2023 Updated Surgery SG PDF

- 1. ACUTE ABDOMEN Define what is meant by Acute Abdomen Signs and symptoms of abdominal pain and tenderness, a clinical presentation that often requires emergency surgical therapy. Work up = H&P, labs, and imaging studies 🡪 H&P are the most important parts of making the correct diagnosis! Surgical causes of acute abdomen are in 5 broad categories: o obstructive, inflammatory, perforation, ischemic, and hemorrhage Nonsurgical causes of acute abdomen can be endocrine/metabolic, hematologic, or toxins/drugs Discuss the anatomy of the region Visceral pain can be estimated as epigastric (foregut), periumbilical (midgut), or hypogastrium (hindgut). Peritonitis = peritoneal inflammation, usually recognized on PE by severe tenderness to palpation, with or without rebound tenderness, and guarding. Vomiting THEN pain 🡪 think tx medically Pain THEN vomiting 🡪 think tx surgically. On PE – palpation is the most important component – provides the most amount of info o If considerable pain is induced at the outset of palpation, the patient is likely to voluntarily guard and continue to do so, limiting the information obtained o Involuntary guarding, or abdominal wall muscle spasm, is a sign of peritonitis and must be distinguished from voluntary guarding ▪ To accomplish this, the examiner applies consistent pressure to the abdominal wall away from the point of maximal pain while asking the patient to take a slow, deep breathmall ▪ In the setting of voluntary guarding, the abdominal muscles will relax during the act of inspiration; if guarding is involuntary, they remain spastic and tense. DRE exam needs to be performed on all people w/ acute abdominal pain; Gynecological exam on all women Describe the investigative studies used in the workup of the acute abdomen Routine laboratory studies for acute abdomen include CBC, CMP, urinalysis, urinary hCG for females, LFT’s Stool testing for occult blood can be helpful but is nonspecific. Stool O&P and culture can be helpful if diarrhea is a component of the patient's presentation. Plain radiographs continue to play a role in imaging for patients with acute abdomen o Specifically, x-rays can detect pneumoperitoneum which would allow for urgent move to the OR for laparotomy o Plain films also show abnormal calcifications (10% of gallstones and 90% of renal stones contain enough calcium to be opaque). Many of the most common causes of the acute abdomen are readily identified by CT scanning with contrast if possible Pt w/ peritoneal signs 🡪 get X-ray to look for pneumoperitoneum Pt w/ no peritoneal signs 🡪 get CT scan Intra-abdominal pressure can be measured by a pressure transducer attached to a foley catheter in the bladder o Normal intra-abdominal pressure is 5-7 mmHg o Abnormally elevated pressure is >11 mmHg and is graded I-IV by severity. o Really bad abdominal pressure (Abdominal compartment syndrome) will decrease cardiac output, increase central venous pressure, increase peak inspiratory pressure, decrease GFR and decrease organ perfusion Diagnostic laparoscopy has a diagnostic accuracy of 90-100%, with its only limitation being retroperitoneal causes of abdominal pain Laparotomy is when you slice midline down the entire abdomen and explore o Laparotomy done when Pt is in a life-threatening situation. Diagnostic peritoneal lavage – stick a big needle into abdomen and suck up the fluid then test fluid for a bunch of things o Good for hemorrhagic and infectious causes o Used when Pt too unstable to be transported 137989 to other departments (ex: radiology) for workup Develop a differential diagnosis for a patient with an acute abdomen Describe the algorithm for management of the acute abdomen Describe the indications and preparation for surgical exploration Patients are more likely to be harmed by delaying surgical treatment to perform confirmatory tests, than by misdiagnoses discovered at operation. Discuss the preparation for emergency surgery. IV access should be obtained, and electrolyte abnormalities corrected (hypokalemia is common) Start IV fluid resuscitation Preoperative acidosis may respond to IV hydration and bicarbonate infusion o If due to intestinal infarction/ischemia, then may not respond Almost all patients will require antibiotic infusions o The most common bacteria in acute abdominal emergencies are gram-negative enteric organisms, and anaerobes o Abx should be initiated once a presumptive diagnosis is made. Patients with generalized paralytic ileus (absent or hypoactive bowel sounds) benefit from nasogastric tube to reduce the risk of vomiting/aspiration. Foley catheter drainage to assess urine output, which can adequately measure success of fluid resuscitation Preoperative urine output of 0.5 mL/ kg/hr, systolic blood pressure of at least 100 mm Hg, and a pulse rate of 100 beats/min or less are indicative of an adequate intravascular volume. Patients should be cross-matched and have blood available during operation in case of transfusion needed Describe atypical situations where acute abdomen is seen and its treatment Pregnancy: Since lab results are out of whack (ex: WBC of 16000 normal in pregnancy), pregnant women already experience symptoms like n/v., gravid uterus makes PE hard to perform, and don’t want to order x-ray/CT – acute abdomen dx can be delayed o A delayed diagnosis is more morbid than the surgeries themselves. Abdominal surgery in 2nd < 3rd trimester associated w/ increased preterm labor ▪ Appendicitis is the most common, non-obstetric disease requiring surgery Location of the appendix moves cephalad as the uterus enlarges, so it should be considered even with RUQ pain Graded compression ultrasound is 98% accurate in detecting appendicitis in pregnant patients MRI is also very accurate ▪ 2nd and 3rd in pregnancy are biliary tract dz and bowel obstruction Either the second trimester or postpartum are the safest times to perform surgery in a pregnant pt Bowel obstruction is most likely to occur during one of three periods when the uterus undergoes rapid change: o 16-20 weeks, 32-36 weeks, or early postpartum. o Gallstone pancreatitis tx: IVF and Abx 🡪 no improvement 🡪 surgery (ERCP) Pediatrics: workup and tx usually same as adults 🡪 add Meckel’s diverticulum, intussusception, gastroenteritis, foreign body, food poisoning and C diff to differential o Studies have shown that kids tx’ed medically (abx) instead of surgically for appendicitis had fewer complications o peritonitis in kids = don’t want to move… think pneumococcus/beta hemolytic streptococcus Critically ill: Many patients have altered mental status or are intubated and cannot provide detailed information o Cardiopulmonary bypass, vasoconstrictive drugs and ventilators have been associated w/ acute abdomen. Immunocompromised: Usually present atypically o Patients may not be able to mount a full inflammatory response, and therefore may experience less abdominal pain and a blunted leukocytosis o Abdominal CT becomes more important in these patients due to unreliable symptomology, and a low threshold for laparoscopy or laparotomy should be maintained o Pseudomembranous colitis is a condition increasingly seen in immunocompromised patients, which presents on CT as bowel wall thickening in pancolonic distribution and pericolic stranding. Can have atypical infections. o Steroids block mucus production and decrease inflammatory rxn Morbidly obese: Abdominal sepsis/peritonitis is a more subtle diagnosis in this population and may only be associated with symptoms such as malaise, shoulder pain, hiccups, and shortness of breath o Severe abdominal pain is not common, and appreciation of distention or mass is difficult o Imaging is affected adversely o Low threshold for surgical exploration must be maintained 2. Adrenal Masses Define the work-up of an adrenal mass noted incidentally (incidentaloma) on a CT scan Hormonal evaluation with size criteria o Biochemical thresholds that prompt operative TX are lower in patients with an initial radiographic presentation (incidentalomas) compared with patients with an initial clinical presentation. Tumor size correlates strongly with risk of malignancy and is an additive effect in favor of surgical management. Adrenocortical carcinomas: Tumors >6 cm have 25% risk of malignancy o Should remove all incidentalomas measuring >4 cm via laparoscopy in low-risk surgical patients o Consider removal in 3-4 cm, especially in younger patients. ▪ If observation is chosen, should repeat imaging in 6-12 months, then repeat annually, as 5-25% may ↑ in size. Define the basic physiology of aldosterone secreting tumors (Conn syndrome). Understand the basic diagnostic work-up Primary hyperaldosteronism- Unregulated release of excess aldosterone from one or both adrenal glands o SX = resistant HTN and hypokalemia 🡪Responsiveness to spironolactone is predictive of good response to surgical treatment o Mostly due to adenomas (aldosteronoma) or bilateral adrenal hyperplasia, aka idiopathic hyperaldosteronism. o DX: ▪ finding ratio of plasma aldosterone conc to plasma renin activity , PAC/PRA (normal = 30). ▪ IV isotonic saline loading (2-3 L given for 4-6 hours, then PAC is measured) ▪ oral salt loading (AKA Sodium loading = 200 mEq = 5000 mg Na daily for 3 days → 24-hour urine aldosterone excretion). CT then used to attempt noninvasive localization (thin-cut (3mm) CT is preferred). ▪ If unilateral tumor and a normal contralateral adrenal gland, can do laparoscopic adrenalectomy with a >90% cure rate. ▪ Adrenal vein sampling (AVS)- use if CT not definitive, >60 y/o, or bilateral tumor Nonconclusive AVS is an indication of bilateral adrenal hyperplasia, which is managed medically. Define the basic physiology of pheochromocytoma ,understand the basic diagnostic work-up, define which MEN syndrome is related to pheochromocytoma Pheochromocytoma: adrenal tumor that stains brown when treated with chromaffin (dusky-colored tumor). Secretes catecholamines (Epi and NE) 🡪 HTN (sustained or episodic), HA, palpitations, diaphoresis (sweating), tachycardia. ▪ Rule of 10s: 10% are bilateral, 10% extra-adrenal, 10% malignant, and/or 10% familial. Organ of Zuckerkandl (Para-aortic body): MC extra-adrenal site o A chromaffin body derived from neural crest (sympathetic fibers) located at the bifurcation of the aorta or at the origin of the IMA. ▪ DX: ↑ serum metanephrines (Excludes pheochromocytoma if neg). Confirm with ↑ 24-hour urine metanephrine & vanillylmandelic acid. ▪ TX: surgical excision o MEN 2A and 2B have pheochromocytoma, Thyroid C-cell hyperplasia, medullary thyroid carcinoma metastases, adrenal medullary hyperplasia, ▪ MEN1 = Pancreatic tumor (ZES), PTH tumor, pituitary adenoma (prolactinoma) ▪ MEN2A = MTC, pheochromocytoma, parathyroid tumors, ▪ MEN2B = MTC, pheochromocytoma, mucosal neuromas, skeletal abnormalities, ganglioneuromas of GIT, marfanoid habitus Have a basic understanding of glucocorticoid physiology and the difference between Cushing syndrome and Cushing disease Cushing syndrome- Obesity, easy bruising, muscle weakness, plethora (red face due to thinning of the skin), hirsutism 🡪Due to glucocorticoid excess Cushing disease- Endogenous Cushing syndrome due to an ACTH-hypersecreting pituitary adenoma. +HTN only in Cushing dz. o No ↓ in ACTH with low dexamethasone o Will suppress ACTH with HIGH dexamethasone. Primary adrenal Cushing syndrome and ectopic ACTH syndrome -- neuroendocrine or bronchogenic malignancies arising in the thorax. Be familiar with some of the characteristics of adrenocortical carcinomas (size, symptoms, CT appearance) Adrenocortical carcinomas: secrete cortisol 🡪 ↓ ACTH. Criteria (same as adrenal adenoma); >6 cm (over 100 grams) o Adrenal gland is encapsulated, invasion of the capsule important ▪ Metastasis to lymph nodes, liver, lungs o SX: Cushing syndrome is usually seen, followed by virilization o DX: CT, which typically reveals a heterogeneous mass with irregular or indistinct borders, central necrosis, and invasion. Be aware that needle biopsy of adrenal masses is rarely indicated and should be deferred to a specialist before ordering a biopsy CT-guided fine-needle aspiration is rarely helpful in the evaluation of adrenal masses 🡪 DX cannot reliably be made on cytologic criteria alone. FNA is generally for extra-adrenal malignancy in whom the clinician seeks to establish a diagnosis of metastatic disease. In all cases, pheochromocytoma MUST be excluded before attempting needle biopsy (avoid fatal hypertensive crisis). Discuss open versus laparoscopic adrenalectomy and understand the major complications of adrenal surgery and the anatomy of the region Laparoscopic adrenalectomy- Preferred (90% of cases). ↓ hospitalization, ↓ pain, ↓ blood loss, ↓ complications Open adrenalectomy: use if adrenal malignancy, large size (>8 cm), clinical feminization, hypersecretion of steroid hormones, local or vascular invasion, regional adenopathy, and metastases o Prefer a transabdominal approach through a subcostal incision. Major complications of adrenal surgery: venous hemorrhage, bleeding from solid organ capsular injuries, pancreatic injuries, and fistulas with left-sided procedures; port site hernias and port site metastases, o Violation of the tumor capsule and tumor spillage can lead to tumor recurrence, especially in the case of pheochromocytoma o In retroperitoneal approach, subcostal nerve is sometimes injured 🡪 relaxation or hypoesthesia of the abdominal wall 3. ANORECTAL DISEASE Describe the important anatomical landmarks of the anorectal area Anal canal musculature is conceptualized as two tubular structures overlying each other o The inner component is the continuation of the smooth circular layer of the rectum, forming the thickened and rounded internal sphincter, which ends 1.5 cm below the dentate line o The internal sphincter is innervated by the autonomic nervous system, and is independent of voluntary control. o The outer component is a continuous sheet of striated muscle comprised of levator ani, puborectalis, and external sphincter ▪ The external sphincter is innervated by the inferior rectal branch of the internal pudendal nerve and perineal branch of the fourth sacral nerve, and is under voluntary control. o Loss of pudendal nerve or bilateral S3 sacral roots = fecal incontinence o Perineal body is in front of the anus The dentate line = rectal columnar mucosa meets squamous epithelium o Above is insensate, below is sensate o Significant bleeding almost always from above the dentate line H&P of anal problems: o Bleeding is the most common symptom of dz of anus and large bowel o Anal fissure = extreme pain w/ defecation “passing glass” and blood on toilet paper o Hemorrhoids = blood dripping out, may or may not be associated w/ passing stool o Passage of clots or melena = bleed from colon or upper GI ▪ Always consider the source of bleeding to be from colon cancer if can’t find source in the anus! o Throbbing pain = abscess/poorly draining fistula o Can do anoscopy (look at just anus) or proctosigmoidoscopy (look at anus, rectum, and left colon) Define the causes and treatment of pelvic floor disorders, including Incontinence Defined as uncontrolled passage of feces for 1 month in anyone > 4 y.o. Causes = Functional (impaction, diarrhea, psychological), Sphincter weakness (nerve/muscle injury), or Sensory loss (spinal cord injury, MS, neuropathy). o Diarrhea = MC non-anatomical cause of incontinence Nerve/muscle injury most likely obstetrical caused (ex: having birth stretches the pudendal nerve) Workup= manometry, transrectal US, pudendal n. Tx = conservative (diet mod – increase fiber, sphincter training/biofeedback, anti-diarrheal – loperamide/hyoscyamine) 🡪 fails 🡪 Surgical o MC is the direct overlapping sphincteroplasty o Specialized repairs include sacral nerve stimulation and artificial bowel sphincter using gracilis muscle flap to encircle anus) o Sphincteroplasty = overlap external anal sphincter upon itself to tighten things up o Colostomy (low Hartman) is a definitive cure in people who fail all other methods Rectal prolapse (procidentia) Gradual process most common in women, who strain often, possibly with mental disorders. Complete prolapse = all layers of rectal wall prolapse (concentric rings** vs prolapsed hemorrhoid is radial folds) o Partial = only mucosal layer prolapses. Symptoms = hx of constipation/straining, feeling of incomplete evacuation and pressure, mucus discharge Two surgical approaches: o Perineal = less taxing on patient, higher recurrence rate (older patients with limited life expectancy) o Abdominal (rectopexy to sacral promontory) = better long term results (younger, healthier patients) Rectocele posterior vaginal wall defect causes anterior rectum to prolapse into vaginal canal. Pt needs to press on vagina in order to poop. Develop a differential diagnosis for a patient with perianal pain. (Be sure to include benign, malignant and inflammatory causes.) Discuss the characteristic history findings for each of the above, including - character and duration of complaint, presence or absence of associated bleeding, relationship of complaint to defecation. Describe physical exam findings for each diagnosis. Indicate in which part of exam (external, digital, anoscopic, or proctoscopic) these findings are identified. Discuss treatment plans for each diagnosis listed in objective “C”, including non-operative, interventions and role, and timing of surgical interventions. Benign Anal Disorders Hemorrhoids – engorged veins in the anus. Tx for both: conservative measure (high fibers/increasing fluids, prepH, sitz bath) first o External hemorrhoids (pic A) ▪ Distal to dentate line – covered in anoderm (skin) ▪ Very painful and itchy – especially if thrombosed but don’t bleed. Dx = external. ▪ Tx: if conservative measures fail 🡪 hemorrhoidectomy… especially if thrombosed ▪ Most resolve in 2 weeks… o Internal hemorrhoids (pics B-E) ▪ Proximal to dentate line – covered in mucosa (pink) ▪ Not painful but bleed (“blood dripping/squirting into toilet”) ▪ Can prolapse beyond the dentate line. ▪ Associated w/ hx of pregnancy and straining 🡨 know chart o Dx made by inspection, DRE, and anoscopy o Note: may want to consider doing a colonoscopy to r/o colon cancer as source of the bleed! o Tx = rubber band ligation using anoscope Anal Fissures o Usually occur in the anterior and posterior midline distal to dentate line b/c weakest amount of blood flow there and weakest muscular support. If fissure in lateral midline look for other causes (crohn’s, STI, SCC) o Due to high anal sphincter tone or trauma/constipation. MC cause of severe localized anorectal pain. o Symptoms = severe excruciating pain w/ defecation “passing glass” that classically goes to an achy pain and streaks of bright red blood on toilet paper. Chronic anal fissure associated w/ skin tag o Dx = external or rectal exam = severe pain and sphincter spasm. o Tx = Nitroglycerin cream, CCB’s (diltiazem, nifedipine), botulinum toxin injections (to decrease anal sphincter tone) 🡪 if conservative tx fails 🡪 surgery 🡪 lateral internal sphincterotomy (evaluate for incontinence before performing this surgery) Perianal Abscess o Anorectal abscesses usually originate in the intersphincteric space then spread to the other sites in the picture o Symptoms = pain out of proportion to physical examination and throbbing pain o Tx = incision and drainage (when incising perianal abscess don’t cut the anal sphincters! Pt can have hard time controlling passage of gas after drainage) + Abx if Pt is immunocompromised… module said most people get Abx though… Pt may develop anal fistula as complication ▪ MC complication is a levator muscle spasm (tx = sitz bath) o Tx = ALL ABSCESSES MUST BE DRAINED SURGICALLY. o Perirectal (larger than perianal) abscess originates from anal gland ▪ Tx = OR, post-op IV Abx Anal Fistula o MC is intersphincteric; may present as abscess or draining sinus. o Dx: digital exam may reveal a palpable nodule in anal canal indicating the opening to the fistula o Tx = fistulotomy to open tract and drain infection for intersphincteric fistula or draining seton placement for complex fistulas Pilonidal Disease o Infected hair follicle in the sacrococcygeal area of young very hairy men o Pathogenesis due to hair in the gluteal cleft. o Tx: incision and drainage and keep the hair free of hair (shave) Rectovaginal Fistula o usually due to unsuccessful repair of 3rd/4th perineal tear after delivery. Pt has poop coming out the vagina. Inflammatory Anal Disorders STI’s of the Anus o RF’s = multiple sexual partners and anal receptive intercourse o Entamoeba causes hourglass shaped ulcers. Giardia causes a more diffuse ulcer. o AIDS: 1/3 of Pt’s w/ HIV develop anorectal dz Hidradenitis Suppurativa o Due to blockage of apocrine glands by keratotic debris 🡪 bacteria grow 🡪 infection spreads to subcutaneous tissue 🡪 infected tissue becomes fibrotic and thickened o They can create fistulas and abscesses 🡪 must diff from Crohn’s fistula (Hidradenitis fistulas are distal to dentate line and Crohn’s fistulas are proximal) o Tx: I&D, topical clindamycin or oral abx (tetracyclines/augmentin) Crohn’s Disease of Anus o 40% of people w/ Crohn’s develop perianal dz o Can present as pain due to fissures (lateral midline), fistulas, or abscesses o Examination must include endoscopy o Tx: fissures (conservative, avoid sphincterotomy), fistulas (fistulotomy/seton), abscesses (drained). o Consider Abx and immunomodulators (infliximab*, azathiopurine, and mercaptopurine) Malignant Anal Disorders Condyloma Acuminatum o due to HPV, MC STI, more common in immunosuppressed. o If Pt w/ this – screen them for immunocompromised state (HIV*, on immunosuppressant b/c transplant, cancer) o Also do an anal pap smear and biopsy to assess for AIN (anal intraepithelial neoplasm) o Tx: drugs (podophyllin, trichloroacetic acid, 5-FU) or excision – high rate of recurrence!! Squamous Cell Carcinoma o usually presents in the anal canal w/ bleeding and pruritus o Test for HIV and CD4 count if Pt presents w/ this o Tx: Nigro protocol 🡪 chemo (5-FU w/ mitomycin C) and radiation ▪ HIV Pt 🡪 Nigro protocol and maximize HAART. High success rates even if Pt has HIV! Adenocarcinoma o Paget’s dz is an intraepithelial adenocarcinoma o Presents w/ itchy, eczematous rash on 70 y.o. Associated w/ underlying invasive carcinoma. Other anal cancers = basal cell CA, melanoma 4. APPENDICITIS [+] Describe the embryology and anatomy of the appendix Appendix first appears at eighth week of gestation as an outpouching of the cecum. It is supplied by the appendiceal artery, a branch of the ileocolic artery Cell types in the adult appendix include goblet cells (in mucosa), lymphoid tissue (in submucosa), columnar epithelium and neuroendocrine cells. Average length 9 cm, base of appendix is located at the inferior aspect of the cecum right where the taenia (smooth strip) ends. Normal appendix wall thickness is 1mm Tip may lie in various locations – MC position of the tip is retrocecal and intraperitoneal o Also found in pelvis and retroperitoneal For example, patients with a retroperitoneal appendix may present with back or flank pain, just as patients with the appendiceal tip in the midline pelvis may present with suprapubic pain/dysuria. Describe the pathophysiology of acute appendicitis Obstruction of the lumen is believed to be the major cause of acute appendicitis 🡪 usually by fecalith/fecal stasis (MC), lymphoid hyperplasia, tumor, barium, ascaris lumbricoides (large round worm nematode?) o Blockage 🡪 Bacterial overgrowth/gas production and mucus secretion 🡪 luminal distention 🡪 block venous drainage 🡪 mucosal ischemia/gangrene 🡪 full thickness ischemia 🡪 perforation 🡪 intraperitoneal abscesses (or phlegmon) o Phlegmon is a spreading of diffuse inflammatory process with formation of purulent exudate Bacteroides and E. coli are the most common bugs in the appendix. o Enterococcus and pseudomonas also present. (same bugs as in colon) We do not want perforation of the appendix b/c that releases all the bacteria into the peritoneum Abx should cover for gram neg rods and anaerobes Discuss its differential diagnosis Should suspect appendicitis in any Pt that comes in w/ acute abdominal pain!! Children – mesenteric lymphadenitis (follows a URI), gastroenteritis, Meckel’s diverticulum, intussusception, inflammatory bowel dz, testicular torsion Women – think GYN probs – ovarian cysts, mittelschmerz, endometriosis, PID, ovarian torsion, ectopic pregnancy** Elderly – diverticulitis, cancer Neutropenic Pt – typhlitis (aka neutropenic enterocolitis) … Also check for kidney stones and pyelonephritis Discuss its diagnosis Periumbilical pain FIRST, THEN activation of visceral afferents 🡪 nausea/vomiting o Pain migrates to RLQ 🡪 migratory pain is the most reliable symptom of acute appendicitis. o Usually single bout of vomiting, not repeated vomiting and anorexia o Migration of pain is due to the tip of the appendix getting inflamed and causing local peritonitis Initial diagnostic workup is the PE o Low grade fever is common o Diminished bowel sounds, guarding, pain at McBurney's point (one third of distance from ASIS to umbilicus) o Pt usually very ill looking and lying still b/c peritonitis makes moving hurt too much and hips may be flexed to take tension off peritoneum o Diffuse peritonitis or abdominal wall rigidity due to involuntary spasm of the overlying abdominal wall musculature is strongly suggestive of perforation. o -If rovsing, obturator (pain w/ internal rotation of hip) or psoas sign present then just means there is peritonitis – not specific for appendicitis but can help dx ▪ Dunphy’s sign: cough = pain ▪ Obturator sign looks for pelvic appendix. Psoas sign looks for retrocecal appendix. WBC 12-15,000 in regular appendicitis. WBC 18-20,000 in perforated appendicitis w/ > 75% neutrophils. Urinalysis can exclude pyelonephritis or nephrolithiasis. Pregnancy testing is MANDATORY in women of childbearing age presenting w/ signs of appendicitis CT w/ PO and IV contrast is most commonly used in the evaluation of adults with suspected appendicitis o 90%/90% sens/spec HOWEVER if their symptoms are strongly + for appendicitis then you don’t get a CT and take them to surgery Characteristic CT scan findings: o Target/halo sign – thickened, inflamed appendiceal wall > 7mm w/ periappendiceal fluid o Fat stranding Use US to evaluate appendix in pediatric (4 y.o. and younger) or pregnant Pt to avoid harmful effects of radiation. Sens/spec varies b/c it is operator dependent o Ring of fire is characteristic on US for appendicitis o Appendiceal wall > 7mm in diameter MRI reserved for pregnant Pt and is highly sensitive and specific Describe the diagnostic algorithm for appendicitis Describe its treatment Fluid resuscitation [to ensure safe induction of general anesthesia] and broad spectrum Abx IMMEDIATELY to cover gram neg rods and anaerobes followed by prompt surgical removal of the appendix. Open appendectomy: 3 different types of incisions (oblique = McAurther-McBurney, transverse = Rockey-Davis, and midline) Laparoscopic appendectomy = higher operating room cost, but less infection risk and improved quality of life scores. Laparoscopy also allows for diagnostic laparoscopy and observation of remainder of abdomen and pelvis. nonperforated appendix = single dose of pre-operative antibiotics and Pt can usually leave the next day Pregnant women 🡪 the gravid uterus displaces the appendix cephalad o Appendicitis is the MC non-OBGYN emergency o US = initial study of choice, but MRI is the better test. Discuss perforated appendix and an appendiceal abscess Perforated appendix occurs w/in 48 hours from sx onset (rigid, temp, tachy) May require more aggressive fluid resuscitation and broad spectrum Abx for 4-7 days post-op Perforation - laparoscopic is favored because of decreased risk of further infection o Pus is drained and cultured. Patients with abscesses larger than 4-6cm benefit from abscess drainage – an abscess is a major source of morbidity related to perforation Discuss chronic or recurring appendicitis Inflammatory changes in appendicitis can wax/wane b/c sometimes appendicitis can resolve on its own and come back. If have symptoms and see appendiceal changes on CT 🡪 elective appendectomy If have symptoms of but don’t see changes on CT 🡪 usually don’t offer appendectomy unless radiographic evidence 🡪 consult lots of specialties to do a work up 🡪 if do diagnostic laparoscopy and see inflamed appendix then do the appendectomy Discuss appendicitis occurring in the elderly. Should think appendicitis in any elderly person presenting w/ abdominal pain and no prior appendectomy Elderly more likely to present with atypical findings (no fever, normal WBC, no RLQ pain), and have a higher rate of perforation at time of presentation SIncreased incidence of post-op morbidity Laparoscopic benefit is more pronounced in the elderly (Lap appy in 80 yr old). Emergent laparoscopy in elderly Pt w/ diffuse peritonitis Describe the diagnosis and treatment of appendiceal cancer. 50% of appendiceal cancers present as appendicitis usually diagnosed after pathologic evaluation of appendix removed for suspected appendicitis o Rupture of mucinous tumor can be associated with pseudomyxoma peritonei. Appendiceal carcinoids are neuroendocrine tumors and the most common tumor of the appendix, usually of enterochromaffin cell type For carcinoid lesions smaller than 1 cm that are located in the tip of the appendix, appendectomy is curative almost 100% of the time. o Size of the carcinoid tumor is the best predictor of malignant and metastatic behavior over histology and invasion ▪ 1- 2cm is scary – may need right hemicolectomy 5. ANESTHESIA [+] Describe preoperative evaluation for the patient undergoing anesthesia All Pt receiving anesthesia must undergo preanesthetic evaluation Healthy person for elective surgery - no laboratory tests indicated. Testing is recommended based on pertinent medical history concerning cardiovascular, pulmonary, and other systemic dz. Laboratory tests within 6 months generally do not need to be repeated unless significant change in medical status. Sexual hx and date of last menstrual period needed in women of childbearing age. Describe airway assessment The airway exam is completed by systematic inspection of the mouth opening, thyromental distance (want to be at least 7 cm), neck mobility, and size of tongue in relation to the oral cavity. The pt is observed in frontal and profile views (note-- many airway abnormalities such as a receding mandible will not be evident from a frontal view). Mouth opening should be 6-8 cm (three to four finger-breadths) o If mouth only opens 4 cm, that would be an anesthesia obstacle. Mallampati class I-IV classifies size of tongue in relation to oral cavity o Class 1--visualization of the soft palate, fauces, uvula, and anterior and posterior pillars (easy to vent mask and intubate) o Class 2--visualization of the soft palate, fauces, and uvula o Class 3--visualization of the soft palate and the base of the uvula o Class 4--soft palate not visible at all (difficult to vent mask and intubate)u by B Describe assessment of physical status using the ASA classification – multiple questions from this! scale categorizes preoperative morbidity independent of procedure. o I = no disturbance. o II = systemic dz with no functional limitation (well-controlled HTN, uncomplicated DM). o III = systemic dz with functional impairment (diabetic w/ neuropathy, uncontrolled HTN, previous MI) o IV = systemic dz with constant threat to life (congestive heart failure, unstable angina) o V = moribund patient who is not expected to survive (ruptured AAA, brain hemorrhage) o VI = declared brain-dead whose organs are being harvested o E= emergency (use numerical class and add E) Discuss the risks of death or major complications with anesthesia Cardiac arrest < 1/10,000 Discuss the factors behind selection of anesthetic techniques Monitored Anesthesia Care - supplements local anesthesia provided by surgeons. Differs for each patient. Regional (epidural and spinal)- avoids general anesthesia and seems safer, but there are hazards including post dural puncture headache, local anesthetic toxicity, and peripheral nerve injury. o Inadequate regional anesthesia may require intraoperative switch to general. General - Amnesia, analgesia, inhibition of noxious reflexes, and skeletal muscle relaxation o Risks include respiratory depression, cardiovascular depression, loss of airway protection o Best anesthesia for upper thoracic and pelvic surgeries (propofol helps w/ n/v) Regardless of suitability of technique, anesthesia choice must be personalized to the patient and their wishes must be taken into account. Define the benefits and risks among the regional anesthetic techniques including Local, Spinal, Epidural and peripheral blocks. Local: the 2 classes of local anesthetic drugs are amino esters (e.g chloroprocaine) and amino amides (e.g. lidocaine) o MOA is dose-dependent blockade of sodium currents in nerve fibers. o Benefits--> local anesthetics have played a critical role in intraoperative anesthesia ▪ They exist primarily in the ionized form which does not penetrate nerves ▪ The have great potency and a long duration of action o Risks--> local anesthetic toxicity involves the CNS and cardiovascular system including numbness, tingling, metallic taste, visual disturbances, seizures, cardiovascular collapse o Adding epinephrine, which slows absorption, decreases the likelihood of a toxic response Spinal: = subarachnoid block and has many applications for urologic, lower abdominal, perineal, and lower extremity surgery o Spinal anesthesia is induced by a single injection of local anesthetic into the subarachnoid space o If well-performed, it provides excellent sensory and motor blockade below the level of the block o Most cases administered as a single bolus injection, so only suitable for shorter procedures. o Benefits of spinal anesthesia--> provides the advantage of avoiding manipulation of the airway and potential complication of tracheal intubation, as well as potential side effects of general anesthesia such as nausea, vomiting, and prolonged drowsiness ▪ It also provides benefits for several types of surgeries including endoscopic urologic procedures, particularly transurethral resection of the prostate, in which an awake pt provides a valuable monitor for assessment of hyponatremia or bladder perforation. o Risks of spinal anesthesia--> hypotension (sometimes refractory), bradycardia, post-dural puncture headache (typically if female, younger, large bore needle), transient radicular neuropathy, backache, urinary retention, epidural hematoma, infection, epidural hematoma, cardiovascular compromise. Epidural anesthesia: has application in a wide variety of abdominal, thoracic, and lower extremity procedures o Generally, a catheter is inserted after the epidural space has been located with a needle – allows for continuous anesthesia o The presence of the catheter provides several benefits including: ▪ (1) local anesthetic can be added in a controlled fashion so that the time of onset of the block can be well-controlled ▪ (2) the catheter can be used for repeated dosing so that anesthesia can be provided for the duration of lengthy procedures ▪ (3) local anesthetics or opiates can be administered for several days to provide post- operative analgesia. o Benefits of epidural anesthesia 🡪 advantages for thoracic surgery, peripheral vascular surgery, and GI surgery ▪ Also use has shown to decrease blood loss and DVT during joint arthroplasty ▪ Post-op epidural analgesia for thoracic surgery provides superior pain control, less sedation, and better pulmonary function than parenteral opiates. o Risks of epidural anesthesia: similar to spinal anesthesia risks and also epidural hematomas (associated with anticoagulation--> perioperative use of LMW heparin) ▪ The timing of catheter placement and removal in the setting of LMWH use is critical for avoiding this catastrophic event ▪ In general, a catheter should NOT be placed earlier than 24 hours after treatment w/LMWH, and LMWH should NOT be started before 6 hours after epidural placement. Define “Conscious Sedation”, its benefits and risks. When non-anesthesia personnel administer sedation for surgical procedures, the process is generally termed conscious sedation or moderate sedation. Patient can respond to verbal or tactile stimulation, and the airway is patent and requires no intervention Hypoventilation and hypoxemia are rare complications Drugs usually include opioids(fentanyl/morphine), and anxiolytics(midazolam). Each hospital has their own policy on conscious/moderate sedation and what kind of drugs can be used o Propofol is sometimes used, but is riskier as it can produce rapid descent into deep sedation/apnea. Recognize malignant hyperthermia and its treatment Triggered by volatile inhalational anesthetics ( halothane, enflurane, isoflurane) + succinylcholine Hypermetabolism of skeletal muscles due to mutated ryanodine receptor in sarcoplasmic reticulum 🡪 increased heat production, oxygen consumption, CO2 production 🡪 mixed metabolic and respiratory acidosis S/Sx: rising temp, tachycardia, generalized muscular rigidity, skin mottling, ETCO2 > 100mmHg Treatment: external cooling, dantrolene (inhibits calcium ion release from SR) Describe what is involved in postanesthesia care(PACU) in terms of complications and treatment including the following: respiratory complications Most frequent major complication is respiratory/airway obstruction (usually the tongue) o Airway obstruction caused by obstruction of the oropharynx by tongue and soft tissue o Also laryngospasm, fluids/debris in airway, glottic edema, vocal cord paralysis o Provide oxygen and relieve obstruction w/ head tilt, jaw thrust, or suctioning. o In case of laryngospasm, administer CPAP plus succinylcholine. o Hypoxemia is common for many reasons, treatment is oxygen, assurance of adequate ventilation, and treatment of underlying causes (ex. incentive spirometry for post-op atelectasis) o Hypoventilation/hypercapnia 🡪 can be from airway obstruction, prolonged somnolence Nausea and vomiting o Propofol can decrease post-op N/V o IV ondansetron plus metoclopramide can produce bradyarrhythmia o FDA black box warning on droperidol mandates ECG monitoring because of an alleged increase in cardiac arrythmias caused by QT prolongation ▪ Studies do not support that warning, however it has caused a significant reduction in droperidol use. o Anticholinergics, serotonin receptor antagonist (ondansetron), antidopaminergics (metoclopramide), and antihistamines can be used for post-op N/V hypothermia o Forced air and circulating water warmers are the most effective techniques for providing intraoperative warming. o General anesthesia has profound effect on thermoregulatory mechanisms and active intraoperative warming is required to maintain normothermia under most conditions o Prophylactic pre-operative warming may be appropriate in some situations. circulatory complications o Hypotension in the PACU is usually caused by hypovolemia, left ventricle dysfunction, or arrythmias. o Tx = support with fluids, administration of inotropic agents if indicated, use of the Trendelenburg position, and delivery of oxygen to prevent ischemia o Hypertension is common and can be due to pain, anxiety, and inadequately managed essential hypertension ▪ Hypoxemia and hypercapnia need to be ruled out 6. BOWEL OBSTRUCTION [+] Discuss the causes involved in the three categories of SBO Extraluminal (adhesions(60% in US), carcinomas(20%), hernias(10%), abscesses) o Adhesions: These are fibrous bands that form connections between tissues and organs often as a result of injury during surgery ▪ These tissues are not normally connected. ▪ As scar tissue forms, fibrin is deposited onto injured tissues and acts as a glue ▪ This prevents free movement of tissue Intrinsic to bowel wall (primary tumors) Intraluminal (gallstones, enteroliths, foreign bodies, bezoars) Other causes of SBO: o Crohn’s disease (5%) - Inflammation, edema, strictures (creeping fat sign) o Intraabdominal abscess - Commonly seen w/ ruptured appendix, diverticulum, dehiscence of an intestinal anastomosis o Misc. causes: intussusception (in adult is usually secondary to a pathologic lead point—polyp/tumor), MC cause of SBO = adhesions. MC cause of LBO = colon cancer. Describe the pathophysiology behind SBO Early in course, gastric motility increases to attempt to propel luminal contents forward o The increase may be diffuse, leading to diarrhea. o Later on, as the intestine becomes fatigued, it slows and dilates. (why you have increased bowel sounds then decreased/absent) As the bowel dilates, water and electrolytes accumulate intraluminally and in the bowel wall (3rd spacing), leading to dehydration and hypovolemia (oliguria, tachy, HoTN, azotemia) o Other complications include increased abdominal pressure, decreased venous return, and elevation of the diaphragm compromising ventilation. Progressive bowel wall edema and increased intraluminal pressure can lead to decreased blood flow and ischemia o Ischemia leads to necrosis 🡪 perforation 🡪 peritonitis. Discuss the clinical manifestations and diagnosis of SBO including: History colicky abdominal pain, n/v, abdominal distention, and a failure to pass flatus/feces(obstipation). Typical crampy abdominal pain occurs in paroxysms at 4-5 minute intervals, and less frequent with more distal obstructions Early diarrhea is secondary to increased peristalsis Vomitus may become feculent late in process. Physical examination General: Fever and tachycardia are a sign of strangulation/bacterial overgrowth. Tachycardia, oliguria, dry mucous membranes, and hypotension are signs of dehydration. Abdominal exam: Inspect for distension, hernias, and surgical scars. On auscultation high pitched or hypoactive bowel sounds can indicate an SBO. Percussion with resulting tympani and tenderness are more indications an SBO may be present. o Palpation: Peritonitis (rebound, guarding) type pain indicates strangulation/perforation/infection Digital Rectal Exam (DRE): Empty rectum, rectal mass, gross/occult blood Radiologic and laboratory studies The diagnosis of SBO is often immediately evident after H&P Labs: Leukocytosis with leftward shift and metabolic acidosis can be seen o It is also important to check complete blood count, amylase, lipase, electrolyte, magnesium and calcium levels. Radiology: Characteristic findings on supine X-ray: dilated loops of small intestine w/o evidence of colonic distention. Upright X-ray: multiple air fluid levels that layer in a stepwise pattern CT scan: Used if plain x-ray is not diagnostic o Do with oral and IV contrast o Can be used to locate the obstruction, detect the cause and find a possible strangulation o May be helpful in Pt w/ malignancy or hx of abd surgery Describe the causes of and the terms used to describe ileus and postoperative bowel obstruction Ileus = decrease in peristalsis that may not be due to a blockage o May be due to muscle or nerve problems following surgery or medications (narcotics) Postop ileus pathophys = Surgical stress & manipulation of bowel 🡪 sustained inhibitory sympathetic activity & release of hormones & NTs as well as activation of local molecular inflammatory response 🡪 suppression of neuromuscular apparatus Post-op bowel obstruction = mechanical obstruction of bowels after surgery due to intestinal adhesions Discuss the nuances of simple versus strangulated obstruction Simple obstruction = mechanical blockage w/o vascular compromise Strangulation = mechanical blockage with vascular compromise. Only takes 6 hours of ischemia for bowel to become gangrenous and perforate o Classic signs: tachycardia, fever, leukocytosis, *constant* non-cramping abd pain o CT only detects late stages of irreversible ischemia (pneumatosis intestinalis, portal venous gas) o There is no test or clinical parameter that is known to reliably diagnose or exclude strangulation. Describe diagnostic modalities for diagnosing SBO. X-ray: z o Need to obtain: ▪ 1. Upright chest film to look for free air/perforation ▪ 2. Upright abdominal film to look for air fluid levels ▪ 3. A supine abdominal film looking for distended loops of bowel o It is diagnosed when multiple air-fluid levels are seen along with distended loops of small bowel o Absence of air in the colon or rectum suggests a complete obstruction while presence of air can indicate a partially obstructed colon o Characteristic findings are dilated loops of small intestine without evidence of colonic distension. CT: This is becoming the imaging modality of choice for differentiating partial versus complete obstruction as well as early identification of strangulated bowel o CT can be used to identify causes such as adhesions, hernias, neoplasms, or crohn’s disease. Discuss treatment of SBO overall tx: o partial obstruction = IV fluids, Abx, and nasogastric tube decompression o Complete obstruction or strangulation = surgery Patients require aggressive IV replacement with isotonic saline solution such as lactated ringers this is to correct the dehydration that happens w/ SBO o Monitor urine output with Foley, and take serial electrolyte labs as well as hematocrit and WBC. Broad spectrum Abx are given prophylactically to prevent bacterial overgrowth o Additionally, the prophylaxis is indicated for possible resection or inadvertent enterotomy. Nasogastric suction with a Levin tube empties the stomach, reducing the hazard of pulmonary aspiration of vomitus and minimizing further abdominal distention from preoperatively swallowed air o Do this if Pt has hiccups or vomiting Patients with partial obstruction may be treated conservatively with resuscitation and tube decompression alone o 60-85% of patients with partial obstruction saw resolution of symptoms and discharge with this treatment, without the need for surgical intervention. Operative management o in most cases, complete obstructions or strangulation require surgical management o The nature of the obstruction dictates operative approach ▪ Secondary to adhesions = lysis of adhesions ▪ Secondary to hernia = manual correction and hernia repair ▪ Secondary to Crohn's = conservative management may be appropriate unless chronic fibrotic stricture is present ▪ Secondary to abscess = percutaneous drainage of abscess may be sufficient ▪ Secondary to malignancy = level of disease should be assessed, and in some cases a bypass may be more appropriate than a long and complicated resection. **Only pts w/ adhesions (prior surgeries) are able to have non-operative mgmt. o If no previous surgery, it can’t be adhesions, so you must go in and find what is causing the obstruction!!** Describe the unique aspects of etiology, diagnosis, and treatment of SBO in the geriatric population. MC cause of SBO in old age = adhesions Obturator hernias and luminal obstructions are more common in elderly Gallstones and phytobezoars (large concentrations of undigested fruit/veggies) also more common Harder to distinguish functional (ileus) vs mechanical obstruction and simple vs strangulated obstruction Tx = conservatively w/ fluids and NGT decompression o Prolonged immobilization can lead to venous stasis, pulmonary comps (aspiration, pneumonia), and deconditioning Discuss management of specific SBO issues including: Recurrent intestinal obstruction Usually due to many abdominal procedures and adhesive disease. To date, the most effective means of limiting adhesions is a good surgical technique, which includes: o gentle handling of bowel to reduce serosal trauma o avoidance of unnecessary dissection o exclusion of foreign material from the peritoneal cavity o use of absorbable sutures o avoidance of excessive use of gauze sponges o removal of starch from gloves o adequate irrigation and removal of infectious/ischemic debris o preservation and use of omentum around the site of surgery. Acute postoperative obstruction More than 90% of early postoperative obstructions are partial and will resolve spontaneously Conservative management in the form of bowel rest, resuscitation, electrolyte replacement, and parental nutrition if necessary is routinely successful Ileus Ileus = flatus, diarrhea (how diff from SBO), intestinal distention and slowing or absence of passage of luminal contents without a demonstrable Tx is resuscitation, nasogastric decompression, and correction of electrolytes o All possibly offending medications should be stopped, and sympathetic dominance should be countered with neostigmine or an epidural anesthetic. o AE of neostigmine = bradycardia 🡪 reverse w/ atropine. Discuss the diagnosis and treatment of LBO. Dx = contrast enema very good mechanical obstruction. Causes = metabolic/electrolytes (especially hypokalemia), drugs, inflammation, ischemia, or sepsis. The treatment of ileus is entirely supportive, with nasogastric decompression and IV fluids o Treat underlying conditions, like sepsis. Discuss the classification, diagnosis and treatment of Large Bowel Obstruction (LBO) and pseudo obstruction Dynamic (mechanical obstruction) or adynamic (pseudo-obstruction). o Adynamic means that there is no mechanical obstruction, and that there is absence of intestinal motility. Colorectal cancer is the single most common cause of LBO in the US o Other causes = volvulus and diverticulitis History and PE provide important clues Plain films can diagnose volvulus CT scan can reveal inflammatory process Contrast enema can diagnose volvulus or mass. If obstruction is caused by cancer, treatment is generally resection of bowel segment o The exception is rectal cancer, in which loop colostomy is performed, and the cancer is treated with chemoradiation, with the plan to resect the primary lesion at another time. Describe Ogilvie’s Syndrome Ogilvie's syndrome is pseudo-obstruction of the colon o Distention and reduced motility without mechanical obstruction due to autonomic instability causing decreased contractility This occurs in severely ill Pt’s – suspect this if very ill Pt suddenly gets signs of bowel obstruction o Usually see this in orthopedic Pt’s b/c of the large amounts of opioids Primary pseudo-obstruction is rare and due to either "hollow visceral myopathy syndrome" or a diffuse motility disorder due to problem w/ autonomic innervation of the intestinal wall Secondary pseudo-obstruction is more common o Due to neuroleptic meds, opiates, metabolic illness, diabetes, and other systemic dz o Sympathetic overactivity plays a role. The most useful investigation is a water-soluble contrast enema which can differentiate between mechanical obstruction and pseudo-obstruction o Colonoscopy is an alternate with the advantage that it can be used for treatment, however it can distend the colon further which is problematic d for differentiating b/w mechanical and pseudo-obstruction Tx depends on cause, general principle: Relieve obstruction before vascular compromise o NG tube placement, correct electrolytes, hydrate 7. BURN MANAGEMENT Describe the more common types of burns: Describe the most common types of burns and their mechanisms of injury Scald – superficial; MC burn in children and elderly. Kitchen > bathroom. Extent = temperature X exposure. Electrical- deeper than they appear, concern for associated trauma; worst type of burn o Divided by low (1000 volts). o Acute renal failure from myoglobinuria o Eye involvement – premature cataracts – even years later! Define emergency care of first and uncomplicated second degree burns First degree- painful and erythematous and blanch. Ex. Sunburn. TX: aloe and NSAIDs, no scar Second degree - Superficial - dermal damage - erythematous and painful, +blanch, blister. Ex. Hot water burn Second degree- Deep- into reticular dermis- pale and mottled, no blanch, painful. Tx- 2-5 wks loss hair and sweat glands and scars Third degree- full thickness through dermis into SQ fat, hard leathery, painless and black, white, red. TX- excision and skin graft Fourth degree- involve organs, muscle, bone, brain Define the rule of Nines for burn assessment (mine was 18%) Palmar surface of patient’s hand (incl. extended fingers) = 1% of total body surface area o jk Define criteria for transfer to a major burn center Use Lactate Ringers, if less than 2 yo use LR + 5% dextrose. Initial rate per hour = [((4 X Weight X TBSA )/2)/8] Recognize the Parkland and similar formulas and recognize the magnitude of fluid that may be required to manage a major burn 2 large bore IVs. Parkland formula: weight X % TBSA X 4 = amount of fluid required in initial 24 hours o ½ should be given in first 8 hours, including pre-hospital fluid o ½ in next 16 hours. Adjust for urine output. Recognize inhalational injury - the importance of careful assessment of patients burned in closed spaces (apartments, garages, etc.) CO poisoning – most common, most important Inhalation injury if all 3 are present: ▪ 1) History of closed space injury ▪ 2) Carbonaceous sputum (not spit) ▪ 3) CO hemoglobin >10% o Diagnosed via bronchoscopy o Treatment: First 100% O2 (nasal cannula or mask) 🡪 Usually requires intubation. Recognize the necessity of tetanus prophylaxis in burns All patients with burns > 10% TBSA should receive 0.5 mL of tetanus toxoid. Recognize the basics of treatment of chemical burns in the emergency setting 8. CHOLECYSTITIS AND BILIARY SYSTEM DISEASE [+] Describe the anatomical arrangement of the hepatobiliary system Biliary anatomy is extremely variable Distally, the common bile duct inserts into the duodenum via the ampulla of Vater, passing through the sphincter of Oddi o CBD may or may not join with the pancreatic duct prior to opening into the duodenum. The distal CBD is encompassed by the head of the pancreas, and in some cases the pancreatic duct joins the CBD within the pancreas. The insertion of the cystic duct marks the differentiation between the common bile duct distally, and the common hepatic duct proximally o The cystic duct drains the gall bladder, which is roughly the size of a lightbulb and holds 30-60 mL of bile as an extrahepatic reservoir o The cystic duct drains at an acute angle into the common bile duct and is 1 to 5 cm in length. The attachment of the gallbladder to the liver, known as the gallbladder fossa, separates the liver into right and left lobes o Glisson's capsule does not form over the gallbladder fossa. The liver is perfused mostly via portal venous flow. The biliary tree is perfused by arteries. Inferior bile duct (below duodenal bulb) = posterosuperior pancreaticoduodenal and gastroduodenal aa. Superior bile duct (duodenal bulb to cystic duct) = right hepatic artery and cystic arteries o Although variable, the cystic artery usually arises from the R hepatic artery, which usually passes posterior to the duct and runs along the cystic duct, common hepatic duct, and the edge of the liver o That area is known as the triangle of Calot and is susceptible to injury during cholecystectomy. Discuss the general considerations of biliary tree disease, including: Biliary colic (pain), fever, jaundice Despite the term "colic," biliary pain is usually constant and may be associated with meals It is usually located in RUQ or epigastrium and is seen 1 hour or more after a meal due CCK secretion caused gallbladder contraction Tenderness of RUQ can indicate inflammation or infection. Voluntary cessation of respiration when the examiner exerts constant pressure under the right costal margin is known as Murphy's sign and suggests inflammation of the visceral and parietal peritoneal surfaces. Fever associated with RUQ is hallmark of infectious process of the biliary tree Serum bilirubin levels over 2.5 mg/dL are necessary to detect scleral icterus routinely, and levels over 5 mg/dL will manifest as cutaneous jaundice o Acute cholecystitis does NOT actually cause jaundice because there is no blockage of bile exiting the liver RUQ pain + fever + jaundice = Charcot's triad = Ascending cholangitis Explain treatment options for the hepatobiliary disorders and cite pertinent historical and physical examination facts related to gallbladder disease, including: cholelithiasis vast majority are asymptomatic o To become symptomatic, the gallstone must obstruct a visceral structure such as the cystic duct o Biliary colic occurs after meals. asymptomatic patients should not undergo prophylactic cholecystectomy for gallstones unless they have hemolytic anemia such as sickle cell anemia o Pts with hemolytic anemia have an extremely high rate of pigment stone formation, and cholecystitis can precipitate a crisis o Prophylactic cholecystectomy may also be indicated in immunosuppressed patients in whom an infection can be life threatening. Medical treatment of gallstones is generally unsuccessful and is used rarely. The widespread use, safety, and efficacy of laparoscopic cholecystectomy have relegated nonoperative therapy to patients for whom general anesthesia presents a prohibitively high risk. acute cholecystitis Cholecystitis = inflammation/infection Tenderness, Murphy's sign, and possibly fever will be present o Jaundice would indicate ascending cholangitis Mild elevations of alkphos, bilirubin, transaminases, and leukocytes support acute cholangitis. pericholecystic fluid, gallbladder wall thickening on ultrasound o CT is less sensitive than ultrasound. Tx = NPO, IV fluids plus antibiotics o Gram-negative aerobe>anaerobe>gram-positive aerobe 🡪 broad spectrum abx are warranted o Parenteral opioids for pain. chronic cholecystitis Recurrent attacks of biliary colic Pain occurring after ingestion of a fatty meal 🡪 CCK is secreted in response to fat in the duodenal lumen. repeated self-limited episodes of inflammation results in fibrosis. To perform a cholecystectomy, one needs presence of symptoms and documentation of stones(usually via transabdominal ultrasound). In more than 90% of patients, cholecystectomy is curative emphysematous cholecystitis this is infection of the gallbladder wall by gas-forming organisms such as clostridium or e.coli. Presents with radiographic evidence of air inside gallbladder wall or lumen. Tx = cholecystectomy gallstone ileus A large gallstone fistulizes into the duodenum, eventually blocking the small intestine and causing an ileus. Suspect in a patient who presents with small bowel obstruction without history of abdominal surgeries(adhesions) or hernias Abdominal pain can be constant or intermittent because stone can shift, blocking the intestine intermittently Most common site of stone impaction is the distal ileum Air fluid levels will be present on CT. Tx = exploration and enterotomyza o Any suggestion of nonviability of the affected segment, should mandate resection o The surgeon should inspect the rest of the small intestine o If patient is healthy, the surgeon can also address the biliary enteric fistula during the surgery ascending cholangitis All three of Charcot's triad are seen in less than 50% of patients with acute cholangitis, with P jaundice being the most variable o Mental status changes and hypotension complete Reynold's pentad and indicate septic shock. Leukocytosis with an abnormal liver panel is common o AST/ALT/Alkphos significantly elevated. Tx = adequate hydration and IV antibiotics should be started immediately o Many patients will respond to medical therapy. Patients who progress to shock require emergent decompression of the biliary tree, preferably ERCP. choledocholithiasis Common bile duct stones; Most remain asymptomatic o When not asymptomatic, symptoms can range from biliary colic, to the full Charcot's triad, indicating acute blockage. Ultrasound may show choledocholithiasis or only biliary duct dilatation(>8mm is highly suggestive of stone). ERCP is highly sensitive and specific for choledocholithiasis and can be therapeutic by clearing the duct of all stones in 75% of patients during the first procedure, and 90% with repeat procedure. MRCP is non-invasive and also sensitive/specific for choledocholithiasis but does not provide a therapeutic solution. Tx = 1/3 of patients who undergo ERCP eventually require cholecystectomy, suggesting that cholecystectomy should be offered to patients who present with choledocholithiasis o Laparoscopic common bile duct exploration can be done during a cholecystectomy to ensure all calculous biliary tree disease is managed. biliary dyskinesia patients present with classic symptoms of calculous biliary disease, but have no ultrasonographic evidence of stones or sludge These patients should undergo a CCK-stimulated HIDA scan, in which the ejection fraction of the gallbladder is observed An ejection fraction of less than one third, after 20 minutes following CCK administration, is considered diagnostic of dyskinesia, and should be managed with cholecystectomy 85% of patients are responsive to cholecystectomy In non-responders, ERCP or sphincterotomy may prove useful sphincter of Oddi dysfunction Biliary tract pain, with normal liver function tests, and recurrent pancreatitis, can be caused by sphincter dysfunction Abnormalities of the sphincter can be due to trauma, pancreatitis, gallstone passage, or congenital abnormality. Pts will have a dilated bile duct (>12 mm) 🡪 the bile duct will dilate further in response to CCK, and the pancreatic duct will dilate in response to secretin. Therapy includes endoscopic sphincterotomy or transduodenal sphincteroplasty. 60-80% of patients are responsive to division of the sphincter. Differentiate among the various diagnostic modalities used to diagnose hepatobiliary disease, describe the indications for selective cholangiography, discuss the complications in dealing with these disorders, including: bile duct injury can be prevented by maintaining inferolateral traction on the gallbladder infundibulum, retracting Hartmann's pouch and opening the triangle of Calot, displacing the cystic duct from the porta usually presents in the post operative period, with leak of bile into the peritoneal cavity, with subsequent bile peritonitis Fever, abd pain, jaundice, or bile leakage from an incision Injury causing stricture and not bile leakage will cause jaundice. reconstructive procedures are generally successful, showing 90% of patients free of jaundice and cholangitis when referred to experienced centers. lost stones Inadvertent opening/perforation of the gallbladder with spillage of stones occurs in 20-40% of cholecystectomies Risk factors include cholecystitis, pigmented stones, >15 stones, and performance of operation by a resident Complications can include chronic abscess, fistula, and bowel obstruction In the case of spilled stones, treatment should include extensive irrigation, significant attempt to retrieve the stones, a course of antibiotics, and documentation of perforation in the operative notes. Post-cholecystectomy pain pain may recur, mandating thorough evaluation of the biliary tree Secondary choledocholithiasis or biliary leak may cause. retained biliary stones secondary common duct stones can be identified for up to 2 years following cholecystectomy Endoscopic removal of stones via a generous sphincterotomy is almost universally successful. biliary leak leak from cystic duct or unrecognized duct of Luschka Symptoms similar to bile duct injury with leakage More likely if cholecystitis was present CT should be performed and will show ascites or RUQ collection of bile Endoscopic cholangiography should be performed, with percutaneous drainage. Re-exploration is only indicated in patients with evidence of septic shock or those in whom the leakage is not percutaneously accessible. Describe the recognition and treatment of post cholecystectomy syndromes, discuss non-calculous biliary disease, its diagnosis and management Primary sclerosing cholangitis o fibrosis & inflame. of intra/extrahepatic bile ducts 🡪 cirrhosis. See in young men a/w ulcerative colitis. Tx: endoscopic balloon/stent. Biliary cysts o congenital bile duct abnormality. Clin: abd. pain + vague RUQ pain +/- jaundice. Dx: US/PTC/ERCP. Tx: surgery Gallbladder cancer o see w/chronic inflammation. Clin: jaundice + pain + bloating. Dx: US, LFT/CA-19-9/CEA. Tx: surgery+chemo+rads. Bile duct cancer 🡪 see above 9. COLON CANCER [+] Discuss colorectal cancer genetics and specific genetic mutations Tumor suppressor genes (gatekeeper genes) provide cell cycle inhibition and regulatory control at cell division checkpoints APC is a tumor suppressor gene and acts by regulating the intracytoplasmic pool of B-catenin, which regulates Wnt signaling proteins o Found on chrome 5q21 Loss of APC = increased B-catenin = activation of Wnt signaling = activation of Wnt target oncogenes = increase production of cyclin D1 and Myc. MYH gene and associated MAP (MYH Associated Polyposis) has same phenotype as FAP but doesn’t have a missing APC o MYH causes excision repair of DNA damaged by oxidative stress 🡪 can promote APC defects The most frequently mutated tumor suppressor gene in human neoplasia is p53, located on chromosome 17p 🡪 activates the BAX gene 🡪 induces apoptosis and causes G1 cell cycle arrest o Mutations in p53 are present in 75% of colorectal cancers and occur late in the adenoma-carcinoma sequence. Ras = proto-oncogene o Mutated in 50% of sporadic colon cancers. Describe what is meant by “mismatch repair genes” Mismatch repair (MMR) or "caretaker genes" police the genome and correct DNA replication errors MMR gene mutations result in errors in S phase when DNA is newly synthesized 🡪 LOF of MMR = tumor growth increased o Also causes microsatellite instability ▪ Microsatellites = sections of repeating DNA (marker for genomic integrity) Mutations in MMR genes (including hMLH1, hMSH2, hMSH3, hPMS1, hPMS2, hMSH6) result in Hereditary Non-Polyposis Colorectal Cancer or Lynch syndrome. Discuss the adenoma-carcinoma sequence Benign polyps 🡪 invasive cancer Larger the polyp, higher risk for cancer Villous polyps have highest risk for cancer development Benign polyps have been observed to develop into cancers (so remove them Removal of polyps decreases the incidence of cancer Polyps usually develop in 50’s & cancer is most common in 60’s suggesting a 10 year progression of adenomatous polyp 🡪 cancer Process of CRC carcinogenesis: o invasion of muscularis mucosae 🡪 pericolic tissue 🡪 lymph nodes 🡪 finally distant metastasis. Describe colorectal polyps, their diagnosis and treatment. Pedunculated (stalk – can be removed during colonoscopy) or sessile (flat – needs partial colectomy to be removed) o Pedunculated is the MC polyp type. Tubular (branched tubular glands) vs villous (long finger-like projections of epithelium) vs tubulovillous. Smaller than 1cm = 5% incidence of carcinoma Larger than 2cm = 50% incidence of cancer MC polyp overall w/o neoplastic potential = hyperplastic polyp (histo = serrated) MC benign polyp w/ neoplastic potential = tubular adenoma (pedunculated) Worst type of polyp = sessile, > 2cm, and villous > tubulovillous > tubular Invasive carcinoma = malignant cells have penetrated the muscularis mucosa Tx for polyp = removal, usually by colonoscopy Tx for invasive carcinoma based on Haggitt Criteria o Haggitt Criteria: tells how deep the carcinoma has invaded ▪ Level 0: carcinoma does not invade the muscularis mucosae (carcinoma-in-situ or intramucosal carcinoma) ▪ Level 1: carcinoma invades through the muscularis mucosae into the submucosae, but is limited to the head of the polyp ▪ Level 2: Carcinoma invades the level of the neck of the polyp (jxn btw the head & the stalk) ▪ Level 3: Carcinoma invades any part of the stalk ▪ Level 4: Carcinoma invades into the submucosa of the bowel wall below the stalk of the polyp but above the muscularis propria o All sessile polyps w/ invasive carcinoma are level 4! o Sessile polyps are tx’ed aggressively o Level 1-3 have low risk of met/recurrence. tx = excise completely. Repeat colonoscopy in 3-6 months o If cancer cells found in lymphovascular space = tx aggressively b/c will met 10% of time Discuss issues involved in hereditary cancer syndromes – ALL ARE AD, TSG’S AND CARRY RISK FOR CANCER! Peutz-Jeghers is an AD syndrome characterized by the combination of hamartomas of the intestinal tract, and hyperpigmentation of the buccal mucosa, lips and digits o Tumor suppressor STK11 (serine threonine kinase) is implicated in this disease o Increased risk for lots of cancer (GI, pancreas, cervix, breast) o Polyps may cause bleeding or intestinal obstruction due to intussusception, and if surgery is required, an attempt should be made to remove as many polyps as possible o Colonoscopy every 2 years Juvenile polyps = benign, should be removed b/c cause bleeding and intussusception Multiple Polyposis Coli aka Familial Juvenile Polyposis= AD syndrome with high penetrance that carries high risk for both GI and extraintestinal cancer o Juvenile/hamartomatous polyps o Tumor suppressor gene SMAD4 believed to cause up to 50% of cases. FAP = 100s-1000s of colorectal, duodenal, and gastric polyps o Osteomas, dermoid cysts, retinal hypertrophy o Colorectal cancer risk approaches 100% lifetime o Recommend: Flexible proctosigmoidoscopy at age 10-12, repeat every 1-2 years until 35, every 3 years after 35, Upper GI endoscopy every 1-3 years after polyps identified (b/c at risk for duodenal, pancreatic, and ampullary CA’s) o Autosomal Dominant mutation of APC tumor suppressor gene o Some polyps may regress if tx’ed w/ sulindac and celecoxib o Tx = prophylactic colectomy and remove the rectum w/ ileoanal anastomosis HNPCC = Small number of colorectal polyps o 70% lifetime Colorectal cancer risk o 30-60% risk for endometrial cancer o Recommend: Colonoscopy at age 20-25, repeat every 1-3 years. Transvaginal ultrasound or endometrial aspirate at age 20-25, repeat every year o Autosomal Dominant mutation of MLH1, MSH2, other Mismatch Repair Genes o Lynch I syndrome: cancer of proximal colon occurring at relatively young age o Lynch II syndrome: families at risk for both colorectal & extracolonic cancers, including endometrial, ovarian, gastric, small intestinal, pancreatic, ureteral, & renal pelvic o Management is controversial ▪ Close surveillance, colonoscopies starting at 20 q 2 yrs until 40, then annually ▪ When colon cancer is detected, abd colectomy-ileorectal anastomosis is tx of choice ▪ Women should have prophylactic total abd hysterectomy w/ b/l salpingo-oophorectomy ▪ Prophylactic colectomy is not universally accepted Describe and discuss sporadic colon cancer MC colon cancer overall = sporadic Right sided cancer symptoms = melena, iron deficiency anemia (IDA) o Note: bleeding more common in R sided cancers even though can also be seen in left sided. o Incidence of right sided colon cancer has increased in past 4 decades Left sided cancer symptoms = hematochezia, IDA, decreased stool caliber, change in bowel habits o Sigmoid cancer can mimic diverticulitis and create a fistula Ulcerative colitis > crohn’s dz has a greater risk for colon cancer Describe treatment options for colon cancer Gold standard for dx of colon cancer = colonoscopy o Can see polyps > 5mm o Get colonoscopy every 10 years starting at age 45. Sigmoidoscopy only detects 50% of cancers. Cancers that present as obstruction are best diagnosed through resection of the tumor (since you can’t do colonoscopy) o Can use water soluble enema to establish location more accurately o Usually do Hartmann’s procedure, establish a colostomy, & then re-establish intestinal continuity later with an anastomosis o New endoscopic approach: place a stent to remove the obstruction, allow passage of stool, and permit bowel prep so you can then do an elective operation w/ primary anastomosis Pts w/ tumors that are non-obstructing should have a full workup to identify possible metastatic disease: o CXR, LFTs, CEA (levels + CT/MRI/ or x-ray… want a LFT b/c colon cancer likes to met to liver o Even if there is hepatic metastasis, you can resect colon for palliation (unless hepatic mets are extensive); if hepatic mets are small, can possibly resect them for cure o Add chemo and radiation to take care of the metastases Tx of left sided cancer = Hartmann procedure (resection w/ colostomy 🡪 anastomosis later) Tx of right sided cancer = Right hemi-colectomy with drain, to decrease need for temporary colostomy (hemi-colectomy for lesions involving cecum, ascending colon, hepatic flexure). Attach ilium to colon distal to obstruction Total colectomy in person w/ widespread cancer of HNPCC o It is well tolerated in Pt < 60 and causes increased bowel movements The goal of surgery is to remove that tumor and ensure adequate margins free of cancer and to restore continuity to the GI tract by anastomosis. Follow up after surgery: o CEA every 3 months for the first 2 years ▪ CEA is the most cost-effective approach to detecting potentially resectable metastases from colon cancer, 64% of all recurrences were detected first by CEA. ▪ CT scan is appropriate if CEA levels rise. o Colonoscopy 1 year after surgery and then between every 1-5 years based on results. Patients with a strong family history of colorectal cancer include those with multiple first-degree relatives with colorectal cancer, or a single first degree relative (father) with cancer diagnosed before 60 years of age risk for developing cancer is 3-4 times the average Dukes Classification o Stage A: confined to bowel wall/mucosa o Stage B: penetrates bowel wall ▪ B1: partial penetration of muscularis propria ▪ B2: fully penetrates muscularis propria o Stage C: lymph node mets ▪ C1: tumors that invade lymph nodes but did not penetrate entire bowel wall ▪ C2: tumors that invaded lymph nodes & did penetrate entire wall o Stage D: distant metastases Describe the epidemiology of CRC regarding prevalence in different parts of the colon, age at diagnosis, gender, frequency of hereditary versus sporadic. CRC incidence is directly associated with age, 71% of new cases occur in adults 65 years old and older 3rd MC site of new cancer cases in men and women – a little more common in women than men. 2nd leading cause of cancer death in USA **90% cure rate if discovered early. Most arise from benign polyps. General U.S. population at 6% risk for colon cancer; familial setting raises risk 1.5 to 4-fold. Sporadic colorectal cancer - generally affects an elderly (60-80 y/o), and usually an isolated colon or rectal lesion, usually in the L colon. o *Sporadic is MC type of CRC. Lynch syndrome is more common than FAP. Discuss the importance of screening colonoscopy as a way to decrease colorectal cancer mortality USPSTF recommends screening for colorectal cancer in adults beginning at age 45/ years and continuing until age 75 years. 1. Annual fecal occult blood testing 2. flexible sigmoidoscopy every 5 years 3. Full colonoscopy for + FOBT or adenomatous polyps on flexible sigmoidoscopy. Should do colonoscopy every 10 years. o Can alternatively do Double contrast barium enema (DCBE) every 5 years What is the appropriate preoperative workup (staging) for a patient diagnosed with colorectal cancer? Pathologic staging: of the resected specimen (pTNM) provides a basis for prognosis and consideration of the need for further (adjuvant) TX. Patients with non-obstructing tumors should undergo a thorough evaluation for metastatic disease 🡪 CXR, CEA level. CT or MRI to inspect the intra-abdominal cavity for metastases. In patients with tumors causing complete obstruction, the diagnosis is best established by resection of the tumor without the benefit of preoperative colonoscopy and often without benefit of good staging. *Radiation therapy offers significant benefit, and preoperative radiation is superior to postoperative radiation. Preoperative radiation (combined with chemotherapy) is used for locally advanced distal rectal cancers (within 10 to 15 cm of the anal verge, stage II or higher). Discuss the surgical management of colon cancer with respect to the location in the colon. What is the appropriate bowel resection? What about lymphadenectomy? What are the main prognostic features? Lymphovascular pedicle: Right colon = R colic artery. Transverse colon = middle colic artery. L colon and sigmoid = inferior mesenteric artery Total mesorectal excision. Distal margin of 2 cm is acceptable; if unobtainable, patient may require an abdomino-perineal resection. o **A minimum of 12 lymph nodes are required for an adequate oncologic resection. ______________________________________________________________________________________________________________________________________________________________________________________ _ 10. DISEASE OF THE BREAST [+] ______________________________________________________________________________________________________________________________________________________________________________________ _ Review the anatomy of the breast Suspensory ligaments of Cooper = fibrous bands that provide structural support and insert perpendicularly into the dermis. Lies between subdermal layer of adipose tissue and superficial pectoral fascia Suspensory ligaments of cooper provide structural support o Level I nodes are located lateral to lateral boarder of pector minor o level II nodes are located posterior to the pectoralis minor muscle o level III nodes include the subclavicular nodes medial to the pectoralis minor muscle. o Lymph nodes between pect major and pect minor are called rotter’s nodes o Sentinel node is the first node to drain the breast. The costoclavicular ligament defines the apex of axilla. Long thoracic nerve course the chest wall on medial side of axilla. Thoracodorsal nerve arises from posterior cord of brachial plexus and enters the axillary space under the axillary vein. Medical pectoral nerve lies within a neurovascular bundle that wraps around the lateral border of the pectoralis minor Discuss breast development and physiology, both normal and abnormal NORMAL: o Puberty (thelarche and pubarche) begins between ages 9-12, and menarche begins at 12-13 ▪ Before puberty there is primarily dense fibrous tissue and scattered ducts ▪ Thelarche entails increased deposition of fat, formation of new ducts by branching and elongation, and 1st appearance of lobules ▪ This process of growth and cell division is under the control of estrogen, progesterone, adrenal hormones, PULSATILE pituitary hormones, and the trophic effects of insulin and thyroid hormone The dominant process of growth is hypertrophy o Fibrocystic change -- An exaggerated response of breast stroma and epithelium to a variety of circulating and locally produced hormones and growth factors o Galactocele = milk-filled cyst due to cessation of lactation. ABNORMAL: o prepubertal gynecomastia is breast enlargement and projection of the breast bud in girls < 12 y.o o Boys may get a unilateral enlargement of breast tissue during puberty (if doesn’t regress than need to excise) o Supernumerary (polythelia) nipples are common ▪ They are usually rudimentary and occur along the milk line from the axilla to the pubis in males and females o Accessory breast tissue usually found superior to breast. Amastia/athelia = no breast. Describe the diagnosis of breast disease Triple Test = Clinical Exam (find a mass), Imaging (diagnostic mammography), and Sampling (CNB) Patient history – age, repro history, age at menarche, age at menopause, history of pregnancy, OB surgical history Investigate specific breast complaints such as mass, discharge, and skin changes Physical exam – inspect for masses, asymmetries, and skin changes o Look for nipple inversion, excoriation of epidermis, or retraction o Also assess the skin to look for edema (peau d’orange) o Palpate the breast for underling masses with the patient supine and arms stretched above the head ▪ benign are well circumscribed and movable, Carcinoma are less circumscribed and drag surrounding tissue Dimpling of the skin or nipple retraction is a sensitive and specific sign of underlying cancer Describe breast imaging Fine needle aspiration (FNA) 🡪 22 gauge needle inserted into mass 🡪 cells fixed on slide immediately o Used to diff solid from cystic masses o Now replaced by US o If there is blood or the mass does not completely resolve from FNA 🡪 proceed to CNB Core needle biopsy (CNB) 🡪 preferred for dx of palpable lesions o Skin incised and 11-gauge needle inserted to get sample o Only do an excisional biopsy if you can’t do a CNB Mammography 🡪 primary imaging for asymptomatic women o 2 views – mediolateral oblique (can see tail of spence) and craniocaudal o Can’t be used in women < 40 b/c the breast tissue is too dense. Ultrasonography is useful in determining whether a lesion detected by mammography is solid or cystic in Pt w/ dense breasts and young women o Not a good screening tool due to operator dependence. MRI is useful locating primary tumor when there is axially LN mets w/o evidence of breast tumor on mammography o It is an appropriate screening tool for patients with known BRCA mutations o 90% sensitivity for invasive cancer. 60% sensitivity for DCIS. USPSTF recommended biennial screening (every 2 years) mammography for women aged 50 to 74 year USPSTF recommended against screening for those aged 40-49 or >75 due to high false positive rate American Cancer Society recommends annual screening mammography for women older than 40 + annual clinical breast exam + monthly self breast exam Identify and manage high-risk breast patients Risk Factors: o Age (> 65), family history, hormonal factors, proliferative breast disease, irradiation of breast/chest wall at an early age, personal hx of malignancy (cancer in one breast increases risk of cancer in the other), and lifestyle factors (alcohol, smoking, obesity), menarche before 12 y.o., first child after 30 y.o., nulliparity, menopause after 55 y.o. o Age is probably the most important risk factor High risk patients are defined as having a 5-year risk of 1.7% or higher using the NCI risk calculator (family or personal hx is not included in the number!) o Options for these women include: ▪ Close surveillance with self-breast examination beginning at 18-20 years of age OR semiannual clinical breast exam at 25 OR annual mammography beginning at 25 OR annual screening MRI. ▪ Genetic counseling/BRCA testing ▪ Chemoprevention for breast cancer: Tamoxifen is an estrogen antagonist with proven benefit for the treatment of ER-positive BC Raloxifene is a selective ER modulator (SERM) ▪ Prophylactic mastectomy reduces the chance of developing breast cancer in high-risk women by 90%. Describe benign breast tumors and related diseases with attention to diagnosis and treatment Cyst – fluid filled epithelial lined cavity o Dx = palpable mass (may be tender*), FNA/US o May be straw colored, opaque or dark green o Tx = aspiration Fibroadenoma – MC benign breast tumor of young women (< 30 y.o.) o Rubbery feel on palpation and nontender o Benign tumor of stroma and epithelium o Dx = palpable, moveable mass/US/FNA o Tx = usually nothing but surgery for cosmetic purposes or if mass if uncomfortable. Hamartoma – proliferation of epithelium and stroma – can’t diff from fibroadenoma Adenoma – benign tumor of ductules 🡪 form sheet of tiny glands o Dx = biopsy required Abscess – usually due to S. aureus o Tx = abx, drainage of breast and I&D if a true abscess o If chronic then duct ectasia/periductal mastitis o Associated w/ smoking and diabetes o Mixed infection of anaerobe and aerobic skin flora o Can cause nipple retraction (so think it is cancer), but usually will clear up w/ Abx ▪ If doesn’t, then look for inflammatory CA Papilloma – polyp of epithelial lined ducts o Not associated w/ increased risk of cancer o MC cause of nipple discharge (usually bloody) o Tx = excision through circumareolar incision (must r/o invasive papillary CA). Papillomatosis – epithelial hy

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