BREAST

HISTORY & PHYSICAL

HPI. Duration, timing, intensity. Previous breast problems (biopsies). Results of recent mammography. Signs of malignancy: unilateral bloody discharge. FH. Breast cancer, ovarian cancer. Gyn Hx. Age at onset of menses, natural or surgical menopause OB Hx. Age at first full-term pregnancy, number of pregnancies Meds. Birth control pills, hormone replacement therapy, current medications PMH. Past radiation therapy, previous infections (asymmetric densities) PSH. Past operative procedures (asymmetric densities)

RISK ASSESSMENT - mainly useful in women without complaints. Most women who develop breast CA do not have significant risk factors. RR >4 RR 2-4 1st degree relative with Breast CA Hx primary CA ovary/endometrium Age @ 1st term pregnancy No Oophorectomy Obesity (postmenopausal) North American, Northern European Upper class Hx fibrocystic disease RR 1-2 Marital status (Single) Urban, northern US White race Menarche <12 y. Menopause >55y.

Age Hx of CA in 1 breast FH premenopausal bilateral breast CA

**NO link: environmental, breast implants, lack of exercise, smoking, abortions, antiperspirants, underwire brassieres. PHYSICAL EXAM

Inspection. Sitting, arms at side arms elevated toward ceiling pressing at waist ---> leaning forward. Look for dimpling, symmetry, discoloration, edema, nipple. o Nipple. Eversion/inversion. Scaliness, dryness, ulceration, retraction suggest cancer. Axilla. Arm rests on forearm of examiner. Examine lymph nodes. Palpation. Examine breasts in supine position. o Nipple. If hx spontaneous nipple discharge localize source of discharge via palpation. o Mass. Tender, fluctuant abscess.Hard, irregular cancer.

DIAGNOSTIC EVALUATION

Mammography (2-views). Suspicious: irregular/spiculated, pleomorphic/linear/ branching microcalcifications. BI-RADS classification to qualify risk... o BI-RADS. 0 Needs additional evaluation; 1 Normal; 2 Benign findings, recommend routine screening; 3 Probably benign, recommend short initial follow-up (6 month); 4 Suspicious, biopsy should be considered; 5 Highly suggestive of malignancy. Ultrasound. Best for Women <30 y. Distinguish cysts from masses. Suspicious: poorly defined margins, heterogeneous internal echoes, taller than side, irregular internal shadowing. Used for pregnant patients with breast mass. MRI. For dense tissue, scars, implants. Can do MRI-directed breast biopsy. Tissue-Sampling. Three methods: fine-needle aspiration cytology, core-needle biopsy, and open biopsy.

DIFFERENTIAL, CHEAT SHEET BY AGE

<30. Likely benign. Cystic: fibrocystic changes, cysts. Solid: fibroadenomas, phylloides. Young people have higher risk from radiation. 30-50. Assume cancer. >50. Postmenopausal Sx likely to be malignant: pain, nipple discharge, new masses.

DIAGNOSTIC WORKUP, BY FINDING Mammographic abnormality. Compare to prior mammograms.

Mass or Asymmetric Density. Can supplement with ultrasound. o Bi-Rads 3. Probably benign follow-up (observe; consider bx if pregnancy, transplant candidate, or other suspicious lesions). o Bi-Rads 4. Suspicious core needle biopsy if positive, surgery. Asymmetric Density. Can supplement with ultrasound. Microcalcification (non-palpable). Need additional spot magnification mammography. o Do stereotactic guided core needle biopsy if less suspicious. Do surgical bx with needle localization to check for ductal carcinoma if more suspicious. NO ultrasound.

Breast Mass. Tissue diagnosis.

<35. Dx by ultrasound and PE. Differential includes fibroadenoma or Phylloides tumor (large bulky mass, ulceration of overlying skin). Excision or biopsy or FNA.

Management. E.g. <1 cm, Bx shows fibroadenoma observation 14 cm local excision and axillary excision if palpable nodes with chemo if over 5 cm. Stromal overgrowth. >40. Mammogram +/- ultrasound if mass feels cystic. o Cystic. Ultrasound. Asymptomatic, simple. Re-evaluate in 3 months. Symptomatic/complex. Aspirate. Bloody biopsy; Clear fluid discard. No residual mass 2-6 month follow-up; Residual mass biopsy. o Solid. FNA/Core biopsy after imaging. Non-diagnostic/negative depends on PE/mammogram; positive treat. If mass enlarges or becomes suspicious , do a core needle biopsy. o Skin changes & edema. Inflammatory carcinoma of breast. Biopsy.

Breast Pain. Differential includes fibrocystic disease and cysts. Ask if pain varies with menstrual cycle (fibrocystic). Feel for lumpy breasts (fibrocystic).

Diagnosis. Mammography if suspicious. For cysts, aspirate (straw-colored or green fluid in fibrocystic) Management. o Fibrocystic disease. Compressive elastic bra, decrease caffeine consumption, NSAIDs, evening primrose oil capsules, Vitamin E (fibrocystic). Danazol after other treatment failure (AE: deepening of voice, hirsutism), OCPs. Discontinue HRT in postmenopausal women.

No physical/radiologic abnormality. Reassurance/follow-up.

Nipple Discharge. Differential includes ductal ectasia (clear; most likely), fibrocystic disease (clear), and intraductal papilloma (bloody). Find out if its unilateral or bilateral, if theres blood, if its single or multiple ducts, and if theres a mass.

Diagnosis and management. Mass/Mammographic abnormality default to mass work-up. o Clear discharge observation. o Bloody discharge surgical bx, mammography & physical exam, ductogram due to increased risk of cancer.

Skin changes. Differential includes breast abscess, mastitis, Pagets, inflammatory breast cancer. Mastitis shows fever, breast pain, and indurated mass.

Diagnose abscess with ultrasound and treat with surgical drainage and antibiotics. R/o inflammatory breast cancer and Pagets via tissue biopsy. Mastitis caused by staph and strep, so treat with Dicloxacillin or clindamycin. Mom can continue breastfeeding with mastitis. Nipple lesions. Differential for crusty lesion of nipple includes chronic eczematoid lesion and Pagets disease. If theres a mass, then work up the mass. If no mass, then biopsy the affected nipple.

BREAST CANCER

Lobular carcinoma in situ. Increased risk of invasive ductal or lobular carcinoma. Can just observe because theres no risk for axillary metastasis. Observe with mammogram every 6 months f or several years (risk for carcinoma is in both breasts). If its next to benign mass, still just observe. Can give Tamoxifen, which leads to 50% risk reduction. Ductal carcinoma in situ. Preinvasive, with 30-50% malignant in ten years. Must r/o atypical ductal hyperplasia with needle localization and excision (but you treat atypical ductal hyperplasia similarly to DCIS). Often find incidental microcalcifications on mammography. Rarely a mass on exam. Need biopsy (histology is solid/cribriform/ micropapillary/comedo; comedo has highest malignant potential). Treatment is simple mastectomy w/ or w/o reconstruction (<1 cm you can do lumpectomy with 1 cm margins +/- radiation; >1 cm: lumpectomy w/ 1 cm margin & radiation or total mastectomy withOUT axillary dissection). Adjuvant therapy is tamoxifen. Risk for future malignancy is in same breast. Sclerosing adenosis. Typically find clustered microcalcifications on mammography. Need core needle biopsy. Treatment is routine follow-up and observation. Infiltrating ductal carcinoma. 90% of invasive breast cancer. Firm, irregular mass, more defined than infiltrating lobular carcinoma. Infiltrating lobular carcinoma. 10% of invasive breast cancer. Difficult to detect (indistinct borders). Higher incidence of multicentricity, contralateral breast. Inflammatory carcinoma. 3% of invasive breast cancer. PE shows skin edema (peau dorange) & erythema. Diagnosis is via punch biopsy of skin changes. To stage, order CBC, LFTs, Ca, and CXR with subsequent bone scan, CT chest, CT abdomen if abnormal. Management is multimodality (pre-op chemo followed by radical mastectomy, adjuvant chemo, hormone therapy if ER+, radiation therapy to chest and LNs, and possibly more chemo). Poor prognosis. Pagets. PE shows cutaneous nipple abnormality associated with itching, burning, sticking pain. Diagnosis is by nipple biopsy, which shows dermis infiltrated by Pagets cells. Usually associated with underlying malignancy. Other breast carcinomas. o Tubular carcinoma of the breast. 1-2% of invasive breast cancer. Forms small tubules in younger women. Better prognosis than ductal or lobular. o Medullary carcinoma of the breast. 5% of invasive breast cancer. Extensive tumor invasion by small lymphocytes. Rapidly growing. Less well differentiated than tubular. Associated with DCIS. Good prognosis. o Colloid/mucinous carcinoma of the breast. 2-3% of invasive breast cancer. Clumps and strands of epithelial cells in polls of mucoid material. Older women. Good prognosis. o True papillary carcinoma. 1% of invasive breast cancer. Difficult to distinguish from intraductal papilloma. Slow rate of growth. Small, better prognosis than ductal.

BREAST CANCER, STAGING. TNM.

To stage. o Lymph involvement. Remove lymph nodes at levels 1 and 2. Can also do sentinel node technique. Look for hard, fixed lymph nodes on exam. Soft nodes could just be from inflammation/infection. o Metastasis. Most common mets to bone, lung, liver. Order CXR and LFTs. If abnormal or if symptoms present, order CT abdomen, bone scan, or CT/MRI head. Tumor size and lymph node involvement are correlated with risk of distant spread. Supraclavicular LN is a met, so automatically stage IV disease.

T: Primary Tumor o Tis Carcinoma in situ o T1 Tumor <2 cm o T2 Tumor 2-5 cm o T3 Tumor >5 o T4 Tumor any size w/ extension to chest wall/skin N: Regional Lymph Nodes o N0 No lymph node metastasis o N1 Metastasis in 1-3 axillary LNs o N2 Metastasis in 4-9 axillary LNs o N3 Metastasis >10 axillary lymph nodes M: Distant Metastasis o M0 No distant metastasis o M1 Distant metastasis Staging. Stage 0 means TisN0M0. Stage I means T1N0M0. Stage II and III are very confusing. Stage 4 means T_N_M1. Prognosis decreases with increase in stage (Stage I 96%, IV 18%).

BREAST CANCER, MANAGEMENT.

Management options. Surgery Chemo Radiation Hormone

Tamoxifen

Lumpectomy/segmental (solitary <5cm) + adjuvant Wide Excision Partial mastectomy Simple Mastectomy: (LCIS, DCIS) breast, nipple, skin total mastectomy Radical (direct extension) get LNs, pecs Modified: spare pec major Axillary Dissection

Cyclophosphamide Doxorubicin 5-Fluorouracil Taxanes

Post lumpect omy greatly decreas es likelihoo d of recurren ce

Anastrozole

Management. Stage 1 & 2 lumpectomy or radical; Stage 3 add chemo pre-op (node-positive, big lesion); Stage 4 palliative radiation, and chemo, do surgery for local control. o Surgery. Establish diagnosis, completely eradicate tumor, determine regional nodes or distant mets. Localized tumor wide excision with radiation therapy (consider cosmetics). Multicentric tumor mastectomy. Accurate staging remove axillary nodes, complete clearance is not necessary. o Cheat sheet. Adjuvant therapy depends on ER status and menopausal status. Chemo is for metastatic or recurrent disease or premenopausal women. Stage 0&1 with small tumor (<1 cm) lumpectomy, axillary sampling, radiation. If ER + do hormone therapy. Premenopausal chemo. Node-negative: ER+ hormone therapy (aromatase therapy, tamoxifen); ER- no adjuvant therapy. Node-positive: Chemo in premenopausal. ER + add tamoxifen, keep chemo in postmenopausal. Stage 1 with large tumor (>2 cm) lumpectomy, axillary sampling, radiation. Stage 2 larger lesion, node-positive disease lumpectomy/radical mastectomy for large lesions/small breasts. DCIS lumpectomy, does not require axillary staging

Atypical ductal hyperplasia, LCIS, strong FH, BRCA+ Bilateral simple (prophylactic) mastectomy.

Complications. o Surgical. Wound infection, seroma, hematoma. Poor cosmetic result. Local recurrence. Axillary ln dissection lymphedema, decreased ROM in shoulder. Long thoracic nerve injury winged scapulae. Thoracodorsal n. paralysis latissimus dorsi paralysis. Intercostobrachial n. division loss of sensation to inner upper arm. Post axillary dissection do not draw blood or put on blood pressure cuff, avoid infection to prevent permanent lymphedema. o Chemo. Nausea, vomiting, leukopenia, thrombocytopenia, alopecia, cardiotoxicity, sepsis, hemorrhagic cystitis. Use recombinant erythropoietin & GCS-F to maintain Hct & PMN levels o Tamoxifen. Hot flashes, fluid retention, vaginitis, thrombocytopenia (endometrial carcinoma, vascular thrombosis, pulmonary embolism). o Radiation. Breast edema w/ altered sensation. Chronic changes fibrosis & hyperpigmentation. Rare complications: pneumonitis & bone necrosis.

Follow-up. Bilateral mammogram 6 months after surgery, then yearly. See physician in person 2x yearly with PE every 3-6 months for 3 years then yearly thereafter. Annual CXR and LFTs. If pt received lumpectomy with radiation, do mammography every 6 months for two years with yearly mammogram thereafter. If stage 3 and 4, do pre- and post-treatment MRI. Sequelae. Abnormality of surgical site at any time biopsy for suspicion of recurrent cancer. Mammographic abnormality in opposite breast assume new cancer. Elevated LFTs mets to liver CT or MRI with gadolinium. Fracture bony mets. Decreased sensation and motor fxn R. leg extradural metastases to spine MRI. New-onset seizure brain met CT/MRI. Coma/confusion acute hypercalcemia due to bony mets & parathormone related peptide with increased alk phos.

BREAST CANCER, SCREENING

USPSTF. Biennial screening mammography for women 50-74. Decision to start screening before then based on individuals risk factors. Insufficient evidence for screening over 75. No self breast exams. Insufficient evidence for clinical breast exams.

ACOG. Women aged 40 and older receive annual screening mammography and clinical breast exams. CBEs for women aged 20-39 ever 1-3 years.

COLON
DIFFERENTIAL

Abdominal Pain. Inflammatory bowel disease, ischemic bowel. RLQ: Appendicitis, UTI, kidney stone, PID, gastroenteritis, bladder outlet obstruction, carcinoid tumor, pelvic abscess, etc. LLQ: Diverticulitis,perforation, intra-abdominal abscess, etc. Bleeding. Diverticulosis, ischemic bowel, colon cancer, angiodysplasia, ulcers, varices, rectal bleeding, inflammatory bowel disease, hemorrhoids, fissure, anal/rectal carcinoma, polyp , vascular ectasia, meckels, aortoenteric fistula, etc. Distension and N/V. Obstruction/volvulus, constipation, ileus, etc. o Obstruction. Cancer, diverticular stricture, polyps, benign tumors, ischemic structure, crohns colitis

HISTORY

HPI. Age, gender (UC: younger ppl). Pain location, quality, progression (LLQ: diverticulitis, RLQ: appendicitis, diffuse: Ischemic bowel). Prior history of similar sx. Mental/nursing institution (volvulus), seriously ill ICU (Ogilvies). ROS. Weight loss, dehydration. Abdominal pain, diarrhea, cramps, weight loss, bloody diarrhea (Crohns, UC). Skin erythema (fistula). Constipation, diarrhea, obstipation, hematochezia, melena, amount of bleeding, tenesmus (advanced carcinoma, UC), gas, time since gas/BM. Nausea/vomiting (obstruction, volvulus). Dysuria, pneumaturia, recurrent UTI. PMH. Cancer, history of STDs, atherosclerosis, Crohns, lymphogranuloma venereum, findings on prior colonoscopy, ankylosing spondylitis, peripheral arthritis, uveitis, pyoderma gangrenosum, sclerosing cholangitis, pericarditis. PSH. Prior abdominal surgeries. Medications. Aspirin (cancer protective, ischemia protective), sulindac, etc. SH. Diet (fiber intake, fat intake), alcohol, tobacco, and physical activity. FH. Cancer (FAP, Gardners, HNPCC)

PHYSICAL EXAM

Vitals: orthostatic hypotension. Inspection: Skin erythema (fistula), distension (cicatricial obstruction), scleral icterus (mets to liver). Bowel sounds: Absent, high-pitched, metallic rushes, gurgles (obstruction). Percussion: tympani (obstruction). Palpation: LLQ tenderness (diverticulitis), palpable mass (carcinoma, occ. diverticulitis), hernia sites. Rectal examination : hemorrhoids, fissures, Blummers shelf (peritoneal seeding).

LABORATORY

Laboratory. CBC for WBC (appendicitis, diverticulitis), Hgb (diverticulosis, carcinoma). Nutritional status (prealbumin, albumin, total protein). Carcinoembryonic antigen (useful for following recurrence of cancer).

DIFFERENTIAL DIAGNOSIS, BY FINDING Bleeding.

Management, general. Start 2 large IV bore needles LR, EKG, routine blood studies, CXR, coag eval., prepare blood for transfusion, place foley cath, NG tube for upper GI bleeding, anoscopy for LGI. If NG is positive for blood, do upper endoscopy.

If bleeding stops colonoscopy Vascular ectasia coagulate with monopolar current Diverticula localized for later Polyp coagulate OR Tattoo site, then operate

Technetium-labeled RBC scan (if more stable) or mesenteric angiography (if less stable) Angiogram usually pre-op

If 4-6 u. of blood given exploration (R or L hemicolectomy likely) Do NOT try to be precise. Other indications for surgical exploration include unable/hard to determine blood type, refusal of blood products. To stop bleeding before surgery, can do direct infusion of vasoconstrictor as bridging method (vasopressin, embolization during angiography).

Diverticulosis. Diagnosis is by barium enema, CT, or colonoscopy. Management includes that for general bleeding. Do not manage asymptomatic patients. o Outpatient liquid diet, PO antibiotics 7-10 days, bowel rest. o Inpatient NG suction if N/V, antibiotics, NPO. Avoid morphine, use meperidine. If massive bleeding, you can transfuse and consider surgical resection. o Nuggets:

o o o

Congenital, true diverticula: full-wall thickness in diverticular sac Acquired, false diverticula: mucosal herniations through muscular wall Most favorable area for herniation: where branches of marginal artery penetrate wall of colon

Rectal bleeding plus change in bowel habits. Diagnostic methods include DRE, Barium enema/complete colonoscopy, sigmoidoscopy, anoscopy.

Pain.

Diverticulitis. LLQ pain. Diff Dx includes perforated colon cancer, so be complete. Can follow up with barium enema in 2-3 weeks for definitive diagnosis (contraindicated acutely). If suspect perforation do CT w/ contrast (gastrografin). Can also do abdominal obstructive series. Management... o If uncomplicated and stable outpatient management with antibiotics.

o o o

If uncomplicated and elderly, immunosuppressed, high fever, very high WBC, or comorbidities admit, IV hydration, NPO, IV antibiotics (cipro/flagyl or augmentin) for 5-7 days. Serial abdominal exams to look for progression. Encourage high fiber diet. Complications of diverticulitis: Life-threatening: perforation or abscess >fistula > obstruction. If abscess <3 cm IV antibiotics, observation in hospital >3 cm CT-guided drainage >2 bouts (increased risk of complications) elective sigmoid colectomy. 30% recurrence rate of diverticulitis. Perform the surgery 4-6 weeks after inflammation resolves. Remove the affected colon. Need preop colonoscopy to localize the diverticula. Can usually do an anastomosis.

F/U with Barium Enema or Colonoscopy

Ulcerative Colitis. Classic is abdominal pain with bloody diarrhea and weight loss. Diagnosis is via endoscopy (colonoscopy) with biopsy friable, reddish mucosa w/ no normal intervening areas, mucosal exudates, pseudopolyposis. Can also try barium enema which will show lead -pipe appearance. AXRs show distended colon with mucosal edema. Other adjuncts include abdominal obstructive series, routine blood series, CT abdomen. o Treatment: Medical (antidiarrheals, sulfasalazine, mesalamine, steroids, anti-TNF, eliminate milk from diet, antibiotics). If this fails, do total colectomy with mucosal proctectomy and ileoanal pull-through. o Get colonoscopy every 1-2 years starting 8 years after onset of disease (if pancolitis; every 10 years if just left colon). Anything suspicious biopsy + random biopsies thereafter Severe dysplasia remove colon and rectum

Complications of ulcerative colitis: toxic megacolon, colonic perforation, massive hemorrhage, anorectal complications, carcinoma (risk related to extent of disease). Toxic megacolon. Abdominal pain, fever, diarrhea. Treat with gastric decompression, antibiotics, IV admin fluids, hyperalimentation, discontinue anticholinergics, NG tube, high-dose IV steroids, close observation, serial abdominal exams, abdominal x-rays. Colectomy if not improved after 24 hours. Free air or air in wall of colon ex-lap.

Obstruction.

Large bowel obstruction. Causes include carcinoma, diverticulitis, sigmoid volvulus, cecal volvulus. Abdominal X-ray shows distended proximal colon, air-fluid levels, no distal rectal air. If no sign on plain films barium enema (never give orally). If localized paralyzed ileus colonoscopy to r/o Ogilvies. Complications of large bowel obstruction include perforation, abdominal peritonitis, sepsis. o Tx: Complete bowel obstruction (no gas/BM 8-12 h.) emergent operation. o Tx: Partial bowel obstruction (some gas/stool passed) nasogastric decompression, IV fluids prepare for surgery. o Ogilvies syndrome colonoscopic decompression, possibly cecostomy. <9 cm : conservative, serial radiographs. >11-12 cm: endoscopic decompression, trial of neostigmine to increased colonic tone surgical decompression or R. colectomy.

Volvulus. AXR shows dilated cecum/sigmoid w/o haustra. Can do barium enema which shows funnellike narrowing (Birds beak). Complications include strangulation/perforation which would show fever, leukocytosis, peritoneal signs, peritonitis, and/or sepsis. o Tx: Sigmoid Volvulus. Stable detorse colon w/ rigid proctosigmoidoscopy and placement of rectal tube. Definitive sigmoid colectomy with either colostomy or anastomosis. o Tx: Cecal Volvulus urgent surgery usually R. colectomy. o Strangulation/perforation emergency operation (resection w/o anastomosis w/ temporary colostomy)

Constipation. Abdominal x-ray shows colon is full of stool. Clear vault before laxatives.

COLON PATHOLOGY, MISC. Colon cancer.

Diagnosis. Colonoscopy, CXR, CEA, LFTs. If LFTs abnormal CT of liver. Management. Local excision w/ length of normal bowel, resection of potentially involved lymph node draining basin + lymphatics. Bowel prep, oral antibiotics, single preoperative dose of 2nd gen cephalosporin. If cancer no longer confined to bowel en bloc resections. o Rectal 5-FU, resect rectum and perineum. Radiation if large bulky lesions, or extend outside bowel wall. If they dont want colostomy sphincter preserving proctecto my OR local resection. In females with cancer of the ant rectal wall take out post. vagina. For mets, do serial CEA and yearly colonoscopy. If elevated CEA CXR, CT abdomen w/ repeat colonoscopy.

Polyps.

Pedunculated. o Small. Polypectomy with further resection determined by pathology. Repeat colonoscopy in 36 months. Surveillance colonoscopy every 3 years. o Large. 5cm. Removal, because larger = more malignant risk. Again, surveillance with colonoscopy. o Severe atypia. Polypectomy w/ close colonoscopy follow up.

Sessile.

o o

Small. <2 cm. Remove via colonoscopy. Large. >2 cm. Surgical resection.

Carcinoma in situ in head of polyp polypectomy. Carcinoma in stalk of polyp polypectomy, but might need surgical resection if margin greater than 2 mm, if poorly differentiated, or if lymphatic/tissue invasion. Carcinoma in sessile lesion bowel resection with colonoscopy after 1 year.

Colovesical fistula.

Differential includes carcinoma, Crohns, radiation injury, trauma, etc. Symptoms inclu de UTI, fecaluria, pneumaturia, and sensation of voided air. Diagnose with Barium enema, cystography, or IV pyelogram.

ANAL PATHOLOGY Anal carcinoma.

Presents as a perianal fungating mass. Biopsy for histologic dx and ultrasound for depth of invasion.

Hemorrhoids. Visualize with anoscopy or sigmoidoscopy. Initial treatment with Sitz baths, stool softeners, add fiber to diet. If continued bleeding, remove in OR. Most surgeons recommend colonoscopy or sigmoidoscopy to r/o cancer.

Thrombosed hemorrhoid conservative management. If extreme pain, I&D hemorrhoid.

Squamous cell carcinoma of anus. Diagnosed via biopsy. Do TNM staging using CT and transrectal U/S for depth of invasion and presence of nodes. Local excision (surgery not necessary as first line). Follow the Nigro protocol.

Nigro protocol. Chemo and radiation for 4-6 weeks, followed by resection if biopsy shows residual cancer.

Angiodysplasia.

Most bleeding stops on its own.

Rectal prolapse.

Treatment. o Entirely internal high fiber diet o External + rectal bleeding surgery. Rectopexy (resect part of rectum with transabdominal or peritoneal rectal excision.

Perianal problems.

Anal fissure. Sx: rectal pain severe during defecation w/ ulcerated area in canal, painful when touched. Often has blood on toilet paper after wiping. Caused by trauma from passage of hard stools or IBD. Usually posterior midline. o Management: debulking agents, stool softeners, sitz baths. Biopsy any suspicious fissures to r/o cancer. If deep/chronic fissure, do a lateral sphincterotomy. o Crohns anal fissure. Symptoms include tender perineum and inflammation. Management includes surgery if... Perirectal abscess surgery. Superficial fistula open tract plus metronidazole.

Persistent perianal drainage. Sinus tract w/ granulation tissue. Differential includes fistula in-ano and residual of previous abscess that did not completely heal. o Management: unroof tract, drain, and allow tract to re-epithelialize.

Perianal abscess. Severe anal pain, fluctuant anal mass, fever. Four types. o Perianal or ischioanal drainage with perianal incision. o Intersphincteric drainage from within anal canal. o Supralevator site of drainage depends on origin. o All of the above drainage without antibiotics.

Pilonidal cyst. Sacrococcygeal. o Management: unroofing remove all hair and leave wound open to heal by secondary intention.

COLON CANCER SCREENING Normal/Mild Risk 50 Flexible Sigmoidoscopy every 5 years Yearly fecal occult blood test (3 samples) Combination of the F.S. and FOBT Colonoscopy every 10 years less proven Double contrast barium enema every 5 years

Intermediate Risk High risk

40 Teens IBD: >10 y.

Every 3-5 years Annual colonoscopy

Risk qualification. o 1st degree relative with colon CA intermediate. o Family hx FAP yearly flexible sigmoidoscopy. Colectomy at sign of first polyp. o Family hx HNPCC colonoscopy every 1-2 years starting age 20, yearly after 40 years. o Hx large/multiple adenomatous polyps re-examine three years after initial exam. o Hx resected colorectal cancer yearly colonoscopy 1 year after operation, screening at 3 years, then 5 year intervals; start screening CEA every 2-3 months for at least 2 years. Screen LFTs.

COLON CANCER STAGING

Stage A B1 B2 C1 C2 D

Dukes classification. Description Confined to mucosa Negative nodes; extension into muscularis propria Negative nodes; extension through muscularis propria Positive nodes; extension into muscularis propria Positive nodes; extension through muscularis propria Distant metastasis 5-year Survival 85-90 70-75 60-65 30-35 25 <5

TX T0 Tis T1 T2 T3 T4 NX N0 N1 N2 N3 Mx M0 M1

Primary tumor cannot be assessed no evidence of primary tumor Carcinoma in situ; intraepithelial tumor or invasion of lamina propria Submucosal invasion Muscularis propria invasion Subserosal invasion or into non peritonealized pericolic or perirectal tissues Directly invading other organs/structures or perforating visceral peritoneum REgional LNs cannot be assessed No regional LN metastasis (nodes are most important prognostic variable) 1-3 pericolic or perirectal LNs >4 pericolic or perirectal LNs Any LN along course of named vascular trunk or >1 apical node Presence cannot be assessed No distant metastasis Distant metastasis (most commonly liver; metastasizes hematogenously, intraluminally, direct extension/peritoneal seeding [Blummers shelf on DRE]) examination)

Gallbladder
PHYSIOLOGY REVIEW

Cholecystokinin and autonomic neural activity cause GB contraction. Bile contains cholesterol, bile acids, lecithin, conjugated bilirubin and protein. High [cholesterol] and low [lecithin] increased risk of stone formation. o Black stones: hemolytic diseases and cirrhosis. Found in GB. o Brown stones: infected bile. Found in ducts.

RISK FACTORS FOR GB PATHOLOGY

Increased risk. Obese, female, old, multiparity, high dose estrogen OCP, cholesterol lowering drugs, rapid weight loss, prolonged TPN, hemolytic diseases, alcoholic cirrhosis, recent pregnancy, previous diagnosis of GB pathology, and family history. NOT diabetes. Protective factors. Avoid obesity, high-fiber diet, eating meals at regular intervals, eating food with low/none saturated fats.

HISTORY History of present illness.

Biliary colic. Aka chronic gallstone pain. Steady, severe RUQ pain that can radiate to the back. Dull or aching, poorly localized, and lasts 1-4 hrs. Pain is postprandial, worse after a fatty meal. Can happen at night and not be related to food. Caused by temporary block of the gallbladder by a stone. Patient is normal between attacks. Can have nausea and vomiting. May radiate to scapula. Inflammation/infection. Sharp steady well localized pain in RUQ or epigastrium, >3hrs and can last days. Nausea and vomiting.

Extrahepatic biliary obstruction. E.g. stone in common duct. Jaundice, light-colored stool and dark tea colored urine. Sharp and severe pain. Malignancy. Dull vague pain in RUQ associated with weight loss.

Review of systems. Nausea and vomiting, flatus, intolerance to fatty foods, belching, indigestion. Past medical history. Any hemolytic disease, liver disease, pancreatic disease. Past surgical history. Any abdominal surgeries. Meds. High dose estrogen OCP, cholesterol lowering drugs. Social history. EtOH, tobacco, drugs, multiparity Family history: Anything in the differential DIFFERENTIAL

Acute cholecystitis, chronic cholecystitis, cholelithiasis, choledocholithiasis, cholangitis, gallstone pancreatitis, gallstone ileus, gallbladder cancer, ductal cancer, bile duct injury, pancreatitis Non gallbladder pathology: peptic ulcer, gastric ulcer, GERD, IBS, angina, MI, kidney stone, gastroenteritis, acute hepatitis , pleural based pneumonia.

**Basically anything that can give RUQ or epigastric abdominal pain. PHYSICAL EXAM

General: Restless or doubled over (biliary colic); sitting still due to pain (GB inflammation). Vitals: increase in pulse, fever, low BP. Abdomen: Soft with tender RUQ, Murphys sign is positive in acute chole. May get peritoneal signs or tender mass, if nontender mass think cancer.

LABORATORY

CBC with diff will show mild leukocytosis with cholelithiasis, marked leukocytosis with infections, etc. Amylase and lipase to r/o pancreatitis. LFTs (AST, ALT, Alk Phos and GGT) to localize site of injury. High alk phos indicates biliary tract pathology. Total bili and direct bili elevated in biliary tract obstruction. Ordre INR, PT, PTT if patient may go to surgery soon.

IMAGING

Ultrasound. Can detect stones in the GB and dilation of the ducts and is okay at detecting stones in ducts. Will show thickened wall or pericholecystic fluid in acute cholecystitis. Can also demonstrate liver lesions or pancreatic masses. HIDA. Will show defect in filling of GB in acute chole. Defect in filling of ducts in gallstone. Will show defect in passage of bile into small bowel in duct stone.

Also: PTC, CT, MRCP, ERCP.

MANAGEMENT OF DIFFERENTIALS

Asymptomatic gallstones. Do nothing, F/U on any future pain, watchful waiting. Biliary colic or symptomatic cholelithiasis. Elective lap chole. Dont need abx, but still need the cefotetan preop dose. If you spill bile intraoperatively you need longer dose of abx. Complications of lap chole include injury to the common duct and hepatic artery. Chronic Cholecystitis. Biliary colic with no leukocytosis or left shift. Give IV analgesics. Elective lap chole. Add cholangiogram or ERCP if ductal obstruction is suspected. Give ursodeoxycholic acid to dissolve gallstones. If you cant do surgery due to comorbidities or the patient refuses surgery, do extracorporeal shock wave lithotripsy.

Acute Cholecystitis. Often demonstrates fever, Murphys positive, leukocytosis, and left shift. Symptoms include nausea and vomiting. Rule out peritoneal signs because theres always the possibility of perforation. AXR and gallbladder U/S. HIDA for definitive diagnosis. False positive HIDA in people with TPN and those who have been fasting for long time. o Management. NPO with abx to cover gram neg and enterococcus (2nd gen cephalosporin). IV analgesics. NGT if abdominal distension and vomiting (if these Sx are present, consider ileus). Lap chole in 72 hrs of onset of symptoms. If too ill for surgery, do a cholecystostomy tube (gall bladder drain). o Complications.

Acute gangrenous cholecystitis. Abx, emergent lap chole or chole drain. Acute emphysematous cholecystitis. Affects older DM people. Air fluid level in gallbladder. Abx for anaerobes and emergent lap chole. If high fever, consider... Pericholecystic abscess, empyema, acute suppurative cholangitis. U/S for each.

Empyema. Distended gallbladder with fluid that has internal echoes and gallstones. Tx: IV Abx, emergent ex lap with chole, PTC.

Suppurative cholangitis. Dilated common bile duct, air in GB, and previous removal of GB. Jaundice. Tx: urgent decompression of the tree, IVF, Abx, ERCP w/ sphincterotomy, and stone removal. Transhepatic cholangiogram and stone extraction performed by IR. Cholecystectomy with common bile duct drainage. Acute biliary sepsis. Abx, ivf and resuscitation. Acalculous cholecystitis. History often shows pt on TPN, vent and got blood (ICU PICC pt). Same as above only w/o a stone. Use U/S to diagnose distention of GB and thick wall. HIDA will be negative. Insert percutaneous or operative chole drain. High risk for surgery due to all the other ICU comorbidities. Choledocholithiasis and Acute cholangitis. o Stone in duct = Choledocholithiasis. o Stone in duct + infection = Acute cholangitis. Charcots triad: jaundice, RUQ pain, fever. Reynolds pentad: triad plus altered mental status and hypotension. Tx: NPO, IVF, Abx and blood cultures (metronidazole, piperacillin with tazobactam, imipenem with cilastatin, cefepime). IV analgesics. NGT if vomiting from paralytic ileus. If pt is decompensating consider ERCP, PTC or open surgery. Surgery includes ERCP then lap chole; Lap chole with cholangiogram and exploration; or Lap chole with post op ERCP.

Gallstone Pancreatitis. Obstruction in the ampulla of vater. Amylase and lipase elevation. Management: NPO, IVF, analgesics. Lap chole with cholangiography and possible duct exploration. If urgent therapy needed then ERCP with sphincterotomy. Gallstone Ileus. Fistula between the duodenum and GB. Stone usually gets obstructed in the distal ileum before the valve. Pt presents with SBO. AXR shows SBO and air in GB (pneumobilia). U/S may find stone. Barium study may show biliary-enteric fistula. May need celiotomy and enterolithotomy (stone removal). Possible cholecystectomy and fistula correction. Often comorbidities prevent this surgery. High mortality rates.

Gallbladder cancer. Rare as hell, so found incidentally on histo review of GB after lap chole. Often presents with weight loss and RUQ mass. If localized disease, perform cholecystectomy. Larger/diffuse disease: wedge resection of the GB fossa w/ lymphadenectomy. Porcelain GB (50% Ca). Polyp larger (10% Ca). Mass in Fossa malignant gallbladder adenocarcinoma. Ampullary, duodenal, or cholangiocarcinoma Whipple procedure. Bile duct cancer. Risk factors: Ulcerative colitis, sclerosing cholangitis, choledochal cysts, parasitic disease and stones. are above cystic duct. The one third that are proximal may require resection of left and right hepatic ducts. Management with Roux-en-Y hepaticojejunostomy. Prognosis is very very poor (<5% in 5 yrs). o Middle resection Roux-en-Y hepaticojejunostomy. Prog ~10%. o Distal Whipples procedure.

Congenital Choledochal cyst. Females, teens and 20s. Management with Roux-en-Y hepaticojejunostomy. Bile duct injury and stricture. Iatrogenic. Perform cholangiography intraop when suspected. T-tube stent is placed and brought out through another location in the common duct. Consider choledochojejunostomy.

LAP CHOLE COMPLICATIONS/SEQUELAE

Retained stone. Stone present >2 years after cholecystitis.

Biliary stricture. Surgery (choledochojejuostomy).

Post-op Complications. o Fever or abd pain. Think infection or biliary leak. Diagnosed with U/S or HIDA. Can do ERCP to look for more leaks. Can place stent to stop leak. o Jaundice. U/S or HIDA to look for common bile duct obstruction. Do biliary drainage procedure. o Painless jaundice. Obstruction of biliary tree. Differential includes CA, stricture, pancreatic CA, common bile duct stone, cholangiocarcinoma. Do U/S to look for obstruction. CT if U/S is neg. EGD U/S to look at the head of the pancreas with transduodenal biopsy if appropriate.

Small intestine
PHYSIOLOGY REVIEW

Location of absorption of nutrients. Iron duodenum, folate jejunum, B12 ileum, ADEK ileum, protein duodenum and jejunum, carbs jejunum, majority of Fats + bile duodenum and jejunum, bile ileum.

MECKELS DIVERTICULUM

Represents a remnant of the embryonic vitelline or omphalomesenteric duct. Supposed to close between 8th and 10th week of gestation. History. Can present with hemorrhage, ileus, intussusception diverticulitis, perforation or fistula. Can mimic appendicitis pain.

Physical exam. Mass in abd and possible currant jelly stool. Labs/Imaging. Technetium 99m pertechnetate scan is diagnostic. Differential diagnosis (especially more likely in older patients)... o Appendicitis, SBO, enteritis, diverticulosis/litis, angiodysplasia, etc.

Management. Laparoscopic resection if symptomatic. If asymptomatic, you can do a prophylactic lap resection of the diverticulum in the young, but if the pt is old you can just observe. Resect in old only if:

CROHNS DISEASE

it has a narrowed base mesodiverticular band is present heterotopic tissue is present

Chronic transmural inflammatory. Skip lesions, noncaseating granuloma on histo; fistulas; fibrotic strictures; on gross exam: fat creeping, aphthoid ulcers, fissures, abscess, or crypt abscess. History. HPI: abd pain, diarrhea, weight loss, wax and wane. If pain is due to partial obstruction then they can have nausea and vomiting. Pain is usually RLQ (ileocecal area). SH: Smoking, diet (vitamin intake). PMH: any disease in the PE noted. Fat & B12 vitamin def. gallstones, developmental delay, growth retardation. Meds: NSAIDs. FH: Crohns. ROS: Malaise, fatigue, fever, weight loss, and anorexia. Physical exam. o Eye. Conjunctivitis, iritis, uveitis, iridocyclitis, episcleritis o Skin. Pyoderma gangrenosum, erythema nodosum multiforme o Joint. Ankylosing spondylitis, Hypertrophic OA, arthritis o Biliary manifestations. Sclerosing cholangitis, pericholangitis, granulomatous hepatitis. o Vasculitis. o Mouth. Aphthous stomatitis.

Labs and imaging. 1st line: colonoscopy. Also can do barium enemia, small bowel contrast studies. 2nd line: Enteroclysis study. EGD. Upper GI contrast study. Cystography or cystoscopy for ppl with fistula. Differential diagnosis. UC, appendicitis, acute regional ileitis due to yersinia, PID, TB of the bowel, etc. Management. o Medical Antidiarrheal: Loperamide, diphenoxylate, codeine, cholestyramine. Lactose avoidance and/or lactase use. Enteral nutrition or TPN (for ppl w/ SBO, severe dz and fistula). Sulfasalazine or mesalamine Corticosteroids: Prednisone 60mg, IV hydrocortisone or methylprednisolone, Budesonide.

Immunosuppressants: Azathioprine, 6-mp, mtx, cyclosporine, tacrolimus, mycophenolate mofetil. May need prophylaxis Trimeth/Sulfa for PCP.

Infliximab (for steroid resistant) Probiotics (decrease relapse)

Surgical

For complicated disease that is refractory to meds. For fistulas (especially enterovesical), sbo, perforation. Limited bowel resection b/c Crohns will return. Mechanical bowel preparation. Abx prophylaxis. Usually remove the appendix. Decreases confusion between CD and appendicitis Treat fistulas medically first then surgically.

Complications:

SE of drugs: Steroids and immunosuppressants. Surgery: All the surgical complications such as wound infection, fistula, adhesions, anastomotic leaks, short bowel syndrome (<100 cm of bowel left), def in vitamins, gallstones, kidney stones (oxalate), malnourished. Post ileum resection there is bad reabsorption of bile acids and B12, diarrhea, depletion of bile salt pool, malabsorption, oxalate stones, and increased gallstones.

Stricture: complication of Crohns that can cause bowel obstruction. Management is TPN, bowel rest. Surgery if it doesnt improve. R&A or Strictureplasty.

SMALL BOWEL OBSTRUCTION

Most common cause is adhesion from past abdominal surgery and hernia. Other causes include volvulus, intussusception, polyp/tumor, Crohns, gallstone ileus, SMA Progression. SBO edema Ischemia infarct local infection sepsis perforation. History. Nausea vomiting, constipation and obstipation. Fever, Tachycardia, leukocytosis, localized abdominal tenderness high risk for strangulation. HPI: Prodromal bulges or focal pain. If vague pain it could be cancer or IBD. Dehydration symptoms. o Complete SBO. Colicky abdominal pain in the periumbilical area. Localized pain irritation and possible ischemia, be worried. Nausea and vomiting. Abd distension, constipation, no flatus. o Partial SBO. Passage of stool, some diarrhea, and some flatus (AXR will show some air in rectum)

Physical exam. General: acutely distressed or lethargic and dehydrated. o Vitals: tachycardia, hypotension o Abd: distension, tympanic (full of air) or dull (full of shit or fluid), ascites, high pitched sounds. BS crescendo-decrescendo. No bowel sounds is bad peritonitis. No stool in rectum. Blood in rectum ischemia bowel or obstructing tumor.

Laboratory. o If vomiting, labs will show dehydration with hypokalemia and alkalosis. o Leukocytosis secondary to ischemia. o Possibly hyperamylasemia (must rule out pancreatitis). o UA necessary to r/o UTI or kidney stone. o Lactic acidosis ischemia or infarction (but may be absent).

Imaging.

o o

Abdominal series including supine and upright AXR and upright CXR (looking for renal or biliary calculi, free air, pneumatosis intestinalis, and pneumonia), air/fluid levels in bowel, and no free air. Can use water soluble contrast enema to help differentiate fluid from tissue or small and large bowel. Small bowel follow through. CT (only when you are very confused). Contrast studies of the small bowel (try to really avoid this, since it can obscure other tests if needed).

Differential diagnosis. o Paralytic ileus. Bowel motility is suppressed as a consequence of systemic or inflammatory illness, and there is no mechanical obstruction like in SBO. Caused by: narcotics, bed rest, trauma, hypothyroidism, electrolyte deficiencies, anesthesia, psychotropic meds, inflammatory illness, sepsis. Most likely a combination of these causes. Diagnosis. Difference on axr there will be dilation of all the bowel without a transition zone like in SBO. Can do contrast enema to exclude colonic obstruction. May need small bowel contrast.

Management. IVF and electrolytes for several days for uncomplicated SBO. Need serial exams and serial AXRs. Keep track of urine output via foley for hydration status. NGT. NPO. 80% of the time the above will resolve the sbo. D/c when patient tolerates food. o Fix cause: e.g. lysis of adhesions, hernia repair, debunking procedure if previous ovarian CA, etc. o If it is a non reducible hernia surgery right away after IVF with laparotomy to see if it is incarcerated and ischemic. o No PSH or hernias surg most likely cancer or internal hernia. o Surgery if no improvement in 24 to 48 hours. if surg is required... need abx to cover gram negative aerobes and anaerobes. can use fluorescein dye or doppler U/S to tell if bowel is alive. resection if you find cancer. intussusception resection in adults or pneumatic enema in peds.

Complications. SBO + localized pain tenderness, marked leukocytosis, fever, and acidosis, think closed loop obstruction, ischemia, abscess, or perforation. o Closed loop obstruction: IVF and ex lap. o Ischemia: Resection with reanastomosis and second look operation. o Free air: Ex lap.

ISCHEMIC BOWEL

Essentially SBO with sirs. Proceed to OR if necrotic. Give IVF, O2, and sigmoidoscopy. If this is negative, do mesenteric angiogram. If positive, start abx and IVF. Revascularization and long term management with ASA. Worsening pain, marked leukocytosis, marked leukopenia, mod-sev metabolic acidosis straight to OR. History and physical exam. Afib, abdominal bruits ( angiogram with embolism), polycythemia ( IVF, angiogram (for operative planning), CHF (causes a low flow state), aortic dissection ( angiogram), or hypotension ( measure hemodynamics, angiogram, possibly surgery). Scenarios. o Ischemic bowel with bloody diarrhea... if it affects the full wall thickness resection and reanastomosis. If it is not full thickness IVF, abx and observation. o Necrosis of 2 feet of jejunum resection and anastomosis. Consider 2nd look. Ileostomy if really sick. o Occlusion SMA Revascularize bypass or removing occlusion

APPENDIX

History. Between the ages of 5 and 35 and presents with pain periumbilical within 24-48 hrs. Most common cause: obstruction with lymphoid hyperplasia, second is fecalith. Initial discomfort is due to luminal distension and poorly localized. Disease progresses peritoneum irritation. ROS: Nausea and vomiting, low grade fever, leukocytosis, anorexia. Physical exam. Abdominal: McBurneys point tenderness. May illicit pain on rectal exam. Rebound tenderness and percussion tenderness with involuntary guarding. Hyperesthesia. Rovsings sign. Psoas sign. Obturator sign. Rectal exam. Pelvic exam (retrocecal appy). Progression. Rupture improvement of pain peritonitis (fatality >35%). Labs and imaging. Appy is a clinical diagnosis. o Labs. CBC with diff, UA (can have WBC and RBC in urine), preg test o Imaging. Used to exclude other diagnoses. Appendicitis is a clinical diagnosis. CXR, AXR (not really helpful, may see a fecalith or free air but overall is a waste). Barium enemia: If the appendix was not visiualized it must be blocked possible appendicitis. U/S may show non compressing tubular structure with pain in RLQ. CT will show distension of the appendix, nonfilling when contrast is used, inflammatory changes in the surrounding fat, abscess formation, and/or free fluid.

Differential diagnosis. PID, pyelonephritis, gastroenteritis, IBD (e.g. 2 mo hx of diarrhea), endometriosis, ovulatory pain (mittelschmerz), ruptured or hemorrhagic ovarian cyst, Meckels diverticulum, cecal or sigmoid diverticulum, acute ileitis, cholecystitis, perforated peptic ulcer, UTI, kidney stones, hepatitis, right lower lobe pneumonia, menstrual pain, appendix abscess with continuity of the bladder, bladder outlet obs, etc. Management. Surgery. IVF and NPO. Abx (need to cover colonic flora): cefoxitin (2nd gen cephalo) or broad-spec pcn or fluoroquinolone and metronidazole. If no rupture d/c abx 24 hrs after surgery. If perf and contamination or abscess keep abx until pt is afebrile with normal wbc and normal GI function. o Chance of rupture increase after 24-36 hrs so operate quickly. o If there is an abscess, do percutaneous radiologic drainage with appendectomy 6-8 weeks later.

If diagnosis unclear, wait and watch.

Complications: Normal red inflammed tip, acute gangrenous appendectomy all the way to the cecum, perforation with local abscess (remove appendix and drain to the outside), fecalith (cut it out), if normal appendix look for other shit and take it out too, yellow firm mass in the tip of the appendix (appendectomy), if the tumor is at the base of the appendix (right colectomy), 3 cm pedunculated mass that is obstructing the lumen (carcinoid or adenoid carcinoma; obtain 5HIAA and serotonin baseline levels, CT abd, octreotide scan).

SPLEEN
DIFFERENTIAL

By finding... o Possible splenomegaly on palpation. Splenomegaly, feces in the colon, fluid in the stomach. Light Splenomegaly Chronic passive congestion Acute malaria Typhoid fever Subacute bacterial endocarditis Acute/sub-acute infection SLE Thalassemia minor Moderate Rickets Hepatitis hepatic cirrhosis Lymphoma (leukemia) Infectious Mono Pernicious anemia Abscesses, infarcts Amyloidosi Great CML Myelofibrosis Gauchers disease Neimann-Pick disease Thalassemia major Chronic malaria Leishmaniasis Splenic vein thrombosis Hairy-cell leukemia

o o
Tender splenomegaly. Infective process, splenic infarction, or splenic trauma.

By pathology... o Splenic trauma. o Hyposplenism/asplenia. Splenectomy. Sickle cell anemia. Etc. o Hypersplenism. Hemolytic anemia. ITP.

o o o o o
PHYSICAL EXAM

Secondary hypersplenism. Infiltrative diseases Congestive diseases Feltys syndrome Splenic cyst. Splenic abscess. Splenic tumor. Splenic artery aneurysm. Lymphoma/leukemia

Spleen is difficult to palpate. Located behind and parallel ot the 10th rib in the midaxillary line. Normal size 12cm x 7cm. Size not related to hematologic function. May rise to 4th intercostal space during inspiration.

Palpation and percussion used to determine the size of the spleen. o Percussion. Splenic dullness in LUQ. o Palpate. Bimanual. As we learned. Stand on R. of patient. One hand behind rib cage, other hand pushing under ribs from umbilicus outward. Patient turned towards examiner. Middletons method. Stand on L. of patient. Curl fingers of both hands under ribs to palpate. Edge of enlarged spleen may be palpable at costal margin, extending into L. iliac fossa. Rarely crosses to right fossa. Enlarged spleen typically not tender.

Thrombocytopenia o Multiple petechiae in areas of the body that encounter pressure. Purpura is a confluence of petechiae.

LABS

Peritoneal signs

CBC, blood smear, bone marrow aspiration, anti-platelet antibodies (r/o immune cytopenic purpura), coagulation factors (r/o coagulation disorder), CMP w/ LFT (r/o liver failure, hemolytic anemia) Blood smear Howell-Jolly bodies, Heinz bodies, Pappenheimer bodies (iron inclusions) all normally removed by spleen. *most useful

IMAGING

AXR. To suggest splenomegaly or possible trauma. Can suggest splenomegaly by showing displacement of colon or stomach, elevation of L. diaphragm, or large splenic shadow. Also, look for rib fractures.

U/S Abd. To evaluate splenomegaly. To show splenic infarction or cysts. To evaluate traumatic injury. Gas in intestine may interfere. *CT. To determine splenic size. To detect and follow splenic injury. To clearly show splenic cysts or abscesses and to percutaneously drain with guidance. To show pathology in adjacent organs. To obtain information about patency of splenic vessels. Radionuclide scan. To look for missed accessory spleens after unsuccessful splenectomy to control hemorrhagic disorders. Rarely used. o Colloid suspension of technetium. To give information about splenic size and function. Taken up by RES.

Angiography. To show splenic vein thrombosis. To aid in planning portal venous decompressive procedures. To show splenic tumors. To perform splenic artery embolization before lap splenectomy or partial embolization to control hypersplenism in children with portal hypertension and to control bleed in splenic injuries.

WORK-UP FOR DIFFERENTIALS

Splenic trauma. Most commonly injured organ after blunt abdominal trauma. o HPI. Three injury types: penetrating, blunt compressive, and blunt deceleration. Spleen is fixed, so prone to blunt compressive injury and capsular avulsion from rapid deceleration. o PE. Look for signs of peritoneal irritation, LUQ TTP, Kehrs sign (pain at top of L shoudler), Ballances sign (percussion dullness of left flank). o CXR. Look for rib fractures. 20% if splenic trauma. Shows rupture w/ hematoma, etc. o Hemodynamic instability requires laparotomy. Stable patients with signs of abd injury w/ impaired neuro status (poor historians) require CT, U/s, or DPL. Grade Description I II Hematoma: subcapuslar <10% surface area Laceration: <1 cm deep Hematoma: subcapsular 10%-50% surface area; Parenchymal <5cm diam. Laceration: 1-3cm deep, not involving trabecular vessels Hematoma: subcapuslar >50% surface area; parenchymal >5cm diam; any expanding or ruptured. Laceration: >3cm deep or involving trabecular vessels Laceration: segmental vessels involved with devascularization <50% Completely shattered spleen or hilar vascular injury with devascularization

III

IV V

o
Hyposplenism o Prior splenectomy o Sickle Cell Anemia. We know this... o Etc.

Hypersplenism. On PE, splenomegaly. On blood smear, pancytopenia (or isolated thrombocytopenia, anemia, or leukopenia). Hyperplastic bone marrow. o Hemolytic anemias. We know this... o ITP. PE shows S/S of thrombocytopenia. Bone marrow shows normal or increased megakaryocytes. HPI often shows recent acute viral infection. o Secondary hypersplenism Infiltrative disease. Congestive disease. HPI/PE consistent with liver failure and portal hypertension, including other sequelae. Felty syndrome. HPI/PE shows S/S of RA, splenomegaly, leg ulcers, recurrent infection. CBC shows neutropenia.

Splenic abscess. Not discussed. Splenic cyst. Not discussed. Splenic tumor. Not discussed. Splenic artery aneurysm. Not discussed. Lymphoma/leukemia. Not discussed.

MANAGEMENT OF DIFFERENTIALS

Indications for splenectomy. Splenic rupture, hematologic disorders, hypersplenism, leukemia/lymphoma, splenic abscess, primary and metastatic tumors, splenic cysts, splenic artery aneurysm.

Splenic trauma. Splenectomy if grade V or if pt unstable. In stable pts, preserve spleen w/ splenorrhaphy (operative repair of spleen). Can just observe grade III or less hematoma. Over grade three, definitely open them up. Try to avoid blood transfusion. If 50% spleen intact, immune function remains. In hemodynamically stable children dont operate and observe. First try bed rest, serial PEs & H/H. Spleen will heal, maybe. If not stable, exploratory laparotomy.

Hyposplenism o Prior splenectomy o Sickle Cell Anemia. We know this... o Etc.

Hypersplenism. Splenectomy for pts with splenomegaly and hypersplenism; with hypersplenism and plt <50,000 w/ bleeding; with hypersplenism and neutrophil count <2000; or with hypersplenism and anemia requiring transfusion. o Hemolytic anemias. Splenectomy for hereditary hemolytic anemias and some acquired (often-hydrocytosis; usually-

spherocytosis, pyropoikilocytosis; rarely-elliptocytosis, xerocytosis, PKD, Sickle cell, Thalassemias; never-G6PD). Cholecystectomy performed simultaneously cuz of risk of pigment gallstones. ITP. 80% recover completely w/out Tx. For chronic ITP, begin w/ course of corticosteroid therapy. If no response, splenectomy. If thrombocytopenia recurs after steroids D/Cd, splenectomy. Platelets for transfusion after splenectomy if count <20,000. If splenectomy fails, start vincristine plus gamma-globulin. Secondary Hypersplenism. Splenectomy usually not curative of cytopenia. Infiltrative disease. Partial splenectomy and splenic embolization for benign disease. Splenectomy for neoplastic causes. Congestive disease. Liver failure Portal HTN. Treat HTN. Splenectomy contraindicated because then you cant do a selective splenorenal shunt procedure (a more approp. procedure for portal HTN). Felty syndrome. RA, splenomegaly, neutropenia. Splenectomy w/ recurrent leg ulcers/infections.

Splenic abscess. Splenectomy one option. Not discussed further. Splenic cyst. Splenectomy one option. Not discussed further. Splenic tumor. Splenectomy one option. Not discussed further. Splenic artery aneurysm. Splenectomy one option. Not discussed further. Lymphoma/leukemia. No splenectomy for acute leukemia. Splenectomy in some chronic leukemia with hypersplenism and symptoms from splenomegaly. Hairy-cell leukemia (leukemic reticuloendotheliosis) Tx w/ alpha-interferon and 21deoxycoformycin first line with splenectomy for palliating cytopenias and Sx of splenomegaly. Essentially, symptomatic splenectomy only for hypersplenism/massive and symptomatic splenomegaly.

POST SPLENECTOMY

Hematologic changes.Howell-Jolly bodies, Pappenheimer bodies, and pitted red cells show up on peripheral smear. Thrombocytosis in 50% of pts, but DVT proph w/ heparin or warfarin not indicated. Immune consequences. Postsplenectomy sepsis (OPSS) 40x that of gen pop. Encapsulated organisms (SHiN). Get vaccinated w/ polyvalent pneumococcal polysaccharide vaccines (ideally before surgery). Vaccination against H.Flu and N.Meningitidis should be considered as well. Long term Abx prophylaxis w/ penicillin for immunocompromised pts, children under 6, and those receiving chemo. Anatomic complications. Atelectasis most common. Intraop injury to pancreas and stomach.

THYROID
HISTORY

Thyroid CA more common in women. Solitary lesion in man more likely to be malignant than in a woman. So, be concerned about a man w/ a thyroid nodule. Suggest local invasion. Duration of presence of nodule, local symptoms such as pain/pressure/hoarseness. Radiation. Childhood radiation exposure >200 rad increases risk of CA, and >2000 rad will destroy thyroid. Sources: Tx of enlarged thymus in infancy, Tx of ringworm/acne/tubercular lymphadenopathy in the olden days, Chernobyl (Ukraine, 1986). Risks for CA: radiation Hx, family Hx, voice/airway Sx, thyroid nodule pattern.

DIFFERENTIAL DIAGNOSIS

ROS

Thyroid CA Toxic adenoma Multinodular goiter MEN Hashimotos thyroiditis

Pain, pressure, hoarseness/dysphonia, dyspnea/dysphagia (compression), Sx of toxicity Thyrotoxicosis. Heat intolerance, weight loss, tachycardia, tremor. Malignancy. Hoarseness,dysphagia, hard fixed nodule, dyspnea, cervical lymphadenopathy, vocal cord paralysis.

PMH/PSH/MEDICATIONS:

FHx/PMH of MEN PMH of radiation exposure

PHYSICAL EXAM

Enlarged thyroid. Often with multinodular goiter, Hashimotos thyroiditis. o Careful palpation. Thyroid and regional lymph nodes. o Pembertons sign. Raising the arms above the head causes venous compression of thoracic inlet causing feeling of strangulation and engorgement of head/neck.

LABS

TSH. Simplest test. Low: thyrotoxicosis. High: underactivity (e.g. Hashimotos). Sufficient when no S/S of toxicity. Thyroid Function. Measure when TSH abnormal. Often called thyroid function tests and include TSH, T4, and sometimes T3.

Serum Calcium. Measure in pts with radiation exposure Hx or FHx of MEN. Thyroglobulin. May be elevated in follicular or papillary carcinomas and in benign disease. Increased in pregnancy, which can falsely elevate total T4 but does not affect free T4.

IMAGING/PROCEDURES

Indirect laryngoscopy. Indicated for hoarseness or when S/S suggest malignancy. Fine needle aspiration cytology (FNA). Most important study in evaluating thyroid mass. Multiple nodules difficult to evaluate, may require resection. U/S Neck. Help determine if nodule is cystic or solid, whether additional nodules or nodes exist, and the exact size of the nodule. Mainly used to follow size/recurrence of cyst after FNA. Thyroid scan. Hot or cold. Rarely used. Cold more likely to be malignant.

WORK-UP FOR DIFFERNTIALS

Thyroid nodule. o Cystic. FNA. If fluid benign and mass disappears, it is resolved. If residual mass, consider resection b/c its risk for malignancy. o Solid. Aspiration or biopsy.

Hyperthyroidism. If TSH decreased, its a thyroid problem. If TSH increased, its a pituitary problem.

Graves disease (diffuse toxic goiter). PE/ROS shows diffusely enlarged thyroid, exophthalmos, tachycardia, tremor, heat intolerance, and weight loss. Order T4, T3, TSH, thyroxine-binding globulin (TBG), and thyroidstimulating antibody (TSab). Low TSH in the presence of high thyroid hormone levels.

o o o

Toxic adenoma. Labs show high T3 and T4 and suppressed TSH. PE shows thyroid normal or small w/ a palpable nodule that is hot on thyroid scan. S/S of thyrotoxicosis. Toxic multinodular goiter. Thyrotoxicosis factitia. Struma ovarii.

Thyroid Cancer o Papillary. Pathology shows psammoma bodies (concentric layers of calcium). Poor prognosis with male sex, age over 50, tumor >4cm, less-well-diff cells, and invasive/metastatic disease. Metastases to regional lymph nodes. o Follicular. Pathology shows monotonous microfollicles. Difficult to distinguish from follicular adenoma b/c it requires architectural characteristics, so requires surgical resection for Dx. Show capsular and vascular invasion if CA. Poor prognosis with age over 45, local invasion to neck structures, and distant mets. o Medullary. FNA. Order calcitonin (tumor marker). Screen with calcium and pentagastrin infusion tests to show elevated calcitonin. Associated with MEN. o Anaplastic. Pathology shows totally undifferentiated cells. o Lymphoma. To distinguish from Hashimotos, core-needle or open biopsy with flow cytometry. Lymphocytic infiltrate.

MEN. Order serum calcium. Order urinary catecholamines and catecholamine metabolites when FHx of MEN-2 (looking for pheochromocytoma).

MANAGEMENT OF DIFFERENTIAL

Thyroidectomy. Preserve the parathyroids, recurrent laryngeal nerve (vocal cord paralysis, B/L tracheostomy), and superior laryngeal nerve (loss in voice quality). o Serious complications following thyroid surgery include injury to the recurrent laryngeal, or external branch of the superior laryngeal nerves as well as to the parathyroid, with resultant hypocalcemia.

Thyroid nodule. o Cystic. FNA initially, workup like it is solid if FNA noncurative. o Solid.

Benign. Follow for 3 to 6 months while being Tx w/ oral thyroid hormone to suppress TSH stimn of tumor growth. Carefully monitor TSH level. If nodule remains same size, do FNA again. If it shrinks, continue suppression therapy. If it enlarges, excise is cuz its prolly cancer. E.g. colloid nodule shown on FNA. Working Dx of CA. Surgical exploration. Begin with thyroid lobectomy (ipsilateral lobe) and isthmectomy. Dont just remove the nodule. Send for pathology. If frozen-section analysis shows cancer, thyroidectomy, extent determined by disease.

Hyperthyroidism

o o o o

Graves disease (diffuse toxic goiter). Three choices. Medical blockade. Potassium iodide/Lugols solution temporarily inhibit release of thyroid hormone. Propanolol (B-blockers) ameliorate peripheral Sx. So, propanolol and iodide are shortterm Tx, e.g. for before surgery. Definitive medical Tx is w/ thionamides (e.g. popylthiouracil, methimazole). Radioiodine ablation. I131. Effective. May require multiple doses. No secondary thyroid CA from the radiation. Favored over resection. Surgical resection. For pts who are pregnant or wish to become pregnant, who cannot comply with antithyroid medications or follow-up b/c of mental or emotional incapacity, are allergic to iodine, or refuse antithyroid drugs or radioiodine ablation. For exophthalmos/pretibial myxedema, try local or systemic cortisol. External beam radiation for severe ophthalmopathy. Toxic adenoma. Preop prep w/ propanolol or thionamides. Then nodule excision by thyroid lobectomy and isthmectomy. No ablation here. Toxic multinodular goiter (aka Plummers disease). Total or subtotal thyroidectomy (total if goiter is large and compressive). No ablation here. Thyrotoxicosis factitia. Struma ovarii.

Thyroid Cancer. Surgery for localized CA unless it is anaplastic or lymphoma. o Papillary. Thyroid lobectomy and isthmectomy, or total thyroidectomy. Extent of resection depends on risk (quantified with AMES or AGES criteria). Anything >1cm, do total thyroidectomy with post-op radioiodine ablation therapy of residual or metastatic disease. Remove

o o

obviously involved lymph nodes. Require thyroid replacement with maintenance of suppressed TSH levels. Metastases to lung and bones. Iodine scan for uptake once all of thyroid removed. Treat metastases with radioiodine or external beam radiation. Psammoma bodies. AMES: age, metastatic disease, extent of disease, and tumor size. AGES: age, histologic grade, extent of disease, and tumor size. Follicular. Similar to papillary. Spreads by vascular, not lymph so for prognosis look for vascular invasion. Post-op, can use I-131 w/ ablation of residual thyroid. Lobectomy for diagnosis. Medullary. Without lymph node metastases, total thyroidectomy and central lymph node dissection (removal of cervical lymph nodes medial to both recurrent laryngeal nerves and carotids). Modified radical lymph node dissection if lymph node involvement. Amyloid deposits. I131 and thyroid suppression not useful b/c its from C-cells. Monitor w/ calcitonin and CEA. Anaplastic. Surgical resection does not help. Chemotherapy and external beam radiation do not help. 2 year survival. Undifferentiated cells. Lung is site of metastases. Multimodality therapy is used. Lymphoma. Tx similar to lymphoma at other sites. Radiosensitive. Hurthle cells. Represent adenoma or low grade carcinoma. Lobectomy with total thyroidectomy if recurrence. Associated with Hashimotos thyroiditis.

TRAUMA
STEPS IN EVALUATING A TRAUMA: 51. 52. 53. 54. Primary survey. Resuscitation. Secondary survey. Definitive Care.

PRIMARY SURVEY. Dx and Tx of immediately life threatening injuries, in the following sequence:

Airway. Maintain patency of the upper airway, specy the mouth, oropharynx, larynx, and trachea. o Give EVERY injured pt supplemental oxygen. o Determine if pt is unconscious. Listen and feel for air movement from mouth. o Ask pt if theyre okay. Talking patient = patent airway. o Stabilize spinal cord while opening airway (in-line immobilization of the cervical spine). Stablize C-Spine! Ask them to move fingers and toes, check for sensation. Eventually youll order a lateral C-spine XR in all accidents.

Open mouth and look inside using jaw-thrust or chin-lift maneuvers. Gag reflex=clear. Absence=finger inspection for foreign bodies. o Remove foreign bodies, suction, etc. o Look for evidence of injury to neck. Penetrating. Intubate the pt or do a surgical airway. Blunt. Laryngeal edema (dysphonia, stridor, etc). Intubate. o Establish airway w/ oropharyngeal (oral) airway or nasopharyngeal (nasal ) airway. o Tracheal intubation. If oral/nasal airways fail. Prior to placement, must inspect and palpate neck to see if trachea is midline, larynx/trachea is Fx, or neck veins are distended. Indications: inadequate resp effort, severely depressed mental status (GCS<8), inability to protect airway, severely compromised resp mechanics (e.g. multiple rib fx). Orotracheal intubation. Visualise vocal cords w/ laryngoscope and then place endotracheal tube. Listen for breath sounds. Monitor CO2. Nasotracheal intubation. Tube passed into trachea through nose. For breathing adults. Surgical cricothyroidotomy. Place index finger in sternal notch, move up trachea, pass over prominent cricoid cartilage into depression, which is the cricothyroid membrane. Hold skin taut. Make 2cm transverse incision. Put knife handle in incision and rotate. Insert tube. For those over age 12. Needle cricothyroidotomy. Pierce cricothyroid membrane with IV catheter. Intermittent insufflation by putting finger over side hole for 1 sec and releasing for 4 secs. Can maintain for 30-45 min. For those under age 12. Tracheostomy. Not for emergencies, done in OR. o ROS: stridor/snoring/gurgling (supraglottic problem), dysphonia/hoarseness/pain with speaking (laryngeal problem), agitation (hypoxia), obtundation (hypercarbia). Breathing. Is air moving in and out of both lungs equally? o Inspect chest for rise and fall. Auscultate for breath sounds. o Percuss. Dullness=hemothorax. hyperresonance=pneumothorax. o Satisfactory SpO2=okay breathing. Circulation o Auscultate heart sounds and palpate peripheral pulses. o First: Control obvious hemorrhage w/ direct pressure, check peripheral perfusion (pulse, skin color, and LOC), start IV fluids. o Shock. First step: Recognize shock. Second step: Identify cause. Most common in trauma is hemorrhage, so stop bleeding and give fluids. o Capillary refill. Measures degree of vasoconstriction/peripheral perfusion. Normal appx 2 sec. o Lactated Ringers. Restores volume and increases tissue perfusion. o Blood loss. See picture. o Initial management. Rapid diagnosis, replacement of IV volume, and control of obvious hemorrhage.

Insert two large-bore (>16 gauge) peripheral IV catheters. Central access if peripheral fails. Interosseous infusion in kids less than 6. Start lactated Ringers. Normal saline is second choice b/c LR results in fewer electrolyte disturbances with large volumes compared to NS. Amount of fluid=3mL per 1mL blood loss. Initial response is best guide for Tx. Fluid bolus is 1 to 2 L. In children its 20mL/kg. Reassess vitals and U/O after bolus. Give another bolus with blood if no response. Also monitor lactic acidosis and venous oxygen sat for correction of anaerobic metabolism. Rapid responder. Hemodynamically normal after initial bolus. Fluids go to maintenance. Transient responder. Responds to bolus, but requires more for stability. Minimal responder/nonresponder. No stability with bolus. Usually have exsanguinating blood loss. surgery (laparotomy/thoracotomy).

Cardiogenic shock. Myocardial dysfunction secondy to myo. contusion (blunt injury), tamponade, tension pneumo, air embolus, or rarely MI. Neurogenic shock. Injury to desc symp fibers in spinal cord (cervical or high thoracic). Hypotensive w/out tachy. IV fluids and pressors, can use atropine. Septic shock. Not immediately after an injury. Warm extremities, wide pulse pressures, elevated CO. IV fluids, Abx, and eradication of infxn source. Hypoadrenal shock. Exogenous steroids risk. Shock not responsive to fluids or inotropes. Dx w/ cosyntropin stimn test. Replace IV hydrocortisone.

neurologic Disability. Establishes LOC, pupillary size and rxn, and motor response to stimuli. o AVPU. Measures LOC. Is the patient Alert, responsive to Vocal stimuli, responsive to Painful stimuli, or Unresponsive. o GCS. More detailed. Exposure/Environment o Disrobe pt for complete PE. Cover pt with warm blankets and raise room temp to avoid hypothermia. o Control environment factors (e.g. remove burnt clothes).

SECONDARY SURVEY.

Detailed PE and AMPLE history to identify all injuries.

AMPLE. Allergies, medications, past illnesses, last meal, and events surrounding incident.

Tubes and fingers in every orifice o Urinary and gastric catheters. o Continuous EKG and pulse ox. o Baseline lab studies. o Portable radiographs. Essential=lateral cervical spine, AP chest, AP pelvis. o Other procedures if indicated: U/S, DPL, radiography.

NG and bladder intubations are critical. o NG tube. Remove air and gastric contents. Reduces risk of vomiting and aspiration. Dx (blood=injury). Prevents acute gastric dilation. o Bladder catheter (Foley). Decompress bladder. Provides means to monitor U/O. Dx (hematuria=trauma, red/brown=crush injury/mm damage, dark yellow=hypovolemia). UO is great way to check status of resuscitation. Want at least 30mL/hr in adults, 1mL/kg/hr in kids, and 2mL/kg/hr in infants under 1. Suprapubic bladder cath if urethral injury. Retrograde urethrogram if injury suspected.

DEFINITIVE CARE.

Pt reevaluated, injuries prioritized. Further Dx and Tx procedures occur, such as CT, angiography, and surgical procedures.

DIFFERENTIAL DIAGNOSIS OF TRAUMA

Thoracic injury. o Tension pneumothorax. PE/Hx. Ipsilateral lung collapse, mediastinal shift away from injury, contralateral lung compressed. Compress SVC/IVC dec. venous return. Clinical Dx (respiratory distress, tachycardia, hypotension, JVD, tracheal deviation toward noninjured side, decreased breath sides on injured side with hyperresonance to percussion). No CXR, takes too long. Tx. Decompression with >14-gauge needle. Above 3rd rib in 2nd ICS. Wait for rush of air. Leave catheter in place. Chest tube placement for definitive treatment. o Open pneumothorax (sucking pneumothorax). PE/Hx. With breathing, air is heard/bubbling seen from wound. Ipsilateral lung collapse, with signs as above. Tx. Cover wound immediately with impermeable dressing (e.g. Vaseline gauze, plastic wrap), taped on one side, to create a one way flap valve. Chest

tube at different location and surgical closure for definitive treatment. Massive hemothorax. Loss of >1500 mL blood in thoracic cavity. PE/Hx. Hypotensive pt with decreased/absent breath sounds and dullness to percussion on one side of chest. Portable supine CXR shows complete opacification on injured side. Tx. Insert large chest tube (36-40 Fr). If you evacuate >1500mL initially or have ongoing blood loss of >200mL/hr, you gotta do thoracotomy. Posttube CXR to verify complete drainage. Flail chest. Consecutive ribs fx in multiple places. Often w/ pulm contusion. PE/Hx. Chest wall moves paradoxically with I/E. Tx. Hypoventilation is from pain, so give analgesia. With sigt vent impairment require intubation. Reexpansion of lung, adequate oxygenation, judicious use of fluids, and adequate analgesia for definitive Tx. Cardiac tamponade. PE/Hx. Becks Triad: muffled (distant) heart sounds, elevated CVP (JVD), and hypotension. Pulsus paradoxus (dec of >10mmHg during inspiration). Kussmauls sign (increase in CVP with inspiration). Tachycardia, respiratory distress. Often blunt trauma, classically MVA with sternum thrust into steering wheel. Bedside U/S for Dx. Measurement of elevated CVP can be helpful. Tx. Administer large volumes of IV fluids. Emergent thoracotomy required or pericardiocentesis with subxiphoid approach or needle is Dx and Tx (performed under U/S or ECG guidance), only temporarily. Thoracotomy to stop source of bleed is definitive Tx. Pulmonary contusion. PE/Hx. Hypoxemia. Chest wall contusions, rib fx, sternal fx, and flail chest with blunt trauma. Could be penetrating, too. CXR shows poorly defined opacification that develops over time (present in 1 hour, but may take as long as 6 to be visible). Tx. Observation, supplemental oxygen, and analgesics. Mechanical vent and PEEP if really bad ventilation. Blunt cardiac injury (myocardial contusion). PE/Hx. Again, sternum into steering wheel/dashboard. Fx of sternum or ribs may be present. May have R. heart failure, hypotension, arrhythmia, or rupture. Dx with BP monitoring, continuous ECG, and 12-lead ECG. Consider Dx in pts with blunt thoracic injury with unexplained hypotension. Confirm with cardiac enzyme analysis and cardiac imaging. Tx. Sx treatment, e.g. antiarrhythmics, inotropic support, etc. Aortic rupture. PE/Hx. Severe chest or back pain. CXR (get PA if suspected b/c of magnification): widened mediastinum, indistinct aortic knob, opacification of

the aortopulmonary window, 1st or 2nd rib fx, deviation of esophagus or NG tube to right, pleural apical cap, depression of l. mainstem bronchus, widened paratracheal or paraspinous stripe. Gold standard=arteriography, but CT is screener of choice. Transesophageal echocardiography (TEE) is alternate Dx. Tx. Preop: control BP (hypotension w/ IV fluids or blood, HTN w/ drugs), Tx other immediately lifethreatening injuries. Rapid operative repair with partial cardiopulmonary bypass is definitive Tx. Diaphragm rupture. PE/Hx. 90% L side. Bowel sounds in chest. CXR showing NG tube in chest is Dx w/out any further tests. If nondiagnostic, can do upper GI contrast study. Tx. NG tube to decompress stomach. Direct repair from an abdominal approach is definitive Tx. Esophageal injury. PE/Hx. Usually penetrating. Severe epigastric or L chest pain, dysphagia, hematemesis, left pleural effusion, subQ emphysema, pneumothorax, and pneumomediastinum. Chest tube thoracostomy may show food particles in chest. Dx confirmed w/ esophagogram or esophagoscopy. Tx. Operative repair and drainage. If missed sepsis, requiring wide drainage and esophageal exclusion, including proximal diversion with a cervical esophagostomy, gastrostomy, and feeding jejunostomy. Tracheobronchial tree disruption. PE/Hx. Laryngeal/tracheal injuries: hoarseness, subQ emphysema, heomptysis, and resp distress. Severe crush injuries to AP chest w/ trachea/mainstem bronchus injury: lateral deformation of thorax, hemoptysis, subQ emphysema, pneumothorax, or pneumomediastinum. Dx w/ bronchoscopy. E.g. if you place chest tube for pneumothorax and lung fails to reinflate after 6 hours. Tx. Airway maintenance w/ endotracheal tube. Thoracotomy and partial lung resection if major disruption. Simple pneumothorax. lung laceration extending into pleural space. PE/Hx. Decreased or normal breath sounds. Dx by CXR: expiratory CXR makes it more visible. Tx. Chest tube. or observe if it is small, not enlarging, without effusion, asymptomatic, and associated with no other chest injuries or surgeries of any kind. Simple hemothorax. Less than 1500mL in pleural cavity. PE/Hx. S/S of restrictive lung disease. Tx. Chest tube to evacuate chest and monitor blood loss. Bleeding usually self-limited. 1500mL on initial insertion or rate of 200mL/hr thoracotomy. Rib fracture.

PE/Hx. Pain with movement causes pt to sit still. Dx with localized pain, tenderness, and crepitus. CXR to explude pneumo, etc. Tx. Supportive. Pain control: intercostal nerve blocks if oral/IV analgesia not sufficient.

Abdominal trauma. Trauma pts with hypotension, normal breath sounds, and no external signs of blood loss, think abd. o Physical examination. Occurs during secondary survey. Inspection. Abrasions, contusions, lacerations, and penetrating wounds. Scaphoid/flat/distended. Gently separate thighs and buttocks. Look for lower GU injury (blood at urethral meatus, scrotal hematoma). Seat belt sign or ecchymoses on ant abdomen assocd w/ small bowel/duodenal injury. Auscultation. Absent BS implies ileus. Vascular bruits (continuous=L-R shunt or A-V fistula). Percussion. Subtle signs of peritoneal irritation, rebound tenderness. Gastric distension w/ tympany in LUQ. Tympany/absence of dullness in RUQ may be free air. Palpation. Gentle: tenderness, guarding, or presence of mass. Involuntary guarding=significant peritoneal inflammation. Rebound tenderness=peritoneal irritation, often after hollow viscus injury. Also palpate iliac crests and pubis symphysis, with manual compression of iliac wings to look for pelvic fx. Perineal and rectal exams. DRE mandatory: abnl sphincter tone=neuro injury; boggy/spongy/soft prostate may = periurethral bleeding; nonpalpable or highriding prostate may = urethral transection. Blood in rectum indicates rectal injury until proven otherwise. Bimanual exam. Often requires speculum. o Diagnostic evaluation. Abd U/S, CT, and DPL are primary Dx tools. Abd U/S. Look for intraabd fluid (assumed to be blood). FAST=examine two quadrants for presence of fluid (blood) in four areas: RUQ (Morisons pouch); LUQ (splenorenal recess), pelvis, and pericardium. Dx of choice for blunt abdominal trauma. DPL. Decompress stomach and bladder. Midline incision below umbilicus peritoneal catheter enters peritoneal cavity. Fluid aspirated. 10mL gross blood straight to OR for laparotomy. Otherwise, send to lab. Positive findings for blunt trauma = 100,000 RBCs, 500 WBCs, presence of bacteria/bile/food particles, or amylase > serum amylase. Negative doesnt exclude retroperitoneal injury. Abd CT. Dx standard for stable pts. Oral and IV contrast. Only for hemodynamically stable pts. Not as good as U/S for hollow organs. Best thing for retroperitoneal and solid organs.

Summary: Unstable or peritonitis Dx/Tx laparotomy Unstable + pos FAST or DPL Laparotomy, fast! Stable CT then specific Tx Stable + solid organ injuries nonoperative mgmt Treatment. Blunt. Hemodynamic instability/peritonitis laparotomy. Spleen. See above. Low grade injury observe with VS, serial abd exams, I/Os, and H/H. Stable w/ radiographic signs of splenic hemorrhage selective transcatheter embolization of bleeding vessel. Hemodynamic instability laparotomy w/ splenorraphy (repair) or splenectomy. Liver. Low-high grade injury nonoperative mgmt w/ close ICU monitoring. Stable w/ CT evidence of hepatic arterial bleeding angiographic transcatheter embolization or observation depending on grade. Hemodynamically instability/shock laparotomy. Pack lacerations instead of trying to suture vessels. Kidney. Angiography to look for vascular injuries. If need to remove kidney, ensure theres a second kidney there before you do. Pancreas. Minor transection debridement and drainage. Major resection of devitalized tissue w/ repair of injuries. Severe divert intestinal fluids away from injury (duodenal diverticularization). Small bowel/Duodenum. Dx w/ free intraperitoneal fluid w/ no solid organ injury on Abd CT and/or DPL w/ WBC >500. Repair or resection of injured bowel segment.

Hematoma common in children. Do upper GI series. Observe if isolated, NPO until resolution (one week). If persists, do exploration.

Penetrating. Gunshot to abdomen that violates peritoneum laparotomy regardless of hemodynamics. Determine peritoneal violation w/ abd CT, DPL, or laparoscopy. Stab Wounds to OR if unstable. If stable, further testing is fine. Anterior wound wound exploration under anesthesia, if

fascia penetrated then DPL. Flank/back wounds triple contrast CT. Thoracoabdominal wound likely diaphragmatic injury, so laparoscopy or laparotomy. Pelvic fracture. Fluid resuscitation, then look for other visceral injuries b/c theyre likely to be present if theres pelvic fx. Gotta do DPL, this time in supraumbilical incision. Stabilize fracture w/ external pelvic fixation. If this doesnt control bleeding, arteriography to look for artery to treat w/ embolization. Look for GU injury, too, w/ hematuria (blunt trauma + microscopic hematuria=renal contusion; penetrating trauma to GU hematuria; blood at urethral meatus=urethral injury, need urethrogram; bladder injury needs cystogram; kidney and ureteral injury needs CT). Urethral injuries. Sx: blood at meatus, scrotal hematoma, high riding prostate. Dx: Retrograde cystourethrogram. If present, give suprapubic catheter instead of Foley.

Head trauma. o Neurologic evaluation. Primary survey. ABCs first, then think about neuro status. Observation/Hx. Is pt alert? LOC? Moving all four extremities? Have any seizures? Primary survey uses AVPU. Secondary survey uses complete neuro exam. LOC, pupillary status, etc. Use GCS. Secondary survey. Observation. Scalp for lacerations. Periorbital ecchymoses (raccoon eyes), perimastoid ecchymoses (Battles sign), hemotympanum, and leakage of CSF from the nose or ear are signs of of basilar skull fracture. Palpate. Skull for stepoffs (depressed skull fractures). Bleeding controlled w/ direct pressure. Ring/Target sign. Drop drainage (otorrhea/rhinorrhea) onto paper. Blood in, pinkish ring around it. CSF present. Noncontrast brain CT. Dx of choice. Shows intracranial hematomas, areas of swelling in the brain, midline shift, and skull fractures. Normal CT r/o head injury, d/c home. Cervical spine radiographs. In all head injury pts. Quick cheats. Hypotension+head injury=blood loss. HTN+bradycardia+bradypnea=ICP. HTN+/hyperthermia=central autonomic dysfunction. Abnormal respiration=herniation.

Cushing response regulates perfusion to brain in response to brain injury, so typically pts wont bleed out from head injury. GCS. Assess LOC. Dead <3 (intubate, get neurosurgery), severe/comatose <9; moderate 912; minor >12, normal 15. See chart.

Management. Non-op head injuries ICU w/ tracheal intubation, mechanical ventilation, and ICP monitoring (w/ ventricular catheter, subarachnoid bolt, or fiberoptic transducer). Goal: Support CPP and prevent elevation of ICP reverse Trendelenburg position (elevate had to 30 degrees); sedation; moderate hyperventilation (pCO2 26-28), phenytoin loading to prevent seizures, prudent fluid administration, and diuretics. Avoid meds that depress CNS function. After initial eval, maintain pt in normocarbic state.

Penetrating neck injury. If unstable, do urgent surgical exploration. Early intubation preferable. Put direct pressure on active hemorrhage. o Physical exam. Careful evaluation of neck. Enlarging hematoma neck exploration (esp. anterior triangle). Look for carotid & vagus, trachea and esophagus. Zone 1: sternal notch inf. cricoid cartilage High mortality rate Subclavian

Stable continue eval (preopangiogram) surg planning Unstable surgery

Zone 2: inf. cricoid angle of mandible

Lower mortality rate

selective/mandatory surgic exploration OR Angiography, esophagogra endoscopy, CT angiograph

Zone 3: angle of mandible base of skull

Increased likelihood of injury to carotids

Similar to Zone 1 Arteriography, esophagogr endoscopy surgery

o
Post exploration scenarios. o Respiratory distress should make you think hematoma. Urgently remove sutures, release hematoma to relieve pressure on trachea. o Emphysema be concerned for esophageal/tracheal injury neck exploration.

o o o o o

Suspected airway injury with no other injuries bronchoscopy. Difficulty swallowing injury to esophagus. Hoarseness injury larynx or laryngeal nerves. Hemiparesis carotid artery injury or thrombosis angiogram, consult neurosurgery. Blunt trauma to neck intimal disruptions carotid thrombosis, neurologic defects.

Management of asymptomatic carotid injuries anticoagulants Management of symptomatic carotid injuries controversial (thrombectomy, anticoagulation alone).

Stab wound, no sx, stable Some might do conservative (bronchoscopy, EGD, CT). Some would cut.

Spine & spinal cord. o History and physical exam. Hypotension + bradycardia, think neurogenic shock (flaccid areflexia, diaphragmatic breathing, ability to flex, not extend elbow). Local pain and tenderness. Anatomic deformity or step-off. Palpate spine. Motor/sensory function. o Diagnostic workup. Order lateral cervical spine, AP chest, AP pelvis radiographs, as well as open-mouth odontoid, AP cervical, thoracolumbar AP and lateral radiographs. CT scanning is valuable. o Management. Suspected injury rigid cervical collar + long spine board. If hypotension, give IV fluids. High-dose steroids if within first 8 hours. Extremity trauma. o Differential diagnosis. Potentially threatening: major crush injuries, severe open fractures, proximal amputations, multiple fractures. Limb-threatening: vascular injury, compartment syndrome, open fracture, crush injury, major dislocations. o History and physical exam. Inspection: note color, look for wounds, deformities, swelling. Palpation: temperature, tenderness, crepitations, capillary fill,

o o

quality of pulses, feel every long bone, assess ROM. Sensory/motor. Initial management. Primary survey: control obvious hemorrhage with direct pressure. Alignment & splinting. Restoration of perfusion. Wound care. Tetanus prophylaxis. Vascular Injury. Hard signs of vascular injury: hx significant blood loss, brisk arterial bleeding, expanding hematoma, bruits, thrills, abnormal pulses. Secondary survey: obtain radiographs. Continuous wave Doppler flow probe, ABI, arteriography (gold standard). Blunt/Penetrating injury. Dx eval required for supracondylar humerus fractures, severely displaced knee fractures, knee dislocation, gunshot/stab wounds in close proximity to major blood vessels. Traumatic amputation. Crushed amputated part - cannot replant. Management involves cleaning off gross dirt, wrapping in sterile towel, transporting in insulated container with crushed ice and water. Fractures. Reduce dislocations. Open fractures administer IV antibiotics, irrigation, debridement, reduction in OR. Compartment Syndrome. History of arterial injury, crush injury, fracture, prolonged compression, reperfusion. Early sign: decreased sensation. Other signs: pain exacerbated by passive stretch, tense swollen compartment, weakness of muscle. Late signs: decreased pulses and capillary filling. Definitive diagnosis is compartmental pressures >35-40. Management: surgical fasciotomy. Complication: Myoglobin-induced acute renal failure, so strive to maintain high urine output.

WOUND HEALING
HISTORY

When did it begin? What does it look like? What were the circumstances of trauma? What changes have occurred? Any perforation of bowel? Any entry in GI, GU tract? PMH: Diabetes, enzyme deficiencies, coronary artery disease, hospitalized, neurologically impaired, venous stasis, uremic, jaundice. Medications: steroids, chemotherapy.

SH: Tobacco, diet, living situation (nursing home?).

PHYSICAL EXAM

Look at wound. Look for depth of injury (1st degree; 2nd degree; 3rd degree goes through entire layer of epithelium + sweat glands & hair follicles). Edematous, erythematous (first 4 days) Inflammatory phase of healing

Raised, red, hard (~month) proliferative Wound scar flattens, pale and supple (9-12 months) maturation phase

LABS

Culture wound for type and amount of bacteria, look for uremia.

MANAGEMENT

Local anesthetics: amides, esters - decrease membrane permeability to sodium. Pain temperature touch proprioception skeletal muscle tone. Assess maximum dose before using. 3rd degree skin graft Clean wound/clean-contaminated primary Contaminated surgeons preference primary/secondary tertiary Infected if >10^5 organisms/gram tissue Debride. Dressing changes <2x per day. Topical antibacterials (Do not use mafenide acetate or silver sulfadiazine on face). Chronic wounds (diabetic foot ulcers, venous stasis ulcers, open wounds) debridement, careful cleaning, dressing changes. Negative pressure devices, recombinant growth factors, hyperbaric O2, enzymatic debridement If Streptococcal infection do not close. If devitalized tissue prophylaxis against C. tetani. Provide adequate nutrition (fat, Vit. A, Magnesium, Zinc). Control diabetes. Use limited steroids. Proper oxygenation. Cannot lift things 4-6 weeks (collagen still building for first few weeks).

MANAGEMENT, SCENARIOS

Hard structure likely suture knot o Absorbable leave it o Non-absorbable leave it for a few months until healed remove Small, sore, draining red area that then seals stitch abscess remove suture 4 cm defect in fascia, bulges when coughs ventral hernia due to dehiscence repair surgically Scar is red, sensitive to touch, unsightly probably just inflammatory process reassurance if no infection present let it stay for 6 months before considering revision Raised, hypertrophic appearance to scar hypertrophic observe until stabilizes can revise it, but recurrence is common unless you use steroids, local pressure dressings Raised hypertrophic appearance, spreading outside immediate incision area keloid (more pronounced than hypertrophic, extends outside original wound margins). Wound does not heal for prolonged period biopsy to rule out squamous cell carcinoma (Marjolin ulcer)

DEFINITIONS

Wound = disruption of normal anatomic relations as a result of an injury Cardinal Signs of Inflammation: o Rubor: Redness o Calor: Heat o Tumor: Swelling o Dolor: Pain o Loss of function

PHASES OF WOUND HEALING. 2nd & 3rd begin once wound is covered by epithelium

Inflammatory/Substrate. Neutrophils (1-2 d.) complement, kallikrein; macrophages (3-4 d.) wound debridement; TGF-B IL-1; tissue matrix metalloproteinases debridement. Proliferative. Production of collagen. Fibroblast collagen; glycine, hydroxyproline, hydroxylysine required for collagen. Maturation/Remodeling (9-12 m.). Maturation of collagen by intermolecular cross-linking. Great metabolic activity. Important growth factors: PDGF: chemotactic for macrophages, fibroblast, neutrophils; TGF-B: increases collagen synthesis; Fibroblast Growth factor hastens wound contraction; EGF epithelial migration and mitosis epithelialization.

WOUND DESCRIPTIONS

Clean. No entry made in resp, GI, GU, no active infection. Infection rate: <2%. Example: uncomplicated ventral hernia repair, no mesh. Low risk of infection (<1%). Close primarily, no antibiotics.

o If mesh antibiotics Clean-contaminated. GI, respiratory, GU tract entered, tract is prepared mechanically and antibacterially. Infection rate: <3%. Example: elective colectomy with preoperative bowel prep. <10% chance of wound infection. Close primarily. Contaminated. Major contamination of wound. Infection rate: <5%. Give perioperative antibiotics. Example: perforated colon. Leave open, treat with saline-soaked gauze, close after granulation or continue to observe wound contraction. 50% chance of wound infection with primary wound closure some say acceptable. If wound infection occurs open wound. Infected wound. Established infection before a wound is made. Infection Rate: >50%. Example: appendiceal abscess.

WOUND CLOSURE

Primary closure.Close wound edges with sutures, allowing rapid coverage by epithelium. Secondary closure. Were contaminated at initial surgery, left open OR wounds that became infected, required opening in immediate post-op period. Granulation tissue forms, fills in cavity wound contraction and reepithelialization + myofibroblasts contraction (contractures). Tertiary closure. Grossly contaminated wound heals no contamination w/ granulation tissue close with sutures once bacterial count has diminished.

WOUND HEALING COMPLICATIONS

Wound infection. Redness, tenderness in middle of wound suspect wound infection drain infection completely debride nonviable tissue Does not require antibiotics apply moist gauze daily to further debride necrotic tissue when removed. Antibiotics if wound cellulitis appears to spread despite drainage. Wound has beefy red edges local wound care (slow) leads to terrible scars (best for significant infections or problematic healing OR Place skin graft (split thickness).

BURNS
BURN TYPES

First degree. Burns epidermis only. Red, moderately painful, blanch with pressure Blistering is absent. Tx: analgesics, oral hydration, topical compounds No scar and heals in days. Superficial second degree.Blisters. Proteinaceous fluid from damaged capillaries Very painful, blanches on pressure, moist 24 - 48 hrs --> eschar.Dead tissue, coagulated serum and debris. Deep second degree. Dry, leathery texture, no erythema,waxy white color, may be less painful. Destruction of nerve endings Heal poorly --> scar. Tx: excision of burnt tissue and skin graft. Third degree. Dry, avascular coagulum, painless, waxy white to black and charred. Protein coagulation --> contraction --> constriction of circulation. Small size --> contraction. Large size -> skin graft

AIRWAY BURN

Carbonaceous sputum, facial burn, facial or nasal hair burns, hoarseness, low oxygen saturation, or dyspnea

BURN CARE

Stop the burning process. Dousing with water, smothering, or rolling patients on the ground. Estimate total body surface area covered by burn. Trauma surveys (primary and secondary survey). Primary Survey ABCDE: Morbidity and mortality associated with smoke inhalation injury, carbon monoxide, upper airway obstruction, pulmonary injury. Tx: intubation, oxygen, Foley cath, two large bore IV. Burns mask other injuries

Burn Care: Resuscitation, Wound Closure, Rehabilitation o Resuscitation IV fluids. Burns > 15% TBSA => burn shock. Capillary breakdown => edema => decrease in circulating volume. Use Parkland Formula and start LR at a rate determined by burn size and weight. 1/2 fluid in first 8 hrs, the rest over 16 hrs to maintain urine output of >30 ml/hr.

Total volume of lactated Ringer's solution = % BSA burned X weight (kg) X 4 mL/kg Frequent pulse checks. Eschar => escharotomy.

WOUND CLOSURE AND CARE

Early excision (Tangential excision, fascial excision). Can wait 10-14 days if mixed skin graft. Can do autograft, full thickness, split thickness. Expansion by mesh, cadaver allograft, pigs skin, amniotic membrane, synthetic materials. Infection control silver sulfadiazine. Wash regularly. Debridement. Dressing change twice a day. Enteral feedings High protein diet (1.5 - 2.0 g protein/kg).

REHABILITATION

Motion and stretching exercises. Most begin as early as possible. Prevent contractures. Hypertrophic scars --> tight-fitting anti burn scar garments.

TRANSFER TO BURN CENTER

Indications. Full-thickness burn >5% BSA, partialthickness burn >20% BSA, age <5 or >50 years, burns of face, hands, feet, genitalia, perineum, or over major joints, inhalation injury, circumferential burns of the chest or extremities, chemical or electrical burns.

ASSOCIATED INJURY

Myoglobinuria. Can cause ATN. Give IVF and Alkalinize the urine. CO. Give O2 or hyperbaric O2. Methemoglobinemia. Give IV methylene blue. Circumferential burn. May need escharotomy. Electric burn. Normal on surface. Interior damage to muscles, nerves, and vessels. Order EKG and cardio enzymes. Watch for myoglobinuria.