Hi Yield Notes in Surgery PDF [PDF]

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HI-YIELD NOTES IN SURGERY [from USMLE clerkshipsurgery & Surgical Recall] SURGERY SIGNS, TRIADS, AND ETC... Important triads to remember ABCD of melanoma Achalasia triad Beck’s triad Bergman’s triad Cantrell pentalogy Carcinoid syndrome triad Carney’s triad Charcot’s triad in multiple sclerosis In cholangitis Cystitis triad Fat embolism triad Glucagonoma triad Grave’s disease triad Hand-Schuller-Christian triad Hematobilia triad Hereditary hemochromatosis triad HUS triad Hutchinsons triad of late congenital syphilis Hypersplenism triad Intususception triad Kartagener’s syndrome triad Kasabach-Merit syndrome triad Macklers triad Meig’s syndrome triad Meniere’s triad Miller-Dieker syndrome triad Multiple myeloma triad Necrotizing enterocolitis triad Pellagra [niacin, vitamin B3 - 3 D’s] Pheochromocytoma triad Plummer-Vinson syndrome triad Reiter’s syndrome triad Renal cell CA triad Reynold’s pentad Rubella syndrome triad Saint’s triad Sjogren syndrome triad Somatostatinoma tumor triad Thrombotic thrombocytopenic purpura, TTP pentad Tuberous sclerosis clinical triad Virchow triad of thrombus formation Wegener’s granulomatosis triad Wernicke triad of alcoholic encephalopathy Wilm’s tumor triad Wiskott-Aldrich triad Whipple’s triad of insulinoma



Important signs to remember



Asymmetric, border [irregular, color variation, diameter > 0.6 cm and dark black color Dysphagia, regurgitation, weight loss Hypotension, JVD, muffled heart sounds Mental status changes, petechiae, dyspnea seen in fat emboli syndrome Omphalocele, diaphragmatic hernia, cleft sternum, absent pericardium & intracardiac defects Flushing, diarrhea and R sided heart failure Gastric leiomyosarcoma, pulmonary chondromas, extraadrenal paraganglioma Scanning speech, intention tremor, nystagmus Jaundice, RUQ pain, fever/chills Urinary frequency, suprapubic pain, dysuria Confusion, dyspnea, petechiae DM, necrotizing skin erythema, anemia Hyperthyroidism, ophthalmopathy, pretibial myxedema Calvarial defects, diabetes insipidus, exopthalmos Abdominal injury, GIT bleeding, colicky pain Pigment cirrhosis w/ hepatomegaly, skin pigmentation & DM Anemia, thrombocytopenia & ARF Interstitial keratitis, notched teeth, CN 8 deafness Splenomegaly, reduced cellular blood elements w/ high BM activity, correction of blood cytopenias w/ splenectomy intermittent colicky abdominal pain, billous vvomiting, currant-jelly stool Bronchiectasis, sinusitis, situs inversus Rapidly enlarging cavernous hemangioma, DIC, hrombocytopenia Emesis, lower chest pain, cervical emphysema R –sided hydrothorax, ascites, ovarian fibroma Hearing loss, tinnitus, vertigo Seizures, MR, lissencephaly PAM [Punched-out lytic lesions, Atypical plasma cells, Monoclonal gammopathy] Feeding intolerance, abdominal distention & hematochezia Dermatitis, diarrhea, dementia Palpitations, headache, episodic diaphoresis Microcytic hypochromic anemia, atrophic glossitis, esophageal webs Conjunctivitis, polyarthritis, infection [urethritis or cervicitis] Hematuria, costovertebral pain, palpable mass Charcot’s triad + shock & mental status changes Cataracts, heart defects [PDA, PAH, VSD, TOF] Cholelithiasis, hiatal hernia and diverticular disease Xerostomia, keratoconjunctivitis sicca, CT / autoimmune dse Gallstones, DM, steatorrhea “port wine facial nevus, cortical atrophy and seizures + calcification of cortex appearing as “tram tracks” on x-ray FAT RN [Fever, Anemia, Thrombocytopenia, Renal and Neurologic dysfunction] MR, adenoma sebaceum [perivascular fibromata], seizures. Endothelial injury, stasis, blood hypercoagulability Acute necrotizing granuloma; focal necrotizing or granulomatous vasculitis; cresentic glomerulosclerosis Confusion, ataxia, ophthalmoplegia Flank mass, hematuria, HPN Pyogenic infections, thrombocytopenic purpura, eczema Hypoglycemic attacks [ 20 mmHg higher than in the arms Calf pain on forced dorsiflexion of foot in pxs w/ DVT. Pain along the inner aspect of thigh seen in an obturator hernia due to nerve compression Severe L shoulder pain in pxs w/ splenic rupture due to referred pain from diaphragmatic hernia Tapping on the head of a hydrocephalic infant produces a cracked pot sound Choking sensation aggravated by raising hand above the head [thyroid CA] Relief of pain by elevation of testicle, may be indicative of epididymitis Alternating blushing and blanching of the fingernails when gentle pressure is applied. Phrenic nerve manual compression causing neck tenderness in splenic rupture. Px may be able to walk further if there is something to lean on [found in spinal stenosis] Indirect hernial sac in pediatric px, the sac feels like a finger of a silk-glove when rolled under the examining finger. Radicular pain produced w/ downward pressure on head when neck is extended and tilted toward the affected side Carpopedal spasm following inflation of shygmomanometer cuff to above BP for several mins. RLQ pain from perforated PUD due to sucus/pus draining into the RLQ Decrease pulmonary vascular markings on CXR in pulmonary embolus



Radiologic + Histologic hallmarks & tests to remember “apple core” filling defect” on barium L-sided colon CA “Bamboo spine” in plain films Diffuse Idiopathic Skeletal Hyperostosis/Forestier synd. “beads on string appearance” bile ducts Sclerosing cholangitis “bent inner tube” or “omega sign” Sigmoid volvulus. Bird’s beak or steeple sign Achalasia [no gas bubble] Boomerang sign Hydrocephalus “calcium sign’ on CXR Thoracic aortic aneurysm Cork-screw shaped Diffuse esophageal spasm “Dance, target, donut & pseudokidney sign” Intususception “Double lumen sign” beaking, string and Carotid dissection pearl sign” on angiogram “egg-shaped heart” on CXR Transposition of great vessels “Ground glass or bubbly lytic lesion” x-ray Fibrous dyspasia “kidney-bean” sigmoid colon & cecum + Volvulus “bird’s beak” colon on x-ray “Lamellated onion-skin” on x-ray Ewing’s tumor “Lead pipe appearance” on barium IBD [ulcerative colitis] “Mushroom-like” bony prominence on x-ray Osteochondroma Neuhausser’s sign/”soap bubble sign” or Meconium ileus “ground glass appearance” in RLQ on AXR Pneumatosis intestinalis on AXR NEC “popcorn-like” lesion on x-ray Pulmonary hamartoma “Chain of lakes” on pancreatography Chronic pancreatitis AXR:“Sentinel loop sign & colon cutoff sign” Acute pancreatitis “soap-bubble” appearance Giant cell tumor “soap-bubble appearance” on x-ray Multiple myeloma. “stepladder” arrangement on upright film Paralytic ileus “String sign, shoulder & double tract sign” Pyloric stenosis “Sunburst patern” of sulfur granules Actinomycoses infection “Sun burst or sun ray pattern” on x-ray Osteosarcoma



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“thumb printing” on barium enema “tram tracks” on x-ray Allen’s test Tinel’s test



Ischemic colitis Sturge-Weber syndrome Test for patency of ulnar artery prior o placing a radial arterial line or performing an ABG. Tapping over median nerve at wrist produces pain and paresthesia



SURGICAL SYNDROMES Leriche’s synd. Claudication of buttocks, impotence, atrophy of buttocks Li-Fraumeni synd. Associated w/ breast CA and soft tissue sarcoma Red reaction synd. Syndrome of rapid vncomycin infusion resulting in skin erythema Ogilvie’s synd. Massive non-obstructive colonic dilatation Gardner’s synd. GI polyps w/sebaceous cysts, osteomas, and desmoid tumors Eagle-Barret’s Aka prune-belly syndrome, congenital inadequate abdominal musculature Fitz-Hugh-Curtis Perihepatic gonorrhea syndrome Heerfordt’s synd. Sarcoidosis w/ parotid enlargement, faial nerve paralysis, and uveitis Horner’ syndrome Miosis, ptosis, enopthalmos, decreased sweating Tietze’s syndrome Costochondritis of rib cartilage, aseptic, tx w/ NSAIDS Poland’s synd. Absence of pectoralis major and minor muscle, often associated w/ ipsilateral hand malformation Plummer-Vinson Esophageal web, IDA, dysphagia, spoon-shaped nails, atrophic oral and tongue mucosa Carcinoid synd. Bronchospasm, flushing, diarrhea, R-sided heart failure Afferent loop synd. Obstruction of afferent loop of a billroth 2 gastrojejunotomy Short gut synd. Malnutrition resulting from < 100 cm of viable small bowel Stewart-Treves Lymphangiosarcoma arising in chronic lymphedema after axillary for breast CA Blind loop synd. Bacterial overgrowth of intestine caused by stasis Frey’s synd. Flushing, pain, and diaphoresis in auriculotemporal nerve distribution [crocodile tears] Rendu-OslerSyndrome of GI tract telangiectaasia, and AVA malformations weber syndrome Ramsay-hunt synd Painful facial nerve paralysis from herpes-zoster of the ear Boerhaave’s synd. Esophageal perforation Thoracic outlet Compression of structures exiting from thoracic outlet Munchausen Self-induced illness synd. Mikulicz’s synd. Any cause of bilateral enlargement of parotid, lacrimal & submandibular glands Nelson’s synd. Functional pituitary adenoma producing excessive ACTH and mass effect producing visual disturbances, hyperpigmentation, amenorrhea, w/ elevated ACTH levels SVC syndrome Obstruction of SVC [e.g. tumor, thrombosis] Trousseau’s synd. Syndrome of DV associated w/ CA Mirrizzi’s synd. External compression of CHD by gallstone impacted in cystic duct. Budd-chiari synd. Thrombosis of hepatic veins Mendelson’s synd. Chemical pneumonitis after aspiration of gastric contents Millard-Gubler VI & VII nerve palsy, contralateral hemiplegia in pons infarct Compartment Swelling of injured extremity w/ pain, paresthesia, pallor, pulselessness, syndrome poikilothermia. DiGeorge Absence of parathyroids and thymic agenesis [chief cells] Sheehan’s Postpartum infection & necrosis of pituitary leading to hormonal failure Fitz-Hugh-Curtis Perihepatitis associated w/ chlamydial infection of cervix Felty’s syndrome Rheumatoid arthritis, splenomegaly, and leucopenia or neutropenia Lutembacher Ostium secundum defect + mitral stenosis Maffucci Multiple enchondromas associated w/ multiple hemangiomas syndrome Albright syndrome Polyostotic fibrous dysplasia w/ precocious puberty & darkly pigmented skin Sjogren’s Autoimmune exocrinopathy associated w/ rheumatoid arthritis, decreased salivary & lacrimal gland secretion & lymphoid proliferation SURGICAL ANATOMY PEARLS Artery of Adamkiewicz Responsible for anterior spinal syndrome Cantle’s line Line drawn from IVC to just left of the gallbladder fossa, it separates the R and L lobes of the liver Gerota’s fascia Fascia surrounding the kidney Ilioinguinal nerve Located on top of the spermatic cord Morrison’s pouch The hepatorenal recess, the most of the posterior cavity w/in peritoneal cavity Part of GIT w/o serosa Esophagus, middle and distal rectum Pouch of Douglas Pouch between the rectum and bladder or uterus Retroperitoneal GIT Duodenum, ascending and descending colon, and pancreas Rotter’s LN Lymph nodes in between pectoralis major and minor muscles Space of Retzius Preperitoneal space anterior to bladder Submucosa Strongest layer of the small bowel T10 Dermatome at umbilicus White lines of Toldt Lateral peritoneal reflections of the ascending and descending colon Vein of Mayo Vein that overlies the pylorus



SURGICAL OPERATIONS – MUST KNOW Billroth 1 antrectomy w/ gastroduodenostomy Bilroth 2 antrecomy w/ gastrojejunostomy Roux-en Y limb Jejunojejunostomy forming a y-shaped figure of small bowel + gastrojejunostomy Brooke’s ileostomy Standard ileostomy that is folded on itself to prude from the abdomen Bassini herniorrhaphy Repair of inguinal hernia by approximating transverses abdominis aponeurosis and conjoint tendon to poupart’s lig. McVay herniorrhaphy Repair of inguinal hernia by approximating the ransversus abdominis aponeurosis and conjoint tendon to cooper’s ligament Lichtenstein “tension-free” inguinal hernia repair using synthetic graft maternal herniorrhaphy Shouldice Repair of inguinal hernia by imbrication of the transversalis fascia, herniorrhaphy transversus abdominis, and the conjoint tendon and approximation of transverses abdominis aponeurosis and conjoint tendon to the inguinal ligament APR Abdomino-perineal resection; removal of the rectum and sigmoid colon through abdominal and perineal incisions [patient is left w/ colostomy] used for low rectal CA < 8cm from anal verge LAR Low-anterior resection; resection of low rectal tumors through an anterior abdominal incision Hartmann’s procedure Proximal colostomy, distal stapled-off-colon or rectum that is left in peritoneal cavity Mucus fistula Distal end of end of colon is brought to abdominal skin as stoma Kocher maneuver Dissection of duodenum from R sided peritoneal attachment o allow mobilization and visualization of the back of duodenum / pancreas Puestow procedure Side-to-side anastomosis of pancreas and jejunum [pancreatic duct is filleted open] Stamm gastrostomy Gastrostomy placed by open surgical incision and tacked to abdominal wall Highly-selective Transaction of vagal fibers to body of stomach w/o interruption of fibers to vagotomy pylorus LOA Lysis of adhesions [enterolysis] Nissen fundoplication 360 degrees wrap of stomach by its fundus around the distal esophagus to prevent GERD and esophageal hiatal hernia Graham patch Placement of omentum w/ stitches over a gastric duodenal perforation Heineke-Miculicz Longitudinal incision thru all layers of pylorus to make it non-functional, pyloroplasty used after truncal vagotomy Modified radical Removal of breast, nipple and axillary LN [no muscles are removed] mastectomy Lumpectomy Removal of breast mass and axillary LN, normal surrounding breast tissue is spared TURP – transurethral Femoral artery to popliteal artery bypass using synthetic graft or resection of prostate saphenous vein; used to bypass blockage in the femoral artery CABG – coronary Via saphenous vein graft or internal mammary artery bypass grafts to artery bypass grafting coronary arteries from aorta [cardiac revascularization] Hartmann’s pouch Oversewing of a rectal stump after resection of a colonic segment, px is left w/ a proximal colostomy Ileoanal pull-through Anastomosis of ileum to the anus after total proctocolectomy Whipple’s procedure Removal of GB, CBD, anthrum of stomach, duodenum, proximal jejunum and head of pancreas [en bloc]. Rastelli procedure Aorta is rerouted internally to L ventricle across VSD WOUNDS • Steps in wound healing 1. coagulation 2. inflammation 3. collagen synthesis 4. angiogenesis 5. epithelialization – usually complete by 24-48 hrs 6. contraction • risk of infection for wounds: Clean 1.5% Clean-contaminated 3% Contaminated 10% Dirty 30-35% • Classic sins of wound infection: Calor Heat Rubor Redness Tumor Swelling Dolor Pain Functio laesa Loss of function • 5 W’s in post-op fever: wound infection, wind [atelectasis], water [UTI], walking [DVT], wonder drugs



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Rapid recall Early surgical infections that occur in the 1 st 24 hrs post-op are MC due to MC source of wound infection is MC cause of poor wound healing MC cause of post-op fever w/in 1st 24 hrs



Streptococcus & clostridium Host’s normal flora Tissue hypoxia Atelectasis



FLUIDS, ELLECTROLYTES AND NUTRITION • Even w/o intake, a person must excrete 800 ml/day in urine waste products. • Third spacing is the shift of ECF from plasma compartment to elsewhere [interstitial or transcellular process] • Normal urine output: 0.5 cc/kg/hr for adults and 1 cc/kg/hr for children. • Hyponatremia = < 130 mEq/L, symptomatic when < 120 mEq/L • Hypernatremia = > 145 mEq/L • Hypokalemia = < 3.5 mEq/L [ECG – flattened T waves, ST depression, U wave] • Hyperkalemia = > 5 mEq/L [ECG – peak T waves, wide QRS, T wave disappearance w/ sine wave pattern] • Hypocalcemia = < 8 mg/dl [ECG – prolonged QT interval] • Hypercalcemia = > 15 mg/dl • Causes of elevated anion gap metabolic acidosis: MUDPILES [Methanol, Metabolism, Uremia, DKA, Paraldehyde, Iron, INH, Lactic acidosis, Ethylene glycol, Salicylates] • Causes of normal anion gap metabolic acidosis: HARD UP [Hyperparathyroidism, Adrenal insufficiency, RTA, Diarrhea, Uteroenteric fistula, Pancreatic fistulas] Rapid recall MC fluid disorder MC cause of normovolemic hyponatremia The 1st organ affected in hypovolemic/cardiogenic shock [both cold shocks] MC cause of hypovolemic shock in 1st 24 hrs after abdominal surgery MC fluid disorder in surgical px



DHN SIADH Kidneys Hemoperitoneum ECF volume deficit



TRAUMA • Crystalloids include normal saline and LR, while colloids include blood products such as RBC and albumin. • An enlarging pupil w/ decrease in level of consciousness is suggestive of: uncal herniation • Retroauriccular ecchymosed [Battle’s sign] and periorbital ecchymoses [Racoon’s eye] is suggestive of: Basilar skull fractures • A 20 y/o female has a brief loss of consciousness following a head injury. She is awake but is amnestic for the event and keeps asking the same questions again and again: concussion • A 21 y/o male w/ head injury has loss of consciousness flowed by a brief lucid interval. He presents w/ an ipsilateral fixed and dilated pupil and contralateral hemiparesis: epidural hematoma [biconvex or lenticular in shape]. • Measures to lower ICP: HIVED [Hyperventilation, Intubation, Ventriculostomy, Elevate head, Diuretics] • A 70 y/o male presents to the ED after a whiplash injury. He is ambulating well but has an extremely weak handshake: central cord syndrome • Distraction/seat-belt injury/chance fracture – a horizontal fracture thru the vertebral body, spinous processes, laminae, pedicles, and tearing of the posterior spinous ligament. • A 19 y/o male, who was stabbed in the chest complaints of dyspnea. Breath sounds on the left are absent: pneumothorax • A 25 y/o female presents after a high speed MVC w/ dyspnea and tachycardia. There is focal bruising over the R side of her chest. CXR shows a RU lobe consolidation: pulmonary contusion • Criteria for a [+] DPL: 1. > 10 ml gross blood on initial aspiration 2. > 100,000 RBC 3. > 500 WBC 4. gm stain w/ bacteria or vegetable matter 5. amylase > 20 IU/L 6. presence of bile Classification of severity of hypovolemic shock Class Amount Description % blood loss 1 750 cc Slight tachycardia, normal BP & UO 15% 2 750-1500 cc tachyC, tachypnea, CRT< 2, orthostasis, ↓ BP, 15-30% agitation, confusion 3 1500-2000 cc All of the above, [+] lethargy, & ↓ UO 30-40% 4 > 2000 cc > 40% Types of sepsis SIRS Sepsis Severe Shock



T< 36 or >38, PR>90, RR>20, PaCO212,000 or 3 gm/dl > 0.6 Low High High High



Rapid recall MC cause of shock MC injured abdominal organ in blunt trauma MC injured abdominal organ in penetrating trauma MC injured solid organ associated w/ penetrating trauma MC surgical cause of emergency MC level of spinal fracture MC level of subluxation MC finding in thoracic great vessel injury MC thoracic traumatic injury MC renal traumatic injury MC cause of non-traumatic pneumothorax MC cause of spontaneous pneumothorax MC cause of chylothorax MC Sx of pneumothorax MC cause of pneumoperitoneum in adults In infants Least common GUT injury Clinically apparent tamponade may result from Jeferson’s fracture Hangman’s fracture CSF is formed in the choroid plexus at a rate of Procedure of choice for px w/ laryngotracheal separation. Region most vulnerable to injury in spinal trauma Most sensitive test for retroperitoneal injury Occlusion of the portal triad manually or w/ an atraumatic vascular clamp. Occlusion should not exceed 20 mins



Hemorrhage Spleen > liver Small bowel Liver Acute appendicitis C5 C5 on C6 Indistinct aortic knob Pulmonary contusion Renal contusion Ruptured pulmonary bleb Rupture of subpleural space Distal esophagectomy Chest pain Gastroduodenal perforation Ruptured Meckel’s diverticulum Ureteral injury 60-100 ml of blood C1 or atlas C2 or dens 150 cc Tracheostomy Cervical vertebrae CT scan Pringle maneuver



THERMAL INJURY • Burn scar CA called Marjolin’s ulcer is usually squamous cell CA w/c metastasizes via lymph node. • “Rule of nines” in burns: i. Each upper limb = 9% ii. Each lower limb = 18% iii. Anterior and posterior trunk = 18% each iv. Head and neck = 9% v. Perineum and genitalia = 1% • “Rule of palm” – the surface area of the pxs palm is approximately 1% of TBSA used for estimating size of small burns. • Types of burns: Degree PE Depth Sensation Color Healing 1st Blush Superficial Painful Red 7 days Desquamate Thickness nd 2 Blister, wet Partial Very painful Glistening 7-21 thickness pink superficial 21-35 - deep rd 3 Charred Full thickness Painless White/black Grafting NOTE: Mild [< 10% TBSA], moderate [10-30% TBSA], severe [> 30% TBSA] Rapid recall MC compartment requiring fasciotomy MC causes of post-burn pneumonia Common organisms found in burn wound infections MC type of burns in children MC complication of electrical burns



Anterior tibial compartment S. aureus, Pseudomonas S. aureus, Pseudomonas, Strep, C. albicans Scalding injury Peripheral nerve injury



BREAST Anatomy • Have ligaments that extend from deep pectoral fascia to superficial dermal fascia that provide structural support referred to as cooper’s ligaments. • Boundaries of axilla for dissection: Superior Axillary vein Posterior Long thoracic nerve Lateral Latissimus dorsi muscle Medial Lateral to, deep to, or medial to pectoral minor muscle • Rotter’s nodes lies between the pectoralis major and minor muscles.



Properties of pleural effusion fluid



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• Blood supply of breast: axillary A. [via lateral thoracic & thoracoacromial branches], internal mammary A. [via perforating branches] & intercostal A. • A nerves that surgeon must be aware of during axillary dissection: long thoracic, thoracodorsal, medial and lateral pectoral nerves. • Levels of axillary LN of breast: Level 1 [low] Lateral to pectoral nerve Level 2 [middle] Deep to pectoral minor Level 3 [high] Medial to pectoral minor Breast pathology • Developmental disorders of the breast: Mastitis neonatorum Witch’s milk Amastia Absent breast Athelia Absent nipple Amazia Nipple is present, glandular tissue is absent Polythelia Supranemerary nipples Polymastia Accessory breast tissue • Skin dimpling in breast CA is due to traction on Cooper’s ligament. • A female w/ 1 or more risk factors for breast CA presents w/ a mass in upper outer quadrant of breast. She’s at risk of cancers occur in the: upper outer quadrant • Axillary V. is responsible for the majority of venous drainage in breast. • Venous drainage is largely responsible for metastases to the spine thru Batson’s plexus. [communication w/ vertebral veins, route for hematogenous spread to vertebral column and hips • Long thoracic nerve causes “winging of scapula” in post-mastectomy pxs [serratus anterior muscle] • Breast exam recommendations: For all ages SBE every month 20-40 y/o Breast exam 2-3 yrs by physician > 40 y/o Annual breast exam by physician [+] hx of breast CA PE every 3-4 mos. for 2 yrs w/ lobular CA in-situ 2x/yr clinical breast exam, annual mammography w/ atypia Annual clinical breast exam & mammography w/ AD pattern 2x/yr clinical breast exam, annual mammography • Breast CA mutations: BRCA 1 Mutation linked w/ breast, ovarian & prostate CA BRCA 2 Mutation linked w/ male & female breast CA



Chr. 17q21 Chr. 13q12



• Chemoprevention of breast CA: Tamoxifen Decreases the incidence of contralateral breast CA in pxs w/ previous hx S/E: hot flushes, vaginal discharge, endometrial CA, DVT, embolism Raloxifen SERM, also used to treat osteoporosis • Indications for prophylactic mastectomy: i. Hereditary breast CA: BRCA 1 & 2 ii. Strong family of breast CA iii. Personal hx of lobular CA iv. Personal hx of atypia & breast CA v. Women anxious of CA development • The smallest breast mass palpable on PE is 1 cm. • A female complains of nipple pain during breastfeeding w/ focal erythema and warmth of breast on PE: mastitis • A 25 y/o female presents w/ painful breast mass several weeks after sustaining breast trauma by a seat belt car injury: fat necrosis • A 20 y/o female presents w/ a well-circumscribed mass in her L breast. It is mobile, nontender and has defined borders on PE: fibroadenoma • A female presents of acute pain in her axilla and lateral chest wall, and a tender cord is identified on PE: mondor’s disease [superficial thrombophlebitis of lateral thoracic & thoracoepigastric V.] • A 35 y/o female presents w/ straw colored nipple discharge and bilateral breast tenderness that fluctuates w/ her menstrual cycle: fibrocystic changes [no ↑risk for breast CA] • A 45 y/o female presents w/ breast pain that does not vary w/ her menstrual cycle w/ lumps in her nipple-areolar complex and a hx of non-bloody nipple discharge: mammary duct ectasia • A 46 y/o female presents w/ 1 month hx of spontaneous unilateral bloody nipple discharge. Radical compression of the involved breast results in expression of blood at 12 o’ clock position: intraductal papilloma • MC invasive breast CA: infiltrating ductal CA [in peri/postmenopausal women] • 2ND MC type of invasive breast CA: Infiltrating lobular CA • 20% of infiltrating lobular breast CA have simultaneous contralateral breast CA. • A 65 y/o female presents w/ pruritic pain, scaly rash on her nipple discharge: paget’s disease • A 45 y/o female presents w/ enlargement of her L breast w/ nipple retraction, erythema [peau de orange], warmth, and induration: inflammatory breast CA • Breast CA risk factors: early menarche < 12, late menopause > 55, 1 st pregnancy > 30 • Screening for breast CA: annual mammograms after age 50 • BRCA 1 is associated w/ ovarian CA. • 5-10% of breast masses have [-] mammograms



• Recommended therapy for breast CA: CAF [Cyclophosphamide, Adriamycin, 5-FU] or CMF [methotrexate instead of adriamycin] • Prognosis depends more on stage than on histologic type of breast CA. • Type of chemotherapy used in breast CA: CMF [cyclophosphamide, methotrexate, 5-FU] or CAM [cyclophosphamide, adriamycin, 5-FU] • Chemotherapy for DCIS: tamoxifen after lumpectomy and radiation Reporting mammogram results I No abnormality II Benign abnormality III Probably benign finding IV Suspicious for CA V Highly suspicious for CA Staging of breast CA Stages S.R 0 100% 1 92% 2 87% 3 75% 4



13%



Description DCIS or LCIS Invasive CA < 2 cm [+] LN, [-] mets Invasive CA < 5 cm, [+/-] movable axillary LN, [-] no mets Invasive CA > 5 cm, [+] fixed axillary LN, [+] ipsilateral internal mammary LN or any CA w/ skin involvement, pectoral & chest fixation, [-] distant mets Any form of breast CA w/ distant mets including ipsilateral supraclavicular LN



Lobular vs. Ductal CA in-situ Features Lobular CA in-situ Age of onset Premenopausal PE Mammogram Diagnosis Incidental Risk In all breast tissue Treatment Observation vs. chemotherapy vs. prophylactic mastectomy Breast operations Radical mastectomy MRM Simple mastectomy Lumpectomy & axillary node dissection Sentinel node biopsy



Ductal CA in-situ Postmenopausal Palpable mass Microcalcification Work-up abnormality At site of diagnosis Lumpectomy + radiation vs. ipsilateral simple mastectomy, tamoxifen



Resection of all breast tissue, axillary LN, pectoralis major & minor M. Same as radical mastectomy except pectoralis M. is left intact Same as radical mastectomy except pectoralis M. is left intact & NO axillary node disection Resection of mass w/ rim of normal tissue & axillary node dissection, good cosmetic result LN are identified on preoperative scintigraphy & blue dye is injected



Rapid recall Hx of female w/ backpain [if reproductive, young age] Hx of male w/ backpain Ideal breast self-examination is done at Most worrisome radiologic feature for breast CA: Most lethal breast CA MC histologic type of breast CA in MALES MC cause of bloody nipple discharge in young women MC breast tumor in pxs < 30 y/o MC cause of green, straw or brownish nipple discharge MC cause of breast mass after breast trauma MC site of breast metastasis Tumors running and leeping promptly to bone Thrombophlebitis of superficial breast veins Most important factor in prognosis of patients Most important prognostic factor in breast CA



High risk for breast CA High risk for prostate CA 1 week after menstrual period SpIculated masses w/ microcalcific & linear branching calcifications Inflammatory carcinoma Infiltrating ductal CA Intraductal papilloma Fibroadenoma Fibrocystic disease fat necrosis lungs > bone Thyroid, Renal, Lung, Prostate, Breast Mondor’s disease Axillary lymph node status Stage of disease [axillary node mets]



THYROID Anatomy & embryology • Thyroid forms at base of tongue a 3rd wk AOG • Ligament of Berry: ligament that attaches thyroid to the cricoid. • The recurrent laryngeal nerve innervates all of the intrinsic muscles of the larynx except the cricothyroid. • Thyroglossal duct obliterates after 2nd month. • Thyroid follicles store enough hormones to last 2-3 mos • Iodine trapping & T4 synthesis begin by 3-4 mos. AOG. • Relationships: Anterior SCM, sternothyroid, thyrohyoid, omohyoid Posterior Trachea Posterolateral Common carotid A., IJV, vagus nerves • Composed of cuboidal epithelium & central colloid • W/in stroma are C cells w/c secrete calcitonin



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• Blood supply of thyroid: superior [from 1st branch of external carotid A. at level of carotid bifurcation] & inferior thyroid A. [from thyrocervical trunk of subclavian A.], thyoridea ima [from aortic arch or innominate A.] • Venous drainage: superior [to IJV], middle [to IJV] & inferior thyroid [to brachiocephalic V.] • Innervation: R recurrent & L recurrent [from vagus], & superior + middle symphathetic ganglia [sympathetic] & vagus N. [parasympathetic] Nerve injuries Superior laryngeal nerve Recurrent laryngeal nerve



Sensory Motor Sensory Motor



Inability to perceive foreign body Unilateral – huskiness & weakness of voice Bilateral – easy fatigability in speaking, ↓ volume & pitch of voice Loss of sensation to lower pharyngeal mucosa Unilateral – unilateral paralysis of vocal cords, hoarse voice Bilateral – respiratory difficulty



Important terms & concepts Myxedema coma Caused by severe hypothyroidism triggered by stress [infection, alcohol, drugs], leads to inspiratory or respiratory insufficiency, hypothermia Metyrapone test Test for anterior pituitary hypofunction, blocks cortisol production, evaluates pituitary ACTH production Plummer disease Nodular toxic goiter, autonomously hyperfunctioning thyroid gland, normal thyroid tissue functions are suppressed Thyroid storm Extreme hyperthyroidism precipitated by surgery or infection. Sx of high fever, DHN, tachycardia, w/ high-output cardiac failure & coma. 25% mortality. Tx: beta-blocker, PTU, iodine, cooling measures Thyroid anomalies: Lingual thyroid Lateral aberrant thyroid Pyramidal lobe Thyroglossal duct cyst – MC thyroid anomaly



Thyroid tissue that failed to descend presenting as posterior tongue mass Mass at lateral thyroid lobe, may manifest as enlarged L thyroid gland Fibrous remnant of thyroglossal duct that persists as finger-like projection from isthmus Mass btw hyoid bone & isthmus that moves upward on tongue protrusion Managed by Sistrunk procedure



Thyroid diseases Refetoff’s syndrome Jod-Basedow syndrome Pendred’s syndrome Plummer’s disease



T4 refractoriness Hyperthyroidism 2◦ to ↑ I2 intake Goiter w/ deafness Toxic multinodular goiter



The only anti-thyroid drug that can be given to pregnant pxs: PTU 15% of solitary thyroid nodules are malignant 85% of cold nodules have 10-25% chance of malignancy. 5% of hot nodule have 1% chance of malignancy



Thyroid CA Features Risk factors Sex S/Sx



Papillary – MC Radiation F>M Painless mass, dysphagia, SOB



Follicular Dyshormogenesis F>M Painless mass



Medullary MEN - risk F>M Painful mass, dysphagia, SOB



Dx



FNAB, CT-MRI



FNAB, CT-MRI



Grossly



Encapsulated, hard, multifocal Psammoma bodies, orphanannie eyes Lymphatic Lobectomy, isthmetomy, total or near-total thyroidetomy Worse for old age Sclerosis 74-93%



Encapsulated, solitary Solitary, encapsulated



FNAB, [+] amyloid -dxtic Unilateral, midupper lobes C cell-origin, sheet of cells, amyloid, collagen Lymphatic Total thyroidectomy & central neck dissection



Histologic Metastases Tx



Prognosis Variants 10-yr SR



Thyroid lobecomy and isthmectomy, near total thyroidectomy or total thyroidecomy Total thyroidectomy



• Causative agents for thyroiditis: strep pyogenes, staph aureus, pneumococcus pneumoniae



Assessment of thyroid function • If T production is increased, both tT4 & fT4 increase & vice-versa • If amount of TBG changes, ONLY tT4 changes [NOT fT4] • TT3: useful to confirm dx of early hyperthyroidism • Pemberton’s sign: choking sensation aggravated by raising hand above the head



• • • •



• Surgical operation for thyroid: < 1.5 cm w/ no hx of neck radiation exposure > 1.5 cm, bilateral, + cervical node mets or hx of radiation exposure



Hematogenous Lobectomy & isthmectomy, total or near-total thyroidetomy Worse for old age Hurtle cell tumors 70%



70-80%



Anaplastic Iodine deficiency F>M Hard, fixed LN, neck pain, dysphonia FNAB Macroinvasion, clinically + LN Sheets of heterogenous cells Aggressive D-bulking resection of thyroid, external radiation tx Poor prognosis Median: 4-5 mos.



• Risks of thyroid surgery include: recurrent laryngeal nerve injury, hypoparathyroidism, and persistent hyperparathyroidism [w/ subtotal thyroidectomy]



Thyroid nodules are likely to be malignant when: 1. occur in young men 2. hx of radiotherapy to head or neck during childhood 3. nodule grows rapidly w/ hoarseness or dysphagia 4. not suppressed by L-thyroxine 5. cold nodules on RAI scintiscan 6. nodules appear solid or heterogenous on UTZ Subacute vs. Hashimoto’s thyroiditis Features Subacute thyroiditis Etiology Viral [mumps, coxsackievirus] History/PE Malaise, URI, fever, tender thyroid, hyper to hypothyroidism Evaluation ↓ RAI w/ ↑ T4 & T3, ↓ TSH Treatment



Symptomatic, self-limited



Hashimoto’s thyroiditis Autoimmune disorder Painless thyroid enlargement, pain & tender, hyper to hypothyroidism Antithyroid antibody assay is generally [+], ↓ T3 & T4, ↑ TSH Exogenous thyroid hormone



Thyroid hormones L-thyroxine [T4] Produced only in thyroid gland Half life: 7 days Only free hormones are active



Triiodothyronine [T3] 80% from peripheral conversion 1 day 3x more potent than T4 99.7% protein bound More abundant lesser Bigger Smaller ➢ thyroid enlargement + ↑TH = toxic goiter ➢ ↑TH + thyroid not enlarged = hyperthyroid ➢ ↑TH + S/Sx = thyrotoxicosis ➢ Enlarged thyroid = goiter



Surgical treatment of Thyroid diseases Grave’s disease Bilateral subtotal thyroidectomy or radioiodide ablation Papillary CA Total thyroidectomy Follicular CA Total thyroidectomy, [+] RAI Medullary CA Total thyroidectomy, [+] neck LN dissection Anaplastic CA Debulking & tracheostomy Thyroid lymphoma Chemotherapy & radiation 1◦ hyperparathyroidism Parathyroidectomy 2◦ hyperparathyroidism Treat underlying cause, parathyroidectomy PARATHYROIDS Anatomy & embryology • Superior glands originate from 4th pharyngeal pouch, Inferior glands originate from 3rd pharyngeal pouch [in conjunction w/ thymus] • Contains chief cells w/ occasional oxyphils, secretes parathormone [calcitonin] • Tubercle of Zuckerkandl: most posterior extension of lateral thyroid lobes • Ligament of Berry: connects thyroid to trachea • Vasculature: inferior thyroid A., superior, middle & inferior thyroid V. • Innervation: External branch of Cricothyroid M. Causes disability on phonation superior laryngeal N Recurrent laryngeal N. Intrinsic muscles R: near subclavian A. of larynx L: near ligamentum arteriosus Parathyroid pathology • Hypercalcemic crisis: Ca+ > 13 mg/dl. Treat w/ saline, diuretics, & anti-arrhythmic agents • A patient complains of tingling around her lips on post-op day 1 S/P total thyroidectomy: hypoparathyroidism causing hypocalcemia • Parathyroid CA: high Ca+, PTH, & alk phosphatase ADRENALS Anatomy & histology • Located at level of T11 • Vasculature: branches of aorta, inferior phrenic & renal A. • Venous drainage: central V. to IVC [on R] & L renal V. [on L] • Cortex: aldosterone [zona glomerulosa], cortisol [fasciculata], sex steroids [reticularis]



5



Adrenal pathology • CA commonly associated w/ hypercalcemia: breast CA metastases, prostate CA, kidney; lung, pancreatic, multiple myeloma • Procedures for adrenal diseases: Cushing’s disease Transphenoidal resection of pituitary adenoma Adrenal adenoma Laparoscopic adrenalectomy Adrenal carinoma Open adrenalectomy Ectopic ACTH Resection of primary lesion • A px w/ known addison’s disease presents w/ acute upper abdominal painw/ peritoneal signs and confusion: addison’s crisis • MC extra-adrenal location of neuroblastoma: organ of Zuckerkandl [to L of aortic bifurcation of IMA] Adrenal diseases Cushing’s disease Addison’s disease Conn’s disease Primary Conn’s Secondary Conn’s



Adrenal cortisol hypersecretion ↓ ↑



Ectopic ACTH production ↑ ↑



↑



↑



Primary vs. secondary adrenal insufficiency Features Addison’s disease ACTH High Cortisol after ACTH challenge Low



2◦ adrenal insufficiency Low High



PITUITARY Anatomy • Parts; adenohypophysis [from Ratche’s pouch]; anterior lobe while neurohypophysis from neural primordial]; posterior lobe • Anterior lobe lacks direct supply. Portal channels from hypothalamus & posterior pituitary supply it • Posterior pituitary is supplied by middle & inferior hypophyseal arteries [from ICA] • Drains via cavernous sinus to petrosal sinus to jugular veins Pituitary pathology [see IM notes] • Microadenoma: > 1 cm diameter while macroadenomas: < 1 cm Familial syndromes w/ pheochromocytoma Syndrome Components MEN type 2 or 2A Medullary thyroid CA and C cell hyperplasia, pheochromocytomas and adrenal medullary hyperplasia, parathyroid hyperplasia MEN type 3 or 2B Medullary thyroid CA and C cell hyperplasia, pheochromocytomas and adrenal medullary hyperplasia, mucosal neuromas, marfanoid features Von hippel-Lindau Renal, hepatic, pancreatic and epididymal cysts, renal cell CA, pheochromocytomas, angiomatosis, cerebellar hemangioblastomas Von Recklinghausen Neurofibromatosis, cfe au lait spots, schwannomas, meningiomas, gliomas, pheochromocytomas Sturge-Weber Cavernous hemangiomas of 5th cranial nerve distribution, pheochromocytomas MEN syndromes Type Pituitary Parathyroid Pancreatic islets Adrenal Thyroid Extraendocrine changes Mutant gene locus



MEN 1 [Wermer] Adenomas Hyperplasia, adenomas Hyperplasia, adenoma, CA Cortical hyperplasia C-cell hyperplasia



MEN 2 OR 2A [Sipple]



MEN 2B OR 3



Hyperplasia, adenoma



Hyperplasia



Pheochromocytoma Medullary carcinoma



MEN I



RET



Pheochromocytoma Medullary carcinoma Mucocutaneous ganglioneuromas, marfanoid habitus RET



Rapid recall Most sensitive test for thyroid function Most definitive procedure to assess thyroid malignancy MC thyroid anomaly



Anaplastic type [giant & spindle cells] Bone HCG Small cell lung CA Organ of Zukerkandl [near abdominal aorta] Iatrogenic [glucocorticoid therapy] Prolactinoma [tx by bromocriptine] HPN Diarrhea Secondary amenorrhea Hypothyroidism Tetany Skin pigmentation



ACUTE ABDOMEN • Kehr sign [pain referred to L shoulder due to irritation of L hemidiaphragm] is seen in: splenic rupture • Murphy’s sign is seen in: acute cholecystitis • The pain of appendicitis localizes into: McBurney’s point



Hypercortisolism Adrenal insufficiency Hyperaldosteronism Secondary to excessive aldosterone secretion Secondary to increase renin



Laboratory findings in Cushing’s syndrome Iatrogenic Pituitary ACTH hypercortisolism hypersecretion ACTH ↓ ↑ Urinary free ↑ ↑ cortisol DHEA ↓ ↑



Most aggressive of the thyroid tumors: MC site of distal metastasis for follicular CA: Common tumor marker for parathyroid CA MC ectopic ACTH production MC extra-adrenal site of ACTH production MC cause of secondary adrenal insufficiency MC pituitary adenoma MC sign of pheochromocytoma MC Sx of medullary thyroid CA MC Sx of Prolactinoma MC manifestation of MEN syndrome MC manifestation of hypoparathyroidism MC manifestation of primary adrenal insufficiency



TSH FNAC Thyroglossal duct cyst



Rapid recall MC cause of free air under the diaphragm MC surgical emergency in pregnant women MC cause of UGI bleeding MC cause of abdominal pain in elderly Blood needed to have melena MC cause of massive lower GI bleed MC cause of occult blood loss MC surgical disease of small bowel MC cause of LLQ pain MC cause of RLQ pain



Perforated peptic ulcer Appendicitis PUD Cholecystitis > 50 cc of blood Diverticulosis Cholangitis Crohn’s disease Diverticulitis Appendicitis



ESOPHAGUS [see GIT in IM notes] Anatomy • Vetebral levels at w/c the following traverse: T8 Inferior vena cava T10 Esophagus T12 Aorta Pathology • Esophageal varices is MC due to: alcoholic cirrhosis • An alcoholic man presents after severe retching, complaining of retrosternal and upper abdominal pain: Boerhaave syndrome [full thickness – L side posterolateral wall of distal esophagus] or Mallory-Weiss syndrome [partial thickness – R side posterolateral wall of distal esophagus] • Mediastinal emphysema heard as “crunching” sound w/ heartbeat [Hammon’s crunch] is characteristic of: Mallory-Weiss syndrome • Pharyngoesophageal & epiphrenic diverticula are called pulsion diverticula [false diverticula] while midesophageal are traction diverticula [true diverticula] • Diffuse esophageal spasm is associated w/ risk for IBS & spastic colon • FB ingestion is most likely lodged in these anatomic narrowings: above upper esophageal sphincter, near aortic arch & above LES Characteristic findings in barium swallow: Bird’s beak or Achalasia [no gas bubble] steeple sign Cork-screw Diffuse esophageal spasm shaped



Tx: endoscopic dilatation or esophagomyotomy w/ fundoplication, high risk for SCCA] Tx: nitrates or CCBs to decrease LES pressure, esophagomyotomy is not successful



Clinically significant portal-systemic sites: Cardio-esophageal junction Esophageal varices Periumbilical region Caput medusae Rectum Hemorrhoids Types of fistula or atresia A Esophageal atresia w/o TEF B Proximal esophageal atresia w/ proximal TEF C Proximal esophageal atresia w/ distal TEF D Proximal esophageal atresia w/ proximal or distal TEF E “H type” TEF w/o esophageal atresia Stages of esophageal CA Stages Description 1 Tumor invades lamina propria or submucosa 2a Invades m. propria or adventitia, [-] LN 2b Invades m. propria or adventitia, [+] regional LN 3 Tumor invades adventitia, [+] LN, & adjacent structures 4 Distant metastases



5-yr SR 80% 33% 33% 15% 0%



6



Rapid recall Mc complication of balloon tamponade of esophageal varices MC procedure for esophageal diverticula Most feared complication of esophageal dilatation MC cause of defective LES MC cause of esophageal perforation MC sign of esophageal atresia MC Sx of esophageal CA STOMACH [see GIT in IM notes] Anatomy • Innervation: Anterior gastric wall Posterior gastric wall Sympathetic afferents • Vasculature: Greater curvature Lesser curvature Pylorus Fundus Gastric vs. Duodenal ulcer Gastric ulcer Less common 40-60 y.o Pain aggravated by food Lesser curvature Blood type “A” Associated w/ malignancy ↓ HCO3 production



Perforation Cervical esophagomyotomy w/ resection of diverticulum. Esophageal rupture Inadequate sphincter pressure Iatrogenic Regurgitation of saliva Progressive dysphagia



R & L gastroepiploic A. R & L gastric A. Gastroduodenal A. Short gastric A. Duodenal ulcer Common 20-45 y.o Pain relieved by food Duodenal papilla Blood type “O” Not associated ↑ acid production



Features suggesting benign gastric ulcer 1. gastric folds radiating into base of ulcer 2. thick radioluscent edematous collar [Hampton’s line] 3. smooth crater 4. pliable gastric wall in area of ulcer



Important S/Sx in adenocarcinoma Krukenberg’s tumor Blumer’s shelf Virchow,s node Sister mary joseph nodules



Staging of gastric adenocarcinoma Stages Description 1 Mucosal involvement 2 Thru muscularis propria 3 Any LN involvement, [-] distant mets 4 Distant mets, extension to adjacent structure Rapid recall MC site of GI tract lymphoma 2nd MC malignant gastric CA MC type of gastric sarcoma The only polyps w/ malignant potential MC location of duodenal ulcer MC location of gastric ulcer MC site of ZES MC non-pancreatic site of ZES MC cause of upper abdominal abscess MC site of intraabdominal abscess Mucosal end artery that causes pressure necrosis and erodes into stomach and ruptures. MC Sx of gastric CA Most important prognostic factor in gastric CA



L vagus N. R vagus N. T5-T10 [senses gastric pain]



Classification of gastric ulcers: Types Description Type 1 Ulcer in lesser curvature at incisura angularis Type 2 Simultaneous gastric and duodenal ulcer Type 3 Prepyloric ulcer Type 4 Ulcer in gastric cardia



Staging of gastric lymphoma [by Ann-Arbor classification] Stage 1 Disease limited to stomach Stage 2 Spread to abdominal LN Stage 3 Spread to LN above & below diaphragm Stage 4 Disseminated lymphoma



Treatment Antrectomy Antrectomy High selective vagotomy Subtotal gastrectomy, roux-enY esophagogastrojejunostomy



Metastasis to ovaries Metastasis to pelvic cul-de-sac, felt on DRE Metastasis to LN palpable in L supraclavicular fossa Metastasis to umbilical LN



• A fasting serum gastrin level > 1,000 pg/ml is pathognomonic for gastrinoma • Surgery is indicated when ulcer is refractory to 12 wks of medical tx or if hemorrhage, obstruction or perforation is present. [TOC = high selective vagotomy – parietal cell vagotomy or proximal gastric vagotomy] • A px w/ known PUD has sudden onset of severe epigastric pain. PE reveals guarding and rebound tenderness: perforation • A 53 y/o woman presents due to 3 mos. early satiety, weight loss and non-billous vomiting: gastric outlet obstruction • A 33 y/o female smoker presents w/ burning epigastric pain improved after eating meals: DU • A 45 y/o Japanese male smoker presents w/ weight loss and epigastric pain exacerbated by eating: gastric ulcer • A 58 y/o woman who is 6 days post-op from a gastrojejunostomy for PUD presents w/ postprandial RUQ pain and nausea. She reports that vomiting relieves her suffering: afferent loop syndrome • Coffee ground refers to an old, brown digested blood found in gastric lavage w/c indicates bleeding proximal to the ligament of Treitz. • GUs are 3x more likely to rebleed than DUs. • Often presents like “umbilicated dimple”: ectopic pancreas • Complications of chronic gastritis: gastric atrophy, metaplasia & pernicious anemia • Gastric operations: Anthrum Distal subtotal gastrectomy Midbody Total gastrectomy Proximal Total gastrectomy



5-yr survival 66% 33% 10% 0%



Stomach Gastric lymphoma Leiomyoma [hemogenous spread] Adenomatous polyps Posterior duodenal wall w/in 2 cm of pylorus Lesser curvature Pancreas [neck] Duodenum Left Subphrenic space Dieulafoy’ lesion Anorexia & weight loss Advance stage of the disease



SMALL BOWEL GI embryology & anatomy • At 4th wk, the primitive gut begins to develop where the endoderm becomes intestinal epithelium & glands, while the mesoderm becomes the CT, muscle & wall of intestine. • At 5th wk, the cranial limb of midgut becomes distal duodenum & proximal ileum, while the caudal limb becomes the distal ileum to proximal transverse colon • All of the small intestine is derived from the midgut except for the proximal duodenum w/c is derived from the foregut. • The small bowel has a total length of 5-10m [25 cm duodenum, 100-110 cm jejunum, 15-160 cm ileum] • The entire small bowel is supplied by SMA except the proximal duodenum w/c is supplied by celiac trunk. • Jejunum begins & duodenum ends at ligament of Treitz • A 70 y/o male w/ PVD and hyperlipidemia presents w/ severe diffuse abdominal pain. BP is 170/100 and his pulse is 90 bpm. Supine abdominal radiograph shows air w/in the wall of the small intestine: small bowel infarct • A px presents w/ pigmented spots on lips and hx of recurrent colicky abdominal pain: peutzjegher’s syndrome • A 60 y/o male presents w/ a hx of cutaneous flushing, diarrhea, wheezing and an unintentional weight loss: carcinoid syndrome • Appendiceal carinoid < 2 cm: appendectomy while appendiceal carcinoid > 2 cm: R hemicolectomy • Specific disease states: Peutz-Jeghers syndrome Hamartomatous polyps Crohn’s disease Adenocarcinoma Gardner’s syndrome Adenoma Familial adenomatous polyposis Adenoma Celiac disease Lymphoma, carcinoma • MC causes of small bowel adhesions: ABC [Adhesions, Bulge or hernias, and Cancer] • Air fluid levels in “stepladder” arrangement on upright film are characteristic of paralytic ileus. Surgical ulcers Peptic Duodenal Gastric Curling’s Cushing’s Dieulafoy’s Marjolin’s Apthous Decubitus Venous stasis



General term for gastric/duodenal ulcer disease Ulcer in duodenum [ductal papilla] Ulcer in stomach [antrum] Gastric ulcer after burn injury Peptic ulcer after neurologic insults Pinpoint gastric mucosal defect bleeding from underlying arterial malformation SCCA ulceration overlying chronic burn scar GIT ulcer seen in Crohn’s disease Stress ulcer, skin/SQ ulceration from pressure necrosis seen on buttocks/sacrum Skin ulceration on medial malleolus caused by venous stasis of lower extremity



7



Rapid recall Longest organ of the GI tract Largest immune organ in the body Most prevalent type of immunoglobulin in lumen of GI tract. MC cause of RUQ pain MC cause of LLQ pain MC surgical disease of the small bowel MC cause of adult intussusceptions MC cause of fistula



Ileum Gut IgA Cholelithiasis Diverticulitis Crohn’s disease Adenomas Previous abdominal surgery



LARGE BOWEL Anatomy & embryology • Unlike small intestine, colon has taenia coli, haustra & appendices epiploicae • Retroperitoneal organs of the colon: ascending and descending colon, posterior hepatic and splenic flexures. • Intraperitoneal: cecum, transverse and sigmoid colon • Rectal fascia is composed of Waldeyer’s fascia & Denonvilier’s fascia • Rectum is 12-15 cm in length and can store approximately 500 cc of feces • Blood supply of large intestine SMA Ileocolic Cecum R colic Ascending colon Middle colic Proximal 2/3 of transverse colon IMA L colic Distal 2/3 transverse colon Sigmoidal Sigmoid Superior rectal Superior 3rd rectum Internal iliac Middle rectal Middle 3rd rectum Int. rectal Distal 3rd rectum Internal pudendal Direct branch Anus • Innervation: Sympathetic N. Parasympathetic



T7-12 [R colon] L1-3 [L colon & rectum] Vagus N. [proximal colon] S2-4 [distal colon]



Inhibits peristalsis Stimulates peristalsis



Pathology • L sided colon CA present w/ change in bowel habits, obstruction and hematochezia • R sided colon CA presents w/ anemia, fatigue and melena. • “Sunburst patern” of sulfur granules on histopathologic examination is characteristic of actinomycoses infection. • “thumb printing” on barium enema is characteristic of ischemic colitis • Distended loop of sigmoid colon often in the classic “bent inner tube” or “omega sign” w/ loop aiming toward the RUQ is seen in sigmoid volvulus. • A 70 y/o male w/ hx of HPN, develops lower abdominal pain 2 days S/P AAA repair. Few hours later, he develops bloody diarrhea: ischemic colitis • “Lead pipe appearance” of colon on barium enema is characteristic of IBD [ulcerative colitis]. • 3 MC causes of obstruction of the large bowel: adenocarcinoma, diverticulitis and volvulus • “kidney-bean” appearance of sigmoid colon and cecum + “bird’s beak appearance of colon on xray is characteristics of volvulus. • The “apple core” filling defect in descending colon on barium enema is classic for L-sided colon CA. • Operative management based on location: Cecum R hemicolectomy R colon R hemicolectomy Proximal/mid transverse colon Extended R hemicolectomy Splenic flexure and L colon L hemicolectomy Sigmoid or rectosigmoid colon Sigmoid colectomy Proximal rectum Low anterior resection [LAR] Distal rectum Abdomino-perineal resection [APR] • 3 hemorrhoid quadrants: L lateral, R posterior and R anterior • Grading of hemorrhoids: Stage Description Symptoms 1 Protrudes into lumen, Bleeding no prolapse 2 Prolapse w/ straining, Bleeding, perception of spontaneous return prolapse 3 Prolapse, needs Blleding, prolapse, mucinous manual reduction soilage & pruritus 4 Prolapse, can’t be Bleeding, prolapse, mucous reduced soilage, pruritus, pain



Treatment Non-resectional measures Nonresectional measure Excision Excision



• Paget’s disease of the anus is Adenocarcinoma in situ, and bowen’s disease of the anus is a squamous CA in situ.



• Mucosal findings: Crohn’s disease Apthoid ulcers, granulomas, linear ulcers, transverse fissures, swollen mucosa, full-thickness wall involvement



Ulcerative colitis Granular and flat mucosa, ulcers, crypt abscess, dilated mucosal vessels, pseudopolyps, “backwash ileitis”



Surgical repair for Hirschprung’s disease Boley Remove aganglionic colon, perform pull-through anastomosis at same time Duhamel Anterior aganglionic region of rectum is preserved & anastomose to posterior part of healthy bowel, functional rectal pouch is created, dural barrel side by side Soave Endorectal pull-through, bringing proximal normal colon thru aganglionic rectum w/c has been stripped of its mucosa but otherwise present Swenson 1◦ anastomosis btw anal canal & healthy bowel, rectum is removed Duke’s classification of colonic CA Stages Description A Within mucosa B1 Mass extruding into muscularis propria, no nodes B2 Involvement of entire wall, no nodes C1 Limited wall, [+] nodes C2 Entire wall, [+] nodes D Distant metastasis [liver, lungs, spine] Determination of malignant potential of polyps Size Histology < 1 cm 1-3% Tubular 5% 1-2 cm 10% Tubulovillous 20% > 2cm 40% Villous 40% R colon vs. L colon vs. Rectal CA Basis Right colon Parts Cecum to hepatic flexure Appearance Bulky, polypoid lesions Tumor type Signet-ring cell adenoCA Clinical Mx Anemia No obstructive Sx Melena Dull, persistent RLQ pain Other Mx



Excessive weight loss



Frequency of polyps: Type Tubular – most common Tubulovillous Villous - ↑ CA r Rectal CA surgical options: Upper rectum [10-15 cm above anus] Mid-rectum [5-10 cm above anus] Lower rectum



Atypia Mild Moderate Severe



5% 20% 35%



Left colon Hepatic flexure to sigmoid Scirrous or annular type Signet-ring cell adenoCA Constipation More obstructive Sx Bloody & mucoid stools Change in bowel habits w/ decrease stool caliber Napkin ring lesions



Frequency 75% 15% 10%



Rectal Sigmoid to rectum adenoCA Hematochezia Less obstructive Sx Fresh blood w/ mucus [+] tenesmus, crampy abdominal pain Rectal pain, extensive



CA potential 5% 22% 40%



Low anterior resection Depends on histology, size, age, sex abdomino-perineal resection [APR] or Mile’s procedure



Rapid recall Widest part of the colon MC site of diverticular disease MC site of distant metastasis from colorectal CA MC site of diverticulosis MC site of anal fissure MC type of adenomatous polyp 2nd MC cause of cancer deaths worldwide Classic presentation of diverticulosis MC carcinoma of the anus MC Sx of Peutz-Jegher’s syndrome MC Sx of ulcerative colitis Most important prognostic factor in colorectal CA



Cecum Sigmoid colon Liver Sigmoid colon Posterior midline Tubular Colorectal CA Massive lower GI bleeding SCCA [Bowen’s disease] > adenoCA [paget’s] Recurrent colicky abdominal pain Bloody diarrhea LN involvement



APPENDIX Anatomy • The appendix buds off from the cecum beginning at 6th wks of life • Its lymphoid tissue first appears at 2 wks after birth • Luminal capacity is about 0.1 ml [not actual lumen] • Fold of Treves is an ileal fold just proximal to ileocecal valve, contains the antimesenteric fatty appendage on small bowel. • Just 0.5 ml raises the appendiceal intraluminal pressure by -60 cm H2O. • Sign’s for appendicitis:



8



Direct & rebound Dunphy’s Hamburger sign Iliopoas Obturator Psoas Rovsing’s Rectal exam



Tenderness manifested in RLQ Increased pain w/ coughing If a px wants to eat, consider dx other than AP Pelvic pain upon extension of the R thigh [signifies retrrocecal appendicitis] Pelvic pain upon internal rotation of R thigh [signifies pelvic type AP] [+] hyperextension of R thigh will produce RLQ pain [due to direct extension of retrocecal appendix to psoas muscle] Pain in RLQ when palpation pressure is exerted in LLQ [due to peritoneal irritation] [+] pararectal tenderness at the R



• Risk of rupture of appendicitis is highest w/in 48 hrs [75%] • MC type of appendiceal tumor: carcinoid HEPATOBILIARY SYSTEM Anatomy of liver • Arterial supply: Artery Celiac trunk Common hepatic A.



Origin Aorta



Branches L gastric, splenic & common hepatic A. Proper hepatic A., duodenal A.



• Venous drainage: Left , middle & Right hepatic veins drain into IVC • Receives 75% of its blood supply from Portal vein & 25% from hepatic arteries • Ligaments of liver: Falciform ligament Connects anterior abdominal wall to liver, contains ligamentum teres [obliterated umbilical vein] Coronary ligament Peritoneal reflection on cranial aspect of liver that attaches it to diaphragm Triangular ligaments R & L lateral extensions of coronary ligament • • • •



Normal daily bile output: 500-1,200 ml Bare area: the posterior section of liver against diaphragm, has NO peritoneal covering Glissons capsule: peritoneal membrane that covers the liver Cantlie’s line [portal fissure]: line hat passes from L side of GB to L side of IVC, divides liver into R & L lobes • Liver enzymes: AST & ALT [from hepatocytes], alkaline phosphatase [from ductal epithelium] Common procedures of hepatobiliary system: Pringle maneuver Compressing the hepatoduodenal ligament to control bleeding from the liver Liver resection Up to 80% of liver can be removed & still retain adequate function Sphincterotomy A cut to Sphincter of Oddi to allow passage of tones from CBD into papillotomy] duodenum. Often done during ERCP Kocher incision Incision at the R subcostal margin performed during open cholecystectomy ERCP Passage of endoscope into duodenum & introduction of catheter to ampulla of Vater & injection of contrast medium into CBD & pancreatic duct PTCA Passing of needle thru skin & SQ tissues into hepatic parenchyma & advancement into a peripheral bile duct Pathology on liver • Amebic abscess are classically described as “anchovy paste” in appearance caused by Entamoeba histolitica. • A 27 yo female presents w/ hx of hepatocellular adenoma that resolved after discontinuing OCPs. She now wants to get pregnant: hepatocellular adenomas • Mass of veins extending around umbilicus producing periumbilical bruit [Cruveilheir-Buumgarten bruit] seen in caput medusa. Causes of portal HPN Presinusoidal Splenic or portal V. thrombosis, schistosomiasis, granulomatous



Sinusoidal Cirrhosis, granulomatous disease



Child-Pugh score for liver failure Variable 1 Bilirubin [mg/dl] 3.5 Ascites [clinical] None Neurologic disorder None PT [secs] 3 < 2.8 Poorly controlled Advanced >6



Anatomy of biliary tree & gallbladder • Cystic duct comes off the GB & joins the common hepatic duct to form the common bile duct [empties into duodenum via ampulla of Vater] • Cystohepatic or Calot’s triangle: inferior border of liver, common hepatic duct, and cystic duct. It contains the cystic & R hepatic artery • The infundibulum of gallbladder is called: Hartman’s pouch • The valves within cystic duct are called spiral valves of Heister • The GB collects bile directly from liver via small bile ducts called ducts of Luschka



Pathology of HBT • Hydrops of gallbladder is the complete obstruction of the cystic duct by a gallstone, causing the gallbladder to fill w/ fluid. • Charcot’s triad: RUQ pain, fever and jaundice. • Reynold’s pentad: chrarcot’s + CNS Sx and septic shock • “Beads on a string appearance” of bile ducts is seen in sclerosing cholangitis. • Cholangiocarcinomas are common located at bifurcation of the R and L hepatic ducts called as: Klatskin’s tumor. Types of biliary calculous disease Stone type Pathogenesis Cholesterol Altered bile components, cholesterol, stasis of bile Black Altered bilirubin solubilization pigment Brown Bacterial deconjugation of bilirubin, bile pigment stasis Biliary Bile stasis sludge



Composition Cholesterol crystals Ca+ bilirubinate, bile acids, bilirubin polymers Ca+ bilirubinate, bile acids, bilirubin polymers, bacteria Ca+ bilirubinate, cholesterol crystals, mucin gel matrix



Staging & treatment of gallbladder adenoCA Stages Description Treatment 1 Mucosal involvement only Cholecystectomy 2 [+] muscularis layer of GB Radical cholecystectomy [+], wedge resection of liver around the bed of GB [+] regional LAD 3 All layers of wall involved 4 Cystic node involvement 5 Distant spread Palliative Staging of cholangiocarcinoma 1 Tumor invading but not thru bile duct wall 2 Tumor invading thru wall & involving perimuscular CT 3 Stage 2, [+] LN involvement 4 Tumor invading adjacent organs [liver, pancreas, duodenum & vascular organs 5 Distant metastatic spread Anatomic variants of choledochal cysts 1 Dilatation of CHD & CBD w/ cystic duct entering the cyst. MC type 2 Lateral saccular cystic dilatation 3 Choledochocele represented by an intraductal cyst 4 Multiple extra or intrahepatic cysts or both 5 Single or multiple intrahepatic cysts Bismuth classification of bile duct injuries or strictures 1 > 2cm of CHD is preserved below the bifurcation 2 < 2cm remains 3 Involves hilum w/ preserved continuity btw R & L sides 4 Destruction of hepatic confluence w/ separation of R & L 5 Separate inserting sectoral duct w/ or w/o injury to CBD Rapid recall Causative agents in bacterial/pyogenic liver abscess MC antecedent cause of pyogenic liver abscess MC cause of liver pyogenic abscess MC site of liver abscess MC liver nodule MC hepatic malignancy MC primary benign liver tumor MC benign tumor of liver MC primary liver sarcoma MC primary liver malignancy Subtype of hepatocellular CA w/c has the best prognosis MC primary CA of GB MC primary cancer of HBT MC cause of portal HPN MC finding in portal HPN MC site of obstruction in gallstone ileus Adenomas of bile ducts are commonly seen in Most sensitive in dx of acute calculous cholecystitis. Gold standard for dx of CBD stones MC Sx of choledochal cyst MC Sx of gallbladder CA MC Sx in liver cell CA MC manifestation of alcoholic liver disease



E. coli, Klebsiella, Proteus Liver trauma Biliary obstruction [thru portal vein] R lobe [MC type – amebic abscess] Hemangioma Metastases Hepatic hemangioma Cavernous hemangioma Angiosarcoma Hepatocellular CA Fibrolamellar hematoma adenoCA Bronchogenic CA Cirrhosis from alcoholism Splenomegaly Ileocecal valve Ampulla of vater HIDA scan ERCP Intermittent jaundice RUQ pain Weight loss & jaundice Steatosis



PANCREAS



9



Anatomy & embryology • Begins development during 4th wk AOG from endoderm of duodenum • Lies retroperitoneal posterior to stomach, transverse mesocolon & lesser omentum at body of L2 • 2 ducts: Wirsung [main duct] & Santorinni [accessory duct] • Sphincter of Oddi: smooth muscle around ampulla • Head is closely associated w/ duodenum [anterior & posterior pancreaticoduodenal A.] • Body & tail are supplied by branches of dorsal pancreatic A. & splenic A. • Innervation: Sympathetic Thoracic sympathetic ganglia to splanchnic N. to celiac ganglia Parasympathetic From vagal nuclei [for islets, acini & ducts] • Pancreatic anomalies: Heterotrophic pancreas Pancreas divisum Annular pancreas



Wrong location of pancreatic tissue [stomach, duodenum, meckel’s diverticulum Failure to fuse 2 duct systems [Santorini becomes the main duct] Ventral pancreas malrotates & encircles 2 nd part of duodenum



Pathology • Cullen’s [periumbilicus] and Grey-Turner’s [flank] sign are indicative of severe, hemorrhagic pancreatitis. • “Sentinel loop sign” and colon cutoff sign” on AXR is characteristic of acute pancreatitis. • A 32 y/o male who underwent laparotomy for a gunshot wound to the abdomen 2 days ago is found to have a tender belly w/o rebound and is leaning forward on his stretcher breathing at a 28/min: pancreatitis • Gallstones are not common cause of chronic pancreatitis. • Pancreatic calcifications on xray and “chain of lakes” pattern on pancreatography are characteristics of chronic pancreatitis. • Whipple’s procedure: removal of GB, CBD, anthrum of stomach, duodenum, proximal jejunum and head of pancreas [en bloc]. • A 30 y/o male complains of feeling faint and confused most notably after he exercises. His symptoms improve after he has a soft drink: insulinoma • A 4 y/o male complains of chronic epigastria pain following meals and notices increasing doses of his anti-ulcer medication: Gastinoma or Zollinger-Ellison syndrome • A 57 y/o male presents w/ a hx of severe watery diarrhea characterized by hypokalemia and achlorhydria: VIPoma or Verner-morrison syndrome or WDHA syndrome. • Necrolytic migratory erythema is the skin condition associated with: glucanogoma • Tx of pancreatic CA based on location: Head of pancreas Whipple’s procedure [pancreaticoduodenectomy] Body or tail Distal resection Ranson’s criteria for acute pancreatitis [predicts risk of mortality in pancreatitis] On admission [GA LAW] After 48 hrs [C-HOBBS] Glucose > 200 mg/dl Ca+ < 8 mg/dl Age > 55 y.o Hct decrease by 10% LDH > 350 IU/L [700/] O2 PaO2 < 60 mmHg AST/SGOT > 250 IU/dl Base excess > 4 meq/L WBC > 16, 000/ml BUN increase > 5 mg/L Sequestered fluid > 6L [base deficit] Number of risk factors Mortality 6 70-100% Risk of mortality: 20% [3-4 signs], 40% [5-6 signs], 100% [> 7 signs] Rapid recall MC sites of Cystadenocarcinoma MC islet cell tumor MC sign of pancreatitis on AXR



Pancreatic body and tail Insulinoma [“spells or blackouts” due to hypoglycemia] Sentinel loops



SPLEEN Anatomy • Located at LUQ of abdomen btw 8th & 11th ribs • Boundaries: Superior L diaphragm leaf Inferior Colon, splenic flexure, phrenicocolic ligament Medial Pancreas [tail], stomach Lateral Rib cage Anterior Rib cage, stomach Posterior Rib cage Pathology • Conditions associated w/ splenic rupture include: mononucleosis, malaria, blunt LUQ trauma, and splenic abscess • A 27 y/o HIV [+] female presents w/ fever, waxing and waning mental status and hematuria. CBC shows pancytopenia: TTP Indications for splenectomy Disease Description & caveats



Trauma ITP TTP Myeloproliferative disease Lymphoma Hereditary spherocytosis Felty’s syndrome Splenic abscess Parasitic cysts Sarcoidosis Splenic vein thrormbosis



Resection w/ hilar involvement, parenchymal damage, active bleeding Steroid tx, IV gammaglobulin, plasmapheresis, resection if refractory Resection if medical Tx failed Resection for symptomatic splenectomy Resection for symptomatic splenomegaly Resection is curative Resection improves response to infection & treats Sxtic splenomegaly CT-guided percutaneous drainage Resection indicated Gaucher’s resection Resection cures the sinistral portal HPN



Grading & classification of splenic injuries Grade Description 1 Subcapsular hematoma < 10% SA, capsular tear < 1 cm 2 Subcapsular/intraparenchymal hematoma 10-15% SA, laceration 1-3 cm depth 3 Large, > 50% SA, > 5 cm diameter, subscapular/intraperitoneal hematoma, > 3cm laceration involving trabecular vessels 4 Laceration involving hilar or segmental vessels 5 Hilar avulsion or shattered spleen Rapid recall MC cause of hypersplenism Portal HPN MC primary non-lymphoid tumor of spleen Hemangioma MC presentation of splenic traumatic injury Splenic rupture Mainstay of tx for TTP Plasmapheresis MC cause of failure to correct thrombocytopenia after Missed accessory spleen splenectomy HERNIAS AND ABDOMINAL WALL PROBLEMS Groin anatomy • Abdominal wall layers: skin, SQ fat, Scarpa’s fascia, external oblique, internal oblique, transversus abdominis, transversalis fascia [strongest layer], extra-peritoneal fat & peritoneum • Innervation: intercostals & upper lumbar nerves • Inguinal canal boundaries: Anterior wall External oblique aponeurosis Posterior wall Transverse abdominal M. aponeurosis, transversalis fascia Medial border Transverse aponeurosis, transversalis fascia Lateral border Transverse abdominal M. Inferior rectus Transverse aponeurotic fascia Superior rectus Transverse aponeurosis • Spermatic cord contents: vas deferens & its artery, 1 testicular A., 2-3 veins, lymphatics, autonomic nerves & fat • Ligaments: Inguinal ligament Stringly brace the myopectineal orifice, constitutes the medial border of femoral canal Henle’s ligament The portion of tendon of rectus abdominal M. that curves laterally into pecten pubis Hesselback’s ligament Fascial condensation in region of inferior epigastric vessels • Vasculature: cremaster vessels arise from inferior epigastric vessels & pass thru posterior wall of epigastric canal via their own foramen. It supplies cremaster muscle & testis tunica • Nerves: Genital N. L1-2 Innervates cremaster vessels to for neurovascular bundle & may substitute for absence of ilioinguinal N. Iliohypogastric, ilioinguinal & genital T12Innervates the skin of groin, base of penis & medial branch of genitofemoral N. L1 upper thigh • Femoral canal contents: Nerve, Artery, Vein, Empty space, LN [NAVEL] • Nerve that travels on the spermatic cord: ilioinguinal nerve • Nerve that travels w/in the spermatic cord: genital branch of genitofemoral nerve • Anatomical triangles: Hesselbach’s Site of direct Inferior: inguinal ligament; medial: rectus abdominis; triangle inguinal hernia lateral: inferior epigastric vessels Triangle of Superiorly: 12 th rib; anterior: internal oblique; floor: Grynfeltt quadratus lumborum M. Triangle of Petit Aka Inferior lumbar Posterior: latissimus dorsi, inferior: iliac creast; floor: triangle inferior oblique & transversus abdominis M.



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Pathology • Diagnostic signs: Sister Mary Joseph nodules Grey-Turner sign Fothergill’s sign Caput medusae • Hernia calendar: 0-2 yrs 2-20 yrs 20-50 yrs > 50 yrs



Nodule that enlarges at umbilicus, sign of advanced GIT malignancy Bluish hematoma at flanks, sign of retroperitoneal hemorrhage Bluish discoloration of skin, differentiates intra from extraabdominal mass Very fine veins, due to portal HPN sec. to cirrhosis or alcoholism



Indirect inguinal hernia Hernia is uncommon Indirect inguinal hernia Direct inguinal hernia



• Surgical repair of hernias: Lytle’s repair Lichtenstein Bassini’s repair Shouldice repair Ogilvie’s repair Plug and patch McVay’s or Cooper’s High ligation TAPP procedure TEPA procedure



Narrowing of deep ring by suturing medial wall “tension free” repair using mesh Suturing conjoint tendon to the incurved part of inguinal ligament Double breasting of transversalis fascia Plication of transversalis fascia Placing a plug of mesh in hernial defect Conjoint tendon sutured to cooper’s ligament [femoral] Ligation and transaction of indirect hernial sac w/o repair of inguinal floor [usually used in children] Trans-abdominal preperioneal inguinal hernia repair Totally extraperitoneal approach



• Strangulation in hernia is highest in femoral [R side mostly in females] > indirect > direct hernia • Indications for laparoscopic inguinal hernia repair: 1. bilateral inguinal hernia 2. recurring hernia 3. need o resume full activity as soon as possible • Common types of hernia: Richter’s Only part of intestinal wall is in the hernia. Littre’s The hernial sac contains Meckel’s diverticulum Petit’s Hernia thru inferior lumbar triangle Grynfeltt’s Hernia thru superior lumbar triangle Garengoff’s The hernial sac has the appendix Pantaloon’s A combination of direct and indirect inguinal hernia Parasomal Hernia adjacent to an ostomy Maydl’s W type of intestinal loop herniates Morgagni Anterior parasternal diaphragmatic hernia Spigelian Sac passes thru spigelian or semilunar fascia Sliding hernia Hernial sac partially formed by the wall of a viscus [ex. bladder/cecum] Cooper’s Involves the femoral canal and tracts to labia majora in females and scrotum in males Incisional Resulting as a surgical complication Epigastric Primary defect in linea alba above umbilicus Eventration Loss of integrity of the abdominal wall Internal hernia Hernia into or involving intra-abdominal structure Obturator Hernia thru obturator canal Lumbar hernia Petit’s hernia or Grynfeltt’s hernia Bochdalek’s Hernia hru the posterior diaphragm, usually on the left Femoral hernia Hernia medial o femoral vessels [under inguinal ligament] Indirect inguinal Inguinal hernia lateral to Hesselbach’s triangle Direct inguinal Inguinal hernia w/in Hesselbach’s triangle Hiatal hernia Hernia thru esophageal hiatus Umbilical hernia Hernia thru umbilical ring Internal Hernia thru defect in visceral structure Perineal Hernia thru floor of perineum Sciatic Hernia thru greater sciatic foramen Intraparietal Hernia in w/c abdominal contents migrate btw layers of abdominal wall Hesselbach’s Hernia under inguinal ligament lateral to femoral vessels Ventral Incisional hernia on ventral abdominal wall Parastomal Hernia adjacent to an ostomy [ex. colostomy] Properitoneal Intraperitoneal hernia btw peritoneum & transversalis fascia • Anterior vs. posterior hernioplasty Anterior hernioplasty Marcy-simple ring closure Bassini-Shouldice repair – gold standard McVay-Lotheissen ligament repair Lichtenstein – tension free repair



Posterior hernioplasty Nyhus iliopubic tract repair Cheatie-Henry midline approach Stoppa procedure Laparoscopic herniopasty



• Complications of hernioplasty: ischemic orchitis, testicular atrophy, neuralgia, recurrence



• Descriptive terms for hernia: Reducible Ability to return the displaced organ to usual anatomic site Incarcerated Swollen or fixed w/in hernial sac, may cause obstruction Strangulated Incarcerated hernia w/ resulting ischemia Complete Hernial sac and its contents protrude all the way thru the defect Incomplete Defect present w/o sac or contents protruding completely thru it Rapid recall MC site of abdominal hernias MC hernias in females MC hernia in both sexes MC inguinal hernia in children MC site of direct inguinal hernia MC organ in inguinal hernial sac in men MC organ in inguinal hernial sac in women



Inguinal canal Indirect inguinal hernia [tx: McVay repair] Indirect inguinal hernia Indirect inguinal hernia [R usually] Hesselbach’s triangle Small intestine Ovary or fallopian tube



PEDIATRIC SURGERY Fetal circulation • Blood from placenta returns to fetus by way of umbilical vein thru the ductus venosus directly into IVC • Most of saturated blood is shunted directly thru the foramen ovale to the left • De-saturated blood thru ductus arteriosus enters placental circulation Cardiovascular changes after birth • Systemic + pulmonary vascular resistance increases & ductus arteriosus closes • Remnants of the following will become: Umbilical vein Ligamentum teres UmbilicAL artery MediAL umbilical ligament Urachus Median umbilical ligament Tongue remnant [thyroid] Foramen cecum Vitelline duct Meckel’s diverticulum Ductus venosus Ligamentum venosus Ductus arteriosus Ligamentum arteriosus • • • • • •



Ductus arteriosus closes w/in 1st 24 hrs Ductus venosus closes after 2 wks, Foramen ovale closes in the 1st month Characterized by “egg-shaped heart” on CXR: transposition of great vessels Rastelli procedure: aorta is rerouted internally to L ventricle across VSD Ostium primum ASD [aka partial endocardial cushion defect or partial atrioventricular canal]. It is common among Down syndrome patients. • Among the supravalvular lesions, the hour-glass type is most amenable to surgical treatment. Pulmonary system • L: S ratio is a marker of fetal lung maturation. Delayed lung maturation is seen in DM & Rh isoimmunization • L:S ratio < 2: high risk for RDS • Lungs reach full maturity at 8 yrs • Esophagus & trachea originate from a single diverticulum & divide at 8 wks AOG Renal system • Normal GFR = 50 ml/min/m2 [neonates] & 1—ml/min/m2 [adults] • Normal urine output = 1-2 ml/kg/hr • Urine production starts at 9-12 wks AOG. • Nephrogenesis is complete by 35 wks. Pediatric pathological diseases • A newborn presents w/ respiratory distress and a scaphoid abdomen: diaphragmatic hernia • An infant has excessive oral secretions, chokes and has apneic episodes during feeding: tracheoesophageal malformation • Types of tracheoesophageal malformations: esophageal atresia & TEF, pure esophageal atresia & H-type TEF • Radiologic characteristics of pyloric stenosis: String sign From elongated pyloric channel Shoulder sign Bulge of pyloric muscle into the antrum Double tract sign Parallel streaks of barium in narrow channel • • • • • •



Biliary atresia accounts for 90% of extrahepatic obstruction in neonates. Optimal time of surgery for biliary atresia is at < 8 weeks of age. “Dance’s sign” - absence of bowel in RLQ [intussusception] “Target sign” – 2 concentric circles of fat density “Target or donut sign” – single hypoechoic ring w/ hyperechoic center “Pseudokidney sign” – superimposed hypoechoic [edematous walls of bowel] and hyperechoic [areas of compressed mucosa] layers • If a meckel’s diverticulum is found w/in a hernial sac, it is called: Littre’s hernia. • Correction of inguinal hernia is the most frequent surgical intervention in children.



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• A premature infant born at 33 week’s gestation now at 1 week of age has developed feeding intolerance, is febrile, and has hematochezia and a distended belly: necrotizing enterocolitis [NEC] • Pneumatosis intestinalis [gas w/in bowel wall] on AXR is seen in NEC • Surgical management of cleft lip & palate: Cleft lip 10 wks-3 mos. Rule of tens: 10 wks age, 10 gm/dl, 10 lbs wt, 10,000 WBC/mm3 Cleft palate 12-18 mo. • Types of fistula/atresia: Type A Esophageal atresia w/o TEF Type B Proximal esophageal atresia w/ proximal TEF Type C Proximal esophageal atresia w/ distal TEF Type D Proximal esophageal atresia w/both proximal + distal TEF Type E “H type” TEF w/o esophageal atresia



Treatment Resection Resection & chemotx Resection & chemotx 3 + w/ or w/o radiation Same as 4



OPHTHALMOLOGY • The red eye diseases: Bacterial conjunctivitis Viral conjunctivitis Allergic conjunctivitis Acute narrow angle glaucoma Iritis Corneal ulcer Corneal abrasion Orbital cellulitis 5-yr SR 90% 80% 40% 15% 80%



Age of presentation of the ffg: Pyloric stenosis From 2 wks to 2 mos. of age Intussusception From 4 mos. to 2 yrs [80%] Wilm’s tumor Btw 1-4 y.o Malrotation Birth to 1 y.o [>85%] Neuroblastoma 50% by 2 yrs, > 80% by 8 yrs of age Hepatoblastoma Younger than 3 y.o Appendicitis Older than 3 y.o Rapid recall MC cyanotic malformation MC CHD MC VSD requiring surgery MC type of VSD MC type of ASD MC branchial cyst MC lymphatic malformation in children MC congenital lung lesion 2nd MC congenital lung lesion MC malformation MC type of intestinal atresia MC site of atresia MC cause of acute intestinal obstruction under 2 y/o Most frequent congenial GI abnormally MC cause of lower intestinal obstruction in neonate MC intra-abdominal malignancy in childhood MC site of metastasis of neuroblastoma MC form of cleft palate MC site of intussusception MC ectopic tissue in meckel’s diverticulum MC cause of lower GI bleeding in children MC benign liver tumor in children MC solid neoplasms in infants MC solid tumor in children MC cause of SBO in children MC Sx of AML in children MC manifestation of hemophilia A



Droperidol Hydroxyzine, diphenhydramine Atropine, scopolamine, glycopyrolate metoclopramide Ranitidine Clonidine Ondansetron



Rapid recall Most popular regional anesthesia Most ideal for hemorrhoidectomy



• Stages of Wilm’s tumor: Stage 1 Limited to kidney and completely Stage 2 Extends beyond kidney, but completely resected, capsule invasion and perirenal tissues may be involved Stage 3 Residual non-hematogenous tumor after resection Stage 4 Hematogenous metastases [lung, distal LN, brain] Stage 5 Bilateral renal involvement Stages of neuroblastoma Stages Description 1 Tumor confined to organ of origin 2 Extends beyond organ but not across midline 3 Tumor extends across midline 4 Metastatic disease is found 4S Stage 1 & 2 tumor w/ mets to liver, BM, etc.



Tranquilizer Antihistamine Anticholinergic Gastrokinetic H2-blockers Alpha-2 agonists 5HT antagonists



Tetralogy of fallot [Coeur en sabot] VSD Perimembranous type Muscular VSD Ostium secundum type 2nd branchial cleft cyst Cystic hygroma Lobar emphysema Congenital cystic adenomatoid malformation Esophageal atresia w/ TEF Duodenal atresia Papilla of Vater Intussusception [MC site – ileocolic] Meckel’s diverticulum Hirschsprung’s disease [Sx: enterocolitis] Wilm’s tumor or nephroblatoma Lungs Total cleft palate Terminal ileum [ileocecal valve] Gastric mucosa Meckel’s diverticulum w/ ectopic gastric mucosa Hemangioma Neuroblastoma CNS tumors Hernia Fatigue Spontaneous traumatic hemorrhage



ANESTHESIA • Spinal anesthesia – needle is inserted at L3-L4 or L4-L5 [at this level cauda equina is present and spinal cord has already ended] • Epidural anesthesia - needle is placed in epidural space [outside CSF] commonly an indwelling catheter is left in place. • Epinephrine is nor use in this areas: SPF-10 [Scrotum, Penis, Fingers, Toes, Ears and Nose] • Commonly used pre-op anesthetic medications: Benzodiazepines Midazolam



• Important terms: Astigmatism Esotropia Exotropia Hypertropia Hyperopia Diplopia Strabismus Hyphema Chemosis Endophthalmitis Ptosis Anisocoria Nystagmus Dacrocystitis Mydriasis Miosis Myopia



Subarachnoid block in spinal anesthesia Caudal block



Conjunctival redness w/ purulent discharge Conjunctival redness w/ serous discharge Clear conjunctival discharge Acute pain, cloudy cornea, perilimbal redness, blurred vision Perilimbal redness, irregular pupil, pain, decreased vision Epithelial defect w/ infiltrate, pain Epithelial defect, no infiltrate, pain Periocular swelling, erythematous ocular surface, ↓ vision



Asymmetric cornea Eyes inward Eyes outward Eyes upward Farsightedness Double vision Eye malalignment Blood in anterior chamber of the eye Edema of conjunctiva Intraocular infection Eyelid droop Asymmetric pupil diameter Back and forth jerky movement of the eyes Lacrimal sac infection Pupil dilatation Pupil constriction Nearsightedness



EARS, NOSE AND THROAT • Menier’s disease is characterized by intermittent vertigo, tinnitus, hearing loss, and aural fullness due to excess endolymph. • Inflammation of the salivary gland: sialadenitis • Classic Sx of croup/laryngotracheobronchitis: barking [seal-like] non-productive cough • Le Fort classification: [see figure on surgical recall] Le Fort 1 Transverse maxillary fracture above dental apices, also traverses the pterygoid plate, palate is mobile, but nasal complex is stable Le Fort 2 Fracture thru the frontal process of maxilla, thru the orbital floor and pterygoid plate, midface is mobile Le Fort 3 Complete craniofacial separation: differs from II in that it extends thru nasofrontal fracture and frontozygomatic sutures • “Tripod” fractures: frontozygomatic suture, zygomaticomaxillary suture, inferior orbital rim, zygomaticotemporal suture Zones of the neck [see figure on surgical recall] Zone 1 Below cricoid cartilage Selective exploration Zone 2 Cricoid to angle of mandible Surgical exploration Zone 3 Angle of mandible & up Selective exploration Modified Neck dissection Type 1 Spinal accessory nerve is preserved Type 2 Spinal accessory N. & internal jugular N. is preserved Type 3 Spinal accessory N. & internal jugular N. & SCM nerves are preserved Rapid recall The only muscle not innervated by the vagus. MC site of angiosarcoma in head & neck MC salivary gland tumors MC site of subclinical 2nd primary tumor MC cause of otitis externa [swimmer’s ear] MC type of external ear tumor MC cause of acute otitis media in adults



Stylopharyngeus Scalp Pleiomorphic adenoma of parotid Esophagus Pseudomonas [tx w/ amoxicillin, PCN] Squamous cell CA [from auricle] Strep peumoniae & H. influenzae



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MC causes of chronic otitis media MC etiology in infants younger than 6 mos. MC cause of bilateral facial nerve palsy MC cause of unilateral facial weakness/paralysis MC encountered vascular mass in nasal cavity MC cause of parotid swelling MC benign salivary gland tumor 2nd MC benign salivary gland tumor MC malignant salivary gland tumor MC parotid malignancy 2nd MC submandibular gland malignancy 2nd MC malignant salivary tumor in adults 2nd MC parotid malignancy MC malignancy in submandibular & minor salivary glands Usual causative agent in epiglotitis MC salivary gland site of stone formation MC malignant neck mass in children, adolescents, and young adults MC primary malignant solid tumor of head & neck in kids MC Sx of oropharyngeal CA MC Sx of laryngeal CA MC manifestation of retinoblastoma Most important prognostic factor in head, neck CA PLASTIC SURGERY • Axial flaps and their arterial supply: Forehead flap Superficial temporal A. Deltopectoral 2nd-4th anterior perforators of flap internal mammary A. Groin flap Superficial circumflex iliac A.



S. aureus and P. aeruginosa S. aureus, E. coli, Kebsiella Lyme disease [B. burgdorferi] Bell’s palsy Juvenile nasopharyngeal angiofibroma Mumps Pleiomorphic adenoma [parotids] Warthin’s tumor [parotids] Mucoepidermoid CA Mucoepidermoid CA Mucoepidermoid CA Adenoid cystic CA Adenoid cystic CA Adenoid cystic CA H influenzae type B Submandibular gland Lymphoma Rhabdomyosaroma Persistent sore throat Hoarseness Leukoria Nodal metastasis



For intraoral lesions For head and neck wounds Hand/forearm wounds



• Donor sites for skin grafts: STSG Thigh, buttocks, abdomen, back FTSG Inguinal, upper lids, posterior auricular, supraclavicular • Types of skin grafts: Split-thickness skin graft Thin STSG Medium STSG Thick STSG Full-thickness



Size 0.008-0.012 inch 0.013-0.016 0.017-0.020 > 0.020



Rapid recall MC bacteria in tenosynovitis and paronychia MC hand [wrist] tumor MC cause of carpal tunnel syndrome MC posterior fossa tumor MC site of sinus cancer MC cell type in head and neck CA MC dressing material used MC cause of skin graft failure



Location Upper ¼ of dermis Upper ½ of dermis Upper ¾ of dermis Both epidermis & dermis



• Postradiation somnolence syndrome: lethargy for a period of 2-6 mos. after treatment • Spinal diseases [test of choice – MRI] Spondylosis Degenerative changes in spine, arthritis Spondyloliisthesis Subluxation of 1 vertebral body on another Spondylolysis Fracture or defect in pars interarticularis, mostly congenital at L5 [spina bifida oculta] • Lumbar spine maneuvers: Straight leg raise Radicular sx produced w/ leg elevation in supine position Crossed straight Radicular sx produced in affected leg w/ elevation of leg raise opposite leg. • Cervical spine maneuver: Spurling’s sign Radicular pain produced w/ downward pressure on head when neck is extended and tilted toward the affected side • Herniated disc terminology: Bulge Symmetric extension Protrusion Asymmetric extension Extrusion Free disc fragment Degenerated Narrowed disc space



• Herniated disc syndromes: Level Motor weakness C4-5 Shoulder abduction C5-6 Forearm flexion C6-7 Forearm, wrist, and finger extension C7-T1 Wrist and finger flexion L3-4 Quadriceps L4-5 Tibialis anterior and extensor hallucis longus L5-S1 Gastrcnemius/soleus • • • • •



S. aureus Ganglion cysts Synovitis Acoustic neuromas [cerebellopontine angle] Maxillary sinus Squamous cell CA Alginates [Caltostat] Bleeding or hematoma



NEUROSURGERY • Boomerang sign – one of the earliest manifestations of hydrocephalus in w/c temporal tips of the lateral ventricle appear. • Macewen’s sign: tapping on the head of a hydrocephalic infant produces a cracked pot sound. • An 83 y/o female w/ a hx of diabetes, HPN and atherosclerosis presents w/ painless, mononuclear vision loss that lasted a few minutes and has now completely resolved. She has no other neurologic deficits: amaurosis fugax • Cerebral hypoperfusion syndrome: unilateral headache due to poor autoregulation w/c can cause seizure. • CN III palsy is characterized by blown pupil w/ down and out eyes as seen in uncal herniation. • CN VIII is affected most frequently in neuroma. • “Fried egg or chicken wire pattern’ – a fixation artifact not routine seen. • Tumors arising from paraganglion cells: carotid body tumors, glomus jugulare tumors, pheochromocytomas • Common sources of metastatic tumors: bronchogenic lung CA, melanoma, breast CA, renal cell CA, colon adenocarcinoma • Certain metastasis are more likely to hemorrhage: melanoma, renal cell CA, choriocarinoma • Most metastases occur in the cerebral hemispheres at gray-white junction or in cerebellum. • Radiosensitive metastasis are characteristic of: small cell lung CA, lymphoma, multiple myeloma, and germ cell tumors • “Subependymal tubers” or calcific hamartomas + “ash leaf spots” on skin are characteristics of tuberous sclerosis. • Surgery for hydrocephalus is usually done at 3-4 mos. • Presents as “worst headache” of my life: spontaneous subarachnoid hemorrhage



Reflex affected Deltoid Biceps, brachioradialis Triceps Finger jerk Patellar Medial hamstring Achilles



“Bamboo spine” in plain films – osteophytic growth over intervertebral discs connecting adjacent vertebrae are characteristic: Diffuse Idiopathic Skeletal Hyperostosis/Forestier syndrome Cystic cavitation w/in spinal cord: syringomyelia Erb-Duchenne palsy or “Bellhop/Waiter’s tip palsy [C5/6 injury]: arm medially rotated w/ wrist and fingers flexed. Klumpke’s palsy [C8-T1 injury]: in an adult w/ insidious progressive development, think Pancoast tumor. There may be associated Horner’s syndrome. Meralgia paresthetica: entrapment as nerve emerges through inguinal ligament causing lateral thigh paresthesia. Spinal cord traumatic syndromes, diseases and fractures Anterior cord Affecs coricospinal and lateral spinothalamic tracts, paraplegia, syndrome loss of pain/temperature sensation, preserved touch/vibration/proprioception Central cord Preservation of some lower extremity motor and sensory ability syndrome w/ upper extremity weakness Brown-Sequard Hemisection of cord resulting in ipsilateral motor weakness synd. and touch/proprioception loss w/ contralateral pain/ temperature loss Posterior cord Injury to posterior spinal cord w/ loss of proprioception distally Jefferson’s fx Fracture thru C1 arches from axial loading [unstable fracture] Hangman’s fx Fracture thru pedicles of C2 from hyperextension Odontoid fx Fracture of odontoid process of C2 Priapism Penile erection seen w/ spinal cord injury Chance fx Transverse vertebral fracture Clay-Shoveler’s Fracture of spinous process of C7 Berry aneurysm Saccular outpouching of vessels in circle of Willis, usually at bifurcations Cauda equina Herniated disc compressing multiple S1, S2, S3, S4 nerve syndrome roots, resulting in bowel/bladder incontinence, “saddle anesthesia” over buttocks/perineum, low back pain, sciatica



Acute epidural vs. Subdural hematomas Features Epidural hematoma Supratentorial 70% Skull fracture Source of hemorrhage Arterial or venous Vessels involved Middle meningeal A. Location Temporoparietal Features Blown pupil [fixed, dilated], classic “lucid interval” [mins/hrs] CT scan findings Lens-shaped, convex hyperdensity Seizures



< 25%



Subdural hematoma 30% Venous Ruptured bridging veins Frontoparietal HA, mental status changes, contralateral hemipharesis Crescent-shaped, concaved hyperdensity 75%



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Treatment Mortality Infratentorial Frequency Skull fracture Source of hemorrhage



Neurosurgical evacuation High



Surgical evacuation Low



More common Almost always Venous



Less common Frequent Venous



• Glasgow coma scale Points Best eye opening Best verbal 6 5 Oriented 4 Spontaneous Disoriented 3 To speech Inappropriate words 2 To pain Incomprehensible sounds 1 None None Note: Mild: 13-15; moderate: 9-12; severe < 8



Best motor Obeys Localizes pain Withdraws to pain Flexion [decorticate] Extension [decerebrate] None



• Differentiating linear skull fractures from normal plain films findings Feature Linear fracture Vessel groove Suture line Density Dark black Grey Grey Course Straight Curving Follows course of suture lines Branching None Branching Joins other suture lines Width Very thin Thicker than Fx jagged, wide • Types of subdural hematoma: Acute Sx w/in 48 hrs of injury Subacute Sx w/in 3-14 days Chronic Sx after 2 weeks or longer Rapid recall Gold standard in dx of carotid artery stenosis. Gold standard in dx of carotid dissection w/c shows “beaking, string and pearl sign, and double lumen sign” Pathognomonic for neurofibromatosis 2 MC affected in ependymoma MC adult posterior fossa tumor MC pathology in pineal tumors “Ghost tumor” and is the great imitator of brain tumor Mainstay of treatment in CNS lymphoma MC malignant pediatric brain tumor MC intracranial tumors in adults MC intracranial tumors in children MC primary bone tumors in adults MC location of medulloblastoma MC site of brain abscess MC cranial nerve injury MC type of glioma MC cause of subdural empyema MC pathogen in spinal epidural abscess MC bacteria causing post-neurosurgery meningitis MC etiology for spinal epidural abscess MC pathogen in cerebral abscess MC etiology of mycoic aneurysm MC parasitic infection involving CNS MC fungal infection involving CNS MC site of vertebral osteomyelitis Most lethal & the majority of brain injuries “Ivory vertebrae” is characteristic of MC location of hypertensive intracerebral hemorrhage MC site of spinal injury in children MC site of herniated disc at lumbar level MC site of herniated disc at cervical level MC type of fracture to axis MC cause of subarachnoid hemorrhage [SAH] MC cause of non-traumatic SAH in adults MC cause of morbidity & mortality in SAH MC cause acute compression neuropathy. MC physical sign of brain metastasis MC sign of epidural hematoma Most important prognostic factor in neuroblastoma CARDIOTHORACIC SURGERY



Carotid angiogram Angiogram Bilateral CN 8/acoustic neuromas 4th ventricle Hemangioblastoma Germinoma CNS lymphoma Radiation therapy Primitive neuroectodermal tumors [PNET] Metastatic > gliomas > meningiomas Medulloblastomas > astrocytomas > ependymomas Glioblastoma multiforme Cerebellar vermis [children] or cerebellar hemispheres [adults] Frontal lobe CN 7 Ependymoma Frontal sinusitis Staph aureus Staph aureus Staph aureus Streptococcus Streptococcus Neurocysticercosis Candidiasis Lumbar GSW to head Chordoma Putamen Cervical > thoracic L5-S1, then L4-5 C6-7, C5-6 Odontoid type 2 Trauma Ruptured berry aneurysm Re-bleeding Peroneal Focal neurologic deficit Ipsilateral blown pupil Age at time of diagnosis



• Pancoast tumor: tumor at apex of lung or superior sulcus that may involve the brachial plexus, sympathetic ganglia, and vertebral bodies, leading o pain, upper extremity weakness, and horner’s syndrome • Benign lymphatic tumor is called cystic hygroma while a malignant lymphatic tumor is called lymphagiosarcoma • “popcorn-like” lesion on x-ray is diagnostic of: pulmonary hamartoma • Plaque rupture is the main cause of escalation of symptoms. Intermittent closure of dynamic plaques underlies symptoms of unstable angina. • The intra-aortic ballon pump [IABP] sits in the descending aorta [just distal to where the left subclavian takes off]. • Austin flint murmur: low pitched diastolic rumble secondary to regurgitated blood striking the anterior leaflet. • Anatomic classification of thoracic aortic aneurysms: Debakey type 1 Ascending and descending aorta Debakey type 2 Ascending aorta only Debakey type 3 Descending aorta only • “Tearing or ripping” chest pain radiating to the back is characteristic of thoracic aortic aneurysm. • “calcium sign” – reflects separation of intimal calcification from adventitial surface on CXR is seen in thoracic aortic aneurysm • Crawford classification for thoracoabdominal aneurysms: Type 1 Descending thoracic aorta + abdominal Thoracic incision aorta proximal to renal arteries Type 2 Descending thoracic aorta + abdominal Incision from 6th ICS aorta distal to renal arteries into abdomen Type 3 Distal ½ of descending thoracic aorta + Same as type 2 abdominal aorta proximal to renal arteries Type 4 Distal ½ of descending thoracic aorta + Retroperioneal incision abdominal aorta distal to renal arteries from L flank→umbilicus Mediastinal contents Superior Aortic arch, great vessels, upper trachea, esophagus Anterior Thymus, ascending aorta, LN Middle Heart, lower trachea & bifurcation, lung hilus, phrenic nerves, LN Posterior



Esophagus, descending aorta, thoracic duct, vagus & intercostals N., sympathetic trunks, azygos & hemiazygos V., LN



Rapid recall MC benign lung tumor 2ND MC benign lung tumor MC etiology of chronic mediastinitis MC cause of embolus from the heart MC site of arterial occlusion by an embolus MC site of arterial occlusion from atherosclerosis: MC site of abdominal aortic aneurysm MC benign cardiac tumor MC malignant cardiac tumor in children MC intervention in thoracic trauma MC cause of malignant pleural effusion MC cause of chylothorax 2nd MC cause of chylothorax MC type of bronchial gland tumor in lower respiratory tract MC neoplasm of anterosuperior mediastinum MC primary mediastinal cysts MC mediastinal tumor MC cause of ascending aortic aneurysm MC cause of mitral stenosis. Most important risk factor for atherosclerosis Most important manifestation in rheumatic fever Type of lung CA arising from non-smokers MC symptom of lung cancer Method of choice for centrally-located masses [squamous cell and small cell CA] Method of choice for peripherally located nodules Test of choice for pxs w/ pleural effusion and suspected malignancy



Thymoma, thyroid, germ cell, lymphoma Pericardial cysts, lymphoma, mediastinal granuloma, bronchogenic cysts Neurogenic tumors



Hamartoma Bronchial adenoma Histoplasma capsulatum Atrial fibrillation Common femoral artery Superficial femoral artery Infrarenal artery Myxoma [L atrium] Rhabdomyoma Closed tube thoracostomy Lung CA Lymphoma Trauma Adenoid cystic teratoma Thymoma Bronchogenic cysts Neuroblastoma [children] Cystic medial necrosis RHD Systemic HPN Rheumatic heart disease Adenocarcinoma Chronic cough Bronchoscopy Transthoacic needle biopsy Thoracentesis



VASCULAR SURGERY • You are asked to see a px w/ bleeding from an angiogram puncture site. She has an oozing, pulsatile expanding mass in her groin at the puncture site: expanding hemangioma • ”blue toe syndrome” is seen in embolism. • Chronic ischemia MC affects: infrarenal aorta, iliac arteries and superficial femoral artery • Infrainguinal disease affects: superficial femoral artery at adductor canal



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• Size at w/c abdominal aortic aneurysm is considered for surgical repair: 5cm • External iliac artery is never involved when cause of aneurysm is atherosclerosis. Hard signs & soft signs of arterial injury Hard signs Hemorrhage Distal pulse deficits Large expanding pulsatile hematoma Distal ischemia Bruit or thrill Rx: exploration



Soft signs Hemorrhage Hx of hypotension Deficit in anatomically related nerves Small, stable, non-pulsatile hematoma Proximity of an injury to arterial supply Rx: angiography



Rapid recall MC site of peripheral aneurysm MC vascular disorder MC site of arterial atherosclerotic occlusion in lower extremities MC level for non-viable foot MC complaint of chronic arterial ischemia MC manifestation of chronic mesenteric ischemia Best chance of healing particularly in pxs w/ PVD.



Popliteal artery Varicose veins SFA in hunter’s canal Below knee amputation Intermittent claudication Postprandial abdominal pain & weight loss Above knee amputation



Overflow incontinence Urge incontinence Mixed type Enuresis



Whitmore’s staging for prostate CA Stage Description A CA not detectable by PE but incidentally on surgical specimen B Palpable but confined to prostate B1: involves 1 nodule w/ normal tissues B2: involves the gland more diffusely C Palpable tumor extends beyond prostate but no distant mets D Distant mets present D1: to pelvic nodes only D2: widespread mets Surgical staging & treatment for prostate CA Stages Description 1 Clinically inapparent tumor, No LN or mets 2 3 4



TRANSPLANT • Definitions: Autograft Allograft Isograft Xenograft Orthotopic Heterotopic Paratopic



Donor + recipient are same individual or of same genetic makeup Donor + recipient belong to same species but different genetic makeup Donor and recipient are genetically identical [identical twins] Donor and recipient are of different species Transplant graft placed into its anatomic position Transplant graft placed at different site Donor organ is placed closed o original organ



• A kidney transplant recipient is seen in the ER for nausea and abdominal pain , fever and elevated creatinine: acute rejection • Storage temperature of an organ: 4 degrees Celsius, on ice in a cooler • Optimum and maximum times for each organ: Heart and lungs 4-6 hrs; preferred w/in 5 hrs Pancreas Up to 30 hrs, preferred by 10-20 hrs Liver 24 hrs; preferred 6-12 hrs Kidney 48 hrs • L kidney is preferred by surgeons because of its longer renal vein. • Pancreatic transplant is placed in abdominal cavity rather than in retroperitoneal space because of a lower incidence of peripancreatic fluid collections and lymphocele. Rapid recall Drug of choice for liver transplant MC solid organ being transplanted MC cause of kidney transplants MC infectious complication after pancreas transplant



Tacrolimus [FK-506] Kidney Diabetes UTI



GENITO-URINARY SYSTEM • Cremasteric reflex: retraction of the testicle as the medial aspect of thish is stroked • Always suspect torsion in px w/ inguinal pain and an empty scrotum. • An adolescent presents w/ acute testicular pain and swelling immediately after a sporting event. He is ill appearing, writhing in pain. He had similar episodes of this in the past: testicular torsion • A 40 y/o man presents w/ sudden onset of L-sided flank pain that he rates 10/10. He is writhing, unable to stay still or find a comfortable position: renal colic • During passage of a stone, there are 5 sites where passage is likely to become arrested: calyx of kidney, ureteropelvic junction, pelvic brim, ureterovesical junction and vesicle orifice • Stones < 5-8 mm pass spontaneously • An 87 y/o man w/ hx of prostate CA presents w/ low back pain: bony metastasis w/ cord compression • Radical prostatectomy is indicated for stage 2B prostatic CA. • Peyronies disease: abnormal fibrosis of penis shaft resuling in bend upon erection. • Seminonas are radiosensitive. • Type of bony lesions seen in metastatic prostate CA: osteoblastic [radiopaque] • “Bag of worms” = grade 3 varicocoele



• Types of incontinence: Stress Loss of urine associated w/ coughing, lifting, exercise, seen incontinence most often in women secondary to relaxation of pelvic floor



Failure of bladder o empty properly, may be caused by bladder outlet obstruction or detrusor hypotonicity Loss of urine secondary to detrusor instability in pxs w/ stroke, dementia and parkinson’s disease Combination of urge & stress incontinence Bedwetting in children



Tumor w/in prostate, no LN or mets Tumor thru prostate capsule, no nodes or mets Tumor extends into adjacent structures, [+] LN & mets



Staging & treatment of testicular CA Stages Description 1 Confined to testis into tunica albuginea or epididymis, no LN or mets 2 [+] LN, no mets, any tumor 3 Distant mets, any nodal status, any tumor size



Treatment Radical prostatectomy, [+/-] external beam radiation Same as 1 Radiation tx Hormonal tx



Treatment Inguinal orchiectomy & radiation to retroperitoneal LN Same as 1 Orchiectomy & chemotherapy



Renal cell CA staging Stages Description 1 Tumor confined within kidney capsule 2 Invasion thru kidney capsule but confined within Gerota’s fascia 3 Involves regional LN or vena cava 4 Distant metastases Types of nephrolithiasis Type Freq. Ca+ oxalate or 83% PO4 Struvite [Mg-NH4PO4]



9%



Uric acid



7%



Cystine



1%



Etiology & characteristics Idiopathic hypercalciuria, elevated uric acid sec. to diet & 1◦ hyperthyroidism. Alkaline urine. Radiopaque “Triple-phosphate stones”. Associated w/ Proteus. Form staghorn calculi. Alkaline urine. Radiopaque Gout & high-purine diet turnover states. Acidic urine. Radioluscent Defect in cystine, ornithine, lysine & arginine-COLA]. Hexagonal crystals. Radiopaque.



5 yr-SR 60-75% 45-65% 25-505 < 5% Treatment Hydration, thiazides Hydration, treat UTI if present Hydration, alkalinize urine w/ citrate Hydration, alkalinize urine, penicillamine



Bladder CA staging [using CT scan of abdomen & pelvis & surgical staging] Superficial St. 0 CIS, mucosal involvement Tumor < 2.5 cm, no nodes/mets 1 St. A Submucosal involvement > 2.5 cm, limited to kidney, no 2 nodes or mets Invasive St. B Involvement of UB 3 Extends to IVC, [+] regional LN muscularis but < 2 cm diameter, & extends past gerota’s fascia St. C Involvement of perivesical fat Metastatic St. D1 Metastatis to LN 4 Distant mets, [+] LN, > 2cm diameter & extends past St. D2 Mets to bone or other viscera gerota’s fascia of the body Rapid recall Classic sign of testicular torsion MC malignancy to affect young men MC testicular tumor Most precise method of determining the anatomy of ureter and renal pelvis in diagnosing renal calculi Procedure of choice in BPH Most sensitive test for early detection of prostatic CA Primary method for evaluating renal masses Method of choice for diagnosis & staging of renal cell CA TOC if no evidence of metastasis is seen in renal CA



High-riding testis w/ a horizontal lie Testicular tumor Germ cell tumor Retrograde pyelogram Transurethral prostatectomy PSA IVP w/ nephrotography CT scan Radical nephrectomy



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Mainstay of treatment in bladder CA Classic presentation of bladder CA MC cause of ARF in surgical pxs MC cause of ARF in surgical patient MC histology of prostate CA Type of stone NOT seen on x-ray Stone associated w/ UTI Stones seen in IBD Area of prostate where BPH arise Area of prostate where CA arise MC site of distant metastasis in renal cell CA MC solid renal tumor of childhood MC injured urinary organ Least injured urinary organ MC correctable surgical cause of infertility MC Sx of BPH MC Sx of renal stone MC manifestation of Alport’s syndrome MC manifestation of amyloidosis Most important factor in DM 2 pathogenesis MC kidney lesion in DM Most important prognostic factor in prostatic CA Most important prognostic factor in CA of UB Most important prognostic factor in anal CA



Simple or radical cystectomy Painless hematuria Sequestered 3rd space loss [post-op site] Hypovolemia Adenocarcinoma Uric acid Struvite stones Calcium oxalate Periurethral Periphery Lung Wilm’s tumor Kidneys Ureters Varicocoele Oliguria & urinary retention Flank pain Asymptomatic hematuria Renal involvement Insulin resistance Nodular glomerulitis Grading Depth of invasion Stage of disease



ORTHOPEDICS • Synovial fluid lacks fibrinogen thus it is non-clotting • Most stress fractures occur in lower extremities and commonly affect individuals involved in sports and military recruits “march fracture” • Incidence of stress fractures by site: metatarsal [50%], calcaneous [25%], tibia [20%], tarsalnavicular [common in basketball players] • Study on Salter-Harris fracture on page 467: surgical clerkship book = [SALTR] Salter 1 Thru physeal plate only Separated Salter 2 Involves physis and metaphysis Above Salter 3 Involves physis and epiphysis Lower Salter 4 From metaphysis thru physis into epiphysis Through Salter 5 Axial force crushes the physeal growth plate Ruined • Fracture healing: Stage 1 Inflammation & hematoma formation Day 1 Stage 2 Hematoma organization Day 2-7 Stage 3 Callus formation, longest phase Day 8-90 Stage 4 Remodeling • A 25 y/o male complains of difficulty breathing. He was noted to be acting a little confused, and that he has spotty purplish rash. 2 days ago, he sustained a femur fracture after a high speed MVA: fat embolism syndrome • Hallmark finding in compartment syndromes: pain in a conscious and fully oriented person that is out of proportion to injury or findings. • “Sun burst or sun ray pattern” on x-ray is seen in: osteosarcoma [2/3 of distal femur and proximal tibia], it metastasize to thee lungs • Enchondromas in multiple bones is called Ollier’s disease. • Still’s disease: rheumatoid arthritis, fever, rash & splenomegaly • “soap-bubble” appearance due to a thin subperiosteal bone shell is seen in: giant cell tumor • “Lamellated onion-skin” appearance on x-ray is characteristic of: Ewing’s tumor • “soap-bubble appearance” on x-ray is also seen in: multiple myeloma • Most likely site of origin for metastatic tumors: BLTKP [Breast, Lung, Thyroid, Kidney, Prostate] • Types of histiocytosis: Letterer-Siwe disease Most severe form [< 2 y.o]. Hepatomegaly, LAD, rash, bleeding diathesis, anemia, exopthalmos, DI Hand-Schuller-Christian dse < 5 y.o. associated ww/ systemic severe illness in children Eosinophilic granuloma Mildest form, in older age group. Minimal S/Sx • Miscellaneous bone diseases Legg-Calve-Perthes dse Slipped capital femoral epiphysis Blount’s disease Osgood-Schlatter’s disease



Idiopathic vascular necrosis of femoral head in children Migration of proximal femoral epiphysis on the metaphysic in children Idiopathic varus bowing of tibia Apophysitis of tibial tubercle resulting from repeated powerful contractions of quadriceps



Rapid recall MC pathologic condition associated w/ pathologic fx



Osteoporosis



MC orthopedic injury MC fractured bone MC fractured long bone MC dislocated joint MC sprained joint MC site of non-union MC etiology for volkman’s ischemia contracture MC cause of acute hematogenous osteomyelitis MC site for acute osteomyelitis MC site of giant cell tumor MC osteiod forming benign tumor MC benign tumor of the bone MC primary malignant bone tumor MC pediatric bone tumors MC malignant sarcomas in adults MC site of Ewing’s sarcoma MC site of osteosarcoma Most important indicator whether bone growth is MC type of melanoma MC malignant sarcomas in children MC type of sarcoma to metastasize to lymph nodes MC sarcoma of retroperitoneum MC site of melanoma MC metastatic site of osteosarcoma MC site of solitary fibrous dysplasia Hallmark finding in fat embolism syndrome:



Hip dislocation Clavicle Radius, tibia Shoulder joint Ankle joint Middle distal tibia Compression of anterior aspect of elbow and upper forearm after a supracondylar fracture in childhood Staph aureus Metaphyseal end of a single long bone [especially around the knee] Around the knee [distal femur and proximal tibia] Osteiod osteoma [MC site: diaphysis of long tubular bones] Osteochondroma [MC site: metaphysis of long bones of extremities] Multiple myeloma Osteochondroma Fibrous histiocytoma, liposarcoma and leiomyosarcoma Knee 2/3 of distal femur Benign or malignant is the zone of transition Superficial spreading [>70%] Rhabdomyosarcoma, fibrosarcoma Malignant fibrous histiocytoma Liposarcoma Men [back], in women [legs] Lungs Ribs Arterial hypoxemia [PO2 ¸60 mmHg]



HAND INJURIES • The radial nerve does NOT innervate any of the intrinsic muscles of the hand. • Clinical maneuvers for testing muscles of the hand Patient maneuver Muscle tested Bending the tip of the thumb Flexor pollicis longus Bending each individual fingertip against resistance Flexor digiorum profundus while PIPs are stabilized by examiner Bring thumb out to side and back Extensor pollicis brevis and abductor pollicis longus Flexing and extending a fist at the wrist Extensor carpi radialis longus and brevis Raising thumb only while rest of the hand is laid flat Extensor pollicis longus Making a fist w/ little finger extended alone Extensor digiti minimi • Kanavel signs of tensynovitis: STEP [Symmetrical swelling of finger, Tenderness over flexor tendon sheath, Extension of digit is painful, Posture of digit at rest is flexed] • Volkmann’s contracture: contracture of forearm flexors secondary to forearm compartment syndrome, usually due to brachial artery injury or supracondylar humerus fracture. • Dupuyren’s contracture: thickening and contracture of palmar fascia • A 37 y/o female presents w/ pain in her R wrist and fingers, accompanied by a tingling sensation. The pain awakens her from sleep, and she is unable to perform her duties as a word processor: carpal tunnel syndrome • Common hand and wrist injuries: Avulsion fracture In w/c tendon is pulled from bone, carrying w/ it a bone clip Boxer’s fracture Fx of neck of 5th metacarpal sustained in a closed fist injury Bennet’s fracture Fracture dislocation of base of thumb Boxers fracture Fracture of metacarpal neck “classically” of small finger Clay shoveler’s Fracture of spinous process of C6-7 Colle’s fracture Dinnerfork deformity, distal radius fx w/ dorsal angulation Jones fracture Fracture at base of 5th metatarsal diaphysis Galleazzi fracture Distal 1/3 radial fracture w/ dislocation of distal radioulnar joint caused by a direct blow to the back of wrist Hangman’s fracture Fracture of the pedicles of C2 Monteggia’s fracture Proximal 1/3 ulnar fx w/ dislocation of radial head caused by direct blow to posterior ulna Nightstick fracture Isolated fx of the ulnar shaft Periarticular fracture Fracture close but not involving the joint Pott’s fracture Fracture of the distal fibula Intra-articular fracture Fracture thru the articular surface of a bone Rolando fracture Comminuted fracture of the base of the thumb Scaphoid fracture MC cause by a fall on outstretched hand, snuffbox is tender Smith’s fracture Distal radius fx w/ volar angulation caused by direct trauma to dorsal forearm Transcervical fracture Fracture thru the neck of the femur



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Tibial plateau fracture Torus fracture or buckle fracture



Intra-articular fracture of the proximal tibia Impaction injury in children in w/c cortex is buckled but not disrupted



• Miscellaneous hand injuries Charcot’s joint Joint arthritis from peripheral neuropathy Tennis elbow Tendonitis of the lateral epicondyle of the humerus Turf toe Hyperextension of great toe [tear of tendon of flexor hallucis brevis], seen in football players Shin splints Exercise-induced anterior compartment hyperextension [compartment syndrome] seen in runners Heel spur Plantar fasciitis w/ abnormal bone growth in plantar fascia, seen in runner and walkers Traumatic myositis Abnormal bone deposit in a muscle after blunt trauma, deep muscle contusion, benign Marjolins ulcer SCCA that arises in chronic sinus from osteomyelitis Bouchard’s nodes Enlarged PIP joints of hand from cartilage/bone growth HeberDen’s nodes Enlarged DIP joints of hand from cartilage/bone growth Pannus Inflammatory exudates overlying synovial cells inside the joint Gamekeeper’s thumb Avulsion of ulnar collateral ligament of 1 st metacarpal joint, usually associated w/ ski pole injury Mallet finger Rupture of extensor tendon at its insertion into base of distal phalanx Trigger finger Stenosis of tendon sheath of flexor digitorum + nodule formation • Motor sensation tests of different peripheral nerves Radial N. Wrist extension, dorsal web space btw thumb and index finger Ulnar N. Little finger abduction, little finger-distal ulnar aspect Median N. Thumb opposition or thumb pinch, index finger-distal radial aspect Musculocutaneous Arm abduction, deltoid patch on lateral aspect of arm •



Definitions of fractures: [see diagram on surgical recall p. 648] Closed fracture Intact skin over fracture/hematoma Open fracture or Wound overlying fracture, thru w/c fracture segments are compound fracture continuity outside environment Simple fracture 1 fracture line, 2 bone fragments Comminuted fracture Results in > 2 bone fragments, aka fragmentation Transverse fracture Fracture line perpendicular to long axis of bone Oblique fracture Fracture line creates an oblique angle w/ long axis of bone Spiral fracture Severe oblique fracture in w/c fracture plane rotates along the long axis of bone, caused by twisting injury Longitudinal fracture Fracture line parallel to long axis of bone Impacted fracture Resulting from compressive force, end of bone is driven into contiguous metaphysis w/o displacement Pathologic fracture Fracture thru abnormal bone [ex. osteoporitic bone] Stress fracture Fracture in normal bone from cyclic loading of bone



Rapid recall MC cause of tenosynovitis and osteomyelitis MC cause of osteomyelitis in pxs w/ sickle cell disease MC cause of pathologic fracture in adults MC cause of hip dislocation MC type of hip dislocation MC type of elbow dislocation MC type of shoulder dislocation MC orthopedic tumors in adults MC entrapment neuropathy MC site of compartment syndrome in legs In arms



Staph aureus Salmonella Osteoporosis High-velocity trauma [ex. MVA] Posterior “dashboard dislocation” Posterior [brachial A., ulnar, median] Anterior [axillary nerve and artery] Metastasis [prostate – MC, breast, lung, kidney, thyroid and multiple myeloma] Carpal tunnel syndrome Calf Anterior compartment



MISCELLANEOUS Most common complications of surgical diseases MC complication of adult MI MC complication of PUD MC complication of meckel’s diverticulum MC complication of diverticulitis Most serious complication of acute MI & MC COD in 1st hr after an MI Most serious complication of carotid endarterectomy MC urologic complication of Crohn;s disease MC cardiac complication after thoracic surgery MC complication of pacemaker insertion MC complication of appendectomy MC complication of pancreaticoduodenal resection MC complication of thyroidectomy



Arrhythmia Bleeding Intestinal obstruction Abscess formation Ventricular arrhythmia Perioperative stroke Ureteral obstruction Supraventricular arrhythmias [usually AF] Migration of facing electrode Wound infection Pancreatic fistula Wound hematoma



MC complication after gastrectomy MC complication after splenectomy MC complication of pulmonary artery cathetherization MC complication of heparin therapy MC complication after varicose operation Most serious complication of lower extremity thrombophlebitis Most severe complication of rheumatic fever Most severe complication of Kawasaki disease Most severe complication after repair of thoracic abdominal aortic aneurysm Most severe complication of thyroid surgery Most severe complication of trauma surgery Most severe complication of portal HPN Most severe complication of colitis Most severe complication of Barret’s esophagus Common causes of death in surgical diseases MC COD in Alzheimer’s disease MC COD in premature infants MC COD in MI MC COD in dialyzed CKD px MC COD among hospitalized px w/ acute MI MC COD in cystic fibrosis MC COD in DM MC COD in Mallory-Weis syndrome MC COD in Marfan’s syndrome MC COD in HPN Most important COD in pxs w/ HPN MC COD in SLE MC COD in CML MC COD in sickle cell anemia MC COD in USA MC COD in Philippines MC fatal genetic defect in Caucasians MC CA among black African countries MC perioperative COD following a shunt procedure MC post-op COD in px undergoing AAA surgery MC post-op COD in repair of aortic dissection MC COD after major vascular injury MC COD after a major pelvic fracture MC COD in ruptured rectosigmoid colon



Alkaline reflux disease Left lower lung atelectasis PVCs Thrombocytopenia Ecchymosis Pulmonary infarct Endocarditis Coronary artery aneurysm Paraplegia Hemorrhage Descending aorta tear Bleeding esophageal varices Toxic megacolon AdenoCA Pneumonia Hyaline membrane disease Arrhythmia Heart disease Cardiogenic shock Respiratory failure MI [IHD] Massive hemorrhage at EG junction Dissecting aortic aneurysm AMI [2nd=lenticulostriate stroke, 3rd = CRF] CHF Lupus nephropathy type 4 [diffuse proliferative] Blast crisis Pneumococci & Hib Ischemic hear disease CVD Cystic fibrosis Cervical & uterine CA Hepatic failure [secondary to decrease blood flow] MI Hemorrhage CAD Fat embolism Peritonitis



Definitive procedures & treatment for common surgical diseases Most definitive surgery for rectal CA 4 cm above anal verge Most definitive operative tx for lung abscess Most definitive operation for idiopathic pseudoobstruction MC procedure for aortic root replacement MC procedure for pancreatic head CA MC procedure to treat BPH MC procedure for follicular thyroid CA MC procedure for supravesical urinary diversion MC trauma resuscitation fluid MC electrolyte mediated ileus Most effective treatment for hypokalimea Most characteristic of intestinal obstruction in upright AXR MC abdominal x-ray finding in SBO MC x-ray finding in traumatic thoracic injury MC sign of pancreatitis on AXR MC indication for laparoscopic splenectomy MC indication for surgery in regional enteritis MC indication for surgery in Crohn’s disease MC indication for emergent laparoscopy in NB Most important diagnostic procedure for suspected esophageal CA Most direct method of visualizing urethra & UB Most reliable method to detect gastric CA Most reliable renal imaging study Most reliable indicator of biliary tract disease Most reliable in identifying colon pathology Most reliable method to confirm esophageal caustic injury Most reliable invasive method to investigate pulmonary disease Most reliable & complete exam for large bowel



APR Pulmonary resection Subtotal colectomy w/ ileorectal anastomosis Composite valve graft procedure Whipple’s resection [pancreaticoduodenectomy] TURP Near-total thyroidectomy Cutaneous ureteroileostomy Plain LR Hypokalimea Hemodialysis Stepladder appearance Air-fluid level in upright film Widened mediastinum Sentinel loop ITP Obstruction SBO NEC Barium swallow Cystoscopy Endoscopy CT scan Biliary UTZ Barium enema Endoscopy Bronchoscopy Colonoscopy



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Most reliable non-invasive method for detecting vascular lesion Most reliable method to evaluate DVT Most reliable method to evaluate CAD Most reliable method to document location & severity of infrainguinal arterial occlusive disease Most reliable procedure in detecting UGIB Most reliable method for localizing GU bleeding Most reliable method to dx thoracic aortic aneurysm Most reliable test for peritonitis Most reliable test to determine presence of intra-abdominal injury Most reliable test for pheochromocytoma Most useful test in establishing the cause of hypercortisolism & in determining whether cause is pituitary dependent or independent Most reliable liver function test in detecting hepatic metastasis Most reliable indicator of thyroid function Most sensitive test of thyroid function MC screening procedure for colonic CA MC used contrast study for colorectal CA



Duplex scan Venography Angiography Arteriography Arteriography Direct visualization Chest x-ray Paracentesis DPL Urinary level of metanephrine & VMA Dexamethasone suppression test Alkaline phosphatase Free thyroxine index TSH assay Occult blood test Air-contrast barium enema



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