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ABSITE

BODY AS A WHOLE

Clinical management

1. Diagnosis rejection renal allograft: 1B 39


2. Hyperacute reject renal transplant: 1B 39
3. Tissue typing renal transplant:
4. Histologic findings of hyperacute rejection
5. Antibiotic treatment CMV pneumonia
6. Characteristics and treatment of Von Willebrand's Disease
7. Perioperative treatment of hemophilia
8. Treatment urokinase overdose
9. Indications for placement Swan-Ganz Catheter
10. Conditions associated with Warfarin-induced skin necrosis
11. Coagulopathy due to hypothermia
12. Complications of protamine reversal of heparin
13. Estimated blood loss in hematochezia
14. Fluid therapy child in shock
15. Treatment neurogenic shock
16. Treatment acidosis in hypovolemic shock
17. Intraoperative diagnosis of tension pneumothorax
18. Diagnosis colonic ischemia, after ruptured AAA
19. Hypermetabolic response to burn injury
20. Treatment burn wound
21. Calories in nutrient supplements
22. Abscess requiring open drainage
23. Diagnosis / Treatment pancreatic abscess
24. Diagnostic test in soft tissue sarcoma thigh
25. Adjuvant chemotherapy sarcoma extremity
26. Treatment melanoma thigh
27. Neurological findings associated with brain death
28. Tetanus prophylaxis
29. Antibiotic treatment human bite wound
30. Recurrence rate laparoscopic hernia repair
31. Diagnosis of hyperaldosteronism
32. Findings hypomagnesemia
33. Treatment of penetrating stab wound to the thigh
34. Treatment Ca hepatic flexure
35. Pain management Ca pancreas
Basic science
36. Characteristics of pharmacokinetic principles
37. Effectiveness of spinal anesthesia with morphine
38. Comparison of somatic vs. visceral pain
39. Characteristics of anesthetic agents
40. Site of action of systemic opioids
41. Characteristics of anesthetic agents
42. Treatment of asystole due to succinylcholine
43. Kilocalorie expenditure in the adult male at rest
44. Calorie requirements in sepsis
45. Nitrogen balance in the critically injured patient
46. Mechanical fuel available in starvation
47. Protein requirements in TPN
48. Hormonal response to hemorrhage
49. Physiologic hemodilution in hemorrhage
50. Primary substrate for gluconeogenesis
51. Number of non-protein cal nutrition formula
52. Mechanism of protein production from RNA
53. Dose/Interval gentamicin Rx
54. Characteristics of intraperitoneal bacteria
55. Most abundant fecal bacterial flora
56. Production of TNF in gram negative bacteremia
57. Antibiotic treatment of clostridia perfringens
58. Characteristics of early septic shock
59. Presence of clostridia difficile in the stool of neonate
60. Characteristics of glucose metabolism in gram negative sepsis
61. Characteristics multi drug microbe resistance
62. Hepatitis free blood products
63. Characteristic of Bacterial Endotoxins
64. Major histocompatibilty class II molecule
65. Characteristics of adoptive immunotherapy
66. Characteristics of B lymphocytes
67. Cellular source of TNF
68. Peyer patch immunoglobulin synthesis
69. Immunology of human malignancy
70. Characteristic of Lynch Syndrome
71. Cancer, greatest sensitivity to radiation rx
72. Biologic effect of p53 gene
73. Characteristics of hereditary colon Ca
74. Fuel source of neoplastic cells
75. Radiation resistance of large tumors
76. Tumor marker with greatest sensitivity
77. Characteristics of angiogenesis
78. Characteristics of shift in the hemoglobin dissociation curve
79. Lateral boundary of femoral hernia sac
80. Etiology wound infection in hernia repair
81. Maturation of an incisional scar
82. Define statistical power
83. Renal regulation of body fluid pH
84. Characteristics of micelle
85. Mechanism of gout
86. Characteristic of platelet function
87. Production of Von Willebrand factor and factor S
88. Conditions associated with intraoperative hypothermia

GASTROINTESTINAL

Clinical management

89. Treatment esophageal lesion


90. Diagnosis caustic ingestion
91. Treatment caustic ingestion*
92. Treatment perforation esophagus
93. Manometry lower esophageal sphincter
94. Diagnostic test post meat impaction
95. Etiology of dysphagia in Nissen fundoplication
96. Diagnosis of resectability of esophageal Ca
97. Complication esophagogastrectomy
98. Treatment Barretts esophagus with high grade dysplasia
99. Treatment of esophageal leiomyoma
100. Treatment gastric varices
101. Diagnosis gastric leiomyoma
102. Diagnosis acute gastric dilatation
103. Treatment perforated duodenal ulcer
104. Treatment hematochezia unknown source
105. Treatment duodenal obstruction Crohns disease
106. Diagnosis / Treatment duodenal atresia
107. Characteristics post-op acalculous cholecystitis
108. Treatment complication lap. cholecystectomy
109. Treatment laparoscopic injury CBD
110. Treatment retained gallstone* via T-tube
111. Treatment gallstones Chronic congestive heart failure/MI
112. Treatment retained CBD stones
113. Treatment papillary Ca. Gallbladder wall
114. Treatment of adenocarcinoma of the gallbladder
115. Prev treatment of Ca bile duct
116. Treatment jaundice/choledochal cyst
117. Treatment liver lesions
118. Treatment of hepatic cysts
119. Diagnosis pyogenic abscess of the liver
120. Treatment of liver hemangioma
121. Diagnostic test Budd Chari Syndrome
122. Treatment of varices secondary to splenic vein thrombosis
123. Treatment recurrent cholangitis in chronic ulcerative colitis
124. Diagnosis hemobilia
125. Treatment pain chronic pancreatitis with pancreatic duct dilation
126. Treatment pancreatic fistula
127. Diagnosis CBD stricture chronic pancreatitis
128. Treatment of chronic pancreatitis
129. Treatment of recent 4-cm pseudocyst pancreas
130. Diagnosis gastrinoma*
131. Most common site of extrapancreatic gastrinoma
132. Treatment pancreatic transection
133. Site in primary carcinoid*
134. Treatment of contained anastomotic leak
135. Characteristics Contraindication reversal jejunoileal BP
136. Treatment of gallstone ileus
137. Characteristics of radiation injury of the small bowel
138. Diagnostic study in intussuception
139. Appendectomy in regional enteritis
140. Treatment of carcinoid of the appendix
141. Characteristics of GISTs
142. Treatment incomplete reduction of ileocolic intussuception*
143. Treatment ileocolic intussuception
144. Treatment villous adenoma/adenoCa. polyp
145. Treatment hepatic flexure colon Ca.
146. Treatment villous tumor right colon
147. Treatment short strictures Crohns disease
148. Treatment colonic pseudo-obstruction
149. Diagnosis of sigmoid diverticulitis
150. Treatment of ulcerative colitis
151. Treatment carcinoid tumor rectum*
152. Treatment complicated perirectal abscess
153. Treatment of persistent fistula in ano
154. Treatment Anal fissure
155. Treatment squamous cell Ca anus

Basic science

156. Characteristics omphalomesenteric duct remnants


157. Etiology jejunal/ileal atresias
158. Congenital anomaly associated polyhydraminos
159. Site submucosal tumor spread
160. Etiology of stroke related pneumonia
161. Anatomy Right gastric artery
162. Anatomy gastroduodenal artery
163. Stomach blood supply relevant to transhiatal esophagectomy
164. Final metabolic event in the production of HCL
165. Site intrinsic factor secretion
166. Characteristics receptive relaxation stomach
167. Effects of abdominal truncal vagotomy
168. Characteristics proximal gastric vagotomy
169. Mechanism of increased gastric emptying of liquids post vagotomy
170. Anatomic junction of third and fourth portion of duodenum
171. Secretin/gastrin relationship
172. Highest cure rate resection gastrinoma
173. Electrical slow wave frequency normal duodenum
174. Pancreatic enzymes secreted in active form
175. Characteristics of pancreatic enzyme secretion
176. Inhibits pancreatic secretion
177. Characteristics pancreatic polypeptide
178. Activation of trypsinogen
179. Neurotransmitters in intestinal wall
180. Physiology enteroglucagon
181. Side effect of motilin
182. Substances absorbed in jejunum
183. Diagnostic test adenocarcinoma small intestine
184. Characteristics Roux-en-Y gastrojejunostomy
185. Polyp histology in Peutz-Jeghers
186. Malabsorption associated with ileal resection
187. Etiology kidney stone post terminal iliectomy
188. Characteristics carcinoid tumors
189. Hormonal mediators carcinoid syndrome
190. Characteristics of glutamine
191. Preferred energy source of the colonocyte
192. Form long chain fatty acids leave enterocyte
193. Staging test rectal Ca
194. Site colonic absorptive activity
195. Anatomy aberrant R hepatic artery
196. Segmental anatomy of the liver
197. Physiology glucose formation liver
198. Insulin response of IV vs. PO glucose
199. Biochemistry hepatic lipid degradation
200. Characteristics of lithogenic bile
201. Most potent choleretic agent
202. Composition Primary CBD stones
203. Billiary tract bacteria
204. Result increased destruction red blood cell
205. Presence of antibody hepatitis B antigen
206. Mechanism of hepatocellular carcinoma in chronic hepatitis B
207. Susceptibility to hepatoma
208. Pathophysiology of ascites in alcoholic cirrhosis
209. Findings associated hepatorenal syndrome
210. Pre-op measurement Portal venous pressure
211. Treatment of preoperative coagulopathy(liver failure)

CARDIOVASCULAR AND RESPIRATORY SYSTEMS

Clinical management

212. Characteristics of thoracic outlet syndrome


213. Diagnosis of nerve invasion lung tumor
214. Complications of lung transplant
215. Diagnosis of histoplasmosis
216. Treatment of postpneumonitic effusion
217. Etiology of decreased end tidal CO2
218. Treatment of ruptured bronchus
219. Treatment of post-op atelectasis
220. Characteristics of ARDS
221. Treatment of clotted hemothorax
222. Ventilation / perfusion abnormalities
223. Operative risk assessment pulmonary resection for lung CA
224. Incision site for cricothyroitomy
225. Abnormal hemodynamic values
226. Common anomalies associated with ASD
227. Diagnosis of VSD
228. Diagnostic study rupture thoracic aorta
229. Physiologic defect in transposition of aorta
230. Pharmacologic treatment of transposition of great vessels
231. Prediction risk CABG
232. Most common site of traumatic aortic rupture
233. Indications for surgery in asymptomatic AAA, TAA and TA
234. Treatment of complications AAA/iliac occlusive disease
235. Treatment of vascular trauma femoral artery
236. Treatment post-thrombectomy leg pain
237. Indications for carotid endarterectomy
238. Treatment pulsatile mass post carotid artery endarterectomy
239. Characteristics of splenic aneurysms

Basic science

240. Definition of lung compliance


241. Pulmonary function changes associated with aging
242. Diagnosis of V/Q mismatch
243. Prevalent risk factors for ARDS
244. Physiology of IPP ventilation
245. Role of right angle rigid bronchoscope
246. Pulmonary function tests
247. Characteristics of extralobar pulmonary sequestration
248. Characteristics of respiratory quotient
249. Characteristics of acute hypoxia
250. Ventilator goals in ARDS
251. Contraindications for lobectomy in lung Ca
252. Contraindications for pneumonectomy
253. Adequate alveolar ventilation
254. Fluid turnover in normal pleural space
255. Hemodynamic effects of tension pneumothorax
256. Etiology of death in acute tension pneumothorax
257. Signs of pericardial tamponade
258. Treatment of tachyarrhythmias
259. Effect of aortic clamping in stroke volume
260. Indications for mitral valve replacement in endocarditis
261. Hemodynamic changes in hyperdynamic shock
262. Calculation of oxygen delivery
263. Factors influencing mean arterial pressure
264. Determination of myocardial O2 consumption/energy expenditure
265. Characteristics of O2 extraction ratio
266. Mechanism for blood O2 disparity post aortic valve replacement
267. Characteristics of normal venous pressure study
268. Pulmonary artery catheter findings in right heart failure
269. Defect in development of the endocardial cushion
270. Etiology of late vein graft stenosis
271. Early abnormal carotid ulcer plaque
272. Doppler sign graft thrombosis
273. Anatomy scalenus anticus muscle
274. Anatomy of the internal mammary artery
275. Site of normal nitric oxide production
276. Physiology of nitric oxide
277. Organ with constant blood flow
278. Mechanisms of the action of captopril
279. Characteristics of continuous variables
280. Toxicity bleomycin rx

GU, HEAD AND NECK, MUSKULOSKELETAL, ETC

Clinical management

281. Characteristics tumors of the parotid gland


282. Treatment of mixed parotid tumor
283. Treatment epidermoid carcinoma of the neck node
284. Treatment of squamous cell CA lower lip
285. Diagnosis of torus palatini
286. Treatment of serous otitis in a 70 year old
287. Diagnosis of cystic hygroma
288. Characteristics of Ca anterior tongue
289. Treatment hemangioma of the eyelid
290. Diagnosis of basal cell Ca face
291. Characteristics of melanoma associated with early metastasis
292. Characteristics of malignant transformation o a nevus
293. Treatment preop Phimosis
294. Diagnostic test in blunt renal injury
295. Diagnostic studies in renal trauma
296. Treatment of gunshot wound to the ureter
297. Diagnostic tests in testicular mass
298. Treatment of testicular torsion
299. Treatment of bladder injury
300. Treatment of squamous cell Ca of the penis
301. Conditions associated with peritoneal carcinomatosis
302. Risk factors for endometrial ca
303. Site of spread of ovarian Ca
304. Treatment of postpartum pelvic thrombophlebitis
305. Treatment of a 4-cm ovarian cyst
306. Initial site of spread of ovarian Ca
307. Treatment rectal submucosal mass/dysmenorrhea
308. Glasgow coma score closed head injury
309. Optimal cerebral perfusion pressure
310. Most important component Glasgow coma scale
311. Treatment priority blunt torso/head trauma
312. Treatments of basal skull fracture
313. Characteristics of le fort fractures
314. Treatment of supracondylar fracture humerus in a child
315. Nerve injury in anterior dislocation of the humerus
316. Femoral fx associated with avascular necrosis
317. Treatment of dislocated hip
318. Diagnosis of paralysis of the common peroneal nerve
319. Treatment of tenosinovitis of the hand
320. Pain associated with thoracic outlet syndrome
321. Earliest symptom in compartment syndrome
322. Organism responsible for osteomyelitis in Sickle cell anemia

Basic science

323. Diagnostic study in vesico-ureteral reflux


324. Diagnosis of prerenal azotemia
325. Characteristics adenoca kidney
326. Urine concentration and characteristics in aldosterone tumor
327. Conditions associated with renal disease and hepatorenal syndrome
328. Anatomy of epididymis
329. CA w/ infrequent metastasis to bone
330. Treatment of incomplete bladder emptying in the female
331. Most sensitive test in renal failure
332. Response of kidney to hypovolemic shock
333. Symptoms of compressed 5th lumbar nerve root
334. Rate of nerve regeneration
335. Posterior vessels feeding the circle of Willis
336. Signs of increased intracranial pressure
337. Fibroblast source in the surgical wound
338. Collagen formation in wound healing
339. Vitamin rx wound heal chronic steroid use
340. Pupillary changes in transtentorial herniation
341. Collagen formation in the surgical wound
342. Heat dissipation in hypothermia
343. Na Warfarin induced skin necrosis
344. Nerve injury associated with Claw hand
345. Anatomy of the intrinsic muscles of the hand
346. Amino acid from skeletal muscle catabolism
ENDOCRINE
Clinical management

347. Characteristics of primary hyperaldosteronism


348. Treatment of adrenal mass
349. Site extra-adrenal pheochromocytoma
350. Diagnosis of acute adrenal insufficiency
351. Diagnostic test for extraadrenal pheochromocytoma
352. Treatment of MEN-II
353. Sequence of treatment in MEN
354. Diagnosis and treatment of gastrinoma
355. Most common site gastrinoma
356. Pancreatic lesion associated with secretory diarrhea
357. Treatment of small bowel lymphoma
358. Treatment of LCIS breast
359. Treatment of intraductal papilloma
360. Treatment of inflammatory breast cancer
361. Treatment of phylodes tumor of the breast
362. Emergent treatment of complications post-sella radiation
363. Contraindications for segmental mastectomy in stage I Ca breast
364. Definitive diagnostic test in lymphedema
365. Diagnostic test in lymphangiectasia
366. Risk of recurrence of intraductal/invasive Ca breast
367. Treatment of DCIS breast
368. Etiology of unilateral breast enlargement in a man
369. Treatment of indeterminate thyroid cytology
370. Treatment of cold thyroid nodule
371. Treatment of a hot thyroid nodule
372. Etiology of stridor PO thyroidectomy
373. Treatment of acute thyroiditis
374. Significance of thyroid in a lymph node
375. Treatment of parathyroid hyperplasia
376. Characteristics of calcium levels in parathyroid disease
377. Treatment of missing hyperplastic parathyroid
378. Treatment of critical hypercalcemia
379. Solid/cystic Ca thyroid
380. Diagnostic test of recurrence of ITP
381. Treatment of pediatric splenic injury
382. Timing platelet Rx splenectomy for ITP
383. Stag of Hodgkins disease
384. Diagnosis and treatment of ITP
385. Initial treatment of sarcoma of the thigh
386. Diagnosis of lymphangiosarcoma

Basic science

387. Rationale of splenectomy for ITP


388. Characteristics of phyllodes tumor breast
389. Characteristics fibroadenoma breast
390. Cells independent of somatostatin regulation
391. Physiology of glucagon
392. Distribution of insulinomas
393. Embriology of thyroid and parathyroid glands
394. Artery adjacent to superior laryngeal nerve
395. Findings associated with pseudohypoparathyrodism.
396. Preoperative prep for retroperitoneal parganglioma
397. Cell site accumulation MIBG

ABSITE

BODY AS A WHOLE

Clinical management

398. Hyperacute reject renal transplant


399. Charact/rx von Willebrand's Disease
400. Perioperative rx hemophilia
401. Diagnosis / Treatment pancreatic Abscess
402. Diagnosis rejection renal allograft
403. Indic placement Swan-Ganz Catheter
404. Fluid rx child in shock
405. Recurrence rate laparoscop hernia repair
406. Tissue typing renal transplant
407. Treatment urokinase overdose
408. Conditions associated with Warfarin-induced skin necrosis
409. Diagnosis colonic ischemia, ruptured AAA
410. Treatment neurogenic shock
411. Intraoperative diagnosis of tension pneumothorax
412. Adjuvant chemotherapy sarcoma extremity
413. Abscess requiring open drainage
414. Treatment acidosis in hypovolemic shock
415. Neurological findings associated with brain death
416. Coagulopathy due to hypothermia
417. Tetanus prophylaxis
418. Antibiotic treatment human bite wound
419. Diagnostic test in soft tissue sarcoma thigh
420. Estimated blood loss in hematochezia
421. Histologic findings of hyperacute rejection
422. Complications of protamine reversal of heparin
423. Treatment burn wound
424. Antibiotic treatment CMV pneumonia
425. Hypermetabolic response to burn injury
426. Treatment of penetrating stab wound to the thigh
427. Treatment melanoma thigh
428. Calories in nutrient supplements
429. Treatment Ca hepatic flexure

Basic science

430. Cancer, greatest sensitivity to radiation rx


431. Mechanism of protein production from RNA
432. Dose/Interval gentamicin Rx
433. Effectiveness of spinal anesthesia with morphine
434. Mechanical fuel available in starvation
435. Characteristic of Lynch Syndrome
436. Characteristic of Bacterial Endotoxins
437. Conditions associated with intraoperative hypothermia
438. Lateral boundary of femoral hernia sac
439. Characteristic of platelet function
440. Biologic effect of p53 gene
441. Define statistical power
442. Nitrogen balance in the critically injured patient
443. Etiology wound infection in hernia repair
444. Calorie requirements in sepsis
445. Maturation of an incisional scar
446. Protein requirements in TPN
447. Comparison of somatic vs. visceral pain
448. Renal regulation of body fluid pH
449. Characteristics of anesthetic agents
450. Presence of clostridia difficile in the stool of neonate
451. Site of action of systemic opioids
452. Characteristics multi drug microbe resistance
453. Treatment of asystole due to succinylcholine
454. Characteristics of angiogenesis
455. Characteristics of glucose metabolism in gram negative sepsis
456. Antibiotic treatment of clostridia perfringens
457. Characteristics of early septic shock
458. Production of Von Willebrand factor and factor S
459. Cellular source of TNF
460. Peyer patch immunoglobulin synthesis
461. Characteristics of anesthetic agents
462. Characteristics of B lymphocytes
463. Tumor marker with greatest sensitivity
464. Kilocalorie expenditure in the adult male at rest
465. Mechanism of gout
466. Radiation resistance of large tumors
467. Characteristics of micelle
468. Production of TNF in gram negative bacteremia
469. Characteristics of shift in the hemoglobin dissociation curve
470. Major histocompatibilty class II molecule
471. Hormonal response to hemorrhage
472. Immunology of human malignancy
473. Characteristics of adoptive immunotherapy
474. Hepatitis free blood products
475. Fuel source of neoplastic cells
476. Primary substrate for gluconeogenesis

GASTROINTESTINAL

Clinical management

477. Treatment liver lesion


478. Treatment pain chronic pancr/pancr duct dil
479. Treatment villous adenoma/adenoCa. polyp
480. Charact post-op acalc cholecystatis
481. Complication esophagogastrectomy
482. Diagnosis / Treatment duodenal atresia
483. Treatment esophageal lesion
484. Diagnosis caustic ingestion
485. Treatment complication lap. cholecystectomy
486. Treatment hepatic flexure colon Ca.
487. Treatment ileocolic intussusception
488. Treatment squamous cell Ca anus
489. Treatment choledochal cyst
490. Treatment Barretts esoph/ high grade dysplasia
491. Site in primary carcinoid*
492. Treatment pancreatic fistula
493. Treatment carcinoid tumor rectum*
494. Treatment complic perirectal abscess
495. Diagnosis gastrinoma*
496. Treatment gallstones Chronic congestive hrt failure/MI
497. Treatment retained CBD stones
498. Diagnosis gastric leiomyoma
499. Site carcinoid**
500. Diagnosis hemobilia
501. Diagnosis / Treatment duodenal atresia
502. Treatment villous adenoma/adeno Ca. polyp
503. Treatment gastric varices
504. Treatment caustic ingestion*
505. Treatment colonic pseudo-obstruction
506. Treatment papillary Ca. Gallbladder wall
507. Treatment incomplete reduc ileocolic intussus*
508. Treatment retained gallstone* via T-tube
509. Treatment short strictures Crohns disease
510. Treatment duodenal obstruction Crohns disease
511. Treatment villous tumor right colon
512. Treatment squamous cell carcinoma anal verge
513. Treatment hematochezia unknown source
514. Treatment retained gallstone via T- tube
515. Treatment laparoscopic injury CBD
516. Treatment perforation esophagus
517. Appendectomy in regional enteritis
518. Treatment Anal fissure
519. Treatment Colonic pseudo-obstruction
520. Diagnosis CBD stricture chronic pancreatitis
521. Treatment recurrent cholangitis in chronic ulcerative colitis
522. Diagnosis pyogenic abscess of the liver
523. Treatment perforated duodenal ulcer
524. Contraindication reversal jejunoileal BP
525. Treatment pancreatic transection
526. Diagnosis acute gastric dilatation
527. Treatment incomplete reducible ileocolic intussuception
528. Treatment jaundice/choledochal cyst
529. Treatment of contained anastomotic leak
530. Treatment of adenocarcinoma of the gallbladder
531. Manometry lower esophageal sphincter
532. Treatment of gallstone ileus
533. Diagnostic test post meat impaction
534. Treatment of retained stone via T-tube
535. Treatment complications of laparoscopic cholecystectomy
536. Treatment of persistent fistula in ano
537. Etiology of dysphagia in Nissen fundoplication
538. Treatment of varices secondary to splenic vein thrombosis
539. Diagnostic study in intussuception
540. Treatment of esophageal leiomyoma
541. Prev treatment of Ca bile duct
542. Treatment of perforated duodenal ulcer
543. Treatment of hepatic cysts
544. Treatment of squamous cell Ca anus
545. Treatment of barretts esophagus with high grade dysplasia
546. Diagnostic test Budd Chari Syndrome
547. Diagnosis of sigmoid diverticulitis
548. Most common site of extrapancreatic gastrinoma
549. Treatment of liver hemangioma
550. Treatment of chronic pancreatitis
551. Characteristics of GISTs

Basic science

552. Mechanism hepatocellular Ca. in chronic Hep. B


553. Stomach blood supply/ transhiatal esophagectomy*
554. Neurotransmitters in intestinal wall
555. Charact omphalomesenteric duct remnants
556. Etiol jejunal/ileal atresias
557. Charact receptive relexation stomach
558. site intrinsic factor secretion*
559. Highest cure rate reseation gastrinoma
560. Site submucosal tumor spread
561. Site colonic absorptive activity
562. Charact carcinoid tumors
563. Site intrinsic factor secretion
564. Pre-op measurement Portal venous pressure
565. Electrical slow wave frequency normal duodenum
566. Inhib pancreatic secretion
567. Staging test rectal Ca
568. Anatomy gastroduodenal artery
569. Hormonal mediators carcinoid syndrome
570. Charact proximal gastric vagatomy
571. Result increased destruction red blood cell
572. Physiol enteroglucagon
573. Physiol glucose formation liver
574. Charact pancreatic polypeptide
575. Most potent choleretic agent
576. Findings assoc hepatorenal syndrome
577. Dx test adenocarcinoma small intestine
578. Secretin/gastrin relationship
579. Anatomy Rt gastric artery
580. Charact Roux-en-Y gastrojejunostomy
581. Composition Primary CBD stones
582. Mechanism of hepatocellular carcinoma in chronic hepatitis B
583. Stomach blood supply relevant to transhiatal esophagectomy
584. Characteristics of glutamine
585. Pathophysiology of ascites in alcoholic cirrhosis
586. Segmental anatomy of the liver
587. Final metabolic event in the production of HCL
588. Substances absorbed in jejunum
589. Effects of abdominal truncal vagotomy
590. Etiology kidney stone post terminal iliectomy
591. Anatomy aberrant R hepatic artery
592. Congenital anomaly associated polyhydraminos
593. Pancreatic enzymes secreted in active form
594. Susceptibility to hepatoma
595. Biochemistry hepatic lipid degradation
596. Characteristics of lithogenic bile
597. Insulin response of IV vs. PO glucose
598. Presence of antibody hepatitis B antigen
599. Etiology of jejunoileal atresia
600. Treatment of preoperative coagulopathy
601. Polyp histology in Peutz-Jeghers
602. Anatomy of gastroduodenal artery
603. Activation of trypsinogen
604. Characteristics of truncal vagotomy
605. Characteristics of pancreatic enzyme secretion
606. Etiology of stroke related pneumonia
607. Site with submucosal tumor spread

CARDIOVASCULAR AND RESPIRATORY SYSTEMS

Clinical management

608. Characteristics of thoracic outlet syndrome


609. Indications for carotid endarterectomy
610. Dx nerve invasion lung tumor
611. Prediction risk CABG
612. Abnormal hemodynamic values
613. Dx study rupture thoracic aorta
614. Complications of lung transplant
615. Pharmacologic treatment of transposition of great vessels
616. Diagnosis of VSD
617. Diagnosis of histoplasmosis
618. Characteristics of splenic aneurysms
619. Common anomalies associated with ASD
620. Etiology of decreased end tidal CO2
621. Treatment of postpneumonitic effusion
622. Indications for surgery in asymptomatic AAA, TAA and TA
623. Characteristics of splenic artery aneurysms
624. Treatment of ruptured bronchus
625. Treatment of post-op atelectasis
626. Treatment of complications AAA/iliac occlusive disease
627. Treatment post-thrombectomy leg pain
628. Physiologic defect in transposition of aorta
629. Most common site of traumatic aortic rupture
630. Incision site for cricothyroitomy

Basic science

631. Definition of lung compliance


632. Role of right angle rigid bronchoscope
633. Treatment of tachyarrhythmias
634. Pulmonary function changes associated with aging
635. Contraindications for lobectomy in lung Ca
636. Diagnosis of V/Q mismatch
637. Anatomy scalenus anticus msucle
638. Hemodynamic changes in hyperdynamic shock
639. Early abnormal carotid ulcer plaque
640. Toxicity bleomycin rx
641. Determination of mycardio O2 consumption/energy expenditure
642. Characteristics of continuous variables
643. Site of normal nitric oxide production
644. Prevalent risk factors for ARDS
645. Contraindications for pneumonectomy
646. Doppler sign graft thrombosis
647. Characteristics of O2 extraction ratio
648. Hemodynamic effects of tension pneumothorax
649. Indications for mitral valve replacement in endocarditis
650. Characteristics of normal venous pressure study
651. Pulmonary artery catheter findings in right heart failure
652. Physiology of IPP ventilation
653. Characteristics of extralobar pulmonary sequestration
654. Pulmonary function tests
655. Mechanism for blood O2 disparity post aortic valve replacement
656. Characteristics of respiratory quotient
657. Characteristics of acute hypoxia
658. Ventilator goals in ARDS
659. Physiology of nitric oxide
660. Adequate alveolar ventilation
661. Factors influencing mean arterial pressure
662. Etiology of death in acute tension pneumothorax
663. Organ with constant blood flow
664. Mechanisms of the action of captopril
665. Calculation of oxygen delivery
666. Effect of aortic clamping in stroke volume
667. Signs of pericardial tamponade

GU, HEAD AND NECK, MUSKULOSKELETAL, ETC

Clinical management

668. Treatment of mixed parotid tumor


669. Treatment epidermoid carcinoma of the neck node
670. Nerve injury in anterior dislocation of the humerus
671. Diagnostic studies in renal trauma
672. Treatment of squamous cell CA lower lip
673. Characteristics of melanoma associated with early metastasis
674. Treatment of supracondylar fracture humerus in a child
675. Most important component Glasgow coma scale
676. Rx rectal submucosal mass/dysmenorrhea
677. Rx priority blunt torso/head trauma
678. Rx preop Phimosis
679. Dx torus palatini
680. Femoral fx associated with avascular necrosis
681. Glasgow coma score closed head injury
682. Conditions associated with peritoneal carcinomatosis
683. Treatment of dislocated hip
684. Treatments of basal skull fracture
685. Diagnostic tests in testicular mass
686. Site of spread of ovarian Ca
687. Treatment of squamous cell Ca of the penis
688. Optimal cerebral perfusion pressure
689. Risk factors for endometrial ca
690. Characteristics of Ca anterior tongue
691. Treatment of gunshot wound to the ureter
692. Treatment of testicular torsion
693. Diagnosis of basal cell Ca face
694. Initial site of spread of ovarian Ca
695. Diagnostic test in blunt renal injury
696. Characteristics tumors of the parotid gland
697. Diagnosis of paralysis of the common peroneal nerve
698. Treatment of tenosinovitis of the hand
699. Characteristics of le fort fractures
700. Treatment of serous otitis in a 70 year old
701. Characteristics of malignant transformation o a nevus
702. Treatment hemangioma of the eyelid

Basic science

703. Rate of nerve regeneration


704. Posterior vessels feeding the circle of Willis
705. Heat dissipation in hypothermia
706. Diagnostic study in vesico-ureteral reflux
707. Dx. prerenal azotemia
708. Symp compress 5th lumbar nerve root
709. anat epididymis
710. CA w/ infrequent metastasis to bone
711. Amino acid from skeletal muscle catabolism
712. Charact adeno ca kidney
713. Vitamin rx wound heal chronic steroid use
714. Collagen formation in wound healing
715. Response of kidney to hypovolemic shock
716. Treatment of incomplete bladder emptying in the female
717. Nerve injury associated with Claw hand
718. Signs of increased intracranial pressure
719. Fibroblast source in the surgical wound
720. Urine concentration and characteristics sin aldosterone tumor
721. Conditions associated with renal disease and hepatorenal syndrome
722. Pupillary changes in transtentorial herniation
723. Collagen formation in the surgical wound
724. Na Warfarin induced skin necrosis
725. Most sensitive test in renal failure
726. Anatomy of the intrinsic muscles of the hand

ENDOCRINE

Clinical management

727. Treatment of cold thyroid nodule


728. Treatment of adrenal mass
729. Etiology of unilateral breast enlargement in a man
730. Treatment of acute thyroiditis
731. Diagnosis and treatment of ITP
732. Treatment of DCIS breast
733. Site extra-adrenergic pheochromocytoma
734. Rx MEN-II
735. Dx acute adrenal insufficiency
736. Dx/Rx gastrinoma
737. Etiol st ridor PO thyroidectomy
738. Most common site gastrinoma
739. Dx lymphangiosarcoma
740. Rx LCIS breast
741. Timing platelet Rx splenectomy for ITP
742. Characteristics of calcium levels in parathyroid disease
743. Treatment of small bowel lymphoma
744. Diagnostic test of recurrence of ITP
745. Emergent treatment of complications post-sella radiation
746. Characteristics of primary hyperaldosteronism
747. Treatment of phylodes tumor of the breast
748. Solid/cystic Ca thyroid
749. Treatment of indeterminate thyroid cytology
750. Treatment of pediatric splenic injury
751. Initial treatment of sarcoma of the thigh
752. Treatment of parathyroid hyperplasia
753. Stag of Hodgkins disease significance of thyroid in a lymph node
754. Treatment of inflammatory breast cancer
755. Treatment of adrenal mass
756. Characteristics of primary hyperaldosteronism
757. Treatment of intraductal papilloma
758. Treatment of critical hypercalcemia
759. Contraindications for segmental mastectomy in stage I Ca breast

Basic science
760. Rationale of splenectomy for ITP
761. Character phyllodes tumor breast
762. cells independent of somatostatin regulation
763. Cell site accumulation MIBG
764. Characteristics fibroadenoma breast
765. Artery adjacent to superior laryngeal nerve
766. Physiology of glucagon
767. Distribution of insulinomas
Characteristics of Enterocytes
Enterocytes, or absorptive cells, are found in the mucosa of the small and large bowel.
The normal enterocyte lives for a little more than 2 days. They are columnar and are the
principal cells of the villus. Enterocytes absorb a variety of nutrients including Ca, Fe and
H2O.
The primary fuel source of enterocytes is glutamine. Principles and Practice of Surgical
Pathology, 2nd Edition, Vol II, pgs 1121-23

Secretin/Gastrin Relationship
Secretin is produced by specialized cells in the small bowel mucosa and its release is
stimulated by acidification of the duodenum or by contact with bile and perhaps fat. It
stimulates the release of water and bicarbonate from pancreatic ductal cells, which
neutralizes gastric acid. Secretin also acts to stimulate the flow of bile and inhibits gastrin
release and therefore gastric acid secretion and gastrointestinal motility. Schwartz 6th pg.
1128, 1161-62

Activation of Trypsinogen
Trypsinogen is the inactive precursor of trypsin. It is produced by pancreatic acinar cells
along with other inactive proteolytic enzymes, chymotrypsinogen and
procarboxypolypeptidase. These inactivated enzymes are delivered to the duodenum in
an alkaline environment.
Enterokinase, an enzyme secreted by intestinal mucosa, lyses trypsinogen converting it
into the active enzyme. Trypsin is then able to lyse more trypsinogen into trypsin
(autocatalytic activation). Chymotrypsinogen is lysed into its active form chymotrypsin,
and procarboxypolypeptidase - activated form of trypsin also. Trypsinogen is protected
from activation prior to entering the intestinal lumen by trypsin inhibitor. This substance
is also secreted by the same pancreatic acini cells that secrete the proteolytic enzymes.
Guyton, Medical Physiology, pg 779

Physiology of Enteroglucagon
Enteroglucagon is released from the enteroglucagon cells, occurring predominately in the
distal small intestine. This peptide occurs in two forms - one small and one large form.
Release of this hormone is stimulated by carbohydrate and long-chain fatty acid. Its
primary action is to inhibit intestinal motility. Sabiston, Textbook of Surgery, 14th ed.,
pg. 834
Stimulation of Duodenal Secretin Release
Secretin is a gastrointestinal peptide, which is the principal stimulant for pancreatic water
and electrolyte secretion. It is synthesized and stored in mucosal S-cells, in crypts of
Lieberkuhn in the proximal small bowel.
The most important stimulus for secretin release is duodenal acidification; release occurs
when the intraluminal pH falls below 4.5. Fat also stimulates secretin release, but this
occurs only with high luminal fat concentrations. O'Leary, The Physiological Basis of
Surgery, Williams & Wilkins, 1993

Arterial Blood Supply of Duodenum


The main blood supply to the duodenum is from the superior and inferior
pancreaticoduodenal arteries, branches of the gastroduodenal and superior mesenteric
arteries, respectively. The proximal half of the duodenum is supplied by the superior
pancreaticoduodenal artery and the distal half by the inferior pancreaticoduodenal artery.
These vessels anastomose to form anterior and posterior arterial arcades, which lie in the
angle between the duodenum and the pancreas.
The superior part of the duodenum may, in addition, receive blood from:
1. The supraduodenal artery, arising from the common hepatic or gastroduodenal,
2. The right gastric artery,
3. The right gastroepiploic artery, and
4. The gastroduodenal artery.
These vessels often anastomose with each other. Moore, p. 220. Sabiston, p. 871

Characteristics of Migratory Motor Complex of the Small Bowel


Characteristic patterns of motility occur in the small intestine of humans during fasting
and after feeding. During fasting, activity follows a cyclic pattern called the interdigestive
myoelectric complex (IDMEC) or the migrating motor complex (MMC).
Each cycle has four phases.
Phase I has little or no contractile activity or electric spike activity.
Phase II has intermittent spike activity and thus intermittent contractile activity.
Phase III has maximum spike activity superimposed on every slow wave; this is
associated with regular, strong contractile activity.
It is usually followed by a brief period of intermittent spike activity known as Phase IV.
This serves as a transition phase between the phase of regular contractile activity and the
quiescent phase.
The duration of an entire cycle is approximately 90-120 minutes. Each phase appears first
in the distal esophagus, stomach, and duodenum and migrates down the small intestine.
The migration takes about 2 hours. Eating abolishes the interdigestive cycles and in their
place induces a pattern of intermittent contractile activity. The physiologic significance of
the MMC is not completely understood because the complexes are present only in the
fasted state and in most species they have no apparent role in the mixing or propulsion of
ingested meals. These complexes may act as "housekeepers of the small intestine", in the
sense that they may purge the small bowel of residual foods, secretions, and desquamated
cells during the interdigestive state. The MMC may also serve to limit the overgrowth of
bacteria in the distal small bowel. The development of Phase III of the MMC is
associated with increased secretion of pepsin and hydrochloric acid by the stomach and
of amylase and bicarbonate by the pancreas. The association of bile secretion with the
MMC has been suggested by experiments in human subjects that have demonstrated
increasing duodenal output of bile acid and bilirubin during Phase II of the MMC. Miller,
Physiologic Basis of Modern Surgical

Characteristics of Adult Intussusception


Intussusception occurring in children is usually not associated with a mass lesion, which
leads to the intussusception. In adults, however, benign and malignant tumors are often
found at the leading edge or base. A Meckel's diverticulum, although uncommon in
adults, can also be found. Symptoms include partial or total SBO with cramping
abdominal pain and, less often in adults, bloody diarrhea. Sabiston, 14th Ed, Textbook of
Surgery, 1991, p.803

Complications of Ileal Resection


1. Short bowel syndrome is the fear of patients undergoing bowel resection. Length of
bowel loss leading to this syndrome varies according to whether or not the terminal ileum
and ileocecal valve is resected.
A. Resection of 70% of the small bowel may or may not result in malabsorption.
B. If the terminal ileum and ileocecal valve are included in the resection, even 50% loss
can result in severe malabsorption.
2. The terminal ileum is responsible for the absorption of many substances. The most
important is bile salt.
A. Loss of the active transport site for bile salts in the distal ileum results in bile salt
depletion.
B. The colon and jejunum have a limited capacity to passively absorb bile salts.
C. The liver has a fixed capacity to compensate for losses with increased synthesis.
D. Passage of bile salts and free fatty acids into the colon accentuate the diarrhea
problem.
E. Reduced concentrations of bile salts in bile allows cholesterol to precipitate and the
formation of gallstones.
3. Vitamin B12 is absorbed in the ileum. Chronic loss of this vitamin can result in loss of
body stores after several years.
4. Bacterial overgrowth in the small bowel may result from ileocecal valve loss. Reflux
of colonic contents into the small intestine with the resultant bacterial overgrowth can
lead to deconjugation of bile acids, bile salts malabsorption, and bacterial metabolism of
vitamin B12.
A. It is also postulated that toxic substances may be elaborated by bacteria in the small
intestine. These substances may adversely affect intestinal motility and adaptation.
Shackelford's, Surgery of the Alimentary Tract, 3rd edition. W.B. Saunders Co., 1991

Treatment of Small Bowel Obstruction (SBO)


Obstruction occurs when there is a physical barrier or functional failure, an ileus, to the
normal transit of intestinal contents. The majority is secondary to post-op adhesion (64-
79%), hernia (15-25%), and tumors (10-15%). Classically, the cardinal symptoms are
crampy abdominal pain, obstipation, vomiting and abdominal distention. In addition,
there may be tenderness, fever, leukocytosis, and tachycardia. These additional findings
are suggestive of infection or infarction - complications of small bowel obstruction. Early
radiographic studies are the most important diagnostic maneuver. The presence of
air/fluid levels and its pattern helps the surgeon distinguish between a partial or complete
obstruction and ileus. Partial SBO are frequently resolved without surgical intervention.
The management of bowel obstruction is individualized but the common principles are:
correction of metabolic abnormalities, gastrointestinal decompression by a nasogastric
tube, intravenous hydration and perioperative antibiotic coverage.
If there is a complete obstruction, proper and timely surgery is essential. This may
involve lysis of adhesions, resection and/or bypass of an obstructing lesion, an
enterotomy to remove a foreign object, or the formation of an ileostomy/colostomy
proximal to the obstruction. Schwartz, 6th Edition, pp 1028-1031

Rx of Complication of Small Bowel Resection


The complications of small bowel resection include short bowel syndrome and
anastomotic leak, which can result in either abscess formation or fistula. The typical
presentation of an anastomotic leak occurs 5-7 days after surgery initially as a wound
infection that begins to drain intestinal contents 2-3 days thereafter - an enterocutaneous
fistula. The principles of treatment include electrolyte correction, control of sepsis, skin
protection with control of fistula drainage, and bowel rest with nutritional support. The
treatment of an enterocutaneous fistula can be expectant if sepsis and peritonitis is not
present; it involves placement of a red rubber catheter through the skin tract to control the
fistula and preserve the skin. Decreasing the fistula output is essential in effecting an
earlier closure than occurs with the natural outcome. This is accomplished by
administering H2-blockers, or proton pump inhibitors, which diminishes gastric output,
somatostatin, and TPN - allowing for bowel rest. Definition of the anatomy is
accomplished via fistulogram after a mature tract has formed and/or via small bowel
followthrough or barium enema.
The highest mortality occurs in the group in which surgical treatment is undertaken 1-6
weeks after formation. Greater likelihood of spontaneous closure occurs in patients with
tracts greater than 2 cm in length, distal in the GI tract, and fistulas in which intestinal
continuity is present. At times an anastomotic leak may present as a single accessible
abscess, which may be treated with CT-guided percutaneous drainage allowing for the
formation of a controlled fistula; however, if an abscess is associated with sepsis or
peritoneal signs, surgical exploration is warranted. Current treatment of short bowel
syndrome involves supportive care until the bowel can adapt. In the initial period, bowel
rest, TPN, motility modulating agents (codeine or loperamide), H2-blockers, or proton
pump inhibitors, and replacement of fluids are essential. After the initial or early phase is
complete, initiation of enteral nutrition, and vitamins is begun. Small bowel transplants
have had only limited success. Other bowel procedures such as reversing intestinal
segments has not been proven beneficial. Schwartz, 6th Ed, pp 425-27, 1184-85

Site of Primary in Carcinoid Syndrome


Carcinoid tumors are most frequently identified in the appendix (46%) followed by the
ileum (28%) and rectum (17%).
A malignant potential is related to (1) location, (2) size, (3) depth of invasion, and (4)
growth pattern.
35% of the ileal carcinoids are associated with metastases, whereas only 3% of
appendiceal carcinoids metastasize. Multiple carcinoids of the small bowel occur in 30%
of the cases. Typically, ileal carcinoids tend to be less than 1 cm. Treatment: Treatment
of patients with small bowel carcinoid tumors less than 1 cm in diameter without
evidence of regional lymph node metastases should be treated with a segmental intestinal
resection. For lesions greater than 1 cm, or patients with multiple tumors, and the
presence of regional lymph nodes, a wide excision of the bowel and mesentery is
required, and may entail a right hemicolectomy. Schwartz, 6th Edition, pp 1176

Characteristics of Carcinoid Tumors


Carcinoids have variable malignant potential and are composed of multipotential cells
with the ability to secrete numerous humoral agents, the most prominent of which are
serotonin and substance P. The carcinoid syndrome, characterized by episodic attacks of
cutaneous flushing, bronchospasm, diarrhea, and vasomotor collapse, occurs in fewer
than 5% of patients with malignant carcinoids. Carcinoids may occur in organs derived
from the foregut, midgut, or the hindgut.
In the GI tract, the appendix is the most commonly involved (46%) followed by the ileum
(28%), and the rectum (17%). The malignant potential appears to be related to the site of
origin and the size of the primary. Only about 3% of appendiceal carcinoids metastasize,
but 35% of ileal carcinoids do. The larger the size, the more the likelihood of metastases.
Carcinoids larger than 2 cm in diameter have 80-90% incidence of malignancy.
Most common symptoms associated with ileal carcinoid are pain, obstruction, diarrhea,
and weight loss.
Primary tumors less than 1 cm without regional nodal metastases are treated with
segmental intestinal resection. For those greater than 1 cm in diameter or with regional
metastases, wide excision of bowel and mesentery is required. Malignant carcinoid
tumors of the duodenum may require radical pancreaticoduodenectomy. Carcinoid
tumors of the appendix are commonly located in the tip, thus a simple appendectomy is
curative providing the tumor is 1 cm or smaller and without evidence of metastases.
Right hemicolectomy is indicated for tumors greater than 2 cm because of the potential
for metastases. Schwartz, 6th Edition, pp 1175-78, 1298

Care, pp 350-351

Diagnosis of Gastrinoma
Fasting hypergastrinemia (>200 pg/ml) in the face of gastric acid hypersecretion defined
as basal acid output >15mEq/h with intact stomach or >5mEq/h after ulcer surgery. Most
patients with gastrinoma have serum gastrin levels >500 pg/ml. A secretin provocative
test is usually done to confirm diagnosis when serum gastrin is in the range of 200-500
pg/ml.
Secretin Provocative Test:
Following 2 u/kg secretin IV bolus, a rise in serum gastrin level of 200 pg/ml within 15
min or doubling of the fasting gastrin level is diagnostic of gastrinoma.
Additional Studies: Upper GI or endoscopy will show ulcers often in unusual locations,
i.e. 2nd & 3rd portions of duodenum or jejunum. The stomach may have prominent rugal
folds along with excessive luminal secretions. CT scan may show tumor in the pancreas
or paraduodenal areas. Angiography with portal venous sampling may show "hot spots"
of gastrin secretion. Schwartz, 6th ed, pp 1427-28

Duodenal Hematoma
Intramural hematoma of the duodenum is usually due to blunt abdominal trauma. This
causes rupture of intramural duodenal blood vessels with formation of a dark, sausage-
shaped mass in the submucosal layer of the duodenal wall. It can also occur
spontaneously in patients on anticoagulants. The hematoma may cause partial or
complete duodenal obstruction. The patient has signs of a high small bowel obstruction,
with nausea and vomiting associated with upper abdominal pain and tenderness, and
sometimes a suggestion of a right upper quadrant mass on palpation of the abdomen.
Plain films of the abdomen may show an ill-defined right upper quadrant mass and
obliteration of the right psoas shadow. An upper GI is usually diagnostic with filling of
the duodenal lumen and the appearance of a "coiled spring" in the second and third
portions due to crowding of the valvulae conniventes. The serum amylase may be
elevated. Most infants and children may be successfully treated without surgical
intervention. Nonsurgical treatment of these patients consists of cessation of oral intake,
nasogastric suction, and intravenous replacement of fluids and electrolytes. Schwartz, 6th
Edition. O'Leary, 2nd Edition, Physiologic Basis of Surgery

Treatment of Meckel's Diverticulum


The Meckel's diverticulum is the most common true diverticulum of the gastrointestinal
tract. It arises from incomplete closure of the omphalomesenteric or vitelline duct during
early development. It is generally found 18-24 inches from the ileocecal valve and arises
on the antimesenteric border of the ileum. Most are benign but problems arise from
bleeding and perforation secondary to the heterotopic gastric or pancreatic tissue found in
the diverticulum. The majority of these diverticuli are found in young children with the
most common symptom being bleeding. Other complications that occur are obstruction,
bleeding, acute diverticulitis or the presence of a diverticulum in a hernia sac (Littre's
hernia). Treatment is indicted if any of these complications should occur. Incidental
resection is not indicated because there is only a 2% risk of complications with a simple
Meckel's. If bleeding is present, a segmental small bowel resection should be performed
because the bleeding will be from the surrounding ileal mucosa subjected to the irritating
secretions. If there is a persistent connection to the overlying abdominal wall, this too
should be disconnected. Schwartz, 6th ed, pp 1179-80

Diagnostic Study of Gallstone Ileus


Gallstone ileus occurs when a gallstone obstructs the small bowel, which most commonly
occurs at the terminal ileum. Diagnosis of gallstone ileus is determined through a
combination of clinic findings and radiographs. Air fluid levels on the upright or
decubitus abdominal x-rays suggesting a small bowel obstruction and air in the biliary
tree are pathognomonic of gallstone ileus. The history will reveal past symptoms of
cholelithiasis that suddenly resolved or a history of gallstones. The findings on physical
exam supporting gallstone ileus are symptoms of small bowel obstruction: abdominal
pain, obstipation, vomiting, and abdominal distention. The treatment is an enterotomy
removing the stone, palpation of the entire small bowel to eliminate the possibility of a
second gallstone in transit, and if possible a concomitant cholecystectomy with closure of
the duodenal fistula. Schwartz, 6th Edition, pg 1381

Treatment of Acute Ileitis


Acute ileitis is most often associated with an acute flair of Crohn's disease. Surgery for
Crohn's disease is indicated only for complications (fistula, abscess, obstruction) as
recurrence of disease is quite common. Generally, acute Crohn's disease flair up is treated
medically with bowel rest, parenteral nutrition, antiinflammatory medication (steroids),
antibiotics, and drainage of abscesses (percutaneous) where applicable. Emergent
surgical intervention may be needed for certain situations (perforation, intractable
obstruction, sepsis). Elective resection of the diseased bowel segment responsible for the
complication is indicated once the acute process subsides. As a rule, bowel continuity is
reestablished whenever possible; however, if acute inflammation or infection is present at
surgery then temporary stoma may be necessary. Acute ileitis may also be caused by
Yersinia enterocolitica. Nine percent of these patients, if observed for long periods of
time, develop ileocolic Crohn's disease. Schwartz, 6th Ed., pp 1249-1250. Mazier,
Surgery of the Colon & Rectum, pg 956

Diagnostic Test for Adenocarcinoma of Small Intestine


Endoscopy useful for duodenum and proximal jejunum. Small bowel follow-through is
limited by low diagnostic sensitivity. Enteroclysis - superior to small bowel follow-
through for detection of small filling defects and for changes in mucousal pattern. With
diagnostic accuracy approaching 90% it is radiographic "gold standard" for study of
small bowel. Schwartz, 6th ed, pp 1171-72

Final Metabolic Event in Production of HCL


Cellular and subcellular mechanisms of acid secretion. The oxyntic cell has three distinct
receptors for stimulants of acid secretion on its surface. These receptors are for
acetylcholine, gastrin, and histamine.
Histamine works through generation of cAMP is well established.
Acetylcholine binds to its receptor and mobilization of intracellular calcium with
increased plasma membrane permeability result in the increase in intracellular calcium
which triggers the process that culminates in acid secretion.
Gastrin is thought to act in a manner similar to acetylcholine. Whatever cell surface
receptor is activated, the final event is the generation and activation of H+K+-ATPase,
which finds its way to the microvilli of the secretory vesicles. The H+K+-ATPase is the
proton pump that regulates the final step of secretion of H+. Hence, an inhibitor of the
proton pump (omeprazole) will inhibit acid secretion caused by whatever stimulus is
applied to the oxyntic cell. Miller, Physiologic Basis of Modern Surgical Care, 1988, pg.
287-288.

Physiology of Gastrin Release


The stimuli of the sight and smell of food (cephalic phase) send a signal from the cerebral
cortex to the vagal centers in the hypothalamus. The action potentials then pass down the
vagi and cause release of acetylcholine within the enteric plexuses and their nerve
endings in the gastric wall. The acetylcholine then causes gastrin to be released by the G
cells in the pyloric glands of the antral mucosa and in the proximal small intestine.
Gastrin release is also enhanced by gastric distention (gastric phase), contact of the
gastric mucosa with amino acids, certain foods, as well as antral alkalinity. Schwartz,
Principles of Surgery, 6th ed, 1994, pp 1127-28. Simmons & Steed, Basic Science Review
for Surgeons, 1992, pp 232-33

Effector of Gastric Acid Secretion


The "cephalic phase" of acid secretion refers to the brisk secretion of hydrochloric acid
that results from the site, smell and ingestion of food. Acetylcholine release from the
vagus nerve results in the release of gastrin from the G cells of antral mucosa and the
secretion of acid and pepsinogen from the fundic mucosa. Gastrin itself also stimulates
acid secretion as does histamine. Gastrin release is enhanced by antral distention and the
contact of antral mucosa with protein.
As the duodenum becomes acidified, secretin is released. Secretin inhibits the secretion
of gastric acid and gastrin. Hydrochloric acid is produced by the parietal cell in response
to gastrin, acetylcholine, and histamine. ATPase is the enzyme that exchanges H+ for K+
in the parietal cells.
Agents and their actions:
Acetylcholine - Stimulates Release of Gastrin
Antral distention - Stimulates Release of Gastrin
Gastrin - Stimulates Acid Secretion
Protein in the antrum - Stimulates Acid Secretion
High gastric pH - Stimulates Release of Secretin
Acidification of duodenum - Stimulates Release of Secretin
Secretin - Inhibits Acid Secretion and Gastrin Release. Schwartz, 6th ed, pp 1127-29

Anemia Associated with Blind Loop Syndrome


Blind loop syndrome occurs in segments of the small bowel where there is stasis of
succus entericus due to strictures, stenosis, diverticula or blind pouch. Bacterial
overgrowth occurs in the stagnant areas leading to a vitamin B12 deficiency
(megaloblastic anemia) as the bacteria compete for this and other vitamins. The
Schillings test with and without intrinsic factor is usually diagnostic of B12 deficiency vs
pernicious anemia. The excretion of vitamin B12 in the urine will be low resembling
pernicious anemia. With the addition of intrinsic factor, vitamin B12 excretion will
remain low in blind loop syndrome. In pernicious anemia the excretion of vitamin B12
will increase after IF is added. The next step of the test requires a 3-5 day course of
tetracycline then repeating the Schillings test. With blind loop syndrome the absorption
of vitamin B12 will then return to normal. This will not occur if the macrocytic anemia is
secondary to steatorrhea, which can also be a component of blind loop syndrome.
Medical treatment involves parenteral vitamin B12 therapy and tetracycline; however,
surgical correction of the condition causing the blind loop syndrome is the definitive
treatment. Schwartz, 6th Ed., pp 1182-83

Diagnosis of Afferent Limb Obstruction


Afferent limb obstruction is a complication of patients who have undergone distal gastric
resection and gastrojejunal anastomosis (Billroth II). It is caused by obstruction at the
junction of the afferent limb coming from the duodenum to the gastric remnant.
Patients will complain of severe midepigastric pain after eating, which is relieved by the
emesis of a large amount of bile. Food is not mixed with the emesis, which distinguishes
the symptoms from those resulting from efferent loop obstruction. The obstruction is
usually caused by recurrent ulcer or due to a technical error and re-operation is indicated.
Schwartz, 6th ed., page 1133.

Elevated Serum Gastrin Levels


Gastrin is an intestinal polypeptide, which is produced, stored, and released from G-cells
found in antral mucosa and the mucosa of the proximal small bowel. Gastrin's most
pronounced metabolic effect is the stimulation of gastric acid release from the gastric
parietal cells. Gastrin release is controlled by antral pH, vagal stimulation with eating,
and inhibition by the polypeptide secretin. Elevated serum gastrin levels are present in
conditions of gastrin hypersecretion (Zollinger-Ellison syndrome, gastrinoma) and when
gastrin clearance/metabolism is diminished (chronic renal failure). Sabiston, Textbook of
Surgery, 14th Ed, pp 760-762.

Treatment of Gastric Ulcer/Helicobacter Pylori Infection


Helicobacter pylori is a gram-negative micro-aerophilic curved bacillus found in gastric
biopsy specimens from patients with histologic gastritis. The prevalence is age related
with 10% incidence identified in healthy persons younger than 30 years of age and 60%
in those over 60 yrs of age. The bacteria - H.pylori is more prevalent in patients with
duodenal or gastric ulcers, 100% and 80% respectively. H.pylori is commonly associated
with gastritis. Studies have noted increased acid secretion and exaggerated gastrin
production in patients following a meal if infected with H. pylori. It is now generally
accepted that H. pylori causes gastritis. Data regarding H. pylori and gastric ulcers is
currently inconclusive.
Eradicating H. pylori is no easy matter!
None of the standard ulcer treatments, i.e. H2-receptor antagonist and sucralfate, have
any effect on H. pylori. Bismuth suppresses the organism. Numerous antibiotics have
been used as monotherapy without results and resistance has developed rapidly to
Tinidazole and Metronidazole.
Currently, the recommended treatment is:
Metronidazole, 250 mg TID and Pepto-Bismol, 525 mg QID for four weeks. Before
treatment the diagnosis and sensitivity should be confined by culture of gastric mucosal
biopsy. Recent studies confirm the close association between H.pylori, chronic gastritis
and gastric ulcer. However, clearing H.pylori infectious had no influence on the healing
or recurrence of gastric ulcers. NEJM, Vol. 324, pp 1043-48, April 1991 JAMA, Vol. 269

Characteristics of Heliobacter Pylori Infection


Heliobacter pylori infection of the gastroduodenal mucosa has been implicated in the
pathogenesis of gastric and duodenal ulcers. Antral gastritis is almost always present
histologically in duodenal ulcer patients. H.pylori is almost always isolated from this
antral mucosa and the degree of inflammation strongly correlates with presence of the
organism. The antral mucosa exhibits an inflammatory response closely resembling the
changes seen in the duodenal ulcer. H.pylori is found in 75% of patients with gastric
ulceration and 50% of patients with only dyspepsia. There is a 20% asymptomatic carrier
rate and the elderly are more likely to harbor the bacterium than are the young. It has not
been proven that H. pylori causes duodenal and gastric ulceration. However, treatments
that rid the organism from the GI tract (colloidal bismuth-Pepto-Bismol, antibiotics-
amoxicillin, biaxin, etc.) along with H2-blockers are associated with a significantly
reduced recurrence rate than if the organism persists. Mulholland MW. Duodenal Ulcer
and Kauffman GL, Conter RL. Stress Ulcer and Gastric Ulcer. In: Greenfield et al eds
Surgery: Scientific Principles & Practice. Philadelphia. JB Lippincott. 1993:675 and 698
Characteristics of Metoclopramide
I. Pharmacological activities
A. Antidopaminergic activities, like the phenothlazines, increases gastrointestinal
motility
B. Reverses narcotic-induced nausea and vomiting (i.e., postoperative vomiting)
C. There is some evidence that it may be useful before emergency surgery to empty the
stomach
D. Tightens the lower esophageal sphincter to prevent aspiration during emergency
induction of anesthesia
E. Used in large doses in the treatment of nausea induced by chemotherapy
F. Does NOT prevent motion-sickness
G. Useful in diabetic gastroparesis
H. Enhances response to ergotamine and analgesics in the treatment of migraine
headaches
II. Adverse reactions
A. The primary reactions are sedation and diarrhea
B. Extrapyramidal reactions, including parkinsonian symptoms and tardive dyskinesia,
have been noted when used for months or years
C. Dystonic reactions (oculogyric crises, trismus, torticollis, opisthotonos) and akathisia
are more like to occur within the first 72 hours of treatment. These are more common in
children, young adults, renal impairment, and with larger chemotherapy doses.
Extrapyramidal reactions are reversible with diphenhydramine (Benadryl). May increase
the sedative actions of CNS depressants. May increase severity and frequency of
extrapyramidal reactions produced by other medications, particularly phenothlazines.
III. Contraindications:
1. GI obstruction, hemorrhage, or perforation
2. Convulsive disorders
3. Pheochromocytoma
IV. Pharmacokinetics:
Mostly renal excretion, some hepatic conjugation
1/2-life with normal renal function: 4-6 hours, and is not dose dependent Drug
Evaluations, 6th ed., American Medical Association, 1986

Characteristics of Cisapride
Cisapride (Propulsid) is a prokinetic GI motility agent that acts via 5-HT4 receptors. Its
effects are similar to metaclopromide (Reglan) and Domperidone in that it enhances the
motility of smooth muscle of the stomach, and small bowel. Unlike these agents, it also
increases motility of the colon, which may cause diarrhea. It is useful for treating gastric
hypomotility disorders as well as idiopathic constipation and colonic hypomotility
without the dopaminergic side-effects of metaclopromide. Goodman and Gilman, The
Pharmacological Basis of Therapeutics, 9th ed.
Induction of Gastric Smooth Muscle Relaxation
The stomach is composed of three smooth muscular layers: an outer longitudinal, middle
circular, and inner oblique layer. The longitudinal layers are concentrated along the lesser
and greater curvatures of the stomach. The circular muscle is present throughout the
stomach and is concentrated in a circular, muscular sphincter at the pylorus.
The vagus and sympathetic nerves are the primary effectors of smooth muscle activity.
Although the vagal nerves are considered primarily for their motor activities, afferent
neurons make up the greater part of the cranial nerves.
Neuro control of the stomach is mediated through two gastric myenteric plexuses
(Auerbach's and Meissner's). The stomach has a natural pacemaker located high in the
greater curvature of the body of the stomach. This initiates contractions at 3 cycles/min,
as the electrical potential passes distally, activity increases (Phase 2) and in Phase 3
contractions are repetitive and serve as a "housekeeper potential", which advances food
toward the pylorus.
Only particles less than 1 mm in diameter are emptied into the duodenum.
Relaxation of the smooth muscles is controlled physiologically by CCK,
mechanoreceptors for distention and glucose in the stomach and duodenum (1st portion),
which mediate relaxation via afferent fibers to the medulla. Transient delays of gastric
emptying (smooth muscle inhibition) is seen frequently in the postoperative patient, and
in those patients with pancreatitis, peritonitis, or retroperitoneal bleeding or injury.
Gastric motility returns with resolution of the underlying problems.
Metabolic causes for gastric atony include hypokalemia, hypercalcemia, and
hypocalcemia, hypomagnesemia, hypothyroidism, uremia, hepatic coma, and
hyperglycemia. Correction of the metabolic abnormality usually restores normal gastric
emptying.
Diabetic gastroparesis can occur in insulin-dependent diabetics. The basic defect appears
to be one of impaired neurocontrol with loss of Phase 3 activity in the stomach.
Metoclopramide is often effective in improving gastric emptying in these patients.
Delayed gastric emptying following truncal vagotomy or gastrectomy is a distressing
problem, which is poorly understood. It may be caused in part by the fact that the
antropyloric mechanism is intact, and in part because of concomitant sympathetectomy of
the proximal stomach. Miller, Physiologic Basis of Modern Surgical Care, pp. 280-89

Induction of Gastric Smooth Muscle Relaxation


The major functions of the stomach include storage, digestion, and propulsion of ingested
food. Thus, the contractile activity of gastric smooth muscle is a major factor. The
predominant effort is muscular contraction. In the stomach smooth muscle cells with the
highest frequency of depolarization drive the slower cells that surround them. These high
frequency cells are located in the upper third of the greater curvature of the stomach. This
has been called the pacesetter potential or electrical control activity (ECA) of the
stomach. Contraction is regulated by acetylcholine, and is limited to 3 contractions /
minute by the ECA.
Smooth Muscle Relaxation: Vagal efferents are both excitatory and inhibitory. The
inhibitory fibers are noradrenergic, noncholinergic fibers, and produce fundic relaxation,
inhibit antral contraction, and relax the pylorus. These neurons probably release
vasoactive intestinal peptide (VIP) as a neurotransmitter. Sympathetic efferents coursing
through the celiac ganglia may inhibit gastric contractility through modulation of intrinsic
neurons and the release of norepinephrine. Chemical control of smooth muscle activity in
the stomach is predominately hormonal, and is difficult to determine considering the
overwhelming myoelectric regulation. Cholecystokinin (CCK) has, however, been
demonstrated to cause the slowing of gastric emptying after a fatty meal. The delayed
gastric emptying due to relaxation of gastric smooth muscles continues as long as fat
remains in the intestinal contents of the small bowel. This is due to the continued release
of CCK. Nitric oxide released at nerve terminals may act as a neurotransmitter, and may
regulate relaxation of various muscular sphincters within the GI tract. Thus, nitric oxide
could selectively relax smooth muscle, particularly at the pyloris. Physiologic Basis of
Surgery, 2nd Edition, pp. 419-21

Characteristics of Proximal Gastric Vagotomy


Synonyms: Selective proximal vagotomy, proximal gastric vagotomy, parietal cell
vagotomy, supra- or highly selective vagotomy.
The goal of treating peptic ulcer disease surgically is eliminating/reducing gastric acid.
One newer operation, which aims at denervating only the HCl-producing parietal cell
source while preserving vagal innervation to the remainder of the stomach and abdominal
viscera is the proximal gastric vagotomy. This operation preserves antral innervation
thereby eliminating the need for pyloroplasty/emptying procedure. All branches of the
anterior and posterior vagus nerve are meticulously severed from the distal 6 cm of the
esophagus and continued along the lesser curvature of the stomach to a point 6 cm
proximal to the pylorus. The advantage of the proximal gastric vagotomy over truncal
vagotomy is that gastric acid is reduced without opening the GI tract. Further, it preserves
vagus innervation to the antrum, pylorus and the remainder of the gut. Complications
such as dumping syndrome, diarrhea, and bilious vomiting are rare. The recurrence rate
of 10-20% at 10 years is likely due to technical failure. Management of recurrent peptic
ulceration after proximal gastric vagotomy is usually done with H2-blockers or
antrectomy. This procedure has been advocated for the management of intractable peptic
ulcer disease and in low risk patients with perforation. It has not proven effective in the
management of duodenal stenosis with dilatation due to peptic ulcer disease. Sabiston,
Textbook of Surgery, 14th Edition, pp 777-780.

Origin of Hepatic Vagal Branch


The left or anterior vagus nerve supplies a hepatic vagal branch, sends fibers to the area
of the pylorus, and innervates the anterior wall of the stomach. This hepatic branch
innervates the liver, gallbladder, and pancreas. Division of this hepatic branch, which can
occur during incision and dissection of the gastrohepatic ligament can lead to increased
incidence of gallstones. Nyhus and Baker: Mastery of Surgery, Vol.1, 2nd ed., pg. 672-
674.

Anatomy of Right Gastric Artery


The right gastric artery is a branch of the common hepatic artery. This provides blood
supply to the pylorus and the first part of the duodenum. Schwartz, 6th ed, pp 1123-24
Drug Rx of Duodenal Ulcer/Gastrinoma
Gastrinoma or Zollinger-Ellison syndrome is a condition, which typically presents with
symptoms of gastrc acid hypersecretion. Sixty percent of gastrinomas are non-b islet cell
carcinomas of the pancreas, 25% are solitary adenomas and 10% are microadenomas or
hyperplasia. Whatever the cell type, elevated levels of serum gastrin are produced leading
to low gastric pH.
The most common clinical manifestations are peptic ulcer disease refractory to medical
therapy and diarrhea. The diarrhea results from damaged small bowel mucosa as well as
fat malabsorption secondary to the destruction of pancreatic lipase by gastric acid.
Medical therapy for gastrinoma is aimed at controlling gastric acid hypersecretion.
Although H2-blockers may be effective, omeprazole, a H+-ion pump inhibitor, is the
drug of choice because it has a long duration of action. Approximately 90% of patients
can be controlled on this regime. Doses are adjusted to keep H+-ion output less than 5
meq during the hour preceding the next dose. Schwartz, Principles of Surgery, 6th
Edition, pp 1427-28

Characteristics of Roux-en-Y Gastrojejunostomy


In gastric resections a Roux-en-Y gastrojejunostomy is created by dividing the pylorus
and closing the duodenum with resection of the antrum. The proximal jejunum is divided
and the distal free end is brought up and sutured to the stomach. The proximal free end of
the jejunum is reattached to the jejunum at a point at least 40 cm distal to the
gastrojejunostomy. A vagotomy should also be performed to prevent marginal ulceration.
The advantage of this procedure over a Billroth I or Billroth II is that bile and pancreatic
secretions are diverted away from the stomach preventing bile gastritis. This technique
has also been used successfully for the treatment of early dumping syndrome.
Other Uses: The Roux-en-Y technique can be used as a method of reestablishing
gastrointestinal continuity where the duodenum is obstructed, i.e. peptic ulcer disease, or
when diversion of gastric secretions and food from the duodenum is necessary, i.e.
duodenal trauma or fistula.
General Characteristics:
1. The small bowel (jejunum) is divided at a comfortable distance below the ligament of
Treitz.
2. The distal jejunal end is anastomosed to the stomach.
3. The proximal jejunal end, draining duodenal secretions is anastomosed to the jejunum
40-45 cm below the gastrojejunal anastomosis. This distance prevents reflux of bile and
pancreatic secretions due to 2-3 peristaltic waves which will occur within this segment of
jejunum. Schwartz, 6th ed, pg 1388

*Prevention of Pulmonary Complications of Flail Chest Intercostal nerve block, epidural analgesia,
Pulmonary Toilet
*Dx Adrenal Mass/Hypokalemia Likely Conn Syndrome (primary hyperaldosteronism), will have
elevated serum Na and urinary K, low serum K, aldosterone/renin ratio greater than 400, low renin
activity, high plasma aldosterone, high urine aldosterone after sodium challenge, can localize with MRI,
scintography or venous sampling
*Rx Adrenal Insufficiency IV hydrocortisone, Fluids, ACTH stimulation test, include a
mineralocorticoid (Florinef)
*Extra Adrenal Sites of Pheo Organ of Zuckerandl, near aortic bifurcation, retroperitoneum, vertebral
bodies, bladder, opposite adrenal gland, neck, mediastinum
*Rx Pelvic Fracture Place sheet, external fixator or C-clamp and then go to angio for embolization, if
see hematoma after blunt injury in OR, leave it alone, pack, and get patient to angio, if has colon injury
with fracture will need colostomy, if greater than 3 cm diastasis of symphysis pubis, need anterior
fixator/plating, if sacroiliac joint is displaced, treat with posterior internal fixation with plates, treat
sacral/coccygeal fractures conservatively
Definition of O2 Delivery Cardiac Output X Oxygen Content(Hb x1.34x%O2sat+(PO2x0.003))
Wedge Affected By Pulmonary HTN, Aortic Regurgitation, MS/MR, High PEEP, LV compliance
O2 Consumption CO X (Ca02 Cv02), normal delivery to consumption ratio is 5:1, CO increases to
keep the ration constant
*O2 Extraction ratio (Ca02 Cv02)/Ca02
*Early Gram Negative Sepsis Decreased insulin, increased glucose due to impaired utilization
*Anat Right Renal Artery Goes posterior to IVC
Ventilator Choice in Bronchopleural Fistula High-frequency jet ventilation
*Most Potent Stimulator of SIRS Endotoxin Lipopolysaccharide A
*Rx ARDS Low tidal volumes (6cc/kg), high PEEP (up to 22), permissive hypercapnea (RR less than
35), plateau airway pressure less than 30, FI02 less than 0.5,
*Characteristics of ARDS Diffuse alveolar damage and increased capillary permeability: 1.Diffuse
bilateral infiltrates on CXR, 2.Pa02/FI02 less than 200 3. Wedge less than 18
*V/Q Abnormalities 1. Shunts (lung perfused, but not ventilated) Pneumonia/Atelectasis - O2 sat
doesnt increase with 100% O2, 2. Dead Space (lung ventilated, but not perfused) PHTN, Low CO, PE,
high PEEP
*Dx Post-Op Oliguria Most common cause is hypotension causing ATN, Check FeNa (less than 1),
UOsm (greater than 500), UNa (less than 20), BUN/Cr (greater than 20) in pre-renal failure, check
ultrasound/foley for post-renal obstruction
*Criteria Brain Death Cerebral GSW Precluding diagnosis: uremia, temp less than 30, BP less than
70/40, desat with apnea test, drugs (pentobarb, phenobarb), metabolic derangements.
Must have for 6-12 hours (2 separate exams): unresponsive to pain, absent caloric oculovestibular reflexes,
oculocephalic reflex, positive apnea test (CO2 increases by 20 or is greater than 60 when disconnected
from vent), no corneal reflex, no gag reflex, fixed and dilated pupils. EEG electrical silence, MRA no
blood flow to brain
*Rx Ventilatory Complication Burn Perform escharatomy if burns on chest/torso with difficulty
ventilating
*Adverse Reaction Silver Sulfadiazene neutropenia and thrombocytopenia, inhibition of epithelization
Adverse Reaction Silver Nitrate hyponatremia, hypokalemia, hypocalcemia, hypochloremia and
methemoglobinemia in G6PDH deficiency
*Adverse Reaction Sulfamylon metabolic acidosis
Risk with Claudication 1% per year of amputation, 2% per year of gangrene
Mimic Claudication Lumbar Stenosis
*Dx Test Claudication Rule out neurogenic causes of pain by ordering lumbosacral spine films, EMG,
MRI or CT
To diagnose vascular claudication perform ABI/PVR or segmental systolic pressures after walking on
treadmill. If has claudication due to vascular disease, the SBP difference will be less than 20 between the
brachial and femoral. Gold standard is angiography.
ABI inaccurate in Diabetics, they have calcified, incompressible vessels. Use Doppler waveforms
Edema Following Lower Extremity Bypass Check ultrasound for DVT first, then second most common
cause is reperfusion injury
*Rx Embolus L Femoral Artery Heparinization, Open Embolectomy through groin incision, then
angiogram. If greater than 4 to 6 hours, perform fasciotomy.
*Technique Fem-Peroneal Graft Surveillance Color Flow Duplex Ultrasound
Nerve most commonly injured following fasciotomy Superficial peroneal nerve
*Rx Preop Phimosis Dorsal Slit
*Most Common Metastasis to SB Melanoma
*Treatment of Basal Cell Carcinoma Excision with 0.3 to 0.5 cm margin, XRT if mets, neuro,
lymphatic or vascular invasion
*Characteristics of Keloids Collagen outside of scar, in dark skinned people, treat with steroids,
silicone, pressure garments
*Anatomy of Phrenic Nerve On Anterior Scalene Muscle
*Mircoadenoma in Pituitary Most commonly is prolactinoma, treat with bromocriptine, if fails medical
therapy perform transphenoidal resection, if growth hormone adenoma, treat with resection
Tunnel Vision (Bitemporal Hemianopsia) Pituitary tumor compressing optic chiasm
*Likely Complication Sella Turcica Fracture Panhypopituitarism will have troubling lactating (first
sign), amenorrhea, adrenal insufficiency, and hypothyroidism, can also have cranial nerve injuries, CSF
rhinorrhea
*Pulsatile, bleeding mass after CEA Dx: Pseudoaneurysm prep and drape first, then intubate and
repair with bypass of carotid
*Etiology oliguria post AAA repair Hypoperfusion of kidneys, other less common causes are contrast
administration and atheroembolism
*Rx Effort Thrombosis Pitcher Subclavian vein is thrombosed, start with thrombolytics via catheter,
followed by heparin then Warfarin, will likely need first rib resection for thoracic outlet syndrome
*Dx Effort Thrombosis Subclavian Vein Gold standard is venography
*Femoral Pseudoaneurysm If small may be observed for resolution in 2-4 weeks, otherwise treat with
ultrasound guided compression or with thrombin injection initially, if flow remains or at suture site repair
in OR
*Rx Chylous Ascites PO AAA Repair NPO and TPN is initial treatment, if does not resolve can ligate
thoracic duct
*Signs Primary Hyperparathyroidism Fatigue, weakness, memory loss, renal stones, bone pain,
abdominal pain, psychiatric symptoms, can have neck mass, band keratopathy, and fibro-osseous jaw
tumors
Elevated Calcium, low Phosphorous, Chloride to Phosphorous ratio greater than 33, hyperchloremic
metabolic acidosis, bicarbonate in urine, elevated renal cAMP, can have osteitis fibrosis cystica bone
lesions from hyperPTH
*Hyperthyroidism in Pregnancy PTU initially, propanolol may help, if the pregnant patient is not
controlled with medical therapy do subtotal thyroidectomy in 2nd trimester
*Tx Medullary Thyroid Carcinoma Total thyroidectomy with central node dissection, if has clinically
positive nodes do ipsilateral MRND, if both thyroid lobes have cancer do b/l MRND if clinically positive
nodes, do prophylactic thyroidectomy and central node dissection if child with MEN at age 2
*Tx Parathyroid Cancer Radical parathyroidectomy and resect ipsilateral thyroid lobe, recurrence rate
is 50%
*Tertiary Parathyroidism After renal transplant, treat with resecting 3 glands or total
parathyroidectomy and reimplant in forearm
* Person with LCIS develops Breast Ca Most commonly will be Ductal Carcinoma
Most Common Cause Nipple Discharge Spontaenous discharge from a single duct is intraductal
papilloma, bloody discharge is most commonly intraductal papilloma, Green discharge is most commonly
fibrocystic disease
*Etiology Unilateral Breast Enlargement Man In adolescence due to excess of estradiol compared to
testosterone, In adults, Gynecomastia possibly associated with hepatic cirrhosis, hypo or hyperthyroidism,
estrogen secreting testicular tumors, renal failure, or malnutrition. Digoxin, Thiazides, Estrogens,
Theophylline or phenothiazines may exacerbate gynecomastia
*Rx Breast Mass Post NeoAdj Chemoradiation Mastectomy, radiation and additional chemotherapy
BRCA 1 Ovarian Ca (50%) and endometrial Ca, treat with TAH/BSO and mastectomy if family hx
BRCA2 Associated with male Breast Ca
*Pleural Fluid 1-2L per day, produced by parietal pleural and resorbed by lymphatics in visceral pleura
Site of Lung Abscess Posterior portion of RUL, superior portion of RLL
*Best Long Term Graft Patency for CABG LIMA
*Blood Supply Cervical Esophagus Inferior Thyroid Artery
*Treatment of Zenkers Diverticulum Cricopharyngeal myotomy, dont necessarily need to resect
diverticulum
Tx Achalasia Calcium Channel Blockers first, dilation may help, if failure of medical therapy perform
Heller Myotomy via left thoracotomy, transect circular muscle layer of lower esophagus and then perform
partial 180 degree Nissen
*Dx/Rx Antithrombin III Deficiency Associated with recurrent thrombosis and pulmonary embolism,
found in patients who are resistant to heparin therapy that do not show an increase in PTT, treatment is FFP
or ATIII concentrate, then Heparin, then Coumadin
*Type II Hiatal Hernia Paraesophageal Hernia, all need surgical repair due to incarceration risk,
perform NIssen as well
*Rx Perforation of Esophagus Left Thoracotomy, longitudinal myotomy to see extent of injury,
primary repair with buttressing with healthy tissue, place chest tubes, if greater than 24 hours debride
tissue, create esophagostomy, wide drainage, and placement of G tube
Indication Gastric Bypass BMI greater than 40, BMI greater than 35 with comorbidities,
psychologically stable, no substance dependence, failure of non-surgical methods of weight reduction
*Rx GIST AKA Gastric leiomyoma, seen as hypoechoic on ultrasound with smooth edges, gastric wedge
resection with 1cm margins, no lymph node dissection, chemotherapy if greater than 5cm or 5-10 mitoses
per HPF, chemo is Gleevac if unresectable and metastatic
*Gastric Cancer Risk Factors Adenomatous polyps, chronic atrophic gastritis, type A blood type,
intestinal metaplasia, nitrosamines, tobacco, previous gastric surgery, pernicious anemia, hyperplastic
polyps
*MALT Treatment Triple antibiotics for H. Pylori, if does not cure, then treat with
surgery,chemotherapy (CHOP), and radiation
*Right Hepatic Artery Variation Most commonly off of SMA
*Rx Varices Assoc Splenic Vein Thrombosis Splenectomy
*Characteristics of Lithogenic Bile (Stone Forming) Supersaturated with cholesterol, low amount of
bile acids and lecithin, in obese patients often due to overactive HMG CoA reductase, in thin people due to
7 alpha hydroxylase, pigmented stones due to precipitation of calcium bilirubinate and unconjugated
bilirubin
*Characteristics Focal Nodular Hyperplasia Liver Central stellate scar in liver looks like cancer,
however FNH is benign, Uptakes Sulfer Colloid on liver scan (hot nodule), MRI/CT shows hypervascular
tumor, treatment is conservative
*Hepatic Adenoma Women, OCPs, steroids and Type I Collagen Vascular Disease risk factors, 10-20%
risk of rupture, does NOT uptake Sulfer Colloid on liver scan (cold nodule), CT shows hypervascular
tumor, commonly in right lobe, can become malignant, if asymptomatic stop OCPs and observe, if
symptomatic do resection or emoblize if multiple
Amebic Liver Abscess Commonly in right lobe from amebic colitis and seeding through portal vein, due
to E Histolytica, treat with Flagyl, aspiration if refractory, may see anchovy paste in aspirate
*Pyogenic Liver Abscess Most common abscess, most common organism is E Coli, often due to
contiguous infection from biliary tract, treat with CT guided drainage and antibiotics, only drain surgically
if patient is unstable or septic
Echinococus Liver Abscess Sheep are carriers, transmitted by dog bites, positive Casoni skin test and
positive indirect hemagglutination, CT shows ecto and endocyst with calcifications, treat with albendazole
and then surgical removal of cyst wall, can inject alcohol to kill organisms, DO NOT ASPIRATE FIRST,
can cause anaphylactic shock
*Etiology Shock Post Op Lap Chole In first 24 hours due to hemorrhagic shock from clip that fell off
cystic artery, after 24 hours from septic shock on clip on CBD with cholangitis, diagnose with RUQ U/S to
look for collection, then HIDA to look for leak
*Rx Laparoscopic Injury CBD Place T tube and transfer to tertiary center, if performing repair and less
than 50% of circumference perform primary repair, in other cases will need
choledocho/hepaticojejunostomy
*Rx Adenoca Gallbladder If confined to mucosa (Stage 1) only need cholecystectomy, if into muscular
layer (Stage Ib) need cholecystectomy, wedge resection of liver and lymphadenectomy of hepatoduodenal
ligament/portal triad, if IIa/IIb( through serosa or into liver), needs hepatic 4b and 5 segmentectomy, Stage
3 (into hepatic artery, portal vein) or Stage 4 (distant mets) are unresectable
*Volume-Outcome Pancreatic Cancer 3-5x higher mortality at low volume centers (less than 5) when
compared to centers doing more than 20 per year
Insulinoma Occurs throughout pancreas, 85-95% benign, if <2cm enucleate, if >2cm resection, if
metastatic to liver treat with octreotide, 5-FU, streptozicin, presents with Whipples triad (FS<50,
symptoms of hypoglycemia and relief with glucose)
Gastrinoma Most common pancreatic tumor in MEN I, occurs in gastrinoma triangle (CBD, 3rd portion
of duodenum, head of pancreas), diagnosis is gastrin greater than 200 can be greater than 1000, secretin
stimulation test causes increase of gastrin, best localization is somatostatin scintography, can also do CT or
MRI, if cant find gastrinoma open duodenum to look for microgastrinomas, if <2cm enucleate, if >2cm
resection, if unresectable do vagotomy and pyloroplasty
Somatostatinoma In head of pancreas, diagnose with elevated somatostatin level, presents with diabetes,
steatorrhea, weight loss, gallstones, do cholecystectomy with resection
*VIPoma In distal pancreas, presents with achlorhydria, hypokalemia, watery diarrhea, diagnosed with
elevated VIP level, treat with distal pancreatectomy, 10% in retroperitoneum or thorax
*Glucagonoma Most in distal pancreas, glucagon level greater than 500, presents with diabetes,
stomatitis, necrolytic migratory erythema (treat with parenteral amino acids), weight loss, treat with distal
pancreatectomy, octreotide if unresectable or has recurrence
*Characterstics Puetz-Jeghers Syndrome Autosomal Dominant, ileal and jejunal hamartomas most
frequent sites, 50% with colorectal polys, 25% with gastric polyps, melanotic mucocutaneous
pigmentation, increased risk of colon cancer in patients with polyps, neurogenic cancers, hemangiomas,
lipomas, 2% risk duodenal cancers, increased risk of biliary, breast, and gonadal cancers
*Fuel Source Colonocyte Short Chain Fatty Acids (Butyrate)
*Rx Occult Blood in Feces - Colonoscopy
*Etiology Death Familial Adenomatous Polyposis Metastatic colon cancer but if resected already,
periampullary tumors of duodenum
*FAP Autosomal dominant, Multiple polyps, need total proctocolectomy with ileoanal J pouch by age
20, get duodenal polys, need EGD every 2 years, associated with Gardners Syndrome (sarcomas,
osteomas) and Turcots Syndrome (brain tumors)
*Rx Hematochezia Unknown Source If unstable, needs subtotal colectomy if no bleeding source
identified
HNPCC Right sided colon cancers, metachronous lesions, surveillance by age 25 or 10 years before first
familial cancer, Lynch I only colorectal ca, Lynch II ovarian, breast, bladder, stomach cancers, perform
subtotal colectomy with first operation
*Risk Factors Ovarian Cancer Early menarche, late menopause, lack of OCP use, late first pregnancy
(after 30), late first breast feeding (after 30), nulliparity, perineal talc use, personal or family history of
colon, ovarian or endometrial cancer, age, diet, geography
*Risk Factor Endometrial Cancer Obesity, nulliparity, tamoxifen, unopposed estrogen, late first
pregnancy, early menarche, diabetes, HTN, late menopause
*Rx Squamous Cell Cancer Penis Penectomy with 2 cm margin, may have reactive lymph nodes that
need to be treated with antibiotics. If has adenopathy on CT, needs lymph node dissection. If palpable
inguinal LAD, needs dissection. If has pelvic mets, needs chemo
*Rx Fracture Distal Femur If minimally displaced can be treated with knee immobilizer or long leg
cast. Delayed weightbearing. If displaced or has articular involvement, use IM nail or condylar plates
*Etiology Wrist Drop Associated Upper Extremity Fracture Radial nerve injury along proximal
humerus
*Nerve Injury Associated Fibulectomy Peroneal Nerve
*Indication Preop Nutrition Gastric AdenoCa History of weight loss greater than 15% albumin less
than 3 makes higher risk for complications. Preop nutrition for 7-10 days decreases septic complications.
Randomized controlled trials have shown benefit of IV nutrition in severely malnourished patients with
upper GI tumors
*Rx Nerve Injury Lap Inguinal Hernia Repair If neuralgia in RR, need prompt re-exploration,
otherwise reassurance, NSAIDS and nerve blocks help.
*Rx Seroma PO Ventral Hernia Repair Serial aspiration under sterile technique, if persistent open the
incision and pack with saline gauze
*Achievement Anticoagulation Antithrombin III Neutralizes factor IXa, Xa, Xia and eventually
inhibits thrombin, heparin causes conformational change in ATIII and accelerates inhibitory reaction
*Drugs Affecting Warfarin Metabolism Barbiturates, rifampin and dilantin increase clearance of
warfarin by activating hepatic enzymes. Flagyl, Allopurinol, cimetadine, amiodarone, phenylbutazone,
sulfinpyrazone, disulfiram and alcohol increase response of warfarin (bleeding)
*Conditions Associated with Normal INR/Abnormal PTT Heparin therapy, Lupus Anticoagulant,
Hemophilia A/B
*Etiology Obscured Clinical Difference Type 1 error (falsely reject null hypothesis) use p<0.05 to
prevent this, means less than 5% chance of difference being random, Type 2 error(accepts null hypothesis
when in fact it is false) is due to a small sample size
*Ethics and Physician Error Physician has ethical duty to admit mistakes to patient, if complication
resulted from mistake, physician is ethically required to inform patient of what occurred
*Etiology Pneumoperitoneum HIV Pt Terminal ileum and colon are most common sites for perforation
due to CMV, diagnosis of CMV is made by seeing intranuclear inclusion bodies on biopsy, suture plicate
gastroduodenal perforations, perform SBR if SB involved and colostomy for colonic perforation,
perforation is an ischemic lesion as CMV affects arterioles of GI tract
*Treatment of Malignant Hyperthermia stop inhalation agent, dantrolene, 100% oxygen, cooling
blanket, cold IV, correct acidosis and hyperkalemia
*Characteristics of Blood Circulation Fetal circulation has 2 umbilical arteries which are branches of
iliac arteries and 1 umbilical vein which drains to ductus venosus
*Characteristics of AIDS-related Lymphoma B-cell lymphoma, usually poorly differentiated and
aggressive, managed with chemotherapy, surgery only for GI bleeding, obstruction, or perforation
*Antibiotic Treatment of Human Bite Wound Cefoxitin or cefotetan with a penicillin to cover
Eikenella corrodens, continue for 24 to 48 hours
*Characteristics Epidural Anesthesia Anesthesia (epinephrine/lidocaine) injected into lumbar or
thoracic epidural space. Shown to decrease blood loss, risk of DVT, better pain control, earlier ambulation,
earlier return of bowel function, and superior pulmonary function. Risk is spinal hematoma, epidural
abscess, hypotension, headache, urinary retention.
*Etiology of Hypokalemia in Gastric Outlet Obstruction Due to vomiting of material with potassium
and hydrogen, potassium is then excreted in urine for exchange of sodium lost in vomitus
*Metabolism of Cancer Cells Catabolize glucose at a high rate due to hexokinase that is bound on the
outer mitochondrial membrane, cancer cells are able to maintain increased rates of glucose utilization and
high rates of glycolysis under aerobic conditions
*Metabolic Acidosis after Kidney/Pancreas Transplant Due to excessive urinary loss of bicarbonate
containing exocrine fluids from the pancreas transplant
Most common congenital hypercoagulable disorder Factor V Leiden
*Treatment of Intra-Operative Bleeding with ESRD DDAVP, cryoprecipitate, estrogens
*Treatment of HIT Argatroban or Hirudin
Hemophilia A need Factor VIII levels 100% preop and 30% postop, treat with Factor VIII or cryo
*Most common bacteria in colon Bacteroides vulgatus
*Surgical infection within 48 hours Clostridium or Beta-hemolytic strep
Gentamicin peak too high Decrease dose
Gentamicin trough too high Decrease interval of dose
*Intubated patient with sudden drop in ETC02 With decreased mixed venous CO2 in venous air
embolism, with increased mixed venous CO2 can be CHF, MI, PTX, PE, atelectasis, hypotension
Glycogen Stores Depleted after 24-36 hours of starvation, body then switches to fat
*P53 on Chromosome 17, involved in cell cycle arrest and apoptosis, abnormal gene allows unrestrained
growth
Cyclosporin Binds cyclophilin protein and inhibits cytokine synthesis, side effect is nephrotoxicity,
hepatotoxicity, HUS, tremors, seizures, metabolized in liver and excreted through bile
*Lamivudine Used in post-op liver transplant patients to treat Hep B recurrence
*Macrophages Essential for wound healing