Contents

Introduction .............................................................................................................................. 2

Surgical nutrition .............................................................................................................. 2

Burn ...................................................................................................................................... 4

Breast ........................................................................................................................................ 5

Gastro-Intestinal ....................................................................................................................... 8

Gastric ................................................................................................................................... 8

Intestine .............................................................................................................................. 10

Colon ................................................................................................................................... 11

Hepato-Biliary system............................................................................................................. 14

Liver ..................................................................................................................................... 15

膽道 biliary tract ................................................................................................................ 16

胰臟 Pancrease ................................................................................................................... 17

Spleen 脾臟 ......................................................................................................................... 18

Esophagus 食道 ..................................................................................................................... 19

Cardio 心外 ............................................................................................................................. 20

Endocrine 內分泌 .................................................................................................................. 21

Thyroid................................................................................................................................. 21

Para-thyroid ......................................................................................................................... 23

Pancrease islet ..................................................................................................................... 24

Adrenal gland ...................................................................................................................... 24

Pediatric .................................................................................................................................. 26

Trauma .................................................................................................................................... 29

Laparoscope ............................................................................................................................ 30

Transplantation ....................................................................................................................... 30

1
Introduction
Surgical inf =① 術後 30 天內
② 手術部位(含經過的途徑)
③> 10 萬 organism per gram of tissue
Classification of surgical wound
Elective No entry 1°Clean 唯一不需要 1. Hernioplasty, 感染機率
(不與外界相通) prophylatic antibiotic 2. mastectomy, 2%
3. thyroidectomy
Entry 2°clean 5%
contaminate
Emergency Trauma/perforated Fresh
3°contaminated 20%
(黃金期 6-8hr 內)
4°dirty Delayed>6-8hr 50%
☼ Prophylactic antibiotic – 時機: within 1hr before insicion (劃刀前 1hr)
-if op 時間長, 可追加(every 6-8hr)
-Post-op 後可追加 2-3 劑; Post-op>24hr 再給予,則無降低感染功效

Tetanus 接種史 Clean wound Dirty wound

Td TIG Td TIG
不知道/ <3 劑 要 要 要
>3 劑 要(if > 10yr)s 要(if >5yrs)
Td= tetanus-diphtheria toxoid (if <7 y/o )
TIG=tetanus immune globuline

Tension streght Absoroption

day
Plain-/cat- gut Beef serosa or 7~10d 70d
Absorbable

然天
Chronic gut sheep submucosa 21~28d 90d
合成 Vicryl 多股 供小孩,婦產陰道
較不痛, 不緊縮
Monocryl 單股 整外縫合 50%~60%:1wks 91~119d
20%~30%:2wks
PDS 單股 強度上升
天然 Perma-hand* silk 早期常用
Inabsorbable

絲線
合成 Ethilone 單股 表皮縫合
Nurolon 多股 神外常用
Mersilene
Ethibond 多股 心臟瓣膜縫合
Prolene 單股 供心臟血管,表皮
單股 Less tissue pull force, reduce tissue traction than 多股; 單股-貴
合成 強度增強;少組織纖維反應
Reaction: 天然(>合成) >可吸收(>不可吸收) >多股(單股)
1°union Direct approximation 對象: clean wound
2°union Spontaneous union Contaminated wound
3°union Delayed primary union

Surgical nutrition
IBW: 男 = (身高-80) X 0.7 ; 女 = (身高-70) X 0.6
BMI = kg/m2

Weight looss = 6m 內減少>10% 或 1m 內減少>5%

水
TBW(BW 60%) 2/3 在 ICF(BW40%)—含 K, P, Mg
兒童 TWB=BW70% 1/3 在 ECF(BW20%)—含,Na, Cl, Ca 血管內 1/4(BW5%) = plasma
年輕人 =BW60% 血管外 3/4(BW15%)= interstitial
老人 =BW50%
2
Premature 150 ml/kg
Neonatal(<1y/o) 150-120 ml/kg
Infant 120-100 ml/kg
<10kg 100 ml/kg (4ml/kg/hr)
10-20kg 50 ml/kg (2ml/kg/hr)
20kg 20 ml/kg (1ml/kg/hr)

0.45%N/S/D5W + 20mEq KCL/L

Infusion Therapy

mEq/L Na K Ca Cl HCO3 Dextrose mOsm/L

ECF 142 4 5 103 27 - 280~310
Normal

L-R 130 4 3 109 28 - 273 像細胞外液, 供 燒傷 p’t, hyper[Cl] acidosis

Saline

0.9% N/S 154 - - 154 - - 308 代謝鹼中毒, 肝功能差 p’t, metabolic acidosis
0.45% N/S 77 - - 77 - - 154
Crystalloid

3% N/S 513 - - 513 - - 1026

Linger
lactate

D5W - - - - - 50 252
D5/0.45% NaCl 77 - - 77 - 50 406 (10%G/W X1000cc )+ (0.9%NaCl X 1000cc)

Hestarch (synthetic glycogen)

Colloid

Detran (synthetic glucose polymer, Dextran-40/Dextran-70)

Albumin 5% or 25%
FFP (Fresh frozen plasma)

Antigen
Blood type A A antigen B antibody Rh (-) -- (-)治後會產 Rh-Ab
B B A Rh (+) Rh --
antigen
AB A+ B --
O -- A + B antibody
Comb test/ Direct (DAT Ab in RBC 用於 immune-mediated hemolytic anemia (Ab 或補體 攻 RBC)
anti-globulin 看圖 If(+)autoimmunity, allo-immunity or drug-induced immune
test(AGT) (IgG +/-complement) mediated mechanism

In- (IAT) Ab in serum 用於 Ante-natal Ab screening

看圖 (IgG 過 placentanewborn hemolytic dis )
(IgG +/-complement)
Cross Electron cross 電腦分析
matching Serological Donor RBC Ag + recipient serum Ab 測有無 agglutination
? Donor lymphocyte + recipient serum + complement
Complement-dependent lymphocytoxicity assay, 防 hyperacute rejection
Minor group antigent: Kell, Duffy, Kidd, MNSs systems, Diego, Lewis Ag

Energy 糖 = 4Kcal/g 蛋白質 = 4-5Kcal/g 脂肪 = 9Kcal/g

正常 1g/kg/day
BEE(basal energy Essential a.a 1.必須脂肪酸-linoleic(18:2),
expenditure) 1.BCAA(aliphatic)-val, leu, ile linolenic acid (18:3)
= 30±5 Kcal/kg/day 2.Aromatic- phe, trp 2.Omega-3 fatty acid
3.Basic-His, Lys, Arg 3. Medium chain TG(C:8~10)-碳越短越易代謝
小兒外: 4.Sulfer-met
水的需求量 = 營養量 5.OH-thr
1cc 水 = 1 Kcal
肝 p’t 無 encephalopathy=1~1.5g/kg/d 用 MCT
= 27.5±2.5 Kcal/kg/day 有 = 0.5 g/kg/d
BCAA↑ ±aromatic acid↓
Stress-mild = 1.2 X BEE BCAA-由 肌 細胞代謝
-moderate = 1.2-1.3XBEE -適用於 肝差,創傷,敗血
-severe =1.3-1.5XBEE
Major burn inj =1.2-2.0XBEE
DM diet (from intern note pg27)
BW>IBW, 20-25kcal/kg IBM/day
BW=IBW, 30-35
BW<IBW, 40-45

Enteral feeding TPN, total parenteral feeding

(A)標準: 1Kcal/ml ; 300mOsm 適應症: 無法 enteral>10d
(B)Volume restricted: 2Kcal/ml; 600mOsm (if > 600 易 diarrhea) -內含物:
3
-糖:脂肪:蛋白=54:32:14% (1) 糖:脂肪:蛋白=70:20:10%
-if diarrhea (2)electrolyte
(1)hypertonic 改為 isotonic
(2)↓flow rate; if 量不足,則補以 peripheral nutrition
(3)DO NOT STOP TUBE FEEDING(他日重新開始會瀉更嚴重)
-方式
(1)bolus feeding – 可大量給; NG, gastrostomy;
50~100ml q4h=(+50ml)240~360 q4h
(2)continuous infusion—不可(會瀉); jejunostomy; (3)微量元素: Se, Cu, Cr, Zn, Mn
20~50ml/hr =(+10~20ml)100ml/hr -路徑: (1)中央 line-能承受<1800mOsm/L (serum6 倍)
(2)周邊 line- <600 mOsm/L( 2 )
-Rate40ml/hr(day 1)80ml/hr(day2)100ml/hr(day3)
5 大併發症: pg11

Burn
Degree of Burn
1° Superficial epidermis Pain, redness
2° Partial thickness 1.Superficial Papillary dermis 水泡 Blister(14-17d)
2.Deep Reticular dermis 乳白色
3° Full thickness 皮下脂肪 乳白 , 暗色, 焦黑
4° Deep invasion to fat, 焦黑, 肌肉色 考唯一貫穿 eschar 深入其下
fascia, muscle, bone 藥: mafenide acetate

Rule of 9 -11 個 9%
成人
Head, neck X 1= 9%
Trunk-ant X 2 = 18%
postX2 = 18%
Genitalia organ X1 =9%

Limb-Upper-R’t X1 = 9%
-L’t X1 = 9%
*Palm=1%; digital = 0.5%

Limb-lower- X2 =18%
X2 =18%
小孩
頭 X 1 = 18%
身體-前 X 1 = 18%
身體 後 X1 = 18%
上肢-左 X 1 = 9%
-右 X1 = 9%
下肢-左 X1= 14%
-右 X1= 14%

主要治療 Fluid resuscitation

Oral In adult <20% TBSA
In Children <10-15% TBSA
IV Parkland Formula: L/R 4ml/kg/%TBSA = kg X 4 X % 24hr-前 8hr-給總量的 1/2
Modified brooke formula : L/R 2ml/kg.% 後 16hr- 剩下的 1/2
Monitor -(1)vital sign (2)U/O: 0.5-1ml/kg/hr (1.010-1.030)
可加 colloid (↑osm; ↓infusion vol.)
不可用 hypertonic sodium; 前 24hr 勿用’無電解質’之 glucose water 取代

Skin graft
STSG, split thickness FTSG, full thickness skin graft
內容-epidermis+部分 dermis Epidermis+dermis(沒 subcutaneous fat)
少 primary stricture ; 多 secondary stricture 多 ; 少 (∵怕 hematoma)-need to tie-over dressing
Revascularization 快,易;Innervation 快,差 慢 ; 慢,好
Hyperpigmentation , Hair follicle 少 不會 ; 多
Durability 差 ; growth 差 好 ; 好
4
Resistance to infection Easy to infection(∵healing 慢)
多 Donor site-mesch, microskin, intermingle 有限- post auricular skin, upper eyelid, supraclavicular skin, flexural
-postage, cultured epithelial autograft skin, preputial skin, expended skin.

Flap

Z plasty( ° ) Gain length(%)

30-30 25
45-45 50
60-60 75
75-75 100 (2 倍)
90-90 120

Le Fort 式骨折

Surgical drain: 3 種
1. Open drain Penrose drain
2. Close drain Jackson-Pratt drain 拔除時機: 引流量<300cc/8hr
3. Sump drain 供 irrigation & aspiration
Indiacation: 大量/打顆粒之引流物

Post op fever : 5W
5W POD
Wind Atelectasis 1~3 鼓勵深呼吸,咳嗽,chest care
Water UTI pneumonia 3~5 UTI, IV
Walking DVT/thrombophlebitis
IV line
Wound Wound inf 7 天後 Wound inf, surgical complication
Wonder drugs drug
2wk Drug fever

1mmHg=1.36cmH2O
CVP RA RV PA WP
Rule of 6: <6 <30/6 <30/12 <12
3 3 25 25 8

Breast
★乳房 3 大疾病 (1)fibrocystic change
(2)fibroadenoma
(3)breast.ca

Age: 40~50y/o, 2/3 是停經前 (美國-58y/o; 多停經後)

危險因素: 無影響—(1)口服避孕藥 (2)哺乳
有影響—乳癌病史(對側 16% or 1/7) , 家族病史, Supressor(BRCA 1&2,p53), Oncogen(HER2/neu)
30y/o 後生第一胎, 初經早(<12y/o), 停經晚(>55y/o), 停經後 hormone(稍微增加)
表徵: 66% 無痛性腫塊 ; 11%疼痛性腫塊; 9%異常分泌物
診斷:
5
 篩 1.CBE, Sono XMG
選 2.BUS---年輕<40y/o, 東方 Gland 黑 白
3.XMG—老人>50y/o, 西方 fat 白 黑
腫瘤 白 白
確 Excisional biopsy- gold standard
診 Core biopsy(其次 ,98%) > FNAC(90%)
CBE=clinical breast examination; BUS=Breast ultrasound; XMG=X-ray mamography
位置: 外上方 45% > 中央 25% >內上 15% > 外下 10% >內下 5%
Meta: LN 轉移 (esp axillary LN)
預後因子: (最重要)MNTER,PRHER
必考: 組織型態: 膠體性/小管性(colloid)(預後最好) > medullary > tubular 小葉性 > 導管性 ductal

良性
表面 痛
Non~ Cyst 1X 平滑緊張 痛 壓痛, 月經週期後 還有 symptom
Duct ectasia 1X
Apocrine metaplasia 1X
Fat necrosis 1X 原因:Post-trauma;
病理: 非酵素性壞死
Proliferative Fibroadenoma 最常見良性 1X 20y/o, 可移動性 不 表徵: 懷孕時變大, 停經後退化
without 腫瘤 小
atypia Sclerosing adenosis 1X 月 症狀: 月經前-痛; 後-緩解
Simple FCD 1.Fibrosis 癌機率 經 原因: 與 estrogen 刺激有關
2.Cystic change Normal 前 病理: 考 乳小管阻塞乳汁滯留慢性發炎
Slerosing N 痛 間質 fibrosis乳腺&上皮增生(adenosis, epithelial
Fibrocystic

adenosis hyperplasia)
Proliferative 1.Mild N
change

2.Moderate 2倍
3.atyupical 5倍
Intra-ductal papilloma 1X Bloody/serous discharge; 好犯: 乳暈下方
小
Ductal epithelial hyperplasia Mild: 1X
Florid:1.5~2X
Phyllodes tumor= 15% 60y/o Leaf-like 病理(1.+2.): 1.上皮細胞: 葉狀排列(cleft-like/phyllodes)
cysto-sarcoma phyllodes 大 projection 2.紡錘型間質細胞 (15%可能惡性轉變)
Proliferative Aypical ductal hyperplasia 4X
with Atypia (ADH)
Atypical lobular hyperplasia 4X
惡性
Ductal DCIS Comedo type -----------------級惡 差 Lobular LCIS 病理: 單一型態 monomorphic
stage=0 Non-comedo type stage=0
Infiltrating Indian file 一列縱隊侵犯
stage=1~4
Infiltrating NOS 最常見
stage=1~4
Medullary 周圍 lymphocyte infiltrate 3rd 好
Colloid=mucinous 具 細胞外黏液 2nd 好
Tubular 管狀結構 4th 好
Paget’s dis Nipple eczema + ductal.ca =(TIS) 最好
Sarcoma Cystosarcoma phyllodes
angiosarcoma 好犯-淋巴水腫(s/pMRM), R/T 後

DCIS LCIS
Age 老 50y/o 年輕 40y/o
發生率 多 少
Presentation Mass, pain, discharge 無
影像 Micro-calcification 無
Multicentricity 少 Triad-multicentric, multifocal, bilateral
Axillary metastasis 1% 1%
Synchronous invasive.ca
Subsequent carcinoma
多 少
-inicident 同側 Bi-lateral
5~10y 15~20y
-laterality ductal Ductal / lobular
-dignosis interval
6
 -
Histology
考 2006 男性乳癌— 常見 侵犯性 乳腺管 上皮癌 + ER(+)

Breast.ca
N0 N1 N2 N3 N4
T movable a- a-鎖骨下
b-內乳
Tis 沒穿基底層,Paget 氏 Stage 0
T1 <2cm Stage 1 IIa
T2 2~5 IIa IIb
T3 >5cm IIb IIIa
T4 a-胸壁 IIIb IIIc
b-皮膚 Peaud’s orang
c-a+b
d-發炎
IV metastasis 骨>肺>肝>腦

Stage 0 = non invasive Mastectomy + tamoxifen

I, II = early 局部 全身-C/T
1.MRM(含 ALND)+reconstruction H/T – tamoxifen, aromonatase inhibitor
2.BCS(含 LP+ALND/SLND)+R/T Target –HER♁
--Tratzuzumab(herceptin)Laptinib(tykerb)
III = local advanced C/Top(MRM)R/TC/T
ALND(Axillary LN dissection): 目的: 分期+控制, 範圍: Level I, II, rotter’s node (至少 10~15 個 LN )
SLND(sentinel LN dissection): indication ① T1 或 T2 tumor ② LN gross(-) ③腫瘤在乳房外側
方式: ①lymphazurin blue dye ②Tc-labelled surfur colloid
Reconstruction: ①常用 TRAM(tranverse rectus abd myocutaneous flap)②implants③latissimus dorse myocutaneous flap
淋巴引流 Long thoracic.nant. serratus  wing
1. 外, 上(75%)axillary LN(最重要) scapula
Level I 胸小肌外 Ext.mammary(ant/pectoral) Intercostobrachial.n 上臂內側感覺 喪失
Scapular (post./subscapula) Medial pectoral .n 胸大, 胸小肌
Axillary vein(lat.) Thoracodorsal.nlatissimus dorsi
Level II ~~後方 Central axillary group
Level III~上方 Subclavicular (apical)~
Rotter’s node 胸大胸小之 Interpectoral group
間
2. 內 int.mammary(parasternal)LN
3. 上 supraclaricular LN
4. 下 Abd wall LN

C/T-for LN(+),停經前
H/T- ER(+), 停經後
Pre-menopausal Post-menopausal
LN(-) ER(+)
Low risk No Tx vs. H/T No Tx vs. H/T
Intermediate H/T +/- C/T H/T +/- C/T
High risk C/T +/- H/T H/T + C/T
ER(-) C/T C/T +/- H/T
LN(+) ER(+) C/T +/- H/T H/T + C/T

Hormone therapy 1. Tamoxifen (Nolvadex) 攻佔 estrogen receptor

記 1, 4 就好 antagonist
2. SERM (selective estrogen raloxifen
receptor modulator)
3. Pure anti-estrogen fulvestrant
4. AI (aromatase inhibitor) Anastrazole (arimidex), X estrogen 的合成 易骨鬆
exemenstrane (▼Estrogen↓)
Target therapy 對象: HER-2 (+++)
= monoclonal Ab Tratzuzumab(Herceptin) 先用 對抗 HER extra-cellular domain
Lapatinib (Tykerb) if Herceptin 失敗 對抗 HER intra-cellular domain

個論
mastitis mastitis 急性(常) 時機:產後 postpartum 病理: Cellulits抗生素+哺乳
(與哺乳有關-5%哺乳孕婦有) Cellulites> abcess 25% Abcessop drainage,
7
 S.aureu 最常見 停止哺乳
慢性 時機:peri-menopausal 病理:
1.乳小管∵濃稠分泌物阻塞plasma cell 侵潤
2.乳小管破裂, 分泌物外流到間質granuloma
S.aureus focal deep abscess
Sreptococcusdiffuse cellulitis
Gyncomastia
男性女乳化 病理: 間質 & 導管增生
原發 30~70% 病因:不明 好犯: 青春期, 老年期
續發 病因: 肝硬化(∵testosterone 在肝代謝, if 在體內 1d 會變成女性素), 藥物
Klinerfelter’s synd (47XXY), Leydig cell tumor
Gyncomastia 藥物 usmle pg234: 記 Some Drugs Create Awesome Knockers
Spirolactone, Digitalis, Cimetidine, chronic Alcohol use, estrogens, ketoconazole
Fibroadenoma
Intraductal 症狀: bloody discharge, serous discharge excision
papilloma 特性: 小,non-palpable, close to nipple
診斷: ductography
Fibrocystic
change

Gastro-Intestinal
Gastric

GI .ca.多為☼ 除了(1) femoral hernia (5)hepatic tumor—(a) 良—(1st)hemangioma (2nd) focal nodular hyperplasia (3rd)hepatocellular adenoma
男生 (2)umbilical hernia (b)fibrolamellar pattern
(3)crohn’s dis (6)pancrease cystic neoplasm
(4)rectal prolapsed

Peptic ulcer 藥物: 2wks

Classification: Omeprazole + amoxicillin + clarithromycin
胃潰瘍 95%在 1st portion 或 Ome~ + metronidazole + clarithromycin
H↑ @if 用 H2-Blocker 要 X 6wks
H.pylori 90% 1.hemorrhage 胃 幽門前區後壁 止血+切片± 減酸 op( TV with
12 指潰 95%在胃小彎, 70%在 pyloroplasty)
瘍 胃竇 12 指 1st portion 後壁 Oversewing± 減酸 op( TV with
Type I/ IV— H+正常 gastroduodenal a. pyloroplasty)
Type II/III—H+↑
2.perforation 胃 胃幽門前區 Wedge resection /omental patching+
前壁 切片± 減酸 op
12 指 1st portion 前 Simple omental patching(Gram patch)
壁 ± 減酸 op
Non-op ind: (1)wall off ≥24hr
(2)pain well localized
(3)UGI 水溶性 barium 無 extravasation
3.pyloric Op ind: (1)持續≥7 天 (2)再發性阻塞
obstruction @endoscopic balloon dilatation
4intractability Def: 抗生素+ ≥8wk H2-blocker 或 抗生素 + ≥6wk PPI
胃 Type I Anterectomy + B1
Type II/III Anterectomy + TV with B1/B2
Type IV Pauchet gastrectomy
Billroth I = gastroduodenostomy
Billroth II = closure duodenal stump +
gastrojejunostomy
Roux-en-Y= gastrojejunostomy
12 指 減酸 op(PCV)
8
Stress ulcer 治療:
4 大原因: (1)gastric lavage with chilled water
(1)shock (2) op
(2)sepsis(1/3 出血),
(3)燒傷(curling ulcer, >30%BSA) (4)頭外
傷(cushing ulcer)
機轉: mucosa barrier ↓
胃腫瘤
惡性> 良性
症狀: 位置 H.p 有關 治療 Meta
惡 1st adeno-carcinoma 黏膜層 BW↓ 胃竇>體>噴門 Intestinal—90% op C/T R/T
Diffuse – 30%
2nd lymphoma 黏膜下層 腹痛 胃 60% 很亂, 都有
Leiomyosarcoma= GIST 肌肉層 出血 胃 op C/T (-) By 血
良 Leiomyosarcoma= GIST
GIST –location: mesenchymal stem cell= cajal cell
Location : 2/3 胃 -肌肉層
90%是 benign
st
惡 1 adeno- 病理: Post-gastrectomy synd
carcinoma Intestinal H.P 有關 Signet ring 先前有
Type 90% cell gastritis, 老
常 含 mcuin
@HNPCC 也有
Diffuse type 30% Gland 家族史(+),
formation Blood A,
年輕
型態
早 黏膜±
期 黏膜下
晚 肌肉層 Bormann type I
期 Type II
Type III
Type IV-革囊胃=硬
胃

2nd 主為 B cell, Non-Hodgkin(98%)

lymphoma 與 H.pylori 有關 60%
診斷: endoscopy
Leiomyo-
Sarcoma
= GIST
良 Leiomyo-
Sarcoma
= GIST

基礎:
胃切 Parietal Intrinsic factor B12↓ 肌肉注射 B12
除 cell↓ HCl Fe 吸收'↓ 口服 Fe2+(NOT 3+)
9
 12 指 flora↑
後端
Ca 吸收↓ 口服 Ca 2+

Fe - 12 指 鐵: 三三兩兩
Folate - jejunum 空 3+食物 肝, 脾, 骨
Vit B12- ileum 迴 髓
3+聍儲
2+可吸收
2+Hb

Intestine

小腸
良性>惡性; 近端>遠端 (12 指腸>空>迴)
良 GIST 最常見 無/ 腹痛
惡 Adenocarcinoma 50% Mucosa 12 指降部(近 ampula) 黃疸/腹痛 診斷: 太晚(已 meta)
GIST Muscle 空腸 出血 Cajal cell
20%
Lymphoma 15% Sub- 迴腸 腹痛
carcinoid Sub- 闌尾, 迴腸 腹痛 Kulchistsky cell 來源: entero chromaffin cell(APUDoma)
好犯: 闌尾 > 迴腸> 直腸
年齡: 年輕
症狀: 30%具症狀(疼痛,出血);
10%具 carcinoid synd
meta 與大小/位置有關: ≤2cm : 2% meta

≥2cm : 80% meta

課外 usmle pg 316
APUD cell/ kulchistsky cell
-見於
1) carcinoid (小腸.ca) By serotonin
2) pheochromocytoma 腎上, 成人,尿-VMA,, episodic
HTN
3)neuroblastoma 腎上,sym chain, 小孩, 尿-HVA, 無
small cell lung ca.(oat cell) Usmle pg485

-症狀 carcinoid synd(▼5HT↑): ①wheezing②R’t side murmur(R't valve fivrosis),③ diarrhea,④ flushing/cyanosis(vasomotor disorder)
(症狀只有 meta 到 GI 外才有; GI 內無)
-尿液: 5-HIAA↑
Short bowel synd 原因: 小腸<120cm (正常 300~600cm)
保留 ileocecal valve 可容忍大量切除
SMA synd 夾角 18°; 夾距 2.5cm (正常:50~60°;10~20cm)
壓迫 12 指 3rd 端
診斷: ①UGI barium, ②angiogram(腹主與 SMA 角<25°)
Fistula 原因: op 67~80% 處置:
分類 併發: ①loss of GI content ②malnutrition ③sepsis(主要 初期
1.External 死因) 晚期
2.Internal
1.Proximal >3000cc/天 預後差
10
 2.Distal 流量較低 可自閉
High >500cc/day
output
Low <500cc/day
output
腹壁
1st Inguinal hernia Indirect>direct (1)reduction-暫時性
85% 右>左 方法-朝頭朝外, 採 trendelenburg positio,可
1)Direct Hesselbach∆(inf epigastric a.內側), 鼠蹊管內側 sedation
2)Indirect (inf epigastric a.外側), 鼠 @If stragulation 禁 reduction
蹊管內環, (2)op
位於精索內, 其外覆提睪丸纖維 成人 兒童
3)Combined =pantalon 褲袋型 = Direct + indirect direct RC RC
4)Sliding 疝氣囊壁部分 由 後腹膜器官之臟壁(eg.結腸,膀 indirect HL+RC HL
胱)
5)Richter’s 部分 腹腔內 腸壁 被卡住
6)Litter’s 含 Merkel’s divericulum
DDx: femoral hernia, iguinal adenopathy/lipoma, hydorcele,
undescending testis, epidydimitis
2nd femoral hernia 女>男, 老年人
3~4% 右>左
3rd Umbilical hernia 女> 男 儘早 op, 防 strangulation, incarceration
3% 先天性缺陷, 通常 2y/o 前關閉(開口<1.5cm) Indication: 2y/o 前,開口>2cm
2y/o 後, 依然存在
@Extra: Cryptochidism, hydrocele 是以 1y/o

急性腹痛
Childhood 老人
1st acute appendicitis 1st acute cholecystitis
2nd non-specific abd pain (mesenteric lymphadenopathy) 2nd acute appendicitis
3rd intestinal obstruction
4th ulcer dis

Acute 機轉
appendicitis 1st 黏膜下層淋巴組織增生 60%
2nd fecolith 35%
@catarrhal(6hr)suppurative (12hr) gangranous(24hr)  perforation
症狀: RLQ 痛, 上腹部&肚臍周圍痛(T8~T10)
McBurney’s point tenderness(+)
Roving ‘s sign(+)-壓對稱點,檢視 Mcburney 的反彈痛
Psoas sign(+)-左側躺,右腿往後伸直
Obturator sign(+)-平躺, 右腿 flexion
Intestinal 病因: 3rd neoplasm @if 大腸: 大人-1st colon. Ca. , 2nd diverticulitis 3rd vulvolus
st th
obstruction 1 adhesion (大人常) 4 intussusceptions(小孩常) 小孩-fecalis impaction
2nd incarcerated hernia 5th volvolus
影像: erect CXR + plain abd @If paralytic ileus: 整條胃~大腸皆有 gas
(1)dilated loops with air-fluid level
(2)paucity of colon gas(complete obstruction)
(3)thumb printing(strangulation)-腸壁間有氣 etc
(4)free gas(perforating)
分類
Mechanical Simple obstruction 局部血循 正常 NPO+ decompression;
@if 2~3d 無緩解op (@gastric ulcer 是 7d)
strangulation 局部血循 受阻梗塞壞 op
疽
paralytic Peritonitis 最常見, etc

Colon

大腸
看 Pg27 大腸解剖
結腸帶 taenia = 3 條 縱肌 殘留, 匯聚處為 appendix
結腸袋 haustra = ▼taenia 比 結腸管短
SMA+IMA 吻合: ①arc of Riolan ② marginal.a.→vasa recta
11
Massive LGI bleeding 原因: Laparotomy ind: >6U(3000cc)/24hr
Def: Treitz lig 以下出血 1st diverticular dis 4th polyp (小兒常見) @massive bleeding: >2500cc/次
nd
≥3U(1500cc)/24hr 2 vascular ectaia/angiodysplasia 5th colitis(ischemic/inf),
3rd colon ca.n 自 hemorrhoid??
診斷: NG Ano-/procto/colonscopy
其他: Tc-99m: >0.1cc/min 需 20min; RBC scan>0.5cc/min
需 2hr;
angiography>1cc/min
Intestinal stoma
Ileostomy 永久 目的: replace anus 位置: RLQ, 腹直肌(較高處), everted, 1.skin irritation 最常見
暫時 Decompression, diverted fecal stream mucosa suture to the skin 2~6.
Colonstomy 永久 Replace anus End-colostomy-左髂窩,腹直肌較高處 同上除了 6.
暫時 Decompression, divert fecal stream Loop - 盲腸, 橫結腸,
創傷破裂處
大腸鏡併發症 (1)Perforation Peritonitis(-) OBS (IV 抗生素+ bowel rest)
(+) Urgent laparotomy
(2)bleeding Immediate 或 delayed(7~10d)
Polyps 1)hyperplastic
90%
2) reactive
3) (A)Familia hamartomatous 1)P-J synd 0% 唇圍口腔 pigmentation + GI polypsis
harmatomatous polyposis 2)Diffuse Juvenil polyposis 20% 小兒 GI bleeding 最常見
4)neoplastic (B)FAP(Familiar 1)Polyposis coli 100%
adenomatous 2)Gardner synd 癌變 Osteoma + fibroma/desmoid + GI
polyposis) @↑periampullary ca.
3)Turcot synd Glioblastoma multiform + GI
--形狀 --大小
Tubular 發生率 惡性 5% <1cm 1%癌變
最多 1~2cm 10%
Tubule-villous 2nd 22% >2cm 50%
villous 最少 40%
@familiar polyposis synd (AD) :
(A)Familia hamartomatous P-J synd 0% 唇圍口腔 pigmentation + GI polypsis
polyposis Diffuse Juvenil polyposis 20% 小兒 GI bleeding 最常見
(B)FAP(Familiar Polyposis coli 100%
adenomatous polyposis) Gardner synd 癌變 Osteoma + fibroma + GI
@↑periampullary ca.
Turcot synd Glioblastoma multiform + GI
Colo-rectal ca.
病因
Familial FAP Cancer risk AD, 診斷: (1)>100 adenopolypsis
10~15% 1% 100% APC 基因異常(5q21) 或 (2)家族史(+)+1 adenopolyposis
篩檢: (1) APC gene analysis(周邊血) (2)colonscopy
HNPCC 80% AD, 診斷(1)≥3 親屬 具 大腸直腸癌— (a)1 名為其他的 1 等親
= Lynch MSH2 (b)≥2 代 (連續 2 代)
mismatch repair (2p) (c)≥1 名於 50y/o 前 診斷
10~15% (2)排除 FAP
篩檢: 18y/o 開始(或最年輕家族減 5y/o)
Sporadic Villus -40% 原因: 環境>遺傳
85% >2cm-50%

HNPCC = hereditary non-polyposis colon cancer; APC= adenomatous polyposis coli

Screening: occult blood ; 診斷 : colonscopy + biopsy
12
 Op: 胃,腸的 safety margin 皆是 5cm
肝 是 1cm
Dukes TNM 病理描述 治療
A T1 侷限-mucosa op
B1 T2 侷限-muscularis
B2 T3 超越-肌肉層,擴展到 serosa
C1 B1 + 侵犯 LN If 有 LN(+),
LN(+) 就-加 C/T(主
C2 B2 + 5-FU)
LN(+)
D TxNxM1 侵犯 其他器官
Rectal ca. -Dukes B2,C-須加 Adjuvant CCRT
Prognosis: 1. Stage M  N  T
2. Colon > upper rectum > lower rectum
3. flow cytometry: diploid > aneuploid
4. complication : nil> perforation/ obstruction
5. type : non-mucinous > mucinous (signet ring cell)
6.age : old > young
7. CEA↑
Volvus Sigmoid 好犯: 老人 Plain film: (1)inverted-U (bend inner tube ) 治療
volvulus 原因: 腸管太長 (2)sausage like Peritoneal sign(-)先 保守op
shape(air-fluid level) Peritoneal sign(+)op
(3)Omega sign
Contrast enema 水溶性: bird’s beak deformity
CT : mesenteric whirl
(2)cecal 好犯: 年輕人 Plain film: kidney shaped (in LUQ) op
volvulus 原因: 腸管固定不佳(先天) 或 target sign/ donut sign
Hypague enema: tapered cut off in A-colon
Diverticular dis
Diverticular Pseudo/false 其他特徵: 為 LGI bleeding 最常見的原因
dis (缺肌肉層) 好犯: sigmoid colon
Mesenteric site Diverticulosis 無
好犯: 老人 diverticulitis 有 診斷: CT (壁厚, 膿瘍形 (1)NPO, IV, antibiotic
發 成 ) (2)48h 內改善elective op(4~6wk 後)
炎 不建議 –scopy 或 enema 48h 內無/toxic signemergency op
(防破裂)
4 大 complication:
① perforation
② abcess
③ obstruction
④ fistula
DDx True diverticulum (全層) 其他: (1)具 胃黏膜, 胰組織
Meckel’s Anti-mesenteric site (2)5 rules of 2’s: ①2 ich 長, ②2 feet from ileocecal, ③2% of proportion,
diverticulum 好犯: 小孩 ④常≤2y/o, ⑤具 2 種 epithelial(胃,胰)
Radiation
proctocolitis
IBD Crohn dis = 區域性迴腸炎 Ulcerative colitis= 潰瘍性直腸炎
(Spontaneous 原因 post-inf/沒原因的發炎 Autoimmune
inflammatory 年輕 2 段年齡: 年輕, 老年
bowel dis) Triad: abd pain, diarrhea, malabsorbtion (BW↓) Bloody diarrhea
小腸 (ileum 迴 70%)+大腸 大腸 (直腸 100%)
跳躍式, 全層發炎 連續性,黏膜層發炎
穿孔,廔管, 隱窩膿瘍+++
肉芽腫, 纖維化, 狹窄, 阻塞 假性息肉+++
fissure Pseudo-polyp
黏膜潰瘍 線性潰瘍, 鵝卵石樣 瀰漫性充血, 融合性潰瘍
腸外 關節炎, 虹膜炎 關節炎(最常見’), 虹膜炎
病灶 肛裂, 肛門樓管,肛圍膿瘍 壞疽性膿皮,
Primary sclerosing cholangitis(最嚴重)
大腸癌 Stricture site 7%; 易 adenocarcinoma 10~30%
診斷 Contrast X-ray endoscopy
無法 op— no cure Op 後 會改善—關節炎
Op 後不會 -- 硬化性膽囊炎
Ischemic bowel 原因: (1)SMA embolism/ thrombosis—好犯近端 Triad: ①severe abd pain ②嘔吐,腹瀉 ③ CV 病
dis (2)non-occlusive mesenteric 史
ischemia(NOMI) 診斷: angiography
13
 (3)iatragenic
Haemorrhoid = Dentate 原因: 年輕-▼↑resting pressure 1° 沒脫出 Medication-軟便, 高纖
piles 以上 老人-▼defection 維
straining 2° 自行復位 Ligation (2°~3°)
@但與 便秘 無關 3° 用手復位 Excision(3°~4°) 併發症
病理: 血管擴張 4° 無法復位 -早期: ① urinary retention
表徵: 流血(不痛) ② bleeding
晚期: ① incontinence
② stenosis(esp
whitehead hemorrhoidectomy)
Dentate 原因: 無 處理: <48hr  excision
以下 病理: thrombosis >48hrwarm sitz bath(↓疼痛;↑血流), 軟便, 高纖維
表徵: (不流血)perianal pain
Anal fissure 症狀: Triad: : ① anal fissure(ulcer in anoderm; dentate line 以下) 1st 藥物治療主- warm sitz bath, 軟便劑, 高纖維,
②senile pile 局部 NTG(以利大便排出; 副: 頭痛)
③ hypertrophic papilla 2nd Op :Indication 慢性>1m
原因: forceful dilatation during defecation
位置: midline; Goligher rule: 90% post. 10% ant.
Rectal 好犯: 年長 女性, 子宮切除後, 長期使用瀉劑
prolapsed = 分類:
procidentia 1.mucosal prolapsed, partial thickness = haemorrhoid
2. rectal intussusceptions, full thickness = internal rectal prolaps
3. true prolapsem, full thickness =external rectal prolaps
藏毛症 好犯: 年輕 男性 急性感染發炎期: unroofing + extraction of hair
pilonidal sinus 表徵: sacrococcygeal area 之凹陷, 約位於中線股溝肛門口上方 3~5 公分處; 穩定期 : 完全切除再縫合
內具毛髮長入, 但併無毛囊 or 其他皮膚附件 @非由肛門直腸長入
Anal cancer 分類: 1. SCC – 最常見 70% 1.合併療法: R/T(3000rads) + C/T(5-FU+ Mitomycin)
2.basal cell carcinoma =cloacogenic carcinoma (nigro’s chemoradiation for SCC)
3. malignant melanoma 2.Op 切除
4. adeno-carcinoma = mucoepidermoid carcinoma @課外: 1rad = 1cGy = 0.01 Gy
5. small cell carcinoma = oat-cell carcinoma 3000rad=30Gy
Perianal abcess A. Perianal 原因: infection 治療: I & D (incision & drainage)
& fistula ani abscess
B. fistula ani 原因: infection 治療: fistul-ectomy 切除/-otomy 劃開
表徵: 持續性 肛圍 流膿 @Goodshall’s rule
a. Inter-sphincteric 60% 最多 1. 前半圓 之外口 與 內口 呈一直線[>3cm 之外口, 其
b. tras-sphinteric 35% 內口在壁]
c. supra-sphincteric 4% 2. 後半圓之內口 位 6 o’clock 方位 (呈 彎曲路
d. extra-sphincteric 1% 最少 徑)horseshoe fistula

偽結腸阻塞 = colonic pseudo-obstruction = acute colonic ileus without mechanical 1) 保守性 主 : decompression
Ogilvie’s synd 特性: 好犯 長期臥床, 病危者, 外傷者 2) 當 盲腸管徑 > 9~12cm 用 colonscopic decompression
診斷: diagnosis of exclusion (防 cecum rupture))
3) 當 peritonitis op

Constipation
IBS (irritable Def: chronic(>3m) functional abd pain & bowel complication 保守性 主— bulking agent(high fiber diet),
bowel synd) 診斷: exclusion anticholinergics/antidiarrhea

Hepato-Biliary system
14
Liver 肝

Cantlie’s line = GB fossa + IVC(左側)

Middle hepatic .v 分 左右葉
R’t hepatic .v 分 Ant. Post. Seg
L’t hepatic .v 分 Middle. Lat. Seg

最小= 1 seg
Teres/ round lig=
falciform lig =
5,6,7,8 R’t hepatectomy
R’t hepatic lobectomy
4,5,6,7,8 Extended r’t hepatectomy
Extended r’t hepatic lobectomy
2,3,4 L’t hepatectomy
沒1 L’t hepatic lobectomy
2,3 L’t lateral segmentectomy
2,3,4,5,6 Extended l’t hepatectomy
Extended left hepatic lobectomy
評估 肝 功能= ICG R15 CHILD-PUGH
= indocyanine green retention test 1 2 3
<15% <10% Lobectomy Encephalopathy None Gr 1~2 Gr 3~4
16-20% 10-20% Segmentectomy Bil 2~3
>20% 20-30% subegmentectomy Alb 2.8~3.5
PT 4~6
Ascitis none mild moderate
Class A: 5~6, Class B: 7~9,
Class C: 10~15
Operative mortality A 2% , B:10%,
C:50%
肝昏迷: Gr 1: prodrome(早睡,晚起,個性); Gr 2: impending(嗜睡);
Gr 3: stupor(昏睡可喚醒) ; Gr 4: deep coma

Hepatic tumor
惡性: M>F 良性: F > M
1. metastatic 1st 肺癌 2nd 大腸 1. Hemangioma 最常見 , 不癌化, 不
癌 易出血, obs
2. HCC 成人 2. Focal nodular hyperplasia 2nd , 與 口服避孕藥 , 不癌化, 不易出血, obs
AFP↑
3. hepato-blastoma 嬰幼兒 AFP↑ 3. Hepato-cellular adenoma 3rd ,與口服避孕藥, 癌前期, 1/3 會破 ,
operation
4. cholangio-carcinoma 中華肝吸蟲 2009 年 2 月
a. intrahepatic Hepatocellular adenoma 內科考-停避孕藥(非 op)
b.extra-hepatic upper duct/
hilar/ Klatskin tumor
c. extra-hepatic lower duct
Us pg 肝轉移: Cancer Sometimes Penetrate Benign Liver
Colon > Stomach > Pancrease > Breast > Lung
Hepatic hemangioma 女性 1. Obs
種類: Capillary form 較常見, 多發性, 無症狀 2. If 具症狀 or 外傷性破裂風險(表
Cavernous form 單一性, 具 淺)者- enucleation
症狀, 較大
診斷: US: homogenous hyper-echoic with compressibility
CT: low density with early peripheral enhancement ?? late??
不建議 biopsy(出血)

Focal nodular hyperplasia 年輕女性(40) ; 避孕藥

表徵: 少 破裂
病理: 單性, 無 惡性
Hepatidc adenoma 年輕 女性 (20~40) ; 危險因子: 避孕藥(E & P) Resection 主
表徵: mass(palpable), intraperitonewal bleeding(1/3, esp 懷孕▼E↑)肚痛 @不適合 op 者: 1.regression
病理: hepatocyte (含 glycogen), 缺 portal triad @ pre-malignant 2. Small
3. Multiple, dispersed
4. central-located
HCC 中年 男性 Curative –resection
Screening: (1)sono (2) AFP ; confirm: (1)CT (2)angiography Ablative –(1)PEI— <2cm, <3 個
15
 病理: Classic: (1) massive fibrolamellar (2)TACE—禁忌
線癌 (2) nodular Milan criteria:
(3)diffuse form NOT curative: C/T, R/T
Sex Age 男>女 中年 男=女 年輕
腫瘤 Invasive Well defined; 良性
可切除率 1/4 2/4~3/4
肝硬化 90% 低
AFP 80% 低
HBV 50%~90% 低
Liver abscess Pyogenic 細菌性 Amebic 黴菌膿瘍
中年 男  女 年輕 男
原因(1)膽道感染 (多)
(2)portal 感染
(3)隱發性 cryptogenic
Entamaeba histolytica candidia
E.coli, Klebsiella(DM 病人)
好犯: 右肝(@結石-左,上下) 右肝
Multiple 單一 膿瘍
黃疸, 發燒, WBC↑, Bil↑, 腹痛, RUQ tenderness,
ALP↑ 肝腫大
Blood culure (+) IHA or EIA > 1: 32
drain metronidazole
Liver cirrhosis 原因 肝前性: portal v. thrombosis (1)出血: gastric lavagevasopressin
Def: 肝門壓 15~40mmHg 肝性(常): cirrhosis (病毒> 酒精) (IV) (慢出血)endoscopy
(正常: 5~10mmHg) 肝後性: budd-chiari synd = hepatic v. occlusion sclerotherapy/(快出血)S-B ballon
(polycythemia, lymphoma) tamponadeTIPSS 或 op
(2)selective shunt: Warren shunt
(=distal splenorenal shunt, DSRS,pg59)
(3)total porto-systemic shunt:
portacaral shunt
(4)liver transplantation
(5)TIPSS (transjugular intra-hepatic
porto-systemic stent shunt)

biliary tract 膽道

Cholelithiasis
分 1. Cholesterol stone 4F= female(避孕藥 E↑), forty, fat, fertility 位 1. GB stone
類 2. Pigment stone 置 2. IHD (intra-hepatic) stone 左 > 右 (@與 abcess 相反)
a. black stone -溶血性 貧血(un-conjugated↑) 3. CBD (common bile duct)
b. brown stone -感染 (esp Klebsiella) stone
(bacterial glucuronidasedeconjugation)

3. mixed 常
病程:
Asymptomatic (obs)(colic pain)symptomatic(op) 3 大 complication (①Acute cholangitis, ② CB stone, ③ Gall stone pancreatitis)(op)
Silent stone 診斷: US (incidental 意外發現) If –Porcelain gallbladder (25%-->cancer) 一定要 op
If – large stone(>2~3cm) 建議 op
Biliary colic 表徵: Periodicity(飯後數小時內), RUQ (1) LC (laparoscopic cholecystectomy) 主
診斷: US + 排出併發症(①,② CB stone, 禁忌: ①Peritonitis,② cholangitis, ③出血傾向
③ ) ④無法容忍 pneumoperitoneum(eg. COPD, congestive Heart failure)
技術: Calot’s ∆= liver bed+ cystic duct+ heptic duct
內含 cystic artery
(2)Open cholecystectomy
Acute 表徵: RUQ, Murphy’s sign (沒有 Fever, Jaundice)
cholecystitis US: 膽囊壁增厚 (>3cm), 周圍積液
(1)住院 IV 抗生素(3rd 代 cepha + metronidazole)---①E.coli② klebsiella ③enteroccoci= strep faecalis ④B. fragilis
(2)op
Chole-cyst Emergency(≤2d) 高燒>39, WBC>1 萬 5 千, acalculus 方式: (1) LC
-ectomy 主 主 (2)Open (esp >2d)
Expectancy/delayed≥6~8wks 嚴重內科疾病
Intraoperative cholangiogram
CBD explore + T-tube insertion 記適應症 10d 後照影if 無術後 14d 後拔除

if 有保留 術後 6 週截石

(≥6wk 會有 fistula,則可把 T-tube 拿掉用 foley 取代(for drainage)用 scope 拿石頭)
16
 Cholecystom 適應症: acute cholecystitis + 藥物失敗 + 不適合 ectomy 方式: (1) open
t-otomy For 減壓, 引流 (2) percutaneous
併發症: empyema, perforation, peritonitis, fistula(膽囊與 12 指腸之間), gallstone ileus
@Post-cholecyst-ectomy PAIN: @Post-cholecyst-ectomy CBD STONE:
1 common bile duct stone 2 cystic duct remnant 3 retained <2yrs  retained stone
gallbladder 4stenosing papillitis 5 traumatic stricture 6 biliary >2  recurrent stone
dyskenesia
Specific cholecystitis Emphysematous cholecystitis 老(50~70y/o)男; 好犯: DM p’t 立刻 op
菌種: C.perfinges 主
Acalculous cholecystitis 原因: ischemia/stasis 立即 op
表徵: 像 acute choleystectomy
Chole-docho-lithiasis 表徵: RUQ , 黃膽 (1)LC + CBD exploration (open cholecystectomy + CBD
總膽管結石 診斷: US (20~50%見 stone) exploration + T-tube ininsertion)
(2)ERCP + EPT (endoscopic papillotomy = endoscopic
sphincterotomy)
Acute = inf + obstruction 先 antibiotic 或 減壓 –6wk 後 cholecystectomy + CBD explore
cholangitis 原因: (a)obstruction:Stone(多),stricture, tumor
(b) 1st E.coli, 2nd Klebsiella pneumonia Charcot’s triad = 發燒+黃膽+RUQ 痛
表徵: Charcot’s triad Reynold’s pentad = charcot+心臟血液不穩+精神狀態改變
Reynold’s pentad
Gallstone ileus 原因: 膽石 經 膽囊 12 指腸廔管, 卡在迴腸 Exploratory laparotom+ 經 enterotomy 取出 膽石
表徵: 小腸阻塞 (腹痛, 嘔吐)
Choangio-carcinoma 病理 分類: Bismuth-corlette classification
1.肝內 intra-hepatic 10% Type I Cystic dilatation of common bile duct
2.肝外上段 extra-hepatic upper duct, hilar, 60% II Diverticulum from common bile duct
klatskin III-A Choledochocele
3.肝外下段 extra-hepatic lower duct 30% -B
特徵: 老(60y/o), M>F IV Dilatation of intrahepatic duct
與 下列疾病相關:
a. primary sclerosing cholangitis 中年女, AMA(+)
b. choledochal cyst
c. intra-hepatic stone
d. 中華肝吸蟲
Gall-bladder ca. 與 下列疾病相關:
a. 膽石症 90%
b. Porcelain gallbladder 25%-->膽囊癌
c.

Pancrease 胰臟

Acute 3 大原因: 1st 膽結石 2nd 酒精 3rd 藥物 (1)支持性療法:

pancreatiti 2 大病理: 壞死+出血 a.NPO, NG decompression
s 蛋白溶解(液化壞死); 脂肪溶解(脂肪性壞死皂化反應[Ca]↓) b.止痛 (Demerol>morphine (▼odd’s sphincter 收縮) )
血管壞死(出血Cullen sign(臍圍淤血),turner sign(腰際瘀血)) c.預防壓力性潰瘍
診斷: (1)amylase↑ (與預後無關) d.抗生素 : 適用重度患者
(2)lipase ↑ (更 specific, 經 3~5 天後恢復) (2)op 適應症: 3 大理由:
(3)Ca↓ a.診斷未明: exploratory laparotomy
CT > Sono b.膽石性胰臟炎: 先保守治療待 5~7damylase 恢復op
Ranson Criteria: 記 ASS 乳白, BBS CHO if>24h 無改善ERCP+EPT 恢復 op
admission 最初 48hr c.necrosis wit infection: 診斷: 1. SIRS
Age : > 55y/o 血中缺 Base: >4 mEq/L
Sugar: >200mg/dl BUN↑ :>5 2. contrast CT + FNA
AST(GOT): > 250 IU/L 組織滲液 S :>6L
乳酸 LDH: >350 IU/L Calcium [Ca]: < 8 3. CRP , LDH
白血球 WBC: 1 萬 6 千 Hct↓ :> 併發症: 1st Pseudocyst : 無 上皮性 內襯細胞
10% 2. abcess
PaO2 :<80 3. 休克, 敗血症, DIC, ARDS, 腎衰竭
mmHg
Chronic 原因: 酗酒, 膽石症 Op 適應症:
pancreatiti 表徵: a. 上腹痛後背 a. intractable pain 最主要
s b. 吸收不良: BW↓, 脂漏症(A,D,E,K↓) b. inability to rule out neoplasm
c. 內分泌不足: DM c. complication- pseudocyst
診斷:ERCP > CT > US > X-ray: 胰臟鈣化 - duodenal obstruction
考併發症: a. opioid addiction
b. DM
c. steatorrhea/ malnutrition
17
 d. pseudocyst(急性/慢性皆有)
e. duodenal/ biliary obstruction
Pancreatic 考病理: Courvoisier’s sign: 無 痛性黃膽+ 腫大膽囊
.ca Adeno.ca. Mucinous. Ca Virchow’s node : 左 鎖骨 LN
80% 2% Sister Mary Joseph’s node: 臍 LN
Giant cell ca. Cyst-adenocarcinoma 1% Trousseau’s thrombophlebitis:移動性 表淺 血栓性 靜
4% Un-classified 脈炎
Adeno-squamous. Ca 3% 9% (Pg56Us-ck trousseau synd—▼malignancy 造成的
位置: 胰頭 70%(20%resectable)~ 胰尾(5%resectable) hypercoagulopathy (常 adeno-ca.))
表徵: 腹痛 80% 後背 25%
Obstructive jaundice70% Op:
Peri-ampulla ca. BW↓ If 頭: (a) Whipple procedure
症狀: obstruction jaundice Cholangitis (b) PPPD
檢查: CA19-9, CEA, CA125 If 體/尾: child procedure
(1)pancrease 65~90%
(2)CBD 影像: CT : 膽道&主胰管擴張, 大於 2cm 腫瘤 可見 @whipple: ①胰頭+ ②distal CBD + ③gastric
(3)duodenum ERCP: antrum/duodenum/jejunum +④ vagotomy + ⑤
(4)ampulla vater Endoscopic US: 評估 腫瘤大小, portal & SMA 侵犯程度 chole-cyst-ectomy
@PPPD=pylorus-preserving pancreatico-duodenectomy—
好處: op 時間短,不會 dumping synd
壞處: marginal ulcer, 會 delayed gastric emptying
Pancreatic cyst
2 類:
pseudocyst <4 週: acute fluid collection
>4 週: acute pseudocyst
Cystic neoplasm 佔 pancreatic neoplasm 1%
Pseudo-cys 原因: 胰管斷裂 <5cm : self-resolved
t 特性: 無 內襯 上皮, 與 胰管互通 >6cm 或 囊壁鈣化 : 75%需 op
Lab : amylase↑ (無 lipase)
診斷; CT 主
US: 適用 CT 探測後之追蹤
Pancreatic 特性: 具 內襯 上皮, 不與 胰管互通 診斷:
cystic 考病理: 記 蛇怕 mucin 在尾巴 cyst (1)fluid CA199 無鑑別性 CEA : 黏液性↑
neoplasm a. Serous cyst-adenoma 胰頭; ; analysis: CA 125: 惡性↑
≤2cm ; 無 惡性 Amylase: pseudo-cyst↑
b. Papillary 年輕女性; Lipase :
大 ; 低 惡性 pseudo-cyst↑
(2)percutaneous cytology/ wall biopsy
c. Mucinous 胰體 or 尾; ; 2-20cm; 高
cyst-adenoma 惡
d. Cyst-adeno carcinoma
;10-20cm; 惡性

Spleen 脾臟

脾臟切除
Absolute indication Relative indication
1. Massive splenic trauma 1. thrombocytopenia :
2.Hereditary spherocytosis (a) ITP (▼anti-plt Ab)—診斷 >6wk + plt<1 萬; >3m + plt<3 萬
3.Splenic vein thrombosis wit bleeding 治療:
4.esophageal varices steroidIVIGsplenectomy
5. splenic abscess (b)TTP (▼ADMATS 13) 治療: plasmapheresissplenectomy
6. parasite cyst 禁: 輸 plt
2.hemolytic anemia
3. primary hyper-splenism
4. felty’s syndrome : triad rheumatoid arthritis+splenomegaly+ granunocytopenia
5.Gaucher disease, Sarcoidosis
6. Myelo-proliferative disease, Lymphoma
併發 早期併發症 1. Atelectasis (最常見)
症: 術後 60d 內 2. Thrombocytosis
3. Sub-phrenic abscess
4. 胰臟炎 & 胰皮下廔管
5. 胃穿孔
OPSI 病原: encapsulated bacteria 治療:3rd cepha
①S.pneumoniae 最常見 預防: 術前 2~3 週 vaccination
②H. influenza type B (GNCB) 術後 penicillin(esp<5y/o)≥2yr 或 青春期
③N. meningitis
18
 ITP (1) 急性—兒童; 50%2~3 週前具 virus 感染 ; 多數 self-resolved(6w~6m)
(2) 慢性—成人(發育女性); 具 anti-plt Ab/ 不具 virus 感染史; 不會 self-resolved/ 治療: steroidsplenectomy
@ITP = idiopathic thrombocytopenia pupura
@OPSI= overwhelming post-splectomy infection

Esophagus 食道

3 個 狹窄 處: Esophageal perforate instrumental

(1)上 : C6 : cricoid 後  最易 1st
最窄 3rd
(2)中: T4 : 支氣管分叉處 後2nd 2nd
(3)下: T10: 穿過 橫膈膜
3rd

Gastro-esophageal 診斷: Esophageal pH monitoring: probe 置於 LES 上方 5cm,記錄 24hr 一般: 床頭抬高, 避免緊身衣, 少量多餐,
reflux (GER) 病理進展: metaplasia(Barret’s)dysplasia(mild) BW↓, 酒精咖啡↓, 避免睡前
anaplasia(mod.)adenocarcinoma(severe CIS, not SCC) 吃
藥物:
Op: Nissen fundoplication(360°)最常用
Caustic injury 特性 酸 pH<2 Coagulative necrosis 最初-airway compromise? tracheostomy
鹼 pH>11.5 Liquefactive necrosis 嚴重 - Fluid resuscitation + antibiotic
- NPO @禁催吐, NG tube (會弄破)
病程 Acute(1~4d) Inflammation phase - Early endoscopy/contrast esophagography(≤ 2d)
Subacute (4~14) Granulation 7~14d 最脆弱 後續-無穿孔 supportive tx
Chronic(≥14d) cicatrization 有穿孔/持續處血/持續酸中毒op
\
晚期併發症
①stricture(1~2m 內):
dilator 處理-(a)early(acute stage, 1~4d)
(b)late (3~6m 後)
②食道癌
Esophageal ca. 男>女; 老(50~70y/o); 徵狀: dysphagia 只有 Op (▼R/T, C/T 效果不好)
分類 SCC (常) 好犯中 1/3 Resection margin: proximal10cm
Thoracic inlet Adno.(2nd) 下 Barrett’s esophagus DistalLeft gastric .a
食道上3rd 1/3 @胃 margine: proximal5~7cm
氣管分叉 診斷 Distal 3~4cm
食道中1st T N M Organ—(1)gastric tube (1 anastomosis)
下肺靜脈 1st MRI 1st thoracoscope 1st PET (2)colon interposition (3 anastomosis)
食道下2nd 2nd EUS 2nd EUS 2nd CT (3)jejunum(route-en-Y 2 anastomosis/
Thoracic outlet free graft 5 anastomosis)
Route—(1)subcutaneous—if 有併發症, 可劃開
(2)substernal 最常用
(3)transpleural
(4)post. Mediastinum 最短,為生理路徑
Leiomyoma 最常見 食道 良性 腫瘤 Obs (主)
診斷: barium 切除(enucleation): 適應症: >5cm
Esphagoscopy-排除 食道癌
@禁 biopsy (防出血; 防與黏膜層沾黏不利於日後 具症狀(吞嚥困難/痛)
op(enucleation))
Hiatal hernia 女> 男
表徵: 無症狀
分 I Sliding 最常見, Reflux 無症狀obs
GERD 類 無 症狀 (burning pain) Reflux 藥物op
24h pH monitor
II Para-esophageal 最易 strangulation Compression Op
Esophageal ca scope III Type I + II (post-prandial pian, (if 不開刀, 30%死於併發症(gastric
IV 胃以外的器官(結腸, 脾臟) early satiety, strangulation))
Leiomyoma dysphagia)
診斷: UGI(barium swallow) 確診
Hiatal hernia UGI barrium
Perforation 原因: ①intrument 最多 好犯位置: C6 > T10 > T4 Antibiotic + op (越早越好, mortality 越小)
②foreign 好犯位置: C6
處理區別:
19
大腸鏡 無 Obs
peritnoneal sign op
Instrumental
食道 皆 op
 ③caustic agent : alkaline > acid 預後因子:
④cancer ①delay 最重要: 晚> 早 op
⑤Barotrauma : 原因: Emetogenic = Spontaneous = ②etiology: emetogenic(最差)> instrument(最佳)
Boerhaave’s ③location: thorax (最差) > abd > cervical
好犯位置: 左, 後, 外, 下 1/3
診斷: CXR (pneumo-mediastinum, pleural effusion, air in soft tissue)
Diverticulum Pharyngoesophageal (Zenker) 最常 假 Pulsion GER Op (diverticulectomy)
Midesophageal (parabronchial) 真 traction Mediastinal
範圍: ①mucosa granulomatous dis.
②sub-mucosa Epiphrenic 假 Pulsion Obstruction
③肌肉層 症狀: ①dysphagia ②regurgitation (choking, cough)
假性: ①② 診斷: contrast esophagogram (UGI)
真性: ①②③
Mallory Weiss synd Def: ▼劇烈嘔吐後 (esp 酗酒者) Ice water lavage (90% stop bleeding )
胃-食道 交接處 縱向 裂傷 (胃 > 2 者 > 食道) Endoscopic electrocautery
(mucosa, submucosa) Surgeical repair (少)
症狀: UGI bleeding
診斷: scope @DDx Boehaav’s –吐(emetogenic)
Esophageal motility Primary-(a)achalasia
disorde (b)diffuse esophageal spasm
Secondary-(a)progressive systemic sclerosis(PSS=scleroderma)
(b)polymyositis & dermatomyositis
Achalasia = 男 ; 中年 (35~45y/o) Forceful dilatation (pneumatic bougienage)
mega-esophagus 原因: 缺 Auerbach plexus (像 Pyloric stenosis, Hurspring dis 皆 男>女) Heller myotomy 背
症狀: dysphagia 100%
Retention of ingested food in the esophagus 併發症: aspiration pneumonia
–regurgitation 70%(不含胃酸) Malnutrition
aspiration pneumonia 3~5% SCC (15~25y 後, 不會↓after-op)
診斷: Esophageal manometry : ①缺 body peristalsis②sphincter↑③無法放鬆 @跟 cryptochidism 相似
Diffuse esophageal 表徵: chest pain, dysphagia (無 reflux) 藥物:
spasm 診斷: manometry Op : long esophageal myotomy
barium

Cardio 心外
Ankle Brachial Pressure Index (ABPI)
P Leg—is the systolic blood pressure of dorsalis pedis or posterior tibial arteries
PArm— is the highest of the left and right arm brachial systolic blood pressure

In a normal subject the pressure at the ankle is slightly higher than at the elbow (there is reflection of the pulse pressure from the
vascular bed of the feet, whereas at the elbow the artery continues on some distance to the wrist). The ABPI is the ratio of the
highest ankle to brachial artery pressure and an ABPI of greater than 0.9 is considered normal (Free from significant PAD).
However, an ABPI value greater than 1.3 is considered abnormal, and suggests calcification of the walls of the arteries and
incompressible vessels, reflecting severe peripheral vascular disease.
Provided that there are no other significant conditions affecting the arteries of the leg, the following ABPI ratios can be used to
predict the severity of PAD as well as assess the nature and best management of various types of leg ulcers
ABPI value Interpretation Action Nature of ulcers, if present
Abnormal
above 1.2 Refer routinely
Vessel hardening from PVD
1.0 - 1.2 Normal range Venous ulcer
None use full compression bandaging
0.9 - 1.0 Acceptable
0.8 - 0.9 Some arterial disease Manage risk factors
Mixed ulcers
0.5 - 0.8 Moderate arterial disease Routine specialist referral
use reduced compression bandaging
under 0.5 Severe arterial disease Urgent specialist referral Arterial ulcers

Interpretation ABI
Calcification >1.3
正常 1~1.1
20
< 0.95=significant narrowing of blood vessels <1
< 0.8, pain in the foot, leg, or buttock may occur during exercise (intermittent claudication).
< 0.4, symptoms may occur when at rest.
<0.25 =severe limb-threatening PAD

Endocrine 內分泌
Thyroid 甲狀腺
只有 Thyroid/ para-thyroid dis: 女>男
其他 endocrine : 男>女

少 T3 : 45~120 Hyper-thyroidism Hypo-thyroidism 診斷:

多 T4 : 4.5~12 成人: myxedema ●Hx
Free T4: 幼兒: creatinism ●PE
0.7~1.8 成因: 成因: ●Lab: TSH:↑T4↓, anti-microsomal(+) Hashimoto
TSH : T4↑, T3↑  Grave’s dis
0.3~ 6 ●1st step Sonography : solid vs. cyst
@TC99m scan :cold=function 低(沒 uptake)=惡性
PTH: 10~60 Hot= 高(有 )=良
●2nd step FNAC
5% Empty Malignant Papillary Op
nuclear Medullary
或 濃染 Anaplastic
20 Follicular cell Intermediate Adenoma
Follicular
65 Colloid & Benign Colloid gioter f/u
macrophage
10 In-adequate 不夠 重複 FNAC

Grave’s dis Type2 過敏 T3/T4↑ Thyroid Ab 1st line: 藥: PTU or methimazole

2nd line: I 131
3rd line : subtotal
Hashimoto Type4 過敏 T3/T4↓ Anti-TPO, anti-Tg Levothyroxine
diffuse

De Quervan/ subacute thyroiditis 先↑然後 virus 4~8wks 自癒

Multiple Goiter/ endemic goiter
Plummer dis/ toxic
adenoma/ toxic multinodular
Single 60% colloid nodule
Nodular
↓ (*看下面補充)
↓  TSH↑
↑ I131 or Op
正常

30% follicular adenoma 正常(少數↑)

5% thyroid ca. 正常(晚期↓)
TPO=thyroperoxidase; Tg=thyroglobulin
*補充:
急性 thyroiditis Bacteria 治 NSAID + antibiotic
亞急性 thyroiditis viirus NSAID±steroid

Grave’s (雙料冠軍: 亢進 1st, 腫大 1st)

dis 症狀 Triad: (1)腫大 (2)亢進 (3)眼睛症狀:凸眼
治療:
1. propylthiouracil (PTU) 缺點: 復發率高
anti-thyroid Methimazole (tapazole)
21
 Carbimazole 藥物反應
(neothyrostat)
2. 5~10 mCi, po (4~12wks) 禁忌: 機能 低下
I 131 1. Childbearing yr @不會 thyroid.ca., leukemia,
2. Child (不宜<40y/o) teratogenicity?
3. Con-comitant thyroid noduleop
4. Extremely large gland
op
3. op Bilateral; subtotal 適應症: 復發性 亢進(If 開不完全)
thyroidectomy— 1. Medication failure 永久性 機能低下
2 側留下約 2gm 2.使用 I 131 有禁忌 返喉.n 受損, 副甲狀腺功能↓
(共約 4gm)
PSaMMoma
(1)Thyroid.ca—papillary
(2)ovary Serous cyst adenocarcinoma
(3)Meningioma
Thyroid ca. (4)Mesothelioma
發生率 預 Age 細胞 病程 轉移 治療 指標
後
1.Papillary 高 好 15~30 濾 1.empty LN 1.total ex+central thyroglobulin
nuclear(orphan Annie neck LN(If 摸到)
eye) 2.I-131
2.psammoma body 3.補 thyroxine(讓
2.Folicular 30~45 濾 侵犯 1.capsule 包膜 血 T3,T4↑TSH↓)
特別-*Huethle 2.vessels
cell
3.Medullary 45~60 旁(C) Amyloid 堆積 LN+ Total Ex + Central CEA,
-calcitonin X-ray:見 calcification 血 neck LN Calcitonin
4.Anaplasia 低 差 >60 濾 Giant multinuclear cell LN+ Total Ex-但沒有意
血 義易 meta

Huethle cell 1.老年

2.resistant I-131
3.淋巴轉移
Medullary 類型
非腫瘤區具 腫瘤侵犯性 合併其他
C 細胞增生 內分泌腫瘤
散發性 sporatic 80-90% 老 單一 (-) 弱 (-)
家族性 familiar 10-20% 年輕 多發 (+) 強 (+)
MEN-II: RET
3 種常規 檢查 : 1. 24hr urinary VMA (pheochromocytoma)
2. serum [Ca] (hyper-thyroidism)
3. RET point mutation

手術
方式 Bil. Subtotal thyroidectomy 2 側留下 1~2gm(總量 4gm) Graves’ dis
Diagnostic thyroid lobectomy Nodule with malignant 或 indeterminate FNACN
Nodule in children
Nodule with PHx of neck irradiation
Nodule with PHx of family thyroid.ca
Symptomatic 或 cosmetically bothersome
Total thyroidectomy 甲狀腺 癌

切除 1. Hemorrhage <6hr 內 Endo 或 進 op

6大 2. Hypo-calcemia 不小心拿掉 para-thyroid 1~2d ; 每天 check [Ca] X3d
併發 Chvostek’s, Trousseau’s
症 sign
3. 返喉.n 受損 聲帶 無法 adduction 單側: hoarseness @暫時性失能, 則 4~6 週可恢復
雙側:呼吸道阻塞
4. 上喉.n 受損 無法 高音
5. thyroid storm T3,T4↑↑ PTU( propylthiouracil) & KI( lugol’s sol)
= thyroid crisis β-blocker(propanolol)
steroid (避免 adrenal failure)
物理降溫, O2, fluid
看補充☼-避免方法
6. Post.op. Hypo-thyroidedema
myxedema
22
 ☼甲狀腺功能亢進 欲 op 者:
術 Elective 術前 3~4wks Anti-thyroid(PTU) 或 propanolol(術前 1wk 至術後 4~5d )避免 thyroid storm
前 術前 10~15d KI (lugol’s sol)
減少 甲狀腺 體積&血管
emergency (比照 thyroid storm)1gm PTU, poNaI(KI) + Propanolol + steroid, iv
☼
環甲 緊(拉長) 上 外喉.n 環甲
喉 內喉.n 聲帶皺折以上喉黏膜
環杓 後 開(外展) 返 單側 Hoarseness
側 關(內收) 喉 雙側 dyspnea
甲杓 松(變短)
@返喉.n 經 氣管食道溝, 由 環狀/甲狀軟骨間 進入喉部
@右 返喉.n—右鎖骨下動脈; 左 返喉.n—主動脈弓

Para-thyroid 副甲狀腺

Primary hyperthyroid TRH↓ TSH↓ T3/T4↑ Primary hypo TRH↑ TSH↑ T3/T4↓
Secondary- a)pituitary 常 ↓ ↑ ↑ Secondary ↓
b)hypothalamus 少 ↑
Primary hyper para PTH↑Ca↑, Mg↓ Hypo 甲狀腺切除, Digeroge’s synd
Cl↑, P ↓, HCO3-↓ [PTH]↓ [P]↑ [Ca]↓
PTH↑→Ca↑ 80% adenoma Single
良性 85%
multiple 3%
20% hyperplasia(MEN1, 4 個一起 (無
2A) 單個)
1% carcinoma 1個
Secondary 腎衰竭([P]↑), 缺 Vit D, PHP PTH end organ(骨,腎)產生抗 PTH
Ca↓→PTH↑ 具 AHO 特徵, [PTH]↑↑ [P]↑ [Ca]↓
Tertiary Secondary 刺激太久PTH↑↑高[Ca] Pseudo-PHP 具 AHO 特徵 無低[Ca]
PTH↑→Ca↑ 可正常調節腎臟
腎衰竭 [PTH]↑ [P]↑ [Ca]
缺 Vit D [PTH]↑ [P]↓ [Ca]
PHP-pseudo-hypo-parathyroidism
AHO-albright’s hereditary osteodystrophy-矮胖,圓臉,第四指骨短, 皮下鈣化 etc

高血鈣
原因: 1st 癌症 症狀:
2nd 副 甲 機能 亢進 Renal stone : 腎結石(最常見), polyuria
3rd 肉芽腫性 疾病 Painful bone : osteoporosis, fracture, osteitis fibrosa cystica
sarcoidosis Abd groans: peptic ulcer (gastrin ↑)
Thiazide diuretic Pancreatitis(cholelithiasis)
Hyper-thyroidism constipation
Phychic moans: fatigue, weakness, depression, personality disorder

原發性 副甲狀腺 機能 亢進
臨床特徵: 頭頸部 輻射暴露史 (usmle pg288 會造成 thyroid 治療
papillary) [Ca]<11 & 無症狀 Obs 每 6~12m
Age : 50~60y/o [Ca]≥11 或 有症 Neck exploration
Sex : 女> 男 狀
病理:
1. Single adenoma 85% excision 3 種定位方法: Sono 簡單 70%
2. multiple adenoma 3% T1-Tc 難 75%
3. diffuse hyperplasia 11% MEN-1 Sub-total Tc-MIBI 80%
MEN-2 (去掉 3.5 個,留下 0.5 個) Surgeon 自己 95%
Sporadic
4. cancer <1% excision

23
Pancrease islet

惡
1st β 5% Whipple’s triad: (1)低血糖症狀 頭 -enucleation
Insulinoma(最常見) (2)血糖<50mg/dL 體/尾- resection
(3)給予 IV glucose, 症狀緩
解
診斷: 72hr fasting(或 insulin>5,[glucose]<50)neuroglycopenic
@ Pro-insulin↑, C-peptide↑
定位: endoscopic us, In111-octreotide scan*
2nd gastrinoma = G 2nd 2 大症狀: G 細胞Gastrin①ulcer 藥物: H2 blocker, PPI
Zollinger-Ellison 60% GI (不用 gastrectomy以前會)
synd motility↑②diarrhea, BW↓ 手術: enucleation 或 resection
75% sporadic > 25% MEN-1 If 無法定位partial cell vagotomy
位置: duodenum 45% > pancrease 25%
診斷(1)Gastrin— fasting serum gastrin > @passaro’s ∆ CD/CHD + 2nd/3rd + 胰頭頸
100pg/ml @calot’s∆ liver bed + cystic duct +
Basal gastric acid hep.duct
output(BAO)>15mEq/hr 含 cystic.a (r’t
(2)secretin(2 unit/kg) provocative hep.a 分枝)
test—gastrin>200pg/ml
定位: non-invasive: SRS* (In111-octreotide scan*)
Invasive : endoscopic US
3. VIPoma D1 D1 VIP↑①水瀉 ②[K]↓ ③achlohydria 胃酸↓(WDHA)
4. Glucagonoma α 1st 2 大症狀: α glucagon① DM type II
75% ②
necrolytic erythema/ skin rash
5. δ δ somatostatin↑ ①DM type II
Somatostatinoma 胰液↓ ②脂漏
症
CCK-P↓③膽石
症
@ Pro-insulin—(protease)insulin + C-peptide
@SRS( In111-octreotide scan)= somatostatin receptor scintigraphy
@ 比較 whipple’s triad, whipple procedure

Adrenal gland 腎上腺

Adrenal disorder
來源 原料 分泌 過多 太少
皮質 中胚層 steroid G-aldosterone Conn’s syn Adrenal crisis
F-glucocorticoid Cushing syn Addison’s dz
R-Androgen 測 screeningDST 測 insulin hypoglycemic test
髓質 神經外胚層 Tyrosine Epi, NE Pheochromocytoma
=10% tumor
Cushing syn: adrenal 分泌過多 皮質類固醇 cortisol
Cushing dz :pituitary 分泌過多 ACTH
過多 診斷
Conn’s syn [Na]↑水↑-HTN [K]<3.5, aldosterone>15 增生— 藥:spirolactone
[K]↑[H]↓-代謝鹼 Kaliuresis > 30mEq/d 癌 — op
Adrenal CT
Cushing syn Dexamethasone suppression test Low dose High dose
測 screeningDST 正常人 ↓ ↓
腦下腺 ACTH↑腎上腺皮質增生cortisol↑ ↑ ↓
腺瘤
腎上腺 皮質 腫瘤 成人: 腺瘤 ↑ ↑
幼童: 腺癌
異位性 ACTH↑腎上腺皮質增生cortisol↑ ↑ ↑
-(肺癌 small cell)
醫源性 外源性 cortisolACTH↓腎上皮質
萎縮內生 cortisol↓
24
Pheochromocytoma 具 chromaffin cell(APUD cell) Uspg280 chromaffin cell(APUDoma)來源
=10% tumor NE, Ep, DA↑ Pheochromo- 成人 adrenal 尿 VMA HTN Rule of 10
HTN 主, etc 會 Symptom 5 P’s
10%惡性,多發性,腎上腺外, neuroblastooma 小孩 ①adrenal HVA,VMA 很少 會變成
家族性(MEN-II),幼兒(好犯 ②sympathetic chain ganglioneuroma
30~40y/o) Carcinoid tumor 年輕 闌尾 > 迴腸> 直 5-HIAA↑ ▼5HT↑
腸
Small cell lung.ca (oat cell)— Usmle pg485
Adreno-genital synd=
Congenital adrenal
hyperplasi

AR

21α ↑sex hormone mineralcorticoid↓ [Testosterone] ↑

造成 female pseudo-hermaphroditism BP↓ 尿 17-ketosteroid↑
外像男; 內像女 [Na]↓
17α- ↓sex hormone mineralcorticoid↑
BP↑
外像女; 內像男(無 2°性徵) [Na]↑
11α- ↑sex hormo\ne 11-deoxycorticosteroid↑
外像男 BP↑

Cushing syn screening:

名稱 方法 結果
Screening test Dexamethasone If 被抑制 正常
1mg at midnight If 不被抑制(cortisol>140pg/ml)有 cushing syn進行 DST
Low dose Dexamethasone If 被抑制 正常 pituitary ACTH secretion
dexamethasone 0.5mg q6h X 2 天 If 不If serum ACTH low(<10) adrenal tumoradrenal CT<3cm adenoma
suppression >6cm carcinoma
test(DST)
If ACTH normal(<60)~high(A).pituitary
-ACTH>30~150pg/ml microadenoma
- >200pg/ml macroadenomaMRI 或 IPSS
(B).ectopic ACTH
用 Chest+abd CT 找腫瘤(SCLC,甲狀腺髓質癌,pheochromo etc)
也可用 high Dexamethasone If 被抑制 microadenoma
dose DST 2mg q6h X 2 天 If 不 macroadenoma

MEN AD MEN-I 11q 記 3P

Wermer’s = tumor 1st Parathyroid hyperplasia
suppressor 2nd Pancreatic islet cell tumor :
gene gastrinoma > insulinoma
3rd Pituitary adenoma : prolactinoma,
GHoma
@ sporadic– insulinoma >
gastrinoma
MEN-I --gastrinoma >
insulinoma
RET(10q) 1st pheochromocytoma
-IIa = oncogen 2nd thyroid ca. : medullary carcinoma
Sipple 3rd parathyroid hyperplasia
1st
-IIb 2nd
William 3rd neuroma cutaneous/mucosal &
25
 GI
PGA I Mucocutaneous candidiasis,
(小孩) hypo-parathyroidism,
adrenal insufficiency
II Adrenal insufficiency
(成人) Auto-immune thyroid dis.
DM type I
MEN=Multiple Endocrine neoplasia
PGA=polyglandular autoimmune

Pediatric 小兒
插管
管徑 深度
2 千~4 千 gm= 4.0 3 千 = 9cm
< 1 y/o = 4.0 1 y/o = 11cm
>1 y/o = 2 y/o = 12cm
>2 = 12
4.0 +
+
NPO guidline
< 1 yr Regular till pre-op 5hr Clear liquid till pre-op 2hr
1~14 yr Regular till pre-op midnight Clear liquid till pre-op 3hr
跟大人
兒童死亡
死因: 1st trauma; 2nd cancer
癌症: 1st leukemia;2nd brain tumor , 3rd neuroblastoma

@小兒外 dis: 男=女 或 男>女

除了: choledochocyst 女>男

摘要:
HPS Hypertrophic pyloric stenosis Olive mass in epigastrium
Contrast study: RUQ string sign
DA Duodenal atrexia X-ray: Double bubble sign
NEC Necrotizing enterocolitis X-ray: pneumatosis intestinalis, Portal vein gas
Meconium X-ray: ground glass/ soup bubble
ileus
intussusception Current jelly stool
Air contrast enema:Coiled spring sigh
Sono: pseudokidney sign

Hypertrophic 男>女 手術: Fredet-Ramstedt pyloromyotomy

pyloric steonosis 原因: 先天性(Pyloric 缺 auerbach plexus)
(HPS) 表徵: 右上腹 olive mass
餵食後 30~60min, projectile vomiting(無膽汁性)
@不是出生立刻, 而是”滿月”左右
影像: X-ray: distended stomach
UGI contrast study: string sign
intussusception Age : 5~10m (由餵奶換成副食品) 自大約 1y/o
原因: 小孩: 自發性(30%先前具 腸胃炎 or URTI)
成人: 腫瘤 (<50y/o: leiomyoma; >50y/o: adenoma)
位置: 迴腸盲腸
表徵: 陣發性 哭鬧 (每 10~15min 一次)
Current jelly(dark~red/mucoid)
Abdominal sausage = shape mass
影像: air-contrast enema: “coiled spring” sign
SONO : pseudokidney sign
Hirschsprung’s dis 男>女 Op 前: 目標: 避免 enterocilitis(主要死因)
=congenital 原因: 缺 Auerbac plexus 方法: decompression(rectal tube, NG tube(if 吐))
megacolon 位置: rectum + sigmoid 75% Op
5~10% 具 家族性, 具 Down’s synd (像 duodenal atresia)
新生兒 Colonic 表徵: 胎便延遲>48hr DDx: Cystic fibrosis pg105
26
obstruction 最常 診斷:rectal suction biopsy 必要: 表症: delayed meconium passage
見 ①缺 Auerbach & Meisser plexus 診斷: sweat Cl test: Cl>60mEq/l
②hypertrophy of nerve bundle↑ CFTR gene
③AchE staining: activity↑ 常 meconium ileus
Anal atrexia = 6-7wks 泌尿直腸隔膜 + 泄殖腔膜 相結合 距離會陰<1cm: perineal shift-in anoplasty
imperforate anus 8 wks anal membrane 破裂
男>女 ; 併 VACTERL >1cm: 3 stage reconstruction
分類 pubic Cloacal 廔管
sling malformation 預後
泌尿生殖異常
High Above 90% 最多 無(出生 1 天
後, 照 不易保存 fecal
invertogram, continence(▼sphincter
檢視 PC-line) 發育不好 or 不在)
Intermediate At
Low = below 10%最少 具(注入
membrane urografin 檢視 易便秘 (先天 sphincter
type 性狀&位置) 還在)

Necrotizing 為最常見之 neonatal GI emergency (1)1st non-op: obs, NPO, NG decompression, antibiotic
enterocolitis(NEC) 原因”3I”: ①ischemia ②infection ③immunity (2)2nd op : 適應症: perforation 必要, obstruction,
影像: plain film : pneumatosis intestinalis abscess,
peritonitis
方法: resection + creation
of stomas
併發: stricture, short bowel(malnutrition,if 切太多)
胎便疾病
Meconium 原因: 胎兒的腸管 在子宮內 穿孔 or 壞死胎便溢出腹膜炎
peritonitis Dry =fibroadhesive 症狀沾黏GI 阻塞 (1)Op 適應症: GI 阻塞
type 最常見 Plain X-ray: 見 鈣化. 大量腹水
Wet =generalized 穿孔時間: 出生 1~2wks 內 合併 腸 閉鎖 (整段壞死腹膜
症狀: 腹腔內 含 大量胎便腹水 炎腸閉鎖)
cystic 囊腫型 腹膜 對 胎便 之 炎性反應形 (2)obs: 適應症: 腸穿孔已癒合
成 pseudo cyst 臨床上 無 阻塞
無 腹水
Meconium ileus 原因: 濃稠胎便 堵住 GI(常 terminal ileum) (1)1st non-op: water soluble(N-acetylcysteine) enema
好犯: cystic fibrosis p’t (DDx: Hirschsprung’s dis) (2) 2nd op :
表徵: delayed meconium passage(>48hr),常 出生後 第 1~2d laparotomy – 打入 N-acetylcysteine 入 GI & manipulate
影像: plain –ray: ground glass 或 soup bubble appearanced - Enterotomy to remove the meconium
腹壁缺損
Gastroschisis 纖維性包 腹壁缺損 位於 合併其他先天異 術前
膜 常 手術
無 直徑 3-5cm 臍帶之右 <10% 少 術後
側
Omphalocele Sac 完整 4-12cm 正中線 常 (小心) 如上
Meckel’s Rule of 2% 人口, 2ft(60cm)於迴肠近端, 2in(5cm)長, 2cm 直徑, 2 具併發症時resection
diverticulum 種異生組織 (胃黏膜, 胰臟組織, both)
表徵: 1st 無痛性 出血 2nd obstruction 3rd diverticulitis
影像: Tc99m 最準確-探測 gastric mucosa
Intestinal atresia 12 指腸>近端空腸>遠端迴肠>結腸
12 指腸 相關先天異常: 原因: true embryologic
Down’s synd(30%), abnormality(failure
先天心臟病(20%) recanalization)
其他小腸 無 相關 Intrauterine mesenteric
vascular accident
分類:
Type 1
Type 2
Type 3
Type 4
診斷: 出生前: 羊水過多; 出生後: bilious vomiting
影像: double bubble sign
Esphageal atresia 40%合併其他先天異常: VACTERL (Vertebral anomaly, Anal 仰臥, 頭抬高(30~40°)
anomay, CV anomaly, TE fistula, renal , limbs) 放置 NG/OGdecompression
Esophageal atresia 表徵: 出生前: 羊水過多 IV ampicilin + gentamicin + NPO
出生後: 口水過 Op
27
 多, 餵食後嘔吐(第一次餵食)
分類 Type A
Type B
Type C 最多
Type D
Type E Op 後併發症: GERD 考> 吻合處 stenosis> 吻合處 leakage
診斷/影像: coiled OG 或 NG tube in esophageal tube
Congenital 男> 女 術前: 放置 NG (防 gastric distension 壓到胃)
diaphragmatic 左側 80% Ventilation support-高濃度 O2(可+NO,防
hernia 分類 Bochdalek Postero- ▼septum pul.HTN)
hernia lateral transversum fails to
最常見 fuse -on endo(不要用 mask)
Morgagni hernia Sub-sternal 50%合併 先天心臟 手術: 穩定後(  1~3d 後)
異常 o r 神經管缺損
Para-esophageal
hernia
診斷: pre-natal sonography
X-ray: 腸氣在胸腔; 縱膈腔移位
Choledochal cyst 女> 男 ; 東方>西 Total cyst excision (if 不全拿掉, 會變成
病理: cystic wall(▼被 enzyme 破壞)①無 內襯上皮 cholangiocarcinoma)

②僅 具(纖維包膜)
Type I 最 肝外膽管擴大;
多 呈 saccular 或 fuciform
肝外膽管之 diverticulum
2
總膽管 於 12 指腸 之蓬出
3 choledochocele
4a 肝內 及 肝外膽管 之 多發性囊腫
4b 肝外膽管 之 多發
性囊腫
5 肝內膽管之囊腫=Caroli dis
表徵 Triad: ① jaundice(嬰兒主)
②abd pain(小孩,成人; ▼cholangitis)
③ abd mass
影像診斷: 1st PTC 或 ERCP
@肝膽,胰,脾= sono + CT
Biliary atresia 表徵: ①prolong jaundice>2wks ②clay colored stool Kasai op(60d 內,防止肝硬化惡化)transplantation
診斷: Biopsy—見 bile duct proliferation @DDx – neonatal jaundice
影像: sono—看構造 Biliary atresia
Tc99m scan—看 function Neonatal hepatitis 見 giant cell
Check 小兒2 者都見 giant cell
Wilm’s tumor = 兒童 最常見 之 泌尿道腫瘤(腹部腫瘤) (成人少見) Op + C/T ± R/T
nephroblastoma 原因: WT-1/WT-2 (為 tumor suppression gene) deletion
表徵: ①腹內腫塊(常) ②腹痛
分期:
neuroblastoma 兒童 最常見 之 腹內 mass Op + C/T
原因: N-myc (oncogen) 的 amplication
來源: neural crest cell (adrenal medulla/ sym Ggl)長 胚胎惡性腫瘤
易 血液 meta 到 肺
位置: abd(1st adrenal medulla 2nd 脊椎旁) > post.mediastinum >
頸
表徵: ①腹部腫塊(75%),
②HTN(25%), 臉潮紅, 多汗, 情緒不穩
(catecholamine↑)
Lab: 尿中 VMA↑ HVA↑
影像: sono, CT, MRI位置,大小,範圍
Bone scan bone meta
Hepatoblastoma 兒童(<3y/o) 最常見 之 原發性肝臟惡性腫瘤; 2nd HCC Op + C/T (doxorubicin + cisplatin) ± R/T
易 vascular invasion 預後: 與 ①histology ②resectability 有關
Tumor marker: α-FP
表徵: 腹內腫塊 @HCC 對 C/T, R/T 無效
Troticollis 原因: SCM fibrosis (成人:SCM strain) 復健 主
特性: 20~20% 具 breech delivery hx Op (少)—適應症: 肌肉持續縮短(>1y/o) 或 具併發症
表徵: SCM 具 non-tender mass, 長度縮短 術式 : transverse myotomy
28
 併發症: ①C, T 脊椎 scoliosis(側屈)
②Facial hemihypoplasia @成人 torticolis▼SCM strain
③Plagiocephaly 斜頭症 (可發生於 6m 內無治 @strain – 肌肉,肌腱, 拉傷
療者) Sprain— ligament, 關節囊 扭傷
Hydrocele 原因: 鞘膜腔 聚積 漿液(腹水,not 組織液) 過多 <1y/oobs (待 process vaginalis 自然閉合)
>1y/o op
cryptochidism Def: 睪丸無法入陰囊 <1y/oobs
原因: 不明 >1y/o op (防①blunt trauma ②torsionsichemia)
位置: pubic 前>inguinal canal>腹腔 併發症: ①萎縮: 無法製造精子(2y/o 後開始萎縮)
特性: 單側(右>左) >雙側 會因 op 而下降
②癌化: 睪丸癌 (esp Seminoma)
不會 因 op 而下降
@像 esophageal atresiaSCC
If 雙側可先嘗試 內科 hormone therapy(eg. hCG,
LHRH), if 失敗, 用 op.

Trauma

十大死因 事故傷害 之 原因 事故傷害 之 死因

1st 惡性腫瘤 1st 車禍 1st 腦死
2nd 心臟病 2nd 高處跌落 2nd 出血
3rd CVA 3rd 重物撞擊 3rd 呼吸衰竭
4th 事故傷害

急救處理
Primary Airway Surgical airway : cricothyroid membrane :
survey <12y/o 用 needle cricothyroidotomy
Breathing Tension pneumothorax: 2nd ICS, mid-clavicular line
Massive hemothorax: def:① 起初>1500cc 或 ②持續>200cc/h op
-Chest tube thoracostomy : 5th ICS, ante-mid axillary line
Circulation
Disability AVPU: Alert, Voice, Pain, Unresponse
E4M6V5 E4 M6 V5
15-13 = minor 6 依命令
12- 9 = mod. 5 5 oriented
≤8 = 4 自動 4 對痛-退縮 4 cofused 內容不正確
severe 3 聲音 3 對痛-屈曲 3 inappropriate 無法理解
2 對痛 2 對痛-伸張 2 僅 聲音
1 無 1 無 1 無
Exposure 1. C-spine (① lateral ②AP odontoid )
2. AP chest (不是 PA chest)
3. AP pelvis
2ndary
survey @ 病史: Allergy
Medication
Past illness
Last meal
Event

腹部外傷:
Penetrating 1st 小腸 2nd 肝臟
trauma
Blunt 1st 脾臟 2nd 肝臟 FAST(focused 技術; RUQ, subxiphoid, LUQ, Pelvis
trauma assessment with 目標: 偵測 異常積液
sonography for
trauma)
DPL(diagnostic 技術: NG tube & foley catheter 放置
peritoneal lavage) 臍下正中切口, 放置 catheter
(a)最初抽吸液, 具 gross blood(>5cc) 或 succus  op
(b)注入 1L NS, free drain (>200cc), 具①20ml gross blood (兒童 10cc) op
②≥10 萬 RBC/UL
29
 ③≥ 5 百 WBC/UL
④Amylase ≥ 175U/dL
⑤Bile(+)= bile 破了
⑥Bacteria (+)
⑦ Food particle (+) = colon 破了
肝臟外傷

脾臟外傷

胰臟外傷 Penetration>blunt
膽道外傷
胃外傷
12 指腸
空腸/迴肠 外傷
結腸外傷
直腸外傷

血管外傷

後腹膜血腫 retro-peritoneum hematoma

手肌腱損傷 tendon injury

頸部穿戳傷 neck penetrating injury

枷鎖胸 flail chest

氣胸 pneumothorax

Laparoscope
Laproscopy : 應用: Cholecystectomy, appendectomy, hernia repair, Nissen fundoplication, Heller myotomy,
gastrectomy, esophagectomy, colectomy, splenectomy

Pneumoperitoneum 氣體選擇 CO2 最 易 溶於水, 腹膜刺激大, 不會 引起氣爆

好
N2O 易 , 小, 會
He, Ne, Ar Inert gas no acidosis, 但是 gas emboli↑ (▼難溶於水)
壓力 10~15mmHg (<20mmHg)
@測法: direct —
In-direct— 透過 foley 測 bladder
併發症 Gas emboli (死亡率 30%) 治療: trendelenburg position + R’t up(防 RV outflow obstruction)
Pneumothorax
Pneumomediastinum
Subcutaneous emphysema

Bariatric surgery

Transplantation 移植
基因 分類: 時程 分類:
Auto-graft 自自 Hyper-acute Min Performed Ab
Iso-/ synergeic Identical twintwin Acute rejection Day~month 主 cell mediated
Allo-/ homo- 人人 次 Ab-mediated
Xeno-/hetero- Speciesspecies Chronic rejection Month~yr Ab
30
Donor 供體選擇 –( 一般考慮 2 種 ①donor②cross match)
1. Blood type 避免 hyper-acute rejection Onon-O : safe
Rh(-)Rh(+): safe
Rh(+)Rh(-): relative safe
2. anti-donor cytotoxic Ab Cross matching(complement-dependent lymphocytotoxic assay避免 hyperacute rejection)
@donor lymphocyte + recipient serum + complement
3. HLA matching a. mixed lymphocyte culture
b. ELISA (enzyme liked immunosorbent assay)
c. PCR (polymerase chain reaction) analysis 94°c 15min55°c 60min  72°c 66min

雙單 +primer + DNA polymerase

@基礎 Class I HLA-A, B , C 全部 有核細胞 & 血小板
Class II HLA-D, DR, DQ 單核球 , B, TH1 & TH2
@急性排斥; HLA-D, DR > HLA-A,B,C
@排斥反應: 腎 > 胰 > 心 > 肺 > 肝
@ HLA identical T ½ =23.6 年;
HLA no mismatch T ½ = 11.3 年
@ comb test –(+) 容易 hemolytic anemia
--分類 (a) direct— anti-agglutinin + p’t RBC 測 Ig in RBC
(b)In-direct— 正常 RBC + p’t serum 測 Ig in serum (anti-RBC)

器官保存
肝臟 方式 肝臟 灌注 冰冷(4°C) UV solution(約 500~600cc), 浸泡在盛裝冰冷 UW solution 之無菌塑膠袋中, 封口後覆以碎冰
@ 4°C 降低 代謝率 12 倍
@ UV (University wisconsin) preservative solution = ICF (低 Na 高 K) (胞內: ↑K,P,Mg; ↓Na, Cl,Ca)
-K (避免流失 K)
-Lactobionate, hydroxyethyl starch (避免 細胞腫脹)
-other anti-oxidant
@ free radical 造成 reperfusion injury
保存時間 8~12hr (max = 36hr)
@cold ischemic time: 腎 = 36hr; 胰 = 24hr; 肝 = 16hr; 心肺 = 6hr

肝臟移植
indication 1. End-stage liver disease (ESLD) 適應症 1. Biliary atresia (Kasai op 後持續惡化)
2. 無 其他有效的內, 外科方法可以選 2. Wilson disease
擇 3. CAH (chronic active hepatitis) & 肝硬化
3. 無 肝臟移植禁忌 4. HCC (hepatocellular carcinoma)  Milan Criteria / transplant
indication
1. 無法 resect 者 (eg. Child B,C)
2.單一, 直徑<5cm
3. ≤3 個, 最大<3cm
4. 無 meta 或 LN 或 vessels invasion
5. PBC (primary biliary cirrhosis)  bilirubin≥10mg/dl; 利尿劑抗藥性腹水
6. 自發 肝性 腦病變
禁忌症 1. 嚴重 心肺功能 不全 4. 活動性 酗酒者 7. 腎 功能不全
2. 肝膽系外 嚴重 感染 5. HBsAg(+) & HBeAg(+) 8. 不可逆 CNS 病變
3. 肝膽系外 惡性腫瘤 6. 肝門靜脈 血栓 形成 9. HIV (+)
時機 Bil > 20mg/dl
Albumin < 1.8mg/dl
Hepatoencephalopathy 對 低蛋白飲食(<40g/d), lactulose, neomycin 治療 無效
慮及 門脈 or 門脈減壓 op 時
併發症

31