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Surgery Rotation Notes

Abbreviations
D/C = discharge, discontinue
PCA = patient controlled analgesia
CS = chem stick (Accu check for glucose)
HAL = hyperalimentation
TPN = total parenteral nutrition

Medications
Tylox (oxycodone HCL – Acetaminophen) for mod-severe pain; capsule
Dilaudid (hydromorphone) for mod-severe pain; IV or suppository
Roxicet (oxycodone HCL – Acetaminophen) for med-severe pain; tab
Actiq (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; ↑ warfarin
Flagyl (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 bowel
Cephalosporin is given before surgery for G(+) coverage b/c open skin
Vancomycin is given for G(+) coverage
Neomycin & Erythromycin is given before surgery (13, 6, & 1 hr before surgery) for G(+) coverage

Pentasa – anti-inflam for Ulcerative colitis


Remicade – monoclonal antibody for Crohn’s dz
Sulfasalazine + Prednisone – tx for Crohn’s dz and Ulcerative colitis

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

Zofran (ondansetron) – 5HT3 antagonist; tx of nausea/vomiting


Phenergan (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 Lines


Foley 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

Other
Sequential 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 line
PPN – 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 Care
FLUIDS
Calculating 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/hour
Calculating 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 rate
BUT, 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 ADH
Postop day #1: want ins and outs to be even
Postop 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 urine


1) iatrogenic – too much fluids given
2) diabetes insipidus (central vs nephrogenic)
3) high output renal failure
4) high blood solutes and glucose (above 200, glucosuria)
5) sickle cell anemia

Too little urine


1) acute tubular necrosis
2) chronic renal failure/renal insufficiency
3) obstruction
4) 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 day
Discontinue Abx (Cipro/Flagyl) after 8 days
Discontinue epidurals after 3-5 days
Discontinue Foley as soon as patient can ambulate to bathroom
Convert 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 Ws


1) Wind: atelectasis or pneumonia
2) Water: UTI
3) Wound: infection or abscess
4) Walking: DVT  PE
5) 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 Problems


1) Pain control
a. Oral pain meds last longer than IV pain meds which are fast acting but short lasting
2) Ileus
a. Sx: (-) flatulus, abdominal distention, vomiting
b. 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 Cx
b. Atelectasis
i. Manifests postop day 1 or 2
ii. Tx: ambulate, spirometer
c. Pneumonia
i. Sx: cough, sputum production; Vitals: fever, ↑RR
ii. Findings: CXR infiltrate, Leukocytes on CBC
d. UTI
i. Sx: burning sensation upon urination
ii. Findings: leukocyte esterase and nitrite changes on UA; growth on Urine Cx,
leukocytes on CBC
e. Wound
i. Manifests postop day 4 or 5
ii. Sx: erythematous, swelling, warmth, pain around incision site
iii. Tx: drain and wet-to-dry dressings twice daily
f. DVTs
i. Sx: chest pain, tachycardia, tachypnea, SOB
ii. Tx: ambulate, anticoagulant, consult cardio
g. Medications
h. Line infections
i. Sx: fever, leukocytosis on CBC, bacteremia on blood Cx, (+) culture from line tip
ii. Tx: removal of line and +/- IV Abx
4) Urinary retention
a. Causes: previous bladder outlet obstruction, atony b/c prolonged Foley, meds
b. Dx via bladder scan (U/S)
5) Pre-existing conditions
a. HTN: IV nitrates
b. Diabetes: Insulin sliding scale or Insulin drip

Burn patients:
1) Immediate concerns
a. Fluid loss – inflammation of skin  swelling and leaky cells/blood vessels
b. Protect airway – intubate ASAP; swelling may collapse airway and make intubation
impossible
2) 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
burned
4) % TBSA burned + age = ~mortality rate (better now with ICU care)

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

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

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

Medical conditions
Cerebral 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?)

Fistulas
1) Causes: Foreign body Radiation Inflammation Epithelization Neoplasm Distal obstruction
2) Enterocutaneous fistula
a. Risk factors: Crohn’s dz, infection, pancreatic insufficiency
b. Causes: leaks, trauma, diverticulum, post-surgical adhesions, peritoneal abscess
3) Fistula in Ano: connects rectum to skin around anus; anterior = straight, posterior = curved
4) Pancreaticoenteric fistula: use ERCP (Xray study of pancreas w/ contrast) to help dx
5) Colovesicular fistula: urinate fecal matter; UTIs
6) 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 Obstruction


1) pyloric stenosis
2) pancreatic tumor
3) gastric cancer
4) scars from recurrent ulcers
5) 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 >5.5cm
Future imaging will identify “hot spots” in an aneurysm, thus can tx small aneurysms with high risky
Ruptured AAA
1) Symptoms: hypotension + abdominal/back pain + pulsatile mass in abdomen; operate now
2) 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 day
2) Make sure that patient is hemodynamically stable in the ICU
SYMPTOMATIC AAA ≠ RUPTURED AAA
Treatment: Endovascular repair  1) polyester graft 2) nitinol stent w/ thermal memory 3) suture

Claudication: inadequate blood supply during exercise


Limb threatening ischemia: rest pain (inadequate during rest) + no wound healing (> 4 wks)
70% ischemia   amputation
Symptoms: 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 pedis
2) 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 pressure
Vessel incompressible = >1
Normal = ~0.95
Claudication = 0.5 – 0.95
Rest pain = 0.2 – 0.5
Tissure loss = < 0.2

Carotid Artery Disease (CaAD)


50% of strokes cause by CaAD; biggest risk factor for stroke is TIA
Transient Ischemic Attack (TIA) by definition last <24 hours; most last 5 minutes
Symptoms 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 ↓ cholesterol
2) 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 stroke
If stenosis >50% and asymptomatic, offer endarterectomy; NNT = 20 to prevent stroke
Assess risk/benefit in each patient!
GI Complications Lecture

ACUTE BLOOD LOSS


Physical 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%  tachycardia
3) 20-30%  hypotension @ rest + tachycardia
4) 30+%  organ dysfxn
5) Other PE findings: thirst, ↓ skin turgor
Labs of acute blood loss/volume status:
1) ↓ Urinary output (should make ~30mL/kg/hr); urine specific gravity
2) ↓ 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 resistance
b. resistance is proportional to length and inversely proportional to cross sectional area
i. smaller vessels and longer distance to heart
3) 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 stablize
2) Secondary survey: H&P
3) 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 bleed
ii. 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 here
4) 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 bleeding
2) requires between 6-10 units of blood (10 units = 2500mL of packed RBCs)
3) patient cannot be kept hemodynamically stable
4) 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 OBSTRUCTION
Physical 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 obstruction
Causes 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 surgery
2) Babies normally have lots of air in SB
3) Swallowing air trying to burp

Dx of SB obstruction
1) KUB/flat abdominal XR
2) upright abdominal XR (look for air-fluid levels)
3) L lateral decubitus (look for free air)
4) CT w/contrast after decompression
5) UGI w/SB followthrough after decompression
Tx:
1) NGT to decompress air
2) Replenish fluids if a lot is lost via NGT, vomiting
3) Gastric secretions:
a. Cl- 60-110mL  use NS to replenish; could use ½ NS
b. K+ 5-10mL  use 10KCl to replenish
c. H+, Na+  no action
d. 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 explanation
e. “order” mL for mL replacement of fluid loss from NGT with NS 10KCl
Pediatric Surgery

Case 1: 1 month old vomiting for five days


Ask: age of patient, duration of sx, what is being vomited, fever
Age  limits DDx;
Bilious  distal to pylorus; non-bilious  proximal to pylorus
Fever  infection
Hunger  evaluates how sick patient is
Tearing, skin turgor, UOP (diapers), lethargy  evaluates volume status

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

Pyloric Stenosis
Sx: 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 long
Rad: 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 intact
4) post-op  TPN for several weeks to allow pylorus to loosen

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

Intussusception
Sx: irritable, crampy abdominal pain,↓oral intake, current jelly stool (blood + sloughed mucosa)
Signs: (-) BS in RLQ b/c cecum pushed out of RLQ
Mechanism: Ileum telescoping into cecum; can get so bad that patient presents with rectal prolapse
Age: 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 surgery
Tx:
1) Fluids + Abx
2) 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 stool


Temperature instability  indicates septic state
Premature birth  predisposed to NEC
NEC (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 etiology
Sx: premature baby who has been tolerating feeds but no longer does; often occurs post-infection,
thus temperature instability, lethargy; distension, bloody stool
Signs: 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 death
Tx:
1) Indications for surgery : perforation, fixed loop, portal venous gas
2) 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 workup


1) 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 involvement
3) 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 T4
5) Benign: hyperplastic thyroid nodule, colloid cyst; Malignant: papillary, medullary, anaplastic,
lymphoma, metastatic carcinoma
a. Dx of most thyroid cancers are based on cytoarchitecture, except for follicular cancer
(must see invasion)
b. Prognosis good  bad: papillary, follicular, medullary, anaplastic
c. Stage important for prognosis and drives treatment
d. 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 thyroidectomy
d. Ablation with radioactive iodine (destroy remaining thyroid tissue)
7) Marker for post surgery: thyroglobulin; if recurrent, administer more radioactive iodine
AGES mneumonic:
Age (↓= good prognosis)
Grade (↓ = good)
Extracapsular extension (none = good)
Size (↓= good)
MEN IIa  medullary thyroid cancer, pheochromyctoma, hyperparathyroidism
MEN IIb  medullary thyroid cancer, hyperparathyoidism, mucousal ganglioneuromas in GI tract
RET gene involvement in MEN

Hypercalcemia Workup
1) Hx: cancer, previous thyroid surgery, other endocrine problems, family hx (MEN); Bones,
stones, groans, moans
2) Physical
3) Labs: PTH, BMP with Ca, Mg, Phosph, 24hr urine Ca
a. Cl:Phosph > 33 diagnostic for hyperparathyroidism
b. 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 tissue
b. U/S and CT scan helpful too
5) Tx: Adenoma vs Hyperplasia
a. Adenoma: remove single adenoma
b. Hyperplasia
i. bx most normal one to keep and remove others
ii. freeze some parathyroid tissue and thaw and reinplant if needed
iii. 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 removal
a. hypoparathyroidism  hypocalcemia, need Ca+ supplements
b. also transient “bone hunger”  hypocalcemia
c. icisional hematoma  compresses airway  respiratory distress; evacuate hematoma
d. recurrent laryngeal nerve injury  hoarseness or respiratory distress

Pheochromocytoma Workup
1) Hx: palpitations, ↑BP, headaches, feelings of impending doom family hx
2) Labs: 24hr urine metanephrine and normetanephrine
3) Rad: MIBG (nuclear medicine test) localizes tissue and sites of metastasis
4) 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 surgery
c. IVF b/c volume depleted and to compensate for hypotension post surgery
5) 10% rule: bilateral, familial, malignant, extra adrenal, multiple tumors
6) popular site of extra-adrenal pheo: organ of Zuckerkandl (bifurcation of aorta)

Carcinoid tumor Workup


1) Neuroendocrine tumor secreting 5HT
2) Sx: flushing, diarrhea, wheezing, valvular heart dz
3) 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 receptors
d. CT scan to localize
5) Concern about size of tumor: >2cm likely spread to LN, thus requiring larger resection
6) Tx:
a. <2cm removal small area
b. =>2cm removal of larger area

Adrenal Incidentoma
1) 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 cancer
b. Mammogram: check for breast cancer
c. BMP (K+): ↓ in hyperaldosteronism (aldosteromas are usually small b/c symptomatic)
d. 24hr urine cortisol: check for Cushing’s syndrome
e. 24hr urine metanephrine, normetanephrine: check for pheo
3) Tx:
a. Resect any functional tumor
b. Resect non-functional tumors based on size (=>3cm, remove via laproscopy)

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

ZES (Gastrinoma)  PUD


1) gastrinoma triangle: junction of cystic duct and common bile duct + head/neck of pancreas +
duodenum

Glucagonoma
1) diabetes, weight loss, Necrolytic migratory erythema
Scrotal Mass

General questions to ask: Tender? Location relative to testicle?


Studies: U/S, doppler, transillumination

Enlarged scrotum
DDx:
1) indirect hernia through patent processus vaginalis
2) hydrocele
a. (+) transillumination
b. U/S shows hypechoic area surrounding testicle
c. painless, non-tender
d. swelling of scrotum during day (not swollen in the morning)
3) Spermatocele/Epididymal cyst
a. Communication between cyst and epididymis +/- obstruction of vas deferens
b. Hypoechoic on U/S
c. (+) transillumination
4) Variocele
a. Varicosities of pampiniform plexus of veins
b. Left side often affected b/c drainage into left renal vein
c. “worm-like” appearance
d. pulling sensation, +/- infertility
e. Tx: laparascopically tie off veins above inguinal ligament; venographic embolization

Red, inflammed scrotum


DDx:
1) epididymitis
a. enlarged epididymis
b. tender, pain relieved by elevation of testicle
c. UTI  abnormal UA
d. Elevated white count?
e. Doppler shows ↑ blood flow
f. (-) transillumination
g. reactive hydrocele (fluid collection surrounding area)
h. Tx: Abx, rest, scrotal elevation, NSAIDs
2) testicular torsion
a. kids, young adults usually after strenous activity
b. due to poor fixation – Bell Clapper fixation
c. extremely painful b/c can turn more than 360 degrees
d. Doppler shows ↓blood flow
e. “donut sign” on nuclear medicine study
f. Operate within 6 hours; also fix contralateral side
g. Tx: reduce in ER using local anesthetic
3) Fournier’s Necrotizing Fascitis
a. Alcholics, diabetics at risk
b. Starts as perirectal/genitourinary source
c. Terrible smell because dead tissue receiving no perfusion
d. Can extend upward all the way up to clavicle
e. 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 carcinoma


1) prevent with circumcision
2) odor, late presentation

Phimosis
1) can’t retract foreskin
2) undiagnosed diabetics may first present with this symptom
3) Tx: circumcision
4) 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 cholchicine


Balanitis: infection on glans penis; associated with STDs

Testicular cancer
1) painless mass
2) Left testicle drains to para-aortic LN; Right testicle drains to interaortocaval LN
3) mets to lung  cannon ball lesions on CXR; mets to retroperitoneal LN, mets to brains
4) Hydronephrosis  cancer compresses ureters
5) U/S shows solid mass
6) ↑risk for cryptoorchidism
7) Germ cell >> non-germ cell
a. Germ cell: seminoma, teratoma, embryonal, yolk sac, choriocarcinoma, teratocarcinoma
b. Non-germ cell: leydig, sertoli, gonadalblastoma
8) Adults  seminoma; young  yolk sac
9) Labs: AFP (yolk sac), bHcG (choriocarcinoma), LDH, LFTs, BUN/creatinine
10) 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

REVIEW
Types of shock
Pulmonary wedge pressure