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

1. Absite Topic Review
General Surgery
Nir Hus, MD, PhD.
Mount Sinai Medical Center
Miami Beach

2. Topics
 1) Rx Postop Parotitis.
 2) Rx Non-healing burn wound.
 3) Dx Ruptured tubal pregnancy.
Nir Hus

3. Parotitis
 Can occur in the surgical patient and identified during the
postoperative period.
 Particularly in elderly
 Dehydrated individuals.
 Therapy should be directed toward
 Rehydration
 Enhancing salivation
 Ensuring that no mechanical obstruction of the duct of Stensen
is present
 Obtaining stains and cultures
 Administering antibiotics directed against S. aureus, which is the
most common offending organism.
 In ICU patients who are often colonized with gram-negative
bacteria, the possibility of gram-negative bacterial parotitis
should be considered and appropriate empiric therapy used.
 I&D
Nir Hus

4. Rx Non-healing burn wound.
 Q:30 y.o veteran suffered a burn wound
to arm 2nd or 3rd degree over one year ago
and the wound is ulcerated. What to do
next.
 A: Marjolin’s tumor – need Bx
Nir Hus

5. Ulcers associated with burns
 Curling s ulcer – gastric ulcer that is
associated with burns.
 Marjolin s ulcer – highly malignant
squamous cell CA.
Nir Hus

6. Dx Ruptured tubal pregnancy
 An ectopic pregnancy occurs when a
fertilized ovum implants at a site other
than the endometrial lining of the uterus.
 Ectopic pregnancies occur in the fallopian
tube in 97% of cases, with 55% in the
ampulla; 25% in the isthmus; 17% in the
fimbria; and 3% of cases within the
abdomen, ovary, and cervix.
Nir Hus

7. Pathophysiology
 Ectopic pregnancies are primarily due to
prior tubal/genital infection or surgery,
fallopian anatomic abnormalities, or
endometrial abnormalities.
Nir Hus

8.  Physical: Physical examination is unreliable for clinicians
who face this significant diagnostic challenge. Abbott et al
and Stovall et al reported an alarming rate of missed and/or
delayed diagnoses in the ED. Although findings at physical
examination may be variable, they may include the following:
 Vaginal bleeding may be mild or absent. Abdominal pain may be
minimal or severe.
 Shoulder pain is suggestive of peritoneal free fluid (significant
hemorrhage).
 Ectopic pregnancies can be accompanied by sloughing material,
which is suggestive of a miscarriage.
 Adnexal masses may be palpable in only 60% of patients (under
anesthesia).
 Tenesmus or syncope may occur.
 Clinical shock may occur after rupture.
 No combination of physical findings may reliably exclude the
diagnosis of ectopic pregnancy.
Nir Hus

9. Lab Studies:
 Human chorionic gonadotropin (HCG) levels.
 The discriminatory zone of beta-HCG levels is the
level above which a normal intrauterine pregnancy
reliably is visualized.
 The absence of an intrauterine pregnancy when
the HCG level is above the level in the
discriminatory zone represents an ectopic
pregnancy or a recent abortion.
 Serial blood cell counts should be determined to
quantify blood loss.
Nir Hus

10. Imaging
 A definite ectopic pregnancy is characterized by the presence of a
thick, brightly echogenic, ringlike structure outside the uterus, with a
gestational sac containing an obvious fetal pole, yolk sac, or both.
 Pregnancy of unknown location occurs with an empty uterus on
endovaginal sonograms in patients with serum beta-HCG levels
greater than the discriminatory cutoff value. In this case, an ectopic
pregnancy is considered present until proven otherwise. An empty
uterus may also represent a recent abortion.
 Other ultrasonographic findings include an adnexal mass, free cul-
de-sac fluid, and/or severe adnexal tenderness upon palpation with
the probe. Patients with no definite intrauterine pregnancy and the
aforementioned findings are thought to have a high risk for ectopic
pregnancy.
Nir Hus

11. Tx
 Laparotomy is required for ovarian, abdominal,
and intraligamentous pregnancy.
 Careful curettage, packing of the cervix and
uterine cavity, possible hysterectomy may be
required for a cervical pregnancy.
 An unruptured tubal pregnancy of less than 4
mm in diameter may be treated by
salpingostomy by means of laparoscopy.
Nir Hus