultimately leading to cirrhosis & liver failure. Etiology is unknown.
Sclerosing cholangitis: risk factors (4)
Trauma to common hepatic duct
Sclerosing cholangitis: diagnosis (2)
Elevated alk phos
ERCP PTC: “beads on a string” appearance of bile ducts
Sclerosing cholangitis: treatment (3)
Extrahepatic strictures: hepatoenteric anastomosis + T-tube placement for external drainage
Intrahepatic strictures: liver transplant
Balloon dilation with stent placement for palliation
Sclerosing cholangitis: complications (4)
Obstructive jaundice
Cholangiocarcinoma (10%)
Gallstone ileus
Large stone erodes a hole through gallbladder wall to duodenum –> cholecystenteric fistula –> gallstone enters GI tract –> gets stuck in ileocecal valve, causing obstruction. Seen in women over 70.
Gallstone ileus: signs & symptoms
Symptoms of acute cholecystitis AND small bowel obstruction
Gallstone ileus: diagnosis (3)
AXR: pneumobilia, dilated small bowel, large gallstone in RLQ
Ultrasound: confirms cholelithiasis & may identify fistula
Upper & lower GI series: usually unnecessary
Gallstone ileus: treatment
Exploratory laparotomy to remove gallstone, resect small bowel, remove gallbladder, and repair fistula
Carcinoma of the gallbladder: definition, risk factors (7), signs, diagnosis (4)
Definition: most are adenocarcinomas
Risk factors: porcelain gallbladder, gallstones, choledochal cysts, gallbladder polyps, typhoid carriers with chronic inflammation, female, 75y/o
Signs: none till late
Diagnosis: U/S, CT, MRI, ERCP/PTHC
Carcinoma of the gallbladder: treatment (3)
Confined to mucosa: cholecystectomy
Involves muscularis or serosa: radical cholecystectomy, wedge resection of overlying liver, LN dissection
Involves liver: decompress proximal biliary tree, palliation
Courvoisier’s sign
Palpable, nontender gallbladder often associated with cancer in the head of the pancreas or gallbladder
Benign tumor of the bile duct: definition, signs & symptoms, diagnosis, treatment
Definition: polypoid adenoma <2cm, usually at ampulla of Vater
Signs & symptoms: RUQ pain, jaundice
Diagnosis: intraoperative cholangiogram, U/S, ERCP
Treatment: resection
Cholangiocarcinoma: definition & prognosis
Definition: rare adenocarcinoma, most often at bifurcation of right & left hepatic ducts (Klatskin tumor)
Prognosis: 15-20% 5yr survival
Cholangiocarcinoma: risk factors (6)
Choledochal cyst
Ulcerative colitis
Sclerosing cholangitis
Liver flukes
Contrast dye
Cholangiocarcinoma: diagnosis (3)
Ultrasound: bile duct dilatation
CT scan
ERCP-guided biopsy
Cholangiocarcinoma: treatment
Proximal: resection + Roux-en-Y hepaticojejunostomy
Distal: Whipple procedure
Pancreas divisum
Two pancreatic duct systems fail to fuse in utero –> duct of Santorini becomes main pancreatic duct –> inadequate drainage –> recurrent pancreatitis & chronic pain
Annular pancreas
ventral pancreas malrotates in utero –> encircles duodenum –> pancreatitis, upper GI obstruction, peptic ulcers
Clinical uses of somatostatin
Treat symptoms of neuroendocrine tumors: e.g. islet cell, carcinoid, gastrinoma, VIPoma, acromegaly
Convert high-output filstulae into low-output fistulae, via anti-motility & anti-secretory effects
Causes of acute PANCREATITIS
Posterior perforation of peptic ulcer
Neoplasm (obstructs pancreatic duct or duodenum)
Cholelithiasis, hyperCalcemia
Renal disease (end-stage)
Anorexia (malnutrition)
Trauma, hyperTriglyceridemia
Infection: scorpion venom, mumps, coxsackie, CMV
Toxins (drugs)
Incineration (burn)
Medications that can cause pancreatitis: MED VIPS
Methyldopa, metronidazole
Isoniazid, immunosuppressives (azathioprine)
Acute pancreatitis: signs & symptoms (7)
Severe constant mid-epigastric or LUQ pain that radiates to the back and improves with sitting up & leaning forward
Nausea / vomiting
Low-grade fever
Fluid sequestration in retroperitoneum
Cullen sign (periumbilical bruise)
Grey-Turner sign (flank bruise)
Acute pancreatitis: diagnosis (3)
Labs: amylase 3x ULN, lipase 2x ULN, elevated urinary amylase, elevated amylase-creatinine clearance ratio
AXR: sentinel loop sign (air-fluid level associated with pancreatitis-associated ileus) & colon cutoff sign
CT scan (best): stranding in peripancreatic region
Acute pancreatitis: when to operate (4)
Diagnosis is uncertain
Infected necrosis
Biliary tract disease
Progressive deterioration despite medical care
Disorders with high amylase levels (6)
Acute pancreatitis
Intestinal disease
Perforated ulcer
Ruptured ectopic
Salivary gland disorders
Causes of chronic pancreatitis (6)
Alcohol abuse
Chronic liver disease
Congenital pancreatic anomalies
Chronic pancreatitis: diagnosis
AXR: pancreatic calcifications
ERCP: chain of lakes
CT scan (best): pseudocysts, calcifications
Chronic pancreatitis: when to operate (4)
Persistent pain: decompress pancreatic duct, resect part of pancreas
GI or biliary obstruction
Pseudocyst infection, hemorrhage or rupture
Enlarging pseudocysts
Pancreatic adenocarcinoma: risk factors (4)
African American
Older age
Pancreatic adenocarcinoma: signs & symptoms (5)
Pain radiating to the back
Weight loss
Courvoisier’s sign
Pancreatic adenocarcinoma: diagnosis (3)
Labs: elevated CA 19-9, alk phos, direct bilirubin
CT scan
ERCP or PTHC for periampullary lesions
Pancreatic adenocarcinoma: treatment (4)
Internal biliary decompression with stent
Whipple procedure (high mortality)
Palliation: relieve biliary & duodenal obstruction, splanchnicectomy for pain control
Post-op chemoradiation: controversial
Whipple procedure
Removal of gallbladder, CBD, antrum of stomach, duodenum, proximal jejunum, head of pancreas. Used to treat cancers of the head of the pancreas, the CBD and the duodenum.
Cystadenocarcinoma of the pancreas: definition, patients, symptoms, treatment
Definition: exocrine tumor in body / tail of pancreas with malignant potential
Patients: 40-60y/o females
Symptoms: abdominal & back pain
Treatment: surgical resection
Cystadenoma: types, patients, symptoms, treatment
Types: serous (benign), mucinous (malignant potential)
Patients: middle-aged & older women
Symptoms: vague abdominal symptoms
Treatment: surgical resection
Insulinoma: symptoms, diagnosis, treatment
Symptoms: blackouts due to hypoglycemia, relief of symptoms with glucose, aggressiveness, confusion, coma
Diagnosis: fasting serum insulin >25
Treatment: surgical resection + diazoxide for hypoglycemic symptoms
Gastrinoma: definition, symptoms, diagnosis, treatment
Definition: small slow-growing tumors in pancreas or duodenum, with 60% risk of malignancy; associated with MEN-1
Symptoms: signs of peptic ulcer disease, epigastric pain after eating, diarrhea
Diagnosis: fasting serum gastrin >500pg/mL
Treatment: PPI + surgical resection
Zollinger-Ellison syndrome
Gastric acid hypersecretion + severe peptic ulceration + pancreatic gastrinoma
VIPoma (Verner-Morrison or WDHA syndrome): definition, symptoms, diagnosis, treatment
Definition: overproduction of vasoactive intestinal peptide in pancreas, usually malignant
Signs & symptoms: watery diarrhea, hypokalemia, achlorhydria (absent gastric acid secretion)
Diagnosis: fasting serum VIP >800pg/mL
Treatment: surgical resection + chemo + octreotide
Glucagonoma: definition, symptoms, diagnosis, treatment
Definition: large malignant primary tumor of pancreas that has usually metastasized to LNs & liver by the time of diagnosis
Signs & symptoms: hyperglycemia, anemia, mucositis, weight loss, necrolytic migratory erythema
Diagnosis: fasting serum glucagon >1000pg/mL
Treatment: surgical resection + chemo
Somatostatinoma: definition, symptoms, diagnosis, treatment
Definition: rare large tumor of the pancreas that has usually metastasized by diagnosis
Symptoms: indigestion, diarrhea, abdominal cramps, weight loss, diabetes, gallstones, hypochlorhydria (low gastric acid secretion)
Diagnosis: fasting serum somatostatin >1000pg/mL
Treatment: surgical resection + chemo
Splenomegaly + overactive splenic function, leading to excessive removal of circulating blood elements. May be primary (idiopathic) or secondary
Hemolytic anemias that cause hypersplenism (8)
Hereditary spherocytosis
Hereditary elliptocytosis
G6PD deficiency
Thalassemia major
Sickle cell anemia
Idiopathic autoimmune hemolytic anemia
Neoplasms that cause hypersplenism (6)
Leukemia (CML, CLL, hairy cell)
Metastatic carcinoma
Myelofibrosis with myeloid metaplasia
Polycythemia vera
Chronic inflammatory diseases that cause hypersplenism (4)
Felty syndrome
Porphyria erythropoietica
Felty syndrome
Rheumatoid arthritis + splenomegaly + neutropenia
Congestive diseases that cause hypersplenism (5)
Portal hypertension
Portal or splenic vein obstruction
Splenic venous thrombosis
Severe CHF
Most common cause of hypersplenism
Portal hypertension
Infectious causes of hypersplenism (7)
Bacterial endocarditis
Storage diseases that cause hypersplenism (4)
Spleen is anatomically present, but peripheral blood smear shows signs of asplenism (Howell-Jolly bodies, Pappenheimer bodies, acanthocytes, Heinz bodies)
Causes of hyposplenism (4)
Sickle cell anemia
Collagen vascular disease
Autoimmune disease
Indications for splenectomy (8)
Splenic rupture
Hereditary spherocytosis
Primary tumor or cyst
Parasitic cyst
Symptomatic splenomegaly
Refractory TTP
Splenic abscess
Conditions associated with splenic rupture (4)
Blunt trauma
Splenic abscess
Complications of splenectomy (8)
Pleural effusion on left side
Injury to pancreas
Post-op hemorrhage
Subphrenic abscess
Hodgkin’s lymphoma: histologic types (4)
Nodular sclerosis
Lymphocyte predominant
Mixed cellularity
Lymphocyte depletion
Hodgkin’s lymphoma: signs & symptoms (5)
Pel-Ebstein cyclic fever
Chest pain, especially after EtOH ingestion
Cough, dyspnea, hoarseness
SVC syndrome
Weight loss, malaise, anorexia
Hodgkin’s lymphoma: diagnosis
Giant multinucleated Reed-Sternberg cells in lymphoid tissue
Adverse prognostic factors in Hodgkin’s lymphoma (4)
Bulky mediastinal disease
Age >40
Significant weight loss & fevers
Clinical staging of Hodgkin’s lymphoma
Stage I: limited to one anatomic region
Stage II: >1 regions on same side of diaphragm
Stage III: disease on both sides of diaphragm but limited to spleen, LNs & Waldeyer’s ring
Stage IV: metastatic disease
Treatment of Hodgkin’s lymphoma
Stage I & II: radiation alone
Advanced disease or adverse prognostic factors: add chemo
Non-Hodgkin’s lymphoma: symptoms, treatment
Disease is usually systemic by the time of diagnosis
Symptoms: SVC syndrome, constitutional symptoms
Treatment: chemotherapy
Non-Hodgkin’s lymphoma with low-grade aggressiveness (3)
Small lymphocytic
Follicular small cleaved cell
Follicular mixed cell
Non-Hodgkin’s lymphoma with intermediate-grade aggressiveness (4)
Follicular large cell
Diffuse small cell
Diffuse mixed cell
Diffuse large cell
Non-Hodgkin’s lymphoma with high-grade aggressiveness (3)
Small noncleaved cell
Hairy cell (lymphocytic) leukemia: risk factors (2)
Age >50
Hairy cell (lymphocytic) leukemia: signs & symptoms (5)
Abdominal fullness (splenomegaly)
Easy bruising (thrombocytopenia)
Recurrent infections (leukopenia)
Constitutional symptoms
Hairy cell (lymphocytic) leukemia: diagnosis (3)
Peripheral smear: many mononuclear cells & hairy WBCs
Positive staining for tartrate-resistant acid phosphates (TRAP)
Bone marrow biopsy
Hairy cell (lymphocytic) leukemia: treatment (2)
Splenectomy for symptomatic hypersplenism
Chronic lymphocytic leukemia (CLL): risk factors (2)
Age ~60s
Chronic lymphocytic leukemia (CLL): signs & symptoms (6)
Splenomegaly (autoimmune hemolytic anemia)
Constitutional symptoms
Chronic lymphocytic leukemia (CLL): diagnosis
Peripheral smear: leukocytosis with many immature abnormal lymphocytes
Bone marrow biopsy
Chronic lymphocytic leukemia (CLL): treatment
Splenectomy (only improves symptoms)
Chronic myelocytic leukemia (CML): definition, symptoms, diagnosis, treatment
Definition: overgrowth of granulocytes in bone marrow
Symptoms: splenomegaly
Diagnosis: Philadelphia chromosome t(9;22), low leukocyte alk phos, many myeloblasts & basophils on peripheral smear
Treatment: chemo + splenectomy for symptoms
Spleen hemangioma: complications (3), treatment
Complications: rupture, platelet sequestration, coagulopathy
Treatment: splenectomy
Spleen hamartoma (3)
Cystic or solid
No symptoms unless very large
Diagnose via splenectomy
Spleen lymphangioma: definition & treatment
Definition: cystic mass involving multiple body sites (liver, lung, bone, skin)
Treatment: splenectomy
Immune thrombocytopenic purpura (ITP): definition, symptoms, diagnosis, treatment
Definition: antibodies against platelet surface antigen –> removed from circulation –> thrombocytopenia
Symptoms: petechiae & purpura on trunk & limbs, guiac-positive stool, mucosal bleeding
Diagnosis: unexplained thrombocytopenia
Treatment: corticosteroids, IVIG, splenectomy, platelet transfusion
One unit of platelets increases platelet count by
Thrombotic thrombocytopenic purpura (TTP)
Abnormal von Willibrand factor deposits to form clots at sites of endothelial damage –> platelets clump at this site –> RBCs are sheared as they pass by –> hemolytic anemia + thrombocytopenia
Thrombotic thrombocytopenic purpura (TTP): risk factors (7)
Age 12-45
Drugs (chemo, antiplatelets, OCPs)
Infection (E. coli 0157:H7, HIV)
Autoimmune disease
Thrombotic thrombocytopenic purpura (TTP): signs & symptoms (FAT RN)
Thrombocytopenia: petechiae, purpura, pallor
Renal dysfunction: hematuria, oliguria
Neurologic dysfunction: waxing & waning mental status
Thrombotic thrombocytopenic purpura (TTP): diagnosis (6)
Blood smear: schistocytes, helmet cells
Elevated BUN
Elevated LDH
CBC: elevated reticulocytes, anemia, thrombocytopenia
Decreased haptoglobin
UA: casts or RBCs in urine
Thrombotic thrombocytopenic purpura (TTP): treatment (4)
Plasmapheresis or FFP
Packed RBCs if anemia is symptomatic
Refractory cases: splenectomy, corticosteroids, vincristine, antiplatelet agents
Do NOT transfuse platelets (“fuels the fire”)
Splenic abscess: diagnosis (2)
Ultrasound: enlarged spleen + areas of lucency within
CT scan (best): abscess has lower attenuation than surrounding parenchyma
Splenic abscess: complications (4)
Spontaneous rupture
Most common hernias by age
0-2yrs: indirect inguinal hernia
2-20yrs: uncommon
20-50yrs: indirect inguinal hernia
>50yrs: direct inguinal hernia
Spermatic cord
Contains vas deferens and its artery, testicular artery, 2-3 veins, lymphatics, autonomic nerves, fat
Cremaster vessels
Arise from inferior epigastrics and pass through posterior wall of inguinal canal. Supply cremaster muscle & testis tunica.
Femoral canal structures (NAVEL)
From lateral to medial: nerve, artery, vein, empty space, lymph nodes
Hesselbach’s triangle
Site of direct inguinal hernia, in lower abdominal wall. Bound by inguinal ligament inferiorly, rectus abdominis medially, inferior epigastric vessels laterally.
Differential diagnosis for inguinal hernia
Abdominal wall mass
Rectus sheath hematoma
Inguinal hernia: diagnosis (4)
AXR: bowel gas pattern in pelvis
CT scan
Herniography: image hernia after injecting non-irritating contrast medium into the hernial sac
Inguinal hernia: treatment (2)
Herniotomy: cut through band of tissue that constricts strangulated hernia
Hernorrhaphy: open coverings, return contents to normal place, oliterate hernial sac, and close with strong sutures
Direct inguinal hernia: characteristics (4), risk factors (5), symptoms
Characteristics: enters inguinal canal though a weakened posterior wall, lies posterior to spermatic cord without entering scrotum, wide neck (no strangulation), may damage ilioinguinal nerve
Risk factors: males, older age, smoking (weak connective tissue), hard labor, cough
Symptoms: dull dragging pain referred to testis that increases with straining
Indirect inguinal hernia
Goes though internal inguinal ring and may enter external inguinal ring and then scrotum
Associated with patent processus vaginalis
1/3 are bilateral
Femoral hernia: characteristics (2) & symptoms (5)
Characteristics: high incidence of incarceration & strangulation due to narrow neck; common in elderly
Symptoms: dull dragging pain in groin, swelling, vomiting, constipation, severe pain & shock if strangulated
Abdominal hernia: risk factors (4), complications (2), treatment
Risk factors: ascites, obesity, repeated pregnancies, female
Complications: strangulation of colon & omentum, rupture
Treatment: surgical repair
Pediatric umbilical hernia (3)
Fascial defect in linea alba with protruding abdominal contents covered by umbilical skin & subQ tissue
Incarceration is rare
Surgical repair if defect is >2cm or hernia hasn’t repaired spontaneously within 3yrs
Sliding esophageal hernia (type 1): definition, complications (3), treatment
Definition: gastroesophageal junction & stomach herniate into thoracic cavity
Complications: reflux, esophagitis, increased risk of Barrett’s esophagus
Treatment: head elevation & antacids, or Nissen fundoplication (usually not needed)
Paraesophageal hiatal hernia (type II): definition, complications (3), treatment
Definition: herniation of stomach into thorax via esophageal hiatus, but no disruption of gastroesophageal junction
Complications: obstruction, strangulation, hemorrhage
Treatment: surgical correction
Hernias most associated with obesity
Direct inguinal
Growth hormone: function (5), stimulators (7), inhibitors (1)
Function: opposes insulin, stimulates amino acid uptake, mediates IGF synthesis, stimulates release of fatty acids, stimulates growth of many tissues
Stimulators: GHRH, hypoglycemia, exercise, arginine, L-dopa, clonidine, propranolol
Inhibitors: somatostatin
ACTH: function (1), stimulators (2), inhibitors (1)
Function: stimulates secretion of adrenocortical hormones
Stimulators: CRH, stress
Inhibitors: cortisol
FSH: function (2)
Function: stimulates ovarian follicular growth in females, stimulates spermatogenesis & testicular growth in males
LH: function (4)
Function: ovulation, luteinization of follicle, stimulates production of estrogen & progesterone, promotes production of testosterone in males
Prolactin: function (1), stimulators (5), inhibitors (1)
Function: stimulates milk production
Stimulators: TRH, estrogen, exercise, stress, antipsychotics
Inhibitors: bromocriptine
ADH: function (2), stimulators (2)
Function: water absorption in renal collecting ducts, vasoconstriction of peripheral arterioles
Stimulators: increased plasma osmolality, decreased plasma volume
Thyroid hormone: function (10)
Cardiovascular: increases heart rate & contractility
Respiratory system: increases RR & depth of respiration
GI system: increases motility
CNS: increases nervousness, anxiety
Musculoskeletal system: increases reactivity, causes fine motor tremor
Nutrition: increases basal metabolic rate, O2 consumption, protein synthesis, lipolysis, glycogenolysis, gluconeogenesis
Increases catecholamine sensitivity
Stimulates release of steroid hormones
Stimulates erythropoiesis
Increases bone turnover
Calcintonin: function (2)
Decreases serum calcium by inhibiting osteoclasts, preventing Ca reabsorption in GI tract, and preventing Ca reabsorption in kidneys
Decreases phosphate reabsorption in kidneys
PTH: function (4), stimulators (1), inhibitors (1)
Function: increases Ca reabsorption in kidney; increases excretion of Na, K, phosphate, HCO3 from kidney; stimulates bone resorption, releasing Ca & phosphate; stimulates activation of vitamin D to increase Ca & phosphate absorption from GI tract
Stimulators: low serum Ca
Inhibitors: high serum Ca
Insulin: function (4)
Stimulates glycogenolysis, glycolysis, and synthesis of proteins, TGs, cholesterol and VLDL in liver
Inhibits glycogenolysis, ketogenesis, gluconeogenesis in liver
Stimulates protein synthesis & glycogen synthesis in muscle
Promotes TG storage in fat
Cortisol: function (5), stimulators (2)
Function: stimulates gluconeogenesis & lipolysis; inhibits peripheral glucose uptake & protein synthesis; inhibits bone formation; reduces GI absorption of Ca; reduces inflammation
Stimulators: ACTH, stress
Aldosterone: function
Stimulates absorption of Na in renal tubules, in exchange for K & H –> intravascular volume expansion
Epinephrine & norepinephrine: function (4), stimulators (2)
Function: increases O2 consumption, increases heat production, stimulates glycogenolysis & lipolysis, inhibits insulin secretion
Stimulators: stress, alpha & beta receptor stimulation
MEN-I: mutation & tumors
Mutation: 11q12-13 deletion
Tumors: Pituitary adenoma, Parathyroid hyperplasia, Pancreas islet cell tumors
MEN-IIA: mutation & tumors
Mutation: RET oncogene mutation on chromosome 10 or missense mutation on chromosome 1
Tumors: parathyroid hyperplasia, medullary thyroid carcinoma, pheochromocytoma
MEN-IIB: mutation & tumors
Mutation: RET oncogene mutation on chromosome 10
Tumors: medullary thyroid carcinoma, pheochromocytoma, mucosal neuroma, Marfanoid habitus
Thyroglossal duct cyst (3)
Persistent sinus tract remnant of developing thyroid
Few symptoms but may become infected
Treat via surgical excision of duct remnant & central part of hyoid bone
Causes of hyperthyroidism (6)
Graves’ disease
Toxic nodular goiter
Toxic thyroid adenoma
Subacute thyroiditis
Functional metastatic thyroid cancer
Struma ovarii
Graves’ disease: symptoms (12)
Nervousness, tremor
Increased sweating
Tachycardia, palpitations
Pretibial myxedema
Heat intolerance
Weight loss, fatigue, weakness, dyspnea
Increased appetite
Eye complaints
Thyroid bruit
Decreased libido & fertility
Graves’ disease: treatment
Beta blockers for symptom relief
Antithyroid drugs: PTU, methimazole
Radioablation (NOT if pregnant)
Surgical resection
Toxic nodular goiter (Plummer’s disease): symptoms & treatment
Symptoms: hyperthyroidism
Treatment: lobectomy or nodulectomy
Risks of thyroid lobectomy surgery
Recurrent laryngeal nerve injury
Persistent hyperthyroidism
Thyroid storm: precipitants, symptoms, treatment
Precipitants: infection, labor, surgery, iodide, recent radioablation
Symptoms: disorientation, fever, tachycardia, vomiting, diarrhea
Treatment: fluids, antithyroid drugs, beta blockers, NaI or KI, hydrocortisone, cooling blanket
Causes of hypothyroidism (4)
Autoimmune thyroiditis
Iodine deficiency
Acute thyroiditis: etiology, risk factors (3), symptoms (4), treatment
Etiology: strep pyogenes, staph aureus, pnemococcus
Risk factors: female, goiter, thyroglossal duct
Symptoms: unilateral neck pain, fever, euthyroid, dysphagia
Treatment: IV abx + surgical drainage
Subacute thyroiditis: etiology, risk factors, symptoms (5), treatment
Etiology: post-URI
Risk factors: female
Symptoms: fatigue, depression, neck pain, fever, firm & tender thyroid
Treatment: self-limited to 6wks, NSAIDs
Chronic (Hashimoto’s) thyroiditis: risk factors (5), symptoms (2), treatment
Risk factors: Down’s, Turner’s, familial Alzheimer’s, history of radiation, other autoimmune diseases
Symptoms: painless enlargement of thyroid, neck tightness
Treatment: thyroid hormone +/- partial thyroidectomy
Riedel’s fibrosing thyroiditis: definition, risk factors (2), symptoms (4), diagnosis, treatment
Definition: fibrosis replaces both lobes & isthmus
Risk factors: sclerosing cholangitis, retroperitoneal fibrosis
Symptoms: euthyroid, neck pain, airway compromise, firm nontender enlarged thyroid
Diagnosis: biopsy shows dense invasive fibrosis
Treatment: steroids; isthmectomy if airway compromise present
Initial workup of thyroid nodule
Papillary thyroid cancer: epidemiology, risk factors, symptoms, diagnosis, metastases, treatment
Epidemiology: 80-85% thyroid cancers, 30-40y/o, 2x more in women, 74-93% 10yr survival
Risk factors: radiation
Symptoms: painless mass, dysphagia, dyspnea, hoarseness, euthyroid
Diagnosis: FNA + CT or MRI to assess local invasion
Metastases: lymphatic
Treatment: lobectomy + isthmectomy OR total thyroidectomy; radical neck dissection if +LN; radioablation if residual thyroid or LN mets
Follicular thyroid cancer: epidemiology, risk factors, symptoms, diagnosis, metastases, treatment
Epidemiology: 5-10% thyroid cancers, 50y/o, 3x more in women, 70% 10yr survival
Risk factors: thyroid dyshormnoogenesis
Symptoms: painless mass
Diagnosis: FNA + CT or MRI to assess local invasion
Metastases: hematogenous
Treatment: lobectomy + isthmectomy OR total thyroidectomy; radical neck dissection if +LN; radioablation if residual thyroid or LN mets
Medullary thyroid cancer: epidemiology, risk factors, symptoms, diagnosis, metastases, treatment
Epidemiology: 5-10% thyroid cancers; 50-60y/o, 1.5x more in women, 70-80% 10yr survival
Risk factors: MEN-II
Symptoms: painful mass, palpable LN, dysphagia, dyspnea, hoarseness
Diagnosis: FNA, presence of amyloid, IHC shows calcitonin
Metastases: lymphatic (neck, mediastinum), local (trachea, esophagus)
Treatment: total thyroidectomy + central neck node dissection
Anaplastic thyroid cancer: epidemiology, risk factors, symptoms, diagnosis, metastases, treatment
Epidemiology: 1% thyroid cancers, 60-70y/o, 1.5 more in women, 4-5 month survival
Risk factors: prior well-differentiated thyroid cancer, iodine deficiency
Symptoms: rapidly enlarging neck mass, neck pain, dysphonia, dysphagia, hard fixed LN
Diagnosis: FNA
Metastases: 50% have pulmonary mets at diagnosis
Treatment: debulking resection of thyroid & invaded structures + XRT + doxorubicin
Papillary thyroid cancer: gross pathology (7) & histology (4)
Gross: intrathyroidal, partially encapsulated, multifocal, hard, white, areas of necrosis, cystic changes
Histology: papillary projections, pale abundant cytoplasm, psamomma bodies, Orphan Annie eyes
Follicular thyroid cancer: pathology (2)
Medullary thyroid cancer: pathology
Gross: unilateral in mid-upper lobes
Histology: originates in C-cells; sheets of cells, amyloid, collagen
Anaplastic thyroid cancer: pathology
Gross: microinvasion + positive LNs
Histology: sheets of heterogeneous cells
Hypercalcemic crisis
Definition: calcium >13mg/dL
Treatment: saline, diuretics, antiarrhythmic agents
Primary hyperparathyroidism: signs & symptoms
Stones: kidney stones
Bones: bone pain, pathologic fractures
Groans: N/V, constipation, pancreatitis, peptic ulcer disease
Moans: lethargy, confusion, depression, paranoia
Primary hyperparathyroidism: causes (3)
Solitary adenoma (most)
Four-gland hyperplasia
Primary hyperparathyroidism: treatment
Solitary adenoma: solitary parathyroidectomy
Multiple gland hyyperplasia: remove 3 glands
Hypercalcemia of malignancy
Tumor secretes PTH-related protein –> hypercalcemia. Usually involves lung, breast, prostate, head, neck cancers.
Secondary hyperparathyroidism: causes (2)
Chronic renal failure or intestinal malabsorption –> hypocalcemia –> compensatory increase in PTH
Secondary hyperparathyroidism: symptoms (4)
Often asymptomatic
Bone pain from renal osteodystrophy
Pathologic fractures
Secondary hyperparathyroidism: treatment
Medical: phosphorus-binding agents + Ca + vitamin D supplements
Surgical: 3.5 gland parathyroidectomy if pt is symptomatic
Hypoparathyroidism: causes (4)
Iatrogenic: following total thyroidectomy
DiGeorge syndrome
Functional: chronic hypomagnasemia
Hypoparathyroidism: symptoms (3)
Numbness & tingling of circumoral area, fingers and toes
Chvostek’s sign: contraction of facial muscles when tapping on facial nerve
Trousseau’s sign: carpal spasm after occlusion of blood flow to forearm
Target tissues are resistant to PTH –> low Ca & high phosphate despite high PTH. Treat with Ca & vitamin D.
Parathyroid cancer: signs & symptoms (4), labs (3), treatment, survival
Signs & symptoms: firm fixed mass, bone disease, renal insufficiency, renal stones
Labs: very high Ca, PTH, alk phos
Treatment: surgical resection of mass + ipsilateral thyroid lobe + regional LNs
Survival: 70% at 5yrs
Adrenal cortical carcinoma: epidemiology
Women more than men
Peaks at <5y/o or 30-40y/o
40% 5yr survival because most patients present late
Adrenal cortical carcinoma: signs & symptoms
Vague abdominal pain
Symptoms related to overproduction of a hormone (usually cortisol)
Adrenal cortical carcinoma: diagnosis (3)
24hr urine: cortisol, aldosterone, catecholamines, metanephrine, vanillylmandelic acid, 17-OH corticosteroids, 17-ketosteroids
CT or MRI to assess invasion
CXR to rule out pulmonary invasion
Adrenal cortical carcinoma: treatment
Radical en bloc resection
XRT for bone metastasis
Adrenal cortical carcinoma: locations of recurrence (5)
Lymph node
Cushing syndrome: causes (5)
Iatrogenic: administration of corticosteroids
ACTH-secreting pituitary tumor
Cortisol-secreting adrenal tumor
Cortisol-secreting renal cell carcinoma
Ectopic ACTH production by a tumor elsewhere
Cushing syndrome: signs & symptoms (13)
Weight gain
Truncal obesity
Extremity wasting
Buffalo hump
Moon facies
Glucose intolerance
Decreased libido
Impaired memory
Muscle weakness
Cushing syndrome due to adrenal source: diagnosis (3)
CT or MRI shows tumor or hyperplasia
Low plasma ACTH
High-dose dexamethasone suppression test does NOT suppress urinary cortisol
Cushing syndrome due to ectopic ACTH production: diagnosis (4)
CT shows bilateral adrenal hyperplasia
Very high plasma ACTH
High-dose dexamethasone suppression test does NOT suppress urinary cortisol
Negative petrosal sinus sampling
Cushing syndrome due to pituitary tumor: diagnosis
CT shows bilateral adrenal hyperplasia
Mildly increased plasma ACTH
High-dose dexamethasone suppression test DOES suppress urinary cortisol
Positive petrosal sinus sampling
Most common cause of ectopic ACTH production?
Small cell lung cancer
Low-dose dexamethasone suppression test
Single dose of steroid at 11pm –> measure serum & urine cortisol at 8am
Normal: <5mcg/dL Hypercortisolism: >5mcg/dL
High-dose dexamethasone suppression test
High dose of steroid at 11pm –> measure serum & urine cortisol at 8am
Pituitary-dependent Cushing syndrome: urinary cortisol decreases to <50%
Primary adrenal or ectopic ACTH production: no decrease in cortisol
Metyrapone test
Administer metyrapone at 11pm –> metyrapone should block cortisol production –> stimulates ACTH secretion
Pituitary-dependent Cushing syndrome: increased ACTH
Ectopic ACTH production: no increase in ACTH
Petrosal sinus sampling
Administer corticotropin-releasing hormone –> sinus/plasma ACTH ratio >3 –> identifies pituitary dependent Cushing syndrome
Primary Addison’s disease: causes (8)
Autoimmune adrenalitis
Fungal infection
Metastatic cancer
Familial glucocorticoid deficiency
Bilateral adrenal hemorrhage
Secondary Addison’s disease: causes (4)
Pituitary surgery or irradiation
Empty sella syndrome
Exogenous steroids (most common)
Addison’s disease: signs & symptoms (4)
Nausea / vomiting
Weight loss
Weakness / fatigue / lethargy
Addison’s disease: diagnosis
Labs: hyponatremia, hyperkalemia, elevated ACTH if primary
ACTH stimulation test: give ACTH & measure cortisol 30mn later; no increase in cortisol if adrenal failure is present
Addison’s disease: treatment
Glucocorticoid therapy
Mineralocorticoids if primary
Addisonian crisis: signs & symptoms (10)
Sudden pain in legs, lower back, abdomen
Vomiting & diarrhea
Conn’s syndrome: causes (6)
Primary (excessive aldosterone secretion): aldosterone-secreting tumor, idiopathic adrenocortical hyperplasia
Secondary (elevated renin): renal artery stenosis, cirrhosis, CHF, pregnancy
Conn’s syndrome: signs & symptoms (5)
Muscle weakness & cramping
Primary Conn’s syndrome: diagnosis (5)
Labs: HTN without edema, low renin, high aldosterone, hypokalemia, elevated urine K
Captopril suppression test
CT scan: distinguish between tumor (unilateral) & hyperplasia (bilateral)
Iodocholesterol scan: shows how functional the tumor is
Sample adrenal vein for aldosterone & cortisol pre- & post-ACTH administration
Hypoaldosteronism: causes (4)
Congenital error of aldosterone synthesis
Autoimmune failure of zona glomerulosa
Status post adrenalectomy
Drug inhibition
Hypoaldosteronism: signs & symptoms (4)
Postural hypotension
Persistent severe hyperkalemia
Muscle weakness
Hypoaldosteronism: treatment
Mineralocorticoid therapy
Congenital adrenal hyperplasia: cause, diagnosis, treatment
Cause: mutation in 21-hydroxylase
Diagnosis: 24hr urinary 17-ketosteroids, 17-hydroxysteroids, free cortisol; serum testosterone & estrogen; CT scan
Treatment: glucocorticoid replacement + surgical reconstruction
Definition: asymptomatic adrenal mass found on 0.6% of CTs
Labs: 24hr urinary free cortisol, VMA, metanephrine, catecholamines
Treatment: resect if >5cm or functional
Neuroblastoma: associated with which diseases?
Trisomy 18
Neuroblastoma: signs & symptoms
Abdominal or flank mass
Blueberry muffin sign (subcutaneous blue nodues)
Neuroblastoma: definition
Neural crest tumor usually in children.
Occurs anywhere along sympathetic chain.
May present with distant metastases, e.g. to LN, bone, liver, subQ tissue
Neuroblastoma: diagnosis
Elevated 24hr homovanillylmandelic acid & VMA
CT scan for staging
Neuroblastoma: prognosis
Low mortality if patient is <1y/o
90% 5yr survival if disease hasn’t spread
20-40% 5yr survival for disseminated disease
Neuroblastoma: treatment
Surgical resection for localized disease
Chemo for disease that has spread
Chromaffin cell tumor located anywhere along sympathetic chain, usually in adrenal gland
Pheochromocytoma: associated with which diseases?
Von Hippel-Lindau disease
Pheochromocytoma: signs & symptoms (5)
Pheochromocytoma: diagnosis (3)
24hr urine: elevated catecholamines, VMA, metanephrine
Clonidine test: does NOT suppress plasma catecholamine concentrations in patients with pheochromocytoma
Pheochromocytoma: treatment (4)
Alpha- & beta-blockers
Adrenalectomy of involved gland
XRT for bony mets
+/- chemo
Pituitary macroadenoma: signs & symptoms (4)
Bitemporal hemianopsia
Complications of pituitary adenoma (6)
Death from direct hypothalamic injury
Death from CSF leak
Death from vascular injury
Diabetes insipidus
Cerebrovascular accident
SIADH: pathogenesis & causes
Pathogenesis: hypersecretion of ADH leads to increased urinary Na & urine osmolality
Causes: CNS injury, CNS infection, lung cancer, trauma, drugs
Diabetes insipidus: pathogenesis & causes
Pathogenesis: decreased ADH secretion leads to large volumes of urine, increased plasma osmolality and thirst
Causes: idiopathic, tumor, trauma
Disorders that affect coronary blood flow (5)
Atherosclerosis (most common)
Valvular heart disease
Congenital coronary anomalies
Aortic dissection with involvement of ostia
Risk factors for ischemic heart disease (6)
Family history
Signs & symptoms of ischemic heart disease (8)
Angina pectoris
Abnormal heart sounds
Asymptomatic (esp. diabetics & elderly)
NYHA classification of severity of heart failure
Class I: no symptoms
Class II: symptoms with severe exertion
Class III: symptoms with mild exertion
Class IV: symptoms at rest
Ischemic heart disease: diagnostic tests (4)
EKG: ST segment elevation / depression, inverted T waves or Q waves
Echo: localize dyskinetic walls, estimate EF
Stress test
Cardiac catheterization with angiography & left ventriculography
Ischemic heart disease: treatment
Medical: aspirin, beta blockers, Ca channel blockers, ACE inhibitors, diuretics, nitrates
Percutaneous transluminal coronary angioplasty (PTCA)
Indications for CABG (8)
Stable angina refractory to medical therapy
Unstable angina
Post-infarct angina
Left main coronary disease
Decreased left ventricular function
During elective valve replacement
During surgery for complications of MI (e.g. VSD)
Complications of PTCA stent replacement
Contraindications for CABG (2)
Chronic CHF
Cardiomyopathy without signs of angina or reversible ischemia
When is PTCA preferred over CABG?
Patient has severe symptoms but only mild obstruction (e.g. single vessel), or patient is at higher risk of complications with CABG.
Intra-aortic balloon pump (IABP)
Place it in the descending aorta, just distal to the left subclavian. It inflates during diastole, increasing coronary blood flow. It deflates during systole, creating a negative pressure gradient in the aorta and reducing afterload.
Complications of CABG (9)
Sternal dehiscence
Infection (mediastinitis & sternal infection)
Graft thrombosis
Postpericardiotomy syndrome
Mitral stenosis: etiology
Rheumatic heart disease
Mitral stenosis: signs & symptoms (9)
Loud S1 & mid-diastolic rumbling murmur with opening snap
RV precordial thrust
Signs of RV failure
Hoarse voice (LA impinges on recurrent laryngeal nerve)
Mitral stenosis: diagnosis (4)
Physical exam: loud S1 & mid-diastolic rumbling murmur with opening snap that does NOT change with inspiration
CXR: straight left heart border due to large LA & Kerley B lines from pleural effusion
EKG: LA enlargement, RV hypertrophy, a-fib
Echo: fish-mouth opening of mitral valve, cross-sectional area <2, transmitral pressure gradient >10mmHg
Mitral stenosis: treatment
Medical: endocarditis prophylaxis, anticoagulation, diuretics, inotropes
Surgery: minimally invasive repair via port access technique, open commissurotomy, valve replacement, percutaneous balloon valvuloplasty
Mitral regurgitation: etiology (4)
Papillary muscle dysfunction, due to ischemia or infarction
Ruptured chordae tendineae
Valve destruction due to endocarditis or rheumatic heard disease
Mitral valve prolapse
Mitral regurgitation: signs & symptoms (6)
Atrial fibrillation
Systemic emboli
Mitral regurgitation: diagnosis (3)
Physical exam: loud holosystolic high-pitched murmur radiating to the axilla; wide splitting of S2 with inspiration; S3
EKG: enlarged left atrium
Echo: shows diseased valve, quantifies MR
Mitral regurgitation: indications for surgery (4)
First sign of symptoms
Decline in systolic function
Atrial fibrillation
LA >4.5-5cm
Aortic stenosis: etiology (4)
Idiopathic degenerative calcific disease
Congenital stenosis
Bicuspid aortic valve
Rheumatic heart disease
Aortic stenosis: signs & symptoms (5)
Angina (low BP to coronary arteries)
Syncope (low CO cannot maintain systemic BP)
Heart failure
Aortic stenosis: diagnosis (4)
Physical exam: systolic crescendo-decrescendo radiating to bilateral carotid arteries; paradoxical splitting of S2; S4 (low LV compliance); narrow pulse pressure
EKG: LV strain with ST segment depression & T wave inversion
Echo: quantifies stenosis
CXR: may show calcification of valve
Aortic stenosis: indications for surgery (3)
Transvalvular gradient >50mmHg + LVH or low EF
Aortic valve <0.8cm squared
Aortic regurgitation: etiology (11)
Aortic root dilatation: idiopathic, Marfan, collagen vascular disease
Valvular disease: endocarditis, rheumatic heart disease
Aortic root dissection: cystic medial necrosis (Marfan), Ehlers-Danlos, syphilis, HTN, Turner, 3rd trimester pregnancy
Diseases that cause widened pulse pressure (6)
Aortic regurgitation
Wet beriberi
Hypertrophic subaortic stenosis
Aortic regurgitation: diagnosis (3)
Physical exam: high-pitched blowing decrescendo diastolic murmur; hyperdynamic laterally displaced PMI
Echo: regurgitant valve
Aortic regurgitation: signs & symptoms (6)
Dyspnea & orthopnea
Angina (reduced diastolic coronary flow due to elevated LV end-diastolic pressure)
LV failure
Wide pulse pressure
Bounding pulses
Hill’s sign (systolic pressure in legs >20mmHg higher than in arms)
Aortic regurgitation: indications for surgery (3)
Declining LV function
Rapid increase in cardiac size
Tricuspid stenosis: etiology (3)
Rheumatic heart disease
Tricuspid stenosis: signs & symptoms (3)
Peripheral edema
Hepatomegaly, ascites, jaundice
Tricuspid stenosis: diagnosis (2)
Physical exam: low-pitched rumbling diastolic murmur that INCREASES with inspiration; accentuated precordial thrust of RV; diastolic thrill at lower left sternal border
Echo: quantifies transvalvular gradient
Common complication of tricuspid valve replacement
Heart block, due to close proximity of conduction bundle to tricuspid annulus
Tricuspid regurgitation: etiology (4)
Increased pulmonary artery pressure
RV dilatation stretches the outflow tract
Right papillary muscle rupture
Tricuspid valvular lesions from infection
Causes of holosystolic murmur
Mitral regurgitation
Tricuspid regurgitation
Tricuspid regurgitation: diagnosis
Physical exam: medium-pitched blowing holosystolic murmur that INCREASES with inspiration
EKG: RV enlargement
Echo: diseased valve
Tricuspid regurgitation: treatment (2)
Total valve excision with valve replacement if cause is endocarditis
Small cell lung cancer: ectopic peptide production, location, stages, response to radiotherapy, response to chemo, prognosis
Ectopic peptide production: ACTH, gastrin, vasopressin, calcitonin, atrial natriuretic factor
Location: central
Stages: limited (single radiation portal) or extensive
Response to radiotherapy: 80-90% shrink
Response to chemo: 50% completely regress
Prognosis: 5% 5yr survival, because 70% are metastatic at diagnosis
Non-small cell lung cancer: ectopic peptide production, stages, response to radiotherapy, response to chemo, indications for surgery, prognosis
Ectopic peptide production: PTH
Stages: TNM system
Response to radiotherapy: 30-50% shrink
Response to chemo: 5% completely regress
Indications for surgery: stages I, II, IIIA; not curative if pt has malignant pleural effusion
Prognosis: varies with stage
Lung cancers generally found in center of lung
Small cell
Squamous cell
Lung cancer: etiology (6)
Smoking (EXCEPT bronchoalveolar)
Passive smoke exposure
Radon gas exposure
Lung cancer: signs & symptoms (8)
Post-obstructive pneumonia
Hoarseness (recurrent laryngeal nerve paralysis)
Paraneoplastic syndromes
SVC syndrome: definition, symptoms, causes
Definition: tumor obstructs SVC, reducing venous return
Symptoms: facial edema, dyspnea, cough, headaches, epistaxis, syncope; worse in the morning & with bending forward
Causes: lung cancer, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma
Pancoast syndrome
Superior sulcus lung tumor injures CNVIII, first & second thoracic nerves and ribs –> causes shoulder pain radiating to arm
Lambert-Eaton syndrome
Antibodies attack presynaptic nerve terminals –> decreased ACh release –> muscle weakness primarily affecting proximal legs.
Associated with small cell lung cancer
Trousseau syndrome
Venous thrombosis & hypercoagulability associated with adenocarcinomas of the pancreas & lung
Lung cancer: diagnostic tests (6)
CXR: see nodules >0.8-1cm; may also show bony metastasis or contralateral mediastinal adenopathy
CT: detects mediastinal invasion & other metastases
Bronchoscopy: obtain specimen via biopsy, washings or TBNA; only used for central masses
Transthoracic needle biopsy: used for peripheral masses
Thoracentesis: used for patients with pleural effusion & suspected malignancy
Solitary pulmonary nodule: definition, benign causes, malignant causes
Definition: singla well-marginated intraparenchymal opacity <3cm
Benign: granuloma, hamartoma, intrapulmonary lymph node
Malignant: bronchogenic carcinoma
DeBakey classification of thoracic aortic aneurysms
Type I: ascending & descending aorta
Type II: ascending aorta only
Type III: descending aorta only
Thoracic aortic aneurysm: signs & symptoms
Tearing or ripping chest pain radiating to the back
Acute neurologic symptoms: syncope, coma, convulsions, hemiplegia
Palpable thrust in right 2nd to 3rd intercostal space
Pulsating sternoclavicular joint
Aortic regurgitation murmur
Diminished pulses
Thoracic aortic aneurysm: diagnostic tests (6)
CXR: widened mediastinum, abnormal aortic countour, “calcium sign”
CT with contrast: 2 distinct lumen separated by an intimal flap
MRI without contrast: gives info about branch vessels
TEE: intimal flap separates the true & false lumens; false lumen has larger diameter & slower flow
TTE: can detect ascending & arch dissections
Thoracic aortic aneurysm: indications for surgery
Ruptured aneurysm
Aneurysm >7cm
Aneurysm diameter >2.5x adjacent aorta
Complications of thoracic aortic aneurysm repair (5)
Paraplegia (most common)
Visceral ischemia
Crawford classification of thoracoabdominal aneurysms
Type I: most of descending thoracic aorta + abdominal aorta proximal to renal arteries
Type II: most of descending thoracic aorta + abdominal aorta distal to renal arteries
Type I: distal half of of descending thoracic aorta + abdominal aorta proximal to renal arteries
Type I: distal half of of descending thoracic aorta + abdominal aorta distal to renal arteries
Hematuria: most common causes by age group
0-20y/o: UTI, glomerulonephritis, congenital urinary tract abnormality
20-60y/o: UTI, bladder cancer, renal stones
>60y/o: BPH
Other: coagulopathy, sickle cell disease, collagen vascular disease, pyelonephritis, polycystic kidneys, renal cancer, urethritis, prostatitis, epididymitis
Differential diagnosis for acute scrotal mass (7)
Testicular torsion
Cremasteric reflex
Stroke medial aspect of the thigh –> retraction of testicle
Prehn’s sign
Relief of testicular pain when you elevate the testicle. Suggests epididymitis.
Patient presents with inguinal pain and an empty scrotum
Testicular torsion
Testicular torsion: signs & symptoms (6)
Acute onset of severe pain in testicle, lower abdomen or inguinal canal
Nausea / vomiting
Swollen & tender scrotum
High-riding testis with horizontal lie
Reactive hydrocele
Loss of cremasteric reflex
Testicular torsion: diagnosis
Urinalysis & CBC to distinguish from epididymitis
Doppler ultrasound
Surgical exploration & repair
Testicular cancer: risk factors (4)
History of mumps orchitis
Inguinal hernia in childhood
Testicular cancer in contralateral testis
Testicular cancer: diagnosis (3)
Testicular sonogram
Tumor markers: AFP, HCG
Seminoma: defiintion & staging procedure
Definition: germinal cell testicular tumor that may have elevated HCG but do NOT have elevated AFP
Staging: x-rays of abdomen, pelvis & chest to look for adenopathy or visceral involvement + AFP + HCG
Seminoma: treatment
Early seminoma: orchiectomy + XRT
Advanced seminoma: combination chemo, then restaging
Nonseminoma: definition & staging procedure
Definition: germinal cell testicular tumor that may have elevated HCG or AFP
Staging: x-rays of abdomen, pelvis & chest to look for adenopathy or visceral involvement + AFP + HCG
Testicular cancer: staging
Stage I: no evidence of tumor presence beyond testis
Stage II early: nonpalpable small retroperitoneal adenopathy on CT scan
Stage II advanced: retroperitoneal adenopathy >5cm on CT scan + disease limited to lymphatics below diaphragm
Stage III: visceral involvement
Nonseminoma: treatment
Stage I: orchiectomy + retroperitoneal LN dissection
Stage II: orchiectomy + retroperitoneal LN dissection + chemo
Stage III: orchiectomy + retroperitoneal LN dissection + chemo + tumor reductive therapy
Chemotherapies used for testicular cancer
BEP: bleomycin, etoposide, cisplatin
PVB: cisplatin, vinblastine, bleomycin
VAB-6: vinblastine, actinomycin, bleomycin, cisplatin, cyclophosphamide
Composition of kidney stones
75%: calcium oxalate or calcium oxalate + calcium phosphate
15%: magnesium ammonium phosphate (struvite); only in patients with UTI
10%: uric acid
1%: cystine
Risk factors for kidney stones (7)
History of kidney stone
History of gout
History of UTI
Warm climate
Prolonged immobilization
Drugs: protease inhibitors, uricosuric agents, alkalis, analgesics
GI disease: Crohn’s, UC, peptic ulcer disease
Nephrolithiasis: signs & symptoms (4)
Severe abrupt onset of colicky pain that begins in flank & radiates toward groin
Nausea & vomiting
Abdominal distention from ileus
Gross hematuria
Nephrolithiasis: diagnostic tests (7)
UA: RBCs in urine, high pH with urea-splitting organisms (Proteus), low pH with uric acid stones, WBCs
Blood tests: elevated WBC, BUN, creatinine; measure uric acid, Ca, phosphate
KUB: see radiopaque stones
Renal U/S: see hydronephrosis, radiolucent & opaque stones
Noncontrast CT: see small stones, hydronephrosis, hydroureter, perinephric stranding
IV pyelogram: see hydronephrosis & stones; assess renal function; delayed nephrogram & columnization of dye indicates obstruction
Retrograde pyelogram: only when other tests are equivocal
Nephrolithiasis: treatment (3)
NSAIDs or opiates + wait for stone to pass for stones <5mm
Extracorporeal shockwave lithotripsy: for stone in kidney
Percutaneous nephrolithotomy: if stone is too large
BPH: signs & symptoms (7)
Early: urinary hesitancy, postvoid dribbling, sensation of incomplete emptying
Late: nocturia, overflow incontinence, palpable bladder, frank obstruction
BPH: treatment (4)
Alpha-adrenergic antagonists: terazosin, doxazosin
5-alpha reductase inhibitors: finasteride, dutasteride
Transurethral prostatectomy
Open prostatectomy
Prostatic carcinoma: signs & symptoms (6)
Most are asymptomatic
Urinary retention
Urinary frequency
Back / hip pain
Prostatic carcinoma: diagnosis (4)
DRE: prostate is hard, nodular, irregular
PSA: not specific
Transrectal sonography: hyperechoic densities in peripheral zone
Prostatic carcinoma: Whitmore staging system
Stage A: detected incidentally on surgical specimen
Stage B1: palpable + involves only 1 nodule surrounded by normal tissue
Stage B2: palpable + involves prostate gland more diffusely
Stage C: palpable + extends beyond prostate + no distant metastasis
Stage D1: metastasis to pelvic nodes
Stage D2: widespread metastasis
Prostatic carcinoma: treatment
Radical prostatectomy: stage B disease
Androgen deprivation: GnRH analogues (leuprolide), GnRH antagonists (abarelix), anti-androgens (flutamide), estrogen, surgical castration
Complications of radiation therapy for prostate cancer (4)
Acute proctitis
Rectal strictures & fistula
Renal cell carcinoma: risk factors (3)
Renal cell carcinoma: signs & symptoms
Gross hematuria
Flank pain
Palpable abdominal mass
Constitutional symptoms
Hypercalcemia: due to PTH production
Galactorrhea: due to prolactin production
Cushing syndrome: due to glucocorticoid production
Renal cell carcinoma: diagnosis (3)
IVP with nephrotomography
Ultrasound: differentiated solid (malignant) & cystic (benign) masses
CT scan: for staging
Renal cell carcinoma: staging
Stage I: confined within kidney capsule
Stage II: invasion through kidney capsule but confined within Gerota’s fascia
Stage III: involvement of regional LNs, ipsilateral renal vein, or IVC
Stage IV: distant metastasis
Renal cell carcinoma: treatment
Radical nephrectomy
Bladder cancer: signs & symptoms (5)
Urinary urgency
Urinary frequency
Ureteral obstruction
Bladder cancer: risk factors (4)
Working in dye & chemical plants
Chronic UTI
Recurrent nephrolithiasis
Bladder cancer: diagnosis (4)
Urine cytology
IVP: ureteral obstruction with hydronephrosis or filling defect
Cystoscopy with tumor biopsy
CT scan for staging
Bladder cancer: treatment (4)
Endoscopic resection for superficial carcinoma
Intravesical BCG or laser therapy for superficial recurrence
Simple or radical cystectomy for invasive disease
Chemo for metastatic disease
Weber test
If sound lateralizes, there is conductive hearing loss in the same ear or sensorineural hearing loss in the opposite ear.
Rinne test
If sound is heard louder on bone, there is conductive hearing loss. If not, there is either sensorineural hearing loss or no hearing loss at all.
Conductive hearing loss: definition & diagnosis
Definition: lesion in external auditory meatus, TM or middle ear
Diagnosis: Weber test lateralizes to affected ear + positive Rinne test
Conductive hearing loss: causes (5)
Obstruction of external auditory meatus by cerumen or foreign body
Swelling, stenosis or neoplasm in external canal
Fluid scarring or neoplasms of middle ear
Perforated TM
Sensorineural hearing loss: definition & diagnosis
Definition: lesion in inner ear, CNVIII, or central auditory structures
Diagnosis: Weber test lateralizes to unaffected ear + normal Rinne test
Sensorineural hearing loss: causes (8)
Meniere’s disease
Ototoxic drugs: aminoglycosides
Viral infection: herpes
Loud noise damages hair cells of Organ of Corti
Temporal bone fracture
Cochlear otosclerosis
Acoustic neuroma
Meniere’s disease
Excess endolymph causes intermittent vertigo, tinnitus, hearing loss, aural fullness
Indications for myringotomy (4)
Severe or recurrent acute otitis media
Otitis media with effusion for >3 months
Hearing loss >30dB in patients with otitis media
Impending mastoiditis or intracranial complications due to otitis media
Tinnitus is associated with what disorders?
Conductive or sensorineural hearing loss
Worsens with stress
Glomus jugulare tumor
Causes of epistaxis (10)
Vascular lesions: arteriosclerosis, hereditary hemorrhagic telangiectasis, coarctation of the aorta
Infection: rhinitis, vestibulitis, sinusitis
Inflammation: scarlet fever, malaria, typhoid fever
Trauma: picking your nose, septal perforation
Nasopharyngeal angiofibroma
Complications of tonsillectomy (3)
Bleeding at tonsillar bed after removal
Damage to underlying CNIX
Damage to ICA lateral to tonsil
Indications for tonsillectomy (5)
Chronic tonsillitis (6-7 in 1yr)
Tonsils block breathing
Obstructive sleep apnea
Diphtheria carriers
Chronic middle ear infections
Inflammation of the salivary glands
Pleomorphic adenoma (3)
Most common salivary gland tumor
Most commonly affects parotid gland
Benign but recurs
Warthin’s tumor (3)
Papillary cystadenoma lymphomatosum
Benign tumor of the salivary glands
Affects parotid gland
Oncocytoma (3)
Benign tumor of the salivary glands
Affects parotid gland
More common in elderly patients
Mucoepidermoid carcinoma (2)
Salivary gland tumor that varies from benign or highly malignant
Affects parotid gland
Adenoid cystic carcinoma (3)
Malignant slow growing salivary gland tumor
Affects minor salivary glands
Tends to recur along nerve tracts and cause pain
Salivary gland tumor: treatment (3)
Benign: surgical incision
Malignant: surgery + radiation
Metastatic: surgery + radiation + chemo (doxorubicin or cisplatin)
Plummer-Vinson syndrome
Dysphagia + glossitis + iron deficiency anemia
More common in middle-aged women
Risk factors for oropharyngeal carcinoma (5)
Chewing tobacco
Poor oral hygiene
Plummer-Vinson syndrome
Oropharyngeal carcinoma: diagnostic tests (3)
Nasopharyngeal endoscopy + esophagoscopy + laryngoscopy to find all primary tumors
Most common site of subclinical second primary oropharyngeal carcinoma
Oropharyngeal carcinoma: treatment
Surgery and/or radiation
First-degree sprain
Minimal pain, no detectable joint instability
Second-degree sprain
Severe pain, minimal joint instability
Progressive failure of collagen fibers
Partial ligament rupture
Third-degree sprain
Severe pain, unstable joint
Ligaments can’t support any load
What is a strain?
Injury to muscle or its tendinous attachment to the bone, due to excessive stretching or violent contraction
First-degree strain
Minor tearing of musculotendinous fibers
Slight loss of function, swelling, tenderness
Second-degree strain
Moderate tearing of musculotendinous fibers
Marked loss of strength, swelling, echymosis
Third-degree strain
Total interruption of muscle or tendon
Complications associated with use of splints (7)
Compartment syndrome
Volkmann’s contracture
Drying plaster may cause 2nd-degree burn
Pressure sores
Joint stiffness
Open fracture
Communicates with external environment
Bacterial contamination of soft tissues & bones
Pathologic fracture is associated with what disorders?
Cancer, cysts, enchondroma, giant cell tumor, osteogenesis imperfecta, scurvy, rickets, osteomalacia, Paget’s disease, osteoporosis
Most common locations of stress fractures
1. metatarsals
2. calcaneus
3. tibia
4. tarsal navicular
Comminuted fracture
Bone is divided into >2 fragments
Salter-Harris classification of fractures
Type I: Straight across physis
Type II: Above (through physis & metaphysis)
Type III: Lower (through physis & epiphysis)
Type IV: Through metaphysis, physis, epiphysis
Type V: Rammed (crushed physis)
Greenstick fracture
Incomplete angulated fracture of the long bone (like a twig)
Common in children
Torus fracture
Incomplete fracture with buckling of cortex due to compression
Most often in metaphysis of distal radius in children
Heals with immobilization
Causes of fat embolism
V: hemoglobinopathy, diabetes, cardiopulmonary bypass, renal infarction
I: infection, osteomyelitis
T: long bone fracture, burns, decompression sickness, inhalation anesthesia, blood transfusion
M: metabolic disorder
N: neoplasm
C: collagen disease
Classic symptoms for fat embolism
2-3 days after trauma
Fat embolism: diagnosis (3)
Arterial hypoxemia (O2 <60mmHg)
CXR: snowstorm-like infiltration
Frozen clotted blood reveals presence of fat
Anterior shoulder dislocation: signs, complications, x-ray, treatment
Signs: resist medial rotation & adduction, prominent acromion
Complications: rotator cuff tear, fracture of coracoid, fracture of greater tuberosity, Hill-Sachs deformity
X-ray: Hill-Sachs deformity
Treatment: reduction + immobilization +/- surgery
Hill-Sachs deformity
Compression fracture of humeral head
Associated with anterior shoulder dislocation
Posterior shoulder dislocation: signs, complications, x-ray, treatment
Signs: arm is medially rotated & held to side, limited abduction & external rotation, prominent coracoid process
Complications: fractures of lesser tuberosity, posterior glenoid rim, proximal humerus
X-ray: internally rotated greater tuberosity
Treatment: longitudinal traction +/- surgery
Inferior shoulder dislocation: signs, complications, x-ray, treatment
Signs: severe pain, arm held at 180 degree elevation, arm looks shorter, humeral head felt along lateral chest wall
Complications: rotator cuff tear, fracture of greater tuberosity
X-ray: top of humerus is displaced downward
Treatment: reduce + surgical repair of rotator cuff
Compartment syndrome: signs
Pain out of proportion to findings
Diagnosis of compartment syndrome
Pressure within compartment >30mmHg
Treatment of compartment syndrome
Complete fasciotomy
Volkmann’s contracture
Fibrosis replaces necrotic muscle tissue after inadequately treated compartment syndrome in the forearm. Occurs most commonly after a supracondylar fracture that compresses the anterior aspect of elbow and upper forearm.
Acute osteomyelitis: signs & symptoms
Significant pain in the affected area
Limited joint motion
Swelling of soft tissue
Constitutional symptoms
Acute osteomyelitis: diagnosis
Labs: elevated WBC, ESR, CRP +/- anemia
Physical exam: deep circumferential soft-tissue swelling with obliteration of muscular planes
Most common site for acute osteomyelitis
Metaphyseal end of a single long bone (esp. knee)
Osteomyelitis: treatment
Medical: IV oxacillin or cloxacillin
Surgical: open drainage of abscess if abx fail or abscess appears
Who gets chronic osteomyelitis?
Diabetic patients, especially in lower extremities
Chronic osteomyelitis: signs & symptoms (4)
Persistent drainage after acute osteomyelitis OR inflammation & cellulitis after open fracture
Mild systemic symptoms
Chronic osteomyelitis: diagnosis
X-ray: areas of radiolucency within a deformed sclerotic bone, irregular areas of destruction, periosteal thickening
Chronic osteomyelitis: treatment (3)
Drainage of abscess if present
Debridement of necrotic & granulation tissue + reconstruction of defects + antibiotics
Complications of chronic osteomyelitis (5)
Soft-tissue abscess
Septic arthritis
Metastatic infections
Pathologic fractures
Paraplegia if it involves spine
Brodie’s abscess (3): definition, etiology, x-ray findings
Definition: subacute pyogenic osteomyelitis in the metaphysis
Etiology: S. aureus or S. albus
X-ray: lucent lesions around sclerotic bone
Septic bursitis: definition, etiology, treatment
Definition: infection of superficial bursa, usually bunion, olecranon or prepatellar
Etiology: S. aureus
Treatment: aspirate + broad-spectrum antibiotics
Emergency causes of low back pain: FACTOID
Cauda equina syndrome
Tumor (cord compression)
Osteoarthritis & Other neurologic syndromes
Infection (epidural abscess)
Disk herniation or rupture
Patterns of bone tumor appearances on x-ray
Permeative: rapidly spreading intramedullary tumor that replaces marrow and fat
Moth-eaten: poorly circumscribed slow-growing malignant tumor
Geographic: well-circumscribed slow-growing tumor, so bone has time to react and create sclerotic margins
Osteoid osteoma: definition, symptoms, x-ray, treatment, prognosis
Definition: most common osteoid-forming benign tumor, usually in diaphysis of long tubular bones
Symptoms: localized dull aching pain, worse at night, relieved by NSAIDs
X-ray: localized area of bone sclerosis with central radiolucent nidus
Treatment: NSAIDS +/- surgery to remove nidus
Prognosis: excellent
Osteoblastoma: definition, symptoms, x-ray, treatment, prognosis
Definition: benign bone tumor usually in axial skeleton
Symptoms: pain +/- swelling
X-ray: non-specific
Treatment: vigorous curettement of lesion
Prognosis: may recur, may undergo malignant transformation
Osteochondroma: definition, symptoms, x-ray, treatment, prognosis
Definition: benign bone tumor consisting of an outgrowth of bone capped by cartilage, usually in metaphysis of long bones
Symptoms: asymptomatic or pain
X-ray: mushroom-like bony prominence
Treatment: surgical incision if patient has pain
Prognosis: 1% malignant transformation to chondrosarcoma
Multiple hereditary osteochondroma
Autosomal dominant disorder in which multiple bones have osteochondromas
Ollier’s disease
Enchondromas in multiple bones with higher risk of malignant transformation. May result in bowed & shortened long bones.
Enchondroma: definition, symptoms, x-ray, treatment
Definition: benign bone tumor consisting of mature hyaline cartilage, usually in tubular bones of hands & feet
Symptoms: pathologic fractures
X-ray: geographic lysis in well-circumscribed area + spotty calcifications
Treatment: allow fracture to heal + simple excision + bone graft
Factors that predispose enchondroma to malignancy (4)
Size >4.5cm
Located in long & axial bones
Active growth
Giant cell tumor of bone: definition, epidemiology, symptoms, x-ray, treatment, prognosis
Definition: benign bone tumor arising from mesenchymal stromal cells that support bone marrow, usually in distal femur, proximal tibia, distal radius, or sacrum
Epidemiology: 1.5x more in women, 30y/o
Symptoms: pain, swelling, arthritis, joint effusions, pathologic fracture
X-ray: radiolucent lesion extending from epiphysis to metaphysis + asymmetrical bone destruction +/- “soap bubble” appearance
Treatment: aggressive curettage + phenol + hydrogen peroxide
Prognosis: high recurrence rate
Osteosarcoma: definition, risk factors, symptoms, treatment
Definition: malignant tumor made of osteoid-producing spindle cell stroma, usually around knee, proximal humerus or mandible
Risk factors: male, age 10-30y/o, Paget’s disease
Symptoms: pain, tender mass, dilated veins over mass, constitutional symptoms
Treatment: surgery + chemo
Osteosarcoma: x-ray findings
Poorly defined lesion in metaphysis, with areas of bone destruction & formation
Codman’s triangle: new bone formation under corners or raised periosteum
Sun-ray appearance: bone spicules are formed perpendicular to surface of bone
Chondrosarcoma: definition, risk factors, symptoms, treatment
Definition: low-grade malignant tumor derived from cartilage cells
Risk factors: male, 30-60y/o
Symptoms: pain & swelling over months-years
Treatment: surgical resection
Chondrosarcoma: x-ray findings
Central chondrosarcoma: well-defined radiolucent areas with small irregular calcifications
Peripheral chondrosarcoma: large lobulated masses hanging from surface of long bone with calcification
Ewing’s tumor
Tumor of small round cells arising in medullary cavity. Higher risk in males aged 5-25y/o. Can occur in any bone. Most lethal of any bone tumor.
Ewing’s tumor: symptoms (6)
Pain that increases with time and is more severe at night
Local swelling
Constitutional symptoms
Elevated ESR
Ewing’s tumor: x-ray
Lytic bone lesions with permeative pattern
Lamellated “onion skin” appearance of periosteum
Ewing’s tumor: treatment
Surgery + vincristine + cyclophosphamide + actinomycin D + adriamycin
Multiple myeloma (4)
Malignant plasma cell tumor
Most common primary malignant tumor of bone
Poor prognosis: 90% die in 2-3yrs
Seen more in males over 40
Multiple myeloma: symptoms (6)
Bone pain
Weight loss
Neurologic impairment (if vertebral fractures)
Susceptibility to infections
Kidney damage (proteins plug tubules)
Multiple myeloma: diagnosis
Labs: elevated Ca, elevated uric acid, monoclonal gammopathy, Bence Jones proteinuria, elevated ESR, rouleaux formation, anemia
X-ray: punched-out lytic lesions give soap-bubble appearance
Classic presentation of multiple myeloma: POEMS
M-component spike
Skin changes & Sclerosis of bone
Multiple myeloma: treatment
Chemo + prednisone + bisphosphonates
Most common sites of origin for metastatinc bone tumors: BLT with Kosher Pickle
(Neuroblastoma in kids)
Which is more common: primary or metastatic bone tumors?
Signs of vascular insufficiency
Hairless, shiny skin
Change in skin color: mottled, dark, red, white
Nail changes
Used with Doppler to assess perfusion of distal extremities. Measures changes in volume within an organ or body region. Useful for predicting healing of ulcers and amputations.
Normal ABI
>= 1
ABI indicating claudication
ABI incidacting ischemic rest pain or gangrene
=< 0.3
How is a pseudoaneurysm different from an aneurysm?
Pseudoaneurysm does not contain all three layers of arterial wall.
Penile-brachial index (PBI)
Used to determine whether cause of impotence is vascular. PBI <0.6 indicates likely vascular etiology.
In which cases will penile-brachial index be misleading?
Diabetes: calcification of vessels makes them less compressible, thereby falsely elevating results.
Long-standing insufficiency: collateral flow may artificially improve results.
Decreased pulses after arteriography compared to before: what is it?
If it resolves within 1 hour, it may be due to spasm; otherwise, it may be an arterial injury or a clot.
Arteriography: risks
Risks: hemorrhage, thrombosis at puncture site, embolization of clot, renal dysfunction, allergic reaction to dye, asthma, laryngeal edema, spasm, CV collapse
Digital subtraction angiography (DSA)
Inject dye into vein or artery –> computerized fluoroscopy subtracts bone & soft tissue, so all that is visible is the arterial system
MR angiography: pros and cons
Use: visualization of distal vessels & evaluation of carotid bifurcation and aortic aorta
Pros: no contrast
Cons: gadolinium may cause allergic reaction
Critical arterial stenosis
Cross-sectional area decreased by 75%
Enough to reduce pressure & flow significantly
Effect of exercise on arteries
Dilation of intramuscular arterioles –> decreased resistance and increased flow
Muscle damage: progressive changes in physical exam
First soft, then doughy, then stiff and hard
On physical exam, how do you know when tissue ischemia has become irreversible?
Skin is mottled and no longer blanches
Causes of acute arterial occlusion
Trauma: posterior knee dislocation, long-bone fx, etc.
Iatrogenic (e.g. catheter)
Thrombosis (e.g. atherosclerosis, aneurysm)
Acute arterial occlusion: diagnosis (3)
Physical exam (6 P’s): no further workup required
ABI: confirms site of lesion
Angiography: confirms site of lesion
Common sites of arterial embolism
1. Lower extremity: common femoral, popliteal
2: Common iliac artery
3. Upper extremity
4. Cerebral circulation
5. Viscera
6: Aorta
Patient with no history of peripheral vascular disease has digital ischemia and palpable pulses
Suspect atheroembolism
Phlegmasia cerulea dolens
“Painful blue edema”
DVT in major veins of an extremity that causes sudden severe pain, swelling, cyanosis, edema, gangrene
Associated with underlying malignancies.
Acute arterial occlusion: treatment (2)
Thrombectomy or grafting (most common)
Thrombolytic therapy: tPA, reteplase, stroptokinase, urokinase
Contraindications to thrombolytic therapy (3)
GI or intracerebral lesion
Any contraindication to angiography
Chronic ischemia: symptoms (3)
Rest pain
Most common locations of chronic ischemia (3)
Infrarenal aorta
Iliac arteries
Superficial femoral arteries
Chronic ischemia: risk factors (4)
Systolic hypertension
Leriche syndrome: definition and triad of symptoms
Definition: atherosclerotic occlusive disease involving the abdominal aorta and/or both iliac arteries
Symptoms: claudication of buttocks and thighs, absent or decreased femoral pulses, impotence
Leriche syndrome (aortoiliac disease): diagnosis (3)
Femoral-brachial pressure ratio
Penile-brachial index
Leriche syndrome (aortoiliac disease): treatment (4)
Aortofemoral bypass
Aortoiliac endarterectomy: if distal vessel is normal
Extra-anatomic bypass: ax-fem or fem-fem
Percutaneous transluminal angioplasty: for short non-occluding lesions
Leriche syndrome (aortoiliac disease): complications of bypass surgery (6)
Thrombosis of reconstruction
Distal embolization
Ischemic colitis
Paraplagia (due to lumbar vessel ischemia)
Sexual dysfunction
Infrainguinal chronic ischemia: most common site, diagnosis (4), treatment (5)
Most common site: superficial femoral artery at adductor canal
Diagnostic tests: Doppler, ABI, peripheral vascular resistance, angiogram
Treatment: smoking cessation, pentoxifylline, cilostazol, femoral-popliteal bypass, endarterectomy
Phosphodiesterase inhibitor that reduces blood viscosity, increases flow, and reduces risk of thrombus formation. Used to treat chronic ischemic disease.
Most common causes of upper extremity chronic ischemia
Vasospasm and arteritis
Subclavian steal syndrome: definition, symptoms (3), diagnosis
Definition: proximal stenosis of subclavian artery causes retrograde flow of blood from the vertebral artery or the internal thoracic artery to the arm
Symptoms: syncope, neurologic deficits, blood pressure deficit between arms
Diagnosis: angiogram
When should you operate on subclavian steal syndrome?
Symptoms of subclavian steal
Incapacitating claudication
Embolus to hand or posterior cerebral circulation
When should you amputate?
Nonviable extremity has become infected
Irreparable vascular injury with irreversible ischemia
Elderly patient with infection who can’t undergo surgical revascularization
What is the success rate of below-knee amputation?
90-97% if there is a palpable popliteal pulse
82% if there is no palpable popliteal pulse
Phosphodiesterase inhibitor that decreases platelet aggregation and causes vasodilation. Used to treat peripheral vascular disease.
Postphlebitic syndrome: definition and symptoms (6)
Definition: after DVT, 50% of patients get chronic venous insufficiency due to valvular incompetence of recanalized veins.
Symptoms: edema, pain, fatigue, skin discoloration, scarring, ulcers
Chronic venous insufficiency: definition and symptoms
Definition: incompetent venous valves (e.g. after DVT) reduce veins’ ability to pump blood back to the heart.
Symptoms: pain and swelling, skin darkening, ulcers
Chronic venous insufficiency: treatment
Non-operative: compression stockings, leg elevation, Unna’s boots for ulcers
Operative: ligation of responsible perforators, valvuloplasty, venous reconstruction with grafting
Unna’s boots
Wrap soaked in calamine lotion and applied to the leg, in patients with ulcers due to chronic venous insufficiency.
Degenerative aneurysm (3)
Cause: atherosoclerosis
Intima is replaced by fibrin
Media is fragmented with decreased elasticity
Traumatic aneurysm (3)
Cause: iatrogenic, catheter-related injury, or penetrating trauma
Results in focal defect in the wall, with hemorrhage controlled by surrounding tissue
Fibrous capsule forms around it
Poststenotic aneurysm
Distal to cervical rib in thoracic outlet syndrome
Distal to coarctation of the aorta
Distal to aortic or pulmonary valve stenosis
Dissecting aneurysm
Blood travels through an intimal defect, creating a false lumen between the intima and media
Risk factors for dissecting aneurysm (6)
Marfan syndrome
Cystic medial necrosis
Cannulation during cardiopulmonary bypass
Blunt trauma
Cystic medial necrosis
Autosomal dominant disorder of large arteries, associated with Marfan syndrome. Aging causes degenerative breakdown of collagen, elastin, and smooth muscle, which can lead to formation of fusiform aneurysm or aortic dissection.
Mycotic aneurysm
Aneurysm that results from an infectious process that involves the arterial wall
Anastomotic aneurysm: definition, location, symptoms, diagnosis (2)
Definition: separation between graft and native artery causes formation of sac and fibrous capsule
Location: usually in common femoral artery after aortofemoral bypass
Symptoms: painless pulsatile groin mass
Diagnosis: duplex or angiogram
Risk factors for AAA rupture (3)
Diastolic hypertension,
Large size
Indications for AAA repair (4)
Size >5cm in women or >5.5cm in men
Rapidly increasing size
Risk factors for rupture
Pain over AAA site
Diagnosis of AAA
Physical exam: periumbilical palpable pulsatile mass
CT or MRI for location, size, presence of leak
Ultrasound to follow over time
Ruptured AAA: symptoms (3)
Abdominal pain
Severe back or flank pain
Cardiovascular collapse
Ruptured AAA: mortality
No treatment: 90%
Reach hospital alive: 50%
Syncope, abdominal pain and hypotension in a patient with known AAA
Ruptured AAA until proven otherwise
Hypogastric artery aneurysm: physical exam
Pulsatile mass palpable on digital rectal exam
Iliac artery aneurysm (3)
90% common iliac, 10% hypogastric
Resect when >3cm
Associated with fibromuscular dysplasia in pregnant women
Most common peripheral aneurysm
Popliteal artery
When should you resect a femoral artery aneurysm?
When it is >2.5cm
Diabetic vascular disease: common vessels (4)
Distal profunda femoris
Digital arteries of the foot
When should revascularization be performed in diabetic vascular disease?
When ulcers occur and if there are vessels available to use in the repair.
Why might ABI be falsely elevated in a diabetic patient?
Vessel calcification makes vessels less compressible, so pulse pressure appears normal.
Is the superficial femoral vein deep or superficial?
Acquired causes of DVT (10)
Central venous line placement
Laparoscopic surgery (intra-abd pressure > pressure of venous return from legs)
Prior DVT
Hormone replacement therapy
Prolonged immobility (fracture, surgery, plane)
Congenital causes of DVT (8)
Antiphospholipid antibody syndrome
Antithrombin III deficiency
Plasminogen deficiency
Factor V Leiden
Lupus anticoagulant
Protein C & S deficiency
Prothrombin (factor II) gene mutation
DVT: symptoms (3)
Calf tenderness
Homan’s sign
Homan’s sign
Resistance (not pain) in calf or popliteal region with abrupt dorsiflexion of patient’s foot while the knee is fully extended. Sign of DVT.
DVT prophylaxis (3)
Compression stockings
Sequential compression devices
SQ or low molecular weight heparin
DVT treatment (5)
Bed rest until pain and swelling subside
Lower extremity elevation
Anticoagulation for 6 months
Elastic stockings
Fibrinolytics for large thrombi
Superficial venous thrombosis: cause, symptoms (3), diagnosis, treatment
Cause: usually non-infected localized inflammatory reaction
Symptoms: swelling, pain, erythema
Diagnosis: duplex ultrasound to rule out DVT
Treatment: NSAIDs for 2-3 weeks
What neurologic signs might you see in a patient with carotid artery injury with hematoma?
Defects in cranial nerves 9-12
Mallampati classification of ease of intubation
Class I: visualize soft palate, fauces, uvula, tonsillar pillars
Class II: visualize soft palate, fauces and uvula
Class III: visualize soft palate and base of uvula
Class IV: cannot visualize soft palate
Results in a positive stress test
ST depressions >0.2mV or inadequate response of HR to stress or hypotension
When should you get an EKG pre-op?
Patient is >35 and/or has cardiac history
Patients at risk of endocarditis (4)
Prosthetic valve
Congenital abnormality (e.g. TOF)
Hypertrophic cardiomyopathy
Mitral valve prolapse
Important adverse effect of SQ heparin
Causes thrombocytopenia in 6% of patients
ARDS: causes (3), diagnosis (4), treatment
Causes: pneumonia, decompensation in COPD, trauma / flail chest
Diagnosis: bilateral infiltrates on CXR, PaO2/FiO2 <200, PCWP <19
Treatment: PEEP
Pulmonary edema: causes (6), symptoms (5), treatment
Causes: ARDS, pancreatitis, sepsis, MI, valvular dysfunction, liver failure
Symptoms: dyspnea, tachypnea, rales, wheezing, bronchospasm
Treatment: O2, upright position, furosemide, Swan-Ganz catheter
Fat embolism: cause, treatment, prognosis
Cause: trauma, fractures
Treatment: immobilize fracture +/- corticosteroids
Prognosis: death is uncommon
Child’s classification of operative risk for patients with cirrhosis
Class A: no ascites, excellent nutrition, no encephalopathy, albumin >3.5, bilirubin <2
Class B: controlled ascites, good nutrition, minimal encephalopathy, albumin 3-3.5, bilirubin 2-3
Class C: uncontrolled ascites, poor nutrition, advanced encephalopathy, albumin <3, bilirubin >3
Estimation of creatinine clearance
[(140-age)*(weight)] / (72*creatinine)
How to determine the source of a renal problem
Prerenal disease: FeNa < 1% and U(Na) <10 Intrinsic renal damage: FeNa > 2%
ATN: urine specific gravity = 1.010
ONe unit of platelets raises platelet count by…
Cooper’s ligaments
Ligaments in breast that extend from deep pectoral fascia to superficial dermal fascia and provide structural support.
Why does skin dimple in breast cancer?
Due to traction on Cooper’s ligaments
Where do 50% of breast cancers occur?
Upper outer quadrant
Main path of breast cancer metastases to the spine
Venous drainage via Batson’s plexus
Long thoracic nerve: muscles innervated, deficit if injured
Serratus anterior
Winging of scapula
Thoracodorsal nerve: muscles innervated, deficit if injured
Latissimus dorsi
Can’t push yourself up from a sitting position
Medial & lateral pectoral nerves: muscles innervated
Pectoralis major and minor
Intercostobrachial nerve innervates…
Sensation on inner aspect of arm
Mastitis: cause, signs (3), diagnosis, treatment
Cause: early weeks of breast feeding
Signs: focal tenderness, erythematous & warm skin, fluctuant mass
Diagnosis: ultrasound to localize abscess
Treatment: wound care +/- I&D + IV antibiotics
Fat necrosis: cause, signs (3), diagnosis
Cause: chest wall or breast trauma
Signs: irregular mass without discrete borders, +/- tenderness, collagenous scars
Diagnosis: excisional biopsy with pathologic evaluation for carcinoma
Fibroadenoma: risk factors (3), symptoms, diagnosis, treatment (2)
Risk factors: African American, teens-early 30s, pregnancy
Symptoms: smooth, discrete, circular, mobile mass
Diagnosis: FNA
Treatment: observe if FNA is diagnostic, pt is <30y/o, and tumor is <3cm; excise if FNA is nondiagnostic, pt is >30, or tumor is symptomatic
Mondor’s disease: definition, risk factors (4), signs (2), diagnosis, treatment (3)
Definition: superficial thrombophlebitis of lateral thoracic or thoracoepigastric vein
Risk factors: local trauma, surgery, infection, repetitive arm movements
Signs: acute pain in axilla or lateral breast, palpation of tender cord
Diagnosis: ultrasound
Treatment: warm compresses, surgery to resect affected vein segment, or excisional biopsy (if U/S nondiagnostic)
Fibrocystic changes: age, signs (3), treatment
Age: 20s-40s
Signs & symptoms: bilateral breast swelling & tenderness, non-bloody nipple discharge, discrete areas of nodularity that fluctuate over time
Treatment: NSAIDs, OCPs, tamoxifen
Mammary duct ectasia: definition, age, signs (3), diagnosis, treatment
Definition: inflammation & dilation of mammary ducts
Age: perimenopausal years
Signs & symptoms: noncyclical breast pain, lumps under areola, possible nipple discharge
Diagnosis: excisional biopsy to rule out cancer
Treatment: excision of affected ducts
Cystosarcoma phyllodes: definition, age, signs (2), diagnosis (2), treatment (2)
Definition: variant of fibroadenoma that is usually benign
Age: >30
Signs: large freely movable mass, overlying skin changes
Diagnosis: mammogram or ultrasound (looks like fibroadenoma) + biopsy
Treatment: wide local excision if small, or simple mastectomy if large
Intraductal papilloma: definition, signs (2), diagnosis (2), treatment
Definition: benign local proliferation of ductal epithelial cells
Signs: subareolar mass +/- unilateral serosanguinous or bloody nipple discharge
Diagnosis: mammogram + biopsy
Treatment: excise affected duct
Causes of gynecomastia (8)
Increased estrogen: tumor, endocrine disorder, liver failure, malnutrition
Decreased testosterone: aging, testicular failure, renal failure
Drugs: spironolactone
DCIS: definition, age, diagnosis (3), treatment (3)
Definition: proliferation of ductal cells that spread through ductal system but can’t invade basement membrane
Age: after menopause
Diagnosis: sometimes palpable on exam + clustered microcalcifications on mammogram + malignant epithelial cells in breast duct on biopsy
Treatment: lumpectomy +/- radiation if <2cm; lumpectomy with 1cm margins + radiation if >2cm; simple mastectomy if breast is diffusely involved
LCIS: definition, age, diagnosis (3), treatment
Definition: multifocal proliferation of acinar & terminal ductal cells; >50% bilateral
Age: before menopause
Diagnosis: clinically occult, undetectable on mammogram, incidental on biopsy
Treatment: bilateral mastectomy if patient is high risk; otherwise nothing
Tumors Running and Leaping Promptly to Bone
Infiltrating ductal carcinoma: epidemiology & metastases (5)
Epidemiology: 80% of invasive breast cancers; most common in perimenopausal & postmenopausal women
Metastases: axilla, bones, lungs, liver, brain
Infiltrating lobular carcinoma: epidemiology, signs, metastases (3)
Epidemiology: 10% of invasive breast cancers, >50% bilateral
Signs: ill-defined thickening of the breast
Metastases: axilla, meninges, serosal surfaces
Paget’s disease of the breast: epidemiology, signs (3), treatment
Epidemiology: 2% of invasive breast cancers, usually associated with LCIS or ductal carcinoma
Signs: tender itchy nipple +/- bloody discharge +/- subareolar palpable mass
Treatment: modified radical mastectomy
Inflammatory carcinoma
Epidemiology: 2-3% of invasive breast cancers, most lethal one
Signs: erythema, peau d’orange, nipple retraction
Treatment: chemo + surgery and/or radiation
Risk factors for breast cancer (8)
Early menarche / late menopause
Nulliparity or first pregnancy >30y/o
White race
Family or personal history
Genetic predisposition: BRCA, Li-Fraumeni, Peutz-Jeghers, ataxia-telangiectasia
Estrogen replacement therapy
Radiation exposure
Risk factors for breast cancer in men (5)
Estrogen therapy
Elevated endogenous estrogen
Previous irradiation
Ultrasound for diagnosing breast cancer: pros (3) & cons (2)
Pros: no ionizing radiation, can assist in therapeutic aspiration of cystic disease, results easily reproducible
Cons: worse resolution than mammogram, can’t identify lesions <1cm
FNA for diagnosing breast cancer: pros (3) & cons (3)
Pros: low morbidity, cheap, 1-2% false positives
Cons: 10% false negatives, requires skilled pathologis, may miss deep masses
Diagnostic modalities for breast cancer (6)
Needle localization biopsy
Core biopsy (chance of sampling error)
Stereotactic core biopsy (no breast deformity)
Surgical treatment of breast cancer
Radical mastectomy: all breast tissue + axillary nodes + pectoralis muscles
Modified radical mastectomy: all breast tissue + axillary nodes
Simple mastectomy: all breast tissue
Lumpectomy and axillary node dissection
Sentinal node biopsy
Breast cancer stages
Stage 0: DCIS or LCIS
Stage I: invasive carcinoma =<2cm without LNs or metastases
Stage II: =<5cm + movable axillary LNs; or tumor >5cm without LNs or metastases
Stage III: >5cm + LNs; or any size + fixed axillary LNs, ipsilateral internal mammary LNs, or skin involvement
Stage IV: distant metastases
Side effects of tamoxifen (4)
Hot flashes
Irregular menses
Increased risk of endometrial cancer
Signs and symptoms of congenital heart disease with right-to-left shunts (4)
Hypoxic spells
Squatting: helps increase SVR & pulmonary blood flow
Polycythemia: response to cyanosis
Palliative operations to increase pulmonary arterial blood flow in Tetrology of Fallot
Blalock-Taussig: subclavian-pulmonary arterial anastomosis
Waterston: aorta-right pulmonary arterial anastomosis
Potts: anastomosis between left pulmonary artery & descending thoracic aorta
Glenn: anastomosis between right pulmonary artery and SVC
Transposition of great arteries on CXR (3)
Egg-shaped heart
Narrow cardiac shadow
Marked pulmonary congestion
Congenital heart diseases with right-to-left shunts
Truncus arteriosis
Transposition of the great arteries
Tricuspid atresia
Tetrology of Fallot
Total anomalous pulmonary venous connection
Jatene procedure
Correction of transposition of great arteries
Transection of great vessels just superior to valves –> transfer vessels to correct locations and switch coronary artery ostia
Rastelli procedure
Correction of transposition of great arteries
Aorta is rerouted internally to LV across VSD and pulmonary artery is attached to RV externally
Signs & symptoms of congenital heart disease with left-to-right shunts
Increased pulmonary blood flow
Symptoms of pulmonary congestion appear at first pregnancy
Acyanotic until shunt reversal
Progress to right-to-left shunts over time
What complication should you watch out for during ligation or division of a patent ductus arteriosis?
Injury of left recurrent laryngeal nerve
When should you surgically close a VSD?
CHF not controlled by medical management
VSD doesn’t close by 9 months + pulmonic pressure is 2/3 of systemic pressure
Pulmonary:systemic flow >2:1
Eisenmenger syndrome
Non-cyanotic congenital heart defect –> increased pulmonary blood flow –> hypertrophy of pulmonary arterioles –> increased pulmonary vascular resistance –> right-to-left shunting and cyanosis
Lutembacher syndrome
Ostium secundum ASD + mitral stenosis
Most common type of ASD
Ostium secundum
Sinus venosus ASD
Associated with partial anomalous pulmonary venous return, in which pulmonary veins enter right atrium, SVC or IVC.
Ostium primum ASD: definition, defects, risk factors
Definition: cleft in anterior mitral valve leaflet + low ASD
Defects: mitral regurgitation + left-to-right shunt with early pulmonary hypertension
Risk factors: Down syndrome
When should you surgically close an ASD?
Pulmonic:systemic flow >1.5-2.1
Asymptomatic ASD >1-2cm
Ostium primum
Complete atrioventricular canal (VSD + ostium primum)
When to repair coarctation of the aorta?
Neonate with CHF
Wait until 3-4y/o if no CHF
What complication should you watch out for in repair of coarctation of the aorta?
Paraplegia, due to ischemia of the spinal cord during cross-clamping of hte aorta. Do not occlude the aorta for more than 20mn.
Idiopathic hypertrophic subarotic stenosis: definition, signs (5), treatment
Definition: genetic disease in which asymmetric septal hypertrophy creates obstruction to aortic outflow tract
Signs: fatigue, angina, syncope, a-fib, systemic emboli
Treatment: medical management +/- septal myomectomy
Hypoplastic left heart: definition and treatment
Definition: LV is underdeveloped
Treatment: anastomosis of pulmonary artery to aortic arch (allows flow from RV to systemic circulation) + resection of atrial septum (mixes blood) + subclavian-pulmonary artery shunt (controls pulmonary blood flow)
Lecithin/sphingomyelin ratio (2)
Marker for fetal lung maturity
L/S <2: increased risk of respiratory distress syndrome
Normal ABG for neonate
PaO2 = 75
PaCO2 = 35
pH = 7.30-7.35
How much fluid should you give a neonate?
Bolus: 20ml/kg LR or NS
Maintenance: 100-120mL/kg/day if full-term, 140mL/kg/day if preterm
Normal urine output for neonate
Congenital neck lesions (8)
Midline: thyroglossal duct remnants, dermoid cyst, submental LN, goiter
Lateral: cystic hygroma, branchial cyst, lymphadenitis, lymphoma
Life-threatening causes of congenital neck lesions (3)
Hematoma secondary to trauma
SQ emphysema + airway or pulmonary injury
Non-Hodgkin’s lymphoma with mediastinal mass and airway compromise
Thyroglossal duct cyst: definition, signs, treatment
Definition: midline neck mass arising from base of tongue at foramen cecum
Signs: painless, smooth, mobile, cystic mass; often presents as infection
Treatment: excision + resection of central part of hyoid bone + ligation of duct at foramen cecum
Branchial cleft cyst: definition, signs (4), diagnosis, treatment
Definition: remnant of branchial arches, clefts and pouches
Signs: lateral neck mass at anterior border of sternocleidomastoid, painless, fluctuant, +/- drainage
Diagnosis: ultrasound
Treatment: complete excision +/- antibiotics
Cystic hygroma: definition, signs (3), diagnosis, treatment
Definition: congenital lymphangioma
Signs: painless, soft, mobile mass; transillumination; upper airway obstruction (compresses trachea or spreads into floor of mouth)
Diagnosis: CT scan
Treatment: excision
Congenital diaphragmatic hernia: signs (2), diagnosis (2), treatment (5)
Signs: respiratory distress at birth, scaphoid abdomen
Diagnosis: ultrasound + CXR
Treatment: positive pressure via ET tube, metabolic support, gastric decompression, surgical correction, ECMO
Diaphragmatic hernia on CXR
Bowel gas pattern in hemithorax
Mediastinal shift
Congenital lobar emphysema: definition, signs (3), diagnosis, treatment
Definition: hyperexpansion of one or more lobes of the lung
Signs: respiratory distress at birth, tachypnea, cyanosis
Diagnosis: CXR shows hyperaerated lobe, hyperlucency (air trapping), mediastinal shift
Treatment: ventilation of uninvolved lung + resection of involved lung
Pulmonary sequestration: definition, diagnosis, treatment
Definition: congenital non-functioning pulmonary tissue that receives its entire blood supply from the systemic circulation and doesn’t communicate with functional airways
Diagnosis: MRI or aortography shows sequestration of lung tissue within systemic venous drainage
Treatment: removal
Congenital cystic adenomatoid malformation: definition, signs (2), diagnosis, treatment
Definition: adenomatosis & cyst formation in lungs
Signs: neonatal respiratory distress, recurrent respiratory infections
Diagnosis: CXR shows “swiss cheese” appearance of lung (looks like CDH)
Treatment: surgical resection
Signs and symptoms of tracheoesophageal malformation
Respiratory distress or choking after first feed
Infant drools and cannot swallow saliva
Most common tracheoesophageal malformation
Esophageal atresia with TE fistula
How do you distinguish CDH from congenital cystic adenomatoid malformation?
Tip of NG tube is in thorax in CDH and in abdomen in CCAM.
Tracheoesophageal malformation: diagnosis (3) and treatment (4)
Diagnosis: inability to pass feeding tube, CXR shows tube coiling in thoracic inlet region, AXR
Treatment: decompress blind esophageal pouch + suction to control oral secretions + antibiotics + surgical repair
Gastroschisis: definition & treatment (6)
Definition: abdominal wall defect usually to the right of the umbilicus; no covering over bowel; not usually associated with other anomalies
Treatment: temperature regulation, sterile covering, NG decompression, abx, TPN, surgical correction
Omphalocele: definition & treatment
Definition: herniation of abdominal contents into base of umbilical cord; membrane covers bowel
Treatment: emergent surgical correction if sac is ruptured; surgery later if sac is intact
Anomalies associated with omphalocele (5)
Beckwith-Wiedemann syndrome
Trisomy 13
Trisomy 18
Pentalogy of Cantrell
Exstrophy of the bladder or cloaca
Beckwith-Wiedemann syndrome (4)
Pentalogy of Cantrell (5)
Congenital diaphragmatic hernia
Absent pericardium
Intracardiac defects
Cleft sternum
Pyrloric stenosis: signs and symptoms (5)
Non-bilious projectile vomiting
Midepigastric “olive” mass
Visible peristaltic wave
Hypochloremic hypokalemic alkalosis
Pyloric stenosis: diagnosis
Ultrasound: elongated pyloric channel (>14mm) & thickened pyloric wall (>4mm)
Contrast series: string sign (elongated pyloric channel), shoulder sign (pylorus bulges into antrum), double tract sign (parallel streaks of barium in narrow channel)
Surgical correction of pyloric stenosis
Ramstedt pyloromyotomy
Biliary atresia: signs, diagnosis (3), treatment (3)
Signs: neonatal jaundice beyond 1 week
Diagnosis: radioisotope scanning, ultrasound, direct bilirubin >2mg/dL and >10% total bilirubin
Treatment: Kasai procedure (hepatoportoenterostomy) at <8wks + corticosteroids (increase bile flow) + liver transplantation later
Malrotation and midgut volvulus: signs and symptoms (6)
Acute onset of bilious vomiting
Abdominal distention
Skin mottling
Bloody stool
Malrotation and midgut volvulus: diagnosis (2)
AXR: bowel loops overriding liver, double bubble sign (air in stomach & duodenum), no gas in GI tract distal to volvulus
Upper GI series: duodenal C-loop doesn’t extend to the left
Malrotation and midgut volvulus: treatment
Ladd procedure
Duodenal atresia: associated anomalies, signs, diagnosis, treatment
Associated anomalies: Down syndrome, esophageal atresia, imperforate anus
Signs: polyhydramnios, small for gestational age, bilious vomiting, abdominal distention
Diagnosis: AXR shows double bubble sign
Treatment: side-to-side anastomosis to avoid injury to bile duct and pancreatic duct
Pediatric intussusception: causes (6)
Meckel’s diverticulum
Henoch-Schoenlein purpura
Pediatric intussusception: signs & symptoms (5)
Intermittent colicky abdominal pain
Bilious vomiting
Current jelly stool
Sausage-shaped RUQ mass
Pediatric intussusception: diagnosis (3)
AXR: paucity of bowel gas, “target sign”
Ultrasound: “target” sign, “pseudokidney” sign
Barium enema
Pediatric intussusception: treatment (3)
NG tube for decompression
Barium enema UNLESS there is peritonitis, perforation, profound shock
Air enema
Meckel’s diverticulum: definition, signs, diagnosis, treatment
Definition: persistent vitelline duct in ileum that contains gastric, colonic or pancreatic epithelium
Signs: intermittent painless rectal bleeding, intestinal obstruction, diverticulitis
Diagnosis: Meckel’s scan
Treatment: resection of diverticulum
Imperforate anus: associated anomalies (3), treatment (2), prognosis
Associated anomalies: anomalies of sacrum and spinal & GU tracts
Treatment: colostomy for high lesion (above puborectalis sling), perineal anoplasty or dilatation for low lesions
Prognosis: worse for higher lesions
Hirschsprung’s disease: definition, symptoms (3), diagnosis (3), treatment
Definition: absence of ganglion cells in plexuses of Auerbach and Meissner
Symptoms: delayed meconium at birth, bilious vomiting, chronic constipation
Diagnosis: AXR shows obstruction, barium enema shows transition zone, rectal biopsy shows absence of ganglion cells
Treatment: temporary colostomy proximal to transition zone + definitive repair at 6-12m
NEC: signs & symptoms (5), diagnosis, treatment (3)
Signs & symptoms: lethargy, feeding intolerance, hematochezia, fever, abdominal pain & distension
Diagnosis: AXR shows pneumatosis intestinalis
Treatment: resect section with perforation & full-thickness necrosis, bowel decompression, TPN
Wilm’s tumor: definition, associated anomalies (4), signs (3), diagnosis (4), treatment
Definition: nephroblastoma usually at <6y/o
Associated anomalies: hemihypertrophy, aniridia, GU abnormalities, MR
Signs: flank mass, hematuria, HTN
Diagnosis: IV urography (solid mass), abdominal ultrasound (extension into renal vein & IVC), CT scan (liver metastases), CXR (lung metastases)
Treatment: surgical resection + chemo / radiation
Neuroblastoma: definition, signs (6), diagnosis (4), treatment
Definition: neural crest cell tumor in adrenal glands, sympathetic ganglia, or organ of Zuckerkandl, usually at <1y/o
Signs: painful abdominal mass, fever, FTT, proptosis, opsomyoclonus, hypertension
Diagnosis: elevated urinary VMA & HVA, IV pyelography (“drooping lily sign”), abdominal CT, CXR
Treatment: aggressive chemo / radiation
Etomidate: definition, duration of action, complications, patients to use it in
Definition: induction agent
Duration of action: 5mn
Complications: minimal hepatic and renal effects
Good for patients with decreased cardiac output; bad for patients <10y/o, pregnant, lactating
Ketamine: definition, duration of action, complications, patients to use it in
Definition: IV induction and maintenance anesthesia
Duration of action: 10-20mn
Complications: increased ICP, tachycardia
Good for patients with bronchospasm; bad for patients with head trauma
Thiopental: definition, duration of action, complications, patients to use it in
Definition: induction agent
Duration of action 5-10mn
Complications: hypotension
Good for hemodynamically stable patients and those with increased ICP; bad for patients with asthma
What conditions falsely change the reading on pulse oximetry?
Falsely lowers: methylene blue, indigo carmine dye, nail polish
Falsely raises: carboxyhemoglobin
Falsely 85%: methemoglobin
Complications of spinal anesthesia (in CSF)
Common: hypotension (SNS blockade), nausea (unopposed PNS activity), urinary retention, backache
Less common: postpinal headache from CSF leak
Rare: permanent neurologic injury
Complications of epidural anesthesia
Common: urinary retention, backache, postspinal headache (if inadvertent puncture of dura)
Less common: hypotension (SNS blockade), nausea (unopposed PNS activity)
Rare: epidural abscess / hematoma, permanent neurologic injury
Contraindications to succinylcholine (5)
Narrow-angle glaucoma
Guillain-Barre syndrome
Malignant hyperthermia
Methohexital: definition, duration of action, contraindications
Definition: induction agent
Duration of action: 5-10mn
Contraindications: seizures, hypotension, asthma
Fentanyl: definition, duration of action, contraindications
Definition: induction agent
Duration of action: 45mn
Contraindications: hypotension
Midazolam: definition, duration of action, contraindications
Definition: induction agent for anesthesia
Duration of action: 6-15mn
Contraindications: narrow-angle glaucoma; reduce dosage in elderly and patients receiving erythromycin or drugs that inhibit p450 system
Propofol: definition, duration of action, contraindications
Definition: IV induction and maintenance anesthesia; comes as a lipid emulsion
Duration of action: 3-6mn
Contraindications: use caution in patients with lipid metabolism disorders; use aseptic technique to prevent sepsis
Nitrous oxide: definition and common side effect
Inhalational anesthesia maintenance agent
Can diffuse into closed spaces and lumens, causing expansion of bowel or worsening of pneumothorax
Inhalational agents for maintenance anesthesia (4)
Nitrous oxide
2 main risks during patient emergence immediately post-op
Aspiration and laryngospasm
Benzodiazepines: specific drugs used in anesthesia, function in anesthesia, antidote
Drugs: midazolam, diazepam, lorazepam
Function: amnesia, anxiolysis, paralysis; NO ANALGESIA
Antidote: flumazenil
Opiates: drugs used in anesthesia, function in anesthesia, antidote
Drugs: morphine, meperidine (demerol), fentanyl
Function: analgesia, sedation; NO PARALYSIS
Antidote: naloxone
Neuromuscular blockers: drugs used in anesthesia, function in anesthesia, antidote
Drugs: succinylcholine (noncompetitive), atracurium, pancuronium, rocuronium, vecuronium
Function: paralysis; NO ANALGESIA OR SEDATION
Antidote: anticholinesterase (pyridostigmine, neostigmine, edrophonium)
Anesthetic considerations in patients with hepatic insufficiency (5)
Low albumin –> less drug binding –> increased unbound active drug
Less p450 activity –> slower elimination of many drugs
Decreased blood flow (e.g. cirrhosis) –> slower clearance of drugs
Chronic alcoholism increases anesthetic requirements
Acute alcohol intoxication decreases anesthetic requirements
Anesthetic considerations in patients with renal insufficiency (4)
Hypertension due to fluid overload
Hyperkalemia increases risk for cardiac arrhythmias
Succinylcholine may further increase serum potassium
Effects of renally excreted drugs may be prolonged
Locations where you should NOT use epinephrine (SPF-10)
Local anesthesia: drugs and toxicities
Drugs: esters (e.g. procaine, cocaine) & amides (e.g. prilocaine, lidocaine, bupivacaine)
Toxicity: CNS effects (tinnitus, restlessness, vertigo, seizures), CV effects (hypotension, PR prolongation, QRS widening, dysrhythmias)
Minimum alveolar concentration (MAC)
Minimum concentration necessary to prevent movement in 50% of patients in response to a surgical stimulus. REfers to inhalational anesthetics like NO & isoflurane.
Malignant hyperthermia: manifestations (7), treatment
Manifestations: tachycardia, hyperthermia, hypercarbia, hypoxemia, acidosis, muscle rigidity, ventricular dysrhythmias
Treatment: stop anesthetic + benzos + dantrolene
Antiemetics used in post-op N/V
Metoclopramide (reglan)
prochlorperazine (compazine)
ondansetron (zofran)
Steps of wound healing and factors that inhibit them
1. coagulation: impaired by anticoagulants & antiplatelets
2. inflammation: impaired by steroids & immunosuppression
3. collagen synthesis: impaired by vitamin C deficiency & protein-calorie malnutrition
4. angiogenesis
5. epithelialization: complete by 24-48hrs
6. contraction: takes months
Wound healing by primary intention (3)
Approximate edges of incisional defect using sutures or staples
Minimal devitalized tissue and contamination
Wound strength reaches max at ~3 months and is 70-80% normal
Wound healing by second intention (3)
Wound closure is not approximated with sutures, because a) the defect is very large or b) there is a high risk of infection
Pack loosely with moist gause and cover with sterile dressing
Assess wound daily for development of granulation tissue or infection
Wound healing by third (delayed primary) intention (2)
Wound closure used for contaminated or dirty wounds (e.g. ruptured appendix with pus in peritoneal cavity)
Close parietal peritoneum & fascial layers at end of surgery, but don’t suture skin or subQ tissue until 3-5d later when bacterial contamination has decreased.
When do surgical site infections occur?
Within 30 post-op days
What is the most common cause of early surgical site infections (within first 24hrs)?
Streptococcus or Clostridium
Factors that increase the risk of wound infection post-op (6)
>100,000 microorganisms
Infection remote from surgical site
Immunosuppression (AIDS, cancer, steroids)
Severe protein-calorie malnutrition
Most common causes of post-op fever (5Ws)
Wound infection
Wind: atelectasis, pneumonia
Water: UTI
Walking: DVT, PE, thrombophlebitis
Wonder drugs
Most common cause of post-op fever within 24hrs
Post-op hematoma: manifestations, treatment, complications
Manifestations: localized fluctuant swelling, discoloration at wound site, signs of hypovolemia if very large
Treatment: allow to reabsorb spontaneously if small; aspirate if large
Complications: pain, increased risk of infection
Post-op seroma: definition, treatment, complications
Definition: collection of fluid near wound that is not blood or pus (may be lymph)
Treatment: aspiration + placement of drain
Complications: increased risk of infection
Causes of wound failure (dehiscence or incisional hernia) (8)
Poor operative technique
Liver failure
Poorly controlled diabetes
Increased abd pressure: chronic cough, obesity, ascites, BPH, etc.
Acute abdomen
Abdominal pain + peritoneal signs (rigidity, tenderness, rebound, involuntary guarding) +/- shock
Kehr’s sign
Pain referred to the left shoulder due to irritation of left hemidiaphragm. Seen with splenic rupture.
Radiation of small bowel pain
Epigastrium and periumbilical area
Radiation of large bowel pain
Suprapubic area
Radiation of kidney pain
Flank, groin, genitalia
Disorders associated with colicky pain
Biliary colic
Bowel obstruction
Mesenteric ischemia
Most common cause of free air under diaphragm
Perforated peptic ulcer
Causes of free air under diaphragm
Perforated peptic ulcer
Trauma to hollow viscus injury
Aortic dissection
Mesenteric ischemia (usually on left side)
Large bowel perforation
Surgical causes of abdominal pain: RUQ, RLQ, LLQ, LUQ, diffuse, suprapubic
RUQ: perforated duodenal ulcer, cholecystitis, hepatic abscess, retrocecal appendicitis, appendicitis in a pregnant woman
RLQ: appendicitis, cecal diverticulitis, Meckel’s diverticulitis
LLQ: sigmoid diverticulitis, volvulus
LUQ: splenic rupture, splenic abscess
Diffuse: bowel obstruction, leaking aneurysm, mesenteric ischemia
Suprapubic: ectopic pregnancy, overian torsion, TOA, psoas abscess, incarcerated groin hernia
Non-surgical causes of abdominal pain: RUQ, lower abd, LUQ, midepigastric, diffuse
RUQ: RLL pneumonia, biliary colic, cholangitis, hepatitis, Fitz-Hugh Curtis
RLQ & LLQ: ureteral stones, gastroenteritis, IBD, PID, endometriosis, prostatitis, mittelschmerz, UTI, ruptured ovarian cyst
LUQ: LLL pneumonia, gastritis, splenomegaly, splenic infarct
Midepigastric: PUD, MI, esophagitis, PE, pancreatitis, herpes zoster, rectus sheath hematoma
Diffuse: abd wall hematoma, black widow spider bite, lead poisoning, Addisonian crisis, sickle cell crisis, DKA, diabetic gastropathy, opiate withdrawal, dengue, nerve root compression
Most common cause of abd pain in elderly
Difficulty swallowing
Mechanical dysphagia: definition & causes (5)
Definition: difficulty swallowing solids more than liquids
Causes: foreign body, inflammation, strictures, neoplasm, extrinsic compression (aortic aneurysm, thyromegaly, retropharyngeal abscess)
Neuromuscular dysphagia: definition & causes (8)
Definition: difficulty swallowing solids and liquids
Causes: tongue paralysis, CN 9-10 paralysis, myasthenia gravis, polymyositis, dermatomyositis, scleroderma, achalasia, diffuse esophageal spasm
Achalasia: definition & manifestations (6)
Definition: dysphagia due to nonperistaltic contraction of esophagus, incomplete relaxation of LES after swallowing, and increased resting tone of LES
Manifestations: dysphagia of solids & liquids, regurgitation, halitosis, weight loss, cough, chest pain
Achalasia: diagnosis (4)
CXR: dilated esophagus + air-fluid levels in post. mediastinum + no gastric bubble
Barium swallow: distal bird’s beak or steeple sign
Manometry: nonperistaltic contractions, incomplete LES relaxation, increased LES tone
Esophagoscopy: rule out mass / stricture + biopsy
Treatment of achalasia
Medical: relax LES with nitrates, Ca channel blockers, or botulinum toxin
Surgery: endoscopic dilatation (increased risk of perforation) or esophagomyotomy with fundoplication
Diffuse esophageal spasm: definition & manifestations (4)
Definition: spasms in distal 2/3 of esophagus, due to uncoordinated large-amplitude contractions of smooth muscle
Manifestations: dysphagia of solids & liquids, chest pain, no regurgitation; associated with IBS & spastic colon
Diagnosis of diffuse esophageal spasm (3)
Barium swallow: ‘corkscrew’ appearance or normal (if no ongoing spasm); LES is normal diameter
Manometry: large uncoordinated repetitive contractions in lower esophagus, or normal if no ongoing spasm
Esophagoscopy: rule out mass / stricture / esophagitis
Treatment of diffuse esophageal spasm
Medical: nitrates or Ca channel blockers
Surgery: usually not successful
Manifestations of esophageal varices
Painless unprovoked massive hemorrhage that may lead to hypovolemic shock
Treatment of esophageal varices: not ruptured, ruptured, repair
Not ruptured: reduce portal blood flow with vasopressin, octreotide, somatostatin, or beta blockers
Ruptured: volume replacement + NG suction + repair
Methods for repair: endoscopic sclerotherapy, endoscopic band ligation, balloon tamponade (Blakemore tube), TIPS, intraoperative placement of portocaval shunt, or liver transplant
Most serious complication of balloon tamponade in repair of esophageal varices
Esophageal perforation
Causes of esopheal perforation (4)
Iatrogenic: endoscopy, dilatation, blakemore tube (balloon tamponade), intubation of esophagus, NGT
Boerhaave syndrome
Mallory-Weiss syndrome
Foreign body ingestion
Manifestations of esophageal perforation
Severe constant chest / abd / back pain
Subcutaneous emphysema
Mediastinal emphysema (crunching sound with heartbeat)
Hammon’s crunch
Crunching sound with heartbeat heard in mediastinal emphysema
Diagnosis of esophageal perforation (4)
CXR: pleural effusion + mediastinal or subcutaneous emphysema
Esophagogram wiht water-soluble contrast: extravasation of contrast
CT scan
Thoracentesis for pleural fluid
Treatment of esophageal perforation
Surgical repair
Risk factors for esophageal carcinoma (6)
Diet high in nitrites or nitrosamines
Chronic esophagitis
Plummer-Vinson syndrome (dysphagia, glossitis, anemia)
Diagnosis of esophageal carcinoma (4)
Barium swallow: shows mass
CXR: hilar lymphadenopathy
Esophageal duodenoscopy: see mass + biopsy
Chest CT: define extent of disease
Manifestations and types of esophageal diverticula
Pharyngoesophageal (Zenker’s): dysphagia, halitosis, regurgitation, choking, aspiration
Midesophageal: asymptomatic
Epiphrenic: dysphagia + regurgitation or asymptomatic
Treatment of each type of esophageal diverticula
Pharyngoesophageal (Zenker’s): cervical esophagomyotomy + resection of diverticulum
Midesophageal: only resect if there is a fistulous connection between diverticulum & tracheobronchial tree
Epiphrenic: esophagomyotomy + resection via thoracotomy
Diagnosis of GERD (4)
Barium study: assess severity of reflux, look for anotomical cause, find strictures or ulcers
Continuous pH monitoring: assess severity of reflux
Manometry: assess competence of LES
Esophagoscopy: find ulcers, rule out Barrett’s esophagus, biopsy
Treatment of GERD
Medical: antacids, H2 blockers (ranitidine), PPIs (omeprazole), metoclopramide (increases LES tone)
Behavior: stop smoking, sleep with head of bed elevated
Surgery: fundoplication + forceful dilatation of strictures
Esophageal strictures: definition, risk factors (5), manifestations (2)
Definition: local stenotic regions in esophageal lumen caused by inflammation or neoplasm
Risk factors: GERD, radiation esophagitis, infectious esophagitis, corrosive esophagitis, post-sclerotherapy for varices
Manifestations: progressive dysphagia +/- odynophagia
Diagnosis of esophageal strictures (2)
Barium swallow
Esophagoscopy to evaluate for malignancy & determine appropriate treatment
Treatment of esophageal strictures
Dilation of esophageal lumen (risk of perforation)
Pain on swallowing
Manifestations of duodenal ulcers (3)
Burning gnawing epigastric pain occurring with an empty stomach and relieved by food within 30mn
Nighttime awakening (when stomach empties)
Most common location for duodenal ulcer
Posterior duodenal wall, within 2cm of pylorus
Diagnosis of Zollinger-Ellison syndrome
Fasting serum gastrin level >1000 pg/mL
Secretin stimulation test causes paradoxical rise in serum gastrin
Treatment of duodenal ulcers: medical (6) & surgical (2)
Medical: stop NSAIDs, steroids, smoking; PPIs; clarithromycin + amoxicillin or metronidazole to kill H. pylori; H2 blockers; prostaglandin analogues; antacids
Surgical: highly selective vagotomy; laparoscopic posterior truncal vagotomy + anterior seromyotomy
When do you do surgery for duodenal ulcers?
When ulcer is refractory to 12 weeks of medical treatment or if there is hemorrhage, obstruction, or perforation
Complications of surgery for PUD (9)
Dumping syndrome
Afferent loop syndrome
Postvagotomy diarrhea
Duodenal stump leak
Efferent loop obstruction
Marginal ulcer
Alkaline reflux gastritis
Chronic gastroparesis
Postgastrectomy stump cancer
Types of gastric ulcers (5)
Type 1: lesser curvature at incisura angularis (most common)
Type II: simultaneous gastric & duodenal ulcers with oversecretion of acid
Type III: prepyloric with oversecretion of acid
Type IV: in gastric cardia (proximal)
Type V: throughout stomach, associated with NSAIDs
Manifestations of gastric ulcer (3)
Burning gnawing epigastric pain occurring when anything is in the stomach; worst within 30mn of eating
Anorexia / weight loss
Diagnosis of gastric ulcers
Biopsy to e/f cancer
Treatment of gastric ulcers: medical (6) & surgical (3)
Medical: Medical: stop NSAIDs, steroids, smoking; PPIs; clarithromycin + amoxicillin or metronidazole to kill H. pylori; H2 blockers; prostaglandin analogues; antacids
Surgical: antrectomy (types I/II); highly selective vagotomy (type III); subtotal gastrectomy + roux-en-y esophagogastrojejunostomy (type IV)
Dumping syndrome: definition, manifestations (7), treatment
Definition: gastric contents move too fast from stomach to small intestine, causing symptoms right after or 2-4hrs after eating; associated with gastrectomy
Manifestations: N/V, diarrhea, belching, tachycardia, diaphoresis, dizziness, syncompe
Treatment: avoid high-sugar food & excessive water intake +/- octreotide
Treatment of postvagotomy diarrhea (3)
Usually self-limited
Opioids: kaolin-pectin, loperamide, diphenoxylate
Bile acid sequestrants: cholestyramine
Alkaline reflux gastritis: cause, manifestations (2), treatment
Cause: complication of gastrectomy
Manifestations: chronic abdominal pain & bilious vomiting
Treatment: roux-en-y gastrojejunostomy with long roux limb; recurrences still occur
Afferent limb syndrome: definition, manifestations (4), diagnosis, treatment
Definition: obstruction of afferent limb following gastrojejunostomy, usually presenting in first post-op week
Manifestations: RUQ pain after meal, bilious vomiting, steatorrhea, anemia
Diagnosis: upper GI series shows no contrast in afferent loop
Treatment: endoscopic balloon dilatation + surgical revision
Gastritis: definition, manifestations (2), diagnosis, treatment
Definition: acute or chronic inflammation of stomach lining
Manifestations: burning / gnawing pain worse with food and better with antacids; vomiting relieves pain after eating
Diagnosis: endoscopy
Treatment: treat H. pylori + antacids + H2 blockers, sucralfate or misoprostol
Causes of gastritis: GNASHING
Gastric reflux (bile or pancreatic secretions)
H. pylori and other infections
Glugocorticoids (long-term)
Complications of chronic gastritis (3)
Gastric atrophy
Gastric metaplasia
Pernicious anemia (reduced production of intrinsic factor)
Gastric outlet obstruction: causes (4), symptoms (7), diagnosis (2), treatment (2)
Causes: tumors in stomach or head of pancreas; gastric or duodenal ulcers
Symptoms: first early satiety, gastric reflux, weight loss, abd distention; then vomiting, dehydration, metabolic alkalosis
Diagnosis: endoscopy or barium swallow x-ray
Treatment: endoscopic balloon dilatation or truncal vagotomy + pyloroplasty
Causes of upper GI hemorrhage (5)
Esophageal tear
AV malformation
Vertical banded gastroplasty: definition, advantage, disadvantage
Definition: stomach is partitioned into a small proximal pouch and a distal larger one. When the small pouch is distended, a signal is sent to the hypothalamus, so the patient feels full and stops eating. Leads to decreased consumption and delayed gastric emptying.
Advantage: no change in anatomy or physiology of GI tract
Disadvantage: higher recurrence rate
Roux-en-Y gastric bypass: definition, advantage, disadvantage
Definition: bypass stomach, duodenum & first part of jejunum
Advantage: greater weight loss
Disadvantage: more complications, including dumping syndrome, stomal ulcer / stenosis, pernicious anemia, iron deficiency anemia
Risk factors for gastric adenocarcinoma (7)
Chronic atrophic gastritis
H. pylori
Post-partial gastrectomy
Pernicious anemia
Diet (foods high in nitrites)
Manifestations of gastric adenocarcinoma (8)
Asymptomatic early on
Constant non-radiating pain that is worse with food
Anorexia / weight loss
Nausea / vomiting
Krukenberg’s tumor
Gastric adenocarcinoma metastasized to ovaries
Blumer’s shelf
Gastric adenocarcinoma metastasized to pelvic cul-de-sac; felt on DRE
Virchow’s node
Gastric adenocarcinoma metastasized to lymph node; palpable in left supraclavicular fossa
Sister Mary Joseph’s nodule
Gastric adenocarcinoma metastasized to umbilical lymph nodes
Diagnosis of gastric adenocarcinoma (4)
Endoscopic ultrasound to assess depth of invasion
Upper GI endoscopy to get biopsy
Upper GI series
Abdominal CT to assess extent
Treatment of gastric adenocarcinom
Radical subtotal gastrectomy: curative in early disease
Chemo: for palliation (NOT adjuvant)
Diagnosis of gastric lymphoma
Endoscopic biopsy
Bone marrow aspiration & gallium bone scans to e/f metastases
Treatment of gastric lymphoma
Low-grade MALT lymphoma: treat H. pylori
High-grade or non-MALT: radiation / chemo
Bleeding or perforation: resection
Carney triad
Syndrome seen in women <40y/o
Gastric leiomyosarcoma + pulmonary chondromas + extra-adrenal paraganglioma
Management of gastric lipoma
No need to biopsy or excise unless it’s enlarging, as there is very low malignant potential.
Menetrier’s disease: definition, manifestations (6), diagnosis (2), treatment (3)
Definition: autoimmune disease causing hypertrophic gastritis & protein-losing enteropathy
Manifestations: epigastric pain, third-spacing, decreased gastric acid secretion, occult GI bleed, anorexia, N/V
Diagnosis: barium swallow (large gastric folds & thick rugae) + endoscopic biopsy
Treatment: anticholinergics or H2 blockers to reduce protein loss + high-protein diet +/- gastrectomy if severe
Bezoars: definition, symptoms (4), diagnosis, treatment (3)
Definition: concretions of nondigestible matter accumulate in stomach (hair, persimmon, charcoal)
Symptoms: early satiety, gastric reflux, weight loss, abd distention
Diagnosis: upper GI endoscopy
Treatment: proteolytic enzymes (papain), mechanical fragmentation with endoscope, or surgical removal
Dieulafoy’s lesion: definition, symptoms, diagnosis, treatment (3)
Definition: mucosal end artery causes pressure necrosis, erodes into stomach and ruptures
Symptoms: massive recurrent painless hematemesis
Diagnosis: upper GI endoscopy
Treatment: endoscopic sclerosing therapy, endoscopic electrocoagulation, or wedge resection
Diagnosis of gastric diverticula
Upper GI contrast study
Gastric volvulus: symptoms (3), diagnosis, treatment (3)
Symptoms: intermittent severe epigastric pain & distention, inability to vomit, difficult passage of NG tube
Diagnosis: upper GI contrast study
Treatment: surgical repair of associated paraesophageal hernia, gastropexy, or gastric resection
CNS manifestations of dehydration: moderate (4) & severe (4)
Moderate: sleepiness, apathy, slow responses, anorexia
Severe: decreased tendon reflexes, anesthesia of distal extremities, stupor, coma
GI manifestations of dehydration: moderate (1) & severe (3)
Moderate: progressive decrease in food consumption
Severe: N/V, refusal to eat, ileus
CV manifestations of dehydration: moderate (3) & severe (5)
Moderate: orthostasis, tachycardia, collapsed veins
Severe: cutaneous lividity, hypotension, distant heart sounds, cold extremities, absent peripheral pulses
Tissue manifestations of dehydration: moderate (2) & severe (2)
Moderate: soft small tongue with longitudinal wrinkles, decreased skin turgor
Severe: atonic muscles, sunken eyes
Treatment of dehydration
First hour: 20ml/kg NS or LR in first hour
Next 8hrs: expected maintenance fluid + 1/2 remaining calculated loss
Next 16hrs: expected maintenance fluid + remaining calculated loss
Complication of giving large amounts of normal saline
May cause hyperchloremic metabolic acidosis
Indications for giving colloids (albumin, blood products) to dehydrated patient (4)
Hypovolemia persists after 2L crystalloid
Patient is hypovolemic but has excess Na & water (e.g. ascites, CHF)
Patient can’t synthesize enough protein to exert enough oncotic pressure (liver disease, transplant recipient, malnutrition)
Severe hemorrhage or coagulopathy
Causes of isotonic volume excess (3)
Renal insufficiency
Causes of hypotonic volume excess (3)
Inappropriate NaCl-poor solution as replacement for GI losses
Causes of hypertonic volume excess (2)
Na load without adequate water intake
Rapid infusion of non-electrolyte osmotically active solutes (e.g. mannitol)
Tissue manifestations of volume excess: moderate (2) & severe (4)
Moderate: pitting edema, basilar rales
Severe: anasarca, moist rales, vomiting, diarrhea
Treatment for hypervolemia
Isotonic: restriction of Na & fluids
Hypertonic: free water replacement (D5W or PO)
Hypotonic: normal saline
All: diuresis with furosemide + replace K
Best method for assessing total volume status
Daily weight
Causes of hypovolemic hyponatermia
Hypervolemic hyponatremia: causes, symptoms
Causes: CHF, cirrhosis, nephrotic syndrome
Symptoms: edema, increased thirst (increased vasopressin)
Causes of euvolemic hyponatremia (4)
SIADH: increased ADH & decreased renal free water excretion
Glucocorticoid deficiency (Addison’s): hypersecretion of ADH
Hypothyroidism: decreased CO & GFR lead to increased secretion of ADH
Primary polydipsia: psych patients
Hyponatremia with high plasma osmolality: cause, manifestations (8), treatment
Cause: rapid infusion of glucose or mannitol causes increased osmotic pressure, shifting fluid from ICF to ECF
Manifestations: increased ICP, HTN, hyperactive reflexes, muscle twitching, oliguria, salivation, lacrimation, watery diarrhea
Treatment: free water restriction + normal saline
Symptoms of hypernatremia (8)
Decreased saliva, tears and pee
Red swollen tongue
Causes of hypokalemia (5)
Excessive renal secretion, e.g. after massive NS infusion
Prolonged administration of K-free parenteral fluids
Loss in GI secretions
Manifestations of hypokalemia
Weakness progressing to flaccid paralysis
Decreased reflexes
Paralytic ileus
EKG: flattened T waves, ST depression, U wave, arrhythmias
Treatment of hypokalemia
Replenish at a rate that doesn’t exceed 40mEq/hr
Don’t give to oliguric patient
Manifestations of hyperkalemia (4)
Intermittent intestinal colic
EKG: peaked T waves, wide QRS, ST depression –> progresses to heart block, sine wave and cardiac arrest
Treatment of hyperkalemia (5)
10% Ca gluconate 1g IV
20 units regular insulin + D10W
Correction of serum Ca for low albumin
Ca = 0.8 * ([normal albumin] – [observed albumin]) + observed calcium
Effect of pH on serum Ca
Acidosis: increases ionized fraction
Alkalosis: decreases ionized fraction
Causes of hypocalcemia (8)
Acute pancreatitis
Necrotizing fasciitis
Acute / chronic renal failure
Pancreatic / small bowel fistulas
Severe Mg depletion
Severe alkalosis (decreased ionized fraction of total serum Ca)
Manifestations of hypocalcemia (7)
Numbness & tingling of fingers / toes / mouth
Increased reflexes
Chvostek’s sign (facial nerve tap)
Trousseau’s sign (carpopedal spasm)
Muscle & abd cramps
Prolonged QT on EKG
Treatment of hypocalcemia
IV Ca gluconate or CaCl
Causes of hypercalcemia (3)
Cancer: breast, multiple myeloma
Drugs: thiazides
Manifestations of hypercalcemia (8)
Fatigue / weakness
Nausea / vomiting
Severe headache
Pain in back and extremities
Stupor / coma
Treatment of hypercalcemia
Vigorous volume repletion with normal saline
Treat underlying cause
Kwashiorkor: definition & signs (3)
Definition: adequate fat reserves with significant protein deficits
Signs: slight/no weight loss, low visceral proteins, edema
Marasmus: definition & signs (3)
Definition: protein-calorie malnutrition
Signs: weight loss, fat & muscle wasting, normal/low visceral proteins
Causes of anion gap metabolic acidosis: MUDPILES
Metabolism (IEM) & methanol
Lactic acid
Ethylene glycol
Salicylates & strychnine
Causes of non-anion gap metabolic acidosis: HARD UP
Adrenal insufficiency & carbonic Anhydrase inhibitors
Renal tubular acidosis
DiarrheaUreteroenteric fistula
Pancreatic fistula
Causes of respiratory alkalosis: MISHAPS
Mechanical overventilation
Increased ICP
Hypoxemia, Hyperpyrexia, Heart failure
Anxiety, Asthma, Ascites
Pregnancy, Pain, Pneumonia
Causes of metabolic alkalosis
Renal H+ loss: mineralocorticoid excess, diuretics, potassium-losing nephropathy
GI H+ loss: vomiting, gastric drainage, villous adenoma of colon
HCO3 gain: Milk-alkali syndrome, exogenous NaHCO3
Causes of metabolic acidosis
Hypoventilation: brainstem injury, neuromuscular disease, ventilator malfunction
V/Q mismatch: COPD, pneumonia, PE, foreign body, pulmonary edema
Factors that suppress tachycardic response to hypovolemia
Beta blockers
Damage to autonomic nervous system
Treatment of septic shock
IV antibiotics
Pressors: norepinephrine or high-dose dopamine
Anaphylactic shock: signs & treatment
Signs: urticaria, swelling, angioedema of lips and throat, wheezing, hypotension
Treatment: intubation if airway compromise + epinephrine + diphenhydramine + steroids
Neurogenic shock: signs (5) & treatment (3)
Signs: flaccid paralysis, bradycardia, hypotension, warm skin, normal/wide pulse pressure
Treatment: fluids + pressors (dopamine or dobutamine) + atropine or pacemaker for bradycardia
Treatment of cardiogenic chock
Left heart or biventricular failure: diuretics + nitrates (reduce preload) + pressors (medium-dose dopamine, dobutamine, or amrinone) +/- IABP
Right heart failure: fluids to maintain preload
Normal PCWP
Reflects LV preload
Normal cardiac output
Reflects pump function
Dobutamine: action & use
Action: strong stimulation of beta-1 + mild stimulation of beta-2 –> increases CO & decreases SVR
Use: cardiogenic shock
Isoproterenol: action & use
Action: strong stimulation of beta-1 & beta-2 –> increases CO & decreases SVR
Use: cardiogenic shock with bradycardia
Milrinone: action & use
Action: phosphodiesterase inhibitors that increases cAMP –> increased cardiac inotropy + vasodilation –> increases CO & decreases SVR
Use: cardiogenic shock, heart failure
Dopamine: action & use at each dose
Low dose (1-3mcg/kg/mn): stimulation of dopamine receptors (dilate renal vasculature) + mild stimulation of beta-1; used in renal insufficiency
Intermediate dose (5-10mcg/kg/mn): stimulation of dopamine receptors + moderate stimulation of beta-1 + mild stimulation of alpha-1 –> increased CO; used in cardiogenic shock
High dose (10-20mcg/kg/mn): stimulation of dopamine receptors & beta-1 + strong stimulation of alpha-1 –> increased SVR; used in cardiogenic & septic shock
Norepinephrine: action and use
Action: strong stimulation of alpha-1 + moderate stimulation of beta-1 –> increases SVR & CO
Use: septic shock
Epinephrine: action & use
Action: strong stimulation of beta-1 & alpha-1 + moderate stimulation of beta-2 –> increases SVR, may increase CO, bronchodilation
Use: anaphylaxis, septic shock, cardiopulmonary arrest
Phenylephrine: action & use
Action: strong stimulation of alpha-1 –> increases SVR
Use: septic shock, neurogenic shock, anesthesia-induced hypotension
Sodium nitroprusside: action & use
Action: venodilation + arterial dilation –> decreases preload & afterload
Use: patients with low CO and high BP
Pressure support mechanical ventilation (PS)
Initial boost of pressure is triggered by the patient’s initiation of a breath, to help the patient overcome the resistance of the ET tube.
Usually set to 8-20.
Important weaning mode.
Assist-control mechanical ventilation (AC)
A set tidal volume is given a set number of times per minute. If patient initiates their own breath, vent responds by giving the preset tidal volume.
Intermittent mandatory ventilation (IMV)
When patient initiates a breath, vent gives a boost of pressure to help him overcome the resistance of the ET tube. The amount of tidal volume is determined by the patient’s inspiratory effort. A set tidal volume is also automatically given a preset number of times per minute, in case the patient doesn’t initiate breaths.
CPAP ventilation
Continuous positive pressure without variation throughout the breathing cycle. The patient must breathe on his own.
PEEP ventilation
Provides positive pressure at the end of a breath to maintain alveoli open.
Usually set at 5-20.
Used in CHF & ARDS
Ventilator settings
Respiratory rate (AC & IMV only): 10-20
Tidal volume (AC & IMV only): 400-600cc
FiO2: start at 100% and titrate down, with pulse ox always >90%
Main causes of failure to wean off mechanical ventilation (5)
Drugs (esp. sedatives)
ET tube is too small bore (pt has to overcome a lot of resistance to breathe on own)
Diaphragm dysfunction
Minute ventilation
(respiratory rate) * (tidal volume)
Diagnostic criteria for ARDS
Bilateral fluffy infiltrates on CXR
Refractory hypoxemia
No evidence of heart failure (PCWP <18)
Most common causes of ARDS (5)
Infectious pneumonia
Blood products
Severe trauma & burns
Treatment of ARDS
Treat underlying cause
Mechanical ventilation + PEEP
Criteria for admission to a burn center (7)
2nd-3rd degree burns >10% BSA in pts <10 or >50
2nd-3rd degree burns >20% BSA in pts 10-50
Full thickness burns >5% BSA
Significant burns to face, hands, feet, genitalia, perineum, skin over major joints
Significant electrical or chemical injury
Lesser burn injury + inhalational injury, trauma, or preexisting medical conditions
Burns in patients requiring special rehab (e.g. abuse)
Burn patients who can be treated as outpatients (3)
First-degree burns
2nd-3rd degree burns <10% (except face, hands, etc.)
Acceptable social situation & safe environment at home
Burn patients who required more fluids than expected (4)
High-voltage electrical injury
Inhalational injury
Delayed resuscitation
Intoxicated at time of injury
Burn patients who require less fluid than expected (3)
Patients >50y/o
Patients <2y/o
Patients with cardiac or pulmonary disease
Physiologic effect of burns on CV system
Pre-resuscitation: increased microvascular permeability, Hct (due to low blood volume), SVR; decreased CO; oliguria
Post-resuscitation: increased CO, GFR, metabolic requirements, catecholamines, glucagon; decreased insulin, thyroxine; edema
Physiologic effect of burns on pulmonary system (2)
Rapid shallow respirations at first, then hyperventilation after resuscitation
Increased pulmonary vascular resistance
Physiologic effect of burns on hematologic system (4)
Loss of plasma
RBC desctruction
Decreased platelets & fibrinogen
Increased fibrin degradation products
Physiologic effect of burns on endocrine system (5)
Increased glucagon, cortisol, catecholamines
Decreased insulin, T3
Indications for escharotomy after a burn (5)
Impairment or failure of peripheral circulation or ventilatory exchange, manifested as cyanosis
Impaired capillary refill
Compartment pressure >30mmHg
Signs of infection of a burn (8)
Degeneration of 2nd-degree burn to full-thickness burn
Focal color change to dark brown & black
Degeneration of wound with neoeschar formation
Rapid eschar separation
Hemorrhagic discoloration of subeschar fat
Erythematous or violaceous edematous wound margin
Crusted margin
Metastatic septic lesions in unburned tissue
Mafenide (Sulfamylon): definition & adverse effects (2)
Definition: topical sulfonamide used to treat infected 2nd-3rd degree burns
Adverse effects: pain on application, metabolic acidosis
Cause of death in over half of fatal burns
Inhalational injury: manifestations (7), diagnosis (3), treatment, complications
Manifestations: hoarse voice, cough, wheeze, bronchorrhea, hypoxemia, carbonaceous sputum, singed nose hairs
Diagnosis: CXR, bronchoscopy (edema + ulceration), V/Q scan (carbon particle deposition on endobronchial mucosa)
Treatment: warm humidified O2 or intubation if severe
Complications: pneumonia
Manifestations of electrical injury (6)
Charring at point of contact
Myoglobinuria due to muscle damage
Hyperkalemia due to tissue necrosis
Neuropathy (usually resolves)
Compartment syndrome
Cardiac arrest (high-voltage)
Late complications of electrical injury (2)
Delayed hemorrhage due to inadequate wound exploration, debridement, or exposure of vessels
Treatment of chemical injury (3)
Remove all clothing to prevent further contact
Copious water lavage for at least 30mn
Check pulonary status for edema, mucosal desquamation, bronchospasm
Manifestations of heat shock (7)
Temperature >105 / 40.6
Acid-base distrurbance
CNS dysfunction
Sequelae of frostbite (5)
Cool extremities
Cold sensitivity
Appearance of mild frostbite
Bright red, warm, painful with paresthesia, rapid edema, large vesicles, late superficial eschar. Resolves in 1-2 weeks.
Appearance of deep frostbite
Deep purple, cool, minimally painful, small hemorrhagic vesicles, slow edema, mummification of deep structures.
Treatment of frostbite (6)
1. Remove wet & restrictive clothing
2. Wrap in warm blankets and give warm fluid
3. Immediate rewarming of frozen parts by placing in circulating water at 40 degrees, until pink & perfused
4. Keep wounds exposed to air & vesicles intact
5. Daily wound care
6. No debridement until demarcation has occurred (takes weeks-months)
Signs of urethral injury (4)
Blood at the meatus
High-riding prostate
Perineal or scrotal hematoma
Pelvic fracture
Layers of the SCALP
Connective tissue
Aponeurosis (galea)
Loose areolar tissue
Monroe-Kellie hypothesis
Sum of the volume of the brain, blood and CSF within the skull must remain constant. Therefore, an increase in one of the above must be offset by decreased volume of the other. If not, ICP increases.
Cushing triad
Increased ICP + hypertension + bradycardia
Reflex intended to maintain CPP in the setting of increased ICP
Signs of basilar skull fracture
Periorbital ecchymoses (raccoon’s eyes)
Retroauricular ecchymoses (battle’s sign)
CN palsies
Ring test for CSF rhinorrhea
Sample of blood from nose is placed on filter paper to test for presence of CSF. If present, a large transparent ring is seen encircling a clot of blood.
Injury in intracerebral hemorrhage
Traumatic tearing of intracerebral blood vessels
Epidural hematoma: injured vessel, CT scan, symptoms, outcome
Injured vessel: middle meningeal artery, from overlying temporal bone fracture
CT scan: biconvex or lenticular shape
Symptoms: lucid interval followed by loss of consciousness
Outcome: good if treated promptly
Subdural hematoma: injured vessel, risk factors, outcome
Injured vessel: tearing of bridging veins associated with acceleration-deceleration mechanism
Risk factors: alcoholism, elderly (brain atrophy)
Outcome: 1/3-2/3 mortality due to brain contusion & shear
Methods to lower ICP: HIVED
Ventriculostomy (burr hole)
Elevate head of bed
Diuretics (mannitol, furosemide)
Anterior triangle of the neck
Posterior border of sternocleidomastoid
Posterior triangle of the neck
Posterior border of SCM
Zones of the neck
Zone I: thoracic outlet to inferior aspect of cricoid cartilage
Zone II: cricoid cartilage to angle of mandible
Zone III: angle of mandible to base of skull
Indications for surgical exploration of the neck (6)
Expanding hematoma
SubQ emphysema
Tracheal deviation
Change in voice quality
Air bubbling through the wound
Zone II injury with instability
Traumas in which you should suspect spinal injury (6)
Fall from >3m
Injury above shoulder level
High-speed MVC
Rugby or football injury
Anterior cord syndrome: definition & manifestations
Definition: injury to anterior portion of spinal cord or compression of anterior spinal artery (artery of adamkiewicz), seen in flexion injuries
Manifestations: full / partial loss of bilateral pain & temperature sensation + paraplegia + preservation of proprioception
Brown-Sequard syndrome: definition & manifestations
Definition: hemisection of spinal cord seen in penetrating injury, disc protrusion, hematoma, tumor
Manifestations: ipsilateral loss of motor function & proprioception + contralateral loss of pain & temperature sensation
Central cord syndrome: definition & manifestations
Definition: injury to central area of spinal cord; seen in pts with narrowing of spinal canal & hyperextension injuries
Manifestations: weakness greater in upper extremities than lower extremities, distal worse than proximal
Indications for C-spine films (5)
Tenderness along C-spine
Neurologic deficit
Good mechanism of injury
Presence of distracting injury
Altered mental status
Most common C-spine fracture
Most common C-spine subluxation
C5 on C6
Atlanto-occipital dislocation
Caused by severe traumatic flexion
Survival to hospital is rare
Jefferson fracture: definition, characteristics (2), x-ray (2)
Definition: Burst fracture of anterior and posterior rings of C1 (atlas) due to axial loading when patient falls directly on their head (or something falls on their head)
Characteristics: associated with C2 fractures; considered unstable even though usually not associated with spinal cord injury
X-ray: increase in predental space + displacement of lateral masses on odontoid view
C1 rotary subluxation: patient population, presentation, x-ray
Patient population: children & patients with rheumatoid arthritis
Presentation: head in rotation; head should not be forced into neutral position
X-ray: asymmetry between lateral masses and dens on odontoid view
Odontoid (dens) fractures
Type 1: tip of the dens only; usually stable
Type 2: base of the dens; never stable
Type 3: through base and body of C2; stable or unstable, may require surgery
Hangman’s fracture: definition, cause
Definition: fracture of both C2 pedicles; unstable but not associated with spinal cord injury (spinal canal is wide at C2)
Cause: hyperextension
Burst fracture of C3-C7: effect on spinal cord
Effect on spinal cord: axial loading causes compression of vertebral body –> anterior portion of vertebral body protrudes anteriorly and posterior portion protrudes posteriorly into spinal canal –> anterior cord syndrome
Simple c-spine wedge fracture: definition, x-ray
Definition: flexion injury causes compression on anterior portion of vertebral body
X-ray: appears as wedge-shaped concavity with loss of vertebral height on anterior portion of vertebral body.
Flexion teardrop c-spine fracture: definition, x-ray, effect on spinal cord
Definition: flexion injury causes fracture of anteroinferior portion of vertebral body
X-ray: teardrop-shaped fragment on anteroinferior vertebral body
Effect on spinal cord: associated with tearing of posterior ligament and neurologic damage
Extension teardrop c-spine fracture: definition, x-ray, effect on spinal cord
Definition: extension injury causes avulsion of anteroinferior portion of vertebral body
X-ray: teardrop-shaped fragment on anteroinferior vertebral body (like flexion teardrop fracture)
Effect on spinal cord: none, as posterior ligaments are intact
Clay Shoveler’s fracture
Flexion injury causing avulsion of tip of spinous process (C7 > C6 > T1). May also result from a direct blow.
Unilateral facet dislocation of c-spine: definition, x-ray
Definition: flexion-rotation injury that is usually stable
X-ray: spinous processes don’t line up on AP view of c-spine
Bilateral facet dislocation of c-spine: definition, x-ray
Definition: flexion injury that is extremely unstable and associated with spinal cord injury
X-ray: subluxation of dislocated vertebra greater than 1/2 AP diameter of vertebral body below it
Compression (wedge) fracture of L-spine: cause, stability, treatment
Cause: axial loading & flexion
Stability: can be unstable; neurologic injury is uncommon
Treatment: treat pain & ileus if present
Burst fracture of L-spine: definition, cause, x-ray
Definition: fracture of vertebral end plates with forceful extrusion of nucleus pulposus into vertebral body, causing comminution of vertebral body. May cause spinal cord compression.
Cause: axial loading
X-ray: loss of vertebral height on lateral spine film
Chance fracture: definition, cause
Definition: horizontal fracture through vertebral body, spinous processes, laminae & pedicles + tearing of posterior spinous ligament
Cause: acceleration-deceleration injury of a mobile person moving fwd into a fixed seat-belt
Coccygeal spine fracture: cause, diagnosis, treatment
Cause: direct trauma
Diagnosis: step-off on rectal exam +/- rectal bleeding
Treatment: pain management + doughnut pillow
Beck’s tried (tamponade)
Muffled heart sounds
Manifestations of pericardial tamponade (5)
Muffled heart sounds
Electrical alternans on EKG (alternation of QRS complex amplitude or axis between beats)
Treatment of pericardial tamponade (3)
Immediate decompression via needle pericardiocentesis, pericardial window, or thoracotomy with manual decompression.
Manifestations of cardiac trauma (4)
Beck’s triad (JVD, hypotension, muffled heart sounds)
Pulsus paradoxus
Elevated CVP
Hemodynamic instability
Postpericardiotomy (Dressler’s) syndrome: manifestations (5), treatment
Manifestations: fever, chest pain, pericardial effusion, rub, EKG abnormalities
Treatment: ASA or indomethacin +/- steroids
Potential complications of chest tube placement (7)
SubQ placement (vs. intrathoracic)
Bleeding from intercostal vessels
Injury to intercostal nerves
Lung laceration
Diaphragm injury
Liver injury
Indications for thoracotomy in pt with hemothorax (3)
1500cc initial drainage from chest tube
200cc/hr for 4hrs continued drainage
Decompensation after initial stabilization
Signs & symptoms of traumatic thoracic great vessel injury (8)
Retrosternal chest pain
New systolic murmur
Unequal blood pressures or pulses in extremities
External evidence of major chest trauma
Palpable sternal or thoracic spine fractures
Left flail chest
X-ray findings of traumatic thoracic great vessel injury (8)
Widened mediastinum
Tracheal or NG tube deviation to the right
Depression of left mainstem bronchus
Large hemothorax
Indistinct aortic knob
Presence of left apical cap
Multiple rib fractures
Foreign bodies near great vessels
Iatrogenic causes of great vessel injury (4)
CVP line or chest tube placement
IABP placement
Use of nonvascular clamp during ED thoracotomy
Overinflation of Swan-Ganz balloon
Diagnosis of thoracic great vessel injury (3)
CT: if CXR is normal but mechanism is suspicious
Angiography: localize injury
TEE: only if no airway problem or c-spine injury
Sucking chest wound: mechanism & treatment
Mechanism: if defect is >2/3 diameter of trachea, air preferentially enters through defect; affected lung collapses on inspiration as air enter through defect and expands slightly on expiration
Treatment: cover wound with occlusive dressing sealed on 3 sides
Pulmonary parenchymal injury: signs (3), ABG (2), CXR (2)
Signs: dyspnea, tachypnea, local ecchymosis
ABG: hypoxemia, widened A-a gradient
CXR: local irregular patchy infiltrate at site of injury within 6hrs of trauma + fluid density in lung field
Most frequent complication of pulmonary parenchymal injury
Indications for ED thoracotomy
Salvageable patient with postinjury cardiac arrest
Persistent severe hypotension due to tamponade, intrathoracic hemorrhage, or air embolism
Acute indications for thoracotomy in the setting of trauma (10)
Acute hemodynamic decompensation
Penetrating truncal trauma
Thoracic outlet vascular injury
Traumatic thoracotomy
Massive air leak from chest tube
Significan missile embolus to heart or pulmonary artery
Endoscopic or radiographic evidence of tracheal, bronchial, or esophageal injury
Great vessel injury
Penetrating injury to mediastinum
Nonacute indications for thoracotomy in the setting of trauma (9)
Clotted hemothorax
Chronic traumatic diaphragmatic hernia
Intracardiac injury
Traumatic pseudoaneurysm
Nonclosing thoracic duct fistula
Chronic post-traumatic empyema
Infected intrapulmonary hematoma
Missed tracheal or bronchial injury
Tracheoesophageal fistula
Most frequently injured solid organ in penetrating trauma
Most frequently injured solid organ in blunt trauma
Injuries associated with seat-belt sign (2)
Perforation of bladder or bowel
Lumbar distraction (Chance) fracture
Cullen’s sign
Periumbilical ecchymosis, indicating intraperitoneal hemorrhage
Grey-Turner’s sign
Flank ecchymoses, indicating retroperitoneal hemorrhage
Kehr’s sign
Left shoulder or neck pain associated with splenic rupture. Increases when patient is in Trendelenburg and with LUQ palpation.
Diaphragmatic injury on CXR (4)
Blurring of diaphragm
Bowel gas patterns above diaphragm
NGT in in left chest
Criteria for positive DPL (6)
>10ml gross blood on initial aspiration
>100,000 RBCs
>500 WBCs
Gram stain with bacteria or vegetable matter
Amylase >20IU/L
Contraindications to DPL (5)
Clear indication for laparotomy
Previous abdominal surgeries
Morbid obesity
Gravid uterus
Most sensitive test for retroperitoneal injury in trauma
CT scan
Laparoscopy in trauma patient: advantages (2), disadvantages (2)
Advantages: good for evaluating diaphragm + may halp reduce negative laparotomy rate
Disadvantages: may miss hollow organ injuries + doesn’t assess retroperitoneal injuries
Indications for laparotomy in trauma patient (12)
Abdominal trauma + hemodynamic instability
Bleeding from stomach
Peritoneal irritation
Suspected or known diaphragmatic injury
Free intraperitoneal or retroperitoneal air
Intraperitoneal bladder rupture seen on cystography
Positive DPL
Surgically correctable injury seen on CT
Removal of impaled weapon
Rectal perforation seen on sigmoidoscopy
Transabdominal bullet path
When do you use PO contrast for CT of a trauma patient?
To assess location & integrity of upper GI tract
When do you use no contrast for CT of a trauma patient?
To look for intraparenchymal hematomas
When do you use IV contrast for CT of a trauma patient?
To look for organ or vascular injury
Diaphragmatic injury: manifestations (7), diagnosis (4), treatment
Manifestations: CP, respiratory distress, decreased breath sounds, rib fractures, flail chest, hemo/pneumothorax, abd pain / tenderness
Diagnosis: CXR (elevated diaphragm, irregular diaphragmatic countour, pleural fluid, viscera in chest), upper GI series, U/S, CT
Treatment: surgery
Look for diaphragmatic trauma in patients with the following injuries (5)
Head trauma
Rib & pelvic fractures
Thoracic aorta injury
Intra-abdominal injury
Diagnosis of liver injury in trauma patient
CT scan: detect blood & solid organ damage; do NOT use in unstable patient
Ultrasound: FAST + serial exams
Diagnostic laparoscopy
When can you not operate on a patient with blunt trauma to liver (5)?
Patient is stable or stabilizes after fluid resuscitation
No peritoneal signs
Injury can be precisely delineated and graded by CT
No associated injuries needing laparotomy
No need for excessive hepatic-related blood transfusions
Complications of operative management of liver laceration in trauma patient (5) and next steps for each
Hemorrhage: angiogram if stable, OR if unstable
Hemobilia (upper GI bleed, RUQ pain, fecal occult blood, jaundice): angioembolization
Hyperpyrexia: resolves in 3-5d
Biliary fistula: closes spontaneously
Most common reason for splenectomy
Blunt trauma
Causes of splenic rupture
Left-sided rib fractures (esp. 10th)
Spontaneous rupture (esp. mononucleosis)
Manifestations of spleen injury in trauma patient (4)
Peritoneal irritation
Kehr’s sign
Left-sided lower rib fracture
External signs of injury
Diagnosis of spleen injury in trauma patient (3)
CT scan: defines injury precisely
Angiogram: can use therapeutically in stable patients (embolization of CT-identified injury)
Indications for nonoperative management of spleen injury
No evidence of injury to other intra-abd organs
No coagulopathy
No impairment to physical exam (e.g. head injury)
Injury grade I or II
Indications for operative management of spleen injury (3)
Signs & symptoms of ongoing hemorrhage
Failure of non-op management
Injury grade III or higher
Indications for splenectomy in trauma patient (5)
Spleen is source of exsanguination
Pulverized spleen
Associated life-threatening injuries
Contraindications to prolonged surgery (hypothermia, severe coagulopathy)
Imaging for bowel injury in trauma patient (3)
FAST: look for free fluid
AXR: look for free air
CT scan: high false-negative rate
Duodenal injury in trauma patient: diagnosis & treatment
Diagnosis: upper GI series with water-soluble contrast
Treatment: primary repair +/- omental patch and/or gastric diversion
Signs and symptoms of large bowel injury (3)
Abdominal distention & tenderness
Peritoneal irritation
Guaiac-positive stool
Large bowel injury in trauma patient: diagnosis (3) & treatment
Diagnosis: CXR shows free air; CT may not show injury; contrast enema in pt with injury but no peritoneal signs
Treatment: primary repair for small/medium perforations; no anastomosis in setting of massive hemorrhage
Rectal injury in trauma patient: diagnosis (3) & treatment
Diagnosis: DRE (blood, palpation of foreign body); rigid proctoscopy; x-ray (bullet, foreign body)
Treatment: loop colostomy +/- distal limb closure; or end colostomy + mucus fistula
Pancreatic injury in trauma patient: diagnosis (3) & treatment (3)
Diagnosis: amylase, CT, ERCP (if pt is stable)
Treatment: external drainage if no ductal injury; distal pancreatectomy + duct ligation if distal transection with ductal injury; Whipple or total pancreatectomy if duodenum or pancreatic head is devitalized
In what trauma patients should you suspect GU trauma (4)?
Straddle injury
Penetrating injury to lower abdomen
Fall from height
Hematuria on Foley insertion
Manifestations of GU injury in trauma patient (6)
Flank or groin pain
Blood at urethral meatus
Ecchymoses on perineum and/or genitalia
Evidence of pelvic fracture
Rectal bleeding
High-riding prostate
Evaluation of GU injury in trauma patient (2)
KUB film
Retrograde urethrogram (suspected urethral injury)
Retrograde cystogram (pelvic fracture, gross hematuria)
IV pyelogram (suspected renal injury)
CT scan (suspected renal injury)
Intraperitoneal bladder rupture: when does it occur and what is the treatment?
Occurs after blunt trauma to a full bladder
Surgical repair
Extraperitoneal bladder rupture: when does it occur and what is the treatment?
Occurs after pelvic fracture
Nonsurgical management with Foley catheter
Diagnostic imaging for renal contusion
IVP: normal
CT scan: edema or micro-extravasation of contrast into renal parenchyma
Shattered kidney: definition, treatment
Definition: complete separation of renal parenchyma from collecting system, usually leading to uncontrolled hemorrhage
Treatment: surgery
How is child’s airway different from adult’s?
Narrows portion is at level of cricoid, rather than glottic opening
Who CANNOT be an organ donor (4)?
Age >70 (flexible)
Active sepsis
History of cancer except for primary brain tumor or basal cell carcinoma
History of transmissible disease
What organs can still be donated in people who don’t qualify as organ donation (4)?
Heart valve
Tissue typing in transplant surgery
Determingation of MHC alleles in an individual to minimize differences in histocompatibility. Alleles A, B & DR are used.
Crossmatch in transplant surgery
Test for preformed cytotoxic antibody in serum of potential recipient. Donor lymphocytes are cultures with recipient serum and complement.
In what kind of transplant should you NOT crossmatch?
Liver — it may worsen graft survival
Steroids used in transplant patients: drugs (2), use (2), side effects (7), chronic effects (3)
Drugs: mainly prednisone & methylprednisolone
Use: maintenance therapy to prevent rejection; treats rejection at higher doses
Side effects: impaired glucose tolerance, impaired wound healing, fluid retention, insomnia, depression, nervousness, psychosis
Chronic effects: Cushing syndrome, PUD, osteoporosis
Cyclosporine: MOA, use, side effects (9), drug-drug interaction
MOA: calcineurin inhibitor (prevents T-cell activation)
Use: maintenance immunosuppression in transplant pts
Side effects: nephrotoxicity, hepatotoxicity, HUS, HTN, paresthesias, confusion, seizures, hypertrichosis, gingival hyperplasia
Drug-drug interactions: p450 metabolism!
Mycophenolate mofetil: MOA, use (2), side effects (2)
MOA: non-competitive reversible inhibitor of inosine monophosphate dehydrogenase –> blocks purine metabolism and proliferation of T & B cells
Use: maintenance therapy or treatment of rejection in transplant pts
Side effects: mild diarrhea, nausea
Azathioprine: MOA, use, side effects (2)
MOA: alkylates DNA precursors –> inhibits DNA synthesis
Use: maintenance therapy in transplant pts
Side effects: leukopenia, hepatotoxicity
Tacrolimus: MOA, use, side effects (8)
MOA: calcineurin inhibitor (prevents T-cell activation), 100x more potent than cyclosporine
Use: 1st-line for maintenance immunosuppression in transplant pts
Side effects: nephrotoxicity, hepatotoxicity, HUS, HTN, paresthesias, confusion, seizures, lymphoproliferative disorders
Antithymocyte globulin: MOA, use (3), side effects (4), cautions (3)
MOA: polyclonal antihuman gamma globuline extracted from horse serum
Use: treatment of steroid-resistant transplant rejection; may be used for transplant induction therapy
Side effects: fever/chills, thrombocytopenia, leukocytopenia, rash
Cautions: administer via central line or dialysis catheter + monitor WBC during tx + ask about horse serum allergy
OKT3: MOA, use (2), side effects (3), caution
MOA: monoclonal antibody to CD3 (signal transducer on T cell) that prevents antigen binding & downregulates T-cell receptor
Use: rescue agent for steroid-resistant transplant rejection; transplant induction
Side effects: hypotension, pulmonary edema, cardiac depression
Caution: MUST pre-treat with steroids
Rapamycin: MOA, use, side effects
MOA: inhibits binding to calcineurin complex –> prevents T cell proliferation
Use: synergistically with cyclosporine & steroids
Side effects: hypertriglyceridemia
Hyperacute transplant rejection: cause, timing, mechanism, prevention, treatment
Cause: presensitization of recipient to donor antigen (e.g. from prior pregnancy, transfusion, transplant)
Timing: immediately after graft reperfusion
Mechanism: antibody binds donor tissue –> complement-mediated lysis –> thrombosis of graft
Prevention: ABO typing + negative crossmatch
Treatment: none
Delayed vascular transplant rejection
Transplant rejection that is mediated by humoral immunity, when levels of preformed antibodies are too low to be detected by usual assays, Graft function deteriorates on post-op day 3.
Acute transplant rejection: cause, timing, diagnosis (2), prevention (3), treatment (2)
Cause: normal T-cell activity
Timing: post-op day 5 to post-op month 6
Diagnosis: decreased graft function + biopsy (lymphocytic infiltrate, graft necrosis)
Prevention: minimize MHC mismatch + immunosuppression + monitor for organ dysfunction
Treatment: high-dose steroids; OKT3 or antithymocyte globulin if steroid-resistant
Chronic transplant rejection: cause, timing, diagnosis, prevention, treatment
Cause: cumulative effect of recognition of MHC by recipient immune system
Timing: insidious onset over months to years
Diagnosis: biopsy shows parenchymal replacement with fibrous tissue, lymphocytic infiltrate, endothelial destruction
Prevention: none known
Treatment: none
Principles of organ preservation (4)
Maintain donor’s hemodynamic state
Minimize warm ischemia
Rapid cooling of organ & maintenance at 4 degrees C
Flush blood out of organ at 60-100mmHg
What methods exist to preserve organs for transplant (3)?
Continuous perfusion: fluid pumped continuously through organ, delivering O2 & substrates, allowing continuation of metabolism
Pulsatile perfusion: allows pharmacologic manipulation of perfusate during storage
Top 7 causes of end-stage renal disease in adults
1. diabetes
2. htn
3. glomerular nephritis
4. congenital anomalies
5. urologic anomalies
6. dysplasia
7. focal segmental glomerular sclerosis
Top 7 causes of end-stage renal disease in children
1. congenital urologic anomalies
2. other congenital renal anomalies
3. focal segmental glomerular sclerosis
4. congenital renal dysplasia
5. glomerular nephritis
6. diabetes
7. htn
Who CANNOT be a living kidney donor (7)?
Renal disease
Age >65y/o (flexible)
GU anomalies: proteinuria >250mg/24hr, Cr clearance <80ml/mn, CT findings
Contraindications to kidney transplant: absolute (5) & relative (4)
Absolute: cancer (except SCC / BCC of skin), HIV, TB, active cirrhosis, ongoing drug use
Relative: obesity, likely non-compliance, severe ischemic heart disease w/o possibility of CABG or angioplasty, sickle cell disease
Which donor kidney is preferred in kidney transplant?
Left — renal vein is longer
To which side is kidney preferentially transplanted?
Right — iliac artery and vein are more superficial
Early complications of kidney transplant (5) & their treatments
Delayed graft function: oliguria/anuria with adequate blood flow & no urine leak or obstruction at UVJ on ultrasound –> post-op dialysis
Graft thrombosis: abrupt cessation of urine output –> immediate re-op to save transplant
Urine leak: decreased urine output with lower abd pain, scrotal/labial edema & rising creatinine –> repair
Bleeding: hypotension, graft tenderness, swelling –> may need re-op if bleeding is significant
Wound infection
Diagnosis & treatment of late complications of kidney transplantation (6)
Lymphocele (perinephric fluid collection): swellingn over transplant + unilateral leg edema from compression of iliac vein + increased Cr (ureter is compressed) –> U/S with aspiration and/or Doppler venous U/S of iliac veins –> observe or drain
Ureteral stricture: distal stricture due to rejection or ischemia, rising creatinine, hydronephrosis on U/S –> antegrade pyelogram –> balloon dilatation or surgical repair
Renal artery stenosis: HTN & fluid retention –> angiogram, U/S, MRA –> angioplasty or surgical repair
Wound infection
Who CANNOT get a pancreas transplant (6)?
Significant coronary artery disease
Severe peripheral vascular disease resulting in amputations
Severe visual impairment
Untreated malignancy
Active infection
Indication for pancreas transplant
IDDM + age <45y/o
Immunosuppression regimen for pancreas transplant
Option 1: antithymocyte globulin
Option 2: OKT3/mycophenelate mofetil + cyclosporine
Option 3: tacrolimus + steroids
Acute pancreas transplant rejection: signs, diagnosis, treatment, outcome
Signs: early decrease in exocrine function (urine amylase declines >25%)
Diagnosis: biopsy
Treatment: high-dose steroids for 2 days –> if no response, OKT3 or antithymocyte globulin
Outcome: 90% resolve
Complications of pancreas transplant (7)
Gross hematuria
Urinary leak
Peripancreatic fluid collections on CT & U/S: drain if suspect infection
Metabolic acidosis: due to excessive loss of bicarb in urine
Chronic indications for liver transplant (11)
Primary & secondary biliary cirrhosis
Primary sclerosing cholangitis
Metabolic defects: alpha-1-antitrypsin deficiency, amyloidosis, hemochromatosis, OTC deficiency, sarcoidosis
Malignancy: HCC or cholangiocarcinoma
Biliary atresia
Polycystic liver disease
Histiocytosis X
Acute indications for liver transplant (3)
Viral or alcoholic hepatitis
Wilson’s disease
Hepatotoxic drugs (e.g. acetaminophen OD)
Contraindications to liver transplant (6)
Multisystem organ failure
Severe cardiopulmonary disease
Sepsis secondary to nonhepatic source
Widespread cancer
Noncompliance with medical thearpy
Severely impaired neurologic status
Post-op management of liver transplant (3)
Avoid vasoconstrictors (reduce blood flow to liver)
Diuretics to mobilize fluid
Tacrolimus immunosuppression
Acute liver transplant rejection: timing, incidence, diagnosis (2), treatment
Timing: first 3 months
Incidence: 50%
Diagnosis: elevated LFTs & GGT + eosinophilic infiltrate on biopsy
Treatment: steroids or antilymphocyte therapy
Causes of liver transplant failure (3)
Primary non-function
Recurrence of disease
Biliary or vascular complications
NOT rejection
Indications for small bowel transplant: adults (3), children (5)
Adults: short gut due to Crohn’s, mesenteric thrombosis, trauma
Children: short gut due to NEC, intestinal pseudo-obstruction, gastroschisis, volvulus, intestinal atresia
Small bowel transplant rejection: manifestations (6), diagnosis, treatment
Manifestations: fever, abd pain, elevated WBC, ileus, GI bleed, positive blood cultures
Diagnosis: biopsy shows cryptitis, villi shortening, mononuclear infiltrate
Treatment: tacrolimus; more difficult than other organs
Complications of small bowel transplant
GVHD: prevent with immunosuppression and/or pretreatment of donor
Indications for heart transplant (3)
Severe cardiac disability on max medical therapy
Symptomatic ischemia or recurrent ventricular arrhythmias with LVEF <30% or unstable angina
All surgical alternatives excluded
Contraindications to heart transplant (5)
Irreversible severe pulmonary, renal, hepatic dysfunction
Unstaged or incompletely staged cancer
Psychiatric disease
Severe systemic disease
Age >60y/o (varies)
Post-op management of cardiac transplant patient (5)
Immunosuppression with cyclosporine + azathioprine + prednisone
Monitor pulmonary HTN with Swan-Ganz
Treat transient sinus node dysfunction with temporary pacing + afterload reduction + renal dose dopamine
Expect normal cardiac function by post-op day 3-4
Remove atrial pacers post-op day 7-10
Complications of heart transplant (5)
Acute rejection: treat with pulse steroids, antithymocyte globulin, or OKT3
Chronic rejection: causes diffuse atherosclerosis; treat discrete proximal lesions with PTCA & CABG
Cancer: due to immunosuppression
B-cell lymphoproliferative disorder: associated with EBV; treat with reduced immunosuppression + antiviral therapy
Indications for single lung transplant (5)
Pulmonary fibrosis
Bronchopulmonary dysplasia
Primary pulmonary HTN (w/o cardiac dysfunction)
Post-transplant obliterative bronchiolitis
Indications for bilateral lung transplant (3)
Contraindications to lung transplant (6)
Old age
Significant systemic disease (e.g. hepatic or renal dz)
Active infection
Psychiatric illness or non-compliance
Current smoking
Complications of lung transplant (3)
Acute rejection: fever, dyspnea, decreased PaO2, decreased FEV1, interstitial infiltrate on CXR, lymphocytic infiltrate on bronchoscopic biopsy
Chronic rejection: presents as obliterative bronchiolitis; no treatment
Wrist bones
Zone I of the hand: where is it and when should you repair an injury?
From middle of middle phalanx of fingers & DIP joint of thumb to end of digit
Repair within 1-3 weeks
Zone II of the hand: where is it and when should you repair an injury?
From distal palmar crease to beginning of Zone I
Repair within 1-3 weeks
Zone III of the hand: where is it and when should you repair an injury?
From beginning of palm to distal palmar crease
Repair immediately
Zone IV of the hand: where is it and when should you repair an injury?
Spans carpal tunnel
Repair immediately; technically difficult, because tendons lie within the carpal tunnel
Zone V of the hand: where is it and when should you repair an injury?
Wrist up to beginning of carpal tunnel
Repair immediately; easy to fix, but functional outcome is often poor due to associated nerve injury
Felon: definition, etiology, complications (3), treatment (3)
Definition: infection of pulp space of any of the distal phalanges of the hand
Etiology: minor trauma to dermis over finger pad
Complications: increased pressure within septal compartments may cause cellulitis, flexor tendon sheath infection, or osteomyelitis
Treatment: digital block + I&D + abx
Paronychia: definition, etiology, treatment (4)
Definition: infection of lateral nail fold of the finger/thumb
Etiology: minor trauma, such as nail biting or manicure
Treatment: warm soaks + retraction of skin edges from nail margin + abx +/- I&D if infection is more extensive
Tenosynovitis: definition, etiology, organisms (3), treatment (3)
Definition: infection of flexor tendon & sheath of finger that spreads along tendon sheath and may involve other digits or entire hand
Etiology: penetrating trauma or dirty wounds
Organisms: polymicrobial, Staph, N. gonorrhoeae
Treatment: immobilize & elevate hand + abx + hand consult
Gamekeeper’s thumb: definition, etiology, main symptom, treatment (3)
Definition: avulsion of ulnar collateral ligament of thumb MCP joint, associated with avulsion fracture of metacarpal base
Etiology: forced abduction of thumb (ski pole injury)
Main symptom: inability to pinch
Treatment: RICE, thumb spica cast for 3-6wks if partial tear, surgical repair if complete tear
Signs of tenosynovitis: STEP
Symmetrical swelling of finger
Tenderness over flexor tendon sheath
Extension (passive) of digit is painful
Posture of digit at rest is flexed
Carpal tunnel syndrome: etiology (6), manifestations (3), diagnosis (3), treatment (4)
Etiology: tumor (fibroma, lipoma), ganglion cyst, tenosynovitis of flexor tendons, edema (pregnancy, hypothyroid, amyloidosis), trauma, gout
Manifestations: pain, paresthesias, sensory deficits in distribution of median nerve + worse with activity + thenar atrophy
Diagnosis: Tinel’s test, Phalen’s test, pain with 1mn of max palmar flexion
Treatment: rest + splint + NSAIDs +/- surgery (crippling pain, thenar atrophy, failure of medical management)
Ganglion cyst: definition, etiology, manifestations (3), diagnosis, treatment (4)
Definition: synovial cyst on radial aspect of wrist
Etiology: idiopathic
Manifestations: size increases with use of wrist +/- pain +/- compression of median or ulnar nerve
Diagnosis: x-ray to rule out bone tumor, arthritis, intraosseus ganglion
Treatment: reassurance; wrist immobilization for moderate pain; aspiration for severe pain; excision for median nerve compression or large size
Mallet finger: definition, etiology, main symptom, treatment (2)
Definition: rupture of extensor tendon at insertion into base of distal phalanx
Etiology: avulsion fracture of distal phalanx
Main symptom: inability to extend DIP joint
Treatment: splint finger in extension for 6-8wks; surgery for large avulsions or injuries not splinted early enough
Trigger finger: definition, risk factors (3), main symptom, treatment (3)
Definition: stenosis of flexor digitorum tendon sheath, leading to formation of nodule within sheath
Risk factors: rheumatoid arthritis, middle-aged women, congenital
Main symptom: snapping or clicking sensation when flexing & extending the digit
Treatment: inject corticosteroid into tendon sheath + splint MP joint in extension; surgery if this fails
High-pressure injection injury to finger: manifestations, diagnosis, treatment
Manifestations: seemingly innocuous puncture wound; edema & minimal pain –> severe pain, discoloration, swelling — > intense tissue necrosis within 24hrs
Diagnosis: x-ray shows path of injectate
Treatment: IV abx + I&D + physical therapy +/- amputation
Boxer’s fracture: definition & treatment
Definition: fracture of neck of 5th metacarpal, sustained in closed fist injury
Treatment: thumb spica case for 3-6wks if partial tear; surgery if rotational deformity
Bennet fracture: definition & treatment
Definition: fracture-dislocation of base of thumb
Treatment: immobilization in thumb spica cast, then surgical fixation
Rolando fracture: definition & treatment
Definition: comminuted fracture of base of thumb
Treatment: immobilization in thumb spica cast, then surgical fixation
Scaphoid fracture: cause, main symptom, diagnosis, treatment
Cause: fall on outstretched hand
Main symptom: snuffbox tenderness
Diagnosis: may take 2wks to be seen on x-ray
Treatment: immobilization in thumb spica case for 12wks
Colles’ fracture: definition, cause, main sign, treatment
Definition: distal radius fracture with dorsal angulation
Cause: fall on outstretched hand
Main sign: dinner fork deformtiy
Treatment: short arm cast with volar (ventral) flexion & ulnar deviation for 4-6wks; surgery if open, comminuted, or intra-articular displaced fracture
Smith fracture: definition, cause, treatment
Definition: distal radius fracture with distal fragment displaced ventrally (volar angulation)
Cause: direct trauma to dorsal forearm or fall on flexed hand
Treatment: surgical repair
Galeazzi fracture: definition, cause, treatment
Definition: distal 1/3 radial fracture + dislocation of distal radioulnar joint
Cause: direct blow to back of wrist, or fall on outstretched hand with forearm in forced pronation
Treatment: surgical repair
Monteggia fracture: definition, cause, sign, treatment
Definition: proximal 1/3 ulnar fracture + dislocation or radial head
Cause: direct blow to posterior ulna, or fall on outstretched hand with forearm in forced pronation
Sign: radial nerve injury
Treatment: surgical repair (adults) or closed reduction (children)
Nightstick fracture: definition & treatment
Definition: isolated fracture of ulnar shaft
Treatment: long arm cast for 3-6wks or surgical repair if angulation or displacement >50%
Communicating hydrocephalus
Defect in absorption at arachnoid granulations.
All ventricles affected.
Noncommunicating (obstructing) hydrocephalus
Block in CSF flow proximal to arachnoid granulations (e.g. aqueductal stenosis)
May not affect all ventricles
Hydrocephalus ex vacuo
Atrophic parenchymal tissue loss results in dilated ventricles
Macewen’s sign
Tapping on head of a hydrocephalic infant produces a cracked pot sound
Causes of hydrocephalus
Infection / inflammation
Obstructing mass
Post-op, esp. in pediatric posterior fossa procedures
Manifestations of hydrocephalus (6)
Nausea / vomiting
Abducens palsy
Parinaud syndrome
Bulging anterior fontanelle in infants
Treatment of hydrocephalus (3)
Acetazolamide to reduce CSF production
Furosemide to promote diuresis
VP shunt
Complications of VP shunt (7)
Patient growth (may need to be replaced)
Undershunting (due to kinking or disconnection)
Overshunting (HA similar to post-LP)
Subdural hematoma
Slit ventricle syndrome (decrease in ventricular compliance)
Post-op radiographic evaluation of VP shunts
Shunt series: x-rays to assess location of catheter
Shunt-o-gram: inject radioisotope into shunt to confirm proximal catheter patency and distal flow
Evaluation of suspected carotid artery stenosis (4)
Duplex doppler ultrasound: detects increased flow in stenotic lesions, but not reliable in very high-grade stenoses
MR angiogram: detects functional flow and assesses plaque thickness & intracranial vasculature
Carotid angiogram: gold standard, but can’t assess plaque thickness
Ocular pneumoplethysmography: measures orbital pressure, as surrogate of ophthalmic artery pressure
Treatment of carotid artery stenosis: medical (4) & surgical (2)
Medical: aspirin, dipyridamole, clopidogrel, control risk factors (HTN, DM, smoking)
Surgical: CEA (symptomatic >50% or asymptomatic >80%) or carotid stenting
Complications of CEA for carotid artery stenosis (5)
Hoarseness (recurrent laryngeal nerve)
Horner syndrome
Partial tongue paresis (hypoglossal nerve)
Hematoma causing airway compromise
Cerebral hyperperfusion syndrome (self-limited unilateral headache due to poor autoregulation that may cause seizures)
Carotid dissection: definition, causes (4), presentation (3), angiogram findings (3), treatment (3)
Definition: tear in media layer of carotid artery
Causes: trauma, connective tissue disease, iatrogenic (angiogram), vasculitis
Presentation: HA, ipsilateral Horner syndrome, symptoms of SAH or stroke
Angiogram: vessel ‘beaking’, string & pearl sign, double-lumen sign
Treatment: anticoagulation if dissection is extradural; endovascular stenting or surgical bypass of ECA to ICA if dissection is intradural
Central (transtentorial) herniation: definition, signs (7)
Definition: diencephalon is forced through tentorial incisure
Signs: early decrease in consciousness, cortical blindness (occlusion of PCA), Parinaud syndrome –> Cheyne-Stokes respirations –> decerebrate rigitidy + flaccid paralysis + apnea
Uncal herniation: definition, signs (3)
Definition: lesion in middle fossa or temporal lobe forces uncus over edge of tentorial incisure
Signs: CNIII palsy, contralateral weakness, late decrease in consciousness
Cingulate (subfalcine) herniation: definition, signs
Definition: cingulat gyrus is forced beneath falx cerebri
Signs: often clinically occult
Cerebellar herniation: definition, signs
Definition: posterior fossa mass forces cerebellum upwards, possibly compressing the brainstem
Signs: ataxia, due to occluded superior cerebellar arteries
Tonsillar herniation: definition, signs (3)
Definition: supra- or infratentorial lesion forces hindbrain through foramen magnum
Signs: early-onset apnea, normal level of consciousness, rapid death
Presentation of posterior fossa mass (7)
Nausea / vomiting
Parinaud syndrome
CN paresis
Rotary or vertical nystagmus
Presentation of supratentorial mass (7)
Nausea / vomiting
Parinaud syndrome
Motor weakness
Tumor TIA (due to hemorrhage or vascular compression)
Role of dexamethasone in CNS tumors
May halt or reverse neurologic deterioration caused by vasogenic edema
Low-grade astrocytoma: location (2), presentation (2), MRI (3), treatment
Location: cerebral hemispheres or cerebellum
Presentation: often diagnosed after a seizure, children
MRI: hypointense on T1, hyperintense on T2, non-enhancing
Treatment: observe if asymptomatic; surgery +/- radiation +/- chemo if symptomatic
Malignant glioma: types (2), natural history (2), MRI (6), treatment (3)
Types: anaplastic astrocytoma, glioblastoma multiforme
Natural history: rapidly progressive, elderly
MRI: low T1 signal, high T2 signal, ring-enhancing with surrounding edema, highly vascular, rarely calcific, necrotic core (glioblastoma)
Treatment: palliative excision + chemo + radiation
Meningioma: location (5), natural history (3), MRI (6), treatment (3)
Location: superior convexities, sphenoid wing, orbital rim, cerebellar tentorium, intraventricular
Natural history: slow growth, rarely invasive, many discovered incidentally
MRI: isointense on T1, hyperintense on T2, homogenous enhancement, dural tail, calcifications, hyperostosis of adjacent bone
Treatment: observe if asymptomatic, resect if symptomatic, external beam radiotherapy if unresectable
Pituitary adenoma: manifestations (5), MRI (4), treatment (4)
Manifestations: pituitary apoplexy (emergency), bitemporal hemianopsia, compression of cranial nerves in cavernous sinuses, endocrine abnormalities, slow growth
MRI: low T1 signal, high T2 signal, non-enhancing (rest of pituitary enhances), microadenoma may be too small to see
Treatment: observe if asymptomatic; bromocriptine if prolactinoma; octreotide if acromegaly or TSH adenoma; surgery if Cushing’s disease or no response to medical therapy
Acoustic neuroma: manifestations (5), MRI (2), treatment (3)
Manifestations: unilateral progressive sensorineural hearing loss, tinnitus, disequilibrium, vertigo, slow growth
MRI: homogenously enhancing, protrudes into porous acousticus
Treatment: pretreatment audiometric & vestibular testing + surgical excision or stereotactic radiosurgery + conventional radiotherapy
Ependymoma: location (3), natural history (3), MRI (5), treatment (2)
Location: 4th ventricle (most common), spinal cord, lateral ventricles
Natural history: posterior fossa mass, disseminates through CSF (‘seeding’), children
MRI: non-homogenous T1 signal, high T2 signal, moderate enhancement, cystic components, arises from floor of 4th ventricle
Treatment: surgical resection or radiation (if in 4th ventricle or spinal cord)
Oligodendroglioma: location, natural history (3), MRI (4), treatment (2)
Location: frontal lobes
Natural history: usually presents with seizure; slow progression; middle-aged adults
MRI: hypointense on T1, hyperintense on T2, low-grade forms are non-enhancing, extensive calcifications
Treatment: observe if asymptomatic; surgery + radiation if symptomatic or >5cm
Craniopharyngioma: location (2), natural history (3), MRI (4), treatment (2)
Location: anterior superior pituitary margin or 3rd ventricle
Natural history: HA, visual disturbance, children
MRI: hypointense on T1, hyperintense on T2, cystic regions, strong heterogeneous enhancement
Treatment: observation or surgical resection if symptomatic
Hemangioblastoma: epidemiology (2), location (2), natural history (3), MRI (3), angiogram, treatment (2)
Epidemiology: middle adulthood; associated with Von Hippel-Lindau
Location: posterior fossa, spinal cord
Natural history: benign, posterior fossa symptoms, rarely hemorrhage
MRI: serpiginous flow voids, surrounding hemosiderin deposition, intense enhancement
Angiogram: marked vascularity
Treatment: surgery or radiation if unresectable
Von Hippel-Lindau
Autosomal dominant neurocutaneous disorder
Multiple hemangioblastomas, retinal angioma, pheochromocytoma, and renal cell carcinoma
Pineal tumor: location (2), presentation (3), treatment (3)
Location: pineal region or 3rd ventricle
Presentation: hydrocephalus, Parinaud syndrome, more common in children
Treatment: measure serum AFP & beta-HCG; observe or test dose of radiation to determine responsiveness; surgery if well-encapsulated & symptomatic, no metastases, no response to radiation
Parinaud syndrome: symptoms (3), associated disorders (4)
Symptoms: paralysis of upgaze, eyelid retraction, conjugate down gaze (setting-sun sign)
Associated disorders: pineal tumor, MS, midbrain stroke, obstructive hydrocephalus
CNS lymphoma: associated diseases (4), natural history (4), MRI (3), treatment (2)
Associated diseases: AIDS, connective tissue diseases, chronic immunosuppression, EBV
Natural history: CN palsies, seizures, spinal cord compression, rapid progression
MRI: strongly homogenously enhancing, wispy appearance, vanishes after dose of steroids (but will come back)
Treatment: radiation + chemo (methotrexate, cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone)
Ganglioglioma: presentation, MRI (2), treatment (3)
Presentation: seizure in child or young adult
MRI: high T1 signal, low T2 signal
Treatment: observe if asymptomatic, surgical resection if symptomatic, radiation if recurrence
CNS epidermoid & dermoid tumors: natural history (2), imaging (2), treatment
Natural history: proliferates like normal epithelium; rupture may cause chemical meningitis
Imaging: similar to CSF on MRI; lucent with occasional calcification on CT
Treatment: surgical excision if symptomatic
Primitive neuroectodermal tumors (PNET): epidemiology, location, natural history (3), MRI (5), treatment (3)
Epidemiology: most common malignant pediatric brain tumor
Location: cerebellar vermis
Natural history: early obstructive hydrocephalus, disseminates through CSF (‘seeding’), metastasizes early
MRI: low non-homogenous T1 signal, variable T2 signal, variable contrast enhancement, cystic, arises from roof of 4th ventricle
Treatment: pre-op imaging of spinal neuraxis to detect CSF seeding + surgical resection + post-op radiation
Choroid plexus papilloma: location (2), natural history (4), MRI (3), treatment
Location: 4th ventricle or lateral ventricles
Natural history: infants, may grow rapidly, overproduction of CSF, hydrocephalus
MRI: isointense on T1 & T2, intensely enhancing, deformed ventricles
Treatment: surgical resection
Glomus tumor: definition, presentation (3), MRI (2), treatment (2)
Definition: benign tumor arising from paraganglion cell, i.e. carotid body tumor, glomus jugulare tumor, pheochromocytoma
Presentation: slow growth, may have pulsatile tinnitus, may have CN VIII-XII palsies
MRI: homogenously enhancing, looks like neuroma
Treatment: surgical excision (if small) or radiation therapy (if large)
Chordoma: definition, natural history (3), CT (3), treatment (2)
Definition: low-grade malignant neoplasm of notochord in clivus or sacrum
Natural history: slow growth, osseodestructive, locally invasive
CT: osseolytic, calcified, ‘ivory vertebra’
Treatment: wide en bloc excision (avoid tumor to prevent dissemination) + post-op radiation or proton beam therapy
Common sources of metastatic brain tumors (5)
Bronchogenic lung cancer
Breast cancer
Renal cell carcinoma
Colon adenocarcinoma
Metastatic brain tumors most likely to hemorrhage (3)
Renal cell carcinoma
Location of most metastatic brain tumors (2)
Gray-white junction in cerebral hemispheres
MRI of metastatic brain tumor (3)
Greater surrounding edema than primary tumors
Complete or ring enhancement
Radiosensitive metastatic brain tumors (4)
Small cell lung carcinoma
Multiple myeloma
Germ-cell tumors
Management of suspected metastatic brain tumor (5)
Search for primary source: CXR, pan-CT, bone scan, mammogram, guaiac for occult blood
Biopsy for diagnosis if no other source identified
Resection + post-op radiation if solitary symptomatic lesion or just radiation if multiple lesions
Dexamethasone to reduce vasogenic edema
Anticonvulsants for seizures
Clinical triad of tuberous sclerosis
Mental retardation
Adenoma sebaceum (angiofibromas on face)
Tuberous sclerosis: clinical findings (6)
Mental retardation
Adenoma sebaceum (angiofibromas on face)
Subependymal calcific tubers (hamartomas)
Ash leaf spots on skin
Giant cell astrocytoma
Sturge-Weber: genetics, clinical triad, treatment (2)
Genetics: autosomal recessive or sporadic neurocutaneous disorder
Triad: port-wine facial nevus in V1 distribution, cortical atrophy & calcification, seizures
Treatment: anticonvulsants or lobectomy if seizures are intractible
How do you differentiate between neuroma and glomus (paraganglion) tumor?
Angiogram, because neuroma is avascular and glomus tumor is highly vascular.
Degenerative changes in spine (e.g. arthritis)
Subluxation of one vertebral body on another
Spondylolysis: definition & treatment
Definition: fracture or defect in pars interarticularis
Treatment: spinal fusion if traumatic; nothing if congenital / degenerative
Most common herniated lumbar discs
Most common herniated cervical discs
Indications for surgery in back pain (6)
Cauda equina syndrome (lumbar disc)
Conus medullaris syndrome (lumbar disc)
Myelopathy (cervical or thoracic disc)
Progressive neurologic deficit
Motor weakness
Pain refractory to medical therapy & PT
C4-5 herniated disc: pain distribution, sensory pattern, motor weakness, reflex affected
Pain: shoulder
Sensory: shoulder
Motor: shoulder abduction
Reflex: deltoid
C5-6 herniated disc: pain distribution, sensory pattern, motor weakness, reflex affected
Pain: upper arm, lateral forearm, first 2 digits
Sensory: upper arm, lateral forearm, first 2 digits
Motor: forearm flexion
Reflex: biceps & brachioradialis
C6-7 herniated disc: pain distribution, sensory pattern, motor weakness, reflex affected
Pain: 2nd-4th digits
Sensory: 2nd-4th digits, all fingertips
Motor: forearm, wrist, finger extension
Reflex: triceps
C7-T1 herniated disc: pain distribution, sensory pattern, motor weakness, reflex affected
Pain: upper arm, medial forearm, last 2 digits
Sensory: upper arm, medial forearm, last 2 digits
Motor: wrist & finger flexion
Reflex: finger jerk
L3-4 herniated disc: pain distribution, sensory pattern, motor weakness, reflex affected
Pain: anterior thigh
Sensory: anterior thigh to medial malleolus
Motor: quadriceps
Reflex: patellar
L4-5 herniated disc: pain distribution, sensory pattern, motor weakness, reflex affected
Pain: posterolateral leg to great toe
Sensory: lateral thigh to dorsum of foot & great toe
Motor: tibialis anterior, extensor hallucis longus
Reflex: medial hamstring
L5-S1 herniated disc: pain distribution, sensory pattern, motor weakness, reflex affected
Pain: posterior leg, lateral & plantar aspects of foot
Sensory: posterior thigh & leg to lateral malleolus
Motor: gastrocnemius & soleus
Reflex: Achilles
Lumbar stenosis: presentation, diagnosis, treatment
Presentation: leg pain with walking/standing, relieved by changing positions, leaning, sitting
Diagnosis: MRI
Treatment: first try analgesics & PT; surgical decompression if progressive neurologic deficit or intractable pain
Cervical stenosis: presentation, diagnosis, treatment
Presentation: myelopathy, radiculopathy, diffuse head / neck / shoulder pain, slow progression
Diagnosis: MRI
Treatment: first try analgesics & PT; surgical decompression if signs of myelopathy, increased T2 signal in spinal cord, progressive neurologic deficit or intractable pain
Atlantoaxial dislocation: cause, presentation (2), diagnosis, treatment
Cause: commonly rheumatoid arthritis
Presentation: local pain, hyperreflexia
Diagnosis: lateral c-spine film to assess atlantodental interval (>4mm suggests compromise of transverse ligament)
Treatment: surgical fusion if symptomatic or atlantodental interval >6-8mm
Forestier syndrome (diffuse idiopathic skeletal hyperostosis)
Osteophytic growth along spinal column and over intervertebral discs (“bamboo spine”). Drill off bone over disc space to ‘disconnect’ vertebral bodies if patient has symptoms.
Causes of peripheral neuropathy: DANG THE RAPIST
Drugs, DM
Alcohol, AIDS
Nutrition (vitamins E & B12)
EntrapmentRadiation, renal
Paraneoplastic, porphyria, psychiatric
Toxins (heavy metals)

Erb-Duchenne palsy
Waiter’s tip
C5-6 injury
Klumpke’s palsy
Claw hand: paralysis of intrinsic hand muscles, ulnar nerve distribution numbness
C8-T1 injury
If development is progressive, think of Pancoast tumor
Meralgia paresthetica
Entrapment of lateral femoral cutaneous nerve
Associated with DM, obesity, previous surgery, tight clothes
Thoracic outlet syndrome: neurologic & vascular
Neurologic: paresthesia/pain when rotating head away from affected side and elevating arm
Vascular: pain when rotating head away from affected side and elevating arm + reduction of radial pulse
Causes of thoracic outlet syndrome (2)
Fibrous band compresses C8/T1 roots
Elongated C7 transverse process (‘cervical rib’)

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