Surgery Notes

General Surgery
 Diseases Of The GI System
 Mid And Lower GI System (Small Bowel To Anus)
 GI Bleeding
 The Acute Abdomen
 Hernias
 Diseases Of The Breast
 Diseases Of The Endocrine System
 Surgical Hypertension
 Diseases of GI system
 ESOPHAGUS
 GERD
 MOTILITY PROBLEMS
 ACHALASIA
 CANCER OF THE ESOPHAGUS
 MALLORY WEISS TEAR
 BOERHAAVE SYNDROME
 INSTRUMENTAL PERFORATION OF ESOPHAGUS
GERD
 EPIGASTRIC DISTRESS, pH monitoring is best to establish dx
 Most typical Px: Burning retrosternal pain and ‘heartburn’
brought about by bending over, wearing tight clothing, or
lying flat in bed at night and relieved by ingestion of antacids and
over the counters H2 blockers
 Long hx- then damage might already have been done to the
lower esophagus (peptic esophagitis) and the possible dev’t
of Barrett esophagus.
 Endoscopy and Bx’ies(if severe dysplastic changes) are indicated
tests.
 Nissen fundoplication is the usual procedure.
Motility problems
 Crushing pain with swallowing in uncoordinated massive
contraction , or the suggestive pattern of dysphagia seen in
achalasia where solids are swallowed with less difficulty
than liquids
 Barium swallow is typically done first. Manometry studies
are used for def dx.
Achalasia
 Seen more commonly in Women.
 Dysphagia that is worse for
liquids. Alleviated by sitting up
straight and waiting allows the
weight of the column of liquid to
overcome the sphincter
 Occassional regurgitation of
undigested food
 Xrays- megaesophagus
 Manometry is diagnostic.
 Current treatment is Balloon
dilatation via endoscopy
Esophageal cancer
 Classic progression of dysphagia starting from meat, then
other solids, then soft foods, eventually liquids, and finally saliva
 Wt loss is always seen
 Squamous cell carcinoma – in men with hx of smoking and
drinking (blacks have hi incidence)
 Adenocarcinoma – in people with long standing GERD
 Dx of both is established with endoscopy and biopsies, but barium
swallow must precede endoscopy to prevent perforation
 CT scan assesses operability, but most cases only get palliative
surgery
Mallory weiss tear
 After prolonged, forceful vomitting.
 Bright red blood comes up
 Endoscopy establishes the dx, and allows photocoagulation
(laser)
Booerhaave syndrome
 Starts with prolonged, forceful vomitting esophageal
perforation
 Continuous, severe, wrenching epigastric and low sternal pain of
sudden onset followed by fever, leukocytosis, and a very sick
looking pxt – similar px to acute appendicitis
 Gastrograffin 1st, barium if negative- diagnostic, emergency
surgical repair should follow
 Delay in treatment and dx – have grave consequences.
Esophageal perforation
 Instrumental perforation is by far the most common reason
 Shortly after completion of endoscopy, sx as described above
will develop
 Diagnostic clue- emphysema in the lower neck- air
under the skin – feeling of touching the rice
crispies- crepitus
 CT with Contrast studies and prompt repair are imperative.
Stomach
 Gastric Adenocarcinoma
 More common in the elderly
 Anorexia, wt loss, and vague epigastric distress or early satiety
 Occasional hematemesis
 Endoscopy and biopsies are diagnostic
 CT scan helps assess operability. Sx is the best therapy.
 Gastric Lymphoma
 Presentation and dx are similar to gastric adenocarcinoma
 Treatment is based on chemotherapy or radiotherapy
 Sx is done if perforation is feared as the tumor melts away
 Low grade lymphomatoid transformation(MALTOID) –
reversed by eradication of H.pylori
MID AND LOWER GI SYSTEM
 SMALL BOWEL AND APPENDIX
 Mechanical Intestinal Obstruction
 Strangulated Obstruction
 Mechanical Intestinal Obstruction Caused By An
Incarcerated Hernia
 Carcinoid Syndrome
 Acute Appendicitis
 MECHANICAL INTESTINAL
OBSTRUCTION
 Caused by adhesions who have had a prior laparotomy
 Colicky abdominal pain, protracted vomiting, progressive
abdominal distension (if it’s a low obstruction ), and no passage of
gas or feces.
 Early on – hi pitched bowel sounds coincide with colicky pain
(after a few days there is silence)
 Xrays – show distended loops of bowel with air fluid levels
 Rx: NPO, NG suction, and IV fluids– wait for spontaneous
solution
 Sx is done if conservative mgmt fails, w/in 24 hrs – if it’s a
complete obstruction or w/in few days if it’s a partial obstruction
Strangulated obstruction
 COMPROMISED BLOOD SUPPLY
 Pxt develops fever, leukocytosis, constant pain, signs of peritoneal
irritation, and full blown peritonitis and sepsis
 Emergency surgery is required.
Mechanical Intestinal Obstruction caused by an Incarcerated hernia
 PE- shows irreducible hernia to reducible
 Can eliminate the hernia but not the adhesions
 Surgical repair is warranted- emergently after proper rehydration
in those who appear to be strangulated
 Elective in those who have viable bowel and can be reduced
minimally
Carcinoid syndrome
 Small bowel carcinoid tumor with liver mets
 Sx: includes diarrhea, flushing of the face, wheezing, and
right sided heart valvular damage (look for prominent
jugular venous pulse)
 24 hr urinary collection of 5-HIAA provides the dx.
 HINT: Whenever syndromes produce episodic spells or
attacks, the offending agent will be at high concentration in
the blood only at the time of the attack. Blood sample taken
afterward will be normal.
 Colon
Right colon cancer
Anemia (hypochromic, iron
deficiency anemia), esp in elderly
Stools 4+ for occult blood
Colonoscopy and biopsies are
diagnostic
Sx: right hemicolectomy is Tx of
choice
Premalignant polyps
Descending order of probability
Familial polyposis (variants e.g.
gardner), familial multiple
inflammatory polyps, villous adenoma,
and adenomatous polyps
Left colon cancer
Bloody bowel movements
Blood coats the outside of stool,
narrow caliber of stool, constipation.
Flexible proctosigmoidoscopy exam
(45 or 60cm) and biopsies are usually
the 1st diagnostic study
B4 sx, full colonoscopy is needed to
rule out synchronous second primary
CT scan helps assess operability and
extent. Pre-op chemo and radiation
needed for large rectal cancers.
Non premalignant polyps
Juvenile
Peutz-jeghers
Isolated inflammatory
Hyperplastic

Chronic ulcerative colitis
 Managed medically
 Surgical indications-
 Disease present for >20 yrs (hi
incidence of malignant
degeneration), severe
interference with nutritional
status, multiple hospitalizations,
need for high dose steroids, or
immunosuppressants, or devt of
toxic megacolon (next slide)
 Definitive surgical treatment-
removal of affected colon +
rectal mucosa (almost always
involved)
Pseudomembranous
enterocolitis
 Overgrowth of C.Diff in pxts
who have been on Abx
 Cephalosporins are the MCC
 Profuse, watery diarrhea,
crampy abdominal pain, fever,
leukocytosis
 Dx:stool cx take too long and
pseudomembranes not always
seen on endoscopy
 Metronidazole is RX of choice
with vancomycin –as an
alternate
 Virulent form of the disease-
WBC >50, 0000 and serum
lactate >5 requires emergency
colectomy.
ANORECTAL DISEASE
 In all anorectal disease- must rule out cancer.
 Proper physical exam- proctosigmoidoscopy, even though the
clinical presentation suggest a benign process
 Hemorrhoids
 Internal Hemorrhoids- typically bleed, and can be treated with
rubber band ligation. Can become painful and produce
itching if prolapsed.
 External hemorrhoids- are painful – may need surgery if
conservative mgmt fails.
Anal Fissure
 Mc’n in young females
 Exquisite pain with defecation and blood streaks covering
the stools
 Fear of pain is so intense that they avoid bowel movements, get
constipated and refuse proper PE of the area.
 Tight sphincter- believed to cause the pain and perpetuate the
problem
 Thus Tx is to relax the sphincter- stool softeners, topical
Nitroglycerin, local injection of Botulinum toxin,
forceful dilatation, or lateral internal sphincterotomy
 CCBs e.g. Diltiazem ointment 2% TID topically for 6 wks
80-90% success rate versus botulinum toxin with 50% success
rate.
Crohn’s disease
 Most often affects the Anal area. Starts with a fistula, fissure,
or small ulceration, but if it fails to heal and gets worse after
surgical intervention (esp anal area usually heals very well
b/c it has dual blood supply, but if it fails to do so, that means
Crohn’s disease)
 Surgery is contraindicated – should not be done in crohn’s
disease of anus.
 Rx: Fistula if present could be drained with setons while
medical therapy is underway. Remicade (TNF blocker helps
healing).
Ischiorectal(perirectal) abscess
 Febrile, with exquisite pain – does not let him sit down or
have bowel movements
 PE: all the classic findings of abscess-(rubor, dolor, calor, and
tumor) lateral to the anus, b/w the rectum and ischial
tuberosity.
 I & D are needed, cancer should be ruled out by proper PE
 If pt is severely diabetic and ill, horrible necrotizing
soft tissue infection may follow: watch him closely.
Anal fistula
 Develop in pxts who have had an ischiorectal abscess
drained.
 Pathophysiology: Epithelial migration from anal crypts
(where the abscess originated) and from the perineal skin
(where the drainage was done) form a permanent tract.
 Findings: fecal soiling and perineal discomfort
 PE: opening lateral to the anus, cordlike tract may be felt,
and discharge may be expressed.
 R/O necrotic and draining tumor, and treat with
fistulotomy
Squamous cell carcinoma of Anus
 More common in HIV+, and in homosexual with receptive
sexual practices
 Fungating mass grows out of anus, metastatic inguinal nodes
are often felt.
 Dx: with biopsy
 RX: Nigro chemoradiation protocol followed by surgery if
there is residual tumor
 Currently – 5 wk chemo-radiation protocol has 90% success
rate, so surgery is rarely required.
Hepatobiliary system
 Liver
 Jaundice
 Gallbladder
 Pancreas
 Evaluating Hernias
Liver
 Primary Hepatoma
 Hepatocellular carcinoma – seen in US in people only with cirrhosis
 Develop vague RUQ discomfort and wt loss
 Specific blood marker is AFP
 CT scan will show location and extent
 Resection is done if possible
 Metastatic cancer to the Liver – more common than primary cancer
in the US. Found by CT scan, if follow/up for the treated primary tumor
is under way or b/c of rising CEA in those who had colonic cancer
 If primary is slow growing and mets are confined to one lobe, resection can
be done
 Hepatic adenoma
 arise as a complication of birth control pills
 Important b/c they have a tendency to rupture and bleed massively inside the
abdomen
 CT scan is diagnostic , emergency surgery is required.
 Pyogenic Liver Abscess
 Seen most often as a complication of biliary tract disease,
particularly acute ascending cholangitis
 PE- fever, leukocytosis, and a tender liver
 Dx: Sonogram or CT scan
 Percutaneous drainage is required
 Amebic abscess of the Liver
 Favors men, with a mexico connection – seen in states in
Immigrants
 Px and diagnosis are similar to that of pyogenic liver abscess
 Tx : metronidazole, seldom requires- drainage
 Def dx- via serology (ameba does not grow in the pus) but test
results take wk to be reported.
Jaundice – types
 Hemolytic Jaundice- low level of bilirubin 6-8, but not
35 or 40, elevated bilirubin is Unconjugated (indirect),
With no elevation of the direct /conj bilirubin.
 No change in urine color- no bile in urine.
 Work up should include to determine whats chewing up the
RBCs.
 Hepatocellular Jaundice – elevations of both direct
and indirect with v.high levels of transaminases, with
modest elevation of ALP.
 Hepatitis- most common example, work up should proceed
in that direction (serologies to determine specific type)
 Obstructive Jaundice
 Hi levels of both dir and indir bilirubin, modest elevation of transaminases,
and very hi levels of ALP.
 1st step is sonogram – look for dilataion of biliary ducts
 By stones – stone is obstructing the common duct seldom seen, but stones
are seen in the gall bladder b/c of chronic irritation cannot dilate.
 By tumors – could be caused by
 Adenocarcinoma of the head of pancreas or ampulla of vater, or cholangiocarcinoma
arising in the common duct itself
 Once tumor is confirmed with a dilated gallbladder on the sonogram, do CT
 Pancreatic cancers are big enough to be seen in CT. Percutaneous bx would then follow
 If CT is negative- do ERCP
 Ampullary cancers or cancers of the common duct – produce obstruction even when
they are small.
 E- endoscopy will show ampullary cancers, C- cholangiogram will show intrinsic tumors
arising from the duct(apple core) or small pancreatic cancers (that were not seen in CT)
pushing the ducts from outside.
 Obstructive jaundice by tumors cont’d
 Ampullary cancers
 Suspected when malignant obstructive jaundice coincides with anemia
and + blood in the stools
 Ampullary cancer  bleed into the lumen like any other mucosal
malignancy, it can also obstruct biliary flow by virtue of its location
 Endoscopy should be done first
 Pancreatic cancer
 When huge-Whipple operation (pancreatoduodenectomy) is done.
 Ampullary cancer and cancer of the lower end of common duct have a
common prognosis.
 GALLBLADDER
 Gallstones – common in almost everyone, with increasing age,
Mexican-Americans and Native Americans
 Asymptomatic Gallstones – left alone
 Biliary Colic – a stone temporarily occludes cystic duct.
 Colicky RUQ pain, radiates to the R shoulder, and beltlike to the back,
often triggered by ingestion of fatty food, with N/V, but W/O signs of
peritoneal irritation or systemic signs of inflammatory process
 Episode is self limited – 20-30 minutes, or easily aborted by
anticholingergics.
 Sonogram – establish dx of gallstones, elective cholecystectomy
 Acute Cholecystitis
 Starts at biliary colic, but stone remains at cystic duct until it causes
inflammation – develops in the obstructed gallbladder.
 Constant pain, modest fever, and leukocytosis
 Physical findings- peritoneal irritation in RUQ.
 Sonogram is diagnostic- gallstones, thick walled gall-bladder, and
pericholecystic fluid
 Rarely need HIDA scan- would show uptake of radionuclide in duodenum,
liver, and CBD.
 NG suction, NPO, IV fluids, and antibiotics “ cool down” most cases,
allowing elective cholecystectomy to follow.
 Usually men and diabetics do not respond to conservative mgmt, so
emergency cholecystectomy.
 Emergency percutaneous transhepatic cholecystectomy- in
very sick with prohibitive surgical risk.
 Acute Ascending Cholangitis
 Far more deadly disease, stones have reached the common duct
producing partial obstruction and ascending infection.
 Pxts are older and much sicker.
 T spikes to 104-105F with chills, very high WBC indicate sepsis.
 Some hyperbilirubinemia , key finding is HI levels of ALP.
 IV antibiotics and emergency decompression of CBD(ideally by
ERCP, alternatively by Percutaneous transhepatic
cholangiogram(PTC)
 Eventually cholecystectomy has to follow.
Obstructive Jaundice
 w/out Ascending cholangitis- occur when stones produce complete
biliary obstruction.
 Treatment and mgmt is discussed in jaundice section
Biliary pancreatitis
 Stones become impacted distally in the ampulla , temporarily
obstructing both pancreatic and biliary ducts.
 Stones often pass spontaneously, producing transit episodes of
cholangitis along with the classic presentation of pancreatitis(elevated
amylase or lipase).
 Sonogram – gallstones in the gall bladder
 Conservative treatment- NPO, NG suction, IV fluids- leads to
improvement, allowing elective cholecystectomy
 If not, ERCP and sphincterotomy- required to dislodge the impacted
stone.
Acute Pancreas
 Acute Pancreatitis
 Acute edematous pancreatitis
 Acute hemorrhagic pancreatitis
 Necrosectomy
 Pancreatic Abscess
 Pancreatic Pseudocyst
 Chronic Pancreatitis
Acute Pancreatitis
 Complication of gallstones, or in alcoholics.
 Can be edematous, hemorhagic, or suppurative (pancreatic
abscess)
 Late complications: pancreatic pseudocyst and chronic
pancreatitis.
Acute Edematous Pancreatitis
 In alcoholics or pxt with Gallstones
 Epigastric and midabdominal pain starts after a heavy meal or
bout of alcohol intake
 Constant and radiates straight through the back, and is
accompanied by nausea, vomitting, and after the stomach is
empty) continues to retch.
 Elevated serum amylase, or lipase or urinary amylase or
lipase (after a couple of days)
 Key finding to establish edematous- elevated HCT
 Resolution includes – NPO, NG suction, and IV fluids.
 Acute Hemorrhagic pancreatitis
 Much more deadly disease.
 Starts off as edematous, but early lab clue is lower HCT
 Other findings have been Catalogued (Ranson’s criteria)
 Elevated WBC, elevated BG, and low serum Ca2+.
 Next AM: hct is even lower, serum Ca2+ remains low, BUN
increase, metabolic acidosis and PO2 are evident.
 Prognosis is terrible and intensive supportive therapy is needed (in the
ICU)
 Common final pathways to death – multiple episodes of abscess
developments and drain them if possible, daily CT scans are
recommended.
 IV imipenem or meropenem in those with a seizure
disorder. Also indicated in pxts with signs of infected pxts.
 Necrosectomy
 Best way to deal with necrotic pancreas. Timing is crucial.
 Most practitioners will wait until dead tissue delineate and mature for
dissection.
 Better prognosis if wait 4 wks before debridement of dead pancreatic
tissue.
Pancreatic abscess (acute suppurative
pancreatitis)
 Persistent fever and leukocytosis develop about 10 days
after the onset of pancreatitis
 Imaging studies will reveal collection of pus and
percutaneous drainage and imipenem or meropenem will be
indicated.
Pancreatic pseudocyst
 A late sequelae of acute pancreatitis or pancreatic trauma. In
either case about 5 wks lapses between the original problem and
discovery of the pseudocyst.
 Collection of pancreatic juice outside of pancreatic ducts (most
commonly in the lesser sac), and the pressure symptoms there
of – early satiety, vague discomfort, and a deep palpable
mass.
 CT/sonogram are diagnostic. Cysts 6cm or smaller, have been
present for <6 wks, can be observed for resolution
 Bigger >6cm or older cysts >6wks- more likely to rupture or
bleed, and they needed to be treated.
 Rx: involves drainage of the cyst. Cyst can be drained
percutaneously to the outside, drained surgically into the
GIT, or drained endoscopically into the stomach.
Chronic pancreatitis
 People with repeated episodes of pancreatitis (usually
alcoholic) eventually develop calcified burned out pancreas,
steatorrhea, and constant epigastric pain.
 Diabetes and steatorrhea- can be controlled with insulin
and pancreatic enzymes, but the pain is resistant to most
modalities of therapy and wrecks their lives.
 If ERCP shows specific points of obstruction and dilatation,
operations that drain the pancreatic duct may help.
Evaluating Hernias
 All abdominal hernias should be electively repaired to avoid
the risk of intestinal obstruction and strangulation
 Exceptions include- umbilical hernias <2yrs should be left
alone.
 Esophageal sliding hiatal hernia – “not true hernia”
 Hernias that become irreducible- need emergent surgery to
prevent strangulation
 Those that have been irreducible for yrs- need elective
repairs.
Diseases of the breast
 Mammogrpahy
 Should be started at age 40, earlier if there is fam hx.
 Not to be done before age 20 (breast is too dense) or during lactation, but
can be done during pregnancy if needed.
 Mammographically or sonographically guided multiple core biopsies have
become the most convenient and effective way.
 Fibroadenomas
 Seen in young women (late teens, early twenties)
 Firm rubbery mass that moves easily with palpation
 Either with FNA or core bx and sonogram is sufficient to establish dx.
 Removal is optional
 Giant juvenile fibroadenomas- seen in very young adolescents, have
very rapid growth. Removal is needed to avoid deformity and distortion of
the breast.
 Cystosarcoma phyllodes
 Seen in late 20s. Grow over many yrs, becomes large, and distorting the
entire breast, not invading or becoming fixed.
 Most are benign, but they have potential to become outright malignant
sarcomas
 Core/incisional bx is needed, and removal is mandatory.
 Mammary Dysplasia aka Fibrocystic disease or cystic mastitis
 30-40s, goes away with menopause, w/ b/l tenderness to menstrual
cycle (worse in the last 2 wks)
 Multiple lumps that seems to come and go, and also following menstrual
cycle
 If there is no dominant, mammogram is all that’s needed, but if there is
persistent mass (presumably a cyst but potentially a tumor)- further work up
is warranted.
 Aspiration with a bigger needle and syringe- if clear fluid obtained and mass
goes away, that’s it. If mass persists- formal bx is required. If bloody fluid is
aspirated- needs to be sent for cytology and a formal bx should be
performed. A simple cyst can be diagnosed with sonogram.
 Intraductal papilloma
 Seen in young females(20-40s) with bloody nipple discharge
 Mammography is needed to identify other lesions, but will not show the
papilloma, b.c its very tiny.
 Galactogram or sonogram – diagnostic and guide surgical
resection
 Breast Abscess
 Most commonly seen in lactating women – what appears to be breast abscess
at other times is cancer until proven otherwise.
 I and D is needed, but bx of abscess wall should be part of the procedure.
 Breast Cancer
 Should be suspected in any women with a palpable mass, and index of
suspicion increases with advanced age
 Other strong indicators- ill defined fixed mass, retraction of overlying skin,
recent retraction of nipple, eczematoid lesions of the areola, reddish orange
peel skin over mass (inflammatory cancer), and palpable axillary nodes.
 Hx of trauma does not rule out cancer.
 Breast Cancer Cont’d
 Breast cancer during pregnancy is diagnosed the same way as if there
was no pregnancy. And is treated the same way, except no
radiotherapy during pregnancy, and no chemotherapy during the
1st trimester.
 Termination of the pregnancy is not mandatory
 Radiologic appearance of breast cancer
 Irregular, speculated mass, asymmetric density, architectural
distortion or fine microcalcifications
 Treatment of resectable breast cancer
 Starts with lumpectomy +axillary sampling + post op radiation or
total mastectomy with axillary sampling
 Axillary sampling is done via sentinel node removal.
 Sentinel node bx are only performed when nodes are not performed
on PE.
 Lumpectomy- ideal option when tumor is small, in a large breast,
and away from the nipple and areola.
 Infiltrating ductal carcinoma
 Standard form – other variants- medullary, mucinous, and lobulated,
have better prognosis and treated the same way
 Lobular has higher incidence- b/l, but not severe enough to
justify the b/l mastectomy
 Inflammatory cancer
 Advanced breast cancer, much worse prognosis, and is treated with
chemo before sx,- almost always modified radical mastectomy.
Radiation is added following mastectomy
 Ductal carcinoma in situ – no mets (thus no axillary sampling is
needed. Total mastectomy (aka simple) is recommended for
multicentric lesions throughout the breast, many physicians
include a sentinel node bx due to the possibility of missing an
invasive focus.
 Lumpectomy followed by radiation is recommended if lesion/s are
confined to one quarter of breast.
 Inoperable breast cancer
 Based on local extent, usually treated with chemotherapy
 Adjuvant systemic therapy
 Should follow surgery if axillary nodes are +. Chemo and hormone
therapy is added if tumor is +.
 Premenopausal receieves- tamoxifen, and post menopausal receive
aromatase inhibitor (anastrozole)
 Frail old women- with tumors that are not too aggressive, and
women with low risk tumors – offered hormonal therapy alone if
tumors are estrogen receptor +.
 Metastatic from breast cancer
 Usually vertebral pedicles are the fav location in spine (px. Localized
tenderness)
 Brain mets (persistent headaches) can be radiated.
 In both situations – MRIs are diagnostic
 Diseases of the Endocrine System
 Thyroid nodules – in euthyroid pxts
 FNA is diagnostic, if benign just follow, if malignant or indeterminate-
follow with a thyroid lobectomy.
 Need for further sx- determined by histologic dx given from a frzoen
section
 Total thyroidectomy- should be performed in follicular cancers,
radioactive iodine- used in the future to treat bloodborne mets.
 Thyroid nodules in hyperthyroid
 Almost never cancer, may be hyperfunctioning (hot nodules)
 With clinical sx of Hyperthyroidism, and sometimes Afib or Aflutter
 Lab confirmation – thyrotropin (TSH; low) OR thyroxine (T4; hi)
 Nuclear scan – will show if the nodule is the source
 Most hyperthyroid pxts – treated with radioactive iodine, but those with a
hot adenoma – option of surgical excision of affected lobe.
 Hyperparathyroidism
 Most commonly found by serendipitous discovery of hi serum Ca2+
in blood tests- bones, groans, and stones.
 Repeat Ca2+ - look for low Phosphorous, and rule out cancer with
bone mets.
 If findings persist, do PTH determination and interpret in light of
serum calcium levels
90% have single adenoma. Removal is curative (sestamibi scan may help
locate the culprit gland before surgery).
Cushing syndrome
 Round, ruddy, hairy face, buffalo hump, supraclavicular fat pads,
obese trunk with abdominal striae, and thin weak extremities
 Osteoporosis, diabetes, HTN, and mental instability
 Work up starts with overnight, low dose dexamethasone
suppression test- suppression at low dosage rules out this disease
 If there is no suppression – 24 hr urine free cortisol and if elevated
go to a hi dose suppression test.
 Suppresion at a hi dose identifies pituitary microadenoma
 No suppression at either dosage identifies – adrenal adenoma or
paraneoplastic syndrome
 Next step- MRI for pituitary, CT scan for adrenal, and remove the
offending adenoma.
 Zollinger Ellison (gastrinoma)
 Virulent Peptic ulcer disease resistant to all therapy including
eradication of H.Pylori, and more extensive – several ulcers rather
than one, extending beyond the first portion of duodenum.
 Some have watery diarrhea. Measure gastrin and do secretin test- if
values are equivocal- do CT scan (with contrast) of pancreas, and
remove it. Omeprazole helps those with metastatic disease.
 Insulinoma
 Produces CNS Sx b/c of low blood sugar, always when the pxt is
fasting
 Diff Dx is with reactive Hypoglycemia – attacks occur after eating,
and with self adminstration of insulin – some connection with med
professionals or someone who is familiar with insulin or with a
diabetic pxt. – hi insulin and low C-peptide.
 Insulinoma- both are hi. Do CT with contrast to locate the tumor in
pancreas and remove it
 Nesidioblastosis
 Devastating hypersecretion of insulin in the newborn, requiring 95%
pancreatectomy.
 Glucagonoma
 Migratory necrolytic dermatitis, resistant to all forms of therapy.
 In a pxt with mild diabetes, a touch of anemia, glossitis, or stomatitis
 Glucagon assay is diagnostic, CT scan is used to locate the tumor,
resection is curative.
 Somatostatin and streptozocin- help with mets, inoperable disease.
Surgical Hypertension
 Primary Hyperaldosteronism
 HTN with hypokalemia – thin pxt (usually female) who is not on any diuretics
 Other findings- hypernatremia and metabolic alkalosis
 HI Aldosterone and low renin levels
 Approp response to Postural changes- more aldosterone when upright then lying
down- suggests hyperplasia- treated medically, whereas lack of response or
inappropriate response- diagnostic of adenomas
 Adrenal CT scan localizes it and surgical removal provides care.
 Pheochromocytoma
 Again typically seen in thin, hyperactive females- who have attacks of pounding
headaches, perspiration, palpitations, and pallor- at the time they have extremely hi
BP
 When the attack subsided- by the time pxt are seen, it makes it harder to dx.
 Start work up with 24 hr urinary VMA, metanephrines, or free urinary
catecholamines
 Follow with CT scan of adrenal glands or radionuclide scan for extradrenal
sites
 Need to give alpha blockers before surgery.
 Coarctation of Aorta
 Typically young, hi bp in arms, with low/normal pressure in LE.
 C- xray- scalloping of the ribs (erosion from large collateral
intercostals.
 Spiral CT scan enhanced with IV contrast dye (CT angio) is usually
diagnostic. Surgical correction is curative.
 Renovascular hypertension
 Two groups:Young females with fibromuscular dysplasia
 Or older males with arteriosclerotic occlusive disease
 Both groups- HTN is resistant to usual meds and a telltale faint bruit
over the flank or upper abdomen suggests the dx.
 Workup- multifactorial, but duplex scanning of the renal vessels and
CT angio have prominent roles
 Therapy is imperative in young women, - dilatation and stenting, but
it is much more controversial in the old men may have short life
expectancy from the other manifestations of arteriosclerosis.
Acute Abdomen
 Acute Abdominal pain
a) Caused by perforation- sudden onset, constant, generalized
diffuse pain, guarding. In older or very sick pxts- generalized signs
of irritation are found(tenderness, guarding, rebound tenderness,
silent abdomen)
 Free air under the diaphragm in upright xrays is diagnostic
b) Caused by obstruction – colicky abdominal pain, hyperactive
bowel sounds, constipation, pxt moves constantly to seek a
positional comfort
c) Caused by inflammatory process or infection – gradual
onset and slow buildup (6-12 hrs), constant, ill defined, locates to
the area where the problem is. If there is peritoneal irritation –
fever and leukocytosis
d) Ischemic processes severe abd pain with blood in the
lumen of the gut
When is surgery the answer?
 Peritonitis (excluding primary peritonitis)
 Abdominal pain/ tenderness + signs of sepsis
 Acute intestinal ischemia
 Pneumoperitoneum
 MAKE SURE TO FIRST R/O PANCREATITIS
Primary peritonitis – suspected in a child with nephrosis and
ascites or adult who have mild generalized acute abdomen
with equivocal physical findings and perhaps some fever and
leukocytosis. Cx will grow single organism (garden variety
acute abdomen, multiple organisms grow). Treat with ABX,
not surgery.
When is treat medically the answer?
 Primary peritonitis
 Pancreatitis
 Cholangitis –GI MEDICAL EMERGENCY
 Urinary stones
 Things that can mimic acute abdomen
 Lower lobe pneumonia
 Myocardial ischemia
 Pulmonary embolism
 Ruptured ovarian cysts
 Perforation
 MCC OF GI PERFORATION ARE:
 DIVERTICULITIS
 PERFORATED PEPTIC ULCER
 CROHN’S DISEASE
 Diagnostic test: supine and errect CXR- FREE AIR UNDER THE
DIAPHRAGM
 Rx: NPO, and IV fluid hydration
 Iv ABX e.g. metronidazole and Cipro
 2nd generation Cephalosporins (cefotetan or cefoxitin)
 Ampicillin – sulbactam
 Piperacillin –tazobactam
 Perform emergency surgery
Esophageal perforation
 MCC IS iatrogenic, followed by upper endoscopy, followed
by booerhaave syndrome
 Right after endoscopy- pxt will c/o subcutaneous
emphysema in the neck, other sx pain in chest or upper
abdomen, dysphagia or odynophagia.
 Esophageal perforation -
 GI BLEEDING
 Mcc of GI bleeding – upper GI bleeding (~3/4 originates from
the upper GI, and ¼ from the lower GI- colon, rectum)
 GI bleeding from the lower GI – colon – mcc is diverticulosis,
angiodysplasia, polyps, or cancer.
 Young pxt presents with GI bleed is from upper GI
 Vomitting blood – always upper GI (from tip of the nose to lig of
treitz. Same is true when blood is recovered by NG tube in a pxt
who c/o blood per rectum . Next best diagnostic step – upper GI
endoscopy. Always look at the mouth and nose first.
 Melena – black tarry stools – digested blood – must originate hi
enough to undergo digestion. Start work up with upper GI
endoscopy
 Red blood per Rectum – from anywhere in GIT (including upper GIT)
 If pxt is actively bleeding – place an NG tube, and aspirate gastric contents.
 If blood is present- upper source has been established, follow with upper
GI endoscopy.
 If no blood is retreived and fluid is white(no bile), territory from tip of
nose to pylorus has been excluded, but duodenum is still potential
source.  upper GI endoscopy should follow.
 If no blood and green fluid is retreived- entire upper GI has been
excluded.
 Active bleeding per rectum after upper GI has been excluded
 Must work up for hemmorhoids- 2 ways
 Estimate the rate of bleeding: if it exceeds 2mL/min (1 unit of blood
every 4 hrs) do an angiogram, good chance for finding a source and
may even allow for angiographic embolization
 If bleeding is <.5mL/min, wait until the bleeding stops and then do a
colonoscopy
 For cases in btw they do tagged red cell study- slow test
 If the pxt is stable- do a capsule endoscopy- to localize the spot in the
small bowel
 Pxts with a recent hx of blood per rectum- start workup with
upper GI endoscopy if they are young; if old then do both upper
and lower GI endoscopy
 Blood per rectum in a child – Meckel diverticulum- technetium
99 scan look for ectopic gastric mucosa
 Massive upper GI bleeding – stressed, multi trauma or
complicated post op pxt- stress ulcers. Endoscopy will confirm.
Angiographic embolization is best therapeutic option. Stress
ulcers should be avoided by maintaining gastric ph above 4.
Medical Emergencies – Neuro
Epidural Hematoma – medical emergency, Fatal within hours
 - lucid interval – middle meningeal artery damage
 - CT w/o Contrast – shows LENS SHAPED (Biconvex) VS-
Acute Subdural hematoma ( crescent shaped or concave, with
midline shift, bridging veins are at risk- low pressure system)
 Treatment is emergency craniotomy
ELEVATED ICP
 Classic hx: - Briefly depressed consciousness after head trauma,
improvement, and progressive drowsiness
 Diagnostic Testing:
 Gradual pupillary dilation in one eye and dec responsiveness to light –
indicated clot expansion on the ipsilateral hemisphere
 Get a HEAD CT – look for MIDLINE SHIFT OR DILATED VENTRICLES
 DO NOT DO LP W/O FIRST GETTING HEAD CT, AS YOU MAY
HERNIATE THE BRAIN AND KILL THE PATIENT
 Management:
 1st line measures- head elevation, hyperventilation, and avoid
fluid overload
 2nd line- Mannitol – can reduce cerebral perfusion and Sedation
and Hypothermia (lower O2 demand)
 Remember ultimate goal – to preserve brain perfusion, hence
do not overdo the treatment.
GI MEDICAL EMERGENCIES
 Acute Ascending Cholangitis
 Reynold’s Pentad: Jaundice, fever, abdominal pain, Alt Mental Status,
and Shock
 Pathophysiology: Obstruction of CBD causes obstruction and
ascending infxn
 Key Findings: VERY hi fever, hi WBC, hi levels of ALP, T Bil, and
D- Bil with mild elevation of transaminases
 Treatment: IV antibiotics
 Intervention with emergent ERCP is treatment of choice
 Alternative: PTC
 Rarely by surgery
 Eventually Cholecystectomy
 Pediatric Sx
 Gastrografin enema is diagnostic and therapeutic for these
two GI conditions:
 Meconeum ileus & Intussusception
 AT BIRTH – 1ST 24 HOURS
 ESOPHAGEAL ATRESIA
 Excessive salivation and choking spells after 1st few episodes of feeding
shortly after birth.
 Dx: small NG tube is passed, on upper chest xray it will be seen coiled.
 Most common of the four types:
 a blind pouch in upper esophagus and a Fistula between the lower esophagus, and
tracheobronchial tree – normal gas pattern in the bowel
 B4 initiating therapy, VACTERL ANOMALIES MUST BE RULED OUT 1ST.
 V-VERTEBRAL, A- anal, C- cardiac, T- tracheal, E-esophageal, R- renal, L- limb
deformities
 A gastrostomy has to be done first to protect the lungs from acid reflux-
then primary surgical repair is warranted.
Imperforated Anus
 Clinical dx, noted on PE, when looking for VACTER
anomalies.
 Look for a fistula nearby to vagina or perineum
 If present, repair can be delayed until further growth,
but has to be done before toilet training time.
 If not present, a colostomy is done for high rectal
pouches(and later the repair) or primary repair is done
right away if the blind pouch is at the anus
 The level of the pouch is determined with xrays taken upside
down (so the gas goes up in the pouch) with a metal marker
taped to the anus.
Congenital diaphragmatic hernia
 Always on the left, the bowel will be up in the chest.
 Real problem- hypoplastic lung still has fetal type circulation
 Repair must be delayed ¾ days to allow maturation of lungs.
 Other wise babies are is Respiratory distress, and need
endotracheal intubation, low pressure ventilation (careful not
to blow up other lung), sedation, and NG suction.
 Difficult cases – require extracorporeal membrane
oxygenation
 Many are diagnosed before birth by sonogram
Gastroschisis and Omphalocele
 Abdominal wall defect in the middle of belly
 Gastroschisis- cord is normal (it reaches the baby), defect is to
the right of cord, no protective membrane around, and the bowel
looks angry and matted.
 Need vascular assess for parenteral nutrition, b/c angry looking
bowel will not work for about 1 month.
 Omphalocele- the abdominal wall defect in the middle of the
belly and is covered by thin membrane- one can see normal
looking bowel and a little slice of silver.
 Small defects can be closed primarily, but large ones req’r
‘silo’ to house and protect the bowel. Contents of the silo are then
squeezed into the belly, a little bit everyday, until complete closure
of can be done in about a wk.
Exostrophy of the urinary bladder
 Also an abdominal wall defect, but over the pubis (not
fused), with a medallion of red bladder mucosa, wet and
shining with urine.
 AN EMERGENT SITUATION- A REPAIR NEEDS TO BE
DONE WITHIN 1ST 1-2 DAYS OF LIFE.
 GREEN VOMITTING in A NEWBORN-
SERIOUS PROBLEM EXISTS
BILIOUS EMESIS

BABYGRAM

DOUBLE BUBBLE + Multiple AIR FLUID

NORMAL GAS PATTERN LEVELS
DOUBLE BUBBLE
SIGN
ENEMA INTESTINAL
ATRESIA
DUODENAL ATRESIA OR
MALROTATION MOTHER MOS
ANNULAR PANCREAS LIKELY – USE
Surgery counsel
COCAINE, vascu
Emergent surgery
surgery accident in ute
Weeks to months (few days old – 1st 2
months of life)
 Premature diseases (NECROTIZING
ENTEROCOLITIS , intraventicular
hemorrhage, bronchopulmonary dysplasia,
retinopathy prematurity)
 Meconeum ileus
 Pyloric stenosis
 Biliary atresia
 Hirchsprung’s disease
 Intussusception
Necrotizing Enterocolitis
 Seen in premature infants when they are first fed- bloody bowel
movement after the first feed.
 Feeding intolerance, abdominal distension, and rapidly dropping
platelet count (sign of sepsis)
 Dx: baby gram – pneumatosis intestinalus, must also get U/S of
brain to rule out( intraventicular hemorrhage)
 RX: stop all feedings, broad spectrum ABX, IV fluids and
nutrition- have to let the bowel rest and recover
 Surgical intervention is req’d if they develop abdominal wall
erythema, air in the portal vein, intestinal pneumatosis (i.e.
presence of gas in the bowel wall), or pneumoperitoneum (signs
of intestinal necrosis and perforation)
Meconium ileus
 1st presentation of cystic fibrosis
 Failure to pass meconeum, bilious emesis
 Dx: babygram- will see a ground glass appearance and then
loops of bowel
 Best test and RX of choice: gastrograffin enema- water
soluble, breaks up the meconeum plug and allows the bowel
to move.
Pyloric stenosis
 Very hungry. Eats and then have projectile vomitting, Failure
to pass meconeum
 PE findings- olive shaped mass, maybe able to see or feel the
peristaltic wave- in the RUQ of abdomen
 DX: donut sign on U/S.
 Need to identify the electrolyte abnormality- baby is
constantly vomitting and is losing all HCL in the vomit- baby
develops hypochloremic hypokalemic metabolic alkalosis
 Rx: to rehydrate and replete electrolytes – IV Fluids,
electrolytes, and then surgery- Ramstedt pyloromyotomy on
balloon dilatation
BILIARY ATRESIA
 6-8 WKS- but notice at 1st couple of months of life
 Persistent jaundice- b/c biliary system is atretic, bilirubin
can’t get out of their system
 Usually part of the cystic fibrosis- do serologies and sweat
test to r/o other problems
 DX: HIDA scan, one wk after a phenobarbital injection-
phenobarb – stimulates the biliary tree, if in a HIDA scan
injected PHENO makes it to the duodenum- it’s not a biliary
atresia, but if it pools then its biliary atresia
 Rx: resection
Hirchsprung’s disease
 Can occur in the 1st few days of life (failure to pass meconeum)-
cardinal symptom is failure to pass meconeum, or at any age
(chronic diarrhea)
 Dx: xray or KUB – dilated loop of bowel followed by normal
looking bowel segment- it’s the normal looking bowel that’s bad
segment – aganglionic part.
 Embryonic devt- neurons failed to migrate down to the bowel
segment that’s normal looking all the way to rectum, hence no
peristalsis carried through the bowel, food is stuck in the
distended segment and cant propell through aganglionic segement.
 Dx is made with full-thickness bx of rectal mucosa, remove the
bad segment
Intusussception (6-12month chubby
healthy looking baby)
 Telescoping of bowel into itself- leads to decreased vascular
supply- vascular supply gets pinched by telescoping- bowel
becomes ischemic and dies
 Colicky Abdominal pain –lasts about 1 minute, fetal position
– makes the pain more comfortable
 PE: empty- RLQ or , a vague mass on the right side of
abdomen and Currant jelly stools-
 Dx: sausage shaped mass on KUB
 Best test and treatment of choice- barium or air enema-
undoes the telescoping, if its already the necrotic bowel- you
resect out the necrotic bowel.
Later in infancy
 Child abuse
 Should be suspected when injuries cannot be accounted for
 Classic presentation – subdural hematoma + retinal
hemorrhages (shaken baby syndrome)
 Multiple fractures in different bones at different stages of
healing and scalding burns (esp burns of buttocks – child was
held by arms and legs and dipped into the boiling water)
 Refer to the proper authorities
 Meckel diverticulum
 Lower GI bleeding in the pediatric age group.
 Radioisotope scan – looking for gastric mucosa in the lower
abdomen
CARDIOTHORACIC SURGERY
 Congenital Heart Problems
 Acquired Heart Disease
 The Lung
Congenital Heart Problems
 Vascular Rings
 Left To Right Shunts
 Right To Left Shunts
 Tetralogy Of Fallot
 Transposition Of Great Vessels
Vascular rings
 Produce sx of pressure on the tracheobronchial tree and pressure
on the esophagus
 Includes- stridor, episodes of reespiratory distress with “crowing”
respiration- during which baby assumes – hyperextended position,
and latter- difficulty swallowing
 If only respiratory problems are present think of
TRACHEOMALACIA
 Barium swallow- typical extrinsic compression from abnormal
vessel
 Bronchoscopy- segmental tracheal compression and r/o diffuse
tracheomalacia
 Sx divides the smaller of the two aortic arches.
L R SHUNTS (noncyanotic)
 PRESENCE OF MURMUR, PULMONARY VASCULAR
CONGESTION AND LT DAMAGE TO PULM VASCULATURE
 Hole b/w the left and right side- increase the flow into the pulm
vasculature, increase pulmonary HTN, right heart still pushing
against the pulm vasculature- will have right vent hypertrophy. RV
becomes stiff shunt reverses eisenmenger syndrome
(becomes cyanotic- treat L R shunt before it becomes cyanotic)
 ASD (atrial septal defect)
 Minor, low pressure, low volume shunt
 Grow into late infancy before they are recognized.
 Faint pulmonary flow systolic murmur and fixed spilt of S2
 Hx of freq colds is elicited
 ECHO – diagnostic, closure with cath or surgery.
Ventricular septal defects (MC’n
congenital defect of the heart)
 Holes b/w ventricles.
 Really loud murmur- asymptomatic
 Or soft murmur- into a CHF
 Harsh holosystolic murmur(in kids)- sounds like mitral
regurg(in adult)
 DX: ECHO
 If Asx – you wait, if symptomatic and >/= 1 yr- close it/ use
cath.
Patent ductus arteriosus
 Connection b/w aorta and pulmonary artery
 Continuous machine like murmur – may not be present on
day 1, will be present on the exit of day 1 from neonatal
nursery.
 Dx: echo
 Rx: indomethacin ends the patent ductus arteriosus
 Can keep it open for ToF- prostaglandin – keeps it open
RL SHUNTS(CYANOTIC-
CATASTROPHIC)
 UNOXY BLOOD  PERIPHERY BLUE BABIES CAUGHT
EARLY AND ARE FATAL B/C there is dec pulmonary blood
 All the T diseases
 Transposition of great vessels
 Occurs in babies of diabetic mothers, poor glucose control 
embryologic failure at 8, failure to twist, two independent systems of
aorta and pulmonary vasculature.
 LV PA LA
 RVPERIPHERYRA
 CYANOTIC DAY 1- BABY DIES.
 Rx: initially - prostaglandin
Tetralogy of fallot
 Endocardial cushion defect
 Associated with down syndrome- consists of four components
 - very large defect- VSD
 Overriding aorta
 Pulmonary stenosis
 RV hypertrophy
 Cyanotic baby- profound dyspnea on day 1 (blue baby), older kid
with TET spells(episodes of cyanosis relieved with squatting-
increase venous return but also increase SVR more blood in to
RV pressure into aorta making it more likely to allow the
blood to flow thru the pulmonary artery.
 Dx: boot shaped heart
Coarctation of aorta
 Pathology- descending aorta constriction
 Px: claudication – babies will refuse to walk or will cry when
asked to walk
 Elevated pressure and warm upper extremities
 Low blood pressure and cool lower extremities
 To confirm the dx- perform the angiogram
 Rx: is to remove the coarctated segment and reanastomose.
Acquired heart problems
 Aortic Stenosis
 Chronic Aortic Insufficiency
 Acute Aortic Insufficiency
 Mitral Stenosis
 Mitral Regurgitation
 Coronary Disease
 Post Op Care Of Surgery Pxts
 Chronic Constrictive Pericarditis
Aortic stenosis
 Px: exertional syncope, and chest pain.
 Harsh mid-systolic murmur- crescendo- decrescendo
murmur at the R 2nd intercostal space and along the left
sternal border
 Dx: echocardiogram
 Surgical valvular replacement is indicated if there is pressure
gradient of >50mmhg or at the 1st indication of CHF, angina,
or syncope.
 Aortic regurgitation
Acute
 Endocarditis in young drug
addicts
 Suddenly develop CHF,
angina, new diastolic
murmur at the R 2nd
intercostal space
 Emergency valve
replacement and LT
anticiotics are needed.
Pxt with a prosthetic valve will need Abx prophylaxis for subacute
bacterial endocarditis.
Chronic
 Wide pulse pressure and a
blowing high pitched,
diastolic murmur best heard
at the 2nd intercostal space,
and along the left sternal
border, with full expiration
 Should undergo valve
replacement at the 1st
evidence of beginning LV
dilatation seen on Echo.
Mitral valve Murmurs
 Mitral stenosis
 Hx of rheumatic fever many yrs before px. Produces dyspnea
on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough,
and hemoptysis
 Low pitched, rumbling diastolic murmur apical heart murmur
 Progressively- pxt becomes cachetic and develop A fib.
 Work up starts with Echo
 Sx become more disabling, mitral valve repair becomes
necessary with a surgical commissurotomy or a balloon
valvuloplasty.
Mitral regurgitation
 Most commonly caused by valvular prolapse
 Develop – exertional dyspnea, orthopnea, and A fib
 Apical high pitched holosystolic murmur that radiates to the
axilla and back
 Work up and surgical indications are as above, with repair of
the valve(annuloplasty) preferred over prosthetic
replacement.
Coronary artery disease
 Typical pxt – sedentary mid-aged man, with a family hx, hx of
smoking, type 2 diabetes, and hypercholesteremia
 Progressive, unstable, and disabling angina – main reason to do
cardiac catheterization and evaluate as potential reason for
revascularization
 Intervention is indicated if more than one vessels have 70% or
greater stenosis, and there is a good distal vessel
 Pxt should still have good ventricular function, you cannot
resusciticate the dead myocardium
 Single vessel dz, is more amendable – not the left main or left
anterior descending is perfect for angioplasty and stent.
 Triple vessel dz, makes multiple coronary bypass (using the
internal mammary for the most important vessel) the best choice.
Post op care of heart surgery pxt
 If cardiac output is considerably under normal (5L/min or a
cardiac index of 3), the pulmonary wedge pressure (or left atrial
pressure, or left end diastolic pressure), should be measured.
 Low numbers (0-3)- suggest the need for more IV fluids.
 High numbers >20 + suggest ventricular failure.
Chronic constrictive pericarditis
 Produces dyspnea on exertion, hepatomegaly, and ascites
 Classic square root sign and equalization of pressures
(right atrial, right ventricular diastolic, pulmonary artery diastolic,
pulmonary capillary wedge pressure, and left ventricular diastolic)
on cardiac cath. Surgical therapy relieves it.
The lung
 Coin lesion
 Suspected cancer of the lung
 Diagnosis of caner of the lung
 Small cell cancer of the lung
 Operability of lung cancer
 Potential cure by surgical removal of lung cancer
Coin lesion
 Age >50, hx of smoking- coin lesion found on chest xray-
80% of chance being mailgnant
 Compare with an older (yr or two) xray shows the
unchanged lesion- not cancer
 Seeking the older xray – always the 1st thing to do- in the
pxt found to have lesion.
Suspected cancer of the lung
 Needs an expensive and intense work up to confirm the dx and
assess operability
 Px : hemoptysis or persistent cough – must order a chest x-ray-
showing a suspicion lesion (coin lesion or infiltrate)
 Assumptions: if no older xray is available or lesion was not present
in the previous film – do non-invasive studies
 Sputum cytology and CT scan of chest and liver.
 Dx of cancer of the lung
 Bronchoscopy and biopsies for (central lesions)
 Or percutaneous biopsy for (peripheral lesions)
 If unsuccessful – video assisted thoracic surgery (VATS) and wedge
resection may be needed. Comsidering there is no mets to carinal
LNs or mediastinal LNs, the other lung or the liver.
Small cell cancer of the lung
 Cant be cured surgically, so needs chemo and radiation
Operability of Lung Cancer
 Predicted on residual function after resection – assuming
pneumonectomy is required.
 For lobectomy, function is less of an issue
 Central lesions- req’r penumonectomy
 Peripheral lesions removed – lobectomy- minimum of FEV1
of 800ml is needed
 If <800ml – do not continue expensive tests. The patient is
not a surgical candidate. Treat with chemotherapy and
radiation.
 Potential cure by surgical removal of
lung cancer
 Depends on the extent of metastases
 Hilar mets – removed with pneumonectomy
 But nodal mets at carina and mediastinal – preclude curative
resection
 Ct scan can identify the nodal mets, but recently PET scan
define the presence of actively growing tumor in enlarged
nodes
 Endobronchial U/S more invasive option- to sample
mediastinal nodes
 Cervical mediastinal exploration is rarely needed
 Mets to the other Lung or Liver – can be evident in CT.
 VASCULAR SURGERY
 Subclavian steal syndrome
 Arteriosclerotic stenotic plaque at the origin of subclavian (before it
branches out to vertebral)- allows blood supply to reach the arm for
normal activity but does not allow enough to meet the higher demands
when the arm is exercised
 When that happens – the exercised arm sucks the blood away from the
brain by reversing the flow in the vertebral.
 Clinical Px: claudication of arm (coldness, tingling, muscle pain) and
posterior neurologic signs (visual sx, equilibrium problems) when the
arm is exercised
 Vascular Sx: thoracic outlet syndrome but combination with
neurologic Sx- subclavian steal syndrome
 Duplex scanning – diagnostic – shows reversal of flow
 Bypass surgery cures it.
Abdominal aortic aneurysm
 Asymptomatic, pulsatile abdominal mass (b/w xiphoid and
umbilicus), or found on x-rays, sonograms, or CT scans done
for another diagnostic purpose- usually in older men.
 Size is the key to management, if aneursym is found on PE, ct
scan or sonogram is warranted to determine the size.
 If aneurysm is 4cm or <, can be observed.
 If 5-6cm or >er, pxt should have elective repair b/c the chance
of rupture is very high
 The aneurysm that grow 1cm/yr or faster – also need elective
repair.
Surgery for a ruptured AAA
 Carries high morbidity/ mortality risk , thus effort is to predict
and anticipate the rupture, not wait for it to occur
 Most are treated with endovascular stents inserted percutaneously
 10yr outcome is encouraging, caveats are the case should be
unruptured and the neck should be at least 2.5cm
 Tender AAA – would rupture w/in a day or two, thus immediate
repair is indicated.
 Excruciating back pain in a pxt with a large AAA- aneurysm is
already leaking. Forming Retroperitoneal blowout into the
peritoneal cavity is only minutes away or hours away.
EMERGENCY SURGERY IS REQUIRED.
 Arteriosclerotic Occlusive Disease of
the Lower EXT.
 Unpredicatble natural hx (except for the predictable negative
impact of smoking), and therefore – no role for “prophylactic
surgery”
 Surgery is only done to relieve disabling sx or to save the
extremity from necrosis
 Clinical manifestation- pain brought up by walking and relieved
by rest (intermittent claudication)
 If it doesn’t interfere significantly with pxt’s life- no work up is
needed.
 Cessation of smoking, an exercise program, and the use of
Cilostazol(Quinolone derivative meds- a vasodilator)
can help the pxt in a long run.
Disabling intermittent Claudication
 For disabling intermittent claudication – starts with doppler
looking for a pressure gradient- if no pressure gradient-
disease is in the small vessels- surgery not required
 If there is a significant gradient- CT angio or MRI angio to identify
the specific areas of stenosis or complete obstruction, and to look
for good distal vessels to which a graft could be hooked.
 If multiple vessels are present, proximal ones are usually repaired
before distal ones are addressed. Grafts originating at the
aorta (aortobifemoral) are done with prosthetic
material. Bypasses b/w more distal vessels
(femoropopliteal, or beyond) – usually done with saphaneous
vein grafts.
Rest pain
 Penultimate stage of the disease- the ultimate is
ulceration and gangrene
 Pxt seeks help b/c he cant sleep. Pain in the calf keeps
him from falling asleep. Pain is relieved by sitting up and
dangling the leg helps the pain, and a few minutes after he
does so, the leg that used to be very pale becomes deep
purple
 PE: shows shiny atrophic skin w/out hair, and no
peripheral pulses.
 Workup and therapy – surgery is done to relieve the
disabling sx or to save the extremity from necrosis.
 Arterial embolization from a distant
source
 Seen in pxts with A-fib- clot breaks off from the atrial
appendage or those with recent MI (source of embolus is the
mural thrombus)
 Pxt suddenly develops a Painful, pale, poikilothermic(cold),
pulseless, paresthetic, and paralytic lower extremity.
 Urgent evaluation and treatment- must be
completed w/in 6 hrs
 Doppler studies: locate the point of obstruction
 Embolectomy with Fogarty catheter- done for complete
obstructions, and fasciotomy should be added if several hrs
have passed before revascularization
Dissecting Aneurysm of Thoracic aorta
 Occurs in poorly controlled HTN
 Resembles an MI- sudden onset of extremely severe, tearing chest
pain radiating to the back and migrates down shortly after its
onset.
 Unequal pulses in the upper extr, and xrays – widened
mediastinum
 EKG and cardiac enzymes r/o MI.
 Definitive dx- should be done by non-invasive means – avoid hi
pressure injections needed for the aortogram.
 MRI angiography and transesophageal echo- best option is sprial
CT scan.
 Dissections of ascending aortas – treated surgically, and
descending are managed medically with control of HTN in ICU.
 ORTHOPEDIC DISORDERS IN
CHILDREN
 Developmental dysplasia of the hip – ideally diagnosed right after
birth
 Uneven gluteal folds
 PE: easily dislocated post’ly with a jerk & a click, and returned to normal with
snapping
 Dx: sonogram (DO NOT ORDER X-RAY HIP IS NOT CALCIFIED IN A
NEWBORN)
 Rx: abduction splinting with pavlik harness for ~ 6mos.
 Legg-perthes disease – avascular necrosis of the femoral capital
epiphysis – orthopedic emergency
 Occurs around age 6
 Insidous devt of limping, decr hip motion, and hip or knee pain.
 Walk with an antalgic gait, and passive motion of the hip is guarded
 Dx: AP & lateral hip xrays.
 Rx: controversial – containing the femoral head w/I acetabulum by casting and
crutches
 Slipped capital femoral epiphysis- ORTHOPEDIC EMERGENCY
 Typical pxt: chubby or Lanky boy around age 13.
 C/O groin or knee pain and limping
 They sit with legs dangling , the sole of the foot on the affected side points
towards the other foot.
 PE: there is limited hip motion, and as the hip is flexed, the thigh goes into
external rotation and cannot be rotated internally.
 Xrays – diagnostic and Sx treatment – pinning the femoral head back in
place.
 Septic hip – ORTHOPEDIC EMERGENCY
 Seen in little toddlers, have had a febrile illness, and then refuse to move the hip
 Hold the leg with the hip flexed, in slight abduction and ext rotation, and do not
let anybody touch the affected leg or passively move the affected leg
 Have Incr ESR
 DX: aspiration of the hip under gen anesthesia, further open drainage is done
if pus is obtained.
Other Locations
 Acute hematogenous osteomyelitis
 Seen in little kids who have had a febrile illness – shows up a
localized pain in bone with no hx of trauma to that bone
 Xrays – will not show anything for a couple of wks
 MRI- prompt dx. Treatment: Antibiotics
 Genu varum (bow legs)- normal up to age 3. If persistent
beyond age 3- most commonly BLOUNT DISEASE
(disturbance of medial prox tibial growth plate), for which sx
can be done
 Genu valgus (knock knee)- normal btw ages 4 and 8. no
treatment is needed
 Osgood-schlatter disease (osteochondrosis of tibial tubercle)
 Seen in teenagers with persistent pain over the tibial tubercle- aggravated by
contraction of the quadriceps
 PE: localized pain right over the tibial tubercle and there is no knee swelling
 Rx: immobilization of the knee in an extension or cylinder cast for 4-6 wks,
if more conservative mgmt fails (rice- rest, ice, compression and elevation)
 Club foot (talipes equinovarus)
 Seen at birth. Px: Feet turned inward, plantar flexion of ankle, inversion
of foot, adduction of forefoot and internal rotation of tibia
 Serial plaster casts started in neonatal period- provide sequential
correction starting with the adducted forefoot, then the hindfoot varus, and
last the equinus.
 ~50% are corrected this way, other 50% req’r surgery after 6-8 months but
BEFORE 1-2 YRS OF AGE.
 Scoliosis- seen primarily in adolescent girls
(thoracic location) curved towards the right
 Most sensitive screening- look at the girl from behind to bend
forward and you will see the hump over the right thorax.
 Deformity continues until skeletal maturity is reached- severity
-> decreased pulmonary function.
 Bracing – to arrest progression; severe cases may need surgery.
Tumors In Children And Young Adults
 Primary malignant bone tumors –YOUNG PEOPLE
 c/o persistent low grade pain, present for several months.
 XRAY- invasion of the adjacent soft tissues “sun burst pattern” and
periosteal “onion skinning”
 Rx- highly specialized.
 Osteogenic sarcoma- Most common primary malignant tumor
of the bone
 Seen in ages 10-25 – MC’n location – knee (lower femur or upper
tibia)
 Typical sunburst pattern is often described on X-rays.
 Ewing sarcoma – 2nd most common (5-15yrs age)
 Grows in the diaphyses of the long bones
 Typical “onion skinning” pattern – seen on XRAYS
Adults
 Most malignant bone tumors in adults are metastatic
 localized pain
 Xrays can be diagnostic, CT gives more info’n but MRI is better
 Lytic lesions – pathologic fx (fx precipitated by events e.g. lifting a bag of
groceries)
 Multiple myeloma – old men, with fatigue, anemia, and localized pain at
specific places on several bones
 XR- multiple punched out lytic lesions
 Bencejones proteins in the urine, abnromal Ig in blood, best seen by serum
electrophoresis
 Rx: chemotherapy, thalidomide can be used if chemo fails
 Soft tissue sarcomas – relentless growth (several months of soft
tissue mass)
 Firm, fixed to surrounding structures, METS to LUNGS, but not to LNs
 MRI may help dx malignancy, but wide local excisional biopsy, radiation,
and chemotherapy helps.
General rules about orthopedic sx
 When suspect a Fx, order two views at 90degrees to one another,
and always include the joints above and below the broken bone
 Always X-ray other sites ‘in the line of force’ (e.g L- spine for
someone who lands on the feet)
 For Fxs not badly displaced- CLOSED REDUCTION
 For displaced fractures: OPEN REDUCTION INTERNAL
FIXATION
 OPEN FRACTURES: broken bone sticking out thru a wound,
require cleaning in the OR and reduction w/in 6 hours.
 ALWAYS PERFORM cervical spine films in any pxt with facial
injuries
Wrist fractures
Dinner fork deformity: treatment: closed reduction and
casting
Radius and Ulna fractures
Monteggia Versus Galeazzi?
 How do they occur?
 Galeazzi – direct blow to the radius – results in a combination
of diaphyseal fx and displaced dislocation of the nearby joint
 Monteggia fx – direct blow to the ulna
 Management:
 ORIF for diaphyseal fx and closed reduction for the dislocated
joint.
Carpophalangeal joint disorders
 All of them are common in young females
 Carpal tunnel syndrome – repetitive hand work
 Trigger finger –wakes up in the middle of the night with the
finger acutely flexed
 De Quervain tenosynovitis – common in young mothers, as
they carry their baby, force their hand into wrist flexion and
thumb extension  complain of pain along the radial side of
the wrist and 1st dorsal compartment
Common hand problems in Men
 Dupuytren contracture – occurs in older men of Norwegian
ancestry- contracture of the palm of the hand, and palmar fascial
nodules can be felt. Sx is needed when hand can no longer be
placed flat on table.
 Felon – abscess in the pulp of a fingertip, caused by a neglected
penetrating injury- throbbing pain, fever. Etiology- pulp is a closed
space with multiple fascial trabeculae, pressure can build up and
lead to tissue necrosis; thus surgical drainage must be done
urgently.
 Gamekeeper thumb aka Skier’s thumb- injury of ulnar
collateral ligament sustained by forced hyperextension of the
thumb, PE: collateral laxity at the thumb-MCP joint, if untreated
can be dysfunctional and lead to arthritis. Casting is rx.
More hand problems
Jersey finger
When the flexed finger is forcefully
extended (as in somone grabbing a running
person by the jersey)
Distal phalynx of the injured finger doesn’t
flex with other fingers
1st line treatment: splinting
Mallet finger
When the extended finger is forecfully
flexed (a common volleyball injury), and the
extensor tendon is ruptured-
Tip of the affected finger remains flexed
when the hand is extended – resembling a
mellet
1st line Rx: splinting

Traumatically Amputated digits- are surgically reattached whenever possible.

Amputated digit should be cleaned with sterile saline, wrapped in a saline moistened
gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice.
-With the use of electric nerve stimulation to preserve muscular fcn, entire amputated
finger can be reattached.
Orthopedic Emergencies
 Compartment syndrome
 Occurs most frequently in forearm and lower leg
 Look for a hx of prolonged ischemia followed by reperfusion,
crushing injuries, or other types of trauma
 In the lower leg, by far the MCC is fracture with closed
reduction
 Most reliable finding – excruciating pain with passive extension
 Emergency Fasciotomy is req’d for treatment.
Femoral Fxs
 FEMORAL NECK FRACTURES:
 AT hi risk of avascular necrosis (tenous blood supply)- best
treated with femoral head replacement
 Intertrochanteric fractures- treated with open reduction and
pinning
 Femoral shaft fractures: treated with intramedullary rod
fixation
Anterior Dislocation of the Posterior dislocation of the
hip hip

•Hip fx following a fall- MC’n in •Hx of head on car collision where

the elderly the knees hit dashboard –
•Externally rotated and orthopedic emergency (avoid
shortened leg avasular necrosis)
•Internally rotated and shortened
leg
Knee Injuries – MC’N IS Ant Cruciate
Ligament
 Medial/ lateral collateral injuries
 From a direct blow to the opposite side of the joint
 Casting if single ligament injury, otherwise surgical repair
if multiple ligaments injured.
 Anterior/ posterior cruciate ligament injuries
 Swelling pain and anterior and posterior drawer signs
 Young athletes- arthroscopic repair
 Older pxts: treated with immobilization and rehab
 Meniscal injury:
 Prolonged pain and swelling with “catching” and “locking” during
ambulation
 Rx: arthroscopic repair
Knee injuries Cont’d
 Tibial stress injury
 Seen in young men subjected to forced marches either cadet or
military
 Tenderness to palpation over a specific joint, and xrays are
initially normal
 Rx: cast, and repeat the xrays in 2 weeks. Non weight bearing
(crutches is another option)
Unhappy Triad of knee injury- in the setting of sports trauma
 Ant Cruciate ligament
 Medial collateral ligament (trauma to opposite side of injury)
 Lateral or medial meniscal
BELOW THE KNEE JOINT INJURIES
 LEG Fxs involving the tibia and fibula:
 Seen when a pedestrian hit by a car.
 PE: shows angulation, and xrays are diagnostic
 Casting: for the ones that are easily reduced OR
 Intramedullary nailing : for the ones that cannot be aligned
 The lower leg and forearm are the most common locations for
dev’t of compartment syndrome.
 Rupture of Achilles Tendon
 Out of shape middle age men subject themselves to severe strain (e.g tennis,
or basketball or pxt with hx of Fluoroquinolones)
 C/O sudden “popping” and limping, limited plantarflexion, but it’s the pain
and swelling alongwith limping that brings them to doctor.
 Palpation of tendon reveals a gap
 Casting in equinus position allows healing in several months or surgery
achieves quicker cure
Ankle Fracture
 Falling on an inverted or everted foot- either case both
malleoli break
 AP lateral and mortise Xrays- are diagnostic
 ORIF is needed if fragments are displaced
Other emergencies
 Pain under a cast
 Open fractures
 Posterior dislocation of the hip
 Gas Gangrene – occurs with deep penetrating injury, dirty
wounds (stepping on a rusty nail,, with lots of mud or manure).
In ~ 3 days pxt becomes extremely sick, looking toxic and
moribund. The affected site is tender, swollen, discolored, and
has gas crepitation.
 Rx: IV PENCILLIN AND EXTENSIVE EMERGENCY SURGICAL
DEBRIDEMENT
Neurovascular Injuries
Primary injury Neurovascular S/SX NEXT STEP IN
complication MGMT
OBLIQUE DISTAL RADIAL NERVE Unable to Sx is indicated if
HUMERUS (mid- dorsiflex(extend) the paralysis persists
dist 3rd of humerus) wrist after reduction
Function regained
after reduction(arm
is placed in a hanging
cast or coaptation
sling)
Posterior dislocation Popliteal artery Decreased distal Doppler studies or
of the knee injuries pulses CT ANGIO
Prophylactic
fasciotomy if
reduction is delayed
Injury patterns – 2nd hidden fractures
 Falls from a height – landing on the feet – obvious foot or leg
fractures
 Head on automobile collison – obvious injuries in the head,
face, and torso, but if knee hit the dashboard then femoral
evaluation must be sought for posterior dislocation of the hip
or out of the acetabulum
 Facial fractures and head injuries – must do cervical spine
evaluation
Foot pain – differential dx
 Plantar fascitis – older, obese/overwt individual
 c/o disabling, sharp heel pain every time their foot strikes the
ground, pain is worse in the morning,
 Xray- bony spur matching the location of pain, & there is exquisite
tenderness to palpation over the spur
 Rx: resolves in 12-18 months, surgical resection of bony spur is NOT
indicated.
 MORTON NEUROMA
 An inflammation of common digital nerve that innervates 3rd-4th toes.
 Neuroma is palpable as a very tender spot there
 Etiology: pointed or high heel shoes that force toes to be bunched
together
 Mgmt: analgesics and approp. Footwear
 Gout
Leg ulcers
 Diabetic foot ulcer
 Indolent and located at pressure points – heel, metatarsal head, tip of
the first toe
 Start b/c of neuropathy and progress due to vascular insufficiency
 Can be healed with good diabetes control and keeping them clean and
leg elevation
 Reality: often get worse to the point of amputation
 Ulcers from arterial insufficiency- at the tip of the toes.
 Look dirty, pale base devoid of granulation tissue, pain upon rest or
claudication , absent pulses or trophic changes
 Doppler studies, or MRI OR MR ANGIOGRAM
 Rx: surgical revascularization or angiography or stent therapy
 Chronic foot ulcer
 Venous stasis ulcers: chronically edematous, indurated,
hyperpigmented and above the medial malleolus
 Painless, granulated, have varicose veins, and have freq bouts of cellulitis
 Workup: duplex; Mgmt: keep the veins empty; support stocking, Ace
bandages, UNNA boot.
 Surgery: vein stripping, grafting of the ulcer;
 Endovascular ablation with laser or radiofreq may also be used.
 Marjolin ulcer:
 Sq cell CA of the skin developing in the chronic leg ulcer that’s chronically
healing and untreated for many yrs e.g. most commonly seen in untreated 3rd
degree burns that underwent spontaneous healing, or in chronic draining
sinuses secondary to osteomyelitis
 Dirty looking, deeper ulcer develops at the site, with heaped up tissue
growth around the edges.
 Biopsy is diagnostic. Wide local excision and skin grafting are done
Back Pain – Differentials
 Lumbar Disk herniation
 Occurs almost exclusively at L4-L5 & L5-S1. Peak age (45-46).
 Px: several months of vague aching pain- “the discogenic pain” –
produced by pressure on the anterior spinal ligament, before
the onset of neurogenic pain (like an electric shock that shoots
down the leg). Exiting on the side of the big toe in L4-L5, or
the side of the little toe in L5-S1.
 Exacerbating factors: coughing, sneezing, or defecating – if
the pain is not exacerbated by these activities, the problem is
not herniated disk.
 Pxt cannot ambulate, hold the affected leg in flexed position
 Straight leg raise test- excruciating pain
Lumbar disk herniation cont’d
 MRI: confirms the diagnosis and treatment : bed rest for 3
weeks , often require pain control with nerve blocks under
radiologic guidance
 Surgical intervention is needed if neurologic deficits are
progressing (progressive muscle weakness).
 Emergency intervention: if there is a cauda equina
syndrome (distended bladder, flaccid rectal sphincter, perineal
saddle anesthesia), requires immediate surgical decompression
Ankylosing spondylitis
 Commonly seen in young men in early
30s or 40s
 c/o: chronic back pain and morning
stiffness
 Worse at rest, and improves with
activity, and Sx are progressive
 XRAY- bamboo spine- fused sacroilliac
joints and spicules bridging the
vertebral bodies.
 Many have HLA B27 antigen- also
associated with uveitis, and
inflammatory bowel disease.
 Rx: antiinflammatory agents and
physical therapy
Metastatic Malignancy
 Suspected in elderly with progressive back pain that’s worse at night and
unrelieved by rest or positional changes.
 Additional finding: wt loss.
 Also look for hypercalcemia or elevated ALP
 XRAYs in Women: lytic breast cancer metastasis at the pedicles.
 Other lytic mets causes: Lung, renal, breast, thyroid, multiple myeloma
 Xrays in males: blastic metastasis are from the prostate.
 Causes of blastic lesions: breast and prostate cancers
 BONE SCAN is MOST SENSITIVE IN EARLY DISEASE
 Will not be helpful in purely lytic lesions (multiple myeloma), instead order
plain xray.
 MRI is diagnostic tool – to rule out cord compression – if
there are any neurologic sx.
 PRE-OP AND POST OP CARE
 PRE-OP ASSESSMENT
 Cardiac risk
 Pulmonary risk
 Hepatic risk
 Nutritional risk
 Metabolic risk
Cardiac Risk
 Ejection Fraction
 <35% - prohibits the noncardiac surgeries
 Incidence of peri-op MI would be 75-85%, and mortality is btw 55 and 90%
 Goldman’s index of cardiac risk
 11 points to JVD (evidence of CHF)
 10 pointsto recent MI(within 6 months)
 Other fx to cardiac risk- PVCs, rhythm other than sinue, age>70,
emergency sx, and aortic stenosis, or poor medical conditions
 JVD- worst single finding predictive of hi cardiac risk- indicates CHF.
RX with ACEIs, BBs, digitalis, and diuretics should precede sx.
 Recent transmural or subendocardial MI – next worst predictor of
cardiac complications. Operative mortality w/in 3 months of the
infarct- 40%. Defering surgery until 6 months is best course of axn.
 Otherwise admit pxt to ICU day before the sx to optimize the cardiac
variables.
Pulmonary Risk
 Smoking is MCC of Increased Pulmonary risk, and the
problem is compromised – ventilation(hi PCO2, low FEV1,
rather than compromised oxygenation.
 Smoking hx/copd- lead to evaluation
 Start with FEV1, if it is abnormal , follow with blood
gases.
 Cessation of smoking for 8 wks and intensive respiratory
therapy (physical therapy, expectorants, incentive spirometry,
humidified air) should precede surgery.
Hepatic risk
 Predictors of mortality
 About 40% mortality – with either bilirubin >2, albumin
<3, PT>16, or encephalopathy
 About 80-85% mortality –if 3 of the above are present, or if
all 4 exist- 100% mortality risk, or with either bilirubin
alone over 4, albumin<2, or blood ammonia concentration
alone above 150mg/dL
Nutritional and metabolic risk
 Severe nutritional depletion – loss of 20% body weight/couple
months, serum albumin <3, anergy to skin Ags, or serum
transferrin level <200mg/dl (or a combination of the above)
 Operative risk is multiplied manyfold
 4-5 days of preop nutritional support (preferably via gut) – make a
difference, and 7-10 days is optimal if surgery can be deferred that
long.
 Metabolic risk
 Diabetic coma – absolute contraindication to surgery.
 Rehydration, return of urinary output, and atleast partial correction
of acidosis, and hyperglycemia needs to be done before Sx.
 If the indication for Sx is septic process, complete correction of all
the variables will be impossible as long as the septic process is
present.
POST –OP COMPLICATIONS
 Fever
 Chest pain
 Other pulmonary complications
 Disorientation/coma
 Urinary complication
 Abdominal distension
 Wound
 Fluids and electrolytes
 Severe wound pain + v.hi fever

Fever  possibility of gas gangrene

w/in hrs of surgery

+ ultimate Tx is
bronchoscopy

With heparin

Erythema, warmth, tenderness

Chest pain
But emergency angiop
Fever Cont’d

Prevention: NPO & antacids

 CAUSES OF DISORIENTATION/COMA IN
POST OP PXTS
 Hypoxia
 ARDS
 DELIRIUM TREMENS
 HYPONATREMIA
 Often in pxts, given DFW in a pxt
with hi levels of ADH (ADH triggered
by response to trauma)  confusion,
convulsions, and eventually coma,
often death (“water intoxication”)
 Chart review: large fluid intake, wt  AMMONIUM INTOXICATION
gain, and rapid dec in Na levels
 Use small amts of hypertonic saline-
Aliquots of 100mL of 5%, or 500mL
of 3%, perhaps add osmotic diuretics.
 HYPERNATREMIA – confusion,
lethargy, and coma
 Induced by large, unreplaced water
loss or surgical damage to post
pituitary with unrecognized diabetes
insipidus – good example.
 Chart review: large, unreplaced
urinary output, rapid wt loss, and
rapidly rising serum Na+
concentration.
 Rapid replacement of fluid deficit is
needed, but to “cushion” the impact
on tonicity- preferabbly D51/2 or
D51/3 NORMAL SALINE rather
than D5W.
 Common source of coma in a
cirrhotic pxt with bleeding
esophageal varices who undergoes
portocaval shunt
URINARY COMPLICATIONS
 POST OP URINARY RETENTION – extremely common, In and out
bladder cath should be done at least 6 hrs post op if no spontaneous
voiding has occurred
 Indwelling foley cath is indicated at the 2nd or 3rd post op consecutive cath.
 ZERO URINARY OUTPUT – mechanical problem- look for plugged or
kinked catheter
 LOW URINARY OUTPUT –(<.5ml/kg/hr) in the presence of normal
perfusing pressure (not due to shock) rep’ts fluid deficit or ARF.
 Fluid challenge test- a bolus of 500ml of IV fluid infused over 10 or 20
minutes.
 Dehydrated pxts: response temp increase in urinary output, those in RF will not do so
 Elegant way- to measure urinary sodium- will be <10-20mEQ/L in a
dehydrated pxt with good kidneys, while it will exceed 40mEq/L in cases of
Renal failure.
 EVEN more SOPHISTICATED WAY: FeNa+ - in RF will exceed 1.
ABDOMINAL DISTENTION
 PARALYTIC ILEUS - EXPECTED 1DT FEW DAYS AFTER SX
 Absent bowel sounds, no passage of gas
 Mild distension, no pain
 Prolonged by hypokalemia
 EARLY MECHANICAL BOWEL OBSTRUCTION – MC’n
due to Adhesions, paralytic ileus not resolving after 5-7 days is
now SBO
 XR: dilated loops of small bowel and air-fluid levels
 Dx- confirmed with CT- demo a transition point b/w prox dilated
bowel and distal collapsed bowel at the site of obstruction
 Surgical intervention is needed to correct the problem
 OGILIVE SYNDROME – VERY COMMON- PARALYTIC
ILEUS OF THE COLON – SEEN IN ELDERLY
SEDENTARY PXTS (Alz, nursing home)
 Pxts have become further immobilized owing to surgery
elsewhere(broken hip, prostatic surgery)
 Large abd distension (tensed but not tender); XR- massively
dilated colon
 After fluid and elec correction, mechanical obstruction be ruled
out radiologically or by endoscopy, before giving IV
neostigmine to restore colonic motility. Long rectal tube
is also commonly used.
WOUND – 5th post op day
 WOUND DEHISENCE , mostly after open laparotomy, nonemergent
 Wound looks intact, but large amts of “salmon colored” fluid – soaking
the dressings (i.e.peritoneal fluid)
 Wound has to be taped securely, abdomen bound, and mobilization and
coughing done with great care
 Reoperation needed to avoid early on or later on ventral hernia
 EVISCERATION(EMERGENT) Catastrophic complication of dehisence
 Skin itself opens up and abd contents gush out.
 Typically happens when pxt coughs, strains or get out of bed
 Pxt must be kept in bed, bowel be covered with large sterile dressings
soaked with warm saline. Emergency abd closure is required.
 WOUND INFECTIONS (7TH POST OP DAY) – DESCRIBED IN
MTB3
GIT fistulas – Bowel contents leak thru
a wound or drain site
 If they do not empty directly to the outside, but leak into a “CESSPOOL”
that then leaks outsepsis develops (req’ing comp drainage)
 If drain freely (pxt afebrile, w/ no signs of peritoneal irritation), there are 3
potential probs:
 Fluid and electrolyte loss
 Nutritional depletion
 Erosion and digestion of the belly wall
 These probs are related to location and volume of the fistula: nonexistent in
distal colon, present but manageable in low volume (up to 200-300ml/day)
high GI fistulas (stomach, duodenum, upper jejunum) and daunting in high
volume (several litres per day)
 Fluid replacement, Nutrional support (delivered beyond the fistula), and
compulsive protection of abdominal wall (suction tubes, Ostomy bags)- keep
the pxt alive until nature heals the fistula
 Nature will do so if there is no FETID – Foreign body, Epitheliazation,
Tumor, Infection, I rradiated tissue, Inflammatory bowel dz, or Distal
obstruction
 Steroids will also prevent healing
FLUID AND ELECTROLYTES
 Hypernatremia- pxt has lost water – and has developed
hypertonicity. Every 3mEq/L that serum Na is above
140mEq/L , rep’ts 1L of water lost.
 If happens slowly- brain has time to adapt- vol repletion must
be done in a manner to be corrected rapidly and goes back to
normal in matter of days – use D5W1/2 NS
 If hypernatremia develops rapidly such as in situations
osmotic diuresis or diabetes insipidus- brain has no time to
adapt- correction can be safely done using D51/3NS or even
D5W
Hyponatremia
 Retained water  hypotonicity.
 Scenario 1: Pxt starts with normal fluid volume adds to it by
retaining water due to presence of SIADH (e.g. post op water
intoxication or IADH by tumors)
 Slowly developing hyponatremia- therapy water restriction
 Scenario 2: Pxt is losing large amounts of fluids (from GIT)
forced to retain water, if he hasn’t received approp replacement
with isotonic fluids
 Normosaline or ringer lactate will provide prompt correction and allow
body to adapt slowly to unload the retained water and return to tonicity
normal
Hypokalemia
 Lost via GIT or urine lost (due to LOOP diuretics or too much
aldosterone).
 Develops very rapidly- in matter of hours, esp during correction of DKA
 Rx: IV K+ admin at 10mEq/h- safe “speed limit”

Hyperkalemia
 Occur slowly- if kidney cannot excrete K (RF, or Aldosterone Antagonists)
 Occur rapidly if K is being dumped from the cells (crusing injuries, dead tissue,
acidosis)
 Ultimate therapy: is HEMODIALYSIS; but while waiting can push K into the
cells via (50% dextrose and insulin), sucking it out of GIT (NG suction,
exchange resins (keyxalate)), or neutralizing its effects on the cellular
membrane(IV calcium)
 Latter provides the quickest protection
Metabolic acidosis (pH<7.4, HCO3
<25, base deficit)
 3 CAUSES:
 Excess prod of fixed acids (DKA, low flow states)
 From loss of buffers (Loss of HCO3 rich fluids from GIT)- normal
anion gaps
 From inability of kidney to eliminate fixed acids (renal failure)
 Increased anion gap – MUD PLIES
 Rx in all cases: admin of HCO3 or its precursors- lactate or
acetate, h/e its ideal to replace HCO3 if underlying prob is HCO3
loss, otherwise risk of developing “rebound alkalosis” once the
underlying prob is corrected.
 One also must be prepared to replace K as part of the therapy of
acidosis.
Metabolic alkalosis(pH>7.4, HCO3>25)
& base excess
 3 causes:
 Loss of acid gastric juice
 From excesss admin of HCO3
 Therapy: most cases- an abdundant intake of KCl (btw 5-
10mEQ/h) allow kidney to correct the problem. Only rarely –
NH4CL or .1N HCl is needed.
Respiratory acidosis or alkalosis in conj with abnormal
blood pH
 IMPAIRED VENTILATION (ACIDOSIS)-HI PCO2
 ABNORMAL HYPERVENTILATION(ALKALOSIS)- LOW PCO2
 Therapy must be directed at improving ventilation
OPTHALMOLOGY - Children
 Amblyopia (Lazy eye) – vision impairment
due to interference from the brain with the
processing of images (common in 6-7 yrs
of life)
 Most common expression- Strabismus-
verified by showing reflection from a light
comes from diff areas of cornea.
 If it develops later in infancy- the problem is
exagerrated convergence caused by refraction
difficulties
 Faced with two overlapping images, the
brain suppresses one of them
 If the strabismus is not corrected surgically,
there will be permt cortical blindness
Optho – children cont’d
 Leukocoria – white pupil in a baby- opthalmologic
emergency- maybe caused by retinoblastoma
 Even if its caused by less lethal prob e.g cataracts- should be
attended to prevent amblyopia.
Opthalmology- Adults
 Glaucoma – acute angle closure glaucoma – surgical emergency
 Glaucoma – very common source of blindness
 (severe eye pain of frontal headache)Headaches, halos around lights,
and eye feels hard as a rock- Sx typically start in the evening
 PE: pupil is mid-dilated, and doesn’t react to light, the cornea is
cloudy with a greenish hue, and the eyes ‘feel hard as rock’
 Emergency Rx: opthalmologists will drill hole in the iris- to allow the
fluid to drain from the anterior chamber of the eye
 While waiting for opthalmologist- Adminster systemic Carbonic
Anhydrase inhibitor(Diamox), and apply topical beta blockers
(timolol) & alpha-2 selective adrenergic agonists. Also, Mannitol and
pilocarpine may be used.
Orbital Cellulitis
 Another opthalmologic emergency
 Eyelids are hot, tender, red, and swollen; and the patient is
febrile
 Key findings- eyelids are pried open – pupil is dilated and
fixed, and there is limited motion of eye. Pus in the orbit.
 Emergency ct scan and drainage have to be done.
 Chemical burns of the eye – require massive irrigation like
their counterparts in rest of the body. Irrigation with water start
ASAP until arrival at the hospital. Once the eye has been pried
open and washed, at the hospital irrigation should be cont’d with
normosaline and corrosive particles are removed. pH is tested to
assure that no chemical remains in the conjunctival sac.
 Retinal detachment- FLASHES AND FLOATERS
 Another emergency, pxt reports seeing flashes of light and having
“floaters” in the eye.
 Pxt who describes seeing dozens of floaters like a “snowstorm” w/i
the eye or a big dark cloud at the top of the retina pulled away, and is
at risk of ripping out the rest
 Emergency intervention- laser “spot welding” protect the remaining
retina
 Embolic occlusion of the retinal artery (elderly-w/
sudden loss of vision from one eye)
 Damage will be unreversible in ~ 30 mins- EMERGENCY
 STD Recommendation- breathe into a paper
bag(hyperventilate – to vasodilate and shake the clot into a
more distal location, so that a smaller area is ischemic)
 Newly diagnosed diabetes-
 Type 2 needs opthalmic eval, retinal damage may have already
occurred and proper treatment is to prevent its progression
ENT(OTOLARYNGOLOGY)- CONGENITAL
 Thyroglossal Duct Cyst
 Located on the midline, at the level of hyoid bone, and
connected to tongue(pulling at the tongue retracts the mass). 1-
2 cm in diameter.
 Surgical removal includes the cyst, middle segment of the hyoid
bone, and the track that leads to the base of the tongue.
 Branchial cleft cysts
 Along the ant edge of sternocleidomastoid muscle, from in
front of the tragus to the base of the neck
 Several cms in diameter, have a lil opening and blind tract in the
skin overlying them
 Cystic hygroma
 Found at the base of the neck as a large, mushy ill defined mass –
occupies the entire supraclavicular area and seems to extend deeper
into the chest- often mediastinum
 Found at the left Posterior triangle of the neck and armpits. Most
common form of lymphangioma.
 CT scan before attempted surgical removal is mandatory
Inflammatory versus neoplastic neck
masses
 Most recently discovered enlarged LNs are benign – complete
HNP followed by F/up in 3-4wks. If the mass is still there, work
up still follows.
 Persistent enlarged LNs (hx of wks or months)- could be
inflammatory but neoplasia has to be ruled out
 Lymphoma – seen in young ppl, often have multiple enlarged
LNs, low grade fever, and night sweats. FNA can be done, but
node has to be removed for pathologic study to determine specific
type. Chemotherapy is the usual treatment.
 Metastatic tumor to supraclavicular nodes: comes from
below the clavicles (not from the head and neck). Lung or
intraabdominal tumors are the usual primaries. Node itself maybe
removed to help a diagnosis
Squamous cell Carcinoma of the
mucosae
 Of the head and neck seen in old men who smoke and drink and have
rotten teeth.
 Pxts with AIDS are also prime candidates.
 1st Px: Metastatic node in the neck (jugular chain)
 Other Px: persistent hoarseness, persistent painless ulcer in the floor of
the mouth, and persistent unilateral earache.
 Diagnostic work up – triple endoscopy (or Panendoscopy) looking for
primary tumor. Biopsy or biopsies of the primary establish the diagnosis
and CT examine the extent.
 FNA of the node can be done, but do not perform open biopsy of neck.
An incision of the neck will interfere with surgical approach for the
tumor.
 Rx: resection, radical neck dissection, and very often radiotherapy and
platinum based chemotherapy.
Other Tumors
 Acoustic nerve neuroma- sensory
 Sensory hearing loss in one ear but not the other, and who does
not partcipate in sport shooting that would subject one ear to
more noise than other). MRI is diagnostic.
 Facial nerve tumors
 Gradual unilateral facial nerve paralysis affceting both the
forehead and the lower face.
 Paralysis of sudden onset suggests Bells palsy.
 Gadolinium enhanced MRI is diagnostic.
 Parotid tumors
 Visible and palpable in front of ears, or around the angle of mandible.
 Most are pleomorphic adenomas (benign)but have potential for
malignant degeneration. Do not produce pain or facial nerve
paralysis.
 Hard parotid mass- painful or produced paralysis is a parotid
cancer.
 FNA but no open biopsy. A formal superficial parotidectomy
(or superficial & deep if the tumor is deep to the facial nerve) is
appropriate way to excise.
 Enucleation- surgical excision of a mass without cutting or dissecting
into it.  leads to recurrences. In malignant tumors- the nerve
is sacrificed and the graft is done.
Pediatric ENT
 Foreign bodies – cause of unilateral ENT problems in
toddlers( 2yr old)- with unilateral earache, unilateral
rhinorrhea, or unilateral wheezing has a little toy truck in his
ear canal, up his nose, or into a bronchus.
 Appropriate endoscopy under anesthesia will allow
extraction.
ENT EMERGENCIES AND
MISCELLANEOUS
 Ludwig Angina – abscess of the floor of the mouth, often from
a bad tooth infection. Signs of abscess, real issue is the threat to
the airway. I AND D are done, but intubation and tracheostomy
may also be needed.
 Bell palsy- sudden paralysis of the facial nerve. Current practise-
use of antivirals and steroids are also typically prescribed.
 Facial nerve injuries – multiple trauma setting, produces paralysis
right away. Normal at admission, but paralysis develops later 
will resolve spontaneously.
 Cavernous sinus thrombosis – heralded by devt of diplopia
(from paralysis of extrinsic eye muscles)- pxt suffering from
frontal or ethmoid sinusitis. Serious emergency- requires
hospitalizations, IV abx, CT scans, and drainage of the affected
sinuses.
 Epistaxis
 In children – bleeding comes from ant septum, and phenylephrine
spray and local pressure controls the problem.
 18 and older – prime suspect- cocaine abuse (with septal perforation)
or juvenile nasopharyngeal angiofibroma
 Elderly and hypertensive- nosebleeds can be copious and life
threatening- BP can be controlled, and posterior packing is required.
Sometimes surgical ligation of feeding vessels – only way to control
the problem.
 Dizziness
 Caused by inner ear disease or cerebral disease
 Inner ear- pxts describe room is spinning around them- Rx-
Meclizine, Phenergan, or Diazepam may help.
 Cerebral disease – pxt is unsteady but the room is perceived to be
stable. Neurologic workup warrants the problem.
 Neurosurgery
 General rules- timetable and mode of presentation of neurologic
disease provide 1st clues to its nature
 Vascular problems : suddent onset, w/out headaches when
occlusive, and w/headaches if hemmorhagic
 Brain tumors- timetable of months, produce constant,
progressive, severe headaches, sometime worse in the morning. As
ICP increases, blurred vision and projectile vomiting develops. If
tumor presses on area of a brain, deficits of that function may be
evident.
 Infectious problems- timetable of days or wks, often an
identifiable source of infxn in the hx
 Metabolic problems- develops rapidly (hours-days)affect entire
CNS
 Degenerative diseases- have a timetable of yrs.
 Vascular occlusive disease
 TIA- predictor of stroke
 Transitory loss of neurologic fcn, and resolve spontaneouly w/out any
neurologic sequelae. Mc’n origin is 70% stenosis of internal carotid artery or
ulcerated plaque at the carotid bifurication.
 Work up – duplex studies (non invasive) i.e. hi quality sonogram with
doppler
 Sx: carotid endarterectomy if lesion described above present with sx.
Angioplasty or stent can be done if filter is 1st deployed to prevent
embolization of debris to the brain.
 Ischemic stroke
 Sudden onset w/out headache, but neurologic deficits are present for
>24hrs, leaving permanent sequelae; except very early strokes.
 Complicated by a hemorrhagic infarct if blood supply to the brain is suddenly
increased.
 CT scan is 1st initial mgmt and therapy is centered on rehab and emergent
clot busters e.g use TPA – IV infusion best if started w/in 90 minutes –
3hours after the onset of sx.
 Intracranial bleeding
 Hemmorhagic stroke
 Uncontrolled hypertensive c/o very severe headache of sudden onset and goes
on to develop severe neurologic deficits
 CT w/o contrast to determine the location and extent of bleeding, and therapy
is directed at controlling HTN and rehab efforts.
 Subarachnoid bleeding from intracranial aneurysms
 A high index of suspicion and timely dx can be life saving.
 Salvageable pxts – extremely severe headache of sudden onset like a
“thunderclap”, a headache that is “sudden, severe, and singular”
 Blood in the subarachnoid space- maybe no neurological findings at all and
maybe sent home and return in 10 days with 2nd bleed, and probably much
worse. Early one referred to as “Sentinel bleed”
 Luckier pxts will have nuchal rigidity and menigeal irritation, and be recognized.
 Work up – CT scan , and follows with arteriogram to locate the aneurysm (little
devil off the circle of willis)
 Clipping is surgical therapy and endovascular coiling is the radiological
alternative.
Brain tumors
 Offer no clinical clue to location if press on a ‘silent area’
 Hx of progressively increasing headache for several months, worse in
the morning, and eventually accompanied by signs of increased ICP:
blurred vision, papilledema, projectile vomitting, and at the extreme
spectrum, bradycardia and HTN (cushing reflex).
 Visualized well on CT but MRI gives better detail and is preferred
study.
 While awaiting surgical removal- increased ICP is treated with high
dose steroids (dexamethasone)
 Clinical localization of brain tumors
 Motor strip and speech centers are often affected when lateral side of
brain is affected – producing sx on the opposite side of body
 People speak with the same side of the brain that controls the
dominant hand
 Tumors at the base of frontal lobe
 Foster kennedy syndrome – inappropriate behavior, optic
nerve atrophy on ipsilateral side of tumor, papilledema on
contralateral side, and anosmia
 Craniopharyngioma
 Youngsters short for their age, show bitemporal hemianopsia and a
calcified lesion above the sella on xrays.
 Prolactinoma
 Amenorrhea and galactorrhea in young women.
 D’ic workup: R/O pregnancy, hypothyroidism, determination of
prolactin level and MRI of the sella.
 Rx: bromocriptine. Transnasal, trans-sphenoidal surgical removal is
reserved for those who wish to get pregnant, or those who don’t
respond to medical therapy.
 Acromegaly
 Huge hands,feet, tongue, and jaws
 USMLE- Pic of man showing both hands on eiher side of his face in the
frontal view, and a long prominent jaw in the lateral view.
 Additional px: diabetes, htn, sweaty hands, headache, hx of wedding
bands or hats that no longer fit
 Work up – starts with determination of somatomedin C, and pituitary
MRI. Surgical removal is preferred, but radiation is preferred.
 Pituitary apoplexy
 Bleeding into a pituitary tumor, with subsequent destruction of pituitary
gland. Hx may have long standing sx of pituitary tumor – headache,
vision loss, and endocrine problems.
 Acute episode starts with a severe headache followed by hematoma
(deterioration of remaining vision, b/l pallor of optic nerves) and
pituitary destruction (stupor and hypotension)
 Steroid replacement is urgently needed , and eventually other hormones
will need to be replaced.
 MRI or CT scan will be diagnostic
 Tumors of the pineal gland
 Loss of upper gaze and PFs : sunset eyes (Parinaud syndrome)
 Brain tumors in children
 Most commonly in the posterior fossa
 Give cerebellar Sx(stumbling around, truncal ataxia)
 Children often assume the knee- chest position to relieve their headache
 Brain abscess
 Space occupying lesion (same manifestations as of brain tumors), but a
much shorter timetable (wk or two)
 Fever and obvious source of nearby infxn like otitis media and
mastoiditis
 Typical appearance on CT, thus MRI is not needed
 Actual resection is required
 Pain syndromes
 Trigeminal neuralgia (Tic Douloureux)
 Extremely severe, sharp, shooting pain (like a bolt of lightning), pain in
the face brought about by touching the specific area, and lasting about 60
secs.
 Pxts in 60s have normal neurologic exam. Only PF: unshaven area in the
face (the trigger zone, pxts avoid touching)
 MRI is done to r/o organic lesions
 Rx: anticonvulsants or radiofrequency ablation
 Reflex Sympathetic Dystrophy (Casusalgia)
 Develops several months after a crushing injury
 Constant, burning, agonizing pain that does not respond to the usual
analgesics
 Pain is aggravted by slightest stimulation of the area.
 Extremity is cold, cyanotic, and moist
 Succesful sympathetic block is diagnostic, and surgical sympathectomy is
curative.
 Urology
Urologic Emergencies
 Testicular torsion – seen in young adolescents .
 Very severe testicular pain of sudden onset, swollen testis, exquisitely
tender, “ high riding” and a “horizontal lie”. Cord is not tender.
 One of few urologic emergencies – time wasted will result in malpractice
 Immediate surgical intervention is indicated. After the testis is untwisted,
orchioplexy is done. Many urologists also fix the other side.
 Acute epididymitis can be confused with testicular torsion
 Happens in young men old enough to be sexually active, starts with c/o
severe testicular pain of sudden onset.
 Add Sx: fever, pyuria, testis swollen and tender, but in NORMAL
POSITION, Cord is also very tender.
 Rx: antibiotics, but sonogram must be done to R/O Testicular torsion
 Combo of obstruction and infection of urinary tract- another dire
emergency
 When coexist with testicular torsion destruction of kidney in hrs,
and death from sepsis
 Scenario- a pxt is allowed to pass a ureteral stone spontaneously, suddenly
develops chills, fever spike (104F) and flank pain.
 Therapy: IV antibiotics +immediate decompression of urinary tract
above the obstruction is required, done via ureteral stent or
percutaneous nephrostomy, to defer elaborate instrumentation for
later.
 UTIs (cystitis)- very common in women of reproductive age
 Frequent, painful urination, with small vols of cloudy and
malodorous urine.
 Empiric antibiotics is useful. Most severe infections: like
pyelonephritis in children, or any UTI in children, or young men
requires urinary Cx and urologic work up to R/O obstruction as
source of serious unfection.
 Urologic work up
 Limitations of IVP – potential allergic rxn to the dye, which may be
severe, or in pxts with limited renal function (contraindicated in pxts
with Cr >2)
 Among the newer exams, CT and sonogram- are safe and inexpensive
to look for obstruction
 Only cystoscopy- can look at the bladder mucosa in detail and aid in
detetcing early cancers.
 Pyelonephritis
 Chills, hi fever, N/V, and flank pain
 Hospitalize, iv antibiotics (guided by cultures), and urologic work up
- IVP or sonogram in required
 Acute bacterial prostatis
 Older men, chills, fever, dysuria, freq urination, diffuse low back
pain, and an exquisite tender prostate on rectal exam.
 IV antibiotics are indicated, and do not repeat anymore rectal exams,
otherwise risk of developing a septic shock
Congenital urologic disease
 Posterior uretheral valves
 Most common reason for a newborn boy not to urinate during the
first day of life (meathal stenosis should also be looked for)
 Catheterization- done to empty the bladder (valves- not obstacle to
cath)
 Voiding cystouretherogram is diagnostic test
 Endoscopic fulguration or resection will get rid of them
 Hypospadias
 Easily noted on PE: uretheral opening is on the ventral side of the
penis, somewhere b/w the tip and base of the shaft
 Circumcsion should never be done- skin of the prepuce is needed for
plastic construction
 UTI in Children always do urologic work up, could be due to
VUR or other congenital anomaly
 VUR (vesicoureteral reflux) and infxn
 Burning on urination, freq urination, low abd and perineal pain, flank pain,
and fever and chills,
 Rx: empiric antibiotics followed by Cx and do IVP and voiding cystogram to
look for reflux. LT ABX are used until child gets outta problem
 Low implantation of a ureter
 Asymptomatic in boys, but leads to fascinating clinical presentation in little
girls
 Pxt feels the need to void, void at approp interval, but is also wet with urine
all the time(urine that drips into the vagina from the low implanted ureter.
 PE: doesn’t find the ureteral opening, IVP will show it.
 Corrective surgery is done.
 Uteropelvic junction obstruction
 Anomaly allows normal urine output w/o difficulty, but if a large diuresis
occurs, the narrow area cannot handle it.
 Scenario – adolescent goes on a beer-binge drinking (alcohol is
duretic) for the 1st time in his life, and develops colicky flank
pain.
 Tumors
 Hematuria
 In most cases hematuria is due to benign disease, but except in adult who has a trace
of urine after significant trauma.
 Any pxt with Hematuria needs extensive work up to R/O cancer( CT scan and
cont’s with cystoscopy)
 Renal cell carcinoma -Hematuria, flank pain, and flank mass
 Also produce hypercalcemia, erythrocytosis, and elevated Liver enzymes
 CT gives the best detail – mass to be heterogenic solid tumor and alerting the
urologist to potential growth into the renal vein and vena cava.
 Surgery is the effective therapy
 Bladder cancer
 Transitional cancer in most cases, closely correlated with smoking(even more so than
cancer of the lung)
 Hematuria, sometimes voiding symptoms, pxt may have been treated for UTI, even
though cultures were negative and afebrile.
 Cystoscopy followed by CT scan
 Both Sx and intravesical BCG have therapeutic roles- follow up is necessary due to
inc rate of recurrennce
 Prostatic cancer - incidence inc with age, most asymptomatic
 Sought via rectal exam (rock hard discrete nodule), PSA levels elevated for
age group
 Surveillance is stopped at age 75, b/c beyond 75, survival is not affected
by treatment.
 Transrectal needle biopsy (guided sonogram when discovered by PSA)
establish Dx. CT helps extent and choose therapy.
 Sx and radiation are choices, widespread bone mets respond for a few yrs
to androgen ablation, surgical (orchidectomy) or medical (LHRH agonists,
or antiandrogens like Flutamide)
 Testicular cancer – young men, painless testicular mass
 Benign testicular tumors are nonexistent, Bx is done with a radical
orchiectomy via inguinal route.
 Serum markers (b-HCG and Alpha-AFP) are useful for follow up. Sx
for LN dissection may be done in some cases.
 Platinum based chemotherapy – succesful treatment in advanced
met’ic dz.
 Retention and incontinence
 Acute Urinary Retention men with BPH Sx
 Often precipitated during a cold, antihistamine use, and nasal drops, and
abundant fluid intake
 Pxt wants to void, but cannot, and the huge distended bladder is palpable
 Indwelling cat needs to be placed and left for 3 days
 1st Line of LT therapy- a-blockers, 5-a-reductase inhibitors are used for very
large glands (>40g). Traditional transuretheral resection of prostate(TURP)
is rarely done.
 Post op Urinary Retention- sometimes it masquerades as urinary
retention- infact it is overflow incontinence from retention
 Pxt may not feel the need to void due to meds, or post op pain, but will
report involuntary release of small amts of urine every few mins
 Huge distended bladder will be palpable
 Indwelling bladder catheter is needed
 Stress incontinence mid age women w/ many preg’ies, and Vag deliveries
 Whenever intrabdominal pr increases, leak small amounts of urine
 Includes- sneezing, laughing, getting outta chair, or lifting a heavy object
 Denies incontinence at night
 PE: weak pelvic floor, with prolapsed bladder neck outside of “high
pressure abd area.” pelvic floor exrx sufficient for early cases
 Surgical repair of pelvic floor is indicated in adv cases i.e.large cystocele
Stones
 Passage of ureteral stones – colicky pain, irradiation to inner
thigh, and labia or scrotum, and sometimes N/V
 Most are visible in CT scan
 Small (3mm or <) at UVJ – 70% chance of passing spontaneouly
 7mm stone at UPJ, only 5% probability of passing, hence intervention
 MC’n tool used is Extracorpeal shock wave lithtripsy(ESWL)
 Limitations of ESWL: preg women, bleeding diathesis,
stones that are several cm large.
 Other options: basket extraction, sonic probes, laser beams, and open
surgery
 Abundant water intake is universal
Miscellaneous
 Pneumaturia- bubbles in the urine
 MC’n cause: fistulization between bladder and GIT, Most
commonly sigmoid colon
 From diverticulitis, (2nd sigmoid colon cancer, and 3rd bladder
cancer- rare)
 Work up: Ct scan – show inflammatory diverticular mass,
sigmoidoscopy to R/O sigmoid cancer. Surgical rx is req’d.
Impotence
 Psychogenic sudden onset, partner or situation specific, w/out
interference to nocturnal errections, treated with psychotherapy
 Organic if trauma is the cause- sudden onset (after pelvic sx,
nerve damage, or after trauma to the perineum involves arterial
disruption)
 Chronic disease(arteriosclerosis, or diabetes) – gradual onset, going
from errections not lasting long enough to being of poor quality, to
not happening at all (including absence of nocturnal errections)

 Slidenafil, tadalafil, and vardenafil – 1st choices, other options-

vascular sx (those with arterial injury), suction devices (on almost
everybody), and prosthetic implants (irreversible and fraught with
complications
 Organ Transplantation
 Selection of Donors
 General rule: regular physicians is that all potential donors are
referred to the harvesting teams, they will exclude the few that
cannot be used at all
 HIV STATUS IS ABSOLUTE CONTRAINDICATION TO
ORGAN DONATION
 Transplant rejection occur in 3 ways:
 Hyperacute rejection (w/i minutes)
 Acute rejection (after 1st 5 days, usually w/i 1st 3 months)
 Chronic rejection (seen yrs after the transplant)
Hyperacute rejection
 Vascular thrombosis w/i minutes of reestablishing blood
supply to the organs
 Caused by preformed Abs- prevented by ABO matching
and lymphocytoctoxic cross match, thus not seen clinically
Acute rejection
 Occurs even pxt is on maintenance immunosuppression
 Signs of Organ dysfunction suggest it and bx confirms it
 In case of liver, technical problems are more common than
immunologic rejection. Hence always order (GGT, ALP, and
Bilirubin levels) to R/O obstruction by U/S and vascular
thrombosis by Doppler.
 In case of heart, signs of functional deterioration occur too late to
allow effective therapy- thus routine ventricular bx’ies (via JV,
SVC, and RA) are done at set intervals
 1st line therapy: steroid boluses, if unsuccessful- antithymocyte
agents(OKT3) are used, but(SE of high toxicity.
 Cellular MRI – a non –invasive way to dx rejection w/out the
need for biopsies, is under way
Chronic rejection
 Gradual insidious loss of organ dysfunction.
 Poorly understood and irreversible. There is no treatment
for it.