Breast Mass

1) Hx: Age, Breast Hx, FHx of BrCA 3 most important ?s

Lump: location, #, s, w/ menstruation/Br feeding (fibrocystic dz), pain, d/c (papilloma)
Breast: abnormal MMG, Bx (atypical hyperplasia, LCIS, DCIS), prior BrCA, radiation
GYN: age @ menarche (<12)/menopause (>55), para (#1>35), fertility tx, HRT, Br feeding
PMHx: last MMG, self breast exams, other problems, other CAs (esp ovarian, endometrial)
Meds/Allergies: HRT, OCP,
FHx: BrCA ( risk w/ premenopausal, male, bilateral), ovarian CA, prostate CA
SHx: occupation (radiation exposure)
ROS: wt. loss, bone pain, SOB, chest pain, fevers/chills, skin s, mental status s
2) Physical Exam
Vitals, general appearance, Head-to-toe PE focusing on breasts and axillae
In 4 positions (sitting, arms @ waist, arms pulled forward, supine)
Examine: color, texture, dimpling, edema, ulcers, skin s,
Noting any: assymetry, nipple retraction (coopers ligament involvement), drainage
Palpate in 2 positions: sitting (btw 2 hands), supine w/ same arm above head (vs chest wall)
Examine and express nipple: look for skin s and discharge
Examine supraclavicular and axillary nodes
3) Work Up: U/S, mammogram, biopsy
DDx: fibrocystic s, fibroadenoma, ductal papilloma/ectasia, fat necrosis, abscess, radial scar, simple cyst
Patient <30: observe mass for 1-2 menstrual cycles unless patient high risk
If still present: U/S most = fibrocystic dz or fibroadenomas \
If neither: FNA for cytology
Patient >30:
Cystic feeling mass: U/S w/ FNA, reassure and resume screening
Solid/recurrent cyst: bilateral MMG + core Bx
Core bx in office, get ER/PR/Her2Neu status
Concerning: calcifications/border irregularity 15% w/ microCa on MMG = malignancy
Bx Indications: mass post FNA, solid mass, bloody FNA, suspicious MMG, bloody nipple d/c, nipple
ulceration/dermatitis, patient concern n
High risk/very concerning for CA: excisional Bx
Nipple D/C: galactography
4) Staging
Pathological Staging (TNM)
Tis = CA in situ T1 = < 2 cm T2 = > 2 cm but < 5 cm T3 = > 5 cm T4 = chest wall/skin invasion
N0= no ax nodes N1= mobile ax nodes N2= fixed/matted ax nodes N3= internal mamillary nodes
M0 = no distant mets M1 = distant mets (inc supraclavicular nodes)
Clincal Staging
Stage I = 2 cm w/o mets, no nodes (93% 5y survival)
Stage IIA = 2 cm w/ mobile axillary nodes OR 2-5 cm w/ NO nodes (72%)
Stage IIB = 2-5 cm w/ mobile axillary nodes OR >5 cm w/ NO nodes
Stage IIIA = >5 cm w/ mobile axillary nodes OR ANY size w/ FIXED axillary nodes (41%)
Stage IIIB = ANY tumor w/ ipsilateral internal mammilary nodes OR inflammatory s
Stage IV: Distant metastases (incl ipsilateral supraclavicular nodes) (18%)
5) Cancer Specific Work Up
Most common metastases: lymph nodes > lung > liver > bone > brain > adrenal
Labs: CBC (bone marrow invasion), LFTs (liver mets) liver U/S or abd CT if (alk phos most sens)
Consider BRCA testing if strong FHx (may consider prophylactic bilateral MRM)
Imaging: B/L MMG (U/S if pregnant), CXR (lung mets), bone /PET scan + serum Ca if Sx+, head CT if Sx+
No CT staging until lymph nodes are assessed
6) Specific Diagnoses and Respective Treatment Recommendations
Fibroadenoma: benign tumor of stroma appears as swirls of collagen on Bx,
Tx: observation or elective removal w/o previous bx
Fibrocystic disease: fibrous and cystic s in breast
Sx/Signs: ing pain w/ menstrual cycle, cysts, nodular fullness
Dx: breast exam, Hx, aspirated cysts (straw-colored/green fluid)
Tx: cysts FNA + follow for recurrence; Adj Tx: stop caffeine, NSAIDs, Vit E, Eve Primrose Oil, OCPs
Mastitis/Breast Abscess:
Most common pathogen: S. aureus in lactating women, mixed flora in nonlactating women
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

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

Dx: microcalcifications on MMG
Histologic types: comedo (most aggressive), micropapillary, cribform
Surgical Tx: Determined by size
< 1 cm lumpectomy (1 mm margins) +/- XRT
> 1cm (1) lumpectomy w/ 2-3 cm margins & XRT, no SLNBx; or (2) simple mastectomy & SLNBx
SLNBx w/ comedo subtype, multifocal dz, large lesions, high grade 10-20% infiltrative @ excision
Adjuvant Txs: SERMs, post-op XRT
Pagets Dz: invasion of skin by cells from a ductal carcinoma
Tx: MMG + exam for sub areolar mass (+ in 50% of cases)
No mass= Bx nipple: if pagets cells+ excision; Mass: begin w/u
Inflammatory Breast Cancer: Bx containing skin pre-op chemo MRM adjuvant XRT & staging
Invasive Cancer: 90% infiltrating ductal CA, 10% infiltrating lobular CA, >1% inflammatory and others
Tx: MRM vs. lumpectomy w/ XRT
Both require SLNBx (+ in 1/3 of invasive CAs) ALND if +
Post-op chemo/HT (if nodes+): ER/PR+ = tamoxifen, Her2Neu = Herceptin
Post-op XRT: w/ lumpectomy ( local recurrances ), chest wall invasion, >4LN+
7) Treatment Options for Invasive Cancer - Surgical: (1) lumpectomy & SLNBx w/ XRT, or (2) SM & SLNBx
Lumpectomy +XRT (+ SLNBx if invasive)
For tumors < 5cm w/ good tumor/breast ratio (stage I and II only)
CI to lumpectomy: +margins, tumor > breast size, multifocal disease (DCIS, calcifications)
CI to radiation: prior chest/breast radiation, collagen vascular dz, pregnancy
SLNBx
SE: lymphedema
CI: palpable nodes do U/S or FNA and remove
ALND axillary v (superior), L thoracic n. (posterior), lat dorsi (lateral), pec minor (medial)
If 4+ LN are positive XRT to axilla
SE: nerve damage (L thoracic > thoracodorsal > medial pectoral > lateral pectoral)
Simple mastectomy
Indications: DCIS w/ diffuse microcalcifications, patients w/ C/Is to XRT, diffuse disease
Breast tissue, areola, skin removed; axillary nodes spared
Modified radical mastectomy
Entire breast and axillary nodes removed; pec major and minor spared
Cx: arm edema, infection, nerve injury, skin flap necrosis, hematoma/seroma, phantom Br syndrome
Radical mastectomy
Indications: tumors which invade chest wall
Entire breast, ax nodes (I/II lateral to/deep to pec minor), pec minor and major removed
Borders: clavical (superior), lat (lateral), lateral sternum (medial), inf mam fold (inferior)
Radical mastectomy + XRT
Indications: chest wall invasion w/ +margins OR if > 5cm (XRT to chest wall), >4 +nodes (XRT to axilla)
8) Adjuvant Treatment Options for Invasive Cancer
Chemotherapy: cyclophosphamide w/: MTX and 5-FU (CMR) or adriamycin and 5-FU (CAM)
Indications: patients w/ + nodes, stage III disease, palliative if stage IV
Hormonal therapy: tamoxifen/raloxifene (anti-estrogen) or anastrozole (aromatase inhibitor)
Indications: histologic markers+
9) Follow Up
MMG Q6mos for 2 years yearly MMG; yearly CXR + LFTs
10) Recurrent Breast Cancer: can occur in operative field of prior mastectomy, breast post XRT, or axilla
Most often in same quadrant as original tumor w/ metastatic dz+ in 10% of pts.
Risk factors (for both local and distant recurrence): large tumor, receptor negative status, +axillary nodes
Tx:
Breast: mastectomy (if previously txed w/ lumpectomy + XRT), +/- XRT (for palliation)
Chest wall: XRT (post mastectomy)
Distant mets: hormone therapy (in prior responders), chemotherapy
11) Screening
Low risk pts: 1st MMG @ 40 yearly MMGs, self breast exams monthly @ 20 (1wk post-period)
High risk pts: 1st MMG 5y before dx of 1 relative, self breast exams @ 20, biannual dr breast exams @ 25
12) Prevention
SERMs (tamoxifen/raloxifene): local recurrance by 50%, rate of C/L BrCA as adjuvant
Aromatase Inhibitors (anastrozole): same as above, main SE = osteoporosis

Changing Skin Lesion

1) History
HPI: onset, s, timing, assoc signs/sx (pruritis, pain, bleeding), other spots
Risk factors for malignancy: sun exposure UVA/UVB (sunblock, protective clothing/hats, sunglasses),
immunosupression,
fair skin, red/blonde hair, freckles
SCC: arsenic exposure, AKs, large burns, osteomyelitis sinus tracts, chronic fistula (Marjolins ulcer)
BCC: chronic dermatitis, radiation exposure
Melanoma: blistering sunburns before age 18
PMHx: prior skin CA, previous dysplastic nevi, xeroderma pigmentosum, atopic dermatitis
FHx: melanoma, other CA
SHx:occupation (sun/arsenic exposure, EtOH, tobacco)
ROS (i.e. signs of advanced disease to lung, liver, bone, brain): systemic sx (wt loss, fevers/chills), headaches,
neurologic
s/sx, palpable LNs, SOB, abd pain, GI bleeding (esp rectal bleeding), jaundice, hematuria, bone/muscle pain
2) Physical Exam
Vitals, general appearance,
Head-to-toe PE focusing on skin (including scalp and nails Hutchinsons sign)
Examine skin for: color/texture irregularities, areas of ulceration, irregular nevi
ABCDs of melanoma: Asymmetry, Border, Color, Diameter/Dark/Different
Closely examine ALL SKIN, including SCALP:
Sun exposed areas (head, neck, hands) greatest risk for BCC/SCC
Back (site for 1/3 of melanoma in men), legs (site for 1/3 of melanoma in women)
Perform ophthomologic/fundoscopic exam for retinal melanoma
Examine lips and oropharynx for mucosal melanoma
Palpate cervical, axillary, femoral LNs
Perform rectal/pelvic exams to evaluate for rectal/vulvar melanoma
3) Work Up
Biopsy any lesions suspicious for melanoma: punch bx for Breslow depth, or excision. NEVER SHAVE
<2 cm excisional bx (entire lesion w/ rim of normal tissue cut down to SQ fat to measure depth)
>2-3 cm incisional bx (portion of lesion excised w/ border of unaffected skin)
Labs: CBC, LFTs, coags
Imaging (reserved for +Sx): CXR, Bone/PET scan, head CT/MRI
4) Basal Cell Carcinoma: most common skin CA, arising from germinating basal cell layer of epithelial cells
Distribution: most common on head, neck, and hands
Signs/Sx: slow growing, chronic, scaly mass; chronic scab/ulceration; pearly appearance
Subtypes:
Nodular: flesh-colored, pearly nodule
Superficial: scaly, red plaque resembles SCC
Morpheaform: hypopigmented, deep
Pigmented: often confused w/ melanoma
Treatment (almost anything will work)
Electrodessication & curettage: if lesion < 2cm
95% cure rate
Disadvantages: no specimen
Radiation: if lesion located in an area where tissue preservation crucial (ie eyelids)
90% cure rate
Disadvantages: skin atrophy/hypopigmentation common
Excision w/ primary closure: 1 cm margin
95% cure rate
Reconstruction can occur during same setting
Mohs micrographic surgery: involves tumor mapping to determine adequecy of resection
99% cure rate
Indications: facial lesions (esp nose and perinasal area), morphealike tumors, recurrent lesions
Immediate reconstruction possible good aesthetic results
Cryotherapy: Limited clinical use significantly higher morbidity and less predictable scarring
Topical Chemotherapy: poor cure rates
Recurrent lesions wide re-excision
5) Squamous Cell Carcinoma: CA arising from epidermal cells
Distribution: most common on head, neck, and hands
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

Distribution: 3 most common sites = skin > eyes > anus

Subtypes:
Superficial spreading: most common subtype (75% of all melanomas).
Distribution: any area (both sun-exposed and protected sites) but most commonly back and legs
Lesion appearance: irregular borders w/ varied color pattern
Cell distribution/growth: upper dermis w/ lateral spread
Prognosis: good
Acral lentiginous Melanomas: 10% of all melanomas
common in African Americans (50% of all melanomas in African Americans)
Distributed on mucous membranes, palms, soles
Lesion appearance: typically black, but may be amelanotic
Cell distribution/growth: upper dermis w/ occasional deep invasion spread radially
Prognosis: dependent on depth of invasion
Lentigo maligna: least common subtype (>10% of all melanomas), best prognosis
Distribution: occurs most frequently on head/neck and hand arises from Hutchinsons freckle
Lesion appearance: brown/black w/ elevated nodules w/in a smooth freckle
Cell distribution/growth: upper dermis w/ radial growth; vertical extension = infrequent.
Nodular melanoma: 15% of all melanomas
Distribution: can occur in any of body
Lesion apperance: blue/black nodule
Cell distribution/growth: rapid invasion into dermis
Prognosis: poor
Amelanotic melanoma: no pigment in lesion
Often poor prognosis 2/2 late detection
Staging
Breslows Depth: actual depth of lesion correlates best w/ survival
Measured vertically down from top layer of epidermis
<0.76 mm = 90% cure rate w/ excision vs. >4.0 mm = 80% rate of recurrence/metastases w/in 5y
Measurement may be inaccurate if ulceration+ (ulceration = poor prognosis)
Clarks Depth: based on histologic layers of skin, used if ulceration or thin skin (e.g. eyelid)
I = epidermis
II = into papillary dermis
III = through papillary dermis but not into reticular dermis
IV = into reticular dermis
V = into subQ fat
American Joint Commission for Cancer Staging and End Results
Stage I = < 1.5 cm; Stage II = > 1.5 cm; Stage III = any size w/ +LN; Stage IV = any size w/ metastases
Metastasis: occurs both hematogenously and via lymphatics
Most common sites = local LN > distant skin > lung > liver > bone > heart > brain
Most common malignancy to metastasize to the bowel
Treatment: based primarily on Breslows depth
Excision
Melanoma in situ = 0.5 cm margin
1 mm = 1 cm margin
>1 mm = 2-3 cm margin excision should reach fascia overlying muscle (deep fascia)
Special Cases
Digital melanoma = amputation
Intestinal metastases = surgical resection to prevent bleeding/obstrucion
Anal melanoma (most common Sx rectal bleeding) = APR or wide excision
Lymph node removal
Clinically involved regional LN w/ level II-V disease should be resected w/ an elective LND
Entails resection of levels I, II, and III w/ melanoma
SLNBx with lymphoscintigraphy if > 1.0 mm, LN+ full LN dissection (under clinical trial)
Adjuvant Tx: Interferon 2b
Indicated in : thick T4 tumors, nodal mets (i.e. Stage III)
Stage IV: no surgery; dacarbazine & IL-2. Recurrance PET scan
Prognosis
Indicators: Breslows depth > node status/mets > ulceration > site > age
Disease confined to 1 site = 80-90%
Regional LN involvement = 30-50%
Distant/visceral metastases = 100% die w/in 12 months

Dysphagia
DDx: Zenkers Diverticulum, Achalasia, Esophageal Spasm, GERD, Esophageal CA (adeno, squamous)
1) Dysphagia, Intermittent or Progressively Worse Sx, Chronic GERD 3 most important ?s
Dysphagia subtypes:
Solids > liquids = mechanical dysphagia
DDx: esophageal ring, peptic stricture, esophageal CA, Zenker (pharyngeal) diverticulum (btw lower
pharyngeal constrictor and cricopharyngeal muscle), epiphrenic diverticulum (@EGD), stricture
Liquids > solids = motility related dysphagia achalasia, spasm, scleroderma
Intermittent vs. Progressively Worse
Intermittent: esophageal ring/spasm
Progressively Worse: esophageal CA, achalasia, scleroderma
Chronic GERD may also be caused by other mediastinal masses
2) Hx 1st 3 questions as listed above
HPI:
Zenkers: dysphagia (solids > liquids), halitosis, food regurgitation, aspiration (+/-PNA), neck mass
Achalasia: dysphagia (liquids > solids), regurgitation, wt. loss, +/- aspiration
Esophageal Spasm: spontaneous, intermittent CP radiates to neck/back/jaw/ears/arms ( angina)
GERD: substernal pain, heartburn, regurgitation, aspiration/cough, w/ position, worse w/ EtOH/cigs/fat
Esophageal CA: dysphagia (solids > liquids), wt. loss, back pain, hoarseness (voice changes), sx of metastasis
PMHx:
Achalasia: scleroderma, GERD, other esophageal dzs, CA
GERD: CAD, PUD, hiatal hernia, DM (gastroschesis)
Esophageal CA: GERD, prior CA, DM, premalignant lesions (achalasia, GERD, hiatal hernia, Barretts,
radiation, esophagitis, caustic burns, Plummer-Vinson [webs, Fe-deficiency anemia, dysphagia, koilonychia,
atrophic oral mucosa], divericula, ectopic gastric mucosa, poor dentition
PSHx: prior gastric surgery, travel to Central/South America (Chagas)
FHx: DM, CA
SHx: smoking, EtOH, hot beverages (chronic irritation), Hunan Chinese heritage
ROS: systemic sx (fever/chills, wt loss, appetite s), neuro s, SOB, cough/hoarseness, CP, abd pain, N/V, GI
bleeding, s in urination, back pain, bone pain
3) Physical Exam
Vitals, Ht/Wt, BMI
Gen Appearance: cachectic? Obese (risk of GERD)
HEENT: palpable masses, nodules, LNs, OP exam, swallowing capability, inspect teeth, CNs
Cardiopulmonary/Abd/EXT
4) Work up/Diagnosis
Zenkers:
Barium swallow (+) = no EGD 2/2 perforation risk; (-) = EGD to r/o other esophageal disorders
Achalasia:
Barium swallow = dilated esophagus w/ stricture (birds beak)
Manometry = LES pressure, esophageal pressure, LES relaxation w/ swallowing, peristalsis
EGD = r/o neoplasm + document extent of esophagitis
Esophageal Spasm:
Manometry = high amplitude repetitive contractions w/ normal LES response to swallowing
Barium swallow/CXR = +/- diverticula, segmental spasm, corkscrew appearance of esophagus
GERD:
Must r/o: CAD, aortic dissection, PE, PTX, PUD, in addition to all esophageal disorders
Labs: +/- cardiac enzymes
Manometry = LES pressure
EGD+Bx = esophagitis, ulcers, stricture, Barretts (w/o dysplasia = monitor, w/ dysplasia resect)
24h pH measurements (in lower esophagus) = acidity (should not < 4 for > 4% of the day)
Esophageal CA:
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
Zenkers 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

IIa = invades through muscularis propria/adventitia w/ -LN

Tx: chemo/radiation surgery
IIb = invades up to the muscularis propria w/ + regional LN
III = invades adventitia/adjacent structures w/ +regional LN
Tx: chemo/radiation
IV = distant mets
Tx: chemotherapy
7) Treatment
Zenkers: diverticulotomy, cricopharyngeus myotomy (indicated if diverticulum > 2cm, relieves high pressure)
Achalasia:
Conservative: endoscopic balloon dilation of the LES (60% effective)
Surgical (if refractory to concervative management OR Barretts+): esophagomyotomy (Heller myotomy)
lower esophagus/LES incision w/ 270 fundoplication (i.e. wrap) prevents reflux (100%)
Spasm:
Conservative: Ca Channel blockers, Nitrates
Surgical: esophagomyotomy (aortic arch LES) LES fxn preserved (not usuallyt abnormal w/ spasm)
GERD
Conservative: PPI/H2B, reglan ( LES tone), antacids, lifestyle s (bed, smoking/EtoH, wt loss)
Surgical
Indications= refractory sx, addtl probs (webs/strictures/Barretts/dysplasia), aspiration 2/2 GERD, age
Nissen fundoplication = 360 wrap of stomach around esophagus (done laproscopically)
Belsey Mark IV = 270 wrap performed via L thoracotomy
Hill repair = posterior gastroplexy uses arcuate ligament to reestablish distal esophagus position
Esophageal CA (stage w/ EUS & CT chest/abdomen/pelvis)
Based on location
Cervical esophagus and upper 1/3 = chemoradiation
Middle 1/3 = XRT + chemo to shrink surgical resection to remove entire tumor (possibly curative)
Lower 1/3 = esophagectomy + proximal gastrectomy
Conservative: Palliation ( dysphagia) = XRT, transoral intubation/stenting, G-tube, resection, chemo
Chemo = 5-FU, cisplatin
Surgical (low mortality >5%
Internal Bypass (colon interposition) used for unresectable tumor
+ Mortality = 25-40% (average survival = 6 months post-op)
Transthoracic Esophagectomy (Ivor Lewis) = intrathoracic esophagogastric anastomosis
+ Stomach joined to esophagus in chest
+ Disadvantages: [1] combined thoracoabdominal incision respiratory cx (PNA = leading cause of death);
[2] possible intrathoracic anastomotic leak mediastinitis (50% fatal); [3] reflux esophagitis; [4] possible
tumor recurrence at suture line; [5] long hospital stay
Transhiatal Esophagectomy (THE) = cervical esophagogastric (stomach/larynx) anastomosis
+ Can combine w/ neoadjuvant XRT/chemo (cisplatin, 5-FU)
+ Advantages: [1] No thoracotomy; [2] cervical anastamosis (no mediastinitis if leak occurs, is easier to
manage); [3] no significant post-op GERD/reflux; [5] maximal vertical margins; [6] only need to sacrifice
short gastric aa
+ Cx:[1] anastamotic leak (10%), [2] postop mediastinal bleeding; [3] atelectasis/PNA; [4] RLN injury
Radical Esophagectomy performed w/ en block LND
+ More complex, larger operation
+ No survival benefit
+ Colonic interposition Alternative, but larger/more complex operation
Scleraderma: serial dilation; Lye ingestion: esophagectomy
8) Prognosis Esophageal CA
97% = candidates for THE
5 yr survival = 23%
By stage: Stage I = 80%; Stage II = 33%; Stage III = 15%; Stage IV = 0%

Trauma
PRIMARY SURVEY
1) Airway
Evaluate
Clear airway of debris/foreign bodies/teeth/blood
Stridor/hoarseness laryngeal obstruction/injury
Establish
Finger sweep chin lift/jaw thrust
Decide if early intubation necessary GCS 8, major head/face/neck trauma, ventilation 2/2 paralysis
Intubation = w/ cuffed tube in trachea
Endotrachial (preferred) vs. nasotracheal (contraindicated in facial fractures)
Endotrachial
+ Preoxygenate w/ bag valve mask
+ Maintain C spine stabilization necessary throughough
+ Apply cricoid pressure
+ Suction as needed
Nasotrachial
+ Patient must be awake, breathing, and w/o facial/basilar fractures
+ Smaller tube size used than w/ endotracheal intubation
Confirm intubation by listening/checking end tidal CO2/pulse oximetry
Cricothyroidotomy if unable to establish definitive airway
Place btw thyroid/cricoid cartilage
2) Breathing
Assess rate and quality of breathing (look for condensation; use ABG, O2 sat, CO2 detection)
Establish presence of bilateral breath sounds
Inspect for sucking chest wounds, subcutaneous emphysema, tracheal deviation
Unilateral breath sounds PLUS unstable vitals (esp hypoTN) needle thoracostomy
14/16 gauge angiocatheter in 2nd intercostal space in midclavicular line
MUST FOLLOW w/ chest tube (tube thoracostomy)
Chest tube
5th intercostal space in midaxillary line large (36-40 french) tube
OR Criteria
Blunt trauma = >1500 cc frank blood immediately OR > 200 cc/hr for 2+ consecutive hours
Penetrating trauma = >1000 frank blood immediately OR > 200 cc/hr for 2 consecutive hours
3) Circulation
Obtain pulse and blood pressure, check skin color/capillary refill
Quick/thread pulse = hypovolemia
Slow pulse = neurologic injury w/ ICP
If active bleeding apply direct pressure (no clamps), tourniquet
Tourniquet (can use blood pressure cuff) = inflate to 30-60 mmHg > systolic BP
Assess urine output (place foley unless contraindicated)
Assess shock state
Blood Loss | %Loss |
Pulse
| BP | Pulse Pressure | Mental Status
Class I
<750
<15%
<100
=
=/
slightly anxious
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

LR best (NS okay)

Fluid replacement
Adults
2L of LR wide open
If no response (BP/HR) switch to blood
+ Use O- initially until T+C returns
Pediatric patients
Bolus 20 cc/kg x 3
If no response blood @ 10cc/kg
8) Monitoring
Vitals: EKG, pulse oximetry, non-invasive BP cuff
Lines: NG tube, foley (after FAST)
Before foley check meatus (blood), prostate (high riding), scrotum (hematoma)
If + retrograde urethrogram and place foley under cystoscopy
Labs: ABG, T+C
Imaging: FAST, CXR, CT,
CXR = assess for PTX/hemothorax
Pelvic XR = assess for pelvic fx/retroperitoneal bleed
EXT: assess femur fx lose 2+ L blood
FAST/CT: assess for internal injuries/hemoperitoneum
FAST = Focused Assessment w/ Sonography in Trauma
Locations = perihepatic, perisplenic, pelvis, pericardium
9) SECONDARY SURVEY (return to ABCs if patient decompensates at any time)
AMPLE Hx: Allergies, Meds, Pregnancy/PMH, Last meal, Events
PE: head to toe look for missed injuries
HEENT: pupil size, tympanic membranes, C-spine point tenderness
Raccoon eyes/battle signs basilar skull fx
Rectal: high-riding prostate
Special Procedures: DPL, IVP, central line
Central line = 9 french cordis
Diagnostic peritoneal lavage
Indicated in diagnostic dilemma unclear if bleeding/injury and too unstable for CT (or use FAST)
OR criteria
+ Blunt: 10 ml gross blood, 100K RBCs/mm^3, 500 WBCs/mm^3, bacteria/food on gram stain, bile
+ Penetrating: 10ml gross blood, >1000 RBCs/mm^3, bacteria/food on gram stain, bile
Left thoracotomy
Indications: witnessed loss of vitals < 20 min prior (typically w/ blunt trauma)
Triad of death: cold, acidotic, coagulopathic
Pelvis stabilization
External fixation, mast trousers, sheet/towel clamp
10) OR
Prep patient from chin to knees
Open w/ large midline incision
Pack all 4 quadrants systematically explore for bleeding
Decide damage control laporotomy vs therapeutic

 D/C all nephrotoxic meds

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, -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
s 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/ 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

Oliguria/Anuria

Shock
Definition = failure of end organ perfusion
DIFFERENTIAL DIAGNOSES/CAUSES All = HypoTN (BP) + Tachycardia (HR)
Hypovolemic: HR CO BP SVR PCWP
Etiology: hemorrhage, 3rd spacing, vomiting/diarrhea, inadequate resuscitation/intake, burns, pancreatitis,
corticosteroid withdrawal, SBO
normal response w/ -blockers
Tx: volume repletion
Septic: HR CO BP SVR PCWP (hypoTN refractory to fluids)
Sx/Signs: diaphoretic, flushed, warm, vasodilated, RR
Early = high output HF (trying to overcome BP)
Late = cant overcome CO
Etiology: infection (fever, WBC)
Typically gram (-) organisms
Infection massive inflammation vasodilation
Cx: DIC (hemolysis), ARDS, DKA/HONKC (hyperosmoloar non-ketotic coma),
MOSF (multiorgan system failure)
Tx: ABx, volume repletion, pressors
Cardiogenic: HR CO BP SVR PCWP CVP (volume overload rales, pulmonary edema)
Etiology:
Intrinsic: MI, CHF, valve insufficiency, arrhythmia, papillary muscle dysfunction
Extrinsic: tension PTX, cardiac tamponade, abdominal pressure
Tx: tx cause of shock, inotropes, diuretics
Neurogenic: Hypotension w/ Bradycardia ( sympathetic tone)
Etiology: spinal cord injury, spinal anesthesia
Anaphylactic: wheezing, urticaria, pruritis, vomiting, abdominal cramps
Etiology: Type I hypersensitivity Rxn (IgE mediated)
1) ASSESS ABCs
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 > MSs > 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 (-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

6) STUDIES
Non-Invasive: CXR (pulmonary edema = cardiogenic), EKG, TTE/TEE (if murmurs/EKG s), CT if unknown
etiology (possible abscess)
Invasive: cardiac catheterization (as needed)
7) TREATMENT serially assess response to tx w/ UOP, BP, HR, mental status, CFT, EXT perfusion
Pressors/Inotropes
Pressors = MAP and venoconstriction
Phenylephrine = agonist venoconstriction
Inotropes = contractility
Dobutamine = agonist inotrope
Dopamine
+ renal perfusion via dopamine receptors inotrope
Hypovolemia: stop bleeding resuscitate w/ 3:1 LR & pRBCs if HCT < 30
If unstable after 4-6L crystalloid and 4-6U pRBCS go to OR
NO VASOPRESSORS
Sepsis: must identify source of infection (UTI, PNA, abscess)
Give IVF Xigris (activated protein C) and hydrocortisone
all lines give empiric Abx (Vanc/Gent/Flagyl) drain any/all abscesses
Use pressors/inotropes if BP doesnt respond to 2L of fluids (phenylephrine, dopamine, NE)
Monitor for Cx: MOSF, DIC
Cardiogenic: must identify cause and address ASAP catheterization, pericardiocentesis, surgery
Swan-Ganz catheter
Inotropes/pressors
Intra-aortic balloon pump, ventricular assist device (last resort)
Neurogenic: IVF, phenylephrine
Anaphylactic: epinephrine + albuterol, Benadryl, hydrocortisone, pressors

Liver Mass
DIFFERENTIAL DIAGNOSES
Benign: hemangioma (most common benign), hepatic adenoma, focal nodular hyperplasia, biliary cystadenoma,
simple cyst
Infectious: pyogenic abscess, amoebic abscess (Entameoba histolytica), Echinococcal cyst
Malignant: metastatic disease (most common malignant, often colon CA), hepatocellular CA, cholangiocarcinoma
1) HISTORY
HPI: incidental finding vs. symptomatic (RUQ pain?); onset, recent s
Sxs: pruritis, pain, jaundice, abdominal swelling, fever, anorexia
Specific Risk Factors:
Hemangioma: OCP, women of childbearing age Estrogen related
Hepatic Adenoma: OCP
Entamoeba Histolytica: travel (esp Mexico)
Echinococcal Cyst: travel (esp Central/South America, Middle East, China), exposure to sheep/dogs
HCCA: cirrhosis, Hep B/C, IVDU, transfusions, multiple sex partners, aflatotoxin (peanuts), liver injury
PMHx: extrahepatic CA (colon CA, 1 kidney tumors, breast CA, melanoma), cirrhosis, Hep B/C, PKD
ROS: Systemic Sx (F/C, N/V), hematuria, GI bleeding, bone pain, Sx of cirrhosis (ascites, encephalopathy)
2) PHYSICAL EXAM Head-to-Toe Physical Exam Focusing on Abdominal Exam
Vitals and General Appearance Jaundice, fat distribution, odor (fetor hepaticus)
Ruptured hepatic adenoma = presents w/ intra-abdominal bleeding/shock mortality = 20%
Abdominal Exam: hepato/splenomegaly, ascites, caput medusae, +/- PKD
Skin: jaundice, spider angiomata, palmar erythema, gynecomastia, lymph adenopathy
GU: testicular atrophy Neuro: asterixis
3) LABS
CBC (thrombocytopenia = HCCA, leukocytosis = infection), platelet count
LFTs (Alk phos >> AST/ALT = biliary process, normal AST/ALT = adenoma, focal nodular hyperplasia)
Hepatatis Panel: HBsAg, HCV RNA,
Serum -Feto Protein:
HCCA: in 60% of HCCA cases (inversely proportional w/ survival), AFP > 500-1000 = HCCA
Hepatic Adenoma/Focal Nodular Hyperplasia: normal AFP
CEA, CA19-9: if colon CA suspected
Total bilirubin: Direct vs Indirect
Coags/Albumin: Indicate liver fxn
4) IMAGING
RUQ U/S: Evaluate liver/biliary tree/gallbladder (good screening test)
Single Cyst (no internal echos): Simple Cyst vs. Pyogenic Abscess (WBC, fever, abd pain, IVDU Hx)
Single Multilocular Cyst (Ca + internal echos): Echinococcal Cyst f/u w/ echinococcal serologies
Single Solid Lesion: Hemangioma >> FNH >> Hepatic Adenoma >> Metastasis >> HCCA
Hemangioma: confirm w/ labeled RBC scan (Tc-99)
+ If negative CT/MRI w/ contrast (contrast in periphery > center)
HCCA: diagnose w/ CT
+ If inconclusive Bx
+ If positive no Bx indicated (may seed tumor along needle tract)
Multiple Lesions: Metastasis >> Pyogenic Abscess >> Entamoebic Cysts (r/o w/ negative serologies)
Spiral CT: indicated if U/S inconclusive or more information needed for surgery, requires contrast
Stellate Central Star: FNH
Bx: NEVER indicated unless 100% sure lesion hemangioma
Other: cholangiography, angiography, nuclear med
5) SPECIFIC DIAGNOSES/TREATMENT
Hemangioma = most common liver tumor occurring in 8% of the population
May enlarge throughout life (esp during pregnancy)
>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 s
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 addl 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)

Imaging: US/CT/MRI = tumor mass

Has propensity for vascular invasion often will see satellitosis (multifocal tumors)
Chest/Abdomen CT for metastasis esp hilar/celiac LN
Tx Options (unclear role for LN dissection):
Partial Hepatotectomy
+ Indications: no mets, solitary, <5cm, vascular invasion, low grade, 1 cm margins possible
+ Inflow/outflow = occluded to the section to be resected resect w/ 1cm clear margins
+ Non-cirrhotics = 70% of the liver can be resected w/o Cx
+ Cirrhotics = resection potential is much less (b/c of reserve) use wedge resection instead
Non operative candidates
+ Small, solitary lesion: RFA, EtOH injection, Arterial Chemoembolization
Infusion of chemo + gelatin foam particles tumor ischemia = prolonged local chemo effects
+ Large, multiple lesions/Cirrhosis: Liver Txp eliminates risk of recurrence
Preoperative chemoembolization >> transplant >> post transplant adjuvant chemo = best
+ Metastatic Dz: Txp not an option resection +/- embolization of mets + systemic chemo
Prognostic Factors: 1 cm margins, 5cm in diameter, solitary, vascular invasion, low grade CA
Recurrence Sites: Liver >> Bone/Lung >> Brain/Intraperitoneal
Metastatic Tumors: most common hepatic malignancy most often 1 GI tumors (colon, neuroendocrine, etc.)
Best prognosis if only in liver w/o LN involvement
Tx: wedge resection, cryoablative therapy, chemo for colorectal mets
Wedge resection: best if done <3x
+ Will often recur close f/u needed
Cryoablative Tx: best for unresectable tumors
Cholangiocarcinoma: possible txp Gallbladder adenocarcinoma:
Simple Cysts: Common finding in 10% of population usually small/ASx cysts filled w/ serous fluid
If multiple typically 3 and scattered
Large cysts = more likely to be Sxic pain and early satiety
Tx: repeat imaging in 6 months
If RUQ pain aspiration + sclerosant injection vs. simple excision
Polycystic Kidney Disease: Many cysts scattered throughout liver progressively enlarge
Can resect severely affected areas, but typically dz process doesnt affect synthetic fxn
Cystic Neoplasms: Cystadenomas/Cystadenocarcinomas
Characteristic appearance = thick multiple septations w/in cyst w/ calcified cyst wall
Typically occur in middle-aged women
Tx: resection
Echinococcal/Hydatid Cysts: Humans infected w/ echinococcal paraciteds (typically infect sheep/dogs)
Contracted by fecal (dog/sheep)/oral contact suspect in natives of Alaska/SW USA/foreign countries
Appearance: Unilocular cysts w/in hepatic parenchyma (+/- calcification) can grow to 10-20cm
Multiple daughter cysts inside larger cysts
If Dx suspected = Bx contraindicated can result in peritoneal cavity seeding/anaphylaxis
Tx: Albendazole
If no response laparotomy + exploration
+ Affected areas walled off w/ hypertonic saline and cysts removed intact (w/o spilling contents)
Pyogenic Abscess: usually 2/2 GI/biliary tract seeding (K. pneumonia most common 40% of cases)
Hx: RUQ pain, fever
Labs: CBC = WBC, LFTs = Alk phos
Imaging: CT/US = hypoechoic abnormality w/ hyperechoic and/or hypervascular wall
Tx: percutaneous aspiration and draining Cx and direct ABx therapy vs appropriate organisms
Biliary stenting if old/sick/1 infection unknown
Amoebic Abscess: Rare in US, common in Central/S. America occurs in 10% of infected w/ organism
Percutaneous aspiration anchovy paste
Tx: Flagyl; draining not required

Vomiting Newborn
DIFFERENTIAL DIAGNOSES Malrotation until proven otherwise
Intestinal Malrotation +/- Volvulus: clockwise twisting of bowel around mesentery
Sudden onset bilious vomiting in infants < 1 year + abdominal distention/pain
Volvulus = intestinal twisting on vascular pedicle ischemia + SBO
Duodenal Obstriction/Atresia: bilious vomiting at birth associated w/ VACTERL syndrome
Small Bowel Obstruction/Jejunal Atresia: Hx of polyhydramnios = common + no meconium passed
Annular Pancreas: Assoc. w/ Downs
Intussusception: Hx of viral illness, knees to chest w/ abdominal pain, currant jelly stools, Dances sign
Hirschsprungs Disease: mesenteric plexus chronic constipation, small diameter stools in < 2 y/o
Meconium Ileus: Assoc. w/ CF occurs in ileum
Meconium Plug: Assoc. w/ premature delivery occurs in colon
Necrotizing Enterocolitis: Assoc. w/ prematurity/high stress birth (hypoxia) bloody stools + sepsis
Small Left Colon Syndrome: Assoc. w/ GDM NET Pyloric stenosis Imperforate anus
1) RESUSCITATION
Assess ABCs
IVF = 2cc/kg/hr UOP
Place Foley/NGT
+/- Prophylactic ABx
2) HISTORY
CC: Vomit color (yellow/green), amount, blood-tinged, frequency, timing, progression, hungry afterward?
Age
HPI: onset, context (infants health), assoc. sx/pain, recent health problems
Prenatal/Perinatal Hx:
Birth problems: prematurity/high stress birth NEC/Meconium Plug
Failure to pass meconium in 1st 24hrs: Hirschsprungs
Amniotic Fluid Level: polyhydramnios Small Bowel Atresia
Pregnancy Hx/Cx: Maternal GDM Small Left Colon Syndrome
PMHx: other medical problems
VACTERL = vertebral, anal atresia, cardiac, tracheoesophageal fistula, renal, limb abnormalities
PSHx
Meds/Allergies
FHx: Downs Atresia, CF Meconium Ileus, Hirschsprungs, Pyloric Stenosis
ROS: General (F/C, wt/appetite s, feeding/stooling habits)
Constipation Hirschsprungs 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 = Dances 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 Hirschsprungs
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 Hirschsprungs
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 Ladds Procedure = widen base of mesentery and rotate intestines
Lyse Ladds 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

Appendectomy appendix not correctly placed, removes any future confusion

Examine remaining bowel for abnormalities (duodenal webs)
Intestinal Obstruction/Atresia/Annular Pancreas
NGT, IVF, IV ABx = first
If Duodenal Atresia check other abnormalities in VACTERL first (cardiac probs more life threatening)
OR 1 anastamosis (duodenoduodenostomy = best, duodenojejunostomy = 2nd choice)
Gastrojejunostomy = contraindicated
If Annular Pancreas present bypass w/ duodenoduodenostomy
+ Never divide pancreas not obstructing structure
Check for other intestinal atresia
Hirschsprungs
Resection & bx of involved colon
Early = Colostomy
Later = endorectal pullthrough vs 1 anastamosis
If Cx w/ enterocolitis/peritonitis IVF, ABx, colonic irrigation
Intussusception
85% reduce w/ hydrostatic pressure from air/barium enema
If fails to OR
Meconium Ileus
60% resolve w/ gastrografin enema (H2O soluble)
If fails to OR for enterotomy (incise bowel and remove meconium)
Replace pancreatic enzymes and give IVF
Meconium Plug
Contrast enema (H2O soluble) = diagnostic and therapeutic
Necrotizing Enterocolitis
Medical management = NPO, IVF, NGT, ABx (Amp/Gent/Clinda), Bicarb (correct acidosis), TPN
OR indications = perforation, full-thickness necrosis, clinical instability
Small Left Colon Syndrome
Contast enema = diagnostic and therapeutic
Pyloric Stenosis: 4-6 wk old
Pyloromyotomy: spread muscularis, intact submucosa
Imperforate Anus
Posterior Sagittal Anorectoplasty
Hernia sac
Anterior medial

Cool, Pulseless Foot

DIFFERENTIAL DIAGNOSES
Thrombosis: 2 to atherosclerosis (PVOD) signs of systemic dz also +: angina, claudication
Most common site: Hunters canal (SFA)
Claudication = inadequate blood supply to contracting muscle lactic acid
Rest pain (in PM) = CO, limb perfusion w/ supine position
Embolic Dz: Embolus from Afib, post-MI mural thrombus, valve vegetation, aortic aneurysm, DVT w/ PFO
Neurogenic Claudication: 2 to spinal cord impingement occurs 1 in upright position
Sx = aches in buttocks/thighs/hips assoc. w/ numbness and relieved w/ stopping/ing posture (i.e. variable timing)
Arterial claudication: calf pain, consistent distance
Venous Claudication: Bursting discomfort in limb assoc. w/ activity, h/o DVT, swelling for long time
Signs of chronic venous insufficiency also +
Trauma
Bloodflow to LE: Aortic dissection, GI bleed
Neuropathic Pain: Dermatomal distribution
Sx = aggravated by posture, + @ rest, relieved by posture s that relieve pressure on peripheral nerves
1) HISTORY
HPI: time/onset/severity crucial (must intervene if (1) tissue loss, (2) rest pain, (3) limiting activity)
6 Ps: pain, pallor, pulselessness, poikilothermia, parasthesias, paralysis
Unilateral/bilateral
Associated swelling (Compartment Syndrome)
Rest pain (impending limb loss) vs. claudication
Progressive vs. intermittent
Prior Hx of Sxs if so, prior Txs
Activity level @ time of onset
Level of Sx
Pain will occur below occlusion: aorta = buttock; iliac = thigh; SFA = calf
ROS: HA, s in vision, angina, palpitations, abd pain, urinary s, impotence
Leriches 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, Marfans, 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 s, 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)

Surgical Options:
Thrombectomy w/ Fogarty balloon
Bypass/graft need good flow upstream and downstream of thrombus
+ Conduits: internal mammary aa, saphenous vv, goretex graft ( risk of infxn/thrombus, patency)
Endovascular angioplasty w/ stent only indicated in patients w/ short, focal areas of stenosis
Thrombolytic agents indicated in poor operative candidates
+ Eagles Criteria = mortality w/: age >70, DM, angina, ventricular arrhythmia, Q waves on EKG
Amputation
Long Term Medical Tx (chronic PVOD): Pentoxifylline/Cilastazol, ASA, beta-block, statin, exercise, smoking
cessation
Post Surgery Management
ASA/Plavix
Heparin warfarin if source of embolus unknown/persists
7) POST REPERFUSION COMPLICATIONS
Rhabdomyolysis Renal Failure
Tx: alkalinize urine (supp IVF w/ bicarb), IVF, osmotic diuresis
Hyperkalemia K released from damaged cells
Tx: 1) calcium gluconate (2) glucose/insulin (3) albuterol (4) bicarb (5) kayexelate
Lactic Acidosis
MI most common cause of death (esp w/ multiple + risk factors)
Compartment Syndrome: ischemia muscle edema pressure perfusion further ischemia
Sx/Signs: sensation, pain worse w/ passive dorsiflexion, weakness of involved muscles, swelling
Pulse typically remains +
Dx: Needle > 30 mmHg
Tx: fasciotomy 2 longitudinal incisions (2 compartments released w/ each)
If >6 hr of ischemia: perform PROPHYLACTICLY
Compartments of leg: anterior, lateral, posterior, deep posterior

TIAs
Definition: sudden neurologic deficit (motor or retinal) resolving w/in 24hrs suggests impending CVA
NOT dizziness/syncope, NOT memory lapse
Localization:
Hemiplegia: C/L carotid
Aphasia: C/L carotid to dominant hand
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 s, vision s, weakness/paralysis, speech s, 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

Endovascular Carotid Stent (risk of stroke)

Indications (SAPPHIRE study, CREST study):
+ Surgery difficult lesion high in neck, prior neck radiation
+ Recurrent Disease:
Early intimal hyperplasia
Late recurrent occlusive disease
+ Very ill patients

DVT/PE
Virchows 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 s: 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
Homans 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 s
Tx: support hose

Lung Mass
DIFFERENTIAL DIAGNOSES
Infectious: TB, PNA
Benign Neoplasm: granuloma, hamartoma, scar
Malignant Neoplasm: adenocarcinoma, large cell carcinoma, SCC, mets, lymphoma
1) HISTORY
HPI: cough/ in cough, hemoptysis, dyspnea, hoarseness, dysphagia, sputum, fevers (10% ASx)
PMHx/ PSHx: prior CA, XRT, prior TB, RA, sarcoid, other lung diseases (COPD, asthma)
Meds/Allergies:
FHx: CA
SHx: smoking, EtOH, IVDU, asbestos, radon, XRT, silicon
HMA: prior CXRs (for comparison: stable for 2yr = benign)
ROS:
Systemic Sx: F/C, weakness, weight loss/ in appetite
Pumonary: cough, wheezing, hemoptysis, dyspnea
Associated Syndromes:
SVC Syndrome: facial swelling
Pancoasts/Horners: brachial plexus involvement
PTH-related Peptide (SCC): hypercalcemia/bone pain/kidney stones
Carcinoid: flushing, diarrhea, wheezing
Cushings (Small Cell): striae, moon facies, buffalo hump, acne, weight gain
Eaton-Lambert (Small Cell): weakness, strength w/ exercise
SIADH (Small Cell): Na
Acanthosis Nigricans: assoc. w/ all visceral malignancies
2) PHYSICAL EXAM
Vital signs/general appearance: BMI w/ height and weight cachectic, barrel chest
Skin: acanthosis nigricans
Neuro: weakness (Eaton-Lambert, Pancoasts)
HEENT: swelling (SVC syndrome), LAD
Cardiopulmonary: IPPA
EXT: clubbing (non-small cell), periosteal proliferation (adenoCA), atrophy (Pancoasts), bone pain (PTH)
3) LABS: Tb test, CBC, basic, Ca/Mg/PO4, coags (CA = hypercoagulable state)
Paraneoplastic Specific:
Small Cell: ACTH (Cushings), Na/ADH (SIADH), Ab (Eaton Lambert)
Squamous Cell: PTH-rP
Carcinoid: 5-HT
Adenocarcinoma: coags (DIC)
4) IMAGING/STUDIES Order: CXR >> CT >> Bronch/Mediastinoscopy/Needle Bx >> PET
Non-Invasive:
CXR: may present as nodule, infiltrate, atelectasis
SPN if present on previous CXRs, follow
+ >2.3 cm, ill defined borders, spiculated edges, age >60, +smoking suggestive of CA = get CT
+ Popcorn-appearance = hamartoma
+ Laminated-edges = granulomas
CT: reveals extent of tumor and possibility of mediastinal LN mets must include liver + adrenals
PET Scan: used to assess 1 tumor/mediastinal LNs and screen for metastatic disease
+ Normally bright: brain, heart, bladder; false neg. = BAC, carcinoid; only detects masses >1cm
Sputum Cytology
MRI: indicated in all small cell CAs and symptomatic non-small cell CAs
Pre-op eval: FEV1 >60%, DLCO >50%; VQ scan predicts post-op FEV1 >40%; exercise testing
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, nodes, mets
Ib: Tumor >3cm, nodes, mets
IIa: Tumor <3cm, + nodes to lung/ipsilateral hilum, mets
IIb: Tumor >3cm + nodes to lung/ipsilateral hilum, OR
Invades chest wall/diaphragm/mediastinal pleura/pericardial sac, nodes, mets
IIIa: Invades chest wall, diaphragm, or pericardial sac, + nodes in lung/ipsilateral hilum, mets
LN mets to ipsilateral/mediastinal/subcarinal nodes, medistinal invasion, mets
IIIb: Mediastinal invasion OR mets to C/L hilum/mediastinum/supraclavicular/scalene LN, 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

Multiple lesions seen on CT, but not present on CXR metastasis

Dx: only by Bx
Adenocarcinoma most common lung cancer (35-45% of all malignant lung CAs)
Epidemiology: less commonly assoc. w/ smoking, more common in women
Histology: acinar formation of cells arising from subsegmental airways in lung PERIPHERY
Characteristics: often formed in chronic scars arise via response to chronic inflammation, increased rate of mets
Growth/Mets: slow growth, hematogenous metastasis. May spread w/in lung via tracheobronchial tree.
Squamous Cell Carcinoma 2nd most common lung malignancy (25-40% of all CAs).
Epidemiology: assoc. w/ smoking
Histology: intracellular bridge formation and cell keratinazation.
Arises from squamous metaplasia of tracheobronchial tree.
Characteristics: 2/3 occur in central lung fields, increased rate of recurrance
Tumors typically bulky assoc. w/ bronchial obstruction
Growth/Mets: slow growth, late metastasis. May undergo central necrosis/caviation
Small Cell Carcinoma: highly malignant. Represents 15-25% of all lung malignancies.
Epidemiology: assoc. w/ smoking
Histology: clusters/nests/sheets of small/round/oval cells w/ dark/round nuclei and little cytoplasm.
Electron microscopy = neurosecretory cytoplasmic granules
Characteristics: centrally located
Growth/Mets: early metastasis via lymphatic/vascular routes
Treatment: surgical resection rarely indication instead use cisplatin + etoposide + XRT
Undifferentiated Large Cell Carcinoma: rarest of major lung cancer types
Histo: anaplastic, large cells w/ abundant cytoplasm and no apparent evidence of differentiation
Characteristics: centrally or peripherally located
Growth/Mets: highly malignant spreads early
7) SPECIFIC PARANEOPLASTIC SYNDROMES
Pancoasts Tumor involved superior sulcus
Produces Sx related to brachial plexus invasion, sympathetic ganglion involvement, vertebral collapse
Manifests as pain/weakness of the arm, edema, Horners Syndrome
Horners Syndrome = injury to cervical sympathetic chain ptosis, myosis, enophthalmus, anhidrosis
8) TREATMENT
Based on stage
Stage I: surgical resection
Stage II: surgical resection
Stage IIIa: surgical resection if early stage IIIa & non-small cell, chemo +/- XRT
Stage IIIb: chemo + XRT
Stage IV: chemo +/- XRT
Isolated Brain Mets: surgical resection
Met to the lung: renal cell, testicular, colorectal, sarcoma, melanoma = good prognosis if solitary resection
Contraindications to surgery SSSTOP IT!
Superior Vena Syndrome direct invasion/compression of SVC by tumor/LN
Sx: SOB, HA, JVD, UE edema, dizziness/light-headedness, cough
Supraclavicular Node Metastasis
Scalene Node Metastasis
Tracheal Carina Involvement
Oat Cell CA Tx w/ chemo +/- XRT
Pulmonary Function Tests = FEV1 <1
FEV1 > 2 required for a pneumonectomy FEV1 < 2 = V/Q scan
FEV1 > 1.4 required for lobectomy
Myocardial Infarction
Tumor Elsewhere (metastatic disease)

Neck Mass
Anterior : inferior mandible (superior), vertical midline (medial), SCM (lateral)
Submandibular : inferior mandible (superior), anterior/posterior digastric (medial/lateral)
Submental : vertical midline (medial), anterior digastrics (lateral), hyoid bone (inferior)
Posterior : 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 (Graves), hypothyroidism (Hashimotos), 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, Gardeners
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 s, MS s (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/Graves 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
Graves 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 (Plummers Syndrome) Multiple hyperfunctioning nodules
Sx: tachycardia, refractory CHF, Afib, unexplained/accelerated angina, wt loss, anxiety, insomnia
Pembertons 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, -blockers if sx of hyperthyroidism+
Chronic Thyroiditis 2 subtypes: Hashimotos and Riedels
Hashimotos 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
Riedels 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, Gardners 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
Hrthe 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 s: skin, lip, oral cavity, submandibular/parotid gland, paranasal sinuses
Posterior : 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/LN/ 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 )
Parathyroid injury hypocalcemia + hyperphosphatemia

Painless Jaundice
Hyperbilirubinemia 2.5 yellowing of the skin
Jaundice, fever, RUQ pain = Charcots Triad cholangitis = emergency
Jaundice, fever, RUQ pain, mental status s, hypotension = Reynolds Pentad sepsis
DIFFERENTIAL DIAGNOSES
Prehepatic: hemolysis (sickle-cell, G6PD), blood transfusion
Hepatic (dull pain, fatigue, n/v): hepatitis, cirrhosis, drug toxicity, sepsis, congenital conjugation defects
Posthepatic (colic, itchy): gallstones, cholangitis, biliary duct injury, pancreatitis, PSC, tumors, pseudocyst
Tumors: pancreatic CA, cholangiocarcinoma, gallbladder adenoma, ampullary CA, mets
1) HISTORY
HPI: onset, duration, location (if pain), progression of jaundice (time-frame), dark urine, light stools, pruritis
PMHx: hepatitis (etiology), cirrhosis, PSC/IBD, PBC, gallstones, acute/chronic pancreatitis, DM (esp recent onset),
transfusions, heritable/genetic conditions, new onset depression
PSHx: cholecystectomy, abdominal surgery
Meds/Allergies: tylenol, contrast studies, newly started meds
FHx: CA (esp pancreatic, colon), autoimmune hepatitis, PBC, PSC/IBD, hereditary hemolytic states
SHx: smoking, EtOH, IVDU, sexual history
HMA: last FOBT, colonoscopy
ROS:
General: F/C, fatigue, weight loss, appetite s
GI: abd pain (radiating to back), nausea/vomiting, constipation/diarrhea, stool color/consistency/blood/floating
EXT: bone pain, weakness, transient swelling (Trousseaus 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, Courvoisiers sign (palp/NT GB), distxn, pain, SMJ/Virchows 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, -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, nodes, mets
Stage II: tumor extends into bile duct/peripancreatic tissues/duodenum, nodes, mets
Stage III: tumor extends into bile duct/peripancreatic tissues/duodenum, + nodes, mets
Stage IVa: tumor extends into stomach/colon/spleen/major vessels, any nodal status, 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

Distal: Whipple
Gallbladder Carcinoma
Epidemiology: 4:1 female:male
Risk Factors: gallstones, porcelain gallbladder (precursor lesion in 50%), cholecystenteric fistula
Histology:90% adenocarcinoma
Sx: biliary colic, wt loss, anorexia, may present as acute cholecystitis, many pts Asx until late
Signs: jaundice (invasion into common BD/ pericholedochal LN compression), RUQ mass, palpable GB
Location:60% in fundus
Dx: U/S, CT, ERCP
Growth/Metastasis: contiguous spread to liver
Tx: depends on invasion
Confined to serosa: cholecystectomy
Confined to muscularis/serosa: radical cholecystectomy + wedge resection of overlying liver + LND
+ +/- chemo/XRT
+ If performed laproscopically risk seeding to trocar sites
Choledocholithiasis
Chronic pancreatitis: Ca2+ in pancreas = pathognomonic

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/Dieulafoys Lesion/Aorto-Enteric Fistula/Vasculitis (5%)
Lower GI: Dvtclosis, AVMs, CRC, Colitis (infxious > ischemic > XRT > IBD: UC >> CD), Hemorrhoids
Meckels 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 s, GI, urinary
3) PHYSICAL EXAM
Vitals/General Appearance MS s = 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 ), 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 + -blockers: lowers portal venous pressure (85% effective)
Continue all patients on -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 perfd 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
Boerhaaves 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

Weight Loss/Colon CA
Key = elicit additional symptoms/risk factors w/ history narrow differential
DIFFERENTIAL DIAGNOSES
Vascular: Chronic Mesenteric Ischemia
Inflammatory: IBD
Acquired: Achalasia, Gastric Ulcer, Malabsorbative Diseases
Metabolic: DM (Diabetic Gastroschesis), Hyperthyroidism
Infectious: TB, HIV
Neoplastic: Colon/Pancreatic/Ovarian CA, Polyps, Pheochromocytoma, Hodgkins, Carcinoid tumor
1) HISTORY
Most Important ?s: (1) In-/Voluntary, (2) or in Appetite, (3) % from baseline, (4) Lifetime variability
HPI: assoc. Sx, period of time, amount of weight lost, meals, lifestyle s, depression
PMHx: previous CA, IBD, polyps (villous worst), DM/MI (risk factors for CMI)
PSHx: past surgeries
Meds/All:
FHx: CA (25% CRCs = +FHx), IBD, polyps, genetic dz (FAP/Gardener/HNPCC/Peutz-Jegher), CAD, DM
Specific CA Associations: CRC, breast, ovarian, uterine
SHx: smoking, EtOH, occupational exposures, radiation exposures, travel, diet (fiber/fat = CRC risk)
HMA: annual rectal exams + FOBT (>40), colonoscopy (@ 50 + q3-10y earlier if FHx+)
ROS:
General: fevers/chills, fatigue/appetite s
Cardiopulmonary: palpitations (hyperthyroid, pheochromocytoma), chest pain
GI: dysphagia, N/V, regurg, satiety, BM s (D/C), tenesmus, hematochezia/melena, abd pain, jaundice
GU: urinary sx: urgency/frequency/dysuria (possibility of fistula)
(GYN): LMP, bleeding, pelvic pain
Endo: heat/cold intolerance, restlessness, polydypsia/polyuria/polyphagia
Skin: rashes, ing lesions (SMJ node)
2) PHYSICAL EXAM
Vitals/General Appearance: cachexia
HEENT: proptosis, LNs (cervical/L supraclavicular), neck bruits, thyroid nodules/enlargement, corneal injxn
Cardiopulmonary: wheezes/rales/rhonchi (TB), murmurs/S3
Abd: tenderness (RUQ = liver mets), masses, distension (r/o obstrxn), ascites, umbilical LAD
Rectal: occult blood, masses (10% CRCs = palpable), gross blood, Blummers shelf
Blummers shelf = hardness palpable on rectal mets in recto/uterine or recto/vesicular pouch
(Pelvic): uterine/adenexal masses, cervical lesions
Skin: lesions, acanthosis nigricans, pretibial myxedema, pyoderma gangrenosum/erythema nodosum
3) LABS:
Diagnostic: CBC: iron deficiency anemia (esp R sided CRC), Hodgkins; Basic: DM; TSH/T4: hyperthyroidism;
Albumin: liver function, nutritional status; Amylase/Lipase: pancreatic CA; Coags: liver function; 24hr Urine
Catechols (VMA/HMA): pheochromocytoma; PPD: TB; Genetic Studies: FAP, Gardners, 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 Dukes (Rectal CA)
Dukes A: invades up to submucosa
Dukes B: invades up to muscularis propria
Dukes C: positive LN, but no distant metastases
Dukes 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: 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

SMA: ileocolic, right colic, middle colic

IMA: left colic, sigmoid, superior hemorrhoidal
Internal Iliac: middle/inferior hemorrhoidal
Stage IV: chemotherapy (5-FU/leukovorin/irinotecan) +/- palliative surgery (resect solitary liver mets)
Liver met resection only indicated if no other mets + restage w/ CT of chest/abd/pelvis + PET
Lymph Node Removal: controversial, currently recommended to remove all 17
Follow Up: most important in 1st 3 years time when 90% of CRCs recur
CEA/CBC/LFTs (follow tx response/ID recurrence); PE; stool guaiac = q3mo (1st 3y) q6mo
CXR q6mo (1st 2y) qyear
Colonoscopy years 1 & 3
7) RECTAL CANCER/TREATMENT
Staging: Endorectal U/S gold standard
Treatment = based on lesion location (LAR vs. APR) mesorectum resection = best chance for cure
Upper 1/3 (10-15 cm above anus): low anterior resection
Resection via abdominal incision w/ anastomosis btw L colon + remaining rectum
Middle 1/3 (5-10 cm above anus): low anterior resection
Lower 1/3: abdominoperineal resection
Resection of the rectum, anus, and anal sphincters via combined abdominal/perineal approach
Colostomy formed
Treatment (based on stage) same as CRC
Stage II/III: Pre-Op/Post-Op chemoradiation recommended local recurrence
LN+: Chemo improves survival
8) POLYPS
Anatomic classification: sessile vs. pedunculated
Histologic classification: inflammatory (pseudopolyp) vs hamartomatous vs hyperplastic vs neoplastic
Hyperplastic: benign/normal cells no malignant potential
Neoplastic: proliferation of undifferentiated cells premalignant/malignant cells
Neoplastic subtypes: tubular adenomas (pedunculated), tubovillous adenomas, villous adenoma (sessile)
Tubular most common (85%)
Risk factors for malignancy: size, histologic type, atypia of cells
Size: >2cm = high risk of carcinoma (35-55%)
Histology: villous (40%) >> tubovillous (20%) >> tubular (5%)
Most common location: rectosigmoid colon (30%)
Treatment: Endoscopic resection
Large sessile villous adenomas should be removed w/ bowel resection and lymph node resection
Polyposis Syndromes:
Gardners: CRC by 40, desmoid tumors (abd wall), skull osteomas, sebaceous cysts, adrenal/thyroid tumors,
retroperitoneal fibrosis, duodenal/periampullary tumors
Peutz Jeghers: GI hamartomas (jejunum/ileum > colon > stomach) w/ CA risk, ovarian CA, melanotic
pigmentation of buccal mucosa/lips/digits/palms/soles

Abdominal Pain
Peritoneal signs = guarding, muscle spasm, rebound tenderness,
DIFFERENTIAL DIAGNOSES by location
Esophagus: GERD, Esophageal Spasm
Stomach: PUD, Gastritis
SI: PUD, Appendicitis, Obstruction/Perforation, Acute/Chronic Ischemia, Crohns, Gastroenteritis
Liver: Hepatitis
Gallbladder: Biliary Colic, Cholecystitis,
Biliary Tree: Choledocolithiasis, Cholangitis
Pancreas: Acute/Chronic Pancreatitis, DKA
LI: Appendicitis, Crohns, UC, Ischemia, Infectious Colitis, Diverticulitis, Obstruction/Perforation, Volvulus
GU: Renal Lithiasis, Pylonephritis
GYN: PID, Ectopic Pregnancy, Ovarian Torsion, Pregnancy, Pre/Perimenopausal Pain
Cardiopulmonary: Ruptured Aneurysm, MI, PNA
MSK: MSK Pain, Hernia
1) HISTORY
Key Factors: Age, Gender, Acute vs. Chronic Process
HPI: location, onset, context, timing, quality, progression, duration, h/o similar pain, / (meals, position)
PMHx: Afib, chronic pain, AAA, CAD, CVA, hyperlipidemia, HTN, GI disease, hernias, sickle cell, IBD
PSHx: abdominal/pelvic surgery (esp intraoperative Cx risk for SBO),
Meds/All: NSAIDs, ASA, warfarin, heparin
FHx: CA, DM, heart disease, IBD, AAA,
SHx: smoking, EtOH, IVDU, trauma, sick contacts
GYN: gravity/parity, STDs, LMP, pregnancy
HMA: FOBT, colonoscopies
ROS:
General: fevers/chills, fatigue/appetite s, anorexia
GI: last BM, BM s, D/C/blood, N/V (non/bilious/bloody), regurg/dysphag/foul taste, jaundice, tenesmus
Cardiopulmonary: palpitations, cough, sputum production
GU: urinary sx urgency/frequency/dysuria
(GYN): LMP, bleeding, pelvic pain, vaginal d/c
Skin: rashes, lesions, itching
2) PHYSICAL EXAM Focusing on Vitals General Appearance, Abdominal, Pelvic, & Rectal Exams
Vitals
General Appearance: position in bed, movement (no movement = perotinitis), obvious pain
Cardiopulmonary: wheezes/rales/rhonchi (PNA),rhythm/rate (Afib)
Abd:
Inspect: Cullens/Gray Turners Signs
Cullens Sign = bluish discoloration of periumbilical area retroperit hemorr tracking thru abd wall
Grey Turners Sign = Ecchymosis/discoloration of the flank dissecting retroperitoneal hemorrhage
Auscultate: Bowel sounds
Percuss: distension, organomegaly
Palpate: rebound/guarding (in/voluntary), masses, McBurneys pt, psoas/obturator signs, Rosvigs sign
Rectal: gross/occult blood, masses
(Pelvic): uterine/adenexal masses, cervical motion tenderness
Skin: lesions, acanthosis nigricans, pyoderma gangrenosum/erythema nodosum
3) LABS: CBC, comp, LFTs, -HCG, U/A, amylase/lipase, hep panel, lactate, T+S, cardiac enzymes, +/- T&C
Ransons Criteria:
@ presentation: Age >55, WBC >16K/mm^3, glucose > 200mL/dL; LDH >350U/L; ALT > 250 U/L
@ 24h: HCT 10%; BUN 5mg/dL; Ca <8mg/dL; pO2 <60; base deficit >4mEq/L; fluid seq >6000 mL
4) IMAGING/STUDIES
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:
McBurneys Point = 2/3 : 1/3 umbilicus:superior ischial spine
Rosvigs 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

Tx: Pre-op IVF + 2 cephalosporin/cipro can d/c Abx if not perforated

Non-Perforated: appendectomy, 24h Abx, D/C home on POD #1
Perforated: appendectomy, Abx (Zosyn) for 3-7 days, wound left open
Appendicieal Abscess: percutaneous drainage, Abx, elective appendectomy 6 weeks later
Cholecystitis: obstrxn of cystic duct inflammation (95% gallstones, 5% acalculus)
Presentation: non-stop RUQ pain, fever, N/V, palpable GB, Murphys sign, epigastric/subcapsular pain
Murphys Sign = acute pain + inspiratory arrest w/ RUQ palpation during inspiration
Dx: U/S wall >3mm, pericholecystic fluid, distended GB, stones+, sonographic Murphys sign
Tx: IVF, Abx, early cholecystectomy (open GB in OR to for CA)
Cholangitis infection of the biliary tract from obstrxn (stone >> stricture, CA, pseudocyst)
Presentation: Charcots Triad (F/C, RUQ pain, jaundice), Reynolds Pentad (triad + MSs, shock)
Labs: WBC, BR, alk phos, +blood cx (E. coli, Klebsiella, Pseudomonas)
Dx: U/S + contrast study (ERCP) after patient has cooled off w/ Abx
Tx: IVF + Abx definitive treatment (ERCP, cholecystectomy) later
Suppurative Cholangitis: severe infection w/ sepsis (pus under pressure)
Tx: IVF, ABx, decompression (ERCP, PTC, laparotomy w/ T tube placement)
Pancreatitis
Acute
Causes: gallstones, EtOH > trauma/scorpions/viruses/autoimmune/steroids/ERCP/drugs/hyperlipid
Presentation: epigastric pain, N/V, diffuse abd tenderness, BS, fever, dehydration/shock
Labs: CBC, LFT, amylase/lipase, T+C, ABG, Ca, basic, coags, lipids
Studies: U/S (cholelithiasis w/ phlegmon); CT (pancreatic necrosis w/ phlegmon)
Cx: pseudocyst, abscess/infxn, necrosis, vessel rupture, ascities, DM, ARDS, sepsis, DIC
Tx: NPO, IVF, NGT (if V+), TPN/postpyloric feeds, H2B/PPI, analgesia, supp coags/lytes, watch W/D
+ Abscess: surgical debridement + drain placement if refractory to medical management + infxn
Chronic: chronic inflammation of the pancreas tissue destruction/loss w/ fibrosis & calcification
Causes: EtOH > idiopathic, hypercalcemia, hyperlipidemia, familial, trauma, iatrogenic, gallstones
Presentation: epigastric/back pain, wt loss, steatorrhea, DM
Labs: amylase/lipase (normal may be burned out), 72h fecal fat, glucose tolerance test
Studies: CT (best sensitivity enlargement/atrophy, Ca2+, masses, pseudocysts), ERCP (ductal s)
Cx: IDDM, steatorrhea, malnutrition, biliary obstruction, gastric varices, pseudocyst,
Medical Tx: enzyme replacement, analgesics, insulin (if DM+), EtOH use
Interventional Tx: stent any strictured ducts w/ ERCP
Surgical Tx: longitudinal pancreaticojejunostomy (Puestow), distal pancreaticojejunostomy (Duval)
Pseudocyst Tx: drainage of cysts >5cm after 6 weeks (waiting period)
+ Angiogram if bleeding
+ Cysto-gastrostomy/duodenostomy if compressing stomach/duodenum
Diverticulitis
Presentation: LLQ pain (crampy/steady), BM (diarrhea), F/C, anorexia, LLQ mass, N/V
Labs: WBC
Imaging: A/P CT (edematous bowel good to dx abscess), AXR (ileus, a/f levels, free air if perf-ed)
Cx: abscess, diffuse peritonitis, fistula (colovesical most common), obstruction, perforation, stricture
Initial Tx: IVF, NPO, broad spectrum ABx w/ anaerobic coverage, NG suction
Surgical Indications: obstruction, fistula, perf, abscess (cant be drained percutaneously), sepsis
Elective: 2 episodes should be considered after 1st episode if young/DM/immunosuppressed
Emergent Surgical Tx: Hartmanns procedure
affected segment resected w/ end colostomy + stapled rectal stump (reanastomosis 2-3 mos later)
Elective Surgical Tx: on stage procedure resection of involved segment + 1 anastomosis
Abscess Tx: percutaneous drainage
Mesenteric ischemia: postprandial pain out of proportion to PE, wt loss; Tx: CT, SMA thrombectomy, bypass stent
Mesenteric venous thrombosis: hypercoag or low flow or inflammation; Tx: X-ray, CT, venogram, anticoagulate
AAA: 1.5x normal diameter; Tx: endovascular (no increased survival), repair if >5.5cm

Hypercalcemia/Hyperparathyroidism
1 HPT = PTH secretion Ca, PO4
2 HPT = PTH from Ca 2/2 renal failure/Ca absorption Ca
3 HPT = PTH after Ca corrected in 2 HPT no in PTH secretion from (corrected) Ca levels
DIFFERENTIAL DIAGNOSES CHIMPANZEES
Calcium overdose
Hyperparathyroidism (1/2/3) Hyperthyroidism / Hypocalciuric Hypercalcemia
Immobility / Iatrogenic (thiazide diuretics)
Metastasis / Milk-Alkali Syndrome
Pagets Disease
Addisons Disease / Acromegaly
Neoplasm (breast CA >> prostate CA, kidney CA, lung CA, pancreatic CA, multiple myeloma)
Zollinger-Ellison Syndrome
Excessive Vitamin D
Excessive Vitamin A
Sarcoidosis
1) HISTORY
HPI:
HPT: dysuria, my-/arthralgias, weakness/fatigue, D/C, abd pain, anorexia, MS , neck pain, hoarseness
Metastases: bone pain, hematochezia, hematuria, lymphadenopathy, hemoptysis, cough, prior CA dx
Ca/Vit. A/Vit. D/HCTZ OD: supplements/meds
Hyperthyroidism: palpitations, temperature intolerance, rashes/skin s, anorexia, anxiety
Zollinger-Ellison: ulcers, abdominal pain
Addisons: fatigue, malaise, skin discoloration
Acromegaly: facial s, hand/foot s (rings/shoes not fitting)
Sarcoid: dyspnea, skin lesions
PMHx: CA/ PUD, hyperthyroidism, nephrolithiasis, fractures, gout, pancreatitis, HTN
Known Dxs: Pagets, Addisons, 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 s, wt loss/anorexia, mood/MS s
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 -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

3 Subtypes: parathyroid hyperplasia (all 4 glands), adenoma (1 gland), carcinoma (1 gland)

Hyperplasia: Neck exploration & resection of all 4 glands, explant 100mg of PTH tissue to forearm
+ Draw PTH level pre-surgery redraw @ 0/5/10 min after removal
No in PTH levels search for supernumary parathyroid gland
+ Must r/o MEN I and MEN IIa
Adenoma: Resect adenoma (send for frozen section) + Bx any additionally enlarged glands
+ Draw PTH level pre-surgery redraw @ 0/5/10 min after removal (goal = WNL/50% of prior high)
Carcinoma: Resect carcinoma, ipsilateral thyroid lobe, and all enlarged LN
2 HPT: correct Ca/PO4, list for renal transplantation no role of parathyroid surgery
3 HPT: correct Ca/PO4, remove all parathyroid glands,
Explant 30mg of tissue in forearm if refractory to medical tx.
Parathyroid Carcinoma
Signs/Sx: Ca, PTH, palpable PT gland (50%), neck pain, hoarseness/voice , hypercalcemic crisis
Tx: Resect carcinoma, ipsilateral thyroid lobe, and all enlarged LNs
Guidelines for asx parathyroidectomy: based on age, serum Ca2+, Cr, T-score, 24-hr urine Ca2+
Post-Op Cx of Parathyroidectomy:
Nerve damage: recurrent laryngeal (1 = hoarseness, 2 = airway obstruction), superior laryngeal
Neck hematoma: open at bedside if airway compromised
Hypocalcemia: perioral tingling, parasthesias, +Chovosteks sign, +Trousseaus sign
Chovosteks sign: facial muscles contract if ipsilateral facial nerve tapped @ mandibular angle
Trousseaus sign: hand/forearm spasm if brachial artery compressed via BP cuff
Hungry Bone Syndrome: Ca post HPT surgery Ca-deprived bone absorbs free serum Ca
Hypoparathyroidism Tx:
Acute: IV Ca
Chronic: PO calcium, vitamin D

Burns
PRIMARY SURVEY
1) Airway
Inspect/Evaluate
Identify: singed facial hair, burns to oropharynx, carbonaceous sputum, circumferential burns to thorax
Clear airway of debris/foreign bodies/teeth/blood
Stridor/hoarseness laryngeal obstruction/injury
Establish
Finger sweep chin lift/jaw thrust
Decide if early intubation necessary GCS 8, major head/face/neck trauma, ventilation 2/2 paralysis
Intubation = w/ cuffed tube in trachea
Endotrachial (preferred) vs. nasotracheal (contraindicated in facial fractures)
Endotrachial
+ Preoxygenate w/ bag valve mask
+ Maintain C spine stabilization necessary throughough
+ Apply cricoid pressure
+ Suction as needed
Nasotrachial
+ Patient must be awake, breathing, and w/o facial/basilar fractures
+ Smaller tube size used than w/ endotracheal intubation
Confirm intubation by listening/checking end tidal CO2/pulse oximetry
Cricothyroidotomy if unable to establish definitive airway
Place btw thyroid/cricoid cartilage
2) Breathing
Start 100% O2 (can remove once CO level = WNL)
Assess rate and quality of breathing
Establish presence of bilateral breath sounds
3) Circulation
Start IVF 2 large bore IVs in antecubital fossa wide open
Draw labs simultaneously CBC, basic, ABG, COHb, urine Mgb, T+C, cardiac enzymes
Assess urine output place foley unless contraindicated
Monitor vitals: BP, HR, peripheral pulses (esp if circumferential burns to EXTs), mental status, UOP
peripheral pulses = escarotomy full thickness incision (into healthy fat) thru escar w/ scalpel/bovey
Swann-Ganz Indications: TSA > 30%, unstable, oropharyngeal burns
Assess shock state:
Blood Loss | %Loss |
Pulse
| BP | Pulse Pressure | Mental Status
Class I
<750
<15%
<100
=
=/
slightly anxious
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
4) Disablility
Rapidly assess for neurologic deficits (ideally before intubation)
Evaluate for GROSS deficits only (ie not moving one side/profound weakness)
Assess GCS
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
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)

After 24 hrs D5W + Albumin: 0.5cc/kg/%BSA

Meds: H2-blocker/PPI (prevent curlings ulcers), anabolic steroids, -blocker, SS insulin
Tetanus vaccine
Burn Center: 20% 2, 5% 3, face/hands/feet/perineum burns, inhalation injury, +trauma, electric burns
Follow: Na, glucose, prealbumin
Start PT w/in 1 week
9) BURN TYPES/CARE
Burn Types
1: painful, dry, red areas that do not form blisters (doesn't count in BSA calculation)
Tx: keep clean + neosporin + pain meds
2: painful, hypersensitive, swollen, mottled areas w/ blisters & open, weeping surfaces
Tx: unroof blisters, silvadene, pain meds, +/- STSG (deep 2 only)
3: painless, insensate, swollen, dry, mottled, white and charred areas look like dried leather
Tx: occlusive dressings ( epithelialization rate, pain, fluid losses) w/ BID wet saline dressing s
+ escar excision w/in 1 week + split thickness grafting (IMBIBITION)
+ Monitor for: compartment syndrome
Specific Types:
Chemical: flush for 1h w/ water/NS
Electrical: Perform early escarotomy +/- fasciotomy high risk of compartment syndrome
+ Monitor urine for Mgb
+ EKG = essential high rate of dysrhythmias
+ Look for entry/exit points
+ Muscles damaged > skin BSA often under-represents actual damage
+ Long term cx: myelitis, cataracts
Topical ABx
Silvadene (silver sulfadiazine): painless, little escar penetration, pseudomonas
Indications: 2 burns
SE: idiosyncratic neutropenia
CI: sulfa allergy
Sulfamylon (mafenide acetate): penetrates escar, broad coverage ( staph), painful, allergic rxn (7%)
Indications: 3 burns, already contaminated burns
SE: acid-base imbalances acidosis
Polysporin (polymyxin B sulfate): painless, clear, narrow spectrum
Indications: facial burns
Neosporin bacitracin
Indications: cartilage
Skin grafts (only for 3)
Full thickness (cosmetic)
Split thickness w/ mesh
10) COMPLICATIONS
Contracture start PT early, escharotomy if constricting breathing
Mgburia: tx = alkalize urine
Infection: staph > pseudomonas > strep > candida
Signs: WBC, escar discoloration, green pigment, edema, ecchymosis below escar, 2 3, hypoTN
Dx: Bx w/ 10^5 bacteria/gram
Tx: escarotomy + topical Abx