ROSH Surgery BOOST exam

Preferred method for breast mass workup

Core needle biopsy

When to suspect breast abscess vs mastitis

When symptoms of mastitis do not respond to therapy after 48 hours.

- PE: Fluctuant, tender mass.

Hidradenitis Supportiva

- Clusters of abscesses, epidermoid cysts, sebaceous cysts, pilonidal cysts

- Affects apocrine sweat glands

- Axilla, under breasts, inner thigh, groin, buttox

- Triggered by sweating, hormonal changes related to menstrual cycle, friction.

- Persistent lesions lead to sinus tracts

Fecal Impaction

- Etiology: lack of fiber, opioids, IBS, Diabetes, Hypothyroidism'

- Abdominal pain and distention

- Chronic constipation

- Fecal incontinence/overflow diarrhea

- Can lead to rectal necrosis and ulcers

- Treat with manual disimpaction, stool softening, osmotic laxatives, surgery

Subarachnoid Hemorrhage

- Sudden headache, loss of consciousness, meningismus, N/V

- CT scan, LP (Xanthochromia), CT Angiography

- Supportive (airway), BP control with Nicardipine or labetalol, aneurysm repair, Nimodipine (within4 days), Target fluid resuscitation to euvolemia.

Subdermal Hematoma

- Between dura and arachnoid mater

- Tearing of bridging veins (alcohol use and older population)

- Acute or subacute neurological symptoms

- Neurosurgery consult, BP control, reverse anticoagulation

Post-Operative Voiding Dysfunction in Women General

- Defined in post-op period as retention >100 mL

Post-Operative Voiding Dysfunction in Women Detrusor Etiology

Failure to sense bladder:

- Anesthesia/narcotics

- Nerve injury: surgical or acute overdistension injury

- Missed cystotomy

Failure to contract:

- Anesthetic/narcotic

- Nerve injury

- Pre-existing voiding dysfunction

Post-Operative Voiding Dysfunction in Women Urethra/Pelvic Floor Etiology

Mechanical Obstruction

- Incontinence procedures

- Pelvic organ prolapse

- Urethral perforation/foreign body

- Constipation/pelvic mass

Functional Obstruction

- Failure to relax the pelvic floor

Esophageal Spasm

Dx: Esophageal manometry

Tx

1- CCB

1- TCA

2- Isosorbide-Sildenafil

2- Botulinum Toxin

Burn Infection Prophylaxis

- If NO MRSA: Ceftazidime plus Tobramycin

- If MRSA: Pip-Tazo plus Vanco

Acute Pancreatitis

PE: flank ecchymosis (turner sign), umbilical ecchymosis (Cullen sign)

Labs: Elevated lipase is most sensitive

- Causes: gallstones > alcohol, hypertriglyceridemia, drugs

- Complications: necrotizing pancreatitis, pancreatic pseudocyst

Primary Adrenal Insufficiency

- Adrenal gland: decreased cortisol/aldosterone = low glucose and high potassium

-> MC Cause is autoimmune destruction

- Clinical signs: Hypotension, shock, vomiting, diarrhea, abdominal pain, hypernatremia, hypoglycemia, hyperkalemia

- Dx: serum cortisol at 8 am, then cosyntropin stimulation test

- Tx: Hydrocortisone, supportive

Testing for primary vs secondary adrenal insufficiency

If a patient presents with signs or symptoms of adrenal insufficiency, the first step in evaluation is a basic metabolic panel and a serum cortisol level measured at 8 AM. If the cortisol level is low with a normal to high potassium level and low to normal sodium level, the next step is to perform a cosyntropin stimulation test. In this test, the basal ACTH level is measured before administering intravenous ACTH. Cortisol is measured again 30–60 minutes after administration. If the cortisol level is low and ACTH level is high,

Esophageal Varices Tx

Acutely

- Hemodynamic resuscitation

- Octeotride

- Banding, sclerotherapy

- Prophylactic antibiotics

Chronic

- Beta-Blockers

- Endoscopic Variceal ligation

- Definitive Treatment is Liver transplantation

Lung Cancer Types

- Small Cell

-> Starts centrally

- Non-Small Cell

-> Adenocarcinoma: PERIPHERAL, MOST COMMON

-> Squamous Cell Carcinoma: Starts CENTRALLY, hypercalcemia

Mallory-Weiss Syndrome

RF: Alcohol Use, Hiatal Hernia, Bulimia

Dx: Suspected in patients with upper GI bleed and history of vomiting or retching

- Confirmed by upper endoscopy

PE: Acute-onset GI Bleeding (Hematemesis)

-> History of non-bloody emesis, retching, coughing prior to hematemesis

Management:

- Supportive

- Endoscopic therapy (active bleeding)

- Acid suppression (No active bleeding)

Indications for Dialysis

A: Acidosis (metabolic acidosis <7.1)

E: Electrolytes (hyperkalemia >6.5)

I: Ingestions (dialyzable drugs, such as salicylates, lithium, isopropanol, methanol, ethylene glycol)

O: Overload (Volume overload that does not respond to diuresis, especially with increased oxygen requirements)

U: Uremia (Elevated BUN with signs of uremia, such as bleeding, pericarditis, encephalopathy, neuropathy)

Vitamin B12 deficiency

- Chronic atrophic gastritis

- B12 deficiency

- Increased risk of gastric cancer

- increased risk of carcinoid tumor

- Anemia (Pernicious)

Clinical:

-> Symmetric peripheral neuropathy

-> Ataxia

-> Personality changes

-> Dementia

-> Glossitis, vaginal atrophy, malabsorption

Phyllodes Tumor of the Breast

- Leaf-Like

- Smooth, multinodular, well-defined, firm mass that is mobile and painless

- Management

-> Surgical resection

-> Radiation therapy

-> +/- Chemo

-> HRT not effective

Pancoast Tumor

- Shoulder and arm pain

- Horner syndrome

- Weakness and atrophy of the muscles of the hand

- Cough, hemoptysis, and dyspnea are uncommon

Tx

- Chemo, surgical resection

Anorectal fistula

Presentation: leakage of fecal material

Causes: Crohn disease, infection, malignancy

Dx: CT or MRI

Tx: Fistulectomy or seton placement

Supraventricular Tachycardia

- Regular, narrow complex tachycardia

Tx: Valsalva Maneuvers, Adenosine

Hemorrhoids Classification

Post-op Wound Complications: Infecrtion

- Early wound infections are usually due to GAS or GBS

- Characterized by cellulitis and high fever

- Later infections are more likely to be staph aureus, E colie, proteus mirabilis, or cervicovaginal flora

- Nec fash is a rare but possible complication

Post-op Wound Complications: Hematoma and Seroma

- Collections of blood or serum

- Hematomas more common

- Usually result from failure of primary hemostasis or bleeding diathesis

- Both can cause incision to separate

- Dx clinically, confirm with CT or US

- Small can be managed expectantly, large ones should be drained

- Symptomatic hematomas should opened partially or completely under sterile conditions

- For suspected seroma, aspiration under sterile conditions mat be all that is required

Post-op Wound Complications: Wound Dehiscence

- Due to abdominal wall tension overcoming tissue or suture strength or knot security

- Can occur early or late in the post-operative period and involves a portion of the incision, or the entire incision

- When fascial disruption is suspected, wound exploration should be performed

- Complete fascial dehiscence is associated with mortality rate of 10% and is a surgical emergency.

Acute Cholangitis

- Fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract

- Management: Broad spectrum abx + endoscopic retrograde cholangiopancreatography (ERCP)

Hemorrhoids Treatment

For patients with grade I–III internal hemorrhoids who do not respond to conservative treatment, rubber band ligation is recommended. This is an office-based procedure in which small rubber bands are placed over the hemorrhoid using an anoscope. The banded hemorrhoid becomes necrotic and ischemic over 3–5 days, and healing occurs over the next several weeks. Surgical therapy is recommended for patients with grade IV hemorrhoids.

Empyema

- Analysis of the fluid will show exudative characteristics, such as a pleural fluid protein to serum protein ratio > 0.5, a pleural fluid lactate dehydrogenase (LDH) to serum LDH ratio > 0.6, or a pleural fluid LDH greater than two-thirds the normal upper limit for serum LDH. A high pleural fluid neutrophil count can distinguish empyema from chylothorax.

- Tx: Treat underlying cause, Abx, Thoracostomy

Acoustic Neuroma

- S/Sx: Hearing loss and tinnitus, Ataxia, Facial paralysis

- Treatment options for acoustic neuromas include observation, surgical removal, and radiation therapy. Observation is recommended for small, stable tumors or for patients who are asymptomatic. Surgical removal is the primary treatment option for most cases, and the timing of surgery is dependent on the size, symptoms, and age of the patient. Stereotactic radiation therapy is indicated for tumors measuring < 3 cm, patients who are poor surgical candidates, or patients who prefer to avoid surgery.

Sigmoid Volvus

Dx: Plain film x-ray (low specificity): U shaped, bent inner tube

-> Abd CT scan

-> Contrast enema

RF: Long-term care facility

-> Older age

-> Bed ridden

-> Chronic constipation

Clinical: Insidious onset of abdominal pain

-> Abdominal distention

-> Nausea, Vomiting, Constipation

Management

- Flexible sigmoidectomy (to reduce volvulus)

-> Surgery (to prevent recurrence)

First-Line Surgical Pain Med

- Acetaminophen, or NSAIDs

EKG of severe Hyperkalemia

Hypertrophic Cardiomyopathy

ECG

-> Left axis deviation

-> P wave abnormalities: left or bilateral atrial enlargement

-> Abnormal Q waves in inferior and lateral leads: septal depolarization of hypertrophied tissue (mimics inferior or lateral myocardial infarction)

Clinical

-> Exertional syncope

-> Dyspnea on exertion

Management

-> Beta blockers or CCB (non-dihydropyridines)

- AVOID POSITIVE INOTROPES AND NITRATES

Cholelithiasis

Gallstones: most commonly made of cholesterol

Risk factors: female sex, age 40–50 years, pregnancy, obesity, rapid weight loss

Sx: slowly resolving right upper quadrant pain that begins suddenly after eating a fatty or large meal

Dx: RUQ ultrasound

Tx: observation or cholecystectomy

Cholecystitis

Sx: colicky, steadily increasing RUQ or epigastric pain after eating fatty foods, fever

PE: Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula)

Diagnosis Initial: U/S Gold standard: HIDA

Most commonly caused by obstruction by a gallstone

Acalculous disease can occur when critically ill

Treatment is cholecystectomy, antibiotics, and percutaneous cholecystostomy tube when critically ill or if have comorbidities and do not improve on antibiotics

Causes of post-operative fever

Opioid Receptor Activations

Buprenorphine

The unique pharmacokinetics of buprenorphine include a ceiling effect on its opioid agonist activity at higher doses, which further reduces the risk of overdose compared to full opioid agonists. This ceiling effect means that, above a certain dose, there will be no further increase in opioid effects such as euphoria or respiratory depression, enhancing the safety profile of buprenorphine for patients in treatment for OUD. Additionally, buprenorphine has a high affinity for and slow dissociation from mu-opioid receptors, which gives it the ability to displace other opioids that may be bound to these receptors for a longer period of time, thereby helping to prevent the effects of concurrent opioid use. This characteristic also contributes to buprenorphine’s effectiveness as a maintenance therapy for opioid dependence.

Buprenorphine is usually administered sublingually to optimize its bioavailability, and it is often combined with naloxone to deter intravenous misuse. Buprenorphine (or methadone) administration should be avoided until withdrawal symptoms appear.

Fistula Complications

Primary Closure

- Primary Intention

-> Fastest type of closure

-> Small, clean defect

-> Blood vessels and keratinocytes migrate a small distance

Secondary Closure

- Secondary Intention

-> Wound edges cannot be approximated

-> Requires granulation tissue matrix to be built to fill the wound defect

-> More scar tissue than primary closure

Delayed Primary Closure

- Tertiary Intention

-> Wound is cleaned and observed for a few days to ensure no infection

-> Then surgically closed.

Paget Disease of the Breast

Hallmark: scaly, raw, vesicular, or ulcerated lesion that begins on the nipple and then spreads to the areola

Paget Cell: Atypical cells with large nuclei and vacuolated cytoplasm

- Pain, itching, burning, present before clinically apparent

- Dx: skin biopsy and histology, mammography, ultrasound, MRI

Tx:

-> Simple mastectomy, breast conserving treatment (often selected)

Breast Implant Monitoring for Rupture

- MRI with dedicated breast implant protocol 5 years after the implants are placed, and every 2-3 years after

- In general, can be associated with anaplastic large cell lymphoma, implant associated squamous cell carcinoma, implant associated B-Cell lymphoma

Silicone Breast Implant

- Approved by FDA in November 2006

- Gel-filled implant with silicone shell

- Natural feel and appearance, with lower chance of rippling

- If implant rupture occurs, removal of silicone gel is required

Saline Breast Implant

- Approved by the FDA in May 2000

- Saline-filled implant with a silicone shell

- Can be inserted empty, allowing for more discreet incisions

- If implant rupture occurs, saline will be absorbed by the body.

Pneumothorax vs Tension Pneumothorax Tx

1- Chest thoracotomy

2- Needle Aspiration

Kidney Stone Treatment

An initial trial of supportive measures (e.g., pain control), urine straining, and medical expulsive therapy (e.g., tamsulosin) for 4 weeks is appropriate for stones > 5 mm and ≤ 10 mm in diameter in patients without infection or obstruction. Urologic consultation for surgical intervention, such as shock wave lithotripsy, is the most appropriate next step in management for stones that persist after 4 weeks. The size of the stone (6 mm) and its location at the ureteropelvic junction make it amenable to shock wave lithotripsy, which is a noninvasive treatment that uses shock waves to break the stone into smaller fragments that can be passed spontaneously. Shock wave lithotripsy is typically indicated for stones < 10 mm and located in the kidney or upper ureter. It is not an appropriate option for larger or more complex stones (e.g., staghorn calculi).

Hernias

Hemothorax

Supine CXR can show opacity

Initial treatment is tube thoracostomy

Thoracotomy indications Adults: initial chest tube output > 20 mL/kg (or 1,500 mL) or subsequent output > 200 mL/hour over 3 hours

Pediatrics: initial chest tube output > 15 mL/kg or subsequent output > 2-3 mL/kg over 3 hours

Large Bowel Obstruction

Most commonly caused by colorectal cancer

Most common location is sigmoid colon

Presentation: abdominal distension, obstipation, progressive changes in bowel habits

PE: high-pitched bowel sounds

Treatment is NGT, surgery

Goals of Perioperative Diabetes Management

- Avoid Hypoglycemia

- Prevent ketoacidosis and hyperosmolar stats

- Maintenance of fluid and electrolyte balance

- Avoidance of marked hyperglycemia

Diabetic Patient Pre-Op Work Up

- ECG to assess for asymptomatic ischemia

- Creatinine to assess for kidney injury

- Discontinue SGLT-2 3-4 days before surgery

- Other meds held day of

- Insulin can continue, assuming they don't cause any hypoglycemia

Necrotizing Fasciitis Treatment

- Surgical debridement ASAP

- Broad spectrum abx

- +/- fluids

Foreign Body Aspiration Treatment

Direct laryngoscopy with bronchoscopy

Length of time it takes vasectomy to produce sterility

- Many weeks, recommended to have semen analysis 3 months after

Light's Criteria: Transudate

- Pleural to serum protein ratio: < 0.5

- Pleural to serum LDH ratio: < 0.6

- Pleural Fluid LDH: <2/3 upper limit of normal

- Primary Causes:

-> Heart failure

-> Cirrhosis

-> Nephrotic Syndrome

-> Pulmonary Embolism

Light's Criteria: Exudative

- Pleural to serum protein ratio: >0.5

- Pleural to serum LDH ratio: >0.6

- Pleural Fluid LDH: > 2/3 ULN

- Primary Causes:

-> Malignancy

-> Bacterial or viral pneumonia

-> TB

-> PE

-> Pancreatitis

-> Esophageal Rupture

-> Collagen Vascular disease

-> Chylothorax, hemothorax

Meckel's Diverticulum

Congenital anomaly due to incomplete obliteration of the omphalomesenteric duct

Most common in children, < 5 years old

Sx: painless rectal bleeding, abdominal pain, or obstruction

Rule of 2s

2 years old

2 feet from ileocecal valve

2 inches long

2% of the population

2 epithelial types (typically gastric, intestinal, or pancreatic)

Diagnosis is made by technetium-99m pertechnetate scan (Meckel scan)

Tx: surgical resection if symptomatic

Thoracic Aneurysm X-ray

Hernia Characteristics

- Reducible: soft, easy to place back into defect

- Incarcerated: Firm and painful, non-reducible by direct manual pressure

- Strangulated: painful due to impaired blood flow, ischemia, and necrosis or overlying skin changes

Primary Hyperparathyroidism Symptoms

- Stones (kidney stones)

- Bones (bone pain)

- Groans (GI symptoms)

- Psychiatric Overtones (cognitive changes)

Esophageal Cancer

Risk factors: male sex, chronic GERD, tobacco and alcohol use, HPV infection

Sx: progressive dysphagia to solid foods, weight loss

Diagnosis is made by endoscopy with biopsy

Most common type in the US is adenocarcinoma, second is squamous cell carcinoma

Adenocarcinoma usually a complication of GERD or Barrett esophagus

Post-Operative Ileus RF

- Prolonged abdominal of pelvic surgery

- Lower GI surgery

- Open Surgery

- Delayed Enteral nutrition of NG tube placement

- Intra-Abdominal Inflammation

- Peri\operative complication

- Intraoperative/Post-op bleeding

- Perioperative opioid use

Type 1 Drug Eruption

IgE Mediated

- Urticaria, angioedema, and anaphylaxis

Type 2 Drug Eruption

IgG mediated

- Drug Induced thrombocytopenia

Type 3 drug reaction

- Immune complex

- serum sickness, vasculitis, drug-induced lupus

Type 4 drug reaction

T-Cell mediated macrophage inflammation

- Morbilliform rashes (macular and papular)

- Pruritis and fever

- TB Skin test is this

- most common offending agents are aminopenicillins, cephalosporins, antibacterial sulfonamides, allopurinol, and anticonvulsant drugs

Breast Abscess Management

- Drainage (Needle aspiration 1st, then I and D)

-> I and D if necrotic tissue present

- Antibiotics (dicloxacillin, cephalexin)

-> If MRSA, then TMP-SMX, or clinda

- If breast feeding, DO NOT STOP

Pancreatic Cancer

Risk factors: history of smoking

Sx: abdominal or epigastric pain, painless jaundice, weight loss, anorexia

Labs: CA 19-9 serum marker useful in monitoring

Dx: U/S, ERCP or MRCP, CT, endoscopic ultrasound

Management: Resectable disease: Whipple procedure (pancreaticodudenectomy) + adjuvant chemo

Unresectable disease: FOLFIRINOX or gemcitabine-based chemo

Most common type is adenocarcinoma

Poor prognosis

Courvoisier Sign

An exam finding that refers to a nontender but palpable distended gallbladder at the right costal margin. It is classically associated with biliary or pancreatic cancer but is only present in about 13% of patients with pancreatic cancer.

Laparotomy vs Laparoscopy

-Otomy is 1 large incision

-Oscopy is through multiple small incisions

Achalasia Description of Barium Swallow

- Smooth tapering of the gastroesophageal segment and dilation of the proximal esophageal segment

Process of Informed Consent

- Ensuring the patient or surrogate has decision-making capability

- Discussing pertinent medical information

- Ensuring adequate understanding of the information

- Ensuring voluntaries of the patient's or surrogate's decision

- Jointly deliberating and obtaining the patient's or surrogate's agreement to a plan of care.

Simple Cellulitis Treatment

- Cephalexin, amoxicillin, dicloxacillin

Penicillin Allergic Cellulitis Treatment

- Clindamycin, erythromycin, azithromycin

MRSA Suspected Cellulitis Treatment

- TMP-SMX, Doxycycline, Clindamycin

Inpatient Treatment of Cellulitis

- Ceftriaxone, Clindamycin, Pip-Tazo, +/- vancomycin

Cellulitis

Commonly caused by group A Streptococcus or Staphylococcus aureus

Sx: pain, redness, swelling. More indolent onset than erysipelas

PE: tenderness, erythema with poorly demarcated borders, lymphedema, ± purulence

Abx selection depends on uncomplicated vs complicated cellulitis, PCN intolerance, MRSA risk factors, and purulence

Physiologic Nipple Discharge

Characteristics

- Usually bilateral

- White or clear

- May be straw colored, green, brown, gray

Common Causes

- Hyperprolactinemia

- Medications

- Neurogenic Stimulation

Pathologic Breast Discharge

Characteristics

- Usually unilateral

- Localized to single duct

- Persistent

- Spontaneous

- Serous, clear, yellow

- Sanguineous

- Seroguineous

Common Causes

- Papilloma

Testicular Cancer

Risk factors: cryptorchidism, age 15–35

Sx: testicular lump

PE: painless, hard, fixed mass

Labs: beta-hCG, AFP, or LDH may be elevated based on tumor type

Diagnosis starts with ultrasound

Tx: radical inguinal orchiectomy usually curative, radiation therapy or platinum-based chemo if metastatic

Atelectasis X-Ray

Atelectasis

- Loss of lung volume due to the collapse of lung tissue, leading to impaired gas exchange

- PE: Hypoxia

- Chest X-ray shows pulmonary opacification, displacement of intralobar fissures, and tracheal shift toward the affected side.

Ethical Principles of Consent

Autonomy

- To respect the patient's right to make their own decisions about their medical care

Beneficence

- To take actions that are expected to provide benefit to the patient

Nonmaleficence

- To refrain from actions that may cause harm to the patient

Justice

- To provide equitable care to all patients regardless of age, sex, race, socioeconomic class, and other characteristics

Veracity

- To tell the truth

- To provide informed consent so the patient can exercise autonomy

Fidelity

- To do what one has promised regarding care

Confidentiality

- TO protect the patient's privacy

Professionalism

- Respect patient boundaries and guard against violations

- Maintain competence in the practice of medicine with continuing education

- To interact respectfully with patient's families, staff, colleagues, other professionals

- To guard against actions that may result in impairment and seek help if needed

ACLS Bradycardia Algorithm

Cecal Volvulus

Congenital defect in peritoneum resulting in twisting of mobile segment of cecum

More common in younger individuals compared with sigmoid volvulus

Sx: abdominal pain, distension, vomiting, obstipation

Imaging X-ray: coffee bean or comma appearance

CT: mesenteric whirl sign

Tx: surgery

- second most common site of volvulus (after sigmoid)

Cecal Volvulus X-Ray

Acute Mesenteric Ischemia

ET Tube Complications

Internal Jugular Central Venous Access

Location: anterior and lateral to carotid artery

Trendelenburg

Anterior approach: medial to SCM, aiming toward ipsilateral nipple

Posterior: lateral to SCM, aiming toward sternoclavicular notch

Central: between sternal and clavicular heads of the SCM, aiming toward ipsilateral nipple

Right side preferred

Complications: carotid artery puncture, bleeding, hematomas → airway compression

Dysrhythmias: heart wall irritation, withdraw until cessation

Pulsatile flow: arterial puncture

Stroke Distribution

Vitamin B12 Deficiency

Risk factors: vegan diet, metformin use, gastrectomy

Sx: fatigue, weakness, and peripheral neuropathy

PE: pallor and glossitis

Lab results: MCV > 100 fL, hypersegmented neutrophils, elevated homocysteine, elevated methylmalonic acid

Tx: parenteral vitamin B12, oral considered if no neurologic Sx or malabsorption

Neuropathy is more common with vitamin B12 deficiency (as opposed to folate deficiency)

Pernicious anemia: autoimmune destruction of cells that produce intrinsic factor, resulting in vitamin B12 deficiency

Choledocolithiasis

Presence of gallstones within the common bile duct

Sx: RUQ or epigastric pain, nausea, vomiting

Lab results: elevated LFTs in a primarily cholestatic pattern

Dx: transabdominal ultrasound

Complications: acute cholangitis, acute pancreatitis

Tx based on the likelihood of choledocholithiasis (options include ERCP with stone removal, cholecystectomy)

Diverticulitis

Sx: abdominal pain localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits

PE: localized guarding, rigidity, and rebound tenderness

Diagnosis is confirmed by CT with IV contrast: thickened bowel wall, fat stranding

May show complications (bowel perforation, abscess, fistula, obstruction)

Consider treatment with supportive care or antibiotics based on risk factors and presentation

Antibiotics to cover gram-negative and anaerobic bacteria, bowel rest, and surgery (in severe cases)

High-fiber diet can help in prevention

Complicated Forms of Diverticulitis (Hospital)

Abscess formation, bowel obstruction, fistula formation, and bowel perforation.

Aortic Dissection

Risks: advancing age, male sex, HTN, Marfan syndrome

Sx: acute onset of ripping or tearing chest pain or back pain

PE: asymmetric pulses or SBP difference > 20 mm Hg

CXR: widened mediastinum

Dx: CT angiography or transesophageal echocardiogram (TEE)

Treatment: reduce BP and HR (beta-blockers), pain control, emergency surgery (type A dissection)

Type A: involves ascending aorta

Type B: involves only descending aorta

Aortic Stenosis

Risk factors: advancing age, diabetes, hypertension

Sx: dyspnea, chest pain, syncope

PE: crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop

Murmur decreases with Valsalva

Most commonly caused by degenerative calcification

Treatment: aortic valve replacement