Topnotch Surgery Supplement Handout

TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT - Jules Lopez,MD-MBA,Teddy Carpio,MD-MBA
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com

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SURGERY'REVIEW' !
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This! review! material! is! a! synthesis! of! the! first! few! chapters! of! Table'1.!Cytokines!And!Their!Responses!to!Injury!☺!!
Schwartz’s+ Principles+ of+ Surgery,+ 9th+ edition,+ Absite+ and+ Board+ Cytokines'and'their'Responses'to'Injury'
Review+of+Schwartz’s+Principles+of+Surgery,+9th+edition,!2009+Absite+ • Among!earliest!responders!after!
Clinical+Review+of+Surgery+and+RUSH+integrated+review+of+surgery.! injury!
Tumor.Necrosis.Factor.
• Induces'muscle'breakdown'and'
Integration!with!other!basic!subjects!as!well!as!review!questions! Alpha.(TNF8α ).
cachexia!through!increased!
per!section!are!also!included!to!facilitate!mastery!of!the!course.!! catabolism!
! • Induces!fever!through!
Ready?!God!bless!and!enjoy!Surgery!!☺! prostaglandin!activity!in!anterior!
! Interleukin.1.(IL81). hypothalamus!
B Dr.!Jules!Lopez!and!Dr.!Teddy!Carpio! • Promotes!βBendorphin!release!from!
pituitary!
P.S.! • Promotes!lymphocyte'
! proliferation,!immunoglobulin'
Ophthalmology,! ENT,! Orthopedics,! and! Gynecology! topics! are! not! production,!gut!barrier!integrity!
Interleukin.2.(IL82).
included!in!this!surgery!handout.!! • Attenuated!production!after!major!
! blood!loss!leads!to!
Any! statements,! tables,! figures! marked! with! a! ☺! means! that! the! immunocompromise!
information! highlighted! was! previously! tested! in! previous! board! exams.! • Elicited!by!all!immunogenic!cells!as!
You!should!!master/memorize!those.!Pay!close!attention!to!those!in!bold,! mediator'of'acute'phase'
italicized,! underlines! as! these! are! very! important! facts! to! remember! for! Interleukin.6.(IL86). response!
the!subject.!Master!topics!written!in!our!quick!review,!subject!cross!overs! • Prolongs!activated!neutrophil!
and! end! of! review! question! boxes! because! they! provide! high! yield! survival!!
information,!not!just!for!surgery!but!for!the!rest!of!the!other!subjects!as! • Chemoattractant!for!neutrophils,!
Interleukin.8.(IL88).
well!! basophils,!eosinophils,!lymphocytes!
! • Activates'macrophages!via!TH1!
General!Outline:! cells!that!demonstrate!enhanced!
I. Basic!Principles!in!Surgery! Interferon.(IFN8γ ). phagocytosis!and!microbial!killing!
• Found!in!wounds!5B7!days!after!
a. Systemic!Response!to!Injury!and!Metabolic!support!+
injury!
b. Fluid!and!Electrolyte!management!of!the!Surgical!
!
Patient!+
2. Heat.Shock.Proteins!
c. Hemostasis,!Surgical!bleeding!and!transfusion+
• Group!of!intracellular!proteins!that!are!increasingly!
d. Surgical!Infections!and!Shock!+
expressed!during!times!of!stress!
e. Trauma!+
f. Burns++ • Bind!both!autologous!and!foreign!proteins!and!thereby!
function!as!intracellular!chaperones!for!ligands!such!as!
g. Wound!healing!+
bacterial!DNA!and!endotoxin!
II. Organ!System!Pathologies!
a. Skin!and!soft!tissues!! • Protect'cells!from!the!deleterious!effects!of!traumatic!
b. Breast!! stress!and,!when!released!by!damaged!cells,!alert'the'
c. Head!&!Neck! immune'system'of'the'tissue'damage!
d. Esophagus! !
e. Stomach! 3. Reactive.Oxygen.Species.(ROS)!
f. Small!Intestine! • Small!molecules!that!are!highly!reactive!due!to!the!
g. Appendix! presence!of!unpaired!outer!orbit!electrons!
h. Colon,!Rectum!&!Anus! • Cause'cellular'injury'to'both'host'cells'and'invading'
i. Abdominal!Wall!&!Hernia! pathogens!through!the!oxidation!of!unsaturated!fatty!
j. Liver,!Portal!Venous!System!&!Gallbladder! acids!within!cell!membranes!
!
' 4. Eicosanoids..(Refer!to!Figure'1'☺)!
PART'I:'BASIC'PRINCIPLES'IN'SURGERY! • Derived!primarily!by!oxidation!of!membrane!
phospholipid,arachidonic+acid+
!
• Composed!of!subgroups!including!prostaglandins,+
SYSTEMIC'RESPONSE'TO'INJURY'AND' prostacyclins,+hydroxyeicosatetraenoic+acid,+
METABOLIC'SUPPORT' thromboxanes,!and!leukotrienes+
' • Generate!a!proinflammatory'response!
A. Mediators'of'Inflammation' !
B. Central'Nervous'System'Regulation'of'Inflammation' Figure'1.!Arachidonic!acid!metabolism!☺.!Cycloxygenase!catalyzes!the!
C. Hormonal'Response'to'Injury' formation!of!PG!and!TXA2from!arachidonic!acid.!!LT!=!leukotriene;!!
D. Surgical'Metabolism' PG!=!prostaglandin;!TXA2!=!thromboxane!A2!
!
E. Nutrition'in'the'Surgical'Patient' !
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A.'MEDIATORS'OF'INFLAMMATION' !
1. Cytokines(Refer!to!Table'1'☺)! !
!
• Protein'signaling'compounds!that!are!essential!for!
both!innate!and!adaptive!immunity! !
!
• Mediate!cellular!responses,!including!cell!migration!and!
!
turnover,!DNA!replication,!and!immunocyte!
!
proliferation!
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TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 1 of 85
! 1. Cortisol(Refer!to!Figure2'☺')+
! • Glucocorticoid!steroid!hormone!released!by!the!adrenal!
! cortex!in!response!to!adrenocorticotropic!hormone!
! (ACTH)!
! • Release!is!increased!during!times!of!stress!and!may!be!
! chronically!elevated!in!certain!disease!processes!(e.g.!
⊗ 'PHARMACOLOGY!a! burn8injured.patients.may.exhibit.elevated.levels.for.
! 4.weeks)'
• Aspirin.(Acetylsalicylic.acid,.ASA)!is!one!of!the!nonS • Wound!healing!is!impaired!because!it!reduces!
steroidal'antiSinflammatory'drug'(NSAID)!prototypes! transforming!growth!factorBbeta!(TGFBB)!and!insulinB
• Mechanism.of.action'||! like!growth!factor!I!(IGFBI)!in!the!wound!
o Nonselective'AND'irreversible'inhibitor!of! '
the!enzyme!cyclooxygenase!(COX),!inhibiting! Figure'2.!Steroid!synthesis!from!cholesterol!☺.!ACTH!is!a!principal!
regulator!of!steroid!synthesis.!The!end!products!are!mineralocorticoids,!
both!cylooxygenaseG1!(COXB1)!and!
glucocorticoids,!and!sex!steroids.!
cyclooxygenaseG2!(COXB2)!isoenzymes! !
o AntiBinflammatory!effect!is!mediated!by!COXB2! !
inhibition!via!decreasing!platelet!production!of! !
TXA2,!a!potent!stimulator!of!platelet! !
aggregation! !
• Side.effect'||Gastrointestinal'(GI)'toxicity!due!to! !
inhibition!of!COXB1!and!therebyPG!synthesis! !
• Notes'||Uncoupler'of'oxidative'phosphorylation!and! !
is!associated!with!Reye+syndrome!in!children! !
• Ketorolac!and!Indomethacin!are!bothnonselective' !
BUT'reversible!COX!inhibitors! !
• Celecoxib!is!a!selective'COXS2'inhibitor!with!a!reduced! !
risk!of!GI!toxicity! !
! !
! !
5. Fatty.Acid.Metabolites! !
• OmegaG3+fatty+acids!have!antiSinflammatory'effects,! ⊗ 'BIOCHEMISTRY!a!
including!inhibition'of'TNF'release!from!hepatic! !
Kupffer!cells,!leukocyte!adhesion!and!migration! • Cholesterol!is!a!steroid'alcohol!
6. Kallikrein8Kinin.System! • It!is!a!precursor!of!the!following:!
• Group!of!proteins!that!contribute!to!inflammation,!!!!!!! 1. Cell!membranes!
BP!control,!coagulation,!and!pain!responses! 2. Vitamin!D!(7Gdehydrocholesterol)!
• Kallikrein!levels!are!increased!during!gram!negative! 3. Bile!salts!(cholic!and!chenodeoxycholic+acid)!
bacteremia,!hypotension,!hemorrhage,!endotoxemia,! 4. Adrenal!hormones!(aldosterone+and!cortisol)!
and!tissue!injury! 5. Sex!hormones!(testosterone+and!estradiol)!
• Kinis.mediate!vasodilation,!increased!capillary! • It!is!very!hydrophobic!(which!means,!it!can!cross!lipid!
permeability,!tissue!edema,!pain!pathway!activation,! predominant!barriers),!composed!of!4!fused!
inhibition!of!gluconeogenesis,!and!increased! hydrocarbon!rings!(ABD)!and!8Bmembered!branched!
bronchoconstriction! hydrocarbon!chain!(20B27)!attached!to!the!DBring!
• Elevated!levels!of!both!has!been!associated!with!the! • It!has!a!single!hydroxyl!group!located!at!carbon!3!of!the!
magnitude!of!injury!and!mortality! ABring!to!which!a!fatty!acid!can!be!attached!to!form!
! cholesterol!esters!
7. Serotonin! !
• Released!at!the!site!of!injury,!primarily!by!platelets! !
• Stimulates!vasoconstriction,!bronchoconstriction,!and! !
platelet!aggregation! !
• Ex!vivo!study!showed!that!serotonin!receptor!blockade! !
is!associated!with!decreased!production!of!TNF!andILB1! !
in!endotoxinBtreated!monocytes! !
! !
8. Histamine.(H4)! !
• Associated!with!eosinophil'and'mast'cell'chemotaxis' !
• Increased!release!has!been!documented!in!hemorrhagic! !
shock,!trauma,!thermal!injury,!endotoxemia,!and!sepsis' !
' !
B.'CNS'REGULATION'OF'INFLAMMATION' !
• Vagus'nerve!is!highly!influential!in!mediating!afferent! 2. Macrophage.Migration8Inhibiting.Factor!
sensory!input!to!the!CNS! • Neurohormone!that!is!stored!and!secreted!by!the!
o Parasympathetic'nervous'system'transmits' anterior!pituitary!and!by!intracellular!pools!within!
its'efferent'signals'via'acetylcholine' macrophages!
o Exerts!homeostatic!influences!such!as! • A!counter!regulatory!mediator!that!potentially!reverses'
enhancing!gut!motility,!reducing!heart!rate,! the'antiSinflammatory'effects'of'cortisol!
and!regulating!inflammation! !
o Allows!for!a!rapid!response!to!inflammatory! 3. Growth.Hormones.(GH)!
stimuli!and!also!for!the!potential!regulation!of! • Neurohormone!expressed!primarily!by!the!pituitary!
early!proinflammatory!mediator!release,! gland!that!has!both!metabolic!and!immunomodulatory!
specifically!tumor'necrosis'factor'(TNF)! effects!
o Inhibit!cytokine!activity!and!reduce!injury! • Exerts!its!downstream!effects!through!direct!interaction!
from!disease!process!! with!GH!receptors!and!secondarily!through!the!
! enhanced!hepatic!synthesis!of!IGFBI!
C.'HORMONAL'RESPONSE'TO'INJURY'
• GH!and!IGFBI!promote!protein'synthesis'and'insulin' • Lactate!MUST!first!be!transported!to!the!liver,!where!it!is!
resistance,!and!enhances'mobilization'of'fat'stores' converted!to!glucose!via!hepatic!gluconeogenesis!
! • Glucose!is!then!brought!back!to!musclesfor!usage!
4. Catecholamines! • This!metabolic!pathway!involving!conversion!of!lactate!
• Include!epinephrine,'norepinephrine,'and'dopamine,! to!glucose;!which,!in!turn,!is!brought!back!to!the!muscle!
which!have!metabolic,!immunomodulatory,!and! for!utilization!is!the!Cori.cycle!
vasoactive!effects! • Energy!expense:!4!ATP!molecules!
• After!severe!injury,!plasma!catecholamine!levels!are! !
increased'threefold!to!fourfold,!with!elevations!lasting! !
24!to!48!hours!before!returning!to!baseline!levels! !
! !
5. Insulin! !
• Mediates!an!overall!host!anabolic'state! !
• Insulin'resistance!and!hyperglycemia!are!hallmarks! !
of!critical!illness!due!to!the!catabolic!effects!of! • Lactate!production!is!insufficient!to!maintain!systemic!
circulating!mediators,!including!catecholamines,+cortisol,+ glucose!needs!during!shortBterm!fasting;!therefore,!
glucagon,+and+GH+ significant'amounts'of'protein'must'be'degraded'
• Hyperglycemia!during!critical!illness!has! daily!(75!g/d!for!a!70!kg!adult)!to!provide!the!amino!
immunosuppressive'effects,!and!thus!is!associated! acid!substrate!for!hepatic!gluconeogenesis!
with!an!increased'risk'for'infection! • Proteolysis!during!starvation,!which!results!from!
• Insulin!therapy!(to!manage!hyperglycemia)!decreased! decreased!insulin!and!increased!cortisol+release,!is!
mortality!and!reduced!in!infectious!complications!in! associated!with!elevated'urinary'nitrogen'excretion!
select!patient!populations! from!the!normal!7B10!g/day!up!to!30!g!or!more/day!
! !
√ 'QUICK'REVIEW!a! 2. Metabolism'During'Prolonged.Fasting!
! • Systemic!proteolysis!is!reduced!approximately!20!g/d!
• Burn!patients!may!exhibit!elevated!levels!of!cortisol+for!!! and!urinary!nitrogen!excretion!stabilizes!at!2!to!5!g/d!
4'weeks! due!to!adaptation!by!vital!organs!(e.g.!myocardium,!
• Plasma!catecholamine!levels!are!increased!3B4x!lasting! brain,!renal!cortex,!and!skeletal!muscle)!to!using!
for!24'to'48'hours!before!returning!to!baseline! ketone'bodies!as!their!principal!fuel!source!
! • Ketone!bodies!become!an!important!fuel!source!for!the!
! brain!after!2!days!and!gradually!become!the!principal!
D.'SURGICAL'METABOLISM' fuel!source!by!24!days!
• To!maintain!basal!metabolic!needs!(i.e.!at!rest!and! !
fasting),!a!normal!healthy!adult!requires!~22'to'25' 3. Metabolism'After.Injury!
kcal/kg/dayfrom!carbohydrate,!lipid,!and!protein! • Injuries!or!infections!induce!unique!neuroendocrine!
sources! and!immunologic!responses!that!differentiate!injury!
• Initial!hours!after!surgical!or!traumatic!injury!are! metabolism!from!that!of!unstressed!fasting!
metabolically!associated!with!a!reduced'total'body' • Magnitude!of!metabolic!expenditure!appears!to!be!
energy'expenditure'and'urinary'nitrogen'wasting' directly!proportional!to!the!severity!of!insult,!with!
' thermal!injuries!and!severe!infections!having!the!
1. Metabolism'During'Short8term.Fasting.(<5.days)! highest!energy!demands!(Refer!to!Figure'4)!
• In!the!healthy!adult,!principal!sources!of!fuel!are! !
derived!from!muscle!protein!and!lipids,!with!lipids' Figure'4.!Influence!of!injury!severity!on!resting!metabolism!!!!!!!!!!!!!!!!!!!!!!
(resting!energy!expenditure!or!REE)!
being'the'most'abundant'source'of'energy(40%!or! !
!
!
!
!
more!of!caloric!expenditure)' !
!
Hepatic!glycogen!stores!are!rapidly!and!preferentially!
!
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•
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!
!
depleted!"!fall!of!serum!glucose!concentration!within!
!
hours!(<16!hours)!
!
• Hepatic!gluconeogenesis!is!then!activated!using!lactate! !
from!skeletal!muscle!as!the!main!precursor(Refer!to!
!
Figure'3'☺)!
!
!
!
Figure'3.!The!recycling!of!peripheral!lactate!and!pyruvate!for!hepatic!
gluconeogenesis!is!accomplished!by!the!Cori!cycle.!Alanine!within!skeletal!
!
muscles!can!also!be!used!as!a!precursor!for!hepatic!gluconeogenesis!☺.! !
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• Lipids(Triglyceride)!become!the!primary!source!of!
!
energy!(50B80%)!during!critical'illness'and'stressed'
!
states!
!
o Minimize!protein!catabolism!in!the!injured!
!
patient!
⊗ 'BIOCHEMISTRY!a! o Lipolysis!occurs!mainly!in!response!to!
! catecholamine!stimulus'of'the'hormoneS
• Lactate!is!generated!from!the!skeletal!muscle!during! sensitive'triglyceride'lipase'
anaerobic!metabolism!
• Muscle'CANNOT'reconvert'lactate'to'glucose'
• Injury!and!severe!infections!induce!a!state!of! !
peripheral'glucose'intolerance'(insulin'resistance),! Table'2.!Caloric!Adjustment!Above!BEE!in!Hypermetabolic!Conditions!☺!
despite!ample!insulin!production!at!levels!severalBfold! Caloric'Adjustments'Above'Basal'Energy'Expenditures'in'
above!baseline! Hypermetabolic'Conditions'
o Occur!in!part!due!to!reduced!skeletal!muscle! Normal!or!Moderate!Malnutrition! 25B30!kcal/kg/day!
Mild!Stress! 25B30!
pyruvate+dehydrogenase!activity!after!injury,!
Moderate!Stress!! 30!
which!diminishes!the!conversion!of!pyruvate!
Severe!Stress! 30B35!
to!acetylGCoA!and!subsequent!entry!into!the! Burns! 35B40!
TCA!cycle! !
o Increase!in!plasma!glucose!levels!is!
• Provision!of!30'kcal/kg/d!will!adequately!meet!energy!
proportional!to!the!severity!of!injury,!and!this!
requirements!in!most'postsurgical'patients,!with!low!
net!hepatic!gluconeogenic!response!is!under!
risk!of!overfeeding!
the!influence!of!glucagon!
o Overfeedingusually!results!from!
• After!injury,!the!initial!systemic!proteolysis,!mediated! overestimation!of!caloric!needs!because!actual!
primarily!by!cortisol,!increases'urinary'nitrogen' body!weight!is!used!to!calculate!BEE,!
excretion!to!levels!in!excess!of!30!g/d,!which!roughly! especially!in!special!patients!(e.g.!critically!ill!
corresponds!to!a!loss!in!lean!body!mass!of!1.5%/d! with!significant!fluid!overload!and!the!obese)!
(Refer!to!Figure'5)! o Overfeeding!may!contribute!to!clinical!
! deterioration!via!the!following:!increased!O2!
Figure'5.!Effect!of!injury!severity!on!nitrogen!wasting!
consumption,!increased!CO2!production!and!
!
prolonged!need!for!ventilatory!support,!
!
suppression!of!leukocyte!function,!
!
hyperglycemia,!and!increased!risk!of!infection!
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1. Enteral.Nutrition!
!
• Generally!preferred!over!parenteral!nutrition!due!to:!
!
o Lower!cost!
!
o Associated!risks!of!the!intravenous!route!
!
o Beneficial!effects!of!luminal!nutrient!contact!as!
!
it!reduces!intestinal!mucosal!atrophy!!
!
! • Initiation!should!occur!immediately!after!adequate!
! resuscitation!(adequate!urine!output)!
! • Presence!of!bowel!sounds!and!the!passage!of!flatus!or!
! stool!are!NOT!absolute!prerequisites!to!start!enteral!
! nutrition,!EXCEPT!in!the!setting!of!gastroparesis,!
! feedings!should!be!administered!distal!to!the!pylorus!
• Gastric!residuals!of!200!ml!or!more!in!a!4!to!6!hour!
√ 'QUICK'REVIEW!a!
period!or!abdominal!distention!requires!cessation!of!
!
feeding!and!adjustment!of!infusion!rate!
• Normal!energy!requirement:!22'to'25'kcal/kg/day!
• The!following!are!options!for!enteral!feeding!access!
• Initial!hours!after!surgical!or!traumatic!injury!results!to!a! (Refer!to!Table'3'☺):!
reduced'total'body'energy'expenditure'and'urinary'
!
nitrogen'wasting! Table'3.!Options!for!Enteral!Feeding!Access!☺!
• Fat/lipid!is!the!primary!source!of!calories!during!acute+ Options'for'Enteral'Feeding'Access'
starvation+(<5+days+fasting)!and!after+acute+injury! • ShortBterm!use!!
• Ketone'bodies!is!the!primary!fuel!source!in!prolonged+ Nasogastric.tube. • Aspiration!risks!
starvation+ (NGT). • Nasopharyngeal!trauma!
• Ketone!bodies!becomes!an!important!fuel!source!for! • Frequent!dislodgement!
brain!after'2'days!and!eventually!become!the!principal! • ShortBterm!use!
fuel!source!by!24'days! Nasoduodenal./. • Lower!aspiration!risks!in!jejunum!
! Nasojejunal.tube. • Placement!challenges!(radiographic!
assistance!often!necessary)!
!
• Endoscopy!skills!required!
E.'NUTRITION'IN'THE'SURGICAL'PATIENT'
• May!be!used!for!gastric!decompression!or!
• Goals!of!nutritional!support!in!the!surgical!patient!are! Percutaneous.
bolus!feeds!
as!follows:! Endoscopic.
• Aspiration!risks!
o To!meet!the!energy!requirements!for! Gastrostomy.
• Can!last!12B24!months!
(PEG).
metabolic!processes,!core!temperature! • Slightly!higher!complication!rates!with!
maintenance,!and!tissue!repair! placement!and!site!leaks!
o To!meet!the!substrate!requirements!for! • Requires!general!anesthesia!and!small!
protein!synthesis! laporotomy!
Surgical.
• Energy!requirement!may!be!measured!by!indirect! • Procedure!may!allow!placement!of!
Gastrostomy.
calorimetry!and!trends!in!serum!markers!(e.g.! extended!duodenal/jejunal!feeding!ports!
• Laparoscopic!placement!possible!
prealbumin!level)!and!estimation!from!urinary!nitrogen!
• Commonly!carried!out!during!laparotomy!
excretion,!which!is!proportional!to!resting!energy!
• General!anesthesia,!laparoscopic!
expenditure! Surgical. placement!usually!requires!assistant!to!
• Basal'energy'expenditure'(BEE)!may!also!be! Jejunostomy. thread!catheter!
estimated!using!HarrisBBenedict!equations,!adjusted!for! • Laparoscopy!offers!direct!visualization!of!
the!type!of!surgical!stress!(Refer!to!Table'2)! catheter!placement!
o BEE!(men)!=!66.47!+!13.75!(weight!in!kg)!+!5! • Jejunal!placement!with!regular!endoscope!
(height!in!cm)!–!6.76!(age!in!years)!kcal/d! is!operator!dependent!
o BEE!(women)!=!655.1!+!9.56!(weight!in!kg)!+! • Jejunal!tube!often!dislodges!retrograde!
1.85!(height!in!cm)!–!4.68!(age!in!years)!kcal/d! PEG8jejunal.tube. • TwoBstage!procedure!with!PEG!
• The!BEE!is!then!multiplied!by!the!type!of!surgical!stress! placement,!followed!by!fluoroscopic!
conversion!with!jejunal!feeding!tube!
(Refer!to!Table'2'☺)!that!the!patient!has!to!determine!
through!PEG!
the!total!daily!caloric!need!
!
2. Parenteral.Nutrition! impaired!gut!immunity!
• Continuous!infusion!of!hyperosmolar!solution! !
containing!carbohydrates,!proteins,!fat,!and!other! '''''''REVIEW'QUESTIONS!a!
necessary!nutrients!through!an!indwelling!catheter! !
inserted!into!the!superior!vena!cava! 1. Prostacyclin!has!which!of!the!following!effects!in!
• Principal!indications!include!malnutrition,!sepsis,!or! systemic!inflammation?!
surgical!or!traumatic!injury!in!seriously!ill!patients!for! a. Inhibition!of!platelet!aggregation!
whom!use!of!the!gastrointestinal!tract!for!feedings!is! b. Vasoconstriction!
not!possible! c. Increased!adhesion!molecules!
• Total'(Central)'Parenteral'Nutrition'(TPN)requires! d. Decreased!cardiac!output!
access!to!a!largeBdiameter!vein!to!deliver!the!nutritional! !
requirements!of!the!individual! Answer:!A!
o Dextrose!content!of!the!solution!is!high!(15B +
25%)!! Prostacyclin!is!a!member!of!the!eicosanoid!family!and!
o All!other!macronutrients!and!micronutrients! is!primarily!produced!by!endothelial!cells.!It!is!an!
are!deliverable!by!this!route! effective!vasodilator!and!also!inhibits'platelet'
• Peripheral'Parenteral'Nutrition'(PPN)!uses!lower! aggregation.!During!systemic!inflammation,!
osmolarity!of!the!solution!to!allow!its!administration!via! prostacyclin!expression!is!impaired!and!thus!the!
peripheral!veins! endothelium!favors!a!more!procoagulant!profile.!!
o Reduced!levels!of!dextrose!(5B10%)!and! !
protein!(3%)! 2. Sepsis!increases!metabolic!needs!by!approximately!
o Some!nutrients!cannot!be!supplemented! what!percentage?!
because!they!cannot!be!concentrated!into! a. 25%!
small!volumes! b. 50%!
o Not!appropriate!for!repleting!patients!with! c. 75%!
severe!malnutrition! d. 100%!
o Used!for!short!periods!(<2!weeks);!beyond! !
this,!TPN!should!be!instituted! Answer:!B!
• Complications!are!as!follows!(Refer!to!Table'4'☺):! !
! Sepsis!increases!metabolic!needs!to!approximately!
Table'4.!Complication!of!Parenteral!Nutrition!☺! 150B160%!of!resting!energy!expenditure,!or!50%'
Complications'of'Parenteral'Nutrition' above'normal!(Refer!to!Figure'4).!This!is!mediated!in!
• Rare!occurrences!if!IV!vitamin! part!by!sympathetic!activation!and!catecholamine!
preparations!are!used! release.!
• However,!Vitamin'K!is!not!part!of!any! !
Vitamin.Deficiencies.
commercially!prepared!vitamin! 3. Which!of!the!following!is!the!initial!enteric!formula!for!
solution!so!it!should!be!supplemented! the!majority!of!surgical!patients?!
on!a!weekly!basis!
a. LowBresidue!isotonic!formula!
• Clinically!apparent!during!prolonged!
parenteral!nutrition!with!fatBfree!
b. Elemental!formula!
solutions! c. Calorie!dense!formula!
Essential.Fatty.Acid. • Manifests!as!dry,'scaly'dermatitis'and' d. High!protein!formula!
(EFA).Deficiency. loss'of'hair! !
• Prevented!by!periodic!infusion!of!a!fat! Answer:!A!
emulsion!at!a!rate!equivalent!to!10!to! !
15%!of!total!calories! Most!lowBresidue!isotonic!formulas!provide!a!caloric!
• Essential!trace!minerals!may!be! density!of!1.0!kcal/ml,!and!approximately!1500!to!
required!after!prolonged!TPN! 1800!ml!are!required!to!meet!daily!requirements.!
• Zinc+deficiency!is!the!most'common!
These!provide!baseline!carbohydrates,!protein,!
that!manifests!as!diffuse'eczematoid'
Trace.Mineral.
rash'at'intertriginous'areas''
electrolytes,!water,!fat,!and!fatBsoluble!vitamins.!These!
Deficiencies. solutions!usually!are!considered!to!be!the!standard!or!
• Copper+deficiency!is!associated!with!
Microcytic'anemia! firstBline!formulas!for!stable!patients!with!an!intact!GI!
• Chromium+deficiency!is!associated!with! tract.!
Glucose'intolerance! !
• May!occur!after!initiation!of!parenteral! !
nutrition! FLUID'AND'ELECTROLYTE'MANAGEMENT''
• Manifests!as!glycosuria!
OF'THE'SURGICAL'PATIENT'
• If!blood!glucose!levels!remain!elevated!
or!glycosuria!persists,!dextrose! '
concentration!may!be!decreased,! A. Body'Fluids'and'Compartments'
Relative.Glucose.
infusion!rate!slowed,!or!regular!insulin! B. Body'Fluid'Changes'
Intolerance.
added!to!each!bottle! C. Fluid'Therapy'
• Rise!in!blood!glucose!may!be! D. Special'Case:'Refeeding'Syndrome'
temporary,!as!the!normal!pancreas! E. Electrolyte'Abnormalities''
increases!its!output!of!insulin!in! F. AcidSBase'Disorders'
response!to!the!continuous!
carbohydrate!infusion!
!
• Due!to!large!glucose!infusion,!a! !
significant!shift!of!potassium!from! A.'BODY'FLUIDS'AND'COMPARTMENTS'
Hypokalemia..
(and.Metabolic.
extracellular!to!intracellular!space!may! • Water!constitutes!~50S60%'of'total'body'weight!
take!place! • Relationship!between!total!body!weight!and!total'body'
Acidosis).
• Manifests!as!glycosuria,!which!is! water'(TBW)!is!relatively!constant!for!an!individual!
treated!with!potassium,!NOT!insulin! and!is!primarily!a!reflection'of'body'fat!
• Lack!of!intestinal!stimulation!is!
o Lean!tissues!(e.g.!muscle!and!solid!organs)!
associated!with!intestinal!mucosal!
atrophy,!diminished!villous!height,!
have!higher!water!content!than!fat!and!bone!
Intestinal.Atrophy. o TBW'of'average'young'adult'male'and'
bacterial!overgrowth,!reduced!
lymphoid!tissue!size,!reduced! female'is'60%'and'50%,'respectively'of'
immunoglobulin!A!production,!and! total'body'weight☺'
• Estimates!of!%TBW!should!be!adjusted!downward!! !
~10B20%!for!obese!individuals!and!upward!by!~10%! • Water!is!freely!diffusible!and!distributed!evenly!
for!malnourished!individuals' throughout!all!fluid!compartments!of!the!body!
• Highest!percentage!of!TBW!is!found!in!newborns! • Sodiumis!confined!to!ECF!and!is!associated!with!water!
(~80%)!' o SodiumBcontaining!fluids!are!distributed!
! throughout!the!ECF!and!add!to!bothplasma+
√ 'QUICK'REVIEW!a! (intravascular)!and!interstitial+spaces+
! o SodiumBcontaining!fluids!expand!the!
• TBW!is!~50S60%!of!total!body!weight! interstitial+space!by!~3x!as!much!as!the!plasma!
• TBW!(Male):!60%of!total!body!weight! '
• TBW!(Female):!50%of!total!body!weight! B.'BODY'FLUID'CHANGES'
• Young!lean!males!have!a!higher!proportion!of!TBW!than! • A!healthy!person!consumes!water!an!average!of!2L/d,!
elderly!or!obese!individuals! ~75%!from!oral!intake!and!the!rest!extracted!from!solid!
• Lower!percentage!of!TBW!in!females!generally! foods!(Refer!to!Table'6)!
correlates!with!a!higher!percentage!of!adipose!tissue!and! • Daily!water!losses!include!800B1200!ml!in!urine,!250!ml!
lower!percentage!of!muscle!mass! in!stool,!and!600!ml!in!insensible!losses!through!both!
! the!skin!(75%)!and!lungs!(25%)!
' • Sensible!water!losses!such!as!sweating!or!pathologic!
• TBW!is!divided!into!3!functional!fluid!compartments! loss!of!GI!fluids!vary!widely,!but!these!include!loss!of!
electrolytes!as!well!!
(Refer!to!Table'5☺):!!
o Sweat!is!hypotonic!and!sweating!usually!
o Plasma!(extracellular)!
results!in!only!a!small!sodium!loss!
o Interstitial+fluid!(extracellular)!
o Pathologic+GI+losses!are!isotonic'to'slightly'
o Intracellular+fluid+
hypotonic!and!contribute!little!to!net!gain!or!
!
loss!of!free!water!!
!
!
!
Table'5.!Functional!Body!Fluid!Compartments!☺!
!
Extracellular'fluid' PLASMA'(1)'' !
Total. !(1/3!of!TBW!or!! (5%!of!total!body!weight)! !
Body. 20%!of!total!body! INTERSTITIAL'FLUID'(2)' !
Water. weight)! (15%!of!total!body!weight)! Table'6.!Normal!Fluid!Balance!
(TBW). INTRACELLULAR'FLUID'(3)' ! Water'Gain! Water'Loss!
(2/3!of!TBW!or!40%!of!total!body!weight)! Urine'
' Oral'fluids' 800B1200!ml'
! 1,500!ml! Stool'
Sensible.
• Extracellular+fluid+compartment+(ECF)!is!balanced! 250!ml'
between!sodium'(Na2+),!the!principal!cation,!and! Solid'fluids' Sweat'
chloride'(ClS)!and!bicarbonate'(HCO3S),!the!principal! 500!ml' 0!ml!
Water'of'oxidation' Skin'
anions(Refer!to!Figure'6)+
250!ml! 450!ml'
o Composition!of!the!plasma+and!interstitial+fluid+ Insensible.
Water'of'solution' Lungs'
differs!only!slightly!in!ionic!composition! 0!ml! 150!ml'
o Slightly!higher!protein!content!(anions)!in! '
plasma!results!in!a!higher!plasma!cation! !
composition!relative!to!the!interstitial!fluid! 1. Extracellular.Volume.Deficit.
• Intracellular+fluid+compartment+(ICF)!is!comprised! • Most'common'fluid'disorder'in'surgical'patients!☺!
ofcations,!potassium'(K+)!and!magnesium'(Mg2+),!and! • Can!either!be!acute!or!chronic!(Refer!to!Table'7)!
theanions,!phosphate(HPO4S)!and!proteins! o Acute+volume+deficit!is!associated!with!
• Concentration!gradient!between!compartments!is! cardiovascular!and!central!nervous!system!
maintained!by!adenosine+triphosphate+(ATP)+driven+ signs!
sodiumGpotassium+pumps!located!with!the!cell! o Chronic+deficit+displays!tissue!signs!such!as!
membranes!! decrease!in!skin!turgor!and!sunken!eyes,!in!
! addition!to!acute!signs!
Figure'6.!Chemical!composition!of!body!fluid!compartments! !
!
Table'7.!Signs!and!Symptoms!of!Volume!Disturbances!
!
!
! System' Volume'Deficit' Volume'Excess'
! Weight!loss! Weight!gain!
General.
Decreased!skin!turgor! Peripheral!edema!
!
Tachycardia! Increased!cardiac!output!
! Orthostasis!/! Increased!central!venous!
! Cardio. Hypotension! pressure!
! Collapsed!neck!veins! Distended!neck!veins!
! Murmur!
! Oliguria! BB!
Renal.
! Azotemia!
! GI. Ileus! Bowel!edema!
! Pulmo. BB! Pulmonary!edema!
! !
! • Most'common'cause'of'volume'deficit'in'surgical'
! patients!is!a!loss'of'GI'fluids!from!nasogastric!suction,!
! vomiting,!diarrhea,!or!enterocutanous!fistula!!!!!!!!!!!!!!!
! (Refer!to!Table'8!☺)!
! • ThirdBspace!or!nonfunctional!ECF!losses!that!occur!with!
! sequestration!secondary!to!soft!tissue!
! injuries/infections,!burns,!and!intraabdominal!
! processes!such!as!peritonitis,!obstruction,!or!prolonged!
! surgery!can!also!lead!to!massive!volume!deficits!

! Sodium. • Used!for!correction'of'severe'sodium'deficits!
Table'8.!Composition!of!GI!Secretions!☺! chloride.
Volume' Volume' Na+! K+' ClS' HCO3' • Hypertonic!saline!solution!
(ml/24h)! (ml/24h)! (mEq/L)! (mEq/L)! (mEq/L)! (mEq/L)! • Used!as!a!treatment!modality!in!patients'with'
Saliva. 1000! 10! 26! 10! 30! closed'head'injuries'
Stomach. 1000B2000! 60B90! 10! 130' 0! D5.7%. • Shown!to!increase!cerebral!perfusion!and!
Duodenum. 1500! 120B140! 5B10! 90B120! 0! Sodium. decrease!intracranial!pressure,!thus!decreasing!
Ileum. 3000! 140! 5! 104! 30! chloride. brain!edema!
Colon. 750! 60! 30' 40! 0! • However,!there!also!have!been!concerns!of!
Pancreas. 600B800! 135B145! 5B10! 70B90! 115' increased!bleeding,!because!hypertonic!saline!is!
Bile. 300B800! 135B145! 5B10! 90B110! 30B40! an!arteriolar!vasodilator!
! !
2. Extracellular.Volume.Excess. !
• May!be!iatrogenic!or!secondary!to!renal!dysfunction,! 1. Preoperative.Fluid.Therapy.
congestive!heart!failure,!or!cirrhosis! • Preoperative!evaluation!of!a!patient’s!volume!status!and!
• Both!plasma!and!interstitial!volumes!are!increased! preBexisting!electrolyte!abnormalities!is!an!important!
• Symptoms!are!primarily!pulmonary!and!cardiovascular! part!of!overall!preoperative!care!
(Refer!to!Table'7)! • Administration!of!maintenance'fluidsis!required!in!an!
• In!healthy!patients,!edema!and!hyperdynamic! otherwise!healthy!individual!on!NPO!before!surgery!
circulation!are!common!and!well!tolerated! • The!following!is!the!formula!used!for!calculating!
• However,!the!elderly!and!patients!with!cardiac!disease! maintenance!fluids!in!the!absence!of!preBexisting!
may!quickly!develop!congestive!heart!failure!and! abnormalities!(Refer!to!Table'11):!
pulmonary!edema!in!response!to!only!a!moderate! !
Table'11.!Maintenance!Fluid!Computation!
volume!excess!
! First!0S10'kg' Give!100'ml/kg/dor!4'ml/kg/hr!
C.'FLUID'THERAPY' Next!10S20'kg' Give!additional!50'ml/kg/dor!2'ml/kg/hr!
• Most!commonly!used!solutions!are!as!follows:!!!!!!!!!!!!!! Weight!>20'kg'
!
Give!additional!20'ml/kg/dor!1'ml/kg/hr!
(Refer!to!Table'9)! !
' • However,!may!surgical!patients!have!volume!and/or!
' electrolyte!abnormalities!associated!with!their!surgical!
' disease!
' o Acute!volume!deficits!should!be!corrected!as!
' much!as!possible!!
' o Once!a!volume!deficit!is!diagnosed,!prompt!
Table'9.!Electrolyte!Solutions!for!Parenteral!Administration! fluid!replacement!should!be!instituted,!usually!
Solution' Na+' ClS' K+' Ca2+' Other' mOsm' with!an!isotonic!crystalloid!
ECF. 142! 103! 4! 27! BB! 280! o Patients!whose!volume!deficit!is!not!corrected!
Lactated. Lactate!! after!initial!volume!challenge!and!those!with!
130! 109! 4! 28! 280!
Ringer’s.(LR). 28!mEq/l! impaired!renal!function!and!the!elderly!should!
0.9%.Sodium. be!considered!for!more!intensive!monitoring!
chloride. 154! 154! 0! 0! BB! 308!
of!central!venous!pressure!or!cardiac!output!in!
(PNSS).
Dextrose!!
an!ICU!setting!!
D5.Lactated. o If!symptomatic!electrolyte!abnormalities!
50!g/l!
Ringer’s. 130! 109! 4! 3! 560! accompany!volume!deficit,!the!abnormality!
Lactate!!
(D5LR). should!be!corrected!to!the!point!that!the!acute!
28!mEq/l!
D5.Sodium. symptom!is!relieved!before!surgical!
Dextrose!!
chloride. 154! 154! 0! 0! 588! intervention.!!
50!g/l!
(D5NS). !
D5.0.45%.
Sodium. 77! 77! 0! 0!
Dextrose!!
434!
50!g/l! !
chloride.
D5.0.25%. • Extracellular'volume'deficit!is!the!most!common!fluid!
Dextrose!! disorder!in!surgical!patients!
Sodium. 34! 34! 0! 0! 357!
50!g/l!
chloride. • Most!common!cause!of!volume!deficit!in!surgical!
! patients!is!a!loss'of'GI'fluids!
! • Both!PLR'and'PNSS!are!considered!isotonic!and!are!
• Type!of!fluid!administered!depends!on!the!patient’s! useful!in!replacing!GI!losses!and!correcting!extracellular!
volume!status!and!the!type!of!concentration!or! volume!deficits!
composition!abnormality!present!(Refer!to!Table'10)! • Hypertonic'saline'solution!is!used!as!a!treatment!
! modality!in!patients!with!closed!head!injuries!
Table'10.!Fluid!Therapy! !
Solution' Description' !
• Considered!isotonic'BUT'it'is'slightly'
2. Intraoperative.Fluid.Therapy.
Lactated. hypotonic!due!to!lactate!
Ringer’s.(PLR). • Useful!in!replacing'GI'losses'and'correcting' • With!the!induction!of!anesthesia,!compensatory!
extracellular'volume'deficits! mechanisms!are!lost,!and!hypotension!will!develop!if!
• Considered!isotonic'BUT'it'is'mildly' volume!deficits!are!not!appropriately!managed!
hypertonic! • To!avoid!hemodynamic!instability!intraoperatively,!the!
0.9%.Sodium.
chloride.
• Also!useful!in!replacing'GI'losses'and' following!should!be!ensured:!
correcting'extracellular'volume'deficits,! o Known'fluid'losses'corrected'
(PNSS).
especially!those!associated!with!hyponatremia,+ preoperatively'
hypochloremia,!and!metabolic+alkalosis+ o Adequate'maintenance'fluid'therapy'
• Useful!for!replacement'of'ongoing'GI'losses!as! provided''
well!as!for!maintenance'fluid'therapy'in'the'
D5.0.45%. o Ongoing'losses'replaced'intraoperatively'
postoperative'period!
Sodium. • Among!the!ongoing!losses!during!surgery!include!
• Provides!sufficient!free!water!for!insensible!
chloride. distributional!shifts!via!third+space+or+nonfunctional+ECF+
losses!and!enough!sodium!to!aid!the!kidneys!in!
adjustment!of!serum!sodium!levels! losses!seen!in!the!following:!
D5.3.585%. • Hypertonic!saline!solution!
o Major!open!abdominal!surgeries!in!the!form!of! !
bowel!wall!edema,!peritoneal!fluid,!and!the! !
wound!edema!during!surgery! !
o Large!soft!tissue!wounds,!complex!fractures! !
with!associated!soft!tissue!injury,!and!burns!! !
• Replacement!of!ECF!losses!during!surgery!often! !
requires!500!to!1000!ml/hr!of!a!balanced!salt!solution! !
to!support!homeostasis! !
• Addition!of!albumin!or!other!colloidBcontaining! !
solutions!to!intraoperative!fluid!therapy!is!NOT! !
necessary! !
! • Treatment'||Management'of'water'deficit!
3. Postoperative.Fluid.Therapy. • In!hypovolemic!patients,!volume!should!be!restored!
• Should!be!based!on!the!patient’s!current!estimated! with!normal!saline!before!concentration!abnormality!is!
volume!status!and!projected!ongoing!fluid!losses! addressed!
• Any!deficits!from!either!preoperative!or!intraoperative! • Once!adequate!volume!is!achieved,!water!deficit!is!
losses!should!be!corrected!and!ongoing!requirements! replaced!using!a!hypotonic!fluid!!
should!be!included!along!with!maintenance!fluids! • Rate!of!fluid!administration!should!be!titrated!to!
• In!the!initial!postoperative!period,!an!isotonic'solution! achieve!a!decrease'in'serum'sodium'concentration'
should!be!administered! of'no'more'than'1'mEq/l/h'!
o Adequacy!of!resuscitation!should!be!based!on! • Overly!rapid!correction!can!lead!to!cerebral'edema!
vital!signs!and!urine!output!! and!herniation!
o All!measured!losses,!including!losses!through! !
vomiting,!NGT,!drains,!and!urine!output!as! 2.!Hyponatremia.
well!as!insensible!losses!should!be!replaced!! • Occurs!when!there!is!an!excess!of!extracellular!water!
• After!the!initial!24!to!48!hours,!fluids!can!be!changed!to! relative!to!sodium!
5%'dextrose'to'0.45%'saline!in!patients!unable!to! • Extracellular!volume!can!be!high,!normal,!or!low!(Refer!
tolerate!enteral!nutrition! to!Figure'8)!
• If!normal!renal!function!and!adequate!urine!output!are! • In!most!cases,!sodium!concentration!is!decreased!as!a!
present,!potassium!may!be!added!to!the!IV!fluids! consequence!of!either!sodium!depletion!or!dilution!
! • Symptomatic!hyponatremia!does!not!occur!until!serum'
D.'SPECIAL'CASE:'REFEEDING'SYNDROME'☺' sodium'level'is'20'mEq/l!
• Refeeding.syndrome!potentially!lethal!condition!that! • Clinical.manifestations'||!Primarily!central!nervous!
can!occur!with!rapid'and'excessive'feeding'of' system!in!origin!(headache,+confusion,+seizures,+coma)!
patients'with'severe'underlying'malnutrition!due!to! associated!increases!in!intracranial!pressure!
starvation,!alcoholism,!delayed!nutritional!support,! '
anorexia!nervosa,!or!massive!weight!loss!in!obese! '
patients! '
'
• Shift!in!metabolism!from!fat!to!carbohydrate!substrate!
'
stimulates!insulin!release,!which!results!in!the!cellular!
'
uptake!of!electrolytes,!particularly!phosphate,! Figure'8.!Etiology!of!Hyponatremia
magnesium,!potassium,!and!calcium!
!
!
• Severe!hyperglycemia!may!result!from!blunted!basal! !
insulin!secretion! !
• To!prevent!its!development,!the!following!measures! !
should!be!done:! !
o Underlying!electrolyte!and!volume!deficits! !
should!be!corrected! !
o Thiamine!should!be!administered!before!the! !
initiation!of!feeding! !
o Caloric!repletion!should!be!instituted!slowly,! !
at!20!kcal/kg!per!day,!and!should!gradually! !
increase!over!the!first!week! !
! !
E.'ELECTROLYTE'ABNORMALITIES' !
1.!Hypernatremia. !
• Results!from!either!a!loss!of!free!water!or!a!gain!of! • Treatment'||Water'restriction!and,!if!severe,!the!
sodium!in!excess!of!water! administration'of'sodium!
• Associated!with!either!an!increased,!normal,!or! • If!symptomatic,!3%!normal!saline!should!be!used!to!
decreased!extracellular!volume!(Refer!to!Figure'7)! increase!the!sodium!by!no'more'than'1'mEq/l/huntil!
• Symptoms!are!rare!until!serum'sodium'concentration' the!serum!sodium!reaches!130!mEq/l!or!symptoms!are!
exceeds'160'mEq/l! improved!
• Clinical.manifestations'||!Mostly!central!nervous! • If!asymptomatic,!correction!should!increase!the!sodium!
system!in!nature!(restlessness,+irritability,+seizures,+ level!by!no'more'than'0.5'mEq/l/hr!to!a!maximum!
coma)!due!tohyperosmolarity! increase!of!12!mEq/l/d!
• May!lead!to!!subarachnoid!hemorrhage!and!death! !
'
Figure'7.!Etiology!of!Hypernatremia! !
⊗ INTERNAL'MEDICINE!a!
!
!
! • Central.Pontine.Myelinosisis!a!consequence'of'rapid'
! correction'of'hyponatremia''
! • Characterized!with!seizures,!weakness,!paresis,!akinetic!
! movements,!and!unresponsiveness!
!
• May!result!in!permanent!brain!damage!and!death!
!
• MRI!may!assist!in!the!diagnosis!
!
! • Asymptomatic!hypokalemia,!not!tolerating!enteral!
! nutrition:!KCl!20!mEq!IV!q2h!x!2!doses!
3.!Hyperkalemia. • If!IV!repletion!is!required,!usually!no'more'than'10'
• Serum!K+!concentration!above'the'normal'range'of' mEq/h!is!advisable!in!an!unmonitored!setting!
3.5S5'mEq/l! • K+!supplementation!can!be!increased!to!40!mEq/h!
• Caused!by!excessive!K+!intake,!increased!release!of!K+! when!accompanied!by!continuous!ECG!monitoring,!and!
from!cells,!or!impaired!K+!excretion!by!the!kidneys! even!more!in!the!case!of!imminent!cardiac!arrest!from!a!
(Refer!to!Table'12)! malignant!arrhythmia!associated!hypokalemia!
• Clinical.manifestations'||!Mostly!GI!(nausea/vomiting,+ • Caution!should!be!done!when!oliguria!or!impaired!renal!
diarrhea),!neuromuscular!(weakness,+paralysis),!and! function!is!coexistent!
cardiovascular!(arrhythmia,+arrest)! !
• ECG.changes'||High'peaked'T'waves!☺!(early),! ⊗ PHARMACOLOGY!a!
widened!QRS!complex,!flattened!P!wave,!prolonged!PR! !
interval!(firstBdegree!block),!sine!wave!formation!and! • K+sparing'Diuretics!are!competitive!antagonists!that!
ventricular!fibrillation! either!block!the!actions!of!aldosterone!at!the!distal!
• Treatment'||Reducing!total!body!K+,!shifting!K+!from! convoluted!tubule,!or!directly!inhibit!sodium!channels!
extracellular!to!intracellular!space,!and!protecting!cells! o Aldosterone!antagonists:.Spironolactoneand!
from!the!effects!of!increased!K+! Eplerenone!
• Exogenous!sources!of!potassium!should!be!removed,! o Epithelial!sodium!channel!blockers:!Amiloride.
including!K+!!supplementation!in!IV!fluids! and'Triamterene!
• K+!can!be!removed!from!the!body!using!a!cationB • Non'K+Ssparing'Diureticsinclude!loop!diuretics!and!
exchange!resin!such!as!Kayexalate!that!binds!K+!in! thiazides,!which!both!inhibit!Na+!and!ClB!reabsorption!!
exchange!for!Na+! o Loop!diuretics!(Furosemide)!inhibit!the!Na+B
• Immediate!measures!also!should!include!attempts!to! K+B2ClB!cotransporter!in!the!thick!ascending!
shift!K+!intracellularly!with!glucose,'insulin'and' limb!of!the!loop!of!Henle!
bicarbonate'infusion!and!nebulized'salbutamol(10B o Thiazidesinhibit!the!Na+BClBtransporter!in!the!
20!mg)! distal!tubule!
• When!ECG!changes!are!present,!calcium'chloride'or' !
calcium'gluconate!(5B10!ml!of!10%!solution)!should!be! !
administered!immediately!! !
• All!measures!are!temporary,!lasting!from!1!to!4!hours! !
• Dialysis!should!be!considered!in!severe!hyperkalemia! !
when!conservative!measures!fail! !
! !
4.!Hypokalemia. !
• More!common!than!hyperkalemia!in!the!surgical!patient! !
• Caused!by!inadequate!K+!intake,!excessive!renal!K+! !
excretion,!K+!loss!in!pathologic!GI!secretions,!or! !
intracellular!shifts!from!metabolic!alkalosis!or!insulin! !
therapy!(Refer!to!Table'12)! !
• Clinical.manifestations'||!Primarily!related!to!failure!of! !
normal!contractility!of!GI!smooth!muscle!(ileus,+ !
constipation),!skeletal!muscle!(decreased+reflexes,+ !
weakness,+paralysis),!and!cardiac!muscle!(arrest)! !
!
• ECG.changes'||!U!waves,!TSwave'flattening,☺!STB !
segment!changes,!and!arrhythmias!(with!digitalis!
therapy)!
!
!
Table'12.!Etiology!of!Potassium!Abnormalities!
• Normal!Na+:!135S145'mEq/l'
Etiology!of!Potassium!Abnormalities! • Symptomatichypernatremia!are!rare!until!serum'
Increased'Intake' sodium'exceeds'160'mEq/l!
• Potassium!supplementation! • Symptomatic!hyponatremia!does!not!occur!until!serum'
• Blood!transfusions! sodium'level'is'20'mEq/l'
• Endogenous!load/destruction:!hemodialysis,! !
rhabdomyolysis,!crush!injury,!GI!hemorrhage! • Normal!K+:!3.5S5'mEq/l!
Increased'Release' • Peaked'T'waves!are!the!first!ECG!change!seen!in!most!
Hyperkalemia.
• Acidosis! patients!with!hyperkalemia!
• Rapid!rise!of!extracellular!osmolality!
(hyperglycemia!or!mannitol)!
• TSwave'flattening!is!seen!in!hypokalemia!
Impaired'Excretion' • Hypokalemia!causes!decreased'deep'tendon'reflexes!
• PotassiumBsparing!diuretics! while!hypomagnesemia!and!hypocalcemia+causes!
• Renal!insufficiency/failure! increased!deep!tendon!reflexes!
Inadequate'Intake' !
• Dietary,!potassiumBfree!IV!fluids! !
• PotassiumBdeficient!TPN! 5.!Hypercalcemia.
Excessive'Potassium'Excretion' • Serum!calcium!level!above'the'normal'range'of'8.5S
• Hyperaldosteronism! 10.5'mEq/l'or!an!increase!in!ionized!calcium!above'
Hypokalemia.
• Medications!(NonBK+!sparing!diuretics)! 4.2S4.8'mg/dl'
GI'losses'
• Caused!by!primary+hyperparathyroidism!in!the!
• Direct!loss!of!potassium!from!GI!fluid!
(diarrhea)!
outpatient!setting!and!malignancy!in!hospitalized!
• Renal!loss!of!potassium!! patients!
' • Clinical.manifestations'||!!Neurologic!impairment,!
• Treatment!||!Potassium'repletion,!the!rate!is! musculoskeletal!weakness!and!pain,!renal!dysfunction,!
determined!by!the!symptoms! and!GI!symptoms!(Refer!to!Table'13)!
• Mild,!asymptomatic!hypokalemia:!oral!repletion!is!
adequate!(KCl!40!mEq!per!enteral!access!x!1!dose)!
• ECG.changes.||!Shortened!QT!interval,!prolonged!PR! '
and!QRS!intervals,!increased!QRS!voltage,!TBwave! 7.!Hypermagnesemia.
flattening!and!widening,!and!atrioventricular!block! • Rare!but!can!be!seen!with!severe+renal+insufficiency!and!
• Treatment!is!required!when!hypercalcemia!is! parallel+changes+in+potassium+excretion'
symptomatic,!which!usually!occurs!when!the!serum' o MagnesiumBcontaining!antacids!and!laxatives!
level'exceeds'12'mEq/l' can!produce!toxic!levels!in!patients!with!renal!
• Critical'level'for'serum'calcium'is'15'mEq/l,!when! insufficiency/failure'
symptoms!noted!earlier!may!rapidly!progress!to!death! o Excess!intake!in!conjunction!with!TPN,!or!
• Treatment!||!Aimed!at!repleting!the!associated!volume! rarely!massive!trauma,!thermal!injury,!and!
deficit!and!then!inducing!a!brisk!diuresis!with!normal! severe!acidosis,!may!be!associated!with!
saline! symptomatic!hypermagnesemia'
' • Clinical.manifestations'||!!Mainly!GI!with!
6.!Hypocalcemia. neuromuscular!dysfunction!and!impaired!cardiac!
• Serum!calcium!level!below'8.5'mEq/l!or!a!decrease!in! conduction!(Refer!to!Table'13)'
the!ionized!calcium!level!below'4.2'mg/dl' • ECG.changes.||'(similar!to!hyperkalemia)!Increased!PR!
• Causes!include!pancreatitis,!malignancies!associated! interval,!widened!QRS!complex,!elevated!T!waves'
with!increased!osteoclastic!activity!(breast+and+prostate+ • Treatment!||!!Eliminate!exogenous!sources!of!
cancer),!massive!soft!tissue!infections!such!as! magnesium,!correct!concurrent!volume!deficits!and!
necrotizing+fasciitis,+renal+failure,+pancreatic!and!small+ correct!acidosis!if!present!
bowel+fistulas,!hypoparathyroidism,+toxic+shock+ • To!manage!acute!symptoms,!calcium'chloride(5B10ml)!
syndrome,!and!tumor+lysis+syndrome' should!be!administered!to!immediately!antagonize!the!
• Transient!hypocalcemia!also!occurs!after!removal!of!a! cardiovascular!effects!
parathyroid!adenoma!due!to!atrophy!of!the!remaining! • If!persistently!elevated!or!with!symptoms,!dialysis!may!
gland!and!avid!bone!remineralization' be!necessary!
• Neuromuscular!and!cardiac!symptoms!do!not!occur! '
until!the!ionized'fraction'falls'below'2.5'mg/dl' 8.!Hypomagnesemia.
• Clinical.manifestations'||!!Neuromuscular!symptoms! • Magnesium!depletion!is!a!common!problem!in!
with!decreased!cardiac!contractility!(Refer!to!Table'13)' hospitalized!patients,!particularly!in!the!critically!ill'
• ECG.changes.||'Prolonged!QT!interval,!TBwave! • Result!from!alterations!of!intake,!renal!excretion!and!
inversion,!heart!block!and!ventricular!fibrillation' pathologic!losses'
! o Poor!intake!may!occur!in!cases!of!starvation,+
alcoholism,+prolonged+IV+fluid+therapy,!and!TPN+
⊗ MICROBIOLOGY!a!
with!inadequate+supplementation+of+
!
Magnesium.
• Toxic.Shock.Syndromeis!due!to!the!Staphylococcus+
o Losses!are!seen!in!cases!of!increased+renal+
aureus!toxin,!Toxic'shock'syndrome'toxin'(TSSTS1)!
excretion+from+alcohol+abuse,+diuretic+use,+
• Clinical.manifestations'||Fever,!hypotension,!sloughing!
administration+of+amphotericin+B,!and!primary+
of!the!filiform!papillae!(strawberry'tongue),!
aldosteronism,!as!well!as!GI+losses+from+
desquamating'rash,'andmultiSorgan'involvement'
diarrhea,+malabsorption,+and+acute+pancreatitis.
• Usually!no!site!of!pyogenic!inflammation!"blood'CS'
• Clinical.manifestations'||!!Neuromuscular!and!central!
negative'
nervous!system!hyperactivity,!similar!to!those!of!
• Common!in!tamponSusing'menstruating'women!or!in! calcium!deficiency'
patients'with'nasal'packing!for!epistaxis!
• ECG.changes.||'Prolonged!QT!and!PR!intervals,!STB
• Treatment!||!Remove!the!offending!agent!and!to!start! segment!depression,!flattening!or!inversion!of!P!waves,!
antibiotics!(Clindamycin!and!Vancomycin)!
torsades+de+pointes,!and!arrhythmias'
!
• Can'produce'hypocalcemia'and'lead'to'persistent'
!
hypokalemia'☺'
!
!
! Table'13.!Clinical!Manifestations!of!Abnormalities!in!Ca2+!and!Mg+!
! Increased'Serum'Levels'
⊗ PATHOLOGY!a! System' Calcium' Magnesium'
! Anorexia! Nausea/vomiting!
• Tumor.Lysis.Syndromeconsists!of!multiple'electrolyte' Gastrointestinal. Nausea/vomiting!
abnormalities!that!may!be!seen!after'initiation'of' Abdominal!pain!
cancer'treatment' Weakness! Weakness!
Bone!pain! Lethargy!
• Chemotherapy!causes!release!of!breakBdown!products!of! Neuromuscular.
Confusion! Decreased!reflexes!
dying!cancer!cells! Coma!
• Among!the!electrolyte!abnormalities!include! Hypertension! Hypotension!Arrest!
hyperkalemia,.hyperphosphatemia,.hyperuricemia,! Arrhythmia!
Cardiovascular.
and!hypocalcemia! Worsening!of!digitalis!
• Clinical!consequences!are!acute'uric'acid'nephropathy! toxicity!!
and!acute'renal'failure! Renal. Polyuria! B!
! Decreased'Serum'Levels'
System' Calcium' Magnesium'
!
Hyperactive!reflexes! Hyperactive!reflexes!
• Treatment!||!Calcium!supplementation!and!correction! Paresthesias!! Muscle!tremors!
of!other!metabolic!derangements!! Muscle!cramps! Tetany!
• Asymptomatic!hypocalcemia!can!be!treated!with!oral' Carpopedal!spasm! Positive!Chvostek’s!
Neuromuscular.
or'IV'calcium' Seizures! and!Trousseau’s!
• Acute!symptomatic!hypocalcemia!should!be!treated! Tetany! signs!
with!IV'10%'calcium'gluconate!to!achieve!a!serum! Trousseau’s!sign1! Delirium!and!
Chvostek’s!sign2! seizures!(severe)!
concentration!of!7B9!mg/dl!
Cardiovascular. Heart!failure! Arrhythmia!
• Associated!deficits!in!magnesium,!potassium,!and!pH! 1Spasm!resulting!from!pressure!applied!to!the!nerves!and!vessels!of!the!!
must!also!be!corrected! upper!extremity!with!a!blood!pressure!cuff!
• Hypocalcemia'will'be'refractory'to'treatment'if' 2!Spasm!resulting!from!tapping!over!the!facial!nerve!
coexisting'hypomagnesemia'is'not'corrected'first' !
• Treatment!||!Magnesium!supplementation' • Treatment!||!Restore'perfusion'with'volume'
• Correction!of!magnesium!depletion!can!be!oral!if! resuscitation!rather!than!to!attempt!to!correct!with!
asymptomatic!and!mild!or!IV!if!symptomatic!and!severe' exogenous!bicarbonate!
• For!those!with!severe!deficits!(<1!mEq/L)!or!those!who! • With!adequate!perfusion,!lactate!is!rapidly!metabolized!
are!symptomatic,!1'to'2'g'of'magnesium'sulfate!may! by!the!liver!and!the!pH!level!returns!to!normal!
be!administered!IV!over!15!minutes!or!2!minutes!if! • Administration!of!bicarbonate!for!the!treatment!of!
under!ECG!monitoring!to!correct!torsades' metabolic!acidosis!is!controversial!
• To!counteract!the!adverse!side!effects!of!a!rapidly!rising! o Overzealous!administration!of!bicarbonate!can!
magnesium!level!and!correct!hypocalcemia!(frequently! lead!to!metabolic.alkalosisand!can!be!
associated!with!hypomagnesemia),!simultaneous! associated!with!arrhythmias+!
administration!of!calcium'gluconateis!done' o An!additional!disadvantage!is!that!sodium!
! bicarbonate!actually!can!exacerbate!
√ 'QUICK'REVIEW!a! intracellular!acidosis!
! !
• Normal!Ca2+:!8.5S10.5'mEq/l' 2.!Metabolic.Alkalosis!
• Normal!ionized!Ca2+:!4.2S4.8'mg/dl' • Results!from!the!loss+of+fixed+acids!orgain+of+
• Treatment!is!required!when!hypercalcemia.is! bicarbonate(Refer!to!Table'15)'
symptomatic,!when!the!serum'level'exceeds'12'mEq/l' • Majority!of!patients!will!have!hypokalemia,!because!
• Symptomatic!hypocalcemia!do!not!occur!until!the! extracellular!potassium!ions!exchange!with!intracellular!
ionized'fraction'falls'below'2.5'mg/dl' hydrogen!ions!and!allow!the!hydrogen!ions!to!buffer!
excess!HCO3'
• Hypocalcemia!will!be!refractory!to!treatment!if!
coexisting!hypomagnesemia!is!not!corrected!first! • Treatment!||!Includes!replacement'of'the'volume'
! deficit!with!isotonic!saline!and!then!potassium!
F.'ACIDSBASE'DISORDERS' replacement!once!adequate!urine!output!is!achieved'
1.!Metabolic.Acidosis' !
Table'15.!Etiology!of!Metabolic!Alkalosis!
• Results!from!an!increased+intake+of+acids,+an+increased+ Increased'bicarbonate'generation'
generation+of+acids,!or!an!increased+loss+of+bicarbonate' Chloride'losing!(urinary!chloride!>!20!mEq/l)!
• Body!compensates!by!producing+buffers!(extracellular! • Mineralocorticoid!excess!
bicarbonate!and!intracellular!buffers!from!bone!and! • Profound!potassium!depletion!
muscle),!increasing+ventilation!(Kussmaul's! Chloride'sparing!(urinary!chloride!<!20!mEq/l)!
respirations),increasing+renal+reabsorption!and! • Loss!from!gastric!secretions!(emesis!or!nasogastric!suction)!
generation+of+bicarbonate,!and!increasing+renal+secretion+ • Diuretics!
of+hydrogen+. Excess'administration'of'alkali'
• Evaluation!of!a!patient!with!metabolic!acidosis!includes! • Acetate!in!parenteral!nutrition!
determination!of!the!anion'gap'(AG),!an!index!of! • Citrate!in!blood!transfusions!
unmeasured!anions' • Antacids!
• Bicarbonate!
o AG!=!Na+!–!(ClB!+!HCO3B)'
• MilkBalkali!syndrome!
o Normal:!<12!mmol/l!'
Impaired'bicarbonate'excretion'
• Etiology!of!metabolic!acidosis!is!listed!inTable'14!☺! Decreased'glomerular'filtration'
Increased'bicarbonate'reabsorption!(hypercarbia!or!potassium!
' depletion)!
Table'14.!Etiology!of!Metabolic!Acidosis!☺! !
High'Anion'Gap'Metabolic'Acidosis'(HAGMA)' !
3.!Respiratory.Acidosis'
Exogenous'acid'ingestion! Mnemonic:!“MUDPILES”! • Associated!with!retention+of+CO2!secondary!to!
• Ethylene!glycol! Methanol!
• decreased'alveolar'ventilation'
• Salicylate! • Uremia!(Renal!failure)!
• Methanol! • Principal!causes!are!listed!in!Table'16'
• Diabetic!ketoacidosis!
• Because!compensation!is!primarily!a!renal+mechanism,!
• Propylene!glycol!
it!is!a!delayed!response'
Paraldehyde!
• Infection,!Iron,!Isoniazid! • In!the!chronic!form,!partial!pressure!of!arterial!CO2!
Endogenous'acid'production!
• Lactic!acidosis! remains!elevated!and!the!bicarbonate!concentration!
• Ketoacidosis!
• Lactic!acidosis! • Ethylene!glycol! rises!slowly!as!renal!compensation!occurs'
• Renal!insufficiency! • Salicylates! • Treatment!||!Directed!at!the!underlying!cause'
• Measures!to!ensure!adequate!ventilation!through!!
Norma'Anion'Gap'Metabolic'Acidosis'(NAGMA)' bilevel!positive!airway!pressure!or!endotracheal!
intubationare!also!initiated'
Acid'administration'(HCl)! !
Mnemonic:!“HARD!UP”! !
Loss'of'bicarbonate! • Hyperalimentation! !
• Acetazolamide!(Carbonic! Table'16.!Etiology!of!Respiratory!Acidosis!
GI'losses'(diarrhea,!fistulas)' anhydrase!inhibitor)! Etiology'of'Respiratory'Acidosis'
• Renal!tubular!acidosis! Narcotics'
Ureterosigmoidoscopy' • Diarrhea! Central'nervous'system'injury'
• Ureteroenteric!fistula! Pulmonary!(secretions,!atelectasis,!mucus!plug,!pneumonia,!pleural!
Renal'tubular'acidosis' • Pancreticoduodenal! effusion)!
fistula! Pain'from'abdominal'or'thoracic'injuries'or'incisions'
Carbonic'anhydrase'inhibitor' Limited'diaphragmatic'excursion'from'intraSabdominal'pathology!
(abdominal!distention,!abdominal!compartment!syndrome,!ascites)!
! !
• Lactic.acidosis!is!a!common!cause!of!severe!metabolic! !
acidosis!in!surgical!patients! 4.!Respiratory.Alkalosis'
• In!circulatory!shock,!lactate!is!produced!in!the!presence! • In!the!surgical!patient,!most!cases!are!acute!and!
of!hypoxia!from!inadequate!tissue!perfusion! secondary!to!alveolar'hyperventilation'
• Causes!include!pain,!anxiety,!neurologic!disorders!
(central+nervous+system+injury!and!assisted+ventilation),!

drugs!(salicylates),!fever,!gramBnegative!bacteremia,! respiratory!alkalosis,!insulin!therapy,!refeeding'
thyrotoxicosis,!and!hypoxemia!' syndrome,!and!hungry!bone!syndrome.!Clinical!
• Acute!hypocapnia!can!cause!an!uptake!of!potassium!and! manifestations!include!cardiac!dysfunction!or!muscle!
phosphate!into!cells!and!increased!binding!of!calcium!to! weakness!but!are!usually!absent!until!levels!fall!
albumin,!leading!to!symptomatic'hypokalemia,! significantly.!Refer!to!page'8!for!a!discussion!on!
hypophosphatemia,!and!hypocalcemia!with! refeeding.syndrome.!!
subsequent!arrhythmias,!paresthesias,!muscle!cramps,! Magnesium!containing!laxatives!can!cause!
and!seizures' hypermagnesemia!in!patients!with!renal!failure!but!does!
• Treatment!||!Directed!at!the!underlying!cause' not!affect!phosphorous.!Patients!with!insulin!coma!
• Direct!treatment!of!the!hyperventilation!using! (hypoglycemia)!are!not!at!risk!for!hypophosphatemia.!
controlled!ventilation!may!also!be!required' Rhabdomyolosis!is!associated!with!hyperkalemia!and!
! hyperphosphatemia!
√ 'QUICK'REVIEW!a! !
! !
• Evaluation!of!a!patient!with!metabolic+acidosis!includes! HEMOSTASIS,'SURGICAL'BLEEDING,'
determination!of!the!anion'gap'(AG)!to!differentiate! AND'TRANSFUSION'
HAGMA!from!NAGMA!(TIP:!Memorize!the!mnemonics!)' '
• Normal!AG!is!<12'mmol/l' A. Hemostasis'
• Treatment!of!metabolic+acidosis!is!to!restore'perfusion' B. Evaluation'of'Hemostatic'Risk''
with'volume'resuscitation!rather!than!exogenous! C. Surgical'Bleeding'
bicarbonate' D. Special'Cases'
• Metabolic+alkalosis!is!associated!with!hypokalemia' E. Transfusion'
! !
' !
! A.'HEMOSTASIS'
'''''''REVIEW'QUESTIONS!a! • Function!is!to'limit'blood'loss'from'an'injured'vessel'
! • Four!major!physiologic!events!participate!in!the!
1. A!patient!develops!a!high!output!fistula!following! hemostatic!process(Refer!to!Figure'9):'
abdominal!surgery.!The!fluid!is!sent!for!evaluation!with! o Vascular+constriction.
the!following!results:!Na+!135,!K+!5,!ClB!70.!Which!of!the! o Platelet+plug+formation.
following!is!the!most!likely!source!of!the!fistula?! o Fibrin+formation.
a. Stomach! o Fibrinolysis.
b. Small!bowel! Figure'9.!Biology!of!Hemostasis!
c. Pancreas! !
d. Biliary!tract! !
! !
Answer:!C! !
The!composition!of!pancreatic'secretions!is!marked!by! !
high'level'of'bicarbonate!(Refer!to!Table'8),!compared! !
to!other!GI!secretions.!In!this!example,!the!patient!has!a! !
total!of!140!mEq!of!cation!(Na+!+!K+)!and!only!70!mEq!of! !
anion!(ClB).!The!remaining!70!mEq!(to!balance!the!140! !
mEq!of!cation)!must!be!bicarbonate.! !
! !
2. A!postoperative!patient!with!a!potassium!of!2.9!is!given! !
1!mEq/kg!replacement!with!KCl!(potassium!chloride).! !
Repeat!tests!after!the!replacement!show!the!serum!K!to! !
be!3.0.!The!most!likely!diagnosis!is:! !
a. Hypomagnesemia! !
b. Hypocalcemia! !
c. Metabolic!acidosis! !
d. Metabolic!alkalosis! !
! !
Answer:!A! !
In!cases!in!which!potassium!deficiency!is!due!to! !
magnesium!depletion,!potassium'repletion'is'difficult' 1.!Vascular.Constriction!
unless'hypomagnesemia'is'first'corrected.!! • Initial!response!to!vessel!injury'
Alkalosis!will!change!serum!potassium!(a!decrease!in!0.3! • Dependent!on!local!contraction!of!smooth!muscle'
mEq/l!for!every!0.1!increase!in!pH!above!normal).!This!is! o Thromboxane'A2!(TXA2)☺!,potent!constrictor!
not!enough!to!explain!the!lack!of!response!to!repletion!in! of!smooth!muscle,is!produced!locally!at!the!
the!patient.!Metabolic+acidosis!would!not!decrease! site!of!injury!'
potassium.!Calcium!does!not!play!a!role!in!potassium! o Endothelin!☺,also!a!potent!vasoconstrictor,!is!
metabolism.! synthesized!by!injured!endothelium!and!
! serotonin!'
3. Which!of!the!following!is!a!cause!of!acute! o Bradykinin!and!fibrinopeptidesare!capable!
hypophosphatemia?! of!contracting!vascular!smooth!muscle.!'
a. Chronic!ingestion!of!magnesium!containing! • Extent!of!vasoconstriction!varies!with!the!degree!of!
laxatives! vessel!injury!(more!pronounced!in!vessels!with!medial!
b. Insulin!coma! smooth!muscles)'
c. Refeeding!syndrome! !
d. Rhabdomyolosis! 2.!Platelet.Plug.Formation!
! • Platelets!do!not!normally!adhere!to!each!other!or!to!the!
Answer:!C! vessel!wall!but!during!vascular!disruption,!they!form!a!
Acute+hypophosphatemia!is!usually!caused!by!an! hemostatic+plugthat!aids!in!cessation!of!bleeding!!
intracellular!shift!of!phosphate!in!association!with!

• Injury!to!the!intimal!layer!in!the!vascular!wall!exposes! • Thrombocytopenia,!secondary!to!any!platelet!
von'Willebrand's'factor'(vWF),!a!subendothelial! pathology,!is!the!most'common'abnormality'of'
protein,!where!platelets!adhere!via!glycoprotein+I/IX/V! hemostasis!that!results!in!bleeding!in!surgical!patients!
• After!adhesion,!platelets!initiate!a!release+reaction!that! • Systemic!causes!of!surgical!bleeding!can!either!be!
recruits!other!platelets!to!seal!the!disrupted!vessel! inherited!or!acquired!(Refer!to!Table'17)!
• The!aforementioned!process,!mediated!by!adenosine' • Inherited!platelet!functional!defects!include!
diphosphate'(ADP)'and'serotonin,is!reversible!and!is! abnormalities+of+platelet+surface+proteins,+abnormalities+
known!as!primary'hemostasis! of+platelet+granules,!and!enzyme+defects!
• In!the!second!wave!of!platelet!aggregation,! • Acquired!abnormalities!of!platelets!may!be!quantitative!
anotherrelease+reaction!occurs!that!results!in! or!qualitative,!although!some!patients!have!both!types!
compaction!of!the!platelets!viaglycoprotein+IIb/IIIa!into! o Quantitative!defects!may!be!a!result!of!failure+
a!plug! of+production!due!to!bone!marrow!disorders,!
• With!fibrinogen!as!a!cofactor,!this!process,!mediated!by! shortened+survival,!or!sequestration!
ADP,'Ca2+,'serotonin,'TXA2,!is!irreversible! o Qualitative!defects!include!massive+
! transfusionand!drugs+that+interfere+with+
3.!Fibrin.Formation./.Coagulation! platelet+function+
• As!a!consequence!of!the!release!reaction,!alterations! !
occur!in!the!phospholipids!of!the!platelet!membrane! Table'17.!Etiology!of!Surgical!Bleeding!
that!initiates!coagulation! Congenital'Factor'Deficiencies'
• Coagulation!cascade!typically!has!been!depicted!as!two! Coagulation'Factor'Deficiencies'
von'Willibrand’s'Disease'
intersecting!pathways!
Platelet'Functional'Defects!
o Intrinsic.pathway!begins!with!factor+XII!and!
Acquired'Hemostatic'Defects'
through!a!series!of!enzymatic!reactions,!which! Platelet'Abnormalities:'Quantitative'
is!intrinsic!to!the!circulating!plasma!and!no' Leukemia!
surface'is'required'to'initiate'the'process! Myeloproliferative!disorders!
o Extrinsic.pathwayrequires'exposure'of' Failure'of' Vitamin!B12!or!Folate!deficiency!
tissue'factor'on'the'surface'of'the'injured' Production'' Chemotherapy!or!radiation!therapy!
vessel'wall!to!initiate!the!arm!of!the!cascade! Acute!alcohol!intoxication!
beginning!with!factor+VII! Viral!infections!
o The!two!arms!of!the!coagulation!cascade! ImmuneBmediated!disorders!(Idiopathic!
merge!to!a!common!pathway!at!factor+X,!and! thrombocytopenia,!HeparinBinduced!
activation!of!factors!II!(prothrombin)!and!I! thrombocytopenia,!Autoimmune!disorders!or!BB
(fibrinogen)proceeds!in!sequence!! Decreased' cell!maligancies,!Secondary!thrombocytopenia)!
Survival' Disseminated!intravascular!coagulation!
• Secondary'hemostasis!or!fibrin'clot'formation!
Disorders!related!to!platelet!thrombi!
occurs!after!conversion!of!fibrinogen'to'fibrin' (Thrombocytopenic!purpura,!Hemolytic!uremic!
! syndrome)!
4.!Fibrinolysis! Portal!hypertension!
• During!the!woundBhealing!process,!the!fibrin!clot! Sarcoid!
Sequestration'
undergoes!fibrinolysis,!which!permits!restoration!of! Lymphoma!
blood!flow! Gaucher’s!disease!
• This!is!initiated!at!the!same!time!as!the!clotting! Platelet'Abnormalities:'Qualitative'
mechanism!under!the!influence!of!circulating!kinases,! Massive'transfusion'
tissue!activators,!and!kallikrein,!which!are!present!in! Therapeutic'administration'of'platelet'inhibitors'
the!vascular!endothelium! Myeloproliferative!disorders!
Disease'states' Monoclonal!gammopathies!
• Plasmindegrades!the!fibrin!mesh!at!various!places,!
Liver!disease!
which!leads!to!the!production!of!circulating!fragments! !
that!are!cleared!by!proteases!or!by!the!kidney!and!liver! !
!
B.'EVALUATION'OF'HEMOSTATIC'RISK'
√ PATHOLOGY!a!
!
1.!Preoperative.Evaluation.of.Hemostasis!
• Bernard8Soulier.Syndromeis!caused!by!a!defect'in'the'
• Most!important!component!of!the!bleeding!risk!
glycoprotein'Ib/IX/V'receptor'for'vWF,!leading!to!
assessment!is!a!directed+bleeding+history!
defective'platelet'adhesion.
• When!history!is!unreliable!or!incomplete!or!when!
o Decreased!platelet!count!
abnormal!bleeding!is!suggested,!a!formal+evaluation+of+
o Treatment!||!Platelet!transfusion!
hemostasis+should+be+performed+before+surgery++
• Glanzmann.Thrombastheniais!caused!by!a!defect'in'
o Hemoglobin!levels!below!7!or!8!g/dl!appear!to!
the'platelet'glycoprotein'IIb/IIIa'complex',!leading!to!
be!associated!with!significantly!more!
defective'platelet'aggregation.
perioperative!complications!!
o Normal!platelet!count!
o Determination!of!the!need!for!preoperative!
o Treatment!||!Platelet!transfusion!
transfusion!must!consider!factors!other!than!
!
the!absolute!hemoglobin!level,!including!the!
!
presence!of!cardiopulmonary!disease,!type!of!
!
surgery,!and!likelihood!of!surgical!blood!loss!
!
• Laboratory!tests!of!hemostatic!parameters!in!patients!
!
with!low!risk!of!bleeding!are!NOT!required!
!
!
!
2.!Evaluation.of.Intraoperative.or.Postoperative.Bleeding.
!
• Excessive!bleeding!during!or!after!a!surgical!procedure!
!
may!be!the!result!of!ineffective+hemostasis,+blood+
!
transfusion,+undetected+hemostatic+defect,+disseminated+
!
intravascular+coagulation+(DIC)+or+consumptive+
!
coagulopathy,+and/or+fibrinolysis!
!
!
!
C.'SURGICAL'BLEEDING'
1.!Systemic.Bleeding.Disorders! Treatment!||!Depends!on!the!extent!and!cause!of!
•
platelet!reduction!
o Platelets!are!given!preoperatively!to!rapidly! o Therapeutic!anticoagulation!is!more!reliably!
increase!the!count!in!surgical!patients! achieved!withlow.molecular.weight.
o A!count!of!>50,000/L!generally!requires!no! heparinbecause!laboratory!testing!is!not!
specific!therapy! routinely!done,!which!makes!them!attractive!
o One'unit'of'platelet'concentrate'is'expected' options!for!outpatient!anticoagulation+
to'increase'the'circulating'platelet'count'by' o Warfarin!is!used!for!longBterm!outpatient!
~10,000/L!in!the!average!70Bkg!person! anticoagulation!in!various!clinical!conditions!
o In!patients!whose!thrombocytopenia!is! including!deep+vein+thrombosis,+valvular+heart+
refractory!to!standard!platelet!transfusion,!! disease+(with+or+without+prosthetic+valves),+
the!use!of!human'leukocyte'antigen'(HLA)' atrial+fibrillation,+and+recurrent+myocardial+
compatible'plateletshas!proved!effective! infarction+
! !
2.!Local.Hemostasis! √ PHARMACOLOGY!a!
• Significant!surgical!bleeding!usually!is!caused!by! !
ineffective'local'hemostasis! • Warfarin!inhibits!vitamin+K+epoxide+reductase!and!
• Goal!is!to!prevent!further!blood!loss!from!a!disrupted! thereby!interferes!with!production!of!functional!vitamin!
vessel!that!has!been!incised!or!transected! KBdependent!clotting!and!anticlotting!factors'
• Hemostasis!may!be!accomplished!by!interrupting!the! • Side.effect||bleeding,!warfarinBinduced!skin!necrosis'
flow!of!blood!to!the!involved!area!or!by!direct!closure!of! !
the!blood!vessel!wall!defect! Mnemonic:!“Ethel!Booba!takes!PhenB
o Mechanical.procedure:!When!pressure!is! phen!and!Refuses!Greasy!Carb!Shakes”'
applied!(whether!through!direct+digital+ Cytochrome.P450. • Ethanol!
pressure,+hemostatic+clamp,+or+tourniquet)!to! Inducers.
• Barbiturates!
an!artery!proximal!to!an!area!of!bleeding,! increase!clearance!
• Phenytoin!
profuse!bleeding!may!be!reduced!so!that!more! and!reduce!the!
• Rifampicin!
definitive!action!is!permitted! anticoagulant!
effect!of!warfarin. • Griseofulvin!
o Thermal.agents:!Heat!(via!cautery+or+
• Carbamazepine!
harmonic+scalpel)!achieves!hemostasis!by!
• St.!John’s!Wort!/!Smoking!
denaturation!of!protein!that!results!in!
coagulation!of!large!areas!of!tissue! Mnemonic:!“Inhibitors!Stop!Cyber!Kids!
o Topical.hemostatic.agents:!Include!physical! from!Eating!GRApefruit!Q”'
or!mechanical,!caustic,!biologic,!and! • Isoniazid!
Cytochrome.P450. • Sulfonamides!
physiologic!agents!that!works!either!by! inhibitors.
inducing!protein!coagulation!and!precipitation! • Cimetidine!
reduce!clearance!
or!activating!biologic!responses!to!bleeding! • Ketoconazole!
and!increase!the!
! • Erythromycin!
anticoagulant!
D.'SPECIAL'CASES' effect!of!warfarin. • Grapefruit!juice!
1.!Disseminated.Intravascular.Coagulation.(DIC)! • Ritonavir!
• An!acquired!syndrome!characterized!by!intravascular' • Amiodarone!
activation'of'coagulation! • Quinidine!
Can!originate!from!and!cause!damage!to!the!
!
• '
microvasculature,!which!if!sufficiently!severe,!can! • Bleeding!complications!can!be!manifested!
produce!organ!dysfunction! throughhematuria,+soft+tissue+bleeding,+intracerebral+
• Excessive!thrombin!generation!leads!to!microthrombus! bleeding,+skin+necrosis,!and!abdominal+bleeding!
formation,!followed!by!consumption'and'depletion'of' • Bleeding'into'the'abdominal'cavity'is'the'most'
coagulation'factors'and'platelets,!which!leads!to!the! common'complication'of'warfarin'therapy'
classic!picture!of!diffuse!bleeding! • Intramural'bowel'hematoma'is'the'most'common'
• Causes!include!the!following:! cause'of'abdominal'pain'in'patients'receiving'
o Central!nervous!system!injuries!with! anticoagulation'therapy'
embolization!of!brain!matter! • Certain!surgical!procedures!should!not!be!performed!
o Fractures!with!embolization!of!bone!marrow! such!as!procedures!involving!the!central!nervous!
o Malignancy! system!or!the!eye!
o Organ!injury!(severe!pancreatitis,!liver!failure)! !
o Certain!vascular!abnormalities!(aneurysms)! Table'18.!Reversal!of!anticoagulation!for!patients!undergoing!surgery!
o Others:!snakebites,!illicit!drugs,!transfusion! Reversal'of'Heparin'Therapy'
reactions,!transplant!rejection,!and!sepsis! Not!indicated!when!aPTT'is'<1.3'times'the'control'value!
• Diagnosis!is!made!on!the!basis!of!an!inciting!cause!with! Emergency+ Discontinue!drug!and!use!ofprotamine'sulfate!for!
associated!thrombocytopenia,'prolonged'PT,'low' surgery+ more!rapid!reversal!of!anticoagulation!
fibrinogen'level,'and'elevated'levels'of'fibrin' Reversal'of'Warfarin'Therapy'
markers!(fibrin!degradation!products,!DBdimer,!soluble! Not!indicated!when!the!INR'is'<1.5!
fibrin!monomers)! Discontinue!drug!several!days!before!the!operation!
with!monitoring!of!prothrombin'concentration'
• Treatment!||!Relieving!the!patient's!causative!primary!
(>50%'is'safe)!
medical!or!surgical!problem!and!maintaining!adequate! Parenteral!administration!of!vitamin'K!is!indicated!
perfusion! Elective+
in!patients!with!biliary+obstruction+or+malabsorption+
• If!there!is!active!bleeding,!hemostatic!factors!should!be! surgery+
who+may+be+vitamin+K+deficient!
replaced!using!fresh'frozen'plasma'(FFP),!which! Low'molecular'weight'heparin!should!be!
generally!is!sufficient!to!correct!the!hypofibrinogenemia! administered!while!the!INR!is!decreasing!in!patients+
! with+high+risk+of+thrombosis!
2.Anticoagulation.and.Bleeding' Emergency+ Rapid!reversal!of!anticoagulation!can!be!
surgery. accomplished!with!FFP'!
• Spontaneous!bleeding!can!be!a!complication!of!
!
anticoagulant!therapy!with!either!heparin,+warfarin,or+
!
low+molecular+weight+heparin!
o Risk!of!spontaneous!bleeding!with!heparinis! • Other!drugs!that!interfere!with!platelet!function!are!
aspirin,+clopidogrel,+dipyridamole,!and!glycoprotein+
relatively!high!but!reduced!with!continuous!
IIb/IIIa+inhibitors!
infusion!technique!!

o Aspirin!inhibit!platelet!function!through! blood!loss!"!misleading!in!acute!loss,!
irreversible!acetylation!of!platelet! because!levels!can!be!normal!in!spite!of!
prostaglandin!synthase! severely!contracted!blood!volume!
o Clopidogrelinhibit!platelet!function!through! • Estimated'total'blood'volume'is'7S8%'of'
TBW'
selective!irreversible!inhibition!of!ADPB
• Blood+loss+of+up+to+20%+of+total+blood+volume:!
induced!platelet!aggregation! Replaced!with!crystalloid'solution'
• General!recommendation!is!that!a!period!of!~7'days'is! • Blood+loss+>20%+of+total+blood+
required!from!the!time!the!drug!is!stopped!until!an! volume:Addition'of'packed'RBC,!and!in!the!
elective!procedure!can!be!performed! case!of!massive+transfusion,!the!addition'of'
• Timing!of!urgent!and!emergent!surgeries!is!unclear! FFP!
• Preoperative!platelet!transfusions!may!be!beneficial! !
! !
3.Coagulopathy.of.Liver.Disease' √ 'QUICK'REVIEW!a!
• Liver!plays!a!key!role!in!hemostasis!because!it! !
synthesizes!manycoagulation!factors! • Thrombocytopenia!is!the!most!common!abnormality!of!
• Most!common!coagulation!abnormalities!associated! hemostasis!
with!liver!dysfunction!are!thrombocytopenia'and' • Significant!surgical!bleeding!usually!is!caused!by!
impaired'humoral'coagulation'function!manifested! ineffective'local'hemostasis!
as!prolonged'PT'and'increase'in'the'International' • Most!important!management!of!DIC!is!treatment'of'the'
Normalized'Ratio'(INR)! underlying'cause'
• Thrombocytopenia!is!related!to!hypersplenism,+reduced+ • Bleeding'into'the'abdominal'cavity!is!the!most!
production+of+thrombopoietin,+and+immuneGmediated+ common!complication!of!warfarin!therapy!
destruction+of+platelets+ • Intramural'bowel'hematoma!is!the!most!common!
• Before!any!therapy!for!thrombocytopenia!is!initiated,! cause!of!abdominal!pain!in!patients!receiving!
the!actual!need!for!correction!should!be!strongly! anticoagulation!therapy!
considered! • A!period!of!~7'days'is!required!from!the!time!aspirin+
• Treatment!||!Platelet'transfusions;!however,!the! and/or+clopidogrel+is!stopped!until!an!elective!procedure!
effect!typically!lasts!only!several!hours! can!be!performed!
• Potential!alternative!strategy!is!administration'of' • Most!common!coagulation!abnormalities!associated!with!
interleukinS11,!a!cytokine!that!stimulates!proliferation! liver!dysfunction!are!thrombocytopenia'and'impaired'
of!hematopoietic!stem!cells!and!megakaryocyte! humoral'coagulation'function!
progenitors! • Most!common!indication!for!blood!transfusion!in!
• Less!well!accepted!option!is!splenectomy'or'splenic' surgical!patients!is!volume'replacement!
embolization!to!reduce!hypersplenism+but!reduced! '
splenic!blood!flow!can!reduce!portal!vein!flow!with! !
subsequent!development!of!portal!vein!thrombosis.! • Complications!of!transfusionis!primarily!related!to!
! bloodSinduced'proinflammatory'responses!
4.!Coagulopathy.of.Trauma! • Complications!(discussed!below)!occur!in!
• Recognized!causes!of!traumatic!coagulopathy!include! approximately!10%!of!all!transfusions,!but!<0.5%!are!
acidosis,+hypothermia,+and+dilution+of+coagulation+factors! serious!
• Significant!proportion!of!trauma!patients!arrive!at!the! !
ER!coagulopathic,!and!this!early!coagulopathy!is! 1.!Febrile.Non8hemolytic.Reactions!
associated!with!increased!mortality! • Defined!as!an!increase'in'temperature'[>1°C'(1.8°F)]!
• Shockhas!been!postulated!to!induce!coagulopathy! associated!with!a!transfusion!!
through!systemic!activation!of!anticoagulant!and! • Approximately!1%!of!all!transfusions!
fibrinolytic!pathways! • Preformed+cytokines+in+donated+blood+and!recipient+
• Hypoperfusion!causes!activation!of!thrombomodulin(on! antibodies+reacting+with+donated+antibodies!are!
the!surface!of!endothelial!cells),!which!complexes!with! postulated!causes!
circulating+thrombin!thereby!inducing'not'only'an' • Can!be!reduced!by!the!use!of!leukocyteBreduced!blood!
anticoagulant'statebut!also!enhancing'fibrinolysis! products!with!!
! • Pretreatment!with!paracetamol!reduces!the!severity!of!
5.!Massive.Transfusion! the!reaction!
• WellBknown!cause!of!thrombocytopenia!due!to! • Rare!but!potentially!lethal!febrile!reaction!is!secondary!
hypothermia,+dilutional+coagulopathy,+platelet+ to!bacterial.contamination.of.infused.blood!
dysfunction,+fibrinolysis,+or+hypofibrinogenemia! o GramSnegative'organisms,!especially!
• Impaired!ADPBstimulated!aggregation!occurs!with! Yersinia+enterocolitica!and!Pseudomonas!
massive+transfusion(>10!units!of!packed!RBC)!leading!to! species!are!the!most'common'cause!
surgical!bleeding! o Most!cases!are!associated!with!the!
! administration'of'platelets''
D.'TRANSFUSION' o Pathogenesis!is!related!to!lability!of!factor!V,!
• General!indications!for!transfusion!is!listed!in!Table'19! which!appears!necessary!for!this!interaction'
! o Results!in!sepsis!and!death!in!25%!of!patients!
Table'19.!Indications!for!Replacement!of!Blood!and!its!Elements! o Clinical.manifestations'||fever!and!chills,!
General'Indications'for'Transfusion' tachycardia,!and!hypotension,!GI!symptoms!
Improvement.in. • OxygenBcarrying!capacity!is!primarily!a! (abdominal!cramps,!vomiting,!and!diarrhea),!
Oxygen. function!of!RBC! and!hemorrhagic!manifestations!such!as!
Carrying. • Therefore,!transfusion!of!RBC!should!
Capacity.
hemoglobinemia,!hemoglobinuria,!and!DIC!
augment!oxygenBcarrying!capacity!
• Critically!ill!patients!frequently!receive!
o If!suspected,!transfusion!should!be!
Treatment.of. discontinued!and!the!blood!cultured!
transfusions!at!a!hemoglobin!level!
Anemia. o Treatment'||Administration!of!oxygen,!
approaching!9!g/dl!
• Most'common'indication'for'blood' adrenergic!blocking!agents,!and!antibiotics!
transfusion'in'surgical'patients'is' !
Volume.
Replacement.
thereplenishment'of'the'blood'volume! 2.!Allergic.Reaction!
• Measurements!of!hemoglobin!levels!or! • Occurs!in!~1%!of!all!transfusions!
hematocrit!are!frequently!used!to!assess! • Reactions!usually!are!mild!
• Clinical.manifestations'||rash,!urticaria,!and!fever! • Clinical.manifestations'||fever!and!jaundice!!
within!60!to!90!minutes!of!the!start!of!the!transfusion! • Coombs'!test!usually!yields!a!positive!result!
• In!rare!instances,!anaphylactic!shock!develops! • Treatment'||!Do!not!usually!require!specific!
intervention!
• Caused!by!transfusion!of!antibodies!from!
!
hypersensitive!donors!or!the!transfusion!of!antigens!to!
!
which!the!recipient!is!hypersensitive!
5.!Transmission.of.Disease!
• Can!occur!after!the!administration!of!any+blood+product!
• Among!the!diseases!that!have!been!transmitted!by!
• Treatment'||Administration!of!antihistamines!or!in!
transfusion!are!malaria,+Chagas'+disease,+brucellosis,!
more!serious!cases,!use!of!epinephrine!or!steroids!may!
and,!very!rarely,!syphilis!
be!indicated!
• Transmission!of!hepatitis+C+virus!and!HIVG1has!been!
!
dramatically!minimized!by!the!introduction!of!better!
3.!Respiratory.Complications!
antibody!and!nucleic!acid!screening!for!these!pathogens!
• Circulatory.overload!can!occur!with!rapid!infusion!of!
• Hepatitis+B+virus!transmission!may!still!occur!in!about!1!
blood,!plasma!expanders,!and!crystalloids,!particularly!
in!100,000!transfusions!in!nonimmune!recipients!
in!older!patients!with!underlying!heart!disease!
!
• Clinical.manifestations'||dyspnea,!rales,and!cough!
• Treatment'||!Initiate!diuresis,!slow!the!rate!of!blood! √ 'QUICK'REVIEW!a!
administration,!and!minimize!delivery!of!fluids!while! !
blood!products!are!being!transfused! • GramSnegative'organismsare!the!most!common!cause!
• Another!significant!respiratory!complication!is! of!bacterial.contamination.of.infused.blood,!especially!
Transfusion8related.Acute.Lung.Injury.(TRALI)! with!platelet!administration!
o Defined!as!noncardiogenic!pulmonary!edema! !
related!to!transfusion! • Transfusion8related.Acute.Lung.Injury.(TRALI).most!
o Can!occur!with!the!administration!of!any+ commonly!occurs!within!1!to!2!hours!after!the!onset!of!
plasmaGcontaining+blood+product+ transfusion,!but!virtually!always'before'6'hours!
o Clinical.manifestations'||similar!to!those!of! !
circulatory!overload!and!often!accompanied! !
by!fever,!rigors,!and!bilateral!pulmonary! • Acute.hemolytic.reaction!is!characterized!by!
infiltrates!on!chest!radiograph! intravascular'hemolysis!while!delayed.reaction!is!
o Most!commonly!occurs!within!1!to!2!hours! characterized!by!extravascular'hemolysis'
after!the!onset!of!transfusion,!but!virtually! !
always'before'6'hours! '
o Etiology!is!not!well!established,!but!TRALI!is! !
thought!to!be!related'to'antiSHLA'or'antiS '''''''REVIEW'QUESTIONS!a!
human'neutrophil'antigen'antibodies!in! !
transfused!blood!that!primes!neutrophils!in! 1. What!percentage!of!platelets!can!be!sequestered!in!the!
the!pulmonary!circulation.!! spleen?!
o Treatment'||!Discontinuation!of!any! a. 15%!
transfusion,!notification!of!the!transfusion! b. 30%!
service,!and!provision!of!pulmonary!support! c. 45%!
(from!supplemental!oxygen!to!mechanical! d. 60%!
ventilation)! !
! Answer:!B!
4.!Hemolytic.Reactions! Platelets!are!anucleate!fragments!of!megakaryoctes.!The!
• Can!be!classified!as!either!acute!ordelayed(Refer!to! normal!circulating!number!of!platelets!ranges!between!
Table'20)! 150,000!and!400,000/L.!Up'to'30%'of'circulating'
! platelets'may'be'sequestered'in'the'spleen.!If!not!
Table'20.!Classification!of!Hemolytic!Reactions! consumed!in!a!clotting!reaction,!platelets!are!normally!
Classification'of'Hemolytic'Reactions' removed!by!the!spleen!and!have!an!average!life!span!of!7!
• Occur!with!the!administration'of''ABOS to!10!days.!
incompatible'blood' !
• Fatal!in!up!to!6%!of!cases! 2.
A!patient!on!chronic!warfarin!therapy!presents!with!
• Contributing!factors!include!technical+or+clerical+
acute!appendicitis.!INR!is!1.4.!Which!of!the!following!is!
errors+in+the+laboratory!andadministration+of+ the!most!appropriate!management?!
wrong+blood+type!
a. Proceed!immediately!with!surgery!without!
• Characterized!by!intravascular'hemolysis!and!
consequent!hemoglobinemia!and!hemoglobinuria!
stopping!the!warfarin!
• Clinical.manifestations'||pain!at!the!site!of! b. Stop!the!warfarin,!give!FFP,!and!proceed!with!
transfusion,!facial!flushing,!and!back!and!chest! surgery!
Acute. c. Stop!the!warfarin!and!proceed!with!surgery!in!
pain,!associated!with!fever,!respiratory!distress,!
Hemolytic.
hypotension,!and!tachycardia! 8B12!hours!
Reaction.
• In!anesthetized!patients,!diffuse!bleeding!and! d. Stop!the!warfarin!and!proceed!with!surgery!in!
hypotension!are!the!hallmarks! 24B36!hours!
• Positive!Coombs'!test!!is!diagnostic! !
• Treatment'||!stop!transfusion,!get!a!sample!of!the!
Answer:!A!
recipient's!blood!and!send!along!with!the!suspect!
When!the!INR!<1.5!in!a!patient!taking!warfarin,!reversal!
unit!to!the!blood!bank!for!comparison!with!the!
pretransfusion!samples! of!anticoagulation!therapy!may!not!be!necessary.!!(Refer!
• Urine!output!should!be!monitored!and!adequate!to!Table'18).!However,!meticulous!surgical!technique!is!
mandatory,!and!the!patient!must!be!observed!closely!
hydration!maintained!to!prevent!precipitation!of!
hemoglobin!within!the!tubules! throughout!the!postoperative!period.!
• !
Reactions!occur'2'to'10'days'after'transfusion!
• 3. What!percent!of!the!population!is!Rh!negative?!
Occur!when!an!individual!has!a!low!antibody!titer!
Delayed. at!the!time!of!transfusion!! a. 5%!
Hemolytic. • Characterized!by!extravascular'hemolysis,!mild! b. 15%!
Reaction. anemia,!indirect!hyperbilirubinemia,!decreased! c. 25%!
haptoglobin!levels,!lowBgrade!hemoglobinemia!
d. 35%!
and!hemoglobinuria!!
!
Answer:!B! • Example:!Cholecystectomy,+Elective+GI+surgery(not+colon)+
Rh!negative!recipients!should!receive!transfusion!only!of! (IR:!2.1B9.5%),!Colorectal+surgery(IR:!9.4B25%)!
Rh!negative!blood.!However,!this!groups!represents!only! !
15%'of'the'population.!Therefore,!the!administration!of! 3. Contaminated.(Class.III)!
Rh!positive!blood!is!acceptable!if!Rh!negative!blood!is! • Include!open'accidental'wounds'encountered'early'
not!available.!However,!Rh!positive!blood!should!not!be! after'injury,!those!with!extensive'introduction'of'
transfused!to!Rh!negative!females!who!are!of! bacteria'into'a'normally'sterile'area'of'the'body!due!
childbearing!age.! to!major!breaks!in!sterile!technique!(e.g.!open!cardiac!
! massage),!gross'spillage'of'viscus'contents!such!as!
! from!the!intestine,!or!incision!through!inflamed!albeit!
! nonpurulent!tissue!
! • Example:!Penetrating+abdominal+trauma,+large+tissue+
SURGICAL'INFECTIONS'AND'SHOCK' injury,+enterotomy+(IR:!3.4B13.2%)!
' !
A. Definitions' !
B. Surgical'Wounds'Classification' !
C. Prevention'and'Treatment'of'Surgical'Infections' 4. Dirty.(Class.IV)!
D. Infections'of'Significance'in'Surgical'Patients' • Include!traumatic'wounds'in'which'a'significant'
E. Shock' delay'in'treatment'has'occurred!and!in!which!
! necrotic!tissue!is!present,!those!created'in'the'
! presence'of'overt'infection!as!evidenced!by!the!
A.'DEFINITIONS'' presence!of!purulent!material,!and!those!created'to'
1. Infection.(Refer!to!Figure'10')! access'a'perforated'viscus!accompanied!by!a!high!
degree!of!contamination!
• Identifiable!source!of!microbial!insult!
2. Systemic.Inflammatory.Response.Syndrome.(SIRS)! • Example:!Perforated+diverticulitis,+necrotizing+soft+tissue+
infections!(IR:!3.1B12.8%)!
• Two!or!more!of!the!following!criteria!met:!
!
o Temperature!≥!38°C!or!≤!36°C!
C.'PREVENTION'AND'TREATMENT'OF'SURGICAL'INFECTIONS'
o Heart!rate!≥!90!beats!per!minute!
• Resident!microflora!of!the!skin!and!other!barrier!
o Respiratory!rate!≥!20!breaths!per!minute!or!
surfaces!represent!a!potential!source!of!microbes!that!
PaCO2≤!32!mmHg!or!mechanical!ventilation! can!invade!the!body!during!trauma,!thermal!injury,!or!
o White!blood!cell!count!≥!12,000/uL!or!≤! elective!or!emergent!surgical!intervention!
4,000/uL!or!≥!10%!band!forms! • Maneuvers!to!diminish!the!presence!of!exogenous!
3. Sepsis! (surgeon!and!operating!room!environment)!and!
• SIRS!+!Identifiable!source!of!infection! endogenous!(patient)!microbes!consist!of!the!use!of!
4. Severe.Sepsis! mechanical,+chemical,!and!antimicrobial+modalities,!or!a!
• Sepsis!+!Organ!dysfunction! combination+of+these+methods!
5. Septic.Shock! • These!modalities!are!NOT!capable!of!sterilizing!the!
• Sepsis!+!Cardiovascular!collapse!(needs!vasopressors)!! hands!of!the!surgeon!or!the!skin!or!epithelial!surfaces!of!
! the!patient!BUT!the!inoculum'can'be'reduced'
Figure'10.!Relationship!between!infection!and!SIRS.!Sepsis!is!the! considerably'
presence!both!of!infection!and!SIRS,!shown!here!as!the!intersection!of!
these!two!areas.!Other!conditions!may!cause!SIRS!as!well!(trauma,! • Thus,!entry'through'the'skin,'into'the'soft'tissue,'and'
aspiration,!etc.).!Severe!sepsis!(and!septic!shock)!are!both!subsets!of! into'a'body'cavity'or'hollow'viscus'invariably'is'
sepsis.! STILLassociated'with'the'introduction'of'some'
! degree'of'microbial'contamination'
! • Therefore,!antimicrobial!agents!should!be!given!in!
! patients!who!undergo+procedures+that+may+be+associated+
! with+the+ingress+of+significant+numbers+of+microbes(e.g.,!
! colonic!resection)!or!in+whom+the+consequences+of+any+
! type+of+infection+due+to+said+process+would+be+dire!(e.g.,!
! prosthetic!vascular!graft!infection)!!
! '
! 1.!Appropriate.Use.of.Antimicrobial.Agents'
! • Prophylaxis!is!the!administration!of!an!antimicrobial!
! agent(s)before'and'during'the'operative'procedure!
! to!reduce!the!number!of!microbes!that!enter!the!tissue!
! or!body!cavity!
! o Only!a!single'dose!of!antibiotic!is!required,!
B.'SURGICAL'WOUNDS'CLASSIFICATION'☺' and!only!for!certain!types!of!surgical!
*Based!on!the!magnitude!of!bacterial!load!at!the!time!of!surgery! procedures!(Refer!to!Table'21)!
**IR!=!Infection!rate! o Patients!who!undergo!complex,!prolonged!
1. Clean.(Class.I)! procedures!in!which!the!duration+of+the+
• Include!those!in!which!no'infection'is'present! operation+exceeds+the+serum+drug+halfGlife!
• Only!skin!microflora!potentially!contaminate!the!wound! should!receive'an'additional'dose(s)!
• No!hollow!viscus!(that!contains!microbes)!is!entered! o Administration'of'postoperative.doses'
• Class.ID.wounds.are!similar!except!that!a!prosthetic' DOES'NOT'provide'additional'benefit,!and!
device'(e.g.'mesh'or'valve)'is'inserted! should!be!discouraged,!as!it!is!costly!and!is!
• Example:!Hernia+repair,+Breast+biopsy(IR:!1B5.4%)! associated!with!increased!rates!of!microbial!
! drug!resistance!
2. Clean/Contaminated.(Class.II)! !
• Include!those!in!which!a!hollow'viscus!such!as! Table'21.!Prophylactic!therapy!
respiratory,!GI,!or!GU!tracts!with!inherent!bacterial!flora! Site' Antibiotic' Alternative'
is'opened'under'controlled'circumstances'without' Cardiovascular.. Cefazolin!or!Cefuroxime! Vancomycin!
significant'spillage'of'contents! Cefazolin,!Cefotetan!
Gastroduodenal. Cefoxitin! Fluoroquinolone!
AmpicillinBsulbactam!
Biliary.tract.with. AmpicillinBsulbactam! Fluoroquinolone!+! operative!intervention,!both!to!remove!
active.infection. TicarcillinBclavulanate! Clindamycin!or! contaminated!material!and!infected!tissue!(e.g.!
(cholecystitis). PiperacillinBtazobactam! Metronidazole! radical!debridement!or!amputation)!and!to!
Cefazolin+Metronidazole! Gentamicin!or! remove!the!initial!cause!of!infection!(e.g.!
Colorectal.,.
Ertapenem! Fluoroquinolone!
Obstructed.small. bowel!resection)!
TicarcillinBclavulanate! plus!Clindamycin!
bowel. '
PiperacillinBtazobactam! or!Metronidazole!
Aminoglycoside!+! D.'INFECTIONS'OF'SIGNIFICANCE'IN'SURGICAL'PATIENTS'
Head.and.neck. Cefazolin! 1.!Surgical.Site.Infection.(SSI)!
Clindamycin!
Neurosurgery. Cefazolin! Vancomycin! • Infections'of'the'tissues,'organs,'or'spaces!exposed!
Cefazolin! by!surgeons!during!surgery!
Orthopedics. Vancomycin!
Ceftriaxone! • Development!of!SSI!is!related!to!three!factors!!!!!!!!!!!!!!!!!!!!!!!!!
Breast,.Hernia. Cefazolin! Vancomycin! (Refer!to!Table'23):!
! o Patient+factors+
! o Local+factors+
• Empiric.therapycomprises!the!use!of!an!antimicrobial! o Microbial+factors+
agent(s)when'the'risk'of'a'surgical'infection'is'high,! • Treatment'||!Prophylactic!antibiotics!reduce!the!
based!on!the!underlying!disease!process!(e.g.!ruptured+ incidence!of!SSI!during!certain!types!of!procedures!
appendicitis),!or!when'significant'contamination' o Single'dose'of'an'antimicrobial'agent!
during'surgery'has'occurred!(e.g.!inadequate+bowel+ should!be!administered!immediately!before!
preparation+or+considerable+spillage+of+colon+contents)! commencing!surgery!for!class'ID,'II,'III,'and'
o Prophylaxis!merges!into!empiric!therapy!in! IV!types!of!wounds!
situations!in!which!the!risk!of!infection! • Surgical!management!of!the!wound!is!also!a!critical!
increases!markedly!because!of!intraoperative! determinant!of!the!propensity!to!develop!an!SSI!
findings! o Class'I'and'II'woundsmay!be!closed!primarily!
o Limited!to!a!short'course'of'drug!(3B5!days),! o Class'III'and'IV'wounds!areallowed!to!heal!by!
and!should!be!curtailed!based!on! secondary!intention!where!superficial!aspects!
microbiologic!data!(i.e.!culture!and!sensitivity! of!these!wounds!should!be!packed!open!only!
pattern)!coupled!with!improvements!in!the! !
clinical!course!of!the!patient! Table'23.!Risk!factors!for!development!of!surgical!site!infections!
o Manner!in!which!therapy!is!used!differs! Patient'Factors'
depending!on!whether!the!infection!is! Older!age!
monomicrobial+or!polymicrobial! Immunosuppression!
! Obesity!
Table'22.!General!principles!in!empiric!therapy! Diabetes!Mellitus!
Empiric'Therapy' Chronic!inflammatory!process!
• Frequently!are!nosocomial'infections! Malnutrition!
occurring!in!postoperative!patients,!such! Peripheral!vascular!disease!
asUTIs,.pneumonia,.or!bacteremia' Anemia!
• Therapy!should!be!initiated!in!patients!with! Radiation!
evidence!of!SIRS,!coupled!with!evidence!of!local! Chronic!skin!disease!
infection!(e.g.,!an!infiltrate!on!chest!XBray!plus!a! Carrier!state!(e.g.!chronic!staphylococcus!carriage)!
positive!Gram's!stain!in!BAL!sample)' Recent!operation!
• Within!24!to!72!hours,!culture!and!sensitivity! Local'Factors'
Monomicrobial. reports!will!allow!directed!antibiotic!regimen!' Poor!skin!penetration!
• Empiric!regimen!for!common!infections!are!as! Contamination!of!instruments!
follows:' Inadequate!antibiotic!prophylaxis!
o UTI:!3B5!days'
Prolonged!procedure!
o Pneumonia:!7B10!days'
Local!tissue!necrosis!
o Bacteremia:!7B14!days'
Hypoxia,!hypothermia!
o Osteomyelitis,.endocarditis,.or.
prosthetic.infections:!!!!!!!!!!!!!!!!!6B12! Microbial'Factors'
weeks' Prolonged!hospitalization!(leading!to!nosocomial!organisms)!
• Primary!therapeutic!modality!is!source' Toxin!secretion!
control(discussed!below)!but!antimicrobial! Resistance!to!clearance!(e.g.!capsule!formation)!
agents!play!an!important!role!as!well!! !
• Culture'results'are'of'lesser'importance!in! • Surgical.site.infections!are!classified!into!
managing!these!infections,!as!it!has!been! incisionaland!organ/space.infections!
demonstrated!that!only!a!limited!group!of! • Incisional.infections!are!further!subclassified!into!
Polymicrobial.
microbes!predominate!in!the!established! superficial!(limited!to!skin'and'subcutaneous'tissue)!
infection,!selected!from!a!large!number!present!
and!deep.incisional.categories!
at!the!time!of!initial!contamination!
• As!such,!antibiotic'regimen'should'NOT'be' o Treatment'||Effective!therapy!for!incisional.
modified'solely'on'the'basis'of'culture' SSIs!consists!of!incision'and'drainage'
information! without'the'addition'of'antibiotics!
! o Antibiotic!therapy!is!reserved!for!patients!in!
! whom!evidence!of!significant!cellulitis!is!
2.!Source.Control' present,!or!who!manifest!concurrent!SIRS!
• Primary!precept!of!surgical!infectious!disease!therapy! o Open!wound!often!is!allowed!to!heal!by!
consists!of!drainage+of+all+purulent+material,+ secondary!intention,!with!dressings!being!
debridement+of+all+infected,+devitalized+tissue,+and+debris,! changed!twice!a!day!
and/or!removal+of+foreign+bodies+at+the+site+of+infection,! o Use!of!topical!antibiotics!and!antiseptics!to!
plus!remediation+of+the+underlying+cause+of+infection! further!wound!healing!remains!unproven!
o Discrete,!walledBoff!purulent!fluid!collection! o VacuumBassisted!closure!is!increasingly!used!
(abscess)!requires!drainage!via!percutaneous! in!management!of!problem!wounds!and!can!be!
drain!insertion!or!an!incision!and!drainage!! applied!to!complex!wounds!in!difficult!
o Ongoing!source!of!contamination!(e.g.!bowel! locations!!
perforation)!or!presence!of!an!aggressive,! • Treatment!of!organ/space.infections!is!discussed!in!
rapidlyBspreading!infection!(e.g.!necrotizing! IntraBAbdominal!Infections!section!
soft!tissue!infection)!requires!aggressive! !
2.Intra8Abdominal.Infections/Peritonitis! CFU/ml'of'microbes!are!identified!by!culture!
• Microbial!contamination!of!the!peritoneal'cavity! techniques!in!symptomatic+patients,!or!more'
• Classified!according!to!etiology!(Refer!to!Table'24)! than'105'CFU/ml!in!asymptomatic!individuals'
• Treatment'||Single!antibiotic!therapy!for!3!to!
!
5!days'
! • Indwelling!urinary!catheters!should!be!
Table'24.!IntraBabdominal!infections! removed!as!quickly!as!possible,!typically!
IntraSabdominal'Infections' within!1!to!2!days,!as!long!as!the!patients!are!
• Occurs!when!microbes'invade'the'normally' mobile'
sterile''peritoneal'cavity'via'hematogenous' • Associated!with!prolonged!mechanical!
dissemination!from!a!distant!source!of!infection! ventilation!and!is!frequently!due!to!pathogens!
or!direct!inoculation' common!in!the!nosocomial!environment!
• More!common!among!patients!with!ascites,!and! • Diagnosis!should!be!made!using!the!presence!
in!those!individuals!who!are!undergoing! of!a!purulent!sputum,!elevated!leukocyte!
peritoneal!dialysis' count,!fever,!and!new!chest!xBray!abnormality!
• Often!monomicrobial!and!rarely!require! • Presence!of!two!of!the!clinical!findings,!plus!
Primary. surgical!intervention' Pneumonia. chest!xBray!findings,!significantly!increases!the!
Microbial. • Diagnosis!is!established!based!on!physical! likelihood!of!ventilator8associated.
Peritonitis. examination!that!reveals!diffuse+tenderness!and! pneumonia.
guardingwithout+localized+findings,!absence+of+ • Treatment'||Antibiotic!therapy!for!7!to!10!
pneumoperitoneum,!presence+of+>100+WBCs/ml,+ days'
and+microbes+with+a+single+morphology!on!Gram’s! • Surgical!patients!should!be!weaned!from!
stain!on!fluid!obtained!via!paracentesis' mechanical!ventilation!as!soon!as!feasible,!
• Treatment'||!Antibiotic!therapy!for!14!to!21! based!on!oxygenation!and!inspiratory!effort!
days!and!removal!of!indwelling!devices!(e.g.,! !
peritoneal!dialysis!catheter!or!peritoneovenous!
!
shunt)!'
• Occurs!due!to!contamination'of'the'peritoneal'
E.'SHOCK'
cavity'due'to'perforation'or'severe' • Failure'to'meet'the'metabolic'needs'of'the'cell'and'
inflammation'and'infection'of'an'intraS the'consequences'that'ensue'
abdominal'organ' • Consists!of!inadequate!tissue!perfusion!marked!by!
Secondary. • Examples:!Appendicitis,+perforation+of+any+ decreased!delivery!of!required!metabolic!substrates!
Microbial. portion+of+the+GI+tract,+or+diverticulitis! and!inadequate!removal!of!cellular!waste!products!
Peritonitis. • Treatment'||Effective!therapy!requires!source' (Refer!to!Figure'11)!
control!to!resect!or!repair!the!diseased!organ,!
• Initial!cellular!injury!that!occurs!is!reversible;!however,!
debridement!of!necrotic,!infected!tissue!and!
debris,!and!administration'of'antimicrobial' injury!will!become!irreversible!if!tissue!perfusion!is!
agents!directed!against!aerobes!and!anaerobe! prolonged!or!severe!enough!such!that,!at!the!cellular!
• Develops!by!leakage'from'a'GI'anastomosis'or' level,!compensation!is!no!longer!possible!
intraSabdominal'abscess!in!patients!in!whom! !
standard!therapy!fails! Figure'11.!Pathways!leading!to!decreased!tissue!perfusion!and!shock!!
• Common!in!immunosuppressed!patients!! !
• Microbes!such!as!E.+faecalis!and!faecium,!S.+
epidermidis,!C.+albicans,!and!P.+aeruginosa!can!be!
identified!
• Abscess!is!diagnosed!via!abdominal!CT!!
• Treatment'||!CTBguided!percutaneous!drainage!
for!intraGabdominal+abscess!
• Surgical!intervention!is!reserved!for!patients+
with+multiple+abscesses,+those+with+abscesses+in+
proximity+to+vital+structures+such+that+
Tertiary.
percutaneous+drainage+would+be+hazardous,+and+
(persistent).
those+in+whom+an+ongoing+source+of+
Peritonitis.or.
contamination+(e.g.,+enteric+leak)+is+identified+
Postoperative.
Peritonitis. • Necessity!of!antimicrobial!agent!therapy!and!
precise!guidelines!that!dictate!duration!of!
catheter!drainage!have!NOT!been!established!
• Short!course!(3!to!7!days)!of!antibiotics!that!
covers!for!aerobic!and!anaerobic!bacteria!can!be!
given!
• Unfortunately,!even!with!effective!antimicrobial!
agent!therapy,!this!disease!process!is!associated!
with!mortality!rates!of!more!than!50%!
!
• Drainage!catheter!is!left!in!situ!until!the!abscess! !
cavity!collapse,!its!output!is!less!than!10B20!ml/d!
!
with!no!evidence!of!an!ongoing!source!of!
contamination!and!the!patient's!clinical! • Clinical!manifestations!of!several!physiologic!responses!
condition!has!improved! are!most!often!what!lead!practitioners!to!the!diagnosis!
! of!shock!as!well!as!guide!the!management!of!patients!!
! • Shock!is!classified!into!six!types!(Refer!to!Table'26)!
3.!Postoperative.Nosocomial.Infections' !
• Include!SSIs,!UTIs,.pneumonia,!and!bacteremia! Table'26.!Types!of!Shock!
• Most!infections!are!related!to!prolonged!use!of! Postoperative'nosocomial'infections'
indwelling!tubes!and!catheters!for!the!purpose!of! • Most'common'type'
urinary!drainage,!ventilation,!and!venous!and!arterial! • Results!from!loss'of'circulating'blood'
volumedue!to!loss!of!whole!blood!
access,!respectively!(Refer!to!Table'25).!
(hemorrhagic.shock),!plasma,!interstitial!fluid!
! (bowel!obstruction)'
Table'25.!Postoperative!nosocomial!infections! Hypovolemic. • Clinical!and!physiologic!response!is!classified!
Postoperative'nosocomial'infections' according!to!the!magnitude!of!volume!loss!
• Should!be!considered!based!on!urinalysis!with! (Refer!to!Table'27)'
Postoperative.
WBCs!or!bacteria,!a!positive!test!for!leukocyte! • Treatment'||!Instituted!with!diagnostic!
Urinary.Tract.
esterase,!or!a!combination!of!these!elements' evaluation!to!identify!a!bleeding!source'
Infection.(UTI).
• Diagnosis!is!established!after!more'than'104' • Appropriate!priorities!are!secure'the'airway,'
control'source'of'blood'loss,!and!IV'volume' Table'27.!Signs!and!symptoms!of!advancing!stages!of!hypovolemic!shock!
resuscitation' ☺!
• Patients!who!fail!to!respond!to!initial! ' Class'I' Class'II' Class'III' Class'IV'
resuscitative!efforts!should!be!assumed!to!have! Blood.loss.
ongoing!active!hemorrhage!and!require! Up!to!750! 750B1,500! 1,500B2,000! >2,000!
(ml).
prompt!operative!intervention' Blood.loss.
• Results!from!decreased'resistance'within' (%blood. Up!to!15%! 15B30%! 30B40%! >40%!
capacitance'vessels! volume).
• Evaluationbegins!with!an!assessment!of!the! Pulse.rate. <100! >100! >120! >140!
adequacy!of!airway!and!ventilation! Blood.
Normal! Normal! Decreased! Decreased!
• Treatment'||Fluid!resuscitation!and! pressure.
restoration!of!circulatory!volume!! Pulse. Normal!or!
Vasogenic. Empiric!antibiotics!must!be!chosen!carefully! Decreased! Decreased! Decreased!
• pressure. increased!
(Septic). (gramBnegative!rods,!gramBpositive!cocci,!and! Respiratory.
anaerobes)!! 14B20! 20B30! 30B40! >35!
rate.
• However,!IV!antibiotics!without!source+control+ Urine.
will!be!insufficient!to!adequately!treat!patients! output. >30! 20B30! 5B15! Negligible!
with!infected!fluid!collections,!infected!foreign! (ml/h).
bodies,!and!devitalized!tissue! Confused!
Vasopressors!may!be!necessary!as!well! CNS/mental. Slightly! Mildly! Anxious!and!
• and!
status. anxious! anxious! confused!
• Form!of!vasogenic.shock!in!which!spinal'cord' lethargic!
injury'or'spinal'anesthesia'causes'
!
!
vasodilation'due'to'acute'loss'of'
• Ultimate!goal!in!the!treatment!of!shock!is!restoration!of!
sympathetic'vascular'tone'
• Treatment'||After!airway!is!secured!and!
adequate!organ!perfusion!and!tissue!oxygenation!
ventilation!is!adequate,!fluid!resuscitation!and! • Endpoints!in!resuscitation!can!be!divided!into!systemic!
restoration!of!intravascular!volume!often!will! or!global+parameters+,tissueGspecific+parameters,!and!
Neurogenic.
improve!perfusion!! cellular+parameters!(Refer!to!Table'28)!
• Administration!of!vasoconstrictors!will! • Global!endpoints!include!vital!signs,!cardiac!output,!
improve!peripheral!vascular!tone,!decrease! pulmonary!artery!wedge!pressure,!O2!delivery!and!
vascular!capacitance,!and!increase!venous! consumption,!lactate,!and!base!deficit!!
return!
!
• If!the!patient's!blood!pressure!has!not!
responded,!dopamine!may!be!used!
!
• Results!from!failure'of'the'heart'as'a'pump,! !
as!in!arrhythmias!or!acute+myocardial+ Table'28.!Endpoints!in!resuscitation!
infarction+(most!common)+ Systemic/Global'
• Hemodynamic!criteria!include!sustained! Lactate!
hypotension!(i.e.!SBP!<90!mmHg!for!at!least!30! Base!deficit!
minutes),!reduced!cardiac!index!(<2.2! Cardiac!output!
L/min/m2),!and!elevated!pulmonary!artery! Oxygen!delivery!and!consumption!
wedge!pressure!(>15!mmHg)+ Tissue'Specific'
• Treatment'||Ensure!adequate!airway!is! Gastric!tonometry!
Cardiogenic. present!and!ventilation!is!sufficient! Tissue!pH,!Oxygen,!Carbon!dioxide!levels!
• Treatment!of!cardiac!dysfunction!includes! Near!infrared!spectroscopy!
maintenance!of!adequate!oxygenation!to! Cellular'
ensure!adequate!myocardial!O2!delivery!and! Membrane!potential!
judicious!fluid!administration!to!avoid!fluid! Adenosine!triphosphate!
overload!and!development!of!cardiogenic! '
pulmonary!edema! !
• Significant!dysrhythmias!and!heart!block!must!
'''''''REVIEW'QUESTIONS!a!
be!treated!with!antiarrhythmic!drugs,!pacing,!
or!cardioversion! !
! 1. Which!of!the!following!is!the!most!effective!dosing!of!
' antibiotics!in!a!patient!undergoing!elective!colon!
• Form!of!cardiogenic.shock!that!results!from' resection?!
mechanical'impediment'to'circulation' a. A!single!dose!given!within!30!min!prior!to!skin!
leading'to'depressed'cardiac'output!rather! incision!
than!primary!cardiac!failure! b. A!single!doe!given!at!the!time!of!skin!incision!
• Causes!include!cardiac+tamponade,+pulmonary+ c. A!single!preoperative!dose!+!24!hours!of!
Obstructive.
embolism,+tension+pneumothorax,+IVC+
postoperative!antibiotics!
obstruction+(DVT,+gravid+uterus),+increased+
intrathoracic+pressure+(neoplasm)!
d. A!single!preoperative!dose!+!48!hours!of!
• Treatment'||!Dependent!on!the!etiology!of!the! postoperative!antibiotics!
obstructive!shock! !
• Soft!tissue!and!bony!injury!lead!to!the! Answer:!A!
activation!of!inflammatory!cells!and!the!release! Prophylaxis!is!the!administration!of!an!antimicrobial!
of!circulating!factors!that!modulate!the! agent(s)!before!and!during!the!operative!procedure!to!
immune!response! reduce!the!number!of!microbes!that!enter!the!tissue!or!
• These!effects!of!tissue!injury!are!combined! body!cavity.!Only!a!single'dose!of!antibiotic!is!required,!
with!the!effects!of!hemorrhage,!creating!a!more! and!only!for!certain!types!of!surgical!procedures.!There!
complex!and!amplified!deviation!from!
is!no!evidence!that!administration!of!postoperative!
homeostasis.!
Traumatic. ! doses!provides!additional!benefit.!
• Treatment'||!Correction!of!the!individual! !
elements!to!diminish!the!cascade!of! 2. What!percentage!of!the!blood!volume!is!normally!in!the!
proinflammatory!activation,!and!includes! splanchnic!circulation?!
prompt!control!of!hemorrhage,!adequate! a. 10%!
volume!resuscitation!to!correct!O2!debt,! b. 20%!
debridement!of!nonviable!tissue,!stabilization! c. 30%!
of!bony!injuries,!and!appropriate!treatment!of!
d. 40%!
soft!tissue!injuries!
!
!
' Answer:!B!
Most!alterations!in!cardiac!output!in!the!normal!heart! • Assessment'of'the'“ABCDE”!(Airway'with'cervical'
are!related!to!changes!in!preload.!Increases!in! spine'protection,'Breathing,'Circulation,'Disability,!
sympathetic!tone!have!a!minor!effect!on!skeletal!muscle! and!Exposure)!
beds!but!produce!a!dramatic!reduction!in!splanchnic! !
blood!volume,!which!holds!20%'of'the'blood'volume.!! Table'29.!LifeBthreatening!injuries!identified!during!the!primary!survey!
! Airway'
3. Which!of!the!following!best!describes!the!hemodynamic! Airway!obstruction!
response!to!neurogenic!shock?! Airway!injury!
a. Increased!cardiac!index,!unchanged!venous! Breathing'
Tension!pneumothorax!
capacitance!
Open!pneumothorax!
b. Increased!cardiac!index,!decreased!venous!
Flail!chest!with!underlying!pulmonary!contusion!
capacitance! Circulation'
c. Variable!change!in!cardiac!index!(can!increase!
Massive!hemothorax!or!hemoperitoneum!
or!decrease),!increased!venous!capacitance!
d. Variable!change!in!cardiac!index!(can!increase! Hemorrhagic!shock! Mechanically!unstable!pelvis!fracture!
or!decrease),!decreased!venous!capacitance! Extremity!losses!
!
Cardiogenic!shock:!Cardiac!tamponade!
Answer:!A!
Neurogenic!shock:!Cervical!spine!injury!
Choice!B!and!D!are!most!commonly!associated!with! Disability'
septic!shock.!Choice!C,!on!the!other!hand,!is!most!likely! Intracranial!hemorrhage/mass!lesion!
seen!in!cardiogenic!shock.!! !
! 1. Airway.management.with.cervical.spine.protection!
4. An!unconscious!patient!with!a!systolic!BP!of!80!and!a!HR! • Ensuring'a'patent'airway'is'the'first'priority'in'the'
of!80!most!likely!has?! primary'survey'
a. Cardiogenic!shock! • Efforts!to!restore!cardiovascular!integrity!will!be!futile!
b. Hemorrhagic!shock! unless!the!oxygen!content!of!the!blood!is!adequate!
c. Neurogenic!shock!
• All!patients!with!blunt+trauma!require!cervical'spine'
d. Obstructive!shock!
immobilization!(hard!collar!or!placing!sandbags!on!
!
both!sides!of!the!head!with!the!patient’s!forehead!taped!
Answer:!C!
across!bags!to!the!backboard)!until!injury!is!excluded!
Sympathetic!input!to!the!heart,!which!normally!increases!
• Patients!who!are!conscious,+do+not+show+tachypnea,!and!
heart!rate!and!cardiac!contractility,!and!input!to!the!
have!a!normal!voice!do!not!require!early!attention!to!the!
adrenal!medulla,!which!increases!catecholamine!release,!
airway!EXCEPT!the!following:!
may!also!be!disrupted!(with!spinal!cord!injury),!
o Patients!with!penetrating!injuries!to!the!neck!
preventing!the!typical!reflex!tachycardia!that!occurs!with!
and!an!expanding!hematoma!
hypovolemia.!
o Evidence!of!chemical!or!thermal!injury!to!the!
The!classic!description!of!neurogenic.shock!consist!of!
mouth,!nares,!or!hypopharynx!
decreased'blood'pressure'associated'with'
o Extensive!subcutaneous!air!in!the!neck!
bradycardia!(absence!of!reflex!tachycardia!due!to!
o Complex!maxillofacial!trauma!
disrupted!sympathetic!discharge),!warm!extremities!
o Airway!bleeding!
(loss!of!peripheral!vasoconstriction),!motor!and!sensory!
• Elective!intubation!should!be!performed!on!the!cases!
deficits!indicative!of!a!spinal!cord!injury,!and!
above!before!evidence!of!airway!compromise!
radiographic!evidence!of!a!vertebral!column!fracture.!
! • Altered'mental'status'is'the'most'common'
indication'for'intubation'
!
• Options!for!endotracheal!intubation!include!
TRAUMA' nasotracheal,+orotracheal,+or+surgical+routes+
' o Nasotracheal:!Only!done!in!patients,!who!are!
A. General'Principle' breathing!spontaneously,!requiring!emergent!
B. Primary'Survey' airway!support!in!whom!chemical!paralysis!
C. Resuscitation' cannot!be!used!
D. Secondary'Survey' o Orotracheal:!most'common'technique!used!
E. Diagnostic'Evaluation' to!establish!a!definitive!airway!
F. Definitive'Care' o Surgical.(cricothyroidotomy):!Done!in!
! 2nd ICS
patients!in!whom!attempts!at!intubation!
! have!failed!or!who!are!precluded!from!
A.'GENERAL'PRINCIPLE' intubation!due!to!extensive!facial!injuries!
• Trauma.or.injury!is!a!cellular'disruption'caused'by' o Surgical.(emergent.tracheostomy):!Indicated!
an'exchange'with'environmental'energy'that'is' in!patients!with!laryngotracheal!separation!or!
beyond'the'body’s'resilience' laryngeal!fractures,!in!whom!
• Most'common'cause'of'death!for!all!individuals! cricothyroidotomy!may!cause!further!damage!
between!the!ages'of'1'and'44'years! or!result!in!complete!loss!of!airway!
• Third!most!common!cause!of!death!regardless!of!age! !
• Most!common!cause!of!years!of!productive!life!lost! 2. Breathing.and.Ventilation!
• Initial!management!of!seriously!injured!patients! • Once!a!secure!airway!is!obtained,!adequate!oxygenation!
according!to!the!Advanced!Trauma!Life!Support!(ATLS)! and!ventilation!must!be!assured!
consists!of!the!following:! • All!injured!patients!should!receive!supplemental!oxygen!
o Primary+survey+ and!be!monitored!by!pulse!oximetry!
o Concurrent+resuscitation+ • The!following!conditions!constitute!an!immediate!threat!
o Secondary+survey+ to!life!due!to!inadequate!ventilation!(Refer!to!Table'30)!
o Diagnostic+evaluation+ !
o Definitive+care+ Table'30.!LifeBthreatening!injury!identified!due!to!inadequate!ventilation!
! Inadequate'Ventilation'
B.'PRIMARY'SURVEY! • Diagnosis!is!implied!by!respiratory!distress!
Tension. and!hypotension!in!combination!with!any!of!
• Goal!is!to!identify!and!treat!conditions!that!constitute!an!
Pneumothorax. the!following!physical!signs!in!patients!with!
immediate!threat!to!life!(Refer!to!Table'29)!
chest!trauma:!tracheal+deviation+away+from+
the+affected+side,+lack+of+or+decreased+breath+ !
sounds+on+the+affected+side,+and+ !
subcutaneous+emphysema+on+the+affected+ !
side(Refer!to!Figure'10inset)! !
• Treatment'||Needle'thoracostomy'
!
decompressionin!the!2nd!ICS!in!the!MCL!
may!be!indicated!in!the!acute!setting(Refer! !
to!Figure'10)! !
• Closed'tube'thoracostomy!should!be! !
performed!immediately!before!a!chest! !
radiograph!is!obtained!! '
• Occurs!with!full!thickness!loss!of!the!chest! '
wall,!permitting!free'communication' '
between'the'pleural'space'and'the' '
atmosphere! '
• Compromises!ventilation!due!to! '
equilibration!of!atmospheric!and!pleural! '
pressures,!which!prevents!lung!inflation! '
Open. '
and!alveolar!ventilation,!and!results!in!
Pneumothorax. '
hypoxia!and!hypercarbia!
(Sucking.chest. Figure'14.!Mechanism!of!a!Flail!Chest.Paradoxical!movement!of!the!flail!
• Complete!occlusion!of!the!chest!wall!defect!
wound). chest!during!inspiration!and!expiration.!
WITHOUT!a!tube!thoracostomy!may!
convert!an!open.pneumothorax!to!a! !
tension.pneumothorax! !
• Treatment'||Definitive!treatment!is!closure! !
of!the!chest!wall!defect!and!closed'tube' !
thoracostomy!remote!from!the!wound! !
(Refer!to!Figure'11)!
!
• Occurs!when!3'or'more'contiguous'ribs'
!
are'fractured'in'at'least'2'locations!
(Refer!to!Figure'12)! !
• Paradoxical!movement!of!this!free!floating! !
segment!of!chest!wall!may!be!evident!in! !
Flail.chest.with. patients!with!spontaneous!ventilation,!due! !
underlying. to!the!negative!intrapleural!pressure!of! !
pulmonary. inspiration! !
contusion. • Associated!pulmonary.contusion!is! !
typically!the!source!of!postinjury! !
pulmonary!dysfunction!(Decreased!
!
compliance!and!increased!shunt!fraction)!
• Treatment'||May!require!presumptive! !
intubation!and!mechanical!ventilation! 3. Circulation.with.hemorrhage.control!
! • Initial!approximation!of!the!patient’s!cardiovascular!
' status!can!be!obtained!by!palpating'peripheral'pulses!
Figure'12.!Tension!Pneumothorax!(inset)!with!Needle!Thoracostomy! o Carotid!pulse:!60!mmHg!systolic!BP!!
! o Femoral+pulse:!70!mmHg!!
! o Radial+pulse:!80!mmHg!to!be!palpable!
! • Any!hypotensive.episode!(SBP'<90'mmHg)!is!assumed!
! to!be!caused!by!hemorrhage!until!proven!otherwise!
! • IV!access!for!fluid!resuscitation!is!obtained!with!2!
! peripheral!catheters,!16Bgauge!or!larger!in!adults!
! • In!patients!under!6!years!old,!an!intraosseus!needle!can!
! be!placed!in!the!proximal!tibia!(preferred)!or!distal!
! femur!of!an!unfractured!extremity!
! • External!control!of!hemorrhage!should!be!achieved!
! promptly!while!circulating!volume!is!restored!
! • The!following!conditions!constitute!an!immediate!threat!
! to!life!due!to!inadequate!circulation!(Refer!to!Table'31)!
! !
! Table'31.!LifeBthreatening!injury!identified!due!to!inadequate!circulation!
! Inadequate'Circulation'
! • Defined!as!>1,500'ml'of'blood!or,!in!the!
' pediatrics,!1/3'of'the'patient’s'blood'
' volume!in!the!pleural!space!
Figure'13.!Closed!Tube!Thoracostomy!(CTT).A.!Performed!in!the!MAL!at! • After!a!blunt+trauma,!hemothorax!is!usually!
the!4thB5th!ICS!to!avoid!iatrogenic!injury!to!the!liver!or!spleen.!B.!Heavy! due!to!multiple!rib!fractures!with!severed'
scissors!are!used!to!cut!through!the!intercostal!muscle!into!the!pleural! Massive.
intercostal'arteries,!but!occasionally!
space!done!on!top!of!the!rib!to!avoid!injury!to!the!intercostal!bundle! Hemothorax.
bleeding!isfrom!lacerated!lung!parenchyma!
located!just!beneath!the!rib.!C.!Incision!is!digitally!explored!to!confirm! • After!a!penetrating+trauma,!a!systemic'or'
intrathoracic!location!and!identify!pleural!adhesions.!D.!A!36F!chest!tube! pulmonary'hilar'vessel'injury'should!be!
is!directed!superiorly!and!posteriorly!with!the!aid!of!a!large!clamp.! presumed!
! • Treatment'||!Operative!intervention!
! • Occurs!most!commonly!after'penetrating'
! thoracic'injuries,!although!occasionally!blunt!
! rupture!of!the!heart,!particularly!the!atrial!
! appendage,!is!seen!
! Cardiac. • <100'ml'of'pericardial'blood!may!cause!
! Tamponade. pericardial.tamponade!
(Refer!to!Figure'13'right)!
!
• Beck’s.triad!(dilated!neck!veins,!muffled!
! heart!tones,!and!a!decline!in!arterial!pressure)!
! is!NOT!often!observed!!

Diagnosis!is!best!achieved!by!ultrasound'of' hypotension. abdominal,!extremity,!cervical)!
the'pericardium' .(SBP≤ 60.mmHg).. Air!embolism!
(Refer!to!Figure'13'left)! Contraindications'
• Early!in!the!course!of!tamponade,!blood! Penetrating!trauma:!CPR'>15'min!and!no!signs!of!life!(papillary!
pressure!and!cardiac!output!will!transiently! response,!respiratory!effort,!motor!activity)!
improve!with!fluid!administration! Blunt!trauma:!CPR'>5'min!and!no!signs!of!life!or!asystole!
• Treatment'||Pericardiocentesis!is!successful! '
in!decompressing!tamponade!in! Figure'17.!Emergency!department!thoracotomy!(EDT)!is!performed!
approximately!80%!of!cases!!!!!!!!!!!!!!(Refer!to! through!the!5th!ICS!using!the!anterolateral!approach.!Pericardium!is!
Figure'14)! opened!anterior!to!the!phrenic!nerve,!and!the!heart!is!rotated!out!for!
• Removing!as!little!as!15!to!20!ml!of!blood!will! repair'
often!temporarily!stabilize!the!patient’s! '
hemodynamic!status,!prevent!subendocardial! '
ischemia,!and!associated!lethal!arrhythmias,!
'
and!allow!transport!to!the!OR!for!sternotomy!
• Patients!with!a!SBP!<70!mmHg!warrant!
'
emergency'department'thoracotomy(EDT)! '
with!opening!of!the!pericardium!to!address! '
the!injury!(Refer!to!Table'31)! '
• EDT!is!best!accomplished!using!aleft' '
anterolateral'thoracotomy,!with!the! '
incision!started!to!the!right!of!the!sternum! '
(Refer!to!Figure'15)! '
!
'
!
'
4. Disability.and.Exposure!
'
• Glasgow.Coma.Scale.(GCS).score!should!be!determined! '
for!all!injured!patients! '
• Scores'of'13'to'15'indicate'mild'head'injury,'9'to'12' '
moderate'injury,'and'<9'severe'injury' '
• Abnormal!mental!status!should!prompt!an!immediate! !
reBevaluation!of!the!ABCs!and!consideration!of!central!
⊗ ANATOMY!a!
nervous!system!injury!
!
'
Figure'15.!Cardiac!Tamponade!with!ultrasound!findings!!(*)!on!the!left.! • Closed.Tube.Thoracostomy.(CTT)is!done!on!the!
! superior!border!of!the!lower!ribon!the!4thB5th!ICS!MAL.
' o Directed!superiorly!for!air!drainage!
' o Directed!inferiorly!for!fluid+drainage!
' o Tube!passes!through!the!following:!Skin+!+
' Superficial+fascia+!+Serratus+anterior+!+
' External+intercostals+!+Internal+intercostals+!+
' Innermost+intercostals+!+Endothoracic+fascia+!+
' Parietal+pleura+
' !
' !
' !
Figure'16.!Pericardiocentesis.!Access!to!the!pericardium!is!obtained! !
through!a!subxiphoid!approach,!with!the!needle!angled!45!degrees!up! !
from!the!chest!wall!and!toward!the!left!shoulder.!!
'
'
'
' • Primary.survey!consists!of!the!assessment'of'the'
' “ABCDE”!(Airway!with!cervical!spine!protection,!
' Breathing,!Circulation,!Disability,!and!Exposure)'
' • Ensuring'a'patent'airway!is!the!first!priority!in!the!
' primary!survey'
' • Altered'mental'status!is!the!most!common!indication!
' for!intubation'
' • Massive.hemothorax!is!defined!as!>1,500'ml'of'blood!
' or,!in!the!pediatrics,!1/3'of'the'patient’s'blood'volume'
' in'the'pleural'space'
' • Tension.pneumothorax.is!the!most!common!cause!of!
' cardiogenic!shock!in!trauma!patients'
' !
' '
' C.'RESUSCITATION!
' • Quantity!of!acute!blood!loss!correlates!with!
' physiologicabnormalities!(Refer!to!Table'26)!
' o Tachycardia!is!often!the!earliest'sign'of'
' ongoing'blood'loss!but!watch!out!for!relative.
Table'32.!Emergency!Department!Thoracotomy!(EDT)!Indications!and! tachycardia!(HR<90!in!patients!with!a!resting!
Contraindications.!CPR!=!Cardiopulmonary!resuscitation! pulse!rate!in!the!50s)!
Indications' o Bradycardia,!an!ominous!sign,!occurs!with!
Patients!sustaining!witnessed!penetrating! severe!blood!loss,!often!heralding'impending'
Salvegeable. trauma!with!<15'min'of'prehospital'CPR! cardiovascular'collapse'
postinjury.cardiac. Patients!sustaining!witnessed!blunt+trauma!
o Hypotension!is!NOT!a!reliable!early!sign!of!
arrest. with!<5'min'of''
prehospital'CPR!
hypovolemia,!because!blood!volume!must!
Persistent.severe. Cardiac!tamponade! decrease!by!>30%!before!hypotension!occurs!
postinjury.. Hemorrhage!(intrathoracic,!intraB • Goal!is!to!reSestablish'tissue'perfusion!
o Urine.output!is!a!quantitative,!reliable! • Extended'postoperative'antibiotic'therapy!is!
indicator!of!organ!perfusion! administered!only!for!open+fractures+or+significant+intraG
o Adequate'urine'output'is'0.5'ml/kg/hr'in' abdominal+contamination+
an'adult,'1'ml/kg/hr'in'a'child,'and'2' • Tetanus'prophylaxis!is!administered!to!all!patients!!
ml/kg/hr'in'an'infant'<1'year'of'age' • Trauma!patients!particularly!(a)!those!with!multiple+
o Fluid!resuscitation!begins!with!a!2L!(adult)!or! fractures+of+the+pelvis+and+lower+extremities,!(b)!those!
20!ml/kg!(child)!IV!bolus!of!isotonic! with!coma+or+spinal+cord+injury,!and!(c)!those!requiring+
crystalloid,!typically!Ringer’s!lactate! ligation+of+large+veins+in+the+abdomen+and+lower+
o For!persistent!hypotension,!this!is!repeated! extremitiesare!at!risk!for!venous.thromboembolism!
once!in!adult!and!twice!in!a!child!before!RBCs! and!its!associated!complications!
are!administered! o Low'molecular'weight'heparin!is!initiated!as!
• Based!on!the!initial!response!to!fluid!resuscitation,! soon!as!bleeding!has!been!controlled!and!
hypovolemic!injured!patients!can!be!separated!into! there!is!no!intracranial!pathology!
three!broad!categories:+responders,+transient+responders,+ o In!highBrisk!patients,!removable'inferior'
and+nonresponders! vena'caval'filters!should!be!considered!if!
o Responders:Individuals!who!are!stable!or! there!are!contraindications!to!administration!
have!a!good!response!to!the!initial!fluid! of!low!molecular!weight!heparin!
therapy!as!evidenced!by!normalization!of!vital! o Pulsatile'compression'stockings!or!
signs,!mental!status,!and!urine!output!are! sequential+compression+devices!are!used!
unlikely!to!have!significant!ongoing! routinely!unless!there!is!a!fracture!
hemorrhage,!and!further!diagnostic!evaluation! • Another!prophylactic!measure!is!thermal'protectionby!
for!occult!injuries!can!proceed!in!an!orderly! maintaining!a!comfortable!ambient!temperature,!
fashion!(Secondary!survey)! covering!stabilized!patients!with!warm!blankets,!and!
o Transient.Responders:!Those!who!respond! administering!warmed!IV!fluids!and!blood!products.!!
initially!to!volume!loading!by!an!increase!in! o Hemorrhagic!shock!impairs!perfusion!and!
blood!pressure!only!to!then!hemodynamically! metabolic!activity!throughout!the!body,!with!
deteriorate!once!more! resultant!decrease!in!heat!production!and!
o Nonresponders:!These!patients!have! body!temperature!
persistent!hypotension!despite!aggressive! o Hypothermia!causes!coagulopathy!and!
resuscitation! myocardial!irritability!
• Patients!with!ongoing!hemodynamic!instability,! • PRBC'transfusion!should!occur!once!the!patient's!
whether!nonresponders+or+transient+responders,!require! hemoglobin!level!is!<7!g/dl,!in!the!acute!phase!of!
systematic!evaluation!and!prompt!intervention! resuscitation!the!endpoint!is!10!g/dl!
' • FFP!is!transfused!to!keep!theINR!<1.5!and!PTT!<45!sec!
D.'SECONDARY'SURVEY! • Target!of!100,000/l!is!the!target!platelet!count!with!
• Once!the!immediate!threats!to!life!have!been!addressed,! massive!transfusion!
a!thorough!history!is!obtained!and!the!patient!is! !
examined!in!a!systematic!fashion! 1..Neck!
• Patient!(or!surrogate)!should!be!queried!to!obtain!an! • Divided!into!three!distinct!zones!that!is!important!in!the!
“AMPLE”'(Allergies,'Medications,'Past'illnesses'or' management!of!neck!injuries!(Refer!to!Figure'18'☺)!
Pregnancy,'Last'meal,'and'Events'related'to'the' !
injury)! !
• Physical!examination!should!be!head!to!toewith!special! !
attention!to!the!patient's!back,!axilla,!and!perineum,! !
because!injuries!here!are!easily!overlooked! !
• All!potentially!seriously!injured!patients!should! !
undergo!digital'rectal'examination!to!evaluate!for! !
sphincter+tone,+presence+of+blood,+rectal+perforation,+or+a+ !
highGriding+prostate,!which!is!particularly!critical!in! !
patients!with!suspected!spinal!cord!injury,!pelvic! !
fracture,!or!transpelvic!gunshot!wounds! Figure'18.'For!the!purpose!of!evaluating!penetrating+injuries,!the!neck!is!
• Vaginal'examination!with!a!speculum!also!should!be! divided!into!three!zones.!Zone'I!is!up!to!the!level!of!the!cricoid!and!is!also!
performed!in!women+with+pelvic+fractures!to!exclude!an! known!as!the!thoracic+outlet.Zone'II!is!located!between!the!cricoid!
open!fracture! cartilage!and!the!angle!of!the!mandible.!Zone'III!is!above!the!angle!of!the!
mandible.!☺!
!
!
E.'DIAGNOSTIC'EVALUATION!
!
• Selective!radiography!and!laboratory!tests!are!done!
!
early!in!the!evaluation!after!the!primary+survey!
!
• For!patients!with!severe+blunt+trauma,!lateral'cervical' !
spine,'chest,'and'pelvic'radiographs!should!be! !
obtained,!often!termed!the+big+three! !
• For!patients!with!truncal+gunshot+wounds,! !
anteroposterior'and'lateral'radiographs'of'the'chest' !
and'abdomen!are!warranted! !
• In!critically+injured+patients,!blood!samples!for!a!routine! !
trauma!panel!(type'and'crossSmatch,'complete'blood' !
count,'blood'chemistries,'coagulation'studies,' !
lactate'level,'and'arterial'blood'gas'analysis)!should! !
be!sent!to!the!laboratory! !
• For!less+severely+injured+patients!only!a!complete'blood' !
count'and'urinalysis!may!be!required! • Imaging!options!include!CT'scan!or!five'plain'
! radiograph'views'of'the'cervical'spine:!lateral!view!
F.'DEFINITIVE'CARE! with!visualization!of!C7BT1,!anteroposterior!view,!
• All!injured!patients!undergoing!an!operation!should! transoral!odontoid!views,!and!bilateral!oblique!views!
receive!preoperative'antibiotics!

• Identification!of!penetrating+injuries!to!the!neck!with! • Anterior!abdominal!stab!wounds!(AASW)!should!be!
exsanguination,!expanding!hematomas,!and!airway! explored!under!local!anesthesia!in!the!ED!to!determine!
obstruction!is!a!priority!during!the!primary!survey! if!the!fascia!has!been!violated!
• Management!algorithm!for!penetrating!neck!injury! o Injuries!that!do!not!penetrate!the!peritoneal!
patients!is!based!on!the!presenting!symptoms!and! cavity!do!not!require!further!evaluation,!and!
anatomic!location!of!injury!(Refer!to!Figure'19)! the!patient!is!discharged!from!the!ED!
• All!blunt!trauma!patients!should!be!assumed!to!have! o Patients!with!fascial!penetration!must!be!
cervical!spine!injuries!until!proven!otherwise! further!evaluated!for!intraBabdominal!injury,!
' because!there!is!up!to!a!50%!chance!of!
Figure'19.'Algorithm!for!the!selective!management!of!penetrating!neck! requiring!laparotomy!
injuries.!CT!=!computed!tomography;!CTA!=!computed!tomographic! o Debate!remains!over!whether!the!optimal!
angiography;!GSW!=!gunshot!wound;!IR!Embo!=!interventional!radiology! diagnostic!approach!is!serial!examination,!
embolization!
diagnostic!peritoneal!lavage!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!
(Refer!to!Figure'20),!or!CT!scanning!
!
o Values!representing!positive!findings!for!
!
diagnostic!peritoneal!lavage!are!summarized!
!
in!Table'33!
!
!
! Figure'21.'Diagnostic!peritoneal!lavage!(DPL)!is!performed!through!an!
! infraumbilical!incision!unless!the!patient!has!a!pelvic!fracture!or!is!
! pregnant.!Linea!alba!is!sharply!incised,!and!the!catheter!is!directed!into!
! the!pelvis.!Abdominal!contents!(diagnostic+peritoneal+aspiration)!is!
! considered!positive!if!>10!ml!of!blood!is!aspirated.!If!<10!ml!is!obtained,!a!
! liter!of!NSS!is!instilled.!Effluent!is!withdrawn!via!siphoning!and!sent!to!
! the!laboratory!for!analysis.!
! !
! !
! !
! !
! !
! !
2.!Abdomen! !
• Diagnostic!approach!differs!for!penetrating!trauma!!!! !
(i.e.!gun!shot/stab!wound)!and!blunt!abdominal!trauma!! !
!
• Management!algorithm!for!penetrating!abdominal!
injury!patients!is!primarily!based!on!the!anatomic! !
location!of!injury!(Refer!to!Figure'18)! !
!
• As!a!rule,!minimal!evaluation!is!required!before!
!
laparotomy!for!abdominal!gunshot+or+shotgun+wounds!!
!
because!over!90%!of!patients!have!significant!internal!
!
injuries!EXCEPT!those!isolated!in!the!liver!by!CT!scan;!
!
in!hemodynamically!stable!patients!where!
!
nonoperative!observation!may!be!considered!
!
• Abdominal!stab+wounds!are!less!likely!to!injure!intraB
!
abdominal!organs!and!thus,!diagnostic!evaluation!can!
!
be!afforded!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
Figure'20.'Algorithm!for!the!evaluation!of!penetrating!abdominal!
injuries.!AASW!=!anterior!abdominal!stab!wound!(from!costal!margin!to! !
inguinal!ligament!and!bilateral!MAL);!CT!=!computed!tomography;!DPL!=! '
diagnostic!peritoneal!lavage;!GSW!=!gunshot!wound;!LWE!=!local!wound! '
exploration;!RUQ!=!right!upper!quadrant;!SW!=!stab!wound.! Table'33.!Criteria!for!positive!finding!on!diagnostic!peritoneal!lavage.!
! Between!1,000B10,000/ml,!do!laparoscopy/thoracoscopy!☺!
Anterior' Anterior'Abdominal' Thoracoabdominal'
!
Abdominal'. Stab'Wound' Stab'Wound'
! Red.blood.cell.
! >100,000/ml! >10,000/ml!
(RBC).count.
! White.blood.cell.
! >500/ml!
(WBC).count.
! Amylase..
>19!IU/l!
! level.
! Alkaline.
>2!IU/l!
! phosphatase.level.
! Bilirubin..
>0.01!mg/dl!
level.
! !
! !
! • Blunt!abdominal!trauma!initially!is!evaluated!by!FAST!
! (Refer!to!Figure'22)!exam!in!major!trauma!centers!
! • FAST!is!not!100%!sensitive!so!diagnostic!peritoneal!
aspiration!is!still!advocated!in!hemodynamically!

unstable!patients!without!a!defined!source!of!blood!loss! tracheostomy!should!be!performed.!
to!rule!out!abdominal!hemorrhage! !
! 2. A!patient!presents!with!stable!vital!signs!and!respiratory!
Figure'22.!FAST!is!used!to!identify!free!intraperitoneal!fluid!in!!!!!!!!!!!!!!!!!!!!!! distress!after!a!stab!wound!to!the!chest.!Chest!tubes!are!
(1)!subxiphoid/pericardium,!(2)!Morison's!pouch/hepatorenal!recess,!! placed!and!an!air!leak!is!noted.!The!patient!is!electively!
(3)!left!upper!quadrant/perisplenic,!and!(4)!pelvis.!Although!this!method! intubated.!The!patient!arrests!after!positive!pressure!
is!!sensitive!for!detecting!intraperitoneal!fluid!of!>250!ml,!it!does!not!
ventilation!is!started.!What!is!the!most!likely!diagnosis?!
reliably!determine!the!source!of!bleeding!nor!grade!solid!organ!injuries.!
! a. Unrecognized!hemorrhage!in!the!abdomen!
! b. Tension!pneumothorax!
! c. Pericardial!tamponade!
! d. Air!embolism!
! !
! Answer:!D!
! Air'emboli!can!occur!after!blunt!or!penetrating!trauma,!
! when!air!from!an!injured!bronchus!enters!an!adjacent!
! injured!pulmonary!vein!and!returns!air!to!the!left!heart.!
! Air!accumulation!in!the!left!ventricle!impedes!diastolic!
! filling,!and!during!systole!air!is!pumped!into!the!
! coronary!arteries,!disrupting!coronary!perfusion.!!
! Patient!should!be!placed!in!Trendelenburg’s!position!to!
! trap!the!air!in!the!apex!of!the!left!ventricle.!Emergency!
! thoracotomy!is!followed!by!cross!clamping!(left+picture)!
! of!the!pulmonary!hilum!on!the!side!of!the!injury!to!
! prevent!further!introduction!of!air.!Air!is!aspirated!from!
! the!apex!of!the!left!ventricle!and!the!aortic!root!with!an!
! 18Bg!needle!and!50Bml!syringe!(right+picture).!Vigorous!
massage!is!used!to!force!air!bubble!through!the!coronary!
• Patients!with!fluid!on!FAST!examination,!considered!a!
arteries.!If!unsuccessful,!a!tuberculin!syringe!may!be!
"positive!FAST,"!who!do!not!have!immediate!indications!
used!to!aspirate!air!from!the!right!coronary!artery.!Once!
for!laparotomy!and!are!hemodynamically!stable!
circulation!is!restored,!patient!should!be!kept!in!
undergo!CT!scanning!to!quantify!their!injuries!
Trendelenburg’s!with!the!pulmonary!hilum!clamped!
• Management!algorithm!for!blunt!abdominal!injury!
until!pulmonary!venous!injury!is!controlled!operatively.!
patients!is!shown!in!Figure'23!
!
!
Figure'23.'Algorithm!for!the!initial!evaluation!of!a!patient!with!suspected!
!
blunt+abdominal+trauma.!CT!=!computed!tomography;!DPA!=!diagnostic! !
peritoneal!aspiration;!FAST!=!focused!abdominal!sonography!for! !
trauma/focused!assessment!with!sonography!for!trauma;!Hct=hematocrit! !
!
!
!
! !
! !
! !
! !
! !
! !
! !
! !
! 3. Which!of!the!following!is!the!expected!blood!loss!in!a!
√ 'QUICK'REVIEW!a! patient!with!6!rib!fractures?!
' a. 240!ml!
• Tachycardia!is!the!earliest!sign!of!ongoing!blood!loss! b. 480!ml!
• Adequate!urine!output!is!0.5'ml/kg/hr!in!an!adult,!1' c. 750!ml!
ml/kg/hr!in!a!child,!and!2'ml/kg/hr!in!an!infant+<1+year+ d. 1500!ml!
of+age+ !
• Secondary.survey.consists!of!“AMPLE”'(Allergies,' Answer:!C!
Medications,'Past'illnesses'or'Pregnancy,'Last'meal,' For'each'rib'fracture,'there'is'~100S200'ml'of'blood'
and'Events'related'to'the'injury)+ loss;!for!tibial!fractures,!300B500!ml;!for!femur!fractures,!
! 800B1000!ml;!and!for!pelvic!fractures,!>1000!ml.!
' Although!no!single!injury!may!appear!to!cause!a!patient’s!
' hemodynamic!instability,!the!sum!of!the!injuries!may!
' result!in!lifeBthreatening!blood!loss!
! !
'''''''REVIEW'QUESTIONS!a! !
! !
1. Which!of!the!following!trauma!patients!with!airway! BURNS''
compromise!and!failed!endotracheal!intubation!should! '
undergo!emergency!tracheostomy!(rather!than!a! A. Classification'of'Burns'
cricothyroidotomy)?! B. Burn'Depth'
a. 84!y/o!male!with!blunt!trauma!to!the!neck! C. Initial'Evaluation'of'Burns'
b. 65!y/o!female!with!a!stab!wound!to!the! D. Management'of'Burns'
submandibular!region! E. Inhalational'Injury'
c. 16!y/o!male!with!a!gun!shot!wound!to!the!neck! !
d. 6!y/o!female!with!a!crush!injury!to!the!face! !
! A.'CLASSIFICATION'OF'BURNS'
Answer:!D! 1. Thermal!
In!patients!under'the'age'of'8,!cricothyroidotomy!is!
contraindicated!due!to!the!risk!of!subglottic!stenosis,!and!
•Flame:!Most'common'cause!for!hospital!admission;! a!dense!matrix!of!proteins!
highest!mortality!(due!to!association!with!inhalational! o Stratum.Lucidum!is!only'found'in'regions'of'
injury!and/or!Carbon!Monoxide!(CO)!poisoning)! thick'stratum'corneum!of!palms!and!soles;!
• Contact. not!found!in!thin!skin!
• Scald. o Stratum.Granulosum!is!polygonal!cells!with!
. basophilic!keratohyalin!granules;!1'layer'in'
2. Electrical! thin'skin'while'multiple'layers'in'thin'skin!
• Potential!for!cardiac.arrhythmias;!do!baseline!ECG!i! o Stratum.Spinosum!is!a!multilaminar!layer!of!
• Compartment.syndromes!with!concurrent! cuboidalBlike!cells!that!are!bound!together!by!
rhabdomyolysis!is!more!common!in!highBvoltage! means!of!numerous!desmosomal!junctions!
injuries;!check!for!neurologic!or!vascular!compromise!! (tonofibrils)!and!they!produce!keratin!
• LongBterm!neurologic!and!visual!symptoms!are!also! o Stratum.Basale/germinativum!is!a!
common!and!thus,!neurologic!and!ophthalmologic! mitotically'active,!single!layer!of!columnar!or!
consultation!should!be!done! cuboidal!cells!attached!to!the!dermis!via!
! hemidesmosome!
3. Chemical! o Mnemonics:!“Californians!Like!Girls!in!!String!
• Less!common!but!usually!severe! Bikinis”!
• Offending!agents!can!be!systematically!absorbed;!may! • Dermis!is!the!connective!tissue!layer!below'the'
cause!specific!metabolic!derangements! epidermis!and!its!basement!membrane,!consisting'of'2'
• Careful!removal!of!toxic!substance!from!patient!and! layers:'
irrigation!of!the!affected!area!with!water!(~30!mins)! o Papillary.layer!appears!loose!that!fills!the!
EXCEPT!in!cases!of!concrete!powder!or!powdered!forms! hollows!at!the!deep!surface!of!the!epidermis!
of!lye,!which!should!be!swept!from!the!patient!instead! with!frequent!capillaries!
to!avoid!activation!of!AlOH!with!water! o Reticular.layer!appears!denser!and!contains!
! fewer!cells!
B.'BURN'DEPTH'☺' • Hypodermis!is!a!layer!of!loose!vascular!connective!
• Burn!wounds!are!commonly!stratified!according!to! tissue!infiltrated!by!adipocytes!
depth!as!superficial,+partial+thickness,+full+thickness,+and+ !
fourth+degree+burns,!which!affect!underlying!soft!tissue!! !
• They!are!also!described!according!to!zone!of!tissue! !
injury!(Refer!to!Table'34)! !
' !
1. Superficial.(First.degree.burn)! !
!
• Painful!but!DO!NOT!blister!!
2. Partial.thickness.(Second.degree.burn)! !
!
• Extremely!painful!with!weeping!and!blisters!
!
• Classified!as!either!superficial+or!deep+depending!on!the!
!
depth!of!dermal!involvement!
!
o Superficial:!Heals!with!expectant!management!
!
o Deep:!Requires!excision!and!skin!grafting!
!
!
!
3. Full.thickness.(Third.degree.burn)!
!
• Painless,!hard,!and!nonBblanching! !
!
!
4. Fourth.degree.burn!
!
• Affects!underlying!soft!tissue+ !
! !
Table'34.!Jackson’s!three!zones!of!tissue!injury!following!burn!
!
Jackson’s'three'zones'of'tissue'injury'following'burn'
• Most!severely!burned!area!(typically!the!
C.'INITIAL'EVALUATION'OF'BURNS'
Zone.of. center!of!the!wound)! 1. Airway.management!
Coagulation' • Affected!tissue!is!coagulated!and!sometimes! • With!direct!thermal!injury!to!the!upper!airway!and/or!
necrotic,!and!will!need!excision!and!grafting! smoke!inhalation!(perioral+burns,+signed+nasal+hairs),!
• Between!the!first!and!third!zones!with!local! rapid'and'severe'airway'edema!is!a!potentially!lethal!
response!of!vasoconstriction!and!ischemia! threat!
• It!has!marginal!perfusion!and!questionable! • Anticipating!the!need!for!intubation!and!establishing!an!
viability! early!airway!is!critical!
Zone.of.Stasis.
• Resuscitation!and!wound!care!may!help!
• Signs!of!impending!respiratory!compromise:!hoarse+
prevent!conversion!to!a!deeper!burn!
• Burn!wounds!evolve!over!48B72!hours!after!
voice,+wheezing,+or+stridor+
injury! !
• Outermost!area,!usually!heals!with!minimal!or! 2. Evaluation.of.other.injuries!
Zone.of. Burn!patients!should!be!first'considered'
no!scarring!! •
Hyperemia.
• There!is!increased!blood!flow!in!this!area! traumapatients!(especially!when!details!of!the!injury!
! are!unclear),!as!such,!a!primary!survey!should!be!
! conducted!!
! • An!early!and!comprehensive!secondary!survey!must!
! also!be!performed!in!all!burn!patients!
⊗ ANATOMY!a! • Urgent!radiology!studies!(i.e.!CXR)!should!be!performed!
LAYERS'OF'THE'SKIN' in!the!ER,!but!non!urgent!skeletal!evaluation!(i.e.!
• Epidermis!is!the!outermost'layer!of!the!integument! extremity!XBrays)!can!be!done!later!to!avoid!
composed!of!stratified!squamous!epithelial!layer!that!is! hypothermia!and!delays!in!burn!resuscitation!
devoid!of!blood!vessels,!consisting'of'4S5'layers:! !
o Stratum.Corneum!is!a!superficial!stratum!later! 3. Estimation.of.burn.size!
consisting!of!flat,!anucleated!and!keratinized!
cells!filled!with!keratin!filaments!embedded!in!

• Most!burn!resuscitation!formulas!estimate!fluid! • Therefore,!if!a!patient!receives!large!fluid!bolus!in!a!
requirements!using!the!burn!size!as!%Total.Body. prehospital!setting!or!ER,!that!fluid!has!likely!
Surface.Area.(TBSA). leaked!into!the!interstitium!and!the!patient!will!still!
• “Rule'of'nines”!is!a!crude!but!quick!and!effective! require!ongoing!burn!resuscitation!
method!of!estimating!burn!size!(Refer!to!Figure'24'☺)! • Several!formulas!are!available!to!compute!for!the!
• Thorough!cleaning!of!soot!and!debris!is!mandatory!to! total!fluid!requirement!but!among!the!most!widely!
avoid!confusing!areas!of!soiling!with!burns! used!one!is!the!Parkland.formula(Refer!to!Table'
• Superficial.(first.degree).burns!SHOULD!NOT!be! 36'☺).
included!when!calculating!the!%TBSA! .
! Table'36.!Parkland!formula!☺!
Figure'24.'Rule!of!nines!to!estimate!burn!size!☺! Parkland'formula'
! Total'fluid'requirement*'='4'mg/kg'per'%TBSA'burn'
! ½!volume!during!first!8'hours' ½!during!next!!!!!!!!!!!!!!!!!!!!!!!!!!!!!16'
! postSinjury! hours'postSinjury!
*Use!of!lactated!ringer’s!solution!
!
! !
! • Continuation!of!fluid!volumes!should!depend!on!
! the!time'since'injury,'UO,'and'MAP!
! • As!the!leak!closes,!!patient!will!require!less!volume!
! to!maintain!the!UO!and!BP!
! o Target!MAP:!60'mmHg!to!ensure!optimal!
! endBorgan!perfusion!
! o Target!UO:30'cc/h'in'adults'and'1'to'1.5'
! cc/kg/hr'in'pediatric'patients!
! • Maintenance'IV'fluid'with'glucose'
! supplementation!in!addition!to!the!calculated!
! resuscitation!fluid!with!LR!is!given!in!children'
! under'20'kg'
! o They!do!not!have!sufficient!glycogen!
! stores!to!maintain!an!adequate!glucose!
! level!in!response!to!the!inflammation.!
! • Blood!transfusions!be!used!only!when!there!is!an!
! apparent!physiologic!need!
4. Diagnosis.of.Carbon.Monoxide.and.Cyanide.poisoning! !
# Unexpected!neurologic!symptoms!should!raise!the!level! !
of!suspicion!for!CO.poisoning! 3. Treatment.of.burn.wound!
o Affinity!of!CO!for!hemoglobin!is!200B250x! # Patients!with!acute!burn!injuries!should!NEVER!receive!
more!than!that!of!O2,!which!decreases!the! prophylactic!oral/IV!antibiotics!
levels!of!normal!oxygenated!hemoglobin!and! # This!intervention!has!been!clearly!demonstrated!to!
can!quickly!lead!to!anoxia!and!death! promote!development!of!fungal!infections!and!resistant!
o Treatment'||Administration!of!100%!oxygen! organisms!
is!the!gold!standard,!and!reduces!the!halfBlife! # Silver'sulfadiazine:!most!widely!used!
of!CO!from!250!mins!in!room!air!to!40B60!mins! o Wide!range!of!antiBmicrobial!activity,!
# Cyanide.poisoning!is!seen!in!smoke!inhalation!injury! primarily!as!topical!prophylaxis!against!burn!
o May!have!lactic!acidosis!or!ST!elevation! wound!infections!rather!than!treatment!of!
o Cyanide!inhibits!cytochrome!oxidase,!which!in! existing!infection!
turn!inhibit!cellular!oxygenation! o Not!significantly!absorbed!systemically!
o Treatment'||Consists!of!sodium'thiosulfate,' o Side.effects.||Neutropenia!as!a!result!of!
hydroxocobalamin,'and'100%'oxygen! neutrophil!margination!due!to!the!
! inflammatory!response!to!burn!injury!
D.'MANAGEMENT'OF'BURNS' o Destroy!skin!grafts!and!is!contraindicated!on!
1. Referral.to.a.burn.center.(Refer!to!Table'35)! burns!in!proximity!to!newly!grafted!areas!
! # Others:!Mafenide!acetate,!Silver!nitrate,!Bacitracin,!
Table'35.!Guidelines!for!referral!to!a!burn!center! Neomycin,!and!Polymyxin!B!
Guidelines'for'referral'to'a'burn'center' # Pain'management'
1. Partial!thickness!burns!greater!than!10%!TBSA! o Important!to!administer!an!anxiolytic!such!as!
2. Burns!involving!the!face,!hands,!feet,!genitalia,!perineum,!or! benzodiazepine!with!the!initial!narcotics!
major!joints! !
3. Third!degree!burns!in!any!age!group! 4. Complications.of.burn!
4. Electric!burns!(including!lightning!injury)! • Hypothermia!is!one!of!the!common!preBhospital!
5. Chemical!burns!
complications!that!contributes!to!resuscitation!failure!
6. Inhalational!injury!
o Patients!should!be!kept!wrapped!with!clean!
7. Patients!with!complicated!preexisting!medical!disorders!
blankets!
8. Patients!with!burns!and!concomitant!trauma!in!which!the!burn!
is!the!greatest!risk! • VentilatorSassociated'pneumonia,!like!all!critically!ill!
9. Burned!children!in!hospitals!without!qualified!personnel!for! patients,!is!a!significant!problem!in!burn!patients!
the!care!of!children! o Simple!measures!such!as!elevating!the!head!of!
10. Burn!injury!in!patients!who!will!require!special!social,! the!bed!and!maintaining!excellent!oral!hygiene!
emotional,!or!rehabilitative!intervention! and!pulmonary!toilet!are!recommended!to!
! help!decrease!the!risk!of!postinjury!
2. Resuscitation! pneumonia!
• Rationale:!Burn!(and/or!inhalational!injury)!drives! 4.!Complications.of.burn(continuation)!
inflammatory!response!that!leads!to!capillary'leak! • Massive!resuscitation!of!burn!patients!may!lead!to!an!
• As!the!plasma!leaks!into!the!extravascular!space,! abdominal'compartment'syndrome''
crystalloid'administration'maintains'the' o Characterized!by!increased!airway!pressures!
intravascular'volume! with!hypoventilation,!and!decreased!urine!
output!and!hemodynamic!compromise!
o Treatment'||Decompressive'laparotomy!is! • Physiologic!effects!include!decrease!lung!compliance,!
the!standard!of!care!for!refractory!abdominal! increase!airway!resistance!work!of!breathing,!increase!
compartment!syndrome!but!carries!an! overall!metabolic!demands,!and!an!increase!in!fluid!
especially!lethal!prognosis!in!burn!patients! requirements!during!resuscitation!of!patients!with!burn!
o Adjunctive!measures!such!as!minimizing!fluid,! injuries!!
performing!truncal!escharotomies,!decreasing! • Treatment'||Supportive!care!including!aggressive!
tidal!volumes,!and!chemical!paralysis!should! pulmonary!toilet,!routine!use!of!nebulized!agents!(e.g.!
be!initiated!before!resorting!to!decompressive! Salbutamol)!and!ventilation!for!ARDS!
laparotomy! !
• Burn!patients!may!be!at!higher!risk!for!catheterS '''''''REVIEW'QUESTIONS!a!
related'bloodstream'infections! !
• Full!thickness!burns!with!a!rigid!eschar!can!form!a! 1. Which!of!the!following!patients!should!be!immediately!
tourniquet!effect!as!the!edema!progresses,!leading!to! referred!to!a!burn!center?!
compromised!venous!outflow!and!eventually!arterial! a. 20!y/o!with!a!12%!partial!thickness!burn!
inflow,!leading!to!compartment'syndrome! b. 30!y/o!with!a!major!liver!injury!and!a!15%!
o Common!in!circumferential!extremity!burns! partial!thickness!burn!
o Warning!signs!include!paresthesia,+pain,+ c. 2%!TBSA!partial!thickness!burn!to!the!anterior!
decreased+capillary+refill,+and+progression+to+ leg,!crossing!the!knee!
loss+of+distal+pulses+ d. 10!y/o!with!a!7%!partial!thickness!burn!
+ !
5. Nutrition.of.burn.patients! Answer:!A!
# Burn!injury!causes!a!hypermetabolic'response!raising! All!patients!with!a!partial!thickness!burn!>10%!TBSA!
baseline!metabolic!rates!by!as!much!as!200%,!leading!to! should!be!transferred!to!a!burn!center.!A!patient!with!a!
catabolism'of'muscle'proteins'and'decreased'lean' burn!and!other!major!trauma!can!be!treated!in!the!
body'mass!that!delay!functional!recovery! trauma!center!first.!Burns!that!involve!the!entire!joint!
# Early'enteral'feeding!for!patients!help!prevent!loss!of! should!be!transferred!to!a!burn!center,!but!a!small!burn!
lean!body!mass,!slow!the!hypermetabolic!response,!and! to!the!anterior!surface!of!the!knee!would!not!necessarily!
result!in!a!more!efficient!protein!metabolism! mandate!transfer.!Children!should!be!transferred!if!there!
# If!enteral!feeds!are!started!within!the!first!few!hours! are!no!personnel!able!to!care!for!them,!but!for!a!child!
after!admission,!gastric'ileus!can!often!be!avoided! with!a!7%!TBSA!burn,!this!would!not!be!mandatory!!
! (Refer!to!Table'35)!
6. Surgery! !
# Escharotomies!are!rarely!needed!within!the!first!8! 2. Which!of!the!following!is!indicated!in!a!46!y/o!patient!
hours!following!injury!and!SHOULD!NOT!be!performed! with!a!22%!TBSA!partial!thickness!burn?!
unless!indicated!because!of!the!aesthetic!sequelae! a. Prophylactic!1st!generation!cephalosporin!
# Burn'excision'and'wound'coverage!should!ideally! b. Prophylactic!clindamycin!
start!within!the!first!several!days,!and!in!larger!burns,! c. Tetanus!booster!
serial!excisions!can!be!performed!as!the!patient’s! d. Tetanus!toxoid!
condition!allows! !
# Excision!is!performed!with!repeated!tangential!slices! Answer:!C!
until!only!non!burned!tissue!remains! Patients!with!acute!burn!injuries!should!never!receive!
# It!is!appropriate!to!leave!healthy!dermis,!which!will! prophylactic!antibiotics.!This!intervention!promote!
appear!white!with!punctate!areas!of!bleeding! development!of!fungal!infections!and!resistant!
! organisms!and!was!abandoned!in!the!midB1980s.!A!
7. Wound.coverage/.Grafts! tetanus'booster!should!be!administered!in!the!ER.!
• Split!thickness!sheet!autografts!make!the!most!durable! !
wound!coverings!! 3. Formic!acid!burns!are!associated!with?!
# In!larger!burns,!meshing!of!autografted!skin!provides!a! a. Hemoglobinuria!
larger!area!of!wound!coverage,!allowing!drainage!of! b. Rhabdomyolosis!
blood!and!serous!fluid!to!prevent!accumulation!under! c. Hypocalcemia!
the!skin!graft!with!subsequent!graft!loss! d. Hypokalemia!
! !
8. Rehabilitation! Answer:!A!
# Should!be!initiated!on!admission! The!offending!agents!in!chemical!burns!can!be!
# Immediate!and!ongoing!physical!and!occupational! systematically!absorbed!and!may!causes!specific!
therapy!is!mandatory!to!prevent!loss!of!physical! metabolic!derangements.!Formic'acid!has!been!known!
function! to!cause!hemolysis!and!hemoglobinuria.!
! !
E.'INHALATIONAL'INJURY' 4. The!major!improvement!in!burn!survival!in!the!20th!
• Commonly!seen!in!tandem!with!burn!injuries! century!can!be!attributed!to!the!introduction!of!which!of!
• Drastically!increase!mortality!in!burn!patients! the!following!therapies?!
• Causes!injury!in!2!ways:! a. Antibiotics!
o Direct'heat'injury'to'the'upper'airways' b. Central!venous!fluid!resuscitation!
# Leads!to!maximal!edema!in!the!first! c. Nutritional!support!
24!to!48!hours!after!injury! d. Early!excision!of!the!burn!wound!
# Will!require!short!course!of! !
endotracheal!intubation!for!airway! Answer:!D!
protection! !
o Inhalation'of'combustion'products'into'the' !
lower'airways' WOUND'HEALING'
# Irritants!(combustion!products)! '
cause!direct!mucosal!injury!leading! A. Classification'of'Wound'Healing'
to!mucosal!sloughing,!edema,! B. Normal'Phases'of'Wound'Healing'
reactive!bronchoconstriction,!and! C. Classification'of'Wounds'
eventually!obstruction!of!the!lower! !
airways!
! interaction!and!intercellular!adhesion!
A.'CLASSIFICATION'OF'WOUND'HEALING' molecules!
• Surgical!wounds!can!heal!in!several!ways! !
(Refer!to!Figure'25'☺)! # T'lymphocytes'
o Primary.intention:!an!incised!wound!that!is! o Less!numerous!than!macrophages!
clean!and!closed!by!sutures! o Peak'at'about'1'week'post'injury!and!truly!
o Secondary.intention:!Because!of!bacterial! bridge!the!transition!from!the!inflammatory!to!
contamination!or!tissue!loss,!a!wound!will!be! the!proliferative!stage!of!wound!healing!
left!open!to!heal!by!granulation!tissue! o Role!is!not!fully!defined!
formation!and!contraction! o Theory!is!that!they!play!an!active!role!in!
o Tertiary.intention.or.delayed.primary. modulation!of!the!wound!environment!
closure:!represents!a!combination!of!the!first! o Exert!a!downregulating!effect!on!fibroblast!
two,!consisting!of!the!placement!of!sutures,! collagen!synthesis!by!cellBassociated!
allowing!the!wound!to!stay!open!for!a!few! interferonBgamma,!TNF!alpha,!and!IL1!
days,!and!the!subsequent!closure!of!the! !
sutures! Figure'26.'Phases!of!wound!healing!
!
Figure'25.'Different!clinical!approaches!to!the!closure!and!healing!of!
acute!wounds!☺!!!!!!!
!
!
2.!Proliferation!
# Roughly!spans!day'4'through'12'
# Phase!where!tissue!continuity!is!reBestablished!
# Fibroblasts!and!endothelial!cells!are!the!last!cell!
populations!to!infiltrate!the!healing!wound!
! # Strongest!chemotactic!factor!for!fibroblasts!is!PDGF!
B.'NORMAL'PHASES'OF'WOUND'HEALING'☺'
# Upon!entering!the!wound!environment,!recruited!
• Normal!wound!healing!follows!a!predictable!pattern! fibroblasts!first!need!to!proliferate,!and!then!become!
that!can!be!divided!into!three!overlapping!phases:! activated,!to!carry!out!their!primary!function!of!matrix!
1. Hemostasis+and+inflammation+ synthesis!remodeling!
2. Proliferation+ # Fibroblasts!from!wounds!synthesize!more!collagen,!
3. Maturation+and+remodeling+ proliferate!less,!and!actively!carry!out!matrix!
! contraction!
1.!Hemostasis.and.Inflammation! o Type'I'collagen!is!the!major!component!of!
# Hemostasis!precedes!and!initiates!inflammation!with! extracellular!matrix!in!skin!
the!ensuing!release!of!chemotactic!factors!from!wound! o Type'III,!which!is!also!normally!present!in!
site! skin,!becomes!more!prominent!and!important!
# Cellular!infiltration!after!injury!follows!a!characteristic,! during!the!repair!process!
predetermined!sequence! # Endothelial!cells!also!proliferate!extensively!during!this!
o PMNs!are!the!first'infiltrating'cells!to!enter! phase!of!healing,!participating!in!angiogenesis,!under!
the!wound!site,!peaking'at'24'to'48'hours,! the!influence!of!cytokines!and!growth!factors!such!as!
stimulated!by!increased!vascular!permeability,! TNFBalpha,!TGFBbeta,!and!VEGF!
local!prostaglandin!release,!and!the!presence! # Macrophages!represent!a!major!source!of!VEGF!
of!chemotactic!substances! !
o These!cells!DO!NOT!play!a!role!in!collagen! 3.!Maturation.and.Remodeling!
deposition!and!collagen!synthesis! # Begins'during'the'fibroplastic'phase'
! # Characterized!by!a!reorganization!of!previously!
# Macrophages!(Refer!to!Figure'26)' synthesized!collagen!
o Recognized!to!be!essential!in!successful! # Collagen!is!broken!down!by!matrix.metalloproteases,!
wound!healing! and!the!net!wound!collagen!content!is!the!result!of!a!
o Achieve'significant'numbers'by'48'to'96' balance!between!collagenolysis!and!collagen!synthesis!
hours'post'injury'and'remain'present'until' # There!is!a!net!shift!toward!collagen!synthesis!and!
wound'healing'is'complete' eventually!the!reBestablishment!of!extracellular!matrix!
o Participate!in!wound!debridement!via! composed!of!a!relatively!acellular!collagenBrich!scar!
phagocytosis! # Wound!strength!and!mechanical!integrity!in!the!fresh!
o Contribute!to!microbial!stasis!via!oxygen! wound!are!determined!by!both'the'quantity'and'
radical!and!nitric!oxide!synthesis! quality'of'the'newly'deposited'collagen'
o Activation!and!recruitment!of!other!cells!via! # The!deposition!of!matrix!at!the!wound!site!follows!a!
mediators!as!well!as!directly!by!cellBcell! characteristic!pattern:!fibronectin!and!collagen+type+III!

constitute!the!early!matrix!scaffolding,! !
Glycosaminoglycans!and!proteoglycans!represent!the! !
next!significant!matrix!components,!and!collagen+type+I! !
is!the!final!matrix! !
# By!several!weeks!post!injury,!the!amount!of!collagen!in! !
the!wound!reaches!a!plateau,!but!the!tensile!strength! !
continues!to!increase!for!several!more!months! !
# Scar!remodeling!continues!for!6!to!12!months!post! !
injury,!gradually!resulting!in!a!mature,!avascular,!and! !
acellular!scar! !
# Mechanical'strength'of'the'scar'never'achieves'that' !
of'the'uninjured'tissue' !
! !
! !
4.!Epithelialization! !
# While!tissue!integrity!and!strength!are!being!reB !
established,!the!external!barrier!must!also!be!restored! !
# Characterized!primarily!by!proliferation'and' 2. Chronic!
migration'of'epithelial'cells'adjacent'to'the'wound! • Defined!as!wounds!that!have!failed!to!proceed!through!
# Process!begin'within'day'1'of'injury!and!is!seen!as! the!orderly!process!that!produces!satisfactory!anatomic!
thickening!of!epidermis!at!the!wound!edge! and!functional!integrity!or!that!have!proceeded!through!
# ReBepithelialization!is!complete'in'less'than'48'hours! the!repair!process!without!producing!an!adequate!
in!the!case!of!approximated!incised!wounds,!but!may! anatomic!and!functional!result!
take!longer!in!case!of!larger!wounds,!in!which!there!is!a! • Wounds!that!have!NOT!healed!in!3'months!
significant!epidermal/dermal!defect! !
# Mediated!by!a!combination!of!a!loss!of!contact! Table'37.!Factors!affecting!wound!healing!
inhibition,!exposure!to!constituents!of!the!extracellular! Factors'affecting'wound'healing'
matrix,!particularly!fibronectin,!and!cytokines!produced! Systemic'
by!immune!mononuclear!cells! Age!
! Nutrition!
5.!Wound.Contraction! Trauma!
# All!wounds!undergo!some!degree!of!contraction! Metabolic!diseases!
Immunosuppression!
# Starts'almost'immediately'after'injury!despite!the!
Connective!tissue!disorders!
absence!of!myofibroblasts!
Smoking!
# For!wounds!that!do!not!have!surgically!approximated! Local'
edges,!the!area!of!the!wound!will!be!decreased!by!this! Mechanical!injury!
action!(healing!by!secondary!intention),!the!shortening! Infection!
of!the!scar!itself!results!in!contracture! Edema!
# Myofibroblast!has!been!postulated!as!being!the!major! Ischemic/necrotic!tissue!
cell!responsible!for!contraction,!and!it!differs!from!the! Topical!agents!
normal!fibroblast!in!that!it!possesses!a!cytoskeletal! Ionizing!radiation!
structure! Low!oxygen!tension!
! Foreign!bodies!
C.'CLASSIFICATION'OF'WOUNDS' !
1. Acute! !
• Heal!in!a!predictable!manner!and!time!frame! √ 'QUICK'REVIEW!a!
• Process!occurs!with!few!complications!and!the!end! '
result!is!a!wellShealed'wound! • Normal!wound!healing!follows!a!predictable!pattern!that!
• Normal!process!of!wound!healing!is!characterized!by!a! can!be!divided!into!three!overlapping!
constant!and!continual!increase!that!reaches!a!plateau! phases:Hemostasis'and'inflammation,'Proliferation,'
at!some!point!post!injury! and'Maturation'and'remodeling!
• Wounds'with'delayed'healing!are!characterized!by! • PMNs!are!the!first!infiltrating!cells!to!enter!the!wound!
decreased!wound!breaking!strength!in!comparison!to! site,!peaking!at!24!to!48!hours!
wounds!that!heal!at!a!normal!rate,!however,!they! • Myofibroblast!has!been!postulated!as!being!the!major!
eventually!achieve!the!same!integrity!and!strength!as! cell!responsible!for!contraction!
wounds!that!heal!normally! '
• Delayed.healing!is!caused!by!conditions!such!as! !
nutritional!deficiencies,!infections,!or!severe!trauma! '''''''REVIEW'QUESTIONS!a!
which!reverts!to!normal!with!correction!of!the! !
underlying!pathophysiology!(Refer!to!Figure'27)! 1. The!peak!number!of!fibroblasts!in!a!healing!wound!
• Impaired.healing!is!characterized!by!a!failure!to! occurs?!
achieve!mechanical!strength!equivalent!to!normally! a. 2!days!post!injury!
healed!wounds! b. 6!days!post!injury!
• Patients!with!compromised!immune!system!(diabetics,! c. 15!days!post!injury!
chronic!steroid!usage,!tissues!damaged!by! d. 60!days!post!injury!
radiotherapy)!are!prone!to!impaired!healing! !
(Refer!to!Table'37)! Answer:!B!
! See!Figure!26!
Figure'27.'The!acquisition!of!wound!mechanical!strength!over!time!in! !
normal,!delayed,!and!impaired!healing! 2.
The!first!cells!to!migrate!into!a!wound!are:!
! a. Macrophages!
! b. T!Lymphocytes!
! c. PMNs!
! d. Fibroblasts!
! !
!
Answer:!C! !
PMNs!are!the!1st!infiltrating!cells!to!enter!the!wound!site,! '
peaking!at!24B48!hours.!Increased!vascular!permeability,! ORGAN'SYSTEM'PATHOLOGIES!
local!prostaglandin!release!and!the!presence!of! !
chemotactic!substances,!such!as!complement!factors,!ILB SKIN'AND'SOFT'TISSUES'
1,!TNFBalpha,!TGF!beta,!platelet!factor!4,!or!bacterial!
'
products,!all!stimulate!neutrophil!migration.!
A. Anatomy'and'Physiology'of'the'Skin'
!
B. Injuries'to'the'Skin'and'subcutaneous'
3. The!tensile!strength!of!a!completely!healed!wound!
C. Infections'of'the'skin'and'the'subcutaneous'
approaches!the!strength!of!uninjured!tissue?!
D. Inflammatory'diseases'of'the'skin'and'
a. 2!weeks!after!injury!
subcutaneous'
b. 3!months!after!injury!
E. Benign'tumors'of'the'skin'and'subcutaneous'
c. 12!months!after!injury!
F. Malignant'tumors'of'the'skin'
d. NEVER!
G. Syndromic'skin'malignancies'
!
Answer:!D! !
By!several!weeks!postinjury,!the!amount!of!collagen!in! !
the!wound!reaches!a!plateau,!but!the!tensile!strength! !
continues!to!increase!for!several!more!months.!Fibril! !
formation!and!fibril!crossBlinking!result!in!decreased! !
collagen!solubility,!increased!strength!and!increased! !
resistance!to!enzymatic!degradation!of!the!collagen! !
matrix.!Scar!remodeling!continues!for!many!months!(6B
!
12)!postBinjury,!gradually!resulting!in!a!mature,!
!
avascular!and!acellular!scar.!The!mechanical!strength!of!
A. ANATOMY'AND'PHYSIOLOGY'OF'THE'SKIN'
the!scar!never!achieves!that!of!the!uninjured!tissue.!!
'
!
4. Which!layer!of!the!intestine!has!the!greatest!tensile! ''√ 'QUICK'REVIEW!a!
strength!(ability!to!hold!sutures)?! Layers'of'the'skin'–'p.'26'
! Phases'of'wound'healing'–'p.'29'
a. serosa!
b. muscularis! '
c. submucosa! • Epidermis.
d. mucosa! o Keratinocyte'transit'time!(basal!layer!to!
shedding)!is!approximately'40'to'56'days.!
Answer:!C' o Melanocytes!
The!submucosa!is!the!layer!that!imparts!the! # Derived!from!precursor!cells!of!the!neural!
greatest!tensile!strength!and!gretest!sutureBholding! crest/neuroectodermal!in!origin!
capacity,!a!characteristic!that!should!be!kept!in! # Produce!melanin!from!tyrosine'and'cysteine!
mind!during!surgical!repair!of!GI!tract.!Additionally,! # Despite.differences.in.skin.tone,.the.density.
serosal!healing!is!essential!for!quickly!achieving!a! of.melanocytes.is.constant.among.
watertight!seal!from!the!luminal!side!of!the!bowel.! individuals..It.is.the.rate.of.melanin.
The!importance!of!the!serosa!is!underscored!by!the! production,.transfer.to.keratinocytes,.and.
significantly!higher!rates!of!anastomotic!failure! melanosome.degradation.that.determine.
observed!clinically!in!segments!of!bowel!that!are! the.degree.of.skin.pigmentation+
extraperitoneal!and!lack!serosa!(ex.!Esophagus!and! # Cutaneous!melanocytes!play!a!critical!role!in!
rectum)! neutralizing!the!sun's!harmful!rays.+
! # UVSinduced'damage!affects!the!function!of!
5. A!20!year!old!male!presents!to!the!ER!with!large! tumor'suppressor'genes,!directly!causes!cell!
contaminated!laceration!received!during!a!touch! death,!and!facilitates!neoplastic!
football!game.!It!has!been!irrigated!with!normal!saline! transformation.'!+
and!subsequently!debrided.!Which!suture!should!be! +
used!to!close!the!subcutaneous!layer?! √'√ 'QUICK'REVIEW!a!
! What!factors!increase!melanin!production?!
a. biologic!absorbable!monofilament!(plain!gut)! 1. UV!radiation!
b. synthetic!absorbable!monofilament! 2. Estrogen!
c. absorbable!braided! 3. Adrenocorticotropic!hormone!
d. none!of!the!above! 4. MelanocyteBstimulating!hormone!
Answer:!C' !
In!general,!the!smallest!suture!required!to!hold!the! o Keratinocytes.
various!layers!of!the!wound!in!approximation! # Primarily!found!in!the!spindle!layer!
should!be!selected!in!order!to!minimize!sutureB # Contains!intermediate!filaments!(keratin)"!
related!inflammation.!Nonabsorbable!or!slowly! provides!flexible!scaffolding!"!resist!external!
absorbing!monofilament!sutures!are!most!suitable! stress!
for!approximating!deep!fascial!layers,!particularly! # Point!mutations!cause!blistering'diseases,!such!
in!the!abdominal!wall.!Subcutaneous!tissues!should! as!epidermolysis'bullosa,!associated!with!
be!closed!with!braided!absorbable!sutures,!with! spontaneous!release!of!dermalBepidermal!
care!to!avoid!placement!of!sutures!in!fat.!Although! attachments.!
traditional!teaching!in!wound!closure!emphasized! o Langerhans’.cells'(not!Langhan’s!cells!)!☺'
multipleBlayer!closures,!additional!layers!of!suture! # skin's!macrophages;!from!the!bone!marrow!
closure!are!associated!with!increased!risk!of!wound! # expresses!class'II'major'histocompatibility'
infection,!especially!when!placed!in!fat.!Drains!may! antigens!"!antigenBpresenting!capabilities.!
be!placed!in!areas!at!risk!of!forming!fluid! # Functions:!
collections.! 1. rejection!of!foreign!bodies!
! 2. immunosurveillance!against!viral!infections!
3. immunosurveillance!against!neoplasms!of! oTrench'foot:!reactive!hyperthermia!with!blistering!
the!skin! as!a!result!of!prolonged!exposure!to!iceBcold!water!
• Dermis. after!rapidly!bringing!it!back!to!normal!
o Collagen!(main!functional!component!of!the!dermis)! temperature'
comprises!70%!of!its!dry!weight! '
o Skin!is!primarily!comprised!of!type!I!collagen! c. Pressure.injury.
o Fetal'dermis!is!primarily!comprised!of!type'III! B 1'hour'of'60'mmHg'pressure!"!can!lead!to!
collagen!(reticulin!fibers)!"!provides!tensile!strength! histologically!identifiable!venous!thrombosis,!muscle!
(property!of!the!skin!that!resists!stretching)!to!both! degeneration,!and!tissue!necrosis'
dermis!and!epidermis! B Pressures:'
• Cutaneous.Adnexal.Structures. $ Normal!arteriole:!32!mmHg!
1. Eccrine'glands:!sweatBproducing!glands!located!over! $ Normal!capillary:!20!mmHg!
the!entire!body!but!are!concentrated!on!the!palms,! $ Normal!venule:!12!mmHg!
soles,!axillae,!and!forehead' $ Sitting:!300!mmHg!
2. Apocrine'glands:!Pheromone!producing!glands! $ Sacral!pressure!at!hospital!mattress!bed:!150!
primarily!found!in!the!axillae'and'anogenital'region.! mmHg!
It!is!these!structures!that!predispose'both'regions'to' B Muscle'tissue'is'more'sensitive'to'ischemia'than'
suppurative'hidradenitis' skin.'Implication:!necrosis!usually!extends!to!a!deeper!
3. hair'follicles:'contains!a!reservoir!of!pluripotential! area!than!that!apparent!on!superficial!inspection'
stem!cells!critical!in!epidermal!reproductivity' B Treatment:'relief!of!pressure,!wound!care,!systemic!
enhancement!(nutritional!optimization)!and!surgical!
' management!(debridement!of!all!necrotic!tissue!
' followed!by!irrigation;!if!shallow!ulcer!"!close!by!
' secondary!intention;!if!deeper!ulcer!"!require!surgical!
' debridement!and!coverage)'
' '
B. INJURIES'TO'THE'SKIN'AND'SUBCUTANEOUS' d. Radiation.exposure.
' B Solar'or'UV'radiation:'most!common!form!of!radiation!
a. Exposure.to.Caustic.substances. exposure'
' B Melanin:!most!important!protective!factor!from!UV!
Table'38.'Difference!between!acidic!and!alkali!injury!☺' related!damage'
Acidic' Alkali' B UV'spectrum:'
Coagulative'necrosis'–'can! Liquefactive'necrosis'–' • UVA'(400'to'315'nm):'majority!of!solar!radiation!
damage!nerves,!blood!vessels! causes!fat!saponification!that!
that!reaches!the!Earth'
and!tendons!but!is!less! facilitates!tissue!penetration!
damaging!compared!to!alkali! and!increases!tissue!damage! • UVB'(315'to'290'nm):'less!than!5%!of!all!solar!UV!
injury! "!producing!a!longer!more! radiation;!responsible!for!acute!sunburn!and!
' sustained!injury!compared!to! chronic!skin!damage!leading!to!malignant!
' acidic!burns! degeneration!(known!risk!factor!in!the!
' ' development!of!melanoma.)!'
Tx:!copious!irrigation!with! Tx:!continuous!irrigation!with! • UVC!(290!to!200!nm):'absorbed!by!the!ozone!layer'
either!saline!or!water!for!30! water!for!2!hours!or!until!
'
minutes! symptomatic!relief!is!
' achieved' C. INFECTIONS'OF'THE'SKIN'AND'THE'SUBCUTANEOUS'
' a. Cellulitis,.Folliculitis,.furuncles.&.carbuncles..
Table'39:'Comparison!of!skin!infections!☺'
B Intravenous.fluid.(IVF).extravasation:'leakage!of!
Cellulitis' Folliculitis' Furuncles' Carbuncles'
injectable!fluids!into!the!interstitial!space'
B!Superficial,! Sinfection!of! Sbegins!as!folliculitis! B!deep!seated!
o Is!considered!a!chemical'burn! spreading! the!hair! but!progresses!as!a! infections!
o Produces!chemical!toxicity,!osmotic!toxicity!and! infection!of!the! follicle! fluctuant!nodule! that!result!in!
pressure!effects!in!a!closed!environment.! skin!and!subQ! Busual!cause:! (boil/furuncle)! multiple!
o Culprits:! Busual!cause:! Staphylococc Btx:!warm!water! draining!
# Cationic!substances:!K,!Ca!and!bicarbonate! Grp.!A!strep!&! us,!followed! hastens!liquefaction! sinuses!
# Osmotically!active!agents:!TPN,!hypertonic! S.!aureus! by!G(B)! &!spontaneous! Btx:!incision!
dextrose!solution! Btx!for! organisms! rupture;!incision! and!drainage!
uncomplicated Btx:!adequate! and!drainage!if!
# Antibiotics! cellulitis!with! hygiene' necessary'
# Cytotoxic!drugs!/!chemotherapeutic'drugs!–! no!morbidities:!
most!common!cause!of!extravasation!in!adults! outpatient!oral!
o Most!common!site!of!extravasation!in!adults:! antibiotics!
dorsum'of'the'hand! '
o Most!common!cause!of!extravasation!in!infants! b. Necrotizing.soft.tissue.infections.
causing!necrosis:!high!concentration!dextrose,!Ca,! B Basis!of!classification:!!
bicarbonate!and!TPN!! • the!tissue!plane!affected!and!extent!of!invasion!
! # necrotizing'fasciitis:!rapid,!extensive!
b. Thermal.injuries.–.hypothermic.vs.hyperthermic. infection!of!the!fascia!deep!to!the!adipose!
injuries. tissue!
' # necrotizing'myositis:!primarily!involves!the!
''√ 'QUICK'REVIEW!a! muscles!but!typically!spreads!to!adjacent!soft!
Jackson’s'3'zones'of'tissue'injury'for'hyperthermic' tissues!
injuries'–'p.'26' • the!anatomic!site!
# Most!common!sites:!the!external!genitalia,!
. perineum,!or!abdominal'wall'(Fournier.
Hypothermic.injuries. gangrene)!
o Severe!hypothermia!primarily!exerts!its!damaging! • the!causative!pathogen'
effect!by!causing!direct!cellular!injury!to!bv!walls! # polymicrobial'more'common'than'single'
and!microvascular!thrombosis.!' organism'infections'
o skin's!tensile!strength!decreases!by!20%!in!a!cold! # most!common!causative!organisms:!group!A!
environment![12°C,!(53.6°F)].' streptococci,!enterococci,!coagulaseBnegative!
staphylococci,!S.+aureus,!S.+epidermidis,!and! B (+)!associated!with!a!systemic!disease!50%!of!the!time!
Clostridium!species! (inflammatory!bowel!disease,!rheumatoid!arthritis,!
# others!(Gram!negatives):!Escherichia+coli,! hematologic!malignancy,!and!monoclonal!
Enterobacter,!Pseudomonas!species,!Proteus! immunoglobulin!A!gammapathy)'
species,!Serratia!species,!and!bacteroides! B Tx:!Recognition!of!the!underlying!disease,!systemic!
B risk!factors:!diabetes!mellitus,!malnutrition,!obesity,! steroids!or!cyclosporine!&!chemotherapy!with!
chronic!alcoholism,!peripheral!vascular!disease,!CLL,! aggressive!wound!care!and!skin!graft!coverage'
steroid!use,!renal!failure,!cirrhosis,!and!autoimmune! '
deficiency!syndrome! b. SSS'vs'TEN'
B tx:!prompt'recognition,!broadBspectrum!IV!antibiotics,! Table'41:'comparison!between!SSSS!&!TEN'☺'
aggressive!surgical!debridement!(should!be!extensiveB! SSSS' TEN'
including!all!skin,!subcutaneous!tissue,!and!muscle,!until! Difference:' '
there!is!no!further!evidence!of!infected!tissue!followed! Scaused!by!an!exotoxin!(TSS! Bcaused!by!an!immune!response!to!
by!as!needed!debridement),!and!aggressive'fluid' toxinB1)produced!during!staph! certain!drugs'(sulfonamides,'
infection!of!the!nasopharynx!or! phenytoin,'barbiturates,'
replacement!(needed!to!offset!acute!renal!failure!from!
middle!ear!"!cytokine!release! tetracycline)'
ongoing!sepsis)! throughout!the!body!causing! Smore'than'30%'TBSA'involved'
! diffuse!injury!and!systemic! (if'less'than'10%'TBSA'"'SJS)'
c. Hidradenitis.suppuritiva. symptoms! '
B is!a!defect!of!the!terminal!follicular!epithelium!"! ! '
leading!to!apocrine'gland'blockage!"!gives!rise!to! Bhistopath:!cleavage'plane'in'the' B!histopath:!structural'defect'at'
abscess!formation!in!the!axillary,'inguinal,'and' granular'layer'of'epidermis' dermoepidermal'jxn;'similar'to'a'
perianal'regions' 2nd'degree'burn!
B Tx:!!warm!compresses,!antibiotics,!and!open!drainage!if! Similarity:'
acute;!wide!excision!with!closure!using!skin!graft!or! S'appearance:'skin'erythema,'bullae'formation,'wide'area'of'tissue'
local!flap!placement!if!chronic' loss!
' Bdiagnosis:!skin!biopsy!
d. Actinomycosis. treatment:!fluid'and'electrolyte'replacement,'as'well'as'wound'care'
similar'to'burn'therapy'
B is!a!granulomatous!suppurative!bacterial!disease!&!
S'appearance:'skin'erythema,'bullae'formation,'wide'area'of'tissue'
deep!cutaneous!infections!that!present!as!nodules!and! loss!
spread!to!form!draining!tracts!caused!by!Actinomyces. Bdiagnosis:!skin!biopsy!
(pathognomonic:'(+)'sulfur'granules'within' treatment:!fluid'and'electrolyte'replacement,'as'well'as'wound'care'
purulent'specimen).!' similar'to'burn'therapy'
B Usual!site:!face!or!head!(60%)' '
B Risk!factors:!tooth!extraction,!odontogenic!infection,!or! E. BENIGN'TUMORS'OF'THE'SKIN'AND'SUBCUTANEOUS'
facial!trauma.' '
B Tx:!Penicillin!and!sulfonamides;!surgery!for!deep!seated! a. Cutaneous.cysts:.Epidermal,.dermoid.or.
infections.!' trichelemmal.
. Table'42:'Comparison!between!epidermal,!dermoid!&!trichilemmal!cyst:!
e. Viral.infections.–.HPV. !
B Warts!are!epidermal!growths!resulting!from!human! Epidermal'cyst' Dermoid'cyst' Trichilemmal'(pilar)'
papillomavirus!(HPV)!infection.!' cyst'
' Difference:'
Table'40:!Comparison!of!HPV!infections!' S!most'common! S!congenital!lesions!that! S2nd!most!common!
Common' Plantar' Flat' Venereal'warts' B!single,!firm! result!when!epithelium! B!when!ruptured:!
wart' warts' warts' (condylomata' nodule! is!trapped!during!fetal! produce!an!intense!
(verruca' (verruca' (verruca' acuminata)' ! midline!closure! characteristic!odor!
vulgaris)' plantaris)' plana)' Blocation:! S'most'common' !
anywhere!in!the! location:'eyebrow'' Blocation:!scalp!(of!
Bfingers! Bsoles!and! B!the!face,! B!the!vulva,!anus,!and!
body! ' females)!
and!toes!! palms! legs,!and! scrotum!(relatively!
! ' !
Bdescribed! Bresemble! hands!! moist!areas)!
Bhistopath:! Shistopath:' !
as!rough! a!common! B!slightly! B!STD!
mature' demonstrates! Bhistopath:!no'
and! callus! raised! B!HPV!6!&!11!
epidermis' squamous!epithelium,! granular'layer;!!
bulbous' and!flat.!' Bbuschke'
complete'with' eccrine!glands,!and!
Lowenstein'tumor:!
granular'layer' pilosebaceous!units.!In!
Extensive!growths,!
addition,!these!
facilitated!by!
particular!cysts!may!
concomitant!HIV!
infection' develop!bone,!tooth,!or!
nerve!tissue!on!
occasion'
'
B histopathology:!hyperkeratosis'(hypertrophy'of'the'
horny'layer),'acanthosis'(hypertrophy'of'the' Similiarity:!
spinous'layer),'and'papillomatosis' Bcontain!keratin'(not!sebum)!
B Tx:!formalin,!podophyllum,!and!phenolBnitric!acid;! Bappear!the!same!clinically!(subcutaneous,!thinBwalled!nodule!
containing!a!white,!creamy!material)!
Curettage!with!electrodesiccation!also!can!be!used!for!
Btreatment:!excision;!incision!and!drainage!if!infected;!make!sure!to!
scattered!lesions' remove!the!cyst!wall!to!prevent!recurrence!
B HPV'types'5,'8,'and'10:'(+)'association'with' !
squamous'cell'carcinoma:'' !
$ lesions!that!grow!rapidly,!atypically,!or!ulcerate! b. Keratosis.–.seborrheic.vs.solar.
should!be!biopsied' '
' Table'43.'Comparison!between!seborrheic!keratosis!and!
D. INFLAMMATORY'DISEASES'OF'THE'SKIN'AND' actinic!keratosis:!
SUBCUTANEOUS' Seborrheic''(or'solar)' Actinic'keratosis'
' keratosis'
a. Pyoderma.gangrenosum.
B Main!characteristic:!rapidly!enlarging,!destructive,!
cutaneous!necrotic!lesion!with!undermined!border!and!
surrounding!erythema!'
S'considered'as'a' Sconsidered'as'a' Table'45.'Comparison!of!lipoma,!dermatofibroma!&!
premalignant'lesion'of'SCC' premalignant'lesion'of'SCC' achrochordon!!
B!appearance:!light!brown!or! (although!at!least!25%! Lipoma' Dermatofibroma' Achrochordo
yellow!with!a!velvety,!greasy! spontaneously!regress)! n'(skin'tags)'
texture! ' S!most'common' S!solitary,!softBtissue! S!fleshy,!
Barise!in!sun!exposed!areas! subcutaneous' nodules!measuring!1!to! pedunculated!
(face,!forearms,!back!of!hands)! neoplasm' 2!cm! masses!!
Bcommon!in!old!age!groups! B!soft!and!fleshy! Busual!location:!legs!and! Busual!
Bsudden!eruptions!are! on!palpation! flanks! location:!
associated!with!internal! BBusual!location:! Bhistopath:! preauricular!
malignancies! back! unencapsulated! areas,!axillae,!
Btreatment:!topical!5B Bhistopath:! connective!tissue!whorls! trunk,!and!
fluorouracil,!surgical!excision,! lobulated!tumor! containing!fibroblasts! eyelids!
electrodesiccation,!and! composed!of! B!do!biopsy!for!atypical! Btx:!“tyingBoff”!
dermabrasion' normal!fat!cells! presentation! or!resection'
' Btx:!excision! Btx:!excision'
c. Nevi.–.acquired.vs.congenital:'both!are!histologically! '
similar.! f. Neural.tumors+
' B Benign'
Acquired.melanocytic.nevi. B Arise!from!the!nerve!sheath!
B Classification!is!based!on!different!stages!of!maturation!
$ Junctional:!epidermis! Table'46.'Comparison!of!neurofibroma,!neurilemoma!&!
$ Compound:!extend!partially!into!dermis! granular!cell!tumor'
$ Dermal:!dermis! Neurofibroma' Neurilemoma' Granular'cell'
tumor'
.
Ssporadic,!solitary! S!solitary!tumors! S!solitary!lesions!
Congenital.nevi. Bcan!be!syndromic' arising!from!cells! of!the!skin!or,!
B Rare!(less!than!1%!of!neonates)! (von'Recklingh'S' of!the!peripheral! more'commonly,'
B Giant!congenital!lesions!(giant!hairy!nevi):!appear!in!a! ausen's'disease:! nerve!sheath! the'tongue'
swim!trunk!distribution,!chest,!or!back! café'au'lait'spots,' ! !
B may!develop!into!malignant'melanoma!in!1!to!5%!of! Lisch'nodules,' ! !
cases! and'an'autosomal' ! !
B tx:!total!excision!of!nevus!! dominant' ! !
' inheritance)! ! !
' B!with'direct' ! !
'
'
nerve'attachment' ! !
' ! ! !
' B!histopath:!,! B!histopath:!tumor! Bhistopath:!
'
proliferation!of! contains!Schwann! granular!cells!
'
' perineurial!and! cells!with!nuclei! derived!from!
' endoneurial! packed!in! Schwann!cells!
'
'
fibroblasts!with! palisading!row! that!often!
Schwann!cells! B!tx:!resection' infiltrate!the!
d. Vascular.tumors.of.the.skin.and.subcutaneous.
embedded!in! surrounding!
' collagen' striated!muscle.!
Table'44:'Comparison!between!hemangioma,!vascular!malformation,! Btx:resection'
port!wine!stain!and!glomus!tumors.!
'
Hemangioma' Vascular' Capillary' Glomus' F. Malignant.tumors.of.the.skin.
malformat malformat tumors'
ion' ion'(port' '
wine'
stain)' Basal.cell.carcinoma'☺'
Bmost'common' B!vascular! Sflat,!dullB Bbenign! B most'common'type'of'skin'cancer.'
cutaneous'lesion'of' malformati red!lesion! Blocated!at! B Arises+from+the+pluripotential.basal.epithelial.cells.of.
infancy!! ons!are!a! often! the! epidermis+and+NOT.DERMIS!.
Sbenign'lesion!that! result!of! located!on! extremities! B Slow'growing'and'metastasis'is'rare'but!are!capable!
present'soon'after' structural! the! B!arise!from! of!extensive!local!tissue!destruction'
birth'(not'at'birth!)' abnormalit trigeminal! dermal! B Subtypes:!
Bhistopath:!mitotically! ies!formed' (CN!V)! neuromyoa
$ Nodulocystic/noduloulcerative'
active!endothelial!cells! during' distributio rterial!
surrounding!several,! fetal' n!on!the! apparatus! # 70%'of'BCC'tumors'(most'frequent'form)!
confluent!bloodBfilled! developm face,!trunk,! (glomus! # Waxy!and!frequently!cream!
spaces! ent' or! bodies).! colored/translucent;over!time,!can!present!as!
Benlarge!at!1st!year!of! Bhistopath:! extremities B!usually! a!rolled,!pearly!borders!surrounding!a!central!
life!"!90%'eventually' enlarged! ;! presents! ulcer!(rodent'ulcer)!
involute! vascular! associated! with!severe! $ Morpheaphorm'
Btx:!if!it!interferes!with! spaces! with! pain,!point! # flat,!plaqueBlike!lesion!
airway,!vision,!and! lined!by! sturgeS tenderness!
# most!aggressive!clinically!(due!to!presence!of!
feeding!or!results!to! nonprolifer weber' and!cold!
systemic!problems! ating! symdrome sensitivity! type!IV!collagenase!that!facilitates!local!
(thrombocytopenia!or! endotheliu s! Btx:!tumor! spread)!"!early!excision!
highBoutput!cardiac! m.! (leptomeni excision! $ basosquamous'type'
failure)!"!resection! B!grow!in! ngeal! # combination!of!both!BCC!+!SCC!
and! proportion! angiomato # aggressive!"treated!right!away!!
prednisone/interferon! to!the!body! sis,! B Tx:!
alpha!2!(for!rapidly! and!never' epilepsy,! $ Less'than'2mm'nodular'lesions:!curettage,'
enlarging!lesions)! involute' and!
electrodesiccation,'or'laser'vaporization.'
! glaucoma)!
$ If!located!at!cheek,'nose,'or'lip:'Mohs''surgery!
$ Large'tumors,'those'that'invade'surrounding'
' structures,'&'aggressive'histologic'types'
' (morpheaform,'infiltrative,'and'
' basosquamous):!surgical'excision'with'0.5Scm'
e. Soft.tissue.tumors.. to'1Scm'margins.'
B Syndromic!skin!malignancies!associated!with!BCC:! removal!"!all!specimen!margins!are!evaluated.!
$ basal'cell'nevus'(Gorlin's)'syndrome:!! Recurrence!and!metastases!rates!are!comparable!to!
# autosomal!dominant!disorder!characterized! those!of!wide!local!excision.'
by!the!growth!of!hundreds!of!BCCs!during! '
young!adulthood.!!
# Palmar!and!plantar!pits:!common!physical! Malignant.Melanoma'☺'
finding! B Arise!from!melanocytes!
# Tx:!excision!of!aggressive!and!symptomatic! B Premalignant'lesion:'dysplastic'nevi!(vs!freckles!B!
lesions! benign!melanocytic!neoplasms!found!on!the!skin)!'
$ nevus'sebaceus'of'Jadassohn:!! B Most!common!location:!skin!(>90%);!other!sites:!anus,!
# lesion!containing!several!cutaneous!tissue! eyes!
elements!that!develops!during!childhood.' B 4%:!discovered!as!metastases!without!any!identifiable!
primary!site.!!
Squamous.cell.carcinoma'☺' B Suspicious!features:!pigmented'lesion'with'an'
B Arise!from!epidermal'keratinocytes' irregular'border,'darkening'coloration,'ulceration,'
B Less'common'than'BCC' raised'surface'and'recent'changes'in'nevus'
B Highly'invasive'and'tends'to'metastasize' appearance!!
B Tend!to!occur!in!persons!with!blond!hair,!light,!thin,!dry! B Risk!factors:!'
and!irritated!skin.' $ increased!sun!exposure!of!fair!skinned!people!to!
B In!situ!lesions:!Bowen’s'disease;!if!in!the!penis!"! solar!radiation'
erythroplasia'of'Queyrat' $ Familial'dysplastic'nevus'syndrome!!
B Risk!factors:' # autosomal!dominant!disorder!!
$ Skin!lesions:!actinic'keratosis,'atrophic' B Subtypes:'
dermatitis' '
Table'47.!comparison!of!malignant!melanoma!subtypes:'
$ Occupational!exposure:'arsenics,'nitrates'and'
hydrocarbons'
Superficial' Nodular' Lentigo' Acral'lentiginous'
$ Syndromic!malignancies!associated!with!SCC:! spreading' maligna'
# epidermolysis!bullosus! S!most'common' S15!to!30%! S4!to! S2!to!8%!of!
# lupus!erythematosus! type'(70%'of' of! 15%!of! melanomas!(least'
# Epidermodysplasia'verruciformis! melanomas)! melanoma melano common)'
• rare!autosomal!recessive!disease! B!location:! s' mas! Boccurs!at!palms,!
associated!with!infection!with!HPV! anywhere!on!the! S!darker! B!occur! soles,!and!subungual!
# Xeroderma'pigmentosum!! skin!except'the' coloration! on!neck,! regions!
hands'and'feet' and!often! face,! B!Hutchinson's'sign:!
• autosomal!recessive!disease!associated! B!flat!and! raised! and! presence!of!
with!a!defect!in!cellular!repair!of!DNA! measure!1!to!2! Black' hands!of! pigmentation!in!the!
damage.!! cm!in!diameter! radial' elderly! proximal!or!lateral!
B tumor'thickness'correlates'well'with'malignant' at!diagnosis! growth! Bbest' nail!folds;!diagnostic!
behavior.!! B!Before!vertical! B progno of!subungual!
$ more!than!4!mm:!Tumor!recurrence!is!more! extension,!a! aggressive! sis' melanoma!
prevalent!! prolonged' but!same! Bdark'skinned'+'
$ if!10!mm!or!more:!these!lesions!usually!have! radial'growth' prognosis! acral'lentiginous'
phase!is! with! melanoma:'
associated!metastasis!
characteristic!of! superficial! increased'risk'of'
B Burn'scars'(Marjolin's'ulcer),!areas!of!chronic! these!lesions' spreading' malignancy!'
osteomyelitis,!and!areas!of!previous!injury!"!tend!to! '
metastasize!early.! B Prognostic!indicators:!
B Tx:! • Location:!lesions!of!the!extremities!have!a!better!
$ Excision!with!1!cm!margin!+!histologic! prognosis!than!patients!with!melanomas!of!the!
confirmation!of!tumor!free!borders! head,!neck,!or!trunk!
$ If!located!at!cheek,!nose,!or!lip:!Mohs'!surgery!
• (+)!ulceration!(due!to!increased!angiogenesis):!
$ Regional'LN'excision'is'indicated'for'clinically'
worse!prognosis!
palpable'nodes'
• Gender:!females!have!higher!survival!rates!than!
$ If!SCC!arises!from!chronic!wounds,!
men!
lymphadenectomy!before!development!of!palpable!
• Tumor!types:'
nodes!(prophylactic'LN'dissection)'is'indicated!
# Best:'lentigo'maligna'
because!it!is!more!aggressive!and!lymph!node!
# Worse:'acral'lentiginous'
metastases!are!observed!more!frequently!
B Staging!from!AJCC:!breslow!and!clark!level!
B Metastatic!disease!is!a!poor!prognostic!sign!(13%!
• Breslow'thickness:!the!vertical!thickness!of!the!
survival!after!10!years).! primary!tumor!(from!the!granular!layer!of!the!
epidermis!or!base!of!ulcer!to!the!greatest!depth!of!
''√'MUST'KNOW!a! the!tumor);!most'important'prognostic'variable'
! predicting'survival'in'those'with'cutaneous'
Keratoacanthoma,!which!is!characterized!by!rapid!growth,! melanoma;'considered!to!be!more!precise!in!
rolled!edges!and!a!crater!filled!with!keratin,!can+be+confused+ predicting!biologic!behavior'
with+SCC+or+BCC.!It!spontaneously!involutes!over!time.! # I:!0.75!mm!or!less!
Biopsy!lesion!to!rule!out!carcinoma.! # II:!0.76!to!1.5!mm!
! # III:!1.51!to!4.0!mm!
! # IV:!4.0!mm!or!more!
Moh’s'surgery'for'BCC'and'SCC'(nice'to'know!)' • Clark'level:!anatomic!depth!of!invasion!
B This!precise,!specialized!surgical!technique!uses! # I:!superficial!to!basement!membrane!(in'situ)!
minimal!tissue!resection!and!immediate!microscopic! # II:!papillary!dermis!
analysis!to!confirm!appropriate!resection!yet!limit! # III:!papillary/reticular!dermal!junction!
removal!of!valuable!anatomy.' # IV:!reticular!dermis!
B Done!for!aesthetic!purposes' # V:!subcutaneous!fat!
B uses!serial!excision!in!small!increments!coupled!with! B LN!status!&!Metastasis:!
immediate!microscopic!analysis!to!ensure!tumor!
• Evidence!of!tumor!in!regional!LNs!is!a!poor! body.!Pacinian'corpuscles'are!found!in!the!
prognostic!sign!(automatic!stage!III)! subcutaneous!tissue,!in!the!nerves!of!the!palm!of!the!
• Identification!of!distant!metastasis!is!the!worst! hand!and!the!sole!of!the!foot,!and!in!other!areas.!Each!of!
prognostic!sign!(!automatic!stage!IV)! these!corpuscles!is!attached!to!and!encloses!the!
B Dx:!excisional!biopsy! termination!of!a!single!nerve!fiber.!They!are!involved!in!
B Tx:!! the!sensation!of!pressure.!Ruffini’s'endings!are!a!variety!
• Melanoma!in!situ/lentigo!maligna!melanoma!in! of!nerve!endings!in!the!subcutaneous!tissue!of!the!
face:!0.5!cm!margins! fingers!and!modulate!sensitivity!to!warmth.!Krause’s'
• 1mm!or!less:!excision!with!1!cm!margin!! endSbulbs!are!formed!by!the!expansion!of!the!
• 1!to!4!mm:!excision!with!2!cm!margin! connective!tissue!sheath!of!medullated!fibers!and!are!
• More!than!4!mm!or!(+)!satellosis:!3B5!cm!margin! involved!in!the!sensation!of!cold.!Meissner’s'corpuscles!
• High!dose!interferon!has!a!role!in!high!risk! occur!in!the!papillae!of!the!corium!of!the!hands,!the!feet,!
melanoma! the!skin!of!the!lips!and!other!areas!concerned!with!
• LN!dissection:! tactile!sensation.!Autonomic'fibers!that!synapse!to!
# Sentinel'LN'biopsy:!1mm!or!thicker!with! sweat!glands!and!receptors!in!the!vasculature!govern!
clinically!negative!nodes!or!0.75!mm!thick!+! thermoregulation.'
clark!level!IV!or!ulcerated' !
# Radical'regional'lymphadenectomy:! 2. Select!the!treatment!options(s)!in!the!1st!set!of!choices!
clinically!(+)!nodes!with!no!evidence!of!distant! (UPPER!CASE)!that!is/are!most!appropriate!for!the!
disease!on!metastatic!work!up.' melanoma!case!summaries!outlined!in!the!2nd!set!of!
choices!(lower!case)!
''√ 'QUICK'REVIEW!a! !
Remember:'' A. Level!III!superficial!spreading!melanoma!(0.4!mm!
thick!with!clinically!negative!regional!lymph!nodes!
• Moh’s'surgery'is'not'appropriate'for'any'type'of'
B. Level!IV!nodular!melanoma!(2mm!thick)!with!
melanoma'
satellosis!and!clinically!negative!regional!lymph!
• If'melanoma'is'4mm'or'greater'+'clinically'negative'
nodes!
nodes'"'perform'metastatic'work'up'first'
C. Level!IV!superficial!spreading!melanoma!(1.5!mm!
thick)!with!palpable!regional!lymph!nodes!
!
D. Level!IV!acral!lentiginous!melanoma!(2!mm!thick)!
Merkel.cell.carcinoma.
with!clinically!negative!regional!lymph!nodes!
B Primary!Neuroendocrine!Carcinoma!of!the!Skin'
E. Level!II!lentigo!maligna!melanoma!(0.3!mm)!
B associated!with!a!synchronous!or!metasynchronous!SCC!
25%!of!the!time.'
!
B Tx:!wide!local!resection!with!3Bcm!margins!+!
f. Moh’s!micrographic!surgery!
Prophylactic!regional!LN!dissection!+!adjuvant!radiation!
g. Wide!local!excision!with!0.5!cm!margins!
therapy!are!recommended.!'
h. Wise!local!excision!with!1.0!cm!margins!
B Prognosis:!worse!than!malignant!melanoma'
i. Wide!local!excision!with!2.0!cm!margins!
j. Wide!local!excision!with!4.0!cm!margins!
Kaposi’s.sarcoma.
k. Sentinel!lymph!node!biopsy!
B rubbery!bluish!nodules!that!occur!primarily!on!the!
l. Regional!lymph!node!biopsy!
extremities!(also!skin!and!viscera)!'
m. Radical!regional!lymphadenectomy!
B usually!multifocal!rather!than!metastatic.'
B Histopath:!capillaries!lined!by!atypical!endothelial!cells.'
Answer:!A'–'c;'B'–'e,f;'C'–'d,h;'D'–'d,f;'E'–'b'
B seen!in!people!of!Eastern!Europe!or!subBSaharan!Africa,!
Virtually!all!melanomas!are!best!treated!by!wide!
AIDS!or!immunosuppression!with!chemotx'
excision.!The!excision!margin!that!minimizes!the!risk!of!
B locally!aggressive!but!undergo!periods!of!remission'
local!recurrence!depends!on!the!thickness!of!the!tumor.!
Melanoma!in!situ!and!thin!lentigo!maligna!melanomas!
.
of!the!face!are!treated!adequately!by!margins!of!0.5!cm.!
.
For!melanomas!less!than!1.0!mm!thick,!1!cm!excision!
Extramammary.Paget’s.disease.
margins!are!appropriate.!For!intermediate!thickness!
B cutaneous!lesion!that!appears!as!a!pruritic!red!patch!
melanoma!(1B4!mm),!a!2!cm!margin!is!sufficient.!
that!does!not!resolve'
Margins!of!3B5!cm!are!generally!employed!for!
B histologically!similar!to!the!mammary!type.!'
melanomas!4!mm!in!thickness!and!for!those!with!
associated!satellosis.!Moh’s!chemosurgery!is!not!
!
appropriate!for!the!treatment!of!any!melanomas.!The!
'''''''REVIEW'QUESTIONS!!
indications!for!elective!lymph!node!dissection!remain!
!
controversial.!Sentinel!lymph!node!biopsy!is!indicated!
1. Match!the!item!in!the!left!hand!column!with!the!
for!aptients!with!melanoma!1!mm!or!thicker!with!
appropriate!item!in!the!right!hand!column!
clinically!negative!nodes.!The!indication!is!extended!to!
!
patients!with!0.75!mm!thick!melanomas!if!they!are!
a. modulate!cold!sensation!!!!!!!!!!!!!!!!a.!Ruffini’s!!
Clark’s!level!IV!or!ulcerated.!Patients!with!clinically!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!endings!
positive!lymph!nodes!with!no!evidence!of!distant!
b. modulate!sensitivity!to!warmth!!b.!Krause’!endB!
disease!on!metastatic!workup!(CT!of!chest,!abdomen!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!bulb!
and!pelvis;!MRI!of!brain;!PET)!should!undergo!radical!
c. modulate!sensation!of!pressure!!c.!Meissner’s!!!!!!!!!!!!!!!!!!!!!!
regional!lymphadenectomy.!Patients!with!primary!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!corpuscles!
tumors!4!mm!or!greater!with!clinically!negative!nodes!
d. modulate!tactile!sensation!!!!!!!!!!!!d.!Pacinian!!
should!undergo!metastatic!workup!before!undergoing!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!corpuscles!
sentinel!node!biopsy!and!wide!local!excision.!
e. modulate!thermoregulation!!!!!!!!!e.!autonomic!
!
nerve!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!endings!
3. With!regards!to!keloids!and!hypertrophic!scars,!which!of!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
the!following!statements!is/are!true?!
Answer:'ASb;'BSa;'CSd;'DSc;'ESe'
!
A!variety!of!highly!specialized!structures!are!responsible!
A. There!are!no!histologic!differences!between!the!two!
for!modulating!the!skin’s!various!sensory!functions.!The!
B. The!differences!between!hypertrophic!scar!and!
numbers!of!these!structures!vary!with!the!region!of!the!
keloid!are!clinical,!not!pathologic!
C. Hypertrophic!scars!outgrow!their!original!borders! B The!axillary'tail'of'Spence!extends!laterally!across!the!
D. Hypertrophic!scars!and!keloids!have!been!treated! anterior!axillary!fold.'
successfully!with!intralesional!injection!of!steroids! B upper'outer'quadrant:!greatest!volume;!most'
E. Keloids!are!seen!in!darkBskinned!individuals,! common'site'of'breast'cancer!☺'
whereas!hypertrophic!scars!are!seen!in!fairBskinned! B Blood'supply:''
individuals!
Table'48.'Blood!supply!of!the!breast'
Answer:!A,B,D' Arterial'blood'supply' Venous'blood'supply'
Histologically,!keloids!and!hypertrophic!scars!appear!the! S!perforating!branches!of!the! Bperforating!branches!of!the!
same.!Hypertrophic'scars'are'thick,'red,'raised'scars' internal'mammary'artery! internal'thoracic'vein'
S!lateral!branches!of!the! Bperforating!branches!of!the!
that'do'not'outgrow'their'original'borders,'whereas'
posterior'intercostal'arteries' posterior'intercostal'veins!
keloids'do.!Keloids!are!dense!accumulations!of!fibrous! Bbranches!from!axillary'artery! Btributaries!of!the!axillary'vein.!
tissue!that!form!at!the!surface!of!the!skin.!The!defect! (highest!thoracic,!lateral! B!Batson's'vertebral'venous'
appears!to!result!from!a!failure!in!collagen!breakdown! thoracic,!and!pectoral!branches! plexus!☺:!possible!route!for!
rather!than!an!increase!in!its!production.!Keloids!and! of!the!thoracoacromial!artery' breast!cancer!metastases!to!the!
hypertrophic!scars!have!been!successfully!treated!with! vertebrae,!skull,!pelvic!bones,!
intralesional!steroid!injectin,!radiation,!pressure!and!the! and!central!nervous!system.!'
use!of!silicone!gel!sheets.! '
! B Innervation:''
' $ Sensory!innervation!to!breast!&!anterolateral!chest!
BREAST' wall:!Lateral'cutaneous'branches'of'the'3rd'–'6th'
' intercostal'nerves!(slips!out!in!between!serratus!
A. Embryology'of'the'breast' anterior!muscles)'
B. functional'anatomy'of'the'breast' # Intercostobrachial'nerve:!lateral!cutaneous!
C. Physiology'of'breast' branch!of!the!second!intercostal!nerve;!injury!
D. infectious'and'inflammatory'disorders'of'the'breast' to!this!nerve!results!to!loss!of!sensation!over!
E. common'benign'disorders'and'diseases'of'the' the!medial!aspect!of!the!upper!arm.'
breast' $ Cutaneous!branches!from!cervical!plexus!(anterior!
F. breast'cancer' branches!of!the!supraclavicular'nerve):!supply!a!
G. special'clinical'situations' limited!area!of!skin!over!the!upper!portion!of!the!
breast.!'
! B Lymphatics:'
! $ 6!axillary!lymph!node!groups:'
A. EMBRYOLOGY'OF'THE'BREAST'
Table'49.'Location'and'drainage'pattern'of'breast'☺'
B 5th!or!6th!week!of!fetal!development!"!mammary!ridges!
Name' location' drainage'
(thickened!ectoderm):!precursors!of!breast' Lateral! medial!or! upper!extremity;'receives'
$ Extends!from!the!base!of!the!forelimb!(future! (axillary! posterior!to!the! 75%'drainage'of'the'
axilla)!to!the!hind!limb!(future!inguinal!region)' vein! vein' breast;'most'common'site'
B Witch’s'milk:'(+)!breast!secretions!in!an!infant! group)!–! of'axillary'LN'metastasis'
secondary!to!maternal!hormones!that!crosses!the! level!I!
placenta' Anterior!or! lower!border!of! lateral!aspect!of!the!breast!
B Anomalies'in'embryology:' pectoral! the!pectoralis!
$ Polymastia:'accessory!breast;!can!be!seen!in! (external! minor!muscle!
mammary! contiguous!with!
Turner’s!syndrome!(ovarian!agenesis!and! group)!–! the!lateral!
dysgenesis)and!Fleischer’s!syndrome! level!I! thoracic!vessels!
(displacement!of!the!nipples!and!bilateral!renal! Posterior! posterior!wall!of! lower!posterior!neck,!the!
hypoplasia);!can!enlarge!during!pregnancy!&! of! the!axilla!at!the! posterior!trunk,!and!the!
lactation' subscapula lateral!border!of! posterior!shoulder'
$ Polyethelia:'accessory!nipples;!maybe!associated! r!(scapular! the!scapula! !
with!CVS!and!urinary!tract!anomalies' group)!– contiguous!with!
$ Amastia:!congenital!absence!of!breast!due!to! level!I! the!subscapular!
vessels!
arrest!in!mammary!ridge!development!during!the!
Central! embedded!in! receive!lymph!drainage!both!
6th!week' group!–! the!fat!of!the! from!the!axillary!vein,!
# Poland’s.syndrome:'hypoplasia!or!complete! level!II! axilla!lying! external!mammary,!and!
absence!of!the!breast,!costal!cartilage!and!rib! immediately! scapular!groups!of!lymph!
defects,!hypoplasia!of!the!subcutaneous! posterior!to!the! nodes,!and!directly!from!the!
tissues!of!the!chest!wall,!and!brachysyndactyly' pectoralis!minor! breast!
$ Symmastia:'webbing!between!the!breasts!across! muscle!
the!midline!(no!cleavage)' Apical! posterior!and! from!all!of!the!other!groups!
$ Inverted.nipple:!occurs!in!4%!of!infants' (subclavicu superior!to!the! of!axillary!lymph!nodes!
lar!group)! upper!border!of!
'
–!level!III! the!pectoralis!
B. FUNCTIONAL'ANATOMY'OF'THE'BREAST' minor!muscle!
B It!extends!from!the!level!of!the!2nd'or'3rd'rib'to'the' Interpector interposed! receive!lymph!drainage!
inframammary'fold'at'the'6th'or'7th'rib.!' al!group! between!the! directly!from!the!breast.!The!
B It!extends!transversely!from!the'lateral'border'of'the' (Rotter’s! pectoralis!major! lymph!fluid!that!passes!
sternum'to'the'anterior'axillary'line.!' nodes)B! and!pectoralis! through!the!interpectoral!
B The!deep!or!posterior!surface!of!the!breast!rests!on!the! level!II! minor!muscles! group!of!lymph!nodes!
fascia!of!the!pectoralis!major,!serratus!anterior,!external! passes!directly!into!the!
central!and!subclavicular!
oblique!abdominal!muscles,!&!the!upper!extent!of!the!
groups.'
rectus!sheath.!'
'
B retromammary'bursa:!located!at!posterior!aspect!of! Figure'28.'Axillary!lymph!node!groups'☺'
the!breast!between!the!investing!fascia!of!the!breast!and!
the!fascia!of!the!pectoralis!major!muscles.'

' B Tx:!antibiotics!+!I&D!as!necessary.!!
Reference!point:! '
pectoralis'minor! e. Hidradenitis.suppurativa.
(not!major!)!
B can!also!occur!in!the'nippleBareola!complex!
Level'I:'lateral!to!
the!pectoralis! B originates!within!the!Montgomery!glands!or!axillary!
minor!muscle!(PM)! sebaceous!glands.!
Level'II:'deep!to! B Risk!factor:!chronic!acne!!
PM!! B may!mimic!Paget's!disease!of!the!nipple!or!invasive!
Level'III:'medial'to! breast!cancer.!!
the!PM.!! B Tx:!Antibiotic!+!I&D!
! '
Arrows!indicate!the!
f. Mondor’s.disease.
direction!of!lymph!
flow.!!
B a!benign!self!limited!condition!which!is!a!variant!of!
Also+seen:+axillary! thrombophlebitis!that!involves!the!superficial!veins!of!
vein!&!its!major! the!anterior!chest!wall!and!breast.'
tributaries,! B Involved!veins:!lateral!thoracic!vein,!the!
supraclavicular!LN!! thoracoepigastric!vein,!and,!less!commonly,!the!
' superficial!epigastric!vein.'
C. PHYSIOLOGY'OF'BREAST' B SSx:!acute!pain!in!the!lateral!aspect!of!the!breast!or!the!
B Breast'development'and'function' anterior!chest!wall!with!palpation!of!a!tender,!firm!cord!
$ Hormonal'stimuli:' along!the!distribution!of!the!major!superficial!veins.'
# Estrogen:''ductal!development' B Tx:!antiBinflammatory!medications!+!warm!compresses!
# Progesterone:'differentiation!of!epithelium!&! along!the!symptomatic!vein!+!Restriction!of!motion!of!
lobular!development' the!ipsilateral!extremity!and!shoulder!+!brassiere!
# Prolactin:'1o!hormonal!stimulus!for! support!of!the!breast!are!important!(4!to!6!weeks)!or!
lactogenesis!in!late!pregnancy!&!the! excision!of!vein!(if!not!improving)'
postpartum!period.' '
B Gynecomastia:''enlarged!breast!in!males!!measuring!at! E. COMMON'BENIGN'DISORDERS'AND'DISEASES'OF'
least!2!cm!in!diameter' THE'BREAST'
B Gynecomastia!generally!does!not!predispose!the!male! a. Fibroadenoma.☺ +
breast!to!cancer!unless!syndromic' B seen!predominantly!in!younger!women!aged!15!to!25!
B Physiologic!gynecomastia!occurs!due!to!excess!in! years!!!
circulating!estrogens!(in!relation!to!circulating! B can!be!self!limiting!
testosterone):!' B if!greater!than!3cm!"!consider!giant!fibroadenoma!
$ neonatal!period:!action!of!placental!estrogens!on! B if!multiple!(more!than!5!lesions!in!1!breast)!
neonatal!breast!tissues' "considered!as!abnormal!!
$ adolescence:!excess!of!estradiol!relative!to! B tx:!cryoablation,!surgical!removal!or!observation!
testosterone;!can!be!unilateral' !
$ senescence:!circulating!testosterone!level!falls;! b. Cyclical.mastalgia.and.nodularity.
usually!bilateral' B associated!with!premenstrual!enlargement!of!the!breast!!
' B physiologic.!!
D. INFECTIOUS'AND'INFLAMMATORY'DISORDERS'OF' B If!Painful!nodularity!persists!for!>1!week!of!the!
THE'BREAST' menstrual!cycle!"!consider!a!disorder.!
' B bilateral!bloody!nipple!discharge!"can!be!seen!in!
a. Breast'abscess' epithelial!hyperplasia!of!pregnancy!
B Staphylococcus.aureus!(more!localized!&!deep)!and' !
Streptococcus'(diffuse!superficial!involvement)!species:! c. Breast.cysts.☺ .
causative!organisms! B occurs'when'the'stroma'involutes'too'quickly,!and!
B SSx:!point!tenderness,!erythema,!and!hyperthermia.!! alveoli!remain!"!forming!microcysts!&!macrocysts'
B Risk!factor:!lactation!(because!a!lactating!breast!is!an! B characteristics!of!benign!lesions:!sharp,!smooth!
excellent!culture!medium)! margins,!a!homogenous!interior!and!posterior!
B Tx:!preoperative!UTZ!+!incision!&!drainage!(if!already! enhancement!(vs+malignancy+which+will+show+irregular+
with!suppuration)!+!local!wound!care!(warm! and+jagged+margins,+heterogenous+interior+and+posterior+
compresses!&IV!antibiotics!B!penicillins!or! shawoding)!
cephalosporins).! B management:'needle'biopsy'(!1st!line!investigation!for!
$ Remember:!Biopsy!of!the!abscess!cavity!wall!is! palpable!breast!masses)'
recommended!at!the!time!of!I&D!"!rule!out!breast! $ !if!(+)!fluid!on!aspiration!"!aspirate!to!dryness,!no!
cancer!with!necrotic!tumor.! need!to!do!cytologic!examination'
B Chronic!breast!abscesses:!consider!acidBfast!bacilli,! $ If!after!aspiration,!(+)!residual!mass!"!do!UTZ!
anaerobic!and!aerobic!bacteria,!and!fungi.!! guided!needle!biopsy'
$ If!fungal.!Consider!blastomycosis!or!sporotrichosis! $ If!blood!stained!fluid!"!aspirate!2!mL!for!cytologic!
(rare)! examination,!utz!imaging!and!biopsy!solid!areas'
' B If!complex!cyst!"!rule!out!malignancy.'
b. Epidemic.puerperal.mastitis. '
B MRSA:!causative!organism! d. Calcium.deposits.☺ .
B Transmission!via!suckling!neonate! B benign!
B Tx:!stop!breastfeeding!,!antibiotics!&!I&D! B cause:!cellular!secretions!,!debris!or!by!trauma!and!
' inflammation.!
c. Nonepidemic.(sporadic).puerperal.mastitis.. B (+)!cancer!if!<0.5!mm!in!size,!fine,!linear!calcifications,!
B involvement!of!the!interlobular!CT!of!the!breast! may!branch!(microcalcifications).!!
B tx:!Emptying!of!the!breast!using!breast!suction!pumps!+! !
antibiotics!! e. Sclerosing.adenosis.
' B
Common!in!childbearing!and!perimenopausal!years!'
d. Zuska's.disease.(recurrent.periductal.mastitis). B
no!malignant!potential.'
B recurrent!retroareolar!infections!and!abscesses.! B
characterized!by!distorted!breast!lobules!+!multiple!
B Risk!factor:!smoking! microcysts!+!benign!calcifications'
! # Results!of!Women’s!health!initiative!study!
f. Radial.scars.(1.cm.or.less).or.Complex.central. (2002):!breast'Ca'risk'is'increased'to'3S
sclerosis.(more.than.1.cm).. 4fold'after'>'4'years'of'use'+'no'reduction'
B characterized!by!central!sclerosis,!epithelial! in'CAD'or'CVD'
proliferation,!apocrine!metaplasia,!and!papilloma! '
formation!' $ screening'mammogram'
B can!mimic!cancer!hence!an!excisional!biopsy!is!done!to! # routine!screening!mammography!starting!50!
to!exclude!diagnosis!of!cancer' years!old!age!reduces!mortality!from!breast!
' cancer!by!33%!
g. Ductal.hyperplasia. # baseline!mammography!at!age!35!
B Severity:' # annual'mammographic'screening'
$ Mild:!3B4!cell!layers!above!the!basement! beginning'at'age'40.!
membrane.!' # If!(+)!family!history!for!breast!cancer!
$ Moderate:5!or!more!cell!layers!above!the!basement! • Baseline!mammogram!10!years!before!
membrane.!' the!youngest!age!of!diagnosis!of!breast!ca!
$ Florid!ductal!epithelial!hyperplasia:!occupies!at! among!1st!degree!relatives.!(this!rule!is!
least!70%!of!a!minor!duct!lumen.!' modified!if!age!of!diagnosis!is!less!than!
B associated!with!an!increased!cancer!risk!' 35)!
' !
h. Intraductal.papillomas'☺'' $ Chemoprevention'
B Seen!in!premenopausal!women.' # Tamoxifen:!selective!estrogen!receptor!
B common'symptom:'serous'or'bloody'nipple' modulator'
discharge' • recommended!only!for!women!who!have!
B Gross!appearance:!pinkish!tan,!friable,!' a!Gail!relative!risk!of!1.70!or!↑er.!'
B rarely!undergo!malignant!transformation!&!no! • SE:!deep!vein!thrombosis,!pulmonary!
increased!risk!of!breast!cancer,!unless!multiple' emboli,!endometrial'cancer'
' • reduce!the!incidence!of!LCIS!and!ductal!
i. Atypical.proliferative.disease' carcinoma!in!situ!(DCIS)'
B has!some!of!the!features!of!Ca!in!situ!but!lack!a!major! # Raloxifene:!estrogen!receptor!modulator!
defining!feature!of!Ca!in!situ!or!have!the!features!in!less! • Equivalent!to!tamoxifen!
than!fully!developed!form! • associated'with'a'more'favorable'
B Atypical'ductal'hyperplasia'&'lobar'hyperplasia' adverse'event'profile'
$ Increases.risk.of.breast.cancer.4x;.if.with.(+). • no'effect'on'LCIS'or'DCIS'
family.hx,.10x. '
' $ prophylactic'mastectomy'
F. BREAST.CANCER.☺. # greatly!reduces!risk!for!breast!cancer!!
B risk'factors' # only!for!high!risk!populations!
$ increased'exposure'to'estrogen:'early!menarche,! # +!3!years!"!if!with!40%!risk!of!having!breast!
nulliparity,!late!menopause,!older!age!at!first!live! Ca!
birth!(after!the!age!of!30!yo),!HRT,!obesity,!(major! # +!5!years!"!if!with!85%!risk!of!having!breast!
source!of!estrogen!in!postmenopausal!women!is! cancer!
the!conversion!of!androstenedione!to!estrone!by! !
adipose!tissue)' B BRCA.mutation+
$ radiation'exposure:'patients!with!multiple! $ Constitutes!5B10%!of!breast!cancers!
fluoroscopies,!mantle!radiation!for!treatment!of! $ Autosomal!dominant!inheritance!
hodgkin’s!lymphoma' $ tumorBsuppressor!genes!
$ increased'alcohol'intake!(leads!to!increased! $ prevalent!in!Ashkenazi!Jews!
estradiol!levels)' '
$ high'fat'diet!(increased!serum!estrogen!levels)' Table'50.'Comparison!of!BRCA!1!&!2'
$ prolonged'use'of'OCPs'(particularly!estrogenB BRCA'1' BRCA'2'
plusBprogesterone)'and'HRT' S!location:!ch'arm'17q! Blocation:!ch'arm'13q''
$ (+)'family'history'of'breast'cancer:'the!greater! Bpredisposing!genetic!factor:! B!lifetime!risk!for!carrier!"!
45%!of!breast!Ca!&!85%!of! Ca:!85%!for!breast!ca!&!20%!
the!number!of!relatives!affected,!the!closer!the!
ovarian!Ca! for!ovarian!ca!;!if!male!
genetic!relationship,!the!younger!the!age!at! Blifetime!risk!for!carrier!"! carrier:!6%!
diagnosis,!and!the!presence!of!bilateral!versus! Ca:!90%!for!breast!ca!&!40%! Busually!develops!invasive!
unilateral!disease!all!increased!the!likelihood!of! for!ovarian!ca!! ductal!carcinomas:!well!
development!of!breast!cancer!in!an!individual.' B!usually!develops!invasive! differentiated,!hormone!
ductal!carcinomas:!poorly! receptors!(+)!
differentiated!and!hormone! Bearly!age!of!onset,!bilateral!
''√ 'MUST'KNOW!!
receptor!(B)! breast!cancer,!&!other!
Remember:'' Bearly!age!of!onset,!bilateral! associated!ca:!ovarian,!colon,!
' breast!cancer!and!other! prostate,!pancreatic,!
Smoking.is.not.considered.a.risk.factor.for.breast. associated!ca:!ovarian,!colon! gallbladder,!bile!duct!&!
cancer!!!!!!!!!!!.!Please!don’t!make!the!mistake!of!answering!this! and!prostate!! stomach!cancers,!melanoma.'
as!part!of!the!risk!factors!in!breast!cancer.! '
! $ Risk!mgt!strategies!for!BRCA!carriers:!!
! # Prophylactic!mastectomy!and!reconstruction!
B risk'management' # Prophylactic!oophorectomy!(because!of!↑!risk!
$ Postmenopausal'hormone'replacement'tx' of!ovarian!ca)!at!the!completion!of!
# Widely!prescribed!because!it!is!effective!in! childbreaing!or!manopause!+!HRT!
controlling!symptoms!of!estrogen!deficiency! # Intensive!surveillance!for!breast!and!ovarian!
(vasomotor!symptoms!such!as!hot!flashes,! cancer!
night!sweats!and!their!associated!sleep! # Chemoprevention!
deprivation,!osteoporosis,!and!cognitive! $ BRCA!mutation!carriers!who!do!not!undergo!
changes)! prophylactic!mastectomy!must!do!clinical!breast!
examination!every!6!months!and!mammography!

every!12!months!beginning!at!age!25!years! ' LCIS' DCIS'
(because!the!risk!of!breast!cancer!in!BRCA! Multicentricity! 60B90!%! 40B80%'(more'
mutation!carriers!increases!after!age!30!years)! common'if'
! comedo'type)!
Bilaterality! 50S70%'(more' 10B20%!
B HER82.gene+
common)'
$ Encodes!transmembrane!tyrosine!kinase,!a!protein!
Axillary! 1%! 1B2%!
with!potent!growth!stimulating!activity! metastasis!
$ In!breast!cancer,!this!gene!is!amplified!(indicating! Subsequent!carcinoma!
more!rapid!growth!&!aggressive!behavior)! Laterality! Bilateral! Ipsilateral!
$ Treatment!if!there!is!a!mutation:!Herceptin! Interval!to! 15B20!y! 5B10!y!
! diagnosis!
B Breast'cancer'signs'and'symptoms:' Histo!type! Ductal;!cytoplasmic! ductal!
$ mass.(most.common). mucoid!globules!are!
# if!size!is!1!cm!"!mass!has!been!present!for!5! characteristic!
years! Specifics! Only!in!♀!breast;!more! Other!name:!
$ breast!enlargement!or!asymmetry! common!in!whites;!not' intraductal'
considered'an' carcinoma'(true'
$ nipple!changes!B!retraction,!or!discharge!(!due!to!
anatomic'precursor' anatomic'
shortening!of!Cooper's!suspensory!ligament)! of'breast'ca;!only'a' precursor);!5%!
$ skin!dimpling! risk'marker' of!male!cancers!
$ ulceration!/!erythema!of!the!skin!! (increases'risk'of'
$ axillary!mass!or!mets! breast'ca'9x)!
# firm!or!hard!with!continued!growth!of!the! '
metastatic!cancer.!' # Tx:'
# involved!sequentially!from!the!low!(level!I)!to! • LCIS:'observation,!chemoprevention'
the!central!(level!II)!to!the!apical!(level!III)! with'tamoxifen,!and!bilateral!total!
lymph!node!groups.!' mastectomy!or!may!opt!to!do!close!follow!
# axillary'lymph'node'status:'most'important' up!+!periodic!PE!+!bilateral!mammograms!
prognostic'correlate'of'diseaseSfree'and' for!a!more!conservative!approach'
overall'survival' • DCIS:''
$ peau'd'orange'(Localized'edema):!blocked! o >'4'cm'or'disease'in'>1'quadrant:'
drainage!of!lymph!fluid! mastectomy!
$ musculoskeletal!discomfort.!! o LowBgrade!DCIS!of!the!solid,!
$ Distant'metastases:'most!common!cause!of!death! cribriform,!or!papillary!subtype!that!
in!breast!cancer!patients' is!<0.5!cm:!!lumpectomy!(If!margins!
# Due!to!neovascularization'(hematogenous' are!free!of!disease)!!
spread)!"!cancer!cells!shed!directly!to! o Adjuvant!tamoxifen!therapy!has!a!
axillary!and!intercostals!veins!or!vertebral! role!for!DCIS!pt.!!
column!via!batson’s'plexus'of'veins.!
# Metastatic!foci!occurs!after!the!1o!ca!exceeds! ''√'MUST'KNOW!a!
0.5'cm!in!diameter! Remember:''
# Common!sites!of!involvement!(in!order!of! • Mastectomy'vs'lumpectomy'+'adjuvant'RT:''same'
frequency):!bone,!lung,!pleura,!soft!tissues,!and! mortality'rate'(<2%)'but'lumpectomy'+'adjuvant'RT'has'
liver! a'higher'local'recurrence'rate!(up!to!9%,!compared!to!2%!
for!mastectomy)!
''√'MUST'KNOW!a! • Role'of'RT:'markedly!decreases'the'risk'of'inSbreast'
Remember:'' recurrence!and!significantly!reduces!the!risk!that!any!
• Breast'pain'is'usually'associated'with'benign'disease.' recurrence!will!be!invasive!disease'
• High'recurrence'rate'for'DCIS'comedo'type'
!
B In.situ.breast.cancer+
# Multicentricity:!occurrence!of!a!second!
!
B Invasive.Breast.Cancer.
breast!cancer!outside!the!breast!quadrant!of!
$ Paget's.disease.of.the.nipple'(unrelated!to!Paget’s!
the!primary!cancer!(or!at!least!4!cm!away)!
disease!of!the!bone)'
# Multifocality:!the!occurrence!of!a!second!
# !chronic,!eryhthematous,!eczemamatoid!rash!
cancer!within!the!same!breast!quadrant!as!the!
or!ulcer'
primary!cancer!(or!within!4!cm!of!it)!
# Difficult!to!differentiate!from!atypical! # associated!with!DCIS!&!invasive!cancer.!'
hyperplasia!or!cancers!with!early!invasion! # Pathognomonic'sign:'large,'pale,'
# Subtypes:' vacuolated'cells'(Paget'cells)'in'the'rete'
pegs'of'the'epithelium.'
Table'51.'Comparison!of!LCIS!vs!DCIS! # Rule!out!superficial!spreading!melanoma!'
' LCIS' DCIS' • (+)!sB100!antigen!in!immunostaining!(vs!
Age! 44B47! 54B58! paget’s!disease!which!is!(+)!in!
Incidence! 2B5! 5B10! carcinoembryonic!antigen!
Clinical!sx! None! Mass,!pain!&! immunostaining)'
nipple!discharge! # Tx:!lumpectomy,!mastectomy,!or!MRM!
Mammographic! None!/! Microcalcification (depending!on!the!extent!of!involvement!and!
sx! mammographically! s!(usually!in!areas! the!presence!of!invasive!cancer)'
featureless;!may!have! of!necrosis)!
$ Invasive.ductal.carcinoma.
calcifications!in!
adjacent!tissues! # Occurs!in!perimenopausal!or!postmenopausal!
occasionally! ♀!(5thB6th!decade)'
Premenopausal! 2/3'(more'common)' 1/3! # Most!common!carcinoma!presenting!as!a!
breast!mass'
Incidence!of! 5%! 2B46%! # poorly!defined!margin,!central!stellate!
synchronous! configuration!with!chalky!white!or!yellow!
invasive!ca!

streaks!extending!into!surrounding!breast! # Recommendations:!'
tissues' • normalBrisk!women!at!20!yo!"!breast!
# macroscopic/microscopic!axillary!LN! examination!every!3!years'
metastases!in!60%!of!cases' • at!age!40!yo!"!annual!breast!examination!
!' /!mammography'
$ Medullary.carcinoma. # false'(S)/(+)'rate:'10%'
# Associated!with!BRCA1phenotype!&!DCIS' '
# Gross!appearance:!well!circumscribed,!soft!&! '
hemorrhagic!(when!accompanied!with!a!rapid! '
increase!in!size)' $ Ductography'
# PE:!bulky!and!mass!is!positioned!deep!within! # Indication:!is!nipple!discharge,!(particularly!
the!breast.!' when!bloody)'
# Can'mimic'a'benign'condition'on'diagnostic' # Intraductal!papillomas!are!seen!as!small!filling!
imaging'(looks'like'a'fibroadenoma'on' defects!surrounded!by!contrast!media'
UTZ)' # Ca:!may!appear!as!irregular!masses!or!as!
# Occurs!bilaterally!in!20%!of!cases.' multiple!intraluminal!filling!defects'
# Microscopically:!dense'lymphoreticular' '
infiltrate'' $ Ultrasonography'
' # Ideal!for!younger!patients!(because!of!
$ Mucinous.(colloid).carcinoma. tendency!to!have!denser!breasts!–!can!affect!
# Occurs!in!the!elderly' results!if!mammography!is!used)!
# Characteristic!lesion:!extracellular!pools!of! # Useful!for!resolving!equivocal!mammographic!
mucin' findings,!defining!cystic!masses,!and!
# Gross!appearance:!glistening!&!gelatinous!with! demonstrating!the!echogenic!qualities!of!
a!firm!consistency!' specific!solid!abnormalities.!!
' # breast!cysts:!well!circumscribed,!with!smooth!
$ Papillary.carcinoma. margins!and!an!echoBfree!center!
# Usually!occurs!in!the!7th!decade!of!life!' # features!of!benign!breast!masses:!smooth!
# More!common!in!nonwhite!♀.' contours,!round!or!oval!shapes,!weak!internal!
# defined'by'papillae'with'fibrovascular' echoes,!and!wellBdefined!margins.!!
stalks'and'multilayered'epithelium.'' # Features!of!breast!ca:!irregular!walls!but!may!
' have!smooth!margins!with!acoustic!
$ Tubular.carcinoma. enhancement.!!
# Usually!occurs!during!perimenopausal!or!early! # does!not!reliably!detect!lesions!that!are!1cm.!!
menopausal!periods.!' '
# Microscopically:!haphazard!array!of!small,! B Breast'cancer'staging''
randomly!arranged!tubular!elements!is!seen.!' $ Clinically!based!
# WellBdifferentiated!type!of!infiltrating!ductal! $ tumor!size!correlates!with!the!presence!of!axillary!
cancer' lymph!node!metastases!
# Favorable!diagnosis' $ The'single'most'important'predictor'of'10S'and'
' 20Syear'survival'rates'in'breast'cancer'is'the'
$ Invasive.lobular.carcinoma. number'of'axillary'lymph'nodes'involved'with'
# Histopath:'small!cells!with!rounded!nuclei,! metastatic'disease.!
inconspicuous!nucleoli,!and!scant!cytoplasm;! '
(+)!intracytoplasmic!mucin,!which!may! Table'52.!TNM!breast!cancer!staging!
displace!the!nucleus!(signetSring'cell' T! N! M!
carcinoma).!' T1:!<2cm! N1:!suspicious! M1:!(+)!lung,!
# frequently!multifocal,'multicentric,'and' T2:!2B5!cm! mobile! liver!or!bone!
T3:!>5cm! axillary!nodes! involvement!
bilateral.'
T4:!(+)!chest! N2:!matted!or!
# Hard!to!detect!mammographically!' wall!&!direct! fixed!axillary!
' skin! nodes!
B Diagnosis'of'breast'cancer' involvement! N3:!ipsilateral!
$ Mammography:'' internal!
# Views:' mammary!
• Craniocaudal!(CC)!view:!medial!aspect!of! nodes!
the!breast;!permits!greater!breast! !
compression' $ (+)!supraclavicular!nodes:!stage!III!disease!(not!
• mediolateral!oblique!(MLO)!view:!images! stage!IV!as!formerly!classified)!
the!greatest!volume!of!breast!tissue!&! !
upper!outer!quadrant!and!the!axillary!tail! B Treatment'for'breast'cancer!
of!Spence' $ Treatment!is!dependent!on!the!stage!at!diagnosis!
# Features!suggestive!of!breast!cancer:' $ Early'invasive'breast'cancer'(stage'I,'IIa,'IIb)'
• solid!mass!+/B!stellate!features' # Lumpectomy!+/B!RT!(breast!conservation!sx)!
is!an!acceptable!tx!option!since!survival!rates!
• asymmetric!thickening!of!breast!tissues'
are!comparable!to!total!mastectomy.!'
• clustered!microcalcifications!'
• However,!recurrence!↑er!in!the!
• presence!of!fine,!stippled!calcium!in!&!
lumpectomy!with!no!RT!stage!I!and!II!
around!a!suspicious!lesion!is!suggestive!of!
breast!cancer.!'
breast!cancer;!occurs!in!50%!of!
# CI'to'breast'conservation'sx:'
nonpalpable!cancers.!'
# Mimickers'of'breast'ca'mammographically:' • prior!RT!to!the!breast!or!chest!wall'
radial'scars,'fibromatosis,'granular'cell' • involved!surgical!margins!or!unknown!
tumor'and'fat'necrosis!(surgical!excision!is! margin!status!after!reBexcision'
indicated!for!these!lesions,!owing!to!their! • multicentric!disease'
resemblance!to!ca)' • scleroderma!or!lupus!erythematosus.'
# %!reduction!in!mortality!for!women!after!
screening!mammography.!'
# If'clinically'negative'nodes'but'with'T1ST2' • preserves'pectoralis'major,!pectoralis!
primary'ca'"'perform'sentinel'LN' minor,!level!III!LN!&!medial!(anterior!
dissection' thoracic)!pectoral!nerve'
• If'(+):'perform!axillary!lymph!node! • complications'☺'
dissection!should!be!performed.! o most'frequent:'Seromas!beneath!the!
# Adjuvant!chemotherapy!is!indicated!for!nodeB skin!flaps!or!in!the!axilla'
positive!cancers,!>1!cm,!and!nodeBnegative! o injury'to'the'long'thoracic'nerve'
cancers!of!>0.5!cm!when!adverse!prognostic! (affects'serratus'anterior)'"'
features!(blood!vessel!or!lymph!vessel! winging'of'scapula''
invasion,!high!nuclear!grade,!high!histologic! o lymphatic'fibrosis!"!painless,!slow!
grade,!HERB2/neu!overexpression,!and! progressive!swelling!of!the!involved!
negative!hormone!receptor!status).!! arm'
# Tamoxifen!therapy:!women!with!hormone! o injury'to'the'axillary'vein!"!
receptor!(+)!cancer!that!are!>1!cm.!! sudden!painful!early!postoperative!
# HERB2/neu!expression!is!determined!for!node! swelling!of!the!involved!arm!(due!to!
(B)!breast!ca! acute!thrombosis!as!the!collateral!
• Trastuzumab:!medication!for!HERB2/neu+ channels!do!not!have!the!chance!to!
(–)! develop!"!acute!and!painful)'
• doxorubicin,!cyclophosphamide,!&! o injury'to'the'thoracodorsal'
paclitaxel:!medication!for!HERB2/neu!(+)! vascular'pedicle'"!ischemic!loss!of!
&!node!(+)!breast!cancer.! the!entire!latissimus!dorsi!flap!
' utilized!for!reconstruction'
$ Advanced'local'regional'breast'cancer'(stage' o injury'to'the'medial'pectoral'
IIIa'or'IIIb)' pedicle'"'progressive!atrophy!of!
# Surgery!(MRM)!+!adjuvant!RT!+!CT! the!pectoralis!muscle'
(neoadjuvant)!' o injury'to'the'2nd'intercostals'
• Role!of!CT:!maximize!distant!diseaseBfree! brachiocutaneous'nerve'"!
survival' hypesthesia!of!the!upper!inner!
• Role!of!RT:!maximize!localBregional! aspect!of!the!ipsilateral!arm'
diseaseBfree!survival.' # Halsted'radical'mastectomy:'removes!all!
• If!stage!IIIA!ca:!neoadjuvant! breast!tissue!and!skin,!the!nippleBareola!
(preoperative)!CT!"!reduce!the!size!of! complex,!the!pectoralis!major!and!pectoralis!
the!primary!ca!&!permit!breastB minor!muscles!&!the!level!I,!II,!and!III!LN.!!
conserving!surgery.!' !
B Non!surgical!breast!cancer!tx!
Figure'29.'Treatment!pathyway!for!stage!IIIa!&!IIIb!cancer' $ RT'
# Adjuvant'RT'after'mastectomy'"'decrease'
local'recurrence'rates'but'will'not'prolong'
survival'☺!
o Indicated!for!those!with!high!risk!for!
local!recurrence:!large!tumors,!skin!
involvement,!>!4!axillary!LN!involved!
$ Chemotx!
# Adjuvant!chemotheraphy!
• Indicated!if!node!(B)!tumor!>1cm!that!are!
ER!(B)!
# Neoadjuvant!chemotherapy!
# Neoadjuvant!endocrine!therapy!
'''''''''''''''''' ' • Tamoxifen:!indicated!if!node!(B)!tumor!
$ Distant'metastases'(stage'IV)' >1cm!that!are!ER!(+)!!
# Not!anymore!curative!but!may!prolong! • Herceptin:!(+)!her2/neu!
survival! '
! B breast'cancer'in'pregnancy'
B Breast'cancer'prognosis' $ occurs!in!1!of!every!3000!pregnant!♀!
$ 5!year!survival!rate! $ TX:!
# Stage!I:!94%! # MRM:!1st!&!2nd!trimesters!of!pregnancy!
# stage!IIA:!85%! # lumpectomy!with!axillary!node!dissection:!3rd!
# stage!IIB:!70%! trimester!!
# stage!IIIA:!52%! # adjuvant!RT:!after!delivery.!'
# stage!IIIB:!48%! '
# stage!IV:!18%! B male'breast'cancer'
! $ <1%!of!all!breast!cancers!occur!in!men'
B surgical'techniques'in'breast'cancer'tx' $ preceded!by!gynecomastia!in!20%!of!men.!'
$ sentinel'LN'dissection:'used!to!assess!the!regional! $ associated!with!radiation,!estrogen!tx,!testicular!
LN!in!women!with!early!breast!ca!who!are! feminizing!syndromes,!and!Klinefelter's!syndrome!
clinically!node!negative!by!PE!&!imaging!studies' (XXY)!
$ breast'conservation'therapy'(BCT)' $ usual!types!of!cancer:!DCIS,!infiltrating!ductal!ca!
# if!stage!0,!I!&!II,!BCT!is!preferable!to!total! $ Overall,!men!do!worse!because!of!the!advanced!
mastectomy!(!with!equivalent!survival!rates)! stage!of!their!ca!(stage!III!or!IV)!at!the!time!of!
$ mastectomy'and'axillary'dissection' diagnosis!and!poorer!prognosis.!But!stage!for!stage,!
# simple'mastectomy:!removes!all!breast! the!results!of!treatment!are!similar!to!those!in!
tissue,!the!nippleBareola!complex,!skin!&!level!I! women.!
LN' '
# Modified'radical'mastectomy:!removes!all! G. special'clinical'situations'
breast!tissue,!the!nippleBareola!complex,!skin,! a. nipple.discharge.
&!level!I!and!level!II!LN.!'
$ suggestive!of!cancerous!lesion:!spontaneous,! immunohistomchemical! stains)! have! better! prognosis!
unilateral,!localized!to!a!single!duct,!present!in! compared! to! those! with! zero! or! low! levels.! The! most!
women!40!years!of!age,!bloody,!clear,!serous,!or! common!hormonal!manipulation!is!estrogen!withdrawal,!
associated!with!a!mass.' usually! with! a! receptorBblocking! agent! (tamoxifen).!
$ Suggestive!of!a!benign!condition:!bilateral,! However,! bilateral' oophorectomy! in! premenopausal!
multiductal!in!origin,!occurs!in!women!39!years!of! women! is! still! considered! a! reasonable! option.! Surgical!
age,!or!is!milky!or!blueBgreen.!' hypophysectomy' &' adrenalectomy! were! at! one! point!
# Consider!prolactinBsecreting!pituitary! considered! forms! of! hormonal! manipulation,! but! are!
adenomas!(!↑!serum!prolactin!levels,!Optical! now! being! replaced! by! “medical! adrenalectomy”! in! the!
nerve!compression,!visual!field!loss,!&! form! of! anastrazole,! which! inhibit! the! production! of!
infertility)!' adrenal! steroids! and! conversion! of! androgens! to!
' estrogens! in! the! adrenal! gland! and! peripherally.! The!
b. Cystosarcoma.phylloides.tumor. aromatase! inhibitors! are! beneficial! only! in!
B Resembles!a!giant!fibroadenoma! postmenopausal!women.!!
B Can!occur!in!benign!and!malignant!forms! !
B gross!appearance:!classical!leafBlike!(phyllodes)! 3. a! 39! year! old! woman! presents! with! an! illBdefined! 2! cm!
appearance;!greater!cellular!activity!than!fibroadenoma! mass!in!the!outer!quadrant!of!her!breast.!Mammography!
B metastasis'is'usually'vascular!and!no!axillary!LN! shows! very! dense! tissue! but! no! discrete! lesion.!
involvement!is!expected.! Ultrasound! examination! shows! a! solid! lesion.! An!
B tx:!! ultrasoundBguided! fine! needle! aspiration! (FNA)! is!
$ if!benign!"!total!excision!with!2B3!cm!margin! performed,!and!the!aspirate!is!plated,!fixed,!and!sent!to!
$ if!malignant!"!total!mastectomy!w/o!axillary!LN! the! laboratory! for! cytologic! study.! A! highly! cellular!
dissection;!if!small!"!wide!excision!with!2cm! monomorphic! pattern! is! seen,! with! poorly! cohesive!
margin!is!acceptable!! intact! cells,! nuclear! “crowding”! with! a! variation! in!
$ if!large!"!mastectomy.!! nuclear! size,! radial! dispersion! and! clumping! of! the!
$ Follow!up!is!important!due!to!high!local!recurrence! chromatin,! and! prominent! nucleoli.! Which! of! the!
rate! following!management!choices!is/are!appropriate?!
' !
c. Inflammatory.breast.cancer.☺ . a. MRM!
B variant!of!infiltrating!ductal!ca! b. Reassuring! the! patient! that! the! process! is!
B characterized!by!the!skin!changes!of!brawny! benign!
induration,!erythema!with!a!raised!edge,!and! c. Lumpectomy,!sentinel!lymph!node!biopsy!and!
edema!or!peau!d'orange!(hence!the!name! irradiation!
inflammatory)!+!breast!mass! d. Excision! of! a! fibroadenoma! with! narrow!
B appearance!is!due!to!a!dermal'lymphatic' margins!
invasion! e. Lumpectomy!and!sentinel!lymph!node!biopsy!
without!irradiation!
!
'''''''REVIEW'QUESTIONS!a! Answer:!A,C'
! Aspiration!biopsy!with!a!22!gauge!needle!is!an!effective!
1. a! 58! yo! woman! presents! with! chronic,! erythematous,! and! safe! way! of! assessing! palpable! breast! lesions.!
oozing,! eczematoid! rash! involving! the! left! nipple! and! Performing! the! aspiration! under! ultrasound! guidance!
areola.! There! are! no! breast! masses! palpable,! and! her! ensures! that! the! lesion! has! been! sampled! thoroughly!
mammogram! is! normal.! Which! of! the! following! while!under!direct!vision.!Although!a!smaller!volume!of!
recommendations!is!appropriate?! tissue! is! obtained! than! the! core! needle! biopsy,! FNA!
! frequently! yields! results! that! may! be! equal! to! core!
a. Referral!to!a!dermatologist! biopsy! if! read! by! an! experienced! cytopathologist.! A!
b. Oral!vitamin!E!and!topical!aloe!and!lanolin! fibroadenoma' would! show! broad+ sheets+ of+ cohesive+
c. Biopsy!! cells+ with+ nuclei+ that+ are+ unfirm+ in+ size+ and+ shape.+ The+
d. Non!allergenic!brassiere! chromatin+ pattern+ would+ be+ finely+ granular+ and+ large+
e. Standard! treatment! that! includes! breast! numbers+ of+ bare+ nuclei+ would+ be+ present.+ The' cytologic'
conservation! findings' described' in' this' question' is' diagnostic' of'
! carcinoma.' Appropriate! management,! therefore,!
Answer:!C! includes! either! a! modified! radical! mastectomy! or!
This! is! a! case! of! Paget’s' disease' of' the' breast.! It! is! a! lumpectomy,! axillary! evaluation! by! either! a! sentinel!
case! of! primary! ductal! carcinoma! that! secondarily! lymph! node! biopsy! or! an! axillary! nodal! dissection,! and!
invades! the! epithelium! of! the! nipple! and! areola.! Biopsy! wholeBbreast!irradiation.!
of! any! chronic! nipple! rash! is! mandatory! and! will! show! !
the! distinctive! pagetoid! cells.! Because! of! the! possible! '
invasion!of!the!tumor!on!the!underlying!rich!lymphatics! !
of! the! nipple! areolar! complex,! mastectomy! is! usually! HEAD'and'NECK:'BENIGN'CONDITIONS'&'TUMORS'
indicated.! In! selected! cases,! breast! conservation! '
therapies!can!also!be!employed.!! A. Risk'factors'for'tumors'of'head'and'neck'
! B. Anatomy'of'Oral'cavity'
2. If! patient! with! metastatic! breast! ca! is! ER! (+),! which! of! C. Cancer'of'the'Lip'
the!following!statements!are!appropriate?! D. Cancer'of'the'Tongue''
! E. Tumors'of'Alveolus/gingiva'
a. Bilateral!oophorectomy! F. Anatomy'of'pharynx'
b. Antiestrogen!drugs!(tamoxifen)! G. Tumors'of''Nasopharynx'
c. Hypophysectomy! H. Tumors'of'Oropharynx'
d. Adrenalectomy! I. Tumors'of'Hypopharynx/cervical'esophagus'
e. Aromatase!inhibitor! J. Anatomy'Larynx'
K. Benign'conditions'of'the'Larynx'
Answer:!A,B,E!
L. Laryngeal'Carcinoma'
!
M. Neck'and'associated'conditions'
Patients! with! high! ER! &! PR! levels! (based! on!
N. Salivary'gland'tumors' greater!than!4!cm,!desmoplastic!tumor!&!(+)!
O. Thyroid'and'associated'conditions' perineural!invasion!
' $ Realignment'of'the'vermilion'border'during'the'
! reconstruction'and'preservation'of'the'oral'
! commissure!(when!possible)!are!important!
A. RISK'FACTORS'FOR'TUMORS'OF'HEAD'AND'NECK' principles!in!attempting!to!attain!an!acceptable!
' cosmetic!result.!
B tobacco.&.alcohol:.most.common.preventable.risk. B Prognosis'is'most'favorable'for'all'H&N'CA'
factors.associated.with.head.and.neck.CA.. !
B betel!nut!chewing. D. CANCER.OF.THE.TONGUE.
B reverse!smoking. B !muscular!structure!with!overlying!nonkeratinizing'
B HPV'16'and'18.. squamous'epithelium.'
B UV!light!exposure!(for!lip!CA). B Posterior!border:!circumvallate!papillae'
B Patients!with!H&N!CA!are!predisposed!to!the! B Tongue'cancer!
development!of!a!2nd!tumor!within!the!aerodigestive! $ Same!risk!factors!with!other!H&N!CA!
tract.' $ Associated!with!plummerSvinson'syndrome!
$ presentation'of'a'newSonset'dysphagia,' (cervical!dysphagia,!IDA,!atrophic!oral!mucosa,!
unexplained'weight'loss,'or'chronic' brittle!spoon!finger!nails)!
cough/hemoptysis'must'be'assessed' • Clinical!findings:!ulcerations!or!as!exophytic!
thoroughly'in'patients'with'a'history'of'prior' masses!'
treatment'for'a'head'and'neck'cancer'' • The!regional!lymphatics!of!the!oral!cavity!are!to!the!
$ ex.!If!(+)!primary!malignancy!of!oral!cavity! submandibular'space'and'the'upper'cervical'
orpharynx!"!secondary!malignancy!at!cervical! lymph'nodes'
esophagus;!(+)!primary!malignancy!at!larynx!"! • Involvement!of!lingual!nerve!"!ipsilateral!
secondary!malignancy!at!lungs! paresthesias'
B Synchronous!neoplasm:!a!2nd!1o!tumor!detected!within! • Involvement!of!hypoglossal!nerve!"!deviation!of!
6!months!of!the!diagnosis!of!the!initial!primary!lesion' tongue!on!protusion!+!fasciculations!"!atrophy'
B Metachronous!tumor:!detection!of!a!2nd!1o!lesion!more! • most!common!location:!lateral!and!ventral!surfaces'
than!6!months!after!the!initial.' • if!base!of!the!tongue!"!advanced!stage!and!poorer!
B Initial!evaluation!of!patients!with!primary!CA!of!H&N:! prognosis'
"panendoscopy."! • tx:!'
!! # Surgical!treatment!of!small!(T1–T2)!primary!
B. ANATOMY'OF'ORAL'CAVITY' tumors!is!wide!local!excision!with!either!
B Borders:' primary!closure!or!healing!by!secondary!
$ Anterior:!vermilion!border!of!the!lip!' intention.!'
$ Superior:!hardBpalate/softBpalate!junction!' # If!base!of!tongue"Partial!glossectomy!with!
$ Inferior:!circumvallate!papillae' supraomohyoid!dissection!if!N0!or!MRND!if!
$ Lateral:!anterior!tonsillar!pillars' N(+)'
B The!oral!cavity!includes!lips,'alveolar'ridges,'oral' '
tongue,'retromolar'trigone,'floor'of'mouth,'buccal' E. TUMORS.OF.ALVEOLUS/GINGIVAL.
mucosa,'and'hard'palate.!' B Because!of!the!tight!attachment!of!the!alveolar!mucosa!
B Regional!metastatic!spread!of!lesions!of!the!oral!cavity! to!the!mandibular!and!maxillary!periosteum,!treatment!
is!to!the!lymphatics!of!the!submandibular'and'the' of!lesions!of!the!alveolar!mucosa!frequently!requires!
upper'jugular'region'(levels'I,'II,'and'III)☺' resection!of!the!underlying!bone.'
B Majority.of.tumors.in.the.oral.cavity.are.squamous. B Diagnosis!for'alveolar!or!gingival!cancer'
cell.carcinoma.(>90%). • Panorex:'demonstrate!gross!cortical!invasion'
' • CT:'imaging!subtle!cortical!invasion'
C. CANCER.OF.THE.LIP. • MRI:'demonstrates!invasion!of!the!medullary!
B most!commonly!seen!old!people!(50B70!years!old)!with! cavity'
fair!complexion! B Tx!for!alveolar!or!gingival!cancer'
B Risk!factors:!prolonged!exposure!to!sunlight,!fair! • If!minimal!bone!invasion:!mandibular!resection'
complexion,!immunosuppression,!and!tobacco!use.' • If!(+)!medullary!cavity!invasion:!segmental!
B Most'common'location:'lower'lip'(88'to'98%),!upper! mandibulectomy!'
lip!(2!to!7%)!&!oral!commissure!(1%).!' '
B Predominantly!squamous'cell'CA' F. ANATOMY'OF'PHARYNX'
B Basal!cell!carcinoma!presents!more!frequently!on!the! B three!regions:!'
upper!lip!than!lower.' • nasopharynx'
B Clinical!findings:!' # extends!from!the!posterior!nasal!septum!and!
$ ulcerated!lesion!on!the!vermilion!or!cutaneous! choana!to!the!skull!base'
surface.!' # includes!fossa!of!rossenmuller,!Eustachian!
$ (+)'paresthesia'in'the'area'of'lesion:'mental' tube!orifices!(torus!tuberous)!and!adenoid!pad'
nerve'involvement.' # bilateral!regional!metastatic!spread!in!this!
B unfavorable!prognosticating!factors:!perineural! area!is!common'
invasion,!involvement!of!maxilla/mandible,!upper!lip!or! # Lymphadenopathy!of!the!posterior'triangle'
commissure!involvement,!regional!lymphatic! (level'V)!of!the!neck!should!provoke!
metastasis,!and!age!younger!than!40!years!at!onset.!! consideration!for!a!nasopharyngeal!primary'
B primary'echelon'of'nodes'at'risk'is'in'the' • Oropharynx:!'
submandibular'and'submental'regions! # Includes!tonsillar!region,!base!of!tongue,!soft!
B Tx:!! palate,!and!posterolateral!pharyngeal!walls'
$ T1!&!T2!(≤4cm):!Surgery!=!RT! # Regional!lymphatic!drainage!for!
$ T3!&!T4:!surgical!excision!with!histologic! oropharyngeal!lesions!frequently!occurs!to!the!
confirmation!of!tumorBfree!margins!+!postop!RT! upper'and'lower'cervical'lymphatics'
$ Prophylactic!supraomohyoid!neck!dissection! (levels'II,'III,'IV)'+Retropharyngeal!
should!be!considered!for!patients!with!tumors! metastatic!!spread!'
• hypopharynx.!'
# extends!from!the!vallecula!to!the!lower!border! $ flexible!fiberBoptic!laryngoscopy'
of!the!cricoid!posterior!and!lateral!to!the! $ CT!and/or!MRI!imaging:!check!for!regional!
larynx.' metastases!(paratracheal!and!upper!mediastinal!
# includes!pyriform!fossa,!the!postcricoid!space,! lymph!nodes)'
and!posterior!pharyngeal!wall.!' B Tx:!
# Regional!lymphatic!spread!is!frequently! $ T1:!RT!
bilateral!and!to!the!midS'and'lower'cervical' $ T2!&!T3:!chemoradiation!
lymph'nodes'(levels'III,'IV)' $ LarynxBpreserving!surgical!procedures:!only!if!the!
' tumor!must!not!involve!the!apex!of!the!pyriform!
G. TUMORS'OF'THE'NASOPHARYNX' sinus,!vocal!cord!mobility!must!be!unimpaired,!and!
B Tumors!arising!in!the!nasopharynx!are!usually!of! the!patient!must!have!adequate!pulmonary!
squamous'cell'origin' reserve.!!
B Most'common'nasopharyngeal'malignancy'in'the' $ Bilateral!neck!dissection!is!frequently!indicated!
pediatric'age'group:'lymphoma' given!the!elevated!risk!of!nodal!metastases!found!
B Risk'factors'for'nasopharyngeal'carcinoma:'area'of' with!these!lesions!
habitation'&'ethnicity'(southern'China,'Africa,'
Alaska,'and'in'Greenland'Eskimos.),'EBV'infection,'&' J. ANATOMY'OF'LARYNX:'
tobacco'use.'' B divided!into!3!regions:!!
B Symptoms:!' $ supraglottis:!epiglottis!(lined!by!stratified,!
• nasal'obstruction,'posterior'(level'V)'neck' nonkeratinizing!squamous!epithelium),!false!vocal!
mass,'epistaxis,'headache,'serous'otitis'media' cords!(lined!by!pseudostratified,!ciliated!
with'hearing'loss,'and'otalgia.'' respiratory!epithelium),!medial!surface!of!the!
• Cranial!nerve!involvement!is!indicative!of!skull! aryepiglottic!folds,!and!the!roof!of!the!laryngeal!
base!extension!and!advanced!disease.!' ventricles'
B Lymphatic!spread!occurs!to!the!posterior'cervical,' # has!a!rich'lymphatic'network,!which!
upper'jugular,'and'retropharyngeal'nodes.'' accounts!for!the!high'rate'of'bilateral'spread'
B Bilateral'regional'metastatic'spread'is'common.' of'metastatic'disease'
B Diagnosis!for!nasopharyngeal!CA:!' $ glottis:!the!true!vocal!cords,!anterior!and!posterior!
• flexible!or!rigid!fiberBoptic!endoscope' commissure,!and!the!floor!of!the!laryngeal!
• CT!with!contrast:!determining!bone!destruction' ventricle.!
• MRI:!assess!for!intracranial!and!softBtissue! $ Subglottis:!extends!from!below!the!true!vocal!
extension.!' cords!to!the!cephalic!border!of!the!cricoid!within!
B Tx:!chemoradiation! the!airway'
! # pseudostratified,!ciliated!respiratory!
H. TUMORS.OF.THE.OROPHARYNX. epithelium'
B Direct!extension!of!tumors!from!the!oropharynx!into! # Glottic!and!subglottic!lesions:!spread!to!the!
these!lateral!tissues!may!involve!spread!into!the! cervical!chain,!paralaryngeal!and!paratracheal!
parapharyngeal!space! LN'
B histology!of!the!majority!of!tumors!in!this!region!is! '
squamous'cell'carcinoma! K. BENIGN'CONDITIONS'OF'THE'LARYNX.
B (+)!asymmetrical!enlargement!of!the!tonsils!and!tongue!
base!"!think!lymphoma! Recurrent.respiratory.papillomatosis.(RRP)..
B Clinical!findings:!ulcerative!lesion,!exophytic!mass,! B (+)HPV!6!&!11'
tumor!fetor,!!muffled!or!"hot!potato"!voice!(large!tongue! B larynx!is!the!most!frequently!involved!site!'
base!tumors),!Dysphagia,!weight!loss,!Referred!otalgia,! B presents!in!early!childhood,!secondary!to!viral!
(tympanic!branches!of!CN!IX!&!CN!X),!Trismus! acquisition!during!vaginal!delivery.'
(involvement!of!the!pterygoid!musculature),!ipsilateral! B Sx:!hoarseness,!!airway!compromise!'
or!bilateral!nontender!cervical!lymphadenopathy! B Diagnosis:!endoscopy'
B LN!metastasis!from!oropharyngeal!cancer!most' B Tx:!operative!microlaryngoscopy!with!excision!or!laser!
commonly'occurs'in'the'subdigastric'area'of'level'II.' ablation'
Others!B!levels!III,!IV,!&!V,!!retropharyngeal!&! B High!tendency!to!recur!'
parapharyngeal!LN.!!
$ Bilateral!metastases:!seen!in!tumors!originating! Laryngeal.granulomas.
from!the!tongue!base!and!soft!palate;!if!found!in! B typically!occur!in!the!posterior!larynx!on!the!arytenoid!
these!areas!"!associated!with!poor!survival! mucosa!
B Tx:!! B risk!factors:!reflux,!voice!abuse,!chronic!throat!clearing,!
$ Options:!surgery,!primary!radiation!alone,!surgery! endotracheal!intubation,!and!vocal!fold!paralysis'
with!postoperative!radiation,!&!combined! B Sx:!pain!often!with!swallowing!(less!commonly:!vocal!
chemotherapy!with!radiation!therapy.! ! changes)'
# If!tongue!base!crossing!middling:!do!total! B Dx:!fiberBoptic!laryngoscopy,!voice!analysis,!laryngeal!
glossectomy!with!possible!total!laryngectomy! electromyography!(EMG),!and!pH!probe!testing.!'
$ Tumors!of!the!oropharynx!tend!to!be! B Tx:!voice!rest,!voice!retraining!therapy,!and!antireflux!
radiosensitive.! therapy.!'
'
I. TUMORS.OF.THE.HYPOPHARYNX/CERVICAL. Reinke's.edema.
ESOPHAGUS. B located!at!the!superficial!lamina!propria!due!to!injury!to!
B Squamous!cancers!of!the!hypopharynx!frequently! the!capillaries!that!exist!in!this!layer,!with!subsequent!
present!at!an!advanced!stage,!hence!are!associated!with! extravasation!of!fluid.!!
poorer!survival!rates' B Sx:!rough,!lowBpitched!voice.!'
B Clinical!findings:!neck!mass,!muffled!or!hoarse!voice,! B Risk!factors:!smoking,!laryngopharyngeal!reflux,!
referred!otalgia,!progressive'dysphagia'to'solids'"' hypothyroidism,!and!vocal!hyperfunction.'
liquids,!weight!loss.' !
B Invasion'of'the'larynx'by'direct'extension'"'vocal' Vocal.cord.cyst.
cord'paralysis'(if'unilaterally'affected)'"'airway' B may!occur!under!the!laryngeal!mucosa!(in!regions!
compromise'(if'bilaterally'affected)' containing!mucousBsecreting!glands)!
B Diagnosis:'
B Cysts!of!the!vocal!cord!may!be!difficult!to!distinguish!
from!vocal!polyps!
B Diagnosis:!video!stroboscopic!laryngoscopy'
B Tx:'Large!cysts!of!the!supraglottic!larynx!are!treated!by!
marsupialization!with!cold!steel!or!a!CO2!laser.!'
'
Vocal.cord.paralysis.
B most'commonly'is'iatrogenic!(s/p!thyroid,!
parathyroid,!carotid,!or!cardiothoracic!surgeries)!
B can!be!secondary'to'malignant'processes!in!the!lungs,!
thyroid,!esophagus,!thoracic!cavity,!skull!base,!or!neck.!
B Sx:!presents!with!hoarseness!and!“breathy”!voice!
$ If!superior!laryngeal!nerve!is!affected!"!
demonstrate!aspiration!secondary!to!diminished! !
supraglottic!sensation! 1. Level.I:.submental.&.submandibular.nodes..
$ left!vocal!cord!is!more!commonly!involved! B Level!Ia:!the!submental!nodes;!medial!to!the!anterior!
secondary!to!its!longer!course!of!the!recurrent! belly!of!the!digastric!muscle!bilaterally,!symphysis!of!
laryngeal!nerve!(RLN)!on!that!side! mandible!superiorly,!and!hyoid!inferiorly!!
$ if!anterior!surgical!approaches!to!the!cervical!spine! B Level!Ib:!the!submandibular!nodes!and!gland;!posterior!
are!performed!"!right!RLN!is!at!an!increased!risk! to!the!anterior!belly!of!digastric,!anterior!to!the!
(courses!more!laterally!to!the!tracheoesophageal! posterior!belly!of!digastric,!and!inferior!to!the!body!of!
complex)! the!mandible!'
.
L. LARYNGEAL'CARCINOMA' 2. Level.II:.upper.jugular.chain.nodes..
B Suspect!if!with!(+)!Hx!of!smoking!&!complaint!of!a! B Level!IIa:!jugulodigastric!nodes;!deep!to!
change!in!vocal!quality! sternocleidomastoid!(SCM)!muscle,!anterior!to!the!
B are!primarily!squamous'cell'carcinoma'! posterior!border!of!the!muscle,!posterior!to!the!
B sx:! posterior!aspect!of!the!posterior!belly!of!digastric,!
$ supraglottic'larynx:!chronic!sore!throat,! superior!to!the!level!of!the!hyoid,!inferior!to!spinal!
dysphonia!("hot!potato"!voice),!dysphagia,!or!a! accessory!nerve!(CN!XI)!
neck!mass!secondary!to!regional!metastasis,! B Level!IIb:!submuscular!recess;!superior!to!spinal!
Referred'otalgia'or'odynophagia'is'encountered' accessory!nerve!to!the!level!of!the!skull!base!'
with'advanced'supraglottic'cancers.! '
$ Glottic'larynx:!hoarseness!(early;!because!only!a! 3. Level.III:.middle.jugular.chain.nodes+
small!degree!of!change!is!required!to!produce! B inferior!to!the!hyoid,!superior!to!the!level!of!the!cricoid,!
hoarseness),!Airway!obstruction!(late),!Decreased! deep!to!SCM!muscle!from!posterior!border!of!the!
vocal!cord!mobility!may!be!caused!by!direct!muscle! muscle!to!the!strap!muscles!medially!!
invasion!or!involvement!of!the!RLN.!! !
$ Subglottic'larynx:!vocal!cord!paralysis!(usually! 4. Level.IV:.lower.jugular.chain.nodes.
unilateral)!and/or!airway!compromise!(are! B inferior!to!the!level!of!the!cricoid,!superior!to!the!
relatively!uncommon).! clavicle,!deep!to!SCM!muscle!from!posterior!border!of!
B Lymphatic!drainage:!! the!muscle!to!the!strap!muscles!medially''
$ Supraglottic'larynx:!subdigastric!and!superior! jaime'is'the'best!!'
jugular!nodes!! '
$ glottic'and'subglottic'larynx:!prelaryngeal!node! 5. Level.V:.posterior.triangle.nodes..
(the!Delphian!node),!the!paratracheal!nodes,!and! B Level!Va:!lateral!to!the!posterior!aspect!of!the!SCM!
the!deep!cervical!nodes!! muscle,!inferior!and!medial!to!splenius!capitis!and!
$ glottic!cancers!have!limited!lymphatic!access!"! trapezius,!superior!to!the!spinal!accessory!nerve!!
regional!nodal!metastases!is!low! B Level!Vb:!lateral!to!the!posterior!aspect!of!SCM!muscle,!
B treatment! medial!to!trapezius,!inferior!to!the!spinal!accessory!
$ early!stage!glottis!&!supraglottic!cancer:!RT! nerve,!superior!to!the!clavicle!'
$ small!glottic!cancers:!Partial!laryngectomy! '
$ supraglottic!cancers!w/o!arytenoid!or!vocal!cord! 6. Level.VI:.anterior.compartment.nodes+
extension:!supraglottic!laryngectomy!! B inferior!to!the!hyoid,!superior!to!suprasternal!notch,!
$ advanced!tumors!with!extension!:!total! medial!to!the!lateral!extent!of!the!strap!muscles!
laryngectomy!+!postop!RT! bilaterally!!
$ Subglottic!cancers:!total!laryngectomy.!! !
7. Level.VII:.paratracheal.nodes+
B inferior!to!the!suprasternal!notch!in!the!upper!
M. NECK'AND'ASSOCIATED'CONDITIONS'☺' mediastinum.
B differential!diagnosis!of!neck!masses!is!dependent!on!its!
location!and!patient’s!age! Patterns'of'spread'from'primary'tumor'sites:'
$ pediatric!age:!think!congenital!or!inflammatory! B oral+cavity+and+lip:!levels!I,!II,!and!III!
conditions! $ Skip'metastases'may'occur'with'oral'tongue'
$ adult!+!risk!factors:!rule!out!malignancy! cancers!such!that!involvement!of!nodes!in!level!III!
$ in!terms!of!location,!think!about!patterns!of! or!IV!may!occur!without'involvement'of'higher'
drainage! echelon'nodes'(levels'I'&'II).!!
B oropharynx,+hypopharynx,+and+larynx:!levels!II,!III,!and!
Lymphatic'drainage'of'the'neck'is'divided'into'7'levels.'' IV.!
'
B !nasopharynx+and+thyroid:!level'V!nodes!in!addition!to!
Figure'30.!levels!of!the!neck!bearing!LN!bearing!regions!
the!jugular!chain!nodes.!!
B nasopharynx,+soft+palate,+and+lateral+and+posterior+walls+
of+the+oropharynx+and+hypopharynx:!Retropharyngeal!
lymph!nodes!!

B hypopharynx,+cervical+esophagus,+and+thyroid:!! the!tongue!base,!into!the!lower!anterior!neck!during!
paratracheal!nodal!compartment!+!upper!mediastinum! fetal!development.!
nodes!(level!VII).!! B An!embryological!anomaly!wherein!there!is!failure'of'
B advanced+tumors+of+the+glottis+with+subglottic+spread:! obliteration'of'the'midline'pharyngeal'diverticulum!
Delphian!node! during!thyroid!descent!
! B present!as!a!midline'or'paramedian'cystic'mass'
Neck'dissections:' adjacent'to'the'hyoid'bone.'
' B After!an!upper!respiratory!infection,!the!cyst!may!
B Radical.neck.dissection.(RND.or.CRILE.method):! enlarge!or!become!infected.!!
removes!levels!I!to!V!of!the!cervical!lymphatics!+!SCM!+! B Tx:!removal!of!the!cyst,!the!tract,!and!the!central!portion!
internal!jugular!vein!+!CN!XI!! of!the!hyoid!bone!(Sistrunk'procedure)!+!portion!of!
! the!tongue!base!up!to!the!foramen!cecum.!!
B Modified.radical.neck.dissection.(MRND).or. B Check!1st!for!normal!thyroid!tissue!in!the!lower!neck!
functional.neck.dissection:+Any!modification!of!the! area!&!if!ensure!that!patient!is!euthyroid!
RND!that!preserves!nonlymphatic!structures!(i.e.,!CN!XI,! B 1%!of!thyroglossal!duct!cysts!contain!cancer'(85%'is'
SCM!muscle,!or!internal!jugular!vein)! usually'papillary)'
$ Comparable'to'RND'in'controlling'regional'
metastasis!with!!superior!functional!results! Congenital.branchial.cleft.anomalies:..
B Selective.neck.dissection.(SND):!any!modification!of! B remnants!are!derived!from!the!branchial!cleft!apparatus!
the!RND!that!preserves!lymphatic!compartments! that!persists!after!fetal!development.!!
normally!removed!in!RND! $ 1st!branchial!cleft:!EAC!&!parotid!gland.!!
$ Also'comparable'to'RND'in'controlling'regional' $ 2nd!branchial!cleft:!courses!between!the!internal!
metastasis'with'superior'functional'results! and!external!carotid!arteries!and!proceeds!into!the!
$ Types:! tonsillar!fossa!
1. supraomohyoid'neck'dissection! $ 3rd!branchial!cleft:!courses!posterior!to!the!
# used!with!oral!cavity!malignancies! common!carotid!artery,!ending!in!the!pyriform!
# removes!lymph!nodes!in!levels!I!to!III! sinus!region.++
2. lateral'neck'dissection'
# used!for!laryngeal!malignancies! Dermoid.cysts''
# removes!lymph!nodes!in!levels!II!through!IV! B midline!masses!and!represent!trapped!epithelium!
3. posterolateral'neck'dissection' originating!from!the!embryonic!closure!of!the!midline.!
# Used!for!thyroid!cancer! '
# removes!lymph!nodes!in!levels!II!to!V!! N. SALIVARY'GLAND'TUMORS'
B if!clinically!N(+)!necks:!do!MRND!or!RND!or!SND!(!only! B Majority!of!neoplasms!are!benign!
if!limited!N1!disease)! B Most'common'gland'involved:'parotid'gland!(85%!of!
B if!(+)!extracapsular!spread,!perineural!invasion,! all!salivary!gland!neoplasms)'
vascular!invasion,!and!the!presence!of!multiple!involved! B Most'common'benign'tumor'of'the'salivary'gland:'
lymph!nodes!are!noted!"!neck!dissection!of!choice!+! pleomorphic'adenoma'
Adjuvant!RT!+/B!chemoRT! B Most'common'malignant'epithelial'neoplasm'of'
! salivary'gland:'mucoepidermoid'carcinoma'
Parapharyngeal.space.masses. B 2nd'most'common'malignant'epithelial'neoplasm'of'
B Is!a!potential!space,!shaped!like!an!inverted!pyramid! salivary'gland:Adenoid!cystic!carcinoma,!which!has!a!
spanning!the!skull!base!to!the!hyoid.!' propensity!for!neural!invasion,!'
B Contents!of!the!prestyloid!space:!parotid,!fat,!and!lymph! B Risk'of'malignancy'depending'on'location:'minor'
nodes.!' salivary'gland'>'submandibular,'sublingual'>'
B Contents!of!poststyloid!compartment:!CNs!IX!to!XII,!the! parotid'gland'
carotid!space!contents,!cervical!sympathetic!chain,!fat,! B Symptoms!suggestive!of!malignancy:!pain,!paresthesias,!
and!lymph!nodes.!' facial!nerve!weakness,!skin!invasion,!fixation!to!the!
B Tumors!in!this!space!can!produce.displacement.of.the. mastoid!tip!and!trismus!(invasion!of!the!masseter!or!
lateral.pharyngeal.wall.medially.into.the.oropharynx. pterygoid!muscles'
,.dysphagia,.cranial.nerve.dysfunction,!Horner's! B Tx:'
syndrome,!or!vascular!compression.' $ If!benign!neoplasm:!do!surgical!excision'
B Tumors!found!in!the!parapharyngeal!space:' # If!parotid:!minimal!surgical!procedure!for!
$ 40!to!50%!of!the!tumors!are!of!salivary'gland' neoplasms!of!the!parotid!is!superficial!
origin!' parotidectomy!with!preservation!of!the!facial!
# usually!arising!anterior'to'the'styloid' nerve.'
process' • Most'frequently'injured'nerve'in'
$ 20!to!25%!of!tumors!are!of'neurogenic'origin! parotid'surgery:'greater'auricular'
such!as!paragangliomas!(glomus!vagale,!carotid! nerve'(not!facial!nerve!);!if!transected,!
body!tumor),!schwannomas,!and!neurofibroma' will!produce!numbness!of!the!lower!
# usually!arising!posterior'to'the'styloid' portion!of!the!auricle!&!periauricular!skin'
process' • If'the'auriculotemporal'nerve'is'
# angiography!has!a!role!if!the!tumor!in!question! injured'"'Frey’s'syndrome'
is!located!posterior!to!the!styloid!process' (postoperative'gustatory'sweating)'
# if!a!paraganglioma!is!suspected!"!request!for! '
a!24Bhour!urinary!catecholamine' $ If!malignant:!do!en!bloc!removal!of!the!involved!
$ 15%!represent!LN'metastases'&'1o'lymphoma!. gland!with!preservation!of!all!nerves!unless!
directly!invaded!by!tumor.!
Benign'neck'masses'☺' # if!parotid'tumor'arising'from'the'lateral'
' lobe:!superficial!parotidectomy!with!
Thyroglossal.duct.cyst. ecpreservation!of!CN!VII!is!indicated.!!
B most!commonly!encountered!congenital!cervical! # If!the!tumor!extends!into!the!deep'lobe'of'the'
anomalies! parotid:!a!total!parotidectomy!with!nerve!
B represents!the!vestigial'remainder'of'the'tract'of'the' preservation!is!performed!
descending'thyroid'gland!from!the!foramen!cecum,!at!

#If!submandibular'involvement:!en!bloc! B serum!TSH!levels!reflect!the!ability!of!the!anterior!
resection!of!the!gland!and!submental!and! pituitary!to!detect'free'T4'levels!
submandibular!lymph!nodes.!! B ultrasensitive!TSH!assay:!most!sensitive!and!most!
• Nerves'at'risk'for'a'submandibular' specific!test!for!the!diagnosis!of!hyperthyroidism!and!
gland'removal:'lingual'and'hypoglossal' hypothyroidism!
nerve! !
# Postoperative'radiation'treatment!plays!an! 2. Total.T4.+
important!role!in!the!treatment!of!salivary! B normal:!T4:!55!–!150!nmol/L!
malignancies.!The'presence'of' B Total!T4!levels!reflect!the!output!from!the!thyroid!gland!
extraglandular'disease,'perineural' B Not!suitable!as!a!general!screening!test!
invasion,'direct'invasion'of'regional' B Increased!levels!seen!in!hyperthyroid!patients,!elevated!
structures,'regional'metastasis,'and'highS Tg!levels!secondary!to!pregnancy,!
grade'histology'are'all'indications'for' estrogen/progesterone!use!or!congenital!diseases!
radiation'treatment' B Decreased!levels!seen!in!hypothyroid!patients,!
' decreased!Tg!levels!secondary!to!anabolic!steroid!use!
O. THYROID'AND'ASSOCIATED'CONDITIONS' and!protein!losing!disorders!(i.e.!nephrotic!syndrome)!
' $ These!individuals!maybe!euthyroid!if!their!free!
Important'facts'about'Thyroid'anatomy:' T4levels!are!normal!
' !
B Weight.of.a.normal.thyroid.gland:.20.g!☺! 3. Total.T3+
B pyramidal'lobe!is!present!in!about!50%!of!patients' B Normal:!1.5!–!3.5!nmol/L!
$ in!disorders!resulting!in!thyroid!hypertrophy!(e.g.,! B Total!T3!levels!reflect!peripheral!thyroid!hormone!
Graves'!disease,!diffuse!nodular!goiter,!or! metabolism!
lymphocytic!thyroiditis),!the!pyramidal!lobe! B Not!suitable!as!a!general!screening!test!
usually!is!enlarged!and!palpable' B Measurement!of!total!!T3!levels!is!important!for!
B enveloped!by!a!loosely'connecting'fascia' clinically!hyperthyroid!patients!with!normal!T4!levels!"!
B thyroidea'ima'artery:!arises!directly!from!the!aorta!or! think!T3!thyrotoxicosis!
innominate!in!1B4%!of!individuals!' !
B ligament'of'berry:'posteromedial!suspensory! 4. Free.T4++
ligament;!has!a!close!relationship!with!the!recurrent! B Normal:!12!–!28!pmol/L!
laryngeal!nerve' B Measures!the!biologically!active!hormone!
B inferior'thyroid'artery'crosses'recurrent'laryngeal' B Not!performed!as!a!routine!screening!test!in!thyroid!
disease!
nerve'(RLN)☺,'necessitating!identification!of!the!RLN!
B Its!utility!is!in!detecting!early!hyperthyroidism!in!which!
before!ligation!' total!T4!levels!maybe!normal!but!free!T4!levels!are!
B RLNs'innervate'all'the'intrinsic'muscles'of'the' raised!
larynx,'except'the'cricothyroid'muscles,'which'are' B Refetoff!syndrome:!endBorgan!resistance!to!T4!wherein!
innervated'by'the'external'laryngeal'nerves'☺' free!T4!are!increased!and!TSH!levels!are!normal!
$ Injury'to'one'RLN:!paralysis!of!the!ipsilateral! !
vocal!cord!(lie!in!the!paramedian!or!the!abducted! 5. Free.T3+
position)' B normal:!3!–!9!pmol/L!
$ Injury'to'Bilateral'RLN:!airway!obstruction,! B most!useful!in!the!diagnosis!of!early!hyperthyroidism!in!
necessitating!emergency!tracheostomy,!or!loss!of! which!levels!of!free!!T3!and!T4!rise!before!total!T3!and!T4!
voice.!' !
$ Most'common'position'of'right'RLN:'posterior' 6. Serum.TRH.
to'the'inferior'thyroid'artery' B used!for!the!evaluation!of!pituitary!TASH!secretory!
B Injury'to'the'internal'branch'of'the'superior' function!
laryngeal'nerve'"!aspiration.! !
B Injury'to'the'external'branch'of'the'superior' 7. Thyroid.antibodies.
laryngeal'nerve!"!inability!to!tense!the!ipsilateral! B include!antiBTg,!antimicrosomal,!or!antiBTPO!and!TSI!
vocal!cord!and!hence!difficulty!"hitting!high!notes”! B antiBTg!&!antiBTPO!antibody!levels:!elevated!if!with!
B Loop'of'galen:!where!the!pharyngeal!branches!of!the! autoimmune!thyroiditis!
recurrent!laryngeal!nerve!communicate!with!the! B can!be!elevated!in!Hashimoto’s,!Graves’,!multinodular!
branches!of!the!superior!laryngeal!nerve.!Maybe. goiter!&!thyroid!neoplasms!
injured.when.dissecting.or.ligating.the.superior. !
thyroid.artery! 8. Serum.Thyroglobulin.
B Regional!lymph!nodes!include!pretracheal,! B amount!is!increased!in!destructive!processes!of!the!
paratracheal,!perithyroidal,!RLN,!superior!mediastinal,! thyroid!gland!(thyroiditis)!or!overactive!states!(graves’!
retropharyngeal,!esophageal,!and!upper,!middle,!and! or!toxic!multinodular!goiter)!
lower!jugular!chain!nodes.!! B most.important.use.is.for.the.monitoring.of.
B Histology:! differentiated.thyroid.cancer.recurrence,.after.total.
$ the!thyroid!is!divided!into!lobules!that!contain!20! thyroidectomy.and.RAI.ablation.
to!40!follicles! $ elevated!antiBTg!antibodies!can!interfere!with!the!
$ Each!follicle!is!lined!by!cuboidal'epithelial'cells! accuracy!of!Tg!levels!and!should!always!be!
measured!when!interpreting!Tg!levels.!
$ C'cells'or'parafollicular'cells:!secrete!the!
!
hormone!calcitonin.!!
9. Serum.Calcitonin.
Evaluation'of'patients'with'thyroid'disease:' B normal:!0B4!pg/mL!basal!
' B secreted!by!C!cells!
Tests'of'thyroid'function:' B function:!lower!serum!calcium.
' B sensitive.marker.for.medullary.thyroid.cancer.
1. Serum.TSH.. .
B normal:!0.5!–!5μU/mL! Thyroid'Imaging:'
B only!test!necessary!in!most!patients!with!thyroid! '
nodules!that!clinically!appear!euthyroid! 1. Radionuclide.imaging.
!
Types:! B autoimmune'disease'with'a'strong'familial'
1. iodine.123.(123I). predisposition,'female'preponderance!(5:1),!and!
B emits!low!dose!radiation! peak!incidence!between!the!ages!of!40!to!60!years.!!
B t!1/2!:!12!–!14!hours! B Most'common'cause'of'hyperthyroidism'in'North'
B used'to'image'lingual'thyroids'or'goiter' America'
! B characterized!by!thyrotoxicosis,'diffuse'goiter,'and'
2. iodine.131.(131I). extrathyroidal'conditions!including!ophthalmopathy,!
B higher!dose!radiation!exposure!because!of!longer!t!½!! dermopathy!(pretibial!myxedema),!thyroid!acropachy'
B t!½!:!8!to!10!days! B hallmark:!thyroidSstimulating'antibodies'stimulate'
B used!to!screen!and!treat!patients!with!differentiated! the'thyrocytes'to'grow'and'synthesize'excess'
thyroid!cancers!for!metastatic!disease! thyroid'hormone'
**'Cold:'trap'less'radioactivity'compared'to'the' B associated!with!other!autoimmune!conditions!(ex.!type!I!
surrounding'gland,'risk'of'malignancy'is'higher'in'cold' DM,!Addison's!disease,!pernicious!anemia,!and!
lesions'(20%)'compared'to'hot'lesions'(<5%)' myasthenia!gravis)'
**'Hot:'trap'more'radioactivity,'therefore,'with' B Macroscopic!appearance:!diffusely'and'smoothly'
increased'acitivity' enlarged,'increase'in'vascularity'
! B Microscopic!appearance:!hyperplastic!gland,!minimal!
3. technetium.Tc.99m.pertechnetate.(99mTc). colloid!present'
B this!isotope!is!taken!up!by!the!mitochondria! B Clinical!features:'
B shorter!t!½,!therefore,!less!radiation!exposure! $ Hyperthyroid!Sx:!heat!intolerance,!↑sweating,!
B sensitive'for'nodal'metastases' ↑thirst,!↑!weight!loss!despite!adequate!caloric!
! intake'
4. F8fluorodeoxyglucose.PET.scan. $ adrenergic!excess:!palpitations,!nervousness,!
B used!to!screen!for!metastases'in'patients'with' fatigue,!emotional!lability,!hyperkinesis,!and!
thyroid'cancer'in'whom'other'imaging'studies'are' tremors'
negative.! $ most'common'GI'symptom:'diarrhea'
B May!show!clinically!occult!lesions! $ can!also!develop!amenorrhea,!decreased!fertility,!
! and!an!increased!incidence!of!miscarriages'
2. Ultrasound. B PE:'facial!flushing,!warm!&!moist!skin,!Tachycardia,!
B excellent!noninvasive!imaging!study!of!thyroid!gland. atrial!fibrillation,!fine!tremor,!muscle!wasting,!and!
B no!radiation!exposure! proximal!muscle!group!weakness!with!hyperactive!
B useful!for!the!evaluation'of'thyroid'nodules,! tendon!reflexes!!
distinguinshing!cystic!from!solid!ones,!size,! $ 50%!of!patients"!ophthalmopathy!
multicentricity!and!cervical!lymphadenopathy! # lid!lag!(von'Graefe's'sign)!
! # spasm!of!the!upper!eyelid!
3. CT/MRI' # revealing!the!sclera!above!the!corneoscleral!
B useful!for!the!evaluation'of'extent'of'large,'fixed'or' limbus!(Dalrymple's'sign)!
substernal'goiters'and'their'relationship'to'the' # prominent!stare!
airway'and'vascular'structures!
$ 1!to!2%!of!patients!"!dermopathy!(deposition!of!
glycosaminoglycans!leading!to!thickened!skin!in!
Developmental'abnormalities:'
the!pretibial!region!and!dorsum!of!the!foot)!!
'
B Diagnostic:'suppressed'TSH'with'or'without'an'
Thyroglossal.duct.cyst'(see'Neck)'
elevated'free'T4'or'T3'level.!'
.
$ If!eye!signs!are!present,!other!tests!are!generally!
Lingual.thyroid.
not!needed.!'
B failure'of'the'median'thyroid'anlage'to'descend'
$ 123I!uptake!and!scan:!elevated!uptake,!with!a!
normally''
diffusely!enlarged!gland,!confirms!the!diagnosis!'
B may!appear!as!reddish!brown!mass!at!the!base!of!the!
B Treatment:'
tongue'
$ Antihyroid'drugs:''
B may'be'the'only'thyroid'tissue'present'(hence,'if'
# propylthiouracil!(PTU,!100!to!300!mg!three!
surgical'tx'is'warranted,'evaluation'of'normal'
times!daily)!or!methimazole'(10!to!30!mg!
thyroid'tissue'in'the'neck'must'be'carried'out'1st)'
three!times!daily,!then!once!daily!–!because!it!
B Intervention!becomes!necessary!for!obstructive!
has!a!longer!half!t!½!)'
symptoms!such!as!choking,!dysphagia,!airway!
obstruction,!or!hemorrhage!or!if!suspicious!for! • MOA:!inhibits!the!organic!binding!of!
malignancy!' iodine!and!the!coupling!of!iodotyrosines!
B Tx:!administration!of!exogenous!ORAL'thyroid' (mediated!by!TPO).!'
hormone'to!suppress!thyroidBstimulating!hormone! • PTU!also!inhibits!the!peripheral!
(TSH)!and!radioactive'iodine'(RAI)'ablation!followed! conversion!of!T4!to!T3'
by!hormone!replacement.!' • Most'patients'have'improved'
symptoms'in'2'weeks'and'become'
Ectopic.thyroid. euthyroid'in'about'6'weeks.'
B Normal!thyroid!tissue!in!aberrant!locations!(esophagus,! • IMPORTANT'SIDE'EFFECT'OF'PTU:'
trachea!and!anterior!mediastinum)! AGRANULOCYTOSIS'
# Propranolol'is!the!most!commonly!
Pyramidal.lobe. prescribed!medication!in!doses!of!about!20!to!
B The!distal!end!of!the!atrophied!thyroglossal!duct!that! 40!mg!four!times!daily!for!control!of!
connects!to!the!thyroid,!projecting!up!to!the!isthmus,! adrenergic!symptoms'
lying!just!to!the!left!or!right!of!the!midline.! $ RAI:!most!often!used!in!older!patients!with!small!
or!moderateBsized!goiters,!those!who!have!
Benign'thyroid'disorders' relapsed!after!medical!or!surgical!therapy,!and!
' those!in!whom!antithyroid!drugs!or!surgery!are!
Hyperthyroidism. contraindicated.!!
' # Absolute!CI:!women!who!are!pregnant!or!
Grave’s.disease. breastfeeding!
# Relative!contraindications:!!
• young!patients!(i.e.,!especially!children! B Tx:!parenteral!antibiotics!&!drainage!of!abscesses.!'
and!adolescents)!
• those!with!thyroid!nodules! Subacute.(de.quervain’s).thyroiditis.
• those!with!ophthalmopathy! B strong!association!with!the!HLABB35!haplotype.!
$ Surgery:'' B SelfBlimiting!painful!thyroiditis!most!commonly!occurs!
# Patients!should!be!rendered!euthyroid!before! in!30B!to!40ByearBold!women!'
operation! B characterized!by!the!sudden!or!gradual!onset!of!neck!
# Lugol's'iodide'solution'or'saturated' pain,!which!may!radiate!toward!the!mandible!or!ear.!'
potassium'iodide!generally!is!administered! B History'of'a'preceding'upper'respiratory'tract'
beginning!7!to!10!days!preoperatively!(three! infection'often'can'be'elicited.''
drops!twice!daily)!to'reduce'vascularity'of' B The!gland!is!enlarged,!exquisitely!tender,!and!firm.'
the'gland'and'decrease'the'risk'of' B Diagnosis:!TSH!is!decreased,!and!Tg,!T4!,!and!T3!levels!
precipitating'thyroid'storm.!! are!elevated!(during!the!early!phase)!'
# Indications'for'Total'or'nearStotal' B tx:!symptomatic;!NSAIDs!are!used!for!pain!relief!
thyroidectomy:!Patients!with!coexistent! (steroids!may!be!indicated!in!more!severe!cases)'
thyroid!cancer,!and!those!who!refuse!RAI!
therapy!or!have!severe!ophthalmopathy!or! Hashimoto’s.thyroiditis.(chronic.thyroiditis).
have!lifeBthreatening!reactions!to!antithyroid! B autoimmune!process!leads!to!destruction!of!thyrocytes!
medications!(vasculitis,!agranulocytosis,!or! by!autoantibodies,!which!lead!to!complement!fixation!
liver!failure)! and!killing!by!natural!killer!cells!!
B Antibodies!directed!against!three!main!antigens—Tg'
! (60%),'TPO'(95%),'the'TSHSR'(60%),'and,'less'
√ 'REMEMBER:!a! commonly,'to'the'sodium/iodine'symporter'(25%)'
! B more!common!in!women!(male:female!ratio!1:10!to!20!)!
How!would!you!know!if!there!is!an!undiagnosed! between!the!ages!of!30!and!50!years!old.!'
hyperthyroid!problem!intraoperatively?! B The'most'common'presentation'is'that'of'a'
! minimally'or'moderately'enlarged'firm'granular'
Increased!vascularity!"!increased!bleeding!in!a!sedated! gland'discovered'on'routine'PE''or'the'awareness'of'
patient!☺! a'painless'anterior'neck'mass'
! B Gross!appearance:!mildly!enlarged,!pale,!grayBtan!cut!
surface!that!is!granular,!nodular,!and!firm.!'
!
B microscopic!examination:!the!gland!is!diffusely!
Toxic.multinodular.goiter.
infiltrated!by!small!lymphocytes!and!plasma!cells!and!
B Symptoms!and!signs!of!hyperthyroidism!are!similar!to!
occasionally!shows!wellBdeveloped!germinal!centers,!
Graves'!disease,!but'extrathyroidal'manifestations'
follicles!are!lined!by!Hürthle!or!Askanazy!cells'
are'absent'
B Dx:'elevated'TSH'and'the'presence'of'thyroid'
B Possible!presence!of!cervical!compressive!symptoms!
autoantibodies'usually'confirm'the'diagnosis.''
B Diagnosis:!
B Tx:'Thyroid!hormone!replacement!therapy!or!surgery!
$ suppressed!TSH!level!and!elevated!free!T4!or!T3!
(if!with!compressive!symptoms)'
levels.!!
$ RAI!uptake!also!is!increased,!showing!multiple!
Reidel’s.thyroiditis.
nodules!with!increased!uptake!!
B characterized!by!the!replacement'of'all'or'part'of'the'
$ Treatment:!subtotal!thyroidectomy!
thyroid'parenchyma'by'fibrous'tissue!!
'
B primary!autoimmune!etiology.
Toxic.adenoma.(Plummer’s.disease).
B occurs!predominantly!in!women!between!the!ages!of!30!
B Hyperthyroidism!from!a!single!hyperfunctioning!nodule!!
to!60!years!old.!.
B typically!occurs!in!younger!patients!'
B presents!as!a!painless,!hard!anterior!neck!mass,!which!
B PE:!solitary!thyroid!nodule!without!palpable!thyroid!
progresses!over!weeks!to!years!to!produce'symptoms'
tissue!on!the!contralateral!side'
of'compression,'including'dysphagia,'dyspnea,'
B RAI:!"hot"!nodule'
choking,'and'hoarseness..
B rarely!malignant.'
B Can!result!to!hypothyroidism.
B Tx:!Surgery!(lobectomy!and!isthmusectomy!on!the!
B Associated!with!retroperitoneal!fibrosis!and!sclerosing!
affected!side)!is!preferred!to!treat!young!patients!and!
mediastinitis.
those!with!larger!nodules.'
B PE:!hard,'"woody"'thyroid'gland'with'fixation'to'
surrounding'tissues..
Thyroid.storm.
B Tx:!surgery.
B hyperthyroidism!+!fever,!central!nervous!system!
$ Goal!of!surgery:!to!decompress!the!trachea!by!
agitation!or!depression,!cardiovascular!dysfunction!due!
wedge!excision!of!the!thyroid!isthmus!and!to!make!
to!infection,!surgery,!trauma!or!amiodarone!
a!tissue!diagnosis.
administration.!!
B Tx:!ICU,!Beta!blockers,!Oxygen!supplementation,!Fever!
Solitary.thyroid.nodule.
reduction,!fluids,!hemodynamic!support,!PTU,!
B History:!time!of!onset!(!usually!slow!and!indolent),!
Corticosteroids!(to!prevent!adrenal!exhaustion!and!
change!in!size,!and!associated!symptoms!such!as!pain,!
block!hepatic!thyroid!hormone!conversion)'
dysphagia,!dyspnea,!!choking,!hoarseness!(secondary!to!
malignant!involvement!of!the!RLNs)!
Acute.(suppurative).thyroiditis.
B Risk!factors!for!malignancy:!'
B more!common!in!children!and!often!is!preceded!by!an!
1. exposure!to!ionizing!radiation!
upper!respiratory!tract!infection!or!otitis!media.!!
2. (+)!FH!of!thyroid!and!other!malignancies!
B It!is!characterized!by!severe!neck!pain!radiating!to!the!
associated!with!thyroid!cancer!
jaws!or!ear,!fever,!chills,!odynophagia,!and!dysphonia.!'
3. Men!>!women!
B Complications:!systemic!sepsis,!tracheal!or!esophageal!
4. Children!>!adults!
rupture,!jugular!vein!thrombosis,!laryngeal!chondritis,!
B PE:!nodules!that!are!hard,!gritty,!or!fixed!to!surrounding!
and!perichondritis!or!sympathetic!trunk!paralysis'
structures!(if!malignant)!
B Streptococcus'and'anaerobes'account'for'about'70%'
B Diagnosis:!
of'cases'
!
B Diagnosis:!leukocytosis!on!blood!tests!and!FNAB!for!
Figure'31.!Management!of!a!solitary!thyroid!nodule!☺!
Gram's!stain,!culture,!and!cytology.'
B predominant'thyroid'cancer'in'children'and'
individuals'exposed'to'external'radiation.'
B occurs!more!often!in!women,!2:1!'
B symptoms!of!locally!advanced!disease:!Dysphagia,!
dyspnea,!and!dysphonia'
B Diagnosis:!'
$ FNAB!of!the!thyroid!mass!or!lymph!node.'
$ Complete!neck!UTZ:!to!evaluate!the!contralateral!
lobe!and!for!LN!metastases!in!the!central!and!
lateral!neck!compartments.!'
B The'most'common'sites'are'lungs,'followed'by'bone,'
liver,'and'brain.'
B Spread'via'lymphatic'route'
B Gross!appearance:!hard!and!whitish!and!remain!flat!on!
sectioning!with!a!blade,!macroscopic!calcification,!
necrosis,!or!cystic!change!may!be!apparent.'
B Microscopically:!'
$ papillary!projections!Ba!mixed!pattern!of!papillary!
'
and!follicular!structures!'
$ pure!follicular!pattern!(follicular!variant).'
$ FNAB:'single'most'important'test'in'the' $ Cells'are'cuboidal'with'pale,'abundant'
evaluation'of'thyroid'masses;'1st'diagnostic'test' cytoplasm,'large'nuclei'that'may'demonstrate'
ordered'in'a'patient'with'a'solitary'thyroid' "grooving,"'and'intranuclear'cytoplasmic'
nodule'
# Results:!benign!–!cysts!&!colloid!nodules! inclusions'(Orphan.Annie'nuclei)☺!!'
(65%),!suspicious!–!follicular!or!hurthle!cell! $ Psammoma'bodies☺:!microscopic,!calcified!
neoplasms!(20%),!malignant!(5%),!and! deposits!representing!clumps!of!sloughed!cells,!
nondiagnostic!(10%)! also!may!be!present'
# falseBpositive!results!is!about!1%!! $ Multifocality:!associated!with!an!increased!risk!of!
# falseBnegative!results!occur!in!approximately! cervical!nodal!metastases'
3%! $ Other!variants:!tall!cell,!insular,!columnar,!diffuse!
# a!negative!FNAB!does!not!rule!out!CA! sclerosing,!clear!cell,!trabecular,!and!poorly!
• if!suspicious!result,!the!diagnosis!of! differentiated!types.'
malignancy!relies!on!demonstrating! # are!generally!associated!with!a!worse!
capsular!or!vascular!invasion,!features! prognosis.'
that!cannot!be!determined!via!FNAB.!! B Tx:!
$ RAI'scan:' $ If!less!than!1.5!cm:!lobectomy!+!isthmusectomy'
# Single,!cold,!solid!nodule!"!malignant! $ If!multicentric:!near!total!or!total!thyroidectomy'
# Multiply,!Hot,!cystic!"!benign! $ (+)!cervical!node!mets:!MDRD'
$ Labs:' # patients'with'papillary'thyroid'CA'have'an'
# TSH:'expect!euthyroid! excellent'prognosis'with'a'>95%'10Syear'
# Tg'levels:!useful!for!patients!who!have! survival'rate.!'
undergone!total!thyroidectomy!for!thyroid! # Age'is'the'most'important'prognostic'factor'
cancer!&!for!serial!evaluation!of!patients! in'determining'long'term'survival'
undergoing!nonoperative!management!of! '
thyroid!nodules.! Follicular.CA.
# Serum'calcitonin:!obtained!in!patients!with! B account!for!10%!of!thyroid!cancers!!
MTC!or!a!family!history!of!MTC!or!MEN2! B occur!more!commonly!in!iodineBdeficient!areas.!
# RET'oncogene'mutations:!All!patients!with! B Women!have!a!higher!incidence!of!follicular!cancer,!
MTC!should!be!tested!for!RET!oncogene! with!a!femaleBtoBmale!ratio!of!3:1!
mutations!and!have!a!24Bhour!urine!collection! B usually!present!as!solitary!thyroid!nodules,!occasionally!
with!measurement!of!levels!of! with!a!history!of!rapid!size!increase,!and!longBstanding!
vanillylmandelic!acid!(VMA),!metanephrine,! goiter.!!
and!catecholamine!to!rule!out!a!coexisting! B In!<1%!of!cases,!follicular!cancers!may!be!
pheochromocytoma.! hyperfunctioning,!leading!patients!to!present!with!signs!
$ Ultrasound:!helpful!for!detecting!nonpalpable! and!symptoms!of!thyrotoxicosis.!
thyroid!nodules,!differentiating!solid!from!cystic! B Spread'via'hematogenous'route,'hence'their'spread'
nodules,!and!identifying!adjacent! is'more'distant,'than'regional!
lymphadenopathy! B Most'common'site'of'distant'metastasis:'lung'&'
B Tx:! bone!
$ Malignant!tumors!are!treated!by!thyroidectomy! B Diagnosis:!
$ Simple!thyroid!cysts!resolve!with!aspiration;!if! $ FNAB!shows!follicular!type!"!must!do!lobectomy!
persists!after!3!attempts!at!aspiration!"!unilateral! to!demonstrate!capsular!or!vascular!invasion!
thyroid!lobectomy!is!recommended.! (criteria!for!malignancy)!
$ Lobectomy!is!recommended!for!cysts!>4!cm!in! B Microscopically:!follicles!are!present,!but!the!lumen!may!
diameter!or!complex!cysts!with!solid!and!cystic! be!devoid!of!colloid.!!
components! B Tx:!
$ Colloid!nodule!"!observe!with!serial!ultrasound! $ If!follicular!lesion!"!thyroid!lobectomy!+!
and!Tg!measurements.!! isthmusectomy!because!at!least!80%!of!these!
patients!will!have!benign!adenomas.!!
$ older!patients!with!follicular!lesions!>4!cm:!total!
Thyroid.cancer.
thyroidectomy!
'
$ if!(+)!thyroid!CA:!do!Total!thyroidectomy!
Papillary.CA.
$ (+)!cervical!node!mets:!MDRD!
B 80%'of'all'thyroid'malignancies'in'iodineSsufficient'
areas''

# mortality!from!follicular!thyroid!cancer!is! $ infiltrating!neoplastic!cells!separated!by!collagen!
approximately!15%!at!10!years!and!30%!at!20! and!amyloid!!
years.! $ presence'of'amyloid'is'a'diagnostic'finding!
# Poor!longBterm!prognosis:!age!over!50!years! B Diagnosis:!!
old!at!presentation,!tumor!size!>4!cm,!higher! $ history,!physical!examination,!raised!serum!
tumor!grade,!marked!vascular!invasion,! calcitonin,!or!CEA!levels,!and!FNAB!cytology!of!the!
extrathyroidal!invasion,!and!distant! thyroid!mass'
metastases!at!the!time!of!diagnosis.! $ all'new'patients'with'MTC'should'be'screened'
' for'RET'point'mutations,'pheochromocytoma,'
Hurtle.cell.CA. and'HPT.!If!(+)!carrier,!perform!total!
B account!for!approximately!3%!of!all!thyroid! thyroidectomy'
malignancies!! B Tx:!
B considered'to'be'a'subtype'of'follicular'thyroid' $ Total!thyroidectomy!+!bilateral!central!node!
cancer.' dissection!(level!6)!because!of!high!incidence!of!
B Cannot!be!diagnosed!by!FNAB.!' multicentricity'
B Microscopically:!hurthle!cells!(variable'enlargement,' $ If!(+)!pheochromocytoma!"!manage!this!1st'
hyperchromatic'nuclei'and'granular'cytoplasm)' $ If!with!palpable!cervical!nodes!or!involved!central!
B Difference!from!follicular!CA:' neck!nodes:!ipsilateral!or!bilateral!MDRD'
$ multifocal!' $ If!!tumors!>1!cm,!ipsilateral!prophylactic!modified!
$ bilateral!(about!30%)' radical!neck!dissection!is!recommended!because!
$ usually!do!not!take!up!RAI!(about!5%)'
>60%!of!these!patients!have!nodal!metastases.!"!
$ more!likely!to!metastasize!to!local!nodes!(25%)!'
$ associated!with!a!higher!mortality!rate!(about!20%! if!ipsilateral!nodes!are!positive!"!do!contralateral!
at!10!years)' node!dissection'
$ higher!recurrence!rate' B Postoperative!FollowBUp:!annual!measurements!of!
B Same!management!with!follicular!neoplasms! calcitonin!and!CEA!levels!
B If!(+)!for!hurthle!malignancy:!perform!total! B Prognosis:!'
thyroidectomy!+!routine!central!neck!(level!6)!node! $ 10Byear!survival!rate!is!approximately!80%!but!
removal!or!MDRD!when!lateral!neck!nodes!are!palpable.!' decreases!to!45%!in!patients!with!lymph!node!
involvement.!'
Medullary.thyroid.CA.(MTC). $ best!in!patients!with!nonBMEN!familial!MTC,!
B accounts!for!about!5%!of!thyroid!malignancies!. followed!by!those!with!MEN2A'
B arises!from!the!parafollicular'or'C'cells!of!the!thyroid! $ Prognosis'is'the'worst'(survival'35%'at'10'
usually!located!superolaterally!in!the!thyroid!lobes! years)'in'patients'with'MEN2B.''
(usual!site!of!MTC).
B femaleBtoBmale!ratio!is!1.5:1. Anaplastic.CA.
B Most!patients!present!between!50!and!60!years!old. B approximately!1%!of!all!thyroid!malignancies!
B Most!MTCs!occur!sporadically.. B the'most'aggressive'of'thyroid'malignancies'
$ Occur!singly. B Women!are!more!commonly!affected'
$ unilateral!(80%). B present!in!the!7th!&!8th!decade!of!life'
$ no!familial!predisposition. B Clinical!features:'
B approximately!25%!occur!within!the!spectrum!familial! $ Presents!as!a'longSstanding'neck'mass,'which'
MTC!B!MEN2A!(pheochromocytoma!+!parathyroid! rapidly'enlarges'and'may'be'painful.'Associated!
hyperplasia),!and!MEN2B!(pheochromocytoma!+! symptoms!such!as!dysphonia,!dysphagia,!and!
neuromas)! dyspnea!are!common.'
$ due!to!germline!mutations!in!the!RET'protoS $ Lymph!nodes!usually!are!palpable!at!presentation.!'
oncogene' B Gross!appearance:!firm!and!whitish!in!appearance.!
# encodes!for!tyrosineBkinase!receptor!in!the! B Microscopically:'characteristic'giant'and'
cell!membrane' multinucleated'cells.!with!marked!heterogeneity!are!
# RET!protein!is!expressed!in!tissues!derived! seen!(spindle!shaped,!polygonal,!or!large,!
from!embryonic!nervous!and!excretory! multinucleated!cells)!
systems' B Tx:!if!resectable!mass!"!surgery!will!only!give!small!
$ present!at!a!younger!age! improvement!in!survival!
$ multicentric! B Prognosis:!6!months!
$ (+)'C'cell'hyperplasia:'premalignant'lesion!
B clinical!features:! Thyroid.Lymphoma.
$ present!with!a!neck!mass!that!may!be!associated! B <1%!of!thyroid!malignancies!
with!palpable!cervical!lymphadenopathy!(15!to! B Most!common:!nonBHodgkin's!BBcell!type..
20%).!! B develop!in!patients!with!chronic!lymphocytic!
$ Pain!or!aching!is!common! thyroiditis.!.
$ dysphagia,!dyspnea,!or!dysphonia!–!already! B present!with!a!rapidly!enlarging!neck!mass!that!is!often!
invasive! painless.!.
$ diarrhea!–!indicates!metastatic!disease!(due!to! B may!present!with!acute!respiratory!distress..
increased!intestinal!motility!and!impaired! B Tx:!.
intestinal!water!and!electrolyte!flux)! $ CT(CHOP—cyclophosphamide,'doxorubicin,'
$ 2!to!4%!of!patients!develop!Cushing's!syndrome!as! vincristine,'and'prednisone)'+'RT'.
a!result!of!ectopic!production!of! $ Thyroidectomy!and!nodal!resection:!for!alleviation!
adrenocorticotropic!hormone!(ACTH)! of!airway!obstructive!symptoms!who!do!not!
B tumor!markers:!calcitonin'(diagnostic,'most'sensitive' respond!quickly!to!the!above!regimens!or!who!
tumor'marker),!CEA!(better!predictor!of!prognosis),! have!completed!the!regimen!before!diagnosis..
calcitonin!gene–related!peptide,!histaminadases,! B The!overall!5Byear!survival!rate!is!about!50%;!patients!
prostaglandins!E2!and!F2!&!serotonin.! with!extrathyroidal!disease!have!markedly!lower!
B Microscopically:!! survival!rates.!
$ Heterogenous! !
$ Cells!are!polygonal!or!spindle!shaped! Thyroid'surgeries:'
'
Total.thyroidectomy:!dissection!and!remonal!of!all!visible! multicentricity!becomes!more!common!as!tumor!
thyroid!tissue!bilaterally,!which!usually!reveals!the!entrance!of! size!increases.!Total!thyroidectomy!also!facilitates!
the!recurrent!laryngeal!nerve!as!they!enter!the!ligament!of!berry! the!effectiveness!of!postoperative!radioactive!
' iodine,!since!no!residual!thyroid!tissue!remains!to!
Near.total.thyroidectomy:!complete!hemithyroidectomy!and! serve!as!a!sink!for!the!radioisotope.!
isthmusectomy;!most!of!the!contralateral!side!is!removed!but!a! '
remnant!is!left!to!prevent!damage!to!parathyroid!glands! 3. During!a!total!thyroidectomy!for!papillary!cancer,!
' the!clinician!observes!an!intact!recurrent!laryngeal!
Subtotal.thyroidectomy:'removes!all!visible!thyroid!tissue! nerve!on!the!right!side!and!a!completely!transected!
except!for!a!rim!of!thyroid!tissue!bilaterally!to!ensure! nerve!on!the!left,!with!both!ends!in!view.!What!
parathyroid!viability!and!avoids!damage!to!the!recurrent! should!management!of!this!patient!at!this!point!
laryngeal!nerve' entail?!
! !
'''''''REVIEW'QUESTIONS!! a. Complete!the!operation!and!evaluate!the!vocal!
! cords!postoperatively!via!flexible!
1. Regarding!salivary!gland!tumors,!which!one!of!the! bronchoscopy!
following!statements!is!true?! b. Perform!intraoperative!flexible!bronchoscopy!
! to!evaluate!vocal!cords!
a. The!majority!of!malignant!salivary!gland! c. Repair!the!nerve!using!8.0!monofilament!
tumors!arise!in!the!parotid!gland! sutures!
b. Most!parotid!neoplasms!are!malignant! d. None!of!the!above!
c. Fine!needle!aspiration!biopsy!is!recommended! !
for!all!suspected!salivary!gland!malignancies! Answer:!D'
d. Minor!salivary!gland!tumors!occur!most! If!the!recurrent!laryngeal!nerve!is!injured!or!
commonly!in!the!floor!of!the!mouth! transected!during!an!otherwise!uncomplicated!
operation,!it!should!be!repaired!using!loupes!or!an!
Answer:!A' operating!microscope!to!visualize!the!field,!and!8.0!
The!likelihood!of!a!given!tumor’s!being!malignant!is! or!9.0!monofilament!sutures!to!anstamose!the!cut!
lowest!in!the!parotid!gland!(approximately!20%),! ends!of!the!nerves.!There!is!no!role!for!flexible!
followed!by!the!submandibular!salivary!gland! bronchoscopy!either!intraoperatively!or!
(approximately!50%)!and!sublingual!glands!(nearly! postoperatively!unless!there!is!uncertainty!about!
100%).!However,!because!more!than!75%!of!all!salivary! the!injury!or!the!function!of!the!contralateral!nerve.'
gland!tumors!occur!in!the!parotid!gland,!the!parotid!
gland!accounts!for!the!majority!of!the!malignant!salivary!! '
gland!tumors.!The!diagnostic!evaluation!of!a!salivary! ESOPHAGUS'
gland!mass!depends!on!the!location!and!clinical! '
scenario.!FNAB!is!not!indicated!for!all!parotid!tumors,! A. Diagnostic'tests'for'esophageal'function'
since!a!tissue!diagnosis!does!not!change!the!treatment! B. GERD'
plan!for!a!patient!with!a!small,!mobile!mass!clearly! C. Diaphragmatic'hernia'
within!the!gland.!When!the!location!is!uncertain,!the! D. Schatzki’s'ring'
history!suggests!the!possibility!of!metastatic!disease,!or! E. Scleroderma'of'esophagus'
the!tumor!size!or!location!indicates!a!difficult!facial! F. Zenker’s'diverticulum'
nerve!dissection,!FNAB!may!be!helpful.!Biopsy,!usually!a! G. Achalasia'
punch!or!excisional!biopsy,!should!be!performed!for! H. Diffuse'and'segmental'esophageal'spasm'
suspected!minor!salivary!gland!tumors,!the!most! I. Nutcracker'esophagus'
common!site!of!which!is!the!palate,!usually!at!the! J. Hypertensive'LES'
junction!of!the!hard!and!aoft!palate.!Like!FNAB,!imaging! K. Esophageal'diverticulum'
studies!(CT!or!MRI)!should!be!used!when!they!are!likely! L. Esophageal'perforation'
to!augment!the!clinical!assessment!of!staging!and!affect! M. Mallory'weiss'syndrome'
treatment!planning.! N. Caustic'injury'
! O. Esophageal'carcinoma'
2. A!40!yearBold!woman!comes!to!the!clinician’s!office! !
with!a!thyroid!mass,!which!is!confirmed!on!FNA!
!
and!UTZ!to!be!unilateral,!3.2!cm!follicular!neoplasm.!
A. DIAGNOSTIC'TESTS'FOR'ESOPHAGEAL'FUNCTION'
She!has!been!completely!asymptomatic.!What!will!
'
the!next!intervention!be?!
Tests'to'detect'structural'abnormalities'
!
'
a. Total!thyroidectomy!
1. Barium.swallow.
b. Hemithyroidectomy!or!isthmusectomy!
B 1st!diagnostic!test!in!patients!with!suspected!esophageal!
c. Excisional!biopsy!
disease!(with!full!assessment!of!stomach!and!
d. CoreBneedle!biopsy!
duodenum)!
e. Thyroid!suppression!via!T3!or!T4!analogues!
B can!reveal!anatomic!problems!
! B if!patient!complains!of!dysphagia!and!no!obstructing!
Answer:!A,'B' lesion!seen!in!barium!swallow!"!use!a!bariumB
The!presence!of!a!follicular!neoplasm!as!confirmed! impregnanted!marshmallow,!bariumBsoaked!bread!or!
by!FNA!manadtes!further!evaluation,!since!FNA! barium!hamburger!
does!not!provide!enough!information!about!tissie! $ will!bring!out!the!functional!disturbance!in!the!
architecture!to!differentiate!between!a!benign! esophageal!transport!that!can!be!missed!when!
follicular!adenoma!and!a!follicular!carcinoma.! liquid!barium!is!used.!
Vascular!or!capsular!invasion!confirms!the! !
presence!of!carcinoma.!The!management!of!small,! 2. endoscopic.evaluation.
unilateral!follicular!lesions!is!controversial!(total! B endoscopy!is!indicated!in!patients!complaining!of!
versus!hemiBthyroidectomy!with!frozen!section).! dysphagia!even!with!a!normal!radiographic!study!
Hwoever,!lesions!larger!than!4!cm!should!be!
Tests'to'detect'functional'abnormalities'
treated!with!total!thyroidectomy,!since!
1. manometry. 1. Metaplastic.(Barrett's.Esophagus)+
B indicated!when!a!motor!abnormality!of!the!esophagus!is! # condition!whereby!the!tubular!esophagus!is!
considered!on!the!basis!of!complaints!(dysphagia,! lined!with!columnar!epithelium!rather!than!
odonyphagia,!or!noncardiac!chest!pain)!and!barium! squamous!epithelium!
swallow!and!endoscopy!does!not!show!a!structural! # occurs!in!10!to!15%!of!patients!with!GERD!
abnormality! # end!stage!of!natural!Hx!of!GERD!
B essential!tool!in!preoperative!evaluation!of!patients! # hallmark:'presence'of'intestinal'goblet'
before!antireflux!surgery! cells'in'esophageal'epithelium'(intestinal'
metaplasia)!
Tests'to'detect'increased'exposure'to'gastric'juice' # endoscopically:!difficulty!visualizing!the!
1. 24.hour.ambulatory.pH.monitoring. squamocolumnar!junction!at!its!normal!
B most!direct!method!of!measuring!increased!esophageal! location!&!appearance!of!redder!mucosa!than!
exposure!to!gastric!juice!(not!reflux)! normally!seen!in!lower!esophagus!
B sensitivity!and!specificity!of!96%! # earliest!sign!for!malignant!degeneration:!
B gold'standard'for'the'dioagnosis'of'GERD' severe!dysplasia!or!intramucosal!
' adenocarcinoma!
2. radiographic.exposure.of.gastroesophageal.reflux. # antireflux!surgery!is!an!excellent!means!of!
B radiographic!demonstration!of!spontaneous! longBterm!control!for!most!patients!
regurgitation!of!barium!into!the!esophagus!in!the! # one!third!of!all!patients!with!BE!present!with!
upright!position!is!a!reliable!indicator!that!reflux!is! malignancy!
present! o should!undergo!surveillance!with!
B note:!failure!to!see!this!does!not!indicate!absence!of! biopsy!every!2!years!
disease! o if!(+)!low!grade!dysplasia,!increase!
' frequency!to!6!months!
B. GERD. 2. Esophageal.Adenocarcinoma.
B Clinical!features:! # Most!important!etiologic!factor!in!its!
1. Heartburn:!substernal!burningBtype!discomfort,! development!is!barrett’s!esophagus'
beginning!in!the!epigastrium!and!radiating!upward.' 3. Respiratory.symptoms+
BIt!is!often!aggravated!by!meals,!spicy!or!fatty! # LERD+
foods,!chocolate,!alcohol,!and!coffee!' # AdultBonset!asthma+
Bworse!in!the!supine!position' # Idiopathic!pulmonary!fibrosis+
1. Regurgitation:!effortless!return!of!acid!or!bitter! B Treatment:!
gastric!contents!into!the!chest,!pharynx,!or!mouth;! $ Medical:!!
highly!suggestive!of!foregut!pathology' # Uncomplicated!GERD:!12!weeks!of!empiric!
Bsevere!at!night!when!supine!or!when!bending!over' treatment!of!antacid!
Bsecondary!to!either!an!incompetent!GEJ' # Persistent!sx:!PPIs!or!H2!antagonists!
Bexplains!the!associated!pulmonary!symptoms,! # A'structurally'defective'LES'is'the'most'
including!cough,!hoarseness,!asthma,!and!recurrent! important'factor'predicting'failure'of'
pneumonia.' medical'therapy'
2. Dysphagia:!most!specific!symptom!of!foregut! • They!don’t!respond!to!medical!therapy!
disease;!sensation!of!difficulty!in!the!passage!of! well;!candidates!for!antiBreflux!surgery'
food!from!the!mouth!to!the!stomach. $ Lifestyle!changes:!elevate!the!head!of!the!bed!
3. Chest'pain' during!sleep;!avoid!tightBfitting!clothing;!eat!small,!
B primary!cause!of!GERD:!permanent'attenuation'of'the' frequent!meals;!avoid!eating!the!nighttime!meal!
collar'sling'musculature,'with'a'resultant'opening'of' immediately!prior!to!bedtime;!and!avoid!alcohol,!
the'gastric'cardia'and'loss'of'the'highSpressure'zone' coffee,!chocolate,!and!peppermint!(which!are!
as'measured'with'esophageal'manometry' known!to!reduce!resting!LES!pressure)!
$ characteristics!of!a!defective!sphincter' $ Surgical!
1. LES!with!a!mean!resting!pressure!of!less!than!6! # Nissen.fundiplication:!a!abdominal!or!
mmHg! thoracic!approach!using!a!360!degree!
2. overall!sphincter!length!of!<2!cm! circumferential!wrap!of!the!gastric!fundus!
3. intraSabdominal'sphincter'length'of'<1'cm' # Belsey.operation:!difficult!to!learn,!performed!
(most'important'consideration'affecting'the' through!the!chestm,!involves!placement!of!2!
competence'of'the'GE'jxn)! layers!of!placating!structures!between!the!
B diagnosis:! gastric!fundus!and!lower!esophagus!with!
$ 24'hour'pH'monitoring'(gold'standard):'most' subsequent!creation!of!280!degree!anterior!
sensitive'for'the'detection'of'reflux! gastric!wrap!and!posterior!approximation!of!
$ Endoscopic!examination:!assessing!anatomic! the!crura!
damage!produced!by!reflux!(esophagitis,!ulceration! # Hill.operation:!approach!is!through!the!
and!strictures)!&!for!ruling!out!CA! abdomen,!posterior!approximation!of!the!
# Grading'of'esophagitis' crura!followed!by!anchoring!of!the!posterior!
Grade!I:!small!circular!nonconfluent!erosions! and!anterior!aspects!of!the!GEJ!to!the!median!
Grade!II:!presence!of!linear!erosions!lined!with! arcuate!ligament!adjacent!to!the!aorta,!
granulation!tissue!that!bleeds!easily!when! creating!a!180!degree!gastric!wrap!
touched! # Collis.gastroplasty:!esophageal!lengthening!
Grade!II:!linear!erosions!coaslesce!into!a! procedure!!
circumferential!loss!of!the!epithelium;! # Angelchik.prosthesis:!horshe!shoe!shape!
cobblestone!mucosa! silastic!device!placed!around!the!distal!
Grade!IV:!(+)!stricture! esophagus,!keeping!this!segment!in!the!
! abdomen!
**absence!of!esophagitis!above!a!stricture!
suggest!chemical!induced!injury!or!neoplasm! ''√'MUST'KNOW!a!
as!a!cause.! Principles'of'surgical'therapy'in'reflux'disease'☺'
i. ! '
$ Manometric!studies:!rule!out!motility!DO! 1. the!operation!should!restore!the!pressure!of!the!distal!
B Complications:! esophageal!sphincter!to!a!level!twice!the!resting!gastric!
pressure! B Symptoms:!brief!episodes!of!dysphagia!during!hurried!
2. the!operation!should!place!an!adequate!length!of!the! ingestion!of!solid!foods.!'
distal!esophageal!sphincter!in!the!positiveBpressure! B Treatment!options:!dilation!alone,!dilation!with!
environment!of!the!abdomen!by!a!method!that!ensures! antireflux!measures,!antireflux!procedure!alone,!
its!response!to!changes!in!intraBabdominal!pressure! incision,!and!excision!of!the!ring'
3. the!operation!should!allow!the!reconstructed!cardia!to! '
relax!on!deglutition! E. SCLERODERMA.OF.ESOPHAGUS.
4. the!fundoplication!should!not!increase!the!resistance!of! B Scleroderma!is!a!systemic!disease!accompanied!by!
the!relaxed!sphincter!to!a!level!that!exceeds!the! esophageal'abnormalities'in'approximately'80%'of'
peristaltic!power!of!the!body!of!the!esophagus! patients.!
5. the!operation!should!ensure!that!the!fundoplication!can! B onset!of!the!disease!is!usually!in!the!third'or'fourth'
be!placed!in!the!abdomen!without!undue!tension,!and! decade'of'life,'occurring'twice'as'frequently'in'
maintained!there!by!approximating!the!crura!of!the! women'as'in'men.!
diaphragm!above!the!repair! B Small'vessel'inflammation'appears'to'be'an'
initiating'event,'with'subsequent'perivascular'
! deposition'of'normal'collagen,'which'may'lead'to'
C. DIAPHRAGMATIC.HERNIA. vascular'compromise.!!
B Types:! B Muscle!ischemia!due!to!perivascular!compression!has!
1. type'I'(sliding'hernia)' been!suggested!as!a!possible!mechanism!for!the!motility!
# upward!dislocation!of!the!cardia!in!the! abnormality!in!scleroderma.!
posterior!mediastinum' B predominant!feature!at!GI!tract:!smooth!muscle!
# the'phrenoesophageal'ligament'is' atrophy.!!
stretched'but'intact' B Diagnosis:!!
# most!common' $ Manometrically:!observation!of!normal!peristalsis!
# can!evolve!into!a!type!III!hernia'' in!the!proximal!striated!esophagus,!with!absent!
2. type'II'(rolling'or'paraesophageal'or'giant' peristalsis!in!the!distal!smooth!muscle!portion!
hiatal'hernia)' $ Barium'swallow:!dilated,!bariumBfilled!esophagus,!
# upward!dislocation!of!the!gastric!fundus! stomach,!and!duodenum,!or!a!hiatal!hernia!with!
alongside!a!normally!positioned!cardia' distal!esophageal!stricture!and!proximal!dilatation!
# defect'in'the'phrenoesophageal'membrane'
# rare' F. ZENKER’S.DIVERTICULUM.
# more!likely!to!occur!in!women!(4:1)' B most!common!esophageal!diverticulum!
3. type'III'(the'combined'slidingSrolling'or'mixed' B classified!as!false'diverticulum!
hernia)' B clinical!features:!dysphagia'associated'with'the'
# upward!dislocation!of!both!the!cardia!and!the! spontaneous'regurgitation'of'undigested'food,!
gastric!fundus;!therefore' halitosis,!weight!loss,!chronic!aspiration!and!repetitive!
# the'esophagogastric'junction'is'in'the' respiratory!infection!
mediastinum'
B due!to!weakness!of!the!cricopharyngeal!muscle!"!
4. type+IV:+colon,+herniates+as+well+(in+some+
weakness!at!the!Killian’s!area!
classifications)'
B Diagnosis:!Barium!swallow!(to!exclude!neoplasia!or!
5. intrathoracic'abdomen'
ulceration)!
# the!end!stage!of!type!I!and!type!II!hernias!
B Treatment:!
occurs!when!the!whole!stomach!migrates!up!
$ Pharyngomyotomy:!2!cm!or!less!
into!the!chest!by!rotating!180°!around!its!
$ Diverticulectomy/diverticuopexy:!>2cm!
longitudinal!axis,!with!the!cardia!and!pylorus!
!
as!fixed!points!'
G. ACHALASIA.
B most'common'complications:'
B Characterized!by!complete!absence!of!peristalsis!in!the!
$ occult!GI!bleeding!from!gastritis'
esophageal!body!and!failure!of!LES!relaxation!
$ ulceration!in!the!herniated!portion!of!the!stomach!'
B Classic'triad'of'symptoms:'dysphagia,'regurgitation'
$ gastric'volvulus'(surgical'emergency):!or+
and'weight'loss;!also!associated!with!nocturnal!asthma!
Borchardt’s.triad'of!pain,!nausea!with!inability!to!
and!foul!smelling!esophageal!contents.
vomit!and!inability!to!pass!NGT'
B pathogenesis!of!achalasia!is!presumed!to!be!a!
B Diagnosis:'
neurogenic!degeneration,!which!is!either!idiopathic!or!
$ Barium'esophagogram:'for'!diagnosis!of!
due!to!infection.!.
paraesophageal!hiatal!hernia'
B Can!be!caused!by!T.!cruzi!which!demonstrates!
$ FiberBoptic!esophagoscopy'
destruction!of!smooth!muscle!myenteric!auerbach’s!
# Detection!of!pouch!lined!with!gastric!rugal!
plexus!.
folds!lying!2!cm!or!more!above!the!margins!of!
B Diagnosis:.
the!diaphragmatic!crura!(identified!by!having!
$ Barium!Esophagogram:!dilated!esophagus!with!a!
the!patient!sniff)'
tapering!or!other!wise!known!as!"bird's'beak".
B Treatment:!surgical!
$ Manometric!studies:!failure!of!the!LES!to!relax,!
$ Important!principles!
progressive!peristalsis!in!proximal!esophagus!(if!
# Reduce!the!hernia!contents!
late!disease).
# After!reduction,!excise!the!sac!
$ Has!a!10%!chance!of!developing!carcinoma!due!to!
# The!use!of!mesh!can!reduce!recurrence!rates!
prolonged!mucosal!irritation.
of!hernia!is!>!than!8!cm!
B Tx:!!
'
$ heller’s'myotomy!(surgical!myotomy!of!the!LES)!
D. SCHATZKI’S.RING.
$ goal!of!surgery:!relieve!functional!obstruction!at!
B thin!submucosal!circumferential!ring!in!the!lower!
the!LES!
esophagus!at!the!squamocolumnar!junction,!often!
!
associated!with!a!hiatal!hernia.!
H. DIFFUSE.AND.SEGMENTAL.ESOPHAGEAL.SPASM.
B probably!an!acquired'lesion!that!can!lead!to!stenosis!
B characterized!by!substernal'chest'pain'and/or'
from!chemicalBinduced!injury!by!pill!lodgment!in!the!
dysphagia.'
distal!esophagus,!or!from!refluxBinduced!injury!to!the!
B The!LES!in!patients!with!DES!usually!shows!a!normal!
lower!esophageal!mucosa!'
resting!pressure!and!relaxation!on!swallowing!

B Diagnosis:! $ usually!follows!an!injury!occruing!during!dilation!
$ Manometric'studies:'frequent!occurrence!of! of!esophageal!strictures!or!pneumatic!dilations!of!
simultaneous!waveforms!and!multipeaked! achalasia!
esophageal!contractions,!which!may!be!of! $ indications!
abnormally!high!amplitude!or!long!duration.' 1. barium!swallow!must!show!the!perforation!to!
$ Esophagogram:!corkscrew.esophagus'or. be!contained!within!the!mediastinum!and!
pseudodiverticulosis' drain!well!back!into!the!esophagus!
' 2. mild!symptoms!
I. NUTCRACKER.ESOPHAGUS. 3. minimal!evidence!of!clinical!sepsis!
B Other!name:!supersqueezer!esophagus! B approach:!
B most'common'of'the'primary'esophageal'motility' $ hyperalimentation!
disorders' $ antibiotics!
B characterized!by!peristaltic!esophageal!contractions! $ cimetidine:!to!decreased!acid!secretion,!diminish!
with!peak!amplitudes!greater!than!two!SDs!above!the! pepsin!activity!
normal!values!(up!to!400!mmHg)' !
B Treatment!in!these!patients!should!be!aimed!at!the! M. MALLORY.WEISS.SYNDROME.
treatment!of!GERD' B Longitudinal!tear!in!the!mucosa!of!the!GE!junction!
' B Characterized!by!acute'upper'GI'bleeding!caused!by!
J. HYPERTENSIVE.LES. forceful'vomiting'and/or'retching!
B This!disorder!is!characterized!by!an!elevated!basal! B Commonly!seen!in!alcoholics!
pressure!of!the!LES!with!normal!relaxation!and!normal! B arterial!"!massive!
propulsion!in!the!esophageal!body.!! B mechanism:!an!acute!increase!in!intraBabdominal!
B Treatment:!Myotomy!of!the!LES!may!be!indicated!in! pressure!against!a!closed!glottis!in!a!patient!with!a!
patients!not!responding!to!medical!therapy!or!dilation.. hiatal!hernia.!
' B Diagnosis:!!
K. ESOPHAGEAL.DIVERTICULUM. $ requires!a!high!index!of!suspicion!(the'pattern'of!
B Classification:! sudden'upper'GI'bleeding'following'prolonged'
$ Location:!proximal,!mid,!distal! vomiting'or'retching'is'indicative).!
$ Pathology! $ Upper!endoscopy:!longitudinal!fissures!in!the!
# Pulsion:!motor!DO! mucosa!of!the!herniated!stomach!as!the!source!of!
# Traction:!inflammatory!DO! bleeding.!
B Epiphrenic'diverticula:'' B Treatment:!
$ terminal!3rd!of!the!thoracic!esophagus!&!are!usually! $ bleeding'will'stop'90%'of'the'time'
found!adjacent!to!the!diaphragm' spontaneously'with'nonoperative'management.'!
$ associated!with!distal!esophageal!muscular! $ Decompression!
hypertrophy,!esophageal!motility!abnormalities,! $ antiemetics!
and!increased!luminal!pressure' !
$ considered!as!"pulsion"!diverticula' N. CAUSTIC.INJURY.
$ classified!as!false!diverticulum!(pouch!of!mucosa! B Alkalies!vs!acids!
that!is!protruding!in!the!wall!of!the!esophagus)' $ Alkalies'dissolve'tissue,'and'therefore'
B Midesophageal'or'traction'diverticula' penetrate'more'deeply'(more'serious)'
$ Classified!as!true!diverticulum!(composed!of!all! $ acids'cause'a'coagulative'necrosis'that'limits'
layers!of!the!esophageal!wall)!' their'penetration'
$ noted!in!patients!who!had!mediastinal!LN! B The!strength!of!esophageal!contractions!varies!
involvement!with!tuberculosis,!mediastinal! according!to!the!level!of!the!esophagus!
lymphadenopathy,!such!as!pulmonary!fungal! B weakest!at!the!striated!muscle–smooth!muscle!interface!
infections!(e.g.,!aspergillosis),!lymphoma,!or!
sarcoid'
"!slower!clearance!"!allowing!caustic!substances!to!
+ remain!in!contact!with!the!mucosa!longer!"!explains!
L. ESOPHAGEAL.PERFORATION☺ . why!the!esophagus!is!preferentially!and!more!severely!
B true'emergency.!! affected!at!this!level!than!in!the!lower!portions.'
B It'most'commonly'occurs'following'diagnostic'or' B Phases'of'injury:'
therapeutic'procedures'(endoscopy).!' $ acute!necrotic!phase:!'
B Boerhaave's'syndrome:!spontaneous!perforation,!' # lasting!1!to!4!days!after!injury'
B Clinical!features:!chest!pain!(very!striking!and! # coagulation!of!intracellular!proteins!results!in!
consistent!symptom),!fever,!tachycardia,!subcutaneous! cell!necrosis'
emphysema,!dysphagia,!dysnea' # living!tissue!surrounding!the!area!of!necrosis!
B Diagnosis:!' develops!an!intense!inflammatory!reaction.'
$ contrast'esophagogram'with'water'soluble'(like' $ ulceration!and!granulation!phase:!
gastrografin)'medium:'(+)'extravasation' # 3!to!5!days!after!injury'
(diagnostic)' # Considered!a!quiescent!period!because!
$ chest!xray:!air!or!effusion!in!pleural!space,! symptoms!seem!to!disappear'
mediastinal!or!cervical!emphysema! # the!superficial!necrotic!tissue!sloughs,!leaving!
B treatment:! an!ulcerated,!acutely!inflamed!base,!and!
$ the!incidence!of!mortality!is!related!to!the!time! granulation!tissue!fills!the!defect!left!by!the!
interval!between!perforation!and!treatment;!hence' sloughed!mucosa.!'
the'key'to'optimum'management'is'early' # This!phase!lasts!10!to!12!days'
diagnosis.'! # period'that'the'esophagus'is'the'weakest'
$ The!most!favorable!outcome!is!obtained!following! $ cicatrization!and!scarring!
primary'closure'of'the'perforation'within'24' # begins!!third!week!following!injury.!'
hours,'resulting'in'80'to'90%'survival.! # previously!formed!connective!tissue!begins!to!
$ The!most!common!location!for!the!injury!is!the!left! contract,!resulting!in!narrowing!of!the!
lateral!wall!of!the!esophagus,!just!above!the!GEJ! esophagus'
B nonBoperative!management! # characterized'by'dysphagia'
# It!is!during!this!period!that!efforts!must!be!
made!to!reduce!stricture!formation.'
B Clinical!features:!pain!in!the!mouth!and!substernal! Stage!IIA:!invaded!esophageal!wall!but!not!surrounding!
region,!hypersalivation,!pain!on!swallowing,!and! structures!
dysphagia,!fever'(strongly'correlated'with'the' Stage!IIB:!LN!(+);!primary!tumor!has!only!invaded!
presence'of'an'esophageal'lesion)' submucosa!or!muscularis!propria!
B Diagnosis:!!early'esophagoscopy'is!advocated!to! Stage!III:!invaded!the!adventitia!and!surrounding!
establish!the!presence!of!an!esophageal!injury! structures!(pericardium,!pleura!and!aorta)!
$ To!lessen!the!chance!of!perforation,!the!scope! Stage!IV:!(+)!metastasis'
should!not!be!introduced!beyond!the!proximal! B Clinical!factors!that!indicate!advanced!stage!(and!
esophageal!lesion.! therefore!exclude!surgery!for!curative!intent):!
B Treatment:! $ Horner’s!syndrome!
! $ Persistent!spinal!pain!
Figure'32.!algorithm!for!acute!caustic!injury! $ Paralysis!of!diaphragm!
$ Fistula!formation!
$ Malignant!pleural!effusion!
B Treatment:!
$ Surgery:!
# Ivor'lewis'procedure:!!
• primarily!for!middle!esophageal!lesion;!all!
LNs!are!removed!en!bloc!with!the!lesser!
curvature!of!the!stomach!
• most!radical!"!highest!number!of!
complication!rate!
# Left'thoracoabdominal'approach!
• excellent!exposure!of!distal!esophagus!
# Transhiatal'blunt'resection:'resection!of!the!
thoracic!esophagus!from!abdomen!with!
subsequent!pullBup!of!stomach!and!
esophagogastric!anastomosis!in!the!neck!
• Goes'against'the'principle'of'enSbloc'
! resection'of'cancer'surgery!
• Minimized'morbidity'and'mortality'
' compared'to'the'other'procedures!
O. ESOPHAGEAL.CARCINOMA.
B Squamous'carcinoma'accounts'for'the'majority'of' !
esophageal'carcinomas'worldwide.'' !
B Risk!factors:' '''''''REVIEW'QUESTIONS!a!
$ nitroso!compounds!in!pickled!vegetables!and! !
smoked!meats' 1. a!4!year!old!child!is!brought!to!the!ER!15!minutes!
$ zinc!&!molybdenum!deficiency' after!accidentally!ingesting!a!drain!cleaner.!The!
$ smoking!(more!squamous!CA)' child!exhibits!a!hoarse!voice!and!is!stridorous.!
$ alcohol!consumption!(more!squamous!CA)' Which!of!the!following!apply?!
$ achalasia' !
$ lye!strictures' a. Laryngeal!ulceration!
$ tylosis!(an!autosomal!dominant!disorder! b. Instillation!of!vinegar!into!the!stomach!
characterized!by!hyperkeratosis!of!the!palms!and! c. Immediate!fiberoptic!endoscopy!
soles)' d. tracheostomy!
$ human!papillomavirus.' !
$ Barrett’s!esophagus!(more!adenocarcinoma)' Answer:!'A'&'D!
B Most'common'presenting'symptom:'dysphagia' This!is!a!case!of!caustic!ingestion.!Since!the!child!
(already!a!late!symptom)' already!exhibits!laryngeal!and!epiglottic!edema,!
B Diagnosis:!' preservation!of!the!airway!must!be!the!priority.!
$ barium!esophagogram!"(if!with!lesion)!"!upper! Therefore,!endoscopy!is!deferred.!
endoscopy' !
$ CT!scan!of!chest!and!abdomen:!delineate!the!tumor! 2.
A!50!year!old!healthy!man!is!brought!to!the!ER!with!
and!detect!distant!pulmonary!or!hepatic!metastasis' retching!followed!by!hematemesis.!
B Characteristics!based!on!tumor!location!and!treatment:! !
$ Cervical!esophagus!(proximal!1/3)! a. Treatment!is!by!balloon!tamponade!
# Almost!always!squamous!carcinoma! b. Bleeding!often!stops!spontaneously!
# Frequently!unresectable!because!of!early! c. It!is!not!caused!by!forceful!vomiting!
invasion!of!larynx,!great!vessels!or!trachea! d. There!is!air!in!the!mediastinum!
# Tx:!stereotactic!radiation!with!concomitant! e. Diagnosis!is!not!made!by!endoscopic!
chemotherapy! examination!
$ thoracic!esophagus!(middle!1/3)! !
# almost!always!squamous!carcinoma!with!LN! Answer:!B'
metastasis! This!is!a!case!of!MallorySweis'tear.!The!mechanism!
# tx:!video!assisted!thoracic!surgery!(VATS)!±! is!similar!to!boerhave!syndrome!(postemetic!
thoracotomy! esophageal!rupture)!in!which!there!is!associated!
$ distal!1/3!or!near/at!cardia! perforation!and!vomiting!against!a!closed!cardia.!It!
# almost!always!adenocarcinoma! is!diagnosed!by!endoscopic!examination,!and!the!
# tx:!curative!resection!requires!cervical!division! bleeding!usually!stops!spontaneously.!Because!the!
of!esophagus!+!>50%!proximal!gastrectomy! bleeding!is!arterial,!a!pressure!tamponade!(i.e.!
B Staging:! SengstakenBblakemore!tube)!does!not!help!and!may!
Stage!0:!in!situ,!highBgrade!dysplasia,!no!LN!mets! lead!to!esophageal!disruption.!If!bleeding!does!not!
Stage!I:!invaded!lamina!propria! stop,!gastrotomy!and!oversewing!of!the!bleeding!
point!is!the!proper!therapy,!although!nonsurgical!
alternatives,!such!as!endoscopic!injection!of!
epinephrine!and!cautery!have!been!attempted.! # easily'missed!during!truncal'or'highly'
! selective'vagotomy'(HSV).'
3. After!diagnostic!esophagoscopy,!a!patient! B Gastric'relaxation!is!due!to!CCK,!distention!of!
complains!of!odynophagia!and!chest!pain,!but! duodenum!and!presence'of'glucose'in'the'duodenum'
results!of!waterBsoluble!contrast!swallow!are! !
negative.!Which!of!the!following!apply?! ''√'MUST'KNOW!a!
! '
a. Discharge!the!patient!if!ECG!is!normal.! Atonic'gastritis'and'abnormal'distention'and'failure'to'
b. Use!of!barium!in!the!chest!is!devastating! empty'of'the'stomach'can'occur'in'the'postoperative'patient'
c. Esophageal!manometry!should!be!performed! due'to'electrolyte'disturbances,'hyperglycemia'and'uremia.'
immediately! '
d. Repeat!swallow!with!barium! Gastric'ulcers'located'in'the'PYLORUS'are'associated'with'
Answer:!D' increased'gastric'production'(see'below'–'Type'II'&'III'
Chest!pain,!fever,!tachycardia,!subcutaneous! ulcers)'
emphysema,!dysphagia!and!dyspnea!are!typical!of! '
esophageal'perforation.!Perforation!may!result! '
from!iatrogenic!operations,!external!trauma,! !
primary!esophageal!disease!or!postemetic! B. DIAGNOSTIC'TEST'FOR'STOMACH'
(“spontaneous”)!esophageal!hypertension.!The! '
incidence!of!mortality!from!esophageal!perforation! 1. EGD.
is!clearly!related!to!the!time!interval!between! B patients!with!one!or!more!of!the!alarm!symptoms!must!
perforation!and!definitive!treatment.!Whenever! undergo!immediate!upper!endoscopy!
perforation!is!suspected,!a!contrast!study!should!be!
performed!with!waterBsoluble!contrast!material.! Table'53.!Alarm!symptoms!
However,!if!this!study!does!not!demonstrate!the! Alarm!symptoms!that!indicate!the!need!for!upper!endoscopy!
perforation,!it!should!be!repeated!with!barium.! Weight!loss!
Although!barium!is!contraindicated!in!the!presence! Recurrent!vomiting!
Dysphagia!
of!colonic!injuries!because!of!the!harmful!effects!of!
Bleeding!!
feces!and!barium,!it!does!not!cause!a!problem!in!the! Anemia!!
chest.!Barium!is!more!accurate!than!water!in! !
detecting!esophageal!leakage.!Contrast!studies!are! B requires!an!8!hour!fasting!
important!not!just!for!verifying!esophageal!rupture! B more!sensitive!than!double!contrast!upper!GI!series!
but!also!for!documenting!the!level!of!injury,!which! B most'serious'complication:'esophageal'perforation'
has!important!implications!for!treatment.!! '
! 2. Radiologic'tests'
! .
! Plain.abdominal.xray.
! B helpful!in!the!diagnosis!of!gastric!perforation!
STOMACH' (pneumoperitoneum)!or!delayed!gastric!emptying!
' (large!airBfluid!level)!
A. Anatomy'
B. Diagnostic'tests'for'stomach' Double.contrast.upper.GI.series.
C. Peptic'ulcer'disease' B better!then!EGD!in!detecting!the!ff:!diverticula,!fistula,!
D. ZollingerSEllison'syndrome' tortuisity!or!stricture!location,!and!size!of!hiatal!hernia!
E. Gastritis'' !
F. stress'ulcer' 3. CT.and.MRI.
G. Malignant'neoplasms'of'the'stomach' B is!part!of!routine!staging!workBup!for!most!patients!
H. Benign'gastric'neoplasms:'polyps' with!a!malignant!gastric!tumor!
I. Gastric'volvulus' !
J. Postgastrectomy'problems' 4. Gastric.secretory.analysis.
B maybe!useful!in!the!evaluation!of!patients!with!
! hypergastrinemia,!including!ZollingerBEllison!
! syndrome,!patients!with!refractory!ulcer!or!GERD!or!
A. ANATOMY' recurrent!ulcer!after!operation!
B Stomach!is!composed!of!3!smooth!muscle!layers:! !
1. Outler'longitudinal'layer!–greater!and!lesser! 5. Tests'for'Helicobacter'pylori'
curvatures!of!the!stomach!
2. Middle'circular!–!!pylorus! Serologic.test.for.H..pylori.
3. Inner'oblique' B a!positive!test!is!a!presumptive!evidence!of!active!
B Majority!of!parietal!cells!are!in!the!Body'of'the' infection!if!the!patient!has!never!been!treated!for!H.!
stomach! pylori!infection!
B Largest!artery!to!the!stomach!is!the!left'gastric'artery'
(from!the!celiac!trunk)! Histologic.examination.of.antral.mucosal.biopsy.(with.
special.stains).
B Gastric!contraction!is!via!the!vagus'nerve!(primarily!
B gold!standard!for!H.+pylori!
due!to!parasympathetic!fibers)!☺!
1. The!vagus!nerves!forms!LARP'(left:anterior'&' Urease.breath.test.
right:posterior)!at!the!esophageal!hiatus!as!it!B standard!test!for!to!confirm!eradication!of!H.!pylori!
descends!from!the!mediastinum! postBtreatment!
2. Anterior!branch!of!vagus:'nerves'of'Laterjet! B basis:!the!patient!ingests!urea!labeled!with!
# they!send!segmental!branches!to!the!body!of' nonradioactive!13C!"!labeled!urea!is!acted!upon!by!the!
the'stomach!before!they!terminate!near!the! urease!present!in!H.+pylori+"!converts!urea!into!
angularis'incisura!as!the!"crow's'foot”' ammonia!and!carbon!dioxide!"!radiolabeled!carbon!
3. Posterior!branch:'Criminal'nerve'of'Grassi' dioxide!is!excreted!from!lungs!and!is!detected!in!
(posterior'fundus)! expired!air.'
# !
''√'MUST'KNOW!a! Type'IV:'occur!near!the!GE!junction,!and!acid!secretion!is!normal!
+ or!below!normal'
H.pylori!!has!the!enzyme!urease,!which!converts!urea!into! Type'V:'NSAID'induced,'can!occur!anywhere!in!the!stomch'
ammonia'and'bicarbonate,!thus!creating!an!environment! '
around!the!bacteria!that!buffers!the!acid!secreted!by!the!stomach.! ''√'MUST'KNOW!a!
! '
! Curling'ulcers:'peptic!ulcers!formed!after'severe'burn'injury'
' Cushing’s'ulcers:'peptic!ulcers!formed!after'severe'brain'
H..pylori.fecal.antigen.test. damage'
B sensitive!and!specific!for!active!H.!pylori!infection! '
B can!also!be!used!to!confirm!cure! '
' B Pathophysiology,'Clinical'manifestations,'diagnosis'
C. PEPTIC'ULCER'DISEASE' and'treatment'
B focal!defects!in!the!gastric!or!duodenal!mucosa!that!
extend!into!the!submucosa!or!deeper! Table'54:'Comparison!between!gastric!vs!duodenal!ulcer'
B caused!by!an!imbalance!between!mucosal!defenses!and! ' Gastric'ulcer' Duodenal'ulcer'
acid/peptic!injury.! Pathophysiology' H.pylori,!overuse!of! ↑!acid!production!&!
B Etiology' NSAIDS!&!steroids! H.pylori!
Clinical' Sharp!burning!pain!in! Severe!epigastric!pain!
$ H..Pylori:'associated!with!both!gastric!and!
manifestation' epigastrium!shortly! 2B3!hours!after!eating;!
duodenal!ulcer!but!is!a!higher'predictor'of' after!eating;!nausea,! epigastric!pain!can!
duonal'ulcer'formation' vomiting!and!anorexia! also!awaken!them!
$ NSAID'–'patients!taking!NSAID!and/or!aspirin!need! from!sleep!
acid!suppressing!medication!if!any!of!the!ff!are! Diagnosis' Endoscopy!and!biopsy! Endoscopy,!history,!
present:!age!over!60!yo,!hx!of!PUD,!concomitant! (must!for!all!gastric! PE,!test!for!H!pylori!
steroid/anticogualant/high!dose!NSAIDs!intake' ulcers!to!rule!out!
$ Smoking'–!largest!positive!predictor!of!risk!(also! cancer;!test!for!
with!alcoholic!drinking)' H.pylori)!
Best'test'to'confirm'eradication'of'H.'pylori:'
$ Stress.–+both!physiologic!and!psychologic!stress.
negative'urea'breath'test'
$ Others' treatment' Triple!therapy;!PPI,! Triple!therapy;!stop!
# More!common!in!Type.A.personality. antacids!and!H2! smoking,!alcohol!
# Sex:'duodenal!ulcer!is!twice!more!common!in! blockers! consumption!
males;!same!incidence!between!sexes!for! '
gastric!ulcer' B More!than!90%!of!patients!with!PUD!complain!of!
# Blood!type:' abdominal'pain'(nonBradiating,!burning!in!quality!&!
• Type.O:!duodenal!ulcer' epigastriac!in!location)!
• Type.A:!gastric!ulcer' B Indication'for'endoscopy'in'PUD:'
B Types'of'ulcer'based'on'location'and' $ Any!symptomatic!patient!45!yo!and!up!
pathophysiology' $ Any!symptomatic!patient!regardless!of!age!with!
$ Duodenal'ulcers'patients'have!↑!daytime!and! alarm'symptoms'(see'table'54)☺ !
nocturnal!acid!secretion,!↑!BAO!and!MAO,!↑!gastric! B Medical!treatment!for!PUD:!PPIs'are!the!mainstay!of!
emptying!compared!to!gastric!ulcer!patients' therapy!for!PUD.'
$ Gastric'ulcers'patients'have!variable!patterns!of!
secretion' table'50.'treatment'regimens'for'H.'pylori!
PPI!+!clarithromycin!500!mg!BID!+!amoxicillin!1000!mg!BID! 10B14!d!
Figure'33.'Modified'Johnson'classification'of'gastric'ulcer' PPI!+!clarithromycin!500!mg!BID!+!metronidazole!500!mg! 10B14!d!
BID!
PPI!+!+!amoxicillin!1000!mg!BID,!then! 5!d!
PPI!+!clarithromycin!500!mg!BID!+!tinidazole!mg!BID! !
Salvage'regimens'for'patients'who'fail'one'of'the'above'initial'
regimens'
Bismuth!subsalicylate!525!mg!qid!+!metronidazole!250!mg! 10B14!d!
qid!+!tetracycline!500!mg!qid!+!PPI!
PPI!+!amoxicillin!1000!mg!bid!+!levofloxacin!500!mg!daily! 10!d!
!
B Indications!for!surgical!treatment!for!PUD!
$ bleeding!
$ perforation!
$ obstruction!
$ intractability!or!nonhealing!ulcers!(with!discretion)!
B For!nonhealing!PUD!
$ Rare!indication!for!surgery!
$ Consider!possible!differentials!for!nonhealing!PUD!
first!
$ Surgical!treatment!is!considered!in!patients!with!
nonhealing!or!intractable!PUD!who!have!multiple!
recurrences,!large!ulcers!(>2!cm),!complications!
' (obstruction,!perforation,!or!hemorrhage),!or!
'
suspected!malignancy!
Type'I:'located!near!the!angularis!incisura!on!the!lesser!
!
curvature;!usually!have!normal!or!decreased!acid!secretion;!most'
B Complications!of!PUD:!
common'
Type'II:'same!with!type!I!but!with!an!associated!active!or!
quiescent!duodenal!ulcer;!associated!with!normal!or!increased! Table'55:'Comparison!of!complications!of!PUD!☺!
gastric!acid!secretion' Bleeding'PUD' Perforation' Gastric'outlet'
Type'III:'prepyloric!ulcer!disease;!associated!with!normal!or! Obstruction'
Bmost'common' B2nd!most!common! Brare!(5%!of!all!PUD!
increased!gastric!acid!secretion'
cause'of'ulcer' complication!of!PUD! complications)!

related'death' Bclassic'symptom:' Busually!due!to! B principal!mediator!of!gastrinBstimulated!acid!
Smost'common' patient'can' duodenal!or! production!is!histamine'from'mucosal'ECL'cells!!
cause'of'UGIB'in' remember'the'exact' prepyloric!disease! ''
admitted'patients! time'of'onset'of' Bpresents!with!bilous!
'
Bpresents!with! abdominal'pain! vomiting,!profound!
melena,!hematemesis,! Bpresents!acute! hypochloremic,! B Gastrinoma'triangle'(or'Pasaro’s'triangle)'☺:'where!
shock! abdomen!with! metabolic!alkalosis! 90%!of!ZES!tumors!are!found!
Babdominal!pain!is! peritoneal!signs! Btx:!nasogastric! $ boundaries:!jxn!of!cystic!&!CBD,!confluence!of!2nd!&!
uncommon! (+)pneumoperitoneum! suction,!IV!hydration! 3rd!segments!of!the!duodenum!and!jxn!of!body!and!
Btx:!acid!suppression! on!upright!chest!xray! and!electrolyte! neck!of!pancreas!
and!NPO,!transfusion! (80%!of!patients)! repletion,!and!
and!endocopic!tx! BTx:!analgesia,! antisecretory!
B most!common!symptoms!of!ZES!are!epigastric!pain,!
(electrocautery!+!epi)! antibiotics,!isotonic! medication,!OR! GERD!&!diarrhea.!Can!also!be!associated!with!
for!high!risk!group! fluid!resuscitation,! B!rule'out' steatorrhea!and!other!symptoms!of!malabsorption.!
immediate!OR! pancreatic,'gastric'&' B Diagnosis:!
duodenal'CA'as'a' $ Fasting!gastrin!of!1mg/L,!BAO!>15!mEq/h!or!>5!
cause'of'obstruction! mEq/h!(if!with!previous!procedure!for!peptic!
' ulcer)!are!suggestive!of!ZES!
''√'MUST'KNOW!a! $ Confirmatory'test:'secretin'stimulation'test!
' # (+)!secretin!stimulation!test:!paradoxical!rise!
High!risk!lesions!for!massive!bleeding!(based!on!location):! in!gastrin!levels!(200!pg/mL!or!greater)!upon!
Bposterior'duodenal'ulcer'with!erosion!of'gastroduodenal' administration!of!IV!bolus!of!secretin!(an.
artery' inhibitor.of.gastrin)!
Blesser'curvature'gastric'ulcer'with!erosion!of'left'gastric' $ Should.also.check.for.serum.calcium.and.PTH.
artery'or'branch'' levels.to.rule.out.MEN1..
' $ Preoperative'imaging'of'choice'for'gastrinoma:'
' somatostatin'receptor'scintigraphy'(octreotide'
B Surgical'options'for'PUD' scan).
1. HSV'or'parietal'cell'vagotomy'or'proximal'gastric' # Basis:!Gastrinoma!cells!contain!type!2!
vagotomy' somatostatin!receptors!that!bind!the!indiumB
B safe!(mortality!risk!<0.5%)!with!minimal!side!effects! labeled!somatostatin!analogue!(octreotide)!
B done!by!severing!the!vagal!nerve!supply!to!the!proximal! with!high!affinity,!making!imaging!with!a!
2/3!of!the!stomach!(where!essentially!all!parietal!cells! gamma!camera!possible.
are!located)!&!preserves!the!vagal!innervation!to!the!
antrum!and!pylorus!and!remaining!abdominal!viscera.! ⊗ 'PHYSIOLOGY!a!
2. Taylor'procedure' Somatostatin'
B posterior!truncal!vagotomy!and!anterior!seromyotomy! B produced!by!D'cells'located!throughout!the!gastric!
B attractive!to!HSV!with!similar!results! mucosa.!
3. Vagotomy'+'drainage'(V+D)'procedures' B major!stimulus!for!somatostatin!release!is!antral'
B Truncal!vagotomy!dennervates!the!antrapyloric! acidification!
mechanism,!therefore,!some!sort!of!procedure!is!needed! B acetylcholine'inhibits'its'release!
to!bypass!or!ablate!the!pylorus! B Somatostatin!effects:'inhibits'acid'secretion'from'
B Types:! parietal'cells,'inhibits'gastrin'release'from'G'cells'&'
$ Truncal!vagotomy!and!pyroplasty! decreases'histamine'release'from'ECL'cells.!!
# Pyroplasty!–!useful!in!patients!who!require! B Octreotide!is!a!somatostatin!analogue!
pyloroduodenotomy!to!deal!with!the!ulcer! !
complication!(i.e.!posterior!bleeding!duodenal! '
ulcer),!limited!focal!a!scarring!in!the!pyloric! B Treatment:!
region! $ Surgical!resection!of!gastrinoma!
$ Truncal!vagotomy!and!gastrojejunostomy! # If!(+)!MEN1,!perform!parathyroidectomy!1st!
# ! before!resection!of!gastrinoma!
B disadvantage:!10%!of!significant!dumping!/!diarrhea! $ PPI!for!symptomatic!relief!
! +
4. Vagotomy'and'distal'gastrectomy' E. GASTRITIS..
' B Definition:!Mucosal!inflammation!
D. ZOLLINGER8ELLISON.SYNDROME. B Most'common'cause:'H.'pylori!
B uncontrolled'secretion'of'abnormal'amounts'of' $ Other!causes:!alcohol,!NSAIDs,!Crohn's!disease,!
gastrin!by!a!duodenal!or!pancreatic!neuroendocrine! tuberculosis,!and!bile!reflux!!
tumor!(i.e.,!gastrinoma)!leading.to.excessive. B Pathophysiology:!
production.of.HCl.by.the.parietal.cells,.further. $ infectious!and!inflammatory!causes:!result!in!
excacerbating.PUD.. immune!cell!infiltration!and!cytokine!production!
B The!inherited!or!familial!form!of!gastrinoma!is! which!damage!mucosal!cells.!!
associated!with!multiple'endocrine'neoplasia'type'1' $ chemical!agents!(alcohol,!aspirin,!and!bile):!disrupt!
or'MEN1'(parathyroid,!pituitary,!and!pancreatic!!or! the!mucosal!barrier,!allowing!mucosal!damage!by!
duodenal!tumors). back!diffusion!of!luminal!hydrogen!ions.!!
'
⊗ 'PHYSIOLOGY!a! F. STRESS'ULCER'
Gastrin'' B Pathophysiology:!due'to'inadequate'gastric'mucosal'
B produced!by!antral'G'cells' blood'flow'during'periods'of'intense'physiologic'
B major!hormonal!stimulant!of!acid!secretion!during!the! stress.!!
gastric!phase.! $ Adequate!mucosal!blood!flow!is!important!to!
B The!biologically!active!pentapeptide!sequence!at!the!CB maintain!the!mucosal!barrier,!and!to!buffer!any!
terminal!end!of!gastrin!is!identical'to'that'of'CCK! backBdiffused!hydrogen!ions.!When!blood!flow!is!
B Luminal'peptides'and'amino'acids!are!the!most! inadequate,!these!processes!fail!and!mucosal!
potent!stimulants!of!gastrin!release! breakdown!occurs'
B luminal'acid!is!the!most!potent!inhibitor!of!gastrin! '
secretion.! G. MALIGNANT'NEOPLASMS'OF'THE'STOMACH'

B The!three!most!common!primary!malignant!gastric! # Sister'Joseph’s'nodule:'palpable!umbilical!
neoplasms!are!adenocarcinoma'(95%),'lymphoma' nodue;!pathognomonic'for'advanced'
(4%),'and'malignant'GIST'(1%)' disease'
# Blumer'nodes:!palpable!nodularity!in!the!
GASTRIC'ADENOCARCINOMA' pouch!of!douglas;!evidence!of!drop'
B Epidemiology!&!etiology! metastasis'
$ Gastric!adenoCA!is!a!disease!of!the!elderly! '
$ Risk!factors:! B Diagnosis!
# Black!race:!twice!more!common!in!blacks! $ Do!endoscopy!and!biopsy!
compared!to!whites! $ PreBoperative!staging:!abdominal/pelvic!CT!
# Pernicious!anemia! scanning!with!IV!and!oral!contrast!
# Blood!group!A! !
# FH!of!gastric!CA! B Treatment!
# Diet:!starchy!diet!high!in!pickled,!salted,!or! $ Surgery!is!the!only!curative!treatment!for!gastric!
smoked!food,!nitrates!increases!risk! cancer!(radical!subtotal!gastrectomy)!
# H.!pylori! $ Goal!in!resecting!gastric!adenocarcinoma:!grossly'
# Smoking! negative'margin'of'at'least'5'cm'to'achieve'R0'
# EBV!infections! resection!
# Remember:.Alcohol.has.no.role.in.gastric.CA! !
$ protective!factors:!aspirin!(Yes!+Schwartz+says+so.+
You+don’t+believe+me?+Check+p.+927,+9th+edition),! GASTRIC'LYMPHOMA'
vitamin!C!and!diet!high!in!fruits!and!vegetables!! B stomach'is'the'most'common'site'of'primary'GI'
$ premalignant!conditions:!! lymphoma'
# polyps! B over!95%!are!nonBHodgkin's!type.!'
• hyperplastic'and'adenomas'are'the' B Most!are!BBcell!type,!thought!to!arise!in!MALT'
types'associated'with'carcinoma! B MALT!lymphomas!is!a!form!of!NHL!arising!from!the!B!
cells!in!the!marginal!zone!of!MALT'
• inflammatory,!hamartomatous!and!
B Is!associated!with!chronic!inflammation!due!to!H.!pylori'
heterotropic!polyps!are!considered!
B Diligent!search!for!extragstric!disease!should!be!done!
benign!lesions!
before!giving!a!diagnosis!of!primary!gastric!lymphoma'
# atrophic'gastritis:!most'common'
B Treatment:!chemotx!is!equivalent!to!surgery'
precancerous'lesion'/'precursor'of'gastric'
cancer'
GASTROINTESTINAL'STROMAL'TUMOR'(GIST)'
# intestinal!metaplasia:!can!be!caused!by!H.!
B Are!submucosal!solitary!slow!growing!tumors!arising!
pylori!
from!interstitial'cells'of'Cajal'(ICC)'
B Pathology!
B 2/3.of.all.GISTs.occur.in.the.stomach,.occurring.
$ Gastric'Dysplasia:'universal'precursor'to'
commonly.in.the.body'
gastric'adenocarcinoma!
B defining'feature'of'GISTS'is'their'gain'of'function'
$ Early'gastric'cancer:'adenocarcinoma!limited!to!
mutation'of'protooncogene'KIT,'a'receptor'tyrosine'
the!mucosa!and!submucosa!of!the!stomach,!
kinase'(majority!of!GISTS!have!activated!mutation!in!
regardless!of!lymph!node!status.!
the!cBkit!protooncogene,!which!causes!KIT!to!be!
$ 4'forms'of'gastric'cancer'(Gross'morphology):!
constitutively!activated,!presumably!leading!to!
1. Polypoid:'bulk!of!tumor!is!intraluminal,!not!ulcerated!
persistence!of!cellular!growth!or!survival!signals)'
2. Fungating:'bulk!of!tumor!is!intraluminal,!ulcerated!
B Epithelial'cell'stromal'GIST:!most!common!cell!type!
3. Ulcerative:'bulk!of!tumor!is!within!the!stomach!wall!
arising!in!the!stomach;!cellular'spindle'type!is!the!next!
4. Scirrhous'(linitis'plastic):'bulk!of!tumor!is!within!the!
most!common;!glomus'tumor'type!is!seen!only!in!the!
stomach!wall;!infiltrate!the!entire!thickness!of!stomch!
stomach.'
and!cover!a!large!surface!area,!poor!prognosis!
B Markers:!(+)'cSKIT,!a!protooncogene;!a!characteristic!
$ Location!of!primary!tumor:!40%!distal!stomach,!
shared!with!ICC'
30%!middle!stomach!and!30%!proximal!stomach!
B Diagnosis:!endoscopy!and!biopsy,'
$ Most'important'prognosticating'factors:''lymph'
B Mode!of!metastasis:!hematogenous'route;!most!
node'involvement'and'depth'of'tumor'invasion'!
common!sites:!liver!and!lung'
'
B Treatment:!'
B Clinical!manifestations:!
$ Wedge'resection'with'clear'margins!is!adequate!
$ Most!patients!diagnosed!with!gastric!CA!have!
surgical!treatment'
advanced'stage'III'or'IV'disease!
$ Imatinib'(Gleevec):!a!chemotherapeutic!agent!
$ S/Sx:!
that!blocks.the.activity.of.the.tyrosine.kinase.
# weight'loss'and'decreased'food'intake'due'
product.of.c8kit,!is!reserved!for!metastatic!or!
to'anorexia'and'early'satiety'(most'
unresectable!GIST.!benign!gastric!neoplasms!'
common)!
'
# Abdominal!pain!(usually!not!severe!and!often!
H. BENIGN'GASTRIC'NEOPLASMS:'POLYP'(see!also!
ignored)!
premalignant!conditions!of!gastric!adenoCA)'
# nausea,!vomiting,!&!bloating.!!
B most'common'benign'tumor'of'the'stomach'
# Acute!GI!bleeding!(unusual)!
B 5!types:'
# chronic!occult!blood!loss!(iron!deficiency!
1. Adenomatous:!(+)!malignant!potential;!10B15%!of!all!
anemia!and!heme+!stool)!
gastric!polyps'
# Dysphagia:!if!the!tumor!involves!the!cardia!of!
2. hyperplastic!(regenerative):!most'common'gastric'
the!stomach.!!
polyp'(75%'of'all'gastric'polyps);!occurs!in!the!
# Paraneoplastic!syndromes!B!Trousseau's!
setting!of!gastritis!and!has!a!low!malignant!potential'
syndrome!(thrombophlebitis),!acanthosis!
3. hamartomatous:!benign'
nigricans!(hyperpigmentation!of!the!axilla!and!
4. inflammatory:!benign'
groin),!or!peripheral!neuropathy!can!be!
5. heterotopic!(e.g.,!ectopic!pancreas):!benign!'
present.!
***Polyps.that.are.symptomatic,.>2.cm,.large.
$ Physical!examination:!
hyperplastic.or.adenomatous.should.be.removed,.
# Enlarged!Cervical,!supraclavicular!(on!the!left!
usually.by.endoscopic.snare.polypectomy.!'
referred!to!as!Virchow's!node),!and!axillary!
'
lymph!nodes!!
I. GASTRIC'VOLVULUS' determine!inadequate!vagotomy!
B is!a!twist!of!the!stomach!that!usually!occurs!in!
association!with!a!large!hiatal!hernia!or!unusually! Answer:'C'
mobile!stomach!without!hiatal!hernia.! Historically,!gastric!analysis!was!performed!most!
B Gastric!volvulus!is!a!chronic!condition!that!can!be! commonly!to!test!for!the!adequacy!of!vagotomy!in!
surprisingly!asymptomatic.' postoperative!patients!with!recurrent!or!persistent!
B Clinical!manifestations:!abdominal!pain!and!pressure! ulcer.!Now!this!can!be!done!by!assessing!peripheral!
related!to!the!intermittently!distending!and!poorly! pancreatic!polypeptide!levels!in!response!to!sham!
emptying!twisted!stomach,!dyspnea!(due!to!pressure!on! feeding.!A!50%!increase!in!pancreatic!polypeptide!
the!lung),!palpitations!(due!to!pressure!on!the! within!30!minutes!of!sham!feeding!suggests!vagal!
pericardium)!and!dysphagia!(pressure!on!the! integrity.!
esophagus)' !
B Management:!' 2. Which!of!the!following!procedures!for!PUD!has!the!
$ Vomiting!and!passage!of!a!NGT!may!relieve! highest!incidence!of!postoperative!diarrhea?!
symptoms' !
$ Gastric'infarction'is'a'surgical'emergency' a. Graham!patch!
' b. Parietal!cell!vagotomy!
J. POSTGASTRECTOMY'PROBLEMS' c. Truncal!vagotomy!and!pyloroplasty!
d. Distal!gastrectomy!without!vagotomy!
DUMPING'SYNDROME' !
B occurs!after!bariatric!surgery!and!PUD!repair!(after! Answer:!C'
pyloroplasty,!pyloromyotomy!or!distal!gastrectomy)! ! Parietal! Truncal! Truncal!
Cell! vagotomy!&! vagotomy!&!
B mechanism:!there!is!accumulation!of!digested!food!in! vagotomy! pyloroplasty! Antrectomy!
the!small!intestine!(or!abrupt!delivery!of!hyperosmolar!
load!into!the!small!bowel)!leading!to!circumferential! Operative! 0! <1! 1!
mortality!
expansion,!additional!accumulation!of!fluids!emptying! rate!(%)!
from!stomach!to!duodenum!and!sudden!expulsion!of! Ulcer! 5B15! 5B15! <2!
recurrence!
food!to!GIT!"!possibly!due!to!ablation!of!the!pylorus!or! (%)!
decreased!gastric!compliance!with!accelerated! Dumping(%)! ! ! !
emptying!of!liquids!(after!highly!selective!vagotomy)!
Mild! <5! 10! 10B15!
B clinical!manifestation:!tachycardia,!crampy!abdominal!
pain!and!diarrhea,!dizziness,!lightheadedness,! Severe! 0! 1! 1B2!
diaphoresis,!nausea!and!vomiting!after!ingestion!of!a!
fatty!or!carbohydrate!laden!meal!! Diarrhea! ! ! !
$ due!to!sudden!shift!in!electrolytes!and!fluids!
Mild! <5! 25' 20!
combined!with!increased!blood!flow!to!small!
intestine! Severe! 0! 2' 1B2!
B treatment:!
$ decreasing!fluid!and!food!intake!to!small!frequent! !
portions!
$ avoid!fatty!and!simple!sugars! !
! !
+
AFFERENT'LIMB'OBSTRUCTION'(BLIND'LOOP' SMALL'INTESTINE'
SYNDROME)'
!
B occurs!usually!after!a!Billroth!II!procedure!(distal!
A. Gross'Anatomy'and'Histology'
gastric!resection!followed!by!gastrojejunal!
B. Small'bowel'obstruction'
anastomosis)!
C. Ileus'&'other'disorders'of'intestinal'motility'
B location!of!obstruction:!at!the!limb!associated!with!the!
D. Crohn’s'disease'
gastric!remnant!going!to!the!duodenum!
E. Intestinal'fistulas'
B clinical!manifestations:!severe!epigastric!pain!following!
F. Small'bowel'neoplasms'
eating,!bilous!emesis!without!food!
G. Radiation'enteritis'
B treatment:!convert!Billroth!II!to!roux!enBY!gastric!
H. Meckel’s'diverticulum'
bypass!(possible!problem:!can!delay!gastric!emptying)!
I. Acquired'diverticulum'
!
J. Mesenteric'Ischemia'
GASTRIC'OUTLET'OBSTRUCTION!(see!complications! K. Obscure'GI'bleeding'
of!PUD!as!well)! L. Intussuception'
B presents!with!hypochloremic,'hypokalemic' M. Short'bowel'syndrome'
metabolic'alkalosis!☺!"!dehydration! !
B as!a!compensatory!response!due!to!worsening!
!
dehydration,!Na!conservation!occurs!in!the!kidney,!
A. GROSS'ANATOMY'AND'HISTOLOGY'
leading!to!renal!tubular!acidosis!with!subsequent!
B raison'd'être'of'the'GI'tract!!because!it!is!the!principle!
aciduria!
site!of!nutrient!digestion!and!absorption.'
B Layers!of!the!small!intestine!(from!innermost!to!
'''''''REVIEW'QUESTIONS!!
outermost!layers):!mucosa,!submucosa,!muscularis!
!
propria!and!serosa'
1. A!patient!with!a!vagotomy!and!pyloroplasty!
$ Contraction!of!the!inner!circular!layer!causes!
returns!with!a!recurrent!ulcer.!The!best!method!
results!in!luminal!narrowing'
for!determining!if!there!was!an!inadequate!
$ Contraction!of!the!outer!longitudinal!layer!results!
vagotomy!performed!is!
in!bowel!shortening'
!
$ Contraction!of!the!muscularis!mucosa!contribute!to!
a. Direct!vagal!stimulation!
mucosal!or!villus!motility!(but!not!peristalsis)'
b. Stimulated!gastric!analysis!
B Mucosal!folds:!plicae'circulares'/'valvulae'
c. Stimulated!PPI!(pancreatic!polypeptide)!levels!
conniventes'
d. None!of!the!above!–!there!is!no!good!test!to!
B Peyer’s'patches:!most!commonly!located!in!the!ileum! $ With!obstruction,!the!luminal!flora!of!the!small!
which!are!aggregates!of!lymphoid!follicles!and!is!a!local! bowel!(which!is!usually!sterile)!changes!"!
source!of!IgA' Translocation!of!these!bacteria!to!regional!lymph!
B Difference'between'jejunum'and'ileum:!jejunum.has. nodes!!
larger.circumference,.thicker.wall,.less.fatty. '
mesentery,.and.longer.vasa.recta' Partial'SBO:'only!a!portion!of!the!intestinal!lumen!is!
B Calcium!is!primarily!absorbed!in!the!duodenum! occluded,!allowing!passage!of!some!gas!and!fluid.!!
through!both!transcellular!transport!and!paracellular! '
diffusion.' Complete'SBO:!complete!occlusion!
. '
Closed'loop'obstruction:!dangerous!form!of!SBO,!in!
⊗ 'PHYSIOLOGY!a! which!a!segment!of!intestine!is!obstructed!both!
' proximally!and!distally!(e.g.,!with!volvulus).!In+such+
Representative'Regulatory'Peptides'produced'in'the'small' cases,+the+accumulating+gas+and+fluid+cannot+escape+
Intestine:' either+proximally+or+distally+from+the+obstructed+segment,+
' leading+to+a+rapid+rise+in+luminal+pressure,+and+a+rapid+
Hormone' Source' Actions' progression+to+strangulation.!
Somatostatin' D!Cell! Inhibits!GI!secretion,!motility!&! !
splanchnic!perfusion! B Clinical!presentation!
Secretin'(1st! S!cell! Stimulates!exocrine!pancreatic! $ Symptoms:!colicky!abdominal!pain,!nausea,!
hormone!discovered!in! secretion;!stimulates!intestinal! vomiting!(a!more!prominent!symptom!with!
the!human!body)'
secretion! proximal!obstructions!than!distal;!vomitus!is!
Cholecystokinin' I!cell! Stimulates!exocrine!pancreatic! usually!feculent),!and!obstipation,!continued!
secretion;!Stimulates!GB! passage!of!flatus!and/or!stool!beyond!6!to!12!hours!
emptying;!Inhibits!sphincter!of! after!onset!of!symptoms!(more!for!partial!SBO!than!
Oddi!contraction! complete!SBO)!!
Motilin' M!cell! Stimulates!intestinal!motility! $ Signs:!abdominal!distention!(pronounced!if!the!site!
of!obstruction!is!distal!ileum!&!absent!if!the!site!of!
GlucagonSlike' L!cell! Stimulates!intestinal!
obstruction!is!in!the!proximal!small!intestine),!
peptide'2' proliferation!
initially!hyperactive!bowel!sounds!(maybe!minimal!
Peptide'YY' L!cell! Inhibits!intestinal!motility!&!
towards!the!late!stages!of!bowel!obstruction)!
secretion!
'
$ Lab!findings:!hemoconcentration!and!electrolyte!
'
abnormalities!(reflect!intravascular!volume!
depletion)!&!Mild!leukocytosis!!
.
$ Features'of'strangulated'SBO:!abdominal'pain'
B. SMALL'BOWEL'OBSTRUCTION'
often'disproportionate'to'the'degree'of'
B Epidemiology:!
abdominal'findings!(!suggestive!of!intestinal!
$ most'frequently'encountered'surgical'disorder'
ischemia),!tachycardia,!localized!abdominal!
of'the'small'intestine.!!
tenderness,!fever,!marked!leukocytosis,!&!acidosis.!
$ Lesions!can!be!described!as:!
!
# Intraluminal:!foreign!bodies,!gallstones,!
B Diagnosis!
meconium!
$ Confirmatory'test:'abdominal'series'(radiograph+
# Intramural:!tumors,!Crohn’s!disease!
of+the+abdomen+with+the+patient+in+a+supine+position,+
associated!inflammatory!strictures!
upright+position+&radiograph+of+the+chest+with+the+
# Extrinsic:!adhesions,!hernias,!carcinomatosis!
patient+in+an+upright+position)!
B Etiology:'
# Sensitivity'of'abdominal'radiographs'for'
$ IntraSabdominal'adhesions'related'to'prior'
detecting'SBO'is'70S80%!
abdominal'surgery:'most'common'cause'(75%'
# Triad!of!dilated'small'bowel'loops'(>3'cm'in'
of'cases)'
diameter),'airSfluid'levels'seen'on'upright'
$ Hernias'
films,'and'a'paucity'of'air'in'the'colon!is!
$ Malignancy:!due!to!extrinsic!compression!or!
MOST'SPECIFIC!
invasion!by!advanced!malignancies!arising!in!
$ CT!scan!!
organs!other!than!the!small!bowel'
# 80!to!90%!sensitive!!
$ Crohn's!disease.'
# 70!to!90%!specific!!
$ Congenital!abnormalities!(i.e.!midgut!volvulus!and!
# Apperance'of'closedSloop'obstruction'in'
intestinal!malrotation)!diagnosed!at!adulthood.'
CT:'presence!of!UBshaped!or!CBshaped!dilated!
$ superior!mesenteric!artery!syndrome:!rare;!
bowel!loop!associated!with!a!radial!
compression!of!the!3rd!portion!of!the!duodenum!by!
distribution!of!mesenteric!vessels!converging!
the!superior!mesenteric!artery!as!it!crosses!over!
toward!a!torsion!point.!
this!portion!of!the!duodenum;!seen!in!young!
# Appearance'of'strangulation'in'CT:'
asthenic!individuals!who!have!chronic!symptoms!
thickening!of!the!bowel!wall,!pneumatosis!
suggestive!of!proximal!small!bowel!obstruction.'
intestinalis!(air!in!bowel!wall),!portal!venous!
!
gas,!mesenteric!haziness!and!poor!uptake!of!IV!
B Pathophysiology!
contrast!into!the!wall!of!the!affected!bowel.!
$ Gas!(usually!from!swallowed!air)!and!fluid!(from!
!
swallowed!liquids!and!GI!secretions)!accumulate!
B Treatment!
within!the!intestinal!lumen!proximal!to!the!site!of!
$ Fluid!resuscitation:!isotonic!replacement!
obstruction!"!intestinal!activity!↑!to!overcome!the!
$ Broad!spectrum!antibiotics!
obstruction!(seen!as!colicky!pain!and!diarrhea)!"!
$ NGT!placement!for!decompression!
bowel!distention!"!!↑!intraluminal!and!intramural!
$ If!complete!SBO,!perform!surgery!
pressures!rise!"!intestinal!motility!is!eventually!
$ If!partial!SBO,!may!be!approached!conservatively!
reduced!with!fewer!contractions"!If!intramural!
given!that!there!is!no!fever,!tachycardia,!
pressure!becomes!high!enough!"!impaired!
tenderness,!or!an!increase!in!white!cell!count!
intestinal!microvascular!perfusion!"!intestinal!
(indicates!perforation)!
ischemia!"!necrosis!(strangulated.bowel.
$ most.patients.with.partial.small.obstruction.
obstruction)!
whose.symptoms.do.not.improve.within.48.hours.
after.initiation.of.nonoperative.therapy.should. !
undergo.surgery.!! '
$ Obstruction!presenting!in!the.early.postoperative. D. INFLAMMATORY'BOWEL'SYNDROME:'CROHN’S'
period'(particularly!those!undergoing'pelvic' DISEASE'VS'ULCERATIVE'COLITIS'☺'
surgery,'especially'colorectal'procedures)!pose! '
the!greatest.risk.for.developing.early. table'56.'Inflammatory!bowel!syndrome'
postoperative.small.bowel.obstruction... ! Crohn’s'disease' Ulcerative'colitis'
# obstruction!should!be!considered!if.Sx.of. description! chronic,!idiopathic! Chronic!inflammatory!
intestinal.obstruction.occur.after.the.initial. transmural!inflammatory! disease!affecting!only!the!
disease!with!a!propensity! colonic!mucosa!and!
return.of.bowel.function.or.if.bowel.function.
to!affect!the!distal!ileum! submucosa!!
fails.to.return.within.the.expected.3.to.5. Etiology!&! Bmore!common!in! Higher!chance!of!leading!to!
days.after.abdominal.surgery.. epidemiology! Ashkenazi!jews!&! colorectal!cancer!
$ Regardless!of!etiology,!the!affected!intestine!should! caucasaians,!females,!has!
be!examined,!and!nonviable!bowel!resected.! a!bimodal!age!
# Criteria'for'viability:'normal'color' distribution!(3rd!&!6th!
(pinkish),'(+)peristalsis,'and'marginal' decade),!(+)!strong!
arterial'pulsations.'! pattern!of!family!
inheritance,!smokers!&!
higher!SocioBeco!status!
Ogilvie'syndrome'
Pathology! Focal'transmural' Inflammation!is!limited!to!
B Distention!of!the!abdomen!leading!to!obstruction! inflammation,! mucosa!and!submucosa!
B Tends!to!occur!following!nonBabdominal!procedures! aphthous'ulcers' only;!lead'pipe'colon!
(i.e.!cardiac!surgery)! (earliest'lesion'of' (lacks!haustral!markings);!
B Due!to!a!neurologic!dysfunction,!electrolyte! Crohn’s),!! no!granulomas!
abnormality!and!↑age! non'casseating' !
B Treatment:!NGT,!IV'neostigmine,!IV!atropine!(to! granulomas,' !
counter!bradycardia!as!SE!of!neostigmine),!exploratory! cobblestoning,'' !
**fat'wrapping! !
laparotomy!during!worst!case!scenario)!
(encroachment!of! !
' mesenteric!fat!onto!the! !
C. ILEUS'&'OTHER'DISORDERS'OF'INTESTINAL' serosal!surface!of!the! !
MOTILITY! bowel):!pathognomonic+ !
B Ileus!is!a!temporary!motility!disorder! of+crohn’s! !
B Postoperative'ileus:'most'frequently'implicated' ! !
cause'of'delayed'discharge'following'abdominal' spares'rectum,can!occur! !
operations! anywhere!in!the!GI!tract,! Primarily!affects!the!colon!
skip'lesions,!targets' &!rectum!and!is!continous;!
B Pathophysiology:'!
terminal'ileum! can!also!manifest!with!
$ Common!etiologies:!abdominal!operations,! ! backwash!ileitis!
infection!and!inflammation,!electrolyte! fistula,!!
abnormalities!(↓K,!↓&↑Mg,!↓!Na)!&!drugs! !
(anticholinergics,!opiates,!phenothiazine,!CCB,! !
Tricyclic!antidepressants)! S/Sx! Inisiduous!onset!with! bloody!diarrhea!and!
$ Proposed!mechanisms:!surgical!stressBinduced! waxing!and!waning! crampy!abdominal!pain.!
sympathetic!reflexes,!inflammatory!response! course!of!abdominal!pain! Proctitis!may!produce!
mediator!release,!and!anesthetic/analgesic!effects! (usually!RLQ),!nonbloody! tenesmus;!can!proceed!to!
diarrhea!&!weight!loss;! fulminant!colitis!and!toxic!
$ Normal'temporal'pattern'of'return'of'GI'
! megacolon!
motility'☺:'small'intestinal'motility'(1st'24' (+)!extraintestinal!
hours),'gastric'motility'(48'hours)'and'colonic' manifestation:!arthritis,!
motility'(3'to'5'days)! uveitis,!iritis,!eythema!
B Clinical'presentation'(usually'resembles'SBO):' nodosum,!pyoderma!
gangrenosum,!primary!
Inability!to!tolerate!liquids!and!solids!by!mouth,!nausea,!
sclerosing!cholangitis,!
and!lack!of!flatus!or!bowel!movements,!vomiting,! nephrolithiasis!
abdominal!distention!&!diminished!or!absent!bowel! Diagnosis! Endoscopy!(skip!lesions,! Endoscopy!&!proctoscopy!
sounds! cobblestoning,!abscess! (earliest!manifestation!is!
B diagnosis:'If!ileus'persists'beyond'3'to'5'days' formation!and!fistulas);! mucosal!edema;!mucosal!
postoperatively'☺!or!occurs!in!the!absence!of! histology!demonstrate! friability!;!ulceration;!(+)!
abdominal!surgery,!further!investigation!is!warranted! granulomas;!(+)!(pANCA)! Pus!and!mucus)!
to!rule!out!possibility!of!mechanical!obstruction!' and!anti–Saccharomyces+
cerevisiae!antibody!
(ASCA!
⊗ 'CLINICAL'PEARLS!a! Treatment! Sulfasalazine!+!steroids;! Similar!to!Crohn’s;!
' surgery!if!unresponsive! colectomy!after!15!years!of!
Measures'to'REDUCE'postoperative'ileus:' to!aggressive!medical!Tx! symptoms!
Intraoperative'measures:' !
B minimize!handling!of!bowel! E. INTESTINAL'FISTULAS'
B laparascopic!approach,!if!possible! B abnormal!communication!between!two!epithelialized!
B avoid!excessive!intraoperative!fluid!administration! surfaces'
' B can!be!internal!(within!GI!tract!or!adjacent!organs)or!
Postoperative'measures' external!(with!communication!to!external!environment)'
B early!enteral!feeding! B Kinds:!
B epidural!anesthesia,!if!indicated! $ low'output'fistulas!B!drain!less!than!200!mL!of!
B avoid!excessive!IV!fluid!administration! fluid/day'
B correct!electrolyte!abnormalities! $ high'output'fistulas!B!drain!more!than!500!mL!of!
B consider!mBopiod!antagonists!(! fluid/day'
B 80%'of'enterocutaneous'fistulas'are'due'to'
***Remember,!though!often!recommended,!the!use'of'early' iatrogenic'complications'
ambulation'and'routine'NG'intubation!has!NOT!been! B Clinical'presentation'
demonstrated!to!be!associated!with!earlier!resolution!of!
postoperative!ileus.!
$ usually!become!clinically!evident!between!the!5th!&! '
10th!postop' '
$ initial!signs:!Fever,!leukocytosis,!prolonged!ileus,! '
abdominal!tenderness,!and!wound!infection' B Clinical'presentation'
$ (+)!drainage!of!enteric!material!through!the! $ Partial'SBO'is'the'most'common'mode'of'
abdominal!wound!or!through!existing!drains:! presentation'
associated!with!intraBabdominal!abscesses.' $ Only!becomes!symptomatic!when!it!becomes!large'
B Diagnosis' B Diagnosis:'Because!of!the!absent!or!nonspecific!
$ CT!scan:!most!useful!initial!test' symptoms!associated!with!most!small!intestinal!
$ small!bowel!series!or!enteroclysis!examination:!can! neoplasms,!these+lesions+rarely+are+diagnosed+
be!obtained!to!demonstrate!the!fistula's!site!of! preoperatively+
origin!in!the!bowel.' B Treatment:'surgical!resection'
$ Fistulogram:!greater!sensitivity!in!localizing!the! '
fistula!origin.' G. RADIATION'ENTERITIS'
B Treatment' B An!undesired!side!effect!of!radiation!therapy!is!
$ Should!follow!orderly!steps!(done+to+maximize+ radiationBinduced!injury!to!the!small!intestine'
spontaneous+closure)' B The'SI'is'susceptible'to'radiationSinduced'injury'
# Stabilization:!fluid!&!electrolyte!resuscitation,! because'it'has'a'high'rate'of'rapidly'proliferating'
TPN,!antibiotics,!' cells'compared'to'the'other'portions'of'the'GI'tract'
# Investigation:!see!diagnosis' B Pathophysiology'
# Decision!to!do!perform!surgery!or!do! $ principal!mechanism!of!radiationBinduced!cell!
conservative!treatment' death!is!believed!to!be!apoptosis!resulting!from!
• Surgeons!usually!do!2'to'3'months'of' freeBradical–induced!breaks!in!doubleBstranded!
conservative'therapy'before' DNA'
considering'surgical'intervention.' $ The!intensity!of!injury!is!related!to!the!dose!of!
• This!approach!is!based!on!evidence!that! radiation!administered'
90%'of'fistulas'that'are'going'to'close,' B Pathology!
close'within'a'5Sweek'interval' $ acute!injury:!villus!blunting,!dense!infiltrate!of!
B Definitive!management:!surgery!(if!failure!of! leukocytes!and!plasma!cells!within!the!crypts,!
spontaneous!closure!during!time!period!or!with! mucosal!sloughing,!ulceration,!and!hemorrhage!!
complications!and!risk!factors)! $ chronic!injury:!progressive!occlusive!vasculitis!that!
B rehabilitation' leads!to!chronic!ischemia!and!fibrosis!that!affects!
all!layers!of!the!intestinal!wall,!rather!than!the!
''√'MUST'KNOW!a! mucosa!alone!"!leading!to!strictures,!abscesses,!
' and!fistulas!
Remember!FRIEND!(factors!that!inhibit!spontaneous!closure!of! B Clinical'presentation'
fistulas):! $ Acute:!nausea,!vomiting,!diarrhea,!and!crampy!
Foreign!body!within!the!fistula!tract! abdominal!pain.'
Radiation!enteritis! $ Chronic:!becomes!evident!within!2!years!of!
Infection/Inflammation!at!the!fistula!origin!Epithelialization!of! radiation!administration,!most!commonly!presents!
the!fistula!tract! with!partial'small'bowel'obstruction!with!
Neoplasm!at!the!fistula!origin! nausea,!vomiting,!intermittent!abdominal!
Distal!obstruction!of!the!intestine! distention,!crampy!abdominal!pain,!and!weight!loss!
' The!terminal'ileum'is!the!most!frequently!affected!
' segment'
F. SMALL'BOWEL'NEOPLASMS' B Diagnosis'
B Adenomas!are!the!most!common!benign!neoplasm!of! $ Enteroclysis:!most!accurate!imaging!test!for!
the!small!intestine! diagnosing!chronic!radiation!enteritis,!'
B Most!common!location!for!primary!adenocarcinoma! $ CT!scan!findings!are!neither!very!sensitive!nor!
and!adenomas!of!the!small!bowel!is!DUODENUM' specific!for!chronic!radiation!enteritis;!should!be!
(EXCEPT'in!patient’s!with!Crohn’s!disease,!which!is! obtained!to!rule!out!the!presence!of!recurrent!
found!mostly!in!the!ileum)! cancer!(because!of!overlap!in!clinical!
B Primary'small'bowel'cancers'are'rare;!1.1!to!2.4%!of! manifestations)'
all!GI!malignancies' B Treatment:'supportive'therapy'
$ Adenocarcinomas:!35!B!50%!' '
$ Carcinoid!tumors:!20!to!40%' H. MECKEL’S'DIVERTICULUM'☺'
$ Lymphomas:!10!to!15!%' B most'prevalent'congenital'anomaly'of'the'GI'tract'
$ GISTs:!most!common!location!is!STOMACH'(60S B considered!a!true!diverticula'
70%),'2nd!most!common!location!is!small!intestine! B location!is!usually!found!in!the!ileum'within'100'cm'of'
(25B35%)' the'ileocecal'valve'
B Pathophysiology:'proposed!explanations!for!the!low! B 60%!of!Meckel's!diverticula!contain!heterotopic'
frequency!of!small!intestinal!neoplasms!! mucosa!(most'common:'gastric'mucosa'–!60%;!
$ dilution!of!environmental!carcinogens!in!the!liquid! others:!Pancreatic!acini,!Brunner's!glands,!pancreatic!
chyme!present!in!the!SI!lumen' islets,!colonic!mucosa,!endometriosis,!and!hepatobiliary!
$ rapid!transit!of!chime!(limiting!the!contact!time! tissues).'
between!carcinogens!and!the!intestinal!mucosa)'
$ relatively!low!concentration!of!bacteria!in!small! ''√'MUST'KNOW!a!
intestinal!chime!(therefore,!low!concentration!of!
rule'of'TWOs'of'Meckel’s'diverticulum:'
carcinogenic!products!of!bacterial!metabolism)' !
$ mucosal!protection!by!secretory!IgA!and! 2%!prevalence!
hydrolases!such!as!benzpyrene!hydroxylase!"! 2:1!female!predominance!
render!carcinogens!less!active' location!2!ft!proximal!to!the!ileocecal!valve!in!adults!
$ efficient!epithelial!cellular!apoptotic!mechanisms! one!half!of!those!who!are!symptomatic!are!under!2!years!of!age!
that!serve!to!eliminate!clones!harboring!genetic!!
mutations.' '
B Pathophysiology'
$ Failure'of'the'the'omphalomesenteric' Acute'mesenteric'ischemia' Chronic'mesenteric'ischemia'
(vitelline)'duct'to'undergo'obliteration!during! source:'heart;'most'common' mesenteric,!and!inferior!
the!8th'week'of'gestation' location:'SMA' mesenteric!arteries!
B Littre’s'hernia:!Meckel's!diverticula!found!in!an! Barterial'thrombosis:!occur!in! Brarely!leads!to!infarction!
proximal!mesenteric!arteries! !
inguinal'or'femoral'hernia!sacs;!when!incarcerated,!
Bvasospasm'(nonocclusive' BPostprandial'abdominal'pain!
can!cause!intestinal!obstruction! mesenteric'ischemia):! is!the!most'prevalent'
B Clinical'presentation! diagnosed!in!critically!ill! symptom,!producing!a!
$ most!common!presentations!associated!with! patients!receiving!vasopressor! characteristic!aversion!to!food!
symptomatic!Meckel's!diverticula:!bleeding'(most' agents.! ("foodSfear")!and!weight!loss!
common'in'pediatric'age),'intestinal' Svenous'thrombosis:!involves! (can!be!mistaken!as!a!symptom!
obstruction'(most'common'in'adults),'and' the!superior'mesenteric'vein! of!malignancy)'
diverticulitis! in!95%!of!cases;!associated!with!
heritable!or!acquired!
B Diagnosis'
coagulation!DO!
$ Usually!discovered+incidentally!on!radiographic! !
imaging,!during!endoscopy,!or!at!the!time!of! Golden!period:!3!hours!–!
surgery.' intestinal!sloughing;!6!hours:!
$ CT!scan:!low!sensitivity!and!specificity!' full!thickness!intestinal!
$ Enteroclysis:!has!75%!accuracy!but!u!not! infarction!
applicable!during!acute!presentations' '
$ Radionuclide!scans!(99mTcBpertechnetate):!positive! Hallmark'of'acute'mesenteric'
ischemia:''Severe!abdominal!
only!when!the!diverticulum!contains!associated!
pain,!out!of!proportion!to!the!
ectopic!gastric!mucosa!that!is!capable!of!uptake!of! degree!of!tenderness!on!
the!tracer!' examination'
B Treatment:'surgical'' '
$ diverticulectomy!' K. INTUSSUCEPTION'☺'
$ If!the!indication!for!diverticulectomy!is!bleeding,! B refers!to!a!condition!where!one!segment!of!the!intestine!
segmental!resection!of!ileum!that!includes!both!the! becomes!drawn!in!to!the!lumen!of!the!proximal!
diverticulum!and!the!adjacent!ileal!peptic!ulcer! segment!of!the!bowel!
should!be!performed.!' B usually!is!seen!in!the!pediatric!population'
$ Segmental!ileal!resection!may!also!be!necessary!if! B Adult!intussusceptions!are!rare;!usually!with!distinct!
the!diverticulum!contains!a!tumor!or!if!the!base!of! pathologic!lead!point!(which!can!be!malignant)'
the!diverticulum!is!inflamed!or!perforated.' B commonly!present!with!a!history!of!intermittent!
$ The!management!of!incidentally!found! abdominal!pain!and!signs!and!symptoms!of!bowel!
(asymptomatic)!Meckel's!diverticula!is! obstruction'
controversial.!' B CT'scan:'diagnostic'of'choice'
' $ Finding:'"target'sign"'
I. ACQUIRED'DIVERTICULUM' B Treatment:!surgical!resection!of!the!involved!segment!
B Considered!as!false'diverticula'(because!their!walls! and!the!lead!point,!which!needs!to!undergo!pathologic!
consist!of!mucosa!and!submucosa!but!lack!a!complete! evaluation!to!rule!out!an!underlying!malignancy.!
muscularis)' !
B more!common!in!the!duodenum,!near!the!ampulla! L. SHORT'BOWEL'SYNDROME'
(periampullary,!juxtapapillary,!or!periGVaterian+ B presence!of!less!than!200!cm!of!residual!small!bowel!in!
diverticula)' adult!patients!'
B Diverticula!in!the!jejunum!tend!to!be!large!and! B usually!acquired!(s/p!intestinal!resection)'
accompanied!by!multiple!other!diverticula,!whereas! B can!result!to!malabsorptive!symptoms:!diarrhea,!
those!in!the!ileum!tend!to!be!small!and!solitary.' dehydration,!and!malnutrition,!'
B Pathophysiology' B most!common!etiologies:!'
$ Due!to!acquired!abnormalities!of!intestinal!smooth! $ adults:!acute!mesenteric!ischemia,!malignancy,!and!
muscle!or!dysregulated!motility!"!leading!to! Crohn's!disease'
herniation!of!mucosa!and!submucosa!through! $ pedia:!intestinal!atresias,!volvulus,!and!necrotizing!
weakened!areas!of!muscularis.' enterocolitis'
B Clinical!presentation! B Pathophysiology'
$ Acquired!diverticula!are!asymptomatic!unless! $ Normal:!Resection!of!less!than!50%!of!the!small!
associated!complications!arise' intestine!is!generally!well!tolerated.!'
$ Complications!(6!to!10%!of!patients):!intestinal! $ Symptomatic!when!greater!than!50!to!80%!of!the!
obstruction,!diverticulitis,!hemorrhage,! small!intestine!has!been!resected.!'
perforation,!and!malabsorption.!' $ Malabsorption!in!patients!who!have!undergone!
B Diagnosis! massive!small!bowel!resection!is!exacerbated!by!a!
$ Most!acquired!diverticula!are!discovered! characteristic!hypergastrinemiaSassociated'
incidentally!on!radiographic!imaging,!during! gastric'acid'hypersecretion'that!persists!for!1!to!
endoscopy,!or!at!the!time!of!surgery.!' 2!years!postoperatively'
$ Enteroclysis!is!the!most!sensitive!test!for!detecting! B Treatment:!
jejunoileal!diverticula' $ TPN!&!enteral!nutrition!
B Treatment! $ Pharmacotherapy!
$ If!asymptomatic,'observe'
$ If!(+)complications,!such!as!bleeding!and! '''''''REVIEW'QUESTIONS!!
diverticulitis:!segmental!intestinal!resection!for! !
diverticula!located!in!the!jejunum!or!ileum.' 1. Vitamin!B12!deficiency!can!occur!after!
' !
J. MESENTERIC'ISCHEMIA' a. Gastrectomy!
b. Gastric!bypass!
Table'57:'comparison'of'acute'vs'chronic'mesenteric'ischemia' c. Ileal!resection!
Acute'mesenteric'ischemia' Chronic'mesenteric'ischemia' d. ALL!OF!THE!ABOVE!
Causes:!! S!results!from!atherosclerotic!
Sarterial'embolus:'most' lesions!in!the!main!splanchnic! Answer:'D'
common'cause;'most'common' arteries!(celiac,!superior!
Vitamin!B12!(cobalamin)!malabsorption!can!result!
from!a!variety!of!surgical!manipulations.!The! fibers)!that+is+referred+to+the+periumbilical+region+
vitamin!is!initially!bound!by!salivaBderived!R! (via+autonomic+innervations)+"+Right+lower+
protein.!In!the!duodenum,!R!protein!is!hydrolyzed! quadrant+pain+and+tenderness+(via+somatic+
by!pancreatic!enzymes,!allowing!free!cobalamin!to! innervations+due+to+involvement+of+the+parietal+
bind!to!gastric!parietal!cellBderived!intrinsic!factor.! peritoneum)'
The!cobalaminBintrinsic!factor!complex!is!able!to! $ Vomiting!usually!follows!abdominal!pain'
escape!hydrolysis!by!pancreatic!enzymes,!allowing! $ Anorexia!is!a!constant!symptom;!if!not!present,!
it!to!reach!the!terminal!ileum,!which!expresses! question!diagnosis;!usually!precedes!abdominal!
specific!receptors!for!intrinsic!factor.!Subsequent! pain'
events!in!cobalmin!absorption!are!poorly! $ Variations!in!the!anatomic!location!of!the!
characterized,!but!the!intact!complex!probably! appendiceal!tip!account!for!the!different!
enters!enterocytes!through!translocation.!Because! manifestation!of!the!abdominal!pain'
each!of!these!steps!is!necessary!for!cobalamin! # Retrocecal:!flank!or!back!pain'
assimilation,!gastric!resection,!gastric!bypass!and! # Pelvis:!findings!maybe!absent;!painful!DRE!
ileal!resection!can!each!result!in!Vitamin!B!12! exam'
insufficiency.! B PE!maneuvers:!
! $ Dumphy’s'sign:'increased!pain!during!coughing!or!
2. Which!of!the!following!is!the!LAST!to!recover! jumping'
from!postoperative!ileus?! $ Rovsing’s'sign:'pain!in!the!RLQ!when!pressure!is!
! applied!on!the!LLQ;!this!suggests!peritoneal!
a. Stomach! irritation'
b. Small!Bowel! $ Psoas'sign:!pain!on!extension!of!the!right!thigh!
c. Colon! with!the!patient!lying!on!the!left!side;!this!is!due!to!
d. NONE!of!the!above!–!recovery!is!simultaneous! the!pain!elicited!by!the!stretched!psoas!muscle!
irritating!the!inflamed!appendix'
Answer:!C' $ Obturator’s'sign:!pain!with!passive!rotation!of!the!
The!return!of!normal!motility!generally!follows!a! flexed!right!hip;!suggests!that!the!inflamed!tip!lies!
characteristic!temporal!sequence,!with!small! in!the!appendix'
intestinal!motility!returning!to!normal!within!the!1st! B Diagnosis:!usually!based!on!history!and!physical!
24!hours!after!laparotomy!and!gastric!and!colonic! examination!even!in!the!absence!of!laboratories!and!
motility!returning!to!normal!by!48!hours!and!3!to!5! imaging!
days,!respectively.!Because!small!bowel!motility!is! $ Laboratory'findings!
returned!before!colonic!and!gastric!motility,!listening! 1. Moderate!leukocytosis!with!
for!bowel!sounds!is!not!a!reliable!indicator!that!ileus! polymorphonuclear!predominance!(if!above!
has!fully!resolved.!Functional!evidence!of!coordinated! 18,000!–!suspect!abscess!or!perforation)!
GI!motility!in!the!form!of!passing!flatus!or!bowel! 2. Can!also!have!normal!WBC!count!(1/3!of!
movement!is!a!more!useful!indicator.! patients)!
! 3. Minimal!albuminuria,!(+)!WBC!and!RBC!in!
! urine!if!appendix!is!retrocecal!
! 4. Anemia!in!elderly!should!raise!suspicion!of!
APPENDIX' carcinoma!of!the!cecum!
' ' $ Imaging'
A. Anatomy' 1. Plain'abdominal'films:!fecalith,!localized!
B. Acute'appendicitis' ileus!on!the!RLQ!&!loss!of!peritoneal!fat!
C. Appendiceal'tumors'S'Carcinoid' strip'
! 2. UTZ:'tubular,!immobile!and!
! noncompressible!appendix,wall!thickness!of!
A. ANATOMY' >2mm!and!outer!diameter!of!at!least!6!mm!
B Function:!immunologic!organ;!a!GALT!tossie!that! are!indicative!of!appendicitis'
secrete!immunoglobulins! 3. CT'scan:'thickened!by!more!than!5B
B The!base'of'the'appendix!can!always!be!found!at!the! 7mm&fluid!filled,!periappendiceal!
confluence'of'the'taenia! inflammation!along!with!fat!stranding,!fluid!
B Tip!of!the!appendix!varies:!retroceccal!(most!common),! collections!&!phlegmons'
pelvic,!subcecal,!preileal,!or!right!pericolic!position! B Differential'diagnosis'
$ ***The!location!of!the!tip!of!the!appendix! $ Acute'mesenteric'adenitis:!associated!with!URTI!
determine!the!location!of!physical!findings! and!presents!with!a!more!diffused!abdominal!painl!
produced!by!irritation!of!parietal!peritoneum! also!with!generalized!lymphadenopathy!with!
B the!luminal!capacity!if!the!normal!appendix!is!0.1!cc.! lymphocytosis'
secretion!of!as!little!as!0.5!cc!of!fluid!distal!to!the! $ Acute'gastroenteritis:'crampy!abdominal!pain!
obstruction!raises!intraluminal!pressure!to!60!cm!H20.! with!watery!stools,!nausea!and!vomiting'
! $ Diverticulitis:!of!cecum!or!perforated!carcinoma!
B. ACUTE'APPENDICITIS' of!cecum!is!difficult!to!distinguish!clinically!from!
B Etiology' appendicitis;!diagnosis!is!usually!done!
$ Fecalith:!most!common!cause!of!appendiceal! intraoperatively'
obstruction;!usually!in!adults' $ Epiploic'apendagitis:!infarction!of!the!appendage!
$ Lymphoid'hyperplasia:!most!common!cause!of! due!to!torsion;!pain!shift!is!unusal!and!patient!is!
appendiceal!obstruction!in!patients!of!pediatric!age' usually!not!ill'
$ Gynecologic'conditions:'ruptured!ectopic!
B Pathogenesis:'Luminal!obstruction!"!bacterial!
pregnancy,!PID,!ruptured!grafian!follicle,!twisted!
overgrowth,!active!mucosal!secretion!&!increased!
ovarian!cyst'
luminal!pressure'
$ Intussusception:!patient’s!age,!type!of!pain,!
B Natural'history:!rarely!resolves;!ultimately!lead!to!
palpable!mass!in!the!lower!quadrant!and!passage!
gangrene!and!perforation'
of!currant!jelly!stool!may!help!with!diagnosis;!
B Clinical'presentation'
barium!enema!offers!both!diagnostic!and!
$ Hallmark!of!appendicitis:!poorly+localized+pain+(due!
therapeutic!option!for!intussusception.'
to!distension!stimulates!visceral!afferent!pain!
'
B Special'conditions:' laparotomy,!other!causes!should!be!sought.!If!
' Crohn’s!disease!is!encountered!and!the!cecum!and!
AP'IN'THE'YOUNG' base!of!the!appendix!are!normal,!an!appendectomy!
B Diagnostic!accuracy!in!these!age!group!is!lower! should!be!performed.!If!the!base!is!involved!with!
compared!to!adults!due!to!imprecise!history!and! Crohn’s!disease!and!the!appendix!is!normal,!
nonspecific!abdominal!complaints! appendectomy!should!not!be!performed.!If!the!
B Hx:!vomiting,!fever!and!diarrhea!are!common! finding!of!Crohn’s!disease!is!uncomplicated!by!
complaints' perforation!or!obstruction,!ileal!resection!is!not!
B PE:!abdominal!distention,!maximal!tenderness!in!the! indicated.!However,!in!the!case!of!perforation!or!
right!lower!quadrant,!the!inability!to!walk!or!walking! Crohn’s!disease!with!obstruction,!the!involved!
with!a!limp,!and!pain!with!percussion,!coughing,!and! bowel!should!be!resected.!
hopping' !
B Gangrene!and!rupture!are!more!common!in!these!age! '
group!because!of!delays!in!diagnosis' !
!
' !
AP'IN'THE'ELDERLY! !
B Usually!with!atypical!presentation:!fever,!leukocytosis! !
and!RLQ!pain!maybe!minimal!or!absent! COLON,'RECTUM,'ANUS'
B Have!60B90%!rupture!rate!
'
B The!atrophic!omentum!is!less!capable!of!walling!off!a!
A. Embryology'
perforated!appendix!"!diffuse!peritonitis!or!distant! B. Diagnostic'evaluation'of'Colon,'Rectum'and'Anus'
intraBabdominal!abscess!are!expected! C. Evaluation'of'Common'symptoms'
B If!patient!is!older!than!60yo,!always!rule!out!cancer! D. Diverticular'disease''
because!the!definitive!treatment!for!that!is!right! E. Colorectal'adenocarcinoma'
hemicolectomy!(if!affecting!the!cecum)! F. Colorectal'carcinoid'tumors'
G. Anal'intraepithelial'neoplasia'(Bowen’s'disease)'
AP'IN'PREGNANCY' H. Volvulus'
B Most'common'surgical'emergency'in'pregnancy' I. Colonic'pseudoobstruction'(Ogilvie’s'syndrome)'
B In!pregnancy,!the!gravid!uterus!pushes!the!appendix! J. Hemorrhoids'
superiorly!and!the!tip!medially' K. Anal'fissure'
B Most!consistent!sign!of!AP!in!pregnant!women:!pain!in! L. Anorectal'abcess'
the!right!side!of!the!abdomen' M. Fistula'in'ano'
B Common!occurrence!of!abdominal!pain,!nausea!and!
leukocytosis!in!the!normal!course!of!pregnancy!makes! !
diagnosis!difficult' '
B Most!cases!occur!during!2nd!trimester' A. EMBRYOLOGY''
B Fetal!mortality!is!2B8.5%;!increases!to!35%!with! B Embryonic!GI!tract!begins!developing!during!4th'week'
rupture' of'gestation'
AP'IN'HIV'OR'AIDS'PATIENTS' Table!57.!Embryology!of!GI!tract!
B Similar!presentation!to!nonBinfected!patients! FOREGUT' MIDGUT' HINDGUT'
B Risk!of!appendiceal!rupture!is!higher!for!these!patients' Esophagus,!stomach,! small!intestine,! distal!transverse!
B DDx:!CMV!enteritis,!typhilitis,!fungal,!protozoal!and! pancreas,!liver,! ascending!colon,! colon,!descending!
mycobacterial!infections' duodenum! and!proximal! colon,!rectum,!and!
transverse!colon! proximal!anus!
Treatment:'appendectomy' Celiac!artery! SMA! IMA!
' ***distal!anus!is!derived!from!the!ectoderm;!BS:!internal!pudendal!
C. APPENDICEAL'TUMORS'S'CARCINOID' artey!
!
B most!common!location!is!appendix!(50%),!ileum!(25%)!
B The!colon!has!5!distinct!layers:!mucosa,!submucosa,!
then!rectum!(20%)'
inner!circular!muscle,!outer!longitudinal!muscle,!and!
B ileal!carcinoid!has!the!highest!potential!for!metastasis!
serosa!
(arounf!35%)!vs!appendiceal!carcinoid!which!has!
lowest!potential!for!metastasis!(3%)'
B Gross!appearance:!small,!firm,!circumscribed,!yellowish! ''√'MUST'KNOW!!
'
tumor!
Most'common'bacterium'within'the'colon'is'B.'fragilis'
B Treatment:'
followed'by'E.'coli'and'Enterococcus'sp.'
$ <2cm!at!distal!appendix:!appendectomy'
'
$ >2cm!or!at!base:!right!hemicolectomy'
'
'''''''REVIEW'QUESTIONS!! B. DIAGNOSTIC'EVALUATION'OF'COLON,'RECTUM'AND'
! ANUS'
1. A!patient!suspected!of!having!appendicitis!underwent! !
exploration,!Crohn’s!disease!was!found.!Which!of!the! ENDOSCOPY:'
following!are!true?! '
a. The!normal!appendix!should!always!be! 1. Anoscopy'
removed! B useful!instrument!for!the!examination!of!the!anal!canal!
b. All!grossly!involved!bowel,!including!the! B not!attempted!without!anesthesia!if!patient!complains!
appendix,!should!be!resected.! of!severe!perianal!pain!and!does!not!tolerate!digital!
c. An!inflamed!appendix,!cecum!and!terminal! rectal!examination!
ileum,!should!be!resected! 2. Proctoscopy'
d. Perforated!bowel!and!advanced!Crohn’s! B useful!for!the!examination!of!the!rectum!and!distal!
disease!with!obstruction!should!be!resected.! sigmoid!colon!
B can!be!both!therapeutic!and!diagnostic!
Answer:!D' B length:!25!cm!
If!a!normal!appendix!is!found!at!the!time!of!
B 15B19!mm!diameter!proctoscope!is!useful!for!diagnostic! B is!used!primarily!to!evaluate!the!depth!of!invasion!of!
examination! neoplastic'lesions'in'the'rectum'and!detecting!
B useful!for!polypectomy,!electrocoagulation,!detorsion!of! sphincter!defects!&!outlining!complex!anal!fistulas!
sigmoid!volvulus! B normal!rectal!wall!can!be!seen!as!a!5!layer!structure!
! B UTZ!can!reliably!differentiate!benign!polyps!from!
3. Flexible'sigmoidoscopy'and'colonoscopy' invasive!tumors!based!upon!the'integrity'of'the'
B provides!excellent!visualization!of!colon!and!rectum! submucosal'layer.!
B can!be!both!diagnostic!and!therapeutic! B Accuracy!in!detecting!depth!of!mural!invasion!is!81B
B length:!! 94%!
$ 60!cm:!sigmoidoscope!
$ 100B160!cm:!colonoscope! PHYSIOLOGIC'AND'PELVIC'FLOOR'INVESTIGATIONS:!
B full!length!insertion:!! useful!in!the!evaluation!of!patients!with!incontinence,!
$ may!allow!visualization!as!far!as!splenic!flexure:! constipation,!rectal!prolapse,!obstructed!defecation!and!
sigmoidoscope! other!pelvic!floor!disorders!
$ may!allow!visualization!as!far!as!terminal!ileum:! !
colonoscope! 1. Manometry'
B procedure:!pressureBsensitive!catheter!is!placed!in!the!
IMAGING:' lower!rectum!"!catheter!is!withdrawn!through!the!anal!
! canal!and!pressures!recorded!
1. Plain'xSray'and'contrast'studies' B values:!
B plain'xSrays'of'abdomen!(upright,!supine!and! $ resting'pressure!(normal:!40B80!mmHg):!reflects!
diaphragmatic!views)!are!useful!for!detecting!free!intraB the!function!of!the!internal!anal!sphincter!
abdominal!air,!bowel!gas!patterns!suggestive!of!small!or! $ Squeeze'pressure'(normal:!40B80!mmHg!above!
large!bowel!obstruction!and!volvulus! resting!pressure):!maximum!voluntary!contraction!
B contrast'studies!are!useful!for!evaluationg!obstructive! pressure!minus!resting!pressure,!reflects!the!
symptoms,!delineating!fistulous!tracts!and!diagnosing! function!of!the!external!anal!sphincter'
small!perforations!or!anastomotic!leaks.! $ High'pressure'zone'(normal:!2B4!cm):'estimates!
B Gastrografin'(water!soluble!contrast!agent)!is! the!kength!of!the!anal!canal'
recommended!if!perforation!or!leak!is!suspected! B Absence'of'rectoanal'inhibitory'reflex'is'
B Double'contrast'barium'enema!is!70B90%!sensitive! characteristic'of'Hirschsprung’s'disease'
for!the!detection!of!mass!lesions!greater'than'1'cm'in' '
diameter! 2. Neurophysiology'
$ If!a!small,!non!obstructing!lesion!is!considered,! B Neurophysiologic!testing!assesses!function!of!the!
colonoscopy!is!the!preferred!imaging!modality!of! pudendal!nerve!and!recruitment!of!puborectalis!muscle!
choice! fibers!
!
2. CT' LABORATORY'STUDIES:'
B the!utility!of!CT!is!in!the!detection'of'extraluminal' '
disease,!such!as!intraBabdominal!abscesses!and! 1. Fecal'Occult'Blood'testing'(FOBT)'
pericoloic!inflammation!and!in!staging'colorectal' B is!a!screening!test!for!colonic!neoplasms!in!
carcinoma'(because!of!its!sensitivity!in!detecting! asymptomatic,!averageBrisk!individuals!
hepatic!metastasis)' B occult!bleeding!from!any!GI!source!will!produce!a!
$ REMEMBER:'a'standard'CT'scan'is'INSENSITIVE' positive!result!(since!it!is!a!non!specific!test!for!
for'detection'of'intraluminal'lesions' peroxidase!contained!in!hemoglobin)!
B If'considering'a'perforation'/'anastomotic'leak:' B any!positive!FOBT!mandates!further!investigation,!
check!for!extravasation!of!oral!or!rectal!contrast' usually!by!colonoscopy!
B Bowel'wall'thickening'/'mesenteric'stranding' !
suggests!inflammatory!bowel!disease,!enteritis/colitis! 2. Stool'studies'
or!ischemia' B helpful!in!the!evaluation!of!etiology!of!diarrhea!
' B wet!mount!examination:!(+)!fecal!leukocytes!indicate!
3. MRI' colonic!inflammation!or!presence!of!invasive!organisms!
B the!main!use!of!MRI!in!colorectal!DO!is!in!the!evaluation! (such!as!E.!coli!or!Shigella)!
of!pelvic'lesions! B Sudan!red!stain!to!stool!sample:!to!evaluate!steatorrhea!
B more!sensitive!than!CT!for!detecting!bony'involvement' !
or'pelvic'sidewall'extension'of'rectal'tumors.! 3. CEA:!tumor!marker'
B Can!be!useful!in!the!detection!and!delineation!of! B elevated!in!60B90%!of!patients!with!colorectal!cancer;!
complex'fistulas'in'ano.! however,!not!an!effective!screening!agent!for!colorectal!
! CA!
4. Positron'Emission'Tomography' B serial!monitoring!used!after!curativeBintent!surgery!is!
B useful!for!imaging!tissues!with!high!levels!of!anaerobic! done!
glycolysis,!such!as!malignant'tumors! C. EVALUATION!OF!COMMON!SYMPTOMS!
B FSfluorodeoxyglucose!is!injected!as!a!tracer!"!its! 1. Pain'
metabolism!results!in!positron!emission! B abdominal!pain!related!to!colon!and!rectum!can!result!
B Used!as!an!adjunct!to!CT!in!staging!colorectal!cancer! from!obstruction!(inflammatory!or!neoplastic),!
! inflammation,!perforation!or!ischemia!
5. Angiography' B pelvic!pain!can!originate!from!distal!colon!and!rectum!
B used!for!the!detection!of!bleeding!within!the!colon!or! or!adjacent!urogenital!structures!
small!bowel! $ tenesmus:!due!to!proctitis!or!from!rectal!or!
B to!visualize!hemorrhage!angiographically,!bleeding! rectrorectal!mass!
must!be!relatively!brisk!(0.5!to!1!cc!per!minute)! $ cyclical!pain!+!menses!+!rectal!bleeding:!
B if!extravasation!of!contrast!is!identified,!infusion!with! endometriosis!
vasopressin!or!angiographic!embolization!can!be! B anorectal!pain!is!most!often!secondary!to!anal!fissure,!
therapeutic.! perirectal!abscess!and/or!fistula,!or!a!thrombosed!
! hemorrhoids!
6. Endorectal'and'Endoanal'UTZ' !
2. Lower'GI'bleeding'
B first!goal!in!managing!a!patient!with!GI!hemorrhage:! B Hinchey'staging'for'complicated'diverticulitis'
ADEQUATE'RESUSCITATION! Stage'I:!colonic!inflammation!with!an!associated!
B insert'NGT!(1st!test!that!should!be!performed)!since!the! pericolic!abscess!
most!common!cause!of!bleeding!can!either!be! Stage'II:!colonic!inflammation!with!a!retroperitoneal!or!
esophageal,!gastric!or!duodenal! pelvic!abscess!
$ if!(+)!return!of!bile!"!suggests!that!bleeding!is! Stage'III:!purulent!peritonitis!
distal!to!the!ligament!of!Treitz! Stage'IV:!fecal!peritonitis.!
$ if!bloody/nonBbile!secretions!"!suggests!an!upper! B Diagnosis:!CT'scan'
intestinal!source;!do!EGD!right!away! $ Appears!as!pericolic'soft'tissue'stranding,'
B technetiumB99Btagged!RBC!scan:!highly!sensitive!(as! colonic'wall'thickening,'and/or'phlegmon!
little!as!0.1!cc/hour!of!bleeding!can!be!detected);! B Treatment:!
however!location!is!imprecise!"!perform!angiography! $ Uncomplicated!diverticulitis:!outpatient!therapy!
to!localize!bleeding! with!broadBspectrum!oral!antibiotics!for!7B10!days!
B if!sharp,!knifeBlike!pain!+!bright!red!rectal!bleeding!with! &!lowBresidue!diet;!failure!to!improve!within!48B72!
bowel!movements!"!anal!fissure! hours!indicates!abscess!formation!
B if!painless,!bright!red!rectal!bleeding!secondary!to! $ If!2nd!episode!of!uncomplicated!diverticulitis!or!1st!
bowel!movements!"!internal!hemorrhoids! episode!of!complicated!diverticulitis:!elective!
! sigmoid!colectomy!is!recommended!
3. Constipation'and'obstructed'defecation' $ Small!abscesses!(<2!cm!diameter)!may!be!treated!
B A!very!common!problem!! with!parenteral!antibiotics.!
B rule!out!an!underlying!metabolic,!pharmacologic,! $ Larger!abscesses!are!best!treated!with!CTBguided!
endocrine,!psychological!and!neurologic!causes!first! percutaneous!drainage!
before!work!up! !
B a!stricture!or!mass!lesion!should!be!excluded!by! E. COLORECTAL'ADENOCARCINOMA'
colonoscopy!or!barium!enema! B Most!common!malignancy!of!the!GIT!
B once!other!causes!have!been!ruled!out,!perform!transit! B Risk!factors:'
studies! 1. Aging:!dominant!risk!factor!for!colorectal!cancer;!
B Medical!management!is!the!mainstay!of!treatment!for! incidence!increases!after!50!yo'
constipation!(High!fiber,!increase!fluids!&!laxatives)! 2. Known!FH!of!cancer:!accounts!for!20%!of!cases'
! 3. Diet:!high!in!animal!fat!and!low!in!fiber'
4. Diarrhea'and'irritable'bowel'syndrome' 4. Inflammatory!bowel!syndrome'
B Acute!bloody!diarrhea!and!pain!can!be!due!to!infection! 5. Cigarette!smoking!
or!inflammation! !
B chronic!diarrhea!has!a!more!difficult!diagnostic! B Pathogenesis:!genetic!defects!
dilemma!since!causes!are!myriad!(ulcerative!colitis,!
crohn’s!colitis,!malabsorption,!shortBgut!syndrome,! Figure'34.!Schematic!diagram!showing!progression!from!normal!
carcinoid,!islet!cell!tumors,!etc)! colonic!mucosa!to!carcinoma!of!colon!
!
5. Incontinence'
B ranges!in!severity!from!occasional!leakage!of!gas!and!
liquid!stool!to!daily!loss!of!solid!stool!
B can!be!neurogenic!or!anatomic!
!
$ Neurogenic:!diseases!of!CNS,!spinal!cord,!pudendal! APC'
nerve!injury! B Tumor!suppressor!gene!located!at!chromosome!5!
$ Anatomic:!congenital!abnormalities,!procidentia,! B Function:!the!protein!product!of!APC!is!for!maintain!
overflow!incontinence!secondary!to!impaction,! cellular!adhesions!and!suppressing!neoplastic!growth!
neoplasm!or!trauma! B APC.inactivation!leads!to!sporadic!colorectal!cancer!
B Most!common!traumatic!cause!of!incontinence!is!injury! B Mutated!in!individuals!with!familial!adenomatous!
to!the!anal!sphincter!during!vaginal!delivery! polyposis!(FAP)!
!
D. DIVERTICULAR'DISEASE'' KSRAS'
B Diverticulosis:!presence!of!diverticula!without! B ProtoBoncogene!located!in!chromosome!12!
inflammation.!! B Function:!encodes!for!plasma!membrane!based!protein!
$ Common!in!patients!with!low!fiber!diet! involved!in!transduction!of!growth!and!differential!
$ Majority!tend!to!occur!after!the!age!of!85! signals'
$ Sigmoid'colon:'most'common'site'of' B Mutation!leads!to!uncontrolled!cell!division'
diverticulosis! B K8RAS.activation!leads!to!colorectal!cancer!
$ Common!symptom:!massive!LGIB! B '
B Diverticulitis:!inflammation!and!infection!associated!
with!diverticula.! DCC!
$ 5%+of+complicated+diverticulitis+develop+a+fistula+to+ B Tumor!suppressor!gene!located!at!chromosome!18!
an+adjacent+organ.!Most!common!of!which!is!a! B Function:!encodes!for!a!protein!responsible!for!cell!to!
colovesical'fistula.! cell!contact!
B More!common!is!false!diverticula!type' B Loss!of!DCC!gene!(or!inactivation)!tend!to!present!in!
$ Only!mucosa!and!muscularis!mucosa!have! more!advanced!carcinomas!
herniated!(also!called!pulsion!diverticula)!through! B Present!in!70%!of!colorectal!carcinomas!
the!colonic!wall,!in!between!taenia!coli!(area!of!
weakness)' P53'
B True!diverticula,!comprises!all!layers!of!the!bowel,!is! B Tumor!suppressor!gene!located!at!chromosome!17!
congenital!and!rare! B Mutations'of'this'gene'are'the'most'common'genetic'
B Clinical!manifestations!of!diverticulitis:!! abnormality'found'in'human'cancer'genes!
$ Uncomplicated!diverticulitis:!leftBsided!abdominal! B Function:!crucial!for!initiating!apoptosis!in!cells!with!
pain,!with!or!without!fever,!mass!and!leukocytosis! irreparable!genetic!damage.!!
$ complicated!diverticulitis:!abscess,!obstruction,! B Mutations!in!p53!are!present!in!75%!of!colorectal!
diffuse!peritonitis!(free!perforation),!or!fistulas! cancers!
(most!common!is!colovesical!fistula)! B p53.inactivation!leads!to!colorectal!cancer!
! osteomas!(Gardner's!syndrome),!and!central!
B Polyps:' nervous!system!tumors!(Turcot's!syndrome).!!
$ NonBneoplastic!polyps!(no!malignant!potential)' $ HNPCC'or'Lynch'syndrome'
# Hyperplastic'polyp:'most'common'type'of' # Rare!autosomal!dominant!disorder!arising!
all'polyps;!usually!small,!multiple!and!sessile;! from!errors!in!mismatch+repair'
occur!frequently!in!the!rectosigmoid!region' # is!characterized!by!the!development!of!
# Pseudopolyps'(or'inflammatory'polyps):' colorectal!carcinoma!at!an!early!age!(average!
occur!most!commonly!in!the!context!of! age:!40!to!45!years).!'
inflammatory!bowel!disease,!amebic!colitis,! # The!risk!of!synchronous!or!metachronous!
ischemic!colitis,!and!schistosomal!colitis;!not! colorectal!carcinoma!is!40%.!'
premalignant,!but!they!cannot!be! # HNPCC!also!may!be!associated!with!
distinguished!from!adenomatous!polyps!based! extracolonic!malignancies,!including!
upon!gross!appearance!&!therefore!should!be! endometrial!(most!common),!ovarian,!
removed.' pancreas,!stomach,!small!bowel,!biliary,!and!
# Hamartomas:'similar!appearance!to! urinary!tract!carcinomas.'
adenomatous!polyps!but!is!not!considered!to! # Diagnosis:!Amsterdam+criteria!for!clinical!
be!premalignant' diagnosis!of!HNPCC!are!three!affected!
• Familial'juvenile'polyposis:'autosomal! relatives!with!histologically!verified!
dominant!DO!in!which!patients!develop! adenocarcinoma!of!the!large!bowel!(one!must!
hundreds!of!polyps!in!the!colon!and! be!a!1st!degree!relative!of!one!of!the!others)!in!
rectum;!degenerate!into!adenomas!"! 2!successive!generations!of!a!family!with!1!
carcinoma' patient!diagnosed!before!age!50!years.!!
• Peutz'Jeghers'syndrome:'characterized! # Screening!colonoscopy!is!recommended!
by!polyposis!of!the!small!intestine!and,!to! annually!for!atBrisk!patients!beginning!at!
a!lesser!extent,!of!the!colon!and!rectum.!;! either!age!20!to!25!years!or!10!years!younger!
Characteristic!melanin!spots!are!noted!on! than!the!youngest!age!at!diagnosis!in!the!
the!buccal!mucosa!and!lips!of!these! family,!whichever!comes!first.'
patients.' '
• CronkiteSCanada'syndrome:!GI! $ Familial'colorectal'cancer'
polyposis!+!alopecia!+!cutaneous! # Nonsyndromic!familial!colorectal!cancer!
pigmentation!+!atrophy!of!the!fingernails! accounts!for!10!to!15%!of!patients!with!
and!toenails;!SSx:!Diarrhea,!vomiting,! colorectal!cancer'
malabsorption,!and!proteinBlosing! # Screening!colonoscopy!is!recommended!every!
enteropathy!' 5!years!beginning!at!age!40!years!or!beginning!
10!years!before!the!age!of!the!earliest!
• Cowden'syndrome:!autosomal!dominant!
diagnosed!patient!in!the!pedigree.'
disorder!with!hamartomas!of!all!three!
!
embryonal!cell!layers;!Facial!
B Routes!of!spread!&!natural!history:!
trichilemmomas,!breast!cancer,!thyroid!
$ Regional'lymph'node'involvement!is!the!most!
disease,!and!GI!polyps!are!typical!of!the!
common!form!of!spread!of!colorectal!carcinoma!
syndrome.!'
and!usually!precedes!distant!metastasis!
$ Neoplastic!polyps!
$ T'stage'(depth'of'invasion)'is!the!single!most!
# Tubular'adenomas:'most'common'type'of'
significant!predictor!of!lymph!node!spread!
neoplastic'polyps;!asymptomatic,!
$ The!number!of!lymph!nodes!with!metastases!
pedunculated,!less!than!1!cm!in!size!and!occur!
correlates!with!the!presence!of!distant!disease!and!
commonly!in!the!rectosigmoid!region'
inversely!with!survival:!4!or!more!involved!lymph!
<1cm:+rare+chance+for+malignany+
nodes!predict!a!poor!prognosis!
1G2cm:+10%+chance+for+malignancy+
$ most'common'site'of'distant'metastasis'from'
>2+cm:+30%+chance+for+malignancy+
colorectal'cancer'is'the'liver!(via!hematogenous'
# Tubulovillous'adenoma:'mixed;!22%!chance!
spread!to!the!portal!venous!system)!
for!malignancy!
!
# Villous'adenoma:!sessile,!larger!and!
B Screening:!
symptomatic,!can!cause!malignancy!by!40B
$ annual!DRE!at!age!40!
50%;'highest'risk'of'cancer'
$ FOB!at!age!50!
# Sessile+adenomas+are+more+likely+to+harbor+
$ Flexible!signoidoscopy!every!5!years!at!age!50!
malignancy+compared+to+pedunculated+ones'
$ Colonoscopy!if!with!risk!factors!
'
B Clinical!presentation:!change'in'bowel'habits,'rectal'
B Inherited'colorectal'carcinoma'
bleeding,'melena,'unexplained'anemia,'or'weight'
$ Familial'adenomatosis'polyposis'
loss'
# rare!autosomal!dominant!condition!accounts!
B Staging!and!treatment!
for!only!about!1%!of!all!colorectal!
adenocarcinomas.'
Table'58.!Duke!staging!of!colorectal!cancer!&!treatment!
# Due!to!mutation!in!the!APC!gene,!located!on! Stage' description' 5'year' Treatment'
chromosome!5q' survival'
# Clinically,!patients!develop!hundreds!to! Stage!A! Cancer!limited! 90%! Wide!resection!
thousands!of!adenomatous!polyps!shortly! to!mucosa!&! of!colon!with!
after!puberty.!' submucosa! sampling!of!LN!
# The!lifetime!risk!of!colorectal!cancer!in!FAP! Stage!B! Cancer!invades! 70%! (to!rule!out!↑er!
patients!approaches!100%!by!age!50!years.' the!muscularis! disease!stage);!
# Flexible!sigmoidoscopy!of!firstBdegree! propria! stage!B!can!
relatives!of!FAP!patients!beginning!at!age!10! also!employ!
RT+CT!
to!15!years!
Stage!C! Invasion!of! 30%! Surgery!+!
# FAP!may!be!associated!with!extraintestinal! local!LN! chemotx!(5B
manifestations!such!as!congenital!hypertrophy! fluorouracil!+!
of!the!retinal!pigmented!epithelium,!desmoid! leucovorin)!+!
tumors,!epidermoid!cysts,!mandibular! RT!

Stage!D! Distant! Limited! palliative! Initial'management:'fluid' Bsurgical!exploration!once!
metastasis! survival! resuscitation'followed'by' diagnosis!is!made;!no!room!for!
! endoscopic'detorsion'(rigid' endoscopic!detorsion!
$ LAR:!for!tumors!located!5B10!cm!from!anal!verge! proctoscope);!if!suspecting!
$ APR:!tumors!less!than!5!cm!from!ananl!verge!and!if! gangrene!or!perforation,!perform!
immediate!surgical!exploration!
recurrent!cancer!at!LAR!site!
'
!
!
F. COLORECTAL'CARCINOID'TUMORS'
B Result!of!a!neuroendocrine!tumor!that!secretes!
neurotransmitters!(serotonin,!ACTH,!histamine,! ''√'MUST'KNOW!a!
dopamine,!tryptophan,!substance!P,!bradykinin)' '
B occur!most!commonly!in!the!GI!tract' Bird’s'beak'is'also'seen'in'barium'esophagogram'of'
B most!common!location!is!appendix!(50%),!ileum!(25%)! achalasia!'
then!rectum!(20%)' '
B ileal!carcinoid!has!the!highest!potential!for!metastasis' !
B appendiceal!has!lowest!potential!for!metastasis' '
B Carcinoid!tumors!in!the!proximal!colon!are!less! I. COLONIC'PSEUDOOBSTRUCTION'(OGILVIE’S'
common!and!are!more!likely!to!be!malignant.' SYNDROME)'
B Can!be!part!of!MEN!type!I' B Distention!of!the!abdomen!leading!to!colonic!
B risk!of!malignancy!increases!with!size!(more!than!60%! obstruction!(even!if!there!is!no!obvious!signs!of!
of!tumors!greater!than!2!cm!in!diameter!are!associated! obstruction)!
with!distant!metastases)' B most!commonly!occurs!in!hospitalized!patients!and!is!
B clinical!manifestation:!' associated!with!the!use!of!narcotics,!bedrest,!and!
$ triad!of!flushing!(due!to!excess!bradykinin),! comorbid!disease.!
diarrhea!(due!to!excess!serotonin)!&!valculhar! B Due!to!a!neurologic!dysfunction,!electrolyte!
heart!disease!(primarily!affects!the!mitral!valve! abnormality!and!↑age!
from!excess!serotonin)' B Treatment:!NGT,!IV'neostigmine,!IV!atropine!(to!
$ others:!hypotension,!tachycardia,!alcohol! counter!bradycardia!as!SE!of!neostigmine),!exploratory!
intolerance' laparotomy!during!worst!case!scenario)!
B diagnosis:! !
$ 24!hour!5BHIAA!collection!(5BHIAA!is!a!metabolite! J. HEMORRHOIDS'
of!serotonin)' B are!cushions!of!submucosal!tissue!containing!venules,!
B treatment:! arterioles,!and!smoothBmuscle!fibers!that!are!located!in!
$ Small!carcinoids!can!be!locally!resected,!either! the!anal!canal!
transanally!or!using!transanal!endoscopic! B Excessive!straining,!increased!abdominal!pressure,!and!
microsurgery.!' hard!stools!lead!to!further!prolapsed!of!hemorrhoids!
$ Larger!tumors!or!tumors!with!obvious!invasion! B Difference!between!internal!and!external!hemorrhoids:!
into!the!muscularis!require!more!radical!resection'
'
$ Medical:!somatostatin!analogues!(octreotide)' '
$ RT' '
' '
G. ANAL'INTRAEPITHELIAL'NEOPLASIA'(BOWEN’S' '
DISEASE)' '
B refers'to'squamous'cell'carcinoma'in'situ'of'the' '
anus.! Table'60:!comparison!of!internal!and!external!hemorrhoids!
B precursor!to!an!invasive!squamous!cell!carcinoma! Internal'hemorrhoids' External'hemorrhoids'
BExaggerated!submucosal!vascular! B!are!dilated!veins!of!the!inferior!
(epidermoid!carcinoma)!
cushions!normally!located'above' hemorrhoidal!plexus!located'
B may!appear!as!a!plaqueBlike!lesion,!or!may!only'be' dentate'line;'covered'by' below'the'dentate'line'and'
apparent'with'highSresolution'anoscopy'and' insensate'transitional'mucosa'of' covered'by'anoderm;!can!cause!
application'of'acetic'acid'or'Lugol's'iodine'solution.! the'anal'canal'and'not'by' significant!pain!
B associated!with!HPV!infection!types!16!and!18.!! anoderm;!only!become!painful!
B Incidence!has!increased!dramatically!among'HIVS when!already!thrombosed!/!
positive,'homosexual'men.'! necrosis!
B Treatment:!! '
$ Ablation! Bprolapsing'hemorrhoids:!are!
internal!hemorrhoids!beyond!the!
$ Topical!immunomodulators!such!as!imiquimod,! dentate!line!
Topical!5BFU! !
'
H. VOLVULUS' B Types'of'internal'hemorrhoids:!graded+according+to+
B occurs!when!an!airBfilled!segment!of!the!colon!twists! extent+of+prolapsed☺!
about!its!mesentery! '
B clinical!manifestations:!similar!to!SBO;!abdominal! 1st'degree:'bulge!into!the!anal!canal!and!may!prolapse!
distention,!nausea,!and!vomiting;!can!rapidly!progress! beyond!the!dentate!line!on!straining!
to!generalized!abdominal!pain!and!tenderness;!Fever' 2nd'degree:!prolapse!through!the!anus!but!reduce!
and'leukocytosis'are'heralds'of'gangrene'and/or' spontaneously!
perforation' 3rd'degree:!prolapse!through!the!anal!canal!and!require!
manual!reduction!
Table'59.'Comparison!of!sigmoid!vs!cecal!volvulus' 4th'degree:'prolapse!but!cannot!be!reduced!and!are!at!
Sigmoid'volvulus' Cecal'volvulus' risk!for!strangulation+
B90%!of!cases! B<20%!of!cases! B Combined'internal'and'external'hemorrhoids:!
Bplain!abdominal!xray:!bent'inner' Bplain!abdominal!xray:!kidneyS straddle!the!dentate!line;!mixed!characteristics!
tube'or'coffee'bean'appearance! shaped,!airBfilled!structure!in!the! B Post'partum'hemorrhoids:!result!from!straining!
with!the!convexity!of!the!loop!lying! LUQ!
in!the!RUQ!(opposite!site!of!
during!labor,!which!results!in!edema,!thrombosis,!
obstruction)! and/or!strangulation.!'
Bgastrografin!enema:!bird’s'beak' B Treatment:'
(pathognomonic)!
$ Dietary!fiber,!stool!softeners,!↑OFI,!avoid!straining:! Figure'35.'Goodsall’s!rule'
for!1st!&!2nd!degree!hemorrhoids'
$ Rubber!band!ligation:!for!persistent!1st!&!2nd!
degree!hemorrhoids!&!selected!3rd!degree!
hemorrhoids'
$ If!thrombosed!hemorrhoids,!perform!excision'
$ Most'common'complication'of'
hemorrhoidectomy:'urinary'retention'
!
K. ANAL'FISSURE'
B is!a!tear!in!the!anoderm!distal!to!the!dentate!line!
B 90%'of'fissures'are'located'at'the'posterior'midline,!
an!area!where!the!anoderm!is!least!supported!by!the! '
sphincter' S'Treatment:!fistulotomy!with!adequate!drainage!or!seton!
B Fissures'located'laterally'should'arouse'suspicion'of' placement'
Crohn’s,'UC,'syphilis,'TB,leukemia' !
B Clinical'manifestation:'tearing!pain!with!defecation! !
and!hematochezia;!often!too!tender!to!tolerate!DRE' '''''''REVIEW'QUESTIONS!!
B Treatment' !
$ Initially,!can!be'managed'conservatively'with' 1. Which!of!the!following!is!important!in!maintaining!
lubricants,'warm'sitz'bath'and'bulk'laxatives' the!integrity!of!the!colonic!mucosa?!
(treatment'of'choice)' !
$ Surgery:!lateral!subQ!partial!internal! a. shortBchain!fatty!acids!
sphincterectomy' b. alanine!
# Posterior'fissurectomy'&'sphincterectomy' c. mediumBchain!fatty!acids!
can'lead'to'keyhole'defect'&'constant' d. glutamine!
soiling'
' Answer:!A'
L. ANORECTAL'ABCESS'☺' Short!chain!fatty!acids!are!produced!by!bacterial!
B Perianal'abscess:'most!common!manifestation!and! fermentation!of!dietary!carbohydrates.!Short!chain!
appears!as!a!painful!swelling!at!the!anal!verge! fatty!acids!are!an!important!source!of!energy!for!
B Ischiorectal'abscess:'happens!when!there!is'Spread! the!colonic!mucosa,!and!metabolism!by!colonocytes!
through!the!external!sphincter!below!the!level!of!the! provides!energy!for!processes!such!as!active!
puborectalis;!may!become!extremely!large!and!may!not! transport!of!sodium.!Lack!of!a!dietary!source!for!
be!visible!externally;!DRE!will!reveal!a!painful!swelling! production!of!short!chain!fatty!acids,!or!diversion!of!
laterally!in!the!ischiorectal!fossa' the!fecal!stream!by!an!ileostomy!or!colostomy,!may!
B Intersphincteric'abscess:'occur!in!the!intersphincteric! result!in!mucosal!atrophy!and!diversion!colitis.!
space!and!are!notoriously!difficult!to!diagnose;!causes! !
deep!pain!in!the!rectum!without!external!manifestation' 2. Match!the!organs!in!the!left!hand!column!with!the!
B Pelvic'and'superior'levator'abscess:!rare;!may!result! location!of!their!referred!pain!in!the!right!hand!
from!extension!of!an!intersphincteric!or!ischiorectal! column.!(items!in!the!right!may!be!used!more!than!
abscess!upward,!or!extension!of!an!intraperitoneal! once)!
abscess!downward' !
B Horseshoe'abscess:!bilateral!ischiorectal,!supralevator! A. Gallbladder!!!!!!!!!!!!!!!!!!!!!!!!!!a.!epigastrium!
or!perianal!abscesses!that!communicate;!begins!as!a! B. Jejunum!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!b.!periumbilical!
posterior!midline!infection' C. Rectum!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!c.!hypogastrium!
B Treatment:!drainage!with!local!anesthesia' D. Pancreas!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!d.!shoulder!
B Signs!of!(+)!fistula:!nonhealing!of!an!abscess!wounds!or! E. Appendix!
recurrence!of!an!abscess!at!the!same!location'
! Answer:!A'–'a,d;'B'–'b;'C'–'c;'D'–'a;'E'–'b'
M. FISTULA'IN'ANO' !
B Classification!(based!on!relationship!to!the!anal! The!visceral!peritoneum!is!innervated!by!C!fibers!
sphincter!complex)! coursing!with!the!autonomic!ganglia.!C!fibers!are!
1. Intersphincteric'(most'common)☺:'tracks! unmyelinated,!slowBconducting!(0.5B5.0!m/s),!
polymodal!nociceptors!that!travel!bilaterally!with!the!
through!the!distal!internal!sphincter!and!
sympathetic!and!parasympathetic!fibers.!Visceral!pain!is!
intersphincteric!space!to!an!external!opening!near!
a!response!to!injury!of!the!visceral!peritoneum.!
the!anal!verge!
Distension,'stretch,'traction,'compression,'torsion,'
2. Transsphincteric:!often!results!from!an!ischiorectal!
ischemia'and'inflammation'trigger'visceral'pain'
abscess!and!extends!through!both!the!internal!and!
fibers.'Abdominal'organs'are'insensate'to'heat,'
external!sphincters!
cutting'and'electrical'stimulation.'
3. Suprasphincteric:!originates!in!the!intersphincteric!
'
plane!and!tracks!up!and!around!the!entire!external!
Visceral!pain!is!typically!vague!and!crampy!and!is!
sphincter!
perceived!in!the!region!of!oprigin!of!the!embryologically!
4. Extrasphincteric:!originates!in!the!rectal!wall!and!
derived!autonomic!ganglia.!Foregut'organs!(proximal!
tracks!around!both!sphincters!to!exit!laterally,!
to!the!ligament!of!treitz)!refer!pain!to!the!celiac!chain,!
usually!in!the!ischiorectal!fossa!
and!the!pain!is!felt!in!the!epigastrium.!The!organs'of'the'
B Goodsall’s'rule'☺:'states.that,.if.the.external.opening. midgut'(small!intestine,!ascending!colon)!refer!pain!to!
is.anterior.to.the.imaginary.line.drawn.between.the. the!superior!mesenteric!chain!(periumbilical!chain)!and!
ischial.tuberosities,.the.fistula.runs.directly.into.the. those!of!the!hindgut'(transverse!and!descending!colon,!
anal.canal..If.the.external.opening.is.posterior,.the. sigmoid!colon!and!rectum)!to!the!inferior!mesenteric!
tract.curves.to.the.posterior.midline.. ganglia!and!hypogastrium.!
' !
***EXCEPTION:!if.an.anterior.external.opening.is. !
greater.than.3.cm.from.the.anal.margin,.these.
ABDOMINAL'WALL'&'HERNIAS'
fistulas.usually.track.to.the.posterior.midline!!!.
'
A. Abdominal'Incisions' B In!the!postpartum!setting,!rectus!diastasis!tends!to!
B. Rectus'abdominis'diastasis' occur!in!women!who!are!of!advanced!maternal!age,!who!
C. Rectus'sheath'hematoma' have!a!multiple!or!twin!pregnancy,!or!who!deliver!a!
D. Abdominal'wall'hernias' highBbirthBweight!infant.!'
E. Incisional'hernias' B Diagnosis:'
F. Retroperitoneal'fibrosis' $ CT!scan:!can!differentiate!rectus!diastasis!from!a!
G. Inguinal'hernias' true!ventral!hernia'
H. Femoral'hernia' B Treatment:!surgery!
!
! C. RECTUS'SHEATH'HEMATOMA'
' B As!a!result!of!hemorrhage!from!any!of!the!network!of!
' collateralizing!vessels!(superior!and!inferior!epigastric!
A. ABDOMINAL'INCISIONS' arteries!or!veins)!within!the!rectus!sheath!and!muscles!'
' B History:!trauma,!sudden!contraction!of!the!rectus!
Figure'36.'Abdominal!incisions' muscles!with!coughing,!sneezing,!or!any!vigorous!
physical!activity.'
B Clinical!manifestations:!sudden!onset!of!unilateral!
abdominal!pain!that!increases!with!contraction!of!the!
rectus!muscles;!palpable!tender!mass'
$ (+)Fothergill's.sign:'palpable'abdominal'mass'
that'remains'unchanged'with'contraction'of'the'
rectus'muscles'
B Diagnosis:'
$ Abdominal!UTZ!may!show!a!solid!or!cystic!mass!
within!the!abdominal!wall!'
$ CT!scan:!most!definitive!study!to!establish!the!
correct!diagnosis!and!to!exclude!other!disorders!'
B Treatment:!nonoperative;!surgery!is!indicated!in!
instances!of!expensing!hematoma!and!hemodyanamic!
instability!
!
D. ABDOMINAL'WALL'HERNIAS'
' B This!is!due!to'defects!in!the!parietal!abdominal!wall!
A.Midline! Bare!used!because!of!the!flexibility!offered!by!this!
fascia!and!muscle!through!which!intraBabdominal!or!
incision! approach!in!establishing!adequate!exposure.!!
Bthe!incision!in!the!fused!midline!aponeurotic! preperitoneal!contents!can!protrude!
tissue!(linea!alba)!is!simple!and!requires!no! B ACQUIRED'HERNIAS'
division!of!skeletal!muscle.! $ may!develop!through!slow!architectural!
B.paramedian! Bmade!longitudinally!3!cm!off!the!midline,! deterioration!of!the!muscular!aponeuroses!or!they!
incision! through!the!rectus!abdominis!sheath!structures,! may!develop!from!failed!healing!of!an!anterior!
and!have!largely!been!abandoned!in!favor!of! abdominal!wall!incision!(incisional.hernia).'
midline!or!nonlongitudinal!access!methods! $ most!common!finding!is!a!mass!or!bulge!on!the!
C.right! BSubcostal!incisions!on!the!right!(Kocher!incision! anterior!abdominal!wall,!which!may!increase!in!
subcostal! for!cholecystectomy)!or!left!(for!splenectomy)!are!
incision! archetypal!muscleBdividing!incisions!that!
size!with!a!Valsalva!maneuver'
D.bilateral! generally!result!in!the!transaction!of!some!or!all! $ PE!reveals!a!bulge!on!the!anterior!abdominal!wall!
subcostal! of!the!rectus!abdominis!muscle!fibers!and! that!may!reduce!spontaneously,!with!recumbency,!
investing!aponeuroses.!! or!with!manual!pressure'
BThese!incisions!generally!are!closed!in!two! $ Treatment:!if!incarcerated!(cannot!be!reduced)!or!
layers!(anterior!aponeurotic!sheath!of!the!rectus! strangulated!(BS!is!compromised)!"!do!surgical!
muscle!medially,!transitioning!to!external!oblique!
muscle!and!aponeurosis!more!laterally!&! correction'
posterior,!deeper!layer!consists!of!internal! B PRIMARY'VENTRAL'HERNIAS'
oblique!and!75ransverses!abdominis!muscle)! $ Non!incisional!or!true!ventral!hernias'
E.Rocky!davis! Right!lower!quadrant!incision!or!muscle!splitting! $ Examples:'
incision! incision!for!appendectomy! !
F.McBurney! it!begins!2!to!5!centimeters!above!the!anterior! Epigastric'hernias:!congenital!due!to!defective!
incision! superior!iliac!spine!and!continues!to!a!point!oneB midline!fusion!of!lateral!abdominal!wall;!occurs!in!
third!of!the!way!to!the!umbilicus!(McBurney's! multiples!and!are!small;!located!in!the!midline!
point).!Thus,!the!incision!is!parallel!to!the!
between!the!xiphoid!process!and!the!umbilicus;!
external!oblique!muscle!
G.Transverse! Similar!to!kocher!incision!(subcostal!incision).!
found!to!contain!omentum!or!a!portion!of!the!
incision! Preferred!for!newborns!and!infants!because!more! falciform!ligament.!!
abdominal!exposure!is!gained!per!length!of!the! .
incision!compared!to!vertical!exposure! Umbilical'hernias:!due!to!a!patent!umbilical!ring;!
H.Pfannenstiel! Pfannenstiel!incision,!used!commonly!for!pelvic! more!common!in!premature!infants;spontaneous!
incision! procedures,!is!distinguished!by!transverse!skin! closure!can!occur!at!age!of!5,!no!closure!by!that!
and!anterior!rectus!sheath!incisions,!followed!by! time,!do!elective!surgical!repair!!
rectus!muscle!retraction!and!longitudinal!incision! .
of!the!peritoneum.!
Spigelian'hernias:!occur!anywhere!along!the!
'
length!of!the!Spigelian!line!or!zone—an!
B. RECTUS'ABDOMINIS'DIASTASIS'
aponeurotic!band!of!variable!width!at!the!lateral!
B Other!name:!diastasis!recti'
border!of!the!rectus!abdominis.!'
B is!a!clinically!evident!separation!of!the!rectus!abdominis!
'
muscle!pillars!resulting!to!a!characteristic'bulging'of'
E. RETROPERITONEAL'FIBROSIS'
the'abdominal'wall'in'the'epigastrium!(sometimes!
B class!of!disorders!characterized!by!hyperproliferation!of!
mistaken!for!a!ventral!hernia)'
fibrous!tissue!in!the!retroperitoneum!
B may!be!congenital'
B if!primary,!it!is!known!as!Ormond'disease'
B can!be!associated!with!advancing!age,!in!obesity,!or!
after!pregnancy'
B may!be!secondary!to!inflammatory!process,!malignancy,! Pott’s'repair:!high!ligation!of!the!sac!only,!with!no!
or!medication'(methysergide,'ergotamine,' repair!of!the!inguinal!canal;!used!for!indirect!hernias!
hydralazine,'methyldopa'and'B'blockers)' only!
B Men!are!twice!as!likely!to!be!affected!as!women' '
B primarily!affects!individuals!in!the!4thB6th!!decades!of! McVay'repair:!anterior!approach,!nonprosthetic;!the!
life.' conjoined!tendon!is!sutured!to!the!cooper’s!ligament!
B Clinical!manifestations:!' laterally;!can!be!used!for!indirect,!direct!&!femoral'
$ Sx:!insidious!onset!of!dull,!poorly!localized! hernias'
abdominal!pain,!unilateral!leg!swelling,! ***problem'with'anterior'non'prosthetic'
intermittent!claudication,!oliguria,!hematuria,!&! approaches:'high'recurrence'rates'
dysuria.' '
$ PE:!hypertension,!the!palpation!of!an!abdominal!or! Lichenstein'tension'free'repair:'addition!of!a!mesh!
flank!mass,!lower!extremity!edema!(unilateral!or! prosthesis!effected!a!reconstruction!of!the!posterior!
bilateral),!or!diminished!lower!extremity!pulses! inguinal!canal,!without!placing!tension!on!the!floor!itself!
(unilateral!or!bilateral).' '
B Diagnosis:! ReadSrives'repair:'anterior!preperitoneal!approach!!
$ ↑ESR,!BUN!&!creatinine! '
$ Most'definitive'noninvasive'diagnostic'test:' Rives,'stoppa,'wanz'repair:'giant!prosthetic!
intravenous'pyelography! reinforcement!of!the!visceral!sac;!preperitoneal!
B Treatment:!corticosteroids!with!or!without!surgery! approach!
(only!indicated!when!renal!function!is!compromised)! '
! Kugel'repair:'maximize!on!the!preperitoneal!approach!
F. INGUINAL'HERNIAS' while!minimizing!on!the!length!of!the!skin!and!fascia!
' incision!
Table'61.!comparison!of!Inguinal!hernias' '
' Indirect'inguinal'hernia' Direct'inguinal'hernia' Laparoscopic'repair:'uses!preperitoneal!approach!
etiology! B!usually!congenital;!due! BUsually!acquired;! with!small!incisions;!can!asses!and!repair!unilateral!or!
to!patent!processus! weakness!in!the! bilateral!inguinal!hernias!!
vaginalis! abdominal!wall! Emergent'inguinal'hernia'repair:'reserved!for!
musculature!
strangulated,!incarcerated!and!sliding!hernias!
Risk! Strenuous!physical!activity,!obesity,!ehler’s!danlos,!
factors:! smoking!
anatomy! protrude!lateral!to!the! protrusions!medial!to!the!
'
inferior!epigastric! inferior!epigastric! Figure'37:'treatment!algorithm!for!hernia!repair!
vessels,!through!the!deep! vessels,!in!Hesselbach's!
inguinal!ring! triangle!
PE:! cough!impulse!is! Cough!impulse!is!
inguinal! controlled;!felt!on!the! manifest;!felt!on!the!
occlusion! dorsum!of!fingertip! fingertip!
test!
'
!
''√'MUST'KNOW!a!
'
Hesselbach’s'triangle:'
Inferior:!inguinal!ligament!
'
Medial:!rectus!abdominis! !!
Superolateral!border:!inferior!epigastric!vessels! !
' !
' !
! !
! !
''√'MUST'KNOW!a! !
' !
Femoral'hernias'are'more'prevalent'in'females'compared'to' !
males'but'the'most'common'type'of'groin'hernia'in'females' !
is'still'indirect'inguinal'hernia.' !
' !
! !
! !
B Clinical!manifestations:!groin!pain! !
B Diagnosis:!usually!employed!for!ambiguous!diagnosis! !
(i.e.!obese!patients)! !
B Treatment:'definitive'treatment'is'surgical'repair! !
' '''''''REVIEW'QUESTIONS!!
Bassini'repair:'anterior!approach,!nonprosthetic,! !
hernia!reduced!and!the!defect!oversewn,!&! 1. Which!of!the!following!is!the!most!important!initial!
reconstruction!the!site!of!weakness;!disadvantage:!(+)! therapy!for!a!patient!with!portal!hypertension,!
tension!on!the!reconstructed!tissue! ascites,!and!a!tense!umbilical!hernia?!
' !
Shouldice'repair:'anterior!approach,!nonprosthetic,! a. Primary!repair!with!concurrent!placement!of!a!
multilayer!(4Blayer!suture!repair)!reconstruction! peritoneal!venous!shunt!
distributes!the!tension,!effectively!resulting!in!a! b. Emergency!primary!repair!to!avoid!hernia!rupture!
tensionBfree!repair;!lowest!recurrence!rate! c. Medical!therapy!to!control!ascites!
! d. Transjugular!intrahepatic!portocaval!shunt!
followed!by!umbilical!hernia!repair!

Answer:!C' $ Cantlie’s'line:!plane!from!the!gallbladder!fossa!to!
Treatment!and!control!of!the!ascited!with!diuretic,! the!IVC!that!separates.the.liver’s.right.and.left.
dietary!management!and!paracentesis!is!the!most! lobes.grossly.!
appropriate!initial!therapy.!Patients!with!refractory! $ Falciform'ligament:!separates!the!left!lateral!and!
ascited!may!be!candidates!for!transjugular!intrahepatic! left!medial!segments!along!the!umbilical!fissure!
portocaval!shunting!or!eventual!liver!transplantation.! and!anchors!the!liver!to!the!anterior!abdominal!
Umbilical!hernia!repair!should!be!deferred!until!after! wall;!does!not!separate!the!liver!to!right!and!left!
the!ascites!is!controlled.! lobes!
! $ Couinaud’s'segments:!divides!liver!into!8!
2. In!the!setting!of!an!equivocal!examination,!which! segments,!in!clockwise!direction!with!caudate!lobe!
of!the!following!has!the!greatest!sensitivity!in! as!segment!1!
diagnosing!an!inguinal!hernia?!
! !
a. Repeat!examination!by!a!second!surgeon! Figure!38.!Segmental!anatomy!of!liver!
b. Ultrasound!
c. CT!scan!
d. MRI!
Answer:!D'
Although!Ct!scan!is!useful!in!ambiguous!clinical!
presentations,!little!data!exist!to!support!its!routine!use!
in!diagnosis.!The!use!of!MRI!in!assessing!groin!hernias!
was!examined!in!a!group!of!41!patients!scheduled!to!
undergo!laparoscopic!inguinal!hernia!repair.! ! !
Notes!to!figure!
Preoperatively,!all!patients!underwent!US!and!MRI.! Segments! part! Corresponding!side! Venous!drainage!
Laparoscopic!confirmation!of!the!presence!of!inguinal! Segment!I! Caudate!lobe! ! IVC!
hernia!was!deemed!as!gold!standard.!Physical! Segment!II! Left!lateral!superior!segment! Left!lobe! Left!hepatic!vein!
!
Segment!III Left!lateral!inferior!segment! Left!lobe! Left!hepatic!vein!
examination!was!found!to!be!the!least!sensitive.!False! Segment!IV! Left!medial!segment!(quadate! Left!lobe! Middle!hepatic!
positives!were!low!on!physical!examination!and!MRI! lobe!–!outdated)! vein!
Segment!V! Right!anterior!inferior!segment! Right!lobe! Right!&!middle!
(one!finding),!but!higher!with!US!(four!findings).!With! hepatic!vein!
further!refinement!of!technology,!radiologic!techniques! Segment!VI! Right!posterior!inferior!segment! Right!lobe! Right!hepatic!vein !
qill!continue!to!improve!sensitivity!and!specificity!rates! Segment! Right!posterior!superior!segment! Right!lobe! Right!hepatic!vein !
VII!
of!diagnosis,!thereby!serving!a!supplementary!role!in! Segment! Right!anterior!superior!segment! Right!lobe! Right!!&!middle!
cases!of!undertain!diagnosis! VIII! hepatic!vein!
!
!
B The!hepatic!veins!divides!the!liver!into!4!sectors!
! B The!liver!has!dual'blood'supply:!!
LIVER,'PORTAL'VENOUS'SYSTEM'&'GALLBLADDER' $ hepatic'actery:'25%!
' # branch!of!celiac!artery!
A. Anatomy' # most!common!variation:!right!hepatic!artery!
B. Liver'function'tests' from!SMA!
C. Radiographic'evaluation'' $ portal'vein:'75%'(majority)'
D. Liver'cirrhosis' # confluence!of!splenic!vein!and!SMV!
E. Portal'Hypertension' B normal!pressure:!3B5!mmHg!
F. BuddSChiari'syndrome' B communication!of!portal!vein!and!systemic!circulation!
G. Infections'of'the'liver' (important!for!location!of!varices!&!bleeding!in!portal!
H. Benign'neoplasms'of'the'liver' hypertension):!gastroesophageal'junction,'anal'
I. Malignant'tumors' canal,'falciform'ligament,'splenic'venous'bed'and'
J. Gallstone'disease' left'renal'vein,'and'retroperitoneum!
K. Acute'cholecystitis' B Biliary!tree!
L. Choledocholithiases' $ Hepatic!ducts!follow!arterial!branching!of!the!liver!
M. Cholangitis' $ Left!hepatic!duct!has!a!longer!extrahepatic!course!
N. Biliary'pancreatitis' !
O. Acalculous'cholecystitis' B. LIVER'FUNCTION'TESTS'☺!
P. Biliary'or'choledochal'cysts' B Term!used!to!frequently!measure!the!levels!of!group!of!
Q. Sclerosing'cholangitis' serum!markers!for!evaluation!of!liver!dysfunction.!
B A!misnomer!because!the!panel!measures!cell!damage,!
! and!not!liver!function!
!
A. ANATOMY' Table''62.!Different!components!of!liver!function!tests!
Serum'albumin,' BMeasures!liver’s!synthetic!function!
Liver' prothrombin' B!prothrombin'time'and'INR:!best!test!
time'&'clotting' among!the!3!to!measure!the!liver’s!synthetic!
B Largest!organ,!weighing!approximately!1500!g!
factors!(except! function!
B Hepatoduodenal'ligament'☺!contains!the!porta! factor!VIII)! B!PT!is!prolonged!with!conditions!such!as!
hepatis!(portal!vein,!hepatic!artery!and!common!bile! vitamin!K!deficiency!or!warfarin!therapy!
duct)! (because!vitamin!K!is!involved!in!the!YB
$ Pringle'maneuver:'!used!to!clamp!this!ligament!in! carboxylation!of!factors!used!to!measure!
the!event!of!injury!to!the!right!hepatic!artery! prothrombin!time)!
***factor+VIII:+not+synthesized+exclusively+in+the+
during!cholecystectomy!
liver;+has+the+shortest+half+life;+useful+for+
$ Relationship:!CBD!is!located!at!the!right!of!the! determining+liver+failure+
hepatic!artery!and!anterior!to!the!portal!vein! AST'(formarly! BIndicators'of'integrity'of'hepatocellular'
$ From!the!right!and!deep!to!the!porta!hepatis!is!the! SGOT)!&'ALT' membranes;'increased'levels'reflect'
foramen'of'winslow'(or'epiploic'foramen)! (formarly!SGPT)' hepatocellular'injury'with'leakage!
B Segmental!anatomy! BAST:!can!also!be!found!in!liver,!cardiac!
muscle,!skeletal!muscle,!kidney,!brain,!
pancreas,!lungs,!and!red!blood!cells!and!thus!is!
less'specific!!
BALT:!more'specific'for'liver'disease! B if!chronic'cholecystitis:!contracted!thickBwalled!GB!
BAST:ALT!ratio!of!>2:1!"!alcoholic!liver! B Extrahepatic'ducts!are!well!visualized!using!UTZ!
disease! (except!for!retroduodenal!portion)!
moderate!increases:!viral!hepatitis! B Dilation!of!the!ducts!+!stones!in!the!GB!+!jaundiced!
Bin!the!thousands!"ischemia,!toxin!ingestion!
(acetaminophen),!fulminant!hepatitis! patient!"!think!extrahepatic!obstruction!
Indirect' Belevations!point!to!intrahepatic!cholestasis,! $ Periampullary'tumors'can!be!difficult!to!diagnose!
(unconjugated)' hemolytic!disorders!(hemolytic!anemia,! on!UTZ!
bilirubin' resoprtion!of!hematomas),!bilirubin!defects!in! $ UTZ!is!useful!for!evaluating!tumor!invasion!and!
hepatic!uptake!or!conjugation!(acquired!or! flow!in!the!portal!vein!–!an!important!guideline!in!
inherited)!! the!resectability!of!periampullary!and!pancreatic!
Direct' Belevations!point!to!extrahepatic!or!obstructive!
head!tumors!
(conjugated)'' cholestasis,!inherited!or!acquired!disorders!of!
bilirubin' intrahepatic!excretion!or!extrahepatic!
obstruction! ORAL'CHOLECYSTOGRAPHY'
Alkaline' Bfound!in!liver!and!bones;!! B Considered!as!a!diagnostic!procedure!of!choice!for!
phosphatase' Bindicative!of!biliary!obstruction! gallstones!but!it!largely!replaced!now!by!UTZ.!
B!since!half!life!of!AP!is!7!days,!it!may!take! B Mechanism:!oral!administration!of!radiopaque!
several!days!for!the!levels!to!normalize!even! compound!that!is!absorbed!and!excreted!by!the!liver,!
after!resolution!of!biliary!obstruction!
passed!into!the!GB!"!stones!are!noted!on!a!film!as!a!
GGTP' Bearly!marker!and!sensitive!test!for!
hepatobiliary!disease! filling!defect!in!a!visualized,!opacified!GB!
Bnonspecific;!can!also!be!elevated!in!overdose! '
of!certain!medications,!alcohol!abuse,!
pancreatic!disease,!myocardial!infarction,! BILIARY'RADIONUCLIDE'SCANNING'(HIDA'SCAN)'
renal!failure,!&!obstructive!pulmonary!disease! !
B!interpret!GGTP!elevations!with!other!enzyme! B Provides!a!noninvasive!evaluation!of!the!liver,!GB,!bile!
abnormalities! ducts!and!duodenum!with!both!anatomic!and!functional!
'' information!
⊗ BIOCHEMISTRY' B Mechanism:!TechnetiumSlabeled'derivatives'of'
' dimethyl'iminodiacetic'acid'(HIDA)!are!injected!IV!
AST'(aspartate!transaminase):'an!enzyme!in!gluconeogenesis! "!cleared!by!Kuppfer!cells!in!the!liver!"!excreted!in!
that!transfers!amino!groups!from!aspartic'acid!to!ketoglutaric' the!bile!
acid!to!produce!oxaloacetate.' $ 10!minutes:!time!it!takes!for!the!liver!to!detect!it!
' $ 60!minutes:!time!it!takes!for!the!GB,!bile!ducts!and!
ALT'(alanine!transaminase):'an!enzyme!in!gluconeogenesis!that! duodenum!to!detect!it!
transfers!amino!groups!from!alanine!to!ketoglutaric'acid!to! B the'primary'use'of'biliary'scintigraphy'is'the'
produce!pyruvic'acid! diagnosis'of'acute'cholecystitis'
' $ appearance:!nonvisualized!GB,!with!prompt!filling!
' of!the!common!bil!duct!and!duodenum,!biliary!
C. RADIOGRAPHIC'EVALUATION'' obstruction'
$ sensitivity!&!specificity:!95%!'
ULTRASOUND' B can!also!detect!obstruction!of!the!ampulla!
' $ appearance:!filling!of!the!GB!and!CBD!with!delayed!
Liver' and!absent!filling!of!the!duodenum!
B Useful!initial'test'imaging'test'of'the'liver!because!it! B can!also!be!used!for!detection!of!biliary!leaks!as!a!
is!inexpensive,!involves!no!radiation!exposure,!and!is! complication!of!GB!surgery!
well!tolerated!by!patients! !
B It!is!excellent!for!diagnosing!biliary!pathology!and!liver!
lesions.' COMPUTED'TOMOGRAPHY'
B Limitations:' Liver'
$ Incomplete!imaging:!dome!or!beneath!the!ribs!on! B Contrast'medium!is!routinely!used!for!liver!evaluation!
the!surface,!lesion!boundaries!are!not!as!visualized' because!of!the!similar'densities'of'most'pathologic'
$ Obesity' liver'masses'and'normal'hepatic'parenchyma.'
$ Overlying!gas!bowels' $ Uses!dual'or'triple'phase'bolus'of'IV'contrast'
B If!a!mass!is!detected,!further!evaluation!by!CT!or!MRI!is! $ Exploits!the!dual!blood!supply!of!the!liver:!most'
required!since!UTZ!has!lower!sensitivity!and!specificity! liver'tumors'receive'their'blood'supply'from'
B Intraoperative'ultrasound:' the'hepatic'artery'and'normal'hepatic'
$ Gold'standard'for'diagnosing'liver'lesions' parenchyma'from'portal'vein' '
$ Useful!for!tumor!staging,!visualization!of! $ 2!phases:'
intrahepatic!vascular!structures,!guidance!of! 1. Arterial'dominant'phase'(20!to!30!
resection!plane!by!assessment!of!relationship!of! seconds!after!beginning!of!contrast!
mass!to!vessels,!for!biopsy!of!tumors!and!tumor! injection)!–!the!phase!where!hepatic!tumors!
ablation' and!other!hypervascular!lesions!are!well!
delineated.!
Gallbladder' 2. Venous'or'portal'dominant'phase'(60!to!
B UTZ!is!the!initial'investigation'used'for'any'patient' 70!seconds!after!contrast!injection)!–!the!
suspected'of'disease'in'the'biliary'tree.! phase!where!there!is!optimal!enhancement!
B UTZ!will!show!gallbladder!stones!with!sensitivity!and! of!normal!liver!parenchyma!and!
specificity!of!>90%! hypovascular!lesions!(will!appear!
$ Appearance!of!GB!Stones:!(+)'acoustic'shadow,' attenuated!in!contrast!with!brighter!normal!
move'with!changes!in!position!(vs!polyps:!may! liver!parenchyma)!
also!have!a!shadow!but!does'not'move!with!
changes!in!position)! gallbladder'
$ If!a!stone!obstructs!the!neck!of!the!GB:!large!GB!but! B It!is!the'test'of'choice'in!evaluating!patients!with!
thin!walled! suspected'malignancy'of'the'GB,'extrahepatic'
B if!acute'cholecystitis:!(+)!edema!within!the!wall!of!the! biliary'system'or'nearby'organs,'in'particular,'the'
GB!or!between!the!GB!and!liver!in!association!with! head'of'pancreas'
localized!tenderness!
B Abdominal'CT'scan'is'inferior'to'UTZ'in!diagnosing! $ Micronodular'cirrhosis:'characterized!by!thick!
gallstones' regular!septa,!small!uniform!regenerative!nodules,!
' and!involvement!of!virtually!every!hepatic!lobule!
$ Macronodular'cirrhosis:'frequently!has!septa!and!
PERCUTANEOUS'TRANSHEPATIC'CHOLANGIOGRAPHY' regenerative!nodules!(irregularly!sized!
B Useful'in'patients'with'bile'duct'strictures'and' hepatocytes!with!large!nuclei!and!cell!plates!of!
tumors,'as!it!defines!the!anatomy!of!the!biliary!tree! varying!thickness)!
proximal!to!the!affected!segment' $ Mixed'cirrhosis:'present!when!regeneration!is!
B Mechanism:!intrahepatic!ducts!are!accessed! occurring!in!a!micronodular!liver!and!over!time!
percutaneously!with!a!small!needle!under!fluoroscopic! converts!to!a!macronodular!pattern!
guidance!"!catheter!is!placed!"!cholangiogram! B Etiology:'viral,!autoimmune,!drugBinduced,!cholestatic,!
and!metabolic!diseases'
performed!"!can'do'therapeutic'interventions'as'
B Clinical'manifestation'
well!(biliary!drain!insertion,!stent!placement)'
$ Fat!stores!and!muscle!mass!are!reduced'
B Very!little!role!in!management!of!uncomplicated!
$ resting!energy!expenditure!is!increased'
gallstone!disease'
$ (+)!Muscle!cramps:!respond!to!administration!of!
!
quinine!sulfate!and!human!albumin'
$ increased!CO!&!HR!'
MAGNETIC'RESONANCE'IMAGING'
' $ Prone!to!infections!"!due!to!impaired!phagocytic!
Liver' activity!of!the!RES'
B Also!uses!contrast!agent,!just!like!in!CT!scan,!to! '
differentiate!normal!and!pathologic!lesion!in!the!liver! B Diagnosis'
B Types:! $ mild!normocytic!normochromic!anemia.'
$ Gadopentate!dimeglumine!–!behaves!in!a!manner! $ Decreased!WBC!&!PC'
similar!to!iodine!in!CT! $ bone!marrow:!macronormoblastic'
$ Feruxomide!–!excretion!of!kuppfer!cells! $ prothrombin!time!is!prolonged!&!does!not!respond!
$ Iminoacetic!acidBderivative!radionuclide!–! to!vitamin!K!tx'
secretion!in!bile!by!hepatocytes! $ serum!albumin!level!is!decreased'
$ serum!levels!of!bilirubin,!transaminases,!and!
Gallbladder' alkaline!phosphatase!are!all!elevated'
B MRI'with'MRCP'(magnetic'resonance' '
cholangiopancreatography)'"!offers!a!single! B CHILDSTURCOTTESPUGH'SCORE:'evaluate!the!risk!of!
noninvasive!test!for!the!diagnosis!of!bliary!tract!and! portocaval!shunt!procedures!secondary!to!portal!
pancreatic!disease! hypertension!and!also!useful'in'predicting'surgical'
! risks'of'other'intraSabdominal'operations'
performed'on'cirrhotic'patients'
ENDOSCOPIC'RETROGRADE'CHOLANGIOGRAPHY'(ERCP)'
Table!63.!ChildBTurcotteBPugh!Score!
B It!is!the'diagnostic'and'therapeutic'procedure'of'
variable! 1!point! 2!points! 3!points!
choice'for'stones'in'the'CBD'associated'with'
Bilirubin! <!2!mg/dL! 2B3!mg/dL! >3!mg/dL!
obstructive'jaundice,'cholangitis'and'gallstone' Albumin! >3.5!g/dL! 2.8B3.5!g/dL! <2.8!g/dL!
pancreatitis' INR! <1.7! 1.7B2.2! >2.2!
B Provides!direct!visualization!of!the!bilary!and! Encephalopathy! none! controlled! uncontrolled!
pancreatic!ducts,!particularly!the!ampullary!region!and! Ascites! none! controlled! uncontrolled!
distal!common!bile!duct!' ChildBTurcotteBPugh!Class!&!overall!surgical!mortality!rates!
B Therapeutic!interventions!include!sphincterotomy,! Class!A!=!5B6!points!"!10%!
stone!extraction!if!indicated' Class!B=!7B9!points!"!30%!
' Class!C=!10B15!points!"!75B80%!
'
POSITRON'EMISSION'TOMOGRAPHY' E. PORTAL'HYPERTENSION!
liver' B definition:!direct!portal!venous!pressure!that!is!>5!
B PET!offers!functional!imaging!of!tissues!with!high! mmHg!greater!than!the!IVC!pressure,!a!splenic!pressure!
metabolic!activity,!including!most!types!of!metastatic! of!>15!mmHg,!or!a!portal!venous!pressure!measured!at!
tumors! surgery!of!>20!mmHg!
B With!high!value!for!colorectal!cancer!with!liver! B normal!portal!venous!pressure:!5!to!10!mmHg!
metastases! $ at!this!pressure,!very!little!blood!is!shunted!from!
$ 20%!of!patients!with!colorectal!cancer!present! the!portal!venous!system!into!the!systemic!
initially!with!liver!metastasis! circulation!
$ presence!of!extrahepatic!disease!is!a!poor! $ as!portal!venous!pressure!increases,!the!
prognosticator!and!precludes!surgical!intervention! communication!with!the!systemic!circulation!dilate!
# valuable!tool!for!the!diagnostic!work!up!of! "!Large!amount!of!blood!is!shunted!around!the!
patient!with!potentially!resectable!hepatic! liver!and!into!the!systemic!circulation!"!
disease! complications!
# must!be!combined!with!CT!to!improve! $ A!portal!pressure!of!>12!mmHg!is!necessary!for!
diagnostic!accuracy! varices!to!form!and!subsequently!bleed!
' B Etiology:!most'common'cause'is'cirrhosis'
D. LIVER'CIRRHOSIS' (intrahepatic)!
B final!sequela!of!chronic!hepatic!insult,!is!characterized! B Clinical!manifestation!
by!the!presence'of'fibrous'septa'(due'to' $ Most'significant'clinical'finding:'
accumulation'to'ECM'matrix'or'scar'tissue)! gastroesophageal'varices!
throughout!the!liver!subdividing!the!parenchyma!into! # Major+BS+of+GE+varices:+anterior+branch+of+the+
hepatocellular!nodules! left+gastric+or+coronary+vein!
B 2!consequences:!hepatocellular!failure!and!portal! $ May!present!with!splenomegaly,!hemorrhoids,!
hypertension! ascites,!caput!medusa!&!upper'GI'bleeding'due'to'
B Classification! variceal'bleeding'(leading'cause'of'morbidity'
and'mortality)'
B Diagnosis:'most!accurate!method!of!determining!portal! B most!patients!are!women!
hypertension!is!hepatic'venography' B mean!age!of!diagnosis:!30!yo!
B Management' B clinical!manifestations:!abdominal!pain!(RUQ),!ascites,!
$ Prevention!of!variceal!bleeding:!improve!liver! and!hepatomegaly!or!long!standing!portal!hypertension!
function!(avoid!alcohol),!avoid!aspirin!&!NSAID,! B diagnosis!
beta!blockers' B abdominal!UTZ:!initial!investigation!of!choice!
$ Management!of!acute!variceal!bleeding' $ check!for!absence!of!hepatic!vein!flow,!spider!web!
# Specifics:' hepatic!veins!&!collateral!circulation!
• ICU'admission:!must!' B definitive'imaging:'hepatic'venography'
• Blood'resuscitation:!goal!is!Hgb!of! B initial'treatment:'anticoagulation'
8g/dL!and!above! !
• FFP'and'platelets!for!patients!with! G. INFECTIONS'OF'THE'LIVER'
severe!coagulopathy!
• Short!term!prophylactic!antibiotics:! PYOGENIC'LIVER'ABSCESS'
ceftriaxone'1g/day!(proven!to!decrease! B most'common'liver'abscesses'seen'in'the'United'
the!rate!of!bacterial!infections!and! States.'
increase!survival)! B Risk!factors:!IV!drug!abuse,!teeth!cleaning,!diverticulitis,!
• Vassopressin!at!0.2!to!0.8!units/min!IV! Crohn's!disease,!subacute!bacterial!endocarditis,!(+)!
for!vasoconstriction!(most!potent)! infected!indwelling!catheters!&!immunocompromised!
• Octreotide/somatostatin!for!splanchnic! states'
vasoconstriction! B may!be!single!or!multiple'
• Endoscopic!variceal!ligation!(EVL)! B more!frequently!found!in!the!right'lobe'of'the'liver'
B causative!organisms:'
• Balloon!tamponade!using!sengstakenB
$ monomicrobial:'40%';'polymicrobial:'40%;'
blakemore!tube!
culture'negative:'20%'
• Shunt'therapy'(surgical'shunts'or'
$ most'common:'gramSnegative'organisms!
TIPS)''
(Escherichia+coli+–+2/3;!Streptococcus+faecalis,+
• Even!with!aggressive!pharmacologic!and!
Klebsiella,!and!Proteus+vulgaris!are!also!common)'
endoscopic!therapy,!10S20%'of'patients'
$ Anaerobic!organisms!(ex.!Bacteroides+fragilis)!are!
with'variceal'bleeding'will'continue'to'
also!seen!frequently'
rebleed'
$ If!(+)!endocarditis!/!indwelling!catheter:!think!
• Shunt'therapy'(surgical'shunt'or'TIPS),! Staphylococcus!and!Streptococcus!'
on!the!other!hand,!has!been!shown!to!
B Clinical!manifestations:!RUQ!pain,!fever!&!jaundice!(1/3!
control'refractory'variceal'bleeding'in'
of!patients)!
>90%!of!treated!individuals'
B Diagnosis:!'
• Surgical'shunt:'CTP!class!A' $ Leucocytosis,'↑ESR'&'AP!(most!common!
• TIPS:'CTP!class!B!&!C' laboratory!findings)'
• Balloon!tamponade!using!sengstakenB $ Blood!cultures!reveal!the!causative!organism!in!
blakemore!tube!can!control'refractory' approximately!50%!of!cases.!'
bleeding'in'>80%'of'patients' $ Liver'UTZ:'round'or'oval'hypoechoic'lesions'
• Complication:!aspiration,!esophageal! with'wellSdefined'borders'and'a'variable'
perforation' number'of'internal'echoes.'
$ CT'scan:'highly'sensitive'in'the'localization;'
Table.64!Comparison!of!Surgical!shunts!vs!TIPS! appear'as'hypodense'mass'with'airSfluid'levels'
Surgical'shunts'(can'be'selective' TIPS'(Transjugular'Intrahepatic'
(indicating'a'gasSproducing'organisms)'&'
or'non'selective'shunts)' Portosystemic'Shunt)'
Baim:!reduce!portal!venous! Bconsidered!as!a!nonselective'
peripheral'enhancement'
pressure,!maintain!total!hepatic! shunt' B Treatment:!cornerstones!of!treatment!include!
and!portal!blood!flow!and!avoid'a' Binvolves!implantation!of!a!metallic! correction!of!the!underlying!cause,!percutaneous!needle!
high'incidence'of'complicating' stent!between!an!intrahepatic! aspiration,!and!IV!antibiotic!therapy!
hepatic'encephalopathy! branch!of!the!portal!vein!and!a! $ Initial'antibiotic'therapy'needs'to'cover'gramS
! hepatic!vein!radical! negative'as'well'as'anaerobic'organisms;'must'
BnonSselective'shunt!(ex.! BTIPS'can'control'variceal' be'continued'for'at'least'8'weeks.'
portacaval!shunt!or!eck!fistula:! bleeding'in'>90%'of'cases'
$ If!aspiration!and!IV!antibiotics!fail,!undergo!
joins!the!portal!vein!to!the!IVC!in! refractory'to'medical'treatment!
an!endBtoBside!fashion!&!disrupts! Bdisadvantages:!bleeding!either!
surgical!therapy!(either!laparoscopic!or!open!
portal!vein!flow!to!the!liver,!or! intraBabdominally!or!via!the!biliary! drainage)'
joins!it!in!a!sideBtoBside!fashion! tree,!infections,!renal!failure,! $ Anatomic!surgical!resection!is!reserved!for!patients!
and!maintains!partial!portal! decreased!hepatic!function,!and! with!recalcitrant!abscesses.'
venous!flow!to!the!liver;!non! ↑er'hepatic'encephalopathy' $ Always'rule'out'necrotic'hepatic'malignancy'
selective;!rarely!performed!now! (because'it'is'a'non'selective' '
because!it!has'a'higher'incidence' shunt)!
of'hepatic'encephalopathy!and! AMEBIC'ABSCESS'
decreased!liver!function!resulting!
B most'common'type'of'liver'abscesses'worldwide.'
from!the!reduction!of!portal!
perfusion;!controls!bleeding! B Causative!agent:!Entamoeba.histolytica'
effectively! B can!be!single!or!multiple'
! B most!commonly!located!in!the!superiorSanterior'
Bselective'shunt!(ex.!Warren! aspect'of'the'right'lobe!of!the!liver!near!the!diaphragm!'
shunt!–!distal!splenorenal!&!left! B Gross:!necrotic+central+portion+that+contains+a+thick,+
gastric!caval!shunt)!have'↓er' reddish+brown,+pusGlike+material!(anchovy'paste'or'
incidence'of'hepatic' chocolate'sauce)'
encephalopathy!!
B Clinical!manifestation:!RUQ!pain!+!fever!+!hepatomegaly!
!
+!travel!to!an!endemic!area'
F. BUDDSCHIARI'SYNDROME'
B Diagnosis:'
B uncommon!congestive!hepatopathy!characterized!by!
$ most!common!biochemical!abnormality:!↑'AP'
the!obstruction!of!hepatic!venous!outflow!due!to!
level.'
endoluminal!venous!thrombosis!(primary)!or!
$ (+)!Leukocytosis'
compressive!lesion!external!to!the!veins!(secondary)!
$ ↑transaminase!levels!and!jaundice!are!unusual.!'
B risk!factors:!coagulopathies,!thrombotic!disease!
$ (+)!fluorescent!antibody!test!for!E.+histolytica!' B Diagnosis:!appear!as!thinSwalled,'homogeneous,'
$ Ultrasound!and!CT!scanning:!very!sensitive!but! fluidSfilled'structures'with'few'to'no'septations.'
nonspecific!for!the!detection!of!amebic!abscesses' B Treatment:!'
$ Appears!to!be!as!a!wellBdefined!lowBdensity!round! $ Observation'if'asymptomatic'
lesions!that!have!enhancement!of!the!wall,!ragged! $ If!symptomatic,!perform!UTZB!or!CTBguided!
in!appearance!with!a!peripheral!zone!of!edema;!has! percutaneous!cyst!aspiration!followed!by!
a!central!cavity!with!septations!&!fluid!levels' sclerotherapy'
B Treatment' $ excised!cyst!wall!is!sent!for!pathologic!analysis!to!
$ Metronidazole'750'mg'tid'for'7'to'10'days'is'the' rule!out!carcinoma,!and!the!remaining!cyst!wall!
treatment'of'choice'and'is'successful'in'95%'of' must!be!carefully!inspected!for!evidence!of!
cases.' neoplastic!change.!'
$ Defervescence!usually!occurs!in!3'to'5'days.'
$ Time!of!resolution!of!abscess:!30'to'300'days!from! HEMANGIOMA'
presentation' B consist!of!large!endothelialBlined!vascular!spaces!and!
$ Aspiration!of!the!abscess!is!rarely!needed!and! represent!congenital!vascular!lesions!that!contain!
should!be!reserved!for!patients!with!large! fibrous!tissue!and!small!blood!vessels!which!eventually!
abscesses,!abscesses!that!do!not!respond!to! grow'
medical!therapy,!abscesses!that!appear!to!be! B most'common'solid'benign'masses'that'occur'in'the'
superinfected,!and!abscesses!of!the!left!lobe!of!the! liver'
liver!that!may!rupture!into!the!pericardium' B more!common!in!women'
' B clinical!manifestation:'
$ most'common'symptom'is'abdominal'pain'
HYDATID'DISEASE' $ can!be!asymptomatic!as!well'
B due!to!the!larval!or!cyst!stage!of!infection!by!the! B diagnosis:'
tapeworm!Echinococcus.granulosus.(causative!agents)! $ biphasic!contrast!CT!scan:!asymmetrical!nodular!
$ intermediate!hosts:!Humans,!sheep,!and!cattle' peripheral'enhancement!that!is!isodense!with!
$ definitive!host:!dogs' large!vessels!and!exhibit!progressive!centripetal!
B commonly!involve!the'right'lobe'of'the'liver,!usually! enhancement!fillBin!over!time'
the!anteriorSinferior'or'posteriorSinferior'segments' $ MRI:!hypointense!on!T1Bweighted!images!and!
B clinical!manifestations:!dull!RUQ!or!abdominal! hyperintense!on!T2Bweighted!images'
distention;!can!be!clinically!silent;!if!ruptured,!may!lead! $ Caution!should!be!exercised!in!ordering!a!liver!
to!an'allergic'or'anaphylactic'reaction.' biopsy!if!the!suspected!diagnosis!is!hemangioma!
B Diagnosis:' because!of!the!risk!of!bleeding!from!the!biopsy!site'
$ (+)ELISA!for!echinococcal!antigens;!maybe!(B)!if! B treatment:'Surgical'resection'(enucleation'or'
cyst!has!not!leaked!or!does!not!contain!scolices,!or! formal'hepatic'resection)'only'if'symptomatic;'
if!the!parasite!is!no!longer!viable' observation'if'asymptomatic'
$ Eosinophilia!of!>7%!is!found!is!approximately!30%! '
of!infected!patients.!'
$ UTZ!&!CT!scan!of!the!abdomen:!sensitive!for! HEPATIC'ADENOMA'
detecting!hydatid!cysts.' B benign!solid!neoplasms!of!the!liver!
# hydatid!cysts:!appear!as!wellSdefined' B most!commonly!seen!in!young!women!(aged!20B40)!
hypodense'lesions'with'a'distinct'wall;'(+)' B typically!solitary!
RingSlike'calcifications'of'the'pericysts! B risk!factors:!Prior'or'current'use'of'estrogens'(oral'
(present!in!20!to!30%!of!cases);!healing!occurs! contraceptives)!
"!the!entire!cyst!calcifies!densely,!and!a! B Gross!appearance:!soft!and!encapsulated!and!are!tan!to!
lesion!with!this!appearance!is!usually!dead!or! light!brown.!!
inactive.!Daughter!cysts:!occur!in!a!peripheral! B Histology:!does'not'contain'Kuppfer'cells!
location!&!!are!slightly!hypodense!compared! B (+)'risk'of'malignant'transformation'to'a'wellS
with!the!mother!cyst.!' differentiated'HCC!
B Treatment:!! B Clinical'manifestation:!
$ Unless!the!cysts!are!small!or!the!patient!is!not!a! $ carry'a'significant'risk'of'spontaneous'rupture'
suitable!candidate!for!surgery,!treatment!of! with'intraperitoneal'bleeding.'!
hydatid!disease!is!surgically'based!(laparoscopic! $ The!clinical!presentation!may!be!abdominal!pain!
or!open!complete!cyst!removal!+!instillation!of! B Diagnosis:!
scolicidal!agent)!! $ CT!scan:!with!sharply!defined!borders;!can!be!
$ caution'must'be'exercised'to'avoid'rupture'of' confused!with!metastatic!tumors!
the'cyst!with!release!of!protoscolices!into!the! # venous!phase!contrast:!hypodense!or!isodense!
peritoneal!cavity.!! (in!comparison!with!background!liver!
$ Peritoneal.contamination.can.result.in.an.acute. # arterial!phase!contrast:!subtle!hypervascular!
anaphylactic.reaction.or.peritoneal. enhancement!!
implantation.of.scolices.with.daughter.cyst. $ MRI:!hyperintense!on!T1Bweighted!images!and!
formation.and.inevitable.recurrence! enhance!early!after!gadolinium!injection.!
$ Medical!treatment!of!choice:!albendazole'S!initial! $ nuclear!imaging:!"cold”;'no'uptake'of'
treatment!for!small,!asymptomatic!cysts.! radioisotope!
! B Treatment:!surgical!resection!
H. BENIGN'NEOPLASMS'OF'THE'LIVER' !
HEPATIC'CYST' FOCAL'NODULAR'HYPERPLASIA'
B most'common'benign'lesion'found'in'the'liver'is'the' B A!benign,!solid!neoplasm!of!the!liver!
congenital'or'simple'cyst' B more!common!in!women!of!childbearing!age!
B female:male!ratio!is!approximately!4:1' B FNH!lesions!usually'do'not'rupture'spontaneously'
B Clinical!manifestation:!asymptomatic!if!small;!Large! and'have'no'significant'risk'of'malignant'
simple!cysts!may!cause!abdominal!pain,!epigastric! transformation.!
fullness,!and!early!satiety.!Occasionally!the!affected! B diagnosis:!
patient!presents!with!an!abdominal!mass.' $ biphasic!CT!scan:!well'circumscribed'with'a'
typical'central'scar!
# Arterial!phase!contrast:!intense!homogeneous! # presents!with!obstructive'and'painless'
enhancement! jaundice!rather!than!an!actual!liver!mass!
# Venous!phase!contrast:!isodense!or!invisible!! B treatment:!
$ MRI!scans:!hypointense!on!T1Bweighted!images!&! $ surgical!resection!is!the!treatment!of!choice!
isointense!to!hyperintense!on!T2Bweighted!images! # hilar'cholangiocarcinoma'+'primary'
# After!gadolinium!administration,!lesions!are! sclerosing'cholangitis:!surgical!resection!has!
hyperintense!but!become!isointense!on! no!role!&!transplantation!provided!dismal!
delayed!images.!! results!
$ nuclear!imaging:!(+)'uptake'by'Kupffer'cells.!! # neoadjuvant'chemoradiation'has'a'role!
B Treatment:!surgical!resection!only!if!symptomatic! !
BILE'DUCT'HAMARTOMA' GALLBLADDER'CANCER'
B small!liver!lesions!(2!B!4!mm)! B rare!aggressive!tumor!with!a!very!poor!prognosis.!
B usually!visualized!on!the!surface!of!the!liver!at! B Cholithiasis!is!the!most!important!risk!factor!for!
laparotomy.! gallbladder!carcinoma!
B Gross!appearance:!firm,!smooth,!and!whitish!yellow!in! B 80B90%!of!gallbladder!tumors!are!adenocarcinomas!
appearance.! B signs!and!symptoms!of!GB!carcinoma!are!
B can!be!difficult!to!differentiate!from!small!metastatic! indistinguishable!from!cholecystitis!and!cholelithiasis!
lesions! B sensitivity!of!UTZ!in!detecting!GB!carcinoma!ranges!
B excisional!biopsy!often!is!required!to!establish!the! from!70B100%.!
diagnosis! B Treatment:!surgery!is!the!only!curative!option!for!
' gallbladder!cancer!
I. MALIGNANT'TUMORS' $ reoperation!for!an!incidental!finding!of!gallbladder!
cancer!after!cholecystectomy!(central!liver!
HEPATOCELLULAR'CARCINOMA'(HCC)' resection,!hilar!lymphadenectomy,!and!evaluation!
B 5th!most!common!malignancy!worldwide' of!cystic!duct!stump)!
B Risk!factors:!viral!hepatitis!(B!or!C),!alcoholic!cirrhosis,! $ reoperation!should!be!considered!for!all!patients!
hemochromatosis,!and!nonalcoholic!steatohepatitis' who!have!T2!or!T3!tumors!or!for!whom!the!
B HCCs!are!typically!hypervascular!with!blood!supplied! accuracy!of!staging!is!in!question!
predominantly!from!the!hepatic!artery' $ radical!resection!in!patients!with!advanced!disease!
B Most!common!site!of!metastasis!is!lungs' # usually!with!dismal!results!if!already!with!(+)!
B Clinical!manifestations:!jaundice,!pruritus,! hilar!LN!!
hepatosplenomegaly,!bleeding!diathesis,!cachexia,!
encephalopathy,!asterixis,!ascites!and!varices' METASTATIC'COLORECTAL'CANCER'
B Diagnosis:' B Over!50%!of!patients!diagnosed!with!colorectal!cancer!
$ CT!scan:!appears!hypervascular!during!the!arterial! will!develop!hepatic!metastases!during!their!lifetime.!!
phase!of!CT!studies!&!relatively!hypodense!during! B Resection!is!the!preferred!treatment!for!liver!
the!delayed!phases!due!to!early!washout!of!the! metastases!from!colorectal!CA,!provided!that!patient!
contrast!medium!by!the!arterial!blood.' has!adequate!liver!reserve,!no!extrahepatic!metastases,!
$ MRI:!HCC!is!variable!on!T1Bweighted!images!and! total!hepatic!involvement!and!advanced!crirhosis,!vena!
usually!hyperintense!on!T2Bweighted!images;!HCC! cava!or!portal!vein!invasion!
enhances!in!the!arterial!phase!after!gadolinium! B volume!of!future!liver!remnant!and!the!health!of!the!
injection!because!of!its!hypervascularity!and! background!liver,!and!not!actual!tumor!number,!as!the!
becomes!hypointense!in!the!delayed!phases!due!to! primary!determinants!in!selection!for!an!operative!
contrast!washout' approach.!
$ (+)'thrombus'in'portal'vein'is'highly'suggestive' '
of'HCC' J. GALLSTONE'DISEASE'
$ ↑AST,ALT,AFP' B Prevalence'and'incidence'
B treatment!options!for!liver!cancer! $ most!common!problems!affecting!the!digestive!
$ hepatic'resection:'reserved!for!patients!without! tract'
cirrhosis!&!Child's!class!A!cirrhosis!with!preserved! $ Women!are!3x!more!likely!to!develop!gallstones!
liver!function!and!no!portal!hypertension! than!men'
$ liver!transplantation:!if!with!poor!liver!function! $ risk'factors:'Obesity,!pregnancy,!dietary!factors,!
and!the!HCC!meets!the!Milan!criteria!(one!nodule! Crohn's!disease,!terminal!ileal!resection,!gastric!
<5!cm,!or!two!or!three!nodules!all!<3!cm,!no!gross! surgery,!hereditary!spherocytosis,!sickle!cell!
vascular!invasion!or!extrahepatic!spread)! disease,!and!thalassemia'
$ Chemoembolization!can!also!be!of!benefit!! B Natural'history'
$ 5!year!survival!after!complete!resection:!30%! $ Most!patients!will!remain!asymptomatic'
' $ prophylactic'cholecystectomy'in'asymptomatic'
persons'with'gallstones'is'rarely'indicated'
CHOLANGIOCARCINOMA' $ cholecystectomy!is!advisable!for!the!ff!
B 2nd!most!common!primary!malignancy!within!the!liver! asymptomatic!patients:'
B It!is!the!adenocarcinoma!of!the!bile!ducts!that!forms!in! 1. elderly'patients'with'diabetes'
the!biliary!epithelial!cells! 2. individuals!isolated!from!medical!care!for!
B Most!commonly!occurs!at!the!bifurcation!of!the! extended!periods!of!time'
common!hepatic!duct! 3. in!populations!with!increased!risk!of!
B Subclassification:! gallbladder!cancer!(porcelain'gallbladder'
$ peripheral!(intrahepatic)!bile!duct!cancer! –'premalignant'lesion)'
# tumor!mass!is!within!the!lobe!or!peripheral!of! 4. symptomatic'Cholesterolosis:!
the!liver! accumulation!of!cholesterol!in!macrophages!
# less!common!that!extrahepatic!bile!duct! in!the!gallbladder!mucosa,!either!locally!or!
Cancer! as!polyps;!produces!the!classic!macroscopic!
$ central!(extrahepatic)!bile!duct!cancer! appearance!of!a!"strawberry'gallbladder."!'
# if!it!is!proximally!located,!referred!to!as!a!hilar. 5. symptomatic''Adenomyomatosis'or'
cholangiocarcinoma'(Klatskin's'tumor).! cholecystitis'glandularis'proliferans:!
characterized!on!microscopy!by!
hypertrophic!smooth!muscle!bundles!and! unremitting!epigastric!or!RUQ!pain,!may!persist!for!
$
by!the!ingrowths!of!mucosal!glands!into!the! several!days,!may!radiate!to!the!right!upper!part!of!
muscle!layer!(epithelial!sinus!formation)' the!back!or!the!interscapular!area;!febrile,!
6. symptomatic'granulomatous'polyps'' anorexia,!nausea,!and!vomiting,!reluctant!to!move,!
B Gallstone'formation' (+)!focal!tenderness!and!guarding!on!the!RUQ,!(+)!
$ Cholesterol'stones'(80%'of'gallstones)' Murphy's!sign!(an!inspiratory!arrest!with!deep!
# multiple,!variable!size,!may!be!hard!and! palpation!in!the!right!subcostal!area)!is!
faceted!or!irregular,!mulberryBshaped,!and! characteristic!'
soft;!colors!range!from!whitish!yellow!and! $ mirizzi’s'syndrome:!Severe!jaundice!due!to!
green!to!black!' common!bile!duct!stones!or!obstruction!of!the!bile!
# Most!cholesterol!stones!are!radiolucent' ducts!by!severe!pericholecystic!inflammation!
# formation!is!due!to!supersaturation!of!bile! secondary!to!impaction!of!a!stone!in!the!
with!cholesterol' infundibulum!of!the!gallbladder!that!mechanically!
$ Pigment'stones'(15S20%'of'gallstones)' obstructs!the!bile!duct!'
# dark!because!of!the!presence!of!calcium! $ in!elderly!patients!and!in!those!with!diabetes!
bilirubinate' mellitus,!acute!cholecystitis!may!have!a!subtle!
# Black'pigment'stones:!small,!brittle,!black,! presentation!resulting!in!a!delay!in!diagnosis.'
and!sometimes!speculated;!In!Asian!countries! B Laboratory!diagnosis:'
such!as!Japan,!black!stones!account!for!a!much! $ A!mild!to!moderate!leukocytosis!(12,000!to!15,000!
higher!percentage!of!gallstones!than!in!the! cells/mm3)'
Western!hemisphere;!typically!occur!in! # if!high!WBC!(above!20,000):!suggests!a!
patients'with'cirrhosis'and'hemolysis' complicated!form!of!cholecystitis!such!as!
# Brown'pigment'stones:!<1!cm!in!diameter,! gangrenous!cholecystitis,!perforation,!or!
brownishByellow,!soft,!and!often!mushy;!they! associated!cholangitis.!'
are!formed!usually!due!to!secondary'to' $ mild!elevation!of!serum!bilirubin,!<4!mg/mL!
bacterial'infection'(ex.'E.'coli)caused'by' $ mild!elevation!of!alkaline!phosphatase,!
bile'stasis.;!associated!with!stasis!secondary! transaminases,!and!amylase.!
to!parasite!infection' B diagnosis:!
B Clinical!presentation! $ UTZ:'most'useful'radiologic'test'for'diagnosing'
$ Abdominal!pain:!epigastrium!or!RUQ,!constant,! acute'cholecystitis!
increasing!in!severity,!episodic,!usually!after!a!fatty! # Is!95%!sensitive!and!specific!
meal,!nausea,!vomiting! # Appears!as!thickening!of!the!gallbladder!wall!
$ Hydrops'of'gallbladder:!manifests!as!a!palpable. and!(+)!pericholecystic!fluid!!
nontender.gallbladder! # (+)!sonographic!murphy’s!sign!
# Usually!due!to!impacted!stone!without! $ Biliary'radionuclide'scanning'(HIDA'scan):''
cholecystis!(pathophysio:!bile!gets!absorbed,! most'accurate'in'the'diagnosis'of'acute'
but!the!gallbladder!epithelium!continues!to! cholecystitis'
secrete!mucus,!and!the!gallbladder!becomes! B Treatment'
distended!with!mucinous!material)! $ IV!fluids'
# Is!usually!an!indication!for!cholecystectomy! $ Antibiotics:!should!cover!Gram!(B)!aerobes!+!
B Diagnosis! anaerobes!B!3rd!generation!cephalosporin!or!2nd!
$ Abdominal'UTZ:'standard!diagnostic!test!for! generation!cephalosporin!+!metronidazole'
gallstones! $ Analgesia'
# Presence!of!hyperechoic!intraluminal!focus! $ Cholecystectomy:!definitive!treatment'
# Shadowing!posterior!to!the!focus! $ Laparoscopic!cholecystectomy:!procedure!of!choice'
# Movement!of!the!focus!with!positional!changes! !
of!the!patient! L. CHOLEDOCHOLITHIASES!
B Management:!Patients!with!symptomatic!gallstones! B Common!bile!duct!stones!
should!be!advised!to!have!elective'laparoscopic' B Common!over!the!age!of!60!
cholecystectomy' B clinical!manifestations:!may!be!silent!or!incidental;!if!
' symptomatic,!may!cause!pain,!nausea!and!vomiting!with!
K. ACUTE'CHOLECYSTITIS' mild!epigastric!or!RUQ!tenderness!+!mild!icterus!
B Pathogenesis:' B diagnosis:!
$ Acute!cholecystitis!is!secondary!to!gallstones!in!90! $ ↑!of!serum!bilirubin,!alkaline!phosphatase,!and!
to!95%!of!cases' transaminases!
$ In!<1%!of!acute!cholecystitis,!the!cause!is!a!tumor! $ UTZ:!dilated!common!bile!duct!(>8!mm!in!
obstructing!the!cystic!duct!(leads!to!gallbladder! diameter)!
distention,!inflammation,!and!edema!of!the! $ Endoscopic!cholangiography:!gold!standard!for!
gallbladder!wall)' diagnosing!CBD!stones;!can!be!therapeutic!as!well!
$ Gross!appearance:!gallbladder!wall!is!grossly! $ IOC!can!be!done!to!evaluate!CBD!stones!
thickened!&!reddish!with!subserosal!hemorrhages;! B Treatment:'sphincterotomy!and!ductal!clearance!of!the!
(+)!pericholecystic!fluid!often;!mucosal!hyperemia! stones!is!appropriate,!followed!by!a!laparoscopic!
&!patchy!necrosis' cholecystectomy!
$ When!the!gallbladder!remains!obstructed!and! !
secondary!bacterial!infection!supervenes!"!an! M. CHOLANGITIS!
B Complication!of!choledochal!stones!
acute!gangrenous!cholecystitis!develops!"!
B Gallstones!are!the!most!common!cause!of!obstruction!in!
abscess!or!empyema!forms!within!the!gallbladder;!
cholangitis!
can!also!lead!to!perforation!of!ischemic!areas!'
B Normal:!bile!is!sterile!
$ emphysematous.gallbladder':'(+)!gas!may!be!seen!
B Causative!organisms:!E.+coli,!Klebsiella+pneumoniae,!
in!the!gallbladder!lumen!and!in!the!wall!of!the!
Streptococcus+faecalis,!Enterobacter,!and!
gallbladder!on!abdominal!radiographs!and!CT!
Bacteroidesfragilis!
scans!due!to!gasBforming!organisms!as!part!of!the!
secondary!bacterial!infection' B Clinical'manifestations'☺:!
B clinical'manifestations:'' $ most!common!presentation!is!fever,'epigastric'or'
right'upper'quadrant'pain,'and'jaundice!
(Charcot's.triad)!
$ charcot’s!triad!+!septic'shock'+'mental'status' B associated!with!ulcerative!colitis,!Riedel's!thyroiditis!
changes!"!reynaud’s'pentad! and!retroperitoneal!fibrosis!
B diagnosis:' B increased!risk!for!developing!cholangiocarcinoma.!
$ Leukocytosis,!hyperbilirubinemia,!and!elevation!of! B mean!age!of!presentation!is!30!to!45!years!
alkaline!phosphatase!and!transaminases!are!seen' B men!are!affected!twice!as!commonly!as!women!
$ UTZ:!(+)gallbladder!stones,!dilated!ducts' B clinical!manifestations:!jaundice,!fatigue,!weight!loss,!
$ ERC:'Definitive'diagnosis' pruritus,!and!abdominal!pain;!usually!with!cyclic!
B Treatment! remissions!and!excacerbations!
$ IV'antibiotics:'initial'management;'cover'for' B diagnosis:!
gram'(S)! $ elevated!ALP!&!bilirubin!
$ Fluid'resuscitation:'initial'management! $ ERCP:!confirmatory!test!
$ Emergency!biliary!decompression:!if!failed!to! # multiple'dilatations'and'strictures'
improve!with!IV!antibiotics!and!resuscitation! (beading)'of'both'the'intraS'and'
measures! extrahepatic'biliary'tree!
!
N. BILIARY'PANCREATITIS! !
B Obstruction!of!the!pancreatic!duct!by!an!impacted!stone! !
or!temporary!obstruction!by!a!stone!passing!through! !
the!ampulla!leads!to!this!condition! !
B Diagnosis:!UTZ!of!biliary!tree! !
B Treatment:!ERC!with!sphincterotomy!and!stone! !
extraction!+!cholecystectomy!(upon!resolution!of! !
pancreatitis!during!same!admission)! !
! !
O. ACALCULOUS'CHOLECYSTITIS' !
B develops!in!critically!ill!patients!in!ICU!(patients!on! !
parenteral!nutrition!with!extensive!burns,!sepsis,!major! !
operations,!multiple!trauma,!or!prolonged!illness!with! !
multiple!organ!system!failure)! !
B histopathology:!reveals!edema!of!the!serosa!and! !
muscular!layers,!with!patchy!thrombosis!of!arterioles! !
and!venules! emen!
B clinical!manifestations:! '''''''REVIEW'QUESTIONS!!
$ alert!patient:!right!upper!quadrant!pain!and! !
tenderness,!fever,!and!leukocytosis! 1. A!patient!presents!with!biliary!colic.!On!ultrasound!
$ sedated!or!unconscious!patient:!fever!and!elevated! there!are!multiple!small!gallstones!in!the!
WBC!count,!as!well!as!elevation!of!alkaline! gallbladder!and!the!common!bile!duct!measures!
phosphatase!and!bilirubin! 9mm!in!diameter.!No!stone!is!visualized!in!the!
B diagnosis:! common!bile!duct.!Which!of!the!following!is!the!
$ UTZ:!diagnostic!test!of!choice;!appears!as!distended! most!reasonable!next!step?!
gallbladder!with!thickened!wall,!biliary!sludge,! !
pericholecystic!fluid,!and!(+)!abscess!formation! a. Repeat!UTZ!in!24B48!hours!
B Treatment!of!choice:!Percutaneous!ultrasoundB!or!CTB b. MRCP!with!contrast!
guided!cholecystostomy!! c. Percutaneous!cholangiography!
! d. Laparoscopic!cholecystectomy!and!intraoperative!
P. BILIARY'or'CHOLEDOCHAL'CYSTS' cholangiography!
B congenital!cystic!dilatations!of!the!extrahepatic!and/or!
intrahepatic!biliary!tree! Answer:!D'
B rare! For!patients!with!symptomatic!gallstones!and!
B more!common!in!women! suspected!CBD!stones,!either!preoperative!endoscopic!
B more!frequently!diagnosed!during!childhood! cholangiography!or!an!intraoperative!cholangiogram!
B types:! will!document!the!bile!duct!stones.!If!an!endoscopic!
type'I:'cystic'dilatation'of'the'extrahepatic'bile' cholangiogram!reveals!stones,!sphincterotomy!and!
duct;'most'common'type' ductal!clearance!of!the!stones!is!appropriate,!followed!
type!II:!diverticulum!of!the!CBD' by!a!laparoscopic!cholecystectomy.!An!intraoperative!
type!III:!a!“choledochocele”!extending!from!the!distal! cholangiogram!at!the!time!of!cholecystectomy!will!also!
duct!into!the!duodenum' document!the!presence!or!absence!of!bile!duct!stones.!
type!IV:!combined!intrahepatic!and!extrahepatic!cysts' Laparoscopic!common!bile!duct!exploration!via!the!
type!V:!cystic!disease!confined!to!intrahepatic!ducts' cystic!duct!or!with!formal!choledochotomy!allows!the!
! stones!to!be!retrieved!in!the!same!setting.!If!the!
B clinical!manifestations:!jaundice!or!cholangitis!(for! expertise!and/or!the!instrumentation!for!laparoscopic!
adults);less!than!½!of!patients!present!with!the!classic! common!bile!duct!exploration!are!not!available,!a!drain!
clinical!triad!of!abdominal!pain,!jaundice,!and!a!mass! shuld!be!left!adjacent!to!the!cystic!duct!and!the!patient!
B diagnosis:!Ultrasonography!or!CT!scanning!will!confirm! scheduled!for!endoscopic!sphincterotomy!the!following!
the!diagnosis,!but!endoscopic,!transhepatic,!or!MRC!is! day.!An!open!common!bile!duct!exploration!is!an!option!
required!to!assess!the!biliary!anatomy!and!to!plan!the! of!the!endoscopic!method!has!already!been!tried!or!is,!
appropriate!surgical!treatment! for!some!reason,!not!feasible.!
B treatment:!complete!cyst!excision!with!rouxBenBY! !
hepaticojejunostomy! 2. Which!hepatic!cells!provides!the!primary!defense!
' against!lipopolysaccharide!(LPS)?!
Q. SCLEROSING'CHOLANGITIS' !
B is!a!progressive!disease!that!eventually!results!in! a. Hepatocytes!
secondary!biliary!cirrhosis!characterized!by! b. Kuppfer!cells!
inflammatory!strictures!involving!the!intrahepatic!and! c. Bile!duct!epithelial!cells!
extrahepatic!biliary!tree! d. Intrahepatic!endothelial!cells!
!
Answer:!B'
The!complications!of!Gram!negative!sepsis!is!
initiated!by!the!endotoxin!LPS.!The!liver!is!the!
main!organ!in!the!clearance!of!LPS!in!the!
bloodstream!and!plays!a!critical!role!in!the!
identification!and!processing!of!LPS.!Kuppfer!cells!
are!the!resident!macrophages!in!the!liver!and!have!
been!shown!to!participate!in!LPS!clearance.!
'
'


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TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT - Jules Lopez,MD-MBA,Teddy Carpio,MD-MBA

For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com

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