Surgery Rotation Notes

AbbreviationsD/C = discharge, discontinuePCA = patient controlled analgesiaCS = chem stick (Accu check for glucose)HAL = hyperalimentationTPN = total parenteral nutrition

MedicationsTylox (oxycodone HCL – Acetaminophen) for mod-severe pain; capsuleDilaudid (hydromorphone) for mod-severe pain; IV or suppositoryRoxicet (oxycodone HCL – Acetaminophen) for med-severe pain; tabActiq (Fentanyl) – narcotic agonist analgesic for severe pain; much stronger than Dilaudid

Ciprofloxacin (a fluoroquinolone) – inhibit DNA topoisomerase II; tx URI, GI, and UTI; given IV; contraindicated in pregnant women & children b/c damage to cartilage, tendons; antacids ↓ absorption; ↑ warfarinFlagyl (metronidazole) – toxic metabolite; antiprotozoan + antibacterial (trichomonas, amebiasis, gardnerella, bacteriodes, clostridium); given IV; disulfiram-like with EtOH, ↑warfarin)Lamisil (Terbinafine) – nail fungal infections; can cause liver damage (not cream form though)

Cipro & Flagyl are given before surgery for G(-) coverage b/c open bowelCephalosporin is given before surgery for G(+) coverage b/c open skinVancomycin is given for G(+) coverageNeomycin & Erythromycin is given before surgery (13, 6, & 1 hr before surgery) for G(+) coverage

Pentasa – anti-inflam for Ulcerative colitisRemicade – monoclonal antibody for Crohn’s dzSulfasalazine + Prednisone – tx for Crohn’s dz and Ulcerative colitis

Propofol – sedative/hypnotic; IVVersed (midazolam) – benzodiazepine for sedation; IV

Zofran (ondansetron) – 5HT3 antagonist; tx of nausea/vomitingPhenergan (promethazine HCl) for nausea/vomiting

Heparin – prophylaxis of DVTs; always given post surgery; dose = 18 units/kg/hr

Toradol – NSAID for pain; renal toxicity and possible bleeding from platelet dysfxn

PCA doses basal rate / dose / frequency / total allowed in 1 hour (max pushes + basal rate)example 0.4 / 0.3 / 6 / 3.4

Catheters, Drains, and LinesFoley catheter – kept in until patient can ambulate to bathroom; hard to walk around with catheter in

PICC line (peripherally inserted central catheter) – inserted into vein in arm and threaded to SVC; used to take blood samples, deliver drugs, or hyperalimentation; less likely to be infected and can be kept for long periods of time compared to IV lines and central lines

HL IV – Heparin Lock Intravenous – flushes IV line, maintains patency

VP shunt – ventriculoperitoneal shunt; fluid shunted from ventricles in brain to abdominal cavity to reduce intracranial pressure

Labs

Prealbumin – used as marker for protein-calorie malnutrition; earliest indicator of nutritional status; correlates with patient outcomes; highest ratio of essential:nonessential amino acids

Urine analysis – check leukocyte esterase and nitrite levels; also specific gravity

OtherSequential Compression Devices (SCD) - placed on legs to enhance blood circulation to prevent DVTs

Silver nitrate – used to cauterize leaky blood vessel (also in hemophiliacs)

TPN – total parenteral nutrition; must be administered via PICC line or central linePPN – partial parenteral nutrition (without lipids); can be adminstered via IV line

Use quantitative culture to differentiate normal colonization vs infection

Small bowel fxn never stops; stomach and large bowel stops after major abdominal surgery

Etiology of any disease process: think infection, tumor/mass, obstruction, injury/trauma

Patient CareFLUIDSCalculating Fluid Input (shortcuts)

1) Adult input per day = [(weight – 20) x 20] + 1500 (i.e. for 70kg person, 70 – 20 = 50 x 20 = 1000 + 1500 = 2500mL/day

2) Adult input per hour = weight + 40 = 110mL/hourCalculating Urine Output

1) Adult expected urine output = .5 -1 cc/kg/hr (i.e. 70kg adult should produce at least 35cc/hr or 840 cc/day); needs more fluids if producing less than 30cc/hr or 720 cc/day)

2) Infant/child expected urine output = 1-2cc/kg/hr (i.e. 10kg child should produce at least 10cc/hr or 240 cc/day)

3) Bolus for adults (i.e if not peeing enough) = 10cc/kg (i.e. for 70kg adult, give bolus of 700cc or 23oz of fluid b/c 30cc in 1oz); in acute distress, can give up to 20cc/kg bolus

4) Bolus for children in acute distress, can give up to 20cc/kg (i.e. for 10kg child, give bolus of 200cc or 6.6oz)

5) Bolus should be normal saline (NS) or lactated ringer (LR)

Lactate converted to HCO3- in liver (lactate is unstable in solution)Post surgical patients need more fluid than maintenance rate; consider 1.5 maintenance rateBUT, beware of hypernatremia for 70kg patient, 1.5 maintenance fluid = 3.75L D5 ½ NS = 289mEq of Na+; body needs ~3mEq/kg of Na+ per day = 210mEq for 70kg patient

Dextrose included in IV fluids to protect against muscle breakdown caused by gluconeogenesis [hypoglycemia glycogenolysis until glycogen stores depleted in 1-2days gluconeogenesis in liver (substrates used are breakdown of muscle proteins into amino acids); need small amount of dextrose to inhibit gluconeogenesis

During surgery: vasodilatory state; need to give IV fluids; also body compensates by release of ADHPostop day #1: want ins and outs to be evenPostop day #3: fluid in third space goes to intravascular space; check urine output and ↓ if too high

Must replace fluid loss from NGT (H20 + electrolytes) due to gastric outlet obstruction with LR: losing HCO3-, Na+, Cl- so LR therapy is appropriate

Must replace fluid loss (from NGT or severe emesis) with NS + KCl-losing Cl-, H+, Na+, K+ from gastric secretions-state of hypokalemic hypochloremic metabolic alkalosis with paradoxic aciduria-loss of volume + electrolyte imbalances reabsorption of Na+ for volume, and other electrolytes for stability-↓Na+ kidneys attempt to reabsorb Na+ but loses K+ in process via Na+/K+ exchanger in collecting duct-Cl- needed for Na+ reabsorption in ascending loop and DCT, but ↓Cl- compromises this process-as K+ ↓, Na+/K+ exchanger function ↓; Na+ reabsorption proceeds in collecting duct but excretes H+ in process via Na+/H+ exchanger paradoxic aciduria-NS has higher [Cl-] than LR; thus can better help with Na+ reabsorption-KCl provides K+ that ↑ Na+ reabsorption

Too much urine1) iatrogenic – too much fluids given2) diabetes insipidus (central vs nephrogenic)3) high output renal failure4) high blood solutes and glucose (above 200, glucosuria)5) sickle cell anemia

Too little urine1) acute tubular necrosis2) chronic renal failure/renal insufficiency3) obstruction4) SIADH

Discontinue NG tube when output is low (<200mL) and clear (intestinal contents aren’t backing up)Discontinue JP drains when output is <30mL a dayDiscontinue Abx (Cipro/Flagyl) after 8 daysDiscontinue epidurals after 3-5 daysDiscontinue Foley as soon as patient can ambulate to bathroomConvert meds to PO if regular diet is tolerable (oral pain meds last longer than IV meds which are faster acting)Start clears when + flatulus and NGT output low

Concerns for infection post surgery – Five Ws1) Wind: atelectasis or pneumonia2) Water: UTI3) Wound: infection or abscess4) Walking: DVT PE5) Wonderdrug: drug reaction or allergy

HAL = TPN (dextrose + protein + fat+ electrolytes)

Criteria for patient discharge – eating/drinka regular diet, ambulate by themselves, normal bowel movement, adequate pain control, and no fever

Bowel function usually returns 3-5 days after major surgery

Bowel prep: 1) Motility GoLyte (1L), magnesium citrate, Fleet enema (last option)2) Prophylatic Abx Neomycin, erythromycin

Okay to transfer to floor if… NOT insulin drip, fentanyl, propofol, versed, intubated, etc

Common Postoperative Problems1) Pain control

a. Oral pain meds last longer than IV pain meds which are fast acting but short lasting2) Ileus

a. Sx: (-) flatulus, abdominal distention, vomitingb. Tx: NPO + MIVF; NGT for decompression of stomach; check electrolytes & limit narcotic

use (both exacerbate ileus)3) Fever (think of five W’s: Wind, Water, Wound, Walking, Wonderdrug)

a. Workup: CBC, CXR, 2 blood cultures, UA, Urine Cxb. Atelectasis

i. Manifests postop day 1 or 2ii. Tx: ambulate, spirometer

c. Pneumoniai. Sx: cough, sputum production; Vitals: fever, ↑RRii. Findings: CXR infiltrate, Leukocytes on CBC

d. UTIi. Sx: burning sensation upon urinationii. Findings: leukocyte esterase and nitrite changes on UA; growth on Urine Cx,

leukocytes on CBCe. Wound

i. Manifests postop day 4 or 5ii. Sx: erythematous, swelling, warmth, pain around incision siteiii. Tx: drain and wet-to-dry dressings twice daily

f. DVTsi. Sx: chest pain, tachycardia, tachypnea, SOBii. Tx: ambulate, anticoagulant, consult cardio

g. Medicationsh. Line infections

i. Sx: fever, leukocytosis on CBC, bacteremia on blood Cx, (+) culture from line tipii. Tx: removal of line and +/- IV Abx

4) Urinary retentiona. Causes: previous bladder outlet obstruction, atony b/c prolonged Foley, medsb. Dx via bladder scan (U/S)

5) Pre-existing conditionsa. HTN: IV nitratesb. Diabetes: Insulin sliding scale or Insulin drip

Burn patients:1) Immediate concerns

a. Fluid loss – inflammation of skin swelling and leaky cells/blood vesselsb. Protect airway – intubate ASAP; swelling may collapse airway and make intubation

impossible2) Long-term concerns

a. Infection/sepsis – think Pseudomonas, Staph aureus, Strep; tx with topical antibiotic, i.e. silvadene cream

b. Skin grafting – auto vs allograft (cadaveric)3) Rule of 9’s and Palm 1% rule to estimate Total Body Surface Area (TBSA) that has been

burned4) % TBSA burned + age = ~mortality rate (better now with ICU care)

Blood transfusions: dose = 10cc/kg; 250mL in one unit of blood

Related PathologyCellulitis – inflammation of skin (usually around wound) that is tender, erythematous, swollen, and warm

Medical DevicesTele – portable heart monitors that are used to watch patients with heart problems

Medical conditionsCerebral palsy – symptoms: spasticity of movements + mental retardation + speech problems; caused by ischemia to brain

Sepsis – severe illness caused by overwhelming infection of bloodstream by toxin-producing bacteria; in hospitalized patients, think infections of IV lines, wounds, wound drains, and decubitis ulcers (bedsores)

Marginal ulcer – can occur in gastric bypass cases b/c…1) Zollinger-Ellison Syndrome (gastrinoma)2) Dragstedt ulcer (recurrent duodenal ulcer that scars so frequently that it obstructs, causing an

increase in acid in stomach, leading to a gastric ulcer)3) Incomplete vagotomy (psympa stimulates gastric fxn)4) Inadequate gastric resection (leave too many parietal cells)5) Retained antrum of stomach (site of G cells that ↑ H+ secretions)6) ↑sensitivity of certain areas to HCl (i.e. areas such as the jejunal side of anastamosis that

previously were not exposed to acid)

Achalasia – tx w/ Ca++ ch blocker (to relax lower esophageal spinchter?)

Fistulas1) Causes: Foreign body Radiation Inflammation Epithelization Neoplasm Distal obstruction2) Enterocutaneous fistula

a. Risk factors: Crohn’s dz, infection, pancreatic insufficiencyb. Causes: leaks, trauma, diverticulum, post-surgical adhesions, peritoneal abscess

3) Fistula in Ano: connects rectum to skin around anus; anterior = straight, posterior = curved4) Pancreaticoenteric fistula: use ERCP (Xray study of pancreas w/ contrast) to help dx5) Colovesicular fistula: urinate fecal matter; UTIs6) Colovaginal, colocutaneous, coloenteric (diverticula are high risk factors for colon fistulas)7) Medical management: put patients on TPN b/c they are likely malnourished

Crohn’s dz fistulas; Ulcerative colitis colorectal cancer

Gastric Outlet Obstruction1) pyloric stenosis2) pancreatic tumor3) gastric cancer4) scars from recurrent ulcers5) duodenal atresia

Vascular Surgery Lecture

Abdominal Aortic Aneurysm (AAA)Age group with highest risk: 65+AAA size 4.0-5.5cm low risk for rupture, 5.0-5.5cm 2% risk, 6.0+cm 10+%Repair recommended with AAA >5.5cmFuture imaging will identify “hot spots” in an aneurysm, thus can tx small aneurysms with high riskyRuptured AAA

1) Symptoms: hypotension + abdominal/back pain + pulsatile mass in abdomen; operate now2) CT findings: retroperitoneal hematoma (won’t see contrast leaking out of vessel b/c that would

happen with extreme blood loss and is a condition not compatible with life)Symptomatic AAA

1) Abdominal/back pain + tender abdomen; can operate next day2) Make sure that patient is hemodynamically stable in the ICU

SYMPTOMATIC AAA ≠ RUPTURED AAATreatment: Endovascular repair 1) polyester graft 2) nitinol stent w/ thermal memory 3) suture

Claudication: inadequate blood supply during exerciseLimb threatening ischemia: rest pain (inadequate during rest) + no wound healing (> 4 wks)70% ischemia amputationSymptoms: pain in large muscle groups, i.e. calf muscles; tip of toe has lowest perfusion, so often painful (metatarsalgia)Physical exam:

1) Check pulses – femoral, popliteal, dorsalis pedis2) Foot exam – cool?, elevation pallor/dependent rubor (elevate leg turns white; lower red)3) Lesion – punched down? Ascending or local infection?

Ankle-brachial index (ABI): ankle pressure/arm pressureVessel incompressible = >1Normal = ~0.95Claudication = 0.5 – 0.95Rest pain = 0.2 – 0.5Tissure loss = < 0.2

Carotid Artery Disease (CaAD)50% of strokes cause by CaAD; biggest risk factor for stroke is TIATransient Ischemic Attack (TIA) by definition last <24 hours; most last 5 minutesSymptoms of TIA:

1) Unilateral weakness (contralateral to side of CaAD)2) Amaurosis fugax (temporary vision loss; curtains dropping)3) Aphasia

Treatment: 1) Medications: ↓htn, ASA to thin blood, statins to ↓ cholesterol2) Surgical: carotid artery endarterectomy (remove plaque, sew vessel; risk of stroke b/c leave

thrombogenic area) or endovascular repair (see AAA aneurysm tx)Studies show…If stenosis >50% and symptomatic, offer endarterectomy; NNT = 15 to prevent strokeIf stenosis >50% and asymptomatic, offer endarterectomy; NNT = 20 to prevent strokeAssess risk/benefit in each patient!

GI Complications Lecture

ACUTE BLOOD LOSSPhysical Exam:

1) <10% no real Sx, possibly fatigue; orthostatic hypotension: systolic pressure is lower by 20mmHg when standing than sitting (blood pools when sitting, doesn’t compensate fast enough)

2) 10-20% tachycardia3) 20-30% hypotension @ rest + tachycardia4) 30+% organ dysfxn5) Other PE findings: thirst, ¯ skin turgor

Labs of acute blood loss/volume status:1) ¯ Urinary output (should make ~30mL/kg/hr); urine specific gravity2) ¯ Hematocrit (nl at first, then ↓ b/c fluids go intravascularly to compensate; check @ 24 hrs)

a. hematocrit can increase if fluid volume low (6-8 points for 1L fluid deficit)2) ¯ Central venous pressure (nl = 2-3)

a. distal measures of CVP (i.e. femoral vein) not as good b/c valves + higher resistanceb. resistance is proportional to length and inversely proportional to cross sectional area

i. smaller vessels and longer distance to heart3) BUN:Cr ratio >20 (BUN b/c absorption of blood by GI tract)4) Lactic acid b/c of anaerobic ATP formation due to hypotension

-1 unit of blood (250mL of packed RBCs) ≈ 3L of crystalloid for resusitation purposes (b/c crystalloid equilibrates with surrounding tissue, but RBCs stay intravascular)-If patient is tachycardic expect about 10-20% blood loss ~.5 - 1L loss (if total blood = ~5L)give one unit of blood (250mL packed RBCs or 3L of crystalloid expect ↓in tachycardia)-If patient’s tachycardia improves but then returns, continue with alternating cystalloid replacement and blood transfusion; if active bleeding give blood right away, not crystalloid-Resusitation fluid NS; LR good, but may have problems (K+, etc); no D5 b/c sugar ↑osmolality, combined with extra glucose released by stress hormones (i.e. cortisol)

Assessing hypervolemia: look for edema, weight gain, distended veins, mucosal membranes

What would happen if you took all of your blood out and replaced it after a few minutes (before brain injury normally occurs) irreversible shock; wouldn’t die immediately b/c brain intact, but renal failure and shock lung would lead you to death in several days

Patient comes into ER b/c bleeding from rectum… What do you do?

1) ABCs to stablize2) Secondary survey: H&P3) Determine location of bleeding: UGI or LGI

a. UGI: large NGT (to decompress and to clear out blood for upper endoscopy) + upper endoscopy

i. Blood in NGT indicates UGI bleedii. Possible to have UGI bleed but no blood in NGT (blood in duodenum sometimes

can’t make it past pyloric sphincter)b. LGI: check rectum + colonoscopy + radioactive-labeled RBC + angiogram

i. Radioactive-labeled RBC study: important to r/o UGI bleed b/c liver, spleen, and kidneys will light up on nuclear study (these sites take up lots of blood), obscuring any indication of UGI bleed; also difficult to see rectum on nuclear study; high sensitivity, low specificity

ii. Angiogram if nuclear studies (+); high specificity, low sensitivity; rectum difficult to see

iii. Check rectum first b/c nuclear and angiogram studies aren’t good here4) If continued bleeding per rectum, clamp off parts of colon or subtotal/total colectomy

The following types of bleeding require surgical intervention…1) Localized and identifiable source of active bleeding2) requires between 6-10 units of blood (10 units = 2500mL of packed RBCs)3) patient cannot be kept hemodynamically stable4) rebleed while in hospital

Causes of bleeding per rectum:1) AVM (70+yo)2) Diverticulosis (50-70yo)3) Colorectal cancer (50+yo)4) Hemorrhoids

BOWEL OBSTRUCTIONPhysical exam:

1) Hyperactive bowel sounds aka “Borborygmus” (↑in attempts to push blocked substance through); hypoactive later when bowels become distended (overstretches and ↓ overlap of SM fibers)

2) “Tinkle” high-pitched sounds of bowel b/c high air:volume ratio; diagnostic of SB obstructionCauses of SB obstruction:

#1 adhesions (from previous abdominal surgery)partial vs full obstruction; watch to see if partial obstruction resolves itself

#2 hernia (incarcerated loop of bowel); also think of femoral hernia in pregnant patients#3 cancer (polyp grows so large it obstructs)

Causes of LB obstruction:#1 cancer#2 diverticulitis/infection #3 volvulus

Causes of air in the SB (radiographic findings)1) GI procedures (i.e. endoscopy) + post surgery2) Babies normally have lots of air in SB3) Swallowing air trying to burp

Dx of SB obstruction1) KUB/flat abdominal XR2) upright abdominal XR (look for air-fluid levels)3) L lateral decubitus (look for free air)4) CT w/contrast after decompression5) UGI w/SB followthrough after decompression

Tx:1) NGT to decompress air2) Replenish fluids if a lot is lost via NGT, vomiting3) Gastric secretions:

a. Cl- 60-110mL use NS to replenish; could use ½ NSb. K+ 5-10mL use 10KCl to replenishc. H+, Na+ no actiond. Need to replenish Cl- and K+ to help replenish Na+; aciduria resolves with correction of

Cl-, K+, and Na+; refer to Fluids part for better explanatione. “order” mL for mL replacement of fluid loss from NGT with NS 10KCl

Pediatric Surgery

Case 1: 1 month old vomiting for five daysAsk: age of patient, duration of sx, what is being vomited, feverAge limits DDx;Bilious distal to pylorus; non-bilious proximal to pylorusFever infectionHunger evaluates how sick patient isTearing, skin turgor, UOP (diapers), lethargy evaluates volume status

DDx: pyloric stenosis, overfeeding, reflux, CNS lesions, bowel obstruction, intususseption, volvulus

Pyloric StenosisSx: one month old, non-bilious emesis, hunger after vomiting, +/- coffee-brown emesis (gastritis due to stasis some blood in emesis)Signs: Gastric waves, palpable olive (near liver edge)Dx: 4mm thick & 16mm longRad: UGI “string sign” (elongated pylorus) + “shoulder sign” (bulge of pylorus into antrum)Tx:

1) stabilize electrolytes: lose Cl-, H+, Na+, K+ hypokalemic hypochloremic metabolic alkalosis with paradoxical aciduria

a. recusitate with NS fluid bolus (20cc/kg) + D5 ¼ or ½ NS with 10 or 20KCl @ 1.5 maintenance rate; ½ NS b/c want lots of Cl-; 20 KCl b/c want lots of K+

b. monitor UOP (wet diaper)2) operate on baby after electrolytes stable; anesthesia causes respiratory alkalosis which is

deadly if patient has underlying metabolic alkalosis;↓CO2 ↓of CNS respiratory drive respiratory distress death

3) pyloric myotomy open vs lap; destroy muscularis and serosa layer, mucosa intact4) post-op TPN for several weeks to allow pylorus to loosen

Case 2: 10 month old, lethargic, irritable, not eating well, unusual dark stoolsDDx: intussusception, gastroenteritis, Hirshsprung’s dz, volvulus, Meckel’s diverticulum, polyps, food allergy (all of these could cause bleeding and thus included in DDx)

IntussusceptionSx: irritable, crampy abdominal pain,↓oral intake, current jelly stool (blood + sloughed mucosa)Signs: (-) BS in RLQ b/c cecum pushed out of RLQMechanism: Ileum telescoping into cecum; can get so bad that patient presents with rectal prolapseAge: 10 month old, range = 6 mon – 3 yrs (usually b/c of hyperplasia of lymphoid tissue in distal ileum or Meckel’s diverticulum acting as a lead point); in adults with suspected intussusception, think of cancer or Meckel’s diverticulum as a lead point; if recurrent intussusception, think about lead points (i.e. Meckel’s diverticulum) and do surgeryTx:

1) Fluids + Abx2) Reduction via barium/air enema (contraindicated in pts with perforation or peritoneal signs)3) Reduction via surgery (squeeze colon distally so that SB comes out)4) Concurrent appendectomy if surgery is indicated

Case 3: 1 wk old, temperature instability (hypothermia), lethargy, distension, bloody stoolTemperature instability indicates septic statePremature birth predisposed to NECNEC (Necrotizing Enterocolitis)

Mechanism: post-infection, loss of blood diversion of blood to critical parts (i.e. brain) ↓blood flow to intestines ischemia to mucosa (typically in distal ileum b/c watershed area) air tracks between mucosa and serosa (pneumotosis); possible infectious etiologySx: premature baby who has been tolerating feeds but no longer does; often occurs post-infection, thus temperature instability, lethargy; distension, bloody stoolSigns: may be able to palpate same loops of bowel on abdominal exam (dead bowel may be fixed)Rad: “soap bubble” pattern on ab Xray; pneumotosis; portal vein gas; free air if perforated “football sign”Labs: gangrenous bowel low platelet count + metabolic acidosis (both b/c bleeding)Stage 1: Sx (-) rad findings; Stage 2: (-) rad findings; Stage 3: near deathTx:

1) Indications for surgery : perforation, fixed loop, portal venous gas2) severe cases: if patchy, gangrenous bowel all the way from ligament of Treitz to mid-

transverse colon bowel resection with high jejenostomy and Hartman’s pouch; maintain with TPN and Abx until bowel transplant possible; 5yr survival is 60%; some parents; long term TPN difficult b/c frequent line infections and possible need for liver transplant

3) moderate cases: resect dead portions of bowel and anastomose the remaining parts; create a proximal ostomy to allow anastomotic areas to heal; may have short bowel syndrome after

4) less severe cases: NGT to decompress bowel, Abx, NPO with TPN for 2wks to allow bowels to heal (non surgical management); follow CBC (platelets) and Lactic acid (metabolic acidosis)

Endocrine Lecture

Thyoid nodule workup1) Hx: painful, sweating, weight change, bowel fxn, palpitations, appetite, heat/cold intolerance,

previous surgeries, radiation exposure, family hx (MEN)2) Physical: palpation of nodule (mobile, fixed, firm, soft), exopthalmus, LN involvement3) Fine needle aspiration of any neck lump; U/S helpful for guiding needle and to determine if

cystic vs. solid (solid more indicative of cancer)4) Labs: TSH, free T45) Benign: hyperplastic thyroid nodule, colloid cyst; Malignant: papillary, medullary, anaplastic,

lymphoma, metastatic carcinomaa. Dx of most thyroid cancers are based on cytoarchitecture, except for follicular cancer

(must see invasion)b. Prognosis good bad: papillary, follicular, medullary, anaplasticc. Stage important for prognosis and drives treatmentd. Age determines stage in thyroid cancer (i.e. <45yo, no higher than Stage II)e. Histology determines stage: anaplastic (Stage IV))

6) Tx:a. Lobectomy

i. Resecting less thyroid↓ chance of damaging parathyroid glands and vagus nerve (hoarseness if 1 damaged, airway destruction if 2 damaged)

b. Sub-total thyroidectomy (leave rim of thyroid tissue)c. Total thyroidectomyd. Ablation with radioactive iodine (destroy remaining thyroid tissue)

7) Marker for post surgery: thyroglobulin; if recurrent, administer more radioactive iodineAGES mneumonic:Age (↓= good prognosis)Grade (↓ = good)Extracapsular extension (none = good)Size (↓= good)MEN IIa medullary thyroid cancer, pheochromyctoma, hyperparathyroidismMEN IIb medullary thyroid cancer, hyperparathyoidism, mucousal ganglioneuromas in GI tractRET gene involvement in MEN

Hypercalcemia Workup1) Hx: cancer, previous thyroid surgery, other endocrine problems, family hx (MEN); Bones,

stones, groans, moans2) Physical3) Labs: PTH, BMP with Ca, Mg, Phosph, 24hr urine Ca

a. Cl:Phosph > 33 diagnostic for hyperparathyroidismb. Rule out familial hypocalcinuric hypercalcemia with 24hr urine Ca (don’t want to remove

parathyroids in this situation b/c it won’t help them)4) Rad:

a. Sestimibi scan: localizes parathyroid producing tissueb. U/S and CT scan helpful too

5) Tx: Adenoma vs Hyperplasiaa. Adenoma: remove single adenomab. Hyperplasia

i. bx most normal one to keep and remove othersii. freeze some parathyroid tissue and thaw and reinplant if needediii. removal with autotransplantation (placement on SCM or forearm for easy access)

6) Intraoperative PTH assay: used in surgery to assess amount of PTH remaining

7) Complications of removala. hypoparathyroidism hypocalcemia, need Ca+ supplementsb. also transient “bone hunger” hypocalcemiac. icisional hematoma compresses airway respiratory distress; evacuate hematomad. recurrent laryngeal nerve injury hoarseness or respiratory distress

Pheochromocytoma Workup1) Hx: palpitations, ↑BP, headaches, feelings of impending doom family hx2) Labs: 24hr urine metanephrine and normetanephrine3) Rad: MIBG (nuclear medicine test) localizes tissue and sites of metastasis4) Preop management

a. phenoxybenzamine (alpha blocker) for 3wks to prevent alpha response during manipulation of tumor during surgery

b. propanolol (beta blocker) the day before surgeryc. IVF b/c volume depleted and to compensate for hypotension post surgery

5) 10% rule: bilateral, familial, malignant, extra adrenal, multiple tumors6) popular site of extra-adrenal pheo: organ of Zuckerkandl (bifurcation of aorta)

Carcinoid tumor Workup1) Neuroendocrine tumor secreting 5HT2) Sx: flushing, diarrhea, wheezing, valvular heart dz3) Common sites: end of small bowel (appendix), anywhere in GI track, lung, liver mets (b/c of

venous drainage)4) Labs

a. 24hr urine 5-HIAA (breakdown product of 5HT)b. serum Chromagranin A (cells stain positive)c. Octreotide scan (nuclear medicine test) to localize b/c cells have octreotide receptorsd. CT scan to localize

5) Concern about size of tumor: >2cm likely spread to LN, thus requiring larger resection6) Tx:

a. <2cm removal small areab. =>2cm removal of larger area

Adrenal Incidentoma1) Hx: Sx of hypercortisol, hyperaldosteronism, and pheochromocytoma; hx of cancer (could be

mets from another breast or lung cancer)2) Labs

a. CXR: check for lung cancerb. Mammogram: check for breast cancerc. BMP (K+): ↓ in hyperaldosteronism (aldosteromas are usually small b/c symptomatic)d. 24hr urine cortisol: check for Cushing’s syndromee. 24hr urine metanephrine, normetanephrine: check for pheo

3) Tx: a. Resect any functional tumorb. Resect non-functional tumors based on size (=>3cm, remove via laproscopy)

Insulinoma1) Whipple’s triad: hypoglycemia + sx present during fasting + improves with glucose

ZES (Gastrinoma) PUD1) gastrinoma triangle: junction of cystic duct and common bile duct + head/neck of pancreas +

duodenum

Glucagonoma1) diabetes, weight loss, Necrolytic migratory erythema

Scrotal Mass

General questions to ask: Tender? Location relative to testicle? Studies: U/S, doppler, transillumination

Enlarged scrotumDDx:

1) indirect hernia through patent processus vaginalis2) hydrocele

a. (+) transilluminationb. U/S shows hypechoic area surrounding testiclec. painless, non-tenderd. swelling of scrotum during day (not swollen in the morning)

3) Spermatocele/Epididymal cysta. Communication between cyst and epididymis +/- obstruction of vas deferensb. Hypoechoic on U/Sc. (+) transillumination

4) Variocelea. Varicosities of pampiniform plexus of veinsb. Left side often affected b/c drainage into left renal veinc. “worm-like” appearanced. pulling sensation, +/- infertilitye. Tx: laparascopically tie off veins above inguinal ligament; venographic embolization

Red, inflammed scrotumDDx:

1) epididymitisa. enlarged epididymisb. tender, pain relieved by elevation of testiclec. UTI abnormal UAd. Elevated white count?e. Doppler shows ↑ blood flowf. (-) transilluminationg. reactive hydrocele (fluid collection surrounding area)h. Tx: Abx, rest, scrotal elevation, NSAIDs

2) testicular torsiona. kids, young adults usually after strenous activityb. due to poor fixation – Bell Clapper fixationc. extremely painful b/c can turn more than 360 degreesd. Doppler shows ↓blood flowe. “donut sign” on nuclear medicine studyf. Operate within 6 hours; also fix contralateral sideg. Tx: reduce in ER using local anesthetic

3) Fournier’s Necrotizing Fascitisa. Alcholics, diabetics at riskb. Starts as perirectal/genitourinary sourcec. Terrible smell because dead tissue receiving no perfusiond. Can extend upward all the way up to claviclee. Tx: Abx, repeat debriedment, bury testes in thigh or create new scrotum

Scrotum with “blue dot”1) appendix testis, appendix epididymis (Mullerian remnants) torsion/twist

2) Tx: reassurance, NSAIDs

Squamous cell carcinoma1) prevent with circumcision2) odor, late presentation

Phimosis1) can’t retract foreskin2) undiagnosed diabetics may first present with this symptom3) Tx: circumcision4) Paraphimosis: can’t replace retracted foreskin (iatrogenic, i.e. placing foley and not replacing

retracted foreskin)

Peyronnie’s dz: trauma, fibrosis of tunica albuginea; Tx with Ca ch blockers, or cholchicineBalanitis: infection on glans penis; associated with STDs

Testicular cancer1) painless mass2) Left testicle drains to para-aortic LN; Right testicle drains to interaortocaval LN3) mets to lung cannon ball lesions on CXR; mets to retroperitoneal LN, mets to brains4) Hydronephrosis cancer compresses ureters5) U/S shows solid mass6) ↑risk for cryptoorchidism7) Germ cell >> non-germ cell

a. Germ cell: seminoma, teratoma, embryonal, yolk sac, choriocarcinoma, teratocarcinomab. Non-germ cell: leydig, sertoli, gonadalblastoma

8) Adults seminoma; young yolk sac9) Labs: AFP (yolk sac), bHcG (choriocarcinoma), LDH, LFTs, BUN/creatinine10) Studies: U/S, CXR (check for lung met), CT (check for brain met)11) Tx: inguinal orchiectomy (b/c fast doubling time), radiation therapy (seminoma very sensitive)

12)4) http://depts.washington.edu/surgstus/primer.html

REVIEWTypes of shockPulmonary wedge pressure