Absite High Yield 2008

HighYieldReviewforthe2008ABSITE
CLINICALREVIEWOFSURGERY
HIGHYIELDEDITION
SURGISPHERECORPORATION
UnitedStatesofAmerica
2008
SYMBOLS
Relatedquestionsandconceptsfoundin
companionquestionbook.
Thedrugofchoiceforaparticulardisease
process
Importantpropertyofaparticular
medication
Highyieldinformationthatisparticularly
noteworthy.
Topicofspecialinterestthatisoccasionally
tested
Importanttopicthatistestedonwritten
examsandalsoimportantinclinical
practice
Vitaltopicessentialforthemodern
practiceofsurgery.Commonlytestedon
bothwrittenandoralexams.
CCopyright2008SurgisphereCorporation
ThepurposeofSurgisphereCorporationeducationalmaterialsistoprovideaccesstoabroadrange
ofmedicalinformation,nottogivemedicaladviceorinterpretation.Informationprovidedby
SurgisphereCorporationdoesnotendorseorrecommendparticularproductsorcoursesoftherapy.
Theinformationcontainedhereindoesnotsubstituteforconsultationwithahealthprofessional.
SurgisphereCorporationasaservicetoitsreadersonanasisbasisforinformationalpurposes,
providesthematerialscomprisingthispublicationonly.SurgisphereCorporationassumesno
responsibilityforanyerrorsoromissionsinthesematerials.Thisinformationisintendedtoprovide
youwithinformationonly,anditshouldnotbeconstruedasmedicaladvice,diagnosis,treatment,
prevention,firstaid,emergencymedicalcare,instruction,orendorsement.Theinformationshould
notbeconsideredcomplete,norshoulditbeusedtosuggestadiagnosis,courseoftreatment,or
othermedicalapplicationsforaparticularindividual.Thisinformationshouldnotreplaceavisit,
consultation,orcalltoaqualifiedprofessionalhealthcareprovider.
TheinformationwithinSurgisphereCorporationeducationalmaterialhasbeencompiledfroma
numberofdifferentsources,includingvariousmedicalauthorities,publications,andalsonon
authoritativesources.Itisneitherpracticalnorfeasibletoconfirmtheaccuracyorvalidityofevery
pieceofinformation.Neverdisregardmedicaladviceordelayseekingaprofessionalhealth
consultationduetosomethingcontainedherein.
SurgisphereCorporation,itsemployees,executives,officers,partners,andassociatedpersonnelshall
notberesponsibleforthecontentprovidedhereinunderanyformofliabilityorindemnity.Any
liabilityofSurgisphereCorporationfordamages(including,butnotlimitedto,liabilityarisingoutof
negligence,contract,strictliability,tort,copyright,orpatentinfringement)shallnotexceedthe
directpurchasepricepaidbytheparticularcustomerfortheinformation,service,orproduct.
Byuseofthismaterial,youagreetoindemnifySurgisphereCorporationanditsaffiliatesofany
liabilityarisingthroughdirectorindirectuseofthisproduct.
Copyright2008SurgisphereCorporation,U.S.A.AllRightsReserved.Nopartofthistextbookmay
beusedorreproducedinanymannerwithoutpriorwrittenpermissionofSurgisphereCorporation.
Youmaynotalterorremoveanynoticeofcopyrightorownershipfromthiscontent.
SurgisphereCorporationistheownerofvarioustrademarksusedwithinthispublication.Persons
makingillegalorunauthorizedcopiesofthismaterialwillbepursuedtothemaximumextentofthe
lawandpenalizedtothemaximumextentallowedbytheireducationalinstitution.
REPRODUCTIONORDISSEMINATIONWITHOUTEXPRESSEDWRITTENPERMISSIONISAVIOLATION
OFCOPYRIGHTLAW.VIOLATORSWILLBEPROSECUTEDTOTHEMAXIMUMEXTENTOFTHELAW
ANDASPERMITTEDBYINSTITUTIONALPOLICY.THISDOCUMENTCONTAINSPERSONALLY
IDENTIFIABLEASSETRECOVERYFEATURES.
08/1098765432
PRINTEDINTHEUNITEDSTATESOFAMERICA
ClinicalReviewofSurgeryHighYieldEdition
LIVER
CONTENTS
.............................................................31
PANCREAS
TOPICSINBASICSCIENCE....................................3
CANCERSTATISTICS
BIOSTATISTICS
................................................................33
......................................................3
.............................................................3
PHARMACOLOGY
SPLEEN
.......................................................32
.........................................................4
ENDOCRINESURGERY.......................................33
PITUITARY
............................................................33
THYROID
.........................................................34
CLINICALTOPICSINSURGERY..............................4
PARATHRYOID
INFECTIONANDANTIBIOTICS
.................................4
ADRENAL
PERIOPERATIVEMANAGEMENT
..................................6
ENDOCRINEPANCREAS
IMAGINGSTUDIES
........................................................6
......................................................35
.............................................................36
...........................................37
MULTIPLEENDOCRINENEOPLASIA
........................38
HEADANDNECKSURGERY..................................7
CONGENITALANDSTRUCTURAL...........................................7
TRAUMASURGERYANDCRITICALCARE............38
METABOLICANDDEGENERATIVE
.....................................8
SHOCKANDRESUSCITATION
INFLAMMATORYANDINFECTIOUS
...................................8
VASCULAR
..................................................................8
TRAUMA
....................................................................8
CANCER
TRAUMA
.........................................................38
................................39
FLUIDANDELECTROLYTES
NUTRITION
...................................40
......................................................42
WOUNDHEALING
.............................................42
............................................................9
TRANSPLANTSURGERYANDIMMUNOLOGY.....42
THORACICSURGERY...........................................9
ESOPHAGUS
.....................................................11
DIAPHRAGMANDMEDIASTINUM.......................................12
PLEURALCAVITY
................................................13
IMMUNOLOGY
.................................................42
LIVER...........................................................................43
GYNECOLOGY...................................................43
BREAST
CARDIACSURGERY............................................16
...............................17
..............................20
..............................................................21
TRAUMA
CANCER
....................................................................21
...........................................................43
REPRODUCTIVESYSTEM
..........................................44
UROLOGY.........................................................45
KIDNEY,URETERS,ANDBLADDER
MALEREPRODUCTIVEORGANS
..............................45
.....................................46
VASCULARSURGERY........................................21
ORTHOPEDICSURGERY.....................................47
ARTERIAL
HEAD,NECK,ANDSPINE
LYMPHATIC
.........................................................21
...........................................................23
GASTROINTESTINALSURGERY...........................23
STOMACH/DUODENUM
SMALLBOWEL
HERNIAS
..............................................26
..........................................................28
HEPATOPANCREATICOBILIARYSURGERY...........29
BILIARYTRACT
UPPEREXTREMITIES
..........................................47
LOWEREXTREMITIES
.........................................47
INFECTIOUS
...............................................................48
.....................................24
..................................................25
COLONANDRECTUM
..............................................47
..................................................29
Visitusonthewebatwww.ClinicalReview.com.
SURGICALONCOLOGY......................................48
HEMATOLOGY
.......................................................48
TOPICSINBASICSCIENCE
CANCERSTATISTICS
SPECIFICITY
TOP3CANCERSBYINCIDENCE
Aspecifictestisusedtoconfirmapositivetestresultobtained
fromaninitialscreeningtest.
Aspecifictesthasaverylowrateoffalsepositives,soatrue
positiveisconsideredtobetrustworthy.
Ifapatientobtainsapositiveresultonaspecifictest,itis
consideredtobeindicativeofhavingadisease(i.e.rulingin).
Prostate/BreastCancer
LungCancer
ColorectalCancer
TOP3CANCERSBYDEATH
POSITIVEPREDICTIVEVALUE
LungCancer
Prostate/BreastCancer
ColorectalCancer
PREVENTIVEHEALTHCARE
PrimarypreventionProphylaxisfordisease
SecondarypreventionDiagnosisofdisease
TertiarypreventionTreatmentofdisease
Apositivepredictivevalueisusedtodeterminethechanceof
havingadiseasegivenapositivetestresult
Atestwithaverylowfalsepositiveratewillhaveamore
meaningfulpositiveresult
Rememberthatthepositivepredictivevalueisalwaysusedin
conjunctionwiththepretestprobabilitytodeterminethechance
thepatienttrulyhasadisease
GAUSSIANDISTRIBUTION
CANCERSCREENING
BREASTCANCER
Alargemulticentertrialwith40,000womencompletedin2005
suggeststhatmammogramsusingdigitalimagingmightbe
appropriateforyoungerwomen.
COLORECTALCANCER
CancerScreening
Breast
Colorectal
Prostate
Skin
Selfexameverymonth,clinicalbreastexamevery3yearsuntil
40.Mammogramsevery12yearsbetween4049.
FOBTwithDREeveryyearafter50.Sigmoidoscopy every5years
orcolonoscopyevery10years.
DREandPSAyearlyafter50.AfricanAmericanmalesearlierthan
50.
Physicalexamofskinevery3yearsuntilage40,thenyearly.
BIOSTATISTICS
PREVALENCEANDINCIDENCE
PrevalenceThenumberofcasesofaparticulardiseaseata
pointintime
IncidenceThenumberofnewcasesofaparticulardisease
withinaspanoftime
SENSITIVITY
Onceaverysensitivetestidentifiedapatientasnothavinga
disease,sheorheiseffectivelyruledout
Averysensitivetesthasalowrateoffalsenegative.Hence,you
cantrustatruenegativeresult,indicatingthatifatestresultis
negative,thepatientdoesnothaveadiseaseandiseffectively
ruledout.
Thispermitssensitiveteststobeusedonapopulationasa
screeningtest.Positiveresultsareconfirmedwithaspecifictest.
Bestdescriptorsofnonparametricdistributionmedianand
quartiles
HYPOTHESISTESTING
NullhypothesisAssumesthataparticulartreatmenthasno
effect
TYPEIERROR
Acceptingthataparticulartreatmenthasadesiredeffectwhenit
reallydoesnot
Occurswhenyourejectthenullhypothesis
POWER
Powerisdirectlyrelatedtosamplesize
Increasingsamplesizeincreasespower
Powerisalsodependentonmeasurementfidelity
Thepowerofastudyisdeterminedbytheneedtoestimate
expecteddifferences
CASECONTROLTRIAL
Retrospectivetrialthattakesagroupofpatientswithknown
diseaseandlooksintothepasttodeterminetheeffectofvarious
measuredriskfactors
Veryusefulstudywhenattemptingtoanalyzeriskfactorsleading
toararedisease
DREshouldbedoneinallpatientsasupto50%ofallcolon
cancersmaylaywithinreachofthecliniciansfinger.
COHORTSTUDY
Prospectivestudythatusestwogroupsofpatientsonewitha
knownexposuretoariskfactor,andacontrolgroupknownnot
tobeexposedtotheriskfactor
Usefulwhenexaminingtheeffectofvariousriskfactorsonthe
developmentofdisease
CLINICALTRIAL
CLINICALTOPICSINSURGERY
INFECTIONANDANTIBIOTICS
SURGICALPROPHYLAXIS
Samplingbiasthesampleusedinthestudyisnot
representativeofthepopulationandsoconclusionsmaynotbe
relevant
Selectionbiaslackofrandomizationleadstopatientschoosing
theirexperimentalgroupandintroducesconfounding
PHARMACOLOGY
SurgeryType
GeneralSurgery
UpperGI proceduresor
hepatobiliary
Largebowel resections
Prophylaxis
Cefazolinorcefuroxime.
Ciprofloxacinorceftizoxime with
metronidazole.
Erythromycinwithceftizoxime, bisacodyl,CLD.
GoLytelyisoftenused.
Ceftizoximeorcefotetanwiththeadditionof
metronidazole.
Vancomycin
Appendectomy
Pancreas orkidneys
PHARMACOKINETICS
Steroidhormonestraveltothenucleusofacelltoexerttheir
effects
AminoglycosideagentsinhibitRna/proteinsynthesis.
Specifically,theirexerttheireffectsbycausingmRNAmisreading
bypreventingformationofinitiationcomplex.
Rfactorresistanceleadstodruginactivationanddecreased
uptake.Mayalsobemodifiedthroughacetylating,adenylation,
orphosphorylationofthecompound.Excretedunchangedby
kidney.
MechanismoffluoroquinolonesinhibitbacterialDNAsynthesis
viapreventionoftheactionoftopoisomeraseII.
FluconazoledecreasesthemetabolismofCoumadin,alongwith
numerousotheragentsthroughcompetitionwithclearing
enzymesintheliver.
Theoptimaltimingofantibioticsistogivethematleast30
minutespriortoincision.Mostpractitionerswillcontinue
prophylacticantibioticsfor24hourspostsurgery.
Prophylaxis
Randomizedminimizesselectionbiasandtherebyexcludes
chance
Doubleblindminimizesinvestigatorandpatientbias
(measurementbias)
Multicenteredreducesconfoundingfromanarrowsample
Placebocontrolhelpsensurethetrialisdoubleblindand
reducesmeasurementbias
Crossovercontrolpatientreceivestreatmentforhalfofthe
trial,thenplacebofortheremainder
o Alsoreducesmeasurementbias
Inorderforarandomizedstudytobeproperlyevaluated,the
samplesizemustbeknown
BIAS
COMMONANTIBIOTICS
Clearancereferstotherateofeliminationofadrugfromthe
bodyascomparedtoitsplasmaconcentration
Clearanceatsteadystateistheratioofmassgenerationand
plasmaconcentration
Zeroorderelimination
o Proceedslinearlywithafixedamountofdrug
eliminatedperunittime
o Typicallyduetosaturationoftheeliminationenzymes
Firstorderelimination
o Proceedsasexponentialdecaywithfixedratioofdrug
eliminatedperunittime
o Enzymesarefunctioningbelowsaturationlevels
DRUGDEVELOPMENT
Involveshundredsofmillionsofdollarsincapitalwithdozensof
potentialdrugcandidates
Afterextensivetesting,afewprototypicdrugsarechosenfor
furtheranalysis
Basedonearlytrialsinpatients,thenumberofpotentialdrugsis
narrowed
Approvalissubmittedforthebestdrugs,aprocessthattakes
nearly10years
ANTIMICROBIALS
PENICILLINS
DRUG
INDICATIONS
PenicillinG
Grampositivecocci (Streptococcus,meningococcus,
enterococcus);Grampositiverods;Gramnegativecocci;
Spirochetes
Resistancetopenicillinscomesfrombetalactamasesthatcleave
thepenicillinstomakethemimpotent.
PenicillinsbindtoPBPswithsubsequentinhibitionofthe
transpeptidasestepleadingtocelllysis.Itwillnotaffectorganisms
thatdonothaveacellwall.
Penicillinsareclearedrenally,whichcanbeslowedwiththe
administrationofprobenecid
CEPHALOSPORINSFIRSTGENERATION
DRUG
Cefazolin
INDICATIONS
Grampositivecocci;E.coli;K.pneumoniae;P. mirabilis
Resistancetocephalosporinscomesfrombetalactamasesthat
cleavethepenicillinstomakethemimpotent.
CEPHALOSPORINSSECONDGENERATION
DRUG
Cefoxitin
INDICATIONS
Ceftriaxone
Gramnegatives.
Meningitis
Resistant
organisms
Seriousinfections
Broadrange.
Lowactivity
againstgram
positives.
MECHANISMOF
ACTION
Inhibitcellwall
synthesisby
preventingcross
linking.
Bactericidal.
Sulfamethoxazole
DRUG
NOTES
Crossblood
brainbarrier.
Ceftazidimeis
especiallygood
against
Pseudomonas.
DRUG
INDICATIONS
Severegramnegativeinfections.
Aerobesonly.;Pseudomonas.
uptake.
Mayalsobemodifiedthroughacetylation,adenylation,or
phosphorylationofthecompound.Excretedunchangedbykidney.
TETRACYCLINES
DRUG
INDICATIONS
PneumoniaandURTI,Grampositivecocci,Mycoplasma,
Legionella,Chlamydia,Neisseria
ResistancebyrRNAmethylationleadingtopreventionofbindingto
50Sunit.
FLUOROQUINOLONES
DRUG
Ciprofloxacin
INDICATIONS
Gramnegativerods;Pseudomonas;
Neisseriaspp.;Grampositives;UTI;
GIinfections
MECHANISMOF
ACTION
Preventsaction
oftopoisomeraseII.
Bactericidal.
Vancomycin
Clindamycin
Anaerobes.
Bacteroides.
Clostridiumspp.
Seriousinfections
Grampositivebacteria
resistanttoother
agents
S.aureus/MRSA/
PRSP
C.difficile
Anaerobicinfections.
B.fragilis.
C.perfringens.
NOTES
UsedfornumerousSTDs.
Avoidredmansyndrome with
antihistaminesandgradual
administration.
PO.Treatpseudomembranous
colitiswithmetronidazole.
Alincosamide.
ResistancetovancomycincomesfrommutationofDalaDalatoD
alaDlac.Plasmidmediated.
Rfactorresistanceforchloramphenicolleadstodruginactivation
byacetyltransferaseinactivationanddecreaseduptake.
COMMONINFECTIONS
GENERALPRINCIPLES
MRSA
DRUG
Metronidazole
INDICATIONS
MACROLIDES
CombinedwithTMP.
ResemblesPABA.
PenetrateCNS.
INDICATIONS
S.Aureus
Chlamydia;V.cholerae
NOTES
GeneralAntibiotics
uptake.Alsohasincreasedremovalfromcell.
Avoiddairyfoods,ironcontainingpreparations,andantacidswith
useoftetracyclines.
Azithromycin
DRUG
INDICATIONS
Grampositives
Gramnegatives
Nocardia
Chlamydia
Recurrentotitismedia
UTI
OTHERANTIBACTERIALS
Grampositivecocci;Gramnegativerods;Anaerobes;
Enterobacter
ResistancebymodificationofDHPsynthase,increasedsynthesisof
PABA,ordecreaseduptakeofdrug.
INDICATIONS
AMINOGLYCOSIDES
Doxycycline
Broadest
range.
MONOBACTAMS/CARBAPENEMS
Gentamicin
DRUG
Grampositivecocci;E.coli;Enterobacter;H.influenzae;K.
pneumoniae;Neisseriaspp.;P.Mirabilis;Serratiaspp.
DRUG
Imipenem
SULFONAMIDES/TRIMETHOPRIMS
INDICATIONS
CEPHALOSPORINSTHIRDGENERATION
ResistancebychangeinDNAgyrase.Drugpenetrationmayalso
change.
Coagulase
organisms
GAS &GBS
Enterococci
infections
E.coli & Proteus
spp.
Nafcillin orcloxacillin.Analternativetopenicillinis
cefazolinforMSSA.
Vancomycin.AnalternativeregimenisTMPSMX or
minocyclinewithrifampin.
Vancomycinornafcillin.Alternativetreatmentincludes
cefazolinorclindamycin.
Clindamycin,withbackupsincludingbenzylpenicillinand
cefazolin.
Ampicillin andgentamicin,andvancomycinisthe
alternativetreatment.
Ampicillin, thencefazolin,gentamicin, orlevofloxacin,if
thefirsttreatmentfails.
PNEUMONIA
Pneumonia
Community acquired
Mycoplasmaor
Chlamydia
ICUpatients
Aspiration&
Bronchiectasis
Hospitalacquired E.
coli,Enterobacter,
Pseudomonas,or
Ceftriaxoneorcefuroximeanderythromycin,
clarithromycin,,orazithromycin.Quinolonescan
alsobeused.
Ampicillinandsulbactamorpiperacillin and
tazobactamareused.
Ciprofloxacinwithclindamycin ormetronidazole is
usedorampicillinandsulbactam
Piperacillinandtazobactam withtobramycin, or
clindamycinandciprofloxacin,orceftazidime,or
imipenemwithanaminoglycoside.Infectionwith
Cephalosporinshaveahexagonalringwithtwofunctionalgroups.
Penicillinshaveapentagonalringwithonefunctionalgroup.Both
aresusceptibletobetalactamases.
Klebsiella
Staphylococcusaureusistreatedwithnafcillin if
MSSA;otherwise,vancomycinisusedforMRSA.
GASTROINTESTINALINFECTIONS
Cholecystitisandcholangitishaveariskofbacterialinfectionby
Enterococci,andcefotetan,piperacillinandtazobactam,
ampicillinandsulbactamarethepreferredagents.Gentamicinis
commonlyaddedtothiscocktail.
Diverticulitismayhavesuperimposedinfectionbyanaerobesor
Enterococci,andanyoftheaboveregimensorclindamycinwith
ciprofloxacincanbeused.Ceftazidimeisalsoeffective.
Peritonitisorabscessformationistreatedwithanyoftheabove
agents,imipenem,orceftizoxime.
ETIOLOGY
Clostridium
difficile
Clostridium
perfringens
PRESENTATION
TREATMENT
Pseudomembranouscolitisdiarrhea,
fever,sepsis.
Vancomycin.
Metronidazole.
Myonecrosisgasgangrenewith
severeinfection.
Foodpoisoningfromreheatedmeat.
Symptomatic
GRAMNEGATIVERODS
AEROBES
ETIOLOGY
Pseudomonasaeruginosa
GIInfections
Enterococci
Cefotetan,piperacillinandtazobactam,ampicillin and
sulbactamarethepreferredagents.Gentamicinis
commonlyaddedtothiscocktail.
Anyoftheaboveorclindamycinwithciprofloxacin.
Ceftazidimeisalsoeffective.
Anyoftheaboveandimipenem,orceftizoxime.
Anaerobes
Peritonitisor
Abscess
COMMONINFECTIONS
GRAMPOSITIVECOCCI
Staphylococcus
aureus
PRESENTATION
TREATMENT
Toxicshocksyndromefever,
hypotension,distalextremity
desquamation,hyperemia.
Scaldedskinsyndromeexfoliative
dermatitisininfantsandchildrenleading
tosepsisanddeath
Foodpoisoningfrommeats,mayonnaise
Acutebacterialendocarditis
Osteomyelitis
Methicillin
Vancomycin
Cefazolin
Clindamycin
TMPSMX
Linezolid
STREPTOCOCCUS
ETIOLOGY
Streptococcus
pneumoniae
Streptococcus
pyogenes
PRESENTATION
Meningitiswithhighfever,
headache,stiffneck.
Otitismedia.
Pneumonia
Pharyngitis
Cellulitis/Necrotizingfasciitis
Toxicshocksyndrome
Rheumaticfevererythema
marginatum,mitralvalvedamage,
chorea,subcutaneousnodules,
polyarthritis
Acuteglomerulonephritis(PSGN)
TREATMENT
Penicillin
Ampicillin
Penicillin
Ampicillin
Clindamycinand
vancomycinfor
necrotizingfasciitis
IgAproteasepermitsorganismstocolonizemucosalsurfacesand
causeinfection.
Encapsulatedbugsthatcauseinfectionfollowingsplenectomy:S.
pneumoniae,N.meningitidis,H.influenzaeB.,K.pneumoniae.
GRAMPOSITIVERODS
SPOREFORMERS
PRESENTATION
TREATMENT
Burninfections
PneumoniainCF
Sepsis
UTI
Ampicillinandgentamicin
Ceftazidime
Ciprofloxacin
FACULTATIVEANAEROBES
ETIOLOGY
Helicobacter
pylori
PRESENTATION
Gastritis
Duodenal
ulcer
Gastriculcer
TREATMENT
Bismuth,metronidazole,amoxicillin,
clarithromycin,omeprazole.
COMMONINFECTIONS
STAPHYLOCOCCUS
ETIOLOGY
Acommoncauseofinfectionfromagrampositivesporeforming
organismislikelytobeClostridiumperfringensunlessotherwise
indicated
Potentexotoxinsaremadegenerallybygrampositiveorganisms.
TheseincludeS.aureus,C.perfringens,E.coli,andV.cholerae.C.
botulinumgenerallyhasthemostpotentexotoxin,with1mg
sufficienttokillthousandsofpeople.
Themostcommoncauseofacuteosteomyelitisinsicklecell
patientsisfromSalmonella,especiallyinchildren.Thesecond
mostcommoncauseisS.aureus.
Themostcommoncauseofbacteremiainthebiliarytractisfrom
E.coli.
Themostcommoncauseofliverabscessinapatientwith
diverticulitisisfromEnterobacter.
B.fragilisisthemostabundantbacteriainstool.
H.pyloriusestheenzymeureasetomakeitslocalenvironment
morebasic
ThebesttreatmentforC.difficileisviaoralflagyl.IVantibiotics
havelittleeffect.
Theacceptedtreatmentforclostridialgangreneiswithsurgical
debridementandpenicillin.
ThehepatitisBsurfaceantibodyispresentfollowingvaccination
inahepatitisnaveperson
PERIOPERATIVEMANAGEMENT
Themostsignificantperioperativeriskfactorisanalbuminofless
than2.5.AccordingtotheGoldencriteria,thenextmost
significantcriteriaisthepresenceofanS3.
IMAGINGSTUDIES
Theuseofgadoliniumdyemayleadtodizzinessand
hyperventilationinpatients.UsingcontrastMRIviagadolinium
inpatientswithacreatinineoflessthan1.5mayleadtosystemic
nephrogenicsclerosiswithsystemicfibrosisandultimatelydeath.
ImagingofflowispossiblewhenusingcolorinaDoppler
ultrasound.
Lymphoscintigraphyisneededfortheconfirmationofunilateral
nonpittingedema.
PERIPHERALNERVEINJURIES
BRACHIALPLEXUS
ANATOMY
HEADANDNECKSURGERY
CONGENITALANDSTRUCTURAL
EpiduralHemorrhage
o Middlemeningealarteryrupture(branchofmaxillary
artery)
o Lucidintervalfollowedbyrapiddeterioration
o Massdoesnotcrosssuturelines
SubduralHemorrhage
o Bridgingveinrupturewithvenousbleeding
o Delayedsymptomsfollowedbyprogressive
deterioration
o Crossessuturelines
SubarachnoidHemorrhage
o APKD,EhlersDanlos,Marfan
o Berryaneurysmrupture
o BerryaneurysmsoccurattheCircleofWillisbifurcation
pointespeciallyattheanteriorcommunicatingartery.
o WorstHAofthepatientslife
IschemicStroke
o Lossofbloodsupplyalongacranialartery;commonlya
resultofAfib,DCM,thrombosis,endocarditis,orDVT
withPFO
o Anaerobicmetabolismwithintracellularsodiumand
wateraccumulationthatprogressestoglutamate
releaseatlowerlevelsofperfusionfollowedby
calciummediatedexcitotoxicity.
o Maximumswellinginnecroticzoneby3days
HemorrhagicStroke
o Subarachnoidbleeds,intracerebralbleedsleadingto
hypoperfusionwithinwatershedareaswithdirect
neuronaltoxicitythroughblood
o Masseffectsfromhematoma
o HTN,smoking,CHD,LVH,atrialfibrillation,
hypertriglyceridemia,oralcontraceptiveuse,
pregnancy,andhypercoagulablestates
PSEUDOBULBARPALSY
Asignificantfindinginpseudobulbarpalsyisaspirationdueto
failureofdeglutination.
UNCALHERNIATION
Ipsilateralpupilllarydilationwithasluggishreactionsuggests
uncalherniation.Thissuggestscompromiseoftheipsilateral
oculomotornerve.
CRANIALNERVEINJURIES
Injurytothevagusnervetypicallypresentswithhoarseness.
Beabletodescribethepositionofthevariousbrachialplexus
rootsinrelationtothescalenemuscle.
Theulnarnerveisresponsibleforinnervationstotheintrinsic
musclesofthehand.Transectionofthisnerveisnotrepaired
primarily.
INJURIES
C5Shoulderabduction,extension,andexternalrotation;some
elbowflexion
C6Elbowflexion,forearmpronationandsupination,some
wristextension
C7Diffuselossoffunctionintheextremitywithoutcomplete
paralysisofaspecificmusclegroup,consistentlysuppliesthe
latissimusdorsi
C8Fingerextensors,fingerflexors,wristflexors,handintrinsics
T1Handintrinsics
ErbDuchennepalsy
o Injurytothesuperiorrootsofthebrachialplexus,C5
andC6,leadstoparalysisofthefollowingmuscles:
Deltoid,Biceps,Brachialis,Coracobrachialis,
Brachioradialis,Supraspinatus,Infraspinatus,
Teresminor,Subscapularis
o Upperlimbisadductedatshoulder,mediallyrotated,
andextendedattheelbow
o Resultfromtoomuchtractionontheneck,orforcible
lateralneckbending,ascanoccurduringdelivery.
Klumpke'spalsy
o Lowerbrachialplexusinjury
o Dorsalandventralrootsofthespinalnervesthatform
theinferiortrunkofthebrachialplexus(C8andT1)
maybeavulsed
o Shortmusclesofthehandareaffected
o Clawhand
Saturdaynightpalsy
o Radialnerveisofteninjuredwhenthehumerus
fracturesatmidshaft
o Wristdrop
CENTRALNERVOUSSYSTEMINJURIES
Deepbranchoftheradialnervecanbeinjuredbydeep
puncturewoundstotheforearm
ExtendsthethumbandtheMPjoints
o Superficialdamageleavesacoinshapedareadistalto
thebasesofthe1stand2ndmetacarpalswithout
sensation.
Brachialplexussyndrome
o Maybeduetocervicalrib
o Alsooccursinpregnancyandtumordevelopment
o Symptoms
o Unilateralnumbness,weakness,andatrophyofhand
o Someclaudicationwitharterialinvolvement
o Involveslowertrunkofbrachialplexus
o
REFLEXES
Themechanismofmyastheniagravisinvolvestheformationof
antibodiesagainsttheacetylcholinereceptor.
SUPPURATIVEPAROTIDITIS
OTITISMEDIA
Serousotitisinanyonewithasignificanthistoryofsmokingor
alcoholabusedeservesanasopharyngoscopyasascreeningtest
forcancer.
VASCULAR
LARYNGEALNERVE
Damagetothesuperiorlaryngealnerveaffectsthetimberofthe
voice.Thisfrequentlyleadstolossofhighpitchedspeech.
Thesuperiorlaryngealnerveissensorytothesupraglottisregion.
Bilateralrecurrentlaryngealnerveinjuryrequirespermanent
tracheostomytopreventlossoftheairway.
Damagetoarecurrentlaryngealnervetypicallyrequires
medializationofthevocalfoldstohelpprotecttheairwayand
avoidhoarseness.
Therateofperipheralnerveregenerationfollowinginjuryis
approximately1cmpermonth.
MULTIPLESCLEROSIS
MultipleSclerosis(MS)
Weaknessandfatigue,opticnervedysfunctionmayoccur
leadingtotransientblindness.Cognitivechangesoccurin
some,ataxia,hemiparesis,depression,andpsychomotor
changes.Bilateralfacialweaknessandtrigeminalneuralgiaare
strongindicators.Incontinence&sexualdysfunctioncommon.
CSFexaminationindicatesoligoclonalbanding,normalglucose,
normalorhighprotein,andhighWBCcountwithahighIgG
index.MRI.
MyastheniaGravis(MG)
Presentation
Diagnosis
Treatment
Weaknessworsensonexertionandimproveswithrest.EOM
areweakandptosismaybepresent
EMGandRNS,facialmuscleweaknessisobviousonphysical
exam,alongwithweaknessinthebulbarmuscles,extremities,
respiratorymuscles,andocularmuscles,antibodiesagainstthe
AChR.
InhibitorsofAChEhavebeenusedwithsomeeffect;
medications.Plasmapheresisandthymectomyarebeneficial.
PEisusefulinminimizingexacerbations.Immunomodulation
withprednisone,azathioprine,andCsAhavesomebenefit.
AnteriorSpinalArteryInfarction
Presentation
Diagnosis
Treatment
Trauma, dissectingaorticaneurysm,aortography,polyarteritis
nodosa,hypertensivecrisis
Flaccidparalysisfollowedbyspasticparesis, loops ofpain and
temperature.
Imagingstudies
Symptomatic
Thepresenceofanteriorspinalsyndromeisoftenmanifestwith
hyperreactivedeeptendonreflexes.
DIAGNOSISOFSTROKE
ImagingTests
NoncontrastCT
Lumbarpuncture
NERVEREGENERATION
MYASTHENIAGRAVIS
ANTERIORSPINALARTERYINFARCTION
Etiology
Diagnosis
ThemostcommoncauseofsuppurativeparotiditisisbyS.
aureus.Thetreatmentishydrationandappropriateantibiotic
coverage.
BicepsC5,C6(MCnerve)
TricepsC6,C7(radialnerve)
KneeJerkL3,L4(femoralandcommonperonealnerves)
AnkleJerkL5,S1(tibialnerve)
Presentation
Carotidduplex
scanning
Echocardiography
Angiography
Distinguishesvarioustypesofstrokes.
Patients suspectedofhavingsubarachnoid
hemorrhage.
Patients whomayhavestenosis ofthecarotid
artery.
Ifparticularcausesofstrokearesuspected.
Preciselyidentifiesocclusions.
Anypatientwithastrokethathasacontraindicationfor
anticoagulationneedsaninferiorvenacavafilteriftheyhave
additionalcomorbidities.ThisincludespathologiessuchasGI
bleedoraDVT.Mostpractitionerswillnotbegintoheparinize
foratleasttendays.
TRAUMA
BROWNSEQUARDSYNDROME
DamagetoCNS
Seeningeneralbraindefects,stroke,centraltractlesions
Hemiparesiswithsomelimbdrift,hyperreflexia,spasticity,
Babinski
DamageaboveT1leadstoHornersyndrome(miosis,ptosis,
anhidrosis)especiallycommoninlungCA
BrownSequardsyndromeleadstolossofipsilateralmotorand
contralateralpainandtemperaturefunctionduetohalfofthe
spinalcordbeingsevered.
CRICOTHYROIDOTOMY
Melanomaismostlikelytometastasizetothesmallbowel.Ifthe
primarysourceisunknown,anexploratoryaxillaryresectionhas
beenshowntohaveasurvivalbenefit.Afullworkupshouldbe
donebeforehand,andtheinitialmanagementisaCTofthe
abdomenandpelvistoensurethatthereisnotmetastatic
disease.
SARCOMA
OTORRHEA
Basilarskullfracturesmaypresentwithotorrhea.Thetreatment
fortraumaticotorrheaiselevationoftheheadabove30degrees
andobservation.Antibioticsarenotusuallyindicated.
TETANUS
TetanusvaccinesintheformofTdshouldbegivenevery10
years,andshouldberepeatedinthefaceofaninfectedwound.
CANCER
PAROTIDTUMOR
NECKMASS
Amobileparotidtumor(typicallyalowgradeacinartumor)can
betreatedwithasuperficialparotidectomywithsparingofthe
facialnerve.Thisisalsothetreatmentofchoicewhenan
indeterminatefineneedleaspirationresultsoncytology.
80%ofparotidtumorsarebenigninnature.
BASALCELLCANCER
Basalcellcancermaybeexcisedwithmarginsof0.5mm.It
typicallypresentswithapearlyappearanceandiscommonly
locatedontheface.
SQUAMOUSCELLCANCER
Theprognosiswithsarcomaismadebasedofftumorgrade.
Anincisionalbiopsyisrequiredforthetreatmentofsarcomatous
lesionsover4cm.Alongitudinalplaneofexcisionisusedto
avoidtraumatothelymphaticsandpreventseedingofthelymph
system.
Kaposisarcomaisduetothelossoftumorsuppressorgenes.
Followingthediagnosisofasofttissuesarcoma,acorebiopsy
shouldbeobtainedtoevaluatethetissueforstaging.Afine
needleaspirationisinsufficient.
Squamouscellcarcinomaofthetonguetendstobelateralin
locationandpresentswithanulceratedappearance.
Squamouscellcarcinomaoftheliprequiresprimaryresectionof
1/3ofthelipandasearchfornodaldisease.
Squamouscellcarcinomaofthenasopharynxmaymetastasizeto
secondarylocationsandcanpresentseveralyearslater.
SquamouscellcancerwithonelymphnodeisconsideredstageI
disease.Stage2diseasehastwolymphnodesonthesamesize
ofthediaphragm.Stage3diseasehaslymphnodesonboth
sidesofthediaphragm.Stage4diseasehaspositivelymph
nodesinorgansystems.
Aneckmassoflessthan4cmdeservesafineneedleaspiration
astheinitialstepindiagnosis.
Asofttissuemasslargerthan4cmreceivesanincisionalbiopsy
alongthelongitudinalplane.Radiotherapyismandatoryfor
masseslargerthan5cm.
Thepresenceofapalpablecervicallymphnodeintheelderlyis
theresultofmetastaticcanceruntilprovenotherwise.
THORACICSURGERY
GENERALCONCEPTS
LUNG
ALVEOLI
TypeIalveoliformthestructureofthealveolarwall.
TypeIIalveolisecretesurfactanttodecreasethesurfacetension
ofwaterandpermitgasexchange.
TypeIIIalveoliareimmunecellsthatdestroyforeigninvaders.
LUNGVOLUMES
MARJOLINSSKIN
Marjolinsskincancertypicallyoccursinpatientswithsignificant
burninjuries.Afiveyearcoursefordevelopmentistypical.
MALIGNANTMELANOMA
Thepresenceofmelanomalessthan1mminsizerequiresawide
localexcisionwith1cmmargins.Noexplorationforlymphnodes
isnecessary.
Thepresenceofmelanomagreaterthanorequalto1mminsize
requires2cmmarginsandasentinellymphnodebiopsy.Ifthis
sentinellymphnodebiopsyisnegative,nolymphnodedissection
isrequired.
FRC = ERV (normal breath)
Acricothyroidotomyisanincisionthroughthecricothyroid
membraneandintothetrachea.Inthisprocedure,thethyroid
cartilageisclearlyidentifiedviapalpation.Justbelowthethyroid
cartilageisthecricothyroidmembrane.Justbelowthis
membraneisthecricoidcartilage.Theincisionismadethrough
thecricothyroidmembrane(belowthethyroidcartilageand
abovethecricoidcartilage).
10
Expiratory flow rate =
Hemoglobin
FEV1
= FEF
FVC
Oxygentransportreliesonsufficientcardiacoutputand
hemoglobinofsufficientsaturationandquantity.
InpatientswithpoorCOorHgb,givingthepatient100%oxygen
doeslittletoimprovetheoxygenation.
Calculatingoxygenationcanbedonewiththealveolararteriolar
gradient:
RespiratoryQuotient
Carbohydrateoxidation
Fatoxidation
Proteinbreakdown
Lipogenesis
Normal
1
0.7
0.8
>1.0
0.8
Notes
pH
7.35
7.45
pCO2
35 45
pO2
75 100
HCO3
22 30
Base
excess
2 +2
Determinesacidosisvs.alkalosis andhelps
determinethepresenceofmixeddisordersand
compensation.
PCO2 isdeterminedbyventilation. AhighPCO2
withlowpHindicatesrespiratoryacidosis.Alow
PCO2withhighpHindicatesrespiratoryalkalosis.
Valuesabove60mayindicatetheneedfor
mechanicalventilation.
Valuesbelow60mayindicatetheneedfor
mechanicalventilation.
Indicatesthepresenceofametabolicderangement.
AlowHCO3indicatesmetabolicacidosis;high
valuesindicatemetabolicalkalosis.
Negativebaseexcessindicatesacidosis. Positive
valuesindicatealkalosis.
Acuterespiratoryacidosis:
pH = 0.08
pH = 0.03
pH = 0.08
RightShift
LeftShift
Temperature
2,3DPG
PCO2
PCO
pH
High
High
High
Low
Acidosis
Low
Low
Low
High
Alkalosis
(PaCO 2 - 40)
10
(40 - PaCO 2 )
10
Chronicrespiratoryalkalosis:
pH = 0.03
(40 - PaCO 2 )
10
Finally,theexpectedrespiratorycompensationforametabolic
disturbancecanbecalculated.Thisisduetoalinearrelationship
betweenchangesinHCO3andcompensationbythelungto
changePaCO2.ThisformulaisknownasWintersformula:
Expected PaCO2 = (1.5 HCO3 -) + (8 2 )
VariationoutsideoftherangespecifiedbyWintersformula
indicatesaconcurrentrespiratorydisturbance.
Wintersformulacanonlybeusedformetabolicacidosis;itdoes
notpredicttherespiratorycompensationinresponsetoa
metabolicalkalosis.
ArterialBloodGas(ABG)
Metabolic
acidosis
Variable
10
Acuterespiratoryalkalosis:
Measures
OXYGENHEMOGLOBINDISSOCIATIONCURVE
(PaCO 2 - 40)
Chronicrespiratoryacidosis:
Themostsignificantcontributortooxygencarryingcapacityis
hemoglobin.IncreasingPO2over100increasesoxygenonly
slightlyviaincreaseddissolvedoxygenintheblood.
Fe3+improvesoxygendelivery
Oxygendeliveryisdefinedastheamountofoxygenmade
availabletothebodyinoneminute.Itisequaltothecardiac
outputtimesthearterialoxygencontent.Thisisapproximately
1,000mLO2perminute.
Oxygenconsumptionistheamountofoxygenusedeveryminute.
Approximately25%ofthearterialoxygenisusedeveryminute
(95%+saturationofbloodleavingtheheart,~70%saturationof
venousbloodreturningtotheheart).
Oxygenextractiondecreaseswiththevolumeofoxygen,asit
becomeshardertoremoveoxygenfrominsufficientlypopulated
hemoglobinmolecules.
SVO2increaseswithanincreaseincardiacoutput.
Therespiratoryquotientisaunitlessnumbercalculatedasthe
ratiobetweentheamountofcarbondioxideproducedandthe
amountofoxygenconsumed.Thisvaluecorrelatestothecaloric
valueforeachliterofcarbondioxideproduced.
Process
Normal
Range
A - a gradient = PA O2 - Pa O2
Variable
PaCO 2
PAO2 = 150 0.8
Fetalhemoglobin
ARTERIALBLOODGAS
Thediffusingcapacityofthealveoli(DLCO)isgenerallydecreased
withinterstitiallungdiseaseandemphysema.
Improvingoxygenationinapatientwhoisalreadyon100%
oxygenwithadequateventilationcanbedonebyimproving
recruitmentofthelung.ThisisdonebyincreasingthePEEP,
whichinturnincreasesFRC.
IncreasedventilationleadstoadropinCO2.
OXYGENATIONANDDELIVERY
Adulthemoglobin
Metabolic
alkalosis
Respiratory
acidosis
Respiratory
alkalosis
Oxygenationofthebloodandtodeterminethenatureofany
potentialhypoxia
Abnormalgaininhydrogenionsorloss ofbicarbonate. Lab
valuesincludeadropinpH,adropinPaCO2,andadropin
HCO3.
Abnormalloss inhydrogenionsorgainofbicarbonate. Lab
valuesincludeariseinpH,ariseinPaCO2,andarisein
HCO3.
Abnormalhypoventilationleadingtocompensation bythe
bodytogeneratebicarbonate.Labvaluesindicateadropin
pH,increaseinPaCO2,andanincreaseinHCO3.
Duetohyperventilationleadingtoconsumptionof
bicarbonate,withchangesinlabvaluessuchasadropinpH
andadropinPaCO2.
11
ACIDBASE
Treatment
METABOLICACIDOSIS
AnionGapMetabolicAcidosis
Etiology
Duetolacticacidosis,ketoacidosis,uremiainchronicrenal
failure,andingestionoftoxinssuchasaspirin,ethyleneglycol,
methanol,andparaldehyde.
DecreasedDTR,hypotension,paresthesia,coma, andspecific
EKGchanges.
Ketoacidsbeingpresentorketoacidsbeingabsent(seeabove
textfordiscussion).
Symptomatictreatment;treatreversiblecauses;hydration
Presentation
Diagnosis
Treatment
Nitroglycerin torelievesymptoms, calcium channel

blockers,botulinumintoLES,pneumaticdilationofLES.
NUTCRACKERESOPHAGUS
NutcrackerEsophagus
Pathophysiology
Diagnosis
Treatment
Highamplitudeperistalticcontractions, dysphagia, chest

pain.
Manometry (highamplitudecontractions).Barium
swallow(differentiatesfromDESinthatDEShascorkscrew
appearanceNutcrackerdoesnot).
SameaswithDES.
ESOPHAGEALOBSTRUCTIONS
NonAnionGapMetabolicAcidosis
Etiology
Treatment
RTA,diarrhea,fistulaswiththepancreas,carbonic anhydrase
inhibitors,acidingestion,dilutionofalkali,ileostomy,andvarious
medications.
Correcttheunderlyingetiologybuttoavoidhypernatremia, fluid
overload,andexcessivebicarbonateinfusion.
MetabolicAlkalosis
Etiology
Diagnosis
Treatment
Chlorideresponsiveiscommonlyduetovomiting,pyloric
stenosis,laxativeabuse,diuretics,andfollowinghypercapnia.
Chlorideresistantarecommonlyaresultofseverepotassiumor
magnesiumdeficiency,increasedmineralocorticoids,Bartters
syndrome,chewingtobacco,andlicoriceconsumption.
Neuromuscularexcitability,hypokalemia,andhypovolemiaare
commonlyfoundonexam.
Correctunderlyingdisorder.KClissometimesgiventocorrect
significantelectrolyteabnormalities.
EsophagealObstructions
Etiology
Diagnosis/
Treatment
Complications
PlummerVinsonhypopharyngealwebs inconjunction
withirondeficiencyanemia
Schatzkiringsnarrowmucosalringslocatedinthe
loweresophagus
Bariumswallow,balloondilation, surgery
PlummerVinsonelevatedriskofsquamouscell
carcinoma
ZENKERDIVERTICULUM
ZenkerDiverticulum
Pathophysiology
Presentation/
Diagnosis
Treatment
Pouchextendingoutsideoftheesophagus duetoa
defectinthemuscularlayeroftheepithelium.Typically
inposteriorhypopharynx.
Halitosis,aspirationoffood,dysphagia. Diagnose
throughbariumswallow.
Surgicalremoval.
RespiratoryAcidosis
Presentation
Treatment
Commonlyduetohypoventilation.CausesincludeCOPD,
airwayobstruction,pneumothorax,myastheniagravis,MD,
GBS,botulism,tetanus,organophosphatepoisoning,and
centraldepressionoftherespiratorysystem.
Confusionleadingtostuporandcoma,andencephalopathy.
Treatingtheunderlyingcauseandusingartificialventilation.
Oxygenationofthesepatientsmayleadtofurtherdepression
oftherespiratorydrive.Onlytheminimumamountofoxygen
viaNCshouldbeprovided.
RespiratoryAlkalosis
Etiology
Presentation
Treatment
Hyperventilation,shock,pulmonarydisease,pregnancy,
cirrhosis,hyperthyroidism,andaspirinpoisoning.
ElevatedpH,decreasePCO2,andadecreaseinbicarbonate,
rapid,deepbreathing,anxiety,chestpain,andcircumoral
paresthesia.
Minimizeanxietyinthepatient,breathingintoapaperbag,
anddecreasingminutevolume,ifthepatientisartificially
ventilated.
ESOPHAGUS
ACHALASIA
Achalasia
Pathophysiology
Diagnosis
LossofconductingneuronswithincreasedLES tone;failure
ofnormalperistalsis;severedysphagia;weightloss;cough;
diffusechestpain.
Bariumswallow(birdbeaknarrowingininferior
esophagus);manometry(normaltohighpressureatLES),
EGDtoruleoutgastriccarcinoma;gastricbubbleabsenton
plainfilm.
GASTROESOPHAGEALREFLUXDISEASE
Gastroesophagealrefluxdiseaseispredominantlydueto
incompetenceoftheloweresophagealsphincter(LES).
Othercausesincludethepresenceofahiatalhernia,delayed
emptyingofthestomach,anddecreasedmotilityofthe
esophagus.
Thehighlevelofprogesteroneinpregnancycontributesagreat
dealtothesymptomsofheartburnandsubsternalburningthat
causesmanypregnantwomensuffering.
SmokinghasalsobeentiedtoadecreaseinLEStone.
Finally,avarietyofmedicationsthathaveeffectsonmuscletone,
suchascalciumchannelblockers,blockers,nitrates,
anticholinergics,andtheophyllinehavebeenimplicatedashaving
anegativeeffectonmaintainingthetoneoftheLES.
DysphagiainGERDisoftenaresultoftheformationofanatomic
defectsintheesophagus,suchaswebsandstrictures.
ANissenfundoplicationcanalsobedoneasasurgicalrepair.
Inabout10%ofpatients,pepticstricturescanformthatfurther
heightenthesymptomsofdysphagia.
Columnarcellmetaplasiaofthelower2/3softheesophaguscan
alsooccurinaconditionknownasBarrettsesophagus.
Finally,smokingcanleadtothedevelopmentofsquamouscell
carcinoma.
SCLERODERMA
Scleroderma
Etiology
12
Etiology
Presentation
Diagnosis
Treatment
Autoimmunedisorderthatcausessignificantfibrosis
throughoutthebodywithnumeroussystemiceffects.
Skinchangesareamongtheinitialchangesdetected.
Esophagealfibrosispresentswithprogressivedysphagia.
Telangiectasiaearenotedthroughoutthebody.Scleroderma
mayalsopresentaspartoftheCRESTsyndrome.
ThepresenceofanSCL70antibodytotopoisomerase,
antibodiestocentromeresandvariouscomponentsofthe
nuclei,anormocyticnormochromicanemia,elevationsinESR
andCRP,andrestrictivelungdisease.
Therapyforsclerodermaincludespenicillaminetodecrease
permanentfibroticchanges,captopriltolimittheextentof
renalHTN,andcalciumchannelblockerstodecrease
Raynaudsphenomenon.
ESOPHAGEALPERFORATION
BOERHAAVESYNDROME
BoerhaaveSyndrome
Pathophysiology
Etiology
Presentation
Diagnosis
Treatment
Fullthicknesstearofesophaguslocatedinleft,
posterolateral,distal1/3.
Forcefulvomiting,strongcough,heavylifting, direct
trauma.
Bleeding,hematemesis.Severepainthatradiatestothe
chest,back,andabdomen.
CXR(identifiespleuraleffusionandemphysema);
esophagogram;endoscopy.
Pressuretostophemorrhage,surgicalrepair.
MALLORYWEISSSYNDROME
MalloryWeissSyndrome
Pathophysiology
Perforationthroughthesquamocolumnarjunctionnear
theLES.Transientbleeding,vomiting.
Presentation
Severpainthatradiatestochest,backandabdomen,
dysphagia.
CXR(identifiespleuraleffusionandemphysema);
esophagogram;endoscopy.
Pressuretostophemorrhage,surgicalrepair.
Diagnosis
Treatment
LEIOMYOMA
Thepresenceofanesophagealleiomyomarequiresenucleation.
Smoothfillingdefectsonacontraststudyinapatientwith
intermittentdysphagiashouldhaveenucleationofthemasses.
ESOPHAGEALCANCER
EsophagealCarcinoma
Pathophysiology
Treatment
BARRETTESOPHAGUS
Barrettsesophagusisthetransformationofsquamouscell
epitheliumtomucusproducingcolumnarcellepithelium.
Thistransformationislikelysecondarytoanattemptbythebody
toprotecttheloweresophagusfromcontinuingdamagedueto
acidrefluxfromanincompetentLES.
Thesemetaplasticchangesaremostcommoninpatientswith
GERD,affectingsome20%ofthesepatients.
Barrettsmetaplasiaisastrongpositivepredictorof
adenocarcinoma,carryingarelativeriskof30timesthatof
normal.
ThepresenceofBarrettsmetaplasiaplusdysplasiaisknownas
Orringersyndrome.
DiagnosisofBarrettsesophagusismadebyexaminingbiopsied
specimensforcolumnarcellepitheliumsuperiortotheLES.
RepeatedEGDsshouldbedoneafterdiagnosis.
Highgradedysplasiaisastrongpredictorofadenocarcinoma,
andprophylacticesophagealresectionshouldbedone.
Adenocarcinomaismorelikelytooccurinthedistal1/3ofthe
esophagus,whilesquamouscellcarcinomaismorelikelyinthe
proximal1/3oftheesophagus.
Squamouscellcarcinomahasanumberofriskfactors,including
ahistoryofalcoholconsumption,alongstandinghistoryof
smoking,esophagealmotilitydisorderssuchasachalasia,
anatomicdefectssuchasPlummerVinsonsyndrome,and
consumptionofcarcinogenssuchasfoodsrichinnitratesand
certainspices.
Thelargestpositivepredictivevalueofsquamouscellcarcinoma
riskissmoking.
Esophagealcancerspreadsinwardcircumferentiallytocause
progressivedysphagia.
Hypercalcemiaissometimespresent.
Diagnosisofesophagealcancerisinitiallymadethroughbarium
swallowstudies.
BiopsythroughEGDisrequiredtoestablishthediagnosis.
Theprimarytreatmentforesophagealcanceriswithsurgical
resection,aprocedurethatcarriesahighmortalityrate.
Chemotherapyisstandardwithaplatinumagentsuchas
cisplatin,and5fluorouracil(5FU).Radiationtherapyisalso
usedtohelppreventrecurrence.
Esophagealcancerhasapoorprognosisandveryfewpeoplestill
surviveafter5years.
Diagnosis
CANCER
Squamous cellcarcinomariskfactors: smoking, alcohol,

achalasia,carcinogens.
Bariumswallow(detectsjaggededges);biopsy through
EGD.
Surgicalresection,chemotherapy(5FU, cisplatin),
radiation.
Thedetectionofunresectablesquamouscellcancerofthe
esophagusshouldbefollowedbybronchoscopyandpossible
stentingtopreservetheairway.
Submucosalspreadofatumoristhebehaviorexhibitedby
esophagealcancer.
DIAPHRAGMANDMEDIASTINUM
HODGKINDISEASE
Hodgkinlymphoma(HL)isadistinctmalignantlymphomawitha
clonalBcellpopulationproliferatingasReedSternberg(RS)cells.
IthasbeenpostulatedthatinfectionbyEBVisapredecessorto
HL.
HLpresentswithsupradiaphragmaticlymphadenopathy(typically
seenintheneckandaxilla),chestpain,intermittentfever,and
pruritus.
Hepatosplenomegalyistypicallyevidentonphysicalexam.
13
CTscansareusedtoidentifytheextentofdisease,andflow
cytometryisthekeyfordiagnosis.
Stage
Features
StageI
Stage
II
Stage
III
Singlelymphnodeorsingleextralymphaticsiteinvolvement
Twoormorelymphnodesonthesamesideofthediaphragmorone
lymphnoderegionandonecontiguousextralymphaticsite
Involvementoflymphnodesoneithersideofthediaphragm
(includingspleen),orlimitedcontiguousextralymphaticorgan
involvement
Disseminateddiseaseinextralymphaticorgans
Stage
IV
HListreatedwithradiationtherapyandchemotherapy.The
MOPPorABVDregimenisoftenused.
PETscansareusedtoassessthesuccessofthetherapy.
Etiology
Presentation
Diagnosis
Treatment
Duetomalignant expansionofBcells, Tcells,NKcells,or

macrophages,butthemajorityareduetoBcellexpansion.
Painless peripheraladenopathy,extensiontothebone marrow
andsubsequentpancytopenia,multipleconstitutional
symptoms,andextranodalmanifestations.Bowelobstruction
mayoccur,alongwithsignificantgrowthofthelymphoma
leadingtocranialnerveimpingement.Hepatosplenomegalyis
common,andmoreadvanceddiseasemayalsopresentwith
testicularenlargement,skinlesions,andamediastinalmass.
CBC, elevationofLDH,andscreenforinvolvementofother
organsthroughvariousenzymefunctiontests.Imagingstudies
helptoidentifytheextentofthetumor.
Radiation therapy,chemotherapy(CHOP regimenorCVP)is
sometimesusedinhighriskpatients.Monoclonalantibodies.
AMoreaggressivetumoristreatedwithhighdose
chemotherapy,radiotherapy,followedbyBMT.
HodgkinLymphoma(HL)
Diagnosis
Treatment
ClonalBcellpopulationproliferatingasRScells.
Supradiaphragmaticlymphadenopathy(typicallyseeninthe
neckandaxilla),numerousconstitutionalsymptoms,chest
pain,intermittentfever,andpruritus..Hepatosplenomegaly
istypicallyevidentonphysicalexam.
ESRandLDHareelevated.CBCtypicallyindicatesananemia
ofchronicdisease.CTscansareusedtoidentifytheextentof
disease,andflowcytometryisthekeyfordiagnosis.
Radiationtherapyandchemotherapy.MOPPorABVDregimen
isoftenused.BMTissometimesalsoused.PETscansare
usedtoassessthesuccessofthetherapy.
Themostcommonsiteforasinglepositivelymphnodeisthe
axilla.StaginglaparoscopyisnotindicatedforstageIdisease.
StagingofHodgkinlymphomawhensupraclavicularand
mediastinallymphnodesarepositivewithoutabdominal
involvementinasymptomaticpatientisstage2Bdisease.
Stagingtypicallyoccurswithlaparotomy.
NONHODGKINLYMPHOMA
NonHodgkinlymphoma(NHL)maybeduetomalignant
expansionofBcells,Tcells,naturalkiller(NK)cells,or
macrophages,butthemajorityareduetoBcellexpansion.
CausesofNHLincludeachromosomaltranslocationthat
predisposestothepatienttothelymphoma,historyofinfection
byEBV,humanTcellleukemiavirus(HTLV),HCV,and
herpesvirus8(HHV8),exposuretocertainenvironmentaltoxins
orchemotherapeuticagents,variouscongenitalcauses(severe
combinedimmunodeficiencydisease[SCID]),astateofchronic
inflammation,andH.pyloriinfection.
NHLpresentsasapainlessperipheraladenopathy,pancytopenia,
andextranodalmanifestations.Bowelobstructionmayoccur,
alongwithsignificantgrowthofthelymphomaleadingtocranial
nerveimpingement.
Advanceddiseasemaypresentwithtesticularenlargement,skin
lesions,andamediastinalmass.
StageIVdiseaseisconfirmedbybonemarrowbiopsy.
Laparotomyisnotindicatedforstaging;CTscanissufficient.
EarlystageNHListreatedwithradiationtherapy,but
chemotherapyissometimesusedinhighriskpatients.More
advancedstageshaveacombinationofradiotherapyand
chemotherapywiththeCHOPregimen.
NHLisnotanindicationforlaparotomy.
NonHodgkinLymphoma(NHL)
PLEURALCAVITY
SPONTANEOUSPNEUMOTHORAX
SpontaneousPneumothorax
Etiology
Presentation
Treatment
COPD,cystic fibrosis,pneumonia,cancer,andillicitdrugabuse.
Pleuriticchestpainanddecreasedbreathsounds.
Oxygenandobservation.Ifthepneumothorax issignificant,
airmayneedtoberemovedviatubethoracostomy.
Pleurodesismaybenecessarytosealthehole.
Volumecontrolmodeonventilationwillincreaseairway
pressuresintheeventofapneumothorax.
Emphysemawithincreasedairwaypressuresisdueto
pneumothorax.
TENSIONPNEUMOTHORAX
TensionPneumothorax
Presentation
Treatment
Similartospontaneouspneumothorax, withtheadditionof
trachealdeviationawayfromthesideofthepneumothorax,
hypotension,andtachycardia.Traumatotheregionmayalso
leadtothepresenceofblood.
Decompressionbyneedlefollowedbytubethoracostomy.
Atensionpneumothoraxexertsitsphysiologiccompromise
throughvenacavacompression.
Atensionpneumothoraxwilleventuallyleadtokinkingofthe
greatveinsandocclusionofbloodflow.
Bewareoftensionpneumothoraxfollowingcentralline
placement.
Traumapatientswithapneumothoraxshouldbeintubatedfirst
(airway).
ATELECTASIS
Atelectasis
Causes
Presentation
Treatment
Poorinspiratoryeffort,lackofsufficientcoughing andlung
expansion,andfailuretousedevicesthataidininspirationand
expiration.
Fever, tachycardia,dyspnea,tachypnea,andhypoxemia.
Deviationsofthetracheaorelevationsofthediaphragmmay
bepresentonCXR,whilemoresignificantatelectasismayhave
mediastinalshifts.
Incentivespirometry,inducingcough, anddeepbreathing.
Treatinganyconcomitantpulmonarydisordersisalso
necessary,alongwithremovinganyobstructionsorforeign
bodiesviabronchoscopy.
Etiology
Presentation
14
CHRONICOBSTRUCTIVEPULMONARYDISEASE
TheunderlyingpathophysiologyofCOPDisincreasedairway
resistanceinbronchitis,anddecreasedlungrecoilin
emphysema.
Patientswithchronicbronchitisaretypicallyknownasblue
bloatersandpresentwithRHF,Polycythemia,andhighPCO2
withlowO2onABG.
Patientswithemphysemaaretypicallyknownaspinkpuffers
withabarrelchest,anorexicappearance,andalowPCO2with
normalPO2onABG.
PFTsindicateanincreasedTLCandRV,butareductioninFEV1:
FVCandFEF.DLCOisdecreasedinemphysema.
Surgicaloptionsarelimited,butincludelungreductionto
improveFEV1.
Presentation
Diagnosis
Treatment
PLEURALEFFUSION
Diagnosis
Treatment
Ronchiandwheezesuponauscultation,CXRindicates
pulmonarymarkings.
Distantbreathsounds,CXRincludelunghyperinflation,
flatteningofthediaphragm,smallheartsize,andincreased
retrosternalspace.PFTsindicateanincreasedTLCandRV,
butareductioninFEV1:FVCandFEF.DLCOisdecreased,PFTs
indicateanincreasedTLCandRV,butareductioninFEV1:
FVCandFEF.DLCO.
PFT,CXR
Oxygenationwithhomeoxygensupportandnighttime
oxygensupport.Vaccinationsagainstinfluenzaand
Streptococcuspneumoniaearemandatory,andantibiotic
treatmentisgivenprophylacticallyagainstHaemophilus
influenzaeandStreptococcuspneumoniae.Betaagonistsare
usedalongwithipratropiumbromide,andsteroidsareused
withsignificantlypoorFEV1.Thefirstlinetreatmentis
composedofsteroids,especiallyinacuteexacerbations.
SurgicaloptionsincludelungreductiontoimproveFEV1.
Smokingcessationismandatory.
ACUTERESPIRATORYDISTRESSSYNDROME
Adultrespiratorydistresssyndromeisaseverediffusealveolar
injurythatleadstopulmonaryinfiltrates,hypoxemia,andfailure
ofnormallungfunction.
Increasedpermeabilityofthealveolileadstofluidinfiltrationinto
thealveoliandsubsequentdamagetotheirsensitiveepithelia.
Damageoccursprimarilytothevascularendotheliumoralveolar
epithelium,dependingonthenatureoftheinfiltrate.
PulmonaryedemaoccurswithdamagemostlytotypeIcells.
Longstandingdamageleadstohypoxemia,pulmonaryHTN,and
inmoreseverecases,fibrosiswithpermanentandprogressive
pulmonarydamage.
Limitedacuteinjurytypicallyresolves.
Oftensecondarytosepsis.
Acuteonsetofdyspneaandhypoxemia.
DiagnosisismadebyABGthatindicatesrespiratoryalkalosisor
metabolicacidosis,ifARDSoccursduetosepsis;andCXRthat
indicatespulmonaryinfiltratesbilaterallywithalveolarfilling.
Respiratorysupportmaybenecessary.Permissivehypercapnia
shouldbeallowed.
AdultRespiratoryDistressSyndrome(ARDS)
Etiology
Severediffusealveolarinjurythatleadstopulmonary
infiltrates,hypoxemia,andfailureofnormallungfunction.
PleuralEffusion
Etiology
ChronicObstructivePulmonaryDisease(COPD)
Presentation
ofbronchitis
Presentation
of
emphysema
Acuteonsetofdyspneaandhypoxemiafollowingan
identifiablecause.Physicalfindingsincludetachypnea,
tachycardia,DOE,oxygensupplementation,signsofhypoxia,
andsignsoftheunderlyingetiology.ARDSoftenoccurswith
sepsisandshock.
ABG thatindicatesrespiratoryalkalosisormetabolicacidosis if
ARDSoccursduetosepsis;andCXRthatindicatespulmonary
infiltratesbilaterallywithalveolarfilling.
Treatingtheunderlyingetiology.Respiratory supportmaybe
necessary.Fluidmanagementisimportantforcertain
patients.
Diagnosis
Treatment
Transudativeeffusion:increasedhydrostaticpressure or
decreasedoncoticpressure,whichoftenoccursinCHF,cirrhosis,
nephroticsyndrome,andpulmonaryembolism
Exudativeeffusions:Cancer,infection,andtrauma,tendtobe
unilateral.
ThoracentesisandtheLDHandproteintiters aremeasuredas
wellasaleukocytecount.Checkforblood,lowglucose,and
elevatedamylasetiters.Elevatedamylasetitersrequireruling
outpancreatitis,renalfailure,esophagealrupture,andtumors.
Transudativeeffusionandexudativeeffusions shouldbedealt
withbytreatingtheunderlyingcause(s).
PULMONARYEMBOLISM
PEiscommonlyduetovenousstasis,intimalinjury,and
hypercoagulability(Virchowstriad),andoftenoccursindeep
veinsofthelowerextremities.
OthercausesofPEincludeuseoforalcontraceptives,cancer,
thrombophilias(includingfactorVLeiden,antithrombinIII(ATIII)
deficiency),proteinC(PrC)deficiency,proteinS(PrS)deficiency,
andantiphospholipidantibody(APA).
RespiratoryeffectsofPEincludealveolarnecrosis,hypoxemia,
andhyperventilation.
Arterialhypoxemiaisacommonfindingduetoventilation
perfusion(V/Q)mismatch,formationofshunts,decreased
cardiacoutputfromincreasedpulmonarycirculationpressure,
andpatencyofaforamenovale(PFO).
Infarctionofthelungisrareduetocollateralcirculationfromthe
bronchialarteries.
IncreasedpulmonaryvascularresistanceleadstoincreasedRV
afterloadwithsubsequentRVH.
Suddenincreasesinloadcanleadtosuddencardiacdeathfrom
excessiveRVload.
SmallerPEscanpresentwithpulmonaryinfarctionwithpleuritic
chestpainandhemoptysis.
Themostcommonsignsandsymptomsincludetachypnea,rales,
tachycardia,S4gallop,andaccentuatedP2heartsound.
AsuddendecreaseinendtidalCO2duringsurgicalprocedures
likelyindicatesapulmonaryembolism.
Ddimerisanonspecifictestthatindicatesfibrinbreakdown;it
shouldnotbeusedalonefordiagnosisbutraisestheclinical
suspicionifpositive.
CXRisnormalintheacutephase,butlatershowsdilationof
pulmonaryvessels,atelectasis,pleuraleffusions,andanelevated
diaphragm(Westermarksign).
15
PulmonaryEmbolism(PE)
Etiology
Presentation
Diagnosis
Treatment
Commonlyduetovenousstasis,intimalinjury, and
hypercoagulability,andoftenoccursindeepveinsofthelower
extremities.Useoforalcontraceptives,cancer,
thrombophilias,ATIIIdeficiency,PrCdeficiency,PrSdeficiency,
andAPA.
AlargePEpresentswithcirculatorycollapseanddeath.
SmallerPEscanpresentwithpulmonaryinfarctionwith
pleuriticchestpainandhemoptysis.SOB,DOE,pallor,and
hypotension.Themostcommonsignsandsymptomsinclude
tachypnea,rales,tachycardia,S4gallop,andaccentuatedP2
heartsound.
ABG,Ddimertest,CXR,V/Qscanning,segmental perfusion
defects,ultrasound,helicalCT,pulmonaryangiography,EKG.
Anticoagulationtherapyforatleastsixmonths.Thrombolytic
therapymustbegivenshortlyaftertheeventtoachieve
maximaleffectiveness.AnIVCfilterisplacedinpatientswith
contraindicationstoanticoagulation.
HEMOTHORAX
Highchesttubeoutputinatraumasituationrequiresa
thoracotomy.
Widenedmediastinum,hypotension,andthelackofhemothorax
deservesevaluationforanaorticinjury.
OVERVIEW
About95%ofalllungcancersareeithersmallcelllungcancer
(SCLC)ornonsmallcelllungcancer(NSCLC).
OftheNSCLCs,adenocarcinoma(adenoCA)andsquamouscell
carcinoma(SCC)arethemostcommon,eachmakingup30%of
alllungcancers.SCLCmakesupanother30%.
Withoutquestion,themostsignificantpositivepredictoroflung
cancerriskisahistoryofsmoking.
Lungcancerpresentswithoutsymptomsinuptoaquarterof
patientsatthetimeofdiagnosis.
Paraneoplasticsyndromescanalsooccurwithproductionof
gastrin,ACTH,ADH,calcitonin,ANF,andPTHrP.
Theresultcanbeclubbing,metastaticossification,anemia,
weakness,constitutionsymptoms,neuraldegeneration,
anorexia,andhyponatremia.
CTandMRIaremoresensitiveandcandetectsmallernodules,
andarealsousefulforstaging.
Localspreadisoftengaugedbyamediastinoscopy.
SCLCtendstobemoreaggressiveandrapidlygrowing.
SCLCproducesgastrin,ACTH,ADH,ANF,andcalcitonin.
TreatmentofSCLCinvolvesradiotherapyandchemotherapy,as
themajorityofthesetumorsrespondwelltothismodality.
Surgicalresectionistypicallynotpossible.SCLChasalow5year
survival.
Pathophysiology
o ADH,ACTHproduction
o LambertEaton
o 25%ofalllungcancers
o Central
Presentation
o ParaneoplasticSyndromes
Paraneoplasticsyndromescanoccurwith
productionofgastrin,ACTH,ADH,calcitonin,ANF,
andPTHrP.
Theresultcanbeclubbing,metastaticossification,
anemia,weakness,constitutionsymptoms,neural
degeneration,anorexia,andhyponatremia.
SCLCproducesgastrin,ACTH,ADH,ANF,and
calcitonin
NSCLCproducesPTHrP
FEATURESANDTREATMENTOFNSCLC
NSCLCproducesPTHrP.
Thistypeoftumorislessresponsivetoradiotherapy,andbarely
responsivetochemotherapy.
Surgicalresectionisanoptionincaseswithlimitedspread.Five
yearsurvivalisbetterforNSCLCthanitisforSCLC.
SurvivalwithstageINSCLChavea70%5yearsurvival;stageII
offersa30%survival,stageIIIoffersa20%survival,andhigher
stagesofferonlya9monthsurvivalperiod.SCLCthatistreated
withchemotherapyhasa10%5yearsurvival;advancedSCLChas
a6monthsurvivalperiod.
SomeinstitutionsofferCTscansasascreeningtestinhighrisk
patients;earlydataappearstoindicatethatCTscanscandetect
lungcancerearlier,andinsomepatients,thismayleadtoearlier
treatmentsandpotentialsurgicalresectionbeforesignificant
metastasisoccurs.
Lungcancerisassociatedwithnumeroussyndromes,including
superiorvenacavasyndrome,Hornersyndrome,Pancoast
tumor,SIADH,EatonLambertsyndrome,andTrousseau
syndrome.
Superiorvenacavasyndromeoccursduetocompressionofthe
SVCwithswellingoftheupperextremity,head,andneck.
Cough,headache,epistaxis,andsyncopearecommonly
associatedsymptoms.
Hornersyndromepresentswithparalysisofthesympathetic
nerveduetodamagetotheganglion;itpresentswithptosis,
enophthalmos,miosis,andanhidrosis.
Pancoasttumorpresentswithdamagetothe8thcervicalnerve,
st
nd
1 and2 thoracicnerve,anddamagetotheribsthatleadsto
painthatradiatestotheipsilateralarm.
SIADHpresentswithhyposmolalityandhyponatremia.
V/Qscanningprovidesameaningfuldiagnosisinmanycases;
segmentalperfusiondefectsarehighlyindicativeofPEbutmany
patientsfallintheintermediateprobabilitycategory.
Additionaltestingiswarranted,andincludesultrasoundtodetect
aDVT,helicalCTwithcontrasttoidentifyasignificantpulmonary
embolus(smalleronesarenotdetected),andpulmonary
angiography(thegoldstandard).
SignsofaPEonEKGincludeSTTwavechanges,rightaxis
deviation,Swavesinlead1,Qwavesinlead3,andinvertedT
wavesinlead3(S1Q3T3).
Anticoagulationtherapystartingwithheparinfollowedby
warfarinisused;treatmentistypicallycontinuedforatleastsix
months.
Aninferiorvenacavafilterisplacedinpatientswith
contraindicationstoanticoagulation,fragilepatientswhocannot
tolerateanotherPE,andthosewithriskofrecurrence.
16
EatonLambertsyndromeoccurswithanautoimmunereactionto
nerveterminalsleadingtodecreasedreleaseofacetylcholine
(ACh).
Trousseausyndromeisahypercoagulablestatethatleadsto
venousthrombosis.
PCO2>60oranFEV1of1areallprohibitiverisksforlung
resectionduetotheelevatedchanceforpermanentventilation.
PoorDLCOratiosarealsoprohibitiverisks.
Rightupperlobectomiesrequiretheuseofarigid90degree
bronchoscope.
LARGECELLCARCINOMA
Pathophysiology
o 15%
o Peripheral
Presentation
o Cough,hemoptysis,pneumonitis,pneumonia,effusion,
dyspnea,wheezing,stridor,chestpain,anorexia,
phlebitis,bonepain,coinlesions
SQUAMOUSCELLCARCINOMA
Pathophysiology
o PTHrPproduction
o M>F
o 17%
o Central
Presentation
ADENOCARCINOMA
Pathophysiology
o Distallung
o F>M
o 40%ofalllungcancers
o Peripheral
Presentation
BENIGNTUMORS
AnteriorMediastinum
o Thymoma,thyroidenlargement,Tcelllymphoma
MiddleMediastinum
o Vascularlesion,enlargedlymphnodes
PosteriorMediastinum
o Neurogenictumor
CARDIACSURGERY
GENERALCONCEPTS
Theinternalmammaryarteryisthefirstbranchoffthe
subclavianartery
TheinternalmammaryarteryhasthebestpatencyforaCABG
Thesubclavianarteryislocatedbetweentheanteriorandmiddle
scalenemuscles
SAnode
RCAviasinusnodebranch
AVnode
RCAviasinusnodebranch
RA
RCAviasinusnodebranchandatrial
branch
RV
RCAviaacutemarginalandRVbranches
LA
LCAviacircumflex;RCAandLCAdirectly
AnteriorLV
LCAviaLAD
LateralLV
LCAviadiagonalbranches
PosteriorLV
LCAviaobtusemarginal,posterolateral,
andposteriordescendingviaRCA
Anteriorseptum
LCAviaLADandseptalbranches
Posteriorseptum
RCAviaposteriordescending(right
dominant)
Apex
LCAviaLADandIVbranches
Thethoracicductterminatesatthejunctionoftheleftsubclavian
veinandtheleftinternaljugularvein.
HEMODYNAMICS
EF =
( EDV ESV )
SV
=
EDV
EDV
CO = HR SV
Thecompensatoryreactionformild,normovolemicanemiaisvia
increasedcardiacoutput.
Meanarterialpressureis2/3softhediastolicpressureplus1/3
ofthesystolicpressure.MAPsshouldbekeptabove60.
ComponentsofMAParecardiacoutputandperipheralvascular
resistance.
Oxygendeliveryisaffectedbycardiacoutput,hemoglobin,and
oxygensaturation.
PerStarlingsrule,cardiacoutputincreaseswithleftventricular
enddiastolicvolume.
Leftheartvalvedisordersleadtodistortionsinpulmonary
capillarywedgepressure.AsignificantdiscordanceinPCWPand
centralvenouspressureindicaterightheartfailure.
Cardiopulmonarybypasshasconstantflowtothebrain,lung,
muscle,andliver.Thelackofpulsatileflowmayleadtopump
organ.Thoughthecauseiscontroversial,mostinvestigators
believethatthisoccursduetomicroinfarction.
Thepresenceofdarkbloodaftercomingoffcardiopulmonary
bypassshouldleadtothereintroductionofpulmonary
ventilation.
PULMONARYARTERYCATHETER
Apulmonaryarterycatheterisanexcellentmethodfor
measuringpulmonaryvascularresistance.
Afixedreadingonthepulmonaryarterycatheterwithlossof
respiratoryvariationisanindicationformalposition.
Indicationsincludehypovolemiawithsignificantfluid
managementissues,andlowurineoutputfollowingan
operation.
effects
Intraaorticballoonpumpsdecreaseafterloadandareindicated
withsignificantischemicdamagetotheheartthatcannotbe
alleviatedwithafterloadreducers.Afterloadreductionisthe
onlymethodtopreventadditionalischemicdamage.
PHARMACOLOGY
INDICATIONS
Dopamine
Norepinephrine
Shockwith
renalprotection
CHF
D1,D2
1
Shock
1,2,1,2
Openangle
glaucoma
Acuteasthma
MECHANISMOF
ACTION
Epinephrine
1,2,1,2
Increasesaqueous
humoroutflow
Anaphylactic
shock
Metoprolol
GivenIV due
tosignificant
firstpass
effects
GivenIV due
tosignificant
firstpass
effects
GivenIV due
tosignificant
firstpass
effects
Clonidine
Milrinone
SeeAdrenergic
AgonistsNon
Catecholamines
Hypertension
Increasecardiac
contractility
CLASSIAANTIARRHYTHMICS
DRUG
Amiodarone
Procainamide
DRUG
Lidocaine
Phosphodieserase
inhibitor
Dont
discontinue
without
talkingto
M.D.
Increased
mortality,no
beneficial
effects
MECHANISMOF
ACTION
Suppressectopic
rhythmsfrom
abnormalpacemaker
cells
Phase3and4effects
Decreasephase4
depolarizationand
increasefiring
threshold
Statedependent
effectstarget
abnormalpacemaker
cells
INDICATIONS
Ventricular
arrhythmia
Phase3and4
DecreaseAP
duration
NOTES
Longhalflife,
verytoxic
MECHANISMOF
ACTION
NOTES
conductionvelocity to
ERPandPRdueto
calciumchanneleffects
Targets AV node
Ca2+channel
blocker
ANGINA
Etiology
Presentation
NOTES
Types
Sodium
channel
blocker
NOTES
Treatment
Alsousedindigitalis
toxicity
Targetsischemicand
blocker
Generally,classIAandICdecreasephase0depolarizationtoslow
conduction,classIBdecreasephase3repolarizationtoslow
conduction,classIIsuppressesphase4depolarization,classIII
prolongsphase3repolarization,andclassIVshortenstheaction
potentialtomakereachingthresholdmoredifficult
MECHANISMOF
ACTION
AP,ERP,QT,
IK
CLASSIVANTIARRHYTHMICS
NOTES
MECHANISMOF
ACTION
Lastlinefor
arrhythmia
SVT
cAMPwithCa2+
current
Leadstophase4inAV
nodewithPR
INDICATIONS
INDICATIONS
NOTES
Nochangein
APduration
MECHANISMOF
ACTION
Suppress ectopic
focus,HTN
Amiodarone
INDICATIONS
CLASSIBANTIARRHYTHMICS
MECHANISMOFACTION
INDICATIONS
DRUG
Increasethresholdoffiring
anddecreasephase4
depolarization
CLASSIIIANTIARRHYTHMICS
Diltiazem
GivenIV due
tosignificant
firstpass
effects
Phenylephrine
VT andVF
DRUG
DRUG
CHF
INDICATIONS
NOTES
Increaselocal
anesthetic
duration
Dobutamine
DRUG
CLASSIIANTIARRHYTHMICS
ADRENERGICAGONISTSCATECHOLAMINES
DRUG
depolarizedtissue
CLASSICANTIARRHYTHMICS
Flecainide
17
Angina
SevereBPincreasesthatresultinendorgandamage.
Retrosternalpain thatradiatestotheleftshoulder,arm,or
jaw.Lastsafewminutesandisintermittent.Thepainis
typicallyaheavypressuresensation.Anginaalsopresents
SOB,N+V,diaphoresis,andpalpitations.Physicalsignsof
anginaincludetachycardiawithorwithoutanS4gallop.
Stableangina:duetoischemiaofthemyocardium leadingto
episodicpain.Chronicinnatureanddoesnotprogressover
time.Occurswithpredictivechangestomyocardialoxygen
consumption,isrelievedwithrest.
Unstableangina:newonsetanginathatprogressesovertime
withrespecttolocation,frequency,orseverity.Canoccurat
rest,andtypicallyrequiresincreasingamountsofmedication
tohaverelieffromsymptoms.
Prinzmetalangina:rarevariantofanginathatisdueto
vasospasmsofthecoronaryarteries.Chronic,intermittent
chestpainunrelatedtoexertion,andtendstooccurat
predictabletimesinthemorning.Thepainwakesupthe
patientatnight.PresentswithischemicchangesandST
elevationsonEKGduringexacerbation.
Initiallytreatedbylifestyleanddietarymodifications
Stableangina:SLNduringexacerbations,PCTAoracoronary
arteryCABG,betablockade,andASA.
Unstableangina:SLN,PCTAandCABGasindicated,andshould
INTRAAORTICBALLOONPUMP
18
alsobemonitoredCCU.HeparinorlowLMWHshouldbeused
inconjunctionwithASA.
Prinzmetalangina:calciumchannelblockersandnitrates.
MYOCARDIALINFARCTION
AcuteMI(AMI)canoccurasatransmurallesion,whichis
typicallyaccompaniedwithQwaves.
Asubendocardialinfarctisconfinedtotheinnermostportionof
theventricularwallanddoesnotpresentwithQwaves;
regardlessofthecauseoftheMI,thesubendocardialtissueof
theleftventricleisthemostsusceptibletodamageduetothe
tenuousoxygensupplyfromlackofdirectarterialflow.
After20minutes
After6hours
Afteraday
After37days
Etiology
Risk factors
Presentation
PathophysiologyofanMI
Permanentdamagetomyocytes.
CoagulationnecrosiswithinfluxofPMNs.
Totalcoagulationnecrosis.
Granulationtissuestartstoform.
Cardiogenicshockwithhypotension,jugularvenousdistention
(JVD),andS3gallop,andralesmaydevelopifmorethanhalfof
themyocardiumhasbeencompromised.
InferiorMIsmaypresentwithbradycardia.
MImaybeentirelysilentindiabetics,theelderly,patientswith
HTN,andinpostsurgicalpatients.
InferiorwallMI
AnteroseptalMI
LateralwallMI
PosteriorwallMI
TransmuralMI
Themostcommoncauseofaholosystolicmurmurfollowinga
myocardiacinfarctionisacuteventricularseptaldefectandmitral
regurgitation.FormaldiagnosisshouldbeconfirmedbyaTTE.
EKGFindings
STeinleadsII,III,andaVF
STeinleadsV1V3
STeinV4V6
STdinV1andV2
QwavesafteranSTelevationMI(STEMI)
Diagnosis
Treatment
CONGESTIVEHEARTFAILURE
CPK
TnT,TnI
CKMB
DiagnosiswithCardiacEnzymes
Oneoftheearliestmarkerswithinonehourofexperiencingan
MI;Notveryspecific.
Occurswithin6hours.Notspecific.
Risewithin34hours,remainelevatedforuptoaweek,andare
highlysensitivemarkers.
Highlyspecificandsensitivemarkerforcardiacdamage thatis
positivewithin46hoursandremainssoforatleast1or2days.
TheCKMBfractionrisesonlywithmyocardialnecrosis,butCK
itselfmayrisewithgeneralcardiactraumaormanipulationwith
resuscitationprocedures.
Aspirin,oritsalternative,clopidogrel,areadministered,
immediatelygivenevidencethataspirincanreducemortalityfrom
MIbyover25%throughdecreasedclotformation.
Betablockershavealsobeenshowntodecreasemortalityby
limitingtheextentofdamage;metoprololistypicallygiventhree
timesevery5minutesandstoppediftheheartratefallsbelow60.
IfgiveninthefirstfewhoursafteranMI,thrombolytictherapyhas
alsobeenshowntodecreasemortalitybybreakingupclots;agents
includestreptokinaseandalteplase.
Heparinisgiventopreventthefurtherdevelopmentofclots.
Oxygenisgiventoincreaseoxygensaturationandforpatient
comfort.
Nitroglycerinisalsogiventorelievesymptomsbydilatingcoronary
arteriesandreducingcardiacoxygendemandthroughdecreased
preload.
Morphineisgiventoreducepainandanxiety,andtherebyfurther
decreaseoxygendemandbythedamagedmyocardium.
RightsidedCHF(RHF)leadstooverflowinthesystemic
circulationleadingtosystemicvenouscongestion.
LeftsidedCHF(LHF)leadstopulmonarysymptomsdueto
pulmonaryvenouscongestion.
ThemostcommoncauseofrightsidedCHFisleftsidedCHF.
EF =
Myoglobin
MyocardialInfarction(MI)
Development ofmyocardialnecrosisfollowingprolonged
ischemia.Suddenruptureofaplaque,anembolismfroma
secondarysource,shock,andcoronaryvasospasm.
Malesover55yearsofage,postmenopausal women, smokers,
HTN,hyperlipidemia,DM,andatherosclerosis.
Severe,retrosternalchestpainformorethan20minutes.
Leadstonauseaandvomiting,diaphoresis,weakness,and
anxiety.SOB,tachycardia.Cardiogenicshockwith
hypotension,JVD.Arrhythmiasandseptalrupturemayoccur.
InferiorMIsmaypresentwithbradycardia.Typically,anMI
willpresentaspainthatradiatestotheleftarmorshoulder,or
thejaw.Itismostlikelytooccurintheearlywakinghours.MI
maybeentirelysilentindiabetics,theelderly,patientswith
HTN,andinpostsurgicalpatients.Psychologicalsymptoms
includeafeelingofimpendingdoom.
EKG, myoglobin, CPK,TnT,TnI,CK,CKMB, LDH.
Aspirin orclopidogrel,Betablockers,metoprolol,
streptokinaseandalteplase,heparinoxygen,nitroglycerin,
morphine,PTCA,angioplasty,patientcounseling,pacemaker.
Etiology
Diastolic
dysfunction
Systolic
dysfunction
Pericarditis
Cardiovascular
compensation
Renal
compensation
Presentation
( EDV ESV )
SV
=
EDV
EDV
CO = HR SV
CongestiveHeartFailure(CHF)
MostcommoncauseofCHFisfollowingMI andthe
resultantischemicchanges.Cardiomyopathy,sarcoidosisor
hemochromatosis,pulmonaryHTNoraorticregurgitation.
Structuralabnormalities,congenitalheartdisease,CAD,
constrictivepericarditis,RCM,
DecreasedCO duetoelevatedSBPwithnormalEF.
DecreaseinEFduetodecreasedSVleadstoadecreasein
COintheabsenceofanychangeinHR
DecreasedcontractilityleadingtodecreasedEF.
DecreasedEFleadstodecreasedSV,whichintheabsence
ofchangestoHR,leadstodecreasedCO.
Dresslersyndrome.
DecreasesinSV causesincreaseintheHR.Theheart
increasesstretch,leadingtoventriculardilationand
therebyincreasingEDV.Myocardialhypertrophyresults
fromtheincreasedpressures,andaftersometime,the
heartdecompensates,andanyfurtherdilationonlyleadsto
worseningCHF.Asystemiccompensationcanalsooccurby
wayofdecreasedactivationofstretchreceptorsinthe
heartandcarotidartery,leadingtoincreasedsystemic
vascularresistance,increasedafterload,anddecreasedSV.
RAAsystem isactivated,leadingtovasoconstriction&
retentionofsodiumchloride&water.Increasedvolume
loadleadstoanincreaseinpreload,whichworsensthe
congestionastheheartisunabletocompensateforthe
increasedstretchbyincreasingitscontractility.
RHF hepatic congestion,hepatomegaly,RUQpain,JVD,
ascites,peripheraledema,cyanosis,HJR.
LHFDOE,PND,orthopnea,rales,nocturia,diaphoresis,an
S3gallop,andtachycardia
19
Diagnosis
correction canbeachieved.Diuretics, anticoagulation,

vasodilators,andreplacementofthevalve.
MITRALVALVEPROLAPSE
Etiology
Presentation
Diastolic
Systolic
TreatmentofDysfunctions
Surgery,diuretics,betablockersandcalciumchannelblockers,
decreasepreloadthroughsodiumrestriction,furosemidediuresis,
andvenodilationwithnitrates,ACEinhibitors.
Decreasedcardiacoxygendemand,improvingcardiacfunction,
andreducingvascularload.Decreasesaltintake,anddecreasing
majorstressors.Diureticsandvasodilators,betablockers.
Spironolactone,digoxin,dobutamine,andamrinone,andARBs.
Surgeryandhearttransplantarethefinaloptions.
Presentation
Diagnosis
Treatment
PulmonaryEdema(APE)
CommonlytheresultofCHF,arrhythmia,MI,severeHTN, PE,
ARDS,uremia,shock,anaphylaxis,anddrugreactions.
Tachypnea,pinksputumdischargedwithcough, cyanosis,
dyspnea,rales,ronchi,wheezing,andcrackles.
CXRindicatingKerleyBlines,pulmonaryeffusion,
cardiomegaly.ABG.
Nitroglycerin,PEEP,morphine,aspirin,diuretics, amrinone,
dobutamine,dopamine.
VALVULARHEARTDISEASE
Treatment
AORTICSTENOSIS
Etiology
PULMONARYEDEMA
Etiology
Diagnosis
Presentation
Diagnosis
Treatment
MITRALSTENOSIS
Etiology
Presentation
Diagnosis
Treatment
MitralStenosis(MS)
DevelopmentofanarrowingbetweenLAandLV.
Abnormalitiesofthevalvularleafletsarethetypicalcause,and
mostcasesaresecondarytoRFandsubsequentRHD.
Onsetofcough,DOE,hemoptysis,RHFwithventricular failure,
hoarseness,andthromboembolicphenomenoninthesystemic
vasculature.Orthopnea,PND,fatigue,hepatomegaly,ascites,
andperipheraledemaareothersymptomsandareespecially
likelyinthelaterstages.
Apicaldiastolicmurmur.CXR,alargepulmonaryartery and
pulmonaryHTN.EKGtypicallyindicatesRVH,atrialfibrillation,
andLAH.Echocardiographydemonstratesthickenedmitral
valveleafletsandLAH.
Prophylaxisforendocarditis,controllinganyarrhythmiathatis
present,beginninganticoagulationtherapy,andconsidering
balloonvalvuloplastyoropensurgicalrepair.
MITRALREGURGITATION
Etiology
Presentation
Diagnosis
Treatment
MitralRegurgitation(MR)
Ischemicchangesleadingtodysfunctionofthepapillary
muscles,suddenruptureofthechordaetendineae,damage
secondarytoRHD,progressivechangesfromMVP,
endocarditis,HCM,congenitaldefects,andsevereLVdilation.
Developmentofthromboemboli,dyspnea,fatigue &
weakness,orthopnea,PND,andRHFwithpulmonaryHTN.
Presenceofphysicalsymptoms,LAHonCXRandEKG, and
valvulardysfunctiononechocardiogram.LAoverloadis
obviousoncatheterization.
Medicaltreatmentistheonlyoptionavailableuntilsurgical
MitralValveProlapse(MVP)
MostcommonlyseeninMarfandisease andotherconnective
tissuediseases.RHD,IHD,andASD.MVPisacongenitalvalve
defectthatleadstomildregurgitation.
Typicallyasymptomatic,butmaypresentwithatypical chest
pain,amidsystolicclick,lightheadedness,syncope,
palpitations,fatigue,SOB,andthedevelopmentof
arrhythmias.
Echocardiography demonstratesdisplacement ofthebicuspid
valveleafletsandsubsequentmeetingatsomepointdistalto
thevalveopening.
Chestpain andarrhythmiasarecontrolledwithbetablockers,
andprophylaxisforendocarditisisstartedinallindividuals.
Closeobservationisrequiredtoavoidcomplications.
AorticStenosis(AS)
Acongenitaldisorder.Abnormalcalcification ofthevalve
leafletsinanotherwisenormaladult,presenceofabicuspid
valvethatpredisposestofibrosisandcalcification,or
secondarytoRHD.
S4gallop. Syncope&angina(worsewithexertion),andDOE,
CHF.SymptomsoccurlateinthecourseofAS
Physicalsigns ofanaorticejectionclick,harshSEM leadingtoa
palpablethrill,narrowpulsepressure,andacarotidthrill.On
echocardiography,apulsustardusetparvus.EKGchanges
indicateLVstain,andechocardiographydemonstratesthe
damagedaorticvalve.CXRcandetectcalcificationofthe
aorticvalve,alongwithcardiomegalyandpulmonaryHTN.
Endocarditis prophylaxis.PriortoGIorGUprocedures,
ampicillinandgentamicinshouldbegivenSurgeryviaballoon
valvuloplastytocorrecttheaorticvalvedefectisdonewith
severesymptoms,buttherateofrestenosisisveryhighand
mayeventuallyrequirereplacementoftheentirevalve.
Patientsshouldbeadvisedtoavoidexercise.
AORTICREGURGITATION
Etiology
Presentation
Diagnosis
Treatment
Aortic Regurgitation(AR)
CommonlytheresultofRHD,alsooccursininfective
endocarditis,indilationsoftheaorticrootduetoHTN,CVD,or
Marfansyndrome,inproximaldissectionsoftheaorticroot,
syphilis,HTN,CVD,pregnancy,andTurnersyndrome,andin
conditionsthataffecttheascendingaorta,ankylosing
spondylitis,andtrauma.
Dyspnea, orthopnea,andPND,angina, awidepulsepressure,
bounding,bisferiens,andrapidfemoralpulses.Duroziezsign;
Hillsign;Quincke;DeMussetsign.
Physicalexam inwhichablowingdiastolicmurmur is
worsenedbyleaningthepatientforward.EKGdemonstrates
LVH.Echocardiographydemonstratesregurgitation.CXR
demonstratesLVHandaorticdilation.
Prophylaxis againstendocarditis,treatingLV failure with
preloadandafterloadreduction,digitalisforpositiveinotropy,
andvalvereplacementwithcardiacdecompensation.
TRICUSPIDSTENOSIS
Etiology
Diagnosis
TricuspidStenosis(TS)
CommonlysecondarytoRHD,carcinoid, andcongenital
malformations.ItpresentswithJVD,peripheraledema,and
signsofhepaticcongestionleadingtohepatomegaly,ascites,and
jaundice.
Lowpitched,rumbling,diastolicmurmur. Athrillispalpableat
theLLSB,andthereisaRVthrustpresent..TSisdistinguished
BothRHF&LHFankleedema,whitesputum withflecksof
blood,&cardiomegaly.Dyspnea,suddencomplaintsof
SOB.
CXRdemonstratingcardiomegaly,congestion ofpulmonary
vasculature,KerleyBlines,pulmonaryeffusion.
Echocardiography,EFcanalsobeevaluatedusingaMUGA
scan.AUAwilldemonstrateoliguria,increasedSG,hyaline
casts,andproteinuria.Diastolicdysfunctionwillpresent
withnormalEFanddecreasedCO;systolicdysfunctionwill
presentwithdecreasedEFanddecreasedCO.SBPisoften
increasedindiastolicdysfunction.
20
Treatment
fromMSinthatTSworsenswithinspiration.
Treatmentrequiressurgicalrepair.
TRICUSPIDREGURGITATION
Etiology
Diagnosis
Treatment
ATRIOVENTRICULAR(AV)BLOCK
AtrioventricularBlock
Etiology
TricuspidRegurgitation
TheresultofLHFormitralvalvedeficitsleadingtoincreased
pressurefromthepulmonaryartery.StretchingoftheRV.
Presentswithsignsandsymptomsoflivercongestion,JVD,&
RHF.
Holosystolic,blowingmurmurloudestalongtheLLSB. Worsens
withinspiration.EKGsignsindicateRVH,andatrialfibrillation.
TreatasLHF.Preloadreduction,surgery,endocarditis
prophylaxis.
ARRHYTHMIA
Presentation
SINUSBRADYCARDIA
SinusBradycardia
Etiology&
presentation
Treatment
Itiscausedbyexcessivevagaltone,whichinturnmaybedue
tovasovagalsyncope,MI,carotidsinuspressure,vomiting,
parasympatheticagonists,cardiacglycosides,andValsalva
maneuvers.Overmedicationwithbetablockersandcalcium
channelblockersalsocontribute.IncreasedICP,
hypothyroidism,andhypothermiaareothercauses.Itis
typicallyasymptomatic.
Symptomaticpatientsaretypicallytreatedwithatropine.
Continuingbradycardiawithsymptomsrequirestheuseofa
pacemaker.Adopaminedripmayalsobeusedinan
emergentsituation.
Treatment
VENTRICULARARRHYTHMIAS
VentricularArrhythmias
Etiology
Presentation
SINUSTACHYCARDIA
SinusTachycardia
Etiology
Treatment
Commonlyduetofever,lowBP,stress,medications, and
hyperthyroidism.Mayoccurforashortperiodoftimefollowing
cessationofbetablockers.
Carotidsinusmassageandincreasingvagaltone.
Treatment
PAROXYSMALATRIALTACHYCARDIA(PAT)
ParoxysmalAtrialTachycardia
Etiology
Treatment
PrematuresupraventricularbeatleadingtoanAVnodalreentry
rhythmwitharategreaterthan130BPM.
Increasevagaltone,calciumchannelblockersoradenosine,
betablockers,andcardioversion.
Etiology
Treatment
ItiscommonlytheresultofCOPD,PE,MVP,ETOH,and
thyrotoxicosis.
Cardioversion,calciumchannelblockers,anddigoxin.
TorsadedePointes
Etiology
Diagnosis/
treatment
Treatment
ATRIALFIBRILLATION
AtrialFibrillation
Etiology
Diagnosis
Treatment
Resultofchaoticelectricalactivitythroughtheconduction
system.Commonlyinpatientswithdilatedatria,CHF,valvular
heartdisease,elderlypatients,CAD,cardiomyopathy,ETOH
abuse,sepsis,RHD,andthyrotoxicosis.
Presentswithpalpitations,missedheartbeats,fatigue, chest
pain,andTIAs,irregularlyirregularpulse,andnondistinctP
wavesonEKG.
Warfarin.PatientswithaHRgreaterthan100BPM mayreceive
IVbetablockersorcalciumchannelblockers,digoxin,and
cardioversion.Unstablepatientsreceivecardioversionfollowed
bymaintenancetherapy.
VT,VF, WPW, andTorsadedePointes.VTiscommonin

patientswithMI,cardiomyopathy,metabolicchanges,and
digoxintoxicity.WPWandantiarrhythmicagentscanalsolead
toVT.VFistheendresultofachaoticelectricalactivitywithin
theventricles.
Hypotension,CHF,syncope,andcardiac failure. SBP varies
overtime,andextraheartsoundsmaybepresent.Cannon
wavesmaybepresentintheJVP.Thereisalsowidesplitting
ofS1andS2.VFpresentswithsyncopeandleadstodeathif
noemergentinterventionsaretaken.
Increasingvoltagecardioversion,followedbyepinephrine,and
repeatedcardioversion.Amiodarone,lidocaine,magnesium,
andprocainamidearegivenwithcardioversionrepeated
betweeneachmedicationadministration.Ifsuccessful,
maintenancetherapyincludespacemakerimplantation,an
ICD,andablationofanybypasstracts.
TORSADEDEPOINTES
ATRIALFLUTTER
AtrialFlutter
Firstdegreeheartblock:CommonlyduetoAVconduction
systemdegenerationwithaging,excessivevagaltone,
inflammation,ischemia,anddigoxintoxicity.
Seconddegree:isdividedintoMobitzIandMobitzII.Mobitz
IistypicallyduetoAVnodalblockinconduction,andthismay
occurduetopoorperfusion.MobitzIIsiteisusually
infranodal.
Thirddegree:TypicallyattributedtoLenegredisease.Other
causesincludeinferiororposteriorMI,infection,
inflammation,digoxintoxicity,andankylosingspondylitis.
HLAB27islinkedwiththedevelopmentofcompleteheart
block.
Firstdegree andseconddegreeheartblocks aretypically
asymptomatic.Thirddegreeheartblockmaypresentwith
intermittentCHF,transientventriculararrhythmiasleadingto
circulatoryfailure,andbradycardiawhichcanworsenCHF.
Firstdegree heartblockistypicallynottreated.Mobitz I is
treatedwithatropineandpacing.MobitzIItypicallyrequiresa
pacemaker.Completeheartblockrequiresepinephrineor
isoproterenol,thenmaintenancewithapacemaker.
Causedbyhypokalemia,hypomagnesemia, TCAs,
procainamide,disopyramide,psychotropicagents,CVA,
congenitalQTsyndrome,quinidine,bradycardia,complete
heartblock,&idiopathiccauses.
Syncope whichmayworsenintoventricular fibrillation. Itmay
alsobeinitiatedbysuddenauditorystimuli.LongQT
syndromepresentswithrecurrentlightheadednessand
syncope.
Treattheunderlyingetiology,usemagnesium tostabilizethe
heartrhythm,andusingbetablockersformaintenance.
Pacingmaybenecessary.
EISENMENGERSYNDROME
OccurslaterinlifewithlongtermRVHthateventuallyreversesa
LRshuntandmakesitRL.
OccurswithPHTNandrequiresheartlungtransplant.
Shuntreversalleadstocyanosis,hypoxia,clubbing,and
polycythemia.
21
DILATEDCARDIOMYOPATHY
Diagnosis
DCMisdistinguishedwithdecreasedCOduetodecreasedSVand
EF,anincreaseinventricularfillingpressure,increasein
ventricularvolume,anddecreasedcompliance.
Thedefinitivetreatmentishearttransplant.Allpatientsrequire
lifelonganticoagulation.
Etiology
Diagnosis
Treatment
DilatedCardiomyopathy(DCM)
Viralinfections,alcoholabuse,cocaineabuse,heavymetal
poisoning,doxorubicinpoisoning,endocrinedisease,
pheochromocytoma,CTD,GSD,DMD,pregnancy,metabolic
disorders,inheriteddisorders,andgeneticpredilections.
Presentsasheartfailure&angina.Diagnosis:CXR thatindicates
cardiomegalyandpulmonaryedema,EKGthatindicatesLVH
withLBBBorRVHwithRBBB,echocardiographythat
demonstratesadilatedventricle,wallmotionabnormalities,and
valveregurgitation.Physicalexam:oftenyieldsmurmur,rales,
andregurgitationmurmurs.
Preload,afterload,andvolumereductionthroughdiuretics,
vasodilators,andpositiveinotropicagents.Pacemaker(with
arrhythmia).Hearttransplant.Lifelonganticoagulationtherapy.
HYPERTROPHICCARDIOMYOPATHY
CausesofHCMincludegenerallyidiopathicconditions(abouthalf
ofallcases),andgeneticcauses(theremainderofallcases).The
geneticdefectsaretypicallyonchromosome14withthefamilial
form,andautosomaldominant(AD)withvariablepenetrance.
HCMleadstodecreasedventricularcompliancebutanincrease
inCO,astheheartfunctionmovesalongtheFrankStarlingcurve
duetovolumechanges.
Diastolicdysfunctionmayoccurastheheartisunabletorelax.
HCMisdistinguishedbynormalCOduetoincreasedSVandEF,
anincreaseinEDP,andadecreaseinchambersize.
HCMpresentswithsyncopeandangina,butmayproceed
directlytosuddencardiacdeath.
Hearttransplantationisrequiredinmostcases.
DopaminewillworsenoutflowobstructioninHCM.
Etiology
Presentation
Diagnosis
Treatment
HypertrophicCardiomyopathy(HCM)
Idiopathicconditions&geneticcauses.Thegeneticdefects
aretypicallyonchromosome14,andADwithvariable
penetrance.
Syncope&angina,butmayproceeddirectlytosuddencardiac
death.
EKGindicatesPVCs,atrialfibrillation,Q,ST,andTwave
changes.Echocardiographyisdefinitivewithseptal
hypertrophy,LVH,reducedLVEDV,andmidsystolicaortic
valveclosure.ACXRindicatesLVHwithdilatedLA.
Arrhythmiasuppressants,betablockers,septalmyomectomy,
replacementofthemitralvalveandavoidingexercise.Heart
transplantationisrequiredinmostcases.
ENDOCARDIALDISEASE
Etiology
Presentation
Endocarditis
Resultofaninfectiveprocessleadingtovegetation onthe
leaflets.BothABEandSBEcanoccur.Rare,butisincreasingin
incidenceinchildrenwithcongenitalheartdefects.
Fever,anorexia,headache,arthralgia,andanewheart
murmur.ABEinparticularpresentswithacuteonsetof
infection,anewmurmur,andinfectionsinotherpartsofthe
bodyfrombacteremialeadingtomeningitisandpneumonia.
SBEpresentswithgradualonsetofinfectionandhas
Treatment
splenomegaly.Patientswitharightsidedendocarditis should
besuspectedofIVdrugabuse,andsepticPEmaybetheresult
fromthetricuspidinfestation.
ThreepositiveBCxarerequiredfordiagnosisMultiple
petechiaeonthechestandmucousmembranes,Oslernodes,
Janewaylesions,splinterhemorrhages,Rothspots,and
hemorrhage.Vegetationonvalveleafletsarepathognomonic,
TEE.ElevationsinESR,CRP,andWBCsarecommon,andthe
UAmayhavehematuria.CXRmayindicateawaterbottle
configuration.
Prophylacticantibiotictreatmentpriortomajorprocedures.
Followinginfection,treatmentwithceftriaxoneforonemonth
isrequiredforstreptococcusinfectionandoxacillinfora
monthwithstaphylococcusinfection.Vancomycinisusedfor
resistantstrains.
TRAUMA
PERICARDIALTAMPONADE
Pericardialtamponadeleadstodecreasedventricularvolume
duetoincreasedexternalcardiacpressurefromthepericardial
effusion.ThedecreasedfillingleadstodecreasedSVandCO,
withasubsequentdropinSBP.Failureintamponadeoccurs
fromimpaireddiastolicfilling.
PericardialtamponadepresentswithBeckstriad,whichincludes
JVD,muffledheartsounds,andhypotension.
Pericardiocentesisandsurgicaldrainagearethetreatmentsof
choice,andmustbedoneonanemergentbasis.
AIREMBOLISM
Theinitialtreatmentofanairembolusisplacingthepatientin
Trendelenburgwiththeleftsidedown.Thepurposeofthis
maneuveristohavetheairembolismfloatintherightventricle
andslowlybedissolvedbythepassingblood.
CANCER
MYXOMA
Leftatrialballvalveobstructiontumor
Leadstoepisodicobstruction
Mostcommonprimarytumoroftheheartinadults
RHABDOMYOMA
Mostcommonprimarytumoroftheheartinchildren
VASCULARSURGERY
ARTERIAL
CAROTID
Thepresenceofgreaterthan50%internalcarotidarterystenosis
andthepresenceofamaurosisfugaxisanacuteindicationfor
operation.
Thepresenceofacarotidpseudoaneurysmisanindicationfor
operativemanagement.
ThepresenceofretrogradeophthalmicarteryflowindicatesICA
stenosis.
CARDIOMYOPATHY
22
THORACICOUTLETSYNDROME
ThoracicoutletsyndromehasaT8C1distribution.Anteriorscale
musclereleaseleadstoresolutionofulnarnervesymptomsand
relievessupraclavicularpain.
Themostcommonpresentationofthoracicoutletsyndromeis
neurologic.
SUBCLAVIANSTEALSYNDROME
Thepresenceofsubclavianveinstenosisinpatientsthatcannot
berelievedwithphysicaltherapyisanindicationforresectionof
thefirstrib.
ARTERIOVENOUSFISTULAS
Largearteriovenousfistulasleadtoadecreaseinperipheral
vascularresistance.
AORTA
ABDOMINALAORTICANEURYSM
ExpansionoftheAAAover5cmheraldsasignificantriskof
rupture,andthusaveryhighmorbidityandmortality.
Atrueaneurysmhasadefectinallthreelayersoftheaorticwall,
whileapseudoaneurysmaffectsonlythetunicaintimaand
media.
DiagnosisofAAAisbyUS,butMRIwithIVcontrastispreferred
todemonstratetheprecisedimensionsofthemassandwhether
aleakispresent.Angiogramwaspreviouslythegoldstandard.
AbdominalAorticAneurysm(AAA)
Etiology
Presentation
Diagnosis
Treatment
Dilationoftheabdominalaortasecondarytoatherosclerosis.
OthercausesincludecysticmedialnecrosisinCTD,syphilis,
fungalinfections,aortitis,andtrauma.
Abdominalpainorbackpainandapalpable,pulsatilemass in
theabdomen.SyncopeissometimespresentaswellasHTN.
US,butMRIwithIVcontrastispreferred.
TwolargeboreIVaccesspointsandaTxC.Patients inwhom
rupturehasoccurredshouldreceiveemergentlaparotomyand
surgicalcorrection.Unstablepatientswithahighclinical
suspicionofAAAshouldbetakenimmediatelytotheOR.
AORTICDISSECTION
AorticdissectionisattributabletoHTN,congenitalheartdefects,
CTD,syphilis,pregnancy,coarctationoftheaorta(asinTurner
syndrome),abuseofcocaine,andtrauma.
Aorticdissectionpresentsasatearingsensationwithsevere
chestpainthatradiatestotheback.HTNistypicallypresent,
discordantpulsesbetweenextremitiescanbemeasured,andAR
istypicallypresent.
AorticDissection
Etiology
Classifications
DeBakey
Stanford
Presentation
Diagnosis
AttributabletoHTN,congenitalheartdefects,CTD, syphilis
pregnancy,coarctationoftheaorta,cocaineabuse,&
trauma.
TypeIinvolvestheascendingaortaandpartofthedistal
aorta
TypeIIinvolvesonlytheascendingaorta
TypeIIIinvolvesonlythedescendingaorta.
TypeAiftheascendingaortaisaffected
TypeBifthedescendingaortaisaffected.
Atearingsensationwithseverechestpainthatradiatesto
theback.HTN,discordantpulses,andAR.
CXRindicateslossoftheaorticknob&awidened
Treatment
mediastinum, CT withIVcontrastorTEE thatdemonstrates

anintimalflapwithextravasationofblood,andangiogram.
BPcontrol,immediatesurgicalrepairfortypeA/typeII
dissections,andmedicalmanagementfortypeB/typeIII
dissections.
MESENTERICARTERYISCHEMIA
MesentericischemiaisthecompromiseofGIbloodflow
andiscausedbyCADleadingtoceliacartery,superior
mesentericartery(SMA)orinferiormesentericartery
(IMA)obstruction.
Atrialfibrillationleadingtothromboembolicphenomenon,
lowflowstatescontributingtohemostasis,mesenteric
thrombi,andhypercoagulablestatesalsocontributeto
mesentericischemia.
Mesentericischemiapresentswithsevereabdominalpain
thatworsenswithingestion.Latesignsincludemetabolic
lacticacidosiswithBRBPR.Diagnosisisconfirmedby
angiography,butaspiralCTwithcontrastcanalsobe
used.
MesentericIschemia
Etiology
Presentation
Diagnosis
Treatment
Itistypicallycaused byCADleadingtoceliac artery,SMA or

IMAobstruction.Atrialfibrillation,lowflowstates,mesenteric
thrombi,&hypercoagulablestatesalsocontributeto
mesentericischemia.
Severeabdominalpainthatworsenswithingestion.Latesigns
includemetaboliclacticacidosiswithBRBPR.
Angiography,butaspiralCTwithcontrastcanalsobeused.
Surgeryisrequired.Supportivelywithtissueperfusion.
FEMORAL
Thepresenceofacoldlegfollowinganaortobifemoralbypassis
anindicationfortakebacktotheoperatingroomforre
explorationofthegroin.
Demarcationoffindingsatthemidthighindicatecompromiseof
theexternaliliacartery.
TheconversionofDopplerfindingsfrombiphasictomonophasic
signalsistheearliestsignofathrombosedfemoralpopliteal
bypass.
Thepresenceofreversedvenousflowandswellingoftheleg
withnegativeDopplerfindingsindicatespossibleobstructionof
lymphaticchannels.
POPLITEAL
Themostcommoncomplicationofapoplitealaneurysmisdistal
embolization.
Poplitealaneurysmsgreaterthan2cmrequireoperative
resection.
AVASCULARNECROSIS
AvascularNecrosis(AVN)
Etiology
Presentation
Diagnosis
Ischemia duetoWristfracturesintheanatomicalsnuffbox
andfracturesoftheheadofthefemur.Useofsteroids,
radiationtherapy,alcoholism,sicklecellanemia,&Gaucher
disease.
AVN ofthehip presentsasreferredpain totheknee andis
worsenedwithinternalrotationofthehip.
MRI andbone scans.
23
Surgery,replacementofjoint.
Thefindingofavascularnecrosisinawristboneismostlikelyto
affectthescaphoid.
Treatment
CLAUDICATION
Thepresenceofstableclaudicationwithnotissuelossistreated
withreassuranceforthepatientandexercise.
UPPERGASTROINTESTINALBLEEDING
Severebleedingleadstomelenawithblack,tarlikestools,
hypotension,andtachycardiafromthedecreaseinblood
volume.
Verybriskbleedsmayleadtohypovolemicshockandbrightred
bloodperrectum(BRBPR).
Orthostatichypotensionindicatesthatmorethan20%ofthe
intravascularvolumehasbeenlostduetohemorrhage.
DiagnosisofupperGIbleedsismadebydirectlyvisualizingthe
bloodviaanasogastric(NG)lavage.
Arectalexamwithhemocculttestingisalwaysperformed.
Activebleedingisoftenidentifiedusingtaggedredbloodcells
(RBCs)orarteriography.
EndoscopyisthestandardofcareinallupperGIbleeds.
Totalbowelimmobilizationtominimizebloodflowtothe
gastrointestinalsystemmayberequiredthroughtheuseof
somatostatin.
Finally,theriskofrecurrentbleedsduetoPUDmaybereduced
throughtheuseofprotonpumpinhibitorssuchasomeprazole.
UpperGastrointestinalBleeding
Pathophysiology
Presentation
Diagnosis
Treatment
BleedproximaltotheligamentofTreitz(epistaxis,
esophagealvarices,ruptures,PUD,gastricerosion,AVMs,
tumors).
Minorbleedingasymptomatic,hematemesis (brightredor
coffeeground);Severebleeds(tarlikestools,hypotension,
tachycardia,shock,BRBPR,elevatedBUN.
VisualizedbloodviaNGlavage,rectalexam, FBOT,tagged
RBCs,CBC,endoscopy.
EGDwithelectrocoagulation,sclerotherapy, ligationof
varices,tamponade,Ivs.
LOWERGASTROINTESTINALBLEEDING
ThemostcommoncauseoflowerGIbleedintheelderlyisdueto
diverticulosis,allGIbleedsinthispopulationshouldbesuspected
asheraldinggastrointestinalcanceruntilthisetiologyisruled
out.
DiagnosisoflowerGIbleedsismadeafterrulingoutcausesof
upperGIbleed(throughNGlavage).
Adigitalrectalexamismandatorytotestforoccultbleeding,
followedbyacolonoscopyinanattempttodirectlyvisualizeand
potentiallycorrectobvioussourcesofbleeding.
AsperupperGIbleeds,ataggedRBCscanandarteriographyare
oftendone.
ThemostcommoncauseofalowerGIbleedisanupperGIbleed.
Achildwithbloodydiarrheashouldbeimagedusingabarium
enemafirst.
LowerGastrointestinalBleeding
Pathophysiology
Presentation
Diagnosis
Occurdistaltotheduodenalsuspensoryligament.Maybe
diverticulosis(elderly),hemorrhoids(young),cancer,
inflammatoryboweldisease,AVM,Meckel diverticulum.
BRBPR.
RuleoutupperGIbleed.Digitalrectalexam, colonoscopy,
taggedRBCs,CBC.
IVs,colectomy.
ANGIOFIBROMA
Thefindingofaspindlecellcancerduringavascularintervention
requiresechocardiographytoruleoutthepresenceofatrial
myxoma.
LYMPHATIC
Organsthatdonothavedrainageoflymphincludemuscleand
brain.
Lymphedemacanbeimagedusinglymphoscintography.
LymphedemafindingsincludethickeningoftheskinonMRI.
Thepresenceofpittingedemaistypicallytreatedwithpressure
stockings.
GASTROINTESTINALSURGERY
GENERALCONCEPTS
PEYERSPATCHES
PeyerspatchesarethelocalsourceofIgAproduction.Theyare
animportantpartofmaintainingimmunityandareareasonthat
manysurgeonswillbegintofeedpatients.
Somestudieshaveshownthatthishelpstopromoteanoverall
immunesystemresponseandmayplayaroleinpromoting
resistancetooverallinfection.
DUODENUM
TheSMAcrossesatthejunctionofD3andD4.
VASCULAR
Thebloodsupplytothegastricpouchfollowing
esophagogastrectomyiscarriedbytherightgastroepiploic
artery.
SALIVA
Saliva,gastricacid,andsmallintestinefluidhaveveryhighlevels
ofpotassium.Overall,salivahasthehighestamountof
potassiumat1170mg,followedbygastricacidat1120mg.
MUCUS
Epithelialcellslocatedinthegastricmucosasecretemucus.This
secretion,alongwiththesecretionofbicarbonate,areinhibited
byaspirin.
GASTRIN
Thereleaseofgastrinisinhibitedbyantralacidificationaspartof
afeedbackreaction.
SECRETIN
Gastrinsecretionbyagastrinomawillincreasewiththe
administrationofsecretin.
Treatment
24
MOTILIN
Motilinincreasesthemigratingmyoelectriccomplex,therefore
stimulatinggastrointestinalmotility.
Motilinalsostimulatestheproductionofpepsin.
AlkalinepHintheduodenumappearstostimulateitsrelease.At
lowpH,motilininhibitsgastricmotoractivity;whileathighpH
motilinstimulatesgastricmotoractivity.
CCK
CCKisapeptidehormonethatstimulatesfatandprotein
digestion.ItisproducedbytheIcellsoftheduodenum,andalso
leadstothesecretionofdigestiveenzymesbythepancreasand
bilefromthegallbladder.
CCKsuppresseshunger,andithasrecentlybeenimplicatedas
playingasignificantroleindrugtolerancetoopioids.
SUBSTANCEP
SubstancePhasbeenimplicatedinplayingaroleininhibiting
smallbowelmotility.
ACIDPRODUCTION
Gastricacidisproducedbytheparietalcellsinthestomach.
INTRINSICFACTOR
Parietalcellsproduceintrinsicfactor,whichplaysarolein
bindingtovitaminB12andpromotingitsabsorptionintheileum.
IGAPRODUCTION
IgAisanantibodyfoundinmucoussecretionssuchastears,
saliva,intestinaljuice,vaginalfluid,prostatesecretions,andthe
respiratoryepithelium.
PANCREATICENZYMES
Centroacinarcellsofthepancreassecretebicarbonate,andare
stimulatedbysecretin.
Basophiliccellsoftheexocrinepancreassecretepancreatic
amylase,lipase,trypsinogen,chymotrypsinogen,andother
digestiveenzymes.ThesecellsarestimulatedbyCCK.
Trypsinogenisactivatedbyenterokinase,anenzymefoundinthe
intestinalbrushborder.
Trypsinistheactiveformoftrypsinogen,andactivates
pancreaticenzymesintheduodenum.
Highflowpancreaticductsecretionstendtobelowinchloride,
dueprimarilytothestimulationbysecretin.
FATABSORPTION
Nutrientsandfluidareabsorbedbytheascendingcolon.
Coloniccellsreceivetheirenergyfromshortchangefreefatty
acids,typicallybutyrateacids.
Fat,water,sodium,folicacid,proteins,andcalciumareabsorbed
bythejejunum.
Micellesarecomposedoflecithinandcholesterol.
LipidsarenotdirectlyconvertedtocarbohydratesasacetylCoA
cannotbereversedtocreatepyruvate.
Steatorrheafollowingilealresectionistypicallyduetothelossof
bilesaltsfromchronicloss.Bilesaltsareabsorbedintheileum.
STOMACH/DUODENUM
GASTRICOUTLETOBSTRUCTION
Gastricoutletobstructionistheresultofpyloricobstruction,
leadingtoprojectilebutnonbiliousvomiting.
AdoublebubblesignonCTscanshouldelicita
duodenojejunostomy.
Anincompletelyreducedintussusceptioninachildrequires
operativemanagement.
Atresiaofthejejunumandileummaybeduetoadefectinthe
vasculaturetotheuterus.
GASTROPARESIS
Gastroparesis
Pathophysiology
Presentation
Diagnosis
Treatment
Delayinnormalemptyingrateofstomach dueto
degenerationofstomachnerves.
Earlysatiety,nausea,vomiting.
Radiolabeledstudiesthatgaugedigestivefunction ofthe
GItract.
Metoclopramide.
Ahighlyselectivevagotomyisperformedbytransectionofthe
criminalnerveofGrassi.
Delayedgastricemptyingcanbearesultofdiabeticautonomic
neuropathy.
Theemptyingofliquidstypicallyincreasesfollowingvagotomy
duetothelossofreceptiverelaxation.
DUMPINGSYNDROME
DumpingSyndrome
Pathophysiology
Presentation
Treatment
OccursafterGIsurgery&PUDrepair.
Usuallyoccursaftereatingfattymeals. Dizziness, nausea,
vomiting,suddenexpulsionoffoodthroughGIsystem.
Decreasefluidintaketosmall,frequentamounts.Small
meals.Avoidfattyfoods,simplesugars.
ABilrothIIproceduredoesnotdelayemptying,whileaRouxen
Ygastricbypassdoes.
GASTRICULCERS
GastriculcerformationismostcommonlyassociatedwithH.
pyloriinfectionandoveruseofNSAIDsorsteroidalmedications.
Gastriculcersoccurduetoadiminishedprotectivebarrier
againststomachacid,includingathinnermucosalgeland
decreasedsecretionofbicarbonateintothemucosalgel.
Gastriculcerspresentwithasharp,burningpaininthe
epigastriumshortlyfollowingtheconsumptionoffood.Thelag
timeistypicallybetween1030minutes.
Nearlyonequarterofallindividualswithgastriculcerswill
experiencesignificanthemorrhaging.
Biopsyismandatoryforallendoscopalexplorationsofgastric
ulcerduetotheincreasedassociationofgastriculcerwith
stomachcancer.
Treatmentoptionsforgastriculcerprimarilyinvolvethe
eradicationofH.pylorithroughatripletherapy,including
bismuthsalts,metronidazole,andamoxicillin.
GastricPepticUlcer
Pathophysiology
Presentation
H.pylori ,overuseofNSAIDsandsteroids.
Sharp,burningpaininepigastriumshortlyaftereating.
Nausea,vomiting,anorexia.
25
Endoscopyandbiopsy, presenceofH.pylori.
Tripletherapy.Protonpumpinhibitors,antacids, H2
blockers.
GastriculcerdiseaseduetoH.pyloritypicallyisdiagnosedby
biopsy.Thesebiopsysamplescanbetakenrandomlythroughout
thecorpusandantrum.
Benigngastriculcerstendtobelocatedalongthegreater
curvature.
Ulcersmostlikelytobleedhaveavisiblevesselonly50%ofthe
time.
DUODENALULCERS
Duodenalulcersaredistinctfromgastriculcersinthattheyare
commonlyduetoincreasedgastricacidproduction.Combined
withtheinsulttotheprotectivemucosalbarrierfromH.pylori
infectionfoundinnearlyallcasesofduodenalulcers,thetwo
factorscombinetocauseepitheliumdestructionandsubsequent
ulcerformation.
90%ofpatientswithZEsyndromedevelopPUD.
Duodenalulcerstypicallybecomesymptomaticseveralhours
afteringestingameal.
DuodenalUlcerDisease
Pathophysiology
Presentation
Diagnosis
Treatment
Duetoincreasedacidproduction&H.pylori
Severeepigastricpainseveralhoursaftereating.
Endoscopy,history,physicalexam.TestforH.pylori
Tripletherapy,stopsmoking&alcoholconsumption,no
NSAIDsorsteroids,surgery.
CURLINGANDCUSHINGULCERS
CurlingandCushingUlcers
CurlingUlcers
CushingUlcers
Pepticulcersformedafterseverburninjury.
Pepticulcersformedafterseverebraindamage.
GASTRICVARICES
Gastricvaricesfollowingacutepancreatitisrequiresplenectomy
toavoidsplenicveinthrombosis.
BENIGNGASTRICTUMORS
VIPOMA
ThehighexcretionofVIPcanleadtosignificantchronicwatery
diarrhea,leadingtodehydration,hypokalemia,andachlorhydria
(WHDA:waterydiarrhea,hypokalemia,dehydration,and
achlorhydria).
VIPomacanbetreatedwithsomatostatin.
SEROTONINOMA
Aserotoninomaisasmallboweltumorthatcancauseflushing.It
isararepresentationofcarcinoid.
ZOLLINGERELLISONSYNDROME
ZollingerEllisonSyndrome
Pathophysiology
Presentation
Diagnosis
Treatment
Uncontrolledproductionofgastrin.Gastrinomas often
foundinheadofpancreas.
GastrinomasoftenwithPUD,diarrhea,steatorrhea,
malabsorptionsymptoms.
Fastingbloodtestsrevealingelevatedgastrin titers,
secretinstimulationtest.
Surgicalresectionofaffectedarea.Protonpumpinhibitors.
Sporadicgastrinomasmaybelocatednearthejunctionofthe
pancreasandduodenum.Agastrinomatriangleisdemarcatedby
thebifurcationofthecysticandcommonbileduct,theheadof
thepancreas,andthethirdportionoftheduodenum.
GASTRICLYMPHOMA
MALTomasarecancersoriginatingfromBcellsinthemarginal
zoneoftheMALT.
GastricMALTlymphomaisfrequentlyassociated(7298%)with
chronicinflammationduetoH.pyloriinfection.
PatientswithaMALTomashouldbetreatedforH.pylori
presumptively.
Chemotherapyisequivalenttosurgeryforthetreatmentof
gastriclymphoma.Surgeryisreservedforcasesthathave
significantcomorbidities,suchasgastricoutletobstruction.
SMALLBOWEL
INTESTINALPERFORATION
Thetreatmentofaduodenalperforationwithoutpriorsymptoms
orcomplicationscanbetreatedprimarilybyaGrahampatch
repairandprotonpumpinhibitors.
MALABSORPTIONSYNDROMES
PATHOPHYSIOLOGYLIPIDS
Theabsorptionoflipidsandlipidsolublevitaminssuchas
vitaminsD,E,K,andAtypicallyaffectstheduodenummoreoften
thanintheotherpartsofthesmallintestine.
Forproperabsorptiontooccur,pancreaticlipasemustbe
presentinappropriateamountstohydrolyzetriglycerides,bile
saltsmustbepresenttoemulsifyfatsandformmicelles,and
digestiveproductsmustbereabsorbedintheileumandnot
sooner.
PATHOPHYSIOLOGYAMINOACIDSANDNUCLEICACIDS
Theabsorptionofaminoacidsoccursmoreofteninthejejunum
thaninotherpartsofthesmallintestine.
Cotransportofmostaminoacidsrequiressodium,butthereare
alsovarioussodiumindependenttransportersavailablefor
certainaminoacids.
PATHOPHYSIOLOGYFLUIDS
Fluidsareabsorbedmostlyinthejejunum,followedbytheileum
andthencolon.
PATHOPHYSIOLOGYVITAMINSANDBILESALTS
Thetransportofwatersolublevitaminsprimarilyoccursinthe
duodenumthroughpassivediffusion.
VitaminB12isanexceptiontothisrulebecauseitrequires
intrinsicfactortobeproducedbytheparietalcellsinthe
stomachforabsorptionintheterminalileum.
Bilesaltsarereabsorbedthroughanactivetransportprocessin
theileumforrecycling.
PATHOPHYSIOLOGYELECTROLYTES
Diagnosis
Treatment
26
Themajorityofchloride,calcium,andirontransportoccurinthe
duodenum.
Sodiumionsareabsorbedthroughanactiveandapassive
mechanism,whilesecretionofsodiumionsintotheintestinal
lumenoccursthroughtheNa+K+ATPasetransportsystem.
Calciumionsareactivelytransportedwiththeassistanceof1,2,5
dihydroxycholecalciferolandfurtherassistedbyprotein
absorption.
Adiethighinphosphatesoroxalatesinhibitscalciumion
transport.
Ironiontransportisgenerallypoorandisbestdonewhenironis
intheFe2+form,asthisferrousformfreelydiffusesthroughthe
mucosaandbindstotheironstoragemolecule,apoferritin.
APPENDICITIS
Thepresenceofanovariancystthatislikelyleadingtothesigns
andsymptomsofwhatwasoriginallythoughttobeappendicitis
shouldbetreatedbyremovingtheappendixandpursuing
treatmentforthecystafterwards.
Thepresenceofterminalileitisbutanormalcecumandappendix
shouldalsopromptthesurgeontoremovetheappendix.
COLONANDRECTUM
INFLAMMATORYBOWELSYNDROME
CROHNDISEASE
Crohndiseaseisthreetimesmorelikelytocausecoloncancer,
withtheriskincreasingovertime.
Itaffectsallofthelayersofthebowel,leadingtotheformation
offistulasandabscesses.
Crohndiseasemaybefoundinanylocationofthe
gastrointestinaltract.
Discontinuous,skippinglesionsarepresentwithnormalbowel
locatedbetweenstretchesofdiseasedbowel.
Thickeningofthesubmucosallayerinthediseasedregionalso
leadstoacobblestoneappearancethatalternateswithregions
ofulcerationofthesubmucosallayer.
Themostcommonlyaffectedregionsofthegastrointestinaltract
aretheterminalileum(1/3ofallcases),thecolon(1/3ofall
cases),orbothregions(1/3ofallcases).
Crohndiseasemayalsohaveanumberofextraintestinal
manifestationssuchasarthritis,uveitis,iritis,erythema
nodosum,andpyodermagangrenosum.
Crohndiseaseisdiagnosedthroughcolonoscopy(skiplesions,
cobblestoning,abscessformation,andfistulasmaybe
pathognomonic).Histologyoftendemonstratesgranulomas.
CrohnDisease
PROCIDENTIA
Adiagnosticsignofprocidentiaisthepresenceofconcentric
folds.
Pathophysiology
Presentation
PSEUDOMEMBRANOUSCOLITIS
C.difficilereleasesatoxinthatmayleadtodamagetothe
mucosaandfurthercontributestothediarrhea.
Themostcommonlyimplicatedantibioticsareclindamycin,
vancomycin,metronidazole,andcephalosporins.
Oralmetronidazoleispreferredunlessthestrainisresistant,
thenoralvancomycinbecomesthepreferredregimen.
Severediarrhea,sepsis,andtoxicmegacolonifnottreated
promptly.Thestandardofcare,ifthesecomplicationsarise,is
colectomy.
PseudomembranousColitis
Etiology
Clostridiumdifficile.Mayoccuraweektoamonthafter
stoppingantibiotics.
Presentation Waterydiarrheathatcontainslittleornoblood,abdominal
cramps,fever.
Diagnosis
PositiveCdifficiletest,sigmoidoscopyorcolonoscopy showing
yellowplaques.
Treatment
Metronidazoleorvancomycin;ifsevere,colectomy.
IRRITABLEBOWELSYNDROME
IrritableBowelsyndrome
Presentation Fluctuationbetweendiarrheaandconstipation,frequent
abdominalpainforatleast3months.
Diagnosis
TwoelementsofRomecriteria.Differentialdiagnosis
EliminateGiardia,inflammatoryboweldisease,lactase
deficiency,hypothyroidism,coloncancer.
Treatment
Highfiber,lowfatdiet.Eliminategasformingfoods.Psyllium,
antispasmodics,anticholinergics,antidiarrheals,osmotic
laxatives,anxiolytics.
Diagnosis
Treatment
Affectsalllayersofbowelleadingtofistulasandabscesses.
Discontinuouslesions.
Nonbloodydiarrhea,crampyabdominalpain, fever,
malaise,tenderRLQ.
Colonoscopy (skiplesions,cobblestoning,abscesses,
fistula).Histology(granulomas),highESR.
Sulfasalazine, corticosteroids,metronidazole forbowel
floracontrol,antidiarrheals.
PyodermagangrenosumisassociatedwithIBD.
Themosteffectiveacutetreatmentforaperirectalfistula
secondarytoCrohndiseaseisinfliximab.
Astricturoplastyisthetypicaltreatmentofchoiceinyoung
patientswithmultiple,shortCrohnsrelatedstrictures.
DiarrheafollowingileocecectomyforCrohndiseaseisduetoa
paucityofbilesalts.Itcanbealleviatedbytheadministrationof
exogenousbilesalts.
ULCERATIVECOLITIS
Theriskofcoloncancerwithulcerativecolitisissignificantly
greaterthanwithCrohndisease:thereisa30foldincreaseinrisk
withulcerativecolitis.
Ulcerativecolitistendstohavecontinuouslesionsthatare
restrictedtothemucosa.Thistendstoleadtoarectaldischarge
ofmostlymucus,blood,andpus.
Signsandsymptomsofulcerativecolitisincludebloodydiarrhea
andrectalpain.
Diagnosisofulcerativecolitisismadethroughacolonoscopythat
demonstratescontinuouslesionsemanatingfromtherectum,
andaleadpipecolonthatissecondarytochronicdamage
leadingtoscarring.Granulomasarenotpresent.
Colectomyismandatoryafter15yearsofsymptomstominimize
theriskofcoloncancer;thisistypicallycurative.
27
Presentation
Diagnosis
Treatment
Continuouslesionsrestrictedtothemucosa. Beginsin
rectum.
Bloodydiarrheaandrectalpain.
Colonoscopyshowscontinuouslesionsstarting atrectum.
Nogranulomas.
SimilartoCrohndisease.Colectomyafter15yearsof
symptoms.
Complications
Ulcerativecolitis
Extraintestinal
(Ulcerative
colitis&Crohn)
Perforation,strictureformation,andtoxicmegacolon.
Hemorrhage,ifthereissignificantdamagetoblood
vessels.Toxicmegacolonislikelytooccur,ifsevere
inflammationleadstodilationofthebowel.Hypotension
andsepticchangesmayalsooccurinlongstanding
ulcerativecolitis.
Episcleritis,uveitis,erythemanodosum,colicarthritis,
pyodermagangrenosum,aphthousulcers,ankylosing
spondylitis,primarysclerosingcholangitis,colitis,and
renalfailure,duetoamyloidosis.Note:Allformsof
inflammatoryboweldiseasemaybecomplicatedwith
anemia,thromboembolicdisorders,steatohepatitis,and
cholelithiasis.(seetextforcomplicationsthatoccurmore
ofteninonediseasethananother).
Thetreatmentofchoicefordysplasiainthesettingofulcerative
colitisistotalproctocolectomywithilealpouchanalanastomosis.
DIVERTICULOSIS
Diverticulosisisthedevelopmentofasaclikeoutpouchingofthe
colonthatherniatesinbetweentheteniaecoli.
Diverticulosisisthemostcommoncauseofsignificantbleeding
fromthelowergastrointestinaltractinelderlypatients.
Theoutpouchingsofdiverticulosisgenerallyoccurinthesigmoid
colon,likelyduetothehigherpressuresexperiencedinthis
sectionofthegastrointestinaltract.
Diagnosisofdiverticulosisismadethroughcolonoscopythat
detectstheoutpouching.Amoresensitivetestisbariumenema,
whichisalsoasafertestasthecolonoscopycanleadto
perforationofthesac.
Diverticulosis
Etiology
Presentation
Diagnosis
Treatment
Saclikeoutpouchingofthecolonthatherniatesbetweenthe
teniaecoli.
LowerGIbleeding(BRBPR),mostcasespainless.
Colonoscopy,(showsoutpouching),bariumenema, tagged
RBCs,angiography.
CorrectGIbleeding,highfiberdiet.
DIVERTICULITIS
Diverticulitisistheinflammationoftheoutpouchingofthecolon
duetotheformationofafecalithandsubsequentproliferationof
bacteriawithinthediverticulum.
Diverticulitis
Presentation
Diagnosis
Treatment
Inflammationofoutpouchingofcolonduetofecalith and
bacterialproliferation.Lowerabdominalpain(typicallyleft
quadrant),constipation,fever.
Bloodculturespositiveforinfection,leukocytosis,CT scan
(confirmdiverticulum).
NPO,hydration,antibiotics,sigmoidresection, testingtorule
outcoloncancer.
Thepresenceofpneumaturiaandleftlowerquadrantpain
shouldbeginasearchfordiverticulitis.
CARCINOID
Carcinoidistheresultofaneuroendocrinetumorthatsecretes
hormonesorneurotransmittersthathaveaneffectonthe
gastrointestinalsystem.
Theseactivecompoundscanincludeserotonin(5HT),
adrenocorticotrophichormone(ACTH),histamine,dopamine,
tryptophan,substanceP,andbradykinin.
Themajorityofcarcinoidsareintheappendix,buttheendocrine
cellsinthislocationtendnottohaveanyeffect.
Carcinoidtypicallycausesmostofitseffectsthroughthe
conversionoftryptophantoserotonin,andtheunchecked
productionofserotoninmayleadtosymptomsofniacin
deficiencyandsubsequentpellagra.
Theclassictriadofcarcinoidrarelypresentswiththetripartite
symptoms,butitincludesflushingduetoexcessivebradykinin
production,diarrheafromexcessiveserotonergiceffects,and
valvularheartdiseasethatprimarilyaffectsthemitralvalvefrom
excessserotonin.Otherclassicsymptomsincludehypotension,
tachycardia,andalcoholintolerance.
Diagnosisofcarcinoidsyndromeismadewitha24hour5
hydroxyindolaceticacid(5HIAA)collection,withelevatedtiters
100%specificforcarcinoid.CTofthelungandabdomenare
compulsorytodetectmetastasis.
Carcinoidsyndromeisbesttreatedwithsurgicalresectionand
radiationtherapy.
Withmetastasistotheliver,embolizationandalphainterferon
therapyareoftenused,inadditiontosurgicalresection.
Symptomaticcontrolofcarcinoidcansometimesbeachieved
withthesomatostatinanalogoctreotide.
Carcinoidprimarilylocatedintheappendixcarriesaverygood
prognosis,whileprimarycarcinoidoutsideoftheappendixhasa
50%5yearsurvival.
UlcerativeColitis
Etiology
Pathophysiology
Presentation
Diagnosis
Treatment
Idiopathic.
Majorityinappendix,thoseinileum aresecreting,niacin
deficiency.
Mostasymptomatic,possiblesymptomsofappendicitis,SI
blockage,diarrhea.
24hour5HIAAcollection(elevatedtiters specificfor
carcinoid)CTlung&abdomen.
Surgicalresectionandradiationtherapy.
Arectalcarcinoidover5mmrequireslocalexcision.Appendiceal
carcinoidslessthan2centimetersatthedistalendcanbe
treatedbyappendectomy.Carcinoidsover2centimetersor
thoseatthebaserequirearighthemicolectomy.
COLORECTALCANCER
Thesecondmostcommoncauseofdeathduetocancerisfrom
coloncancer,affectingbothmalesandfemalesequally.
Themostcommonunderlyingetiologyisthepresenceofsessile,
villous,adenomatouspolypsgreaterthan2cminsize.
Riskfactorsforcoloncancerincludeapositivefamilyhistory,the
presenceofAPCgeneorp54genedefects,ulcerativecolitis
(morethanCrohndisease),andsmoking.
LongstandinginfectionwithStreptococcusboviscanalso
predisposeindividualstocoloncancer,whilechronicaspirinuse
UlcerativeColitis
Pathophysiology
28
overalongperiodoftimesomewhatreducestheriskofcolon
cancer.
FAMILIALADENOMATOUSPOLYPOSIS
Coloncancerdevelopsoverapproximatelyadecadeofhaving
largevillousortubulovillousadenomatouspolyps.
Thepresenceoffamilialadenomatouspolyposis(FAP)
syndromes,duetoanautosomaldominantgene,isacertain
predictorofmalignancy.
FAPisduetoadeletiononchromosome5q,anditrequirestotal
colectomytoavoidcoloncancerfromthenumerouspolypsthat
inevitablyformbytheageof25.
Withouttreatment,coloncancerislikelytohaveoccurredin
nearlyallindividualsbytheageof40.
HEREDITARYNONPOLYPOSISCOLONCANCER
Hereditarynonpolyposiscoloncancer(HNPCC)isanautosomal
dominantdisorderwithastrongfamilyinheritance.
HNPCCisastrongpredictoroffuturecoloncancerdevelopment
inthepatient.
Cancerarisesspontaneouslyfromthemucosa,anditisastrong
predictoroffutureovarianorendometrialcancer.
Endometrial,gastric,andbladdercancersareassociatedwith
nonpolyposiscoloncancers.
LynchIIsyndromesincluderightsidedcoloncancerdueto
mismatchrepair.Itistypicallyautosomaldominant.
Thepresenceofmicrosatelliteinstabilityislikelytobelaterstage
withaworseprognosis.
GARDNERSYNDROME
Gardnersyndromeisthedevelopmentofnumerouspolypsdue
toanautosomaldominantdisorder.
Gardnerssyndromeisfurthercomplicatedbythepresenceof
fibrousdysplasiaoftheskull,osteomas,andextrateeth.
Gardnersyndrometypicallyevolvesintocoloncancer.
TURCOTSYNDROME
Turcotsyndromeisthedevelopmentofpolypsandtumorswithin
thecentralnervoussystem(CNS).Itpresentsasignificantriskfor
coloncancer.
PEUTZJEGHERSYNDROME
PeutzJegherssyndromepresentsarelativelylowriskof
developingcoloncancer.
Manypolypsdevelopwithinthesmallandlargeintestine,but
theyaretypicallyhamartomasandthereforebenign.
PeutzJeghersshouldraisethesuspicionofcancersthatoccurin
women.
JUVENILEPOLYPOSISSYNDROME
Juvenilepolyposissyndromeisaninsignificantcauseofcolon
cancer,withpolypsoftenoccurringasaresultofbenign
hamartomaswithintheintestines.
OtherColonicSyndromes
Gardner
syndrome
Turcot
syndrome
Numerouspolypsduetoautosomaldominantdisorder.
Evolvesintocoloncancer.
PolypsandtumorsinCNS.Highriskforcolon cancer.
PeutzJeghers
synd.
Juvenile
Polyposis
Manypolyps inSIandLI,lowcancer risk.

Benign hamartomasinintestines.
StagingofColonCancerDukesStages
StageA
StageB
StageC
StageD
Cancer limitedtomucosa andsubmucosa.90%5yearsurvival.

Cancer invadesthemuscularispropria.70%5yearsurvival.
Invasionoflocallymph nodes.30%5yearsurvival rate.
Distantmetastases.Limitedsurvival.
TreatmentofColonCancer
StageA
&B
StageC
StageD
Surgeryandwideresectionofcolon,samplingoflymph nodes
(radiationandchemoaresometimesusedinB).
Surgeryandchemotherapy(5FU,leucovorin),radiation mayalso
beutilized.
Palliation.
SQUAMOUSCELLCARCINOMA
Squamouscellcanceroftheanusistypicallytreatedwith
chemoradiation.
Apatientwithan8cmvillous,sessilepolypapproximately8
centimetersabovetheanalvergecanbetreatedwithatransanal
excision.FartherlesionswillrequireanAPR.
Apatientwhoisrecentlys/pLARwhonowhasanewonsetileus
andacontainedleakcanbetreatedwithexistingmanagement.
Nonewinterventionsareneeded.
TherecurrenceofcolorectalcanceratthesiteofanLAR
anastomosismustbetreatedwithanAPR.
T3rectalcancersinvadethroughtotheserosaorpericolicfat.
DukesCadjuvanttherapyincludes5FU.Leucovorinandradiation
maybeaddedasindicated.
Sigmoidcancerthatinvolvesthedomeofthebladderrequires
colonresectionwithapartialbladderresection.
Coloncancerisleastlikelytometastasizetothebone.Themost
commoncancerthatdoesisprostate,followedbybreast,lung,
kidney,andthyroidcancer.
Thegenelostincoloncancerisp53,atumorsuppressorgene.
Asessilevillousadenomawithnegativemarginsrequiresno
furthertherapy.However,massesover4cmcannotbetreated
endoscopically;theyrequiresurgicalinterventionandresection.
Avillousadenomamaypresentwithadecreaseinbicarbonate,a
dropinurinepH.
HERNIAS
FEMORALHERNIA
Thefemoralcanalislocatedbelowtheinguinalligamentonthe
lateralaspectofthepubictubercle.
Inguinalherniasareaboveandmedialtothepubictubercle,
whilefemoralherniasareinferiorandlateraltothepubic
tubercle.
Thefemoralcanalisboundedbytheinguinalligamentanteriorly,
thepectinealligamentposteriorly,thelacunarligamentmedially,
andthefemoralveinlaterally.
Femoralherniasoccurwhenabdominalcontentspassthrough
thefemoralcanal.
29
INGUINALHERNIA
Anindirectinguinalherniaprotrudesthroughtheinguinalring
andistypicallycongenitalinnatureduetofailuretoclosethe
internalinguinalringafterthetesticlepassesthroughitduring
development.
Indirectinguinalherniasarelateraltotheinferiorepigastric
vesselsandarecoveredbytheinternalspermaticfascia.
Directinguinalherniasenterthroughaweaknessinthe
abdominalfloorandareacquired.Theyarelocatedmedialtothe
inferiorepigastricvesselsandarenotcoveredbytheinternal
spermaticfascia.
MDs(directhernia,medialtoinferiorepigastricvessels)dontLie
(indirecthernia,lateraltovessels).Also,Indirect=Infantile.
Areducedincarceratedherniathatpresentswithasmallbowel
obstructionrequiressurgicalexploration.
Thepresenceofoliguriafollowinglaparoscopicherniarepairmay
beduetoureteralinjury.
ThemostcommonnerveinjuredintheTAPP(transabdominal
preperitoneal)approachtoherniarepairisthegenitofemoral
nerve(2%)ofthetime.Thisiscloselyfollowedbytheilioinguinal
nerve(1.1%)andlateralcutaneousnerveofthethigh(1.1%).
PARASTOMALHERNIA
Parastomalherniascanbeobserveduntilsymptomsdevelop.
SPIGELIANHERNIA
Spigelianherniasarelocatedatthesemilunarline.
HEPATOPANCREATICOBILIARYSURGERY
GENERALCONCEPTS
LIVER
Theliverisdividedintorightandleftlobesusinganartificial
demarcationbetweentheinferiorvenacavaandthegallbladder
fossa.
Asindicatedintheabovediagram,theliversegmentlateralto
thegallbladderfossaissegment5.
Thecommonbileductislocatedparallel,anterior,andlateralto
thehepaticartery(i.e.totherightofthehepaticartery).The
portalveinislocatedposteriorly.
Thecentralareawherethecommonbileduct,hepaticportal
vein,andhepaticarteryentertheliverisknownasthehilumor
portahepatis.
Theinferiormesentericveinandsplenicveincombinetogether
andthenjointhesuperiormesentericveintoformthehepatic
portalvein.
Thehepaticarteryisabranchoftheceliactrunk.
Approximately3/4softhebloodtothelivercomesfromthe
portalvenoussystem,while1/4comesfromthehepaticartery.
Occasionally,hepaticarterieswillemanatefromthesuperior
mesentericartery.Thistendstobeintheformofadisplaced
righthepaticartery.
PANCREAS
Thebloodsupplytotheheadofthepancreasisfromthepaired
anteriorandposteriorbranchesemanatingfromtheceliacartery
andsuperiormesentericartery,respectively.
Intheeventofatransectionofthepancreaticneck,adistal
pancreatectomyshouldbedone.
GALLBLADDERREGULATION
Bileiscomposedofwasteproducts,cholesterol,andbilesalts
andisresponsibleforthedarkcoloroffeces.
Impairedbilesecretionleadstoclaycoloredstools.
BileisreleasedfromthegallbladderthroughstimulationbyCCK.
Emptyingofthegallbladderisinhibitedbyparasympathetic
blockade.
PANCREAS
Nearly3Lofbicarbonateandenzymerichfluidareproduced
everydaybythepancreas,andthereleaseofthesecompounds
isfacilitatedbycholecystokinin(CCK),secretin,andbilesalts.
Theamountofbicarbonatesecretionfromthepancreasis
inverselyrelatedtotheamountofchloridesecretion.
BILESALTMETABOLISM
Themostimportantbileacidsarecholicacid,deoxycholicacid,
andchenodeoxycholicacid.
Bileacidsareconjugatedpriortosecretionbytheliver.
Conjugationincreaseswatersolubilityandtherebyprevents
passivereabsorptiononcesecretedintothesmallintestine.
Theconcentrationofbileacidsinthesmallintestinecanthereby
stayhighenoughtoformmicellesandsolubilizelipids.Bileacid
saltsarereabsorbedintheterminalileum.
Biliverdinisthebilepigmentformedfromthebreakdownof
hemoglobin.
Urobilinogenisproducedbybacteriaintheintestines.Itcanbe
convertedtostercobilin,whichgivesfecestheirbrowncolor.It
maybeconvertedtourobilin,whichisabsorbedandsecretedin
urine.
Conjugationofbileacidsisrequiredforabsorption.
Thecholesterolcontentinbileisentirelyderivedfromthat
createdbytheliver.
Theconcentrationofbileinthegallbladderisdeterminedbythe
extentofactivesodiumreabsorption.
HEPATICBIOSYNTHESIS
HepaticbiotransformationisdependentonthecytochromeP450
system.
GLUCONEOGENESIS
Thefuelsourcetothebodyduringperiodsofprolonged
starvationcomefromketonebodies.Theseketonebodiesare
generatedbytheoxidationoffattyacids.
BILIARYTRACT
CHOLEDOCHOCELE
Femoralherniaislocatedmedialtothefemoralvein
30
Acholedochoceleistreatedbyresectionofthecommonbile
ductfollowedbyahepaticojejunostomyanastomoticdiversion.
Acholedochalcysthasariskofcholangiocarcinomaand
thereforemustberesected.Ahepaticojejunostomyisthen
performed.
POSTCHOLECYSTECTOMYSYNDROME
Thepresenceofacysticductleakwithabilomaistreatedwitha
sphincterotomyfollowedbypercutaneousdrainage.
Ifacommonbileductinjuryoccursduringacholecystectomy,
thepropertreatmentisreturningthepatienttotheoperating
roomandtopermitanexperiencedsurgeonperforma
hepaticojejunostomy.
CHOLELITHIASIS
Cholesterolstonesarethemostcommonandaretypically
locatedinthegallbladder.
Stonesinthecommonbileducttendtobepigmentedstonesor
calciumbilirubinatestones.Pigmentedstonesaremore
commoninliverdisease,alcoholabuse,andhemolyticanemia.
Itisseveraltimesmorecommoninwomen,andhasanumberof
riskfactorsincludingpatientswhoareintheir40s,fertile,
female,overweight,currentlyfasting,rapidweightloss,Crohn
disease,hypertriglyceridemia,ahistoryofcysticfibrosis,a
familialtendency,sicklecelldisease,diabetes,oruseoforal
contraceptivedrugs(OCDs).
Cholelithiasispresentswithcolicky,RUQpainthatlastsseveral
hoursatatime.Thepainissevereandmadeworsewitheating.
Ultrasoundisthebestwaytodetectgallstonesanddiagnose
cholelithiasis.Stoneswithinthecommonbileductarediagnosed
andtreatedwithERCP.
Cholelithiasis
Pathophysiology
Presentation
Diagnosis
Treatment
Formationofgallstones(cholesterolorcalcium
bilirubinate)leadstostoppageofbileflow.
RUQpain,painworsewitheating.Nausea/vomiting,
tendernessinRUQ.
Elevatedserumalkalinephosphatase,radiolucent
cholesterolstones,ERCP.
ERCPwithsphincterotomy,lithotripsy,UDCA, pain control.
Cholesterolstonesmakeup80%ofallgallstonesandare
composedprimarilyofcholesterol.Pigmentstonesarefound
about20%ofthetimeandaremadeofcalciumandbilirubin.
Riskfactorsforpigmentstonesincludecirrhosis,biliarytract
infections,andredbloodcelldyscrasias.
AretainedstonefollowingaTtubeplacementthatisnot
amenabletoERCPshouldberemovedwithinterventional
radiology.
GALLSTONEILEUS
Ingallstoneileus,thegallbladdercanbeleftbehindif
significantlyinflamed.
Acholecystoduodenalfistulatypicallypresentswithsmallbowel
obstructionduetogallstoneileus.
Thepresenceofsmallbowelobstructionandpneumobilia
typicallyindicatestheonsetofgallstoneileus.
GALLSTONEPANCREATITIS
Anintraoperativecholangiogramthatindicatesnoemptyinginto
theduodenumwhenperformedforgallstonepancreatitiscanbe
checkedbygivingglucagontothepatient.
Apatientwhohashadresolutionofgallstonepancreatitisshould
betreatedwithalaparoscopiccholecystectomywitha
cholangiogram.
CHOLECYSTITIS
Cholecystitisisinflammationandinfectionthatresultsfollowing
cholelithiasis.
Nearlyofallpresentationsofcholecystitishaveconcurrent
infectionbyentericbacteria,includingE.coli,Klebsiella,
Enterococcus,andBacteroidesspecies.
Charcotstriadispositiveincholecystitis,includingfever,
jaundice,andRUQpain.Guardingandreboundtendernessare
common,andapositiveMurphyssignisoftenpresent
(inspirationissuddenlyarrestedduringpalpationoftheRUQ).
Murphyssignisverysensitiveforcholecystitis.
DiagnosisofcholecystitisisbestmadewithaHIDAscan.
Complicationsofcholecystitisincludetheformationofabscesses
andfistulas,gallstoneileus,andpancreatitis.
Onevariantofcholecystitisiswithacalculuscholecystitis,which
occursinabout10%ofallcases.
EmphysematouscholecystitisiscausedbyClostridiuminfection
andleadstogangreneandperforation.
Cholecystitis
Pathophysiology
Presentation
Diagnosis
Treatment
Infection &inflammationaftercholelithiasis, infections

withentericbacteria.
Charcotstriad,reboundtenderness,Murphyssign.
HIDAscan,highPMN,ultrasoundfindings.
Antibiotics, meperidine,cholecystectomyinrefractory
cases.
Anintraoperativecholangiogramperformedfollowinga
laparoscopiccholecystectomywithnoproximalductsfound
shouldelicitopenexploration.
Apatientwhoundergoesanuncomplicatedlaparoscopic
cholecystectomybutthendevelopsastrictureattheleftand
rightbiliaryductsyearslaterhascholangiocarcinomauntil
otherwiseproven.
AdecreaseinendtidalCO2duringalaparoscopic
cholecystectomymaybeduetoavenousairembolism.The
patientshouldbeplacedwiththeleftsidedowntofacilitate
absorptionofthegasbubblebytherightatrium.
ASCENDINGCHOLANGITIS
Ascendingcholangitisisduetoobstructionofthecommonbile
ductleadingtoobstructionofthebiliarytree.
CholedocholithiasispresentswithCharcotstriad,includingfever,
RUQpain,andjaundice.Itisnotspecifictocholedocholithiasis
andispresentinonlysomecases.
Reynoldspentadmayalsodevelop,whichincludesthetripartite
Charcotstriadinadditiontoalteredmentalstatusandshock.
Reynoldspentadisanindicatorofpooroutcome.
AscendingCholangitis
31
Obstructionofcommonbileduct.
Charcotstriad,fever,RUQpain,jaundice.
Ultrasound.
IVs,vasopressors,antibiotics,ERCPtoremoveblockage,
surgery.
PRIMARYSCLEROSINGCHOLANGITIS
PrimarySclerosingCholangitis(PSC)
Presentation
Diagnosis
Treatment
Chronic,progressing,inflammationandscarringofbile
ducts.
Elevatedalkalinephosphatase,GGT,bilirubin.
US,ERCP,PTC.
Surgery.
PRIMARYBILIARYCIRRHOSIS
PrimaryBiliaryCirrhosis(PBC)
Epidemiology
Presentation
Diagnosis
Treatment
LIVER
Cirrhosis
PSCiscommoninpatientswithulcerativecolitis,andpresentsas
chronic,progressiveinflammationandscarringofthebileducts.
ItisthoughtthatPSCisduetoahypersensitivityreaction.
DiagnosisofPSCismadebyultrasound(US),ERCP,andPTC.PSC
presentswithelevatedalkalinephosphatase,GGT,bilirubin,and
symptomsofcholestasisandliverdisease.Treatmentisthrough
surgicalinterventiontodecompressthebiliarytree.
Pathophysiology
Nohepaticencephalopathyhasascoreof1,whilesevere
symptomshaveascoreof3.Noascitesisgivenascoreof1,
whilesevereasciteshasascoreof3.AChildscoreofAhasa15
20yearsurvival;ChildclassCsurvivalhasasurvivalofonlyafew
years.
Autoimmunedisorderwhichdestroyintrahepatic bile ducts.

Morecommoninwomen.
Jaundice,fatigue,weakness,pruritus,Xanthomas,RA.
ElevatedalkalinephosphataseandGGT.AST andALT usually
normal.PositiveAMA.
Surgery,livertransplant.
VARICES
Esophagealvaricesaretheresultofdilatedbloodvesselswithin
thedistalportionoftheesophagusthatcanbecomeabradedand
subsequentlyhemorrhage.
HEMANGIOMA
Anasymptomatichemangiomacanbeobserved;surgeryisnot
indicateduntilthedevelopmentofclinicallysignificant
symptoms.Thesetumorstendtobecontrastenhancinglesions.
Pathophysiology
Cause
Presentation
Diagnosis
Treatment
Prognosis
Alpha1antitrypsindeficiencyisadefectinalpha1antitrypsin
productionleadingtoexcessdepositionofabnormalA1AT
proteininlungandliver.TheresultisCOPDandcirrhosis.
Treatmentinvolvesalungandlivertransplant,whenever
possible.
HEPATORENALSYNDROME
Hepatorenalsyndromeisduetotheinabilitytoconcentrate
urineandisassociatedwithportalhypertension.
IValbuminhasbeenshowntoimproveoutcomesinsome
studies.Octreotideormidodrineusedindividuallyhaveno
beneficialeffects.
LIVERABSCESS
Pyogenicabscessescanbediagnosedbythepresenceoffever,
andabluntingofthecostophrenicangle.
Thepresenceofaringenhancinglesionintheliverwith
numeroussatellitelesionsshouldbetreatedwithabendazole.
HEPATITIS
HEPATITISBVIRUS
HepatitisB(HBV)
Pathophysiology
Diagnosis
HEPATICCIRRHOSIS
Causesofcirrhosisincludealcohol,viralinfection,primarybiliary
cirrhosis(PBC),Wilsondisease,alpha1antitrypsindeficiency,
andhemochromatosis.
Medicationsthatcanfurtherdamagetheliverareavoided,
includingacetaminophenandisoniazid(INH).
TheprognosisofcirrhosisismadebytheChildPughscore,which
examinesthelevelsofbilirubin,albumin,PT,thepresenceof
hepaticencephalopathy,andthegradeofascites.Thescorefor
eachcategoryissummed,andaChildclassassignedbasedonthe
rangeofthescores.ChildclassAisascorebetween5and6,
classBwithascorebetween7and9,andclassCwithascore
greaterthan9.Withserumbilirubinlessthan2,ascoreof1is
given;bilirubingreaterthan3hasascoreof3.Serumalbumin
morethan3.5hasascoreof1;lessthan2.8hasascoreof3.PT
of4orlessisgivenascoreof1;PTmorethan6hasascoreof3.
Repeatedliverdamageleadingtofibrosis, necrosis,
regeneration,andHCC.
Alcohol, viralinfection,PBC,Wilsondisease,
hemochromatosis.
Jaundice, nausea/vomiting,hepatomegaly,ascites,
encephalopathy,portalhypertension,Dupuytren
contracture,palmarerythema.
AbnormalLFTs,elevatedASTtoALT ratio, highbilirubin
andGGT,longPT.
Avoidingrisk factors,highproteindiet, vitamins.
MadebyChildPughscore(seeabove).
Treatment
DNAvirus spreadthroughsex,blood, saliva.

HbcAGinhepatocytesbutnotinserum IgM toHBV. Also
HBsAg,HBcAb,HBeAg,HBeAb,HBsAbatvariousstages
(seetext).
ImmunoglobulinstoHBV,lamivudine,alphainterferon,
transplant.
HEPATITISCVIRUS
HepatitisCVirus(HCV)
Pathophysiology
Presentation
Diagnosis
Treatment
SinglestrandedRNA.Spreadthroughsex, saliva,blood.
Symptomsofhepatitis,PANandcryoglobulinemias.
PositiveserumlevelsofHCVAb.
Alphainterferonandribavirin,amantidine,rimantadine.
PORTALHYPERTENSION
Portalhypertensionistheelevationofbloodpressure(BP)within
theportalveinduetoelevatedbackpressurefromtheflowof
bloodthroughtheliver.
Portalhypertensionmaypresentwithsplenomegaly,
hemorrhoids,ascites,esophagealvarices,andcaputmedusa.
Pathophysiology
Presentation
Diagnosis
Treatment
32
Portalhypertensionistreatedwiththesurgicalformationofa
transjugularintrahepaticportacavalshunt(TIPS)tobypassthe
liver,andalsoviaportasystemicshunts.
Themostcommoncauseofportalhypertensionis
schistosomiasisinfection.
Thepresenceofaleftsidedportalhypertensionrequiresa
splenectomytoavoidsplenicveinthrombosis.
HEPATICADENOMA
Anadenomaoftheliverismostlikelytopresentwithshockdue
tothehighriskofbleeding,especiallyinpregnancy.
HEPATOCELLULARCARCINOMA
Primaryhepatocellularcarcinomaisahighlymorbidandlethal
cancerthatcommonlyoccursfollowingchronicliverinjurysuch
ascirrhosis.
Themostcommoncausesincludechronicalcoholism,HBV,HCV,
hemochromatosis,andaflatoxinpoisoning.
VaccinationforHBVandHCVisprotective,andavoidingalcohol
isimportant.
Useofchemoembolizationtechniquestoprovidetargetedtumor
therapyisbeneficialinsomepatients.
Transplantationisalsoanoptionforlocalizeddisease.
HepatocellularCarcinoma
Etiology
Chronicalcoholism,HBV,HCV,hemochromatosis, andaflatoxin
poisoning.
Presentation
Jaundice,pruritus,hepatosplenomegaly(oftenwithhepatic
nodulesasincirrhosis),bleedingdiatheses,cachexia,
encephalopathy,asterixis,ascites,andvarices.
Diagnosis
Biopsyconfirmsthediagnosis.LFTsareelevatedalongwith
AFP.
Treatment
Avoidingalcohol,vaccinationisimportant.Complicationsare
treatedtominimizepatientdiscomfort.Paracentesisand
diuretics,lactulose,ursodiol,bandligation,and,prophylactic
antibiotics.Surgicalresectionwithclearmarginsisthe
definitivecare.Transplantationisalsoanoptionforlocalized
disease.
Thepresenceofalivermassinapatientwithahistoryof
cirrhosisishepatocellularcarcinomaunlessotherwiseproven.
Over90%ofpatientswillhaveanelevationinalphafetoprotein.
Alllivermetastasesmusthaveanarterialsupplyandsoare
susceptibletochemoembolization.
Alivertumorwithacentral,stellatescarisfocalnodular
hyperplasia.
METASTATICLIVERCANCER
Longtermsurvivalfromasinglecolorectallivermetastasishasa
2550%5yearsurvival.
PANCREAS
ACUTEPANCREATITIS
shock,multiorgansystemfailure,andadultrespiratorydistress
syndrome(ARDS).
Causesofacutepancreatitisincludeperforationofapepticulcer,
alcoholism,neoplasticdisorders,cholelithiasis,endstagerenal
disease(ESRD),endoscopicretrograde
cholangiopancreatography(ERCP),malnutritionleadingto
anorexia,directtraumatothepancreas,certaininfections,useof
drugsthatleadtotoxicbyproducts,burninjuries,surgery,and
scorpionbites.
Themostcommoncausesarealcoholabuseandgallstones.
Acutepancreatitispresentsassevereepigastricpainthat
radiatestotheback.Thepainworsensafterconsumptionof
foodandmayimproveifthepatientleansforward.
Cullensignisthepresenceofabluishhuetotheumbilicusdueto
hemorrhagingwithintheperitoneumitismostcommonly
foundinnecrotizingpancreatitis.
Turnersignisabluishdiscolorationintheflanksdueto
hemoglobindepositionanddecompositioninthesofttissue.
Themostspecifictestforpancreatitisislipaselevels,whilethe
mostsensitivetestisamylasetiters.
Theearliestchangesthatcanbedetectedarethedevelopment
ofaphlegmon,whichistypicallyobviouswithinacoupleofdays.
Pancreaticnecrosisandpseudocystformationaretypically
apparentwithinacoupleofweeks.
Complicationsofacutepancreatitissuchaspseudocystor
abscessformationmaybedrainedwithCTguidedaspiration.
Mostcasesareselflimited,andsothestandardofcareisto
providesupportivetherapy,IVfluids,paincontrolwith
meperidine,nothingbymouth(NPO),andbowelrest.
Surgicaldebridementisusedincasesrefractorytostandard
management.
TheprognosisofacutepancreatitisisgaugedbyRansoncriteria.
Mortalitydependsonthenumberofriskfactorspresent.The
riskfactorsaredividedintothosepresentonadmissionand
thosethatdevelopaftertwodays.Riskfactorsthatincreasethe
riskofmortalityandmaypresentonadmissionincludeageover
55,elevationsinbloodsugarover200,elevatedwhitebloodcell
(WBC)countsover16,000,elevatedaspartatetransaminase
(AST)over250,andelevatedlactatedehydrogenase(LDH)over
350.Riskfactorspresentaftertwodaysincludeadecreaseof
morethan10%inthehematocrit(HCT),increaseinBUNover5,
calciumlessthan8,PO2lessthan60mmHg,abasedeficit
greaterthan4,andafluiddeficitofmorethan6L.Theriskof
mortalityislowiflessthanthreeriskfactorsarepresent.Three
or4riskfactorscarriesa1/6riskofdeath.Fiveor6riskfactors
increasethemortalityto2/5,andmorethan6riskfactorshavea
mortalitythatapproaches100%.
AcutePancreatitis
Acutepancreatitisistheresultofdirectdamagefrom
prematurelyactivatedpancreaticenzymesdigestingthe
parenchymaoftheorgan.
Severediseasecanleadtosystemicinflammatoryresponse
syndrome(SIRS)andsubsequentlyprogresstosevereseptic
Epidemiology
Etiology
Presentation
Directdamage fromprematurelyactivatedpancreatic
enzymes.
Perforation formPUD,alcoholism,cancer, cholelithiasis, ESRD,
ERCP,directtrauma,infections,toxicdrugs,burninjuries,
surgery.
Severeepigastricpainradiatingtoback.Pain isworseafter
eating.Nausea/vomiting,fever,tachypnea,CullenandTurner
signs,tenderabdomen.
33
Treatment
Prognosis
Bloodtests(elevatedamylase&lipase),CTscan,CXR, AXR,
ultrasound.
Treatmentforalcoholism,ERCP,surgicaldebridement.
Ransoncriteriascores:Mortalitylowifunder3factors; 1/6,
34riskfactors;2/5,56factors,morethan6,100%.
Thepresenceofacutepancreatitiswithhyponatremiamaybe
duetosignificanthypertriglyceridemia.
Anecroticpancreasthatdevelopsshortlyaftertheonsetofacute
pancreatitisshouldelicitsurgicaldebridement.
CHRONICPANCREATITIS
Themostcommoncauseofchronicpancreatitisiscontinued
abuseofalcohol.
Replacementofpancreaticenzymesisoftenrequiredinaddition
todietarychangessuchasdecreasedfatintake,vitamin
supplements,anduseofspontaneouslyabsorbedmediumchain
fattyacids.
ChronicPancreatitis
Cause
Presentation
Diagnosis
Treatment
Alcoholabuse(3/4),idiopathic(1/4),cysticfibrosis.
Similartoacutepancreatitis.
History,bloodtests(amylase,lipaselevels),calcification on
plainfilms,secretinstimulationtest.
Primarilysupportive,modificationofriskfactors, replacement
ofenzymes.
releasinghormonesare:thyrotropinreleasinghormone,
corticotropinreleasinghormone,lutenizinghormonereleasing
hormone,growthhormonereleasinghormone,prolactin
releasingpeptide,gonadotropinreleasinghormone.
ADHreleasemaybestimulatedbyhypotensionandanincrease
inextracellularosmolarity.Theformerisamorepotentstimulus.
HYPERPROLACTINEMIA
Hyperprolactinemia
Etiology
Presentation
Diagnosis
Treatment
HYPOPITUITARISM
Hypopituitarism
Etiology
Presentation
Adilated,tortuouspancreaticductinthesettingofchronic
pancreatitisshouldbetreatedwiththePeustowprocedure.
PANCREATICADENOCARCINOMA
Thepresenceofunresectablepancreaticcancerinthesettingof
worseningpainmaybetreatedwithadoublepancreaticbypass
andinjectionofthesplanchnicbed.
SPLEEN
Prolactinomasanddopamineinhibition.
Amenorrhea, gynecomastiaandgalactorrhea,bitemporal
hemianopsia.
Exclusion ofotherconditionsandexcludingmedication
inducedhyperprolactinemia.Prolactingreaterthan100ng/
mL.
Reversingelevatedlevelsofprolactin. Disease refractoryto
medicalmanagementrequiressurgicalexcisionorradiation
therapy.
Diagnosis
Treatment
Lesions maybetheresultoftraumaordamage fromtumor

overgrowth.Infarctionofapituitarytumor,infectionbyTBand
syphilis,alongwithsarcoidandvariousautoimmunedisorders.
Inability tolactateinpregnantwomen; amenorrhea,
infertility,decreasedsexualdesire,impotence,lossofsexually
maturehairpatterns,insulinsensitivity,growthfailurein
children,symptomsofhypothyroidism,symptomsofAI.
InsulinchallengetesttoseeifGHincreases,measuringthe
titersofcortisol,LH,FSH,andeitherestrogenortestosterone,
measuringthyroidhormones.
Replacementofthelosthormones,especiallycortisol.
Reversalofanyunderlyingetiologyshouldbeundertaken
immediately.
DIABETESINSIPIDUS
SPLENECTOMY
Splenectomycanleadtooverwhelmingsepsis(OPSI)especially
withencapsulatedorganismsduetoinabilitytoopsonize
organismsandpermitcomplementmediateddestruction.
SplenectomyinpatientswithITPisadvisableasameansto
reducethedestructionofplateletsduetothepresenceof
antibodiesagainstplateletsandtheirsubsequentdestructionby
macrophagesinthespleen.
SPLENICINJURY
Childrenwithsplenicinjuriesrequiresurgicalexplorationif
significantbloodproductsarerequiredforresuscitation.They
maybeobservedifhemodynamicallystable.
DiabetesInsipidus(DI)
Etiology
Presentation
Diagnosis
Treatment
Secondarydamagetotheendocrinegland,whilenephrogenic
DIisduetoalackofrenalresponse.
Concomitantloss ofanteriorpituitary hormones. Theinability
toconcentrateurineandlossofsaltexcretion,inordinate
amountsofdiluteurinesecretionandincreasedwaterintake.
Comparingurine toplasmaosmolarity.
CentralDI istreatedwithADHreplacementalongwithany
othermissingpituitaryhormones.IncreasedADHsecretion
canbeinducedbychlorpropamide,clofibrate,and
carbamazepine.NephrogenicDIisbesttreatedwithHCTZ,
amiloride,orchlorthalidone.
DDAVPisatreatmentforDI.Urineosmolaritymayexceed300in
DI.
SECRETIONOFINAPPROPRIATEANTIDIURETICHORMONE
SecretionofInappropriateAntidiureticHormone(SIADH)
ENDOCRINESURGERY
Etiology
PITUITARY
Presentation
Theposteriorpituitaryisdirectlyinnervatedfromthe
hypothalamusandreleasesoxytocinandvasopressin.
Theanteriorpituitaryiscontrolledbythereleasingfactorsofthe
hypothalamus.Eachanteriorpituitaryhormonehasitsown
uniquehypothalamicreleasingfactor(hormone).Themain
Diagnosis
Treatment
Resultofendocrineactivitybytumors, infections,CNStrauma,
byvariousmedicationsandnormallyinhypovolemicstates
leadingtohypoperfusion.
ECFanddilutionalhyponatremiawithhypernatriuria.
ConcentratedurineisformedandtheRASisalsosuppressed.
Concentratedurinewithsodiumconcentrationover20mEq/
L.TheRASisalsosuppressed.
Fluidrestriction,demeclocycline.
PITUITARYTUMORS
Diagnosis
34
PituitaryTumors
Etiology
Presentation
Treatment
Adenomas,craniopharyngiomas,
Headache,compressionoftheopticchiasm,and
endocrinologiceffects.
Decreasehormoneproduction,radiationtherapy, orsurgical
excision.
Thesuddenonsetofacne,hirsutism,hypertension,amenorrhea,
andhypertensionmaybeattributedtoapituitaryadenoma.
THYROID
Hyperthyroidismleadstoexcessiveamountsoftriiodothyronine
(T3)and/orthyroxine(T4)leadingtothyrotoxicosis.
CommoncausesincludeGravesdisease,toxicmultinodulargoiter
(alsoknownasPlummerdisease),toxicadenomas,andsubacute
thyroiditis.
Lesscommontypesofthyrotoxicosisemanatefromiodide
induceddisease,excessbetahumanchorionicgonadotropin(B
hCG),factitiousdisease,pituitaryadenomasthatproducean
excessofthyroidstimulatinghormone(TSH),metastaticcancer
fromthethyroid,andstrumaovarii.
Gravesdiseaseisthemostcommoncause,andistheresultofan
autoimmunecomplexthatproducesantibodiesagainstvarious
thyroidproteins,antithyroperoxidase(antiTPO),andantibodies
againstTSH.
Hyperthyroidismpresentswithanxiety,anorexia,heat
intolerance,diaphoresis,tremor,hyperactivity,palpitations,and
oligomenorrhea.HTNmayoccur.
Gravesdiseaseitselfmaypresentwiththetriadofproptosis,
exophthalmos,andpretibialmyxedema.
Surgicaloptionsareavailableinrefractorycases,andinclude
surgicalexcisionofpartofthethyroidglandwithcaretakento
avoidtheparathyroidglands.Itiscommonlyemployedinsevere
cases,pregnancy,andthosewithseriouscardiacmanifestations
ofthyrotoxicosis.
Hyperthyroidism
Etiology
Presentation
Diagnosis
Treatment
THYROTOXICOSIS
Gravesdisease,toxicmultinodulargoiter,toxicadenomas, and
subacutethyroiditis.
Anxiety,anorexia,heatintolerance,diaphoresis,tremor,
hyperactivity,palpitations,&oligomenorrhea
Thyroidmaybediffuselyenlargedandfirm.Maypresentwith
thetriadofproptosis,exophthalmos,andpretibialmyxedema.
Signsofthyrotoxicosisincludetachycardia,atrialfibrillation,
HTN,smoothskin,diaphoresis,lidlag,tremor,and
hyperkinesis.Fullthyroidpanelanddetectingthepresenceof
anythyroidautoantibodies.Imaginginvolvestheuseofa
nuclearthyroidScintigraphy.
Bblockers,oralrehydration.MethimazoleandPTU, iodine,
radioactiveiodide.Overtime,supplementalTH,surgical
excision.
ThyroidStorm(ThyrotoxicCrisis)
Etiology
Presentation
Thethyroidproducescalcitonin(alsosecretedbymany
malignancies)whichhelpstoregulatecalciumlevels.Calcitoninis
antagonistictoPTH.
Therecurrentlaryngealnerveislocatedneartheinferiorthyroid
arteryandmustbepreservedduringthyroidsurgery.
Follicularcellsofthethyroidareinvolvediniodineuptake.
HYPERTHYROIDISM
Hyperthyroidisminpregnancythatisrefractorytomedical
nd
managementshouldbetreatedwithsurgeryinthe2 trimester.
Themostcommoncomplicationofradioactiveiodineablationof
thethyroidishypothyroidism.
Diagnosis
Treatment
Stressors tothebodyorpsyche.
Risingfever, elevatedanxiety,delirium,tachycardia,
restlessness,nausea,vomiting,anddiarrhea.Comacanresult.
Hyperpyrexia outofproportiontootherfindings,elevatedT3,
T4,andFT4,suppressedTSH
Antithyroidmedications,steroids,volume infusions,highdose
steroids
Tachycardiaandfeveraftersubtotalthyroidectomyfortoxicosis
maybetreatedwithpropranololtomitigatetheeffectsofthe
thyroidstorm.
SUBACUTETHYROIDITIS
SubacuteThyroiditis
Etiology
Presentation
Diagnosis
Treatment
Viralinjury,variousautoimmuneconditions,followingrelease
ofexcessiveinterferonalphaorbeta,cellularinjurymediated
byamiodarone,trauma,postpartumstate,orfollowing
radiationtherapy.
Similartothatofhyperthyroidismbutwithoutthetriadof
Gravesdisease.
Similartohyperthyroidism.
NSAIDs, corticosteroids,glucocorticoids.
Enlargementofthethyroidwithpainandsymptomsof
hypothyroidismfollowinganupperrespiratoryinfectionmaybe
treatedwithaspirin.
HYPOTHYROIDISM
Hypothyroidism
Etiology
Presentation
Diagnosis
Treatment
Congenitaldisease, autoimmunedisease,inflammation leading

totransientsymptoms,medications,priorinjuryfrom
correctionofhyperthyroidism,postpartumhypothyroidism,
andavarietyofcentralcausesleadingtodecreasedhormone
production.
Asymptomaticgoiter,weightgainwithlethargy anddecreased
energy.Coldintoleranceandconstipationarecommonly
present.Drycoarsehairwithmyxedema.
Examinationandafullthyroidpaneltoidentifydeficiencies.
Supportivetherapyandbyhormonereplacement. Goiter
resectionmaybenecessary.
PAPILLARYTHYROIDCANCER
Papillarycarcinomaofthethyroid(PTC)makesupsome70%of
allthyroidcancers.
Papillarycarcinomaishighlyamenabletotreatmentandhasa
lowmorbidityandmortalityduetoitsslowgrowingnature.
Adysfunction(possiblyhereditary)withthetyrosinekinase
receptorshasbeennotedinsomepatients.
Increasedriskofpapillarythyroidcancerisfoundinpatients
exposedtoradiationandiodinedeficiency.
Metastasistothelungsandbonesthroughthelymphatic
drainagemayoccur.
35
Medullarythyroidcancercanbetreatedwithresectionofthe
affectedlobeandisthmus.Iflymphnodesintheneckarealso
positive,amodifiedradicalneckdissectionisalsodone.
ANAPLASTICTHYROIDCANCER
AnaplasticThyroidCancer(ATC)
Etiology
Presentation
PapillaryThyroidCancer(PTC)
Etiology
Presentation
Diagnosis
Treatment
Radiation,iodineinsufficiency,possiblyhereditary
Subclinicaldisease,butamassmaybepalpableonexam.
Apainless,hardnodulemaybepresentonexam. Elevated
thyroidfunctiontestsarefoundinsomepatients.Scintigraphy
isthediagnostictestofchoice.FNABisusedtoidentifythis
typeofcancer.
Thyroidectomy,theuseofradioactiveiodine,and
levothyroxinereplacement.Radiationisusedagainst
metastases.
Thepresenceofahot,hyperactivethyroidnodulemaybe
treatedwithonlymedicaltherapyifthelongtermrisksof
surgeryarenotindicated,suchasintheelderly.
Apatientwithknownpapillarycancerwithmetastaticdisease
requiresatotalthyroidectomy,nodaldissection,andradioactive
iodinetherapy.
Theappearanceofnormalthyroidstructureinacervicallymph
nodefineneedleaspirateheraldsadiagnosisofpapillarycancer.
Thepresenceofstridorfollowingthyroidectomyrequires
openingofthewoundtoprotecttheairwayduetothe
presumptionofawoundhematoma.
FOLLICULARTHYROIDCANCER
FollicularThyroidCancer(FTC)
Etiology
Presentation
Diagnosis
Treatment
Unknownbutradiationariskfactor.
Subclinicalwithonlyamasspalpableonphysicalexam.
Elevationsinthyroidfunctiontestsmaybefound.Madeina
methodsimilartoPTC:echographytoidentifythepresence
andlocationofnodules,followedbythyroidscintigraphy,
FNAB.
Thyroidectomywithhormonereplacement,RT,occasionally
chemotherapy.
Thepresenceoffollicularcellsonafineneedleaspiration
requiresatotalthyroidectomy.Postoperativeradioactiveiodine
therapyisalsoindicated.Indeterminatefineneedleaspiration
resultsshouldberepeated;ifstillnoresults,thensurgeryis
indicated.
MEDULLARYTHYROIDCANCER
Presentation
Diagnosis
Treatment
PARATHRYOID
ANATOMY
Theparathyroidsareembeddedinthethyroidglandandare
underthecontrolofthepituitarygland.Theparathryroids
releasePTHwhichremovescalciumfromthebonesandreleases
itintothebloodstreamtomaintaincalciumhomeostasis.
Theinferiorparathyroidsarederivedfromthethirdpouch,along
withthethymus.
Thebloodsupplytotheparathyroidglandsemanatesfromthe
inferiorthyroidartery.
Thesuperiorparathyroidglandsarelocatedneartherecurrent
laryngealnerveandinferiorthyroidartery.
PHYSIOLOGY
Parathyroidhormoneincreasestheconcentrationofcalciumin
thebloodbystimulatingitsreleasefrombones,increasing
reabsorptioninthedistaltubulesandthickascendinglimbof
Henleinthekidney,andincreasingtheproductionofvitaminD
topromoteintestinalabsorption.
Duetoitseffectonthekidney,phosphateexcretionis
stimulated.
Paradoxically,osteoblastsareactuallystimulatedasprolonged
osteoblasticstimulationactuallystimulatestheosteoclastsofthe
bonetopromotecalciumrelease.
Calcitoninreducestheconcentrationofserumcalciumby
decreasingtheabsorptionofcalciumfromtheintestines,
promotingthemineralizationofbonesbystimulating
osteoblasts,andincreasesitseliminationfromthebodythrough
thekidney.Calcitoninalsodecreasesphosphatereabsorption.
MedullaryThyroidCancer(MTC)
Etiology
Diagnosis
Treatment
Relatedtooncogenes,andmaybetheendresultofa
longstandingpapillaryorfollicularthyroidcancer.
Rapidlygrowingneckmassthatimpingesuponother
structures,anddistantmetastasesthatleadtolocaland
systemiceffects.
FNAB
Thyroidectomy withchemotherapyandradiotherapy maybe
attemptedinsomecases,butthemajorityoftherapyis
palliative.Chemotherapeuticagents.
Unilateraldiseasearisesspontaneously,whilebilateraldisease
ismorecommoninthosewithafamilialheritage.
Asymptomaticthyroidmassthatmayoccasionallypresent
withcarcinoidsyndrome,diarrhea,andsymptomsfromdistant
metastases.
Abnormalcalcitoninlevelsandapentagastrininducedincrease
incalcitoninarediagnostic.Retoncogenetestingisalsoused.
FNABconfirmsthediagnosis.
Thyroidectomy,hormonereplacementandtreatingany
secondarydiseasefromMEN2orMEN3.
PRIMARYHYPERPARATHYROIDISM
PrimaryHyperparathyroidism
Etiology
Presentation
Diagnosis
Treatment
Hyperplasia oftheparathyroidglands andreset ofthenormal

PTHsetpoint.MayberelatedtoMEN1andMEN2,although
themajorityofcasesareisolated.
Bone pain, nephrolithiasis,metastaticcalcification, osteopenia
andosteoporosis,fatigue,andotherconstitutionalsymptoms.
Examiningtotalcalciumandionizedcalciumlevels, PTH titers,
anda24hoururinecalciumexcretion.RuleoutFHH.
Calcium supplements,volumeexpansion, loopdiuretics, and
surgicalinterventionthatexcisestheabnormaltissue.
Scintigraphyusingradioisotopesofiodinearethediagnostictest
ofchoice;CTandMRIareusedonlytoidentifydistant
metastases.
Fineneedleaspirationbiopsy(FNAB)isuniversallyusedto
identifythistypeofcancer.
TreatmentofPTCinvolvesthyroidectomy,theuseofradioactive
iodine,andlevothyroxinereplacement.Radiationisusedagainst
metastases;chemotherapyishelpfulinonlyafractionof
patients.
36
Diarrheaassociatedwithhyperparathyroidismislikelydueto
concomitantMENsyndromeleadingtoagastrinoma.
Fourglandhyperplasiaismanagedbyatotalresectionfollowed
byreimplantationofasinglegland.
Ifparathyroidglandsaremissingonaneckexploration,an
ultrasoundshouldbedonetoruleoutanintrathyroidgland.A
sternotomyisnotindicated.
Themostcommonpresentationofhyperparathyroidismis
asymptomatichypercalcemia.
SECONDARYHYPERPARATHYROIDISM
Thepresenceofparathyroidcancerwhenexploringfor
hyperparathyroidismshouldelicitawideexcision.Hypercalcemia
andnodulesinthelungmaybeotherpresentingsignsofcancer.
ADRENAL
HYPERCORTISOLISM(CUSHINGSYNDROME)
CushingSyndrome
Etiology
Presentation
SecondaryHyperparathyroidism
Etiology
Presentation
Diagnosis
Treatment
DuetoCRF,vitaminDdeficiency,andothersecondarycauses.
Commonlyfoundinpatientsreceivingdialysis.
Metastaticcalcification,osteitisfibrosacystica,bone erosions
leadingtoagroundglassappearanceintheskull,
hyperphosphatemia,andnormalcalcium.
HighCRFandPTHlevels
Calciumsupplements,calcitonin,andcontrollingphosphate
levelswithphosphatebindersanddiet.Mayleadtosurgical
treatment.
TERTIARYHYPERPARATHYROIDISM
TertiaryHyperparathyroidism
Etiology
Presentation
Treatment
Followinghypertrophyofglandsinsecondary
hyperparathyroidism.
Elevationsinphosphateoccuranddiffusecalcinosis also
occurs.
Parathyroidectomywithhormonesupplementation.
HYPOPARATHYROIDISM
Hypoparathyroidism
Etiology
Presentation
Diagnosis
Treatment
Primaryparathyroidectomy,destructionoftheglands in
radiationtherapyoraccidentalexcisioninthyroidectomy,
autoimmunesyndromes,andvariouscongenitalcauses.
SecondarylowPTHlevelsduetohypercalcemiacausedby
anotheretiology.
Seizures,personalityandmoodchanges,paresthesias,
hoarseness,musclecramps,andirritability.
ChvostekandTrousseausignsandchoreoathetosis mayoccur.
Paraplegia,Parkinsonism,dystonia,andothermotordefects
mayalsooccur.PTHtitersaredecreasedinprimarydisease
withhypocalcemia;secondaryhypoparathyroidismmay
presentwithlowPTHandelevatedcalcium.
PTHsupplements,calciumsupplements,andvitamin D
supplements.
PSEUDOHYPOPARATHYROIDISM
Pseudohypoparathyroidism(PHP)
Etiology
Presentation
Diagnosis
Treatment
Duetogeneticdefectsthatleadtohypocalcemia,
hyperphosphatemia,increasedPTH,andinsensitivitytoPTH.
AHO,hypocalcemia.
Confirmationofhypocalcemia,PTHassays,assessingPTH
responsiveness,andconductingotherendocrinefunction
tests.BasalgangliacalcificationmayalsobepresentonCT.
Calciumchlorideisthepreferredagent.IVcalcium,vitamin D,
calcitriol,andcarefulmanagementofcalciumandphosphate
homeostasis.
Pseudohypoparathyroidismisduetoendorganresistance.
PARATHYROIDTUMORS
Diagnosis
Treatment
Adrenal adenoma,pituitarytumor.Mostcommonlyattributed
toexcessglucocorticoidadministration.
Moonfacies,buffalohump,fatpadsinthehead andneck,
truncalobesity,striae,proximalmuscleweakness,bruising,
hirsutism,HTN,DM.
Excesscortisol productionidentifiedbyUFClevel,apositive
dexamethasonesuppressiontest,andvariousimagingstudies
toidentifypituitaryoradrenaladenomas.
Surgicalresectioninprimarydisease,radiation therapy.
Glucocorticoidreplacementmaybenecessary.Possible
chemotherapeuticintervention(seeabovetext).
EctopicproductionofACTHshouldbesuspectedinthepresence
ofpersistenthypercortisolismafterresectionofatranssphenoid
adenoma.
LossofcortisolfeedbackmayleadtoACTHderangementsin
shock.
SmallcelllungcancersometimesproducesACTH.
PSEUDOCUSHINGSYNDROME
PseudoCushingSyndrome
Etiology
Presentation
Diagnosis
Treatment
Excessalcohol consumption
PresentslikeCushingsyndromewithspontaneousresolution
withinamatterofweeksormonthsafteravoidingalcohol.
Historyofalcohol abuseandincreasedCRH.
Spontaneouslyresolvesafteravoidingalcohol.
HYPERALDOSTERONISM(CONNSYNDROME)
ConnSyndrome
Etiology
Presentation
Diagnosis
Treatment
Adenomaoradrenal hyperplasia.
Muscleweakness, DI,HTN,CHF,andothersymptomsof
hypernatremiaandhypokalemia.SuppressionoftheRAA.
Abnormal24hoururinealdosteronetest,CT.
Symptomatic treatmentofHTNandcorrectingunderlying
electrolytedisturbances.Sodiumrestriction,diuretics,ACE
inhibitors,calciumchannelblockers,andARBs,
adrenalectomy.
HYPOALDOSTERONISM(ADDISONDISEASE)
Hypoaldosteronism
Etiology
Presentation
Diagnosis
Treatment
DecreasedreninproductioninCRF.
Arrhythmia,mildacidosiswithHTN.
CRF withhyperkalemiaconfirmsthediagnosis.
Loopandthiazidediuretics,sodiumbicarbonate,
fludrocortisone.Resinsthatbindtopotassium.
ADRENALINSUFFICIENCY
AdrenalInsufficiency
Etiology
Presentation
Adrenal failure. Duetowithdrawalfromsteroidtherapy, asa

consequenceofsepticshockandinpatientswhousecertain
medications.
Presentssuddenlyandcanleadtoshock.Inability toregulate
temperature,nauseaandvomitingcanalsooccur.Abdominal
painiscommon.
37
Diagnosis
Treatment
AbnormalACTHtestthatleadstolittlechangeincortisol.
EKG.
Glucocorticoidsadministration.Fluidandelectrolyte
correction,hypotensionreversalwithdopamineor
norepinephrine.
Diagnosis
Treatment
Electrolyteabnormalitiesinadrenalinsufficiencyinclude
hyperkalemiaandhyponatremia.
ApostoppatientwithahistoryITPandshockshouldreceive
hydrocortisonetoforestalltheadrenalcrisis.
complicationscausedbyNIDDMarenumerous.
GCT
Reversingdeleteriousexerciseanddiet trends.Reducingrisk
factors.Controllingconcurrentdiseases.Tightglycemic
control.Forpregnantwomen,glyburide.Insulinistheonly
recommendedtreatmentforwomenwithahistoryofNIDDM.
Medicalinterventionsincludesulfonylureas,meglitinides,
biguanides,metformin,alphaglucosidaseinhibitors,
glitazones,andexenatide.Obeseindividualsareinitially
startedonmetformin.Sulfonylureasareacceptableinpersons
ofnormalweight.
PHEOCHROMOCYTOMA
Treatment
Catecholaminesecretingtumors.
SymptomsofveryhighBP.Endorgandamage maybeevident.
Metanephrineiselevated,alongwithvanillylmandelicacid and
catecholamines.
Alphablockadeusingphenoxybenzaminefollowedbybeta
blockade.Resectionisnecessary.
AMIBGscanshouldbeconductedwhenimagingforextra
adrenalpheochromocytoma.Thesetendtohaveahigher
malignancypotentialandtendtobelocatedneartheaortic
bifurcation.Theytendtobeontheleftsideneartheoriginofthe
inferiormesentericartery,inanareaknownastheorganof
Zuckerkandl,aderivationoftheneuralcrest.
Whenproceedingwiththepreoperativeworkupforresectionof
apheochromocytoma,alphablockadeshouldbedonefirst
followedbybetablockade.Phenoxybenzamineisagoodfirstline
agent.
Incidentaladrenalmassesover5cmshouldbeexcised.Smaller
onesmaybeobserved.Atransabdominalapproachistypically
used.
ENDOCRINEPANCREAS
DiabeticKetosis(DKA)
Etiology
Presentation
Diagnosis
Treatment
ExacerbationsofDM,includinginfection, missingmedications,
andseriousillnessorstressorssuchasMI,CVA,pregnancy,
andsurgery.
Hyperglycemia,constitutionalcomplaints,andgeneralmalaise.
Drymucousmembraneswithdecreasedskinturgor.Reflexes
aretypicallydiminished,andrespirationislabored.
Tachycardiaandhypotensioncanoccur,alongwithtachypnea
andhypothermia.Afruitysmellofketonesispresentonthe
breath.
Hyperglycemia, bicarbonatelessthan15,andpHbelow7.3.
Ananiongapmetabolicacidosisispresent.
Correctunderlyingelectrolyteabnormalities. Treatunderlying
infectionsquickly.FollowNSwithNS,andreplenish
potassium.SignificantlyacidicpHshouldbecorrectedwith
bicarbonate.InsulinisadministeredtoreversetheDKA.
HYPEROSMOLARHYPERGLYCEMICNONKETOTICCOMA
HyperosmolarHyperglycemicNonketoticComa(HHNC)
Etiology
Presentation
Glucoseuptakeintheintestinesisanactiveprocessandrequires
asodiumgradient.
Glucosemetabolisminearlysepsisisretardedduetodecreased
utilization.
Theintermediarybetweenlactateandglucoseispyruvate.
Ahormonepresentinearlysepticshockisglucagon.
TYPEIDIABETESMELLITUS
DIABETICKETOACIDOSIS
Diagnosis
Treatment
Coma duetodehydrationandhyperglycemia. Itiscommonly

secondarytostressorsorinfection.
Delirium andotherCNSchanges,seizures, hemiparesis,
paresthesias,andsensorydeficitsculminatingwithstuporthen
coma.Signsandsymptomsofdehydrationandhyperglycemia
arepresent.
Examinationshouldfocusonrulingouteasilydiscernable
infections.Electrolytederangementsarecommonlypresent,
andglucoseisoftennear1,000mg/dL.Someoverlapwith
DKAispossible.
MaintainingtheABCs,correctingthedehydration, andtreating
thehyperglycemia.LargebolusesofNSaregivenearly.
Thiamine,dextrose,andnaloxonearegivenifthepatientis
comatose.Insulintherapycanamelioratesymptoms.
TypeIDiabetesMellitus
Etiology
Presentation
Diagnosis
Treatment
Autoimmunedestructionofpancreaticbetacells.
Polyuria,polydipsia,andpolyphagiawithsymptomsof
hyperglycemia,ketoacidosis.Patientstendtobethinand
complainofnumerousconstitutionalsymptoms.Blurred
visioniscommon.
Fastingglucose,anabnormalOGTT,andabnormalinsulin
titers.
Insulinandmonitoringofglucoselevels.Transplantofbeta
cellscanbeattemptedinsomepatients.Dietandexerciseare
thekeystogoodmanagement.
TYPEIIDIABETESMELLITUS
Type2DiabetesMellitus
Etiology
Presentation
Multifactorialinheritancewithenvironmentaltriggersinthe
formofapoordietandlackofexercise.
Typicallyasymptomatic.Obesityisacommonpresentation,
andpregnantwomenmaydeliveraninfantthatisLGA.Later
HYPOGLYCEMIA
Hypoglycemia
Etiology
Presentation
Diagnosis
Treatment
Variousstressors inadditiontohyperinsulinemia.
Profoundmentaldeficitsleadingtopermanentdefects can
occur.Cardiacdefectscanalsoarise,andallofthisdamage
canleadtocoma.
Cpeptideiselevatedwithinsulinomas andnormalorlowwith
exogenousinsulin.CTexammaybenecessarytoidentifythe
preciselocationoftheinsulinoma.
AdmissiontotheICUandrapidcorrectionoftheglucose
deficiency.Supportivetherapyisrequiredandcareful
management.
ACpeptidelevelshouldalwaysbedeterminedinhypoglycemic
patientswhoaresuspectedofsurreptioususeofinsulin.
Glucoseshouldnotbeinfusedfasterthan4mg/kg/min.
Pheochromocytoma
Etiology
Presentation
Diagnosis
38
INSULINOMA
HEADTRAUMA
Insulinomashouldbeconfirmedafterdeterminingaratioof
insulintoglucosegreaterthan0.4bymeasuringtheCpeptide
level.Insulinomascanbelocatedanywhereinthepancreas,and
typicallypresentswithsymptomatichypoglycemia.
MULTIPLEENDOCRINENEOPLASIA
ThepresenceofaMENtumorwithamigratoryrashshouldbegin
asearchforaglucagonoma.Glucagonomastypicallypresentwith
signsandsymptomsofdiabetesmellitus,glossitis,stomatitis,and
amigratorynecrolyticerythematousrash.Thetreatmentis
octreotide.
BothMEN1andMEN2havehyperparathyroidism.Recallthat
thetherapyforthisistotalparathyroidectomywithauto
reimplantationofasinglegland.
InMEN,explorationoftheneckshouldprecedepancreatic
intervention.
Urinecatecholaminesneedtobecheckedbeforeproceeding
withathyroidectomyinMEN.Thisisdonetoruleouta
pheochromocytoma.VMAlevelsshouldbechecked.
MultipleEndocrineNeoplasm(MEN)
Etiology
Presentation
Diagnosis
Treatment
MEN1Autosomaldominantdisorderfoundonchromosome
11thatleadstodefectsintheproteinmenin.
MEN2AutosomaldominantdisorderthataffectsRETproto
oncogene.
MEN3RETprotooncogenedefect.
MEN1symptomsofhyperparathyroidisminconjunction with
ZES.
MEN2MTCandsometimesalsowithpheochromocytoma.
MEN3Marfanoidhabitus,neuromas,andMTC.
Presenceofthetumorthroughavarietyoflaboratory tests
andimagingstudies.
Generallyinvolvessubtotalortotalremovaloftheendocrine
organfollowedbyhormonereplacement.
TRAUMASURGERYANDCRITICALCARE
TRAUMA
GLASGOWCOMASCALE
GlasgowComaScale(GCS)
Eyeresponse
Verbal
response
Motor
response
Interpretation
Noeyeopening(1point),eyeresponsetopain (2),eye
responsetoverbalcommand(3),andspontaneouseye
response(4).
Noverbalresponsegets1point,incomprehensivesounds
(2),inappropriatewords(3),confused(4),andorientedgets
5points.
Noresponse(1),extensiontopain(2),flexiontopain(3),
withdrawalfrompain(4),localizingpain(5),andobeying
commands(6).
>13mildornonexistentbraininjury;129moderateinjury;
<9issevere.
Anunstabletraumapatientwithgrossperitonealsignsanda
widenedmediastinumshouldreceiveanexploratorylaparotomy
first.Anunstabletraumapatientwithalightpinkdiagnostic
peritoneallavageandapelvicfractureshouldreceiveanexternal
fixationofthefracturefirst.
Spinalcordfunctionmayremainintactwithbriskdeeptendon
reflexesinpatientswhoarebraindead.
Apatientwithaclosedheadinjurywhohashypernatremiaanda
urineosmolaritygreaterthan300shouldreceiveDDAVPforthe
treatmentofDI.
Hypotensioninthesettingofheadtraumarequiresurgentfluid
resuscitation.
Thepresenceofalucidintervalfollowingheadtraumashould
beginasearchforanepiduralhematoma.
TheCushingresponseinvolvesbradycardia,hypertension,and
irregularrespirations,andisasignofaheadinjury.
Asubduralhematomaisassociatedwithahighmortalityrate
duetotheunderlyingbraincontusionthatlikelyaccompanies
thispresentation.
Anindicationforathoracotomyinthesettingoftraumaisthe
presenceofchesttubeoutputgreaterthan250cc/hrforover4
hours.
Afluctuantneckmassinanewbornislikelyacystichygroma;
thesetendtohaveahighrecurrencerate.
Freeruptureoftheumbilicalarteryislikelyduetogastroschisis.
BURNS
FIRST,SECOND,ANDTHIRDDEGREEBURNS
Afirstdegreeburnextendsonlyintotheepidermisandtypically
leadstoonlyredness,asmallwhiteplaque,andeventual
resolutionwithoutscarformation.
Aseconddegreeburntypicallycausesclearblisteringwithfluid
andinvolvesthedermis.Painisvariabledependingonlocation
andextent.
Thirddegreeburnsarefullthicknessandtypicallyleadto
charringoftheskin.Hardescharsareformedwithapurplefluid.
Thereisnopainwiththirddegreeburns.
BodyPart
Head
AnteriorTorso
PosteriorTorso
Perineum
EachArm
EachLeg
Adults Infants
9%
18%
18%
1%
9%
18%
18%
18%
18%
1%
9%
14%
Aburnpatientwhohascircumferentialburnsaroundan
extremityrequiresanescharotomytopreventcompartment
syndrome.Thesameisthecaseforfullthicknessburnstothe
chest.
Thepresenceofanonhealingchronicwoundfollowingaburn
needstobebiopsied.
Mafenideacetateisanagentgiventopicallytoburnvictimsthat
cancausemetabolicacidosis.
Cortisolmaybeelevatedinburnpatientsseveraldaysfollowing
injuryaspartoftheadrenalresponsetostress.
Aburnpatientwhoundergoesintubationandanesthesiafora
procedurefollowingtheburnmaygointocardiacarrestdueto
hyperkalemia.
39
Normalurineoutputforayoungchildis1cc/kg/hr.Childrenalso
arenormotensiveatlowerbloodpressurescomparedtoadults.
Traumainchildrenshouldbegiven20cc/kgofLRinitiallyifthey
arehypotensive.
CARDIOGENICSHOCK
Anintraaorticballoonpumpisindicatedinthesettingof
cardiogenicshocktoreduceafterload,reducetheextentof
cardiacischemicinjury,andpromotefilling.
Causesoftoxicepidermalnecrolysisincludedilantinandbactrim.
Biopsyoftheskinwillindicatenondisjunctionofthedermaland
epidermalinterface.
VENTILATIONANDAIRWAYMANAGEMENT
BITES
Followingahumanbite,anincisionanddrainageshouldbedone.
Augmentinshouldbegiventothepatient.Tetanusvaccination
shouldalsobeverifiedandIgGshouldbeconsidered.
Dapsoneisthedrugofchoicefollowingabitebyabrownrecluse
spider.
SHOCKANDRESUSCITATION
ANTICHOLINERGICSNICOTINICANTAGONISTS
DRUG
MECHANISMOF
ACTION
Succinylcholine
POSTOPERATIVEFEVER
FeverPostOperative
Days12
Days35
Days46
Atelectasispreventwithincentivespirometry.
UTIprophylacticmeasures.
DVTpreventwithLowdoseheparinandtheuseofSCD. Have
thepatientambulateassoonaspossiblefollowingsurgery.
Infectionsofsurgicalwoundspreventwithprophylactic
antibiotics.
Iatrogenic(oftenfrommedications).
Days57
Days7
beyond
SYSTEMICINFLAMMATORYRESPONSESYNDROME
SystemicInflammatoryResponseSyndrome(SIRS)
Presentation
Diagnosis
Treatment
Fever(notalwayspresentintheelderly),tachycardia, narrow
pulsepressure,hyperpnea,andhypotensioninseriouscases.
Thereisnoendorgandamage,bacteremia,orsignificant
medicalsupport.
CBC,ABG,CC1,PT,aPTT,Ddimer,fibrinogen, andLFTs.
Panculturesarealsocollected.
AdmissiontotheICU,closeobservation,andsupportive
therapy.Fluidrepletion,andmonitoringcardiacfunction
througha(PAC)isoftendone.
SEPSIS
Sepsis
Etiology
Presentation
Treatment
Infection
SepsismeetsthecriteriaforSIRSinadditiontoasymptomatic
bacteremia.Organdysfunctionmayalsobepresent.Fever
andmentalstatuschangesarecommon.Respiratoryalkalosis
isoftenpresent.
IVlinesshouldbeimmediatelytestedandchanged,especially
centrallines.Acompletephysicalexamshouldbedoneto
identifywhetherothersourcesexist.Laboratoryanalysis
proceedsinamannersimilartothatofSIRS.CXR,US,andCT
arealsooftenusedasnecessary.Supportivetherapyand
maintainingorganperfusionareessentialtodecrease
morbidityandmortality.Antibioticsasdiscussedaboveare
essentialformostcasesofsepsis.InfectionbyIVlinesmaybe
treatedwithimipenem,meropenem,cefoperazone,cefepime,
orvancomycin.
Cisatracurium
Vecuronium
Rocuronium
Dantrolene
CONTRAINDICATIONS
Rapidonsetandshort
durationwithdecrease
inexcitatorypotential
belowthreshold.
Initialstagewith
prolonged
depolarizationleading
tofasciculationsand
musclepain.
Secondstagewith
repolarizationbut
blockadeofreceptors.
Nicotinic receptor
blockade
Malignant hyperthermia
possiblewithuseofHalothane
Avoidinpatientswith
increasedintracranialpressure
andcardiacdisease.
Nicotinicreceptor
blockade
Competesfor
cholinergicreceptorat
motorendplates
Interfereswithcalcium
ionreleaseby
sarcoplasmicreticulum
Activehepatic disease, OPD
Nondepolarizingblockadecanbereversedwithneostigmine,
edrophonium,andcholinesteraseinhibitors.
Avoidtheuseofsuccinylcholineinpatientswithhyperkalemia.
Avoidfollowingburns,inDuchennemusculardystrophy,crush
injuries,andmultiplesclerosis.
Malignanthyperthermiapresentsasadisorderofcalcium
metabolismwithdecreasedreuptakebythesarcoplasmic
reticulumleadingtoincreasedintracellularcalcium.Anearlysign
ofmalignanthyperthermiaisanincreaseinendtidalCO2.Thefirst
physicalfindingisthepresenceofspasmsinthemasseter.
Themusclethatisthelasttobeparalyzedandthefirsttorecover
fromparalysisisthediaphragm.
Themostcommonsideeffectofpancuroniumistachycardia.
Atracuroniumisanondepolarizingagentwithouthepaticorrenal
clearance.ItisclearedbyHoffmanelimination.
SEDATIVES/HYPNOTICS
DRUG
Midazolam
IncreasingPEEPleadstoincreasedrecruitmentofalveoli.PEEP
alsoleadstoaredistributionofbloodflowtothecortexinthe
kidney.
MECHANISMOFACTION
NOTES
Shortacting.
TOXICEPIDERMALNECROLYSIS/STEVENSJOHNSON
SYNDROME
ActivatedproteinC(Xigris)usedinthetreatmentofsepsisleads
tofibrinolysis.
SepsisisassociatedwithanincreaseinIL6.
Glucocorticoidsinshockleadtoinsulinresistance.
40
Diazepam
Flumazenil
Competitivelyinhibits
benzodiazepinereceptorsite
Longacting
Notrecommendedincyclic
antidepressantpoisoning
Toxicitywithbarbiturates,especiallythiopental,presentsas
myocardialdepression.
Benzodiazepinesleadtoamnesiabutnotanalgesia.
ANESTHETICSINHALED
DRUG
Sevoflurane
Nitrous
oxide
Desflurane
Rapidonset
Hypotonic
Minimal
Lowestpotency,
combinedwith
otheragents
Isotonic
DRUG
MECHANISMOFACTION
Midazolam
Ketamine
Dissociativeanesthetic
Hyperpolarizationand
presynapticinhibitionatthe
muopioidreceptor.
Neteffectischangeinneural
activityalongvarious
pathways,especiallypain
pathways.
Fentanyl
Propofol
Mostrapid
onset
DRUG
Lidocaine
Bupivacaine
Hypertonic
Presentation
NOTES
Benzodiazepine;reversew/
flumazenil
Arylcyclohexylamine
Opioid,goodanalgesia
Notolerancetomiosisor
constipation.
Opioid,goodanalgesia.
Morphinebindstomu,
enkephalinsbindtodelta,and
dynorphinsbindtokappa.
Codeineisapartialmu
agonist.
Nocumulativeeffects,strict
aseptictechniquemustbe
maintained.
VisceralpainiscarriedbyCfibers.
Nociceptivestimuliiscarriedviaafferentnervesofthe
spinothalamictract.
Ariskofgeneralanesthesiaindiabetesmellitusishypoglycemia.
Ketamineisahallucinogenthatleadstoamnesia,analgesia,and
musclerelaxation.
ANESTHETICSLOCAL
Hyponatremia
Bradycardia,hepatitis,malignant
hyperthermia,arrhythmia,respiratory
depression,increasedICP
Bradycardia,respiratorydepression,
increasedICP
ANESTHETICSINTRAVENOUS
Morphine
NOTES
Airwayirritation,coughing,respiratory
depression,increasedICP
FLUIDANDELECTROLYTES
HYPONATREMIA
COMPLICATIONS
Halothane
Lidocainetoxicitypresentswithtinnitus,tingling,numbness,
seizures,mentalstatuschanges,andfinallycardiaccollapse.CNS
effectstakeplacefirstfollowedbycardiovascularderangements.
LocalanestheticshavedecreasedefficacyinacidicpH.
SpinalanestheticsarecontraindicatedwhenICPisincreased.
MECHANISMOF
ACTION
NOTES
Amides
Penetrateinuncharged
form,thenbindincharged
form
Greateramountsneededin
infectedtissue(acidictissue)
Diagnosis
Pseudohypona
tremia
diagnosis
Treatment
Thepresenceofhyponatremiainthesettingofcirrhosisshould
bemanagedwithwaterrestrictiononly.
Correctinghyponatremiatooquicklymayleadtothe
developmentofneurologicsymptoms.
ConservationofsodiumisdonethroughanADHindependent
reabsorption.
HYPERNATREMIA
Hypernatremia
Hypovolemic
Isovolemic
Hypervolemic
Smallerfibersaffectedfirst,
sopainislostfirst,thenT,
touch,andfinallyP
Givewithepinephrineto
increaselocaleffects
Noallergiccrossreactivity
betweenestersandamides.
Longduration.
Hypovolemicdiuretics,saltwastingsyndromes,vomiting,
diarrhea,burns,andthirdspacing
Isovolemicrenalfailure,SIADH,deficienciesin
glucocorticoids,hypothyroidism,&variousmedications.
Hypervolemiccirrhosis,CHF,andnephroticsyndrome,
CPMtendstooccurinseverehyponatremia,andpresents
withstupor,confusion.
Excessiveisotonicinfusionswithglucose ormannitol, and
pseudohyponatremia.
Hyperglycemia andhypertonicinfusionsofglucose or
mannitol.
Moderatehyponatremiapresentswithconfusion,lethargy,
anorexia,&myalgia.
Severehyponatremiapresentswithcomaorseizure.
Examiningtheosmolarity,carefullyassessingthepatientfor
objectivesignsandsymptoms(i.e.tachycardia,
dehydration),andmeasuringserumglucose.
Normalorelevatedosmolaritythatdoesnotmatchthe
calculatedosmolarity;causesincludemultiplemyeloma&
hypertriglyceridemiathatincreasetheproteinorlipid
fractionintheplasma.
Correcttheserumsodium.Hypovolemichyponatremia is
correctedwith0.9%NS;hypervolemichyponatremiais
correctedwithsodiumandwaterrestriction.ACEinhibitors
maybebeneficialinthelattercondition.
Presentation
Treatment
Commonlycausedbywaterloss,renalloss throughdiuretics,
GIlosses,respiratorylosses,orskinlosses.
CommonlytheresultofdecreasedTBW withadecreasein
ECF;itmayalsobedueDI,skinlosses,&centraldefectsin
osmolarity.
CommonlyduetoincreasedTBWwithincreasedsodium,
hypertonicfluidorexcesssaltintake,Connsyndrome,and
Cushingsyndrome.
Fatigue, confusion,andlethargythatcanprogress.
NS. VasopressinisusedifthepatienthasDI. Hypervolemic
hypernatremiaistreatedwithNSandloopdiuretics.
HYPOCHLOREMIA
Hypochloremicalkalosisshouldbetreatedwithpotassium.
Vomitingwillleadtoahypochloremicmetabolicalkalosis.
HYPOKALEMIA
Hypokalemia
Etiology
Canbeattributedtopoorintake,increasedexcretion, anda
shiftfromtheextracellularspacetotheintracellularspace.
41
Diagnosis
Treatment
Hyperaldosteronismwillpresentwithhypokalemia.
Presentation
Diagnosis
Treatment
HYPERKALEMIA
Hyperkalemia
Etiology
Presentation
Diagnosis
Treatment
Increasedintakeofpotassium,impairedexcretionof
potassium,orashiftfromtheintracellulartoextracellular
space.Decreasedexcretioniscommonlyduetopotassium
sparingdiuretics,ACEinhibitors,NSAIDs,ortypeIVRTA.
Hyperkalemiaismostcommoninhospitalizedpatientswho
experiencerhabdomyolysis,diabetes,andahighrisksubset
thattakesACEinhibitors.Otherimplicateddrugsinclude
cyclosporine,pentamidine,TMPSMX,heparin,ketoconazole,
andmetyrapone,21hydroxylasedeficiency,and11beta
hydroxylase.
PeakedTwaves,PRintervalprolongation,QRSwidening,
disappearanceofthePwave,asinewavepattern,andfinally,
sinusarrest.Bradycardiamayalsobepresent.
Renalfunctionteststoidentifyrenalinsufficiency, anddoing
anEKG.
Detectingandtreatinganytoxicitycausedbythe
hyperkalemia.Removingexcesssourcesofpotassiumis,
shiftingpotassiumintracellularlywithglucoseandinsulin
administrationorusingbicarbonatetorepairametabolic
acidosisandusingbetablockers.Increaseexcretionof
potassiumwithfluorohydrocortisoneandstoppingany
potassiumsparingdiureticsandACEinhibitors.GIexcretion
canbeincreasedwithpotassiumbinding.Dialysisisanoption
inemergencysituations.
HyperkalemiashouldbetreatedwithcalciumwhenEKGchanges
arepresent.
HYPOCALCEMIA
Hypocalcemia
Etiology
Presentation
Diagnosis
Treatment
Disarrayinnormalcalcium regulationbyvitamin D,
irregularitiesinPTHandcalcitoninalongwithderangementsin
magnesiumandphosphorus.Othercausesinclude
pancreatitis,sepsis,rhabdomyolysis,tumorlysissyndrome,
hypoalbuminemia,magnesiumdeficiency,andexposureto
toxinssuchasfluoride,ethanol,phenytoin,citrate,and
cimetidine.
Presenceofcircumoralparesthesia,apositiveChvosteksign,
andapositiveTrousseausign.
ElectrolytepanelsandEKGfindingspositiveforaprolongedQT
interval.Checkalbuminlevels.
IdentifyinganyPTHdeficitandreplacingwithvitamin Dor
calcitriolalongwiththiazidediuretics,replenishingany
decreasesinmagnesium,phosphaterestriction,oralcalcium
supplementation,andinfusioninemergentsituations.
Hypercalcemiccomashouldbetreatedwithfluidandlasix;
dialysisisthefirstlinetherapy.
Recallthathypercalcemiawithdiarrheashouldbeginasearchfor
MENsyndrome;gastrinlevelsshouldbemeasured.
HYPOPHOSPHATEMIA
Hypophosphatemia
Etiology
Presentation
Diagnosis
Treatment
HYPERPHOSPHATEMIA
Hyperphosphatemia
Etiology
Presentation
Treatment
PrimarilyaffectsthekidneysandCNSleadingtofatigue,
depression,personalitychanges,confusion,somnolence,and
evencomaanddeath.Nephrolithiasisisthemostcommon
renaleffect.Positiveinotropyandarrhythmiasarecardiac
effects,whileGIeffectsmayleadtoconstipationandanorexia.
Thevastmajorityofcasesareduetohyperparathyroidismor
Excessiveintake,decreasedexcretion throughrenal failure or

hypoparathyroidism(includingpseudohypoparathyroidismand
hypomagnesemia),andashiftfromintracellularto
extracellularspace.
Hypocalcemia &malignantcalcification. Mostpatients are
asymptomatic,butmusclecramps,perioralparesthesia,
uremicsymptoms,andgeneralmalaisecanoccur.
Treatingrenal failure,dietaryrestriction,phosphate binders,
insulinandglucoseinfusionasatemporarymeasure,and
dialysisinmoreseriouscases.
HYPOMAGNESEMIA
Hypomagnesemia
Hypercalcemia
Etiology
Poorintakeorrelativelylowintake,increasedexcretion,anda
shiftfromextracellulartointracellular.Alcoholics,patients
witheatingdisorders,Crohndisease,vitaminDdeficiency,
RTA,antacidsthatbindtophosphate,hyperparathyroidism,
hypokalemia,hypomagnesemia,volumeexpansion,and
acetazolamide.
Rhabdomyolysis withmuscleweakness, seizures andcoma,
hemolyticanemia,andplateletdysfunction.
Ruleout:glucose andinsulininfusion, respiratory alkalosis.
Measuretheurinephosphatecontent.
OralrepletioninminorcasesorIVadministrationifsevere.
VitaminDsupplementationisalsooftengiven.
Parathyroidectomymaybeindicatedwithparathyroidcauses.
Hypophosphatemiafollowingrefeedingpresentsasrespiratory
failureduetothephosphorylationofglucoseintermediariesand
adropinavailablePO4andsubsequentlossofATPgeneration.
Etiology
HYPERCALCEMIA
malignancy.Mostcasesofmalignancyareduetometastasis
ofanexistingcancertothebone,whiletheremainderaredue
tocancersthatsecretePTHrP.Otherconditionsinclude
vitaminDexcess,granulomatosis,vitaminAexcess,andrenal
failure.
Presenceofthesymptomsdiscussedabove.Dehydration is
common,andmetastaticcalcificationsinothertissuesis
commoninmoreseverecases,particularlyifphosphorusis
alsohigh.
PTH levelsshouldbemeasuredandasearchformalignancy
shouldbeundertaken.EKG.Checkalbuminlevels.
Volume repletion,mobilization,reducingGIcalcium absorption
withprednisoneandoralphosphate,preventingbone
resorptionwithbiphosphonatessuchaspamidronate,
etidronate,risedronate,andalendronate,andadministering
calcitonin.Dialysismayalsobeusedinmoreseriouscases.A
surgicaloptionincludesapartialparathyroidectomy.
Presentation
Diagnosis
Commonlyduetomalabsorptionorpoordietaryintake,excess
excretionsuchduetodiarrhea,diuretics,ATN,hypokalemia,
hypercalciuria,orendocrinedisturbances,andredistribution
withinthebodyasinhypoalbuminemia,pancreatitis,glucose
andinsulinadministration,andinprolongedexercise.
Weakness, increasedreflexes,seizures, hypokalemia, and
hypocalcemia.
EKG changesincludeprolongedQT,flattenedTwaves, anda
prolongedPRinterval.Atrialfibrillationisacomplication,and
Presentation
OthercausesincludevitaminB12use,Bblockers, correcting
digoxintoxicitywithantibodytherapy,andalkalosis.
HTN,iftheunderlyingcauseisprimaryhyperaldosteronismor
licoriceingestion,whilehypotensionmaysuggestionlaxative
abuse,Barttersyndrome,orbulimia.Itmayalsopresentwith
flaccidity,muscleweakness,lossofDTRs,arrhythmia.
UA
Preventingthepotassiumloss,replenishingthepotassium
storeswithPOorIV,monitoringforhypokalemictoxicity.
42
Treatment
Torsadedepointesmayoccur.
MagnesiumoxidesupplementsorIVmagnesiumsulfate.
Cardiacdysfunctionmustbeaddressed.Suggestionsforother
electrolytedisturbancesalsoapply.
Alcoholicpatientswithhypomagnesemiawillpresentasifthey
havehypocalcemia;magnesiumshouldbegivenfirst.
Scarareaisreducedduetomyofibroblastscausingcontractionof
theaffectedarea.
TENSILESTRENGTH
Theburststrengthofananastomosisislowest35daysfollowing
aprocedureduetotherecruitmentofmacrophagestothearea.
Anastomoticstrengthofananastomosisisattributabletothe
serosa.
Tensilestrengthcomesfromcrosslinking.
HYPERMAGNESEMIA
Hypermagnesemia
Etiology
Presentation
Diagnosis
Treatment
Duetorenalfailurewithdecreasedexcretion,abuse of
antacidscontainingmagnesium,tumorlysissyndromeor
rhabdomyolysis,redistributioninDKAorpheochromocytoma,
andtoxicityfromlithium.
DecreasedDTR,hypotension, paresthesia,coma, andspecific
EKGchanges.
EKG
IVcalciumandusedialysistoregainnormalmagnesium
homeostasis.
NUTRITION
TRANSPLANTSURGERYANDIMMUNOLOGY
IMMUNOLOGY
ANTIBODYCLASSES
TYPE
IgG
FEATURES
NOTES
Monomeric
65%
Mostabundantimmunoglobulinfoundthroughout
thebody.Freelycrossestheplacentaandprovides
formaternalfetalimmunityduringearlyneonatal
period.Bindstowidevarietyofinfectiveorganisms,
activatescomplement(classicpathway)andthrough
opsonization.
IgG1isthemostcommonsubtype(IgG14).IgG2
doesnotbindtomacrophagesbutisacommon
antibodytocarbohydrates(celiacsprue).IgG3does
notplayaroleinrheumatoidfactorantigenbut
stronglybindstocomplementcomparedtotheother
IgGs.IgG4doesnotfixcomplement(Clq)orbindto
macrophages.MostversatileisIgG1followedby
IgG3.
IgGhashigheraffinitythanIgM.
Primaryresponsetoantigenthatoftensignifiesearly
disease.ConvertedtoIgGtogivelonglasting
immunity.AntigenreceptorthatisalsolocatedonB
cellsurface.Formspentamers.Highavidityandisthe
firstimmunoglobulintobeexpressed.
IgMhashigheraviditythanIgG.
IgA1isreadilybrokendownbybacterialIgAprotease.
IgA2isnot.Formsdimers.Secretedonmucus
membranestoplayaroleinprotectingmucosal
surfaces.Secretorycomponentaddedduring
excretionfromepithelialcells.
Alsofoundinbreastmilk,saliva,tears,GItract,and
lungs.
CALORICREQUIREMENTS
TPNisbrokendownasfollows:
o Nonproteincontent:25cal/kg/day
o Proteincontent:1g/kg/day
o Thecaloriccontentofproteinisdeterminedby4
calories/gramx1gramxweight(kg)
100gramsofnitrogenisequivalentto625gramsofprotein
Basalcaloricrequirementsfora70kgmaleis2000calories.
IndirectcalorimetryisdonebycalculatingCO2production
Energyrequirementsinhealthypatientsfollowing
straightforward,uncomplicatedoperationsincreaseonlyslightly
IgM
ESSENTIALAMINOACIDS
Arginineisanessentialaminoacidthataugmentstheimmune
system
Glutamineistheaminoacidmostabundantincirculation
Glutaminelevelsfollowingintestinalsurgeryaredecreaseddue
toanincreaseinutilizationbytheintestinalcells
WOUNDHEALING
IgA
Monomeric
or
Pentameric
10%
Monomeric
ordimeric
20%
VITAMIN
VitaminAhasnoeffectonpromotingwoundhealing.Complete
epithelializationtypicallyoccursinlessthan5days.However,
vitaminAisindicatedinreversingtheeffectsofsteroids.
VitaminCaugmentsprolinecrosslinks.
REPAIRANDREGENERATION
CYTOKINESANDGROWTHFACTORS
INTERLEUKINS
TYPE
IL1
SEQUENCEOFCELLS
Collagenisbrokendownbymatrixmetalloproteases.
Cellspresentinthewoundstartingwithplatelets,PMNs,
macrophages,lymphocytes,andfinallyfibroblasts.
Peakcollagensynthesisoccursat13weeks.
Radiationreducescollagencrosslinking.
Theabsenceofmacrophagespreventsproperwoundhealing.
IL2
IL6
WOUNDCONTRACTION
FEATURES
Secretedby
macrophagesand
activatesacute
phasereaction.
SecretedbyTcells
andstimulatesT
cellresponse.
Secretedby
macrophageand
NOTES
Increasesbodytemperature (resets
hypothalamustemperatureregulation)and
increasesadhesionfactorexpressionbycells
(promotesextravasationofimmunemediators).
IL1receptorantagonistisusedforthe
treatmentofRA.Pyrogen.
Usedasadjunctivetherapyincancer, especially
malignantmelanomaandrenalcellcarcinoma.
ActivatesregulatoryTcellstomoderate
reactiontoself.StimulatesBcells.
Veryhighlevelsfollowingtrauma,burns,and
tissuedamage.Stimulatesosteoblaststo
43
stimulateosteoclasts(almostallpathwaysare
indirectlikethis).EstrogeninhibitsIL6andso
cantheoreticallybeusedforthetreatmentof
osteoporosis.Inducesfever.Worksthrough
gp130.Pyrogen.
GROWTHFACTORSANDACUTEPHASEREACTANTS
TYPE
IFN
alpha
FEATURES
Inhibitviralproteinsynthesis.
NOTES
Majorroleininflammationandacute
phaseresponse.ReleasedbyWBCs
duringinfection/inflammationand
endotheliumduetodamage.
StimulatesCRH,suppressesappetite,
resetsthermostat,andincreasesAPRs
byliver.Strongchemotaxisfor
neutrophils.InducesIL1production
andincreasesinsulinresistance.
COMPLEMENT
Alsoknownascachexin.
Syntheticformsusedfor
thetreatmentof
autoimmunedisorders
butincreasedriskofTBor
activationoflatent
infection(CMV,EBV,
VZV).
TYPE
Type
Type
Type
IV
FEATURES
IgEmediatedresponsethatleadsto
activationofmastcellsand
granulocytesfollowinginitial
sensitization.Netresultisa
degranulationofhistamine,
proteoglycanssuchasheparin,serine
proteases,prostaglandinD2
(vasodilation),cytokines,and
leukotrieneC4.
IgGandIgMmediatedresponsethat
leadstodirectantibodymediatedcell
toxicitywithcelldestruction;either
directphagocytosisorcomplement
mediatedcelldeath.
IndirectIgGandIgMmediated
responsethatleadstoantibodyantigen
complexes.Thesecomplexesdepositin
varioustissuesleadingtoinflammation
andcellulardestruction.
DelayedTcellmediatedcytotoxicity
leadingtodirectTcellmediated
cellulardestruction.
disease
NOTES
Rapidresponse with
immediatereactionthat
presentswithanaphylaxis,
hives,wheals,flares,
urticaria,andintense
pruritus.
Remove
transplant.
Cyclosporin
Remove
transplant.
Remove
transplant.
Hyperacuterejectionofkidneyistreatedbynephrectomy.
GvHDeventuallyleadstolossofthetransplantedheartat10
yearsduetoatherosclerosis.
Lunginfiltratesfollowingtreatmentforrejectionshouldbe
treatedwithganciclovir.
TYPE
DISEASE
Centromere
Mitochondrial
nAChR
Scl70
Smoothmuscle
HYPERSENSITIVITYREACTIONS
Chronic
TREATMENT
TypeIIreactionwithpreformedIgM orIgG
antibodiesfrompriorsensitizationleading
toantibodymediateddestruction.
TypeIVreactionwithcytotoxicTcell
mediateddestruction.
TypeIIandIIIreactionwithantibody
antigendepositionanddirectantibody
cytotoxicity.
TypeIVreactionwithcytotoxicTcell
mediateddestruction.
AUTOANTIBODIES
Thealternativepathwayprovidesameansofactivatingthe
immunesystemwithoutantibodies.
C3biscriticalinbothclassicandalternativepathways.
TheclassicpathwayisactivatedbyIgMorIgG.
Toxins,IgA,andspontaneousactivationoccursinthealternative
pathway.
Type
III
Hyperacute
Acute
FINDINGS
ActivateNKcells.
Theacutephaseresponseleadstoantibodyproduction,a
cytotoxicresponse,phagocytosis,complementactivation,
leukocytosis,fever,increasedantigenprocessing,decreasedviral
orbacterialreplication,anddevelopingofadaptiveimmune
response.
II
TYPE
Graftvs.host
TNF
alpha
TRANSPLANTREJECTION
Thyroidperoxidase
TSHR
NOTES
CREST
Primarybiliarycirrhosis
AMA
Myastheniagravis
Scleroderma
Topoisomerase
Autoimmunehepatitis
Hashimotothyroiditis
Gravesdisease
LIVER
LiverTransplant
Indications
Sideeffects
Liver
dialysis
Finaloptionduetoirreversiblehepaticfailure duetosclerosis,
cirrhosis,HCC,hepaticveinthrombosis,fulminanthepatitis.
Rejectionduetofailureofimmunosuppression.
Experimentaltherapy.Temporarysubstituteuntil
transplantation.
GYNECOLOGY
BREAST
FIBROCYSTICDISEASE
Directantibodymediated
destructionofselfand
withactivationof
membraneattackcomplex
throughcomplement
pathways(classic
pathway).
Activationofimmune
systemwithneutrophils
andmacrophagesleading
tocelldamage.
Tcelleffects.
Fibrocysticdiseaseinbreastismostlikelytodevelopintocancer
ifitisduetoatypicalductalhyperplasia.
Amaleadolescentwithgynecomastiaonlyrequiresreassurance.
BENIGNBREASTPAIN
Breastpainmaybereducedwiththeuseofbromocryptineto
inhibitthereleaseofprolactin.
BREASTCANCER
Breastcancerismostcommonlytheresultofaninvasiveductal
adenocarcinoma;theremainingcausesaregenerallyattributable
tolobularcarcinoma.
Riskfactorsincludeearlyageofmenarche,lateageof
menopause,latefirstpregnancyornulliparity,useoforal
activatesacute
phasereaction.
44
contraceptives,hormonereplacementtherapy(HRT),highfat
intake,alcoholabuse,smoking,exposuretoradiation,anda
positivehistory.
Thegreatestdecreaseinbreastcancerdeathhasbeenattributed
tomammographyforearlydetection.
Radiationisasignificantriskfactorforbreastcancer;smokingis
not.
Pagetdiseaseofthebreastoccursinsomepatientswithbreast
cancerandisduetoanunderlyingmalignancythatleadstoa
superficialeczematousulceration.
Diagnosisofbreastcancerismadebyfocusedhistory,physical
exam,mammogram,FNA,andopenexcisionalbiopsy.
Mammogramcanvisualizethemajorityofbreastcancers,
especiallyinwomenover35yearsofage.
Bonescans,liverultrasound,andCXRareusedinwomenwith
latestagedisease.
LOBULARCARCINOMAINSITU
ThepresenceofLCISatthemarginofbreastexcisionrequiresno
furthertherapy.Tamoxifenreducestheriskofinvasiveductal
cancerby49%.
DUCTALCARCINOMAINSITU
Fibrocysticdiseasewithproliferativechangesisatriskof
developingintoDCIS.
INTRADUCTALPAPILLOMA
Bloodynippledischargebutanormalmammogramislikely
intraductalpapillomaandrequiresexcisionoftheducts.
PHYLLODESTUMOR
Phyllodestumorofthebreastismanagedbyawidelocalexcision
asnearlyaquarterofthemaremalignant.Thesetumorsdonot
spreadviathelymphaticssononodaldissectionisrequired.
Thehighestassociationoftumordevelopingintobreastcanceris
thepresenceofatypicalductalhyperplasia.Anexcisionalbiopsy
isrequiredfordiagnosis.
BRCA1isassociatedwithbreastcancer,andovariancancer
(44%).
BRCA2isassociatedwithbreastcancer,ovariancancer(27%),
andmalebreastcancer(10%).
BRCAisanuclearoncogene.
Tamoxifenfunctionsbyblockingthebindingofestrogento
nuclearreceptors.
Cancercellsuseglutamineastheirprimaryenergysource.
Anearlysignofmalignanttransformationisenlargementofthe
cell.
Large,bulkytumorsarerelativelyinsensitivetoradiationdueto
tumorhypoxia.
Postoperativechemotherapyismostbeneficialinnodepositive
rectalcancer.
Themechanismofangiogenesisislocalproliferationand
migrationofcells.ThismaybemediatedbyVEGF,aparacrine
angiogenesisfactor.
REPRODUCTIVESYSTEM
ECTOPICPREGNANCY
Ayoungwomanwhopresentswithsuddenlowerbackpainand
goesintoshockhaslikelyexperiencedarupturedectopic
pregnancy.
ENDOMETRIOSIS
Abluishgenitalmassanddysmenorrheaisendometriosisand
mayrespondtohormonaltherapy.
Cervicalmotiontendernessplusvaginaldischargeandadnexal
tendernessrequiresadmissiontothehospitalandtreatment
withIVantibiotics.
INFLAMMATORY
Inflammatorybreastcancermayinvadethedermallymphatics
andsorequireslymphnodedissection.
ENDOMETRIALCANCER
EndometrialCancer
Etiology
MALIGNANT
Damagetothelongthoracicnervecancausewingedscapula.
Locallyadvancedbreastcanceristypicallytreatedwith
neoadjuvantchemotherapyfortumorslargerthan5cm,invasion
oflymphnodes,inflammatorycancers,andstage3cancers.
Estrogenreceptorisamarkerfortumordifferentiation.
Ifnosentinellymphnodesareidentified,anaxillarylymphnode
dissectionisrequired.
Radioguidedbreastbiopsyisindicatedforopenbiopsyto
confirmthediagnosisofatypicalhyperplasia.
ApostmenopausalfemalewithER+stageIIabreastcancer
requirestamoxifenandchemotherapy.Tamoxifeniscontinued
foramaximumof5years.
ConcurrentDCISandinvasivecancerisatsignificantriskforlocal
recurrence.
Acontraindicationtosegmentalmastectomyisthepresenceof
multicentricdisease.
Presentation
Diagnosis
Treatment
Mayoccurinwomenwithincreasedtimeoffertility, HRT,
tamoxifentherapyforpriorbreastcancer,obesity,nulliparity,
DM,andHTN,alongwithapositivefamilyhistory.
Periorpostmenopausalvaginalbleeding.Progressionleadsto
enlargeduterusandsofteningofthecervix.
Biopsy throughendocervicalcurettage.Ultrasound is
commonlyusedtoanalyzetheanatomyofthefemalepelvis;
TASandTVSareoftenused;thelatterispreferredoverCTfor
diagnosis,butnotforstaging.
Surgery,radiation therapyandchemotherapy. ATAHBSO is
preferred.Progesteroneisoftengivenasanadjuvant,along
withcisplatin,doxorubicin,cyclophosphamide,paclitaxel,and
carboplatin.
Tamoxifenincreasestheriskofendometrialcancerandshould
notbeusedformorethanfiveyears.Tamoxifenalsoincreases
theriskofthrombosis.
OVARIANCANCER
OvarianCancer
Etiology
Serous ormucinous cystadenocarcinoma,endometroid

carcinoma,undifferentiatedcarcinoma,andclearcell
carcinoma.Germcelltumorssuchasdysgerminomasand
45
Diagnosis
Treatment
Theriskofovariancancerincreaseswithnulliparity.
Thepresenceofovariancancerwithperitonealmetastasis
requiresatotalabdominalhysterectomywithbilateral
salpingooopherectomy,omentectomy,andselectivenode
sampling.Thesiteoffirstmetastasistendstobetheperitoneum.
Ovariancanceristhemostlikelycancertoleadtoascitesand
carcinomatosis.
Treatment
BLADDERDYSFUNCTION
INCONTINENCE
Incontinence
Etiology
Presentation
Diagnosis
CERVICALCANCER
CervicalCancer
Etiology
Presentation
Diagnosis
Treatment
InfectionbyHPV
Maybeentirelyasymptomatic,butabnormalvaginal bleeding,
abnormaldischarge,andlocalpainwithdyspareuniamaybe
present.
Papsmear,colposcopy,conebiopsy
LSILtypicallymonitoredonaregularbasiswithrepeatedPap
smears.
HSILwithsufficientriskfactorsmayleadtoLEEP,laser
conization,andcoldknifeconization.
Uterinecervicalcancerspreadstotheobturatorlymphnode
group.
UROLOGY
GENERALCONCEPTS
Treatment
Leakingwhencompletingthevalsalvamaneuverisdiagnosticfor
stressincontinence
Urinaryretentionistreatedwiththeuseofa
parasympathomimetic;itisespeciallylikelytooccurfollowingan
APR.
AcuteTubularNecrosis(ATN)
Etiology
Phases
Diagnosis
ADULTPOLYCYSTICKIDNEYDISEASE
AdultPolycysticKidneyDisease(APKD)
Etiology
Presentation
Diagnosis
Stressincontinencefromincreasedintraabdominalpressure
withweaknessofthepelvicfloor
Urgeincontinencefromincreasedactivityofthedetrusor
musclewithoutproperneuronalcontrol
Overflowincontinencefrompoordetrusormuscleactivity,
Continuousincontinencecommonlyfromfistulaformation,
congenitalmalformations,traumaticdamagetonervesor
structures,andenuresis.
Frequency,certainpatterns,identifiableprecipitants,dysuria,
incompleteemptying,andurge
Afullneurologic&pelvicexam.AQTiptestisusedtoidentify
excessivemovementofthebladderorurethra,indicatingpoor
supportagainstpelvicpressure.Stresstestingisalsodoneto
identifyweaknessesinthepelvicmuscles.
OveractivityofthedetrusoristreatedwithBMT,bladder
training,relaxingthebladderwithvariousmedications,and
creatinganartificialsphincterinmoreseriouscases.
Stressincontinenceistreatedbyincreasingsphinctertone,
weightreduction,andKegelexercises.Concomitant
conditionsshouldbetreated.
Overflowincontinencecanbereversedwithprazosinto
decreasethesphinctertone,ortheuseofacatheter.
ACUTETUBULARNECROSIS
Aldosteroneincreasespotassiumsecretionandsodium
reabsorptioninthedistaltubule
Aldosteroneincreasessodiumreabsorptioninexchangefor
hydrogenandpotassium;thisfunctionoccursonthe
sodium/hydrogentransporter
Creatinineclearanceislessaccuratethanureaclearancewhen
calculatingGFR
Reninissecretedbythejuxtaglomerularcells
KIDNEY,URETERS,ANDBLADDER
Carefulobservationandcontrolofsymptoms. Dialysis is
eventuallyrequired,alongwithmedicalmanagementwith
ACEinhibitors.Renaltransplantiseventuallyrequired.Cysts
inthekidneyandlivermaybecomeinfectedandrequire
treatmentthroughsurgeryandantibiotics.
ADdisorderwhichleadstoESRDthroughprogressivecystic
dilationoftherenaltubules.
ProgressivedecreasesinrenalfunctionleadingtoESRD.HTN
heraldsrenalfailure,andstrokecanoccur.Flankpainand
flankmassesareobviousonphysicalexam,andhepatomegaly
withnodularenlargementisalsopresent.Familyhistoryis
typicallypositive.ThepreferredinitialimagingstudyisUS,
followedbythemoresensitiveCTscan.MRAisusedto
diagnoseICAs.
UAispositiveforhematuria.Thepreferredinitialimaging
studyisUS,followedbythemoresensitiveCTscan.MRAis
usedtodiagnoseICAs.
Treatment
Oftensecondarytomedicationsthathaveatoxiceffectonthe
kidneys,complicationsfollowingsurgery.Generalcausesinclude
hypotension,toxicinjury,anddepositionofmusclefibersin
rhabdomyolysisordiagnosticcontrastagents.
Prodromaliswithoutanysignsorsymptomsimmediately
followinginjury.
Oliguricoranuricoccursfollowingdamage;
Postoligurictakesplaceduringresolution.
Presenceofbrownurineandepithelialcastsfromtubular cells.
ThereissignificanthypernatriuriawithaFENAgreaterthan1%.
Intrinsicrenalfailuretypicallyhasproteinuriaandsedimentation
viaRBCs,RBCcasts,WBCcasts,andepithelialcastsintheurine.
ATNischaracterizedbyepithelialcellcastsandgranularcastsin
theurine.SerologycanfurtheridentifythecauseofARF:
antibodiestotheGBM.
TreatmentintheearlystagesofATNincludesIVhydrationwith
diuretics,restrictingproteinandpotassiumintake,andmatching
renaloutputwithoralinput.Slowcorrectionofmetabolic
acidosisshouldbedone,andanyconcurrentinfectionstreated
quickly.FeverinATNorARFshouldbeginwithaCXR,
panculturesofthesputum,blood,andurine,andtheuseof
antibiotictherapytailoredtotheoffendingorganism.
CalculatingFENAisasensitivemeasureofdetectingATN
100
Presentation
endometrialsinustumorsmayoccur.Teratomas, embryonal
carcinomas,polyembryona,andchoriocarcinomaareother
rarercausesofovariancancer.
Pelvicmassoradnexalmass,lymphadenopathy,ascites, and
hydrothorax.Constitutionalsymptomsarecommon,along
withfrequenturination,AUBorDUB,constipation,and
referredpaintotheback.
Acarefulhistoryandphysicalexam,followedbyCA125titers,
USusingTVS,andvariousotherimagingstudies.
Laparoscopicdebulking,chemotherapy,andpossibleTAHBSO,
iffuturepregnancyisnotdesired.
46
NEPHROLITHIASIS
Nephrolithiasis
Etiology
Presentation
Diagnosis
Treatment
Increasedurinecontentofcalcium,oxalate,anduric acid, and

renaldysfunctionordamageleadingtoapredispositionto
crystallization.
Symptomsonlywithsignificantobstructionoftheureters.
Renalcolicoccurswithundulatingcrampsandseverepain,
nauseaandvomiting,andpainthatmigratesfromtheflank
towardsthescrotalorlabialregionasthestonemoves.
Staghorncalculitendtoremainwithinthekidneyandpresent
withrenalfailure.AUAisdoneandtypicallyshowshematuria.
Apredispositiontowardscalculusformationisindicatedwith
positivebloodtestsforelectrolyteabnormalities.Diagnosisis
madebyplainfilms,sonograms,IVP),andhelicalCT.
AUAisdoneandtypicallyshowshematuria.Apredisposition
towardscalculusformationisindicatedwithpositiveblood
testsforelectrolyteabnormalities.Diagnosisismadebyplain
films,sonograms,IVP,andhelicalCT.
Painmanagement,increasedwaterintake,antiemetics,
NSAIDs,andobservation.Failuretopassastoneorsignificant
renalstonesistreatedwithEWSL,ureteroscopy,stent
placement,andpercutaneousnephrostolithotomy.
CRF andESRD.
ENDSTAGERENALDISEASE
EndStageRenalDisease(ESRD)
Etiology
Presentation
Treatment
CRF istypicallysecondarytoDMleadingtodiffuse ornodular

glomerulosclerosis,HTN,chronicglomerulonephritis,
tubulointerstitialdisease,APKD,andidiopathiccauses.
Initiallyasymptomatic.WhenGFRdropstolessthanhalf
belowbaseline,thereisinitiallydecreasedurineconcentration
withsodiumlossanddehydration.Latersymptomsleadto
volumeoverloadthroughrenalfailureinducedhypernatremia.
Potassiumexcretiondecreases,ananiongapmetabolic
acidosisdevelops,hypocalcemiaandhyperphosphatemia
occur.Creatininealsoincreases,alongwithBUN.CRF
presentswithsignsandsymptomsofrenalfailure,including
uremicsyndrome,nephroticsyndrome,andESRD.
Maintainingexistingrenalfunctionthroughmedical
managementanddialysisuntilrenaltransplantbecomes
inevitable.Proteinrestrictionisrequiredtominimizerenal
nitrogenload,alongwithsodiumandphosphaterestriction.
ACUTEPYELONEPHRITIS
AcutePyelonephritis
HYPERURICEMIA
Elevateduricacidlevelsinapatientwitharthritismaybedueto
defectsinpurinemetabolism
Etiology
Presentation
HYPEROXALURIA
Apatientwhohashadaterminalileumresectionwithan
ileocolicanastomosistendtoformoxalatestones
Treatment
RENALFAILURE
RenalFailure
AcuteARF
Prerenal
causes
Intrinsic
causes
Postrenal
causes
IncreasingBUNtocreatinineratiowitholiguria.Thebuildup of
toxicsolutescanoccur,alongwithelectrolyteimbalances,
volumeoverload,andmultisystemicfailure.
Duetodecreasedrenalperfusion.Causesincludedecreased
bloodvolumethroughhemorrhage,useofdiuretics,third
spacingoffluidsinpancreatitisorfollowingabdominalsurgery,
dehydration,CHF,nephroticsyndrome,septicshock,RAS,and
Addisondisease.
Directrenalfailure,mostlikelyaresultofATN.AIN withdrug
inducedimmunereactionscanoccurandleadtoATN.Pigment
depositioninmyoglobinuriaorhemoglobinuria,protein
depositioninMM,crystaldepositionbywayofoxalatecrystalsor
uratecrystals,vasculardisordersleadingtothromboembolic
phenomenonorvasculitis,IVcontrast,NSAIDs.Glomerular
failureisothercausesofintrinsicrenalfailureleadingtoARF.
Resultofoutflowobstructionfromthekidney.Causesinclude
benignBPH,bilateralobstructionoftheureters,stricture
formation,andbladderobstruction.Presentswith
hydronephrosis,andpostobstructivediuresis,oncetheblockage
isremoved.
UREMICSYNDROME
UremicSyndrome
Etiology
Presentation
Treatment
Developmentofpruritus,nausea,vomiting,anorexia,
polydipsia,proteinuria,tubularcasts,purpura,wasting,and
pallorassociatedwithCRF.Complicationsincludepericarditis,
anemia,coagulopathy,GIdisruption,andCNSchanges,renal
osteodystrophyandperipheralneuropathies.
Seizures,myopathies,clonus, asterixis,HTN,IHD,valvular
heartdisease,pulmonaryedemaandeffusions,normochromic
normocyticanemias,increasedbleedingtime,reductionin
WBCs,GIbleeds,hypertriglyceridemia.
Uremiaistreatedbytreatingtheunderlyingetiology causing
Theresultofabacterialinfectiontypicallyemanatingfroma
superiorlyprogressingUTI.
PresentswithworseningsymptomsofalowerUTI followedby
flankpainradiatingtothebackorpubicregion,fever,and
numerousconstitutionalsymptoms.CVAtendernessis
common.
Supportivecareandantibioticstailoredtotheinfecting
organism.Surgerytocorrectanatomicdefectsandrepairrenal
damageissometimesdone.
PERINEPHRICABSCESS
PerinephricAbscess
Presentation
Diagnosis
Treatment
Constitutionalsymptomsincludingfever andabdominalpain,
dysuria,andoccasionally,aflankmassapparentonexam
ElevationinWBCsisnotedandanemiaiscommon.ESRis
elevated.Bloodculturesarenotspecificnorsensitive.
Urinalysistypicallyindicatespyuria,proteinuria,hematuria,
andpositivecultures.UltrasoundandCTarepreferred.
Percutaneousdrainage,withopendrainageusedincertain
cases.Penicillins,aminoglycosides,anddirectedantibiotic
treatmentfollowingsensitivityreportsfromcultureareused.
Inintractablecases,nephrectomy.
BLADDERRUPTURE
Apatientwithanextraperitonealruptureofthebladdercanhave
afoleyplacedandbeobserved.
RENALCELLCARCINOMA
Thepresenceofaleftsidedvaricoceleshouldpromptasearch
foraleftsidedrenaltumor.
Resectionofasinglepulmonarymetastasisfromrenalcellcancer
increasessurvival.SuprahepaticIVCresectionsarenot
contraindicated.
MALEREPRODUCTIVEORGANS
PHIMOSIS
Thepresenceofphimosispriortoanelectivecaseshouldbe
treatedwiththecreationofadorsalslit.
PROSTATECANCER
ProstateCancer
Etiology
Presentation
Diagnosis
Treatment
Adenocarcinoma
AsymptomaticuntilapositiveDREisconductedandhard
nodulesfound,oranelevatedPSAfoundinascreeningtest.
Urinarytractobstructionsaresometimespresent.As
metastasistotheboneiscommon,bonepainmaybea
presentingsign
PSA,DRE,biopsy,imagingstudies
Symptomaticmanagementandresection.Radiation therapyis
commonlyusedalongwithradicalprostatectomy.Asmore
mendiewithprostatecancerthanfromprostatecancer,
simplywaitinginanolderpatientmayalsobethebestcourse
ofaction.
SQUAMOUSCELLCARCINOMAOFTHEPENIS
Thepresenceofsquamouscellcarcinomaofthepenisshouldbe
treatedwithapartialpenectomyiflymphnodesarenegative.If
inguinallymphnodesarepositive,sixweeksofantibioticsanda
lymphnodedissectionshouldbeperformed.
TESTICULARCANCER
Theaggressivenessofnonseminomatousgermcelltumorscan
bepredictedbyalphafetoproteinlevels.
ORTHOPEDICSURGERY
47
Apatientwithahumerusfractureandnoradialpulseshould
havethefracturereducedfirst.
Dropwristmaybeduetoadistalhumerusfracture.
HANDANDWRIST
CARPALTUNNELSYNDROME
CarpalTunnelSyndrome(CTS)
Etiology
Presentation
Diagnosis
Treatment
CompressionofthemediannerveoccursduetoRSIor
followingdirecttraumatotheregion.
Distalweakness, thenaratrophy,andtinglinginthefingers.
PositivePhalensandTinelssigns.
Rest,icing,compression,andelevation.Steroids maybeused
temporarily,surgery.
LOWEREXTREMITIES
PELVIC
URETHRALTRANSECTION
Bloodattheurethralmeatusshouldbeexploredbymeansofa
retrogradeurethrogram.
Pelvicfracturewithbleedingshouldbeimagedbyangiography.
Traumawithpubicdiastasisandhypotensionrequiresexternal
fixation.
HIPANDTHIGH
Alkalinephosphataseistheactiveenzymeinosteoblasts.
HEAD,NECK,ANDSPINE
KNEEANDLEG
LUMBARDISCHERNIATION
LumbarDiscHerniation
Etiology
Presentation
Diagnosis
Treatment
Herniationoflumbarvertebraldisc.
DecreasedROM,pain,paresthesia,anddecreasedreflexes
L4impingementleadstoweakenedkneereflexes and
weaknessofthetibialisanterior.
L5effectsleadtoweaknessintheextensorhallucislongusand
diminishedsensationoverthelateralleg.
PinchingofS1leadstoadecreasedanklejerkreflexand
diminishedsensationoverthelateralfoot.
NSAIDs,surgery.
CAUDAEQUINASYNDROME
CaudaEquinaSyndrome(CES)
Etiology
Presentation
Treatment
Sacralandlumbarrootcompression,secondarytospinal
stenosis,diskherniations,andtumorexpansion.
Saddleanesthesia,incontinence,sciatica,andloss ofmotor or
sensoryfunctioninthelowerextremities.
Restingonahardsurfaceatnightandadequatepain control.
Laminectomy.
UPPEREXTREMITIES
SHOULDERANDARM
Afractureofthemidhumeralshaftshouldpromptan
explorationforradialnerveinjury.
Volkmannsischemiccontracturemaybeduetoasupracondylar
humerusfracture.
Earlyopenreductionandinternalfixationshouldbethetherapy
ofchoiceinpatientswithfemoralshaftfracturesinthesettingof
multipletraumas.
Theinitialtreatmentinapatientwithanopentibiaandfibulais
immediateirrigationanddebridementintheoperatingroom.
Thepresentationofashortenedlegandadductionfollowing
traumaislikelyduetoaposteriorhipdislocation.
Thecommonperonealnervemustbepreservedinthecontextof
afibulectomy.
Anarteriogrammustbeperformedtoassessforarterialinjury
followingpoplitealdislocation.
ApositiveLachmantestindicatesinjurytotheACL.
Groinpainfollowingaparticularlystrongkickmaybeduetoa
tearofthesartoriusmuscle.
COMPARTMENTSYNDROME
EXTREMITY
Acompartmentsyndromethatdevelopsfollowinga
thrombectomyrequiresafasciotomy.
Lossofsensationisanearlysignofcompartmentsyndrome.
Thepresenceofcalfpainandlossofsensationinthedistal
extremityfollowingavascularprocedurerequiresafasciotomy.
Compartmentpressuresshouldbecheckedinanypatientwho
wasinstirrupsduringanextendedORcaseandthenpresents
withnumbnessorweakness.
Castsshouldberemovedinthesettingofcompartment
syndrome.
GENERALCONCEPTS
48
ABDOMEN
Atraumapatientwithsignificantfluidresuscitationandrising
airwaypressuresshouldberuledoutforabdominal
compartmentsyndrome.
GOUT
Gout
Etiology
Presentation
Treatment
Abnormalitieswithuricacidmetabolismleadingtoarthritis
andjointdestruction
Amonoarticulararthritis,especiallyaffectingthelower
extremities.Thehalluxistypicallyinflamed,butthiscanbe
presentinpseudogoutandotherarthriticconditions.
Inflammationingoutreachesamaximumafterabouthalfa
daywithredness,swelling,andpain.Resolutionoftheinitial
attacksoccurswithinacoupleofweeks,withrecurrenceover
time.Polyarticulararthritisensuesovertimewithinvolvement
ofnumerousotherjoints.Apolyarticulararthritisdevelops
overtimeandbecomeschronicincourse.
Goutprophylaxisinvolvestheuseofallopurinolorprobenecid
(absolutelycontraindicatedinacuteattacksastheycan
precipitategout).Colchicineisusedasprophylaxisalongwith
NSAIDs.Withasecondattackofgout,loweringuricacidis
undertaken,startingwithprobenecid,thensulfinpyrazone,
thenallopurinol.Dietarychangesincludeavoidingalcoholand
havingalowfat,lowcholesteroldiettoavoidtheancillary
disordersassociatedwithgout.
INFECTIOUS
HEMATOLOGY
Intrinsicurokinaseelevationinthebodycorrelatestomalignancy
(facilitatesmetastasis)
Thromboxaneisavasoconstrictor.
Whiteclotsyndromecanoccurwiththeadministrationof
heparin.
Protaminecanleadtohypotension.
Topicalthrombinactivatesthefibringlueusedinsurgery.
WarfarinskinnecrosisisduetoproteinCderangementsand
shouldbetreatedwithheparin.
Prostacyclininhibitstheaggregationofplatelets.
PT/INRisanindicatorofhepaticsyntheticfunction.
ThepresenceofPTTprolongationshouldelicitatestoffactorVIII
function.
REDBLOODCELLDISORDERS
MICROCYTICANEMIA
IronDeficiencyAnemia
Etiology
Presentation
PUNCTUREWOUND
EpiduralAbscess
Etiology
Presentation
Diagnosis
Treatment
Treatment
CommonlytheresultofinfectionbyStaphylococcusaureus,
gramnegativerods,andTB.
Fever,pain,progressiveweakness,paresthesia,andarisein
WBCs.
Circulationocclusion,nerveimpingement,andspreadto
adjacentstructures.
AntibioticsafterlocalizingtheextentoftheinjurywithMRI.
Etiology
Presentation
Diagnosis
Treatment
Autosomal recessivedefectinthebetachain oftheHbA.

Constitutionalsymptomsandanemia.Painfulcrisesoccur
intermittently.Handfootsyndromemayoccur.Strokeis
common,alongwithTIAsandRIND.Acutepresentationscan
includeACS.ChronicSCAcanpresentwithgrowthretardation,
hepatomegaly,splenomegaly,pallor,jaundice,cardiomegaly
withanSEM,skinulceration,andcholelithiasis.Aproliferative
retinopathyisoftenpresentaswell.
Madebyhemoglobinstudies.
GasGangrene
Presentation
SickleCellAnemia(SCA)
Diagnosis
NECROTIZINGFASCIITIS
Etiology
Poorintake,excessloss,orpoorabsorption.
Constitutionalsymptoms,exertionaldyspnea, anorexia,
melena,hematochezia,and/orhemoptysis
Glossitis, angularstomatitis,koilonychias, pallor; iron
deficiencyanemia.AnisocytosisandincreasedRDWareearly
signsofthisdisorder,andMCVindicatesahypochromic
microcyticanemia,lowferritin.
Replacingiron storesandcorrectinganyunderlyingetiology.
SICKLECELLANEMIA
EPIDURALABSCESS
IRONDEFICIENCYANEMIA
Diagnosis
Apuncturewoundthroughthefingertiprequiresanincisionand
drainagethroughthevolaraspectacrosstheIPjoint.
Myonecrosisandsofttissuedestructionthroughthe
productionoftoxinsandgasbyClostridiumperfringens,but
otherClostridiumspp.mayalsoleadtoinfections.
Suddenpainoutofproportiontoclinicalfindings.Ahistoryof
traumaisoftenelicited,alongwithriskfactorssuchas
alcoholism,IVDA,orDM.Edema,erythema,tenderness,
crepitus,discharge,andmentalstatuschangesareprevalent.
Elevationofaldolase,potassium,LDH,CPK,andevidenceof
myoglobinuria.Anemiaandmetabolicacidosismayalsobe
present.Apositivesialidasetestisalsodiagnostic.
Hyperbaricoxygenexposure,debridement,IVF,andpossible
amputationtoavoiddeath.Antibioticsarealsousedwith
penicillin,clindamycin,orchloramphenicol.
Theantibioticforchoiceinapatientwithclostridiuminfection
andapenicillinallergyisclindamycin.
NORMOCYTICANEMIA
ANEMIAOFCHRONICDISEASE
AnemiaofChronicDisease(ACD)
Etiology
Presentation/Diagnosis
Treatment
Decreasedbonemarrowproduction oferythrocytes
afterlongstandingchronicdisease.Itmayalsobe
theresultofchronicinflammation,cancer,and
systemicdiseases.
Moderateorlowgradeanemia, whichistypically
subclinical.Moreseverecasesmaypresentwith
symptomsofanemia.
Treatmentoftheprimarydisease.
SPECIFICANEMIAS
HEMOLYTICANEMIA
HemolyticAnemia
SURGICALONCOLOGY
Etiology
G6PDdeficiency, hereditaryspherocytosis, sicklecellanemia,

DIC,HUS,TTP,prostheticvalves,andPNH.
49
Presentation
Diagnosis
Treatment
Symptomsofanemia.Tachycardia,dyspnea,andweakness,
cholelithiasis.Ahistoryofuseofcertainmedications,favism.
Pallor,jaundice,splenomegaly,legulcersmaybepresenton
physicalexam.
Diagnosisismadebyperipheralbloodsmearandstandard
testsforanemia.
Transfusionswithsymptomatic,severeanemia, avoiding
triggersthatworsentheanemia,andtreatingreversible
causes.
PLATELETSANDCOAGULATIONDISORDERS
IMMUNETHROMBOCYTOPENICPURPURA
ImmuneThrombocytopenicPurpura(ITP)
Etiology
Presentation
Diagnosis
TRANSFUSIONREACTIONS
Theearliestintraoperativesignofbloodmismatchis
hypotension.
Postoperativetransfusioncriteriaincludeasymptomaticlow
hematocrit,asymptomaticlowcentralvenouspressure,anda
symptomaticlowpulmonarycapillarywedgepressure.
Anegativecrossmatchisrequiredbetweendonorbloodcellsand
recipientserum,inadditiontosatisfactoryABOcompatibility.
TransfusionReaction
Etiology
Presentation
Diagnosis
Treatment
Idiopathic
Intracranial hemorrhageorbleedinginotherpartsofthebody.
Petechiaeandecchymoses.Neurologicexammaybepositive
forfindings,andahemopericardiummaybeidentified.
CBC andlargeplateletsfoundonperipheral blood smear.
Antiplateletantibodiesmayalsobepresent.Apositive
Coombstestiscommon.
Corticosteroids, IVIGorRhIG,andplatelettransfusions if
severebleedingispresent.Splenectomyresultsinremission.
VONWILLEBRANDDISEASE
VonWillebrandDisease(vWD)
Etiology
Presentation
Diagnosis
Treatment
Autosomal disorder.
Bleedingdiathesesleadingtoepistaxis, easybruising, and
hematomaformation
Ristocetinactivitytest,whilethepresenceofvWFcanbe
determinedwithanantigentest.PTTisincreased,whilePTis
normal.
TypeIvWD involvesDDAVP.
TypeIIvWDistreatedwithDDAVPaswell,butconcentrates
withfactorVIIIandvWFmaybenecessarypriortosurgery.
TypeIIIvWDvWFcontainingfactorVIIIconcentrates.
Platelettransfusions.
vWFissecretedbyendothelialcells.
Prolongedbleedingtimesinpatientsondialysisshouldbe
treatedwith20mcgofDDAVP.
vWFassistswithplateletadherencetocollagen.
CryoprecipitatecontainsvWF.
Treatment
Immunereactionsagainstdonatedblood
Allergicreactions,anaphylaxis,shock.Earlysigns include
fever,droppingBP,flushing,anxiety,andwheezing.Later
signsincludeDIC.Innonhemolyticreactions,onlyfeveris
presentalongwithmildconstitutionalsymptomsand
hypotension.Allergicreactionsmaypresentwitha
maculopapularrashandpruritus.Anaphylacticreactionsmay
presentwithdyspnea,wheezing,anxiety,bronchospasm,and
hypotension.InTRALI,SOB,hypoxia,andorthopneawith
cardiacdecompensationmaybepresent.
DiagnosisismadebyworkupsforanemiaandadirectCoombs
test.
Stoppingthetransfusionandcarefulobservation.Prophylaxis
againstrenalfailureandDIC.Diuresismaybenecessary.
Acetaminophenisusedforfever,diphenhydramineformild
allergicreactions,andepinephrineforanaphylacticreactions.
Aworkupforsepsismaybenecessary.
Visitusonthewebatwww.ClinicalReview.com

Absite High Yield 2008

Transféré par

Informations du document

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Absite High Yield 2008

Transféré par

Droits d'auteur :

Formats disponibles

HighYieldReviewforthe2008ABSITE

FRC = ERV (normal breath)

Expiratory flow rate =

Expected PaCO2 = (1.5 HCO3 -) + (8 2 )

Nitroglycerin torelievesymptoms, calcium channel

Highamplitudeperistalticcontractions, dysphagia, chest

Squamous cellcarcinomariskfactors: smoking, alcohol,

Duetomalignant expansionofBcells, Tcells,NKcells,or

correction canbeachieved.Diuretics, anticoagulation,

VT,VF, WPW, andTorsadedePointes.VTiscommonin

mediastinum, CT withIVcontrastorTEE thatdemonstrates

Itistypicallycaused byCADleadingtoceliac artery,SMA or

Manypolyps inSIandLI,lowcancer risk.

Cancer limitedtomucosa andsubmucosa.90%5yearsurvival.

Infection &inflammationaftercholelithiasis, infections

Autoimmunedisorderwhichdestroyintrahepatic bile ducts.

DNAvirus spreadthroughsex,blood, saliva.

Lesions maybetheresultoftraumaordamage fromtumor

Congenitaldisease, autoimmunedisease,inflammation leading

Hyperplasia oftheparathyroidglands andreset ofthenormal

Adrenal failure. Duetowithdrawalfromsteroidtherapy, asa

Coma duetodehydrationandhyperglycemia. Itiscommonly

Activehepatic disease, OPD

Excessiveintake,decreasedexcretion throughrenal failure or

Serous ormucinous cystadenocarcinoma,endometroid

Increasedurinecontentofcalcium,oxalate,anduric acid, and

CRF istypicallysecondarytoDMleadingtodiffuse ornodular

Autosomal recessivedefectinthebetachain oftheHbA.

G6PDdeficiency, hereditaryspherocytosis, sicklecellanemia,

Vous aimerez peut-être aussi