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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

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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
METABOLICANDDEGENERATIVE

...............................17

INFLAMMATORYANDINFECTIOUS

..............................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

HighYieldReviewforthe2008ABSITE

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

CCopyright2008SurgisphereCorporation

DREshouldbedoneinallpatientsasupto50%ofallcolon
cancersmaylaywithinreachofthecliniciansfinger.

ClinicalReviewofSurgeryHighYieldEdition

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

Visitusonthewebatwww.ClinicalReview.com.

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.

HighYieldReviewforthe2008ABSITE

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.

Rfactorresistanceleadstodruginactivationanddecreased
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

Rfactorresistanceleadstodruginactivationanddecreased
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

CCopyright2008SurgisphereCorporation

Cephalosporinshaveahexagonalringwithtwofunctionalgroups.
Penicillinshaveapentagonalringwithonefunctionalgroup.Both
aresusceptibletobetalactamases.

ClinicalReviewofSurgeryHighYieldEdition

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

Visitusonthewebatwww.ClinicalReview.com.

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.

HighYieldReviewforthe2008ABSITE

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

CCopyright2008SurgisphereCorporation

CENTRALNERVOUSSYSTEMINJURIES

ClinicalReviewofSurgeryHighYieldEdition

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.

INFLAMMATORYANDINFECTIOUS
SUPPURATIVEPAROTIDITIS

OTITISMEDIA
Serousotitisinanyonewithasignificanthistoryofsmokingor
alcoholabusedeservesanasopharyngoscopyasascreeningtest
forcancer.

VASCULAR

LARYNGEALNERVE

Damagetothesuperiorlaryngealnerveaffectsthetimberofthe
voice.Thisfrequentlyleadstolossofhighpitchedspeech.
Thesuperiorlaryngealnerveissensorytothesupraglottisregion.
Bilateralrecurrentlaryngealnerveinjuryrequirespermanent
tracheostomytopreventlossoftheairway.
Damagetoarecurrentlaryngealnervetypicallyrequires
medializationofthevocalfoldstohelpprotecttheairwayand
avoidhoarseness.

Therateofperipheralnerveregenerationfollowinginjuryis
approximately1cmpermonth.

METABOLICANDDEGENERATIVE

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.

Visitusonthewebatwww.ClinicalReview.com.

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

HighYieldReviewforthe2008ABSITE

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)

CCopyright2008SurgisphereCorporation

Acricothyroidotomyisanincisionthroughthecricothyroid
membraneandintothetrachea.Inthisprocedure,thethyroid
cartilageisclearlyidentifiedviapalpation.Justbelowthethyroid
cartilageisthecricothyroidmembrane.Justbelowthis
membraneisthecricoidcartilage.Theincisionismadethrough
thecricothyroidmembrane(belowthethyroidcartilageand
abovethecricoidcartilage).

ClinicalReviewofSurgeryHighYieldEdition

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

Visitusonthewebatwww.ClinicalReview.com.

(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.

HighYieldReviewforthe2008ABSITE

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

CCopyright2008SurgisphereCorporation

Etiology

ClinicalReviewofSurgeryHighYieldEdition

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.

Visitusonthewebatwww.ClinicalReview.com.

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.

HighYieldReviewforthe2008ABSITE

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.

CCopyright2008SurgisphereCorporation

Etiology
Presentation

ClinicalReviewofSurgeryHighYieldEdition

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.

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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).

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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.

CCopyright2008SurgisphereCorporation

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.

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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
o Cough,hemoptysis,pneumonitis,pneumonia,effusion,
dyspnea,wheezing,stridor,chestpain,anorexia,
phlebitis,bonepain,coinlesions

ADENOCARCINOMA
Pathophysiology
o Distallung
o F>M
o 40%ofalllungcancers
o Peripheral
Presentation
o Cough,hemoptysis,pneumonitis,pneumonia,effusion,
dyspnea,wheezing,stridor,chestpain,anorexia,
phlebitis,bonepain,coinlesions

BENIGNTUMORS

AnteriorMediastinum
o Thymoma,thyroidenlargement,Tcelllymphoma
MiddleMediastinum
o Vascularlesion,enlargedlymphnodes
PosteriorMediastinum
o Neurogenictumor

CARDIACSURGERY
GENERALCONCEPTS

Theinternalmammaryarteryisthefirstbranchoffthe
subclavianartery

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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.

HighYieldReviewforthe2008ABSITE
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

METABOLICANDDEGENERATIVE

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

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INTRAAORTICBALLOONPUMP

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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.

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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

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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

CCopyright2008SurgisphereCorporation

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.

ClinicalReviewofSurgeryHighYieldEdition

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.

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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.

INFLAMMATORYANDINFECTIOUS

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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.

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CARDIOMYOPATHY

22

ClinicalReviewofSurgeryHighYieldEdition

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

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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

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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.

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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.

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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

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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

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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.

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Presentation
Diagnosis
Treatment

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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

Visitusonthewebatwww.ClinicalReview.com.

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.

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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

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Diagnosis

ClinicalReviewofSurgeryHighYieldEdition

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.

Visitusonthewebatwww.ClinicalReview.com.

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.

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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.

CCopyright2008SurgisphereCorporation

Scintigraphyusingradioisotopesofiodinearethediagnostictest
ofchoice;CTandMRIareusedonlytoidentifydistant
metastases.
Fineneedleaspirationbiopsy(FNAB)isuniversallyusedto
identifythistypeofcancer.
TreatmentofPTCinvolvesthyroidectomy,theuseofradioactive
iodine,andlevothyroxinereplacement.Radiationisusedagainst
metastases;chemotherapyishelpfulinonlyafractionof
patients.

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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

Visitusonthewebatwww.ClinicalReview.com.

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.

HighYieldReviewforthe2008ABSITE

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.

CCopyright2008SurgisphereCorporation

Pheochromocytoma
Etiology
Presentation
Diagnosis

ClinicalReviewofSurgeryHighYieldEdition

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.

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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.

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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.

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TOXICEPIDERMALNECROLYSIS/STEVENSJOHNSON
SYNDROME

ActivatedproteinC(Xigris)usedinthetreatmentofsepsisleads
tofibrinolysis.
SepsisisassociatedwithanincreaseinIL6.
Glucocorticoidsinshockleadtoinsulinresistance.

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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

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Canbeattributedtopoorintake,increasedexcretion, anda
shiftfromtheextracellularspacetotheintracellularspace.

HighYieldReviewforthe2008ABSITE

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

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Presentation

OthercausesincludevitaminB12use,Bblockers, correcting
digoxintoxicitywithantibodytherapy,andalkalosis.
HTN,iftheunderlyingcauseisprimaryhyperaldosteronismor
licoriceingestion,whilehypotensionmaysuggestionlaxative
abuse,Barttersyndrome,orbulimia.Itmayalsopresentwith
flaccidity,muscleweakness,lossofDTRs,arrhythmia.
UA
Preventingthepotassiumloss,replenishingthepotassium
storeswithPOorIV,monitoringforhypokalemictoxicity.

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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

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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

HighYieldReviewforthe2008ABSITE

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

CCopyright2008SurgisphereCorporation

activatesacute
phasereaction.

ClinicalReviewofSurgeryHighYieldEdition

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.

Visitusonthewebatwww.ClinicalReview.com.

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

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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

CCopyright2008SurgisphereCorporation

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

ClinicalReviewofSurgeryHighYieldEdition

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

Visitusonthewebatwww.ClinicalReview.com.

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.

HighYieldReviewforthe2008ABSITE

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.

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GENERALCONCEPTS

48

ClinicalReviewofSurgeryHighYieldEdition

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

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Etiology

G6PDdeficiency, hereditaryspherocytosis, sicklecellanemia,


DIC,HUS,TTP,prostheticvalves,andPNH.

HighYieldReviewforthe2008ABSITE

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.

CCopyright2008SurgisphereCorporation

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.

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