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Nir Hus Q july 7 09

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Slides with topics that are covered and were tested in the recent Absite exams.
Nir Hus MD., PhD.
http://www.nirhus.com

Published in: Health & Medicine, Sports
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Nir Hus Q july 7 09

  1. 1. Q:
  2. 2. Precursors Gastric AdenoCA <ul><li>Gastric adenocarcinoma is among the most common malignancies worldwide (~50% of CA related deaths in Japan). </li></ul><ul><li>Its etiological pathogenesis is complex and, as yet, incompletely understood; however: </li></ul><ul><ul><li>Diet, </li></ul></ul><ul><ul><li>Infection with Helicobacter pylori, </li></ul></ul><ul><ul><li>Genetic factors are involved. </li></ul></ul><ul><li>It may be classified into two main types: </li></ul><ul><ul><li>Intestinal. </li></ul></ul><ul><ul><li>Diffuse (Linitis plastica). </li></ul></ul>
  3. 3. Precursors Gastric AdenoCA <ul><ul><li>The intestinal type has decreased in incidence, whereas the diffuse tumors as well as those confined to the cardia are increasing. </li></ul></ul><ul><ul><li>Numerous conditions, such as gastritis, adenomatous polyps, tobacco, gastric atrophy, and intestinal metaplasia (IM), type –A blood, and nitrosamines are associated with intestinal type gastric cancer in retrospective studies. </li></ul></ul><ul><ul><li>Only epithelial dysplasia has a positive predictive value for malignancy. </li></ul></ul><ul><ul><li>Tx of gastric adenoCa – subtotal gastrectomy w/ 5cm margines. </li></ul></ul>
  4. 4. Rx Carcinoid Tumor Rectum <ul><li>Metastases is related to size of tumor. </li></ul><ul><li>Low rectal carcinoids Tx: </li></ul><ul><ul><li>< 2cm – wide local excision w/ negative margins </li></ul></ul><ul><ul><li>> 2cm – or invasion of muscularis propria  APR </li></ul></ul><ul><li>Colon or high rectal carcinoids – formal resection w/ adenectomy. </li></ul>
  5. 5. Rx Gist <ul><li>AKA Gastric Leiomyomas </li></ul><ul><li>Most common benign gastric neoplasm </li></ul><ul><li>Usually asymptomatic but obstruction and bleeding can occur </li></ul><ul><li>Hypoechoic on US with smooth edges. </li></ul><ul><li>Dx – Bx. </li></ul><ul><li>Tx – resection </li></ul><ul><li>If >5cm or 5-10 mitoses/HPF then consider chemo </li></ul><ul><li>Need 1cm margeens </li></ul><ul><li>Most are c-kit positive. </li></ul>
  6. 6. Rx Gist <ul><li>Tx – resection </li></ul><ul><li>If >5cm or 5-10 mitoses/HPF then consider chemo </li></ul><ul><li>Need 1cm margeens </li></ul><ul><li>Most are c-kit positive. </li></ul><ul><li>Chemo  gleevec (TK-inhibitor) </li></ul>
  7. 7. Rx Hiatal Hernia <ul><li>Four types: </li></ul><ul><ul><li>- Most common. Sliding hernia from dilation of hiatus. Associated w/ GERD </li></ul></ul><ul><ul><li>- Paraesophageal. Normal GE junction. Symptoms – chest pain, dysphagia, early satiety. </li></ul></ul><ul><ul><li>Type I & II combined </li></ul></ul><ul><ul><li>Entire stomach in the chest plus another organ (i.e., colon, spleen). </li></ul></ul>
  8. 8. Rx Hiatal Hernia <ul><li>Type II still requires Nissen because: </li></ul><ul><ul><li>diaphragm repair only might affect the LES. </li></ul></ul><ul><ul><li>Nissen better anchors the stomach. </li></ul></ul><ul><ul><li>High risk of incarceration </li></ul></ul><ul><ul><li>Ischemia – organoaxial rotation. </li></ul></ul><ul><li>Schatzki’s ring: </li></ul><ul><ul><li>Almost all pt have assoc. hiatal hernia. </li></ul></ul><ul><ul><li>Symptoms – short episodes of dysphagia following rapid swallowing. </li></ul></ul><ul><ul><li>Tx – dilation, may need Sx. </li></ul></ul>
  9. 9. Rx Perforated Duodenal Ulcer <ul><li>80% will have free air </li></ul><ul><li>Sudden sharp epigastriv pain, generalized peritonitis. </li></ul><ul><li>Pain might radiate to the pericolic gutters with dependent drainage of gastric contents. </li></ul><ul><li>Elderly – some believe inobservation. </li></ul><ul><ul><li>Need UGI to confirm that the perforation healead. </li></ul></ul><ul><li>Sx – Graham patch only or in addition to highly selective vagotomy – if pt. failed H-pump inhibitors. </li></ul>
  10. 10. Rx Pyogenic Liver Abcess <ul><li>Account for 80% of all liver abscesses. </li></ul><ul><li>Symptoms: fever, chills, weight loss, RUQ pain, Inc. LFTs, WBC, sepsis. </li></ul><ul><li>Higher rate found I Right lobe. </li></ul><ul><li>15% mortality if pt. developed sepsis. </li></ul><ul><li>GNR specifically E. coli – most common organism. </li></ul><ul><li>Commonly 2 nd to contiguous biliary tract infections. </li></ul><ul><li>Can occure following bacteremia such as diverticulitis and appendicitis. </li></ul>
  11. 11. Rx Pyogenic Liver Abcess <ul><li>Dx – aspiration. </li></ul><ul><li>Tx – CT—guided drainage & abx. </li></ul><ul><li>Sx for continued signs of sepsisor hemodynamically unstable. </li></ul><ul><li>May also need biliarry decompression. </li></ul>

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