For almost all mets except liver mets, hormonal therapy should probably be tried
before chemotherapy is used if receptor positive; this is not due to increased effectiveness
but as first line because of low side effects and toxicity. If no response then go to chemo.
Treated breast carcinoma: program for follow-up and management
- Women with a personal history of breast CA should consult their physicians about
the need for more frequent examinations or about beginning periodic mammography
before age 50.
Case Histories
#1 63-YO W female, lump in R breast post-self exam; RF= family Hx with mother died at 41
d/t breast CA; PE=2.5cm firm mobile mss in UOQ with negative axillary exam. Work-up
and options for therapy.
#2 41-YO premenopausal female 10 days post modified radical for infiltrating intraductal
carcinoma; path shows 2/21 nodes positive with positive estrogen receptors. Plans for
adjuvant therapy.
#3 55-YO female with mammogram showing stipling and calcifications in R breast with PE
WNL. Manage?
#4 18-YO student with small, smooth, moveable, nontender, well-circumscribed breast mass.
Plan for work-up and Tx.
#5 32-YO lactating female, painful breast mass and temp of 101. Most likely diagnosis?
Treatment?
SKIN AND SOFT TISSUE
Learning Objectives:
Abscess vs. Cellulitis
- Abscess = localized collection of pus anywhere in the body, surrounded and walled offby damaged and inflammed tissues.
- Cellulitis = diffuse nonblancing erythema and tenderness extending from a break in the skin barrier.
Differentiate subungual hematoma vs. paronychia vs. felon, based on PE
- Subungual hematoma: accumulation of blood within the tissues (beneath nail), which clot to form a solid swelling
- Paronychia: Infection on side of finger nail: Tx by drainage and hot soaks;
staphylococcal infection of the proximal fingernail
- Felon: Infection in tip of finger pad (felon = fingerprint); drain; deep infections of the pulp space of ther terminal phalanx; usually occur after penetrating injuries of the distal phalanx.
Procedure for wound closure using interrupted and running suture techniques
- The most common stitch for skin closure is the simple or over-and-over suture.
The suture may be interrupted (each stitch placed and tied independently) or run in a
continuous fashion. The running simple suture has the advantage of saving time but also has the disadvantage of total wound disruption if the suture breaks or is cut.
Indications, dose and use of LA for simple surgical wounds, abrasions and regional blocks in the hand and elsewhere.
- Local anesthesia is for a small confined area of the body where regional blocks a region of the body. Lidocaine and bupivicaine are used for both. Epinephrine is CI for fingers, toes, penis, lips, areola where end arterioles are present.
- Local anesthesia is generally adequate for smaller wounds. Xylocaine 1% or 0.5%
is usually sufficient. Marcaine may be used for longer duration anesthesia. Epinephrine for vasoconstriction is helpful for areas with a rich blood supply. Difference between good and bad anesthetic is 5 minutes. Toxic dose is 7mg/kg.
Technique for removal of small skin or SQ lesions.
- The most common skin lesions are skin tags, papillomas, which are treatd by
cauterizing; large lesions may require LA then sharp dissection. Warts can be treated with cautery or liquid nitrogen. Sebaceous cysts should be excised.
- Majority of SQ lesions are lipomas and should be incised.
Management of ingrown toenails
- Digital block. Remove the offending portion, the entire nail if very thick and deeply embedded, then curretage if the nail bed.
Pigmented skin lesions, benign vs. malignant: pertinent distinguishing characteristics.
| LESIONS |
CHARACTERISTICS |
| Junctional nevi |
early years of life, particulary adolescence, few mm to several
cm; light to dark brown in color with a flat, smooth survace and
irregular edges |
| Compound nevi |
brown or black with a raised nodular surface frequently
containing hair; usually < 1cm; all age groups |
| Intradermal nevi |
can be very large, usually < 1cm; color from light to dark brown,
raised warty or smooth surface; presence of coarse hairs
distinghishes them |
| Blue nevi |
smooth blue or blue-black lesions < 1cm with well-defined
regular margins; face, dorsum of feet and hands, and buttocks;
rarely associated with melanoma |
| Basal cell carcinoma |
most common in middle-aged; pigmented bcc has a blue-black
coloration with raised edges and capillary neovascularization;
intially smooth but may ulcerate |
| Sehorrheic keratoses |
occasionally black in color; usually 1cm or larger, typically
raised, warty, greasy, with appearance of being "stuck" onto skin |
| Dermatofibroma |
dark brown, usually smooth, slightly raised, y sin pelo; grows
slowly and never malignant |
| Subungual hemorrhage |
sudden in onset and sharply defined beneath the nail bed;
melanoma slow onset and poor borders with streaks along nail;
confimed by puncturing nail |
Sebaceous cyst vs. lipoma: differentiate based on PE.
- Lipomas are freely movable, deep to the skin, and therefore will not move when the skin is moved over them. If the lesion moves when the skin is moved then they are either a sebaceous cyst or a dermatofibroma. A sebaceous cyst can be identified by the pore where the cyst started.
Ddx of lymphadenopathy in the neck vs. supraclavicular area vs. axilla vs. groin.
Melanoma: therapy
- Melanomas are initially assessed by either excisional or incisional biopsy. Local therapy considers two questions: the width and depth of the excision. Current
recommendations are 2-cm lateral margins and to the depth of the fascia. Clinically
palpable lymph nodes should be excised, also if the primary lesion is >0.75-mm thick. Distant dz is managed either by radiation therapy or chemotherapy (DTIC).
Basal and squamous cell carcinoma: Tx
- Two principles involved in Tx both: confirmation of the diagnosis histologically and complete removal or destruction of the tumor. Small lesions receive cryotherapy or curettage. Surgical excision involves taking a 1cm margin in most, 0.5 if around criical structures, and 1..5 for morphea-like or fibrosing tumors. Multiple frozen sections to
determine if complete border is excised. The only major difference with SCC is
consideration of lymph node removal. Close follow-up is needed in both cases.
Tetanus prophylaxis: indications and administration.
- Tetanus is caused by Clostridium tetani with s/s of lockjaw, muscle spasm, laryngospasm, convulsions, and respiratory failure. If pt has a a tetanus-prone injury
and previous immunization x 3 then tetanus toxoid only; if no previous immunization,
or unknown, then requires tetanus immunoglobulin IM and tetanus toxoid IM at
different sites.
- Tetanus prone are > 6 hours old, type (crush, avulsion, extensive abrasion,
burn/frostbite), and contaminants (soil, saliva) are present. If last booster was > 5 years
then should administer toxoid. The only contraindication is a neurologic or sever
hypersensitivity reaction from a previous dose of tetanus toxoid.
Wound infection: clinical signs, management
- S/S: Pain at incision site, erythema, drainage. Tx by removing skin sutures /
staples, digital examination to rule out fascial dehiscence, pack wound open
- Spanish signs: rubor, calor, turgor, dolor, laessa functionale. NEC manifests by nonblanching erythema with blisters and frank necrosis of the skin.
| Infection |
Physical Findings |
Treatment |
| Cellulitis |
Diffuse nonblanching
erythema tenderness |
Systemic abx, local wound
cleansing |
| Furuncle, carbuncle |
localized induration,
erythema, tenderness,
swelling, creamy pus
formation |
I&D, systemic abx for
carbuncle |
| Hidradenitis suppurativa |
Multiple abscesses; drainage;
thick pus from axilla, groin
regions |
I&D small lesions; wide
debridement; excision and
grafting, large areas |
| Lymphangitis |
Swelling and erythema distal
extremity, inflamed streaks
along involved lymphatic
channels |
Local wound cleansing,
removal of any foreign body,
systemic abx |
| Gangrene |
Necrotic skin/fascia, extremity
swelling, grayish liquid
discharge, crepitation /gas
fromation within tissue planes |
Radical debridement of all
involved tissues, parenteral
abx |
ESOPHAGUS, STOMACH AND DUODENUM
Learning Objectives:
Esophago-gastro-duodenoscopy: indications
- The mucosa can be examined in detail and if an ulcer is present it can usually be
seen. In pts who are bleeding, the exact size of hemorrhage can be determined.
Endoscopy can also identify concomitant disease or reveal alternative diagnoses in certain pts. Biopsies can be performed.
Esophago-gastro-duodenoscopy: complications
Esophagoscopy: technique; findings in reflux esophagitis vs. esophageal CA vs.
paraesophageal hernia
- Reflux esophagitis: endoscopy plus bx;
- Esophageal CA:
- Paraesophageal hernia: reveals herniation of the fundus
Esophagoscopy: risks, benefits
Gastric ulcers: fidings in pt with benign vs. malignant
- Gastric ulcer pain usually occurs in the epigastrium and may radiate through to the back. It is produced by the ingestion of food, while duodenal ulcer pain is relieved by eating.
- Because hydrochloric acid is necessary for a true gastric ulcer, if the pt is found to have achorhydria, the chances of malignancy are substantially increased.
- Endoscopy with multiple biopsies will help to establish the presence or absence of carcinoma. Cytology and brushings are also helpful as an adjunct to bx.
- If the ulcer is refractory to medical Tx after 6 weeks then suspicion is heightened for malignancy.
PUD: evaluation and management
- 10% of all Americans will suffer from PUD during their lifetime. S/s pain,
hemorrhage, perforation, obstruction. Associated with Helicobacter pylori.
- Evaluation: Hx of burning epigastric abdominal pain accentuated by fasting,
awakens pt from sleep and is relieved by antacids or food. Weight gain is not uncommon. Pain characterized as "boring in nature" and may radiate to back with posterior-penetrating ulcers. Massive UGI hemorrhage may occur giving s/s of syncope, tachycardia, hypotension, nausea and hematemesis. Perforation may give acute abd. s/s of tachyrardia, severe abd. tenderness and pain, guarding, and rigidity. Scarred duodenal bulb will give gastric outlet obstruction with s/s of weight loss, persistent vomiting immediately postprandial, and chronic gastric dilatation.
- Management is surgical with hemorrhage, perforation, obstruction, or failure of
non-operative management. Perforation without contraindications to surgery should result in exploratory laparotomy. Surgical abdomen less than 6 hours old should result in plication and acid-reducing procedure; if > 6 hours then plication alone.
- UGI hemorrhage should have NG decompression, gastric lavage, and antacid
therapy. Evaluate coagulation status and prep blood; if > 6 units in 12 hours then operate.
Older people tolerate hypotension more poorly than younger folks and should be
candidates for earlier intervention.
- Gastric outlet obstruction should have NG decompression and NPO for 5-6 days.
Should have acid-reducing operation and pyloroplasty.
Case Histories
#1 69-YO B male, 2-month Hx of inreasing swallowing difficulty; 12-pound weight loss over
6 weeks; UGE shows obstructing mass in distal 1/3 of esophagus; Bx reveals
adenocarcinoma of esophagus; CT shows 4cm esophageal mass without evidence of lymph
node spread or metastatic dz. Tx plan.
#2 49-YO W male in ER with sudden severe epigastric pain; diagnosed with duodenal ulcer
via UGE post two year, on cimetidine for one year; Shx= moderate drinker, 1PPD;
PE=hypertensive, tachycardiac, with rigid abdomen, no bowel sounds. Plan for further
eval and Tx.
#3 57-YO W male post UGE for abdominal pain and early satiety, shows 2cm gastric ulcer.
How is pathogenesis different case #2? Plan for further eval and Tx.
#4 61-YO W female with long Hx of PUD in ER with N/V; UGE shows J-shaped stomach
and gastric outlet obstruction. Plan for further eval and Tx.
ABDOMINAL PAIN
Learning Objectives:
Acute abdominal pain: DDX and plan for work-up
- Peritoneal signs: extreme tenderness, rebound tenderness, voluntary
guarding, pain with movement such as rocking the pts pelvis or by striking heel of the pt, decreased or absent bowel sounds, and involuntary guarding / rigidity late.
- RUQ: cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver
tumors, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis,
nephrolithiasis, appendicitis (pregnancy); thoracic causes--pleurisy / pneumonia, PE,
pericarditis, MI (esp. inferior MI)
- LUQ: PUD, perforated ulcer, gastritis, splenic dz or rupture, abscess, reflux,
dissecting aortic aneurysm, thoracic causes per above, pyelonephritis, nephrolihiasis,
hiatal hernia (strangulated paraesophageal hernia), Boerhaave's syndrome, Mallory-Weiss tear
- LLQ: Diverticulitis, sigmoid volvulus, perforated colon, colon CA, UTI, SBO,
IBD, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or
perforation, referred hip pain; GYN causes--ectopic pregnancy, PID, mittelschmerz,
ovarian cyst, fibroid degeneration, endometriosis, GYN tumor, torsion of cyst or
fallopian tube
- RLQ: Same as LLQ, especially appendicitis, also mesenteric lymphadenitis,
cecal diverticulitis, Meckel's diverticulum, intussusception
- Work-up includes a focus on history, especially the pain characterization and
changes, abdominal exam, rectal, exam, pelvic exam, CBC, UA, and PA and lateral
decubitus abd films.
2. Chronic abdominal pain: DDX and plan for work-up.
BILIARY TRACT DISEASE
Learning Objectives:
1. Cholelithiasis: management decisions if dx known
- Initially, gallstones do not cause clinical symptoms. Most data indicated that
asymptomatic gallstones should be followed until such time that they become symptomatic (20% lifetime risk) making a cholecystectomy justifiable. However, select pts should undergo elective cholecystectomy if their course would be complicated by infection (diabetics).
- IVFs, abx, NG tube decompression, Cholecystectomy, or if poor operative
candidate: cholecystostomy
Case Histories
#1 46-YO W female in ER with epigastric and RUQ pain; pain post one hour eating fried
chicken followed by N/Vj and fever to 101; Phx unremarkable except diet-controlled DM;
PE=BP WNL, pulse=94, temp=101.8, exquisitely tender 4cm mass below the right liver
edge and tenderness in the subscapular region on the right, no peritoneal signs; WBC=14.3
58p 17b, bili=2.2 amy=134, LFTs WNL. DDX. Risk factors and suggest plan for
further eval and Tx.
#2 44-YO female, healthy, gallstones in US, no s/s of biliary tract dz. Advise pt.
#3 58-YO female 5 days post elective lap chole d/t multiple stones; pain and tenderness in
RUQ and fever to 101.5. DDX and Tx recommendations for each Dx.
#4 40-YO female 8 weeks post lap chole with RUQ pain and nausea= same s/s prior to
surgery. DDX. Further investigation.
COLON AND RECTAL DISEASE
Learning Objectives:
1. Work-up: occult lower GI bleed, hematochezia, massive lower GI bleed
- Begin on IVFs: LR, PRBC as needed (through at least 16G peripheral IVs
x2), Foley to follow UO. Hx, PE, NG tube aspirate (r/o UGI bleed must see bile or
blood, if not do EGD), then do proctosigmoidoscopy / colonoscopy; proctoscopic
exam in ER. If too much blood to visualize with scope then do radiolabeled RBC
scan (need 0.1 ml/min) or arteriography (need >0.5 ml/min).
- Most common cause = diverticulosis, #2 = angiodysplasia; DDx: diverticular
dz, angiodysplasia, colon CA, hemorrhoids, trauma, hereditary hemorrhagic
telangiectasia, intussusception, volvulus, ischemic colitis, IBD (espec. UC),
anticoagulation, rectal CA, Meckel's diverticulum (w/ ectopic gastric mucosa), colonic ulcer, chemotherapy, irradiation injury, infarcted bowel, strangulated hernia
Colonoscopy: indications
- Primary diagnostic modality to evaluate lower GI bleeding of unknown etiology,
IBD, polyps, equivocal BE findings, posttumor removal, pseudoobstruction, and stricture.
Colonoscopy: complications
Sigmoidoscoopy: indications for flexible and rigid
- Rigid sigmoidoscopy was the standard method of visualizing the distal colon and
rectum; it has largely been replaced by fiberoptic flexible sigmoidoscopy which provides an higher diagnostic yield and is much less uncomfortable for the patient. This examination allows visulaization of the last 30-65cm of the colorectal complex and detects 60% of colorectal neoplasms.
Sigmoidoscopy: complications
Colorectal CA: screening plan
- Annual digital rectal exam starting at age 40 (10% of tumors palpable)
- Annual test for fecal occult blood starting at age 40
- Sigmoidoscopy at ages 50 &51, then every 3-5 years
- More aggressive monitoring for pts with FHx of familial polyposis
Colonoscopy vs. BE: C and C for pt comfort, cost and relative usefulness
Radiographic appearance: diverticulosis, diverticulitis, inflammatory bowel disease, colon and rectal polyps and CA
- Diverticuolsis: segmental spasm and luminal narrowing have been reported.
- Diverticulitis: x-ray = ileus, partially obstructed colon, air fluid levels, free air if perfed; abdominal/pelvic CT = swollen, edematous bowel wall, this test is
particularly helpful to show an abscess that may be a complicating factor
- IBD: UC has lead pipe appearance on BE, Crohn's shows cobblestoning and
string sign
- Polyps show up as clear circular patches (islands) on BE.
- CA shows up as a mass on BE
Colorectal CA: rational follow-up protocol post surgery
- High rate of recurrence (30-40%) prompts post-operative therapy with
radiation combined with 5-FU. To most efficiently detect recurrence, the pt should
be seen for Hx, CEA, and physical every 3 months for 2 years, then every 6 months
for 2 years. A pt without recurrence at 5 years is most likely clear of dz. Further
surveillance should be via screening colonscopy every 3 years thereafter.
Ostomy: common problems and management options
Case Histories
#1 64-YO male with guaiac positive stool and anemia. Plan for diagnostic work-up.
#2 69-YO W male in ER with 3 hours Hx of passing large amounts of dark wine-colored
stool; Hx-diverticular disease from BE post 4 years; Orthostatic on admission, received
adequate fluid resuscitation; DDX for massive lower GI bleed in this age group, how to
proceed with eval? Bleed localized to ascending colon, continues to bleed and receives
total of 10 units PRBCs. Recommendation for eval and Tx?
#3 61-YO male with 4 month Hx of blood streaking the stoosl with a decrease in caliber of
stools; 10 pound weight loss; rectal exam reveals no masses and guiac positive stool; LFTs
are normal but CEA is 27. Plan for further eval and Tx?
#4 67-YO male with guaiac positive stool; air-contrast BE reveals 3cm polyp at splenic
flexure. Appropriate management? Association between polyp size and risk of
carcinoma?
#5 41-YO with 6 year Hx of UC for f/u colonoscopy; Bx reveals a focus of adenocarcinoma
in left colon. Tx recommendation?
#6 64-YO W male with no Hx of intraabdominal problems with cc of passing air in urine over
last several days. DDX? Evaluation of problem?
BENIGN PERIANAL DISEASE
Learning Objectives:
External and internal hemmorhoids: differentiate on PE and describe anatomical
differences.
- External hemmorhoids are below the dentate line and are painful d/t presence
of pain nerve fibers, converse is true for internal hemorrhoids.
- Inferior / external hemorrhoids connect directly to systemic circulation, superior /internal hemorrhoids return to portal system.
Hemorrhoids: 4 clinical stages.
- First degree: hemorrhoids that do not prolapse
- Second degree: prolapse with defecation but return on their own
- Third degree: prolapse with defecation or any type of Valsalva maneuver and require active manual reduction (eat fiber)
- Fourth degree: Prolapsed hemorrhoids that cannot be reduced
Hemorrhoidal disease: etiology and predisposing conditions.
- Engorgement of the venous plexi of the rectum and/ or anus, with protrusion
of mucosa and / or of the anal margin. Predisposed by constipation/straining, portal
HTN, pregnancy.
- Other factors include low-residue diet, excessive exercise, increased anal sphincter tone, musculoskeletal dz, and systemic abnormalities such as portal HTN. Not simply varicose veins, but a complex of the vascular cushion that contains venous and arterial components.
External and internal hemorrhoids: s/s
- Anal mass/prolapse, bleeding, itching, pain.
- External hemorrhoids present with severe pain when they undergo thrombosis.
Internal hemorrhoids often present with discomfort, bleeding, and prolapse.
- Must undergo examination to r/o other concomitant disease such as rectal prolapse, pruritus, anorectal inflammation, CA, IBD, and STD. Look for fissures, masses, perianal dz, protruding external hemorrhoids, skin irritation, lichenification, or hyperemia of the skin. Note sphincter spasm, ulceration, fistulas, draining sinuses, cysts, warts, or discharges. Digital exam checking for polyps, stenosis, tumors, Blumer's shelf, and
fluctuant masses. Instrumentation with proctoscope, rigid sigmoidoscope, or flexible
sigmoidoscope.
- Questions must be asked about: bleeding, constipation, diarrhea, discharge, itching, mucus, pain of the anorectal area, protrusion, stools, and tenesmus.
External and internal hemorrhoids: management (operative and nonoperative)
- High-fiber diet, anal hygiene, topical steroids, sitz baths rubber band
ligation of most (no LA for internal) and surgical resection for large refractory
roids.
- Treatment modalities include sclerotherapy, cryosurgery, dietary manipulation,
banding, and surgical hemorrhoidectomy. First-, second-, and third-degree hemorrhoids do best with banding, while refractory hemorrhoids and fourth-degree require surgical excision.
Role of anal crypts in perineal (perianal?) abscess formation and describe the various types of perianal infections.
- Most abscesses develop from the anal crypts that are present at the dentate line and
become infected. The infecting organisms burrow into the anal glands, producing
circumscribed area of microabscesses in teh subcutaneous, submucosal, and intramuscular
perirectal regions of the rectum.
- Two classifications of abscesses:
- infralevator (common) including perianal,
ischiorectal, and postanal
- supralevator (rare) including postrectal and pelvirectal.
Perianal infections: s/s, physical findings.
- Rectal pain, drainage of pus, fever, perianal mass
- Two categories: infralevator (common) and supralevator (rare). Most are abscesses that develop at teh dentate line and become infected. They present with perianal cellulitis and diffuse inflammation, characterized by generallized edema, swelling, and redness that is not yet localized. Abscesses begin at sites other than the crypts in Crohn's dz and TB. Pain is the most common presenting symptom. Some present with systemic symptoms of fever, chills, generalized malaise, nausea, and vomiting. Supralevator abscess should be considered in pt with rectal pain and systemic symptoms. Digital examination may reveal an abscess higher in the anal canal. Confirmation comes by needle aspiration of pus under LA.
Perianal infections: management (abx, incision and drainage, fistulectomy)
- As with all abscesses, drainage and abx against colonic flora. Anorectal
fistulas require marsupialization of fistula tract and wound care.
- External abscesses are excised under LA with adequate I&D including excision of a portion of the skin, preferably closing with a drain in place.
- Infections with subsequent fistula formation require marsupialization of the tract with complete excision.
Pilonidal cyst: s/s, physical findings, management
Anal fissure: s/s, physical findings, Tx
- Painful linear ulcer at the margin of the anus. Constipation or diarrhea is the most
likely historical antecedent with anal abrasions and acute ulcers at the anal verge.
Associated with infections in the crypts, an enlarged papilla, skin tags, and a narrow anal
canal. May develop secondary to proctitis, anal surgery, or basal cell carcinoma. Dx is by
inspection with a clear, punched lesion, neither large nor indolent, rarely multiple.
- Tx for lesion of < 2 weeks involves non-operative therapy with good anal hygiene, stool softeners, cleansing with sponges, and the application of hydrocortisone foam or suppositories, high-residue diet, and anesthetic ointment. Conditions longer than two weeks generally require surgery. Associated conditions such as skin tags and papillae need to be excised and any hemorrhoids removed. Many surgeons employ a partial internal sphincterotomy.
Case Histories
#1 52-YO W male with long Hx of constipation and hemorrhoids with brbpr; blood on TP
post BM; Hemorrhoidal prolapse during BM requiring manual reduction. Plan for eval
and management?
#2 69-YO W male with Hx or perirectal abscess post 7 yars now with mild periregal pain and
purulent discharge; exam reveals external opening at 2 o'clock. Pathophysiology of this
condition? Treatment?
#3 43-YO W male with severe R-sided perirectal pain; exam reveals temp 101; tender,
fluctuant mass in R perirectal area with overlying edema. How to proceed?
#4 3-YO W female with brbpr on TP with BM; serious problem with constipation over the
last three weeks, cries loudly with each BM; exam reveals 1cm tear in perianal skin in post.
midline. Conservative Tx plan? Recommendation if conservative Tx fails?
#5 39-YO W female with severe perianal itching; itching worse at night and disturbs sleep;
scrkupulous personal hygiene; Exam reveals erythema and oxcoriation of perianal area;
work-up inlcuding BE and sigmoidoscopy fails to reveal colorectal pathology. Tx?
#6 51-YO male truck driver with pain and tenderness in midline just above anus; purulent
drainage from this area; Exam reveals an opening in midline draining pus with surrounding
arythema and fluctuance. Tx plan? Most common complication of surgical
managenet?
HERNIAS
Learning Objectives:
Hernia repair: postoperative instructions
- No lifting or abdominal straining
Indirect and direct inguinal hernias: anatomic and developmental differences.
- Direct: within floor of Hesselbach's triangle, acquired defect from mechanical
breakdown over the years, 1% of all males, increased frequency with advancing age,
no hernia sac.
- Indirect: through the internal ring of the inguinal canal, traveling down toward the
external ring, may enter the scrotum; patent processus vaginalis (i.e., congenital)
which gives an hernia sac; approx. 5% of all males, most common hernia in both
males and females
Inguinal hernias: 3 predisposing clinical conditions
- Increased intraabdominal pressure: straining at defecation or urination (rectal CA,
colon CA, prostatic enlargement, constipation), obesity, pregnancy, ascites,
valsavagenic (coughing), COPD
- Presence of an abnormal congenital anatomical route (i.e., patent processus vaginalis)
4. Indirect, direct, and femoral hernias: relative frequency by age and gender
- 5-10% lifetime incidence overall; 50% are indirect inguinal, 25% are direct inguinal,
and about 15% are femoral. Direct increase in frequency with advancing age being
rare in childhood but 40% of males, indirect always more common. Indirect most
common in both males and females. Femoral more common in females than males
(assoc. with women, pregnancy, exertion), but indirect still most common in females.
"Sliding" hernia, incarcerated hernia, strangulated hernia: define
- Sliding: herina sac is partially formed by the wall of a viscus (i.e., bladder,
cecum); type of hiatal hernia with displacement of GE junction = type I hiatal hernia; > 90% of hiatal hernia
- Incarcerated: bowel swollen and fixed within the hernia sac, may or may not
cause intestinal obstruction (imprisoned); irreducible
- Strangulated: incarcerated hernia with resulting ischemia; will result in s/s of
ischemia and intestinal obstruction (pain and vomiting; = choked
6. Femoral hernia: clinical presentation
- Hernia traveling beneath the inguinal ligament down the femoral canal medial to the
femoral vessels; about 1/3 incarcerate, much higher rate than others.
Groin hernia: management and treatment
- On first encounter, manual reduction is warranted as 60-70% reduce in this
manner. The overall management is by repair: a) reduce any abdominal viscus to the
abdominal cavity; b) obliterate the processus vaginalis (indirect) at a point high against the
abdominal wall; c)reform a snug abdominal ring around the spermatic cord.
Umbilical hernia in infant and adult: etiology, natural Hx, complications
- Three types:
- small, insignificant incomplete closure of umbilicus, covered by all
layers of skin, common in infants with protusion of omentum, bowel, or intraabdominal
organs, usually resolve spontaneously by preschool, may be some threat if remain in
adulthood as stiffness of linea alba may incarcerate and strangulate
- omphalocele from
incomplete closure of abdominal wall by birth with a portion of abdominal contents
herniating into the base of the umbilical cord, only covered by thin membrane of
peritoneum and the amnion
- gastroschisis is an even more severe defect with a full-thickness abdominal wall defect lateral to the umbilicus, no sac covers abdominal contents
which protrude out of the abdomen.
- Tx is by reducing the abdominal contents and establishing abdominal wall
continuity. Surgical therapy for omphalocele and gastroschisis is more intricate and
complex, requiring bowel resections and formation of extraanatomic compartments
fashioned of prosthetic materials. Mortality rates remain high.
Umbilical hernia in infant and adult: Tx
- Hernia is through the umbilical ring, associated with ascites, pregnancy, and
obesity. See Tx above in question #8.
Incisional hernia: 4 factors contributing to development
- Hernia through an incisional site; most common cause is a wound infection.
Other implications include orientation of incision, suture materials chosen, and various technical details
VASCULAR
Learning Objectives:
Asymptomatic aortic aneurysms of various sizes (3cm, 5cm, 7cm): plan for f/u and
management
- No medical therapy for an aneurysm
- 3cm: Watchful waiting, US and/or CT not aortography
- 5cm: Surgical repair, 1/3 of all AAA > 5cm will rupture in 3 years; grow 2-4cm/year on average (larger ones grow faster)
- 7cm: Surgical repair
Extracranial cerebrovascular disease: current noninvasive tests, indications for use indetermining the need for arteriography and surgical intervention
- Stethescope= carotid bruits, angle of the jaw, high-pitched
- Noninvasive methods of evaluating:
- Carotid ultrasound/doppler gives general location and degree and
character of stenosis; enhanced accuracy with duplex scan
- Oculoplethysmography measures indirectly the flow through the
ophthalmic artery, first branch off carotid
- Supraorbital Doppler detects reversal of flow in the supraorbital
arteries seen with occlusion of the internal carotid
- Definitive study is arteriography. Arteriography is appropriate in all symptomatic patients and in asymtomatic patients with high-grade stenoses or ulcers identified by noninvasive tests.
Venous ulcers and varicose veins: diagnostic, operative and nonoperative management.
- Venous ulcers: locaed in"gaiter"distribtion around the ankle, especially medial and lateral
malleoli, diffuse, shallow with some granulation, treated with elastic support and elevation;
ligation may be appropriate if an isolated incompetent perforator can be demonstrated
venographically, otherwise support and debridement.
- Varicose veins: In general, varicose veins should be treated nonoperatively. Primary
varicose veins due to valvular incompetence in greater saphenous vein=familial,
discomfort, no ankle edema or ulcers and no abnormality of deep venous system, may Tx
selected pts with ligation and stripping. Secondary varicose veins d/t abnormalities in deep
venous system from DVT and valvular destruction and incompetent perforating veins,
should only undergo stripping if deep venous system is patent and venous ulcers refractory
to nonoperative Tx.
Claudication: justify choice for conservative or surgical management
- Natural Hx of untrated claudication is generally benign; Framingham study: 5% risk of
major amputation in 5 years if Tx conservatively compare to 20% who die from other
causes
- Conservative: vast majority get conservative Tx, including exercise, stop smoking, Tx HTN and hyperlipidemia, diet
- Surgical:
- rest pain
- tissue necrosis or threatened limb
- severe claudication refractory to conservative Tx and that affects quality of life / livelihood.
Swollen leg: DDX and evaluation process.
- DDx of acute edema with leg pain: DVT, CHF, trauma, ruptured plantaris tendon, acute or chronic arterial insufficiency, infection, lymphangitis, lumbosacral strain and sciatica, muscle hematoma, renal failure
- Physical findings with DVT: calf tenderness, swelling of the leg or ankle, and Homans' sign.
- Noninvasive diagnosis is very accurate. Most common is Doppler US with duplex
scanning to assess venous flow; indirect tests including ipedance plethysmography and
phleborheography can supplement Doppler exam. Invasive techniques inclufe 125I fibrinogen scanning for calf vein thrombosis; venography is the gold standard.
Venous valvular incompetence and DVT: noninvasive and invasive testing procedures.
- Noninvasive: clinical manifestation of postphlebitis syndrome including chronically swollen legs with hyperpigmentation and venous stasis ulcerations; see #5 above noninvasive techniques
- Invasive: venography
Varicose veins: management
- See #3 above. In general, varicose veins should be treated non-operatively.
Chronic venous insufficiency with and without ulceration: management
- Treatment is geared toward reduction of edema and pressure by elevation of the legs and
the use of external support such as elastic stockings or medicinal boots (UNNA boot).
Acute extremity ischemia: evaluation and management steps
- Evaluation: Hx
- in situ thrombosis of preexistent occlusive dz
- arterial emboli,
- vascular trauma
- thrombosis of an aneurysm.
- In situ thrombosis pt may describe claudication or rest pain that has recently and suddenly accelerated. Sudden occlusion gives more sever symptoms. S/S include 6Ps: pallor, pain, paresthesia, poikilothermia, paralysis, and pulselessness. Venous occlusion also gives pain but darker color, venous distension, and swelling. Other Hx include rheumatic mitral stenosis, a-fib, radiation exposure, neoplastic dz. Common sites include axillary, popliteal, iliac arteries, aortic bifurcation, and SMA.
- Management: immediate anticoagulation with IV heparin unless new neurologic defect or
active bleed. Evaluate base deficits, pharmacologic support of severe cardiac dz. May
administer dextran and mannitol. Question of viability of limb would lead o immediate
embolectomy or thrombectomy. Arteriography is not essential in Dx and Tx.
Anticoagulation alone may be sufficient and may cosider thrombolytics in others.
- Surgical approach is considered for bypass grafting or endarterectomy of
preexisting thrombosis. In embolic occlusion thrombectomies can be performed both
proximally and distally. Beware of compartment syndrome which would necessitate a
fasciotomy. Continue anticoagulation as recurrence is 30% in 30 days without post-op
anticoaluation which reduces to 10% recurrence.
Case Histories
#1 72-YO male with Hx of episodic loss of vision in OS for 5-15 minutes; vision is lost "from
top down, like a shade being pulled over the eye;" four episodes in past two weeks; no
motor or sensory deficits during said episodes; PE=BP 118/78 with regular pulse, ocular
exam reveals Hollenhorst plaque in OS; carotid bruit noted on R side but none on L; chest
and heart exam WNL. Plan for further eval and management?
#2 59-YO W male with palpable 5 cm aneurysm on PE; meds for HTN and mild-mod
COPD; MI post 4 years with no current angina; Tx plan? Risks associated with both
observation and surgical management?
#3 54-YO male with worsening cramping pain in L calf after one block of walking, pain
relieved with sitting, no pain at night, Hx of CABG post 3 years and MI post 4 years,
angina only with extreve exertion; PE of extremities reveals no dependent rubor or
elevation pallor, pulses normal in R leg but posterior tib and dorsalis pedis pulse absent on
L, ABI is 0.85 on R and 0.52 on L. Management of pt? Indications for peripheral
vascular bypass?
#4 49-YO female with 2 day Hx of R calf and thigh swelling and pain; PE consistent with
DVT. How to proceed with eval? If DVT confirmed, plan for management?
#5 51-YO male with sudden onset of a cold, painful R leg; long Gx of cardiac problems with
two previous Mis and current A-fib. Plan for eval and management?
#6 52-YO female with venous stasis ulcers over medial melleoli for 4 years; vein stripping and
local wound care have not yielded healing; Trendelenburg test, lower leg veins fill
immediately upon standing with tourniquet in place. Primary or secondary venous
insufficiency? Tx recommendations?