Professional Documents
Culture Documents
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
BIOCHEMISTRY a
5. Fatty Acid Metabolites
Omega-3 fatty acids have anti-inflammatory effects, Cholesterol is a steroid alcohol
including inhibition of TNF release from hepatic It is a precursor of the following:
Kupffer cells, leukocyte adhesion and migration 1. Cell membranes
6. Kallikrein-Kinin System 2. Vitamin D (7-dehydrocholesterol)
Group of proteins that contribute to inflammation, 3. Bile salts (cholic and chenodeoxycholic acid)
BP control, coagulation, and pain responses 4. Adrenal hormones (aldosterone and cortisol)
Kallikrein levels are increased during gram negative 5. Sex hormones (testosterone and estradiol)
bacteremia, hypotension, hemorrhage, endotoxemia, It is very hydrophobic (which means, it can cross lipid
and tissue injury predominant barriers), composed of 4 fused
Kinis mediate vasodilation, increased capillary hydrocarbon rings (A-D) and 8-membered branched
permeability, tissue edema, pain pathway activation, hydrocarbon chain (20-27) attached to the D-ring
inhibition of gluconeogenesis, and increased It has a single hydroxyl group located at carbon 3 of the
bronchoconstriction A-ring to which a fatty acid can be attached to form
Elevated levels of both has been associated with the cholesterol esters
magnitude of injury and mortality
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 andIL-1
in endotoxin-treated 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
2. Macrophage Migration-Inhibiting Factor
B. CNS REGULATION OF INFLAMMATION Neurohormone that is stored and secreted by the
Vagus nerve is highly influential in mediating afferent anterior pituitary and by intracellular pools within
sensory input to the CNS macrophages
o Parasympathetic nervous system transmits A counter regulatory mediator that potentially reverses
its efferent signals via acetylcholine the anti-inflammatory effects of cortisol
o Exerts homeostatic influences such as
enhancing gut motility, reducing heart rate, 3. Growth Hormones (GH)
and regulating inflammation Neurohormone expressed primarily by the pituitary
o Allows for a rapid response to inflammatory gland that has both metabolic and immunomodulatory
stimuli and also for the potential regulation of effects
early proinflammatory mediator release, Exerts its downstream effects through direct interaction
specifically tumor necrosis factor (TNF) with GH receptors and secondarily through the
o Inhibit cytokine activity and reduce injury enhanced hepatic synthesis of IGF-I
from disease process GH and IGF-I promote protein synthesis and insulin
resistance, and enhances mobilization of fat stores
C. HORMONAL RESPONSE TO INJURY
1. Cortisol(Refer to Figure2 ) 4. Catecholamines
Glucocorticoid steroid hormone released by the adrenal Include epinephrine, norepinephrine, and dopamine,
cortex in response to adrenocorticotropic hormone which have metabolic, immunomodulatory, and
(ACTH) vasoactive effects
Release is increased during times of stress and may be After severe injury, plasma catecholamine levels are
chronically elevated in certain disease processes (e.g. increased threefold to fourfold, with elevations lasting
burn-injured patients may exhibit elevated levels for 24 to 48 hours before returning to baseline levels
4 weeks)
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
period or abdominal distention requires cessation of
feeding and adjustment of infusion rate
The following are options for enteral feeding access
QUICK REVIEW a (Refer to Table 3 ):
Normal energy requirement: 22 to 25 kcal/kg/day Table 3. Options for Enteral Feeding Access
Initial hours after surgical or traumatic injury results to a Options for Enteral Feeding Access
reduced total body energy expenditure and urinary Short-term use
nitrogen wasting Nasogastric tube Aspiration risks
Fat/lipid is the primary source of calories during acute (NGT) Nasopharyngeal trauma
Frequent dislodgement
starvation (<5 days fasting) and after acute injury
Short-term use
Ketone bodies is the primary fuel source in prolonged
Nasoduodenal / Lower aspiration risks in jejunum
starvation Nasojejunal tube Placement challenges (radiographic
Ketone bodies becomes an important fuel source for assistance often necessary)
brain after 2 days and eventually become the principal Endoscopy skills required
fuel source by 24 days May be used for gastric decompression or
Percutaneous
bolus feeds
Endoscopic
Aspiration risks
Gastrostomy
E. NUTRITION IN THE SURGICAL PATIENT Can last 12-24 months
(PEG)
Goals of nutritional support in the surgical patient are Slightly higher complication rates with
as follows: placement and site leaks
Requires general anesthesia and small
o To meet the energy requirements for
laporotomy
metabolic processes, core temperature Surgical
Procedure may allow placement of
maintenance, and tissue repair Gastrostomy
extended duodenal/jejunal feeding ports
o To meet the substrate requirements for Laparoscopic placement possible
protein synthesis Commonly carried out during laparotomy
Energy requirement may be measured by indirect General anesthesia, laparoscopic
calorimetry and trends in serum markers (e.g. Surgical placement usually requires assistant to
prealbumin level) and estimation from urinary nitrogen Jejunostomy thread catheter
excretion, which is proportional to resting energy Laparoscopy offers direct visualization of
expenditure catheter placement
Basal energy expenditure (BEE) may also be Jejunal placement with regular endoscope
is operator dependent
estimated using Harris-Benedict equations, adjusted for
Jejunal tube often dislodges retrograde
the type of surgical stress (Refer to Table 2) PEG-jejunal tube Two-stage procedure with PEG
o BEE (men) = 66.47 + 13.75 (weight in kg) + 5 placement, followed by fluoroscopic
(height in cm) – 6.76 (age in years) kcal/d conversion with jejunal feeding tube
o BEE (women) = 655.1 + 9.56 (weight in kg) + through PEG
1.85 (height in cm) – 4.68 (age in years) kcal/d
The BEE is then multiplied by the type of surgical stress 2. Parenteral Nutrition
(Refer to Table 2 ) that the patient has to determine Continuous infusion of hyperosmolar solution
the total daily caloric need containing carbohydrates, proteins, fat, and other
necessary nutrients through an indwelling catheter
Table 2. Caloric Adjustment Above BEE in Hypermetabolic Conditions inserted into the superior vena cava
Caloric Adjustments Above Basal Energy Expenditures in Principal indications include malnutrition, sepsis, or
Hypermetabolic Conditions
surgical or traumatic injury in seriously ill patients for
Normal or Moderate Malnutrition 25-30 kcal/kg/day
whom use of the gastrointestinal tract for feedings is
Mild Stress 25-30
not possible
Moderate Stress 30
Severe Stress 30-35 Total (Central) Parenteral Nutrition (TPN)requires
Burns 35-40 access to a large-diameter vein to deliver the nutritional
requirements of the individual
Provision of 30 kcal/kg/d will adequately meet energy o Dextrose content of the solution is high (15-
requirements in most postsurgical patients, with low 25%)
risk of overfeeding o All other macronutrients and micronutrients
o Overfeedingusually results from are deliverable by this route
overestimation of caloric needs because actual Peripheral Parenteral Nutrition (PPN) uses lower
body weight is used to calculate BEE, osmolarity of the solution to allow its administration via
especially in special patients (e.g. critically ill peripheral veins
with significant fluid overload and the obese) o Reduced levels of dextrose (5-10%) and
o Overfeeding may contribute to clinical protein (3%)
deterioration via the following: increased O2
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 4 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
o Some nutrients cannot be supplemented c. 75%
because they cannot be concentrated into d. 100%
small volumes
o Not appropriate for repleting patients with Answer: B
severe malnutrition
o Used for short periods (<2 weeks); beyond Sepsis increases metabolic needs to approximately
this, TPN should be instituted 150-160% of resting energy expenditure, or 50%
Complications are as follows (Refer to Table 4 ): above normal (Refer to Figure 4). This is mediated in
part by sympathetic activation and catecholamine
Table 4. Complication of Parenteral Nutrition release.
Complications of Parenteral Nutrition
Rare occurrences if IV vitamin 3. Which of the following is the initial enteric formula for
preparations are used the majority of surgical patients?
However, Vitamin K is not part of any a. Low-residue isotonic formula
Vitamin Deficiencies
commercially prepared vitamin
b. Elemental formula
solution so it should be supplemented
on a weekly basis c. Calorie dense formula
Clinically apparent during prolonged d. High protein formula
parenteral nutrition with fat-free
solutions Answer: A
Essential Fatty Acid Manifests as dry, scaly dermatitis and
(EFA) Deficiency loss of hair Most low-residue isotonic formulas provide a caloric
Prevented by periodic infusion of a fat density of 1.0 kcal/ml, and approximately 1500 to
emulsion at a rate equivalent to 10 to 1800 ml are required to meet daily requirements.
15% of total calories
These provide baseline carbohydrates, protein,
Essential trace minerals may be
electrolytes, water, fat, and fat-soluble vitamins. These
required after prolonged TPN
Zinc deficiency is the most common
solutions usually are considered to be the standard or
that manifests as diffuse eczematoid first-line formulas for stable patients with an intact GI
Trace Mineral tract.
rash at intertriginous areas
Deficiencies
Copper deficiency is associated with
Microcytic anemia
Chromium deficiency is associated with FLUID AND ELECTROLYTE MANAGEMENT
Glucose intolerance
OF THE SURGICAL PATIENT
May occur after initiation of parenteral
nutrition
Manifests as glycosuria A. Body Fluids and Compartments
If blood glucose levels remain elevated B. Body Fluid Changes
or glycosuria persists, dextrose C. Fluid Therapy
Relative Glucose
concentration may be decreased, D. Special Case: Refeeding Syndrome
infusion rate slowed, or regular insulin E. Electrolyte Abnormalities
Intolerance
added to each bottle F. Acid-Base Disorders
Rise in blood glucose may be
temporary, as the normal pancreas
increases its output of insulin in
response to the continuous A. BODY FLUIDS AND COMPARTMENTS
carbohydrate infusion Water constitutes ~50-60% of total body weight
Due to large glucose infusion, a Relationship between total body weight and total body
significant shift of potassium from water (TBW) is relatively constant for an individual
Hypokalemia
extracellular to intracellular space may and is primarily a reflection of body fat
(and Metabolic
take place
Acidosis) o Lean tissues (e.g. muscle and solid organs)
Manifests as glycosuria, which is
treated with potassium, NOT insulin
have higher water content than fat and bone
Lack of intestinal stimulation is o TBW of average young adult male and
associated with intestinal mucosal female is 60% and 50%, respectively of
atrophy, diminished villous height, total body weight
Intestinal Atrophy bacterial overgrowth, reduced Estimates of %TBW should be adjusted downward
lymphoid tissue size, reduced ~10-20% for obese individuals and upward by ~10%
immunoglobulin A production, and for malnourished individuals
impaired gut immunity
Highest percentage of TBW is found in newborns
(~80%)
REVIEW QUESTIONS a
QUICK REVIEW a
1. Prostacyclin has which of the following effects in
systemic inflammation?
a. Inhibition of platelet aggregation TBW is ~50-60% of total body weight
b. Vasoconstriction TBW (Male): 60%of total body weight
c. Increased adhesion molecules TBW (Female): 50%of total body weight
d. Decreased cardiac output Young lean males have a higher proportion of TBW than
elderly or obese individuals
Answer: A Lower percentage of TBW in females generally
correlates with a higher percentage of adipose tissue and
Prostacyclin is a member of the eicosanoid family and lower percentage of muscle mass
is primarily produced by endothelial cells. It is an
effective vasodilator and also inhibits platelet
aggregation. During systemic inflammation, TBW is divided into 3 functional fluid compartments
prostacyclin expression is impaired and thus the (Refer to Table 5 ):
endothelium favors a more procoagulant profile. o Plasma (extracellular)
o Interstitial fluid (extracellular)
2. Sepsis increases metabolic needs by approximately o Intracellular fluid
what percentage?
a. 25%
b. 50%
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 5 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
Table 5. Functional Body Fluid Compartments Table 6. Normal Fluid Balance
Extracellular fluid PLASMA (1) Water Gain Water Loss
Total (1/3 of TBW or (5% of total body weight) Urine
Body 20% of total body INTERSTITIAL FLUID (2) Oral fluids 800-1200 ml
Water weight) (15% of total body weight) 1,500 ml Stool
(TBW) INTRACELLULAR FLUID (3) Sensible
250 ml
(2/3 of TBW or 40% of total body weight) Solid fluids Sweat
500 ml 0 ml
Water of oxidation Skin
Extracellular fluid compartment (ECF) is balanced Insensible
250 ml 450 ml
between sodium (Na2+), the principal cation, and Water of solution Lungs
chloride (Cl-) and bicarbonate (HCO3-), the principal 0 ml 150 ml
anions(Refer to Figure 6)
o Composition of the plasma and interstitial fluid
differs only slightly in ionic composition 1. Extracellular Volume Deficit
o Slightly higher protein content (anions) in Most common fluid disorder in surgical patients
plasma results in a higher plasma cation Can either be acute or chronic (Refer to Table 7)
composition relative to the interstitial fluid o Acute volume deficit is associated with
Intracellular fluid compartment (ICF) is comprised cardiovascular and central nervous system
ofcations, potassium (K+) and magnesium (Mg2+), and signs
theanions, phosphate(HPO4-) and proteins o Chronic deficit displays tissue signs such as
Concentration gradient between compartments is decrease in skin turgor and sunken eyes, in
maintained by adenosine triphosphate (ATP) driven addition to acute signs
sodium-potassium pumps located with the cell
Table 7. Signs and Symptoms of Volume Disturbances
membranes
System Volume Deficit Volume Excess
Weight loss Weight gain
Figure 6. Chemical composition of body fluid compartments 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 --
Renal
Azotemia
GI Ileus Bowel edema
Pulmo -- Pulmonary edema
3. Hyperkalemia
Serum K+ concentration above the normal range of
3.5-5 mEq/l
Caused by excessive K+ intake, increased release of K+
from cells, or impaired K+ excretion by the kidneys
(Refer to Table 12)
Clinical manifestations || Mostly GI (nausea/vomiting,
diarrhea), neuromuscular (weakness, paralysis), and
cardiovascular (arrhythmia, arrest)
ECG changes ||High peaked T waves (early),
widened QRS complex, flattened P wave, prolonged PR
interval (first-degree block), sine wave formation and
Treatment ||Management of water deficit ventricular fibrillation
In hypovolemic patients, volume should be restored Treatment ||Reducing total body K+, shifting K+ from
with normal saline before concentration abnormality is extracellular to intracellular space, and protecting cells
addressed from the effects of increased K+
Once adequate volume is achieved, water deficit is Exogenous sources of potassium should be removed,
replaced using a hypotonic fluid including K+ supplementation in IV fluids
Rate of fluid administration should be titrated to K+ can be removed from the body using a cation-
achieve a decrease in serum sodium concentration exchange resin such as Kayexalate that binds K+ in
of no more than 1 mEq/l/h exchange for Na+
Overly rapid correction can lead to cerebral edema Immediate measures also should include attempts to
and herniation shift K+ intracellularly with glucose, insulin and
bicarbonate infusion and nebulized salbutamol(10-
2. Hyponatremia 20 mg)
Occurs when there is an excess of extracellular water When ECG changes are present, calcium chloride or
relative to sodium calcium gluconate (5-10 ml of 10% solution) should be
Extracellular volume can be high, normal, or low (Refer administered immediately
to Figure 8) All measures are temporary, lasting from 1 to 4 hours
In most cases, sodium concentration is decreased as a Dialysis should be considered in severe hyperkalemia
consequence of either sodium depletion or dilution when conservative measures fail
Symptomatic hyponatremia does not occur until serum
sodium level is 20 mEq/l 4. Hypokalemia
Clinical manifestations || Primarily central nervous More common than hyperkalemia in the surgical patient
system in origin (headache, confusion, seizures, coma) Caused by inadequate K+ intake, excessive renal K+
associated increases in intracranial pressure 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,
Table 15. Etiology of Metabolic Alkalosis 1. A patient develops a high output fistula following
Increased bicarbonate generation abdominal surgery. The fluid is sent for evaluation with
Chloride losing (urinary chloride > 20 mEq/l) the following results: Na+ 135, K+ 5, Cl- 70. Which of the
Mineralocorticoid excess following is the most likely source of the fistula?
Profound potassium depletion a. Stomach
Chloride sparing (urinary chloride < 20 mEq/l) b. Small bowel
Loss from gastric secretions (emesis or nasogastric suction) c. Pancreas
Diuretics d. Biliary tract
Excess administration of alkali
Acetate in parenteral nutrition Answer: C
Citrate in blood transfusions The composition of pancreatic secretions is marked by
Antacids
high level of bicarbonate (Refer to Table 8), compared
Bicarbonate
to other GI secretions. In this example, the patient has a
Milk-alkali syndrome
Impaired bicarbonate excretion
total of 140 mEq of cation (Na+ + K+) and only 70 mEq of
Decreased glomerular filtration anion (Cl-). The remaining 70 mEq (to balance the 140
Increased bicarbonate reabsorption (hypercarbia or potassium mEq of cation) must be bicarbonate.
depletion)
2. A postoperative patient with a potassium of 2.9 is given
1 mEq/kg replacement with KCl (potassium chloride).
3. Respiratory Acidosis Repeat tests after the replacement show the serum K to
Associated with retention of CO2 secondary to be 3.0. The most likely diagnosis is:
decreased alveolar ventilation a. Hypomagnesemia
Principal causes are listed in Table 16 b. Hypocalcemia
Because compensation is primarily a renal mechanism, c. Metabolic acidosis
it is a delayed response d. Metabolic alkalosis
In the chronic form, partial pressure of arterial CO2
remains elevated and the bicarbonate concentration Answer: A
rises slowly as renal compensation occurs In cases in which potassium deficiency is due to
Treatment || Directed at the underlying cause magnesium depletion, potassium repletion is difficult
Measures to ensure adequate ventilation through unless hypomagnesemia is first corrected.
bilevel positive airway pressure or endotracheal Alkalosis will change serum potassium (a decrease in 0.3
intubationare also initiated mEq/l for every 0.1 increase in pH above normal). This is
not enough to explain the lack of response to repletion in
the patient. Metabolic acidosis would not decrease
potassium. Calcium does not play a role in potassium
metabolism.
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 11 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
Extent of vasoconstriction varies with the degree of
3. Which of the following is a cause of acute vessel injury (more pronounced in vessels with medial
hypophosphatemia? smooth muscles)
a. Chronic ingestion of magnesium containing
laxatives 2. Platelet Plug Formation
b. Insulin coma Platelets do not normally adhere to each other or to the
c. Refeeding syndrome vessel wall but during vascular disruption, they form a
d. Rhabdomyolosis hemostatic plugthat aids in cessation of bleeding
Injury to the intimal layer in the vascular wall exposes
Answer: C von Willebrand's factor (vWF), a subendothelial
Acute hypophosphatemia is usually caused by an protein, where platelets adhere via glycoprotein I/IX/V
intracellular shift of phosphate in association with After adhesion, platelets initiate a release reaction that
respiratory alkalosis, insulin therapy, refeeding recruits other platelets to seal the disrupted vessel
syndrome, and hungry bone syndrome. Clinical The aforementioned process, mediated by adenosine
manifestations include cardiac dysfunction or muscle diphosphate (ADP) and serotonin,is reversible and is
weakness but are usually absent until levels fall known as primary hemostasis
significantly. Refer to page 8 for a discussion on In the second wave of platelet aggregation,
refeeding syndrome. anotherrelease reaction occurs that results in
Magnesium containing laxatives can cause compaction of the platelets viaglycoprotein IIb/IIIa into
hypermagnesemia in patients with renal failure but does a plug
not affect phosphorous. Patients with insulin coma With fibrinogen as a cofactor, this process, mediated by
(hypoglycemia) are not at risk for hypophosphatemia. ADP, Ca2+, serotonin, TXA2, is irreversible
Rhabdomyolosis is associated with hyperkalemia and
hyperphosphatemia 3. Fibrin Formation / Coagulation
As a consequence of the release reaction, alterations
occur in the phospholipids of the platelet membrane
HEMOSTASIS, SURGICAL BLEEDING, that initiates coagulation
AND TRANSFUSION Coagulation cascade typically has been depicted as two
intersecting pathways
A. Hemostasis o Intrinsic pathway begins with factor XII and
B. Evaluation of Hemostatic Risk through a series of enzymatic reactions, which
C. Surgical Bleeding is intrinsic to the circulating plasma and no
D. Special Cases surface is required to initiate the process
E. Transfusion o Extrinsic pathwayrequires exposure of
tissue factor on the surface of the injured
vessel wall to initiate the arm of the cascade
A. HEMOSTASIS beginning with factor VII
Function is to limit blood loss from an injured vessel o The two arms of the coagulation cascade
Four major physiologic events participate in the merge to a common pathway at factor X, and
hemostatic process(Refer to Figure 9): activation of factors II (prothrombin) and I
o Vascular constriction (fibrinogen)proceeds in sequence
o Platelet plug formation Secondary hemostasis or fibrin clot formation
o Fibrin formation occurs after conversion of fibrinogen to fibrin
o Fibrinolysis
Figure 9. Biology of Hemostasis 4. Fibrinolysis
During the wound-healing process, the fibrin clot
undergoes fibrinolysis, which permits restoration of
blood flow
This is initiated at the same time as the clotting
mechanism under the influence of circulating kinases,
tissue activators, and kallikrein, which are present in
the vascular endothelium
Plasmindegrades the fibrin mesh at various places,
which leads to the production of circulating fragments
that are cleared by proteases or by the kidney and liver
A. General Principle
REVIEW QUESTIONS a B. Primary Survey
C. Resuscitation
1. Which of the following is the most effective dosing of D. Secondary Survey
antibiotics in a patient undergoing elective colon E. Diagnostic Evaluation
resection? F. Definitive Care
a. A single dose given within 30 min prior to skin
incision
b. A single doe given at the time of skin incision A. GENERAL PRINCIPLE
c. A single preoperative dose + 24 hours of
Trauma or injury is a cellular disruption caused by
postoperative antibiotics an exchange with environmental energy that is
d. A single preoperative dose + 48 hours of beyond the body’s resilience
postoperative antibiotics
Most common cause of death for all individuals
between the ages of 1 and 44 years
Answer: A
Third most common cause of death regardless of age
Prophylaxis is the administration of an antimicrobial
Most common cause of years of productive life lost
agent(s) before and during the operative procedure to
reduce the number of microbes that enter the tissue or Initial management of seriously injured patients
body cavity. Only a single dose of antibiotic is required, according to the Advanced Trauma Life Support (ATLS)
and only for certain types of surgical procedures. There consists of the following:
is no evidence that administration of postoperative o Primary survey
doses provides additional benefit. o Concurrent resuscitation
o Secondary survey
2. What percentage of the blood volume is normally in the o Diagnostic evaluation
splanchnic circulation? o Definitive care
a. 10%
b. 20% B. PRIMARY SURVEY
c. 30% Goal is to identify and treat conditions that constitute an
d. 40% immediate threat to life (Refer to Table 29)
Assessment of the “ABCDE” (Airway with cervical
Answer: B spine protection, Breathing, Circulation, Disability,
Most alterations in cardiac output in the normal heart and Exposure)
are related to changes in preload. Increases in
Table 29. Life-threatening injuries identified during the primary survey
sympathetic tone have a minor effect on skeletal muscle
Airway
beds but produce a dramatic reduction in splanchnic
Airway obstruction
blood volume, which holds 20% of the blood volume.
Airway injury
Breathing
3. Which of the following best describes the hemodynamic Tension pneumothorax
response to neurogenic shock? Open pneumothorax
a. Increased cardiac index, unchanged venous Flail chest with underlying pulmonary contusion
capacitance Circulation
b. Increased cardiac index, decreased venous Massive hemothorax or hemoperitoneum
capacitance
c. Variable change in cardiac index (can increase Hemorrhagic shock Mechanically unstable pelvis fracture
or decrease), increased venous capacitance Extremity losses
d. Variable change in cardiac index (can increase Cardiogenic shock: Cardiac tamponade
or decrease), decreased venous capacitance Neurogenic shock: Cervical spine injury
Disability
Answer: A Intracranial hemorrhage/mass lesion
Choice B and D are most commonly associated with
septic shock. Choice C, on the other hand, is most likely 1. Airway management with cervical spine protection
seen in cardiogenic shock. Ensuring a patent airway is the first priority in the
primary survey
4. An unconscious patient with a systolic BP of 80 and a HR Efforts to restore cardiovascular integrity will be futile
of 80 most likely has? unless the oxygen content of the blood is adequate
a. Cardiogenic shock All patients with blunt trauma require cervical spine
b. Hemorrhagic shock immobilization (hard collar or placing sandbags on
c. Neurogenic shock both sides of the head with the patient’s forehead taped
d. Obstructive shock across bags to the backboard) until injury is excluded
Patients who are conscious, do not show tachypnea, and
Answer: C have a normal voice do not require early attention to the
Sympathetic input to the heart, which normally increases airway EXCEPT the following:
heart rate and cardiac contractility, and input to the o Patients with penetrating injuries to the neck
adrenal medulla, which increases catecholamine release, and an expanding hematoma
may also be disrupted (with spinal cord injury),
Imaging options include CT scan or five plain Anterior abdominal stab wounds (AASW) should be
radiograph views of the cervical spine: lateral view explored under local anesthesia in the ED to determine
with visualization of C7-T1, anteroposterior view, if the fascia has been violated
transoral odontoid views, and bilateral oblique views o Injuries that do not penetrate the peritoneal
Identification of penetrating injuries to the neck with cavity do not require further evaluation, and
exsanguination, expanding hematomas, and airway the patient is discharged from the ED
obstruction is a priority during the primary survey o Patients with fascial penetration must be
Management algorithm for penetrating neck injury further evaluated for intra-abdominal injury,
patients is based on the presenting symptoms and because there is up to a 50% chance of
anatomic location of injury (Refer to Figure 19) requiring laparotomy
All blunt trauma patients should be assumed to have o Debate remains over whether the optimal
cervical spine injuries until proven otherwise diagnostic approach is serial examination,
diagnostic peritoneal lavage
Figure 19. Algorithm for the selective management of penetrating neck (Refer to Figure 20), or CT scanning
injuries. CT = computed tomography; CTA = computed tomographic o Values representing positive findings for
angiography; GSW = gunshot wound; IR Embo = interventional radiology diagnostic peritoneal lavage are summarized
embolization in Table 33
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 intra-
abdominal organs and thus, diagnostic evaluation can
be afforded
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
18-g needle and 50-ml syringe (right picture). Vigorous
massage is used to force air bubble through the coronary
arteries. If unsuccessful, a tuberculin syringe may be
used to aspirate air from the right coronary artery. Once
Patients with fluid on FAST examination, considered a circulation is restored, patient should be kept in
"positive FAST," who do not have immediate indications Trendelenburg’s with the pulmonary hilum clamped
for laparotomy and are hemodynamically stable until pulmonary venous injury is controlled operatively.
undergo CT scanning to quantify their injuries
Management algorithm for blunt abdominal injury
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
BURNS ANATOMY a
LAYERS OF THE SKIN
A. Classification of Burns Epidermis is the outermost layer of the integument
B. Burn Depth composed of stratified squamous epithelial layer that is
C. Initial Evaluation of Burns devoid of blood vessels, consisting of 4-5 layers:
D. Management of Burns o Stratum Corneum is a superficial stratum later
E. Inhalational Injury consisting of flat, anucleated and keratinized
cells filled with keratin filaments embedded in
a dense matrix of proteins
A. CLASSIFICATION OF BURNS o Stratum Lucidum is only found in regions of
1. Thermal thick stratum corneum of palms and soles;
Flame: Most common cause for hospital admission; not found in thin skin
highest mortality (due to association with inhalational o Stratum Granulosum is polygonal cells with
injury and/or Carbon Monoxide (CO) poisoning) basophilic keratohyalin granules; 1 layer in
Contact thin skin while multiple layers in thin skin
Scald o Stratum Spinosum is a multilaminar layer of
cuboidal-like cells that are bound together by
2. Electrical means of numerous desmosomal junctions
(tonofibrils) and they produce keratin
Potential for cardiac arrhythmias; do baseline ECG i
o Stratum Basale/germinativum is a
Compartment syndromes with concurrent
mitotically active, single layer of columnar or
rhabdomyolysis is more common in high-voltage
cuboidal cells attached to the dermis via
injuries; check for neurologic or vascular compromise
hemidesmosome
Long-term neurologic and visual symptoms are also
o Mnemonics: “Californians Like Girls in String
common and thus, neurologic and ophthalmologic
Bikinis”
consultation should be done
Dermis is the connective tissue layer below the
epidermis and its basement membrane, consisting of 2
3. Chemical
layers:
Less common but usually severe
o Papillary layer appears loose that fills the
Offending agents can be systematically absorbed; may hollows at the deep surface of the epidermis
cause specific metabolic derangements
with frequent capillaries
Careful removal of toxic substance from patient and o Reticular layer appears denser and contains
irrigation of the affected area with water (~30 mins) fewer cells
EXCEPT in cases of concrete powder or powdered forms
Hypodermis is a layer of loose vascular connective
of lye, which should be swept from the patient instead
tissue infiltrated by adipocytes
to avoid activation of AlOH with water
B. BURN DEPTH
Burn wounds are commonly stratified according to
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)
2. Proliferation
Roughly spans day 4 through 12
Phase where tissue continuity is re-established
Fibroblasts and endothelial cells are the last cell
populations to infiltrate the healing wound
Strongest chemotactic factor for fibroblasts is PDGF
Upon entering the wound environment, recruited
fibroblasts first need to proliferate, and then become
activated, to carry out their primary function of matrix
B. NORMAL PHASES OF WOUND HEALING
synthesis remodeling
Normal wound healing follows a predictable pattern
Fibroblasts from wounds synthesize more collagen,
that can be divided into three overlapping phases:
proliferate less, and actively carry out matrix
1. Hemostasis and inflammation
contraction
2. Proliferation
o Type I collagen is the major component of
3. Maturation and remodeling
extracellular matrix in skin
o Type III, which is also normally present in
1. Hemostasis and Inflammation
skin, becomes more prominent and important
Hemostasis precedes and initiates inflammation with
during the repair process
the ensuing release of chemotactic factors from wound
Endothelial cells also proliferate extensively during this
site
phase of healing, participating in angiogenesis, under
Cellular infiltration after injury follows a characteristic,
the influence of cytokines and growth factors such as
predetermined sequence
TNF-alpha, TGF-beta, and VEGF
o PMNs are the first infiltrating cells to enter
Macrophages represent a major source of VEGF
the wound site, peaking at 24 to 48 hours,
stimulated by increased vascular permeability,
3. Maturation and Remodeling
local prostaglandin release, and the presence
Begins during the fibroplastic phase
of chemotactic substances
Characterized by a reorganization of previously
o These cells DO NOT play a role in collagen
synthesized collagen
deposition and collagen synthesis
Collagen is broken down by matrix metalloproteases,
and the net wound collagen content is the result of a
Macrophages (Refer to Figure 26)
balance between collagenolysis and collagen synthesis
o Recognized to be essential in successful
There is a net shift toward collagen synthesis and
wound healing
eventually the re-establishment of extracellular matrix
o Achieve significant numbers by 48 to 96
composed of a relatively acellular collagen-rich scar
hours post injury and remain present until
Wound strength and mechanical integrity in the fresh
wound healing is complete
wound are determined by both the quantity and
o Participate in wound debridement via
quality of the newly deposited collagen
phagocytosis
The deposition of matrix at the wound site follows a
o Contribute to microbial stasis via oxygen
characteristic pattern: fibronectin and collagen type III
radical and nitric oxide synthesis
constitute the early matrix scaffolding,
o Activation and recruitment of other cells via
Glycosaminoglycans and proteoglycans represent the
mediators as well as directly by cell-cell
next significant matrix components, and collagen type I
interaction and intercellular adhesion
is the final matrix
molecules
By several weeks post injury, the amount of collagen in
the wound reaches a plateau, but the tensile strength
T lymphocytes
continues to increase for several more months
o Less numerous than macrophages
Scar remodeling continues for 6 to 12 months post
o Peak at about 1 week post injury and truly
injury, gradually resulting in a mature, avascular, and
bridge the transition from the inflammatory to
acellular scar
the proliferative stage of wound healing
Mechanical strength of the scar never achieves that
o Role is not fully defined
of the uninjured tissue
o Theory is that they play an active role in
modulation of the wound environment
Answer: C
PMNs are the 1st infiltrating cells to enter the wound site,
peaking at 24-48 hours. Increased vascular permeability,
local prostaglandin release and the presence of
chemotactic substances, such as complement factors, IL-
1, TNF-alpha, TGF beta, platelet factor 4, or bacterial
products, all stimulate neutrophil migration.
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 cross-linking result in decreased
Similiarity:
- histopathology: hyperkeratosis (hypertrophy of the -contain keratin (not sebum)
horny layer), acanthosis (hypertrophy of the -appear the same clinically (subcutaneous, thin-walled nodule
containing a white, creamy material)
spinous layer), and papillomatosis -treatment: excision; incision and drainage if infected; make sure to
- Tx: formalin, podophyllum, and phenol-nitric acid; remove the cyst wall to prevent recurrence
Curettage with electrodesiccation also can be used for
scattered lesions
- HPV types 5, 8, and 10: (+) association with b. Keratosis – seborrheic vs solar
squamous cell carcinoma:
lesions that grow rapidly, atypically, or ulcerate Table 43. Comparison between seborrheic keratosis and
should be biopsied actinic keratosis:
Seborrheic (or solar) Actinic keratosis
keratosis
D. INFLAMMATORY DISEASES OF THE SKIN AND
- considered as a -considered as a
SUBCUTANEOUS
premalignant lesion of SCC premalignant lesion of SCC
- appearance: light brown or (although at least 25%
a. Pyoderma gangrenosum yellow with a velvety, greasy spontaneously regress)
- Main characteristic: rapidly enlarging, destructive, texture
cutaneous necrotic lesion with undermined border and -arise in sun exposed areas
surrounding erythema (face, forearms, back of hands)
- (+) associated with a systemic disease 50% of the time -common in old age groups
(inflammatory bowel disease, rheumatoid arthritis, -sudden eruptions are
associated with internal
hematologic malignancy, and monoclonal
malignancies
immunoglobulin A gammapathy) -treatment: topical 5-
- Tx: Recognition of the underlying disease, systemic fluorouracil, surgical excision,
steroids or cyclosporine & chemotherapy with electrodesiccation, and
aggressive wound care and skin graft coverage dermabrasion
- Prognostic indicators:
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 35 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
Extramammary Paget’s disease melanomas 4 mm in thickness and for those with
- cutaneous lesion that appears as a pruritic red patch associated satellosis. Moh’s chemosurgery is not
that does not resolve appropriate for the treatment of any melanomas. The
- histologically similar to the mammary type. indications for elective lymph node dissection remain
controversial. Sentinel lymph node biopsy is indicated
for aptients with melanoma 1 mm or thicker with
REVIEW QUESTIONS clinically negative nodes. The indication is extended to
patients with 0.75 mm thick melanomas if they are
1. Match the item in the left hand column with the Clark’s level IV or ulcerated. Patients with clinically
appropriate item in the right hand column positive lymph nodes with no evidence of distant
disease on metastatic workup (CT of chest, abdomen
a. modulate cold sensation a. Ruffini’s and pelvis; MRI of brain; PET) should undergo radical
endings regional lymphadenectomy. Patients with primary
b. modulate sensitivity to warmth b. Krause’ end- tumors 4 mm or greater with clinically negative nodes
bulb should undergo metastatic workup before undergoing
c. modulate sensation of pressure c. Meissner’s sentinel node biopsy and wide local excision.
corpuscles
d. modulate tactile sensation d. Pacinian 3. With regards to keloids and hypertrophic scars, which of
corpuscles the following statements is/are true?
e. modulate thermoregulation e. autonomic
nerve endings A. There are no histologic differences between the two
B. The differences between hypertrophic scar and
Answer: A-b; B-a; C-d; D-c; E-e keloid are clinical, not pathologic
A variety of highly specialized structures are responsible C. Hypertrophic scars outgrow their original borders
for modulating the skin’s various sensory functions. The D. Hypertrophic scars and keloids have been treated
numbers of these structures vary with the region of the successfully with intralesional injection of steroids
body. Pacinian corpuscles are found in the E. Keloids are seen in dark-skinned individuals,
subcutaneous tissue, in the nerves of the palm of the whereas hypertrophic scars are seen in fair-skinned
hand and the sole of the foot, and in other areas. Each of individuals
these corpuscles is attached to and encloses the
termination of a single nerve fiber. They are involved in Answer: A,B,D
the sensation of pressure. Ruffini’s endings are a variety Histologically, keloids and hypertrophic scars appear the
of nerve endings in the subcutaneous tissue of the same. Hypertrophic scars are thick, red, raised scars
fingers and modulate sensitivity to warmth. Krause’s that do not outgrow their original borders, whereas
end-bulbs are formed by the expansion of the keloids do. Keloids are dense accumulations of fibrous
connective tissue sheath of medullated fibers and are tissue that form at the surface of the skin. The defect
involved in the sensation of cold. Meissner’s corpuscles appears to result from a failure in collagen breakdown
occur in the papillae of the corium of the hands, the feet, rather than an increase in its production. Keloids and
the skin of the lips and other areas concerned with hypertrophic scars have been successfully treated with
tactile sensation. Autonomic fibers that synapse to intralesional steroid injectin, radiation, pressure and the
sweat glands and receptors in the vasculature govern use of silicone gel sheets.
thermoregulation.
Table 49. Location and drainage pattern of breast D. INFECTIOUS AND INFLAMMATORY DISORDERS OF
Name location drainage THE BREAST
Lateral medial or upper extremity; receives
(axillary posterior to the 75% drainage of the
a. Breast abscess
vein vein breast; most common site
group) – of axillary LN metastasis - Staphylococcus aureus (more localized & deep) and
level I Streptococcus (diffuse superficial involvement) species:
Anterior or lower border of lateral aspect of the breast causative organisms
pectoral the pectoralis - SSx: point tenderness, erythema, and hyperthermia.
(external minor muscle - Risk factor: lactation (because a lactating breast is an
mammary contiguous with excellent culture medium)
group) – the lateral - Tx: preoperative UTZ + incision & drainage (if already
level I thoracic vessels with suppuration) + local wound care (warm
Posterior posterior wall of lower posterior neck, the
compresses &IV antibiotics - penicillins or
of the axilla at the posterior trunk, and the
subscapula lateral border of posterior shoulder cephalosporins).
r (scapular the scapula Remember: Biopsy of the abscess cavity wall is
group) – contiguous with recommended at the time of I&D rule out breast
level I the subscapular cancer with necrotic tumor.
vessels - Chronic breast abscesses: consider acid-fast bacilli,
Central embedded in receive lymph drainage both anaerobic and aerobic bacteria, and fungi.
group – the fat of the from the axillary vein, If fungal. Consider blastomycosis or sporotrichosis
level II axilla lying external mammary, and
(rare)
immediately scapular groups of lymph
posterior to the nodes, and directly from the
pectoralis minor breast b. Epidemic puerperal mastitis
muscle - MRSA: causative organism
Apical posterior and from all of the other groups - Transmission via suckling neonate
(subclavicu superior to the of axillary lymph nodes - Tx: stop breastfeeding , antibiotics & I&D
lar group) upper border of
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 37 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
c. Nonepidemic (sporadic) puerperal mastitis
- involvement of the interlobular CT of the breast e. Sclerosing adenosis
- tx: Emptying of the breast using breast suction pumps + - Common in childbearing and perimenopausal years
antibiotics - no malignant potential.
- characterized by distorted breast lobules + multiple
d. Zuska's disease (recurrent periductal mastitis) microcysts + benign calcifications
- recurrent retroareolar infections and abscesses.
- Risk factor: smoking f. Radial scars (1 cm or less) or Complex central
- Tx: antibiotics + I&D as necessary. sclerosis (more than 1 cm)
- characterized by central sclerosis, epithelial
e. Hidradenitis suppurativa proliferation, apocrine metaplasia, and papilloma
- can also occur in the nipple-areola complex formation
- originates within the Montgomery glands or axillary - can mimic cancer hence an excisional biopsy is done to
sebaceous glands. to exclude diagnosis of cancer
- Risk factor: chronic acne
- may mimic Paget's disease of the nipple or invasive g. Ductal hyperplasia
breast cancer. - Severity:
- Tx: Antibiotic + I&D Mild: 3-4 cell layers above the basement
membrane.
f. Mondor’s disease Moderate:5 or more cell layers above the basement
- a benign self limited condition which is a variant of membrane.
thrombophlebitis that involves the superficial veins of Florid ductal epithelial hyperplasia: occupies at
the anterior chest wall and breast. least 70% of a minor duct lumen.
- Involved veins: lateral thoracic vein, the - associated with an increased cancer risk
thoracoepigastric vein, and, less commonly, the
superficial epigastric vein. h. Intraductal papillomas
- SSx: acute pain in the lateral aspect of the breast or the - Seen in premenopausal women.
anterior chest wall with palpation of a tender, firm cord - common symptom: serous or bloody nipple
along the distribution of the major superficial veins. discharge
- Tx: anti-inflammatory medications + warm compresses - Gross appearance: pinkish tan, friable,
along the symptomatic vein + Restriction of motion of - rarely undergo malignant transformation & no
the ipsilateral extremity and shoulder + brassiere increased risk of breast cancer, unless multiple
support of the breast are important (4 to 6 weeks) or
excision of vein (if not improving) i. Atypical proliferative disease
- has some of the features of Ca in situ but lack a major
E. COMMON BENIGN DISORDERS AND DISEASES OF defining feature of Ca in situ or have the features in less
THE BREAST than fully developed form
a. Fibroadenoma - Atypical ductal hyperplasia & lobar hyperplasia
- seen predominantly in younger women aged 15 to 25 Increases risk of breast cancer 4x; if with (+)
years family hx, 10x
- can be self limiting
- if greater than 3cm consider giant fibroadenoma F. BREAST CANCER
- if multiple (more than 5 lesions in 1 breast) - risk factors
considered as abnormal increased exposure to estrogen: early menarche,
- tx: cryoablation, surgical removal or observation nulliparity, late menopause, older age at first live
birth (after the age of 30 yo), HRT, obesity, (major
b. Cyclical mastalgia and nodularity source of estrogen in postmenopausal women is
- associated with premenstrual enlargement of the breast the conversion of androstenedione to estrone by
- physiologic. adipose tissue)
- If Painful nodularity persists for >1 week of the radiation exposure: patients with multiple
menstrual cycle consider a disorder. fluoroscopies, mantle radiation for treatment of
- bilateral bloody nipple discharge can be seen in hodgkin’s lymphoma
epithelial hyperplasia of pregnancy increased alcohol intake (leads to increased
estradiol levels)
c. Breast cysts high fat diet (increased serum estrogen levels)
- occurs when the stroma involutes too quickly, and prolonged use of OCPs (particularly estrogen-
alveoli remain forming microcysts & macrocysts plus-progesterone) and HRT
- characteristics of benign lesions: sharp, smooth (+) family history of breast cancer: the greater
margins, a homogenous interior and posterior the number of relatives affected, the closer the
enhancement (vs malignancy which will show irregular genetic relationship, the younger the age at
and jagged margins, heterogenous interior and posterior diagnosis, and the presence of bilateral versus
shawoding) unilateral disease all increased the likelihood of
- management: needle biopsy ( 1st line investigation for development of breast cancer in an individual.
palpable breast masses)
if (+) fluid on aspiration aspirate to dryness, no MUST KNOW
need to do cytologic examination Remember:
If after aspiration, (+) residual mass do UTZ
guided needle biopsy Smoking is not considered a risk factor for breast
If blood stained fluid aspirate 2 mL for cytologic cancer!!!!!!!!!!! Please don’t make the mistake of answering this
examination, utz imaging and biopsy solid areas as part of the risk factors in breast cancer.
- If complex cyst rule out malignancy.
Table 52. TNM breast cancer staging Distant metastases (stage IV)
T N M Not anymore curative but may prolong
T1: <2cm N1: suspicious M1: (+) lung, survival
T2: 2-5 cm mobile liver or bone
T3: >5cm axillary nodes involvement - Breast cancer prognosis
T4: (+) chest N2: matted or
wall & direct fixed axillary
5 year survival rate
skin nodes Stage I: 94%
involvement N3: ipsilateral stage IIA: 85%
internal stage IIB: 70%
mammary stage IIIA: 52%
nodes stage IIIB: 48%
stage IV: 18%
(+) supraclavicular nodes: stage III disease (not
stage IV as formerly classified) - surgical techniques in breast cancer tx
sentinel LN dissection: used to assess the regional
- Treatment for breast cancer LN in women with early breast ca who are
Treatment is dependent on the stage at diagnosis clinically node negative by PE & imaging studies
Early invasive breast cancer (stage I, IIa, IIb) breast conservation therapy (BCT)
Lumpectomy +/- RT (breast conservation sx) if stage 0, I & II, BCT is preferable to total
is an acceptable tx option since survival rates mastectomy ( with equivalent survival rates)
are comparable to total mastectomy. mastectomy and axillary dissection
However, recurrence ↑er in the simple mastectomy: removes all breast
lumpectomy with no RT stage I and II tissue, the nipple-areola complex, skin & level I
breast cancer. LN
CI to breast conservation sx: Modified radical mastectomy: removes all
prior RT to the breast or chest wall breast tissue, the nipple-areola complex, skin,
involved surgical margins or unknown & level I and level II LN.
margin status after re-excision preserves pectoralis major, pectoralis
multicentric disease minor, level III LN & medial (anterior
scleroderma or lupus erythematosus. thoracic) pectoral nerve
If clinically negative nodes but with T1-T2 complications
primary ca perform sentinel LN o most frequent: Seromas beneath the
dissection skin flaps or in the axilla
If (+): perform axillary lymph node o injury to the long thoracic nerve
dissection should be performed. (affects serratus anterior)
Adjuvant chemotherapy is indicated for node- winging of scapula
positive cancers, >1 cm, and node-negative o lymphatic fibrosis painless, slow
cancers of >0.5 cm when adverse prognostic progressive swelling of the involved
features (blood vessel or lymph vessel arm
invasion, high nuclear grade, high histologic o injury to the axillary vein
grade, HER-2/neu overexpression, and sudden painful early postoperative
negative hormone receptor status). swelling of the involved arm (due to
Tamoxifen therapy: women with hormone acute thrombosis as the collateral
receptor (+) cancer that are >1 cm.
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 41 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
channels do not have the chance to - tx:
develop acute and painful) if benign total excision with 2-3 cm margin
o injury to the thoracodorsal if malignant total mastectomy w/o axillary LN
vascular pedicle ischemic loss of dissection; if small wide excision with 2cm
the entire latissimus dorsi flap margin is acceptable
utilized for reconstruction if large mastectomy.
o injury to the medial pectoral Follow up is important due to high local recurrence
pedicle progressive atrophy of rate
the pectoralis muscle
o injury to the 2nd intercostals c. Inflammatory breast cancer
brachiocutaneous nerve - variant of infiltrating ductal ca
hypesthesia of the upper inner - characterized by the skin changes of brawny
aspect of the ipsilateral arm induration, erythema with a raised edge, and
Halsted radical mastectomy: removes all edema or peau d'orange (hence the name
breast tissue and skin, the nipple-areola inflammatory) + breast mass
complex, the pectoralis major and pectoralis - appearance is due to a dermal lymphatic
minor muscles & the level I, II, and III LN. invasion
A. RISK FACTORS FOR TUMORS OF HEAD AND NECK D. CANCER OF THE TONGUE
- muscular structure with overlying nonkeratinizing
- tobacco & alcohol: most common preventable risk squamous epithelium.
factors associated with head and neck CA. - Posterior border: circumvallate papillae
- betel nut chewing - Tongue cancer
- reverse smoking Same risk factors with other H&N CA
- HPV 16 and 18. Associated with plummer-vinson syndrome
- UV light exposure (for lip CA) (cervical dysphagia, IDA, atrophic oral mucosa,
- Patients with H&N CA are predisposed to the brittle spoon finger nails)
development of a 2nd tumor within the aerodigestive Clinical findings: ulcerations or as exophytic
tract. masses
presentation of a new-onset dysphagia, The regional lymphatics of the oral cavity are to the
unexplained weight loss, or chronic submandibular space and the upper cervical
cough/hemoptysis must be assessed lymph nodes
thoroughly in patients with a history of prior Involvement of lingual nerve ipsilateral
treatment for a head and neck cancer paresthesias
ex. If (+) primary malignancy of oral cavity Involvement of hypoglossal nerve deviation of
orpharynx secondary malignancy at cervical tongue on protusion + fasciculations atrophy
esophagus; (+) primary malignancy at larynx most common location: lateral and ventral surfaces
secondary malignancy at lungs
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 43 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
if base of the tongue advanced stage and poorer MRI: assess for intracranial and soft-tissue
prognosis extension.
tx: - Tx: chemoradiation
Surgical treatment of small (T1–T2) primary
tumors is wide local excision with either H. TUMORS OF THE OROPHARYNX
primary closure or healing by secondary - Direct extension of tumors from the oropharynx into
intention. these lateral tissues may involve spread into the
If base of tongue Partial glossectomy with parapharyngeal space
supraomohyoid dissection if N0 or MRND if - histology of the majority of tumors in this region is
N(+) squamous cell carcinoma
- (+) asymmetrical enlargement of the tonsils and tongue
E. TUMORS OF ALVEOLUS/GINGIVAL base think lymphoma
- Because of the tight attachment of the alveolar mucosa - Clinical findings: ulcerative lesion, exophytic mass,
to the mandibular and maxillary periosteum, treatment tumor fetor, muffled or "hot potato" voice (large tongue
of lesions of the alveolar mucosa frequently requires base tumors), Dysphagia, weight loss, Referred otalgia,
resection of the underlying bone. (tympanic branches of CN IX & CN X), Trismus
- Diagnosis for alveolar or gingival cancer (involvement of the pterygoid musculature), ipsilateral
Panorex: demonstrate gross cortical invasion or bilateral nontender cervical lymphadenopathy
CT: imaging subtle cortical invasion - LN metastasis from oropharyngeal cancer most
MRI: demonstrates invasion of the medullary commonly occurs in the subdigastric area of level II.
cavity Others - levels III, IV, & V, retropharyngeal &
- Tx for alveolar or gingival cancer parapharyngeal LN.
If minimal bone invasion: mandibular resection Bilateral metastases: seen in tumors originating
If (+) medullary cavity invasion: segmental from the tongue base and soft palate; if found in
mandibulectomy these areas associated with poor survival
- Tx:
F. ANATOMY OF PHARYNX Options: surgery, primary radiation alone, surgery
- three regions: with postoperative radiation, & combined
nasopharynx chemotherapy with radiation therapy.
extends from the posterior nasal septum and If tongue base crossing middling: do total
choana to the skull base glossectomy with possible total laryngectomy
includes fossa of rossenmuller, Eustachian Tumors of the oropharynx tend to be
tube orifices (torus tuberous) and adenoid pad radiosensitive.
bilateral regional metastatic spread in this
area is common I. TUMORS OF THE HYPOPHARYNX/CERVICAL
Lymphadenopathy of the posterior triangle ESOPHAGUS
(level V) of the neck should provoke - Squamous cancers of the hypopharynx frequently
consideration for a nasopharyngeal primary present at an advanced stage, hence are associated with
Oropharynx: poorer survival rates
Includes tonsillar region, base of tongue, soft - Clinical findings: neck mass, muffled or hoarse voice,
palate, and posterolateral pharyngeal walls referred otalgia, progressive dysphagia to solids
Regional lymphatic drainage for liquids, weight loss.
oropharyngeal lesions frequently occurs to the - Invasion of the larynx by direct extension vocal
upper and lower cervical lymphatics cord paralysis (if unilaterally affected) airway
(levels II, III, IV) +Retropharyngeal compromise (if bilaterally affected)
metastatic spread - Diagnosis:
flexible fiber-optic laryngoscopy
hypopharynx.
CT and/or MRI imaging: check for regional
extends from the vallecula to the lower border
metastases (paratracheal and upper mediastinal
of the cricoid posterior and lateral to the
larynx. lymph nodes)
includes pyriform fossa, the postcricoid space, - Tx:
and posterior pharyngeal wall. T1: RT
Regional lymphatic spread is frequently T2 & T3: chemoradiation
bilateral and to the mid- and lower cervical Larynx-preserving surgical procedures: only if the
lymph nodes (levels III, IV) tumor must not involve the apex of the pyriform
sinus, vocal cord mobility must be unimpaired, and
G. TUMORS OF THE NASOPHARYNX the patient must have adequate pulmonary
- Tumors arising in the nasopharynx are usually of reserve.
squamous cell origin Bilateral neck dissection is frequently indicated
given the elevated risk of nodal metastases found
- Most common nasopharyngeal malignancy in the
with these lesions
pediatric age group: lymphoma
- Risk factors for nasopharyngeal carcinoma: area of
habitation & ethnicity (southern China, Africa, J. ANATOMY OF LARYNX:
Alaska, and in Greenland Eskimos.), EBV infection, & - divided into 3 regions:
tobacco use. supraglottis: epiglottis (lined by stratified,
- Symptoms: nonkeratinizing squamous epithelium), false vocal
nasal obstruction, posterior (level V) neck cords (lined by pseudostratified, ciliated
mass, epistaxis, headache, serous otitis media respiratory epithelium), medial surface of the
with hearing loss, and otalgia. aryepiglottic folds, and the roof of the laryngeal
Cranial nerve involvement is indicative of skull ventricles
base extension and advanced disease. has a rich lymphatic network, which
- Lymphatic spread occurs to the posterior cervical, accounts for the high rate of bilateral spread
upper jugular, and retropharyngeal nodes. of metastatic disease
- Bilateral regional metastatic spread is common. glottis: the true vocal cords, anterior and posterior
- Diagnosis for nasopharyngeal CA: commissure, and the floor of the laryngeal
flexible or rigid fiber-optic endoscope ventricle.
CT with contrast: determining bone destruction
MUST KNOW a
Atonic gastritis and abnormal distention and failure to H. pylori fecal antigen test
empty of the stomach can occur in the postoperative patient - sensitive and specific for active H. pylori infection
due to electrolyte disturbances, hyperglycemia and uremia. - can also be used to confirm cure
- Complications of PUD:
Type I: located near the angularis incisura on the lesser Table 55: Comparison of complications of PUD
curvature; usually have normal or decreased acid secretion; most Bleeding PUD Perforation Gastric outlet
common Obstruction
Type II: same with type I but with an associated active or -most common -2nd most common -rare (5% of all PUD
cause of ulcer complication of PUD complications)
quiescent duodenal ulcer; associated with normal or increased
related death -classic symptom: -usually due to
gastric acid secretion -most common patient can duodenal or
Type III: prepyloric ulcer disease; associated with normal or cause of UGIB in remember the exact prepyloric disease
increased gastric acid secretion admitted patients time of onset of -presents with bilous
Type IV: occur near the GE junction, and acid secretion is normal -presents with abdominal pain vomiting, profound
or below normal melena, hematemesis, -presents acute hypochloremic,
Type V: NSAID induced, can occur anywhere in the stomch shock abdomen with metabolic alkalosis
-abdominal pain is peritoneal signs -tx: nasogastric
uncommon (+)pneumoperitoneum suction, IV hydration
MUST KNOW a -tx: acid suppression on upright chest xray and electrolyte
and NPO, transfusion (80% of patients) repletion, and
Curling ulcers: peptic ulcers formed after severe burn injury and endocopic tx -Tx: analgesia, antisecretory
Cushing’s ulcers: peptic ulcers formed after severe brain (electrocautery + epi) antibiotics, isotonic medication, OR
damage for high risk group fluid resuscitation, - rule out
immediate OR pancreatic, gastric &
duodenal CA as a
cause of obstruction
- Pathophysiology, Clinical manifestations, diagnosis
and treatment
MUST KNOW a
Table 54: Comparison between gastric vs duodenal ulcer
Gastric ulcer Duodenal ulcer High risk lesions for massive bleeding (based on location):
Pathophysiology H.pylori, overuse of ↑ acid production & -posterior duodenal ulcer with erosion of gastroduodenal
NSAIDS & steroids H.pylori artery
Clinical Sharp burning pain in Severe epigastric pain -lesser curvature gastric ulcer with erosion of left gastric
manifestation epigastrium shortly 2-3 hours after eating; artery or branch
after eating; nausea, epigastric pain can
vomiting and anorexia also awaken them
from sleep
Diagnosis Endoscopy and biopsy Endoscopy, history, - Surgical options for PUD
(must for all gastric PE, test for H pylori 1.HSV or parietal cell vagotomy or proximal gastric
ulcers to rule out vagotomy
cancer; test for - safe (mortality risk <0.5%) with minimal side effects
H.pylori) - done by severing the vagal nerve supply to the proximal
Best test to confirm eradication of H. pylori: 2/3 of the stomach (where essentially all parietal cells
negative urea breath test are located) & preserves the vagal innervation to the
treatment Triple therapy; PPI, Triple therapy; stop antrum and pylorus and remaining abdominal viscera.
antacids and H2 smoking, alcohol
2. Taylor procedure
blockers consumption
- posterior truncal vagotomy and anterior seromyotomy
- attractive to HSV with similar results
- More than 90% of patients with PUD complain of
3. Vagotomy + drainage (V+D) procedures
abdominal pain (non-radiating, burning in quality &
- Truncal vagotomy dennervates the antrapyloric
epigastriac in location)
mechanism, therefore, some sort of procedure is needed
- Indication for endoscopy in PUD:
to bypass or ablate the pylorus
Any symptomatic patient 45 yo and up
- Types:
Any symptomatic patient regardless of age with
Truncal vagotomy and pyroplasty
alarm symptoms (see table 54) Pyroplasty – useful in patients who require
- Medical treatment for PUD: PPIs are the mainstay of pyloroduodenotomy to deal with the ulcer
therapy for PUD. complication (i.e. posterior bleeding duodenal
ulcer), limited focal a scarring in the pyloric
table 50. treatment regimens for H. pylori
region
PPI + clarithromycin 500 mg BID + amoxicillin 1000 mg BID 10-14 d
Truncal vagotomy and gastrojejunostomy
PPI + clarithromycin 500 mg BID + metronidazole 500 mg 10-14 d
BID
PPI + + amoxicillin 1000 mg BID, then 5d - disadvantage: 10% of significant dumping / diarrhea
PPI + clarithromycin 500 mg BID + tinidazole mg BID
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 58 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
4. Vagotomy and distal gastrectomy Other causes: alcohol, NSAIDs, Crohn's disease,
tuberculosis, and bile reflux
D. ZOLLINGER-ELLISON SYNDROME - Pathophysiology:
- uncontrolled secretion of abnormal amounts of infectious and inflammatory causes: result in
gastrin by a duodenal or pancreatic neuroendocrine immune cell infiltration and cytokine production
tumor (i.e., gastrinoma) leading to excessive which damage mucosal cells.
production of HCl by the parietal cells, further chemical agents (alcohol, aspirin, and bile): disrupt
excacerbating PUD. the mucosal barrier, allowing mucosal damage by
- The inherited or familial form of gastrinoma is back diffusion of luminal hydrogen ions.
associated with multiple endocrine neoplasia type 1
or MEN1 (parathyroid, pituitary, and pancreatic or F. STRESS ULCER
duodenal tumors) - Pathophysiology: due to inadequate gastric mucosal
blood flow during periods of intense physiologic
PHYSIOLOGY a stress.
Gastrin Adequate mucosal blood flow is important to
- produced by antral G cells maintain the mucosal barrier, and to buffer any
- major hormonal stimulant of acid secretion during the back-diffused hydrogen ions. When blood flow is
gastric phase. inadequate, these processes fail and mucosal
- The biologically active pentapeptide sequence at the C- breakdown occurs
terminal end of gastrin is identical to that of CCK
- Luminal peptides and amino acids are the most G. MALIGNANT NEOPLASMS OF THE STOMACH
potent stimulants of gastrin release - The three most common primary malignant gastric
- luminal acid is the most potent inhibitor of gastrin neoplasms are adenocarcinoma (95%), lymphoma
secretion. (4%), and malignant GIST (1%)
- principal mediator of gastrin-stimulated acid
production is histamine from mucosal ECL cells GASTRIC ADENOCARCINOMA
- Epidemiology & etiology
Gastric adenoCA is a disease of the elderly
Risk factors:
- Gastrinoma triangle (or Pasaro’s triangle) : where
Black race: twice more common in blacks
90% of ZES tumors are found
compared to whites
boundaries: jxn of cystic & CBD, confluence of 2nd &
Pernicious anemia
3rd segments of the duodenum and jxn of body and
Blood group A
neck of pancreas
FH of gastric CA
- most common symptoms of ZES are epigastric pain,
Diet: starchy diet high in pickled, salted, or
GERD & diarrhea. Can also be associated with
smoked food, nitrates increases risk
steatorrhea and other symptoms of malabsorption.
H. pylori
- Diagnosis:
Smoking
Fasting gastrin of 1mg/L, BAO >15 mEq/h or >5
EBV infections
mEq/h (if with previous procedure for peptic
Remember: Alcohol has no role in gastric CA
ulcer) are suggestive of ZES
protective factors: aspirin (Yes! Schwartz says so.
Confirmatory test: secretin stimulation test
You don’t believe me? Check p. 927, 9th edition),
(+) secretin stimulation test: paradoxical rise
vitamin C and diet high in fruits and vegetables
in gastrin levels (200 pg/mL or greater) upon
premalignant conditions:
administration of IV bolus of secretin (an
polyps
inhibitor of gastrin)
hyperplastic and adenomas are the
Should also check for serum calcium and PTH
types associated with carcinoma
levels to rule out MEN1.
Preoperative imaging of choice for gastrinoma: inflammatory, hamartomatous and
somatostatin receptor scintigraphy (octreotide heterotropic polyps are considered
scan) benign lesions
Basis: Gastrinoma cells contain type 2 atrophic gastritis: most common
somatostatin receptors that bind the indium- precancerous lesion / precursor of gastric
labeled somatostatin analogue (octreotide) cancer
intestinal metaplasia: can be caused by H.
with high affinity, making imaging with a
pylori
gamma camera possible
- Pathology
Gastric Dysplasia: universal precursor to
PHYSIOLOGY a gastric adenocarcinoma
Somatostatin Early gastric cancer: adenocarcinoma limited to
- produced by D cells located throughout the gastric the mucosa and submucosa of the stomach,
mucosa. regardless of lymph node status.
- major stimulus for somatostatin release is antral 4 forms of gastric cancer (Gross morphology):
acidification 1. Polypoid: bulk of tumor is intraluminal, not ulcerated
- acetylcholine inhibits its release 2. Fungating: bulk of tumor is intraluminal, ulcerated
- Somatostatin effects: inhibits acid secretion from 3. Ulcerative: bulk of tumor is within the stomach wall
parietal cells, inhibits gastrin release from G cells & 4. Scirrhous (linitis plastic): bulk of tumor is within the
decreases histamine release from ECL cells. stomach wall; infiltrate the entire thickness of stomch
- Octreotide is a somatostatin analogue and cover a large surface area, poor prognosis
Location of primary tumor: 40% distal stomach,
30% middle stomach and 30% proximal stomach
- Treatment: Most important prognosticating factors: lymph
Surgical resection of gastrinoma node involvement and depth of tumor invasion
If (+) MEN1, perform parathyroidectomy 1st
before resection of gastrinoma - Clinical manifestations:
PPI for symptomatic relief Most patients diagnosed with gastric CA have
advanced stage III or IV disease
E. GASTRITIS S/Sx:
- Definition: Mucosal inflammation
- Most common cause: H. pylori
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 59 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
weight loss and decreased food intake due
to anorexia and early satiety (most H. BENIGN GASTRIC NEOPLASMS: POLYP (see also
common) premalignant conditions of gastric adenoCA)
Abdominal pain (usually not severe and often - most common benign tumor of the stomach
ignored) - 5 types:
nausea, vomiting, & bloating. 1. Adenomatous: (+) malignant potential; 10-15% of all
Acute GI bleeding (unusual) gastric polyps
chronic occult blood loss (iron deficiency 2. hyperplastic (regenerative): most common gastric
anemia and heme+ stool) polyp (75% of all gastric polyps); occurs in the
Dysphagia: if the tumor involves the cardia of setting of gastritis and has a low malignant potential
the stomach. 3. hamartomatous: benign
Paraneoplastic syndromes - Trousseau's 4. inflammatory: benign
syndrome (thrombophlebitis), acanthosis 5. heterotopic (e.g., ectopic pancreas): benign
nigricans (hyperpigmentation of the axilla and ***Polyps that are symptomatic, >2 cm, large
groin), or peripheral neuropathy can be hyperplastic or adenomatous should be removed,
present. usually by endoscopic snare polypectomy.
Physical examination:
Enlarged Cervical, supraclavicular (on the left I. GASTRIC VOLVULUS
referred to as Virchow's node), and axillary - is a twist of the stomach that usually occurs in
lymph nodes association with a large hiatal hernia or unusually
Sister Joseph’s nodule: palpable umbilical mobile stomach without hiatal hernia.
nodue; pathognomonic for advanced - Gastric volvulus is a chronic condition that can be
disease surprisingly asymptomatic.
Blumer nodes: palpable nodularity in the - Clinical manifestations: abdominal pain and pressure
pouch of douglas; evidence of drop related to the intermittently distending and poorly
metastasis emptying twisted stomach, dyspnea (due to pressure on
the lung), palpitations (due to pressure on the
- Diagnosis pericardium) and dysphagia (pressure on the
Do endoscopy and biopsy esophagus)
Pre-operative staging: abdominal/pelvic CT - Management:
scanning with IV and oral contrast Vomiting and passage of a NGT may relieve
symptoms
- Treatment Gastric infarction is a surgical emergency
Surgery is the only curative treatment for gastric
cancer (radical subtotal gastrectomy) J. POSTGASTRECTOMY PROBLEMS
Goal in resecting gastric adenocarcinoma: grossly
negative margin of at least 5 cm to achieve R0 DUMPING SYNDROME
resection - occurs after bariatric surgery and PUD repair (after
pyloroplasty, pyloromyotomy or distal gastrectomy)
- mechanism: there is accumulation of digested food in
GASTRIC LYMPHOMA the small intestine (or abrupt delivery of hyperosmolar
- stomach is the most common site of primary GI load into the small bowel) leading to circumferential
lymphoma expansion, additional accumulation of fluids emptying
- over 95% are non-Hodgkin's type. from stomach to duodenum and sudden expulsion of
- Most are B-cell type, thought to arise in MALT food to GIT possibly due to ablation of the pylorus or
- MALT lymphomas is a form of NHL arising from the B decreased gastric compliance with accelerated
cells in the marginal zone of MALT emptying of liquids (after highly selective vagotomy)
- Is associated with chronic inflammation due to H. pylori - clinical manifestation: tachycardia, crampy abdominal
- Diligent search for extragstric disease should be done pain and diarrhea, dizziness, lightheadedness,
before giving a diagnosis of primary gastric lymphoma diaphoresis, nausea and vomiting after ingestion of a
- Treatment: chemotx is equivalent to surgery fatty or carbohydrate laden meal
due to sudden shift in electrolytes and fluids
GASTROINTESTINAL STROMAL TUMOR (GIST) combined with increased blood flow to small
- Are submucosal solitary slow growing tumors arising intestine
from interstitial cells of Cajal (ICC) - treatment:
- 2/3 of all GISTs occur in the stomach, occurring decreasing fluid and food intake to small frequent
commonly in the body portions
- defining feature of GISTS is their gain of function avoid fatty and simple sugars
mutation of protooncogene KIT, a receptor tyrosine
kinase (majority of GISTS have activated mutation in
the c-kit protooncogene, which causes KIT to be AFFERENT LIMB OBSTRUCTION (BLIND LOOP
constitutively activated, presumably leading to SYNDROME)
persistence of cellular growth or survival signals) - occurs usually after a Billroth II procedure (distal
- Epithelial cell stromal GIST: most common cell type gastric resection followed by gastrojejunal
arising in the stomach; cellular spindle type is the next anastomosis)
most common; glomus tumor type is seen only in the - location of obstruction: at the limb associated with the
stomach. gastric remnant going to the duodenum
- Markers: (+) c-KIT, a protooncogene; a characteristic - clinical manifestations: severe epigastric pain following
shared with ICC eating, bilous emesis without food
- Diagnosis: endoscopy and biopsy, - treatment: convert Billroth II to roux en-Y gastric
- Mode of metastasis: hematogenous route; most bypass (possible problem: can delay gastric emptying)
common sites: liver and lung
- Treatment:
Wedge resection with clear margins is adequate GASTRIC OUTLET OBSTRUCTION (see complications
surgical treatment of PUD as well)
Imatinib (Gleevec): a chemotherapeutic agent - presents with hypochloremic, hypokalemic
that blocks the activity of the tyrosine kinase
metabolic alkalosis dehydration
product of c-kit, is reserved for metastatic or
- as a compensatory response due to worsening
unresectable GIST. benign gastric neoplasms
dehydration, Na conservation occurs in the kidney,
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 60 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
leading to renal tubular acidosis with subsequent - Layers of the small intestine (from innermost to
aciduria outermost layers): mucosa, submucosa, muscularis
propria and serosa
REVIEW QUESTIONS Contraction of the inner circular layer causes
results in luminal narrowing
1. A patient with a vagotomy and pyloroplasty Contraction of the outer longitudinal layer results
returns with a recurrent ulcer. The best method in bowel shortening
for determining if there was an inadequate Contraction of the muscularis mucosa contribute to
vagotomy performed is mucosal or villus motility (but not peristalsis)
- Mucosal folds: plicae circulares / valvulae
a. Direct vagal stimulation conniventes
b. Stimulated gastric analysis - Peyer’s patches: most commonly located in the ileum
c. Stimulated PPI (pancreatic polypeptide) levels which are aggregates of lymphoid follicles and is a local
d. None of the above – there is no good test to source of IgA
determine inadequate vagotomy - Difference between jejunum and ileum: jejunum has
larger circumference, thicker wall, less fatty
Answer: C mesentery, and longer vasa recta
Historically, gastric analysis was performed most - Calcium is primarily absorbed in the duodenum
commonly to test for the adequacy of vagotomy in through both transcellular transport and paracellular
postoperative patients with recurrent or persistent diffusion.
ulcer. Now this can be done by assessing peripheral
pancreatic polypeptide levels in response to sham
feeding. A 50% increase in pancreatic polypeptide PHYSIOLOGY a
within 30 minutes of sham feeding suggests vagal
integrity. Representative Regulatory Peptides produced in the small
Intestine:
2. Which of the following procedures for PUD has the
highest incidence of postoperative diarrhea? Hormone Source Actions
Somatostatin D Cell Inhibits GI secretion, motility &
a. Graham patch splanchnic perfusion
b. Parietal cell vagotomy Secretin (1st S cell Stimulates exocrine pancreatic
c. Truncal vagotomy and pyloroplasty hormone discovered in secretion; stimulates intestinal
d. Distal gastrectomy without vagotomy the human body)
secretion
Cholecystokinin I cell Stimulates exocrine pancreatic
Answer: C secretion; Stimulates GB
Parietal Truncal Truncal
Cell vagotomy & vagotomy & emptying; Inhibits sphincter of
vagotomy pyloroplasty Antrectomy Oddi contraction
Operative 0 <1 1
Motilin M cell Stimulates intestinal motility
mortality Glucagon-like L cell Stimulates intestinal
rate (%)
Ulcer 5-15 5-15 <2
peptide 2 proliferation
recurrence Peptide YY L cell Inhibits intestinal motility &
(%)
Dumping(%)
secretion
Severe 0 1 1-2
B. SMALL BOWEL OBSTRUCTION
Diarrhea - Epidemiology:
most frequently encountered surgical disorder
Mild <5 25 20 of the small intestine.
Lesions can be described as:
Severe 0 2 1-2
Intraluminal: foreign bodies, gallstones,
meconium
Intramural: tumors, Crohn’s disease
associated inflammatory strictures
Extrinsic: adhesions, hernias, carcinomatosis
- Etiology:
Intra-abdominal adhesions related to prior
SMALL INTESTINE abdominal surgery: most common cause (75%
of cases)
A. Gross Anatomy and Histology Hernias
B. Small bowel obstruction Malignancy: due to extrinsic compression or
C. Ileus & other disorders of intestinal motility invasion by advanced malignancies arising in
D. Crohn’s disease organs other than the small bowel
E. Intestinal fistulas Crohn's disease.
F. Small bowel neoplasms Congenital abnormalities (i.e. midgut volvulus and
G. Radiation enteritis intestinal malrotation) diagnosed at adulthood.
H. Meckel’s diverticulum superior mesenteric artery syndrome: rare;
I. Acquired diverticulum compression of the 3rd portion of the duodenum by
J. Mesenteric Ischemia the superior mesenteric artery as it crosses over
K. Obscure GI bleeding this portion of the duodenum; seen in young
L. Intussuception asthenic individuals who have chronic symptoms
M. Short bowel syndrome suggestive of proximal small bowel obstruction.
- Pathophysiology
Gas (usually from swallowed air) and fluid (from
A. GROSS ANATOMY AND HISTOLOGY swallowed liquids and GI secretions) accumulate
- raison d'être of the GI tract because it is the principle within the intestinal lumen proximal to the site of
site of nutrient digestion and absorption. obstruction intestinal activity ↑ to overcome the
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 61 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
obstruction (seen as colicky pain and diarrhea) If partial SBO, may be approached conservatively
bowel distention ↑ intraluminal and intramural given that there is no fever, tachycardia,
pressures rise intestinal motility is eventually tenderness, or an increase in white cell count
reduced with fewer contractions If intramural (indicates perforation)
pressure becomes high enough impaired most patients with partial small obstruction
intestinal microvascular perfusion intestinal whose symptoms do not improve within 48 hours
ischemia necrosis (strangulated bowel after initiation of nonoperative therapy should
obstruction) undergo surgery.
With obstruction, the luminal flora of the small Obstruction presenting in the early postoperative
bowel (which is usually sterile) changes period (particularly those undergoing pelvic
Translocation of these bacteria to regional lymph surgery, especially colorectal procedures) pose
nodes the greatest risk for developing early
postoperative small bowel obstruction.
Partial SBO: only a portion of the intestinal lumen is obstruction should be considered if Sx of
occluded, allowing passage of some gas and fluid. intestinal obstruction occur after the initial
return of bowel function or if bowel function
Complete SBO: complete occlusion fails to return within the expected 3 to 5
days after abdominal surgery.
Closed loop obstruction: dangerous form of SBO, in Regardless of etiology, the affected intestine should
which a segment of intestine is obstructed both be examined, and nonviable bowel resected.
proximally and distally (e.g., with volvulus). In such Criteria for viability: normal color
cases, the accumulating gas and fluid cannot escape (pinkish), (+)peristalsis, and marginal
either proximally or distally from the obstructed segment, arterial pulsations.
leading to a rapid rise in luminal pressure, and a rapid
progression to strangulation. Ogilvie syndrome
- Distention of the abdomen leading to obstruction
- Clinical presentation - Tends to occur following non-abdominal procedures
Symptoms: colicky abdominal pain, nausea, (i.e. cardiac surgery)
vomiting (a more prominent symptom with - Due to a neurologic dysfunction, electrolyte
proximal obstructions than distal; vomitus is abnormality and ↑age
usually feculent), and obstipation, continued - Treatment: NGT, IV neostigmine, IV atropine (to
passage of flatus and/or stool beyond 6 to 12 hours counter bradycardia as SE of neostigmine), exploratory
after onset of symptoms (more for partial SBO than laparotomy during worst case scenario)
complete SBO)
Signs: abdominal distention (pronounced if the site C. ILEUS & OTHER DISORDERS OF INTESTINAL
of obstruction is distal ileum & absent if the site of MOTILITY
obstruction is in the proximal small intestine), - Ileus is a temporary motility disorder
initially hyperactive bowel sounds (maybe minimal - Postoperative ileus: most frequently implicated
towards the late stages of bowel obstruction) cause of delayed discharge following abdominal
Lab findings: hemoconcentration and electrolyte operations
abnormalities (reflect intravascular volume - Pathophysiology:
depletion) & Mild leukocytosis Common etiologies: abdominal operations,
Features of strangulated SBO: abdominal pain infection and inflammation, electrolyte
often disproportionate to the degree of abnormalities (↓K, ↓&↑Mg, ↓ Na) & drugs
abdominal findings ( suggestive of intestinal (anticholinergics, opiates, phenothiazine, CCB,
ischemia), tachycardia, localized abdominal Tricyclic antidepressants)
tenderness, fever, marked leukocytosis, & acidosis. Proposed mechanisms: surgical stress-induced
sympathetic reflexes, inflammatory response
- Diagnosis mediator release, and anesthetic/analgesic effects
Confirmatory test: abdominal series (radiograph Normal temporal pattern of return of GI
of the abdomen with the patient in a supine position, motility : small intestinal motility (1st 24
upright position &radiograph of the chest with the hours), gastric motility (48 hours) and colonic
patient in an upright position) motility (3 to 5 days)
Sensitivity of abdominal radiographs for - Clinical presentation (usually resembles SBO):
detecting SBO is 70-80% Inability to tolerate liquids and solids by mouth, nausea,
Triad of dilated small bowel loops (>3 cm in and lack of flatus or bowel movements, vomiting,
diameter), air-fluid levels seen on upright abdominal distention & diminished or absent bowel
films, and a paucity of air in the colon is sounds
MOST SPECIFIC - diagnosis: If ileus persists beyond 3 to 5 days
CT scan postoperatively or occurs in the absence of
80 to 90% sensitive abdominal surgery, further investigation is warranted
70 to 90% specific to rule out possibility of mechanical obstruction
Apperance of closed-loop obstruction in
CT: presence of U-shaped or C-shaped dilated CLINICAL PEARLS a
bowel loop associated with a radial
distribution of mesenteric vessels converging Measures to REDUCE postoperative ileus:
toward a torsion point. Intraoperative measures:
Appearance of strangulation in CT: - minimize handling of bowel
thickening of the bowel wall, pneumatosis - laparascopic approach, if possible
intestinalis (air in bowel wall), portal venous - avoid excessive intraoperative fluid administration
gas, mesenteric haziness and poor uptake of IV
contrast into the wall of the affected bowel. Postoperative measures
- early enteral feeding
- Treatment - epidural anesthesia, if indicated
Fluid resuscitation: isotonic replacement - avoid excessive IV fluid administration
Broad spectrum antibiotics - correct electrolyte abnormalities
NGT placement for decompression - consider m-opiod antagonists (
If complete SBO, perform surgery
COLON, RECTUM, ANUS abdominal air, bowel gas patterns suggestive of small or
large bowel obstruction and volvulus
A. Embryology - contrast studies are useful for evaluationg obstructive
B. Diagnostic evaluation of Colon, Rectum and Anus symptoms, delineating fistulous tracts and diagnosing
C. Evaluation of Common symptoms small perforations or anastomotic leaks.
D. Diverticular disease - Gastrografin (water soluble contrast agent) is
E. Colorectal adenocarcinoma recommended if perforation or leak is suspected
F. Colorectal carcinoid tumors - Double contrast barium enema is 70-90% sensitive
G. Anal intraepithelial neoplasia (Bowen’s disease) for the detection of mass lesions greater than 1 cm in
H. Volvulus diameter
I. Colonic pseudoobstruction (Ogilvie’s syndrome) If a small, non obstructing lesion is considered,
J. Hemorrhoids colonoscopy is the preferred imaging modality of
K. Anal fissure choice
L. Anorectal abcess
M. Fistula in ano 2. CT
- the utility of CT is in the detection of extraluminal
disease, such as intra-abdominal abscesses and
pericoloic inflammation and in staging colorectal
carcinoma (because of its sensitivity in detecting
A. EMBRYOLOGY
hepatic metastasis)
- Embryonic GI tract begins developing during 4th week
REMEMBER: a standard CT scan is INSENSITIVE
of gestation
for detection of intraluminal lesions
Table 57. Embryology of GI tract - If considering a perforation / anastomotic leak:
FOREGUT MIDGUT HINDGUT check for extravasation of oral or rectal contrast
Esophagus, stomach, small intestine, distal transverse - Bowel wall thickening / mesenteric stranding
pancreas, liver, ascending colon, colon, descending suggests inflammatory bowel disease, enteritis/colitis
duodenum and proximal colon, rectum, and or ischemia
transverse colon proximal anus
Celiac artery SMA IMA 3. MRI
***distal anus is derived from the ectoderm; BS: internal pudendal - the main use of MRI in colorectal DO is in the evaluation
artey of pelvic lesions
- more sensitive than CT for detecting bony involvement
- The colon has 5 distinct layers: mucosa, submucosa,
or pelvic sidewall extension of rectal tumors.
inner circular muscle, outer longitudinal muscle, and
- Can be useful in the detection and delineation of
serosa
complex fistulas in ano.
MUST KNOW
4. Positron Emission Tomography
- useful for imaging tissues with high levels of anaerobic
Most common bacterium within the colon is B. fragilis
glycolysis, such as malignant tumors
followed by E. coli and Enterococcus sp.
- F-fluorodeoxyglucose is injected as a tracer its
metabolism results in positron emission
- Used as an adjunct to CT in staging colorectal cancer
B. DIAGNOSTIC EVALUATION OF COLON, RECTUM AND
ANUS
5. Angiography
- used for the detection of bleeding within the colon or
ENDOSCOPY:
small bowel
- to visualize hemorrhage angiographically, bleeding
1.Anoscopy
must be relatively brisk (0.5 to 1 cc per minute)
- useful instrument for the examination of the anal canal
- if extravasation of contrast is identified, infusion with
- not attempted without anesthesia if patient complains
vasopressin or angiographic embolization can be
of severe perianal pain and does not tolerate digital
therapeutic.
rectal examination
2. Proctoscopy
6. Endorectal and Endoanal UTZ
- useful for the examination of the rectum and distal
- is used primarily to evaluate the depth of invasion of
sigmoid colon
neoplastic lesions in the rectum and detecting
- can be both therapeutic and diagnostic
sphincter defects & outlining complex anal fistulas
- length: 25 cm
- normal rectal wall can be seen as a 5 layer structure
- 15-19 mm diameter proctoscope is useful for diagnostic
- UTZ can reliably differentiate benign polyps from
examination
invasive tumors based upon the integrity of the
- useful for polypectomy, electrocoagulation, detorsion of
submucosal layer.
sigmoid volvulus
- Accuracy in detecting depth of mural invasion is 81-
94%
3. Flexible sigmoidoscopy and colonoscopy
- provides excellent visualization of colon and rectum PHYSIOLOGIC AND PELVIC FLOOR INVESTIGATIONS:
- can be both diagnostic and therapeutic useful in the evaluation of patients with incontinence,
- length: constipation, rectal prolapse, obstructed defecation and
60 cm: sigmoidoscope other pelvic floor disorders
100-160 cm: colonoscope
- full length insertion: 1. Manometry
may allow visualization as far as splenic flexure: -
procedure: pressure-sensitive catheter is placed in the
sigmoidoscope lower rectum catheter is withdrawn through the anal
may allow visualization as far as terminal ileum: canal and pressures recorded
colonoscope - values:
resting pressure (normal: 40-80 mmHg): reflects
IMAGING:
the function of the internal anal sphincter
Squeeze pressure (normal: 40-80 mmHg above
1. Plain x-ray and contrast studies
resting pressure): maximum voluntary contraction
- plain x-rays of abdomen (upright, supine and
pressure minus resting pressure, reflects the
diaphragmatic views) are useful for detecting free intra-
function of the external anal sphincter
TOPNOTCH MEDICAL BOARD PREP SURGERY SUPPLEMENT HANDOUT Page 67 of 81
For inquiries visit www.topnotchboardprep.com.ph or email us at topnotchmedicalboardprep@gmail.com
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
High pressure zone (normal: 2-4 cm): estimates
the kength of the anal canal 4. Diarrhea and irritable bowel syndrome
- Absence of rectoanal inhibitory reflex is - Acute bloody diarrhea and pain can be due to infection
characteristic of Hirschsprung’s disease or inflammation
- chronic diarrhea has a more difficult diagnostic
2. Neurophysiology dilemma since causes are myriad (ulcerative colitis,
- Neurophysiologic testing assesses function of the crohn’s colitis, malabsorption, short-gut syndrome,
pudendal nerve and recruitment of puborectalis muscle carcinoid, islet cell tumors, etc)
fibers
5. Incontinence
LABORATORY STUDIES: - ranges in severity from occasional leakage of gas and
liquid stool to daily loss of solid stool
1. Fecal Occult Blood testing (FOBT) - can be neurogenic or anatomic
- is a screening test for colonic neoplasms in Neurogenic: diseases of CNS, spinal cord, pudendal
asymptomatic, average-risk individuals nerve injury
- occult bleeding from any GI source will produce a Anatomic: congenital abnormalities, procidentia,
positive result (since it is a non specific test for overflow incontinence secondary to impaction,
peroxidase contained in hemoglobin) neoplasm or trauma
- any positive FOBT mandates further investigation, - Most common traumatic cause of incontinence is injury
usually by colonoscopy to the anal sphincter during vaginal delivery
K. ANAL FISSURE
- is a tear in the anoderm distal to the dentate line
- 90% of fissures are located at the posterior midline, - Treatment: fistulotomy with adequate drainage or seton
an area where the anoderm is least supported by the placement
sphincter
- Fissures located laterally should arouse suspicion of
Crohn’s, UC, syphilis, TB,leukemia REVIEW QUESTIONS
- Clinical manifestation: tearing pain with defecation
and hematochezia; often too tender to tolerate DRE 1. Which of the following is important in maintaining
- Treatment the integrity of the colonic mucosa?
Initially, can be managed conservatively with
lubricants, warm sitz bath and bulk laxatives a. short-chain fatty acids
(treatment of choice) b. alanine
Surgery: lateral subQ partial internal c. medium-chain fatty acids
sphincterectomy d. glutamine
Posterior fissurectomy & sphincterectomy
can lead to keyhole defect & constant Answer: A
soiling Short chain fatty acids are produced by bacterial
fermentation of dietary carbohydrates. Short chain
L. ANORECTAL ABCESS fatty acids are an important source of energy for
- Perianal abscess: most common manifestation and the colonic mucosa, and metabolism by colonocytes
appears as a painful swelling at the anal verge provides energy for processes such as active
- Ischiorectal abscess: happens when there is Spread transport of sodium. Lack of a dietary source for
through the external sphincter below the level of the production of short chain fatty acids, or diversion of
puborectalis; may become extremely large and may not the fecal stream by an ileostomy or colostomy, may
be visible externally; DRE will reveal a painful swelling result in mucosal atrophy and diversion colitis.
laterally in the ischiorectal fossa
- Intersphincteric abscess: occur in the intersphincteric 2. Match the organs in the left hand column with the
space and are notoriously difficult to diagnose; causes location of their referred pain in the right hand
deep pain in the rectum without external manifestation column. (items in the right may be used more than
- Pelvic and superior levator abscess: rare; may result once)
from extension of an intersphincteric or ischiorectal
abscess upward, or extension of an intraperitoneal A. Gallbladder a. epigastrium
abscess downward B. Jejunum b. periumbilical
- Horseshoe abscess: bilateral ischiorectal, supralevator C. Rectum c. hypogastrium
or perianal abscesses that communicate; begins as a D. Pancreas d. shoulder
posterior midline infection E. Appendix
- Treatment: drainage with local anesthesia
MUST KNOW a
Hesselbach’s triangle:
Inferior: inguinal ligament
Medial: rectus abdominis
Superolateral border: inferior epigastric vessels
MUST KNOW a
Answer: D
Although Ct scan is useful in ambiguous clinical Notes to figure
Segments part Corresponding side Venous drainage
presentations, little data exist to support its routine use Segment I Caudate lobe IVC
in diagnosis. The use of MRI in assessing groin hernias Segment II Left lateral superior segment Left lobe Left hepatic vein
Segment III Left lateral inferior segment Left lobe Left hepatic vein
was examined in a group of 41 patients scheduled to Segment IV Left medial segment (quadate Left lobe Middle hepatic
undergo laparoscopic inguinal hernia repair. lobe – outdated) vein
Segment V Right anterior inferior segment Right lobe Right & middle
Preoperatively, all patients underwent US and MRI. hepatic vein
Laparoscopic confirmation of the presence of inguinal Segment VI Right posterior inferior segment Right lobe Right hepatic vein
hernia was deemed as gold standard. Physical Segment Right posterior superior segment Right lobe Right hepatic vein
VII
examination was found to be the least sensitive. False Segment Right anterior superior segment Right lobe Right & middle
positives were low on physical examination and MRI VIII hepatic vein