Clinical Sciences Review for Medical Licensure

Developed at
The University of Oklahoma College of Medicine

Ronald S. Krug, Series Editor

Suitable Review for:

United States Medical Licensing Examination
(USMLE), Step 2
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General
Surgery
Second Edition

M. Alex Jacocks

Rita R. Claudet
Technical Editor

Springer
M. Alex Jacocks, M.D.
Department of Surgery
Health Sciences Center
The University of Oklahoma College of Medicine
Oklahoma City, OK 73190
USA

Library of Congress Cataloging-in-Publication

Jacocks, M. Alex.
General surgery / M. Alex Jacocks. - 2nd ed.
p. em. - (Oklahoma notes)
Includes bibliographical references.
ISBN-13:978-0-387 -94637 -5 e-ISBN-13:978-1-4612-2372-6
DOl: 10.1007/978-1-4612-2372-6
1. Surgery-Outlines, syllabi, etc. 2. Surgery-Examinations,
questions, etc. I. Title. II. Series.
[DNLM: 1. Surgery-outlines. 2. Surgery-examination questions.
WO 18.2 J17g 1996]
RD37.3.J3 1996
617.9-dc20
DNLMIDLC
for Library of Congress 96-13052
Printed on acid-free paper.
© 1996,1993 Springer-Verlag New York, Inc.

All rights reserved. This work may not be translated or copied in whole or in part without
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 Preface to the Oklahoma Notes

The intent of the Oklahoma Notes is to provide students with a set of texts that
present the basic information of the general medical school curriculum in such a
manner that the content is clear, concise and can be readily absorbed.
The basic outline format that has made the Oklahoma Notes extremely popular
when preparing for standardized examinations has been retained in all the texts.
The educational goals for these materials are first to help organize thinking about
given categories of information, and second, to present the information in a for-
mat that assists in learning. The information that students retain best is that which
has been repeated often, and has been actively recalled. The outline format has
always been used in the Oklahoma Notes because students have reported to us
that it allows them to cover subsequent parts of the outline, and use the topic
heading as a trigger to recall the information under the heading. They then can
uncover the material and ascertain whether they have recalled the information
correctly.
This second edition of the Clinical Series of the Oklahoma Notes represents a
major refinement of the first editions. A number of issues have been addressed to
make the texts more efficient, effective and "user friendly." These include:
• Correction of technical errors.
• Addition of new material that has been reported since the first editions were
published.
• Standard presentation of materials in all texts to make information more acces-
sible to the student.
• Review questions written in standardized format. These questions reflect the
major issues of the sections of the texts.
We hope these are helpful to you in your educational progress and preparation for
required examinations.

Ronald S. Krug, Ph.D.

Series Editor
 Preface for Second Edition

Each chapter of this revision has been carefully reviewed for accuracy and up-
dated as new information has been woven into clinical practice. While doing so,
we have tried to maintain brevity and relevance. It covers concepts and details
that most educators and practicing physicians feel finishing medical students
should grasp. Additionally, study questions have been added to help the student
assess his own mastery of the material.

As in the previous edition. this text is intended to help you study for boards and
as such is not a comprehensive textbook of surgery. We have again used the
relevant learning objectives of the Association of Surgical Education as a basis for
the material covered. We hope it will help guide your review of previously learned
material.
 Acknowledgments

I would like to acknowledge the tremendous amount of work put into this effort
by other people on the staff at the University of Oklahoma College of Medicine, in
particular, Ms. Judy Wheeler for her tremendous hours at organizing and typing
this material. Dr. Rita Claudet has provided editing expertise, as well as inspira-
tion toward completion of this revision, that have added to its accuracy and
versatility.
 Contents

Preface to the Oklahoma Notes . v

Preface for Second Edition .. vii
Acknowledgments . ix

Chapter 1 Fluids, Electrolytes, Nutrition . 1

Basic principles . 1
The normal fluids and electrolytes and their maintenance . 1
Abnormalities . 4
Nutrition . 10

Chapter 2 Shock . 13
Introduction . 13
Hypovolemic shock . 14
Cardiogenic shock . 15
Septic shock . 16
Neurogenic shock . 17

Chapter 3 Clotting Disorders and Use of Blood Products . 19

Clotting disorders .. 19
Blood replacement therapy . 22

Chapter 4 Surgical Infections .. 25

Classification of surgical wounds .. 25
Pathogenesis of infection . 25
Prevention of surgical infection . 25
Community acquired infections . 26
Hospital acquired infection . 28

Chapter 5 Multiple Trauma . 31

Primary survey-ABCDE . 31
Secondary survey .. 32

Chapter 6 Burns . 39
Types and classification of burn injuries . 39
Treatment . 40

Chapter 7 Wound Healing . 42

Pathophysiology . 42
Classification of wounds 44
xii Contents

Use of prophylactic antibiotics 45

Wound care 45

Chapter 8 Acute Abdominal Pain 48

General aspects 48
Acute appendicitis 48
Pelvic inflammatory disease 49
Ectopic pregnancy 49
Biliary disease 49
Acute pancreatitis 51
Perforated duodenal ulcer 51
Acute diverticulitis 52
Small bowel obstruction (SBO) 52
Genitourinary problems 53

Chapter 9 Esophagus 54
Anatomic points of interest 54
Physiology 54
Pathology 55

Chapter 10 Stomach 58
Anatomy 58
Physiology 58
Diagnostic tools 59
Peptic ulcer disease 60
Gastric ulcer disease 61
Post-gastrectomy syndromes 62
Gastric cancer 63

Chapter 11 Small Bowel 65

Anatomy 65
Physiology 65
Crohn's Disease 66
Small bowel obstruction 68
Diverticular disease 69
Small bowel neoplasms 70

Chapter 12 Appendix 71
Inflammation 71
Neoplasias 72

Chaper 13 Colon 74
Introduction 74
Neoplastic diseases 74
Diverticular disease 77
Inflammatory bowel disease 77
Large bowel obstruction 79
Lower GI hemorrhage 79

Chapter 14 Rectum and Anus 81

Rectum and anus 81
Anus 81

Chapter 15 Gallbladder and Biliary System 84

Anatomy 84
 Contents xiii

Physiology 84
Congential problems 84
Calculus associated illnesses 85
Cancer 88

Chapter 16 Liver 90
Anatomy 90
Physiology 90
Congenital abnormalities 90
Inflammatory problems 91
Portal hypertension 92
Neoplasias 94

Chapter 17 Pancreas 96
Anatomy 96
Physiology 96
Inflammatory conditions 96
Neoplasia 98

Chapter 18 Spleen 101

Anatomy...................... 101
Function 101
Splenic removal 102
Other 103

Chapter 19 Gastrointestinal Hemorrhage 104

Upper GI bleeding 104
Lower GI bleeding 106
GI hemorrhage in infants and children 108

Chapter 20 Hernias 109

Groin hernias 109
Other hernias 110

Chapter 21 Breast 112

Anatomy/Physiology . 112
Evaluation 112
Benign conditions 113
Malignant conditions .. 114

Chapter 22 Vascular System 118

Atherosclerotic peripheral arterial disease 118
Venous Disease 125
Lymphatic disorders 126

Chapter 23 Heart 128

Congenital disease 128
Acquired cardiac disease 132
Pacemakers 135

Chapter 24 Lung and Mediastinum 136

Pulmonary functions 136
Lung cancer 138
xiv Contents

Primary tumors and cysts of the mediastinum 140

Pleura and pleural space 141

Chapter 25 Transplantation 143

General aspects 143
Organ and tissue donation 147
Kidney transplantation 148
Liver transplant 149
Heart, heart-lung and lung transplantation 149
Pancreas transplant 150
Other 150

Chapter 26 Endocrine 151

Thyroid 151
Parathyroid 153
Adrenal Gland 155

Self-Assessment Examination 159

Answers 189
Chapter 1 FLUIDS • ELECTROLYTES. NUTRITION

L Basic principles

A. Know what makes up normal body fluid compartments and electrolytes and
what sort of maintenance fluid and acid-base balance must be done to
maintain the normal homeostasis. See Figure 1-1

Figure 1-1 - Compartments of Body Fluids

70 Kg llan \ BW
3,500 cc 5\ lIa 142 Cl. 103
Pl.as. . I[ 4 BC~ 27
ca 5
IIg 3

10,500 cc Interstitial. 15\ lIa 144 Cl. 114

Fl.uid I[ 4 BC~ 30
Ca 5
IIg 2
28,000 cc Intracel.l.ul.ar 40\ I[ 150 BP04 150
Fl.uid IIg 40 S04
lIa 10 BC~ 10
Protein 40

B. Know what problems are created by common clinical perturbations of the

system (ie, fever, ventilator, biliary fistula, etc.) (Figure 2-1)

Figure 1-2 COllposition of GI Secretions

TYPE VOLUIIB (1Il.)/24 lIa I[ CL BC~

Sal.ivary 1500 10 26 10 30
Sto. .cb 1500 60 10 130
DuodenlDl 1500 140 5 80
Il.elDl 300 140 5 104 30
Col.on 60 30 40
Pancreas 100-800 140 5 75 115
Bil.e 50-800 145 5 100

c. Know the make-up of various commercially available electrolyte solutions and

nutritional solutions and how to use them.

n. The normal Ooids and electrolytes and their maintenance

Chapter 1

A. Fluid requirements

1. Normal adult male is 60 % body water by weight.

a. 40 % is intracellular - 20 % extracellular (15 % interstitial and

5 % intravascular).

b. Maintenance of body water largely controlled by release of

antidiuretic hormone from the posterior pituitary to increase
tubular water resorption in the kidney and aldosterone secretion
from the adrenal gland to retain sodium and water in a more
passive fashion.

2. Common replacement formula

o - 10 kg body weight - replace 100 ccfkg/24 hr

10 - 30 kg body weight - replace 50 ccfkg/24 hr
> 30 kg body weight - replace 20 ccfkg/24 hr

a. Example: 70 kg man gets 1000 ccs for his first 10 kg of body

weight, 1000 ccs for the next 20 kg of body weight, and 800
ccs for the next 40 kg of body weight. H this is given equally
over 24 hours, a rate of 125 ccs per hour would be used.

3. Assessment of fluid status

a. Physical exam - pulse, blood pressure, skin turgor, mental

activity, etc.

b. Urine output - expect 0.5 ccfkg/hour in adults; 1-2 ccfkg/hour

in infants and children.

c. Careful record of input and output.

d. Invasive monitoring using a central venous pressure line or

pulmonary capillary wedge pressure with a Swan-Ganz catheter.

e. Daily weights - for overall long-term management.

4. Normal losses

2
 FLUIDS. ELECTROLYTES. NUTRITION

a. Urine - most patients lose approximately 1500 ccs of urine per

day.

b. Feces - approximately 260-300 ccs of water loss per day in

feces.

c. Insensible loss - 500-600 ccs of fluid loss per day in insensible

losses (pure water)

B. Electrolytes

1. Sodium

a. Is the most common extracellular cation with normal

concentration of 135-145 mEqJliter in the serum.

b. Total body sodium estimated to be 40 mEqfliter which is also

the normal replacement value of fluids for normal maintenance.

c. Sodium resorption in exchange for potassium and hydrogen

secretion by the distal renal tubules is the direct effect of
aldosterone.

2. Potassium

a. Major intracellular cation with normal serum concentration of

3.5 -5.0 mEqfliter

b. 98 % of potassium is located intracellularly.

c. Potassium excretion is directly related to circulating levels of

aldosterone, cellular and extracellular potassium content
tubular urine flow rates. There is a normal loss of potassium
of approximately 10-15 mEqJliter in urine which must be
replaced.

3. Chloride

a. The major extracellular anion with a normal level of 95-105

mEqfliter.

3
Chapter 1

b. Chloride balance generally parallels that of sodium except in a

hypochloremic state from losses of gastric acid.

4. Calcium

a. Maintained at 4-5.5 mEqJliter (ionized calcium).

b. Most calcium is in bone with only the extracellular fluid

amount being physiologically active.

c. Influences on urinary calcium excretions include parathyroid

hormone, metabolic alkalosis, hypophosphatemia and metabolic
acidosis, depletion of Vitamin D, absorption of small bowel
calcium, etc.

C. Acid-base balance

1. Buffering systems in RBCs and body fluids immediately offset changes

in acid-base balance.

2. Pulmonary ventilation promptly adjusts the excretion carbon dioxide.

3. Renal tubular function modulates urinary excretion or conservation of

acid or base with time.

a. The Henderson-Hasselbach equation is shown below:

pH = pKa + log

or

pH = 6.1 + log [ HC03 ]

[ 0.03 X PcOz ]

m. Abnormalities

A. Fluids

1. Volume depletion

a. "Tennis score" correlates with clinical signs and symptoms of

acute fluid loss.

4
 FLUIDS. ELECTROLYTES. NUTRITION

(1) 6-15% loss (6-750 mI) - minimal signs and symptoms -

decreased pulse pressure.

(2) 15-30% loss (756-1500 mI) - tachycardia, orthostatic

hypotension, moderate decrease in urine output, elevation
of hematocrit.

(3) 30-40 % loss (1506-2000 mI) - stupor or coma, eyes

sunken, pulse rapid, weak and thready, hypotension,
oliguria pronounced.

(4) > 40% loss (>2000 ml) - progressive coma, hypotension

and death.

2. Volume excess

a. Clinical picture depends on the cause, nature and severity of

the challenge and signs can range widely from simple weight
gain and small decreases in hemoglobin and hematocrit to frank
congestive heart failure, pulmonary edema, pleural effusion and
congestive hepatomegaly.

B. Electrolytes

1. Sodium

a. Hyponatremia

(1) Most commonly due to accumulation of excess water

from hypotonic fluid replacement or retention of excess
water due to enhanced ADH activity - numerous other
causes.

(2) CNS symptoms predominant including weakness, fatigue,

hyperactive deep tendon reflexes, muscle twitches, etc -
eventually leading to convulsions, coma and areflexia.

(3) Most cases of dilutional hyponatremia can be treated by

withholding fluids. Severe hyponatremia may need
hypertonic sodium solutions.

b. Hypernatremia

(1) Less common than hyponatremia - most commonly the

5
Chapter 1

result of loss of body fluids or decreased excretion of

sodium.

(2) Symptoms associated include restlessness, weakness,

decreased salivation, dry mucous membranes, dry flushed
skin, decreased skin turgor, hyperpyrexia, tachycardia,
hypotension and ultimately coma, convulsions and death.

(3) Calculation of water deficit is important with

replacement of hypotonic fluids - staged with no more
than 1/2 in the first 8 hours, the remainder over the
next 16 hours.

2. Potassium

a. Hypokalemia

(1) Most commonly due to abnormal losses of potassium

from gastric or intestinal content losses, enhanced
aldosterone activity with associated alkalosis, diuresis with
pharmacologic agents, etc.

(2) Clinical manifestations reflect the role of potassium in

muscle and nerve function. Most severe are cardiac
arrhythmias with low voltage, flattening of the T-waves,
prominent V-waves, prolonged P-R interval and widening
of the QRS complex. Oral or intravenous potassium
chloride salts may be used for replacement. Should be
replaced at no more than 10-20 mEqjhour and should be
on cardiac monitor at upper levels of replacement.

b. Hyperkalemia

(1) Most common cause of hyperkalemia is decreased renal

excretion of potassium - excessive intake or extensive
trauma with rhabdomyolysis can cause hyperkalemia, as
well.

(2) The most important symptom complex relates to

cardiotoxicity, manifested by peaked T-waves, diminished
P-waves, increased P-R intervals, heart block, widening

6
 RumS . ELECTROLYTES. NUTRITION

of the QRS complex and decreased S-T segments.

(3) Treatment of hyperkalemia involves maintenance of cell

membrane function and reduction of total body
potassium.

(a) Calcium gluconate and insulinfglucose/bicarb are

combinations that may stabilize cardiac cell
membranes and shift potassium back into the cells
temporarily.

(b) Use of sodium polystyrene sulfonate (Kayexalate),

a cation-exchange resin, diuretics or dialysis will
all decrease total body potassium level.

3. Calcium

a. Hypocalcemia

(1) May be seen after surgically induced hypoparathyroidism

or due to acute pancreatitis or inadequate absorption
with inflammatory bowel disease or pancreatic exocrine
dysfunction.

(2) Clinical manifestations include circumoral paresthesias,

numbness and tingling of the tips of the fingers and
muscle cramps (Chvostek's sign and Trousseau's sign) -
EKG may show prolongation of Q-T interval.

(3) Treatment involves replacement of calcium deficit orally

or intravenously and vitamin D supplements.

b. Hypercalcemia

(1) The most common causes include primary hyperpara-

thyroidism and metastatic cancer to bones Oung, breast,
colon, prostate), as well as numerous other causes.

(2) Symptoms include weakness, anorexia, nausea and

vomiting, headaches, musculoskeletal pain, polyuria,
polydipsia and eventually coma and death.

7
Chapter 1

(3) Treatment - restrict calcium; improve hydration and

increase urinary diuresis with furosemide; replenish
magnesium; steroids to suppress calcium release from
bone; use of Mithramycin to suppress bone resorption
and calcium release.

C. Acid-base balance (See Table 1-1)

1. Respiratory acidosis

a. Large alveolar levels of PaC0 2 due to inadequate ventilation.

b. Treatment involves improving alveolar ventilation to reduce CO2

levels and may require the use of mechanical ventilatory
support.

2. Respiratory alkalosis

a. Usually the consequence of pulmonary alveolar hyperventilation

ie, apprehension, pain, hypoxia, fever, CNS injuries or elevated
ammonia levels.

b. Treatment aimed at the underlying problem.

3. Metabolic acidosis

a. Occurs because of either loss of bicarb (diarrhea, external

pancreatic fistula, etc.) or from an increase in metabolic acid
load, ie, lactic acidemia secondary to cardiogenic, septic or
hypovolemic shock, ischemia of tissue beds or ketoacidosis.

b. Results in decreased serum concentrations of bicarbonate.

Determination and use of anion gap can help distinguish
metabolic acidosis caused by loss of bicarb from that due to
accumulation of metabolic acid load.

(1) Anion gap = [Na] - [CI] + [HCO)]

Normal = 10-12.
c. Treatment is aimed at underlying disorder. Hypovolemia and

8
 nums . ELECTROLYTES. NUTRITION

sepsis must be controlled. Diabetic ketoacidosis must be

treated. Other severe acid loads may be treated with
hemodialysis.

4. Metabolic alkalosis

a. Associated with GI or renal losses of potassium and chloride

ions, leading to hypochloremic, hypokalemic, metabolic alkalosis.

b. May be associated with increased carbon dioxide retention and

hypoventilation.

c. The clinical problems are mostly related to hypokalemia,

hypochloremia and volume contraction.

d. Treatment - replacement of extrarenal losses of fluid and

electrolytes to correct the abnormalities.

Table 1-1 ACIDOSIS - ALKALOSIS: COMMON CAUSES

Respiratory acidosis Depression of respiratory center
(drngs, CNS injury)
Pulmonary disease - emphysema, pneumonia
Respiratory alkalosis Hyperventilation - emotional, severe pain,
assisted ventilation, encephalitis
Metabolic acidosis Diabetes, azotemia, lactic acid, starvation,
Diarrhea, small bowel fistulae
Metabolic alkalosis Vomiting/NG suction
Excessive intake of bicarb
Diuretics

D. Fluid and electrolyte therapy for the surgical patient.

1. Pre-operative evaluation of abnormalities caused by the disease process

and correction of those prior to anesthetic management is imperative.
This includes replacement of volume and correction of the electrolyte
abnormalities.

2. Intra-operative therapy is directed toward maintenance of normal

circulating volumes. An open peritoneum loses large amounts of

9
Chapter 1

insensible loss (200-300 ccs/hour) and handling of the intestine induces

an isotonic fluid loss into the interstitial spaces, both requiring
replacement during the intraoperative procedure.

3. Post-operative therapy is again directed toward maintenance of

satisfactory intravascular fluid volume with normal renal output and
normal electrolytes.

a. Mechanical ventilation greatly decreases the need for insensible

water loss replacement.

b. Normal elevated levels of ADH and aldosterone post-operatively

should limit the amount of potassium needed and the amount
of fluid needed.

IV. Nutrition

A. Normal caloric requirements

1. Range from 30-80 kcal/kg/day depending on age and stress.

2. Harris-Benedict equations are used for resting metabolic rate.

3. Requirements can be based on 35 kcal/kg/day increased by 12 % after

major surgery, by 20-50% during sepsis and up to 100% with major
burns.

4. Protein requirements for a normal active man are 0.9-1.5

grams/kg/body weight daily. Minimum of 500 ml of 10% lipid
emulsion must be given twice weekly to prevent an essential fatty acid
deficiency; maximum of 60 % of calories can be given as lipid
emulsions.

5. Fat soluble vitamins (A, D, E and K) and water soluble vitamins are
important for replacement and can be given parenterally or enterally.

6. Trace elements including iron, iodine, cobalt, zinc, copper, selenium

and chromium need to be replaced as well as others.

7. Adequacy of nutritional replacement is probably best followed clinically

by the patients anergic response to skin testing.

10
 FLUIDS. ELECTROLYTES. NUTRITION

B. Sources of nutritional replacement

1. Enteral alimentation

a. Can be infused through tubes passed through the nose, directly

into the stomach or into the small intestine.

b. Elemental diets are high osmolar, expensive solutions of

synthetic aminoacids that can be infused through a small
catheter directly into the small bowel. Absorption of single
aminoacids in the small bowel mucosa is reasonable.

c. Semielemental diets are low in osmolality, have good absorption

in the small bowel as dipeptides and tripeptides and are less
expensive than elemental diets. They do, however, need a
larger tube for infusion.

d. Modular formulas - MCT (medium chain triglycerides), etc. are

particular types of formulas to replace specific deficits.

e. The complications of enteral feedings are similar to those

detailed with parenteral nutrition and include diarrhea causing
hyperosmotic non-ketotic dehydration and coma, electrolyte and
mineral deficiency, catheter problems with dislocation and
spillage into abdominal cavity, infection and abscess formation,
small bowel obstruction, etc.

2. Total parenteral nutrition (TPN)

a. Consists of replacement of adequate volume and electrolytes

and, in addition, a large amount of aminoacid solution with
high levels of a non-protein source of calories, most commonly
glucose.

b. Because the fluid is very hyperosmotic, parenteral nutrition

needs to be given through a high flow vein such as the
subclavian or superior vena cava.

c. Because of the high carbohydrate load and osmolality, fluid is

started slowly and kept at a steady rate. It should not be
interrupted during continuous infusion and when discontinuing
TPN the rate must be tapered slowly over a day or two.
Tapering up and down of the rate allows time for pancreatic

11
Chapter 1

insulin levels to adjust to the varying glucose loads.

d. Careful monitoring of electrolytes and fluid volume is vital to

prevent complications.

e. Complications include:

(1) Problems with placement of the catheter including

pneumothorax, hemothorax, carotid injury, tracheal
injury, brachial plexus injury, etc.

(2) Infections with the line, usually Staph species

(3) Infection in the solution itself - especially fungal

organisms (Candida).

(4) Metabolic problems with the solutions or rate of

administration, including hyperosmolar, nonketotic
dehydration and coma and fluid and electrolyte
abnormalities.

f. Special types of aminoacid solutions

(1) Branch-chain in aminoacids are used in hepatic failure

patients.

(2) Fluids replacing only essential aminoacids (to decrease

the nitrogen load) are particularly useful for renal failure
patients.

12
Chapter 2 SHOCK

L INTRODUCTION

A. Shock can be dermed as that state in which the metabolic demands of the
cells (primarily oxygen) are not met by the supply of nutrients from the
body. This results in metabolic dysfunction of cellular activities and is
reversible when treated aggressively in the early state but when allowed to
continue results in cellular death, organ damage and death of the patient.
Although commonly associated with hypotension, shock may be present
without hypotension and may not necessarily be present with hypotension.

B. Pathophysiology

1. The decrease in intravascular volume results in a decrease in mean

arterial pressure and rising heart rate.

2. Immediate result of hypovolemic episode is a surge of catecholamines

from the adrenal glands, resulting in peripheral vasoconstriction and
tachycardia to increase cardiac output.

3. The juxtaglomerular apparatus of the kidney detects the decreased

blood pressure, stimulating the release of renin which is converted to
angiotensin causing peripheral vasoconstriction, as well as stimulating
the release of aldosterone.

a. These two actions result in elevated peripheral vascular

resistance to raise the systolic blood pressure as well as increase
intravascular volume, due to aldosterone effects of sodium and
water retention.

4. Increased secretion of antidiuretic hormone from the pituitary, also

enhances intravascular volume by renal absorption of water.

5. Numerous other hormones including the corticosteroids, growth

hormone and thyroid hormone are secreted in any shock state which
stimulate protective mechanisms for maintenance of blood flow to the
brain and the heart.

C. Four types of pathophysiologic mechanisms leading to cellular dysfunction and

death have been described and will be detailed below. The hemodynamic
parameters which aid in the diagnosis of these shock groups are summarized
in the following table.
Chapter 2

Table 2-1 HEMODYNAMIC PARAMETERS OF SHOCK

BP, PCWP, CI, SVR, dyn/ 02D , °2C ,
Condition mm Hg P mm Hg liters/ sec/cmos mL/mm mL/mm
min/m2
Normal (N) 120/70 80 5-15 2.5-3.5 1000-1500 900-1200 200-300
Hypovolemia ~ t + + t + +
CHF t t t + t + +
Cardiogenic ~ t t ++ tt ~+ ~+
shock
Sepsis ~ t + or N t + t t or N
Neurogenic ~ t
or t or N t or N + t or N N
N
BP, arterial blood p ressure; l", pulse; l"(; W l", pulmonary cap~ary wedge pressure; C1,
cardiac index; SVR, systemic vascular resistance; 02D, oxygen delivery; 02C, oxygen
consumption.

n. Hypovolemic shock

A. General

1. Hypovolemic shock is the most common form of shock manifested by

surgical patients and represents marked reduction in oxygen delivery,
resulting from diminished cardiac output because of inadequate
intravascular volume.

B. Diagnosis

1. Common clinical states associated with hypovolemic shock should

induce a high index of suspicion, such as recent trauma, fever, history
of vomiting or diarrhea, intra-abdominal pain, burns, etc.

2. Blood pressure and heart rate in supine, sitting and standing positions
can be helpful at indicating hypovolemia.

3. Patients tend to have decreased mental function and markedly decrease

urinary outpu t.

14
 SHOCK

4. Invasive hemodynamic monitoring can also be useful to aid in proving

hypovolemia (refer to the table above).

c. Treatment

1. Because patients in hypovolemic shock are hypotensive due to reduced

volume, it is important to replace volume as rapidly as possible.

2. Patients who have lost blood, need blood replaced, in addition to

crystalloid solutions.

3. Lactated Ringer's, normal saline or plasmalyte are good balanced

electrolyte solutions that can be used to replace volume until blood is
available.

a. Typed and crossmatched blood will take approximately 1 hour

to prepare.

b. Typed specific blood can be obtained within 5 to 10 minutes.

c. 0 negative blood is universal donor when needed urgently.

4. Fluid resuscitation can be assessed with the invasive central lines (CVP
and Swan-Ganz), as well as urinary output, mental function, blood
pressure and heart rate.

5. Correction of the underlying problem may then be undertaken safely,

whether it be an intra-abdominal process or injuries with blood loss.

6. Inotropic agents in patients with hypovolemic shock are very seldom

of any benefit.

m. Cardiogenic shock

A. Definition

1. Cardiogenic shock is present when severe reduction in oxygen delivery

is secondary to marked impainnent of myocardial function.

2. The most common etiology for this is ischemic heart disease or

arrhythmia.

15
Chapter 2

B. Diagnosis

1. In a patient with suggestive history of an etiology of cardiogenic

shock, invasive monitoring is very important in identifying the
presence of cardiogenic shock.

2. See table under 2-1.

3. Hemodynamic hallmarks of cardiogenic shock distinguishing it from

hyPOvolemic shock are marked decrease in cardiac output and cardiac
index, as well as increase in filling pressures including pulmonary
artery wedge pressure and CVP.

c. Treatment

1. Treatment involves efforts to maXUDlZe myocardial performance with

the least amount of myocardial oxygen consumption.

2. Concepts involved include, assuring reasonable levels of pre-load, ie,

central venous pressure and intravascular volume while reducing high
levels of systemic vascular resistance.

a. Diuretics and vasodilators can be used to decrease the after

load and to maintain normal filling volumes in the heart.

3. Increased contractility of the heart to improve the performance of the

cardiac muscles.

a. Three drugs commonly used for contractility are dobutamine,

dopamine and isoproterenol.

4. In severe cases, mechanical intervention to improve cardiac function

and reduce myocardial oxygen consumption can be helpful in the form
of an intra-aortic balloon pumping.

IV. Septic shock

A. Early septic shock (warm shock)

16
 SHOCK

1. Most commonly manifested in patients with overwhelming sepsis due

to gram-negative organisms but may also be seen with gram-positive
and fungal organisms.

2. In addition to hypotension and tachycardia, patients with early septic

shock have marked decrease in peripheral vascular resistance because
of endotoxin dismantling of peripheral neurovascular regulatory activity
so that these patients are warm and pink rather than constricted and
cool.

3. This is marked by greatly increased cardiac output that may reach 10

liters per minute.

4. As the shock progresses, there is decreasing compensation by the heart

as the myocardium function decreases, resulting in lower cardiac
output.

a. Ultimately vasoconstriction occurs creating cool extremities. The

patient takes on more characteristics of a patient with
hypovolemic shock.

B. Treatment

1. Treatment is directed toward the underlying etiology, as well as the

hemodynamic problems.

2. The underlying etiology must be treated with antibiotics and drainage

of any abscesses or debridement of any necrotic materials.

3. Fluid resuscitation and inotropic agents to support the heart may also
be important during this phase of septic shock

IV. Neurogenic shock

A. General

1. Neurogenic shock is used to describe hypotension secondary to central

nervous system dysfunction.

2. This type of shock is most commonly seen in trauma patients and

17
Chapter 2

may be combined with other problems such as hypovolemia, tension

pneumothorax, cardiac tamponade, etc.

3. Neurogenic shock results primarily from the disruption of the

sympathetic nervous system with resultant relative hypovolemia due to
widespread vasodilatation.

4. This problem can be improved by placing the patient in the

Trendelenburg's position, using intravascular volume replacement, or
giving some sympathomimetic agents to improve peripheral and
vasoconstriction.

18
Chapter 3 CL01TING DISORDERS AND USE OF BLOOD PRODUCTS

L Clotting disorders

A. Screening

1. History of previous bleeding problems is the most helpful screening

procedure in evaluating patients with possible bleeding problems.

2. Screening tests that are commonly helpful in patients without a history

of bleeding disorder after surgical procedures include a platelet count,
prothrombin time (PT) and partial thro._1boplastin time (pTT).

3. Numerous other tests for evaluation of hemostasis can be undertaken,

depending upon the abnormality of these and the history.

a. Bleeding time - actual prolonged bleeding time is often

associated with platelet aggregation disorder.

b. Thrombin time (TT) - evaluates fibrinogen to fibrin conversion

with an external source of thrombin. Used to evaluate DIe
and chronic liver disease.

c. Evaluations of clotting factors may be undertaken to identify

specific deficiencies such as Type A hemophilia (VIm and von
Willebrand's disease, etc.

B. Acquired bleeding disorders

1. Acquired bleeding disorders are most commonly associated with use

of medications.

a. Exogenous heparin is used for anticoagulation and causes

prolongation of the PTT.

b. Warfarin causes decreased synthesis of liver-manufactured

clotting factors (II, VII, IX and X) - causes prolongation of the
PT (and PTT to a lesser extent) and INR (International
Normalized Ratio).

c. Any chronic liver disease interferes with liver function and may
cause prolonged PT and bleeding abnormalities.
Chapter 3

d. Aspirin and non-steroidal anti-inOammatory medications

interfere with platelet function.

e. Acquired thrombocytopenia may be due to decreased platelet

production due to bone marrow failure, increased destruction
of platelets by increased activity by the spleen, splenic pooling
of platelets and an enlarged abnormal spleen and any
combination of these disorders, such as alcoholic liver failure.
Autoimmune disorders (lTP, TTP, etc.) or drugs (esp. heparin)
may cause excessive platelet destruction by the spleen because
of abnormal antibodies.

Coagulation Pathways

EmiDIlc
VB

~IX
~vm
APIT ~x PTIINR
v
!
Prothrombin (D) - - - - - - - - - Thrombin
F'f.brinogcn --------'--------:::'------
Fibrin (loose)
'------~ / 1 xm
IT
Fibrin (tight)

C. Congenital defects of coagulation factors

1. Autosomal dominant inheritance

a. Von Willebrand's disease - factor VID:C, platelets

b. Hereditary hemorrhagic telangiectasia

c. Factor XI deficiency

20
 CLOTfING DISORDERS AND USE OF BLOOD PRODUCTS

2. Autosomal recessive inheritance

a. Factors X, V, Vll, I deficiency syndromes (variable degrees of

expression)

3. Sex-linked recessive

a. Classic hemophilia (factor VllI)

b. Christmas disease (factor IX)

Fibrinolytic System

Plasminogen

proactivators ...

t ... inhibitors
activators (EACA)
(kinases, strepto-
kinase, urokinase)

Plasmin
~
degradation of fibrin, fibrinogen,
V, Vll
r-------~---
Split products

D. Causes of surgical bleeding

1. Ineffective local hemostasis, complications of blood transfusion and

undetected hemostatic defects are the most common causes of excessive
bleeding during or after an operation.

2. Shock and extensive trauma may be associated with disseminated

intra-vascular coagulation and result in oozing capillaries and massive
blood loss.

21
Chapter 3

3. Rapid transfusion of 10 units or more of stored blood over 4 to 6

hours may result in abnormal bleeding because of reduced numbers
of platelets, decreased coagulation factors, hypothermia and perhaps
hypocalcemia.

4. 50 % of postoperative bleeding is due to inadequate hemostasis during

surgery. Other causes of bleeding during surgery include circulating
heparin remaining after bypass procedures, shock resulting in DIe and
factor deficiencies.

5. Secondary fibrinolysis may be the cause of abnormal bleeding due to

disseminated intravascular coagulation. This is often activated by
shock, sepsis, allergic reactions, etc.

a. The diagnosis of DIC is established by detecting diminished

levels of coagulation factors and platelets and the presence of
fibrin split products.

II. Blood replacement therapy

A. Packed red blood cells

1. When patients have lost red cell volume, the usual replacement is with
packed red blood cells (PRBC), which have a volume of approximately
250 ccs and hematocrit of approximately 70 % .

2. Blood group and type must be taken into consideration when red cells
are given, including ABO blood groups and Rh factors.

a. Universal donor cells are O-negative red blood cells and are
used when type specific or typed and crossmatched blood
cannot be made available.

3. Tests for transmission of infectious agents including hepatitis, HIV and

CMV viruses are done routinely so that the risk is extremely small.

a. Risk for transmission of disease increases as the number of

transfused units increases.

B. Fresh frozen plasma

1. Fresh frozen plasma is used when replacement of coagulation factors

is important.

22
 CWTTING DISORDERS AND USE OF BLOOD PRODUCTS

2. Can be used to reverse the effects of warfarin as it rapidly replaces

ll, Vll, IX and X.

3. Fresh frozen plasma can be used in a non specific manner, not

requiring cross matching. Risk of transmission of disease is similar
with red blood cells.

C. Cryoprecipitate

1. Measures 5 to 30 ml in a single plastic bag and is rich in factor VBI

and fibrinogen.

2. Concentrated from pooled sources of plasma and therefore has a

slightly increased risk of transmission of disease.

3. Is particularly useful ill the treatment of hemophilia A and von

Willebrand's disease.

D. Factor VllI concentrates

1. Useful for treating hemophilia A but not in the treatment of von

Willebrand's disease.

2. Because of additional concentration from various sources of plasma,

the risk of hepatitis virus and HIV is increased.

E. Complications of transfusions

1. Immunologic transfusion reactions include:

a. hemolytic transfusion reaction

b. febrile transfusion reactions

c. post transfusion thrombocytopenia

d. anaphylactic shock

e. urticaria

f. graft versus host dise.ase

23
Chapter 3

2. Symptoms of immediate hemolytic reaction include fever, constrictive

sensation of the chest, pain in the lumbar region, hypotension,
hemoglobinuria, bleeding due to DIC and renal failure.

3. Transfusion should be stopped immediately, documentation of clinical

information double checked, blood samples taken from the patient to
re-check typing and for free plasma hemoglobin.

a. Cultures of the patient's blood and investigation for DIC are

important.

b. Management of hypotension with volume expanders such as

lactated Ringer's and vasoactive drugs and good renal function
maintained with a diuretic therapy.

4. Other complications of transfusions include:

a. bacterial sepsis

b. embolism - air, tubing, particulate matter

c. thrombophlebitis

d. pulmonary edema

e. transmission of disease

(i) hepatitis - B or C
(ii) CMV
(iii) HIV
(iv) Malaria, Chagas ' disease, brucellosis, syphilis

24
Chapter 4 SURGICAL INFECTIONS

L Classification of surgical wounds

Wound Bacterial Soun:e or Inredion Examples

Contaminants Contamination Frequency

Clean Gram positive OR environment, 3% mgmnal henU~

surgica 1 team, thyroidectomy, mastectomy
patient's skin

Clean- Polymicrobial Endogenous 5-15% Common duct exploration,

contaminated colonization of elective colon resection,
the patient gastrectomy for carcinoma

Contaminated Polymicrobial Gross 15-40% "Spill" during elective GI

contaminat ion surgery, perfora ted gastric
ulcer
Dirty Polymicrobial Established 40% Drainage or intra-abdominal
infection abscess, resection of
infan:ted intesti De.

II. Pathogenesis of infection

A. Anything that leads to increased bacterial virulence (numerous adjuvants fall

into this category) or anything that reduces host defense may lead to
increased chances of infection.

B. Numerous adjuvants of bacterial virulence include presence of hemoglobin,

dead tissue, foreign body, decreased oxygen concentration in the tissues, etc.

c. Systemic factors such as shock, hypovolemia and hypoxia deter a host defense
as well as the coexistence of systemic problems such as diabetes, obesity,
starvation, alcoholic liver disease, systemic drug therapy with corticosteroids
or cancer chemotherapy, etc.

m. Prevention of surgical infection

A. Most surgical infections stem directly from the patients own endogenous I

microflora and depend on the degree of contamination present at the time

of the procedure.

B. Personnel in the operating room are the most common source of bacterial
contamination in this setting. Thus, the use of masks, gowns, gloves,
operating room air filtering system, etc. are employed.
Chapter 4

C. Prophylactic antibiotics are used for clean contaminated and

contaminated wounds.

1. Should be started 1 to 2 hours prior to the operating time to allow

for adequate tissue concentration.

2. Prophylactic antibiotics are carried through the operation and for no

more than 24 hours post operatively.

3. Shaving the patient's skin prior to the operating room should not be
undertaken.

4. Elective colon surgery should be done with mechanical bowel prep as

well as either systemic antibiotics or orally administered, poorly
absorbed antibiotics to reduce enteric bacteria within the colon.

5. Prophylactic antibiotics may be used in "clean" procedures that involve

placement of foreign body prostheses such as heart valves, orthopedic
appliances or vascular grafts.

D. When dealing with contaminated wounds and dirty procedures, risk of wound
infections exceed 15 to 20% and therapeutic antibiotics are then used
beginning preoperatively and extending until the infection is well contained.
Additionally, the wound surface is left open after closing the fascia so that
the wound can be managed with wet to dry dressings. Adequate drainage
of pockets of infection is imperative.

IV. Community-acquired infectious.

A. Skin or skin structure infections.

1. Soft tissue infections following minor cuts or abrasions may present

with spreading cellulitis and usually represents infection with
Streptococci or Staphylococci species.

a. Erysipelas is an acute spreading ceUulitisflymphangitis due to

hemolytic strep and marked by skin that has a distinct border
between normal and the red, swollen, tender diseased area.
Especially common on the face.

b. IDlpetigo is an acute contagious skin disease of Staph or

hemolytic strep origin and marked by a series of

26
 SURGICAL INFECTIONS

intraepithelial abscesses coalescing into large areas of

pustules and ulceration with a "honey-crust II exudate.

2. These wounds may be more severe and involve necrotizing

streptococcal gangrene or widespread cellulitis and lymphangitis,
necessitating increased doses of antibiotics toward these bacteria and
surgical debridement of involved tissue.

3. A funmcle (a boil) is an abscess in a sweat gland or hair follicle

(Staphylococcus aureus) while a carbuncle is a multi-locular suppurative
extension of a furuncle into the subcutaneous tissue.

B. Peri-rectal abscess

1. A commonly encountered subcutaneous infection of the perirectal

tissues (obstructed perianal glands) containing mixed enteric flora
bacteria. Wide-spectrum antibiotics are used after incision and
drainage of the abscess.

C. Biliary tract infections

1. Usually the result of obstruction of the cystic or occasionally, common

bile duct.

2. Involved bacteria include Escherichia coli, Klebsiella species, enterococci

and Clostridia.

3. Cephalosporins are particularly highly concentrated in bile and are

very useful for these infections as are other antibiotics for these
organisms.

D. Acute peritonitis

1. Usually the result of mechanical perforation of tbe hollow viscus,

representing a mixed flora infection of the peritoneal cavity.
Anaerobes and gram-negative enteric bacteria are tbe most common
and antibiotics directed toward these should be initiated.

E. Other community-acquired infections

27
Chapter 4

1. Breast abscess - most common in lactating mothers. Characterized by

local pain, swelling and redness and most often caused by
Staphylococcal infections.

2. Gas gangrene - Clostridium perjringens infection of the soft tissues may

include cellulitis and myonecrosis, marked by a brown, watery
drainage from the wound site and marked tenderness around the
wound. Very severe infection requiring wide debridement and
antibiotic dosage.

3. Tetanus - unusual infection caused by the exotoxin of Clostridium

tetani. Management includes debridement of devitalized contaminated
tissue along with immunization and penicillin.

4. Hand infections - result from trauma (especially bites) and mixed flora
invasions. Penicillin treatment and wide drainage are indicated.

V. Hospital-acquired infection

A. Pulmonary infection

1. Post-operative atelectasis leading to fever from entrapped bacteria are

very common in the first 48 hours after a general anesthetic.

a. Respiratory therapy by the nurses, family members or

respiratory technicians to induce deep breathing, coughing, etc.,
will resolve this.

2. Post-operative pneumonitis may be ventilator associated, particularly

in critically ill patients. Most common organisms are gram negative
species, especially Pseudomonas and Serratia.

a. Mechanical cleansing of the bronchial tree and high dose

antibiotics, along with overall nutritional status are important
in patient salvage of these very serious infections.

3. Aspiration is an ever present risk in the post-operative patient.

a. Aspiration leads to chemical damage of the lung and

introduction of local bacteria and can be best prevented by
liberal use of NG decompression of GI tract.

28
 SURGICAL INFECTIONS

B. Urinary tract infection

1. Patients with indwelling Foley catheters will often develop bladder and
urethral infections particularly with gram-negative organisms (E coli).

2. Most positive cultures will clear after removal of the catheter but also
require systemic antibiotics.

C. Wound infection

1. The wound is always a consideration, particularly after third to fifth

day, as a source of fever.

2. Signs and symptoms include tenderness, redness, heat, swelling around

the wound; discharge of pus from the wound is dermitive.

3. Required treatment includes opening the wound, evacuation of pus and

debridement of necrotic tissue, along with systemic antibiotics.

D. Intra-abdominal infection

1. Abscess formation may occur after intra-abdominal operations,

depending on the type of operation performed.

2. These become manifest at five to seven days with spiking fevers,

associated systemic illness (tachycardia, diaphoresis, anorexia, weakness,
etc).

3. X-rays of the abdomen and CT scans are helpful in identifying intra-

abdominal abscess, as are Gallium-67 scans and labelled WBC scans.

4. Abdominal exploration of post-operative abdominal patient with

abdominal tenderness and fever is often the only way to dermitively
diagnose the problem.

5. Abscesses identified on CT scan may occasionally be drained with

percutaneous placement of catheters and irrigation of the cavity.

E. Intravascular device associated bacteremia

1. Bacteremia may be associated with any invasive intravascular catheters

29
Chapter 4

and devices.

2. Clearing bacteria from these devices is very difficult as the

intravascular antibiotics pass quickly and it is difficult for leukocytes
to deal with the bacteria harbored on these devices.

3. Fevers which have no other source and cannot be eliminated with

antibiotics usually require removal of these indwelling devices to clear
the infection.

4. Staphylococcal aureus or epidermidis are the most common types of

organisms involved in these infections.

30
Chapter 5 MULTIPLE TRAUMA

I. Primary survey - ABCDE

A. Airway

1. Chin lift/jaw thrust

2. Oral airway

3. Nasal airway

4. Oral tracheal/nasotracheal intubation

5. Cricothyrotomy

B. Breathing

1. Evaluate for hemothorax, pneumothorax or tension pneumothorax.

2. Life-threatening problems of breathing

a. Tension pneumothorax - results from an opening in the chest

wall and the pulmonary airway which allows air into the
pleural space, but no way to escape. Hypoxia is associated
with decreased breath sounds on the side of the tengion
pneumothorax with deviation of the trachea away from the side
of the tension pneumothorax, resulting in rapid cardiovascular
collapse. Treatment includes large gauge needle inserted into
the second intercostal space anteriorly to relieve the pressure,
followed by a chest tube.

b. Simple pneumothorax - decreased breath sounds on side of

injury with resulting hypoxia and hyperresonance on the
opposite side, no tracheal deviation, treatment with chest tube.

c. Massive hemothorax - results from injury to any vessel either

in the chest wall or mediastinum, associated with hypoxia,
decreased breath sounds and hyporesonance on percussion of
the involved side, treatment involves placement of chest tube
and rapid fluid resuscitation.

d. Flail chest - associated with multiple broken ribs, often broken

in two positions so that during inspiration the chest wall caves
Chapter 5

in and during expiration the chest wall flaps out, results in

hypoxia and agitation. Treated with chest tube and positive
ventilation when necessary.

e. Cardiac tamponade - associated with anterior chest trauma,

resulting in elevated jugular distention (elevated CVP),
decreased blood pressure and decreased heart sounds (Beck's
triad). Water bottle heart on chest X-ray. Treated with
aspiration of blood from the pericardial space, usually only a
small amount needs to be removed (50 ccs).

C. Circulation

1. Start two large bore (14-16 gauge) peripheral IVs with lactated
Ringers or normal saline.

2. Adequacy of volume resuscitation gauged by mental function, blood

pressure and heart rate, urinary output, central venous pressure or
pulmonary artery wedge pressure.

D. Disability

1. Careful neurologic evaluation for acute neurologic deterioration.

E. Exposure

1. Remove all of the patient's clothing; be sure to log roll the patient to
examine his back.

n. Secondary survey

A. General

1. After the initial primary survey and immediate correction of any

problems identified during the primary survey, begin a careful review
of the patient's history and physical exam from head to toe, front and
back. Most neurologic, chest, abdominal and extremity injuries are
identified and cared for during the secondary survey.

2. Frequent repeated reassessments of the patient's airway, breathing,

circulation and neurologic status are important during the secondary

32
 MULTIPLE TRAUMA

survey. Any deterioration should prompt return to the primary

survey and treatment of those major life-threatening injuries.

B. Head and spine injury

1. Closed head injury may result in space occupying lesions such as

intracerebral hematoma, subdural hematoma or epidural hematoma.

a. All are marked by focal neurologic deficit and all have the risk
of tentorial herniation if further brain edema occurs.

b. All use CT scanning or MRI scanning for diagnosis.

c. All may be treated by surgical intervention to relieve the

underlying pressure.

2. Diffuse cerebral contusion is the most common closed injury resulting

in diffuse non-focal CNS deficit. Recovery is variable and largely
dependent upon intracerebral pressure and edema. Is generally not
helped by surgical intervention but may receive some benefit with
mannitol or decadron to decrease swelling in the normal brain
lowering pC02 with ventilation support, and keeping the intravascular
volume low. Intracerebral pressure monitoring may be helpful.

3. Glasgow coma scale is used to predict neurologic recovery. It includes

the major categories of eye opening, verbal response and best motor
response with better prognoses in patients with higher levels of
spontaneity, orientation and following of commands. A GCS score of
8 or less is generally indicative of serious CNS injury.

33
Chapter 5

GLASGOW COXA SCALE

Eye Opening
spontaneous 4
to verbal stimulus 3
to painful stimulus 2
none 1

Motor response
follows commands 6
localize painful stimulus 5
complicated and variable 4
response to pain, arms & legs
decorticate posturing 3
decerebrate posturing 2
no movement to pain 1

Verbal response
oriented 5
confused answers 4
speaks a few words 3
unintelligible noises 2
no verbal response 1

4. Any patient with severe head trauma should be suspected of having

cervical spine trauma.

a. Requires good lateral C-spine revealing all seven cervical

vertebral bodies.

b. Patient must have had his C-spine held rigid until instability of
the cervical spine can be ruled out.

c. Any suspected injury to the spinal cord resulting in distal

paralysis or unstable vertebral injuries must be treated with
immobilization and relative dehydration to help reduce swelling
until definitive repair can be undertaken.

5. Spinal fluid leaks may be detected with otorrhea or rhinorrhea.

Periorbital ecchymoses (raccoon eyes), paramastoid ecchymosis (Battle's

34
 MULTIPLE TRAUMA

sign) and hemotympanum are all indicative of basilar skull fractures

and increase the risk of infectious complications (meningitis or brain
abscess).

6. Seizure disorder, cranial nerve palsies, and diabetes insipidus are

complications of closed head injury of varying frequency.

C. Thoracic injuries

1. Tension pneumothorax, simple pneumothorax, hemothorax, flail chest

and cardiac tamponade are all reviewed in I.B. above.

2. Penetrating trauma to the thorax most often results in simple

pneumothorax or hemopneumothorax and generally only requires
treatment with chest tube.

3. Injury to the great vessels in the thorax often results in death very
quickly. In patients who make it to the hospital, this injury usually
requires aortography for definitive diagnosis and treatment.

4. In patients who arrive in the emergency room alive, trauma to the

great vessels usually does not cause significant hypotension problems.

5. Pulmonary contusion often becomes manifest 1 to 4 hours post injury

resulting in hypoxemia and worsening of the chest X-ray and is
treated by careful judicious use of fluids guided by central pressure
monitoring and treatment of any potential infections.

6. Myocardial contusion, particularly with anterior chest trauma, is

marked by S-T elevations and elevated CPK fractions suggesting
myocardial infarction.

a. Right ventricle most commonly involved. Arrhythmias may

occur.

b. Requires monitoring in an leu for 42 to 78 hours to identify

and treat arrhythmias.

7. Radiographic signs suggesting thoracic aortic injuries include a

widened mediastinum, loss of aortic knob, pleural cap, deviation of
trachea to the right, fracture of the first or second rib or scapula,

35
Chapter 5

elevation of right mainstem bronchus, depression of left mainstem

bronchus, obliteration of aortopulmonary window, deviation of the
esophagus to the left.

8. Esophageal injuries - esophageal ruptures can be identified by

esophagograms or esophagoscopy. They may be suspected by
mediastinal crunch (Hamman's sign) and fever. Particulate matter
may be found in a left pleural effusion which develops.

a. These injuries, if not treated early, are frequently fatal.

b. Surgical repair with wide drainage and occasionally deviation

of GI tract is indicated.

9. Traumatic diaphragmatic hernia may occur after blunt or penetrating

trauma, resulting in tears in the diaphragm which may allow intra-
abdominal contents into the chest.

a. More common on the left than on the right.

b. Results in respiratory distress, requires repair usually through

an intra-abdominal approach.

D. Abdominal injuries

1. The abdominal cavity may extend from the nipple line (with elevated
diaphragm) all the way down to the bottom of the pelvis.

2. Evidence of intra-abdominal injury on examination with either

significant abdominal pain or abdominal distention with hypotension
should be indication for immediate laparotomy.

3. In the unconscious patient with a benign abdominal exam, the patient

who is about to be removed from your ability to frequently examine
the patient, ie, going to the OR for repair of extremity injury; or the
patient on whom the exam is questionable might be served by having
peritoneal lavage.

a. Peritoneal lavage is usually performed using an open technique

below the umbilicus, instilling 1,000 ccs of lactated Ringers into
the abdominal cavity and allowing it to return. The presence

36
 MULTIPLE TRAUMA

of gross blood or intestinal contents on aspiration is indicative

of a positive exam.

b. Also indicative of positive exam is 105 red cells, 500 white blood
cells, amylase greater than serum amylase, bilirubin greater
than serum bilirubin.

c. A negative peritoneal lavage does not rule out injuries to

retroperitoneal organs, such as pancreas, duodenum, aorta, vena
cava or kidneys.

4. A CT scan of the abdominal cavity can also be very good for

identifying intra-abdominal injuries as well as retroperitoneal injuries.

5. Blunt trauma with hemorrhage most commonly results from injury to

the spleen or liver.

a. Massive splenic injuries disrupting the body of the spleen and

particularly the hilum should be treated with splenectomy.
Lesser degrees of injury may be repaired.

b. Liver lacerations (most common) can be treated with suture

control of the bleeding sites and/or packing of the wounds.
Massive liver injuries may require lobectomy.

c. Stable patients with simple lacerations of the spleen or liver

detected on CT but without evidence of continuing blood loss
or other intra-abdominal injury may be treated with
observation only.

6. Other blunt injuries in the abdomen include rupture of the small

bowel (associated with seat belt injuries) and destruction of any of the
major vessels and rupture of the kidneys.

7. Penetrating abdominal trauma occurs with gunshot wounds, knife

wounds or other sharp instruments.

a. All gunshot wounds to the abdomen require laparotomy because

of the danger of blast effect injuring organs not directly in the
path of the missile.

37
Chapter 5

b. Stab wounds that result in diffuse pain, significant bleeding or

extrusion of intra-abdominal contents require laparotomy (some
centers would use peritoneal lavage in patients with lesser
degrees of injury to identify those which require laparotomy).

E. Extremity injuries

1. Assessment of distal pulses and neurologic function is most important

in any extremity injury.

2. Stabilization of fractures or dislocation of extremities is important,

particularly after alignment of those fractures that have been
displaced.

3. Femoral fractures and pelvic fractures may be associated with

hemorrhagic shock without overt external signs of the massive blood
loss that can occur in these areas.

4. Orthopedic lllJuries particularly prone to be associated with

neurovascular injuries are supracondylar fractures of the humerus and
femur and dislocation of the knee.

F. Tetanus prophylaxis

If the patient's immunization history is unknown or patient has been

immunized more than ten years previously, should receive 0.5 ccs of absorbed
toxoid with most non-tetanus prone wounds. Those with very significant
tetanus prone wounds should also receive 250 units of tetanus immune
globulin. Patients who have been immunized more than 5 years previously
and have tetanus prone wounds should also receive 0.5 ccs of absorbed
toxoid. No therapy is needed in patients, who have been fully immunized
with the last booster within ten years (who have a non-tetanus prone wound).

38
Chapter 6 BURNS

L Types and classification of burn injuries

A. Types of burn injuries

1. Scalds

2. Flame burn

3. Radiation burn

4. Electrical burn

B. Classification of depths of burn injury

1. First degree - involves burn of superficial layers of skin, is painful,

does not result in blisters or scarring (example - sunburn).

2. Second degree - more severe injury of the dermis and epidermis

resulting in a red, painful wound which blisters and weeps. Epithelial
regeneration can occur without extensive operative procedures, barring
complications (infection).

3. Third degree - burn involving deeper layers of tissue with total

destruction of dermal, subdermal elements including nerves, resulting
in a white, dry, hard, painless wound. These injuries will not heal by
themselves and require significant contraction or skin grafts to heal.

4. Fourth degree - severe burn involving all layers of the dermal and
subcutaneous tissue down to and including bone and tendon, requires
major reconstructive procedures to repair.

5. Electrical burn - may be associated with any depth of wound.

a. Entry site and exit sites may be the only external manifestations
of the injury, however severe muscle injury may occur
subcutaneously that requires fluid resuscitation and careful
electrolyte balance and renal protection from myoglobin, etc.

6. Inhalation injury is manifested by singed nasal hairs, carbonaceous

sputum, hypoxia, tachypnea and other history suggesting possible
Chapter 6

inhalation injury, including flame burn in a closed environment,

explosion, etc.

a. May need to be managed with endotracheal intubation and

mechanical ventilation.

n. Treatment

A. Fluid resuscitation

1. Rule of 9's

a. The upper extremities and the head and neck each make up
9% of total body surface area each, while the anterior and
posterior torso lower extremities each make up 18 % each;
genitalia make up 1 %. This applies for adults and must be
modified for infants.
9

;\13 ~5

b.
}
18
Adults ~ } :nfanlS
Admit patients with 20 and 30 burns > 15 % BSA; 30 > 2 %
BSA; age < 5 or > 60; airway or inhalation injury; significant
co-morbidity; electrical injury; deep burns of face, hands, feet
or genitalia; suspected child abuse.

2. Parkland formula for fluid resuscitation - 4 ccsfkgJ % BSA burned in

addition to normal maintenance fluids given totally as crystalloid with
1/2 the volume given in the fll'St 8 hours post bum and the second
1/2 given over the next 16 hours.

40
 BURNS

a. Adequacy of fluid resuscitation is judged by urinary output,

central venous pressure monitoring, blood gases, mental function
and serum electrolytes.

b. Colloid replacement begins in the second 24 hours depending on

the patient's hematocrit, serum albumin, etc.

3. Other fluid resuscitation recommendations are available, ie, Brooke

formula, etc.

4. Most common cause of death in the rIrst 24 hours is inadequacy of

fluid resuscitation.

B. Wound care

1. Initial management involves removal of dead or necrotic tissue.

Coverage of the wound with topical antibiotic agents (Silvadene, etc.).

2. Hydrotherapy used commonly to help with debridement and cleaning

of the wound.

3. Early skin grafting with split thickness skin grafts can be helpful.

4. Firm eschars involving thorax or extremities may lead to compartment

syndromes or respiratory difficulties requiring escharotomies.

5. Antibiotics are reserved for use after skin grafting or in the presence
of systemic infection with wound biopsies having greater than 105
organisms present.

6. Most common cause of death after the initial resuscitative phase is

sepsis.

C. General measures

1. In addition to the above wound care, it is important to maintain

adequate nutrition in severely burned patients whose catabolic needs
may exceed five to six thousand calories per day.

2. Extensive rehabilitation with physical therapy, occupational therapy,

etc. may be needed to help wound contractures and to rehabilitate the
patient.

41
Chapter 7 WOUND HFAUNG

L Pathophysiology

A. Normal healing

1. Inflammatory phase (also substrate phase, lag phase, exudative phase)

a. Consists of aggregation of platelets, polymorphonuclearcytes and

macrophages to occlude damaged blood vessels and begin
phagocytosis of foreign bodies. Release of local vasoactive
hormones such as bradykinin, along with activation of the
complement pathway and platelet derived growth factor (pDGF)
induces white cell migration and induction of macrophage
activity. This local hormonal milieu includes angiogenesis
growth hormone to stimulate the development of new blood
vessels and macrophage derived growth factor which stimulates
replication of fibroblasts. Epithelial migration starts in 12
hours. In 1 wound healing, this phase lasts approximately 4
0

days and epithelization will be complete in a few hours.

2. Proliferative phase

a. Proliferation of fibroblasts with extensive collagen production at

about 4-6 days and proliferation of angiogenesis with extensive
capillary production are the main thrust of this phase.
Macrophages have destroyed most of the invasive bacteria and
other foreign bodies in the wound and the wound now becomes
stabilized and rich in vasculature. This is the so-called
granulation tissue.

b. Proliferative phase extends from the end of the inflammatory

stage (48-72) hours and extends until full epithelization occurs.

c. Epithelization also occurs during this phase, depending on the

size of· the denuded wound. Epithelial cells migrate
approximately 1 mm per day toward the center of the wound.

d. An important feature during this period is contraction of the

wound by surrounding myofibrils, thus reducing the size of the
wound.
Chapter 7

3. Maturation phase

a. Between epithelization of the wound on day 5 --7 out to day

40-45, there is extensive re-workirig of· the collagen network
within the wound, aligning collagen fibrils in directions of skin
tension, thus improving wound strength. No additional collagen
is produced after about day 42.

b. The maturation of the scar occurs over the next 9-12 months;
resulting in flattening of the scar with the skin becoming more
pale and supple.

B. Abnormal healing

1. Numerous factors playa role in normal and abnormal wound healing.

Listed below are the items of particular importance.

Tissue oxygen supply

Presence of foreign bodies or necrotic tissue
Widely separated tissue edges
Poor macrophage function (inhibits inflammatory phase)
Diabetes mellitus
Cushing1s syndrome
Glucocorticoid steroid administration
Poor nutritional support
Vitamin C deficiency (collagen bonding deficiency)
Zinc deficiency
Other vitamin and mineral deficiencies
Overwhelming sepsis
Cancer cachexia
Protein malnutrition

2. Keloids - abnormal proliferative response to wound healing, which

seems to be genetically determined, seen more commonly in blacks
than caucasians.

3. Contracture - abnormal condition involving foreshortening of normal

tissues versus contraction which is a normal part of the inflammatory
and proliferative phase of wound healing, which reduces the size of
the wound.

43
n. Classification of wounds

A. Types of wounds

1. Laceration - clean cut edges of epidermis, dermis and varying levels

of subcutaneous tissues

2. Crush injuries which mayor may not involve lacerations but involve
crushing injuries to the subcutaneous tissues.

3. Abrasions - generally involve injury to the epidermis and varying

levels of dermis of the skin, particularly secondary to scrape type
injuries.

4. Stellate - often involve crush injury with laceration to the skin in

several radial patterns, usually indicative of severe force of trauma.

B. Infection risks

1. Clean wounds - elective procedures on non-contaminated areas after

adequate skin prep with sterile instruments. There is very low
incidence of wound infection with these wounds (3 percent), example
would include surgical repair of a hernia.

2. Clean contaminated wounds - involves the operation on potentially

contaminated structures which have been cleaned ahead of time and
would include intra-abdominal operations which do not enter the
viscera. Risk of wound infection is low (5 - 15 percent).

3. Contaminated wounds - this category of wounds involves those that do

enter the abdominal viscera, particularly the colon and esophagus.
Risk of perioperative wound infection is moderately high (15-40
percent).

4. Gross contaminated wounds - include wounds that have been opened

for a prolonged period of time, wounds involving spillage of significant
intra-abdominal contents or wounds involving abscess cavities. Risk
of wound infection is very high (40 percent).

44
Chapter 7

m. Use or prophylactic antibiotics

A. Principles of use

1. Prophylactic antibiotics are administered to reduce the incidence of

perioperative wound infections.

2. They should be started an hour prior to the incision to allow for

adequate tissue concentration.

3. The antibiotic should not be continued more than 24 hours

postoperatively when used in a prophylactic sense.

4. Antibiotic of choice should be that of the most commonly encountered

organisms for the operation involved.

5. Prophylactic antibiotics should be used when there is a significant

chance of perioperative wound infection, particularly the contaminated
group of wounds and some clean contaminated operations.

6. Prophylactic antibiotics are also indicated when the consequences of

infection are extremely devastating, even though the risk of infection
is low. Examples: placement of prosthetic vascular, orthopedic or
cardiac materials.

IV. Wound care

A. Types of closure

1. Closure by r intention - indicates the wound is closed either with

sutures, steri-strips or other mechanical devices after adequate
irrigation and debridement. Wounds are closed layer by layer so that
no dead space remains. Closed suction drains are occasionally useful
to help obliterate dead space and remove accumulating blood or other
fluids.

2. 2° intention - indicates wounds that are allowed to heal while the skin
edges are left open. This allows foreign materials on infected tissues
to be debrided over time and prevents the chances of spreading
underlying wound infections.

45
 3. Delayed 10 closure - in which a wound is loosely closed with a few
stitches and packed with gauze and left for 3 to 5 days, at which time
if no pus is identified, the wound can be fully closed.

a. Delayed primary closure is used in potentially contaminated

wounds in which full primary closure is not felt to be
indicated, but healing by secondary intention may not be
necessary.

4. Skin grafts

a. Split thickness skin grafts (STSG) - thin skin grafts used to

cover large areas of absent epithelium and dermis (ie, large
burn wounds or abrasions). These grafts tend to contract and
their color tends to remain abnormal compared to the
surrounding tissues. In addition, thickness tends to be less than
the surrounding tissues.

b. Full thickness skin graft (FTSG) - used for cosmetically

sensitive areas to fiU in dermal defects of no greater than 1 to
2 cm in diameter because of the difficulty with blood supply.
These grafts contract less, have better coloration with the
surrounding tissue and blend in better.

5. Flaps

a. Local pedicle flap - a segment of skin and subcutaneous tissue

is locally rotated to cover the defect.

b. Muscle flap - the blood supply to a muscle is used and

maintained to allow filling of a large tissue defect. These are
usually covered with split thickness skin grafts.

c. Free flap: Muscle or other soft tissues are removed from one
area of the body and the vascular supply is sewn in elsewhere
to fill in a large soft tissue defect. Again, these are often
covered with split thickness skin grafts.

B. Wound infections

46
Chapter 7

1. Clinical manifestations usually involve erythematous, warm, painful

areas surrounding the wound edges. Leakage of serosanguinous fluid
from the wound edges is an early sign suggesting wound infection.

2. Care usually involves re-opening the wound to allow drainage of the

infected material.

3. Abdominal wounds with fluid draining through the wound suggests

infection of the fascia, requiring return of the patient to the operating
room for irrigation, debridement and re-closure to prevent dehiscence
of wound and evisceration of intestinal contents.

4. Systemic antibiotics are often added to control surrounding cellulitis

or lymphangitis.

5. Cultures of the wound should be undertaken to determine the specific

etiology to enhance adequate antibiotic coverage. Staphylococcal aureus
and streptococcal species are the most common types of wound
infections.

47
Cbapter 8 ACUTE ABDOMINAL PAIN

L General aspects

A. Acute onset of pain in the abdomen that lasts more than six hours without
other preceding events is commonly associated with some sort of surgically
correctable disorder. Associated symptoms include nausea, vomiting, anorexia
and fever.

B. The history and physical exam are the most important criteria for
establishing the diagnosis. With careful evaluation of these aspects of patient
interaction, a fairly limited differential diagnosis can be established which
directs the pertinent laboratory and X-ray examinations.

C. The sequence of signs and symptoms and the age and sex of the patient are
most helpful in identifying a differential diagnosis.

D. A careful examination not only of the abdomen, but one which also includes
full evaluation of the chest and pelvis is very important for establishing the
diagnosis.

n. Acute appendicitis

A. Most common in second and third decade of age caused by obstruction of the
lumen of the appendix.

B. Classic presentation begins with periumbilical diffuse abdominal pain, which

in subsequent hours shifts to the right lower quadrant (McBurney's point)
and becomes much more sharp and more easily localized.

C. Physical exam reveals right lower quadrant tenderness with rebound (psoas
sign, obturator sign, Rovsing's sign) and a mild low grade fever.

D. Pertinent lab values include mildly elevated white blood cell count with a left
shift, normal electrolytes, amylase, urinalysis, usually normal abdominal X-ray
(occasional sentinel loop or fecalith).

E. Treatment consists of appendectomy. Expect normal appendix in 15-20%

of patients.

F. In patients with normal appendices at the time of exploration, look for

evidence of Crohn's disease, Meckel's diverticulitis, cholecystitis,
Chapter 8

perforated ulcer, diverticulitis, ovarian or fallopian tube diseases.

m. Pelvic inflammatory disease

A. Occurs primarily in young, sexually active females and is due to gonorrhea;

late cases may be due to enteric organisms.

B. History commonly includes onset of bilateral lower abdominal pain within a

week after menstrual periods, mild associated nausea and vomiting, commonly
has associated high fever.

C. Exam most notable for diffuse lower abdominal tenderness with poor
localization. Occasional localized pain and mass with tubo-ovarian abscess.
Pelvic exam reveals marked tenderness on cervical motion (chandelier sign).

D. Laboratory notable for markedly elevated white blood cell count (15 to 20,000
with left shift). Urinalysis, electrolytes, amylase, pregnancy test and
abdominal X-rays usually unremarkable.

E. Usually can be treated with antibiotics, occasionally requires removal of tubal

ovarian abscess.

IV. Ectopic pregnancy

A. Manifest in child-bearing age females with lower abdominal pain and

occasional cardiovascular collapse. Pregnancy test mayor may not be
positive as these may occur within two to four weeks of the last menstrual
period. History of IUD, PID or previous tubal pregnancy is helpful.

B. Presence of blood in the cui de sac is suggestive. Lower abdominal

ultrasound may be helpful in the diagnosis. Classically, vaginal bleeding
precedes the abdominal pain.

c. Treatment consists of exploration and removal of the ectopic pregnancy and

tube.

V. Biliary disease

A. Acute cholecystitis

1. Typical patient is middle-aged female who presents with repeated

49
 ACUTE ABDOMINAL PAIN

episodes of fatty food intolerance associated with right upper quadrant

pain, occasional nausea and vomiting as well as mild fever caused by
a stone occluding the cystic duct.

2. Exam reveals tenderness in the right upper quadrant with decreased

bowel sounds, mild fever and an occasional tender mass (Murphy's
sign). Not usually associated with jaundice.

3. Laboratory usually has elevated WBCs with left shift, elevated alkaline
phosphatase, occasionally mild elevation of the SGOT, LDH and
bilirubin but minimal compared to the alkaline phosphatase.

4. Abdominal ultrasound most commonly used for diagnosis. CT scan

is not usually as accurate.

5. Initial treatment usually includes NG suction, IV fluids and antibiotics

toward the gram-negative organisms that are associated with infection
in the gallbladder (E. coli, Klebsiella, Serratia, Clostridium) and
analgesics.

6. Early cholecystectomy is usually indicated with either laparoscopy or

open laparotomy.

B. Ascending cholangitis

1. Marked by Charcot's triad of right upper quadrant pain, fever and

jaundice.

2. Caused by stone occluding the common bile duct.

3. Represents medical emergency as overwhelming sepsis can cause death

of the patient within 12 to 24 hours.

4. Treatment consists of NG suction, IV fluids, high dose antibiotics and

early decompression of the biliary tract through percutaneous drainage
or operation as indicated if the patient does not improve within a few
hours.

50
Chapter 8

VI. Acute pancreatitis

A. Most commonly associated with alcohol abuse or with passage of a gallstone

through the cystic duct and ampulla into the GI tract.

B. Presents with sudden onset of acute epigastric abdominal pain radiating into
the back; may be associated with acute cardiovascular collapse, fever, nausea
and vomiting; often occurs soon after a meal.

C. Abdominal exam is usually indicative of upper abdominal pain that may be

poorly localized. Minimal bowel sounds and usually no masses.

D. Pertinent lab includes elevated white count with left shift, hemoconcentration
on the electrolytes and markedly elevated serum amylase and lipase.
Abdominal X-rays may show a sentinel loop or may show pancreatic
calcifications in patients with chronic pancreatitis with recurrent acute
episodes.

E. Initial treatment involves GI tract rest (NG suction), IV fluids and analgesics.
Decreasing pancreatic secretion by giving secretin exogenously may be
helpful. Nutritional support also important.

F. Operative intervention usually indicated for complications of acute

pancreatitis including development of pseudocyst, development of pancreatic
ascites, development of pancreatic necrosis (hemorrhagic pancreatitis) or onset
of hemorrhage, etc.

VTI. Perforated duodenal ulcer

A. Most often occurs in population groups that commonly have duodenal ulcers,
however, may be the first manifestation of ulcer disease. Classic onset is that
of very sudden onset of excruciating abdominal pain. The patient can often
pinpoint the exact time of onset. The patient mayor may not have previous
history of ulcer disease.

B. Examination marked by the presence of a "board like II abdomen which is

very tense and tight with no bowel sounds.

C. Laboratory reveals elevated white cell count with left shift and a hemo-
concentration on the hemogram and electrolytes. Amylase may be

51
 ACUTE ABDOMINAL PAIN

mildly elevated. The best X-ray for demonstration of free air is upright
chest X-ray. An alternative would be a left lateral decubitus abdominal X-
ray. 20% of the time, no free abdominal air is demonstrated.

D. Treatment consists of NG suction, IV fluids, IV antibiotics and operative

exploration to close the perforation. In patients with chronic ulcer disease,
a definitive ulcer operation is usually undertaken at the same time.

vm. Acute diverticulitis

A. Similar to acute appendicitis, except occurring in older age groups and more
commonly associated with left lower quadrant abdominal pain.

B. History is generally that of onset of pain in the left lower quadrant with
continued worsening, may be associated with fever, nausea and vomiting and
occasional diarrhea or constipation complaints. It generally occurs in older
age patients (greater than 50 years old).

c. Physical exam suggests a tender abdomen with rebound to the left lower
quadrant, decreased bowel sounds, fever, tachycardia, tachypnea. Occasional
mass in the involved area (diverticular abscess).

D. Pertinent laboratory will include elevated leukocyte count with left shift,
hemoconcentration and abdominal X-rays which are generally non-specific.
No attempt at barium enema or colonoscopy should be done early because
of the risk of perforation.

E. Treatment consists of NG suction, IV fluids and antibiotics. Abdominal

exploration may be necessary to remove the offending portion of the colon
and create a fecal diversion if symptoms donlt rapidly improve.

IX. Small bowel obstruction (SBO)

A. SBO may be the cause of acute abdominal pain but is not commonly
associated with acute sudden onset pain. Most common presentation is that
of progressive abdominal distention with crampy colicky abdominal pain,
associated with nausea, vomiting and obstipation.

B. Examination reveals a distended, tympanitic abdomen with high-

52
Chapter 8

pitched, active bowel sounds.

C. Laboratory reveals mildly elevated white cell count and hemo concentration
on hemogram and electrolytes, abdominal X-rays reveal distended loops of
small bowel in a stair step fashion with air fluid levels and no air in the
colon.

D. Treatment consists of NG suction, IV fluids and hydration, usually

prophylactic antibiotics and early abdominal exploration after fluid
resuscitation to prevent development of strangulation and bowel rupture.

X. Genitourinary problems

A. Urolithiasis

1. Sudden onset of extremely severe abdominal or flank pain that

radiates toward testicle. Patient often cannot f"md a position of
comfort.

2. Urinalysis reveals hematuria; 90% of renal stones show up on X-ray.

IVP can be helpful.

3. Treat with IV hydration and analgesics, occasionally retrieval with a

basket in OR, or with lithotripsy.

B. Testicular torsion

1. Occurs in young men « 25 years old). Abrupt onset of severe pain

with associated nausea and vomiting.

2. Requires urgent operative intervention.

53
Chapter 9 ESOPHAGUS

L Anatomic points of interest

A. Two layers: striate muscle upper one-third, smooth muscle lower two-
thirds.

B. Muscle with no serosa (= difficult to sew).

C. Squamous epithelium - columnar epithelium.

D. No anatomic lower esophageal sphincter (LES) - physiologic only,

relying on unique anatomic relationships.

E. Upper esophageal sphincter (DES) formed by the cricopharyngeus

muscle sling.

F. Four points of constriction

1. UES close to 15 cm from incisors.

2. Crossing beneath aortic arch close to 22 cm.

3. Crossing beneath left main stem bronchus at 28 cm.

4. LES at 40 cm.

G. Blood supply from aorta via direct and anastomosing branches.

H. Lies in posterior mediastinum in chest.

I. Wrapped by network of vagal nerve fibers.

n. Physiology

A. General

1. Peristaltic wave - voluntary up high, then involuntary propagation.

a. Produces 200-600 mm Hg intraluminal pressure and travels 9

to 25 cm per second.

2. LES relaxes to accept food passage, then returns to normal resting

pressure (15-25 mm Hg above pressure in stomach).
Chapter 9

a. LES constricts to theophylline, ETOH, nicotine, nitroglycerine,

diazepam, fats and chocolate.

b. LES increases with urecholine, metoclopramide and protein

meals.

3. Tertiary contractions in older patients.

B. Assessment

1. Esophageal manometry

a. Small catheter with pressure transducers at 5 cm intervals

which track pressure wave through swallowing mechanism.

2. pH monitoring to evaluate reflux esophagitis.

a. Same or similar catheter - pH in esophagus at various positions

- check time to clearance of acid - may do 24 hour pH
monitoring for number of reflux episodes and time to clearance
of acid.

3. Bernstein provocative test - instill acid in esophagus to see if

symptoms recur.

4. Barium swallow

5. Endoscopy

m. Pathology

A. Motility disorders

1. Cricopharyngeal m. dysfunction - Zenker's diverticula (post-midline) -

pulsion type (vs traction type in mid-esophagus).

a. Symptoms of regurgitation, putrid breath odor.

b. Treated with excision of redundant mucosa and myotomy.

2. Epiphrenic diverticula - often don't need treatment. Thought to be

55
 ESOPHAGUS

pulsion type etiology.

3. Achalasia - inability to relax LES - dilated esophagus - Bird's beak

appearance on barium swallow - more dysphagia with liquid than
solids. Rx with balloon dilatation or Heller myotomy.

4. Nutcracker" esophagus - increased motility - chest pain - Rx NTG,

II

nifedipine.

5. Presbyesophagus - tertiary contraction.

6. Scleroderma - poor or no motility - difficulty swallowing, weight loss.

B. Reflux esophagitis

1. Often associated with sliding hiatal hernias (Type I).

a. E-G junction moves into mediastinum.

2. Treatment of reflux esophagitis - elevate head of bed, antacids, +/- Hz

blockers, discontinue ETOH, tobacco, caffeine.

3. Operate for intractable symptoms, bleeding, stricture (obstruction) -

Nissen, Hill, Belsey - 80 % + success.

4. Barrett's esophagus - columnar metaplasia of lower part of esophagus,

due to chronic acid injury - increased incidence adenocarcinoma
(10%).

C. Paraesophageal hernias (Type m

1. Potential for incarceration, strangulation, ulcer with bleeding or
perforation, therefore repair the hernia when found before
complications occur.

2. E-G junction remains in place while stomach herniates through hiatus

into mediastinum.

D. Cancer

1. Associated with tobaccofETOH abuse, diet, vitamin deficiency, poor

56
Chapter 9

oral hygiene, caustic burns, Barrett's esophagus, radiation and

Plummer-Vinson syndrome.

2. Squamous cell carcinoma (SCC) in upper two-thirds.

3. Adenocarcinoma in lower one-third with upper gastric cancer.

4. Dysphagia with solids> liquids; weight loss.

5. SCC - some response to radiation and chemotherapy (Cisplatinum) -

usually also requires excision.

6. Adenocarcinoma - minimal response to radiatioD/chemo - treat with

excision.

7. Five year survival - low (5%) for most patients. If diagnosis is made
early (Stage I) without nodal involvement, survival at 5 years
approaches 20 %.

57
Chapter 10 STOMACH

L Anatomy

A. Fundus and body

1. Parietal cells - BCL

2. Chief cells - pepsinogen - activated to pepsin which pB < 2.5

3. Mucous cells

B. Antrum - G cells - gastrin

C. Pylorus - controls rate of gastric emptying

D. Arteries

1. Left and right gastric (via celiac axis)

2. Left and right gastroepiploic

3. Short gastric branches

4. Gastroduodenal

E. Veins and lymphatics follow arteries

F. Nerves

1. Vagus enters via esophageal hiatus with the left trunk anterior (also
supplies gallbladder and liver) and the right trunk posterior (also
supplies mid-gut).

a. Nerves of Latarjet are branches of the vagus to the stomach.

n. Physiology

A. Digestive function

1. BCL and pepsinogen production stimulated by:

Chapter 10

a. Cephalic - sight, smell, thought of food stimulates vagal release

of acetylcholine to increase BCL/pepsinogen (H2 receptors).
Acetylcholine also stimulates the release of gastrin from antral
G-cells. Bistamine is thought to be a critical modulator of the
process.

b. Gastric phase - gastric wall, distention presence of protein, etc,

increases BCL secretion by stretch receptors and stimulates
gastrin release by G-cells which also increase BCL/pepsinogen
secretion.

(1) acid secretion also stimulated by ETOB, caffeine,

tobacco, Ca++

c. Intestinal phase - acidic contents and distention of small bowel

cause decreased gastric motility and gastric acid/pepsin release
by secretin. Secretin also stimulates gallbladder contraction and
pancreas secretion. Low gastric pB inhibits gastrin secretion
(negative feed back mechanism).

2. Motility - gastric motility regulated by vagal innervation of B 2

receptor sites.

a. Pacemaker area high on the greater curve of the fundus.

b. Motility decreased by fats in the stomach.

m. Diagnostic tools

A. Radiography - barium swallow, upper gastrointestinal series (UGI) - easy,

relatively cheap, 80-90% sensitivity/specificity.

B. Endoscopy - flexible "EGD" esophagogastroduodenoscopy - very safe/accurate -

can do biopsies.

C. Acid analyses

1. Basal acid output (normally 2-3 mEqJhr).

2. Maximum acid output - stimulated by histamine or pentagastrin;

inhibited by secretin (normally 10-15 mEqfhr).

59
 STOMACH

IV. Peptic ulcer disease

A. Associated factors - normal to high basal acid output, "Type A" personality,
blood group A, males:female = 4:1.

B. Symptoms - burning epigastric pain on empty stomach (especially middle of

night) - relieved with food or antacids. Tends to be episodic, coming and
going over periods of months.

1. Worse with caffeine, ETOH, various foods for various patients.

C. Helicobacter pylori - bacterium that can be cultured from the ulcer bed of
most patients with peptic ulcer disease. Treatment with appropriate
antibiotics seems to aid in healing. Casual relationship not totally proven.

D. Diagnosis - UGI or EGD - most are in first portion of duodenum or in

pylorus.

E. Treatment

1. Most respond to pharmacologic acid reduction (90 %) - H 2 blockers

(cimetidine, ranitidine, omeprazole) or antacids plus avoidance of high
acid producing foods (ETOH, caffeine, CA++). Antibiotics against
Helicobacter pylori also important.

2. Indications for operation - hemorrhage (> 6 units in 12 hours, re-bleed

in hospital, visible artery in base of ulcer), perforation (25 % don't
have free air), gastric outlet obstruction and intractable symptoms in
spite of good medical management.

3. Operations include:

a. Proximal gastric vagotomy (pGV) - 15% long-term recurrence

but low complication (ie, dumping, early satiety, loop
syndromes, malabsorption syndromes, etc.).

b. Selective vagotomy plus outlet procedure - essentially not done

any more.

c. Truncal vagotomy and pyloroplasty - 10% recurrence rate -

minimal post-vagotomy syndrome.

60
Chapter 10

d. Truncal vagotomy, antrectomy, gastroduodenostomy (Billrotb I)

or gastrojejunostomy (Billrotb m have 1.5 % recurrence rate
(best) but increased incidence of dumping, afferent/efferent loop
problems, etc.

F. Zollinger-Ellison Syndrome

1. Severe ulcer disease associated witb a gastrin-secreting tumor of tbe

pancreas or duodenum.

2. Very bigb BAO (50 mEqJbr) with minimal (if any) increase witb acid
stimulation.

3. Very bigb serum gastrin levels often > 1000 pg/ml).

4. Responds to calcium or secretin (paradoxically) by increasine serum

gastrin levels.

5. May be associated witb multiple endocrine neoplasia.

6. Diagnose witb acid output levels, serum gastrin levels, response to

secretin stimulation and CT scans to look for tumors.

7. Hz blockers and proximal gastric vagotomy are used early to treat.

Total gastrectomy may become necessary.

v. Gastric ulcer disease

A. Associated factors

1. Directed mucosal lDJUry - ASA, steroids, iscbemia associated with

shock (stress ulcers), ETOH (gastritis).

2. Low basal acid output, mucous barrier breakdown with re-diffusion

H + into cells, achlorhydria, type 0 blood group, blue collar economic
class, increased in Far East cultures.

3. Gastric cancers

B. Symptoms - epigastric pain - variable relief with food/antacids - weight loss.

61
 STOMACH

C. Diagnosis - UGI or EGD with biopsy - most are on lesser curve near antrum
- beware of those on greater curve.

D. Treatment

1. Antacids, Hz blockers and cytoprotective agents (sucralfate, omeprazole)

along with avoiding or correcting underlying mucosal injury agents.
Pharmacologic management has 50-60 % recurrence rate for benign
gastric ulcers.

a. Must re-endoscope or UGI series after six weeks to be sure

ulcer has healed.

2. Indications for operation - hemorrhage, obstruction, perforation, or

intractable with best medical management (if ulcer not healed within
6 weeks, the ulcer needs to be excised to eliminate the possibility of
cancer).

3. Operations include:

a. Excision of ulcer - antrectomy if ulcer is distal (the ulcer must

be excised).

b. Vagotomy added if patient secretes a significant amount of acid.

VL Post-gastrectomy syndromes

A. Early dumping

1. Uncontrolled dumping of hypertonic fluid into small bowel - results in

acute hypovolemia and release of vasoactive hormones (serotonin,
histamine, glucagon, VIP, etc).

2. Manifested by weakness, tachycardia, diaphoresis, palpitations and

occasional diarrhea.

3. Treat by avoiding liquids with meals, avoid high CHO, ingest some fat
with each meal and some recommend propranolol.

B. Late dumping

62
Chapter 10

1. Similar symptoms to early dumping but occurs 3-5 hours after meal.

2. Due to rapid changes in insulin and glucose levels.

3. Treated by eating a small snack two hours after meals.

C. Afferent loop obstruction

1. Occurs after Billroth II reconstruction and is associated with a kink

in the afferent limb.

2. Build up of pancreatic and bile juice causes crampy pain and fmally
vomiting without food particles.

3. Treat with conversion of Billroth II to Roux-en-Y anastomosis.

D. Blind loop syndrome

1. Bacterial overgrowth in a loop or limb of bowel which does not have

chyme flowing through it.

2. Interferes with folate and vitamin BIZ metabolism leading to weakness

and anemia.

3. Treat with antibiotics.

E. Alkaline reflux gastritis

1. Weakness, weight loss, nausea, abdominal pain and anemia due to

reflux of alkaline biliary/pancreatic fluid into stomach.

2. Treatment - divert biliary fluid away from stomach.

F. Nutritional deficiencies

1. Especially vitamin BI2J folate, iron.

2~ Many patients have diarrhea and weight loss.

VB. Gastric cancer

63
 STOMACH

A. Adenocarcinoma most common - rare lymphoma, leiomyosarcoma, etc.

B. Associated factors same as with gastric ulcers - also achlorhydria, pernicious

anemia, Barrett's esophagus, lye ingestion, previous partial gastrectomy.

C. Palpable abdominal mass is common (50%) and dysphagia may occur with
cancers in the cardia.

1. Hepatomegaly occurs with metastases.

2. Perineal seeding may result in ascites, involvement of the ovaries

(Krukenberg tumor) or pelvic cul-de-sac (Bloomer's shelf).

D. Diagnosis - UGIfEGD with biopsy.

E. Treatment - operative removal. Chemotherapy, radiation therapy not very

helpful. Survival with operation < 10% 5 year due to advanced stage at
diagnosis.

64
Chapter 11 SMALL BOWEL

L Anatomy

A. Duodenum - 4 parts, pylorus to ligament of Treitz, Brunner's glands.

1. Gastroduodenal artery and pancreatoduodenal arterial arcades

2. Ampulla of Vater (sphincter of Oddi)

B. Jejunum - central two thirds of bowel

1. Superior mesenteric artery and vein (SMA & V)

C. Ileum - distal one third of small bowel

1. SMA & V

2. Meckel's diverticulum

a. Within 2 feet of ileocecal valve, anti-mesenteric border; two

types of aberrant mucosa (gastric and pancreatic); common lead
point of intussusception in 2 year olds.

3. Ileocecal valve

4. Peyer's patches - lymphatic collections

n. Physiology

A. AbsorptionfDigestion

1. Breakdown of proteins to polypeptides, fats to fatty acids, and complex

carbohydrates (CHO) to simple sugars begins in duodenum with
various enzymes (trypsin, chymotrypsin, elastase, lipase, amylase, etc.).

2. Absorption occurs throughout remainder of bowel - proteins and CHO

by active processes, lipids by passive diffusion (mainly in jejunum).
Chapter 11

3. Deum - specialized absorption of Fe (with intrinsic factor secreted by

stomach), bile salts (enterohepatic circulation), and vitamin Bu.

B. Motility

1. Parasympathetic innervation from vagus (X), increases tone and

intestinal motility.

2. Intrinsic motility is present in response to changes in intraluminal

pressures.

3. Sympathetic innervation slows tone and motility.

C. Endocrine

1. Multiple hormones including VIP, secretin, enterogastrone, motilin etc.

2. Trophic hormones for bowel mucosa growth.

D. Immune function

1. Small bowel is major source of IgA

a. Plasma cells in the lamina propria

b. Antibodies in the glycocalix

m. Crobn's Disease

A. Most common surgical disease of small bowel.

1. Etiology unknown.

2. Increased incidence 2nd-3rd decade and 6-7th decade; North

Americans and Northern Europeans most affected.

3. Non-caseating granulomatous inflammation of entire bowel wall.

4. Skip areas frequent - fissures in mucosa.

66
 SMALL BOWEL

5. Most commonly involves terminal ileum; can involve any part of the
bowel.

a. Small bowel involvement only - 30 %

b. Ileocolitis - 55 %

c. Colon only - 15 %

6. May cause enteral fistulae

B. Manifestations

1. Crampy abdominal pain, diarrhea, low grade fever, weight loss, loss
of strength

2. May present like acute appendicitis

3. May present with persistent perianal disease - fistulae, fissures,

abscesses

4. Other extraintestinal manifestations include: arthritis and arthralgias;

uveitis and iritis; hepatitis and pericholangitis; erythema nodosum;
pyoderma gangrenosum.

C. Diagnosis

1. Barium enema, UGI with small bowel follow through - "string" sign
in distal ileum.

2. ColonoscopyfEGD if within reach of the instruments - cobblestoning,

linear erosions/fissures.

D. Treatment

1. Azulfidine/prednisone for acute flare-ups. May need parenteral

hyperalimentation.

2. Maintenance medication occasionally helpful with Azulfidine.

3. Surgical excision for:

67
Chapter 11

a. hemuorrhage

b. obstruction

c. perforation

d. intractable SYJllptomus

4. Recurrence rate of approximuately 50 % in 8 years.

IV. Small bowel obstrnction

A. Etiology

1. Postoperative adhesions (60%)

2. Incarceration in hernias (20 %)

3. Others - Crohn's disease, intussusception, volvulus, tumuors

B. Types of obstruction

1. Simuple obstruction - muost comumuon

2. Closed loop obstruction - early necrosis and perforation with oonimual

prodromual illness (ie, volvulus, etc.).

3. Partial obstruction - continues to pass gas and occasionally will resolve

spontaneous Iy.

4. Strangulated obstruction - bowel necrosis

C. Diagnosis

1. History - nausea, vomuiting, obstipation, cramupy abdomuinal pain.

2. Physical examu - distended, tYEBpanic abdomuen, hyperactive bowel

sounds.

3. X-ray - dilated loops smuall bowel, air-fluid levels, no gas in colon.

68
 SMALL BOWEL

D. Treatment

1. Fluid resuscitation

a. Correct isotonic fluid losses plus hypokalemic, hypochloremic

metabolic alkalosis

2. NG decompression

3. Early laparotomy to relieve the obstruction.

E. Differential diagnosis

Paral.ytic Il.eus s.al.l Intestinal. obstruction

1. Minimal. abdominal pain 1. crampy abdominal pain
2. Nausea and vomiting 2. Nausea and vomiting
3. obstipation and failure 3. obstipation and failure to
to pass flatus pass flatus
4. Abdominal distension 4. Abdominal distension
S. Decreased or absent bowel s. Normal or increased bowel
sounds sounds
6. Gas in the small 6. Gas in the small intestine
intestine and colon on x-ray only on X-ray

V. Diverticular disease

A. Duodenal diverticula

1. Present in 10-20% of patients - 90% are asymptomatic.

2. < 5 % will require operation because of a complication.

B. Jejunal and ileal diverticula

1. Present in only 0.5-1.0% of small bowel X-ray examination.

2. Are usually false diverticula, protruding from mesenteric border.

69
Chapter 11

C. Meckel's Diverticulum

1. Most common true diverticulum of GI tract - on anti-mesenteric

border

2. Rule of 2's - 2 % of population; located within 2-3 feet of ileocecal

valve; 2 types of heterotrophic mucosa (gastric or pancreatic); most
commonly symptomatic in 2 year olds (childhood); likelihood of
symptoms in adults < 2 %.

VL Small bowel neoplasms

A. Adenocarcinoma most common intrinsic cancer of SB (most common in

duodenum).

1. Carcinoids in small bowel, second only to appendix.

a. Carcinoid syndrome - associated with liver metastasis - consists

of episodes of serotonin surge, flushing, hyperperistalsis,
diarrhea, bronchospasm, etc. (5-HIAA in urine)

2. Lymphoma also may involve small bowel.

3. Occasionally leiomyosarcoma, etc.

B. Signs/symptoms - primarily obstruction, also occasional bleeding.

C. Treatment of most tumors revolves around excision.

1. Lymphoma is responsive to chemotherapy.

70
Chapter 12 APPENDIX

L InOammation

A. Pathophysiology

Obstruction of lumen (fecalith, extrinsic lymphatic obstruction, etc.), bacterial

overgrowth and release of or activation of local vasoactive peptides, decreased
absorptive capacity while mucosa continues to secrete, increased intramural
pressure leading to compression of lymphatics, venules, and then arteriolar
capillaries which leads to necrosis and perforation.

B. Diagnosis

1. History - most common in 2nd or 3rd decade - starts with vague

periumbilical discomfort, mild nausea, fever, anorexia pain
subsequently localizes to right lower quadrant with local peritoneal
irritation and signs.

2. Exam - tenderness near right lower quadrant (McBurney's point),

normal bowel sounds, mild fever, right lower quadrant pain on rectal
exam.

3. Lab - mild increased WBC, occasional WBCjRBC in urine, otherwise

normal.

4. X-ray - occasional right lower quadrant fecalith

a. Ultrasound and barium enema not reliably helpful.

5. Negative surgical exploration in 20 % is reasonable (35 % in women

during childbearing years).

C. Treatment - excision, open or through laparoscope

D. Differential diagnosis

1. Pelvic inflammatory disease - in women, look for tenderness with

movement of cervix, bilateral pain, higher fever and WBC.

2. Crohn's disease - may present with clinical picture like acute

appendicitis in 25 % of patients. Diagnosis made by inspection of
bowel at the time of exploration (creeping fat over serosa of small
Chapter 12

bowel; thick, shortened mesentery; prominent neovascularization).

3. Other - Meckel's diverticulitis; urinary tract infection (with right

pyelonephritis); ureteral stone disease; acute cholecystitis; perforated
peptic ulcer disease; torsion of the testes; acute pancreatitis;
gastroenteritis; etc.

E. Groups at low/high risk for perforation

1. Neonates - disease is rare in this age because appendix is a short,

broad-based diverticulum and the very young do not have much
lymphatic tissue in walls of the appendix to cause obstruction. H it
does occur, diagnosis is made late.

2. Pregnant patients - delay in diagnosis of appendicitis and reluctance

to treat; abnormal location of the appendix and the pain associated
with it; inability of the omentum to reach the site of inflammation
and contain the process.

3. Elderly - delay in diagnosis and treatment; low level of suspicion in

elderly patients; signs and symptoms are often not as specific as in
younger patients.

ll. Neoplasias

A. Carcinoid tumor - unusual but most common tumor of appendix

1. Small-cell neuroendocrine (chromaffm cell) cell line origin

2. Found in appendix (50%), rectum, ileum, lungs

3. Metastasizes to liver then becomes symptomatic due to release of

serotonin - measured as 5-HIAA in urine.

4. Primary treatment is excision if < 2 cm; right hemicolectomy if > 2

cm. Anti-serotonin agents will help control symptoms (somatostatin)
or streptozocin directed at the tumor itself.

B. Adenocarcinoma - unusual mass lesion of the appendix; has the histology and
prognosis of adenocarcinoma of the colon; diagnosis rarely made prior to
excision of mass found incidentally.

72
 APPENDIX

C. Lymphoma - unusual

1. Treated like other visceral lymphomas

73
Chapter 13 COLON

L Introduction

A. Anatomy

1. Ileocecal valve - cecum - right (ascending) colon - hepatic flexure -

transverse colon - splenic flexure - left (descending) colon - sigmoid
colon.

a. Ascending colon and descending colon are retroperitoneal in

location.

2. Three longitudinal tinea divide the colon into thirds - 'Y'ertical

incomplete haustra formed by muscular bands that partake in
peristalsis.

3. Arterial supply from superior mesenteric artery to ileocolic artery,

right colic artery and middle colic artery for ascending and transverse
colon. Descending colon supplied by branches of the inferior
mesenteric artery - left colic artery and superior hemorrhoidals.
Arterial supply connects through marginal artery of Drummond and
the meandering artery of Riolan.

4. Venous and lymphatic systems generally follow the arterial patterns.

B. Physiology

1. Tremendous ability to conserve water and electrolytes by absorption.

2. Involuntary peristaltic waves move stool through colon.

a. Segmenting contractions in the right and transverse colon and

"mass movement" contractions on the left.

3. Serves as a vital storage organ.

n. Neoplastic diseases

A. Polyps

1. Juvenile polyps - may cause bleeding in children; usually self-limited;

no malignant potential.
Chapter 13

2. Hamartomas - seen with Peutz-Jeghers syndrome; is associated with

melanin spots on lips; no malignant potential.

3. Tubular adenomas - most common type of polyp found (95%); usually

small « 0.5 em); low malignant potential (5% associated with cancers)
unless numerous or large (> 1 em).

a. Familial polyposis - autosomal dominant disease of thousands of

tubular adenomatous polyps in colon; usually found in 2nd
decade of life in susceptible families; risk of cancer is virtually
100% unless colon removed prophylactically (usually done as
total abdominal colectomy, rectal mucosectomy, ileoanal pouch
anastomosis to retain continence).

b. Gardner's Syndrome - tubular adenomas throughout GI tract

(although not as numerous as familial polyposis); associated
with exostosis (esp. maxilla) and inclusion cysts in skin; -
moderate malignant potential.

4. Villotubular adenomas - histologic picture of both tubular and villous

elements; less common than tubular adenomas but higher association
with malignancy (approximately 20%).

5. Villous adenomas - more unusual than villotubular adenomas but

higher malignant potential (approximately 35 %) especially if larger (>
3 em). May cause a syndrome of watery diarrhea with huge loses of
KCL resulting in hypokalemia.

B. Adenocarcinoma of colon

1. Most common visceral cancer in United States - behind only lung and
breast as cause of cancer deaths.

2. Etiology unknown - thought to be related to dietary habits high in

animal fats and low in fiber. IDgher association with various polyps,
ulcerative colitis, Crohn's colitis, lymphogranuloma venereum, familial
cancer syndromes, and patients who have had ureterosigmoidostomies.

3. More common in left and sigmoid colon (50-70 %). Rectum

approximately 15 %, right colon approximately 24 %.

75
 COWN

a. Synchronous tumors in 5% - 2nd cancer present in the colon

at the same time.

b. Metachronous tumors 3-5 % - 2nd cancer develops at some

future date.

4. Left-sided tumors tend to develop into constricting, lI apple-core ll lesions

resulting in symptoms of II constipation II, pencil-thin stools, occult blood
with occasional bright red blood, partial or total bowel obstruction.

5. Right-sided tumors tend to develop into polypoid, fungating masses

which cause anemia and inanition resulting in fatigue, weight loss,
poor appetite, occult blood in stool, etc.

6. Both are diagnosed by colonoscopy with biopsy or barium enema.

Five percent incidence of synchronous lesions (other tumors present at
the same time but different place).

7. Treatment involves removal of tumor bearing colon, along with wide

margins of normal colon and the lymphatic drainage bed.

8. Prognosis is most related to lymphatic involvement and metastatic

spread - various modification of Duke's classification scheme are used.

a. Disease limited to mucosa, 80-90 % 5 year survival.

b. Disease through wall of colon, no lymph node or distant spread,

60-70 % 5 year survival.

c. Disease involves lymph nodes, 30 % 5 year survival.

d. Distant metastases, < 5 % 5 year survival.

9. Isolated metastases to liver can be removed with improved long-term

survival.

10. Various large scale screening efforts to detect the cancer earlier
(including proctoscopy, fecal occult blood testing, CEA antigen levels
in serum) have been largely unrewarding.

11. Chemotherapy for metastatic disease has had limited success; radiation
therapy has not been helpful except in reducing the bulk of large

76
Chapter 13

rectal cancers, making resection easier.

12. Post-operative follow-up should include annual or biannual colonoscopy.

If a high pre-op serum CEA falls after resection, serial CEA
determinations post-op can be used to detect local recurrence and
distant metastasis if the level rises. Liver enzyme chemistries and
CXR are helpful at detecting metastasis.

m. Diverticular disease

A. Diverticulitis

1. Diverticula are mucosal hernias through the muscularis and occur at

points in the colon where end arteries enter the bowel wall; are
thought to be related to diets low in fiber/bulk - they occur in most
people in Western cultures who live long enough - present in up to
70 % of elderly patients and are most common in sigmoid colon.

2. Erosion into an adjacent artery, without inflammation, may lead to

massive blood loss (diverticulosis). Tends to occur more commonly
from right or transverse colon lesions.

3. Obstruction of the lumen of a diverticulum leads to bacterial

overgrowth, swelling+ inflammation and possibly to rupture and
abscess formation - "diverticulitis".

a. Diagnostic studies (barium enema or colonoscopy) should not be

done during the acute inflammatory stage because of the risk
of perforation

4. Presentation is like a "left-sided" appendicitis in older patients.

5. Treatment of mild cases involves antibiotics against coliforms, low

residue diet during the acute phase, hydration. High fiber, high bulk
diets are started after the inflammation has subsided. Cases involving
intractable symptoms or repeated episodes, hemorrhage, obstruction
due to stricture formation or perforation may need surgical removal
of the diseased colon.

IV. InOammatory bowel disease

77
 COWN

A. Ulcerative colitis

1. Inflammatory process of colonic mucosa and submucosa of unknown

etiology; usually appears in 2nd - 3rd decade, but a second peak
incidence around age 55.

2. Signs and symptoms - crampy abdominal pain, bloody mucous

diarrhea, often with fever, weight loss, fatigue, etc. Clinical picture
varies from occasional flare-ups (55 % of patients) to acute fulminant
illness with massive dilation of colon and sepsis (15% of patients)
(toxic megacolon). Usual process is repeated episodes of illness with
cramps, bloody diarrhea and associated symptoms.

3. Diagnosis is usually with colonoscopy (erosion of mucosa with

"pseudopolyps", covers large areas, no skip areas) or barium enema
during quiescent phases (foreshortening of colon, loss of haustra, "lead
pipe II appearance). Rectum invariably involved along with variable
amounts of remaining colon. Does not involve small bowel.

4. Symptoms can often be controlled (80 %) with systemic steroids,

Azulfidine and motility inhibitors (lomotil, Imodium).

5. Long-term risk includes increased risk of cancer - 4% at 10 years and

cancer risk increased by approximately 2 % per year thereafter. The
greater amount of colon involved and the greater activity of the
disease leads to even greater cancer risk. Prophylactic colectomy is
considered after 10-20 years, depending on the activity of the disease.

6. Disease is cured by removal of all colon mucosa - usually done as

total colectomy, rectal mucosectomy, ileoanal reservoir anastomosis.

B. Crohn's colitis

1. Crohn's disease can involve the colon, as well as the small bowel. The
macroscopic and microscopic characteristics are similar to that
described in Small Bowel chapter, as are the symptoms and treatment.

2. Four clinical patterns of Crohn's disease:

a. ileocolic - ileum and right colon - 41 %

b. colonic involvement without small bowel - 28 %

78
Chapter 13

c. small bowel involvement without colon - 27 %

d. anorectal involvement only - 3 %

3. Surgical therapy indicated for intractable symptoms, obstruction,

perforation with abscess or fistulae, hemorrhage, toxic megacolon,
severe peri-anal involvement and cancers. Aim of operation is to
remove only the involved portion of bowel - proctocolectomy and
ileostomy is most common.

V. Large bowel obstroction

A. Colon cancer (65 %)

B. Diverticular disease (20 %)

C. Volvulus (5%) - sigmoid (90%) followed by cecal (10%) - more common in

older, nursing home patients with poor colonic function - long mesentery
which allows twisting of the involved segment. Diagnosis with plain X-rays
of abdomen. Sigmoid volvulus occasionally relieved with rectal tube but often
recurs, requiring removal of redundant sigmoid. Cecal volvulus usually
treated with right hemicolectomy or cecopexy, if bowel wall viability not in
question.

D. Pseudo-obstruction - (Ogilvie's syndrome) dilated portion of colon - usually

transverse and right side without mechanical lesion; usually in older patients
often on Digoxin and anti-Parkinson medications.

E. Treatment of colon obstruction usually requires colostomy and removal of

offending portion with reanastomosis done separately after the colon can be
prepped.

VL Lower GI hemorrhage

A. Melena

1. Source can be anywhere in GI tract - requires only approximately 50

ccs blood to create guaiac positive stools.

2. Most common source of melena is UGI bleed, therefore investigate

esophagus, stomach, duodenum first.

79
 COWN

3. Sources below ligament of Treitz include small bowel tumors (polyps

or cancers), Meckel's diverticulum, Crobn's disease, A-V malformations,
diverticulosis of the colon (most common source, approximately 70%),
colon cancers, small bowel or colon ischemia and ulcerative colitis.

4. Management includes fluid resuscitation, restoration of clotting factors

and search for etiology.

s. EGD, colonoscopy and arteriography are most useful diagnostic tools.

Labelled RBC nuclear scans are occasionally helpful.

6. Surgical exploration without a diagnosis or location of bleeding pre-op

is often unrewarding.

B. Hematochezia - bright red blood per rectum

1. Consider diverticulosis, colonic telangiectasia (A-V malformations),

hemorrhoids, colon cancers.

2. May occasionally occur with massive upper GI bleed.

80
Chapter 14 RECTUM AND ANUS

L RedJ.m and anus

A. Anatomy

1. Differs from remainder of colon in not having a serosal layer.

Rectum lies outside peritoneal lining from peritoneal reflection (at the
sacral promontory) to the levator ani muscle (12-15 cm).

2. Arterial supply from IMA via superior hemorrhoids and from internal
iliacs via middle and inferior hemorrhoidal arteries. Venous and
lymphatic drainage follow arterial supply.

3. Outer external sphincter of striated, voluntary muscle and inner

smooth, involuntary muscle.

B. Physiology

1. Intricate neuro-muscular involvement in fecal continence - lower

rectum/anus - external and internal sphincters plus puborectalis sling
and levator ani.

C. Adenocarcinoma - similar histologically with adenocarcinoma of colon with

similar staging and prognosis schemes.

1. Because of tendency to invade side walls of pelvis, radiation therapy

pre or post-operative removal is sometimes helpful.

D. Inflammatory disease

1. Crohn's disease and ulcerative colitis both commonly involve the

rectum - diagnosis and treatment is as described above.

2. Other inflammatory conditions include various infectious etiologies and

radiation induced proctitis.

n. Anus

A. AnatomyfPhysiology
Chapter 14

1. Squamous epithelium blends to columnar mucosa at dentate line

(transitional or cloacogenic zone). Columns of Morgagni between
crypts of Lieberkiihn secrete mucous, etc.

2. External (somatic innervation) and internal (autonomic innervation)

sphincters control continence and differentiate gas from stool.

B. Congenital problems

1. Imperforate anus - involves short or long segments of obliterated

anus/rectum - requires immediate attention.

2. Hirschsprung's disease - lack of myomesenteric nerve bodies (Auerbach

and Meissner) leading to poor colonic emptying and an abnormal
constricted distal segment of anus/rectumfsigmoid/colon.

C. Inflammatory lesions

1. Peri-rectal abscess - obstructed mucous glands at dentate line resulting

in an abscess which necessitates to the skin or occasionally will
penetrate the sphincteric muscles to invade the ischial space; treated
by incision and drainage.

2. Peri-anal fistulae often develop after drainage of a peri-rectal abscess;

Goodsall's rule - cutaneous openings posterior to a horizontal line
through the anus usually connect to a posterior midline internal
opening, while cutaneous openings anterior to that line generally run
directly straight to a mucosal opening; treated by opening the tract
widely and debriding granulation tissue. (Recurrent lesions could be
Crohn's disease).

3. Anal fissures - very painful superficial erosions in anterior or posterior

midline, associated with constipation, especially in children; treated
with dilation or internal sphincterotomy.

4. Perianal warts (condyloma acuminata) - papilloma viral etiology, are

the most common.

D. Hemorrhoids

1. Represent dilated veins - external ones are painful, may prolapse and

82
 RECTUM AND ANUS

thrombose or bleed. Internal hemorrhoids are not painful but cause

bright red blood on tissue or outside of stool.

2. Most can be treated with local anti-inflammatory agents, local pain

suppressants, diet to reduce strain and constipation (increase fluids,
increase bulk, stool softeners, etc) and Sitz baths.

3. Thrombosed hemorrhoids, excessive bleeding, severe prolapse are all

indications for excision.

E. Neoplasia

1. Epidermoid (squamous cell) carcinoma is most common - usually

presents as mass lesion, occasionally as fistula that won't heal.

2. Tends to spread into surrounding soft tissues and femoral/iliac nodes.

3. Reasonably responsive to radiation therapy.

4. Cloacal carcinoma - unusual, squamo-adenocarcinoma, often presents

as a submucosal nontender mass. Generally poor prognosis.

5. Malignant melanoma may occur in anus - treated like other

melanomas.

83
Chapter 15 GALLBLADDER AND BILIARY SYSTEM

L AnatoOlY

A. Common bile duct (empties through ampulla of Vater) - cystic duct (lined
with valves of Heister) - common hepatic ducts - right and left hepatic ducts.

B. Common hepatic artery (from celiac axis) - gastroduodenal artery and proper
hepatic artery - cystic artery.

C. Venous drainage and lymphatics follow arterial supply (Calot1s node at

bifurcation of cystic duct).

D. Ductal and arterial anatomy is extremely variable.

D. Physiology

A. Serves as a storage and concentrating organ of liver-produced bile (560-1200

ml/day) - no untoward effects of not having a gallbladder.

B. Bile in gallbladder is a balance of the concentration of bile salts, (75 %)

phospholipids (lecithin) (20 %) and cholesterol (5 %) - abnormalities in this
balance are part of development of stones.

1. Na, CI and H 20 are selectively absorbed. Bicarbonate concentration

is approximately 2 XiS that in serum.

2. Mucosa secretes mucus which protects the mucosa.

C. Contraction stimulated by cholecystokinin (CCK) released from duodenum in

response to fats and acidity. (CCK = pancreozymen)

m. Congenital probleOlS

A. Biliary atresia

1. Varying degrees of atresia of the extrahepatic and intrahepatic ducts

with prognosis inversely proportional to the degree of atresia.

2. Previously treated with biliary-enteric anastomoses; now treated with

liver transplants when organs available.
Chapter 15

IV. Calculus associated iDoesses

A. Composition

1. May be pure "pigment stones" (25%) (bile salts, especially associated

with hemolytic disorders, ie, sickle cell anemia, spherocytosis, etc.),
may be pure cholesterol stones (most responsive to dissolution
therapy), but most commonly are "mixed stones" - pigment, cholesterol,
calcium, etc.

B. Asymptomatic stones

1. Incidence of developing symptoms is approximately 20 % over lifetime;

once symptoms develop they usually recur.

2. High-risk patients with asymptomatic stones (diabetes mellitus,

immunosuppressed, etc.) should have gallbladder out before symptoms
appear.

C. Acute cholecystitis

1. Inflammatory condition of gallbladder associated with stones > 90%.

2. Results from obstruction of cystic duct by stone, bacterial oveq~rowth

with altered mucous membrane permeability, increased secretion versus
absorption, swelling of gallbladder and edema of wall, leading to
congestion of lymphatic, venous and then arterial flow (resulting in
necrosis/perforation/gangrene).

a. Biliary colic represents repeated symptomatic episodes which

spontaneously resolve (presumably because of migration of the
obstructing stone).

3. Clinical manifestations

a. More common in overweight, middle aged, females.

b. Right upper quadrant crampy pain 30 minutes after meals

heavy with greasy, fatty, spicy foods.

c. No reliable relief with antacids.

85
 GALLBLADDER AND Bll.IARY SYSTEM

d. Associated with nausea, vomiting and occasionally fever.

e. A palpable, tender RUQ mass upon inspiration is Murphy's sign

and indicates a distended, inflamed gallbladder.

f. 15% of gallstones show up on plain X-ray.

g. Ultrasound very accurate at diagnosis.

h. Associated lab findings include increased WBC, increased

alkaline phosphatase, only mildly increased bilirubin, mildly
increased hepatocellular enzymes.

4. Initial management includes NG suction, IV fluid resuscitation,

antibiotics (cephalosporins are highly concentrated in bile - usual
organisms include E. coli, Klebsiella, Enterobacter, Salmonella) and
analgesics.

5. Operative cholecystectomy (open or laparoscopic) urgently if symptoms

don't abate or electively once symptoms are better.

6. Approximately 5 % will have unsuspected common duct stones found

by palpation or on intraoperative cholangiograms and require common
duct exploration.

D. Chronic cholecystitis

1. Signs, symptoms, pathophysiology are similar to acute cholecystitis.

Patients have repeated, short, often self-limited bouts of biliary colic.
Incidence of recurrence is very high.

2. Treatment options

a. Operative removal of gallbladder - (open or laparoscopic) is

treatment of choice.

b. Dissolution therapy - use of chenodeoxycholic acid to dissolve

the 36-40 % of stones which are pure cholesterol - requires
months to work - high incidence of stone reformation with
cessation of therapy - numerous complications of treatment,

86
Chapter 15

especially nausea and diarrhea.

c. Lithotripsy - use of directed ultrasound (either extracorporeal,

trans-common duct catheter or laser) to burst the stones -
followed by dissolution therapy - expensive equipment, high
incidence of recurrence, potential for duct, liver, pancreas
injury.

E. Choledocholithiasis

1. 15 % of patients with gallstones will have stones in the common bile

duct.

2. Right upper quadrant pain with jaundice and fever (Charcot's triad)
is associated with acute ascending cholangitis which represents a
surgical emergency.

3. Diagnostic workup of jaundice associated with probable

choledocholithiasis includes:

a. Ultrasound

b. Percutaneous transhepatic cholangiography (PTC)

c. Endoscopic retrograde cholangiopancreatography (ERCP)

4. In the patient with Charcot's triad, urgent antibiotic therapy and

drainage of the biliary tree, either by percutaneous placement of a
catheter or operative opening of the common bile duct, is important
to prevent death from overwhelming sepsis.

5. The patients with a symptomatic common bile duct stone, require

operative removal.

a. The absolute indications for exploring a common bile duct

include a palpable common duct stone or common duct stones
visualized on intraoperative cholangiogram.

b. Relative indications include bile duct dilatation, jaundice, history

of gallstone pancreatitis, multiple small stones and a single,
multifaceted gallstone.

87
 GALLBLADDER AND BILIARY SYSTEM

6. After exploration of the common bile duct, postoperative drainage

through aT-tube is important because of a small chance of residual
stones after exploration.

7. The operative mortality to cholecystectomy and common bile duct

exploration may be as much as 8-10 percent.

F. Gallstone associated pancreatitis

1. Second leading cause of acute pancreatitis in United States (behind

alcoholic pancreatitis).

2. Occurs when a stone passes through ampulla of Vater, causing edema

of orifice of pancreatic duct when pancreas is actively secreting.
Usually do not find an impacted stone in the duct but can find stones
in the stool.

3. Clinical manifestations similar to acute cholecystitis but with elevated

serum amylase and epigastric, boring pain to the back.

4. Requires surgical removal of gallbladder and any common duct stones

during same hospitalization after amylase has decreased and patient
has resolved clinical symptoms.

G. Gallstone ileus

1. Small bowel obstruction caused by a large gallstone which has eroded

into duodenum (or occasionally jejunum) and becomes lodged in the
small bowel (usually distal ileum).

2. Requires removal of the stone and gallbladder as well as repair of the

biliary-enteric fIStula.

V. Cancer

A. Common bile duct

1. Adenocarcinoma may occur in any area of the bile duct but most
commonly involves the extrahepatic ducts. Etiology unknown, but
association with stones may be a contributing factor.

a. Other diseases associated with increased incidence of bile duct

88
Chapter 15

cancers include choledochal cysts, and ulcerative colitis.

2. Patients are usually older (50, 60, 70's) and present with weight loss
and painless, obstructive jaundice. Courvoisier's law or sign is a
palpable non-tender RUQ mass that represents the distended
gallbladder associated with an obstructed CBD.

3. If ultrasound of liver reveals dilated ducts, percutaneous transhepatic

cholangiography (PTC) helps determine whether the tumor is high (i.e.
Klatskin's tumor at ductal bifurcation) or low (near the ampulla) and
thus, the feasibility of operative intervention. CT scan can also help
identify intrahepatic lesions and metastasis to nearby lymph nodes.
Occasionally ERCP will be able to see tumor and biopsy it.

4. Treatment is total excision, if possible, (often requiring a Whipple

procedure) 10% operative mortality. Palliation of obstructed ducts is
done with bypass operation or stents if cure seems unlikely. Total
removal carries a 30-40 % 5 year survival. Chemotherapy and
radiation are not very effective at this time.

B. Adenocarcinoma of gallbladder

1. Very unusual tumor, usually found at the time of cholecystectomy

because of difficulty in dissecting the gallbladder from the liver bed.
(90% are associated with gallstones).

2. Not sensitive to radiation or chemotherapy, so wide local excIsion is

the treatment of choice with good, long term prognosis if tumor
completely removed. Usually, however, tumor has metastasized before
detection, leading to an overall 5 year survival of < 5 %.

3. Calcification of gallbladder wall (porcelain gallbladder) has a 60%

association with gallbladder cancer.

89
Chapter 16 LIVER

L Anatomy

A. Right lobe with (5) segments divided from left lobe (3 segments) through the
bed of the gallbladder. (Falciform ligament divides medial from central
segment of left lobe). Caudate and quadrate lobes are situated centrally.

B. Portal vein (formed from the confluence of the splenic and superior
mesenteric veins) enters the liver at the hilum and disperses into the portal
triads (along with the hepatic artery branches and bile duct branches).
Portal vein supplies 75% of hepatic blood flow but 50% of O 2 delivery.

C. Hepatic artery (branch of celiac axis) supplies only 25% of blood flow but
50 % of O 2 delivery via the portal triads.

D. Bile ducts in portal triads collect the secretions of the hepatocytes and
confluences eventually leading to the right and left hepatic ducts, the proper
hepatic duct and then the common bile duct.

E. Blood from the portal triad vessels (portal vein and hepatic artery) percolates
past the Kupffer's cells (phagocytosis of foreign bodies, bacteria, etc.) down
the columns of hepatocytes into the central vein. The central veins converge
and eventually lead to the right, middle and left hepatic veins which drain
into the inferior vena cava.

IT. Physiology

A. Performs hemopoietic function in fetus and neonate.

B. Complex hepatocellular functions serve to metabolize numerous drugs and

chemicals in the body as well as serving an immunosuppressive function of
phagocytosis and entrapment. This includes detoxifying numerous metabolic
by-products of normal GI function.

c. Bile is formed as a breakdown product of hemoglobin. The enterohepatic

circulation in which bile salts are reabsorbed in the terminal ileum is
important for fatty acid absorption.

D. Synthesis of numerous proteins including cholesterol, albumin and clotting

factors.

ill. Congenital abnormalities

Chapter 16

A. Most surgically important congenital hepatic problems involve atresia of the

biliary tract and are covered in that chapter.

B. Numerous congenital or genetic abnormalities of hepatic function may lead

to the need for hepatic transplant, including Gaucher's disease, Wilson's
disease, etc.

IV. Inflammatory problems

A. Bacterial

t. Non-traumatic bacterial infections of the liver are unusual.

2. Pyogenic hepatic abscesses gain access to the liver via the biliary or
portal venous system; most commonly involve enteric bacilli (E. coli,
Klebsiella, Serratia, Salmonella and anaerobes, etc.) and originate with
cholangitis, appendicitis, diverticulitis or occasionally salpingitis.

3. Plain films of the abdomen may show air fluid levels in the liver of
a patient with fever, right upper quadrant pain, +1- jaundice and
suggest the diagnosis. CT scans and UIS are useful in localizing
abscesses as well.

4. In addition to treating the source of infection, intrahepatic abscesses

should be drained if possible either operatively or now more
commonly through percutaneously placed catheters, and treated with
appropriate antibiotics, mortality 10-40 %.

B. Amebic abscesses

t. Eosinophilia may accompany increased WBC, fever, etc.

2. Usually can be treated with antibiotics with good results

(Metronidazole).

3. "Anchovy paste"-like material in cavity.

4. Occurs without amebic dysentery in 50 % of cases.

C. Echinococcus cyst (Hydatid cysts)

91
 LIVER

1. Unusual - usually accompanies concomitant pulmonary disease - usually

solitary, often calcified cyst in right lobe of liver.

2. Eosinophilia present in 25 % •

3. Attempt to sterilize cyst by injection of hypertonic saline prior to

excision or external drainage.

4. Important to avoid intra-abdominal spread.

D. Sclerosing cholangitis

1. Usually presents in 3rd - 4th decade as sepsis problems related to

multiple intra-hepatic abscesses.

2. ERCP reveals multiple sclerotic bile ducts (intra - and extra-hepatic)

with numerous abscess cavities in both lobes of the liver.

3. Etiology is thought to be autoimmune (associated with ulcerative

colitis, etc.) but exact mechanism has not been determined.

4. Treatment involves drainage of abscesses, antibiotics and

transplantation when possible.

v. Portal hypertension

A. Etiology

1. Pre-hepatic - portal vein occlusion (common in infants and children)

or splenic vein occlusion (usually secondary to pancreatitis or trauma),
associated with normal liver functions.

2. Intra-hepatic - ETOH induced cirrhosis most common in United States,

also, post-hepatitis (post-necrotic) cirrhosis and intra-hepatic infections
or metabolic problems which lead to obstruction of portal venous flow
directly or indirectly via scarring (cirrhosis).

3. Post-hepatic - hepatic vein occlusion (Budd-Chiari syndrome) due to

hypercoagulable state or tumor growth and obstruction of hepatic
veins (hypernephroma) associated with severe ascites.

4. Collateral venous decompression of elevated portal pressures occurs

92
Chapter 16

through 1) coronary vein/esophageal varices, 2) peri-umbilical veins

(Caput Medusa), 3) superior bemorrhoidals, 4) veins of Retzius and 5)
veins of Sappey.

B. Clinical manifestations and management

1. Upper GI bleeding due to enlarged esophageal or gastric varices is the

most common manifestation.

a. Only 30 % of patients with varices will bleed but of those who

do bleed, 75% of patients will re-bleed in one year and 70%
will die in one year.

b. Initial treatment includes IV fluid and coagulation defect

correction, gastric lavage, IV Pitressin, esophagogastric balloon
tamponade (Sengstaken-Blakemore tube).

c. Early endoscopy and sclerotherapy effective in stopping initial

hemorrhage in 85-90 %.

d. Long term management includes repeat sclerotherapy at regular

intervals (problems with ulceration, stricture and development
of gastric varices), portosystemic shunts (portocaval or
mesocaval H-grafts) (5-10% perioperative mortality, 5% re-bleed
rate, 20-30% encephalopathy rate), selective shunting (distal
splenorenal shunt -5 % perioperative mortality, 10 % re-bleed
rate, 5% encephalopathy rate), TIPSS procedures (transjugular
intrahepatic portosystemic shunt), and liver transplantation.

e. Perioperative prognosis predicted on basis of hepatic function.

Child's classification.

A B C

BIUrubin < 2.0 2.0 - 3.0 > 3.0

Albumin > 3.5 3.0 - 3.5 < 3.0

Asdtes None Ea<iily COIl trolled Not easily

controlled

Enceph None Minimum Advanced

Nutrition Excellent Good Poor

MarUIIty 5'1i 10'li 4O'Ii

93
 LIVER

2. Ascites is due to increased perfusion pressure required to move blood

from portal vein through hepatocyte columns to hepatic veins, resulting
in leakage of high protein fluid into lymphatics and through liver
capsule into peritoneal space. Formation further aggravated due to
hemodilution from secondary hyperaldosteronism due to poor
aldosterone metabolism by the sick liver.

a. Ascites usually a very prominent feature of patients with

hepatic vein occlusion (Budd-Chiari) and often of patients with
intra-hepatic cirrhosis, but ascites does not generally form in
patients with portal vein occlusion.

b. Most ascites can be controlled with bed rest, sodium restriction

and gentle diuresis (Spironolactone). Peritoneal - venous shunts
can be helpful but can thrombose or induce a consumptive
coagulopathy or lead to pulmonary edema. Portosystemic
shunts (portocaval or mesocaval) are occasionally done to relieve
severe ascites.

3. Encephalopathy is thought to be due to inadequate hepatic metabolism

of toxic substances in the blood. The degree of encephalopathy varies
from mild forgetfulness through to hepatic coma and has been loosely
related to arterial ammonia level and more closely related to spinal
glutamine levels.

a. Usual treatment includes dietary protein restriction, clearance

of blood from GI tract, lactulose to inhibit ammonia production
by enteric bacteria and treatment of any concomitant infection.

4. Hypersplenism frequently accompanies portal hypertension, does not

correlate with the size of the spleen or degree of hypertension and is
thought to be related to sequestration and destruction of circulating
cells. While any cellular elements may be involved, WBC counts
<4000/mm3 or platelets < lOO,OOO/mm3 are most common.

a. About 2/3 of patients' hypersplenic activity will get better after

selective or non-selective shunts.

VL Neoplasias

94
Chapter 16

A. Benign

1. Hepatic adenomas (associated with birth control pills), focal nodular

hyperplasia and hemangiomas are the most common.

2. These usually do not require any treatment unless they grow to very
large size, rupture, or cause pain, in which cases they are removed.

B. Malignant

1. Most common malignancy in liver is metastatic disease from other

primary sites; especially colon.

2. Resection of isolated metastatic lesions (especially from colon

carcinoma) can increase survival.

3. Primary hepatomas are relatively unusual in USA but more common

in Oriental populations.

a. Three main types are hepatoma, cholangiocarcinoma or mixed

type.

(1) Related to cirrhosis, hepatitis B, alpha-l antitrypsin

deficiency, hemochromatosis.

b. Diagnosis can be made when a tender hepatic mass is identified

on exam, localized by CT and often evaluated for possible
resection with arteriogram.

c. Treatment involves resection when possible. These tumors are

fairly resistant to chemotherapy and radiation therapy.

95
Chapter 17 PANCREAS

L Anatomy

A. Two embryonic buds come together during gut alignment to yield one
gland - main pancreatic duct of Wirsung - minor duct of Santorini.

1. Failure of the ducts to fuse = pancreas divisum

B. Bounded on right by duodenum, left by spleen, anteriorly by stomach
and transverse mesocolon and posteriorly by common bile duct, aorta,
IVC, SMAfV.

C. Arterial supply from gastroduodenal artery, splenic artery and

gastroepiploic arteries. Venous and lymphatic drainage basically follow
arterial routes.

D. Histologic anatomy includes ductal cells, acini cells and islets of

Langerhans.

n. Physiology

A. Exocrine

1. Stimulus of fat, protein and acid in duodenum cause secretion of 1000-

5000 mild of pH 8 fluid, chymotrypsinogen, trypsinogen, lipase, amylase,
carboxypeptidase - all for digestion of proteins, carbohydrates and fats.

2. CCK-PZ and secretin are released from duodenal mucosa in response

to amino acids, fats or acid. CCK increases the enzymes in
pancreatic juice; Secretin stimulates flow of HC0 3-rich water and
electrolytes.

B. Endocrine

1. Includes insulin (beta cells), glucagon (alpha cells), gastrin (delta cells)
and others.

m. InOammatory conditions

A. Acute pancreatitis

1. Most commonly related to ETOH (40%) - induced ductal and

Chapter 17

parenchymal cell injury.

2. Also commonly associated with passage of gallstones past ampulla of

Vater.

3. Other etiologies include trauma, hyPertriglyceridemia medications,

(HCTZ, steroids, furosemide, estrogens) Type I, IV and V
hyperlipoproteinemia, familial and postoperative ischemia.

4. Manifested by epigastric abdominal pain boring through to back, with

fever, nausea, vomiting and elevated serum amylase and lipase levels.

a. Cullen's sign (periumbilical hematoma) or Grey-Turner's sign

(flank hematoma) suggests hemorrhagic pancreatitis.

5. Initial treatment includes NG suction, IV fluids, nutrition, analgesia

and possibly somatostatin to decrease exocrine function.

a. Operations usually reserved for complications.

6. Complications include:

a. Pancreatic necrosis and abscess - manifested by fever, increased

WBC and persistent pain, gas on abdominal X-ray or CT scan.
Requires drainage, antibiotics and nutrition.

b. Pseudocyst - due to leakage of a pancreatic duct and manifested

by continued pain and mass. Those below 2 cm often resolve
spontaneously. Larger ones or those that don't resolve are
allowed to "mature" for 6 weeks and then internally drained
into the stomach or a Roux-en-Y limb of jejunum. Has a
fibrous lining vs. epithelium.

c. Pancreatic ascites - leakage of ductal contents into abdominal

cavity; does not respond to usual treatment of ascites; needs
internal drainage.

d. Hemorrhagic pancreatitis - erosion into surrounding vessels can

lead to pseudoaneurysms, massive bleeding or massive
retroperitoneal bleeding and necrosis.

97
 PANCREAS

e. Other complications include pancreatic fistulae, pulmonary

insufficiency, eventual pancreatic endocrine and/or exocrine
dysfunction, etc.

7. Prognosis of acute pancreatitis is best estimated by Ranson's criteria

(which do not include level of serum amylase)!

a. Ranson's criteria

At admission: age > 55; WBC > 16K; glucose > 200; LDB > 350;
SGOT > 250. During 48 hours after admission: Bet > 10 point
decrease; BUN > 5 increase; Ca++ < 8.0; pOl < 60 mm Bg room air;
base excess > 4 mEqJI; est. fluid sequestration > 6000 mL.

b. Mortality 20% with 3-4 signs; 40% with 5-6 signs; 100% if 7
or more signs.

B. Chronic pancreatitis

1. Similar etiology to acute pancreatitis but marked by endocrine/exocrine

dysfunction (diabetes mellitus/steatorrhea) and calcifications in pancreas
on abdominal X-rays.

2. Chronic pain syndrome is investigated with ERCP and treated with

internal drainage of dilated obstructed ducts (sphincterotomy or
Peustow pancreatojejunostomy) or pancreatic resection if preservation
of pancreatic function no longer an issue.

IV. Neoplasia

A. Non-islet cell

1. Ductal adenocarcinoma is most common - often multicentric, associated

with cigarette smoking and perhaps ETOB.

2. May occur at any location in pancreas - those in tail and body (1/3)
are often far advanced prior to any symptoms. Those in the head
(2/3) often lead to painless obstructive jaundice.

3. Evaluate with CT scans, PTC, ERCP as needed.

98
Chapter 17

4. Treated with excision when possible with 5 % five year survival in the
10-20% which can be resected for cure (Whipple procedure). Not
very responsive to chemotherapy or radiation treatment.

5. Cyst adenocarcinoma may mimic pseudocyst but has an epithelial

lining and requires total excision.

B. Islet cell tumors

1. Gastrinoma, insulinoma, VIPoma and other functional tumors of APUD

cell deviation.

2. Gastrinoma associated with Zollinger-Ellison syndrome of hyperacidity,

unresponsive to further acid output stimulation, resulting in diffuse
peptic ulceration in stomach, duodenum and occasionally small bowel.

a. Marked by increased basal acid output, no increase in acid

with stimulation, increased serum gastrin levels, paradoxic rise
in gastrin with IV secretin (secretin stimulation test).

b. Associated with MEN-I syndrome (pituitary, parathyroid

adenomas and adrenocorticalfhyperplasia).

c. Tumors from delta cells are often very small and may be
multicentric but are not usually histologically malignant.

d. If symptoms are not controlled with Hz blockers, laparotomy

indicated to try to remove tumor or do PGV to relieve
symptoms. Severe or recurrent disease usually treated with
total gastrectomy.

3. Insulinoma associated with Whipple triad of symptoms of

hypoglycemia, with fasting low blood sugar « 50 mg %) and relief of
symptoms with glucose. Have inappropriately high insulin levels.

a. Caused by a benign adenoma, occasionally localized with CT

scan, MR or arteriography.

b. On-line blood glucose determinations helpful during resection to

assure removal of the tumor.

99
 PANCREAS

4. VIPomas - Vasointestinal peptides - neuroendocrine derived adenoma

causing a watery diarrhea, flushing, tachycardia syndrome. Relieved
by tumor excision.

100
Chapter 18 SPLEEN

L Anatomy

A. Usually one lobe but may have lobulations - maintained by four suspensory
ligaments.

B. Accessory spleens are congenital masses of splenic tissue with blood supply
derived from splenic vessels. Present in 15-30 % of patients.

C. Splenosis is bits of splenic tissue embedded in the omentum or mesentery as

a result of splenic injury. Blood supply from local tissues.

D. Histologic architecture involves red pulp (primary vascular) and white pulp
(primary lymph tissue) with a portal venous system.

E. Main arterial supply from splenic artery but also branches from left
gastroepiploic arteries.

F. Venous drainage includes splenic vein (with numerous pancreatic branches)

and short gastric veins.

G. Pancreas, stomach, adrenal and left kidney are all very close anatomically and
can be injured during splenic operations.

n. Function

A. Hematologic

1. Spleen makes RBCs and WBCs in fetus (5th to 8th month) until bone
marrow matures.

2. Spleen clears blood stream of senescent RBCs and other cellular debris
by phagocytosis. Removes nuclear remnants from circulating RBCs
(Howell-Jolly bodies).

B. Immunologic

1. Spleen aids B-cell antibody formation in response to foreign proteins

(especially IgM).

2. Spleen opsonizes foreign material to enhance recognition by B-cells,

especially important in encapsulated bacteria, ie, pneumococcus,
meningococcus, hemophilus.
Chapter 18

m. Splenic removal

A. Non-trauma

1. Splenic removal may be needed because of:

a. abnormal function (ie, ITP (idiopathic thrombocytopenic

purpura) in which the spleen makes abnormal antibodies to
platelets or other blood elements (remove spleen if patient
unresponsive to steroids), or

b. normal splenic function with abnormal stresses (ie, hereditary

spherocytosis, thalassemias, elliptocytosis, sickle cell disease etc. -
normal splenic function on abnormal RBCs leaves the patient
anemic), or

c. involvement in or diagnosis of malignant diseases (ie, staging

lap for Hodgkin's lymphoma, etc.).

B. Trauma

1. The spleen, alone or with other organs, is the most commonly injured
organ following blunt trauma to the abdomen.

2. Tears of the splenic capsule can occasionally be followed with serial

CT scans or VIS to try to salvage the spleen.

3. Deeper lacerations may be repaired with sutures or compressive nets.

4. Severe splenic injuries, especially when associated with other life-

threatening injuries, are treated with splenectomy.

s. Kehr's sign is pain at the tip of the left scapula associated with
diaphragmatic irritation after splenic injury.

C. Consequences of removal

1. Primary concern is lack of opsonization of encapsulated bacteria, esp.

Strep pneumococcus, leading to overwhelming sepsis and death.

2. Incidence of this complication is very low in trauma patients (1-2 %

102
 SPLEEN

in adults) and still fairly low in patients having splenectomy for

hematologic reasons (approx 5 %).

3. Give pneumococcal vaccine preoperatively when possible, but certainly

postoperatively.

4. Children may benefit from penicillin prophylaxis as in rheumatic fever.

5. Patients who have had splenectomy should be given antibiotics at the

slightest suggestion of possible bacterial infection to prevent
overwhelming sepsis.

IV. Other

A. Splenic cysts or abscesses can occur but are unusual and usually are treated
with splenectomy.

103
Chapter 19 GASTROINTESTINAL HEMORRHAGE

L Upper GI bleeding

A. General approach

1. Obtain history and physical exam

2. Begin IV hydration with large bore peripheral IVs.

3. Monitor adequacy of hydration by blood pressure, heart rate, mental

function and urinary output.

4. Begin efforts to stop bleeding and clearing clots with lavage of the
stomach with room temperature water.

5. Early endoscopy is helpful to identify the bleeding site and many times
is helpful to stop bleeding with injection sclerotherapy.

6. IV Pitressin (Vasopressin) resulting in splanchnic arterial constriction

greatly reduces upper GI bleeding from esophageal varices, gastritis
and even peptic ulcer disease.

7. Patients bleeding from gastric esophageal varices may be controlled

with the use of gastric and esophageal balloons (Sengstaken-Blakemore
tube).

8. It is important to correct clotting factors and fluid and electrolyte

abnormalities in preparation for possible surgical intervention.

B. Etiologies of UGI hemorrhage (above ligament of Treitz)

1. The most common cause in non-alcoholic patients is peptic ulcer

disease.

a. Posterior duodenal and pyloric channel ulcers which erode into

the gastroduodenal artery are most commonly the cause.

b. When a visible vessel is identifiable on endoscopy, chance of

recurrent bleeding is extremely high.

2. Gastritis - most common etiology of bleeding in alcoholics and non-

alcoholics combined.
Chapter 19

a. May result from diffuse gastric wall irritation from external

agents (ASA, ETOH, steroids, NSAIDS, etc.) or from ischemic
deterioration of the gastric wall from within.

b. Painless UGI bleeding is a clinical hallmark.

c. Treatment consists of antacids, H 2 blockers, general supportive

measures of the patient and correction of clotting factors.

d. Total gastrectomy may be necessary if these measures do not

control the bleeding.

e. Curling's ulcers are acute gastro-duodenal erosions in burn

patients. Cushing's ulcers are those in patients with neurologic
injury.

3. Esophageal varices - common etiology in alcoholics.

a. Approximately one-third of the patients with esophageal varices

will bleed at some time.

b. Of patients who bleed, 75% will re-bleed within one year and
60% will die from bleeding complications within one year.

c. Acute management in addition to the above measures, includes

endoscopy with injection sclerotherapy which stops the
hemorrhage in approximately 90 %.

d. Definitive management of the esophageal varices usually involves

operative intervention since repeated injection sclerotherapy is
complicated by esophageal ulcers and the development of gastric
varices, which cannot be sclerosed.

e. Surgical options for the management of varices include non-

selective portal systemic shunts (portacaval shunts and
mesocaval shunts, which have a re-bleeding rate of
approximately 5-10% and an associated encephalopathy rate 26-
30%) and selective variceal decompression procedures (distal

105
 GASTROINTESTINAL HEMORRHAGE

splenorenal shunt, which has a re-bleeding rate of 5-10% and

an encephalopathy rate of 5-10%). Transjugular intrahepatic
portosystemic shunts (TIPS) can be done to acutely lower portal
pressure, but have a high incidence of encephalopathy.
Definitive management of these patients· may involve hepatic
transplantation in patients who meet the other criteria for liver
transplants.

f. Varices account for 95% of massive hematemesis in young

children and are usually associated with extrahepatic portal vein
obstruction.

4. Mallory-Weiss syndrome

a. Linear tear at the esophageal junction associated with severe

hard episodes of emesis.

b. Usually self-limited with correction of the etiology of emesis,

generally will resolve.

c. Indications for operation

1. Exsanguinating hemorrhage with hypotension upon admission to the

hospital.

2. Loss of greater than six units of blood in the first 12 hours in the
hospital.

3. Re-bleeding in the hospital after 24 hours of cessation of hemorrhage.

4. Presence of a visible vessel in the bed of the bleeding ulcer site.

5. The higher the likelihood of re-bleeding, the earlier intervention should

be undertaken to avoid the problems associated with massive
transfusion, hypotension, etc.

n. Lower GI bleeding

A. General approach

106
Chapter 19

1. Resuscitative efforts and coagulation defect corrections as indicated in

I.A. above is indicated. Vasopressin can be useful in LGI bleeding as
well.

2. Diagnostic efforts for patients presenting with hematochezia should rely

heavily on arteriography to localize the site of bleeding.

3. Tagged RBC studies to localize site of bleeding can be helpful for

amounts less than 2 ccs per minute. Arteriography requires 3-4 ccs
per minute to identify the bleeding site.

4. Presence of melena may occur with sources of GI blood loss anywhere

from the oral pharynx to the rectum and simply indicates presence of
blood within the GI tract for more than a few hours.

a. Only 50 ccs of blood is required to produce melena. May

persist for 5 days following cessation of bleeding.

b. Investigation of melena should begin with the upper GI tract,

since it is more common.

B. Etiology

1. Massive GI bleeding - most commonly due to diverticulosis of the

colon.

2. Telangiectasias (AV malformations) of the colonic wall are also a

common cause of significant lower GI bleeding.

3. Ulcerative colitis, cancer of the colon, colonic polyps and other various
etiologies are less common sources of lower GI bleeding.

4. Meckel's diverticulum is a significant source in children.

C. Management

1. Lower GI bleeding which can be localized with arteriography or other

localization studies and which continue to bleed in spite of correction
of coagulation defects should be treated with operative removal of the
offending area.

107
 GASTROINTESTINAL HEMORRHAGE

2. Operative exploration of lower GI bleeding without identifiable source

is rarely useful in identifying the source.

m. GI hemorrhage in infants and children

1. Upper GI bleed in infants and children is most commonly from

esophageal varices due to prehepatic occlusion of the portal vein.

a. Usually self-limited and can be treated with fluid resuscitation

and injection sclerotherapy.

2. Intussusception resulting in bright red blood in the stool of an infant

around the age of 2 is the most common cause of lower GI bleeding
in young children.

a. Meckel's diverticulum with ectopic mucosa may also be the

source of bleeding in young children.

108
Chapter 20 HERNIAS

L Groin hernias

A. Indirect hernia

1. These result from a persistent patent processus vaginalis and thus are
considered congenital in origin, although they may not become
manifest until later in life.

2. Hernia contents descend through the internal ring lateral to the

inferior epigastric vessels, descend down the spermatic cord toward
and sometimes into the scrotum.

3. The most common type of hernia in any age or sex group.

4. Development in elderly ages may be associated with COPD and

chronic cough, straining on urination due to prostatic disease, straining
on defecation due to colonic disease (including colon cancers), etc.

5. Treated by reduction of the hernia mass, closure of the internal ring

and in adults is usually associated with repair of the floor of the
inguinal canal (Bassini repair, McVay repair, other). Can be done
laparoscopically.

a. In infants, hernia is treated at the time of diagnosis and usually

requires simple excision of the sac and closure of the internal
inguinal ring.

6. Recurrence rate with first time repair is 2.5-5 %; this increases with
each subsequent repair.

B. Direct hernia

1. Associated with defect in the fascia of the floor of the inguinal canal -
Hesselbach's triangle bounded by the rectus sheath medially and
superiorly, inguinal ligament inferiorly and the inferior epigastric
vessels laterally.

2. Less commonly associated with incarceration or strangulation than

indirect hernias.

3. Associated with chronic use and significant strain on muscle and fascia
Chapter 20

layers, including COPD, BPH and colon cancer.

4. Repair usually involves tight closure of the internal ring and repair
of the floor of the canal by Bassini method, McVay repair, or others.

C. Femoral hernia

1. Herniation of the intra-abdominal contents through the femoral canal

bounded laterally by the femoral vein, anteriorly by the inguinal
ligament, posteriorly by the rim of the pubis. This hernia presents as
a bulge inferior to the medial end of the inguinal ligament.

2. More common in women than in men.

3. Felt to have an increased incidence of incarceration or strangulation

than other groin hernias.

4. Repair requires suprainguinal ligament repair of the McVay type.

D. Complications

1. Incarceration - indicates inability of the hernia contents to be reduced

to their normal position.

2. Strangulation - indicates occlusion of the vascular supply to the hernia

contents and results in much greater morbidity and mortality.

3. Sliding hernia in which part of the wall of the hernia is an intra-

abdominal organ; on the right side this is most commonly cecum and
the left side may be bladder wall or sigmoid. In young females, this
commonly involves the ovaries.

4. Richter's hernia involves incarceration of part of the wall of bowel in

the hernia opening, may lead to necrosis of the bowel wall without
signs of intestinal obstruction.

n. Other hernia

A. Umbilical hernias

1. Most common in young children and often resolve by the age of two

110
 HERNIAS

when the patient begins to walk. Large umbilical hernias or those

occurring in adults may be repaired with a few simple sutures to
prevent incarceration and strangulation.

B. Incisional hernia

1. These hernias occur after previous operative procedures, usually from

the result of wound infection, necrosis of the fascia, breakage of
sutures or other technical problems.

2. May be associated with incarceration or strangulation.

3. Repair is usually indicated and must involve getting back to normal,

healthy fascia.

C. Ventral hernia

1. Ventral hernias involve those of the abdominal wall (other than

incisional hernias). Umbilical hernias are a special type of ventral
hernia.

2. Other special types of ventral hernia, include Spigelian hernia

(herniation at the semilunar line of the rectus sheath and the
semicircular line of Douglas) and Petit's triangle hernia (herniation
through the inferior lumbar triangle posteriorly).

3. These hernias may incarcerate or strangulate and usually do require

repair with re-approximation of normal fascial boundaries.

111
Chapter 21 BREAST

L Anatomy/Physiology

A. Anatomic changes parallel physiologic changes especially in female breast.

B. Breast is a subcutaneous apocrine gland with a blood supply from the chest
wall vessels (internal mammary, lateral thoracic and acromiothoracic arteries)
and a lymphatic system which follows this same pathway - most importantly
draining into the axilla.

c. Histologic structure consists of adipose tissue with lobules (12-24) of

mammary glands which connect through ducts, ultimately emptying into
multiple ducts in the nipple. Fibrous connective tissue from the anterior side
of breast parenchyma to subdermal fascia are "Cooper1s ligaments II

D. Stromal elements and fibrous tissue predominate in the young female, giving
way to more glands and ducts during the reproductive years (esp. during
pregnancy and lactation) and finally becoming more fatty tissue as the ducts
and glands involute after menopause. Similar changes occur, to a lesser
extent, during menstrual periods under the influence of varying hormonal
changes.

E. During lactation, milk is actively expressed from the nipple by myointimal

cells.

II. Evaluation

A. Physical exam by the patient is recommended at monthly intervals and by a

physician at yearly intervals.

B. Mammography recommendations include baseline exam between 35-40 years;

every other year exam, ages 40-50; yearly exam after 50 years old. Patients
with high-risk factors for development of breast cancer may benefit from
more frequent exams.

C. Ominous characteristics on mammography include clusters of

microcalcifications, asymmetric densities, especially those with radiating arms,
and skin and nipple retraction.

D. Stromal tissue in women < 30 years old renders interpretation of

Chapter 21

mammograms virtually impossible.

E. Regular screening mammography has been shown to reduce the incidence of

Stage II or higher cancers and to increase survival by 30 % in those patients
found to have cancer.

F. Xeromammography is less accurate but can be useful.

G. Thermography has not been reliable.

m. Benign conditiom

A. Fibroadenomas

1. Benign fibrous nodules, more common in younger women, that are

often tender and vary with estrogen flux - usually are well
circumscribed. Local excision recommended for symptomatic lesions
or difficulty in distinguishing from cancer.

B. Fibrocystic disease

1. Benign process of cyst formation, more common as women get older,

present to some extent in most women.

2. Present as tender nodules which change during the menstrual cycle.

3. Diagnosis with ultrasound or needle aspiration is often sufficient.

4. Symptomatic lesions, those that recur after aspiration, or those that

have a residual mass after aspiration should be excised.

5. Cysts and fibroadenomas appear similar on mammography.

6. Treatment of chronic cystic mastitis include mild analgesics, local heat,

avoidance of caffeine, Vitamin E and occasionally Danazol (a synthetic
androgen analog).

C. Foci of cellular atypia

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 BREAST

1. May occur with biopsy of any mass lesion and incidence varies with
how diligently it is sought.

2. Greater degrees of atypia suggest greater chances of malignancies.

D. Other

1. Includes fat necrosis, breast abscess, cystosarcoma phylloides, lipoma,

papilloma, etc.

IV. Malignant conditiom

A. General

1. One out of ten women will develop breast cancer during her life.

2. Breast cancer is currently the leading cause of cancer deaths of

women in United States.

3. Risk factors leading to an increased incidence of breast cancer include:

a. previous cancer in the opposite or same breast

b. close blood relative (mother or sister) with breast cancer

c. foci of cellular atypia

d. other possible risk factors include early menarche/late

menopause, late first pregnancy, nulliparity

4. Genetic markers are being evaluated as risk factors for breast cancers.

B. Ductal carcinoma

1. Most common form - subcategories include:

a. carcinoma in situ

b. Paget's disease - scaling, eczematoid lesion of skin of the nipple

which represents primary carcinoma of the ducts of the nipple.

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Chapter 21

c. papillary

d. comedo

e. medullary

f. colloid or mucinous

g. tubular

h. scirrhous (infiltrating ductal)

i. inflammatory carcinoma

2. Diagnosis

a. Physical exam - firm, non-tender mass, fixed to underlying

tissues, peau d'orange, nipple retraction, axillary nodes.

b. Mammography - asymmetric density with radiatiI;tg arms;

microcalcifications.

c. Biopsy of the lesion - excisional or needle biopsy.

3. Clinical staging

a. Tumor < 2 cm, no nodes, no distant metastasis - Stage I

b. Tumor < 2 cm, + nodes, no distant metastasis - Stage IT

c. Tumor > 2 cm, + node, no distant metastasis - Stage m

d. Tumor > 2 cm, + node, + distant metastasis - Stage IV

e. Axillary node involvement can often not be accurately assessed

from exam only.

4. Treatment

a. For Stage I and some Stage II lesions, segmentectomy with

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 BREAST

axillary node dissection, usually followed by chest wall radiation

(to prevent a 15-20 % local recurrence rate) may be offered and
is gaining popularity.

b. Most common procedure recently in United States has been

modified radical mastectomy - removes whole breast plus
axillary contents and is not usually followed with radiation.

c. Tumors involving chest wall muscles may require a classic

radical mastectomy which also removes pectoralis major and
minor muscles.

d. Adjunctive treatment

(1) Tissue is tested for estrogen (ER) and progesterone (PR)

receptors. Pre-menopausal women with ER +, PR +
tumors seem to benefit from anti-estrogen therapy
(Tamoxifen).

(2) Patients with nodal or other distant metastasis benefit

from additional chemotherapy - usually using 3 drugs.

(3) Radiation therapy is usually reserved for bony metastasis

or inflammatory carcinomas.

(4) Adjuvant chemotherapy for node-negative patients is still

being evaluated.

e. Carcinoma in situ has become much more frequently diagnosed

due to improved mammographic techniques and is generally
treated by wide local excision, although some authors advocate
full cancer operations.

5. Survival results

a. carcinoma-in-situ - 10 year survival - > 90 %

b. nodes negative - 10 year survival - 72-76%

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Chapter 21

c. nodes positive (overall) - 10 year survival - 25-48%

d. 1-3 nodes - 10 year survival - 34-68%

e. 24 nodes - 10 year survival - 14-27 %

f. metastatic disease - 10 year survival - 0

C. Lobular carcinoma

1. Much more rare than ductal carcinoma.

2. Lobular carcinoma-in-situ is most frequently found as an incidental

finding during biopsy of some other lesion and has an approximately
25 % incidence of bilaterality.

3. Natural history is slow and variable but thought to be an indication

of increased cancer risk to the patient over time.

4. Classic treatment meant simple mastectomy plus biopsy of the opposite

side. Most are currently treated with wide local excision and close
observation.

5. Invasive lobular carcinomas are generally treated similarly to ductal

carcinomas.

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Chapter 22 VASCULAR SYSTEM

L Atherosclerotic peripheral arterial disease

A. Occlusive arterial disease

1. Development of atherosclerosis (AS) begins with development of "fatty

streaks" in intima and over time develops into a cholesterol plaque
involving intima and inner one half of media.

a. Deposition of lipids in arterial wall may be response to injury,

platelet-endothelium interaction, low or varying wall shear stress
and turbulence.

b. Risk factors for development of AS include genetic

predisposition, diet high in cholesterol and triglycerides, diet
high in animal fats, tobacco use, high blood pressure, high
blood sugar, sedentary life style, male sex, and others.

c. Risk factor reduction, especially control of high blood pressure,

reduction of serum lipids (LDL) and cessation of tobacco have
proven to slow or reverse progression of AS.

2. Acute arterial occlusion

a. Results from emboli lodging at arterial bifurcations (common

femoral, popliteal or aortic) or distally (source of emboli =
heart or higher in arterial tree, AS plaque or aneurysm) or
from acute thrombosis of a chronically diseased artery.
Trauma to an artery may also cause acute occlusion.

b. Symptoms include acute onset of pain, decreased pulses, pallor,

paresthesias with numbness, eventually paralysis and coolness
(polar)(the five "P'llS). In a previously normal extremity,
irreversible neuro-muscular injury will occur in approximately
6 hours.

c. In patients with embolic occlusion of previously normal arteries,

symptoms and examination are usually all that is necessary for
diagnosis. Doppler ultrasound is occasionally helpful -
arteriography is time-consuming and not usually necessary.

(1) Treatment consists of initial heparinization to prevent

Chapter 22

propagation of clot and then opening the artery (usually

the common femoral) to remove all of the clot with a
balloon tipped catheter.

(2) Thrombolytic agents have been used successfully when

given intra-arterially to patients with very distal emboli
unreachable with a catheter.

(3) The source of the embolus must be sought and treated.

d. Acute thrombotic occlusion of diseased arteries often requires

arteriography to plan reconstruction.

(1) Occurs in the setting of a patient with diffuse PVD who

suffers an acute MI with low cardiac output resulting in
thrombosis of a peripheral artery or an elderly patient
who becomes dehydrated after a bout with the flu, etc.

(2) Intra-arterial thrombolytic agents and operative

intervention are used when heparin alone is insufficient,
dependin g on the condition of the patient and the
extremity.

3. Chronic arterial occlusive disease

a. Patients present with 1) exercise-induced pain, aching or fatigue

in a muscle group distal to the obstructing lesion (intermittent
claudication), 2) pain, even at rest in the distal distribution of
the arterial system involved - usually the toes or feet - in
addition to this, erythematous skin with edema and loss of hair
(rest pain) or 3) ulcers or sores which will not heal in spite of
adequate local care.

b. Most commonly involved areas are the aorto-iliac segment

(LeRiche syndrome), the distal SFA (at Hunter's canal or the
adductor canal), and third, the tibioperoneal arteries.

c. Diagnosis of the physiologic consequences of arterial occlusion

is by non-invasive vascular testing of flow velocities and
turbulence as measured by Doppler ultrasound and blood
pressures in the leg and ankle compared to the arm (ankle:arm

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 VASCULAR SYSTEM

index). Other NIVL tests include pulse volume recording,

transcutaneous POz levels and Duplex ultrasound visualization
of the arteries.

d. 66 % of patients with claudication improve or remain stable

with treatment of 1) discontinue tobacco, 2) risk factor
reduction, especially initiating a walking exercise program, 3)
good foot hygiene. Some patients benefit from reduction of
blood viscosity or agents to change RBC deformability
(pentoxifylline). Vasodilators or antispasmodics have not been
helpful. Only 5 % come to major amputation in five years.

e. 33 % of patients worsen or wish to have an intervention because

of an intolerable lifestyle.

(1) Short segment stenoses or occlusions of the iliac and

femoral systems do well with percutaneous balloon
angioplasty (PTA) - 60 to 70%, 3 year patency rates.
Intra-arterial stents may be useful in some areas to
maintain patency.

(2) Long segment occlusions of aorto-iliac segments are

usually replaced by an aorto-bifemoral bypass graft,
perioperative mortality approximately 4 %; 85 % - 10 year
patency.

(3) SFA occlusive lesions not amenable to PTA may be

treated with femoral-popliteal bypass using saphenous
vein (60 %, 5 year patency) or prosthetic (40-50 %, 5 year
patency).

(4) Popliteal and tibioperoneal disease may be treated with

vein bypass as far down as the plantar arch vessels - 5
year patency, approximately 60%.

(5) Longterm careful follow-up with secondary intervention

is important for long term limb salvage.

4. Diabetes mellitus

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Chapter 22

a. Patients with diabetes develop histologically routine AS at an

earlier age, in a more diffuse form, involving more distal
arteries than their non-diabetic counterparts.

b. Early calcification in the walls of the arteries make the

usefulness of blood pressure assessments in the lower extremities
less useful.

c. Severe tibioperoneal artery involvement is very common.

d. Diabetic neuropathy leading to inadvertent injury and often

slow recognition of the injury by the patient, poor leukocyte
function and poor arterial perfusion all lead to common foot
problems and wound healing problems in patients with diabetes.

e. PTA and bypass grafts with suitable conduits can be as

efficacious in patients with diabetes mellitus as those without.

B. Extra-cranial cerebrovascular disease

1. Emboli of atherosclerotic debris from disease at the carotid bifurcation

is thought to play a role in approximately 75% of strokes.

2. Symptoms other than stroke include TIAs (transient ischemic attacks -

focal neurologic deficits which resolve completely < 24 hours),
amaurosis fugax (transient monocular blindness due to Hollenhorst
plaque - AS emboli in ophthalmic artery) and RIND (reversible
ischemic neurologic deficit resolving < 7 days).

3. Patients usually have bruit in neck (but may not and presence or
absence of bruit does not correlate with degree of stenosis) and
stigmata of AS disease in other organ systems - especially the heart.

4. Diagnostic evaluation includes Duplex VIS to assess the degree of

stenosis and the morphology of the plaque and/or OPG
(oculopneumoplethysmography) to indirectly gauge the degree of
stenosis. CT scan or MR scan often reveal previous undetected
cerebral scars.

5. Arteriography is usually done prior to operation to look for AS

disease in sites other than the carotid bifurcation (aortic arch,

121
 VASCULAR SYSTEM

intracranial, etc.)

6. Risk of stroke in a patient with TIAs is 5-6 % Iyear and two recent
studies have shown superior patient outcome when symptomatic
patients with> 75% stenosis are treated with carotid endarterectomy.
Expected perioperative stroke rate 2-4 %, mortality 1-2 % .

7. Asymptomatic patient with critical stenoses ( > 90 %) or even with less

stenosis ( > 60 %) may do better with endarterectomy versus ASA
alone if perioperative stroke rate is < 2 % •

8. Recurrent symptomatic rate after CEA is approximately 1 % Iyear

(similar to population) but restenosis rate may be 10-15%.

9. Bilateral carotid disease along with bilateral vertebral artery disease

may lead to "vertebrobasilar symptoms" of paraplegia, dizziness plus
speech or hemiplegia problems, bilateral blindness episodes, etc. and
may be improved by carotid endarterectomy (or occasionally
repair/revision of vertebral artery).

10. Subclavian steal syndrome is the onset of vertebrobasilar symptoms

with exercise of left arm, due to occlusion of left subclavian artery
proximal to vertebral artery, resulting in reversal of flow in the
vertebral to supply the arm. Symptoms improve with carotid-
subclavian bypass or PTA of subclavian artery. If patient has no
symptoms, nothing is done.

c. Aneurysms

1. Thoracic aortic aneurysms

a. Three major types of AS aneurysms (ascending, arch and

descending) - can also be caused by infection (syphilis) or cystic
medial necrosis (Marfan syndrome).

(1) Ascending and descending are relatively easily repaired

with grafts but arch aneurysms cause problems with
perfusion to brain etc.

b. Traumatic aneurysms due to blunt trauma occur at or just

distal to ligamentum arteriosum and are "false" aneurysms

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Chapter 22

(having no true arterial waD) needing graft replacement.

c. Dissecting aneurysms are related to hypertens ion as well as AS

and present as sudden, tearing chest pain.

(1) DeBakey Type I, II, III - depending on site of entry and

exit points.

(2) Diagnosis made with CT scan and/or arteriography.

(3) Repair concentrates on repair of point of initiation of the

dissection plus ensuring adequate flow to end organs.

2. Abdominal aortic aneurysm (AAA)

a. Most common aneurysm found - 95% below renal artery.

b. Associated with AS but also has a degenerative component to

its development that may be genetic (anti-thrombin III
deficiency, increased elastase activity, etc.)

c. Natural history is that of a variable rate of enlargement (with

more rapid rates occurring as the aneurysm enlarges) and
leakage/rupture at varying sizes (although rupture rate increases
as size increases). Mortality of rupture is 60-80%.

d. Other complications include distal embolization of clot or AS

plaque and local compression of surrounding organs.

e. VIS is useful for size measurement, but CT also good and

reveals more information regarding neck of aneurysm and
concomitant disease.

f. Arteriography helpful to plan reconstruction if patient is a

claudicator or to look for renal involvement if patient is
hypertensive.

g. Aneurysms over 5 cm should be repaired as the risk of rupture

(30 % in 3 years) is greater than the risk of dying from other
causes. Aneurysm 4-5 cm should be repaired if the patient is
in good health - can be followed by ultrasound to observe for

123
 VASCULAR SYSTEM

evidence of enlargement if patient is not a good operative

candidate.

h. Repair usually means replacement of the involved segment of

artery with graft material. Operative mortality is 2-4 % •
Induced thrombosis of the aneurysm with extra-anatomic bypass
can be useful in high-risk patients.

3. Peripheral aneurysms

a. Other common sites include the common femoral arteries and

popliteal arteries.

b. High incidence of bilateral aneurysms (25 % ) and 50 % are

associated with AAA.

c. Repair indicated at any size to prevent the complications of 1)

acute thrombosis or 2) distal embolization. (Rupture can occur
but is unusual).

d. Other intra-abdominal aneurysms include those involving the

splenic, renal or hepatic arteries or any other artery in the
abdomen (in decreasing frequency). All are mostly associated
with AS and most have a low incidence of rupture especially
if the wall has calcified.

D. Non-atherosclerotic arterial disease.

1. Raynaud's syndrome - a vasospastic disorder, more common in women

than men, of unknown etiology, manifested by abnormally severe
reaction of fingers and hands to cold exposure. Usually a benign
condition treated with gloves or low-dose vasodilating agents, ie,
calcium channel blockers. May be associated with other autoimmune
disorders, ie, SLE, anticardiolipin antibody syndrome, scleroderma,
rheumatoid arthritis, etc.

2. Buerger's disease - arteritis obliterans - a disease of smokers, men >

women, involving progressive obliteration of small and medium sized
arteries of the hands and feet. Commonly leads to amputations.
Treatment involves complete abstinence from tobacco.

124
Cbapter 22

3. Polyarteritis nodosa - autoimmune complex disease that can lead to

microaneurysm formation or obliterative processes in the small vessels.

n. Venous Disease

A. Deep vein thrombosis (DVT)

1. Etiology - Virchow's triad: stasis, vessel injury, hypercoagulable state.

2. High-risk groups for development include females, elderly, overweight,

immobile, cancer, previous history of DVT, orthopedic procedures, etc.

3. Preventive measures include low dose heparin (5000 U SQ q 12

hours), calf pumps, early ambulation. For orthopedic patients, dextran
or full anticoagulation.

4. Diagnosis - clinical signs/symptoms of painful, swollen calf with +

Homan's sign is only approximately 50 percent accurate.

a. Non-invasive tests include duplex ultrasound, impedance

plethysmography, and venous Doppler exam.

b. Venography is the radiographic choice.

5. Treatment is anticoagulation for 6 - 12 weeks, first with heparin, then

with warfarin.

6. Thrombolytic agents dissolve clots faster but are more expensive and
ultimate value are still in question.

7. Complications of DVT include pulmonary emboli (PE) and venous

valvular insufficiency (post-phlebitic syndrome).

B. Pulmonary embolism

1. Common cause or contributing factor to deaths in the hospital.

2. Manifestations include sudden chest pain, SOB, tachypnea, feeling of

impending doom, hypoxia, occasionally hemoptysis. These are often
absent.

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 VASCULAR SYSTEM

3. Diagnosis most reliably made with pulmonary angiogram. Nuclear

lung scans are used commonly and can be helpful along with chest X-
ray and compatible clinical scenario.

4. Treatment usually involves 3 - 6 months anticoagulation (heparin

followed by warfarin) but thrombolytics may have value in lysing clots
faster and more thoroughly, leading to less long-term pulmonary
arterial resistance.

5. Patients with recurrent PE on anticoagulation, complications to

anticoagulants or contraindication to anticoagulation should be
protected with an IVC filter (Greenfield filter is most commonly used).

C. Venous valvular insufficiency

1. Causes include malformed valves, chronic stress leading to valve

failure, and injury to the valve after thrombosis.

2. Superficial valvular incompetence leads to varicose veins which can be

treated with graded elastic support hose or, if symptoms such as
phlebitis, bleeding or severe cosmetic deformity result, can be excised
(stripping) or sometimes treated with injection sclerotherapy.

3. Incompetence of the perforating veins and/or deep vein valves leads to

swelling, pigmentation of the skin, symptoms of heaviness, aching, etc,
and occasionally ulcers in the "gaiter" area of the medial and lateral
malleolus. Treatment consists of elevation and external support with
stockings as well as local wound care.

m. Lymphatic disorders

A. Lymphedema of unknown etiology occurring before age 35 years is

lymphedema praecox, generally due to congenitally small lymphatics and most
often becomes manifested in second or third decade of life.

B. Lymphedema at birth is Milroy's disease.

C. Lymphedema occurring after age 35 is lymphedema tarda and usually occurs

because of obliteration of lymphatics which were probably small originally.

D. Secondary lymphedema occurs following destruction of major lymph draining

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Chapter 22

areas by surgery, trauma, cancer, infection or radiation - most commonly

involves groin to leg or axilla to arm.

1. Long-standing acquired lymphedema may predispose to

lymphosarcoma.

E. Work-up of a swollen extremity usually involves 1) ensuring patency of the

venous system (Duplex ultrasound or venogram) and 2) nuclear
Iymphoscintigraphy.

F. Treatment is primarily elevation, graded elastic support hose and careful

treatment of injuries to prevent cellulitis and lymphangitis.

1. Graded mechanical pumping can reduce the swelling as well.

2. Reduction surgery to get rid of excess tissue occasionally is useful.

G. On rare occasions, normal lymph vessels will drain into an area that becomes
obstructed, leading to dilated lymph channels. These can sometimes be
anastomosed to normal veins to promote lymphatic drainage.

127
Chapter 23 HEART

L Congenital disease

A. Left-to-right shunt (non-cyanotic group)

1. Patent ductus arteriosus (PDA)

a. Normal closure occurs in a full-term neonate within the first

10-15 hours mediated by arterial blood oxygen tension, the
distinctive histologic structure of the ductus, and lower levels of
prostaglandin E series - complete closure is complete in 88 % of
newborns by 8 weeks. Becomes the fibrotic ligamentum
arteriosum.

b. Prolonged patency results in a left-to-right shift with pulmonary

congestion and left ventricular volume overload.

c. Incidence increases with prematurity and decreases in birth

weight and is associated with rubella infection during the first
trimester of pregnancy.

d. Manifested by a hyperdynamic cardiac function and continuous

"machinery" murmur and symptoms of heart failure.

e. Usually managed by transthoracic ligation - can occasionally be

managed by transcatheter occlusion with "Ivalon" plug.

2. Atrial septal defect (ASD)

a. The fifth most common congenital cardiac abnormality with no

known precise etiology. Increased incidence with trisomy 21,
Marfan syndrome and Turner syndrome.

b. Ostium secundum defects are the most common with ostium

primum defects and atrio-ventricular canal defects being more
severe degrees and similar hemodynamic abnormalities.

c. With increasing degrees of defects, there is increasing degree of

left-to-right shunt with pulmonary hypertension resulting from
the increased pulmonary flow.
Chapter 23

d. These lesions become manifest relatively early, depending on the

degree of shunting. Treatment is either primary or patch
closure of the defect.

3. Total anomalous pulmonary venous return

a. All of the oxygenated pulmonary venous blood mixes with

desaturated systemic blood in the right atrium.

b. Right atrial output reaches the systemic circulation through

persistent ASD, VSD or PDA.

c. There are at least four different subtypes of T APVR.

d. Infants without pulmonary venous obstruction are usually

tachypneic at birth but may not appear cyanotic.

e. Congestive heart failure becomes progressively worse without

surgical therapy, 75% will die before one year of age.

f. Operative correction requires anastomosis of the common

pulmonary venous channel to the left atrium and obliteration
of the anomalous venous connection. Operative mortality in
infants is decreased to approximately 25 % with good prognosis
for those who survive.

4. Ventricular septal defects (VSD)

a. Isolated VSD is the most common congenital cardiac anomaly,

accounting for 30-40% of all congenital lesions at birth.

b. Four general anatomic types are: supracristal or subarterial

VSD, high or perimembranous VSD, atrio-ventricular canal type
defects, muscular type defects.

c. The direction and magnitude of shunt depends upon the size of

the defect and difference in pressure between the ventricles in
systole and diastole. Sixty to seventy percent of small defects,
causing no symptoms, will close spontaneously in early life.
When the defect is large, it offers little resistance to flow and
relatively small pressure differences may result in significant

129
 HEART

flow across the defect. Early repair of large defects is

generally indicated to prevent the development of pulmonary
artery hypertension.

B. Right-to-left shunt (Cyanotic group)

1. Tetralogy of Fallot (TOF)

a. One of the most frequent serious cardiac conditions

accompanied by cyanosis in which infants develop symptoms
within the first six weeks of life.

b. There are a number of variations and anatomic changes in this

disease. Dextro position of the aorta and hypertrophy of the
right ventricle, along with pulmonary stenosis and VSD are the
four primary anatomic defects.

c. The two most important malformations are obstruction of the

right ventricular outflow tract and the ventricular septal defect
(resulting in right-to-left shunt).

d. Most patients with TOF are candidates for operative repair,

preferably between the ages of 3 and 5, except in the more
severe forms which require early operative intervention.

e. Subclavian artery to pulmonary artery anastomosis (Blalock-

Taussig) is an excellent operation in patients who are not
suitable candidates for total correction.

f. The corrective procedure can be done with a mortality of

approximately 5 %. This is complicated by occurrence of heart
block during closure of the VSD or congestive heart failure due
to failing right ventricle.

2. Transposition of the great vessels (TG V)

a. With complete transposition, the aorta rises anteriorly from the

anatomic right ventricle and the pulmonary artery rises from
the anatomic left ventricle.

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Chapter 23

b. Associated anomalies which permit life include patent ductus

arteriosus, patent foramen ovale, VSD and left ventricular
outflow tract obstruction.

c. Transposition is the leading cause of death resulting from

congenital heart disease in early life. The patient presents in
the first week of life with cyanosis. If they have inadequate
mixing, this can be improved by creating an atrial septal defect
(Rashkind procedure).

d. The Mustard operation switches the great arteries plus coronary

arteries for complete repair. Senning employed a technique to
create the first intra-atrial repair. Jatene has also reported
success in switching the great arteries with reimplantation of
the coronary arteries.

C. Obstructive lesions

1. Pulmonary stenosis

a. May be associated with rubella. Usually no known cause.

b. Manifests with dyspnea and easy fatigability.

c. Operative correction with pressure gradients across the valve of

> 50 mm Hg and generally involves valvulotomy.

2. Aortic stenosis

a. No known cause. Most are bicusp valves or tricuspid valves

with fusion of the commissures. Subvalvular stenosis may also
occur.

b. Fatigue, dyspnea, syncopy and angina develop with pressure

gradients > 50 mm Hg.

c. Operative correction usually involves valvulotomy. Long-term

follow-up is critical.

3. Coarctation of the aorta

131
 HEART

a. Generally occurs adjacent to the ligamentum arteriosum but has

no specific known cause.

b. Most have no symptoms except severe hypertension (although,

can result in heart failure).

c. Correction by resection and re-anastomosis is usually done at

age 3-4.

D. Acquired-cardiac disease

A. Coronary artery disease (CAD)

1. CAD is the most common cause of death in the Western world and
is thought to be the result of a combination of genetic predisposition,
atherogenic diet, hypertension, sedentary lifestyle, tobacco abuse and
diabetes.

2. Manifested by angina pectoris (exercise-induced chest pain), acute

myocardial infarction with acute occlusion to coronary artery
circulation or sudden death.

3. Non-invasive cardiac evaluation with exercise tolerance tests, nuclear

ventriculograms (with and without pharmacologic stress) and
echocardiography help select patients who go onto cardiac
catheterization.

4. Most patients with chronic, stable myocardial ischemia can be

managed by appropriate pharmacologic therapy, including
nitroglycerin, beta blockers and calcium antagonists.

5. Transarterial balloon dilatation (PTCA) of proximal lesions in the

coronary arteries can be done safely to improve perfusion of the
myocardial wall.

6. In general, revascularization is recommended for patients with double

and triple coronary artery disease, including aU of those with left
main coronary artery lesions. Coronary artery bypass grafting
increases longevity as well as providing distinct symptomatic
improvement.

132
Chapter 23

a. Patients with unstable angina not responsive to pharmacologic

agents are also suitable for balloon angioplasty or bypass
grafting.

7. Mortality and morbidity

a. Perioperative death rate should be under 10% overall and near

1 % for low risk patients.

b. Complete relief of pain occurs in 90-95 % of all patients.

c. Improved left ventricular function has been shown following

successful bypass.

d. Patency rate of bypass grafts is approximately 86 % at one

year.

e. Saphenous vein patency at ten years is recently noted to be

53 %, whereas internal mammary artery patency in the same
series is 84 % •

B. Acquired-aortic valve disease

1. Aortic valve stenosis

a. Calcific aortic stenosis occurring primarily in congenital

bicuspid valves is the most common source for aortic stenosis
(approx 50 %) while rheumatic aortic stenosis due to rheumatic
fever secondary to Group A Streptococci infection occurs in
about 1/3 of patients.

b. Significant aortic stenosis results in clinical manifestation of

chest pain, syncope, and congestive failure.

(1) Effort syncope has been related to arrhythmias and may

lead to sudden death syndrome.

c. Patients with significant symptoms of aortic stenosis have a

poor, long-term prognosis and are, in general, candidates for
operative correction.

133
 HEART

2. Aortic valve insufficiency

a. Intrinsic disease of the valve, particularly bacterial endocarditis

(or, less commonly) or congenital bicuspid valves may lead to
aortic insufficiency.

b. Cystic medial necrosis or intimal tears in the lining of the

ascending aorta may result in stretching of the aortic valve ring
and valvular insufficiency.

c. The common manifestations are that of rising left ventricular

filling pressures and symptoms of congestive failure - dyspnea,
fatigue, orthopnea, paroxysmal nocturnal dyspnea or angina.

d. Patients with symptomatic insufficiency are candidates for valve

replacement which is the operation of choice.

s. The overall operative mortality rate for aortic valve replacement is

approximately 7 %.

c. Acquired-mitral valve disease

1. Mitral stenosis (MS)

a. Predominant cause is rheumatic fever, although good history for

this is present in only one-half of the patients.

b. Most patients remain asymptomatic in a latent phase for two

decades before the onset of symptoms. Symptoms are those of
orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, easy
fatigability and episodes of frank pulmonary edema.

c. Peripheral cyanosis may be present as well as hepatic

enlargement and peripheral edema.

d. Surgical approach is indicated when the diagnosis is made

because of progressive stenosis of the mitral orifice. Operation
is indicated if the mitral orifice size is less than 1 cm per
meter square of body surface area.

e. Repair consists of either closed or open mitral

134
Cbapter 23

commissurotomies or mitral valve replacement.

2. Mitral regurgitation (MR)

a. Mitral valve prolapse and ischemic papillary muscle disease are

common causes of mitral regurgitation while 30-45 % of MR
requiring operation is from rheumatic valvulitis.

b. The basic pathophysiology is alteration of left atrial blood

pressure and left ventricular failure. More important symptoms
which develop are dyspnea on exertion, easy fatigability and
palpitations.

c. Patients with significant MR who begin to develop limitation

due to congestive cardiomegaly or pulmonary hypertension
should be treated with mitral valve repair or a prosthetic valve
replacement.

m. Pacemakers

A. The indications for permanent pacing are included in the list below:

1. Sick sinus syndrome with bradytachycardia arrhythmia syndrome.

2. Mobitz Type II AV block

3. Complete AV block

4. Symptomatic bilateral bundle branch block

5. Bivesicular or incomplete trivesicular block with intermittent complete

AV block following acute MI.

6. Carotid sinus syncope

7. Recurrent drug-resistant tachycardia arrhythmias improved by

temporary pacing

8. Intractable low cardiac output syndrome benefitted by temporary

pacing

135
Chapter 24 LUNG AND MEDIASTINUM

L Pulmonary functiom

A. Most commonly used pulmonary function tests for day-to-day management of

the patients, include:

1. Tidal volume (TV) - volume of air inspired during quiet normal

respiration.

2. Vital capacity (VC) - amount of air that can be expired following

maximal inspiration.

3. Forced vital capacity (FVC) - volume of air that can be forcibly

expired with maximal expiratory effort.

4. Forced expiratory volume - one second (FEV I) - the amount of air

that can be forcibly expired in the first second of the FVC.

5. Maximum voluntary ventilation (MVV) - the amount of air that can

be breathed in one minute during maximum effort calculated for 15
seconds of actual ventilation .

6. FEVdFVC % - the fraction of the FVC maximum expired in one

second

B. Numerous other pulmonary function analyses can be made in unusual

situations.

C. Arterial blood gases - measure the pH of the blood, the partial pressure of
oxygen (PaOJ and carbon dioxide (paCOJ in arterial blood.

1. The pH normally ranges from 7.37 to 7.43 and is maintained by

complex interactions of the blood buffering systems, renal
compensation and ventilatory compensation.

a. Acute respiratory alkalosis - low PaC02 and high pH - common

clinical findings resulting from hyperventilation.

b. Respiratory acidosis - high PaC0 2 and low pH, indicative of

hypoventilation.
Chapter 24

c. Metabolic alkalosis - high pH and low PaC02, indicative of a

metabolic alkalosis.

d. Metabolic acidosis, low pH and high PaC02, indicative of extra

acid load.

2. Oxygen dissociation curve can be used to indicate the effect of

temperature and pH on the ability to oxygenate the tissues, as well as
demonstrating the rapid decline of Pa02 that occurs when the oxygen
in the blood is lowered from full saturation (02 saturation of 90 %
correlates with a Pa0 2 of approximately 60 mm Hg).

3. PaC02 is a direct measure of alveolar ventilation. The normal range

is 38-42 mm Hg.

C. Effect of surgical procedures on pulmonary function

1. The degree of pulmonary dysfunction is directly related to the type of

operation and the preoperative status of pulmonary function of the
patient.

2. Total lung capacity is reduced after operations in the upper part of

the torso.

3. Atelectasis results from decreased surface area for gas exchange with
collapse of alveoli, resulting in arterial hypoxemia.

4. Airway closure is due to postoperative splinting of the chest and

altered breathing pattern.

D. Preoperative evaluation of risk

1. Increased age and smoking history. Increased closing volume.

2. Obesity diminishes FRC (functional residual capacity) and ERV (end

residual volume), resulting in airway closure and atelectasis.

3. An FEVI of greater than 2 liters is associated with minimal pulmonary

risk after abdominal operations. Increased risks are associated with
FEVI of 1-2 liters.

137
 LUNG AND MEDIASTINUM

4. When FEV 1 is less than 0.8 liters, there is moderate-to-severe risk of

being unable to wean the patient from the ventilator.

II. Lung cancer

A. Risk factors

1. Cigarette smoking is the primary risk factor in the pathogenesis of

carcinoma of the lung in the Western world today.

2. Lung cancer is the leading cause of cancer deaths in men and women
in the U.S.

B. Pathologic types

1. Squamous cell carcinoma - most common type with incidence of 40-

70 % of total lesions.

a. Nearly all of these patients have a cigarette smoking history.

b. Has a 50 % - 5 year survival with treatment.

2. Undifferentiated - in most series represents 20-30% of the total (oat

cell lesions). Is highly malignant and rapid growing.

3. Adenocarcinoma - occurs in 5-15% and are more often seen

peripherally.

a. Higher incidence in females and higher tendency to metastasize

to liver, brain, bone and adrenals, as well as lymph nodes.

4. Bronchoalveolar carcinoma - very well differentiated neoplasm

associated with the most favorable prognosis of pulmonary cancers.
The five year survival is 50-75%.

5. Giant cell carcinoma - variant of bronchogenic adenocarcinoma,

usually aggressive, incidence of 1-10%. Early metastasis.

C. Clinical manifestations

138
Chapter 24

1. Many patients are asymptomatic at the time of presentation, have an

abnormal chest X-ray being done for other reasons.

2. Among clinical symptoms commonly seen are cough, weight loss,

dyspnea, chest pain, hemoptysis, bone pain, clubbing of fingers,
presence of superior vena cava syndrome.

3. Rare bronchogenic carcinomas produce clinical endocrinopathy,

including inappropriate diuresis (ADH secretion), hypercalcemia,
carcinoid syndrome and Cushing's syndrome.

4. Pancoast tumor is one that arises anatomically on the superior sulcus

of the lung and can infiltrate the upper mediastinum and brachial
plexus and cervical sympathetic nerves.

D. Establishing a diagnosis

1. Radioisotope scanning, CT scanning and MRls can all be used to

identify suspected lesions seen on chest X-ray and tomography. These
tests also help identify the presence of disease in mediastinal or other
lymph nodes.

2. Biopsy of the lesion either with fine needle aspiration for cytologic
studies, through the use of bronchoscopy or through the use of
mediastinoscopy to needle aspirate lymph nodes are all important for
establishing a diagnosis.

E. Treatment

1. With no evidence of metastasis, invasion or obstruction to the thorax,

exploratory thoracotomy in an effort to remove the offending lesion is
the most commonly successful treatment for most types of lung cancer.

2. Radiation is frequently employed in a patient with bronchogenic

carcinoma and prolongs life by reducing symptoms for those with
metastatic lesions in whom resection is inappropriate.

3. Chemotherapy is particularly useful in patients with small cell

carcinoma because of the dismal results with surgery and radiation.
Cyclophosphamide with the addition of Vincristine and Doxorubicin
(Adriamycin) are particularly helpful.

139
 LUNG AND MEDIASTINUM

4. The natural history of bronchogenic carcinoma is dismal with a one

year mortality of 95 % if untreated. Patients without known metastasis
have five years survival in the 50 % range and 30 % if only the hilar
nodes are positive. Best prognosis is found in patients with solitary
peripheral lesions less than 4 cm in diameter.

F. Solitary II coin 'I lesion

1. The younger the patient, the more likely the lesion is to be benign.

2. Solitary coin lesions are dermed as being solitary, round, sharp

margins, less than 4 cm in diameter without associated calcifications,
cavities or other associated lesions within the chest.

3. Evaluation should include review of old chest X-rays, testing for

tuberculosis and histoplasmosis and sputum cytology for malignant
cells, cultures and tuberculosis. Ultimately bronchoscopy with washings
and occasionally a transthoracic needle biopsy may be needed. If no
diagnosis can be obtained, thoracotomy and excision of the lesion is
indicated.

ID. Primary tumors and cysts of the mediastinum

A. Usual location of mediastinal tumors and cysts:

Anterosuperior Middle Posterior

Thymoma Lymphoma Neurogenic tumors

Lymphoma Carcinoma Enteric cysts
Germ cell tumors Pericardial cysts Bronchogenic cysts
Tetratodermoid Bronchogenic cysts Mesenchymal tumors
Malignant germ Enteric cysts
cell tumors Mesenchymal tumors
Carcinoma
Thyroid adenoma
Parathyroid adenoma
Mesenchymal tumors

140
Chapter 24

1. Neurogenic tumors are the most common neoplasms encountered in the

mediastinum - 21 % of all primary tumors and cysts in collected series
- are usually located in the posterior mediastinum - 16-20% are
malignant.

2. Thymoma

a. Second most frequent lesion in the mediastinum - usually the

anterior superior mediastinum

b. Peak incidence in third-to-fifth decade of life.

c. May present with symptoms related to local mass effects,

including chest pain, dyspnea, hemoptysis, cough or symptoms
of superior vena cava obstruction. Thymomas are also
frequently associated with myasthenia gravis, occurring in 10-
50 % of patients with thymomas.

3. Most common malignant tumor in the mediastinum is lymphoma.

IV. Pleura and pleural space

A. Pleural effusion

1. Transudate

a. Causes include CHF, nephrotic syndrome, cirrhosis,

hypoproteinemia, myxedema, peritoneal dialysis.

b. Characteristics include clear, serous color; WBC < 1000; RBe

< 10,000; glucose, LDH and pH normal; protein < 3g/dl;
specific gravity < 1.106; culture and cytology negative.

c. Diagnose, with thoracentesis; usually just treat the underlying

cause.

2. Exudate

a. Causes include malignancy, infection, infarction, sympathetic

(pancreatitis, subphrenic abscess, etc.), traumatic, collagen
vascular disease (rheumatoid arthritis, lupus).

141
 LUNG AND MEDIASTINUM

b. Characteristics include cloudy, tan in color; WBC > 10,000;

RBC > 10,000; glucose low, LDH high, pH low; protein >
3g/d1; specific gravity > 1.016; culture and cytology may be
positive.

B. Tumors

1. Mesothelioma - associated with asbestos exposure

2. Metastatic tumors - especially lung and breast

142
Chapter 25 TRANSPLANTATION

L General aspects

A. Definitions

1. Autograft - tissue transplanted from one site of the body to another

in the same individual.

2. Isograft - tissue transferred between genetically identical individuals

(renal transplant between monozygotic twins).

3. Allograft - tissue transplanted between genetically dissimilar individuals

of the same species.

4. Xenograft - tissue transferred between individuals of a different

species.

5. Orthotopic graft (orthograft) - an organ placed at the normal

anatomic position Oiver, heart).

6. Heterotopic graft - organ placed at a site different than a normal

anatomic position (as in renal transplantation).

B. Immunology

1. Genetic loci for humoral and cellular immune responses are located
on the short arm of the sixth chromosome (major histocompatibility
complex (MHC).

2. Class I antigens are single chain glycoproteins catalogued as HLA-A,

HLA-B, or HLA-C.

3. Class I antigens are detected by serologic testing, using lymphocytes

and a known panel of antisera.

a. In living related donor kidney transplants, these antigens have

a very strong correlation with graft success.

4. Class II antigens are glycoproteins, consisting of two polymeric chains

containing a common subunit.
Chapter 25

a. Present on B lymphocytes, dendritic cells, activated T cells,

endothelial cells and monocytes.

b. Several series within the HLA locus are found including

HLA-D, D, DQ and DW/DR subloci.

c. These antigens are responsible for the cellular arm of the

immune response and are defined by mixed lymphocyte culture
test (MLC).

d. Because it takes 5-7 days to perform MLC, Class II antigens

are generally disregarded except in elective situations such as
related bone-marrow transplantation.

C. Rejection responses

1. HyPeracute rejection - occurs minutes to several hours following

implantation.

a. Associated with preformed antibodies directed toward either

ABO blood group or HLA antigens.

b. Currently is rare because of cross matching and blood group

matching.

2. Accelerated acute rejection - occurs during the first several days

following transplant.

a. In the kidney, is associated with oliguria, DIC,

thrombocytopenia and hemolysis.

b. Thought to represent a second set of anamnestic responses

mediated by both antibodies and lymphocytes.

c. Rare type of rejection with no effective treatment.

3. Acute rejection - occurs in up to 90 percent of cadaver donor

transplants.

a. Characterized by clinical characteristics of organ failure.

144
 TRANSPLANTATION

b. T ~ell infiltration into vascular and interstitial spaces.

c. Treatable with increased doses of immunosuppression and a

good prognosis if reversible.

d. Acute rejections may ultimately damage the organ.

4. Chronic rejection - slow progressive immunologic destruction over

months to years.

a. Vascular intimal hyperplasia, lymphocytic inf"Iltration, atrophy

and fibrosis of renal, cardiac or hepatic tissue.

b. Mediated by humoral and cellular events.

c. Unaltered by increased immunosuppression.

D. Immunosuppressive drug therapy.

1. All immunosuppressive regimens have common side effects of

decreased resistance to infection on the part of the host.

a. These infections are frequently opportunis tic with Candida,

cytomegalovirus, herpes virus and Pneumocystis carinii.

b. Resistance to tumors is also impaired, especially lymphomas and

skin cancers.

2. Azathioprine (Imuran) - antimetabolite which inhibits nucleic acid

synthesis in all replicating cells of the body.

a. Provides baseline immunosuppression and not used for specific

rejection.

b. Frequently used in combination with steroids and Cyclosporin.

c. Has complication of bone marrow depression.

3. Glucocorticosteroids

145
Chapter 25

a. Used in nearly all organ transplants.

b. Mechanism of action poorly understood but it is Iympholytic

and inhibits Interleukin I release from macrophages.
Commonly used to treat rejection episodes as a pulse therapy,
as well as used chronically for baseline immunosuppression.

c. Complications include development of dyspepsia, cataracts,

osteonecrosis of joints, glucose intolerance, acne, capillary
fragility and Cushing's syndrome.

4. Cyclosporin

a. Blocks the secretion of Interleukin II, a T-cell growth factor;

prevents proliferation and maturation of cytotoxic T-cells
responsible for graft rejection.

b. Used for maintenance immunosuppressive therapy in

combination with steroids and Azathioprine - has not been
helpful for acute cellular rejection.

c. Complications include dose-dependent nephrotoxicity,

hypertension, hyperkalemia, hirsutism, gingival hyperplasia,
hepatotoxicity, tumors and breast fibroadenomas.

5. Macrolides - FK506 and Rapamycin

a. New agents which are fungal metabolites and are potent

immunosuppressive agents.

b. Action seems to be specific for T or B cells.

c. Act synergistically with steroids and cyclosporin.

6. Polyclonal antilymphocyte or antithymocyte serums and globulins

(ALG, ATG).

a. Prepared by immunizing an animal with human lymphocytes or

thymocytes.

146
 TRANSPLANTATION

b. Used to induce immunosuppression immediately after transplant

or for the treatment of rejection episodes.

c. Use of these monoclonal antibodies makes it possible to

specifically direct immunosuppressive therapy so that only the
cells responsible for rejection episodes, are immunosuppressed.

d. OKT3 is the most commonly used such agent.

7. Other

a. Blood transfusion, either donor specific or random donor, has

been shown to be productive against rejection - mechanism not
well understood.

b. Total lymphoid inadiation.

(1) Used to prevent occurrence of rejection.

(2) Requires pretransplant radiation to all lymph node

bearing areas.

c. Plasmapheresis is used 011 highly sensitized recipients as

adjunctive therapy for accelerated rejection episode.

d. Thoracic duct drainage is used as an outmoded technique,

requires cannulation of the thoracic duct with subsequent
lymphocyte depletion.

n. Organ and tissue donation

A. Criteria for cessation of brain function.

1. Absence of spontaneous respirations, plus absence of pupillary light

response, plus absence of corneal light reflex, plus absence of
oculocephalic or oculovestibular reflex, plus unresponsiveness to stimuli,
plus known cause for condition, plus duration of condition over time,
plus known irreversibility, suggests brain death!

2. Confirmatory tests

147
Chapter 25

a. Sustained apnea on disconnecting respiratory.

b. EEG

c. Radionuclear brain scan

d. Cerebral angiography

e. Confirmatory tests are not mandatory but serve to support the

diagnosis of brain death.

B. Organ acceptability

1. Acute and chronic diseases affecting certain organs may exclude them
for consideration of transplantation.

2. Helpful lab tests for heart-lung transplants, include cardiac

catheterization, echocardiogram, EKG, chest X-ray, CPK enzymes with
MB fractionation.

3. Lab tests for kidney transplants include BUN, creatinine and

hypertens ion check.

4. For pancreatic transplant - glucose tolerance tests and a careful

history are important.

5. For liver transplant - liver function tests, history of hepatitis B or

chronic hepatic disease is important.

6. All transplant patients receive blood, urine, sputum cultures, hepatitis

screening, vnRL and HIV tests.

C. Organ preservation

1. Kidney, heart, lung, liver and pancreas are routinely flushed in situ
with cold solution to stop metabolism rapidly. They are stored in cold
solutions containing electrolytes and osmotic active agents which best
maintain cellular preservation.

m. Kidney transplantation

148
 TRANSPLANTATION

A. Indication for a kidney transplant is chronic renal failure from any cause,
free of other major diseases and between 1 and 70 years of age.

B. The transplant is nearly always placed as a heterotopic allograft.

C. Immunosuppression varies from center to center but usually involves the use
of Imuran, steroids and cyclosporin. OKT-3 or antithymocyte globulin may
be given for acute rejection episodes.

D. Functional graft survival of 75-85 percent for cadaver kidneys and 95 percent
for living related donors at one year is now common. Patient survival of 95
percent at one year is also common.

IV. Liver transplant

A. Candidates are those with a life expectancy of 1 year or less and free of
malignancy or infection.

B. Diseases treated with liver transplant include cirrhosis (post necrotic or

alcoholic), primary biliary cirrhosis, primary sclerosing cholangitis, metabolic
diseases with and without cirrhosis, congenital biliary atresia, congenital
hepatic fibrosis.

C. Other indications are occasionally indicated as well, including primary liver

tumors.

D. Transplant is almost always an orthotopic graft from the cadaveric donor.

E. Patient and graft survival is approximately 85 percent at one year for

patients operated on before the terminal phase of their disease.

v. Heart, heart-lung and lung transplantation

A. Indication for heart transplant is end stage cardiac failure and the patient is
expected to die within six months. Age is not a contraindication. Patient
must have full rehabilitation potential.

B. Heart-lung transplant is performed where severe pulmonary vascular disease

accompanies heart disease.

149
Chapter 25

c. The usual heart transplant is an orthotopic allograft that is size matched.

D. The current one year graft and patient survival is 80 percent or higher and
5 year rate is 60 to 70 percent.

E. Heart-lung transplant recipients can expect 5 year survival rate of 50 percent.

F. Single or double lung transplant can provide total pulmonary function to

patients with end stage pulmonary disease without suppuration or concomitant
cardiac failure.

G. Rejection is the most common complication after a lung transplant.

H. Results of lung transplant have not been as dramatic as those with heart
transplant but are improving with Cyclosporin and steroids.

VL Pancreas tramplant

A. Indicated in patients with Type I, insulin dependent diabetes and usually

concomitant liver failure, vascular disease, retinopathy, neuropathy or
enteropathy.

B. Most often done with simultaneous renal transplant.

C. Many surgical techniques have been used, most commonly transplantation of

the entire pancreas with the attached C sweep of the duodenum.

D. With routine use of cyclosporin, the one year graft survival of whole organ
transplantation is approaching 80 percent.

VII. Other

A. Allografts of parathyroid tissue, bone and skin have also been successful, as
has bone marrow transplantation.

B. Small intestine transplant and group organ transplants have been performed
but long term success is yet to be achieved.

C. Allografts of skin, bone, fascia, dura, endocrine organs, eyes, blood vessels are
used clinically in a variety of situations or are being investigated.

150
Chapter 26

L Thyroid

A. Anatomy

1. Follicles witb supporting stroma and parafollicular cells (C cells).

2. Rigbt and left lobe plus isthmus whicb occasionally extends past byoid
bone to foramen cecum at base of tongue.

3. Arterial supply - inferior tbyroid arteries - brancbes of tbyrocervical

trunks; superior tbyroid arteries are brancbes of external carotid.

4. Veins - inferior, middle, superior.

S. Superior laryngeal nerve runs witb superior tbyroid artery.

6. Recurrent laryngeal nerve loops around aortic arcb on left, subclavian

artery on rigbt, usually travels near tracheoesophageal groove, behind
inferior thyroid artery to enter larynx at the inferior cornu of thyroid
cartilage.

B. Physiology

1. Serum iodine converted to T3 and T4 whicb have multiple metabolic

effects on various end organs (including heart arteries, fat metabolism,
etc).

2. Parafollicular cells (C cells) secrete calcitonin belps regulate serum

calcium level.

3. Function of thyroid regulated by CNS and level of circulating iodine.

a. Cerebral cortex - bypothalamus - TRH - ant. pituitary - TSH

tbyroid - TI, T. ~

C. The tbyroid mass

1. Diagnosis - studies such as thyroid function tests, nuclear scans,

Chapter 26

ultrasounds or CT/MRI can be done, however, the most useful is

needle aspiration with cytologic evaluation.

2. Colloid nodules or "goiters" are most common, are benign, and often
resolve with aspiration if cystic. Especially common in middle-aged
women.

3. Benign papillary or follicular adenomas may be suggested on needle

aspiration but can't be securely diagnosed until the whole nodule is
excised.

4. Four common types of primary thyroid cancer histologic types:

a. Papillary - most common (58 %) , tends to be multicentric,

relatively rare lymphatic or distant metastasis, treated with lobe
plus isthmus resection or total thyroidectomy with 80-90% 10
year survival.

b. Follicular - second most common, tends to spread to

surrounding nodes and distant sites, treated with total
thyroidectomy and 1-131 for distant metastasis, 66-70% 10 year
survival.

c. Medullary - associated with C cell (Calcitonin production) and

MEN IT syndrome, commonly recurs or metastasizes, treated
with total thyroidectomy, 50% 10 year survival.

d. Anaplastic - very aggressive tumor with no good treatment

alternatives at present, usually treated with debulking procedure
to keep tumor ofT trachea, 0-5 year survivals

5. Other primary and secondary tumors can be found in the thyroid -

lymphoma, metastatic cancers, etc.

6. Risk factors associated with higher incidence of cancer include: male

gender, young « 25 yr) or old (> 50 yr), history of head and neck
radiation, fast growth of mass, hoarseness, tracheal deviation.

D. Hyperthyroidism

152
 ENDOCRINE

1. Hyperfunction of thyroid gland due to a solitary functioning nodule

(rare) (" toxic adenoma"), multinodular goiter or diffuse disease
(including Graves' disease - most common) is an unusual indication for
thyroidectomy.

2. Thyroid storm
II II sudden, massive release of thyroid hormones with
-

hypermetabolic response is also a rare indication for urgent thyroid

operation.

3. When possible, control thyroid metabolic activity and end organ

response fIrst - propylthiouracil (PTU) and Propranolol and/or 1-131.

4. When operation is indicated, total thyroidectomy is usually done.

E. Major complications to thyroid operations include injury to recurrent

laryngeal nerve « 1 %), permanent hypoparathyroidism « 1 %), other cranial
nerve injury « 2 % ).

n. Parathyroid

A. Anatomy

1. Usually 4 glands - 2 inferior ones derived from 3rd pharyngeal pouch

and 2 superior ones from 4th pharyngeal pouch.

2. Blood supply from branches of inferior and superior thyroid arteries.

B. Physiology

1. Produce parathyroid hormone (parathormone) (PTH) in response to a

feed back mechanism with serum calcium concentration such that
serum calcium concentration is carefully maintained below 8.5 and 10.5
mg/dl. Requires Vitamin D.

c. Primary hyperparathyroidism (1 HPT)

0

1. Most common intrinsic cause of hypercalcemia.

a. Other causes of hypercalcemia include metastatic cancer to

bones, vitamin D/A intoxication, sarcoidosis, multiple myeloma,

153
Chapter 26

hyperthyroidism, HCTZ, lithium, milk alkali syndrome.

2. Usually diagnosed in an asymptomatic state with persistent elevated

serum (Ca++) associated with elevated PTH levels.

3. Like hypercalcemia, 1° HPT may be associated with symptoms of

peptic ulcer disease, kidney stones, pathologic bone fracture (Brown's
tumors), hypertension and psychoses.

4. Most common pathology is solitary adenoma.

5. Treated with excision of parathyroid adenoma.

6. Overall most common cause of hypercalcemia is metastatic cancers to

bone - especially from lung, breast, colon, prostate and myeloma.

7. Hyperparathyroidism associated with MEN I or IT usually due to

hyperplasia of all 4 glands.

D. Secondary - Tertiary HPT

1. 2° HPT occurs in renal failure patients on hemodialysis or patients

with malabsorption syndromes whose serum Ca++ is low but whose
PTH level remains high. This promotes soft tissue calcification,
especially in arteries.

2. 3° HPT is diagnosed when the hemodialysis patient gets a kidney

transplant which tries to regulate serum Ca++ level but has persistent
autonomaly increased PTH levels causing hypercalcemia.

a. 2° and 3° HPT is usually associated with 4 gland hypertrophy

and is treated with either excision of 3 1/2 glands or excision
of all glands and reimplantation of 1/2 gland into a forearm
muscle.

E. Parathyroid carcinoma

1. Very rare - may not be associated with severely increased Ca++.

2. Suspect it if a palpable tumor mass is present or the parathyroid

154
 ENDOCRINE

gland does not easily dissect away from surrounding tissues.

F. Hypoparathyroidism

1. Rare except as complication of thyroid or parathyroid surgery.

2. Treated with calcium and vitamin D supplements.

ffi. Adrenal Gland

A. Anatomy

1. Left side - gland juxtaposes kidney, spleen, pancreas, diaphragm.

a. Arterial supply from renal artery branches, aortic branches, and

phrenic branches.

b. Main draining vein empties into left renal vein.

2. Right side - gland juxtaposes kidney, vena cava, liver, diaphragm

a. Arterial supply - branch of renal artery, phrenic branch.

b. Largest vein is very short and drains into Ive.

3. Medulla - synthesizes and secretes epinephrine, norephinephrine and
dopamine.

4. Cortex - secretes corticosteroids, androgens and small amounts of

estrogens.

B. Physiology

1. Responsible for catecholamines and a wide range of cholesterol-derived

hormones - aldosterone (mineralocorticoids), glucocorticoids, estrogens,
androgens, etc.

C. Pheochromocytoma

1. Metabolically active adenoma (only 10% are malignant) of the adrenal

155
Cbapter 26

medulla (although 10 % are in neuroendocrine rests outside the adrenal

gland) that produces catecholamines (r norepinephrine but also
epinephrine).

2. Associated with MEN II (Sipple's syndrome) (parathyroid, medullary

carcinoma of thyroid, pheochromocytoma) and with von
Recklinghausen neurofibromatosis but most commonly is an isolated
tumor (56-70 %). Ten percent are unilateral but in familial cases,
50 % are bilateral.

3. Usual manifestation is that of sustained high blood pressure (HBP) but

the classic manifestations are those of episodic catecholamine release -
bursts of HBP, tachycardia, diaphoresis, headaches, weight loss, nausea
and vomiting, Raynaud's phenomenon, etc.

4. Diagnosis is by detecting VMA and metanephrine levels in urine -

localizing tests include CT scanning and/or iodo-cholesterol scans.

5. Treatment

a. Initial suppression of catecholamine activity - phenoxybenzamine

or phentolamine - plus Beta block (propranolol, etc.) if
tachycardia develops and simultaneous increasing of
intravascular volume.

b. Subsequent adrenalectomy.

D. Primary hyperaldosteronism (Conn's syndrome)

1. The most common etiology is a benign adenoma of zona glomerulosa

of the adrenal gland cortex.

2. Manifestations include sustained hypertension (usually mild to

moderate) with a characteristic hypokalemic metabolic alkalosis and
polyuria, polydipsia and muscular weakness.

3. High serum levels of aldosterone and low levels of serum renin are
diagnostic.

156
 ENDOClUNE

4. Localizing studies include CT scanning or iodo-cholesterol scans.

5. Treatment consists of excision of the involved adrenal gland, usually

through posterior lateral approach.

E. Cushing's syndrome/disease

1. Classic Cushing's disease, consists of adenoma of anterior pituitary

gland secreting cortisol stimulating hormone (ACTH) resulting in
stigmata of chronic excess glucocorticoids (60%).

2. The most common cause of Cushing's syndrome is secondary to

iatrogenic administration of glucocorticoids.

a. May also result from ectopic source of ACTH (ie, oatcell

carcinoma of lung).

b. Adrenal adenomas or carcinomas may occasionally cause

Cushing's syndrome (15 %).

3. Manifestations include hypertension, central obesity, purple stria,

diabetes mellitus, weakness, amenorrhea, nervousness, irritability, bone
pain, osteoporosis, hirsutism, headache, ankle and hand edema,
decreased libido in females and feminization of males.

4. Diagnosis started with urinary and serum cortisol levels.

Dexamethasone suppression best may confirm presence of Cushing's
syndrome and discriminate the syndrome from the disease.

5. Localizing efforts include CT scanning and iodo-cholesterol scanning

after pituitary adenomas have been ruled out.

6. Treatment consists of ablation of pituitary if a tumor can be found or

bilateral adrenal excision with glucocorticoid and mineralocorticoid
replacement.

7. Nelson's syndrome may occur after bilateral adrenalectomy - pituitary

enlargement causing visual field loss and hyperpigmentation.

157
Chapter 26

F. Hypoaldosteronism (Addison's disease)

1. The most common cause of adrenal insufficiency is withdrawal of

chronic exogenous steroid therapy. Eighty percent of spontaneous
adrenal insufficiency are 20 to autoimmune destruction of the adrenals.
Hypoaldosteronism may occur usually secondary to infectious
destruction of the adrenal gland (TB, histoplasmosis) or trauma to the
adrenal gland (hemorrhage in patients on anticoagulation or with
sepsis) and surgical removal.

2. Manifested by unstable blood pressure control and electrolyte

abnormalities (low Na, high K), becomes a life-threatening problem.

3. Treatment requires glucocorticoid and mineralocorticoid replacement.

158
 SELF-ASSESSMENT EXAMINATION

Chapter 1: FLUID, ELECTROLYfES AND NUTRITION

1. A trauma patient who is tachycanlic, has orthostatic hypotension, and a decreased

urine output has probably lost what percent or his intravascular volume?

A.. 0-15%
B. 15-30%
C. ~
D. > 40%
E. cannot be estimated

2. Sodium resorption in exchange for potassium and hydrogen secretions by the distal
renal tubules is the direct effect of aldosterone.

Tme or False?

3. Buffering of acute changes in acid-base balance is first started by:

A.. RBC and body Duids buffering systems

B. pulmonary system
C. renal tubular functions
D. renal blood Dow changes
E. pituitary. hypothalamic . adrenal axis

4. 11Je usual recommended rate of intravenous potassium replacement is:

A.. 5-10 mEqlbour

B. 18-20 mEqlbour
C. 20-40 mEq/bour
D. 5 mEq/kg
E. 20 mEq/kg

5. All of these treatments for hyperkalemia reduce total body potassium concentration
EXCEPr:

A.. ion-excbange resins

B. furosemide
C. dialysis
D. insulin/glucose/bicarbonate

159
6. 1be asymptomatic patient with hypeI'adcemia should be evaluated for:

A. lung cancer
B. colon cancer
C. breast cancer
D. primary b.yperparatbyrodism
E. all of the above

7. Factors that limit the amount of ftuid needed in the post-operative patient, indude
all of the following EXCEPI':

A. mechanical ventilation
B. elevated ADA levels
C. elevated aldosterone levels
D. elevated renin levels
E. fever

8. Hyperosmotic, non-ketotic dehydration and coma is an iatrogenic complication with

an approximately 60% mortality rate.

True or False?

9. Hyperosmotic, non-ketotic dehydration

A. occurs only with TPN

B. occurs only with enteral alimentation
C. both A and B
D. neither a nor b

10. Adequacy of nutritional replacement is best followed clinically by the serum albumin
level.

True or False?

Chapter 2: SHOCK

11. The best way to decide if a patient is in shock is:

A. measure systemic BP and pulse rate

B. place a Swan-Ganz catheter to measure wedge pressure and cardiac output
C. observe mental status and urine output
D. obtain history of preceding events
E. check renin levels

160
12. All of the clinical forms of shock can be initially treated with:

A. volume
B. blood
C. inotropic agents
D. sylDpatholDimetics
E. operative intervention

13. Early septic shock is clIaraderized hemodynamically by high cardiac output and low
peripheral vascular resistance.

True or False?

14. Decrease in cardiac output in an elderly auto accident victim may be from:

A. myocardial ischemia
B. cardiac contusion
C. arrhytIunias
D. cardiac tamponade
E. all of the above

15. An accident victim with obvious blood loss who has not responded to 2 litel"s or
Ringers Lactate in the first 15 minutes should be given:

A. normal saline
B. typed and cross-matclJed blood
C. plasmolyte
D. o-negative or type specific blood
E. fresh frozen plasma

16. Invasive cardiac monitoring (Swan-Ganz catheter) can be useful in managing

A. hypovolemic shock
B. cardiogenic shock
C. septic shock
D. all of the above
E. is rarely helpful

161
17. Early decrease in urine output or a patient in hypovolemic shock is due to:

A. catecholamine-induced vasoconstriction
B. aldosterone release
C. ADH release
D. renin-angiotensin system
E. all or the above

18. Raising the systemic blood pressure in a hypotensive trauma victim with alpha-
adrenergic agents (levophed, etc.) is helpful because it helps perfuse injured organs.

Troe or False?

19. Patients with septic shock often have an undrained abscess. Troe or False?

20. Isolated neurogenic shock is rare in most hospitals.

Troe or False?

Chapter 3: CLOTfING DISORDERS AND BLOOD PRODUCTS

21. The best pre-op test to identify bleeding problems in a patient is

A. History or bleeding problems

B. Yf
C. FIT
D. platelet count
E. thrombin time

22. Patients on heparin or warfarin therapy should not undergo operation because or the
risk or uncontrollable bleeding.

Troe or False?

23. The most commonly used laboratory test to monitor heparin therapy is:

A. Yf
B. FIT
C. TI
D. bleeding time
E. none are effective

162
24. Excessive bleeding during an operation may be due to all of the following EXCEPT:

A. pre-op aspirin use

B. massive transfusion (> 2500 ml)
C. transfusion of incompatible blood
D. gram-negative sepsis
E. hyperthermia

25. The most common complication of red cell transfusion is:

A. hemolytic transfusion reaction

B. febrile transfusion reaction
C. post-transfusion thrombocytopenia
D. HIV transmission
E. anaphylactic shock

Chapter 4: SURGICAL INFECfIONS

26. Clean-contaminated operations such as an elective colon resection have an infection

risk of:

A. < 3%
B. 5-15%
C. 15-40%
D. 40%
E. > 75%

27. Proper use of prophylactic antibiotics include all EXCEPT:

A. administer 1st dose 1-2 hours pre-op

B. continue the antibiotic for no more than 24 hours
C. should be used for essentially all operations
D. Significantly reduce post-op wound infection after colon resection
E. should be used for essentially all procedures placing prosthetic material in
the patient

28. Methicillin-resistant Staph aureus infections are usually treated with:

A. penicillin
B. cephalosporin
C. aminoglycosides
D. vancomycin
E. sulfonamides

163
29. Fever on the night after an elective hip replacement operation is most likely due to:

A. blood transfusion reaction

B. reaction to the foreign material
C. urinary tract infection
D. atelectasis
E. skin-borne bacterial

30. An adult with unknown tetanus immunization and a dirty trauma associated wound
several hours old should receive:

A. 0.5 ml tetanus toxoid

B. 0.5 ml tetanus toxoid and 250 units human TIG
C. penicillin alone
D. 250 units human TIG alone
E. debridement and irrigation alone

31. Peri-rectal abscesses can usually be treated with appropriate antibiotics alone.

Tme or False?

32. Line-associated sepsis usually requires removal of the indwelling line.

Tme or False?

33. Chronic skin or mucous membrane lesions, low grade fever, weight loss, pulmonary
dysfunction, hepatosplenomegaly and lymphadenopathy in a compromised patient
on broad spednun antibiotics, often represent fungal infections.

Tme or False?

34. Intra-abdominal abscess formation after a hysterectomy usually becomes manifested

within 1-2 days of the operation.

True or False?

35. Pseudomembranous colitis may occur after administration of almost any commonly
used antibiotic.

Tme or False?

164
Chapter 5: TRAUMA

36. The first priority in resuscitating a multi-traUlDa victim is:

A stop massive hemorrhage

B. cover open wounds
C. re-align fractures/dislocations
D. establish an airway
E. evaluate ror a neurological emergency

37. A tension pneumothorax is more serious to the patient than a simple pneumothorax
because:

A it is harder to diagnose
B. or hinderance or blood return to the heart because or mediastinal shift
C. more care must be taken with the chest tube
D. great incidence or concomitant injury
E. it is more unusual

38. Restoration or circulating volume

A. uses large bore peripheral IVs versus central venous lines

B. is usually started with crystalloid selection
C. may require uncrossmatched, Type-O, Rb negative blood ir there's no
response to crystalloids
D. may be assessed by urine output, level or consciousness and hemodynamic
stability
E. all or the above

39. The Glasgow coma scale is useful as a prognostic indicator in the comatose patient.

True or False?

40 In assessing a patient with head trauma, it is important to:

A. obtain lateral C-spine X-rays down to C-7

B. obtain CXR and abdominal X-rays early
C. limit Ouids in spite or the patients blood pressure
D. do peritoneal lavage

165
41. The most common source or the problem in a multi-trauma victim who is
hypotensive is:

A. head
B. chest
C. abdomen
D. spine
E. extremities

42. The right ventricle or the heart is the area most commonly injured with cardiac
contusions.

Tme or False?

43. CT scan or the abdomen or a blunt trauma patient is most likely to miss which
injury

A. liver laceration
B. spleen laceration
C. pancreas injury
D. jejunal disruption
E. renal injury

44. Orthopedic injuries prone to neurovascular injury include all EXCEPT:

A. Colles' fracture or radius

B. supracondylar rracture or remur
C. dislocation or knee
D. supracondylar fracture or humerus
E. fracture or first rib

45. Essentially all gunshot wounds to the chest require exploration True or False?

Chapter 6: BURNS

46. The most common cause or death in the first 24 hours after a major burn is:

A. sepsis
B. inadequate Ruid resuscitation
C. associated injuries
D. toxemia
E. inhalation iqjury

166
47. A name bum on the back that is red, blistered and extremely painful is:

A. 1st degree
B. 2nd degree
C. 3n1 degree
D. 4th degree

48. An adult with 40 percent BSA bums is receiving the Parkland fonnula for nuid
resuscitation. Twelve hours after the bum, his urine output in 18-15 cc/hr.
Appropriate management should include:

A. giving plasma
B. mannitol or furosemide to increase urine Dow
C. place a Swan-Ganz catheter
D. increase crystalloid nuid rate
E. giving albumin

49. Antibiotics should be given to all bum patients froID the tilDe of adlDission.

Tme or False?

51. Most bum patients severe enough to be in a special bum unit can meet their
metabolic deDIands by eating.

Tme or False?

Cmpkr7: WOUNDH~mG

51. During the innamlDatory stage (or lap phase) of wound healing, collagen production
is an important early feature.

Tme or False?

52. Contraction of a wound:

A. reduces the size of the wound after the first day or two
B. is an abnonnal process which should be halted if possible
C. both
D. neither

167
53. In general, grossly contaminated wounds should be managed with:

A. primary closure
B. delayed primary closure
C. heal by secondary intention
D. covered with a STSG
E. closed with a local pedicle Rap

54. A wound that has red, swollen, painful edges and serosanguinous drainage 4-5 days
post-op should:

A. be treated with antibiotics alone

B. opened, debrided and treated with antibiotics
C. be protected with a better dressing
D. requires return to the operating room
E. indicate malpractice

55. All of these factors interfere with wound healing EXCEPT:

A. tissue oxygen supply

B. necrotic tissue or foreign bodies
C. Vitamin C toxicity
D. Zinc deficiency
E. exogenous steroid

Chapter 8: ACUTE ABDOMINAL PAIN

56. Abdominal pain lasting more than six hours without prodromal symptoms usually
represents a surgical problem?

True or False?

57. De most helpful aid to diagnosis in most patients with abdominal pain is?

A. careful history and physical exam

B. laboratory studies
C. abdominal X-rays
D. ultrasound
E. cr scan
58. In a patient with acute abdominal pain, it is important to make a precise diagnosis
prior to operation.

True or False?

168
59. Dill'use periumbilical pain that localizes to the right lower quadrant in a 21 year old
sexually active woDlan with a benign pelvic exaDI and negative pregnancy test Dlost
likely represents:

A. PID
B. acute cholecystitis
C. ectopic pregnancy
D. acute appendicitis
E. Crohn's disease

60. It is iDlportant to dill'erentiate acute cholecystitis froDl ascending cholangitis

because:

A. cholecystitis responds to treatment better

B. cholangitis can lead to sepsis and death in 12-24 hours
C. cholecystitis needs an operation while cholangitis usually does not
D. dill'erent types of bacteria are involved
E. late follow-up Dlay be dill'erent

61. Most patients with acute pancreatitis need early operative intervention.

Tme or False?

62. Patients with perforated duodenal ulcers and no preceeding ulcer history are usually
treated with:

A. antacids and Hz blockers

B. oversewing and patch of the perforation
C. vagotoDlY and pyloroplasty
D. vagotoDlyand antrectoDly
E. antibiotics alone

63. The diagnosis of acute diverticulitis DlUst be confirmed with bariuDl eneDla or
colonoscopy before treatment can begin.

True or False?

169
64. A diagnosis of complete small bowel obstrnction can usually be made with a history,
physical exam and:

A. Rat and upright abdominal X-rays

B. cr scan
C. ultrasound
D. barium meal with small bowel follow-through
E. upper endoscopy.

65. A patient with acute onset of abdominal or Rank pain who is in severe distress and
can't seem to find a comfortable position likely needs which tests to help with the
diagnosis?

A. serum amylase
B. serum chemistries
C. WBC and hemoglobin level
D. urinalysis and IVP
E. ultrasound or cr

Chapter 9: ESOPHAGUS

66. Patients with sliding hiatal (Type I) all need treatment.

True or False?

67. Most patients with symptoms of reDox esophagitis can be treated without surgical
intervention.

True or False?

68. Most patients with achalasia

A. have an inability to relax the LES

B. have a "Bini's beak" appearance of esophagogram
C. have more trouble swallowing liquids than solids
D. have an increased incidence of cancer development
E. all of the above

69. Esophageal manometry can:

A. dilfereotiate achalasia f'rum scleroderma

B. dilfereotiate scleroderma f'rum reDox associated with hiatal hernia
C. both
D. neither

170
70. The success rate for commonly used anti-reDox operations in well selected patients
is:

A. 20%
B. 4K
C. 60%
D. 80%
E. 100%

71. All have been associated with esophageal cancer EXCEPT:

A. 8an'ett's esophagus
B. Plummer-Vinson syndrome
C. lye stricture
D. tobacco use
E. long-term Hz blocker use

71.. Treatment for adenocarcinoma usually involves:

A. radiation only
B. surgical excision and reconstruction only
C. radiation and chemotherapy
D. radiation, chemotherapy followed by surgical excision
E. esophageal bypass

Chapter 10: STOMACH

73. Common indications for patients with peptic ulcer disease include all of the following
EXCEPT:

A. hemoITbage
B. obstnlction
C. perforation
D. intractible symptoms
E. risk of cancer development

74. As opposed to peptic ulcers, gastric ulcers have a high rate of response and cure
with medical management.

True or False?

171
75. Patients with Zollinger-Ellison syndrome are distinguished from peptic ulcer patients
by:

A. severe ulcer diathesis, often with multiple ulcers

B. high levels of basal acid output
C. minimal response to pentagastrin stimulation
D. elevated gastrin in response to secretin
E. all of the above

76. Proximal gastric vagotomy for peptic ulcer disease has fewer post-vagotomy
symptoms but more recurrent ulcers than vagotomy and pyloroplasty or vagotomy
and antrectomy.

True or False?

77. Bland diets are thought to be helpful in managing patients with peptic and gastric
ulcers.

True or False?

78. Medical management of uncomplicated gastric ulcers does not include:

A. antacids since the BAO tends to be low

B. should be confirmed successful with EGD or UGI after 6 weeks of treatment
C. has a recurrence rate of 18-15%
D. eliminates the risk of cancer
E. has not changed in 50 years

79. Post-antrectomy nutritional deficiencies include Vitamin B12, folate and iron.

True or False?

80. Factors associated with development of gastric cancer include:

A. previous partial gastric resection

B. achlorhydria
C. pernicious anemia
D. Barrett's esophagus
E. all of the above

172
Chapter 11: SMALL BOWEL

81. Major functions of the small bowel include:

A. absorption/digestion
B. motility
C. hormonal production
D. immunologic activity
E. all of the above

82. Most patients with Crohn's disease never need operative intervention.

True or False?

83. Because cure is not possible, operative treatment for patients with Crohn's disease
is usually reserved for complications of the disease.

True or False?

84. In general, patients with small bowel obstruction:

A. should undergo operative exploration early

B. should be observed for 2-3 days before exploration
C. often improve spontaneously
D. have clear signs and symptoms of impending gangrene
E. should be suspected of having cancer.

85. "Closed-loop" obstructions are dangerous because bowel viability is compromised

early in the course of the illness.

True or False?

86. The most common primary cancer of the small bowel is:

A. malignant carcinoid
B. leiomyosarcoma
C. adenocarcinoma
D. lymphoma
E. liposarcoma

87. Meckel's diverticulum, discovered incidentally, should be removed prophylactically

to prevent future problems.

True or False?

173
Chapter 12: APPENDIX

88. Diagnosing appendicitis in pregnant patients is more difficult than usual because:

A. the appendix may be in an unusual location

B. there is a reluctance to recommend an operation in pregnant patients
C. the variations in nonnal lab values found in pregnancy may obscure the
diagnosis
D. pregnant patients have other processes which cause lower abdominal pain
E. all of the above

89. A surgeon with an appropriate degree of suspicion should have a negative

laparotomy rate for appendicitis of 15-20%.

True or False?

90. The most common tumor of the appendix is:

A. adenocarcinoma
B. carcinoid
C. lipoma
D. mucocele
E. sarcoma

Chapter 13: COLON

91. The major role of the colon is:

A. water absorption
B. storage organ
C. electrolyte balance
D. mineral recovery
E. fatty acid breakdown and absorption

92. Conditions associated with a high risk of cancer include all of the following
EXCEPT:

A. villous adenomas
B. familial polyposis
C. Peutz-Jegbers syndrome
D. Gardner's syndrome
E. ulcentive colitis

174
93. The main reason to do colonoscopy on a partially obstructing sigmoid colon mass
detected on barium enema in a 68 year old man:

A biopsy for tissue diagnosis

B. nile out diverticular disease
C. look for metastases
D. identify synchronous tumors
E. baseline for future studies

94. Five year survival prognosis of a Duke's Stage B lesion is:

A 80-90%
B. 60-70%
C. 30%
D. 5%
E. enhanced by adjuvant chemotherapy

95. CEA levels can be useful in screening for colon cancers in large population group.

TnJe or False?

96. Diverticula of the colon are most common on the left but hemorrhage is most
common from the right or transverse.

TnJe or False?

97. Colon removal to prevent cancer in a patient with ulcerative colitis should include
all of the factors listed EXCEPT:

A degree of activity of the disease and symptoms

B. amount of colon involved
C. length of time of presence of disease
D. age of the patient
E. presence of a positive biopsy

Chapter 14: RECTUM AND ANUS

98. The most common cause of melena is:

A diverticulosis
B. UGI bleeding source
C. colon cancer
D. hemorrhoids
E. ulcerative colitis

175
99. Most patients withperi-anal fistulae will Rquire fecal diversion to obtain healing:

Tme or False?

100. An anal fissure that is off the mid-line may be associated with:

A. Crobn's disease
B. ulcerative colitis
C. leukemia
D. tuberculosis
E. all of the above

101. External hemorrhoids tend to cause more pain symptoms than internal hemorrhoids.

Tme or False?

102. Radiation therapy for the common types of anal neoplasms tends to be more useful
than it is for colonic adenocarcinoma.

Tme or False?

103. Dietary control of cholesterol and phospholipids should be able to eliminate gall
stones.

True or False?

Chapter 15: GALLBLADDER AND BILIARY SYSTEM

104. Most gallstones are made up of:

A. pure cholesterol
B. pure bile pigments
C. calcium
D. mixtures of cholesterol, bile salts and calcium
E. phospholipid concentrates

105. The incidence of symptom development in patients with gallstones has been
estimated at:

A. 5%
B. 2K
C. 40%
D. 60%
E. 80

176
106. Charcot's triad of right upper quadrant pain, fever and leukocytosis is associated
with:

A. hepatitis
B. acute cholecystitis
C. chronic cholecystitis
D. ascending cholangitis
E. gallbladder cancer

107. An elderly patient with jaundice, weight loss and a RUQ mass is likely to have:

A. gallbladder carcinoma
B. bile dud cancer
C. common dud stone
D. choledochocyst
E. duodenal diverticulum

Chapter 16: LIVER

118. An anomalous branch of hepatic artery which originates from the superior
mesenteric artery is known as a "replaced" hepatic artery.

True or False?

109. Pyogenic hepatic abscesses most commonly originate from:

A. cholangitis
B. systemic sepsis
C. appendicitis
D. diverticulitis
E. trauma

110. Hemangiomas of the liver

A. are the most unusual benign tumor of the liver

B. should be excised since they have a high tendency to grow and rupture
C. should be treated with radiation
D. generally do not cause symptoms and should be left alone
E. occurs much more f'requently in males than females

177
111. All are associated with portal hypertension EXCEPT:

A. bleeding esophageal varices

B. hypersplenislD
C. gallstones
D. ascites
E. hepatic encephalopathy

112. Selective shunts for bleeding varices in patients with portal hypertension have the
reported advantage of less encephalopathy compand to systenIic (total) shunts.

True or False?

113. The IDOst cOlDlDon carcinolDa involving the liver is:

A. hepatolDa
B. lDetastasis froID other primaries
C. cholangiocarcinolDa
D. lDix-type carcinolDa

Chaprer17: PANCREAS

114. Prognostic factors helpful in assessing a patient with acure pancreatitis froID alcohol
abuse include all EXCEPT:

A. age
B. alDyiase level
C. glucose level at adlDission
D. fall in hematocrit during first 48 hours
E. fall in calciulD level during first 48 hours

115. Chronic pancreatitis is 1D0re frequent with gallstone pancreatitis than with alcoholic
pancreatitis.

True or False?

116. Pancreatic pseudocysts

A. present with persistent pain, fever and ileus 2-3 weeks following an attack of
pancreatitis or trauma
B. is IDOst reliably diagnosed with cr scan
C. often spontaneously resolve if SIOall (> 2 em)
D. lDay erode into adjacent blood vessels
E. all of the above

178
117. 1be most common cause of painless obstructive jaundice in a 70 year old patient is:

A. carcinoma of the common bile duct

B. duodenal cancer
C. cancer of the pancreas
D. benign tumor of the pancreas
E. cancer of the ampulla of Vater

118. Whipple's triad is most suggestive of:

A. insulinoma
B. gastrinoma
C. glucagonoma
D. VIPoma
E. WDHA syndrome

Chapter 18: SPLEEN

119. Splenectomy following blunt abdominal trauma:

A. should never be done

B. leaves the patient with an inordinate risk of future infections
C. is less of a long-term risk than splenectomy for a hematologic disorder
D. has a high incidence of post-op abscess
E. should be done for any capsular tear.

120. The organ most likely to be injured during splenectomy is:

A. pancreas
B. superior mesenteric artery
C. left kidney
D. left colon
E. duodenum

121. When doing a splenectomy for ITP, it is important:

A. to also do a liver biopsy

B. to evaluate the gallbladder for stones
C. to give platelet transfusions to obtain a platelet count> l00,OOOM pre-op
D. to look for accessory spleens
E. to avoid pneumococcal vaccine for several weeks

179
Chapter 19: GI HEMORRHAGE

122. Initial management of a patient with massive UGI hemorrhage includes:

A. IV ftuid resuscitation
B. irrigation of the stomach
C. replacement of blood and clotting fadors
D. IV vasopressin
E. all of the above

123. An otherwise healthy 42 year old man with a posterior duodenal ulcer which has
bled 3-4 units in the past 12 hours and has a visible vessel in the base by endoscopy
should:

A. undergo operation to oversew the ulcer

B. receive antacids by continuous drip per NG tube
C. be treated with Hz blockers
D. be treated with Hz blockers and antibiotics for H. pylori
E. be given platelet transfusion

124. Bleeding from esophageal varices in a patient who has alcoholic cirrhosis:
A. can usually be managed non-operatively
B. can await definitive treatment until he has proven he will re-bleed
C. needs definitive management during this hospitalization
D. will respond to Omperazole and erythromycin
E. will have his life expectancy extended by a portocaval shunt

125. Massive hematochezia in adults is most likely from:

A. cancers
B. diverticulosis
C. ulcerative colitis
D. Meckel's diverticulum
E. A-V malformations

126. Early localization prior to operation in patients with lower GI bleeding is critical to
operative success.

True or False?

127. Bleeding varices in children are usually going to eventually need liver
transplantation.

True or False?

180
Chapter 20: HERNIAS

128. The groin hernia most easily identified on pbysical exam:

A. indirect
B. direct
C. femoral
D. Richter's
E. sliding

129. Possible reasons for an indirect bernia to be manifested in an elderly patient

include:

A. chronic cough
B. prostatic bypertropby
C. colon cancer
D. COPD
E. all of tbe above

130. Umbilical hernias whicb persist after a patient is walking or whicb occur in adults
sbould be repaired because:

A. they cause severe pain syndromes

B. unacceptable cosmetic problem
C. risk of incarceration or strangulation
D. commonly associated witb intra-abdominal abnormalities
E. none of tbe above

131. Ventral bernias usually require prostbetic mesb for repair.

True or False?

132. A patient witb a tender incarcerated groin bernia:

A. sbould be taken urgently to tbe OR for reduction and repair

B. can be reduced in tbe ER and sent bome
C. can be referred to bis local pbysician tomoITOW
D. can often be treated witb oral analgesics
E. none of tbe above

181
Chapter 21: BREAST

133. A 22 year old woman with a tender breast nodule of 2 weeks duration and no other
risk factors for breast cancer should have a mammogram for evaluation of the mass.

True or False?

134. All are signs suggestive of possible malignancy on mammogram EXCEPT:

A. large clusters of microcalcifications (> 7)

B. skin retraction over a mass
C. large calcified bodies ( > 1 mm)
D. asymmetric densities with radiating arms
E. nipple retraction over a mass

135. Women who get wide local excision of a small breast cancer (l cm) have what chance
of local recurrence if they don't get local radiation treatment?

A. 5-10%
B. 10-15%
C. 15-20%
D. 20-25%
E. 25-30%

136. Needle aspiration of a cyst in the breast:

A. should not leave a residual mass in benign disease

B. should be followed to check for recurrence
C. is an office procedure
D. can be done without ultrasound if the lesion is palpable
E. all of the above

137. Bloody discharge from the nipple most commonly is from a ductal papilloma.

True or False?

138. Survival of a patient with breast cancer is influenced by:

A. stage at diagnosis
B. number of positive nodes
C. estrogen/progesterone sensitivity of the tumor
D. use of adjuvant chemotherapy
E. all of the above

182
Chapter 22: VASCULAR SYSTEM

139. Embolic occlusions of the peripheral arterial tree:

A. most often originate in the heart and occlude the carotid artery
B. originate from the abdominal aorta and occlude the popliteal most commonly
C. most often cause mesenteric artery occlusions
D. are often associated with cardiac arrhythmias or previous infarctions and
occlude the common femoral artery
E. most often occlude the distal aorta

140. Early heparinization of a patient with acute arterial occlusion helps to prevent clot
propagation.

Tme or False?

141. What percentage of patients with calf claudication due to femoro-popliteal occlusive
disease will need intervention?

A. 10%
B. 30%
C. 60%
D. 80%
E. all
142. A diabetic with a non-healing ulcer on the foot

A. is doomed and should proceed to BKA

B. has microvascular disease that can't be helped
C. should be evaluated for large vessel occlusive problems
D. can generally be treated with antibiotics and debridement
E. will improve with better glucose control

143. Patients with TIAs and carotid occlusive disease of > 75% stenosis should

A. undergo endarterectomy
B. be treated with aspirin
C. needs ticlopidine therapy
D. be followed for progression of disease
E. be anticoagulated

183
144. A healthy, asymptomatic 55 year old patient whose father died of a napture
aneurysm now has a 4.5 CID aneurysm. Your recommendation would be:

A. to observe with serial ullrasounds until it is 6 cm diameter

B. to proceed with elective repair
C. to carefully control his blood pressure
D. to consider genetic counselling
E. to proceed with cardiac cath

145. Popliteal aneurysms should be repaired at whatever size they are discovered to avoid
distal embolization.

True or False?

146. Which patient should receive DVf prophylaxis?

A. closed reduction of Colles' fracture

B. hernia repair in an 80 year old man
C. abdominal aneurysm repair in a 65 year old man
D. elective colon resection in a 60 year old obese woman for cancer
E. hiatal hernia repair in a 35 year old man

Chapter 23: HEART

147. While rubella and trisomy-21 are known to be associated with congenital heart
defects, most defects occur as isolated defective embryonic developments without
known cause:

True or False?

148. The most common congenital heart defect is?

A. VSD
B. ASD
C. TOF
D. PDA
E. anomalous venous return

184
149. Relief of angina occurs after revascularization of diseased coronary arteries in:

.A. 10%
B. 30%
C. 5K
D. 70%
E. 90%

150. Calcific aortic valves from acquired or congenital anatomic anomalies are the most
common causes of acquired aortic stenosis.

Tme or False

151. Mitral valve prolapse, if associated with significant mitral regurgitation, tends to
present with angina.

Tme or False?

Chapter 24: LUNG AND MEDIASTINUM

152. Pulmonary function tests can be helpful pre-operatively in assessing operative risks
for thoracic and non-thoracic operations.

Tme or False?

153. An arterial blood gas with low PaC01 and low pH is generally indicative of:

.A. lactic acidosis

B. hypoventilation
C. hyperventilation
D. diabetic ketoacidosis
E. nephrotic syndrome

154. lbe most common cause of cancer deaths in men and women in the US is:

.A. colon cancer

B. skin cancer
C. breast cancer
D. lung cancer
E. lymphoma

185
ISS. The most common type of lung cancer is?

A.. adenocarcinoma
B. small cell (oat cell) carcinoma
C. squamous cell carcinoma
D. bl'Onchoalveolar carcinoma
E. giant cell cancer

156. Most solitary pulmonary nodules newly identified on chest X-ray are benign.

True or False?

Chapter 25: TRANSPLANTATION

157. Prospective HLA cross-matching is primarily important for:

A.. liver transplants

B. kidney transplants
C. heart transplants
D. heart-lung transplants

158. Immunosuppression of transplants between HLA identical patients is still necessary

because of the existence of other histocompatibility foci.

True or False?

159. The expected 1 year survival of liver transplant patients is:

A.. 30%
B. SK
C. 70%
D. 8S~
E. 99%

160. The most important characteristic of viable organ preservation solutions is cold
temperatures.

True or False?

186
161. Functional kidney graft survival for cadaver kidney is:

A. 18-15%
B. 25-30%
C. 75-85%
D. 100%
E. not yet detennined

Chapter 26: ENDOCRINE

162. A thyroid nodule in a 25 year old male is likely to resolve with thyroid suppression
therapy.

True or False?

163. The most common type of thyroid cancer is:

A. papillary
B. follicular
C. Hurtle cell
D. medullary
E. anaplastic

164. Needle aspiration of a thyroid nodule can be done as an omce procedure and is often
helpful in management of thyroid masses.

True or False?

165. The most common cause of hypercalcemia overall is:

A. primary hyperparathyroidism
B. metastatic cancer
C. multiple myeloma
D. secondary hyperparathyroidism
E. iatrogenically induced

187
166. Suspeded pheochromocytoma should be diagnosed prior to operating on a· patient
with 1° HPr because:

A. there may be a familial tendency

B. anesthesia in a patient with unsuspected pheochromocytoma is very
dangerous
C. The patient may be hypertensive
D. other endocrine abnormalities may be present
E. none or the above

167. The most common cause of Cushing's syndl'Ollle is:

A. adenoma of anterior pituitary

B. adenoma of adrenal cortex
C. ectopic ACI1I producing tumors
D. exogenously administer corticosteroids
E. adrenal hyperplasia

168. A young patient with newly discovered hypertension and hypokalemia on screening
chemistries should be evaluated for:

A. Addison's syndrome
B. Sipple's syndrome
C. Conn's syndrome
D. Padget's disease
E. Cushing's syndrome

188
 ANSWERS

1. B. 43. D. 85. True 127. c.

2. True 44. A.. 86. c. 128. E.
3. A.. 45. False 87. False 129. c.
4. B. 46. B. 88. E. 130. False
5. D. 47. B. 89. True 131. A..
6. E. 48. D. 90. B. 132. False
7. E. 49. False 91. A.. 133. False
8. True 58. False 92. c. 134. c.
9. c. 51. False 93. D. 135. c.
10. False 52. A.. 94. B. 136. E.
11. c. 53. c. 95. False 137. True
12. A.. 54. B. 96. True 138. E.
13. True 55. c. 97. D. 139. D.
14. E. 56. True 98. B. 140. True
15. D. 57. A.. 99. False 141. B.
16. D. 58. False 100. E. 142. c.
17. E. 59. D. 101. True 143. A..
18. False 60. B. 102. True 144. B.
19. True 61. False 103. False 145. True
20. True 62. B. 104. D. 146. D.
21. A.. 63. False lOS. B. 147. True
22. False 64. A.. 106. D. 148. A..
23. B. 65. D. 107. B. 149. E.
24. E. 66. False 108. True 158. True
25. B. 67. True 109. A.. 151. False
26. B. 68. E. 110. D. 152. True
27. c. 69. c. 111. c. 153. B.
28. D. 70. D. 112. True 154. D.
29. D. 71. E. 113. B. ISS. c.
30. B. 72. B. 114. B. 156. False
31. False 73. E. 115. False 157. B.
32. True 74. False 116. E. 158. True
33. True 75. E. 117. c. 159. D.
34. True 76. True 118. A.. 160. True
35. True 77. False 119. c. 161. c.
36. D. 78. B. 120. A.. 162. False
37. B. 79. True 121. D. 163. A..
38. E. 80. E. 122. E. 164. True
39. True 81. E. 123. A.. 165. B.
40. A.. 82. False 124. c. 166. B.
41. c. 83. True 125. B. 167. D.
42. True 84. A.. 126. True 168. c.
189