− Ductal Carcinoma In Situ (DCIS): increases risk of cancer in ipsilateral breast

Breast Mass • Dx: microcalcifications on MMG

1) Hx: Age, Breast Hx, FHx of BrCA → 3 most important ?s
• Histologic types: comedo (most aggressive), micropapillary, cribform
− Lump: location, #, Δs, w/ menstruation/Br feeding (fibrocystic dz), pain, d/c (papilloma)
• Surgical Tx: Determined by size
− Breast: abnormal MMG, Bx (atypical hyperplasia, LCIS, DCIS), prior BrCA, radiation
○ < 1 cm→ lumpectomy (1 mm margins) +/- XRT
− GYN: age @ menarche (<12)/menopause (>55), para (#1>35), fertility tx, HRT, Br feeding
○ > 1cm→ (1) lumpectomy w/ 2-3 cm margins & XRT, no SLNBx; or (2) simple mastectomy & SLNBx
− PMHx: last MMG, self breast exams, other problems, other CAs (esp ovarian, endometrial)
○ SLNBx w/ comedo subtype, multifocal dz, large lesions, high grade → 10-20% infiltrative @ excision
− Meds/Allergies: HRT, OCP,
• Adjuvant Txs: SERMs, post-op XRT
− FHx: BrCA (↑↑ risk w/ premenopausal, male, bilateral), ovarian CA, prostate CA
− Paget’s Dz: invasion of skin by cells from a ductal carcinoma
− SHx: occupation (radiation exposure)
• Tx: MMG + exam for sub areolar mass (+ in 50% of cases)
− ROS: wt. loss, bone pain, SOB, chest pain, fevers/chills, skin Δs, mental status Δs
○ No mass= Bx nipple: if paget’s cells+ → excision; Mass: begin w/u
2) Physical Exam
− Inflammatory Breast Cancer: Bx containing skin → pre-op chemo → MRM → adjuvant XRT & staging
− Vitals, general appearance, Head-to-toe PE focusing on breasts and axillae
− Invasive Cancer: 90% infiltrating ductal CA, 10% infiltrating lobular CA, >1% inflammatory and others
− In 4 positions (sitting, arms @ waist, arms pulled forward, supine)
• Tx: MRM vs. lumpectomy w/ XRT
• Examine: color, texture, dimpling, edema, ulcers, skin Δs,
○ Both require SLNBx (+ in 1/3 of invasive CAs) → ALND if +
• Noting any: assymetry, nipple retraction (cooper’s ligament involvement), drainage
• Post-op chemo/HT (if nodes+): ER/PR+ = tamoxifen, Her2Neu = Herceptin
− Palpate in 2 positions: sitting (btw 2 hands), supine w/ same arm above head (vs chest wall)
• Post-op XRT: w/ lumpectomy (↓ local recurrances ½), chest wall invasion, >4LN+
− Examine and express nipple: look for skin Δs and discharge
7) Treatment Options for Invasive Cancer - Surgical: (1) lumpectomy & SLNBx w/ XRT, or (2) SM & SLNBx
− Examine supraclavicular and axillary nodes
− Lumpectomy +XRT (+ SLNBx if invasive)
3) Work Up: U/S, mammogram, biopsy
• For tumors < 5cm w/ good tumor/breast ratio (stage I and II only)
− DDx: fibrocystic Δs, fibroadenoma, ductal papilloma/ectasia, fat necrosis, abscess, radial scar, simple cyst
• CI to lumpectomy: +margins, tumor > breast size, multifocal disease (DCIS, calcifications)
− Patient <30: observe mass for 1-2 menstrual cycles unless patient high risk
• CI to radiation: prior chest/breast radiation, collagen vascular dz, pregnancy
• If still present: U/S → most = fibrocystic dz or fibroadenomas → \
− SLNBx
• If neither: FNA for cytology
• SE: lymphedema
− Patient >30:
• CI: palpable nodes → do U/S or FNA and remove
• Cystic feeling mass: U/S w/ FNA, reassure and resume screening
− ALND → axillary v (superior), L thoracic n. (posterior), lat dorsi (lateral), pec minor (medial)
• Solid/recurrent cyst: bilateral MMG + core Bx
• If 4+ LN are positive → XRT to axilla
○ Core bx in office, get ER/PR/Her2Neu status
• SE: nerve damage (L thoracic > thoracodorsal > medial pectoral > lateral pectoral)
○ Concerning: calcifications/border irregularity → 15% w/ microCa on MMG = malignancy
− Simple mastectomy
− Bx Indications: mass post FNA, solid mass, bloody FNA, suspicious MMG, bloody nipple d/c, nipple
• Indications: DCIS w/ diffuse microcalcifications, patients w/ C/Is to XRT, diffuse disease
ulceration/dermatitis, patient concern n
• Breast tissue, areola, skin removed; axillary nodes spared
− High risk/very concerning for CA: excisional Bx
− Modified radical mastectomy
− Nipple D/C: galactography
• Entire breast and axillary nodes removed; pec major and minor spared
4) Staging
• Cx: arm edema, infection, nerve injury, skin flap necrosis, hematoma/seroma, phantom Br syndrome
− Pathological Staging (TNM)
− Radical mastectomy
• Tis = CA in situ T1 = < 2 cm T2 = > 2 cm but < 5 cm T3 = > 5 cm T4 = chest wall/skin invasion
• Indications: tumors which invade chest wall
• N0= no ax nodes N1= mobile ax nodes N2= fixed/matted ax nodes N3= internal mamillary nodes
• Entire breast, ax nodes (I/II lateral to/deep to pec minor), pec minor and major removed
• M0 = no distant mets M1 = distant mets (inc supraclavicular nodes)
• Borders: clavical (superior), lat (lateral), lateral sternum (medial), inf mam fold (inferior)
− Clincal Staging
− Radical mastectomy + XRT
• Stage I = ≤2 cm w/o mets, no nodes (93% 5y survival)
• Indications: chest wall invasion w/ +margins OR if > 5cm (XRT to chest wall), >4 +nodes (XRT to axilla)
• Stage IIA = ≤2 cm w/ mobile axillary nodes OR 2-5 cm w/ NO nodes (72%)
8) Adjuvant Treatment Options for Invasive Cancer
• Stage IIB = 2-5 cm w/ mobile axillary nodes OR >5 cm w/ NO nodes
− Chemotherapy: cyclophosphamide w/: MTX and 5-FU (CMR) or adriamycin and 5-FU (CAM)
• Stage IIIA = >5 cm w/ mobile axillary nodes OR ANY size w/ FIXED axillary nodes (41%)
• Indications: patients w/ + nodes, stage III disease, palliative if stage IV
• Stage IIIB = ANY tumor w/ ipsilateral internal mammilary nodes OR inflammatory Δs
− Hormonal therapy: tamoxifen/raloxifene (anti-estrogen) or anastrozole (aromatase inhibitor)
• Stage IV: Distant metastases (incl ipsilateral supraclavicular nodes) (18%)
• Indications: histologic markers+
5) Cancer Specific Work Up
9) Follow Up
− Most common metastases: lymph nodes > lung > liver > bone > brain > adrenal
− MMG Q6mos for 2 years → yearly MMG; yearly CXR + LFTs
− Labs: CBC (bone marrow invasion), LFTs (liver mets) → liver U/S or abd CT if ↑ (alk phos most sens)
10) Recurrent Breast Cancer: can occur in operative field of prior mastectomy, breast post XRT, or axilla
• Consider BRCA testing if strong FHx (may consider prophylactic bilateral MRM)
− Most often in same quadrant as original tumor w/ metastatic dz+ in 10% of pts.
− Imaging: B/L MMG (U/S if pregnant), CXR (lung mets), bone /PET scan + serum Ca if Sx+, head CT if Sx+
− Risk factors (for both local and distant recurrence): large tumor, receptor negative status, +axillary nodes
• No CT staging until lymph nodes are assessed
− Tx:
6) Specific Diagnoses and Respective Treatment Recommendations
• Breast: mastectomy (if previously txed w/ lumpectomy + XRT), +/- XRT (for palliation)
− Fibroadenoma: benign tumor of stroma → appears as swirls of collagen on Bx,
• Chest wall: XRT (post mastectomy)
• Tx: observation or elective removal w/o previous bx
• Distant mets: hormone therapy (in prior responders), chemotherapy
− Fibrocystic disease: fibrous and cystic Δs in breast
11) Screening
• Sx/Signs: Δing pain w/ menstrual cycle, cysts, nodular fullness
− Low risk pts: 1st MMG @ 40 → yearly MMGs, self breast exams monthly @ 20 (1wk post-period)
• Dx: breast exam, Hx, aspirated cysts (straw-colored/green fluid)
− High risk pts: 1st MMG 5y before dx of 1° relative, self breast exams @ 20, biannual dr breast exams @ 25
• Tx: cysts→ FNA + follow for recurrence; Adj Tx: stop caffeine, NSAIDs, Vit E, Eve Primrose Oil, OCPs
12) Prevention
− Mastitis/Breast Abscess:
− SERMs (tamoxifen/raloxifene): ↓ local recurrance by 50%, ↓ rate of C/L BrCA as adjuvant
• Most common pathogen: S. aureus in lactating women, mixed flora in nonlactating women
− Aromatase Inhibitors (anastrozole): same as above, main SE = osteoporosis
• Tx: ABx (nafcillin), FNA if abscess +, resect involved ducts if recurrent, must f/u to r/o inflamm BrCA
− Phylloides tumor: mesenchymal tumor arising from breast lobular tissue (99% benign, 1% malignant)
• Signs/Sx: mobile, smooth mass seen in women 35-55. Resembles fibroadenoma on exam/MMG/ US
• Dx: core bx/excision
• Tx: local excision w/ wide margins, send for pathology (malignant potential)
○ If malignant: simple mastectomy w/ ALND only if LN palpable (most often metastasizes to lung)
• Adjuvant Tx: chemotherapy (if > 5cm or w/ stromal overgrowth)
− Intraductal papilloma: ductogram w/ excision of duct/ductal system
− Lobular Carcinoma In Situ (LCIS): → increases risk for cancer in BOTH breasts (30% risk @ 20y)
• Dx: no signs/sx/radiographic findings → found incidentally on Bx
• Prevention/Tx: lumpectomy, no margins needed. Close surveillance, tamoxifen for 5y (↓ risk 50%)
− Atypical ductal hyperplasia: lumpectomy, no margins needed, no XRT needed
• 4-5x ↑ risk for cancer
• 15-50% prove to be malignant
 − Distribution: 3 most common sites = skin > eyes > anus
Changing Skin Lesion − Subtypes:
1) History
• Superficial spreading: most common subtype (75% of all melanomas).
− HPI: onset, Δs, timing, assoc signs/sx (pruritis, pain, bleeding), other spots
○ Distribution: any area (both sun-exposed and –protected sites) but most commonly back and legs
− Risk factors for malignancy: sun exposure UVA/UVB (sunblock, protective clothing/hats, sunglasses),
○ Lesion appearance: irregular borders w/ varied color pattern
immunosupression,
○ Cell distribution/growth: upper dermis w/ lateral spread
fair skin, red/blonde hair, freckles
○ Prognosis: good
• SCC: arsenic exposure, AKs, large burns, osteomyelitis sinus tracts, chronic fistula (Marjolin’s ulcer)
• Acral lentiginous Melanomas: 10% of all melanomas
• BCC: chronic dermatitis, radiation exposure
○ common in African Americans (50% of all melanomas in African Americans)
• Melanoma: blistering sunburns before age 18
○ Distributed on mucous membranes, palms, soles
− PMHx: prior skin CA, previous dysplastic nevi, xeroderma pigmentosum, atopic dermatitis
○ Lesion appearance: typically black, but may be amelanotic
− FHx: melanoma, other CA
○ Cell distribution/growth: upper dermis w/ occasional deep invasion → spread radially
− SHx:occupation (sun/arsenic exposure, EtOH, tobacco)
○ Prognosis: dependent on depth of invasion
− ROS (i.e. signs of advanced disease to lung, liver, bone, brain): systemic sx (wt loss, fevers/chills), headaches,
• Lentigo maligna: least common subtype (>10% of all melanomas), best prognosis
neurologic
○ Distribution: occurs most frequently on head/neck and hand→ arises from Hutchinson’s freckle
Δs/sx, palpable LNs, SOB, abd pain, GI bleeding (esp rectal bleeding), jaundice, hematuria, bone/muscle pain
○ Lesion appearance: brown/black w/ elevated nodules w/in a smooth freckle
2) Physical Exam
○ Cell distribution/growth: upper dermis w/ radial growth; vertical extension = infrequent.
− Vitals, general appearance,
• Nodular melanoma: 15% of all melanomas
− Head-to-toe PE focusing on skin (including scalp and nails → Hutchinson’s sign)
○ Distribution: can occur in any of body
• Examine skin for: color/texture irregularities, areas of ulceration, irregular nevi
○ Lesion apperance: blue/black nodule
○ ABCDs of melanoma: Asymmetry, Border, Color, Diameter/Dark/Different
○ Cell distribution/growth: rapid invasion into dermis
• Closely examine ALL SKIN, including SCALP:
○ Prognosis: poor
○ Sun exposed areas (head, neck, hands)→ greatest risk for BCC/SCC
• Amelanotic melanoma: no pigment in lesion
○ Back (site for 1/3 of melanoma in men), legs (site for 1/3 of melanoma in women)
○ Often poor prognosis 2/2 late detection
− Perform ophthomologic/fundoscopic exam for retinal melanoma
− Staging
− Examine lips and oropharynx for mucosal melanoma
• Breslow’s Depth: actual depth of lesion → correlates best w/ survival
− Palpate cervical, axillary, femoral LNs
○ Measured vertically down from top layer of epidermis
− Perform rectal/pelvic exams to evaluate for rectal/vulvar melanoma
○ <0.76 mm = 90% cure rate w/ excision vs. >4.0 mm = 80% rate of recurrence/metastases w/in 5y
3) Work Up
○ Measurement may be inaccurate if ulceration+ (ulceration = poor prognosis)
− Biopsy any lesions suspicious for melanoma: punch bx for Breslow depth, or excision. NEVER SHAVE
• Clark’s Depth: based on histologic layers of skin, used if ulceration or thin skin (e.g. eyelid)
• <2 cm→ excisional bx (entire lesion w/ rim of normal tissue cut down to SQ fat to measure depth)
○ I = epidermis
• >2-3 cm → incisional bx (portion of lesion excised w/ border of unaffected skin)
○ II = into papillary dermis
− Labs: CBC, LFTs, coags
○ III = through papillary dermis but not into reticular dermis
− Imaging (reserved for +Sx): CXR, Bone/PET scan, head CT/MRI
○ IV = into reticular dermis
4) Basal Cell Carcinoma: most common skin CA, arising from germinating basal cell layer of epithelial cells
○ V = into subQ fat
− Distribution: most common on head, neck, and hands
• American Joint Commission for Cancer Staging and End Results
− Signs/Sx: slow growing, chronic, scaly mass; chronic scab/ulceration; pearly appearance
○ Stage I = < 1.5 cm; Stage II = > 1.5 cm; Stage III = any size w/ +LN; Stage IV = any size w/ metastases
− Subtypes:
• Metastasis: occurs both hematogenously and via lymphatics
• Nodular: flesh-colored, pearly nodule
○ Most common sites = local LN > distant skin > lung > liver > bone > heart > brain
• Superficial: scaly, red plaque → resembles SCC
○ Most common malignancy to metastasize to the bowel
• Morpheaform: hypopigmented, deep
− Treatment: based primarily on Breslow’s depth
• Pigmented: often confused w/ melanoma
• Excision
− Treatment (almost anything will work)
○ Melanoma in situ = 0.5 cm margin
• Electrodessication & curettage: if lesion < 2cm
○ 1 mm = 1 cm margin
○ 95% cure rate
○ >1 mm = 2-3 cm margin → excision should reach fascia overlying muscle (deep fascia)
○ Disadvantages: no specimen
• Special Cases
• Radiation: if lesion located in an area where tissue preservation crucial (ie eyelids)
○ Digital melanoma = amputation
○ 90% cure rate
○ Intestinal metastases = surgical resection to prevent bleeding/obstrucion
○ Disadvantages: skin atrophy/hypopigmentation common
○ Anal melanoma (most common Sx → rectal bleeding) = APR or wide excision
• Excision w/ primary closure: 1 cm margin
• Lymph node removal
○ 95% cure rate
○ Clinically involved regional LN w/ level II-V disease should be resected w/ an elective LND
○ Reconstruction can occur during same setting
○ Entails resection of levels I, II, and III w/ melanoma
• Mohs micrographic surgery: involves tumor mapping to determine adequecy of resection
○ SLNBx with lymphoscintigraphy if > 1.0 mm, LN+ → full LN dissection (under clinical trial)
○ 99% cure rate
• Adjuvant Tx: Interferon α2b
○ Indications: facial lesions (esp nose and perinasal area), morphealike tumors, recurrent lesions
○ Indicated in : thick T4 tumors, nodal mets (i.e. Stage III)
○ Immediate reconstruction possible → good aesthetic results
• Stage IV: no surgery; dacarbazine & IL-2. Recurrance → PET scan
• Cryotherapy: Limited clinical use → significantly higher morbidity and less predictable scarring
− Prognosis
• Topical Chemotherapy: poor cure rates
• Indicators: Breslow’s depth > node status/mets > ulceration > site > age
− Recurrent lesions → wide re-excision
• Disease confined to 1° site = 80-90%
5) Squamous Cell Carcinoma: CA arising from epidermal cells
• Regional LN involvement = 30-50%
− Distribution: most common on head, neck, and hands
• Distant/visceral metastases = 100% die w/in 12 months
− Signs/Sx: raised, slightly pigmented lesion w/ chronic ulceration/exudate; chronic scab; pruritis
− Treatment
• Electrodessication: if lesion < 1cm
• Excision w/ primary closure: <1 cm = 0.5 cm margin, >1 cm = 1-2 cm margin (may require grafting)
○ Regional LND necessary if evidence of nodal disease
○ If regional adenopathy+ → excise at a later date (some will resolve once SCC removed)
• Radiation
• Mohs’ micrographic surgery
− Nodal disease → treat w/ XRT if multiple nodes+
• Tx single node w/ resection
− Prognosis: 95% if adequately excised
• Metastatic disease has a poor prognosis
6) Melanoma: most deadly skin CA, malignant transformation of melanocytes
 − IIa = invades through muscularis propria/adventitia w/ -LN
Dysphagia • Tx: chemo/radiation → surgery
DDx: Zenker’s Diverticulum, Achalasia, Esophageal Spasm, GERD, Esophageal CA (adeno, squamous)
− IIb = invades up to the muscularis propria w/ + regional LN
1) Dysphagia, Intermittent or Progressively Worse Sx, Chronic GERD → 3 most important ?s
− III = invades adventitia/adjacent structures w/ +regional LN
− Dysphagia subtypes:
• Tx: chemo/radiation
• Solids > liquids = mechanical dysphagia
− IV = distant mets
○ DDx: esophageal ring, peptic stricture, esophageal CA, Zenker (pharyngeal) diverticulum (btw lower
• Tx: chemotherapy
pharyngeal constrictor and cricopharyngeal muscle), epiphrenic diverticulum (@EGD), stricture
7) Treatment
• Liquids > solids = motility related dysphagia → achalasia, spasm, scleroderma
− Zenkers: diverticulotomy, cricopharyngeus myotomy (indicated if diverticulum > 2cm, relieves high pressure)
− Intermittent vs. Progressively Worse
− Achalasia:
• Intermittent: esophageal ring/spasm
• Conservative: endoscopic balloon dilation of the LES (60% effective)
• Progressively Worse: esophageal CA, achalasia, scleroderma
• Surgical (if refractory to concervative management OR Barretts+): esophagomyotomy (Heller myotomy)
− Chronic GERD→ may also be caused by other mediastinal masses
○ lower esophagus/LES incision w/ 270º fundoplication (i.e. wrap) → prevents reflux (100%)
2) Hx→ 1st 3 questions as listed above
− Spasm:
− HPI:
• Conservative: Ca Channel blockers, Nitrates
• Zenker’s: dysphagia (solids > liquids), halitosis, food regurgitation, aspiration (+/-PNA), neck mass
• Surgical: esophagomyotomy (aortic arch → LES) → LES fxn preserved (not usuallyt abnormal w/ spasm)
• Achalasia: dysphagia (liquids > solids), regurgitation, wt. loss, +/- aspiration
− GERD
• Esophageal Spasm: spontaneous, intermittent CP → radiates to neck/back/jaw/ears/arms (≈ angina)
• GERD: substernal pain, heartburn, regurgitation, aspiration/cough, Δ w/ position, worse w/ EtOH/cigs/fat • Conservative: PPI/H2B, reglan (↑ LES tone), antacids, lifestyle Δs (↑bed, ∅ smoking/EtoH, wt loss)
• Esophageal CA: dysphagia (solids > liquids), wt. loss, back pain, hoarseness (voice changes), sx of metastasis • Surgical
− PMHx: ○ Indications= refractory sx, addt’l probs (webs/strictures/Barretts/dysplasia), aspiration 2/2 GERD, age
• Achalasia: scleroderma, GERD, other esophageal dzs, CA ○ Nissen fundoplication = 360° wrap of stomach around esophagus (done laproscopically)
• GERD: CAD, PUD, hiatal hernia, DM (gastroschesis) ○ Belsey Mark IV = 270° wrap performed via L thoracotomy
• Esophageal CA: GERD, prior CA, DM, premalignant lesions (achalasia, GERD, hiatal hernia, Barrett’s, ○ Hill repair = posterior gastroplexy → uses arcuate ligament to reestablish distal esophagus position
radiation, esophagitis, caustic burns, Plummer-Vinson [webs, Fe-deficiency anemia, dysphagia, koilonychia, − Esophageal CA (stage w/ EUS & CT chest/abdomen/pelvis)
atrophic oral mucosa], divericula, ectopic gastric mucosa, poor dentition • Based on location
− PSHx: prior gastric surgery, travel to Central/South America (Chagas) ○ Cervical esophagus and upper 1/3 = chemoradiation
− FHx: DM, CA ○ Middle 1/3 = XRT + chemo to shrink → surgical resection to remove entire tumor (possibly curative)
− SHx: smoking, EtOH, hot beverages (chronic irritation), Hunan Chinese heritage ○ Lower 1/3 = esophagectomy + proximal gastrectomy
− ROS: systemic sx (fever/chills, wt loss, appetite Δs), neuro Δs, SOB, cough/hoarseness, CP, abd pain, N/V, GI • Conservative: Palliation (↓ dysphagia) = XRT, transoral intubation/stenting, G-tube, resection, chemo
bleeding, Δs in urination, back pain, bone pain ○ Chemo = 5-FU, cisplatin
3) Physical Exam • Surgical (low mortality → >5%
− Vitals, Ht/Wt, BMI ○ Internal Bypass (colon interposition) → used for unresectable tumor
− Gen Appearance: cachectic? Obese (risk of GERD) + Mortality = 25-40% (average survival = 6 months post-op)
− HEENT: palpable masses, nodules, LNs, OP exam, swallowing capability, inspect teeth, CNs ○ Transthoracic Esophagectomy (Ivor Lewis) = intrathoracic esophagogastric anastomosis
− Cardiopulmonary/Abd/EXT + Stomach joined to esophagus in chest
4) Work up/Diagnosis + Disadvantages: [1] combined thoracoabdominal incision → respiratory cx (PNA = leading cause of death);
− Zenker’s: [2] possible intrathoracic anastomotic leak → mediastinitis (50% fatal); [3] reflux esophagitis; [4] possible
• Barium swallow → (+) = no EGD 2/2 perforation risk; (-) = EGD to r/o other esophageal disorders tumor recurrence at suture line; [5] long hospital stay
− Achalasia: ○ Transhiatal Esophagectomy (THE) = cervical esophagogastric (stomach/larynx) anastomosis
• Barium swallow = dilated esophagus w/ stricture (“birds beak) + Can combine w/ neoadjuvant XRT/chemo (cisplatin, 5-FU)
+ Advantages: [1] No thoracotomy; [2] cervical anastamosis (no mediastinitis→ if leak occurs, is easier to
• Manometry = ↑ LES pressure, ↑ esophageal pressure, ∅ LES relaxation w/ swallowing, ∅ peristalsis
manage); [3] no significant post-op GERD/reflux; [5] maximal vertical margins; [6] only need to sacrifice
• EGD = r/o neoplasm + document extent of esophagitis
short gastric aa
− Esophageal Spasm:
+ Cx:[1] anastamotic leak (10%), [2] postop mediastinal bleeding; [3] atelectasis/PNA; [4] RLN injury
• Manometry = high amplitude repetitive contractions w/ normal LES response to swallowing
○ Radical Esophagectomy → performed w/ en block LND
• Barium swallow/CXR = +/- diverticula, segmental spasm, corkscrew appearance of esophagus
+ More complex, larger operation
− GERD:
+ No survival benefit
• Must r/o: CAD, aortic dissection, PE, PTX, PUD, in addition to all esophageal disorders
+ Colonic interposition →Alternative, but larger/more complex operation
• Labs: +/- cardiac enzymes
− Scleraderma: serial dilation; Lye ingestion: esophagectomy
• Manometry = ↓ LES pressure
8) Prognosis – Esophageal CA
• EGD+Bx = esophagitis, ulcers, stricture, Barretts (w/o dysplasia = monitor, w/ dysplasia → resect)
− 97% = candidates for THE
• 24h pH measurements (in lower esophagus) = ↑ acidity (should not < 4 for > 4% of the day)
• 5 yr survival = 23%
− Esophageal CA:
• By stage: Stage I = 80%; Stage II = 33%; Stage III = 15%; Stage IV = 0%
• Hx = wt. loss almost always +
• Imaging
○ Barium swallow = location/extent of tumor
○ CT of chest/abdomen = location and extent of tumor (needed for staging)
○ EGD = tissue bx and evaluation of tumor extent
+ Landmarks: LES = 15cm (C6-7), carina = 25cm (T4), LES/EGJ = 40cm (T10)
○ EUS = used in staging
○ Bronchoscopy = used w/ proximal esophageal tumors → assesses tumor invasion into bronchial tree
○ PET scan
• Labs: CBC, Basic, LFTs, coags
5) Specific Diagnoses
− Zenker’s Diverticulum → false diverticulum of mucosa herniated btw cricopharyngeal muscle
• Caused by incoordination btw UES relaxation and pharyngeal contraction
• Associated w/ hiatal hernia and GERD
− Achalasia → Failure of LES to relax causing esophageal dilatation
• Unknown etiology, sometimes assoc. w/ Chagas dz
• Risk of esophageal CA 10x higher in patients w/ Achalasia
− Esophageal Spasm → strong non-peristaltic contractions w/ normal sphincter function
6) Esophageal CA Staging → most patients present w/ stage III or w/ distant mets (need EUS & CT to stage)
− I = invades through mucosa/LP up to submucosa
• Tx: surgery
 − LR best (NS okay)
Trauma − Fluid replacement
PRIMARY SURVEY
• Adults
1) Airway
○ 2L of LR wide open
− Evaluate
○ If no response (BP/HR) switch to blood
• Clear airway of debris/foreign bodies/teeth/blood
+ Use O- initially until T+C returns
• Stridor/hoarseness → laryngeal obstruction/injury
• Pediatric patients
− Establish
○ Bolus 20 cc/kg x 3
• Finger sweep → chin lift/jaw thrust
○ If no response → blood @ 10cc/kg
− Decide if early intubation necessary → GCS ≤ 8, major head/face/neck trauma, ↓ ventilation 2/2 paralysis
8) Monitoring
− Intubation = w/ cuffed tube in trachea
− Vitals: EKG, pulse oximetry, non-invasive BP cuff
• Endotrachial (preferred) vs. nasotracheal (contraindicated in facial fractures)
− Lines: NG tube, foley (after FAST)
○ Endotrachial
• Before foley check meatus (blood), prostate (high riding), scrotum (hematoma)
+ Preoxygenate w/ bag valve mask
○ If + → retrograde urethrogram and place foley under cystoscopy
+ Maintain C spine stabilization necessary throughough
− Labs: ABG, T+C
+ Apply cricoid pressure
− Imaging: FAST, CXR, CT,
+ Suction as needed
• CXR = assess for PTX/hemothorax
○ Nasotrachial
• Pelvic XR = assess for pelvic fx/retroperitoneal bleed
+ Patient must be awake, breathing, and w/o facial/basilar fractures
• EXT: assess femur fx → lose 2+ L blood
+ Smaller tube size used than w/ endotracheal intubation
• FAST/CT: assess for internal injuries/hemoperitoneum
− Confirm intubation by listening/checking end tidal CO2/pulse oximetry
○ FAST = Focused Assessment w/ Sonography in Trauma
− Cricothyroidotomy if unable to establish definitive airway
○ Locations = perihepatic, perisplenic, pelvis, pericardium
• Place btw thyroid/cricoid cartilage
9) SECONDARY SURVEY → (return to ABCs if patient decompensates at any time)
2) Breathing
− AMPLE Hx: Allergies, Meds, Pregnancy/PMH, Last meal, Events
− Assess rate and quality of breathing (look for condensation; use ABG, O2 sat, CO2 detection)
− PE: head to toe → look for missed injuries
− Establish presence of bilateral breath sounds
• HEENT: pupil size, tympanic membranes, C-spine point tenderness
− Inspect for sucking chest wounds, subcutaneous emphysema, tracheal deviation
○ Raccoon eyes/battle signs → basilar skull fx
− Unilateral breath sounds PLUS unstable vitals (esp hypoTN) → needle thoracostomy
• Rectal: high-riding prostate
• 14/16 gauge angiocatheter in 2nd intercostal space in midclavicular line
− Special Procedures: DPL, IVP, central line
• MUST FOLLOW w/ chest tube (tube thoracostomy)
• Central line = 9 french cordis
− Chest tube
• Diagnostic peritoneal lavage
• 5th intercostal space in midaxillary line → large (36-40 french) tube
○ Indicated in diagnostic dilemma → unclear if bleeding/injury and too unstable for CT (or use FAST)
• OR Criteria
○ OR criteria
○ Blunt trauma = >1500 cc frank blood immediately OR > 200 cc/hr for 2+ consecutive hours
+ Blunt: 10 ml gross blood, ≥100K RBCs/mm^3, ≥500 WBCs/mm^3, bacteria/food on gram stain, bile
○ Penetrating trauma = >1000 frank blood immediately OR > 200 cc/hr for 2 consecutive hours
+ Penetrating: 10ml gross blood, >1000 RBCs/mm^3, bacteria/food on gram stain, bile
3) Circulation
• Left thoracotomy
− Obtain pulse and blood pressure, check skin color/capillary refill
○ Indications: witnessed loss of vitals < 20 min prior (typically w/ blunt trauma)
• Quick/thread pulse = hypovolemia
○ Triad of death: cold, acidotic, coagulopathic
• Slow pulse = neurologic injury w/ ↑ICP
• Pelvis stabilization
− If active bleeding → apply direct pressure (no clamps), tourniquet
○ External fixation, mast trousers, sheet/towel clamp
• Tourniquet (can use blood pressure cuff) = inflate to 30-60 mmHg > systolic BP
10) OR
− Assess urine output (place foley unless contraindicated)
− Prep patient from chin to knees
− Assess shock state
− Open w/ large midline incision
Blood Loss | %Loss | Pulse | BP | Pulse Pressure | Mental Status
− Pack all 4 quadrants → systematically explore for bleeding
• Class I <750 <15% <100 = =/↑ slightly anxious
− Decide damage control laporotomy vs therapeutic
• Class II 750-1500 15-30% >100 = ↓ mildly anxious
• Class III 1500-2000 30-40% >120 ↓ ↓ anxious / confused
• Class IV >2000 >40% >140 ↓ ↓ confused / lethargic
− Systolic BP estimates based on papable pulses
• Carotid = 60 mmHg
• Femoral = 70 mmHg
• Radial = 80 mmHg
• DP/PT = 90 mmHg
4) Disablility
− Rapidly assess for neurologic deficits (ideally before intubation)
• Evaluate for GROSS deficits only (ie not moving one side/profound weakness)
− Assess GCS: <8 = intubate
• Eye Opening: spontaneous >> to voice >> to pain >> none
• Verbal: oriented >> confused >> inappropriate >> incomprehensible >> none
• Motor: obeys commands >> localizes pain >> withdraws >> flexion >> extension >> none
5) Exposure
− Uncover patient to avoid missed injuries, wash off any chemicals
− Maintain body temperature
• Minimally invasive: warmed IVF, lights, blankets, warmed ventilator air
• Moderately invasive: Inner cool catheter << warmed bladder/stomach/peritoneal lavages
• Most invasive: ECMO
6) Resuscitation → Best if incorporated into 1° survey
− Supplemental O2 (10L NC)
− IVF: 2 large bore (14/16 gauge) in antecubital fossae
• Place away from any injuries
• LE contraindicated in blunt trauma
• If peripheral unavailable → central line/saphenous cut down
• Send T+C when starting IV
7) Fluids
 − D/C all nephrotoxic meds
Oliguria/Anuria 8) DIALYSIS
Anuria = UOP < 100cc/24hrs
− Indications = AEIOU → acidemia, hyper K, fluid overload, uremia (pericarditis, encephalopathy, bleeding)
Oliguria = UOP = 100-400cc/24hrs OR <0.5cc/kg/hr (adult) OR <0.1cc/kg/hr (child)
− Better to dialyze before uremia (ie while patient only azotemic)
Dx: Pre-Renal vs Renal vs Post-Renal
9) SURGICAL INDICATIONS: unstable VS/Hct, signs of hemorrhage → return to OR to explore
− Pre-Renal → most common causes post op (50-90%)
• Hypovolemia (bleeding, 3rd spacing, under-resuscitation)
○ Hemorrhage = ↑↑ HR (>120), hypoTN
○ 3rd spacing (e.g. pancreatitis, burns) = ↑ HR (90-100), normotensive
○ Under-resuscitated = mild tachycardia (105), normotensive
• Poor CO
• Renal vasoconstriction (NSAIDs, ACEi)
• Large vessel disease → renal artery stenosis
− Renal
• ATN 2/2 ischemia, nephrotoxins (contrast, ABx, NSAIDs, Mgb/Hgb)
○ See casts on U/A
○ Ischemia: 2/2 hypotension, emboli; Abx: vanco, cephalo; NSAIDS: toradol; contrast: Tx w/ H2O, bicarb, Mucomyst
• AIN 2/2 allergy (NSAIDs, β-lactams, sulfas), infection, infiltrate (sarcoid, lymphoma)
○ See eosinophils on U/A
• Renovascular Small Vessel Disease: HUS/TTP, DIC, pre-eclampsia, HTN-ive crisis
• Glomerulonephritis
− Post-Renal → typically obstruction resulting in hydronephrosis, e.g. flush foley
1) RESUSCITATION
− Assess ABCs and check all 5 vitals
• If hypoxic or in respiratory distress → add supplemental O2 → intubate
− Check I/Os and UOP
• Look at intraoperative I/Os
• Review records to see if patient has ESRD/is on dialysis
− If foley intact → flush w/ 30 cc, otherwise replace foley
− Check for signs of fluid overload → JVD, pulmonary rales, edema
• If negative → bolus w/ 500cc LR
○ If no response → bolus #2
• If positive + hypoTN + low UOP → check CVP
− If febrile → 5 Ws (wind = atelectasis, water = UTI, wound = infection, walking = DVT, wonder drugs)
2) HISTORY
− HPI: any present Sx → if so address w/ a ROS (F/C, N/V, dizzy/HA, CP/SOB, D/C, urinary)
− PMHx: CKD/dialysis, BPH, neurog. bladder, studies w/ contrast (ATN), liver dz (hepatorenal), CVD, CHF
• Hepatorenal = mimics pre-renal etiologies
− PSHx: abd surgery, review op report → note any significant intraoperative hypoTN and I/Os
− Meds: analgesics (NSAIDs), spinals/epidurals, ABx (vancomycin, aminoglycosides), diuretics
3) PHYSICAL EXAM
− Vitals/General Appearance: skin turgor
− Surgical Site
− HEENT: MMM
− Cardiopulmonary: 3rd heart sounds (CHF), rubs, rales, JVD
− Abdominal: ascites, CVA tenderness
− Rectal: BPH
− EXT: edema, vascular perfusion (pulses)
4) LABS: CBC (HCT), coags, T+C, basic (for BUN, creatinine, Na), Urine Na, Urine creatinine
− Δs in mental status and no response to fluids → basic and U/A
− Pre-renal = FeNa <1% AND/OR BUN/Cr >20%
− Renal = FeNa >3% AND/OR BUN/Cr <10%
• FeNa = (UNa * PCr) / (PNa * Ucr)
• If given diuretic or suspect ATN → use central line or FeUrea
• If coagulopathic → give FFP, vitamin K
− Renal fxn in ATN/AIN/GN/RV = urine sed, CBC, LDH/haptoglobin, CPK
5) STUDIES
− Non-invasive: bladder U/S (PVR), renal vessel U/S (blood flow), EKG, renal U/S (hydronephrosis)
− Invasive: If oliguric w/ fluid overload → Swann
6) RESPONSE TO FLUIDS (UOP should increase within an hour)
− Bolus 500cc LR x2 → monitoring for Sx/signs of fluid overload (rales, hypoxia, JVD)
• Response = increase IVF (D5/½ NS + 20KCl) to 2-3x maintenance rate (4/2/1 ml/hr based on kgs)
− If HCT < 8 (nl adult) or < 10 (sick, old) → give 2 units pRBCs & monitor CBC
7) NO RESPONSE TO FLUIDS → MOVE TO ICU
− Place central line/Swann → insert through subclavian vein → RA/RV → pulm art
• Normal CVP = 8-12
• Normal SVO2 (mixed O2 saturation in venous blood) = 65-75%
• Normal CO = 4-5
• Normal CI> 2
− If cardiogenic shock → give dobutamine and diurese
− If septic shock → give norepinephrine and ABx
− If suspicious of true renal failure → Lasix challenge (100-150mg)
• Polyuria = good prognostic sign → continue Lasix w/ intermittent hemodialysis
• Oliguria = will likely need chronic dialysis
 6) STUDIES
Shock − Non-Invasive: CXR (pulmonary edema = cardiogenic), EKG, TTE/TEE (if murmurs/EKG Δs), CT if unknown
Definition = failure of end organ perfusion
etiology (possible abscess)
DIFFERENTIAL DIAGNOSES/CAUSES→ All = HypoTN (↓BP) + Tachycardia (↑HR)
− Invasive: cardiac catheterization (as needed)
− Hypovolemic: ↑HR ↓CO ↓BP ↑SVR ↓PCWP
7) TREATMENT – serially assess response to tx w/ UOP, BP, HR, mental status, CFT, EXT perfusion
• Etiology: hemorrhage, 3rd spacing, vomiting/diarrhea, inadequate resuscitation/intake, burns, pancreatitis,
− Pressors/Inotropes
corticosteroid withdrawal, SBO
• Pressors = ↑MAP and ↑venoconstriction
• ∅ normal response w/ β-blockers ○ Phenylephrine = α agonist → venoconstriction
• Tx: volume repletion • Inotropes = ↑ contractility
− Septic: ↑ HR ↑CO ↓BP ↓SVR ↑PCWP (hypoTN refractory to fluids) ○ Dobutamine = β agonist → inotrope
• Sx/Signs: diaphoretic, flushed, warm, vasodilated, ↑RR ○ Dopamine
○ Early = high output HF (trying to overcome ↓↓BP) + ↑ renal perfusion via dopamine receptors → inotrope
○ Late = can’t overcome → ↓CO − Hypovolemia: stop bleeding → resuscitate w/ 3:1 LR & pRBCs if HCT < 30
• Etiology: infection (fever, ↑WBC) • If unstable after 4-6L crystalloid and 4-6U pRBCS → go to OR
○ Typically gram (-) organisms • NO VASOPRESSORS
○ Infection → massive inflammation → vasodilation − Sepsis: must identify source of infection (UTI, PNA, abscess)
• Cx: DIC (hemolysis), ARDS, DKA/HONKC (hyperosmoloar non-ketotic coma), • Give IVF → Xigris (activated protein C) and hydrocortisone
MOSF (multiorgan system failure) • Δ all lines → give empiric Abx (Vanc/Gent/Flagyl) → drain any/all abscesses
• Tx: ABx, volume repletion, pressors • Use pressors/inotropes if BP doesn’t respond to 2L of fluids (phenylephrine, dopamine, NE)
− Cardiogenic: ↑HR ↓CO ↓BP ↑SVR ↑PCWP ↑CVP (volume overload → rales, pulmonary edema) • Monitor for Cx: MOSF, DIC
• Etiology: − Cardiogenic: must identify cause and address ASAP → catheterization, pericardiocentesis, surgery
○ Intrinsic: MI, CHF, valve insufficiency, arrhythmia, papillary muscle dysfunction • Swan-Ganz catheter
○ Extrinsic: tension PTX, cardiac tamponade, ↑ abdominal pressure • Inotropes/pressors
• Tx: tx cause of shock, inotropes, diuretics • Intra-aortic balloon pump, ventricular assist device (last resort)
− Neurogenic: Hypotension w/ Bradycardia (↓ sympathetic tone) − Neurogenic: IVF, phenylephrine
• Etiology: spinal cord injury, spinal anesthesia − Anaphylactic: epinephrine + albuterol, Benadryl, hydrocortisone, pressors
− Anaphylactic: wheezing, urticaria, pruritis, vomiting, abdominal cramps
• Etiology: Type I hypersensitivity Rxn (IgE mediated)
1) ASSESS ABC’s
− Note all 5 vitals, UOP, I/Os, mental status, cardiopulmonary exam
• Abnormal exam (rales, JVD, edema) = cardiac failure/fluid overload → need to intubate
− Signs of shock = tachycardia > hypoTN (orthostatic first ) > ↓UOP > tachypnea > MSΔs > poor perfusion
2) RESUSCITATE
− First step = fluid boluses (500cc-1L) to goal → mean BP = 65 mmHg
• Watch for fluid overload/respiratory distress/hypoxia
− Airway/Breathing/Spine Immobilization
• Place on O2 by nasal cannula >> bag/mask >> intubate (if unstable → GCS ≤ 8)
• Establish airway: chin lift/jaw thrust w/ airway placement → ET intubation → cricothyroidotomy
− Circulation
• IV access/foley placement → run fluids
○ Minimal UOP for adult = 50cc/hr
• Swan-Ganz if patient unstable/ has indeterminate fluid status
• Fluids = crystalloid/colloid/blood
○ 3/1 rule for crystalloid after blood loss →
○ Albumin < 2 → give colloid
○ HCT < 25% → give pRBCs
○ PTT > 35 → give FFP
○ PT > 15 → give FFP
○ Platelets < 50,000 → give platelets
3) HISTORY
− #1 Question = What happened to the patient recently
• Elicit: surgery (type/Cx/EBL/I&Os), bee sting, transfusion
− # 2 Question = Cardinal Sx of non-hypovolemic shock
• C/P radiating to jaw, F/C, paralysis/paresthesias, wheezing/itching/cramps
− HPI: Sx→ detail onset, acuity/chronicity
− PMHx: recent infxns, CAD, CHF, HTN, adrenal insuff, immunosuppression (DM, post TXP), bleeding probs
− PSHx: surgery (I/Os, Cx), recent central lines
− Meds: corticosteroids, anti-HTNives (β-blocker ↓ tachy response), coumadin/heparin (FFK/Vit K/protamine)
− Allergies: bee stings, foods, PCN, contrast (shellfish), blood transfusions, meds
− FHx: CAD, bleeding disorders
− SHx: smoking (CAD risk factor), EtOH, IVDU
− ROS: F/C, CP, sweating, SOB, cough, wheezing, N/V/cramps, D/C, urinary pain/frequency/urge, paralysis
4) PHYSICAL EXAM
− Vital signs → Shock = BP < 90
− General Appearance/Mental Status
− Neuro: motor/sensory
− Skin/HEENT: cold/clammy, ↓ cap refill, MMM
− Cardiopulmonary: R&R, murmurs, JVD, edema, rales, wheezes (anaphylaxis)
− Abdominal: pulsatile mass, tenderness
− Rectal: sphincter tone (neurogenic shock)
− EXT: edema, peripheral perfusion, neuro
5) LABS: CBC, basic, ABG (acidosis/base defecit = ↓ tissue perfusion), T+C, coags, cardiac enzymes, blood cx (in
sepsis, before Abx), fibrinogen/D-dimers (DIC = cx of sepsis), lactate (assesses perfusion)
− Pre-op Hct or immediate post-op Hct = baseline
 • Imaging: US/CT/MRI = tumor mass
Liver Mass ○ Has propensity for vascular invasion → often will see satellitosis (multifocal tumors)
DIFFERENTIAL DIAGNOSES
○ Chest/Abdomen CT for metastasis → esp hilar/celiac LN
− Benign: hemangioma (most common benign), hepatic adenoma, focal nodular hyperplasia, biliary cystadenoma,
• Tx Options (unclear role for LN dissection):
simple cyst
○ Partial Hepatotectomy
− Infectious: pyogenic abscess, amoebic abscess (Entameoba histolytica), Echinococcal cyst
+ Indications: no mets, solitary, <5cm, Ø vascular invasion, low grade, 1 cm margins possible
− Malignant: metastatic disease (most common malignant, often colon CA), hepatocellular CA, cholangiocarcinoma
+ Inflow/outflow = occluded to the section to be resected → resect w/ 1cm clear margins
1) HISTORY
+ Non-cirrhotics = ≤70% of the liver can be resected w/o Cx
− HPI: incidental finding vs. symptomatic (RUQ pain?); onset, recent Δs
+ Cirrhotics = resection potential is much less (b/c of ↓ reserve) → use wedge resection instead
− Sxs: pruritis, pain, jaundice, abdominal swelling, fever, anorexia
○ Non operative candidates
− Specific Risk Factors:
+ Small, solitary lesion: RFA, EtOH injection, Arterial Chemoembolization
• Hemangioma: OCP, women of childbearing age → Estrogen related
▫ Infusion of chemo + gelatin foam particles → tumor ischemia = prolonged local chemo effects
• Hepatic Adenoma: OCP
+ Large, multiple lesions/Cirrhosis: Liver Txp → eliminates risk of recurrence
• Entamoeba Histolytica: travel (esp Mexico)
▫ Preoperative chemoembolization >> transplant >> post transplant adjuvant chemo = best
• Echinococcal Cyst: travel (esp Central/South America, Middle East, China), exposure to sheep/dogs
+ Metastatic Dz: Txp not an option → resection +/- embolization of mets + systemic chemo
• HCCA: cirrhosis, Hep B/C, IVDU, transfusions, multiple sex partners, aflatotoxin (peanuts), liver injury
• Prognostic Factors: ≥1 cm margins, ≥5cm in diameter, solitary, Ø vascular invasion, low grade CA
− PMHx: extrahepatic CA (colon CA, 1° kidney tumors, breast CA, melanoma), cirrhosis, Hep B/C, PKD
• Recurrence Sites: Liver >> Bone/Lung >> Brain/Intraperitoneal
− ROS: Systemic Sx (F/C, N/V), hematuria, GI bleeding, bone pain, Sx of cirrhosis (ascites, encephalopathy)
− Metastatic Tumors: most common hepatic malignancy → most often 1° GI tumors (colon, neuroendocrine, etc.)
2) PHYSICAL EXAM → Head-to-Toe Physical Exam Focusing on Abdominal Exam
• Best prognosis if only in liver w/o LN involvement
− Vitals and General Appearance → Jaundice, fat distribution, odor (fetor hepaticus)
• Tx: wedge resection, cryoablative therapy, chemo for colorectal mets
• Ruptured hepatic adenoma = presents w/ intra-abdominal bleeding/shock → mortality = 20%
○ Wedge resection: best if done <3x
− Abdominal Exam: hepato/splenomegaly, ascites, caput medusae, +/- PKD
+ Will often recur → close f/u needed
− Skin: jaundice, spider angiomata, palmar erythema, gynecomastia, lymph adenopathy
○ Cryoablative Tx: best for unresectable tumors
− GU: testicular atrophy − Neuro: asterixis
− Cholangiocarcinoma: possible txp − Gallbladder adenocarcinoma:
3) LABS
− Simple Cysts: Common finding in 10% of population → usually small/ASx cysts filled w/ serous fluid
− CBC (thrombocytopenia = HCCA, leukocytosis = infection), platelet count
• If multiple → typically ≤3 and scattered
− LFTs (Alk phos >> AST/ALT = biliary process, normal AST/ALT = adenoma, focal nodular hyperplasia)
• Large cysts = more likely to be Sxic → pain and early satiety
− Hepatatis Panel: HBsAg, HCV RNA,
• Tx: repeat imaging in 6 months
− Serum α-Feto Protein:
○ If RUQ pain → aspiration + sclerosant injection vs. simple excision
• HCCA: ↑ in 60% of HCCA cases (inversely proportional w/ survival), AFP > 500-1000 = HCCA
− Polycystic Kidney Disease: Many cysts scattered throughout liver → progressively enlarge
• Hepatic Adenoma/Focal Nodular Hyperplasia: normal AFP
• Can resect severely affected areas, but typically dz process doesn’t affect synthetic fxn
− CEA, CA19-9: if colon CA suspected
− Cystic Neoplasms: Cystadenomas/Cystadenocarcinomas
− Total bilirubin: Direct vs Indirect
• Characteristic appearance = thick multiple septations w/in cyst w/ calcified cyst wall
− Coags/Albumin: Indicate liver fxn
• Typically occur in middle-aged women
4) IMAGING
• Tx: resection
− RUQ U/S: Evaluate liver/biliary tree/gallbladder (good screening test)
− Echinococcal/Hydatid Cysts: Humans infected w/ echinococcal paraciteds (typically infect sheep/dogs)
• Single Cyst (no internal echos): Simple Cyst vs. Pyogenic Abscess (↑WBC, fever, abd pain, IVDU Hx)
• Contracted by fecal (dog/sheep)/oral contact → suspect in natives of Alaska/SW USA/foreign countries
• Single Multilocular Cyst (Ca + internal echos): Echinococcal Cyst → f/u w/ echinococcal serologies
• Appearance: Unilocular cysts w/in hepatic parenchyma (+/- calcification) → can grow to 10-20cm
• Single Solid Lesion: Hemangioma >> FNH >> Hepatic Adenoma >> Metastasis >> HCCA
○ Multiple daughter cysts inside larger cysts
○ Hemangioma: confirm w/ labeled RBC scan (Tc-99)
• If Dx suspected = Bx contraindicated → can result in peritoneal cavity seeding/anaphylaxis
+ If negative → CT/MRI w/ contrast (contrast in periphery > center)
• Tx: Albendazole
○ HCCA: diagnose w/ CT
○ If no response → laparotomy + exploration
+ If inconclusive → Bx
+ Affected areas walled off w/ hypertonic saline and cysts removed intact (w/o spilling contents)
+ If positive → no Bx indicated (may seed tumor along needle tract)
− Pyogenic Abscess: usually 2/2 GI/biliary tract seeding (K. pneumonia most common → 40% of cases)
• Multiple Lesions: Metastasis >> Pyogenic Abscess >> Entamoebic Cysts (r/o w/ negative serologies)
• Hx: RUQ pain, fever
− Spiral CT: indicated if U/S inconclusive or more information needed for surgery, requires contrast
• Labs: CBC = ↑WBC, LFTs = ↑ Alk phos
• Stellate Central Star: FNH
• Imaging: CT/US = hypoechoic abnormality w/ hyperechoic and/or hypervascular wall
− Bx: NEVER indicated unless 100% sure lesion ≠ hemangioma
• Tx: percutaneous aspiration and draining → Cx and direct ABx therapy vs appropriate organisms
− Other: cholangiography, angiography, nuclear med
○ Biliary stenting if old/sick/1° infection unknown
5) SPECIFIC DIAGNOSES/TREATMENT
− Amoebic Abscess: Rare in US, common in Central/S. America → occurs in 10% of infected w/ organism
− Hemangioma = most common liver tumor occurring in 8% of the population
• Percutaneous aspiration → anchovy paste
• May enlarge throughout life (esp during pregnancy)
• Tx: Flagyl; draining not required
• >4cm = Giant Hemangioma → typically incidental finding
○ May cause high-output heart failure if massive
• Imaging: U/S = “focal hyperechoic abnormality” vs CT = prominent peripheral → central enhancement (centripetal)
• Generally ASx (spontaneous rupture = rare)
○ If thromboses → transient pain, can ↑ AST/ALT, may appear involuted on imaging
• Tx: If ASx → observe
○ Pain/compressive Sx/risk of rupture/uncertain Dx → surgical resection
− Hepatic Adenoma = Benign tumor typically occurring in women 30-50yrs
• Hx of estrogen exposure from OCP, HRT, pregnancy, anabolic steroids
• Appearance: gross = solitary/unencapsulated mass / microscopic = sheets of hepatocytes w/o portal Δs
• Imaging: CT = solid hypodense lesion w/ adj hemorrhage vs Tc-99 = filling deficit (cells ≠ tracer uptake)
• Tx: resection 2/2 risk of growth, rupture, and HCCA.
○ Must perform intraoperative U/S to assess for add’l tumors/define relationship w/ surrounding vessels
○ ASx: D/C OCP → may spontaneously regress (If persists = surgical resection/enucleation)
○ Sx/>5cm (risk of rupture)/anticipating pregnancy = surgical resection
− Focal Nodular Hyperplasia = Well-defined benign lesion w/ central scar/fibrous septa/nodular hyperplasia
• No premalignant potential, hemorrhage = rare
• Tx: resection only if unclear diagnosis/pain
− Hepatocellular Carcinoma: 90% of all 1° hepatic malignancies
• Hx: HBV/HCV → highest rates in areas where HBV = endemic
○ Cirrhosis = also possibly related but not a 1° risk factor
• Should be suspected in cirrhotics w/ sudden decompensation (worsening ascites/encephalopathy)
 ○ Appendectomy → appendix not correctly placed, removes any future confusion
Vomiting Newborn ○ Examine remaining bowel for abnormalities (duodenal webs)
DIFFERENTIAL DIAGNOSES → Malrotation until proven otherwise
− Intestinal Obstruction/Atresia/Annular Pancreas
− Intestinal Malrotation +/- Volvulus: clockwise twisting of bowel around mesentery
• NGT, IVF, IV ABx = first
• Sudden onset bilious vomiting in infants < 1 year + abdominal distention/pain
• If Duodenal Atresia → check other abnormalities in VACTERL first (cardiac probs more life threatening)
• Volvulus = intestinal twisting on vascular pedicle → ischemia + SBO
• OR → 1° anastamosis (duodenoduodenostomy = best, duodenojejunostomy = 2nd choice)
− Duodenal Obstriction/Atresia: bilious vomiting at birth associated w/ VACTERL syndrome
○ Gastrojejunostomy = contraindicated
− Small Bowel Obstruction/Jejunal Atresia: Hx of polyhydramnios = common + no meconium passed
○ If Annular Pancreas present → bypass w/ duodenoduodenostomy
− Annular Pancreas: Assoc. w/ Down’s
+ Never divide pancreas → not obstructing structure
− Intussusception: Hx of viral illness, knees to chest w/ abdominal pain, currant jelly stools, Dance’s sign
○ Check for other intestinal atresia
− Hirschsprung’s Disease: Ø mesenteric plexus → chronic constipation, small diameter stools in < 2 y/o
− Hirschsprung’s
− Meconium Ileus: Assoc. w/ CF → occurs in ileum
• Resection & bx of involved colon
− Meconium Plug: Assoc. w/ premature delivery → occurs in colon
• Early = Colostomy
− Necrotizing Enterocolitis: Assoc. w/ prematurity/high stress birth (hypoxia) → bloody stools + sepsis
• Later = endorectal pullthrough vs 1° anastamosis
− Small Left Colon Syndrome: Assoc. w/ GDM − NET − Pyloric stenosis − Imperforate anus
• If Cx w/ enterocolitis/peritonitis → IVF, ABx, colonic irrigation
1) RESUSCITATION
− Intussusception
− Assess ABCs
• 85% reduce w/ hydrostatic pressure from air/barium enema
• IVF = 2cc/kg/hr UOP
○ If fails → to OR
− Place Foley/NGT
− Meconium Ileus
− +/- Prophylactic ABx
• 60% resolve w/ gastrografin enema (H2O soluble)
2) HISTORY
○ If fails → to OR for enterotomy (incise bowel and remove meconium)
− CC: Vomit → color (yellow/green), amount, blood-tinged, frequency, timing, progression, hungry afterward?
• Replace pancreatic enzymes and give IVF
− Age
− Meconium Plug
− HPI: onset, context (infant’s health), assoc. sx/pain, recent health problems
• Contrast enema (H2O soluble) = diagnostic and therapeutic
− Prenatal/Perinatal Hx:
− Necrotizing Enterocolitis
• Birth problems: prematurity/high stress birth → NEC/Meconium Plug
• Medical management = NPO, IVF, NGT, ABx (Amp/Gent/Clinda), Bicarb (correct acidosis), TPN
• Failure to pass meconium in 1st 24hrs: Hirschsprung’s
• OR indications = perforation, full-thickness necrosis, clinical instability
• Amniotic Fluid Level: polyhydramnios → Small Bowel Atresia
− Small Left Colon Syndrome
• Pregnancy Hx/Cx: Maternal GDM → Small Left Colon Syndrome
• Contast enema = diagnostic and therapeutic
− PMHx: other medical problems
− Pyloric Stenosis: 4-6 wk old
• VACTERL = vertebral, anal atresia, cardiac, tracheoesophageal fistula, renal, limb abnormalities
• Pyloromyotomy: spread muscularis, intact submucosa
− PSHx
− Imperforate Anus
− Meds/Allergies
• Posterior Sagittal Anorectoplasty
− FHx: Down’s → Atresia, CF → Meconium Ileus, Hirschsprung’s, Pyloric Stenosis
− Hernia sac
− ROS: General (F/C, wt/appetite Δs, feeding/stooling habits)
• Anterior medial
• Constipation → Hirschsprung’s vs. Meconium Plug vs. Meconium Ileus
• Diarrhea + Melena/Hematochezia → NEC
• Red “Currant Jelly” Stools → Intussusception
3) PHYSICAL EXAM → Head-to-Toe Physical Exam Focusing on Abdominal and Rectal Exams
− Vital Signs/General Appearance: crying, discomfort, signs of dehydration (MMM, fontanelle, skin turgor)
− Abdominal: distension, tenderness, bowel sounds, masses, hernias
• RLQ mass/sausage = Dance’s sign → intussusceptions (retraction in R iliac fossa)
− Rectal: r/o anal atresia, currant jelly stool, empty ampulla
4) LABS: CBC, basic, LFTs, amylase/lipase, lactate (↑ w/ NEC), U/A (r/o fistula), Cl sweat test
5) IMAGING
− Abdominal XR: free air → L lateral decubitus → air in the liver
• No distal air = complete obstruction → no further imaging needed → take to OR to Tx Atresia
• “Double Bubble” = indicates Malrotation/Annular Pancreas/Duodenal Atresia → go to OR
• “Soap Bubble” = foamy, meconium-filled bowel in RLQ → Meconium Ileus
• Large amount of stool in proximal colon → Hirschsprung’s
− Upper GI + Small Bowel F/T → indicated if AXR shows proximal obstruction (some distal air)
• Duodenal/Jejunal jxn right of midline w/ beak-like termination → Malrotation
• “String Sign” → Pyloric Stenosis
− U/S
• Pyloric sphincter > 4mm thick or >6 mm long → Pyloric Stenosis
− Barium Enema → if distal obstruction likely (lots of distended bowel loops)
• Cecum in RUQ → Malrotation
• Used to visualize obstruction w/ Meconium Plug
− Rectal Bx → only way to definitively dx Hirschsprung’s
6) SPECIFIC DIAGNOSES/TREATMENT
− Tracheoesophageal Fistula: NG continuous sxn, NPO, emergent gastric tube, etc.
• 4 types
○ Esophageal atresia (proximal pouch) w/ distal tracheoesophageal fistula = most common (86%)
○ Pure esophageal atresia (7%)
○ Tracheoesophageal fistula w/o atresia (5%)
○ Proximal and distal tracheoesophageal fistula combined w/ proximal atresia (2%)
• Assoc w/ endocardial cushion defect and VACTERL syndrome
− Intestinal Malrotation: upper GI study
• NGT, IVF, IV ABx = first
• OR → Ladd’s Procedure = widen base of mesentery and rotate intestines
○ Lyse Ladd’s bands: btw cecum/intestine and abdominal wall (cause duodenal obstruction)
○ Volvulus reduction = cecum tacked down in LUQ; duodenum in R lateral abdomen
+ prevents future obstruction/ischemia
○ Remove dead bowel
 • Surgical Options:
Cool, Pulseless Foot ○ Thrombectomy w/ Fogarty balloon
DIFFERENTIAL DIAGNOSES
○ Bypass/graft → need good flow upstream and downstream of thrombus
− Thrombosis: 2° to atherosclerosis (PVOD) → signs of systemic dz also +: angina, claudication
+ Conduits: internal mammary aa, saphenous vv, goretex graft (↑ risk of infxn/thrombus, ↓ patency)
• Most common site: Hunter’s canal (SFA)
○ Endovascular angioplasty w/ stent → only indicated in patients w/ short, focal areas of stenosis
• Claudication = inadequate blood supply to contracting muscle → ↑ lactic acid
○ Thrombolytic agents → indicated in poor operative candidates
• Rest pain (in PM) = ↓ CO, ↓ limb perfusion w/ supine position
+ Eagle’s Criteria = ↑ mortality w/: age >70, DM, angina, ventricular arrhythmia, Q waves on EKG
− Embolic Dz: Embolus from Afib, post-MI mural thrombus, valve vegetation, aortic aneurysm, DVT w/ PFO
○ Amputation
− Neurogenic Claudication: 2° to spinal cord impingement → occurs 1° in upright position
− Long Term Medical Tx (chronic PVOD): Pentoxifylline/Cilastazol, ASA, beta-block, statin, exercise, smoking
• Sx = aches in buttocks/thighs/hips assoc. w/ numbness and relieved w/ stopping/Δing posture (i.e. variable timing)
cessation
− Arterial claudication: calf pain, consistent distance
− Post Surgery Management
− Venous Claudication: Bursting discomfort in limb assoc. w/ activity, h/o DVT, swelling for long time
• ASA/Plavix
• Signs of chronic venous insufficiency also +
• Heparin → warfarin if source of embolus unknown/persists
− Trauma
7) POST REPERFUSION COMPLICATIONS
− Ø Bloodflow to LE: Aortic dissection, GI bleed
− Rhabdomyolysis → Renal Failure
− Neuropathic Pain: Dermatomal distribution
• Tx: alkalinize urine (supp IVF w/ bicarb), ↑ IVF, osmotic diuresis
• Sx = aggravated by posture, + @ rest, relieved by posture Δs that relieve pressure on peripheral nerves
− Hyperkalemia → K released from damaged cells
1) HISTORY
• Tx: 1) calcium gluconate (2) glucose/insulin (3) albuterol (4) bicarb (5) kayexelate
− HPI: time/onset/severity crucial (must intervene if (1) tissue loss, (2) rest pain, (3) limiting activity)
− Lactic Acidosis
• 6 Ps: pain, pallor, pulselessness, poikilothermia, parasthesias, paralysis
− MI → most common cause of death (esp w/ multiple + risk factors)
• Unilateral/bilateral
− Compartment Syndrome: ischemia → muscle edema → ↑pressure → ↓ perfusion → further ischemia
• Associated swelling → (Compartment Syndrome)
• Sx/Signs: ↓ sensation, pain worse w/ passive dorsiflexion, weakness of involved muscles, swelling
• Rest pain (impending limb loss) vs. claudication
○ Pulse typically remains +
• Progressive vs. intermittent
• Dx: Needle > 30 mmHg
• Prior Hx of Sxs → if so, prior Txs
• Tx: fasciotomy → 2 longitudinal incisions (2 compartments released w/ each)
• Activity level @ time of onset
○ If >6 hr of ischemia: perform PROPHYLACTICLY
• Level of Sx
○ Compartments of leg: anterior, lateral, posterior, deep posterior
○ Pain will occur below occlusion: Ø aorta = buttock; Ø iliac = thigh; Ø SFA = calf
− ROS: HA, Δs in vision, angina, palpitations, abd pain, urinary Δs, impotence
• Leriche’s Triad = buttock claudication, erectile dysfxn, thigh pain → aortoiliac occlusive disease
− PMHx:
• Thrombus: recent LE injury/trauma, CAD, HTN, DM, ↑cholesterol, PVOD, TIAs/CVAs
• Embolus: aneurysms, arrhythmias, MIs, prosthetic valves, rheum. heart dz, Marfan’s, hypercoag states
− PSHx: CABG, CEA, AAA repair, vessel bypass/graft, foot/leg surgery
− Meds/Allergies: warfarin, ASA, Anti-HTNives, HRT
− FHx: vascular disease, aneurysms, arrhythmias
− SHx: smoking, IVDU, EtOH, exercise,
− HMA: prior EKGs, ABIs, vessel scans
2) PHYSICAL EXAM
− Vital signs/General Appearance
− CVS: irregular rhythm/bruits/murmurs/rubs; auscultate carotid/aortic/renal/femoral aa for bruits
− Abd: bruits, pulsatile masses
− EXT: hair loss, burns/escar, wounds/ulcers, thick/discolored skin, thick nails, gangrene, blue/dusky toes
• Palpate: femoral (inflow vs. outflow disease), popliteal, posterior tibeal, dorsalis pedis
• Assess for dependent rubor (foot → pale when raised, red when lowered)
− Neuro: sensation and motor
3) LABS: CBC, Basic, coags,
4) IMAGING
− Non-Invasive:
• Duplex Doppler → d/t location/severity of occlusion
○ Waveform analysis = normally triphasic, becomes biphasic → monophasic w/ disease
• Ankle-Brachial Index
○ Normal = > 1, Claudication = <0.6, Rest pain = <0.4
○ Falsely elevated in diabetics b/c of vascular calcification
• EKG +/- Echo +/- CTA→ if suspicious of embolic disease (MI, Afib, valve veg, AAA)
− Invasive: only indicated w/ operative intervention for pre-existing vascular dz (PVOD/thrombus)
• Contrast Angiography, MRA: used preoperatively for mapping
○ Less risky in patients w/ chronic PVOD → collaterals +
5) IMMEDIATE MANAGEMENT
− IV Heparin Bolus (80U/kg) (or argatroban/danaparoid/lepirudin) → maintenance infusion (18U/kg/hr)
• Contraindications: GIB, new neuro Δs, head injury, active bleeding
• DEADLINE: <6 hr from beginning of sxs
− Aspirin
− Fluid resuscitation +/- correction of metabolic acidosis (if present)
− Dextran/Mannitol: ↑ oncotic load = ↓ thrombus formation
− Maintain affected EXT in dependent position
6) TREATMENT: acute vs. acute on chronic, on-table angiogram (if needed)
− Embolic Source → usually in CFA
• Surgical Options
○ Open embolectomy via cutdown
○ Endovascular embolectomy via Fogerty balloon (+/- tPA)
• Source Control → treat source + transition to warfarin if source unknown/persists (Afib)
− Thrombotic Source/PVOD → usually in SFA (1/3 improve, 1/3 stabilize, 1/3 worsen w/ conservative tx)
• Surgical Indications: lifestyle threatening claudication, rest pain, tissue loss (limb threatening)
 • Endovascular Carotid Stent (risk of stroke)
TIAs ○ Indications (SAPPHIRE study, CREST study):
Definition: sudden neurologic deficit (motor or retinal) resolving w/in 24hrs → suggests impending CVA
+ Surgery difficult → lesion high in neck, prior neck radiation
− NOT dizziness/syncope, NOT memory lapse
+ Recurrent Disease:
Localization:
▫ Early → intimal hyperplasia
− Hemiplegia: C/L carotid
▫ Late → recurrent occlusive disease
− Aphasia: C/L carotid to dominant hand
+ Very ill patients
− Amaurosis Fugax: ipsilateral carotid
DIFFERENTIAL DIAGNOSES
− TIA → 70% d/t embolism from internal carotid a.
• Low flow: cardiac arrest, large vessel stenosis
• Embolic: Afib, LV thrombus, DVT w/ PFO
• Small vessel disease: HTN, vasculitis
− Metabolic: hypoglycemia/hyponatremia
− Hypoxia → cardiopulmonary dz
− Seizures/Migrane Auras/Syncope
− Encephalopathy
− Brain Tumors
− Trauma
− Ingestion/Intoxication
1) HISTORY
− HPI:
• Onset: acuity, time of day, context (aura/LOC/assoc. trauma)
• Frequency/duration: previous episodes
• Progression vs stability
• Amarosis Fugax (dangerous w/ other risk factors: age, afib, HTN, prior CVA, etc.)
− ROS:
• General: F/C, N/V,
• Neuro: MS Δs, vision Δs, weakness/paralysis, speech Δs, LOC, dizziness/syncope, HA, dysphagia
• CVS: claudication, angina, palpitations, chest pain, SOB
• GI: abd pain, jaundice,
− PMHx:
• CVS: HTN, hyperlipidemia, DM, MI, valve dz, arrhythmias,
• Neuro: prior TIAs, CVAs, migranes, seizures, syncopal episodes
• Other: Liver disease (encephalopathy), CA (brain tumors, mets), COPD (hypoxia)
− PSHx: carotid surgery, CEA, CABG, previous radiation to neck
− Meds/Allergies: warfarin, ASA, HRT/OCP,
− FHx: strokes/TIAs, heart disease
− SHx: smoking, EtOH, IVDU
2) PHYSICAL EXAM
− Vitals/General
− Neuro: MSK, CN, motor, sensory, reflexes
− CVS: arrhythmias, murmurs
− Ophthomologic: Hollenhorst plaques → bright spots on retina @ aa branch points = cholesterol emboli
− Peripheral Vascular: auscultate/palpate carotid bruits
3) LABS: CBC, Basic (r/o metabolic causes), coags, LFTs, tox screen
4) IMAGING/STUDIES
− Non-Invasive:
• Carotid duplex +/- transcranial doppler (not good if calcium present)
• Cervical CT/MRI → indicated in all patients w/ suspected TIA/CVA, look for C/L brain lesions
○ Must r/o hemorrhagic stroke before heparinizing
• EKG → assess for embolic source
• Echocardiogram → indicated only if murmur present
− Invasive → indicated only if dx = uncertain by non-invasive methods and proof needed for prevention
• Angiogram (possible stent Tx) / CTA (assess aortic arch) / MRA
5) TREATMENT
− Medical Management: ASA (or ticlopidine, Aggrenox), smoking cessation, exercise, statin,
anti-HTNive, warfarin (if embolic source)
• Indicated in ASx patients w/ <60% disease, high-risk surgery, limited life expectancy
− Surgical Interventions:
• Carotid Entarterectomy
○ Indications:
+ Sx w/ 30-70% stenosis → NASCET study: ↓ stroke from 25% → 10% in 2 yrs
+ ASx w/ ≥60% stenosis → ACAS study: ↓ stroke from 11% → 5% (>70% stenosis at UM)
○ Complications:
+ Hypoglossal nerve damage: tongue deviates to damaged side
+ Vagal nerve damage: hoarseness >> bowel motililty problems
+ Glossopharyngeal nerve damage: dysphagia
+ MI (most common cause of post-op death)
+ Stroke
+ Hematoma → airway edema → intubation
+ Hyper/hypotension
+ Infection
○ Medical management post-CEA: ASA/Plavix
DVT/PE
Virchow’s Triad: hypercoagulability, stasis, endothelial damage (probably involves inflammation also)
DIFFERENTIAL DIAGNOSES
− DVT (assess Well's score, Caprini risk score, hypercoaguable states)
− Compartment Syndrome
− Chronic Venous Insufficiency (valve damage, obstruction) → ulceration
− Cellulitis → fever/chills, erythema, ↑WBCs
− Decreased Venous Return → CHF, cirrhosis
− Trauma
− Lymphangitis
− Renal Failure
1) HISTORY
− HPI:
• Pain: PQRST
• Unilateral vs. Bilateral
• Swelling
• Recent Δs: trauma, kidney problems
− ROS: F/C, SOB, pleuritic CP, cough, hemoptysis
− PMHx: prior DVT, CA, coagulopathy (factor V leiden, homocysteinemia, anti-phospholipid Ab, polycythemia vera),
recent immobilization/paralysis, hospitalization in past 6 mos, pregnancy
− PSHx: trauma/surgery in prior 6 mos
− Meds/Allergies: HRT/OCP, warfarin, ASA
− FHx: DVT in ≥2 1° relatives, PE
− SHx: smoking, recent travel, occupation, EtOH, IVDU
2) PHYSICAL EXAM
− Vitals/General Appearance: ↑HR
− Cardiopulmonary: tachypnea, pleural friction rub (PE), tachycardia, S3 (CHF)
− EXT:
• Appearance: erythema, dilated superficial veins, color changes
• Palpation: warmth, localized tenderness along veins, palpable cord, calf >3cm larger than ASx side
• Homan’s Sign: calf pain w/ dorsiflexion
3) LABS
− DVT: D-Dimers, CBC (↑ w/ polycythemia vera), coags
• D-dimer + Well's score = rule out, NOT rule in DVT
− PE: Coags, ABG (↓ pO2/pCO2 d/t hyperventiliation)
4) IMAGING/STUDIES
− DVT: duplex U/S (assess flow and image, read the actual report: normal vs. fresh vs. chronic)
• If duplex not available → shot of Lovenox, come back in the AM
− PE: EKG, CXR, PT-protocol CT (need to correlate w/ clinical characteristics), pulse ox
• If CT and clinical do not correlate → V/Q scan (not specific), MR, angio
5) TREATMENT
− Anticoagulation (risky period = 1 month):
• Options:
○ IV unfractionated heprin (100 U/kg bolus → 25 U/kg/hr for 4-6 days) → target PTT = 2x normal
+ Followed by warfarin → therapeutic INR = 2-3
○ Lovenox + warfarin (starting on day 1 of Lovenox) outpatient, ambulate when therapeutic, wrap legs
• Length:
○ 1st event: 3-6 months (known cause) vs 5 years (unknown etiology)
+ Once stopped → d-dimer and U/S
○ 2nd event/active cause: 12 mos – lifelong
• Complications:
○ Heparin → HIT
○ Warfarin → hypercoagulable state in first several days (disappears after 2-3 wks)
+ Alternatives to warfarin: dabigatran, rivaroxaban, etc.
− TPA: only used in extensive cases of DVT/PE → causing hemodynamic compromise
− Thrombectomy: indicated in cases of limb-threatening ischemia
− Greenfield Filter: placed in IVC by IR
• Indications: anticoag CI (GI bleed, recent CVA, cerebral AVM, hemophilia, pulm HTN, recurrent DVT/PE)
− Complications
• Recurrence → most common in 1st few months
○ Tx: admit to hospital, IV heparin, support hose
• Post-Thrombotic Syndrome (10%) → edema, ulceration @ ankles, venous claudication, pain, color Δs
○ Tx: support hose
 ○ Multiple lesions seen on CT, but not present on CXR → metastasis
Lung Mass • Dx: only by Bx
DIFFERENTIAL DIAGNOSES
− Adenocarcinoma → most common lung cancer (35-45% of all malignant lung CAs)
− Infectious: TB, PNA
• Epidemiology: less commonly assoc. w/ smoking, more common in women
− Benign Neoplasm: granuloma, hamartoma, scar
• Histology: acinar formation of cells arising from subsegmental airways in lung PERIPHERY
− Malignant Neoplasm: adenocarcinoma, large cell carcinoma, SCC, mets, lymphoma
• Characteristics: often formed in chronic scars → arise via response to chronic inflammation, increased rate of mets
1) HISTORY
• Growth/Mets: slow growth, hematogenous metastasis. May spread w/in lung via tracheobronchial tree.
− HPI: cough/Δ in cough, hemoptysis, dyspnea, hoarseness, dysphagia, sputum, fevers → (10% ASx)
− Squamous Cell Carcinoma → 2nd most common lung malignancy (25-40% of all CAs).
− PMHx/ PSHx: prior CA, XRT, prior TB, RA, sarcoid, other lung diseases (COPD, asthma)
• Epidemiology: assoc. w/ smoking
− Meds/Allergies:
• Histology: intracellular bridge formation and cell keratinazation.
− FHx: CA
○ Arises from squamous metaplasia of tracheobronchial tree.
− SHx: smoking, EtOH, IVDU, asbestos, radon, XRT, silicon
• Characteristics: 2/3 occur in central lung fields, increased rate of recurrance
− HMA: prior CXRs (for comparison: stable for 2yr = benign)
○ Tumors typically bulky → assoc. w/ bronchial obstruction
− ROS:
• Growth/Mets: slow growth, late metastasis. May undergo central necrosis/caviation
• Systemic Sx: F/C, weakness, weight loss/Δ in appetite
− Small Cell Carcinoma: highly malignant. Represents 15-25% of all lung malignancies.
• Pumonary: cough, wheezing, hemoptysis, dyspnea
• Epidemiology: assoc. w/ smoking
• Associated Syndromes:
• Histology: clusters/nests/sheets of small/round/oval cells w/ dark/round nuclei and little cytoplasm.
○ SVC Syndrome: facial swelling
○ Electron microscopy = neurosecretory cytoplasmic granules
○ Pancoast’s/Horner’s: brachial plexus involvement
• Characteristics: centrally located
○ PTH-related Peptide (SCC): hypercalcemia/bone pain/kidney stones
• Growth/Mets: early metastasis via lymphatic/vascular routes
○ Carcinoid: flushing, diarrhea, wheezing
• Treatment: surgical resection rarely indication → instead use cisplatin + etoposide + XRT
○ Cushing’s (Small Cell): striae, moon facies, buffalo hump, acne, weight gain
− Undifferentiated Large Cell Carcinoma: rarest of major lung cancer types
○ Eaton-Lambert (Small Cell): weakness, ↑strength w/ exercise
• Histo: anaplastic, large cells w/ abundant cytoplasm and no apparent evidence of differentiation
○ SIADH (Small Cell): ↓Na
• Characteristics: centrally or peripherally located
○ Acanthosis Nigricans: assoc. w/ all visceral malignancies
• Growth/Mets: highly malignant → spreads early
2) PHYSICAL EXAM
7) SPECIFIC PARANEOPLASTIC SYNDROMES
− Vital signs/general appearance: BMI w/ height and weight → cachectic, barrel chest
− Pancoast’s Tumor → involved superior sulcus
− Skin: acanthosis nigricans
• Produces Sx related to brachial plexus invasion, sympathetic ganglion involvement, vertebral collapse
− Neuro: weakness (Eaton-Lambert, Pancoast’s)
• Manifests as pain/weakness of the arm, edema, Horner’s Syndrome
− HEENT: swelling (SVC syndrome), LAD
− Horner’s Syndrome = injury to cervical sympathetic chain → ptosis, myosis, enophthalmus, anhidrosis
− Cardiopulmonary: IPPA
8) TREATMENT
− EXT: clubbing (non-small cell), periosteal proliferation (adenoCA), atrophy (Pancoast’s), bone pain (PTH)
− Based on stage
3) LABS: Tb test, CBC, basic, Ca/Mg/PO4, coags (CA = hypercoagulable state)
• Stage I: surgical resection
− Paraneoplastic Specific:
• Stage II: surgical resection
• Small Cell: ACTH (Cushing’s), Na/ADH (SIADH), Ab (Eaton Lambert)
• Stage IIIa: surgical resection if early stage IIIa & non-small cell, chemo +/- XRT
• Squamous Cell: PTH-rP
• Stage IIIb: chemo + XRT
• Carcinoid: 5-HT
• Stage IV: chemo +/- XRT
• Adenocarcinoma: coags (DIC)
• Isolated Brain Mets: surgical resection
4) IMAGING/STUDIES → Order: CXR >> CT >> Bronch/Mediastinoscopy/Needle Bx >> PET
• Met to the lung: renal cell, testicular, colorectal, sarcoma, melanoma = good prognosis if solitary resection
− Non-Invasive:
− Contraindications to surgery → SSSTOP IT!
• CXR: may present as nodule, infiltrate, atelectasis
• Superior Vena Syndrome → direct invasion/compression of SVC by tumor/LN
○ SPN → if present on previous CXRs, follow
○ Sx: SOB, HA, JVD, UE edema, dizziness/light-headedness, cough
+ >2.3 cm, ill defined borders, spiculated edges, age >60, +smoking → suggestive of CA = get CT
• Supraclavicular Node Metastasis
+ Popcorn-appearance = hamartoma
• Scalene Node Metastasis
+ Laminated-edges = granulomas
• Tracheal Carina Involvement
• CT: reveals extent of tumor and possibility of mediastinal LN mets → must include liver + adrenals • Oat Cell CA → Tx w/ chemo +/- XRT
• PET Scan: used to assess 1° tumor/mediastinal LNs and screen for metastatic disease • Pulmonary Function Tests = FEV1 <1
+ Normally bright: brain, heart, bladder; false neg. = BAC, carcinoid; only detects masses >1cm ○ FEV1 > 2 required for a pneumonectomy → FEV1 < 2 = V/Q scan
• Sputum Cytology ○ FEV1 > 1.4 required for lobectomy
• MRI: indicated in all small cell CAs and symptomatic non-small cell CAs • Myocardial Infarction
• Pre-op eval: FEV1 >60%, DLCO >50%; VQ scan predicts post-op FEV1 >40%; exercise testing • Tumor Elsewhere (metastatic disease)
− Invasive:
• Bx/Brushings: can be obtained by bronchoscopy, CT guided Bx, VATS (for palpable peripheral/pleural lesions)
○ Needle Bx: 90% definitive → if malignant/indeterminant = resect
5) STAGING
− W/U:
• Intrathoracic: mediastinoscopy or EBUS-guided bx, VATS, thoracentesis
• Extrathoracic: PET, PET-CT
− Specific Stage Definitions:
• Ia: Tumor <3cm, Ø nodes, Ø mets
• Ib: Tumor >3cm, Ø nodes, Ømets
• IIa: Tumor <3cm, + nodes to lung/ipsilateral hilum, Ø mets
• IIb: Tumor >3cm + nodes to lung/ipsilateral hilum, OR
Invades chest wall/diaphragm/mediastinal pleura/pericardial sac, Ø nodes, Ø mets
• IIIa: Invades chest wall, diaphragm, or pericardial sac, + nodes in lung/ipsilateral hilum, Ø mets
LN mets to ipsilateral/mediastinal/subcarinal nodes, Ø medistinal invasion, Ø mets
• IIIb: Mediastinal invasion OR mets to C/L hilum/mediastinum/supraclavicular/scalene LN, Ø distant mets
• IV: Distant mets
6) SPECIFIC DIAGNOSES
− Solitary Pulmonary Nodule → well-circumscribed, peripheral nodules more common in men than women
• If in pt <40 → 2/3 chance of being benign
• CT/CXR → first step in w/u
○ concentric/heavy/”popcorn-like” calcification, <1cm, well-circumscribed → benign
○ Multiple, small flecks of calcification, >1cm → malignant

Neck Mass
Anterior Δ: inferior mandible (superior), vertical midline (medial), SCM (lateral)
− Submandibular Δ: inferior mandible (superior), anterior/posterior digastric (medial/lateral)
− Submental Δ: vertical midline (medial), anterior digastrics (lateral), hyoid bone (inferior)
Posterior Δ: SCM (medial), anterior trapezius (lateral), clavical (inferior)
Supraclavicular Fossa: neck/should jxn (superior), sternal/lateral end of the clavical (medial/lateral)
DIFFERENTIAL DIAGNOSES: Dependent on Location
− Central = Thyroid
• Congenital: branchial cleft cyst, thryroglossal duct, cystic hygroma, hemangioma
• Inflammatory/Infectious: mononucleosis, mumps, cat-scratch disease
• Malignancy: lipoma, lymphoma, SCC (1° or met), thyroid CA, parathyroid CA
• Endocrine: hyperthyroidism (Grave’s), hypothyroidism (Hashimoto’s), subacute thyroiditis
− Peripheral = Not Thyroid → likely metastatic carcinoma
1) HISTORY → Age most important (80% benign in kids, 80% malignant in adults >40y)
− CC: dysphagia, odynophagia, hoarseness, stridor, globus, speech problems, referred ear pain (CN V, IX, X)
• Indicates CA: hoarseness, fixed/hard nodule, dyspnea, dysphagia, ↑ cervical LN, vocal cord paralysis
− HPI → Focus on Mass: #/location, detailed desc, onset/↑ in size, assoc. sx, sx of para/thyroid dz/infection
− PMHx/ PSHx: recent URI (acute suppurative thyroiditis), neck trauma, DM, HIV, other CAs, Gardener’s
− Meds/Allergies:
− FHx: Other CAs → specifically MEN
• MEN I (PPP): pancreatic CAs (gastrinoma, insulinoma), pituitary adenoma, parathyroid hyperplasia
• MEN IIa (PPM): parathyroid hyperplasia, pheochromocytoma, medullary thyroid cancer→ RET mutation
• MEN IIb (PMM): pheochromocytoma, medullary thyroid cancer, marfanoid habitus→ RET mutation
− SHx: smoking, EtOH, cats, sick contacts, sawdust/radiation exposure
− ROS: F/C, fatigue, wt/app Δs, MS Δs (MDD), palp, abd pain, kidn stones, bone pain, new temp sens
2) PHYSICAL EXAM
− Vitals/Gen Appearance: tachycardia/exophthalmus → hyperthyroidism, HTN → pheo (medullary CA)
− Neuro: CN palsies
− HEENT: complete exam: thyroid: masses/tenderness; trachea: mobility/deviation; nose/mouth/OP: lesions
• Mass: single/multiple, dominant, tender, ↑ w/ tongue out, mobile/fixed, LAD, LN mobility/consistency
• Nose/Mouth/OP: in/direct exam of NP, oral cavity/tongue base/OP palpation
− Abd: organomegaly → mono
− EXT: pretibial myxedema, bone pain
3) LABS: CBC, monospot, TFTs (TSH, T3/T4), viral titers (EBV), PTH/Ca, calcitonin (Medullary CA)
4) IMAGING/STUDIES
− Non-Invasive
• U/S: assesses size, cystic vs solid, other nodules, LNs → must be done prior to FNA if pulsatile
• CT/MRI: indicated in deep/suspicious masses
• CXR/Bone Scan: if suspicious for mets
− Invasive: FNA = best → can use U/S or C/T guidance
− Thyroid Nodule Specific FNA Protocol
• 1. TSH: normal= FNA vs low= RAIU → hot = benign toxic adenoma/Grave’s vs. cold/non-specific = FNA
• 2. FNA 4 possible results: (1) benign (70%) = suppress tx (PTU); (2) indeterm (15%) = suppress tx/observe
vs. RAIU vs. surgery; (3) malignant (5%) = surgery; (4) insufficient [also, suspicious (10%) = RAIU vs. surgery]
○ FNA Results:
+ Psomma bodies → papillary CA
+ Follicular cells → lobectomy to d/t adenoma vs. adenocarcinoma (total thyroidectomy indicated)
+ SCC → Find 1°: thorough H&N exam, direct laryngoscopy, endoscopy, pharyngoscopy
+ Lymphoma → must bx/excise node for lymphoma typing
+ Adenocarcinoma → breast/lung w/u
+ Melanoma → skin/scalp exam
5) SPECIFIC DIAGNOSES/TREATMENT – NON-NEOPLASTIC
− Pediatric: (1) thyroglossal duct cyst; (2) cystic hygroma; (3) branchial derivatives
− Grave’s Disease → most common cause of hyperthyroidism/diffuse goiter
• Characteristics: hereditary, associated w/ exophthalmus/pretibial myxedema
• Dx: ↑ T3/T4, anti-TSH Ab+, ↓TSH, global RAI uptake
• Tx – Medical: PTU/methamazole → 12-24 mo course, SE: agranulocytosis, 50% recurrence risk
• Tx – Radiation: 75-80% cure rate; CI: pregnant women, women <30 wanting children, prior radiation tx
○ Assoc w/ hypothyroidism in 75% of patients
• Tx – Surgical: subtotal/total thyroidectomy
○ Cx: permanent hypothy (5-10%), recurrent hyperthy (30% w/ subtotal), recurrent laryngeal n. injury
− Toxic Multinodular Goiter (Plummer’s Syndrome) → Multiple hyperfunctioning nodules
• Sx: tachycardia, refractory CHF, Afib, unexplained/accelerated angina, wt loss, anxiety, insomnia
○ Pemberton’s Sign = facial flushing/JVD distension/stridor when arms raised
• PE: multiple nodules w/ enlargement of entire gland
• Dx: hot nodules identified w/ RAIU scan
• Tx: surgical resection of hyperfunctioning nodules w/ subtotal/total thyroidectomy; radioiodine less efficient
○ Ix: compressive sx, concern of malignancy, hyperthyroidism, cosmesis
• Cx: carcinoma (+ in 50-70% of affected children), thyroid storm
• Thyroid Storm
○ Sx: extreme irriatibility/delirium/coma, fever, tachycardia, restlessness, hypoTN, vomiting, diarrhea
○ Tx: IV hydration, cooling, digitalis (if CHF+), PTU, I, propranolol, dexamethasone (↓ T3/T4 release)
− Toxic adenoma
− Acute Supprative Thyroiditis → hematogenous spread of microorganisms into thyroid gland
• Etiology: Streptococcus, Staphylococcus → often introduced via thyroglossal fistula
• Signs/Sx: painful/swollen thyroid, fever, overlying skin erythema, dysphagia
• Dx: FNA w/ Cx
• Tx: Abx, abscess drainage, +/- fistula resection (later)
− Subacute Thyroiditis → prolonged (2-6 mos) inflammation of thyroid 2/2 viral infection (often follows URI)
• Signs/Sx: sore throat, thyroid enlargement/tenderness/induration, +/- Sx of hyperthyroidism
○ Thyroid hormone released 2/2 inflammation
• Dx: ↑ESR, ↓ RAIU (differentiates from Graves)
• Tx: NSAIDS +/- steroids, β-blockers if sx of hyperthyroidism+
− Chronic Thyroiditis → 2 subtypes: Hashimoto’s and Riedel’s
• Hashimoto’s Thyroiditis → most common cause of hypothyroidism
○ Etiology: autoimmune
○ Presentation: diffuse glandular enlargement (firm/rubbery consistency) w/ +sx of hypothyroidism
○ Dx: ↓RAIU, +antithyroglobulin Abs, +microsomal Abs
○ Tx: synthroid → thyroid will ↓ in size over time
+ Surgical Ix: dominant mass not suppressed by synthroid, gland enlarges despite medical tx
• Riedel’s Thyroiditis: rare inflammatory dz → thyroid parenchyma is replaced w/ dense fibrous tissue
○ Presentation: “stony,” hard gland → may cause pressure sx: dysphagia, cough, dyspnea
○ Tx: Resection
6) SPECIFIC DIAGNOSES/TREATMENT – NEOPLASTIC: (1) surgery; (2) radioiodine; (3) TSH suppression
− Papillary Thyroid CA → most common thyroid CA (70-80%)
• Epidemiology: highest incidence in 30-40 y/os, assoc w/ neck irradiation, Gardner’s Syndrome
• Histology: Psammoma bodies, concentrates iodine
• Growth/Metastasis: slow growing, lymphatic metastasis, can affect 1/both lobes
• Treatment: size dependent
○ Lobectomy + Isthmusectomy: <1cm, clinically -LN, no hx of radiation
+ Intraoperative frozen-section LNs → if + = total thyroidectomy
○ Thyroidectomy: >1cm, clinically +LN, hx of radiation
• Follow Up: synthroid to suppress TSH, scan @ 6 weeks (hold synthroid for 4 wks prior)
○ If negative: measure TG @ 1 yr → if negative no further f/u needed
○ If positive: tx w/ RAI → repeat scans @ 1y, 3y, 5y → continue scanning q5yrs
• Prognosis: good → cervical LN mets/size of tumor ≠ prognosis
− Follicular Thyroid CA → 10% of all thyroid CAs
• Epidemiology: more common in iodine deficient areas, peak incidence = 40-50 y/o
• Histology: FNA indeterminate → tissue structure ( signs of capsular/vessel invasion) needed for Dx
• Characteristics: rubbery, encapsulated, concentrates iodine
• Growth/Metastasis: more aggressive than follicular, hematogenous metastasis (rarely via lymphatics)
• Treatment: size dependent
○ Lobectomy: small, encapsulated, microinvasive tumors
○ Total Thyroidectomy: high-grade, large (>4cm) tumors
○ Bone/Pulmonary Met Tx: RAI
• Prognosis: age/invasion dependent → Good: <40y vs. Bad: >50 y, vascular invasion,
− Medullary Thyroid CA → 7% of all thyroid CAs, test for RET protooncogene
• Epidemiology: sporadic (80%), MEN IIa/IIb associated (20%)
○ MENIIa: bilateral/multicentric tumors → arise from C-cell hyperplasia & develop btw age 12-30.
○ MENIIb: ganglioneuromas, bilateral/multicentric tumors → develop by 2y, more aggressive > MENIIa
• Characteristics: calcitonin from C-cells (neural crest origin), no iodine concentration, amyloid deposits
• Labs: serial infusions of Ca gluconate + pentagastrin → measure serum calcitonin @ 5 + 10 min
○ Serum CEA elevated in 30% → tumor marker
• Growth/Metastasis: metastasizes via lymph & blood (50% of pts have mets at dx)
• Treatment: total thyroidectomy + central compartment LND → modified lateral neck dissection if LND+
• Follow Up: CEA, calcitonin levels
• Prognosis: excellent (95% cure rate) if dx by MEN screening vs. poor (<20%) if dx by palpable mass
− Hürthe Cell Thyroid CA → 3-5% of all thyroid CAs
• Characteristics: Does not concentrate iodine/synthesize thyroid hormones
• Histology: FNA indeterminate → tissue structure needed for Dx (like follicular CA)
• Growth/Metastasis: invades lymphatics early, but also metastasizes hematogenously (bone, lung)
• Tx: total thyroidectomy
− Anaplastic/Undifferentiated Thyroid CA → >2% of thyroid CAs
• Epidemiology: most common in women, and pts > 60 y/o
• Histology: FNA makes Dx. Giant/spindle cells characteristic.
• Characteristics: arises in long-standing differentiated CAs → stems from follicular cells.
• Growth/Metastasis: early metastasis → 30% of pts present w/ distant mets (lung most common)
• Treatment: size dependent
○ Small tumors: total thyroidectomy +/- XRT
○ Large tumors w/ possible airway compromise: Debulking surgery + tracheostomy
• Prognosis: Poor → most patients = stage IV @ dx
− Metastatic Tumors/SCC → represent 80% of non-thyroid neoplastic neck masses (SCC = most common)
• 1° goal: try to locate the 1° tumor by noting location of enlarged LNs
○ Sub-mental/mandibular Δs: skin, lip, oral cavity, submandibular/parotid gland, paranasal sinuses
○ Posterior Δ: nasopharynx, skin, thyroid, infraclavicular 1°
○ Supraclavicular LAN: entire GI tract, lungs, breast, GU tract, thyroid
 • W/U: HEENT exam, laryngoscopy/esophagoscopy/bronchoscopy, CXR, barium swallow, neck/sinus CT
○ Must examine nasopharynx, oropharynx, hypopharynx, larynx
○ If no 1° found → random bxs of tongue base and +/- tonsilectomy
• Tx: Radical/Modified Neck Dissection + postop XRT (esp w/ multiple LN+, large LN, extracapsular LN+)
○ Radical: total dissection of cervical lymphativs → removal of SCM, IJV, and CN XI
+ Ix: SCC found in neck mass w/ unknown 1° or in conjunction w/ tumor removal
+ CI: distant met, fixation to unresectable structure (ie carotid artery), low neck masses
○ Modified: 3 types = I (CN XI preserved); II (CN XI, IJV preserved), III (CN XI, IJV, SCM nn preserved)
+ Ix: elective node dissections, <3cm LN w/ postop XRT, differentiated thyroid CAs, B/L dissections
+ Advantages: ↑ postoperative fx, ↓ morbidity (esp if bilateral)
+ Disadvantages: ↑ mortality from local recurrence
○ 1° tumor: size dependent
+ small (<2cm) oral cavity tumors = resect, small oro/hypopharyngeal tumors → XRT
+ larger oral cavity/oropharyngeal tumors = resection + radical neck dissection + XRT
○ No 1° IDed: modified neck dissection + XRT to upper aerodigestive tract (inc nasopharynx)
− Salivary Gland Tumors → Parotid Gland (80%), Submandibular Gland (15%), Minor Salivary Glands (5%)
• Malignancy Potential: 1/size → minor gland tumors = 80% malignant, parotid tumors = 80% benign
○ Pleomorphic adenoma= most common benign; Mucoepidermoid carcinoma = malignant
• Presentation: benign = mobile/NT/ØLN/Ø weakness; malignant = tender/fixed/local mets/face paralysis
• Dx: FNA → excisional bx always contraindicated on parotid masses
• Tx: surgical resection (try to spare CN VII) + neck dissection (if LN+) +/- XRT
○ XRT Ix: high grade/recurrent CA, residual disease, adjacent structure invasion, T3/4 parotid tumors
− Neck Surgery Cx:
• Nerve injury = recur laryng (1 = hoarseness, 2 = tracheostomy), superior laryng (high-pitched voice Δ)
• Parathyroid injury → hypocalcemia + hyperphosphatemia
 ○ Distal: Whipple
Painless Jaundice − Gallbladder Carcinoma
Hyperbilirubinemia ≥2.5 → yellowing of the skin
• Epidemiology: 4:1 female:male
Jaundice, fever, RUQ pain = Charcot’s Triad → cholangitis = emergency
○ Risk Factors: gallstones, porcelain gallbladder (precursor lesion in 50%), cholecystenteric fistula
Jaundice, fever, RUQ pain, mental status Δs, hypotension = Reynold’s Pentad → sepsis
• Histology:90% adenocarcinoma
DIFFERENTIAL DIAGNOSES
• Sx: biliary colic, wt loss, anorexia, may present as acute cholecystitis, many pts Asx until late
− Prehepatic: hemolysis (sickle-cell, G6PD), blood transfusion
• Signs: jaundice (invasion into common BD/ pericholedochal LN compression), RUQ mass, palpable GB
− Hepatic (dull pain, fatigue, n/v): hepatitis, cirrhosis, drug toxicity, sepsis, congenital conjugation defects
• Location:60% in fundus
− Posthepatic (colic, itchy): gallstones, cholangitis, biliary duct injury, pancreatitis, PSC, tumors, pseudocyst
• Dx: U/S, CT, ERCP
• Tumors: pancreatic CA, cholangiocarcinoma, gallbladder adenoma, ampullary CA, mets
• Growth/Metastasis: contiguous spread to liver
1) HISTORY
• Tx: depends on invasion
− HPI: onset, duration, location (if pain), progression of jaundice (time-frame), dark urine, light stools, pruritis
○ Confined to serosa: cholecystectomy
− PMHx: hepatitis (etiology), cirrhosis, PSC/IBD, PBC, gallstones, acute/chronic pancreatitis, DM (esp recent onset),
○ Confined to muscularis/serosa: radical cholecystectomy + wedge resection of overlying liver + LND
transfusions, heritable/genetic conditions, new onset depression
+ +/- chemo/XRT
− PSHx: cholecystectomy, abdominal surgery
+ If performed laproscopically → risk seeding to trocar sites
− Meds/Allergies: tylenol, contrast studies, newly started meds
− Choledocholithiasis
− FHx: CA (esp pancreatic, colon), autoimmune hepatitis, PBC, PSC/IBD, hereditary hemolytic states
− Chronic pancreatitis: Ca2+ in pancreas = pathognomonic
− SHx: smoking, EtOH, IVDU, sexual history
− HMA: last FOBT, colonoscopy
− ROS:
• General: F/C, fatigue, weight loss, appetite Δs
• GI: abd pain (radiating to back), nausea/vomiting, constipation/diarrhea, stool color/consistency/blood/floating
• EXT: bone pain, weakness, transient swelling (Trousseau’s sign)
2) PHYSICAL EXAM
− Vital Signs/General Appearance: obesity, fetor hepaticus, palpate LNs
− Skin: spider angiomata, palmar erythema, gynecomastia,
− HEENT: sublingual/scleral/cutaneous jaundice
− Abd: caput medusae, ascites, HSM, Courvoisier’s sign (palp/NT GB), distxn, pain, SMJ/Virchow’s node
− Rectal: occult blood, hemorrhoids
− GU: testicular atrophy
− EXT: palmar erythema, muscle wasting, asterixis
3) LABS: CBC, comp metabolic panel, coags, hep panel, amylase/lipase, tox screen,CEA/CA 19-9, α-fetoprotein
4) IMAGING/STUDIES
− Non-Invasive:
• U/S: dilated ducts → indicate obstruction, liver lesions, vascular invasion
• Pancreatic Protocol CT w/ Contrast: may show tumor if present
○ If positive: ERCP for brushings/bx → cytology
○ If negative: EUS for better visualization of the head
• CXR: assess for distant metastases
− Invasive:
• ERCP: collect bx/brushings for cytology • PTC
• EUS: assess tumor invasion for staging → esp liver/peritoneal mets, +LN, portal v involvement
5) STAGING
− Pancreatic CA
• Stage I: tumor limited to pancreas, Ø nodes, Ø mets
• Stage II: tumor extends into bile duct/peripancreatic tissues/duodenum, Ø nodes, Ø mets
• Stage III: tumor extends into bile duct/peripancreatic tissues/duodenum, + nodes, Ø mets
• Stage IVa: tumor extends into stomach/colon/spleen/major vessels, any nodal status, Ø mets
• Stage IVb: any tumor size, any nodal status, + distant metastases
6) SPECIFIC DIAGNOSES/TREATMENT
− Pancreatic CA:
• Surgical Tx: treatment depends on location of tumor → may need to be assessed laproscopically
○ Pancreatic head: Whipple (pancreatoduodenectomy w/ distal gastrectomy & choledocojejunostomy)
+ Whipple = removal of GB, CBD, duodenum (majority), 15 cm jejunum, pancreatic head, +/- antrum
+ Cx/Mortality rate: 25%/3%
+ Cxs: anastomotic leak, wound infxn, sepsis, pancreatitis, postgastrectomy sx, PNA, DVT, abscess
○ Pancreatic Body/Tail: distal resection
• Adjuvant Tx: chemotherapy (5-FU + gemcitabine) and XRT
• Resxn CI: vasc invasion (portal/SMA/hepatic), liver/peritoneal mets, distant +LN (periaortic/celiac)/mets
• Palliative Tx:
○ Biliary Obstruction: stent placement via ERCP/PTC, biliary bypass
○ Gastric Outlet Obstruction: gastrojejunostomy
○ Malabsorption: pancreatic enzyme replacement
○ Pain Relief: celiac plexus block, chemoradiation,
− Cholangiocarcinoma → malignancy of extra/intrahepatic bile ducts = 1° bile duct CA
• Epidemiology: average age at dx = 65
○ Risk Factors: choledochal cysts, UC, PSC, liver flukes, toxin exposure (agent orange), thorotrast dye
• Histology: 100% adenocarcinomas
• Sx/Signs: jaundice, pruritis, dark urine, acholic stool, cholangitis
• Location: most commonly located @ proximal bile duct
○ Klastskin Tumor: tumor @ jxn of R & L hepatic ducts
• Dx: U/S, CT, ERCP/PTC w/ bx/brushings for cytology, MRCP
• Tx: depends on location of tumor
○ Proximal: resection w/ Roux-en Y hepaticojejunostomy (BD/J anast) +/- unilateral hepatic lobectomy

GI Bleeding
1° priority always resuscitation (regardless of site), 2° concern = localization
DIFFERENTIAL DIAGNOSES
− Upper GI
• PUD (50%): duodenal/gastric ulcers
• Gastritis (15%): multiple non-ulcerative lesions in the stomach 2/2 NSAIDs/EtOH/stress
• Mallory-Weiss (10%): longitudinal tears thru stomach mucosa & submucosa near GEJ jxn 2/2 vomiting.
• Varices (10%): primarily in pts w/ cirrhosis → can occur in azygous vein or short gastic veins.
• Erosive Esophagitis (10%): occurs 1° in immunocompromised hosts
• AVM/Dieulafoy’s Lesion/Aorto-Enteric Fistula/Vasculitis (5%)
− Lower GI: Dvtclosis, AVMs, CRC, Colitis (infxious > ischemic > XRT > IBD: UC >> CD), Hemorrhoids
• Meckel’s Diverticulum → most common cause of children <2yrs (50% of all incidents)
1) RESUSCITATION
− ABCs: assess VS, UOP, I/Os, mental status (GCS → intubation), cardiopulmonary exam, brief hx
• Airway/Breathing: consider intubating to protect if massive hematemesis, +/- supplemental O2
• Circulation: establish 2 large bore IVs (16 gauge) in antecubital/femoral, place foley/NG → resuscitate w/ 3 for 1 if
possible
○ T+C: as soon as IV established → order 4 units of blood (use O- if patient exsanguinating)
○ Transfuse → if patient unstable/hypotensive after 2L crystalloid (i.e. NS or LR)
○ Correct coagulopathies → FFP/platelets & d/c any anticoagulants (ASA, heparin, warfarin)
− Labs: T+C, CBC, coags, complete metabolic panel (inc LFTs), FOBT, amylase/lipase, U/A
• BUN/Cr ratio: >36 → UGIB (2/2 GI resorption of blood and/or prerenal azotemia)
− NG Lavage → for gastric decompression (therapeutic) & to initiate diagnostic w/u
• Non-bloody bile → excludes active UGIB
2) HISTORY
− CC: melena (usually UGI) vs. hematochezia (90% LGI) vs. hematemesis (UGI) vs. +FOBT (non-specific)
− HPI:
• GIB: onset, prior bleeding, acute/chronic, context (retching/inebriation), duration/frequency
• Sx: pain (and timing of pain related to eating), vomiting, constipation/diarrhea, post prandial fullness
○ Painful bleeds: PUD/esophagitis/gastritis (UGI); (ischemic) colitis/(ex) hemorrhoids/anal fissure (LGI)
+ Pain/relief w/ eating = gastric/duodenal ulcer
○ Painless bleeds: varices/AVMs (UGI); diverticulosis/tumors/AVMs/(int) hemorrhoids
− PMHx: ulcers, CAD/CHF, burns, EtOH abuse, GERD (“heartburn”), hepatitis, cirrhosis (rule of 2/3s) CA, HIV, DM
− PSHx: aortic grafts (fistulas), recent abdominal/gyn surgeries, recent endoscopy/colonoscopy
− Meds/All: NSAIDs/ASA (#1 cause of UGIB), anticoags (give FFP/Vit K → warfarin, protamine → heparin)
− FHx: CA, PUD, IBD
− SHx: smoking, EtOH, IVDU, exposure to radiation, heightened stress
− HMA: last FOBT, prior endoscopy/colonoscopy
− ROS: F/C, wt/appetite Δs, GI, urinary
3) PHYSICAL EXAM
− Vitals/General Appearance → MS Δs = hepatic encephalopathy, intoxication, hypoglycemia, shock
• Early Signs of Shock: tachycardia, diaphoresis
• Late Signs of Shock: confusion, lethargy
− Skin: cirrhosis stigmata → spider angio, gynecomastia, testicular atrophy, palm erythema, caput medusa, jaundice
− Abd: pain >> exam (ischemia), localized tenderness/peritoneal signs, H/SM, ascites, masses
− Rectal: stool → frank blood/FOBT, hemorrhoids/tags/fissures/fistulas
4) LABS: as above + serial CBCs/coags
5) IMAGING/STUDIES
− Non-Invasive: Acute Abdominal Series → CXR (free air, mediastinal Δ), AXR, CT (if suspicious)
− Invasive → r/o UGIB before attempting to localize LGIB (endoscopy = gold standard)
• NG Lavage = #1 study for all GIB → endoscopy if +
○ Coffee grounds = IV PPI + octreotide → urgent endoscopy (can wait until next AM)
○ Bright red blood = IV PPI + octreotide → emergent endoscopy (now)
• Endoscopy → can be also therapeutic w/ banding/coag/epi injections,
• Angiography → can be also therapeutic w/ vasopressin injections/embolization
6) SPECIFIC DIAGNOSIS/TREATMENT – UGIB
− Varices (AVOID the OR, calculate Child's Score):
• 1. Treat underlying coagulation abnormalities: give FFP/vitamin K
• 2. Octreotide + β-blockers: lowers portal venous pressure → (85% effective)
○ Continue all patients on β-blockers to prevent rebleeds
• 3. Endoscopic banding: 85-90% effective → repeat EGD @ 48h to sclerose/ligate remaining vessels
○ Other endoscopic options: sclerosis, epinephrine/EtOH/thrombin injections
○ Gastric varices less responsive to endoscopic banding/sclerotherapy
• 4. Options if endoscopic banding fails
○ Portosystemic Shunt: only in pts w/ good synth fxn/life expectancy + Childs class A (50% mortality)
○ Sengstaken-Blakemore Tube: hemostasis only when inflated→ must intubate 1st, only use for ≤72h
+ Need X-ray to confirm position
○ Transjugular Interhepatic Portosystemic Shunt (TIPS): artificial connection (shunt) btw hepatic/portal vv
+ Only effective for ≤6mos, may worsen encephalopathy
○ Warren shunt: splenorenal
○ Splenectomy: last resort → if bleeding persists
− Duodenal Ulcers
• Cause: ↑ gastric acid secretion
• Location: w/in 2cm of pylorus
• Medical Tx: H2B + sucralfate + antacids + gastric pH monitoring (maintain pH>5 to ↓ risk of rebleeding)
• H. pylori Tx: high dose PPI (omeprazole) + metronidazole + clarithromycin
• Endoscopy: recent bleeding, big 1st blood loss, risk of rebleeding/death w/ future bleeds, possible CA
○ Therapeutic Interventions: sclerose w/ epinephrine, cauterize, suture, Bx (always) → for gastric CA
○ Rebleed Risk: bleeding >> visible vessel >> clot >> oozing w/o visible vessel >> clean base: ∅
• Arteriography w/ Vasopressin Infusion/Embolization
• Surgical Tx → intractable bleeding, hemorrhage (massive OR relentless), obstrxn (gastric outlet), perf
(vagotomy = stop feeding parietal cells)
○ Bleeding ulcer: duodenum opened via pylorus → vessel oversewn
○ Duodenal perforation:
+ Graham patch (poor candidates, shock, prolonged perforation)
+ Truncal vagotomy + pyloroplasty (incorporating ulcer)
+ Graham patch + highly selective vagotomy
+ Truncal vagotomy + antrectomy (highest mortality, lowest recurrence)
○ Duodenal/Gastric outlet obstruction:
+ Truncal vagotomy + antrectomy + gastroduodenostomy
+ Truncal vagotomy + drainage procedure (gastrojejunostomy)
○ Intractable duodenal ulcer:
+ Highly selective vagotomy
+ Vagotomy + pylorplasty
+ Vagotomy + antrectomy + gastroduodenostomy/gastrojejunostomy (esp if coexisiting gastric ulcer)
○ Ligation of Gastroduodenal Artery → for posterior duodenal ulcers involving the GDA
− Gastric Ulcers
• Causes: smoking, EtOH, burns, trauma, CNS tumor/trauma, NSAIDs, steroids, shock, illness, adv age
○ Prepyloric, pyloric → assoc w/ ↑ acid (coexisting duodenal ulcers often +)
• Location: 70% → lesser curvature, 5% → greater curvature
• Assoc Risk: gastric CA: if ulcer does not heal w/ 6 weeks of medical tx → must rebx
• Endo Ix: dx w/ bx, 6 wks post dx to confirm healing and r/o gastric CA
○ Bx for H. pylori & r/o gastric cancer
• Surgical Tx → intractability, CA (surgery = always if CA not r/o), hemorrhage, obstrxn, perforation
○ Hemorrhage/Obstrxn/Perf: distal gastrectomy + ulcer excision W/O vagotomy (unless duodenal dz+)
○ Duodenal & Gastric Ulcers: resect both ulcers (BI/BII) + truncal vagotomy
○ Pyloric Gastric Ulcer: Truncal vagotomy + antrectomy (BI and BII)
○ Perforation (Poor Op Candidate): Graham patch
− Peptic Ulcer Perforation
• Signs: ↓BS, tympany over liver, peritoneal signs, abd tenderness
• Initial Tx: NPO, NGT, IVF, Foley, Abx, PPIs, surgery
• Surgical Tx:
○ Duodenal U Perf: graham patch +/- selective vagotomy; truncal vagotomy + pyloroplasty (inc ulcer)
○ Gastric U Perf: antrectomy (inc perf’d ulcer); graham patch/wedge resection (poor op candidates)
− Esophagitis/Gastritis → multiple, non-ulcerating erosions in the stomach/esophagus
• Assoc w/: ventilator dependence, major trauma, severe burns, sepsis, renal failure
• Tx: H2 blockers, PPI, antacids → keep pH>5; If ineffective → must perform subtotal gastrectomy
− Mallory-Weiss Tears (75% in stomach)
• Usually stops spontaneously or w/ water lavage
• Active bleeding = endoscopic cautery/embolization → Sengstaken-Blakemore tube contraindicated
− Boerhaave’s Syndrome (postemetic esophageal rupture results in PTX/crepitus/CP) → repair surgically
7) DIAGNOSIS/TREATMENT – LGIB
− Most Common Etiologies: Diverticulosis >> Vascular ectasia
− Diagnostic Studies → test selected by rapidity of bleed
• Low suspicion for LGIB: EGD 1st to r/o UGIB
• Bleeding stops spontaneously: sigmoid/colonoscopy (70% efficacy → potentially tx-ic)
• Stable but continued bleeding: colonoscopy (after rapid lavage/purge) + Tc-99 bleeding scan or angiogram in OR
○ Tc-99 scan (tagged RBC) = detects bleeding @ rates ≥ 0.1 cc/min
• Unstable: arteriography (detects rates ≥ 0.5 cc/min) → potentially tx-ic (vasopressin injxn/embolization)
• Surgical Tx: >6U pRBCs/24h; >3U pRBCs to stabilize; big rebleed (esp if known site), CA/obstrxn/perf
○ Known site w/ massive bleeding: segmental resection
○ Unknown site: ex-lap (+/- SI enteroscopy) + subtotal colectomy w/ ileorectal anastomosis
• ↑/↓ endoscopy fail: capsule endo, push enteroscopy, enteroclysis, bleeding scan, Tc-99/merkel scan
− Tx:
• Diverticulosis: bleeding usually stops spontaneously
○ Endoscopic Tx (epi injxns), arterial vasopressin, embolization, surgery → other options
○ Surgical Indications: Cx (fistula/obstrxn/stricture), recurrent episodes, hemorrhage, CA, abscess
• Fissure: sitz baths, stool softeners, ↑ fiber diet, topical CaCB, surgery = lateral internal sphincterotomy
• Hemorrhoids: same as fissure + band ligation, surgery → hemorrhoidectomy
○ Hemorrhoidectomy Cx: exsanguinations (in colon lumen), infection, incontinence, anal stricture
• Bleeding Polyps/Vascular Ectasias: laser, electrocoagulation, local epi injection
• Angiodysplasia: arterial vasopressin, endoscopic tx (epi), surgery, hormonal risk
• Unknown Etiology w/ Unstable Patient: total abdominal colectomy (85% effective)
○ Reconstruct w/ ileostomy or ileorectal anastamosis
 ○ SMA: ileocolic, right colic, middle colic
Weight Loss/Colon CA ○ IMA: left colic, sigmoid, superior hemorrhoidal
Key = elicit additional symptoms/risk factors w/ history → narrow differential
○ Internal Iliac: middle/inferior hemorrhoidal
DIFFERENTIAL DIAGNOSES
• Stage IV: chemotherapy (5-FU/leukovorin/irinotecan) +/- palliative surgery (resect solitary liver mets)
− Vascular: Chronic Mesenteric Ischemia
○ Liver met resection only indicated if no other mets + → restage w/ CT of chest/abd/pelvis + PET
− Inflammatory: IBD
− Lymph Node Removal: controversial, currently recommended to remove all 17
− Acquired: Achalasia, Gastric Ulcer, Malabsorbative Diseases
− Follow Up: most important in 1st 3 years → time when 90% of CRCs recur
− Metabolic: DM (Diabetic Gastroschesis), Hyperthyroidism
• CEA/CBC/LFTs (follow tx response/ID recurrence); PE; stool guaiac = q3mo (1st 3y) → q6mo
− Infectious: TB, HIV
• CXR → q6mo (1st 2y) → qyear
− Neoplastic: Colon/Pancreatic/Ovarian CA, Polyps, Pheochromocytoma, Hodgkin’s, Carcinoid tumor
• Colonoscopy → years 1 & 3
1) HISTORY
7) RECTAL CANCER/TREATMENT
− Most Important ?s: (1) In-/Voluntary, (2) ↑ or ↓ in Appetite, (3) %Δ from baseline, (4) Lifetime variability − Staging: Endorectal U/S → gold standard
− HPI: assoc. Sx, period of time, amount of weight lost, meals, lifestyle Δs, depression − Treatment = based on lesion location (LAR vs. APR) → mesorectum resection = best chance for cure
− PMHx: previous CA, IBD, polyps (villous → worst), DM/MI (risk factors for CMI) • Upper 1/3 (10-15 cm above anus): low anterior resection
− PSHx: past surgeries ○ Resection via abdominal incision w/ anastomosis btw L colon + remaining rectum
− Meds/All: • Middle 1/3 (5-10 cm above anus): low anterior resection
− FHx: CA (25% CRCs = +FHx), IBD, polyps, genetic dz (FAP/Gardener/HNPCC/Peutz-Jegher), CAD, DM • Lower 1/3: abdominoperineal resection
• Specific CA Associations: CRC, breast, ovarian, uterine ○ Resection of the rectum, anus, and anal sphincters via combined abdominal/perineal approach
− SHx: smoking, EtOH, occupational exposures, radiation exposures, travel, diet (↓fiber/↑fat = ↑CRC risk) ○ Colostomy formed
− HMA: annual rectal exams + FOBT (>40), colonoscopy (@ 50 + q3-10y → earlier if FHx+) − Treatment (based on stage) → same as CRC
− ROS: • Stage II/III: Pre-Op/Post-Op chemoradiation recommended → ↓ local recurrence
• General: fevers/chills, fatigue/appetite Δs • LN+: Chemo improves survival
• Cardiopulmonary: palpitations (hyperthyroid, pheochromocytoma), chest pain 8) POLYPS
• GI: dysphagia, N/V, regurg, satiety, BM Δs (D/C), tenesmus, hematochezia/melena, abd pain, jaundice − Anatomic classification: sessile vs. pedunculated
• GU: urinary sx: urgency/frequency/dysuria (possibility of fistula) − Histologic classification: inflammatory (pseudopolyp) vs hamartomatous vs hyperplastic vs neoplastic
• (GYN): LMP, bleeding, pelvic pain • Hyperplastic: benign/normal cells → no malignant potential
• Endo: heat/cold intolerance, restlessness, polydypsia/polyuria/polyphagia • Neoplastic: proliferation of undifferentiated cells → premalignant/malignant cells
• Skin: rashes, Δing lesions (SMJ node) − Neoplastic subtypes: tubular adenomas (pedunculated), tubovillous adenomas, villous adenoma (sessile)
2) PHYSICAL EXAM • Tubular most common (85%)
− Vitals/General Appearance: cachexia − Risk factors for malignancy: size, histologic type, atypia of cells
− HEENT: proptosis, LNs (cervical/L supraclavicular), neck bruits, thyroid nodules/enlargement, corneal injxn • Size: >2cm = high risk of carcinoma (35-55%)
− Cardiopulmonary: wheezes/rales/rhonchi (TB), murmurs/S3 • Histology: villous (40%) >> tubovillous (20%) >> tubular (5%)
− Abd: tenderness (RUQ = liver mets), masses, distension (r/o obstrxn), ascites, umbilical LAD − Most common location: rectosigmoid colon (30%)
− Rectal: occult blood, masses (10% CRCs = palpable), gross blood, Blummer’s shelf − Treatment: Endoscopic resection
• Blummer’s shelf = hardness palpable on rectal → mets in recto/uterine or recto/vesicular pouch • Large sessile villous adenomas should be removed w/ bowel resection and lymph node resection
− (Pelvic): uterine/adenexal masses, cervical lesions − Polyposis Syndromes:
− Skin: lesions, acanthosis nigricans, pretibial myxedema, pyoderma gangrenosum/erythema nodosum • Gardner’s: CRC by 40, desmoid tumors (abd wall), skull osteomas, sebaceous cysts, adrenal/thyroid tumors,
3) LABS: retroperitoneal fibrosis, duodenal/periampullary tumors
− Diagnostic: CBC: iron deficiency anemia (esp R sided CRC), Hodgkin’s; Basic: DM; TSH/T4: hyperthyroidism; • Peutz Jegher’s: GI hamartomas (jejunum/ileum > colon > stomach) w/ ↑ CA risk, ovarian CA, melanotic
• Albumin: liver function, nutritional status; Amylase/Lipase: pancreatic CA; Coags: liver function; 24hr Urine pigmentation of buccal mucosa/lips/digits/palms/soles
• Catechols (VMA/HMA): pheochromocytoma; PPD: TB; Genetic Studies: FAP, Gardner’s, HNPCC
− Staging: LFTs, Blood Cx (S. bovis), CA 19-9 (pancreatic CA), CEA (CRC, pancreatic CA)
4) IMAGING/STUDIES
− Non-Invasive:
• CXR/Abd plain films: Lung metastases
• Endorectal U/S: best assessment of tumor invasion + LN status
• CT: Liver metastases
− Invasive:
• Endoscopy
• Flexible Sigmoidoscopy > Colonoscopy: obtain Bx
• ERCP: brushing/Bx → cytology
5) STAGING → CRC spreads directly, hematogenously, lymphatically, transperitoneally (“seeding”)
− TMN Staging (Colon CA) → [5 year survival]
• Stage I: invades up to submucosa/muscularis propria (T1-2; N0; M0) → [90%]
• Stage II: invades thru muscularis propria or surrounding tissues w/ negative LN (T3-4; N0; M0) → [75%]
• Stage III: positive LN, but no distant metastases (any T, N1-3, M0) → [50%]
• Stage IV: positive distant metastases (any T, any N, M1) → [5%]
− Astor-Coller Modified Duke’s (Rectal CA)
• Duke’s A: invades up to submucosa
• Duke’s B: invades up to muscularis propria
• Duke’s C: positive LN, but no distant metastases
• Duke’s D: positive distant metastases
6) COLON CANCER/TREATMENT
− Presentation → based on location
• Right-Sided Mass: often larger @ time of dx → R colon = larger luminal diameter, contains more liquid
○ Signs/Sx: microcytic anemia, occult blood/melena > hematochezia, postprandial bloating, fatigue
• Left-Sided Mass: presents earlier → L bowel = smaller lumen + semisolid contents
○ Signs/Sx: Δ in BMs (small caliber), colicky pain, signs of obstrxn, abd mass, BRBPR/maroon stool
− Pre-Op Studies: CXR, colonoscopy, CBC, LFTs, CEA, pathology review
− Pre-Op Bowel Prep: GoLytely → clear, PO Abx (1g neomycin + 1g erythromycin x3)
− Treatment → based on stage at diagnosis
• Stage I: surgery alone +/- pre-op XRT to shrink lesion → resect w/ 5cm/7cm (distal/proximal) margins
• Stage II: surgery (no established role for chemo)
• Stage III: surgery + 5-FU/leukovorin or levamisole + LN removal
 • Tx: Pre-op IVF + 2° cephalosporin/cipro → can d/c Abx if not perforated
Abdominal Pain ○ Non-Perforated: appendectomy, 24h Abx, D/C home on POD #1
Peritoneal signs = guarding, muscle spasm, rebound tenderness,
○ Perforated: appendectomy, Abx (Zosyn) for 3-7 days, wound left open
DIFFERENTIAL DIAGNOSES → by location
○ Appendicieal Abscess: percutaneous drainage, Abx, elective appendectomy 6 weeks later
− Esophagus: GERD, Esophageal Spasm
− Cholecystitis: obstrxn of cystic duct → inflammation (95% gallstones, 5% acalculus)
− Stomach: PUD, Gastritis
• Presentation: non-stop RUQ pain, fever, N/V, palpable GB, Murphy’s sign, epigastric/subcapsular pain
− SI: PUD, Appendicitis, Obstruction/Perforation, Acute/Chronic Ischemia, Crohn’s, Gastroenteritis
○ Murphy’s Sign = acute pain + inspiratory arrest w/ RUQ palpation during inspiration
− Liver: Hepatitis
• Dx: U/S → wall >3mm, pericholecystic fluid, distended GB, stones+, sonographic Murphy’s sign
− Gallbladder: Biliary Colic, Cholecystitis,
• Tx: IVF, Abx, early cholecystectomy (open GB in OR to for CA)
− Biliary Tree: Choledocolithiasis, Cholangitis
− Cholangitis → infection of the biliary tract from obstrxn (stone >> stricture, CA, pseudocyst)
− Pancreas: Acute/Chronic Pancreatitis, DKA
• Presentation: Charcot’s Triad (F/C, RUQ pain, jaundice), Reynold’s Pentad (triad + MSΔs, shock)
− LI: Appendicitis, Crohn’s, UC, Ischemia, Infectious Colitis, Diverticulitis, Obstruction/Perforation, Volvulus
• Labs: ↑WBC, ↑BR, ↑alk phos, +blood cx (E. coli, Klebsiella, Pseudomonas)
− GU: Renal Lithiasis, Pylonephritis
• Dx: U/S + contrast study (ERCP) after patient has “cooled off” w/ Abx
− GYN: PID, Ectopic Pregnancy, Ovarian Torsion, Pregnancy, Pre/Perimenopausal Pain
• Tx: IVF + Abx → definitive treatment (ERCP, cholecystectomy) later
− Cardiopulmonary: Ruptured Aneurysm, MI, PNA
• Suppurative Cholangitis: severe infection w/ sepsis (“pus under pressure)
− MSK: MSK Pain, Hernia
○ Tx: IVF, ABx, decompression (ERCP, PTC, laparotomy w/ T tube placement)
1) HISTORY
− Pancreatitis
− Key Factors: Age, Gender, Acute vs. Chronic Process
• Acute
− HPI: location, onset, context, timing, quality, progression, duration, h/o similar pain, ↑/↓ (meals, position)
○ Causes: gallstones, EtOH > trauma/scorpions/viruses/autoimmune/steroids/ERCP/drugs/hyperlipid
− PMHx: Afib, chronic pain, AAA, CAD, CVA, hyperlipidemia, HTN, GI disease, hernias, sickle cell, IBD
○ Presentation: epigastric pain, N/V, diffuse abd tenderness, ↓BS, fever, dehydration/shock
− PSHx: abdominal/pelvic surgery (esp intraoperative Cx → ↑ risk for SBO),
○ Labs: CBC, LFT, amylase/lipase, T+C, ABG, Ca, basic, coags, lipids
− Meds/All: NSAIDs, ASA, warfarin, heparin
○ Studies: U/S (cholelithiasis w/ phlegmon); CT (pancreatic necrosis w/ phlegmon)
− FHx: CA, DM, heart disease, IBD, AAA,
○ Cx: pseudocyst, abscess/infxn, necrosis, vessel rupture, ascities, DM, ARDS, sepsis, DIC
− SHx: smoking, EtOH, IVDU, trauma, sick contacts
○ Tx: NPO, IVF, NGT (if V+), TPN/postpyloric feeds, H2B/PPI, analgesia, supp coags/lytes, watch W/D
− GYN: gravity/parity, STDs, LMP, pregnancy
+ Abscess: surgical debridement + drain placement → if refractory to medical management + infxn
− HMA: FOBT, colonoscopies
• Chronic: chronic inflammation of the pancreas → tissue destruction/loss w/ fibrosis & calcification
− ROS:
○ Causes: EtOH > idiopathic, hypercalcemia, hyperlipidemia, familial, trauma, iatrogenic, gallstones
• General: fevers/chills, fatigue/appetite Δs, anorexia
○ Presentation: epigastric/back pain, wt loss, steatorrhea, DM
• GI: last BM, BM Δs, D/C/blood, N/V (non/bilious/bloody), regurg/dysphag/foul taste, jaundice, tenesmus
○ Labs: amylase/lipase (normal → may be burned out), 72h fecal fat, glucose tolerance test
• Cardiopulmonary: palpitations, cough, sputum production
○ Studies: CT (best sensitivity → enlargement/atrophy, Ca2+, masses, pseudocysts), ERCP (ductal Δs)
• GU: urinary sx → urgency/frequency/dysuria
○ Cx: IDDM, steatorrhea, malnutrition, biliary obstruction, gastric varices, pseudocyst,
• (GYN): LMP, bleeding, pelvic pain, vaginal d/c
○ Medical Tx: enzyme replacement, analgesics, insulin (if DM+), Ø EtOH use
• Skin: rashes, lesions, itching
○ Interventional Tx: stent any strictured ducts w/ ERCP
2) PHYSICAL EXAM → Focusing on Vitals General Appearance, Abdominal, Pelvic, & Rectal Exams
○ Surgical Tx: longitudinal pancreaticojejunostomy (Puestow), distal pancreaticojejunostomy (Duval)
− Vitals
○ Pseudocyst Tx: drainage of cysts >5cm after 6 weeks (waiting period)
− General Appearance: position in bed, movement (no movement = perotinitis), obvious pain
+ Angiogram → if bleeding
− Cardiopulmonary: wheezes/rales/rhonchi (PNA),rhythm/rate (Afib)
+ Cysto-gastrostomy/duodenostomy → if compressing stomach/duodenum
− Abd:
− Diverticulitis
• Inspect: Cullen’s/Gray Turner’s Signs
• Presentation: LLQ pain (crampy/steady), BM Δ (diarrhea), F/C, anorexia, LLQ mass, N/V
○ Cullen’s Sign = bluish discoloration of periumbilical area → retroperit hemorr tracking thru abd wall
• Labs: ↑WBC
○ Grey Turner’s Sign = Ecchymosis/discoloration of the flank → dissecting retroperitoneal hemorrhage
• Imaging: A/P CT (edematous bowel → good to dx abscess), AXR (ileus, a/f levels, free air if perf-ed)
• Auscultate: Bowel sounds
• Cx: abscess, diffuse peritonitis, fistula (colovesical most common), obstruction, perforation, stricture
• Percuss: distension, organomegaly
• Initial Tx: IVF, NPO, broad spectrum ABx w/ anaerobic coverage, NG suction
• Palpate: rebound/guarding (in/voluntary), masses, McBurney’s pt, psoas/obturator signs, Rosvig’s sign
• Surgical Indications: obstruction, fistula, perf, abscess (can’t be drained percutaneously), sepsis
− Rectal: gross/occult blood, masses
○ Elective: 2 episodes → should be considered after 1st episode if young/DM/immunosuppressed
− (Pelvic): uterine/adenexal masses, cervical motion tenderness
• Emergent Surgical Tx: Hartmann’s procedure
− Skin: lesions, acanthosis nigricans, pyoderma gangrenosum/erythema nodosum
○ affected segment resected w/ end colostomy + stapled rectal stump (reanastomosis 2-3 mos later)
3) LABS: CBC, comp, LFTs, β-HCG, U/A, amylase/lipase, hep panel, lactate, T+S, cardiac enzymes, +/- T&C
• Elective Surgical Tx: on stage procedure → resection of involved segment + 1° anastomosis
− Ranson’s Criteria:
• Abscess Tx: percutaneous drainage
• @ presentation: Age >55, WBC >16K/mm^3, glucose > 200mL/dL; LDH >350U/L; ALT > 250 U/L
− Mesenteric ischemia: postprandial pain out of proportion to PE, wt loss; Tx: CT, SMA thrombectomy, bypass stent
• @ 24h: ↓HCT ≥10%; ↑BUN ≥5mg/dL; Ca <8mg/dL; pO2 <60; base deficit >4mEq/L; fluid seq >6000 mL
− Mesenteric venous thrombosis: hypercoag or low flow or inflammation; Tx: X-ray, CT, venogram, anticoagulate
4) IMAGING/STUDIES
− AAA: 1.5x normal diameter; Tx: endovascular (no increased survival), repair if >5.5cm
− Non-Invasive:
• Upright CXR: for peritoneal air, r/o PNA, assess cardiac shadow,
• Upright/Supine AXR: distended loops of bowel, pneumatosis, abdominal/pelvic fluid
• Abdominal/Pelvic U/S: gallbladder wall thickening, assess liver/pancreas/uterus/adenexa
○ Findings suggestive of cholecystitis: wall > 3mm, pericholecystic fluid, distended GB, +stones
• CT
− Invasive Studies:
• EUS/ERCP: r/o and treat choledocolithiasis/cholangitis/gallstone pancreatitis
• Angiography
5) SPECIFIC DIAGNOSES/TREATMENT
− Appendicitis → most caused by lymphoid hyperplasia or fecolith
• Presentation: poorly localized discomfort w/ low fever, anorexia, N/V, +/- mild leukocytosis
○ Pain = begins periumbilically (referred) → migrated to RLQ (peritoneal irritation)
○ Peritoneal signs = transmural → irritating peritoneum
○ Abnormal presentations: old (vague abd cx), pregnant (abn location), rx w/ steroids (↓ Sx)
• Exam:
○ McBurney’s Point = 2/3 : 1/3 umbilicus:superior ischial spine
○ Rosvig’s Sign = Pain in RLQ when palpating LLQ
○ Obturator = pain w/ passive internal right leg rotation w/ knee flexed → pelvic appendicitis
○ Psoas = pain w/ right hip flexion while knee extended → retrocecal appendicitis
• Imaging: CT, U/S, barium enema
○ best in atypical setting → rarely necessary
 • 3 Subtypes: parathyroid hyperplasia (all 4 glands), adenoma (1 gland), carcinoma (1 gland)
Hypercalcemia/Hyperparathyroidism ○ Hyperplasia: Neck exploration & resection of all 4 glands, explant 100mg of PTH tissue to forearm
1° HPT = ↑PTH secretion → ↑Ca, ↓PO4
+ Draw PTH level pre-surgery → redraw @ 0/5/10 min after removal
2° HPT = ↑PTH from ↓Ca 2/2 renal failure/↓Ca absorption → ↓Ca
▫ No ↓ in PTH levels → search for supernumary parathyroid gland
3° HPT = ↑PTH after ↓Ca corrected in 2° HPT → no ↓ in PTH secretion from (corrected) ↑ Ca levels
+ Must r/o MEN I and MEN IIa
DIFFERENTIAL DIAGNOSES → “CHIMPANZEES”
○ Adenoma: Resect adenoma (send for frozen section) + Bx any additionally enlarged glands
− Calcium overdose
+ Draw PTH level pre-surgery → redraw @ 0/5/10 min after removal (goal = WNL/50% of prior high)
− Hyperparathyroidism (1°/2°/3°) Hyperthyroidism / Hypocalciuric Hypercalcemia
○ Carcinoma: Resect carcinoma, ipsilateral thyroid lobe, and all enlarged LN
− Immobility / Iatrogenic (thiazide diuretics)
− 2° HPT: correct Ca/PO4, list for renal transplantation → no role of parathyroid surgery
− Metastasis / Milk-Alkali Syndrome
− 3° HPT: correct Ca/PO4, remove all parathyroid glands,
− Paget’s Disease
• Explant 30mg of tissue in forearm if refractory to medical tx.
− Addison’s Disease / Acromegaly
− Parathyroid Carcinoma
− Neoplasm (breast CA >> prostate CA, kidney CA, lung CA, pancreatic CA, multiple myeloma)
• Signs/Sx: ↑Ca, ↑PTH, palpable PT gland (50%), neck pain, hoarseness/voice Δ, hypercalcemic crisis
− Zollinger-Ellison Syndrome
• Tx: Resect carcinoma, ipsilateral thyroid lobe, and all enlarged LNs
− Excessive Vitamin D
− Guidelines for asx parathyroidectomy: based on age, serum Ca2+, Cr, T-score, 24-hr urine Ca2+
− Excessive Vitamin A
− Post-Op Cx of Parathyroidectomy:
− Sarcoidosis
• Nerve damage: recurrent laryngeal (1 = hoarseness, 2 = airway obstruction), superior laryngeal
1) HISTORY
• Neck hematoma: open at bedside if airway compromised
− HPI:
• Hypocalcemia: perioral tingling, parasthesias, +Chovostek’s sign, +Trousseau’s sign
• HPT: dysuria, my-/arthralgias, weakness/fatigue, D/C, abd pain, anorexia, MS Δ, neck pain, hoarseness
○ Chovostek’s sign: facial muscles contract if ipsilateral facial nerve tapped @ mandibular angle
• Metastases: bone pain, hematochezia, hematuria, lymphadenopathy, hemoptysis, cough, prior CA dx
○ Trousseau’s sign: hand/forearm spasm if brachial artery compressed via BP cuff
• Ca/Vit. A/Vit. D/HCTZ OD: supplements/meds
• Hungry Bone Syndrome: ↓↓Ca post HPT surgery → Ca-deprived bone absorbs free serum Ca
• Hyperthyroidism: palpitations, temperature intolerance, rashes/skin Δs, anorexia, anxiety
• Hypoparathyroidism Tx:
• Zollinger-Ellison: ulcers, abdominal pain
○ Acute: IV Ca
• Addison’s: fatigue, malaise, skin discoloration
○ Chronic: PO calcium, vitamin D
• Acromegaly: facial Δs, hand/foot Δs (rings/shoes not fitting)
• Sarcoid: dyspnea, skin lesions
− PMHx: CA/ PUD, hyperthyroidism, nephrolithiasis, fractures, gout, pancreatitis, HTN
• Known Dxs: Paget’s, Addison’s, sarcoid, ZES, acromegaly
− PSHx:
− Meds/All: supplements, antacids/baking soda, diuretics, calcium intake
− FHx: pituitary tumors/ulcers/hypoglycemia (MEN I), HTN/pheo/thyroid CA (MEN IIa)
− SHx: activity level
− ROS:
• General: fevers/chills, fatigue/appetite Δs, wt loss/anorexia, mood/MS Δs
• GI: constipation/diarrhea, abdominal pain, melena/hematochezia,
• Cardiopulmonary: palpitations (hypothyroidism), wheezing (sarcoid)
• GU: dysuria, hematuria, polydypsia/polyuria
• Neuro: dysphagia, hoarseness
• Skin: rashes, lesions,
2) PHYSICAL EXAM → Focusing on Vitals/General Appearance, HEENT, MSK
− Vitals/General Appearance: H/W proportionate, affect, jaw prominence (acromegaly)
− HEENT: neck, LAD, oropharynx, CN nerves
• If palpable neck mass → likely parathyroid carcinoma
− Cardiopulmonary: rhythm, wheezes/rhonchi (PTH secreting Lung CA, Sarcoid)
− Abd: tenderness, masses
− MSK: focal (spine) tenderness, CVA tenderness,
− Skin: lesions, sarcoid (yellow plaques), pretibial myxedema
3) LABS: Ca, PTH, PO4, basic (esp Cl/Cr/BUN), urine Ca, HCG (tumor marker)
DDx Labs: TSH, alk phos, CBC, Mg, 1,25-D, serum γ-glob
− ↑ Ca = 3 blood draws, 3 separate occasions
− PTH = most important test
• Metastatic Bone Dz: hypercalcemia w/o ↑PTH
• 2° PTH: ↑PTH, ↓Ca
• PTH = 0 → all patients w/ ↑ Ca EXCEPT HPT, ectopic parathyroid, familial hypocalciuric hypercalcemia
− ↑ Cl in 40% of HPT patients → Cl/PO4 ratio > 33 = HPT
− Urine Ca = best way to distinguish 1° HPT from FHH → ↑urine Ca w/ HPT vs. ↓ w/ FHH
4) IMAGING/STUDIES
− X-ray:
• Skull: ground glass in outer 2/3, sella tucica for pituitary tumor (MEN I)
• Long Bones: bony reabsorption, brown tumors
• Fingers: subperiosteal absorption (radial side of middle phalanges/tufts of terminal phalanges)
○ Pathegnemonic for PTH
− Sestamibi: Tc taken up by thyroid/parathyroid tissue → washes out of thyroid quickly, stays in parathyroid
• Able to assess enlarged glands and ectopic PTH production (ie in mediastium)
• Poor sensitivity for small adenomas/multiglandular disease
• Can be used intraoperatively w/ hand held detector
− U/S: able to detect enlarged parathyroid glands in 70-80% or cases
− CT/MRI: particularly good at localizing enlarged parathyroids in the mediastinum
• Most accurate non-invasive imaging
5) SPECIFIC DIAGNOSES/TREATMENT
− 1° HPT
• Initial Medical Tx: IV fluids, furosemide
• Hypercalcemic Crisis (Ca >13): 4-6L NS/day (200cc/hr), Lasix, bisphosphonates, calcitonin, steroids
 • After 24 hrs → D5W + Albumin: 0.5cc/kg/%BSA
Burns − Meds: H2-blocker/PPI (prevent curlings ulcers), anabolic steroids, β-blocker, SS insulin
PRIMARY SURVEY
− Tetanus vaccine
1) Airway
− Burn Center: ≥20% 2°, ≥5% 3°, face/hands/feet/perineum burns, inhalation injury, +trauma, electric burns
− Inspect/Evaluate
− Follow: Na, glucose, prealbumin
• Identify: singed facial hair, burns to oropharynx, carbonaceous sputum, circumferential burns to thorax
− Start PT w/in 1 week
• Clear airway of debris/foreign bodies/teeth/blood
9) BURN TYPES/CARE
• Stridor/hoarseness → laryngeal obstruction/injury
− Burn Types
− Establish
• 1°: painful, dry, red areas that do not form blisters (doesn't count in BSA calculation)
• Finger sweep → chin lift/jaw thrust
○ Tx: keep clean + neosporin + pain meds
− Decide if early intubation necessary → GCS ≤ 8, major head/face/neck trauma, ↓ ventilation 2/2 paralysis
• 2°: painful, hypersensitive, swollen, mottled areas w/ blisters & open, weeping surfaces
− Intubation = w/ cuffed tube in trachea
○ Tx: unroof blisters, silvadene, pain meds, +/- STSG (deep 2° only)
• Endotrachial (preferred) vs. nasotracheal (contraindicated in facial fractures)
• 3°: painless, insensate, swollen, dry, mottled, white and charred areas → look like “dried leather”
○ Endotrachial
○ Tx: occlusive dressings (↑ epithelialization rate, ↓ pain, ↓ fluid losses) w/ BID wet saline dressing Δs
+ Preoxygenate w/ bag valve mask
+ escar excision w/in 1 week + split thickness grafting (IMBIBITION)
+ Maintain C spine stabilization necessary throughough
+ Monitor for: compartment syndrome
+ Apply cricoid pressure
• Specific Types:
+ Suction as needed
○ Chemical: flush for ≥1h w/ water/NS
○ Nasotrachial
○ Electrical: Perform early escarotomy +/- fasciotomy → high risk of compartment syndrome
+ Patient must be awake, breathing, and w/o facial/basilar fractures
+ Monitor urine for Mgb
+ Smaller tube size used than w/ endotracheal intubation
+ EKG = essential → high rate of dysrhythmias
− Confirm intubation by listening/checking end tidal CO2/pulse oximetry
+ Look for entry/exit points
− Cricothyroidotomy if unable to establish definitive airway
+ Muscles damaged > skin → BSA often under-represents actual damage
• Place btw thyroid/cricoid cartilage
+ Long term cx: myelitis, cataracts
2) Breathing
− Topical ABx
− Start 100% O2 (can remove once CO level = WNL)
− Assess rate and quality of breathing • Silvadene (silver sulfadiazine): painless, little escar penetration, ∅ pseudomonas
− Establish presence of bilateral breath sounds ○ Indications: 2° burns
3) Circulation ○ SE: idiosyncratic neutropenia
− Start IVF → 2 large bore IVs in antecubital fossa wide open ○ CI: sulfa allergy
• Draw labs simultaneously → CBC, basic, ABG, COHb, urine Mgb, T+C, cardiac enzymes • Sulfamylon (mafenide acetate): penetrates escar, broad coverage (∅ staph), painful, allergic rxn (7%)
− Assess urine output → place foley unless contraindicated ○ Indications: 3° burns, already contaminated burns
− Monitor vitals: BP, HR, peripheral pulses (esp if circumferential burns to EXTs), mental status, UOP ○ SE: acid-base imbalances → acidosis
• ↓ peripheral pulses = escarotomy → full thickness incision (into healthy fat) thru escar w/ scalpel/bovey • Polysporin (polymyxin B sulfate): painless, clear, narrow spectrum
− Swann-Ganz Indications: TSA > 30%, unstable, oropharyngeal burns ○ Indications: facial burns
− Assess shock state: • Neosporin bacitracin
Blood Loss | %Loss | Pulse | BP | Pulse Pressure | Mental Status ○ Indications: cartilage
• Class I <750 <15% <100 = =/↑ slightly anxious − Skin grafts (only for 3°)
• Class II 750-1500 15-30% >100 = ↓ mildly anxious • Full thickness (cosmetic)
• Class III 1500-2000 30-40% >120 ↓ ↓ anxious / confused • Split thickness w/ mesh
• Class IV >2000 >40% >140 ↓ ↓ confused / lethargic 10) COMPLICATIONS
4) Disablility − Contracture → start PT early, escharotomy if constricting breathing
− Rapidly assess for neurologic deficits (ideally before intubation) − Mgburia: tx = alkalize urine
• Evaluate for GROSS deficits only (ie not moving one side/profound weakness) − Infection: staph > pseudomonas > strep > candida
− Assess GCS • Signs: ↑WBC, escar discoloration, green pigment, edema, ecchymosis below escar, 2° → 3°, hypoTN
• Eye Opening: spontaneous >> to voice >> to pain >> none • Dx: Bx w/ ≥10^5 bacteria/gram
• Verbal: oriented >> confused >> inappropriate >> incomprehensible >> none • Tx: escarotomy + topical Abx
• Motor: obeys commands >> localizes pain >> withdraws >> flexion >> extension >> none
5) Exposure
− Uncover patient to avoid missed injuries
− Maintain body temperature
• Minimally invasive: warmed IVF, lights, blankets, warmed ventilator air, warm room
• Moderately invasive: Inner cool catheter << warmed bladder/stomach/peritoneal lavages
• Most invasive: ECMO
6) Monitoring
− Vitals: EKG (watch for dysrrhythmia) , pulse oximetry, non-invasive BP cuff, thermometer (foley)
− Labs:
• COHb = ≥10 (smoker), ≥5 (nonsmoker) → 100% O2 + hyperbaric chamber
• Mgburia → start bicarb, ↑fluids, +/- mannitol
• Acidosis → give 50 mEq bicarb q30min
− Lines: NG tube
− Burn Assessment = rule of 9s → head (9), each UE (9%), each side of thorax (18%), each side of LE (9%)
7) SECONDARY SURVEY → (return to ABCs if patient decompensates at any time)
− Burn Hx (AMPLE Hx: Allergies, Meds, Pregnancy/PMH, Last meal, Events)
• Type: chemical, electric, thermal
• Location: enclosed space → inhalation?
• Assoc. Trauma
• Care thus far: Fluids received, time to extrication
• PMH: allergies, last meal, meds
− PE: head to toe → look for missed burns/injuries
• Florescein → if evidence of facial burns
8) FURTHER TX
− Fluids = LR (for massive resuscitation, more physiologic electrolytes):
• 1st 24h → Parklands Formula → %BSA x kg x 2-4cc (1st 1/2 = 1st 8h after burn, 2nd 1/2 = next 16h)