Term
| What are some complications associated with acute pancreatitis? |
|
Definition
| hemorrhage,necrosis, fluid collection, infection, splenic vein thrombosis, pseudocyst, abscess; systemic complications= pulmonary, cardiac, and renal dysfunction |
|
|
Term
| T/F Amylase and lipase correlate with the severity of pancreatitis. |
|
Definition
|
|
Term
| During hospital stay, a pt with pancreatitis should be monitored for what complications? |
|
Definition
| distant organ dysfunction including respiratory insufficiency, renal insufficiency, cardiac dysfunction, and neurologic dysfunction, rapid loss of lean body mass |
|
|
Term
| When does infected pancreatic necrosis occur after pancreatitis? |
|
Definition
| within the first few weeks of onset |
|
|
Term
| How do you treat infected pancreatic necrosis? |
|
Definition
|
|
Term
| When after pancreatitis onset does a pancreatic abscess occur? |
|
Definition
|
|
Term
| How do you treat pancreatic abscess? |
|
Definition
|
|
Term
| When does infected pancreatic psuedocyst occur after onset of pancreatitis? |
|
Definition
| more than 6 weeks after onset of severe pancreatitis |
|
|
Term
| What percent of pancreatitis is mild versus severe? |
|
Definition
| 85% are mild and selflimited; 15% are severe and complicated |
|
|
Term
| What characterizes mild pancreatitis? |
|
Definition
| edema of the pancreas is characterized by edema of the pancreas and rarely proceeds to necrosis or infection |
|
|
Term
| What is severe pancreatitis? |
|
Definition
| necrosis of the pancreas and may be complicated by infection |
|
|
Term
| How often is severe pancreatitis complicated by infection? |
|
Definition
|
|
Term
| Whatcauses intravascular volume loss in pancreatitis? |
|
Definition
| increased microvascular permeability |
|
|
Term
| What are teh most important elements in preventing multiple organ failure in pancreatitis? |
|
Definition
| fluid resuscitation and intensive monitoring |
|
|
Term
| How many ranson criteria do you need to have more severe disease and an increased risk of complications? |
|
Definition
|
|
Term
| What can be used to determine prognosis in patients with pancreatitis? |
|
Definition
| ranson criteria, APACHE II, CRP (all have similar sensitivity and specificity) |
|
|
Term
| When should contrast enhanced CT be performed? |
|
Definition
| if the diagnosis of pancreatitis is in question or in pts who do not improve clinically in 3 to 5 days or who have severe pancreatitis based on teh Ranson score (to determine necrosis) |
|
|
Term
| What are the Ranson criteria on admission? |
|
Definition
| WBC >16,000; Glucose >200, Age >55, AST >250, LDH >350 |
|
|
Term
| What are the Ranson criteria two days later? |
|
Definition
| hematocrit fall of 10%; calcium <8, BUN increas of 5, fluid requirement of >6L, Base excess of >4; PO2 <60 |
|
|
Term
| What imaging should all pts with pancreatitis get? |
|
Definition
| U/S of gallbladder for stones |
|
|
Term
| Initial treatment of acute pancreatitis is nonoperative and focuses on... |
|
Definition
| fluid resuscitation, pain management, maintenance of ventilation, adequate oxygenation, and renal perfusion |
|
|
Term
| What should you do for a pt with pancreatitis with N/V? |
|
Definition
|
|
Term
| What percent of pts with pancreatitis improve after supportive measures? |
|
Definition
|
|
Term
| Name an antibiotic that is effective in penetrating the pancreatic tissue? |
|
Definition
|
|
Term
| What is the managment of a pt with biliary pancreatitis? |
|
Definition
| abdominal U/S on admission and daily monitoring of LFTs; if total bilirubin does not decrease pt should undergo ERCP to clear duct of stones; need cholecystectomy before or soon after discharge |
|
|
Term
| T/F Feeding pts with pancreatitis causes pain associated with acinar stimulation and further injury and destruction of the gland. |
|
Definition
| false; acinar stimulation does not exacerbate the injury and that the pain that some pts experience is not associated with worsening of pancreatitis |
|
|
Term
| Why is glycemic control indicated in pancreatitis? |
|
Definition
|
|
Term
| What arethe indications ofr operative debridement and drainage in pts with pancreatitis? |
|
Definition
| infected pancreatic necrosis and clinical deterioration in pts with sterile necrosis; in chronic pancreatitis= intractable pain, bowel or biliary obstruction, and persistent pseudocysts |
|
|
Term
| What characteristics of nipple discharge are concerning? |
|
Definition
| spontaneous, being bloody or blood tinged, unilateral |
|
|
Term
| Do solitary papilloas increase the risk of breast cancer? |
|
Definition
|
|
Term
| What are the four most common causes of bloody nipple discharge? |
|
Definition
| intraductal papilloma, duct ectasia, carcinoma and infection |
|
|
Term
| squamous carcinoma of the nipple is called... |
|
Definition
|
|
Term
| What is the most common reason for nipple discharge? |
|
Definition
|
|
Term
| What tests should you perform if you suspect infection and/or mastitis or abscess of the breast? |
|
Definition
| gram stain and culture of discharge; complete blood count |
|
|
Term
| Describe the appearance of galactorrhea? |
|
Definition
| bilateral milky white discharge |
|
|
Term
| At what prolactin level can you start to see a prolactinoma with MRI? |
|
Definition
|
|
Term
| What medications can cause galactorrhea? |
|
Definition
| pts taking phenothiazines, metoclopramide, oral contraceptives, alpha methyldiphenylalanine, reserpine, or TCAs |
|
|
Term
| Name some causes of galactorrhea. |
|
Definition
| pituitary prolactinoma, medications, hypothyroidism |
|
|
Term
| T/F Fibrocystic change varies with the menstrual cycle. |
|
Definition
|
|
Term
| Describe the discharge that is typical with fibrocystic change? |
|
Definition
|
|
Term
| What are the tests you should use to evaluate a nipple discharge you suspect to be due to fibrocystic change? |
|
Definition
| hemoccult test; u/s is helpful in delineating cystic lesions and fibroglandular tissue; mammogram may be appropriate |
|
|
Term
| What tests can be used for intraductal papilloma? |
|
Definition
| ductogram; ultrasound may be helpful during workup |
|
|
Term
| Describe the nipple discharge associated with diffuse papillomatosis? |
|
Definition
| serous rather than bloody discharge; often involves multiple ducts more distant from the nipple and can be bilateral |
|
|
Term
| T/F Diffuse papillomatosis is associated with an increased risk of breast cancer. |
|
Definition
|
|
Term
| What tests are useful in diagnosing diffuse papillomatosis? |
|
Definition
| ductogram to identify duct system; needle localization following ductogram may assist in excision; ultrasound may be helpful during workup |
|
|
Term
| Why is a hemoccult test useful for discharge characteristic of fibrocystic change? |
|
Definition
| occasionally the discharge of fibrocystic changes can be difficult to delineat from old blood; however this drainage is rarely spontaneous |
|
|
Term
| Which is better, a cytologic examination of the drainage or a ductogram? |
|
Definition
| ductogram because cytologic exam has false negative and false positive results and can cause further delay and cost without adding any useful data |
|
|
Term
| What must a patient have in order to justify performing a ductogram? |
|
Definition
|
|
Term
| What is the significance of an abnormal ductogram? |
|
Definition
| means surgical biopsy is necessary |
|
|
Term
| How are breast ducts excised? |
|
Definition
| duct is cannulated with a fine lacrimal probe used as the guide for excision; methylene blue dye is injected into the duct with a fine angiocatheter and may also serve as a guide in directing the excision whichis done through a circumareolar incision |
|
|
Term
| What percent of patients with nipple discharge without an associated breast mass have breast cancer? |
|
Definition
|
|
Term
| In a patient with nipple discharge, what other features of the history and exam increase their risk of it being cancer? |
|
Definition
| associated mass; postmenopausal pt |
|
|
Term
| In patients with bilateral severe carotid artery stenosis, which side should be operated on first? |
|
Definition
| the side producing symptoms |
|
|
Term
| What is the leading cause of disability in adults? |
|
Definition
|
|
Term
| Stroke is ranked as the # ___ cause of death. |
|
Definition
|
|
Term
| T/F As a general rule, the more severe the stenosis of a carotid artery, the higher the incidence of symptoms. |
|
Definition
|
|
Term
| What other tests besides ultrasound can be done to evaluate for CEA? |
|
Definition
| magnetic resonance angiogram, conventional carotid angiogram, or a CT reconstruction angiogram; an additional workup fora patient with carotid disease should include a thorough assessment of cardiopulmonary risks |
|
|
Term
| What were the results of the NASCET trial? |
|
Definition
| for pts with symptomatic carotid stenosis >70%, the 5 year stroke risk was 24% for conservative therapy and 7% for CEA |
|
|
Term
| What were the results of the ACAS trial? |
|
Definition
| pts with asymptomatic carotid stenosis >60%, the five year stroke risk was 11.1% for conservative therapy and 5.5% for CEA |
|
|
Term
| To apply the findings of the ACAS and NASCET data, the complication rate must be... |
|
Definition
| 5% or less for symptomatic patients; 2% or lessfor asymptomatic patients |
|
|
Term
| What surgical techniques can be used to reduce risk of perioperative stroke with CEA? |
|
Definition
| intraluminal shunt, cerebral monitoring, and a patch angioplasty |
|
|
Term
| How long is the average hospital stage after CEA? |
|
Definition
| majority are home after 24 hrs |
|
|
Term
| What recent advancement has improved the short term safety of carotid artery stenting? |
|
Definition
| cerebral protection devices during the procedure that trap embolic debris |
|
|
Term
| What types of patients should be considreed for CAS over CEA? |
|
Definition
| those iwth previous neck radiation or recurrent stenosis |
|
|
Term
| What were the results of the SAPPHIRE trial? |
|
Definition
| patients with more than 80% asymptomatic stenosis and more than 50% symptomatic stenosis and high risk operative profiles were randomized to stenting versus endarterectomy and it appears that there is no significant difference acording to a 3 year followup |
|
|
Term
| In a patient with stroke, when is the highest risk of a second stroke? |
|
Definition
| during the first 6 months following the first event |
|
|
Term
| What are the two most common severe complications following carotid CEA? |
|
Definition
|
|
Term
| What symptoms seem like they might be caused by cerebral ischemia but in fact are almost never caused by cerebral artery stenosis? |
|
Definition
| dizziness, syncope, and confusion |
|
|
Term
| When should cough be further evaluated in smokers? |
|
Definition
| if it is new and persistent |
|
|
Term
| What percent of patients with lung cancer have multiple primaries? |
|
Definition
|
|
Term
| What percent of nodules found incidentally on CXR are cancers in pts who are smokers? |
|
Definition
|
|
Term
| If a mass looks like it could be a pneumonia, what should you do? |
|
Definition
| treat with 10 to 14 day course of antibiotics with mandatory radiographic examination on completion; presistence of the mass demands further evaluation |
|
|
Term
| What are the tests you can use to further workup an incidental nodule found on CXR? |
|
Definition
| contrast chest CT, PET imaging, sputum cytologic studies, transthoracic FNA, bronchoscopic boipsy, and surgical resection |
|
|
Term
| How do you manage pts with an incidental finding of pulmonary nodule who are high risk for lung cancer? |
|
Definition
| some form of biopsy or surgical resection |
|
|
Term
| Is PET with CT useful for evaluating pulmonary nodules? |
|
Definition
| sensitivity for detecting malignancy is 82-100%; specificity is 75-100%; but is less effective for smaller lesions (<1cm) or when concomitant infection is present |
|
|
Term
| Is sputum cytology useful in obtaining a tissue diagnosis for pulmonary nodule? |
|
Definition
| establishes a diagnosis in 10 to 15% of cases (higher if lesion is located centrally) |
|
|
Term
| How do you biopsy loung lesions? |
|
Definition
| transthoracic FNA for peripheral lesions; bronchoscopic biopsies for central lesions |
|
|
Term
| What kind of advanced imaging can you get to further evaluate an incidental nodule found on CXR? |
|
Definition
| CT with IV contrast including liver and adrenals to assess for metastasis |
|
|
Term
| What are the five most common sites of metastasis for lung cancer? |
|
Definition
| contralateral and ipsilateral noninvolved lung, liver, adrenals, bone and brain |
|
|
Term
| What is T1 for lung cancer? |
|
Definition
| a tumor that is less than or equal to 3 cm; surrounded by pleura, no evidence of invasion proximal to a lobar bronchus on bronchoscopy |
|
|
Term
| What is a T2 for lung cancer? |
|
Definition
| a tumor more than 3 cm or a tumor of any size that either invades the visceral pleura or has associated atelectasis or obstructive pneumonitis extending to the hilar region. On bronchoscopy involves the lobar bronchus or at least 2 cm distal to the carina. any associated atelectasis or obstructive pneumonitis must involve less than the entire lung |
|
|
Term
| What is T3 for lung cancer? |
|
Definition
| a tumor of any size with direct extension into the chest wall (including superior sulcus tumors), diaphragm, or mediastinal pleura or pericardium without involving the heart, great vessels, trachea, esophagus, or vertebral body, or a tumor in the main bronchus within 2 cm of the carina without involving the carina, or associated atelectasis or obstructive pneumonitis of the entire lung |
|
|
Term
| What is T4 for lung cancer? |
|
Definition
| a tumor of any size with invasion into the mediastinum or involving the heart, great vessels, trachea, esophagus, vertebral body or carina or with the presence of malignant pleural or pericardial effusion or with satellite tumor nodules within the ipsilateral primary tumor lobe of the lung |
|
|
Term
|
Definition
| metastasis to lymph nodes in teh peribronchial or ispilateral hilar region or both, including direct extension |
|
|
Term
|
Definition
| metastasis to ipsilateral mediastinal lymph nodes and subcarinal lymph nodes |
|
|
Term
|
Definition
| metastasis to contralateral mediastinal lymhp nodes, contralateral hilar lymph nodes, ipsilateral or contralateral scalene, or supraclavicular lymph nodes |
|
|
Term
| What is stage IA lung cancer? |
|
Definition
|
|
Term
| What is stage 1B lung cancer? |
|
Definition
|
|
Term
| what is stage IIA lung cancer? |
|
Definition
|
|
Term
| What is stage IIB lung cancer? |
|
Definition
|
|
Term
| What is stage IIIA lung cancer? |
|
Definition
| T3, N1, M0; T3, N2, M0; T1, N2, M0; T2, N2, M0 |
|
|
Term
| What is stage IIIB lung cancer? |
|
Definition
T4, N0,1,2, or 3
T1, N3
T2, N3
T3, N3 |
|
|
Term
| What is stage IV lung cancer? |
|
Definition
|
|
Term
| How do you stage small cell lung cancer? |
|
Definition
| can have limited disease, extensive disease or extrathoracic metastasis; if discovered at an early stage you can use the TNM staging system |
|
|
Term
| What are the paraneoplastic syndromes associated with small cell lung cancer? |
|
Definition
| EatonLambert, hypercalcemia, Cushings, SIADH, paraneoplastic cerebellar degeneration |
|
|
Term
| What tests should you get before lung cancer resection to test pts physiologic reserve? |
|
Definition
| pulmonary function testing and sometimes exercise oxygen consumption studies; smoking cessation for at least 2 weeks is mandatory and pulmonary function can be improved dramatically with thissingle intervention |
|
|
Term
| What is the treatment for small cell lung cancer? |
|
Definition
| limited disease treated with combo chemo and radiation therapy; extensive disease is offered palliativechmo with radiation reserved for symptomatic relief only |
|
|
Term
| What is the minimum necessary criteria to remove pulmonary metastasis? |
|
Definition
| local control of the primary tumor, metastatic disease confined to the lung parenchyma, disease that is resectable, and adequate pulmonary reserve to tolerate the process |
|
|
Term
| What is the five year survival rate for resection of pulmonary metatastasis if the minimum necessary criteria are met? |
|
Definition
| 5 year survival rates approximate 30% |
|
|
Term
| Can you screen for lung cancer? |
|
Definition
| screening with sputum cytology or by CXR isn't sensitiveenough but there is an ongoing trial involving screening of high risk patients using CT scans |
|
|
Term
| When can you resect lung cancer? |
|
Definition
| stage I or II disease with adequate pulmonary function testing |
|
|
Term
| What is the primary purpose of getting a CT scan of chest masses found on CXR? |
|
Definition
| to determine anatomic location of the lesion |
|
|
Term
| What percent of patients with lung cancer present with symptoms versus incidental finding on CXR? |
|
Definition
| 95% with symptoms; 5% with asymptomatic chest findings |
|
|
Term
| What is the most common presenting symptom of lung cancer? |
|
Definition
| cough (75% present with cough) |
|
|
Term
| What percent of patients with lung cancer have paraneoplastic syndromes and what types of cancer are they associated with? |
|
Definition
| 10-20% are affected by paraneoplastic syndromes; mostly small cell and squamous cell |
|
|
Term
| What clinical presentation suggests malignant extrahepatic biliary obstruction? |
|
Definition
| painless jaundice with a palpable nontender gallbladder (courvoisier sign), weight loss and new onset diabetes type II |
|
|
Term
| What is the best initial test if you suspect malignant extrahepatic biliary obstruction? |
|
Definition
| U/S to look for cholelithiasis, choledocholithiasis, etc. then CT to further differentiate between extrinsic compression and stricture and to stage the tumor |
|
|
Term
| What makes a pancreatic tumor no longer resectable? |
|
Definition
absoulute contraindications= if it invades the SMA, presence of distant metastasis
relative contraindications= involvement of the superior mesenteric vein or a portal vein by tumor |
|
|
Term
| How do you treat pancreatic cancer? |
|
Definition
| surgical resection if possible with adjuvant chemotherapy either before or after surgery |
|
|
Term
| Name some common periampullary tumors? |
|
Definition
| pancreas, distal bile duct (cholangiocarcinoma), duodenum, and ampulla of Vater; less commonly= mucinous cystic tumors of the pancreas and pancreatic lymphoma |
|
|
Term
| What is a pancreaticoduodenectomy? |
|
Definition
| operation involving resection of the duodenum, head of the pancreas, the common bile duct, and sometimes the distal stomach |
|
|
Term
| When is pancreaticoduodenectomy indicated? |
|
Definition
| pts with tumors and benign disease located in the area surrounding the ampulla of Vater |
|
|
Term
| What is a whipple resection? |
|
Definition
| classic form of pancreaticoduodenectomy |
|
|
Term
| What is teh operative mortality and complication rate of pancreaticoduodenectomy? |
|
Definition
| 0-2% mortality; 20-40% complication rate |
|
|
Term
| Name the new chemotherapy agent that appears to prolong the survival of patients with pancreatic carcinoma and other periampullary carcinomas? |
|
Definition
|
|
Term
|
Definition
| deoxycytidine analogue that is effective for periampullary carcinomas and radiation sensitizer, so sometimes given in conjunction with external beam radiation therapy |
|
|
Term
| What percent of cancers are pancreatic? How many cancer deaths are due to pancreatic cancer? |
|
Definition
| 2%; 5% (or fourth leading cause of cancer death) |
|
|
Term
| What percent of pancreatic cancers are located in the head of the pancreas? |
|
Definition
|
|
Term
| What are common clinical manifestations of carcinoma in the head of the pancreas? |
|
Definition
| obstructive jaundice, weight loss, diabetes mellitus, abdominal pain, and gastric outlet obstruction |
|
|
Term
| How do patients with tumors in the body or tail of the pancreas typically present? |
|
Definition
| after tumor growth has caused obstruction or chronic pain from splanchnic nerve invasion |
|
|
Term
| What symptoms indicate advanced disease and a worse prognosis of pancreatic cancer? |
|
Definition
| significant weight loss and chronic abdominal and/or back pain |
|
|
Term
| What is the next step after CT imaging demonstrates a mass in teh head ofthe pancreas? |
|
Definition
| some people say CTguidedbiopsy to confirm diagnosis and initiate chemoradiation therapy; others say laparoscopy folloed by open exploration and resection if the tumor looks resectable |
|
|
Term
| In patients who undergo neoadjuvant therapy, what percent eventually undergoes resection? |
|
Definition
|
|
Term
| What is T1 for pancreatic cancer? |
|
Definition
| primary tumor limited to pancreas and measures less than 2cm in diameter |
|
|
Term
| What is T2 pancreatic cancer? |
|
Definition
| primary tumor limited to the pancreas and measures more than 2 cm in diameter |
|
|
Term
| What is T3 pancreatic cancer? |
|
Definition
| primary tumor involvesthe duodenum, bile duct, or peripancreatic tissue |
|
|
Term
| What is T4 pancreatic cancer? |
|
Definition
| primary tumor involves the stomach, colon, or adjacent vessels |
|
|
Term
| What is stage 1 pancreatic cancer? |
|
Definition
|
|
Term
| What is stage II pancreatic cancer? |
|
Definition
|
|
Term
| What is stage III pancreatic cancer? |
|
Definition
|
|
Term
| What is stage IVa pancreatic cancer? |
|
Definition
|
|
Term
| What is stage 4B pancreatic cancer? |
|
Definition
|
|
Term
| T/F The majority of patients with pancreatic carcinoma have unresectable disease at thetime of diagnosis. |
|
Definition
|
|
Term
| What is the prognosis of pancreatic cancer with unresectable disease? |
|
Definition
|
|
Term
| How can you palliate pts with obstructing pancreatic cancer? |
|
Definition
| placement of a biliary stent or percutaneous and/or operative approaches to facilitate biliary drainage |
|
|
Term
| What percent of patients with pancreatic cancer develop gastric outlet obstruction and how do you palliate that? |
|
Definition
| 10-20%; creation of internal bypass (gastrojejunostomy) |
|
|
Term
| How do you paliate severe, persistent abdominal and back pain seen in pts with pancreatic cancer? |
|
Definition
| some have good resutls with the injection of alcohol ito the celiac plexus during abdominal exploration or percutaneous celiac injections for nonoperative patients |
|
|
Term
| T/F The presence of ascites is a contraindication to resection of pancreatic cancer. |
|
Definition
| true; ascites likely indicates poor hepatic reserve or disseminated cancer |
|
|
