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BODY AS A WHOLE
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ENDOCRINE
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760. Rationale of splenectomy for ITP
761. Character phyllodes tumor breast
762. cells independent of somatostatin regulation
763. Cell site accumulation MIBG
764. Characteristics fibroadenoma breast
765. Artery adjacent to superior laryngeal nerve
766. Physiology of glucagon
767. Distribution of insulinomas
Characteristics of Enterocytes
Enterocytes, or absorptive cells, are found in the mucosa of the small and large bowel.
The normal enterocyte lives for a little more than 2 days. They are columnar and are the
principal cells of the villus. Enterocytes absorb a variety of nutrients including Ca, Fe and
H2O.
The primary fuel source of enterocytes is glutamine. Principles and Practice of Surgical
Pathology, 2nd Edition, Vol II, pgs 1121-23
Secretin/Gastrin Relationship
Secretin is produced by specialized cells in the small bowel mucosa and its release is
stimulated by acidification of the duodenum or by contact with bile and perhaps fat. It
stimulates the release of water and bicarbonate from pancreatic ductal cells, which
neutralizes gastric acid. Secretin also acts to stimulate the flow of bile and inhibits gastrin
release and therefore gastric acid secretion and gastrointestinal motility. Schwartz 6th pg.
1128, 1161-62
Activation of Trypsinogen
Trypsinogen is the inactive precursor of trypsin. It is produced by pancreatic acinar cells
along with other inactive proteolytic enzymes, chymotrypsinogen and
procarboxypolypeptidase. These inactivated enzymes are delivered to the duodenum in
an alkaline environment.
Enterokinase, an enzyme secreted by intestinal mucosa, lyses trypsinogen converting it
into the active enzyme. Trypsin is then able to lyse more trypsinogen into trypsin
(autocatalytic activation). Chymotrypsinogen is lysed into its active form chymotrypsin,
and procarboxypolypeptidase - activated form of trypsin also. Trypsinogen is protected
from activation prior to entering the intestinal lumen by trypsin inhibitor. This substance
is also secreted by the same pancreatic acini cells that secrete the proteolytic enzymes.
Guyton, Medical Physiology, pg 779
Physiology of Enteroglucagon
Enteroglucagon is released from the enteroglucagon cells, occurring predominately in the
distal small intestine. This peptide occurs in two forms - one small and one large form.
Release of this hormone is stimulated by carbohydrate and long-chain fatty acid. Its
primary action is to inhibit intestinal motility. Sabiston, Textbook of Surgery, 14th ed.,
pg. 834
Stimulation of Duodenal Secretin Release
Secretin is a gastrointestinal peptide, which is the principal stimulant for pancreatic water
and electrolyte secretion. It is synthesized and stored in mucosal S-cells, in crypts of
Lieberkuhn in the proximal small bowel.
The most important stimulus for secretin release is duodenal acidification; release occurs
when the intraluminal pH falls below 4.5. Fat also stimulates secretin release, but this
occurs only with high luminal fat concentrations. O'Leary, The Physiological Basis of
Surgery, Williams & Wilkins, 1993
Care, pp 350-351
Diagnosis of Gastrinoma
Fasting hypergastrinemia (>200 pg/ml) in the face of gastric acid hypersecretion defined
as basal acid output >15mEq/h with intact stomach or >5mEq/h after ulcer surgery. Most
patients with gastrinoma have serum gastrin levels >500 pg/ml. A secretin provocative
test is usually done to confirm diagnosis when serum gastrin is in the range of 200-500
pg/ml.
Secretin Provocative Test:
Following 2 u/kg secretin IV bolus, a rise in serum gastrin level of 200 pg/ml within 15
min or doubling of the fasting gastrin level is diagnostic of gastrinoma.
Additional Studies: Upper GI or endoscopy will show ulcers often in unusual locations,
i.e. 2nd & 3rd portions of duodenum or jejunum. The stomach may have prominent rugal
folds along with excessive luminal secretions. CT scan may show tumor in the pancreas
or paraduodenal areas. Angiography with portal venous sampling may show "hot spots"
of gastrin secretion. Schwartz, 6th ed, pp 1427-28
Duodenal Hematoma
Intramural hematoma of the duodenum is usually due to blunt abdominal trauma. This
causes rupture of intramural duodenal blood vessels with formation of a dark, sausage-
shaped mass in the submucosal layer of the duodenal wall. It can also occur
spontaneously in patients on anticoagulants. The hematoma may cause partial or
complete duodenal obstruction. The patient has signs of a high small bowel obstruction,
with nausea and vomiting associated with upper abdominal pain and tenderness, and
sometimes a suggestion of a right upper quadrant mass on palpation of the abdomen.
Plain films of the abdomen may show an ill-defined right upper quadrant mass and
obliteration of the right psoas shadow. An upper GI is usually diagnostic with filling of
the duodenal lumen and the appearance of a "coiled spring" in the second and third
portions due to crowding of the valvulae conniventes. The serum amylase may be
elevated. Most infants and children may be successfully treated without surgical
intervention. Nonsurgical treatment of these patients consists of cessation of oral intake,
nasogastric suction, and intravenous replacement of fluids and electrolytes. Schwartz, 6th
Edition. O'Leary, 2nd Edition, Physiologic Basis of Surgery
Characteristics of Cisapride
Cisapride (Propulsid) is a prokinetic GI motility agent that acts via 5-HT4 receptors. Its
effects are similar to metaclopromide (Reglan) and Domperidone in that it enhances the
motility of smooth muscle of the stomach, and small bowel. Unlike these agents, it also
increases motility of the colon, which may cause diarrhea. It is useful for treating gastric
hypomotility disorders as well as idiopathic constipation and colonic hypomotility
without the dopaminergic side-effects of metaclopromide. Goodman and Gilman, The
Pharmacological Basis of Therapeutics, 9th ed.
Induction of Gastric Smooth Muscle Relaxation
The stomach is composed of three smooth muscular layers: an outer longitudinal, middle
circular, and inner oblique layer. The longitudinal layers are concentrated along the lesser
and greater curvatures of the stomach. The circular muscle is present throughout the
stomach and is concentrated in a circular, muscular sphincter at the pylorus.
The vagus and sympathetic nerves are the primary effectors of smooth muscle activity.
Although the vagal nerves are considered primarily for their motor activities, afferent
neurons make up the greater part of the cranial nerves.
Neuro control of the stomach is mediated through two gastric myenteric plexuses
(Auerbach's and Meissner's). The stomach has a natural pacemaker located high in the
greater curvature of the body of the stomach. This initiates contractions at 3 cycles/min,
as the electrical potential passes distally, activity increases (Phase 2) and in Phase 3
contractions are repetitive and serve as a "housekeeper potential", which advances food
toward the pylorus.
Only particles less than 1 mm in diameter are emptied into the duodenum.
Relaxation of the smooth muscles is controlled physiologically by CCK,
mechanoreceptors for distention and glucose in the stomach and duodenum (1st portion),
which mediate relaxation via afferent fibers to the medulla. Transient delays of gastric
emptying (smooth muscle inhibition) is seen frequently in the postoperative patient, and
in those patients with pancreatitis, peritonitis, or retroperitoneal bleeding or injury.
Gastric motility returns with resolution of the underlying problems.
Metabolic causes for gastric atony include hypokalemia, hypercalcemia, and
hypocalcemia, hypomagnesemia, hypothyroidism, uremia, hepatic coma, and
hyperglycemia. Correction of the metabolic abnormality usually restores normal gastric
emptying.
Diabetic gastroparesis can occur in insulin-dependent diabetics. The basic defect appears
to be one of impaired neurocontrol with loss of Phase 3 activity in the stomach.
Metoclopramide is often effective in improving gastric emptying in these patients.
Delayed gastric emptying following truncal vagotomy or gastrectomy is a distressing
problem, which is poorly understood. It may be caused in part by the fact that the
antropyloric mechanism is intact, and in part because of concomitant sympathetectomy of
the proximal stomach. Miller, Physiologic Basis of Modern Surgical Care, pp. 280-89
*Prevention of Pulmonary Complications of Flail Chest Intercostal nerve block, epidural analgesia,
Pulmonary Toilet
*Dx Adrenal Mass/Hypokalemia Likely Conn Syndrome (primary hyperaldosteronism), will have
elevated serum Na and urinary K, low serum K, aldosterone/renin ratio greater than 400, low renin
activity, high plasma aldosterone, high urine aldosterone after sodium challenge, can localize with MRI,
scintography or venous sampling
*Rx Adrenal Insufficiency IV hydrocortisone, Fluids, ACTH stimulation test, include a
mineralocorticoid (Florinef)
*Extra Adrenal Sites of Pheo Organ of Zuckerandl, near aortic bifurcation, retroperitoneum, vertebral
bodies, bladder, opposite adrenal gland, neck, mediastinum
*Rx Pelvic Fracture Place sheet, external fixator or C-clamp and then go to angio for embolization, if
see hematoma after blunt injury in OR, leave it alone, pack, and get patient to angio, if has colon injury
with fracture will need colostomy, if greater than 3 cm diastasis of symphysis pubis, need anterior
fixator/plating, if sacroiliac joint is displaced, treat with posterior internal fixation with plates, treat
sacral/coccygeal fractures conservatively
Definition of O2 Delivery Cardiac Output X Oxygen Content(Hb x1.34x%O2sat+(PO2x0.003))
Wedge Affected By Pulmonary HTN, Aortic Regurgitation, MS/MR, High PEEP, LV compliance
O2 Consumption CO X (Ca02 Cv02), normal delivery to consumption ratio is 5:1, CO increases to
keep the ration constant
*O2 Extraction ratio (Ca02 Cv02)/Ca02
*Early Gram Negative Sepsis Decreased insulin, increased glucose due to impaired utilization
*Anat Right Renal Artery Goes posterior to IVC
Ventilator Choice in Bronchopleural Fistula High-frequency jet ventilation
*Most Potent Stimulator of SIRS Endotoxin Lipopolysaccharide A
*Rx ARDS Low tidal volumes (6cc/kg), high PEEP (up to 22), permissive hypercapnea (RR less than
35), plateau airway pressure less than 30, FI02 less than 0.5,
*Characteristics of ARDS Diffuse alveolar damage and increased capillary permeability: 1.Diffuse
bilateral infiltrates on CXR, 2.Pa02/FI02 less than 200 3. Wedge less than 18
*V/Q Abnormalities 1. Shunts (lung perfused, but not ventilated) Pneumonia/Atelectasis - O2 sat
doesnt increase with 100% O2, 2. Dead Space (lung ventilated, but not perfused) PHTN, Low CO, PE,
high PEEP
*Dx Post-Op Oliguria Most common cause is hypotension causing ATN, Check FeNa (less than 1),
UOsm (greater than 500), UNa (less than 20), BUN/Cr (greater than 20) in pre-renal failure, check
ultrasound/foley for post-renal obstruction
*Criteria Brain Death Cerebral GSW Precluding diagnosis: uremia, temp less than 30, BP less than
70/40, desat with apnea test, drugs (pentobarb, phenobarb), metabolic derangements.
Must have for 6-12 hours (2 separate exams): unresponsive to pain, absent caloric oculovestibular reflexes,
oculocephalic reflex, positive apnea test (CO2 increases by 20 or is greater than 60 when disconnected
from vent), no corneal reflex, no gag reflex, fixed and dilated pupils. EEG electrical silence, MRA no
blood flow to brain
*Rx Ventilatory Complication Burn Perform escharatomy if burns on chest/torso with difficulty
ventilating
*Adverse Reaction Silver Sulfadiazene neutropenia and thrombocytopenia, inhibition of epithelization
Adverse Reaction Silver Nitrate hyponatremia, hypokalemia, hypocalcemia, hypochloremia and
methemoglobinemia in G6PDH deficiency
*Adverse Reaction Sulfamylon metabolic acidosis
Risk with Claudication 1% per year of amputation, 2% per year of gangrene
Mimic Claudication Lumbar Stenosis
*Dx Test Claudication Rule out neurogenic causes of pain by ordering lumbosacral spine films, EMG,
MRI or CT
To diagnose vascular claudication perform ABI/PVR or segmental systolic pressures after walking on
treadmill. If has claudication due to vascular disease, the SBP difference will be less than 20 between the
brachial and femoral. Gold standard is angiography.
ABI inaccurate in Diabetics, they have calcified, incompressible vessels. Use Doppler waveforms
Edema Following Lower Extremity Bypass Check ultrasound for DVT first, then second most common
cause is reperfusion injury
*Rx Embolus L Femoral Artery Heparinization, Open Embolectomy through groin incision, then
angiogram. If greater than 4 to 6 hours, perform fasciotomy.
*Technique Fem-Peroneal Graft Surveillance Color Flow Duplex Ultrasound
Nerve most commonly injured following fasciotomy Superficial peroneal nerve
*Rx Preop Phimosis Dorsal Slit
*Most Common Metastasis to SB Melanoma
*Treatment of Basal Cell Carcinoma Excision with 0.3 to 0.5 cm margin, XRT if mets, neuro,
lymphatic or vascular invasion
*Characteristics of Keloids Collagen outside of scar, in dark skinned people, treat with steroids,
silicone, pressure garments
*Anatomy of Phrenic Nerve On Anterior Scalene Muscle
*Mircoadenoma in Pituitary Most commonly is prolactinoma, treat with bromocriptine, if fails medical
therapy perform transphenoidal resection, if growth hormone adenoma, treat with resection
Tunnel Vision (Bitemporal Hemianopsia) Pituitary tumor compressing optic chiasm
*Likely Complication Sella Turcica Fracture Panhypopituitarism will have troubling lactating (first
sign), amenorrhea, adrenal insufficiency, and hypothyroidism, can also have cranial nerve injuries, CSF
rhinorrhea
*Pulsatile, bleeding mass after CEA Dx: Pseudoaneurysm prep and drape first, then intubate and
repair with bypass of carotid
*Etiology oliguria post AAA repair Hypoperfusion of kidneys, other less common causes are contrast
administration and atheroembolism
*Rx Effort Thrombosis Pitcher Subclavian vein is thrombosed, start with thrombolytics via catheter,
followed by heparin then Warfarin, will likely need first rib resection for thoracic outlet syndrome
*Dx Effort Thrombosis Subclavian Vein Gold standard is venography
*Femoral Pseudoaneurysm If small may be observed for resolution in 2-4 weeks, otherwise treat with
ultrasound guided compression or with thrombin injection initially, if flow remains or at suture site repair
in OR
*Rx Chylous Ascites PO AAA Repair NPO and TPN is initial treatment, if does not resolve can ligate
thoracic duct
*Signs Primary Hyperparathyroidism Fatigue, weakness, memory loss, renal stones, bone pain,
abdominal pain, psychiatric symptoms, can have neck mass, band keratopathy, and fibro-osseous jaw
tumors
Elevated Calcium, low Phosphorous, Chloride to Phosphorous ratio greater than 33, hyperchloremic
metabolic acidosis, bicarbonate in urine, elevated renal cAMP, can have osteitis fibrosis cystica bone
lesions from hyperPTH
*Hyperthyroidism in Pregnancy PTU initially, propanolol may help, if the pregnant patient is not
controlled with medical therapy do subtotal thyroidectomy in 2nd trimester
*Tx Medullary Thyroid Carcinoma Total thyroidectomy with central node dissection, if has clinically
positive nodes do ipsilateral MRND, if both thyroid lobes have cancer do b/l MRND if clinically positive
nodes, do prophylactic thyroidectomy and central node dissection if child with MEN at age 2
*Tx Parathyroid Cancer Radical parathyroidectomy and resect ipsilateral thyroid lobe, recurrence rate
is 50%
*Tertiary Parathyroidism After renal transplant, treat with resecting 3 glands or total
parathyroidectomy and reimplant in forearm
* Person with LCIS develops Breast Ca Most commonly will be Ductal Carcinoma
Most Common Cause Nipple Discharge Spontaenous discharge from a single duct is intraductal
papilloma, bloody discharge is most commonly intraductal papilloma, Green discharge is most commonly
fibrocystic disease
*Etiology Unilateral Breast Enlargement Man In adolescence due to excess of estradiol compared to
testosterone, In adults, Gynecomastia possibly associated with hepatic cirrhosis, hypo or hyperthyroidism,
estrogen secreting testicular tumors, renal failure, or malnutrition. Digoxin, Thiazides, Estrogens,
Theophylline or phenothiazines may exacerbate gynecomastia
*Rx Breast Mass Post NeoAdj Chemoradiation Mastectomy, radiation and additional chemotherapy
BRCA 1 Ovarian Ca (50%) and endometrial Ca, treat with TAH/BSO and mastectomy if family hx
BRCA2 Associated with male Breast Ca
*Pleural Fluid 1-2L per day, produced by parietal pleural and resorbed by lymphatics in visceral pleura
Site of Lung Abscess Posterior portion of RUL, superior portion of RLL
*Best Long Term Graft Patency for CABG LIMA
*Blood Supply Cervical Esophagus Inferior Thyroid Artery
*Treatment of Zenkers Diverticulum Cricopharyngeal myotomy, dont necessarily need to resect
diverticulum
Tx Achalasia Calcium Channel Blockers first, dilation may help, if failure of medical therapy perform
Heller Myotomy via left thoracotomy, transect circular muscle layer of lower esophagus and then perform
partial 180 degree Nissen
*Dx/Rx Antithrombin III Deficiency Associated with recurrent thrombosis and pulmonary embolism,
found in patients who are resistant to heparin therapy that do not show an increase in PTT, treatment is FFP
or ATIII concentrate, then Heparin, then Coumadin
*Type II Hiatal Hernia Paraesophageal Hernia, all need surgical repair due to incarceration risk,
perform NIssen as well
*Rx Perforation of Esophagus Left Thoracotomy, longitudinal myotomy to see extent of injury,
primary repair with buttressing with healthy tissue, place chest tubes, if greater than 24 hours debride
tissue, create esophagostomy, wide drainage, and placement of G tube
Indication Gastric Bypass BMI greater than 40, BMI greater than 35 with comorbidities,
psychologically stable, no substance dependence, failure of non-surgical methods of weight reduction
*Rx GIST AKA Gastric leiomyoma, seen as hypoechoic on ultrasound with smooth edges, gastric wedge
resection with 1cm margins, no lymph node dissection, chemotherapy if greater than 5cm or 5-10 mitoses
per HPF, chemo is Gleevac if unresectable and metastatic
*Gastric Cancer Risk Factors Adenomatous polyps, chronic atrophic gastritis, type A blood type,
intestinal metaplasia, nitrosamines, tobacco, previous gastric surgery, pernicious anemia, hyperplastic
polyps
*MALT Treatment Triple antibiotics for H. Pylori, if does not cure, then treat with
surgery,chemotherapy (CHOP), and radiation
*Right Hepatic Artery Variation Most commonly off of SMA
*Rx Varices Assoc Splenic Vein Thrombosis Splenectomy
*Characteristics of Lithogenic Bile (Stone Forming) Supersaturated with cholesterol, low amount of
bile acids and lecithin, in obese patients often due to overactive HMG CoA reductase, in thin people due to
7 alpha hydroxylase, pigmented stones due to precipitation of calcium bilirubinate and unconjugated
bilirubin
*Characteristics Focal Nodular Hyperplasia Liver Central stellate scar in liver looks like cancer,
however FNH is benign, Uptakes Sulfer Colloid on liver scan (hot nodule), MRI/CT shows hypervascular
tumor, treatment is conservative
*Hepatic Adenoma Women, OCPs, steroids and Type I Collagen Vascular Disease risk factors, 10-20%
risk of rupture, does NOT uptake Sulfer Colloid on liver scan (cold nodule), CT shows hypervascular
tumor, commonly in right lobe, can become malignant, if asymptomatic stop OCPs and observe, if
symptomatic do resection or emoblize if multiple
Amebic Liver Abscess Commonly in right lobe from amebic colitis and seeding through portal vein, due
to E Histolytica, treat with Flagyl, aspiration if refractory, may see anchovy paste in aspirate
*Pyogenic Liver Abscess Most common abscess, most common organism is E Coli, often due to
contiguous infection from biliary tract, treat with CT guided drainage and antibiotics, only drain surgically
if patient is unstable or septic
Echinococus Liver Abscess Sheep are carriers, transmitted by dog bites, positive Casoni skin test and
positive indirect hemagglutination, CT shows ecto and endocyst with calcifications, treat with albendazole
and then surgical removal of cyst wall, can inject alcohol to kill organisms, DO NOT ASPIRATE FIRST,
can cause anaphylactic shock
*Etiology Shock Post Op Lap Chole In first 24 hours due to hemorrhagic shock from clip that fell off
cystic artery, after 24 hours from septic shock on clip on CBD with cholangitis, diagnose with RUQ U/S to
look for collection, then HIDA to look for leak
*Rx Laparoscopic Injury CBD Place T tube and transfer to tertiary center, if performing repair and less
than 50% of circumference perform primary repair, in other cases will need
choledocho/hepaticojejunostomy
*Rx Adenoca Gallbladder If confined to mucosa (Stage 1) only need cholecystectomy, if into muscular
layer (Stage Ib) need cholecystectomy, wedge resection of liver and lymphadenectomy of hepatoduodenal
ligament/portal triad, if IIa/IIb( through serosa or into liver), needs hepatic 4b and 5 segmentectomy, Stage
3 (into hepatic artery, portal vein) or Stage 4 (distant mets) are unresectable
*Volume-Outcome Pancreatic Cancer 3-5x higher mortality at low volume centers (less than 5) when
compared to centers doing more than 20 per year
Insulinoma Occurs throughout pancreas, 85-95% benign, if <2cm enucleate, if >2cm resection, if
metastatic to liver treat with octreotide, 5-FU, streptozicin, presents with Whipples triad (FS<50,
symptoms of hypoglycemia and relief with glucose)
Gastrinoma Most common pancreatic tumor in MEN I, occurs in gastrinoma triangle (CBD, 3rd portion
of duodenum, head of pancreas), diagnosis is gastrin greater than 200 can be greater than 1000, secretin
stimulation test causes increase of gastrin, best localization is somatostatin scintography, can also do CT or
MRI, if cant find gastrinoma open duodenum to look for microgastrinomas, if <2cm enucleate, if >2cm
resection, if unresectable do vagotomy and pyloroplasty
Somatostatinoma In head of pancreas, diagnose with elevated somatostatin level, presents with diabetes,
steatorrhea, weight loss, gallstones, do cholecystectomy with resection
*VIPoma In distal pancreas, presents with achlorhydria, hypokalemia, watery diarrhea, diagnosed with
elevated VIP level, treat with distal pancreatectomy, 10% in retroperitoneum or thorax
*Glucagonoma Most in distal pancreas, glucagon level greater than 500, presents with diabetes,
stomatitis, necrolytic migratory erythema (treat with parenteral amino acids), weight loss, treat with distal
pancreatectomy, octreotide if unresectable or has recurrence
*Characterstics Puetz-Jeghers Syndrome Autosomal Dominant, ileal and jejunal hamartomas most
frequent sites, 50% with colorectal polys, 25% with gastric polyps, melanotic mucocutaneous
pigmentation, increased risk of colon cancer in patients with polyps, neurogenic cancers, hemangiomas,
lipomas, 2% risk duodenal cancers, increased risk of biliary, breast, and gonadal cancers
*Fuel Source Colonocyte Short Chain Fatty Acids (Butyrate)
*Rx Occult Blood in Feces - Colonoscopy
*Etiology Death Familial Adenomatous Polyposis Metastatic colon cancer but if resected already,
periampullary tumors of duodenum
*FAP Autosomal dominant, Multiple polyps, need total proctocolectomy with ileoanal J pouch by age
20, get duodenal polys, need EGD every 2 years, associated with Gardners Syndrome (sarcomas,
osteomas) and Turcots Syndrome (brain tumors)
*Rx Hematochezia Unknown Source If unstable, needs subtotal colectomy if no bleeding source
identified
HNPCC Right sided colon cancers, metachronous lesions, surveillance by age 25 or 10 years before first
familial cancer, Lynch I only colorectal ca, Lynch II ovarian, breast, bladder, stomach cancers, perform
subtotal colectomy with first operation
*Risk Factors Ovarian Cancer Early menarche, late menopause, lack of OCP use, late first pregnancy
(after 30), late first breast feeding (after 30), nulliparity, perineal talc use, personal or family history of
colon, ovarian or endometrial cancer, age, diet, geography
*Risk Factor Endometrial Cancer Obesity, nulliparity, tamoxifen, unopposed estrogen, late first
pregnancy, early menarche, diabetes, HTN, late menopause
*Rx Squamous Cell Cancer Penis Penectomy with 2 cm margin, may have reactive lymph nodes that
need to be treated with antibiotics. If has adenopathy on CT, needs lymph node dissection. If palpable
inguinal LAD, needs dissection. If has pelvic mets, needs chemo
*Rx Fracture Distal Femur If minimally displaced can be treated with knee immobilizer or long leg
cast. Delayed weightbearing. If displaced or has articular involvement, use IM nail or condylar plates
*Etiology Wrist Drop Associated Upper Extremity Fracture Radial nerve injury along proximal
humerus
*Nerve Injury Associated Fibulectomy Peroneal Nerve
*Indication Preop Nutrition Gastric AdenoCa History of weight loss greater than 15% albumin less
than 3 makes higher risk for complications. Preop nutrition for 7-10 days decreases septic complications.
Randomized controlled trials have shown benefit of IV nutrition in severely malnourished patients with
upper GI tumors
*Rx Nerve Injury Lap Inguinal Hernia Repair If neuralgia in RR, need prompt re-exploration,
otherwise reassurance, NSAIDS and nerve blocks help.
*Rx Seroma PO Ventral Hernia Repair Serial aspiration under sterile technique, if persistent open the
incision and pack with saline gauze
*Achievement Anticoagulation Antithrombin III Neutralizes factor IXa, Xa, Xia and eventually
inhibits thrombin, heparin causes conformational change in ATIII and accelerates inhibitory reaction
*Drugs Affecting Warfarin Metabolism Barbiturates, rifampin and dilantin increase clearance of
warfarin by activating hepatic enzymes. Flagyl, Allopurinol, cimetadine, amiodarone, phenylbutazone,
sulfinpyrazone, disulfiram and alcohol increase response of warfarin (bleeding)
*Conditions Associated with Normal INR/Abnormal PTT Heparin therapy, Lupus Anticoagulant,
Hemophilia A/B
*Etiology Obscured Clinical Difference Type 1 error (falsely reject null hypothesis) use p<0.05 to
prevent this, means less than 5% chance of difference being random, Type 2 error(accepts null hypothesis
when in fact it is false) is due to a small sample size
*Ethics and Physician Error Physician has ethical duty to admit mistakes to patient, if complication
resulted from mistake, physician is ethically required to inform patient of what occurred
*Etiology Pneumoperitoneum HIV Pt Terminal ileum and colon are most common sites for perforation
due to CMV, diagnosis of CMV is made by seeing intranuclear inclusion bodies on biopsy, suture plicate
gastroduodenal perforations, perform SBR if SB involved and colostomy for colonic perforation,
perforation is an ischemic lesion as CMV affects arterioles of GI tract
*Treatment of Malignant Hyperthermia stop inhalation agent, dantrolene, 100% oxygen, cooling
blanket, cold IV, correct acidosis and hyperkalemia
*Characteristics of Blood Circulation Fetal circulation has 2 umbilical arteries which are branches of
iliac arteries and 1 umbilical vein which drains to ductus venosus
*Characteristics of AIDS-related Lymphoma B-cell lymphoma, usually poorly differentiated and
aggressive, managed with chemotherapy, surgery only for GI bleeding, obstruction, or perforation
*Antibiotic Treatment of Human Bite Wound Cefoxitin or cefotetan with a penicillin to cover
Eikenella corrodens, continue for 24 to 48 hours
*Characteristics Epidural Anesthesia Anesthesia (epinephrine/lidocaine) injected into lumbar or
thoracic epidural space. Shown to decrease blood loss, risk of DVT, better pain control, earlier ambulation,
earlier return of bowel function, and superior pulmonary function. Risk is spinal hematoma, epidural
abscess, hypotension, headache, urinary retention.
*Etiology of Hypokalemia in Gastric Outlet Obstruction Due to vomiting of material with potassium
and hydrogen, potassium is then excreted in urine for exchange of sodium lost in vomitus
*Metabolism of Cancer Cells Catabolize glucose at a high rate due to hexokinase that is bound on the
outer mitochondrial membrane, cancer cells are able to maintain increased rates of glucose utilization and
high rates of glycolysis under aerobic conditions
*Metabolic Acidosis after Kidney/Pancreas Transplant Due to excessive urinary loss of bicarbonate
containing exocrine fluids from the pancreas transplant
Most common congenital hypercoagulable disorder Factor V Leiden
*Treatment of Intra-Operative Bleeding with ESRD DDAVP, cryoprecipitate, estrogens
*Treatment of HIT Argatroban or Hirudin
Hemophilia A need Factor VIII levels 100% preop and 30% postop, treat with Factor VIII or cryo
*Most common bacteria in colon Bacteroides vulgatus
*Surgical infection within 48 hours Clostridium or Beta-hemolytic strep
Gentamicin peak too high Decrease dose
Gentamicin trough too high Decrease interval of dose
*Intubated patient with sudden drop in ETC02 With decreased mixed venous CO2 in venous air
embolism, with increased mixed venous CO2 can be CHF, MI, PTX, PE, atelectasis, hypotension
Glycogen Stores Depleted after 24-36 hours of starvation, body then switches to fat
*P53 on Chromosome 17, involved in cell cycle arrest and apoptosis, abnormal gene allows unrestrained
growth
Cyclosporin Binds cyclophilin protein and inhibits cytokine synthesis, side effect is nephrotoxicity,
hepatotoxicity, HUS, tremors, seizures, metabolized in liver and excreted through bile
*Lamivudine Used in post-op liver transplant patients to treat Hep B recurrence
*Macrophages Essential for wound healing