One moment please...
^ABDOMEN X-RAY
-USES
..liver/gallbladder calcifications
..opaque gallstones
..biliary tract air
..Hepatic/splenic enlargement
..ascites
^ABDOMINAL PARACENTESIS
-USES:
..evaluate the origin of ascitic fluid (eg, caused by portal hypertension, metastasis, TB, pancreatic ascites)
..diagnose a perforated viscus in a patient with a history of blunt abdominal trauma
..therapeutically to remove ascites caused by portal hypertension and is especially useful in relieving tense ascites causing respiratory
difficulties, pain, or acute oliguria
-CAUTION:. Absolute contraindications include uncorrectable and severe disorders of blood coagulation, intestinal obstruction, and an infected abdominal
wall. Poor patient cooperation, surgical scarnng over the puncture area, and severe portel hypertension with abdominal collateral circulation are relative contraindications.
-PATIENT PREPARATION:
CBC, platelet count, and coagulation studies are obtained before the procedure
-PROCEDURE:
. After emptying the bladder, the patient sits in bed with the head elevated 45 to 90°. A point is located at the midline between the umbilicus and the pubic bone and is cleaned with an antiseptic solution and alcohol. Under sterile
technique, the area is anesthetized to the peritoneum with lidocaine 1%. For diagnostic paracentesis, an 18-gauge needle attached to a 50-mL syringe is inserted through the peritoneum (generally a "pop" is noted). Fluid is gently aspirated and sent for cell count, protein or amylase content, cytology, or culture as needed. For therapeutic (large-volume) paracentesis, a 14-gauge cannula attached to a vacuum aspiration system is used to collect up to 8 L of ascitic fluid. Postprocedure hypotension caused by fluid redistribution is rare as long as interstitial (leg) edema is present.
-COMPLICATIONS:
..Hemorrhage is the most common complication
..Occasionally, with tense ascites, prolonged leakage of ascitic fluid occurs
through the needle site.
^ABDOMINAL PLAIN FILM
(KUB(KIDNEY/URETERS/BLADDER))
^ALLERGY TESTING, PERCUTANEOUS
(Immediate Hypersensitivity Skin Test;Percutaneous Allergy Testing;Prick Test;Puncture Test;Scratch Test;Skin Prick Test)
CPT 95000 (allergenic extracts, up to 30 tests); 95005 (antibiotics, biologicals, stinging insects, local anesthetics, 1-5 tests)
-SEE ALSO:Allergy Testing, Intracutaneous (Intradermal);Fungal Skin Testing;Penicillin Allergy Skin Testing
=Skin testing patients with suspected immediate-type hypersensitivity to
one or more environmental substances. The test is performed by placing a drop of allergen(s) on the skin and making a needleprick through the drop(s) and into the underlying epidermis. Puncture sites are examined over the next 20 minutes
for a wheal and flare skin response which, if present, indicates antibody-mediated (IgE) hypersensitivity to the test allergen. Important differences exist between the prick test and the technically similar scratch test. In the scratch test a superficial linear abrasion is made in the epidermis (instead of a prick) and a drop of allergen is placed on the scratch. Multiple scratches are often required. This technique has fallen out of favor due to a high incidence of nonimmunologic irritant reactions, patient discomfort, scar formation, and poor reproducibility.
-USE
..confirm the presence of immediate-type hypersensitivity to foreign substances (allergens) suspected from the patient's clinical history; in addition to commonly encountered allergens (eg, pollens, animal dander, grasses, molds, house
dust) other potential test substances include antibiotics, stinging insect venom, and a variety of foods
..determine whether environmental allergens are playing a role in difficult to manage cases of asthma, urticaria, eczema, or anaphylaxis
..document immediate hypersensitivity prior to more elaborate allergy testing, such as provocation testing (bronchial provocation, oral food provocation) or prior to allergy desensitization therapy (immunotherapy)
-PRECAUTIONS
..use of antihistamine medications (HI antagonists) within 48 hours of skin testing; antihistamines may inhibit the wheal
and flare response, potentially causing false-negative results. Newer antihistamines with longer half-lives may interfere
with testing for more than 1 week.
..use of hydroxyzine (Ataraxae) within 1 week of testing
..documented anaphylactic reaction on prior percutaneous testing; allergens causing systemic reaction under test conditions should never be retested in the same patient. Unrelated substances, however, are not necessarily contraindicated but require physician approval.
..known systemic reaction to stabilizers or diluents contained in some allergen preparations; albumin is sometimes used as a stabilizer in commercial preparations; some testing centers routinely question patients regarding egg allergy.
..Instruct patient to keep the skin puncture sites clean until well healed
..Patient should contact physician immediately if symptoms of dyspnea, wheezing, lightheadedness, severe pruritus, etc develop later that day (the rare case of late phase response).
..Although skin testing may be performed by nurses or other trained personnel, a physician must be immediately available at all times to treat the rare case of anaphylaxis.
..The most common complication is a mild pruritus localized to positive test sites, usually resolving overnight. The incidence of significant
bleeding or superficial skin infection is diminishingly low. However, as with other types of allergy skin testing, the possibility of systemic reaction exists(generalized urticaria and anaphylaxis).
-PROCEDURE
..Preferred test areas are the back or volar aspect of the forearm
..A drop of each allergen is individually placed in a predetermined location on the skin
..Usually less than 30 allergens are tested in one session and drops are placed in parallel rows approximately 2 cm apart
..A 27-gauge needle is then passed through the drop at a 20 degree angle and the epidermis is penetrated with a stabbing motion. The needle tip is lifted slightly to tent the skin upwards, with care taken not to induce bleeding, and the needle is then removed. This constitutes the prick or puncture.
..Over 30 separate pricks may be made in this fashion in several minutes using a new needle for each allergen. The drop of solution is wiped off 1 minute after needle puncture (some physicians prefer to wait up to 20 minutes)
..Frequently a negative and positive skin test control is included in the test battery consisting of glycerol and histamine, respectively
..Minor variations in the overall techniques may be necessary if optional devices (such as the Morrow Brown needle) are used
-RESULTS
..Test sites are examined for a wheal and erythema reaction, maximal at 15-20 minutes. Late phase reactions (6-8 hours) are not recorded routinely since their significance is unclear
..Largest diameter of the wheal and/or erythema is measured and recorded in
millimeters
..Alternatively, the shape of wheal and flare may be permanently recorded by placing transparent paper directly onto the patient's back and outlining the skin reaction with a pen
..Advanced techniques using ultrasound or Doppler flowmetry of the skin reaction are still primarily research tools
-INTERPRETATION.
__Normal: No wheal or erythema at test sites except for histamine control
...A wheal <5 mm in transverse diameter is of questionable significance
...A wheal >5 mm with accompanying erythema constitutes a positive test
...In clinical practice, grading systems are often employed, but grading criteria lack uniformity.
...If a positive skin test occurs with an allergen strongly suspected from the
history, most clinicians consider this presumptive evidence of causality
...a negative test occurring with a test substance of low suspicion effectively rules out that substance as the cause of a patient's symptoms
...The clinical relevance of a positive test occurring with an allergen not suspected from clinical presentation is very problematic and may require repeat testing or further serologic or provocative testing
...A negative skin test occurring with an allergen strongly suspected from the history may require follow-up with the somewhat more sensitive intradermal allergy test.
-INTERFERENCE
__False-positives
...nonspecific irritant reactions
...dermographism interpreted as a wheal
...hemorrhage at prick site interpreted as erythema
...allergen spread from one site to another when the same needle is reused
...small wheals (eg, 2mm) interpreted as significant; impurities or contaminants in allergen preparations
..test sites improperly spaced
..inappropriate allergen concentrations
__False-negatives
...waning potency of allergens
...inadequate concentration of allergen
...technical errors in epidermal puncture
...drugs such as H1 antagonists, hydroxyzine, tricyclic antidepressants, phenothiazines, dopamine
...skin diseases such as atopic dermatitis
...possibly extremes of age
@2001dec10 dxc
^ALLERGY TESTING,INTRACUTANEOUS(INTRADERMAL)
(Immediate Hypersensitivity Skin Test;Intracutaneous (Intradermal) Allergy Testing)
CPT 95014 (antibiotics, biological, stinging insects, local anesthetics, 1-5 tests): 95020 (allergenic extracts up to 10 tests)
-SEE ALSO:Allergy Testing, Percutaneous;Penicillin Allergy Skin Testing
=Intradermal injection of one or more allergenic substances, including certain inhalants (grasses, molds, trees, weeds), epidermals (animal dander and house dust), ingestants (foods and food additives), drugs (penicillin) and insect venoms is an objective, in vivo means of evaluating IgE-mediated hypersensitivity. Intradermal testing is more expensive and time-consuming than the skin prick test. Both procedures evaluate the presence of IgE-mediated hypersensitivi6
-USE
..demonstrate the presence of immediate-type hypersensitivity to foreign substances
..determine if allergic disease underlies difficult to manage cases of asthma, rhinitis, dermatitis, angioedema-urticaria, or anaphylaxis
..further evaluate 'indeterminate' test results obtained on prior skin prick testing (percutaneous allergy testing)
..follow up on negative skin prick tests when the clinical suspicion for a particular allergen remains high
..document immediate hypersensitivity prior to provocative allergy testing or prior to allergy desensitization therapy
-PRECAUTIONS
..recent use of medications known to inhibit the wheal and flare skin response (antihistamines, hydroxyzine, tricyclic antidepressants, and phenothiazines
..documented anaphylactic reaction on prior skin testing
..known hypersensitivity to a stabilizer or diluent found in some commercial allergen preparations (0.03% human serum albumin, egg allergy)
..perform a brief dermatologic exam to ensure adequate areas of normal appearing skin and to identify the rare patient with dermographism
..Skin sites should be kept clean until well healed
..Patient should contact physician immediately if 6-8 hours later symptoms
of wheezing, lightheadedness, or shortness of breath develop (the unusual case of a 'late phase response'). SPECIAL
..A physician must be immediately available if skin testing is performed by a nurse or other trained personnel
..Emergency equipment should be close by in the rare case of anaphylaxis
-PROCEDURE
..volar aspect of the arm or forearm is the preferred site for testing
..Each allergen is individually drawn up into the tuberculin syringe and bubbles are eliminated to avoid nonspecific 'splash reactions'
..allergen is injected into the dermis using a 27-gauge needle angled at approximately 45 degrees
..volume of solution injected should be enough to raise a small bleb 2 mm in diameter, usually 0.01-0.02 mL. Larger volumes (>0.05 mL) may result in nonimmunologic irritant skin reactions (false-positives)
..discard syringe/needle
..Serial intradermal injections may be made but must be adequately spaced (>2cm apart)
..negative and positive skin test control is often included, consisting of saline and histamine, respectively.
-RESULTS
..Test sites are examined at 15-20 minutes for a wheat and flare reaction. Late phase reactions occurring more than 6 hours later are not recorded because their significance is not known.
..The largest diameter of the wheal and/or erythema is measured and recorded in millimeters
__Normal: No wheal or erythema found at allergen test sites. The histamine control site should be positive and saline control site (if used) should be negative
__Positive: A wheal >5 mm with accompanying erythema
..alternative grading schemes vary considerably, a potential source of confusion and error
-INTERPRETATION
..The 'wheal and flare' dermal response is seen with gE-mediated allergy, regardless of whether the patient's main symptoms are located in the airways, skin, nasal mucosa, gastrointestinal tract, etc.
..a positive skin response indicates only a state of potential hypersensitivity, a heightened immunologic reactivity towards a particular allergen. Instances of positive skin tests in asymptomatic, nonallergic individuals have been well documented.
..By itself, the intradermal test does not definitively prove causality
-INTERFERENCE
__False-positives
...nonspecific irritant skin reactions interpreted as positive. Volume of test substance introduced with intradermal injection is considerably greater than that used with skin prick testing, making the intradermal test potentially 'too sensitive'
...hemorrhage at injection site interpreted as erythema
...dermographism interpreted as a wheal
...allergen contaminating neighboring sites
...test sites too close together
...impurities or contaminants in allergen preparations or the use of nonstandardized test materials
...small wheals (eg, 2 mm) interpreted as positive
__False-negatives
...subcutaneous (not intradermal) injection of allergen
...waning allergen potency or improper volume or concentration
...drugs such as H1 antagonists hydroxyzine, tricyclic antidepressants, phenothiazines, dopamine
...active skin disease such as atopic dermatitis
...possibly extremes of age
@2001dec8 dxc
^ANKLE X-RAY
{73600}
^ANKLE-BRACHIAL INDEX TEST
=Done by measuring blood pressure at the ankle and in the arm while a person is at rest. Measurements are then repeated at both sites after 5 minutes of walking on a treadmill.By dividing the highest blood pressure at the ankle by the highest recorded pressure in either arm, the ankle-brachial index (ABI) can be calculated. A decrease in the ABI result with exercise is a sensitive indicator that significant PAD is probably present.
-USES:
..to screen for peripheral arterial disease of the legs.
..to predict the severity of peripheral arterial disease (PAD)
-REFERENCE INTERVAL:
..1-1.1
-INTERPRETATION:
__Normal
..This means that your blood pressure at your ankle is the same or greater than the pressure at your arm and there is no significant narrowing or blockage of blood flow.
__Abnormal
..Less than 0.95, significant narrowing of one or more blood vessels in the legs
..Less than 0.8, pain in the foot, leg, or buttock may occur during exercise (intermittent claudication .
..Less than 0.4, symptoms may occur when at rest.
..0.25 or below, severe limb-threatening PAD is probably present.
..A very abnormal ABI test result may require more testing to determine the location and severity of PAD that might be present.
-CAUTIONS:
..You may experience leg pain during the treadmill portion of the test if you have peripheral arterial disease (PAD).
-INTERFERENCE:
..Undiagnosed arterial disease in the arms can cause inaccurate test results.
..Blood pressure readings may not be accurate when the blood vessel being measured is hardened by calcium (calcified). Arteries may calcify more than usual if you have diabetes or kidney problems (renal insufficiency)
^ANOSCOPY/SIGMOIDOSCOPY,RIGID/FLEXIBLE
-USES:
..evaluate symptoms referable to the rectum or anus (eg,bright rectal bleeding, discharge, protrusions, pain)
..lesion known to be within reach of the instrument, or the rectum or sigmoid before anorectal surgery
-CAUTIONS:
..cardiac arrhythmias or recent myocardial ischemia (postpone, cardiac monitoring)
..valvular heart disease(antibiotics to prevent endocarditis)
-PATIENT PREPARATION:
..phosphate enema to empty the rectum
-PERFORMANCE:
..The perianal area and distal rectum can be examined with a 7-cm anoscope, the entire rectum with either a rigid 25-cm or a flexible 60-cm instrument, and the sigmoid with a flexible sigmoidoscope. Flexible sigmoidoscopy is about twice as expensive as rigid Sigmoidoscopy but is much more comfortable for the patient and readily permits photography, biopsy, and cytology. Flexible Sigmoidoscopy is performed as descnbed below for colonoscopy, except that IV medication is usually not needed
Rigid Sigmoidoscopy is usually performed with the patient m the knee-chest position. After rectal examination, the perianal area is examined, and the lubricated instrument is gently inserted 3 to 4 cm past the anal sphincter
Ihe obturator is removed, and the instru ment is inserted under direct vision Considerable skill is required to pass it beyond the rectosigmoid junction (15 cm) without producing patient discomfort. An anoscope is inserted its full length as described above for rigid Sigmoidoscopy, usually with the patient
in the left lateral position.
-COMPLICATIONS:
..exceedingly rare when the procedure is properly performed.
^BARIATRIC SURGERY
(weight loss surgery;obesity surgery)
-COMPLICATIONS:
..4 out of 10 patients within 6 months of leaving the hospital
..among privately insured, nonelderly from 21.9% during hospitalization to 39.6 % by the end of the 180-day study period.
..dumping syndrome(vomiting/reflux/diarrhea)(nearly 20 %)
..anastomosis complications(leaks/strictures)(12%)
..abdominal hernias (7%)
..infections (6%)
..pneumonia (4%)
..overall death rate for the entire 180-day postoperative period studied was 0.2%.
..spending $36,542 for obesity surgery patients with complication up to 180 days after surgery
..spending $25,337 for patients without complications
..$65,031 for patients who had to be readmitted because of a complication during the 180-day period
..$27,125 for those who did not have to be hospitalized again.
Findings based on claims care for 5.6 million enrollees under age 65 in employer-sponsored health plans for 45 large employers in 49 States for 2001 and 2002
included information on 2,522 bariatric procedures
@2006oct07 August 2006 Medical Care 44(8), pp. 706-712
^BARIUM ENEMA COLON RADIOGRAPHY;
(AIR-CONTRAST STUDY)
^BERNSTEIN TEST
(Acid Perfusion Test)
=a sensitive means of determining whether acid reflux is the cause
of pain, but may be falsely negative in the patient receiving treatment.
-PERFORMANCE:
..by perfusing the esophagus with alternating solutions of isotonic saline and O.1 N hydrochloric acid through a nasogastric tube at a rate of 6 mL/min.
^CALCANEUS X-RAY
{73650}
^CHOLANGIOGRAPHY OPERATIVE
=entails direct injection of a contrast agent into the cystic duct or common bile
duct at laparotomy. Excellent visualization results
-USES:
..biliary stones when jaundice occurs or when a common duct stone is sus-
pected
..Technical difficulties have limited its use at laparoscopic cholecystectomy. Direct visualization of the common duct can also be obtained by choledochoscopy. IV cholangiography for identifying the common duct has been virtually abandoned because of poor diagnostic yield, the risk of a hypersensitivity reaction, and the advent of ERCP.
^CHOLECYSTOGRAM, ORAL
..simple, reliable, and relatively safe for visualizing the gallbladder; 25% of patients experience diarrhea. Rarely, a patient has a hypersensitivity reaction to the iodine in the contrast agent An abnormal study includes failure to visualize the gallbladder after a second dose of contrast agent, provided the ob-
vious has been excluded: vomiting, gastric outlet obstruction, malabsorption, Dubin-Johnson syndrome, and significant hepatocellular disease. Sensitivity for diagnosing gallbladder disease (eg, cholelithiasis) is about 95%, but specificity is much lower.Conversely, gallstones and tumors are readUy identified and differentiated. Radiologic gallbladder filling is an important criterion when assessing patients for gallstone dissolution therapy with bile salts and for biliary lithotripsy. This technique is also more useful than US for determining stone number and type (lucency implies that the stones are composed of cholesterol). However, US and biliary cholescintigraphy have largely replaced this former gold standard because of their greater ease of use and lower false-negative rates. Cholescintigraphy is also better at assessing gallbladder
filling and emptying.
^CHOLECYSTOGRAPHY
(GALLBLADDER RADIOGRAPHY)
^CHOLESCINTIGRAPHY
=For scanning the hepatobiliary excretory system, uses —"Tc-iminodiacetic acid derivatives. These radiophannaceuticals are organic anions, which the liver avidly clears from plasma into bile much like bilirubin
-PATIENT PREPARATION:
. A minimum 2-h fast is necessary
-RESULTS: A normal scan shows
..rapid, uniform liver uptake; |
..prompt excretion into the bile ducts;
..visible gallbladder and duodenum by 1 h.
..acute cholecystitis (with cystic duct obstruc-
tion gallbladder is not visible by 1 h
..Acute acalculous cholecystitis can similarly
be detected.
Chronic cholecystitis is more problematic: It can be reasonably diagnosed
if gallbladder visualization is delayed beyond I h, sometimes until 24 h, or if the gallbladderis never visualized, but confounded by false negatives and false-positives. Several factors nay contribute to nonvisualization of the
gallbladder (eg, significant cholestasis with markedly elevated bilirubin, a nonfasting state, fasting > 24 h, certain drugs).
Cholescintigraphy also assesses hepato-biliary integrity ( bile leaks may be especially important after surgery or trauma) and anatomy (from congenital choledochal cysts to choledochoenteric anastomoses). After cholecystectomy, this biliary scan can quantitate biliary drainage and assist in defining sphincter of Oddi dysfunction. In neonatal jaundice, hepatobiliary imaging helps distinguish
hepatitis from biliary atresia.Computed tomography(CT is sensitive to variations in density of differing hepatic lesions. The addition of an IV contrast agent
helps differentiate more subtle differences between soft tissues and define the vascular system and the biliary tract. CT shows liver structures more consistently than US; neither obesity nor intestinal gas obscures them. CT is especially useful for visualizing space-occupying lesions (eg, metastases) in
the liver and masses in the pancreas. CT can detect fatty liver and the increased hepatic density associated with iron overload. CT is expensive and necessitates radiation exposure; both factors lessen its routine use compared with US.
^CLAVICLE X-RAY
{73000}
^COLONOSCOPY
..screen for colonic polyps or cancer in high risk individuals (eg, those with a family history of colon cancer)
..evaluate an abnormality seen on barium enema
..determine,the source of occult or active GI bleeding or unexplained (microcytic) anemia
..evaluate patients with colon cancer for other lesions during pre- or postoperative assessment
..determine the extent of inflammatory bowel disease
..removal of polyps
..coagulation of bleeding sites
..reduction of volvulus or intussusception
..decompression of acute or subacute colonic dilatation
-CAUTION:
..acute shock acute MI, peritonitis, intestinal perforation,and fulminant colitis
or poor bowel preparation or massive intestinal hemorrhage, poor patient
cooperation, diverticulitis, recent abdominal surgery, history of multiple pelvic operations, or a large hernia
..Patients with cardiac or proximal joint prostheses need antibiotic
prophylaxis to prevent endocarditis.
-PATIENT PREPARATION:
..cathartics and enemas
..intestinal lavage solution (eg, polyethylene glycol electrolyte)
-PROCEDURE:
..IV narcotic and a short-acting benzodiazepine (eg, midazolam) for sedation
..rectal examination in the left lateral position
..colonoscope
is gently inserted through the anal sphincter
into the rectum. Under direct visualization,
air is infused and the instrument is manipu-
lated through the colon to the cecum and
terminal ileum. Fluoroscopy is rarely
needed. The patient may experience cramp-
like discomfort that can be relieved by aspiration of air, rotation or retraction of the tube, or additional, usually analgesic, medication
..Diagnostic evaluation is performed by visualization of structures, photography,
and obtaining brushings or biopsy specimens of abnormal structures.
..Polypectomy is performed using a flexible wire loop attached to a grounded electrocautery unit. The polyp is snared around its neck, and current is applied as the loop is tightened enough to cut through
..Bleeding lesions are coagulated with electrocautery using a bipolar probe, with a heat probe, or by injection therapy.
-COMPLICATIONS:
..similar to but slightly more frequent than those for upper endoscopy
..Snare cautery of polyps is associated with a 1.7% bleeding and 0.3% perforation
rate.
^DOPPLER US
=measures the frequency change of a backscattered US wave reflected
from moving RBCs
-USES:
..patency of hepatic vessels, particularly the por-
tal vein, and the direction of blood flow.
..hepatic artery thrombosis after liver transplantation
..detect unusual vascular structures (eg, cav-
ernous transformation of the portal vein).
^ELBOW X-RAY
{73070}
^EPISIOTOMY
A surgical procedure in which an incision is made in the perineum to enlarge the vaginal opening for delivery, performed to prevent tearing of the perineum, to hasten or facilitate delivery of the infant ^GASTRIC BYPASS
-SEE ALSO: gastric banding;surgical weight loss;weight loss surgery;bariatric surgery
In bariatric surgery, construction of a proximal gastric pouch whose outlet is a Y-shaped limb of small bowel of varying lengths(Roux-en-Y gastric bypass). The proximal stomach is separated from the remaining part of the stomach with staples. Results in more weight loss than gastric-banding procedure and more likely to reverse the medical problems associated with severe obesity, such as diabetes. Vomiting is a common risk and patients are at greater risk for nutritional deficiencies and the dumping syndrome. Although not all patients are candidates, laparoscopic surgery has reduced mortality rates but advanced surgical skills are required. (N Engl J Med 2004;350(11):1077-9)
^ERCP
(Endoscopic retrograde cholangiopancreatography)
=ERCP combines (1) endoscopy for identifying and cannulating the ampulla
of Vater in the second portion of the duodenum and (2) radiology after injection of a contrast agent into the biliary and pancreatic ducts. This technique places a side-viewing endoscope in the descending duodenum, identifies and cannulates the papilla of Vater, and then injects a contrast agent to visualize the pancreatic duct and the biliary duct systems
-USES:
..excellent images of the biliary tract and pancreas
..some visualization of the upper GI tract and the periampullary area
..Biopsies and interventional procedures may be performed (eg, sphincterotomy, biliary stone extraction, placement of a biliary stent in a stricture).
..ERCP is an outpatient procedure that, in experienced hands, has relatively low risk (mainly pancreatitis in 3% after sphincterotomy). It has revolutionized the diagnosis and management of pancreaticobiliary disease.
ERCP is especially valuable in assessing the biliary tract in cases of persistent
jaundice and in seeking a lesion amenable to intervention (eg, stone, stricture, sphincter of Oddi dysfunction). In jaundice and cholestasis, US to assess duct size should precede ERCP.
^ESOPHAGEAL MANOMETRY
-USES:
..evaluation of patients with dysphagia, heartburn, or chest pain
..pressure in the upper and lower esophageal sphincters and effectiveness and coordination of propulsive movements and detects abnormal contractions
..achalasia, diffuse spasm, scleroderma, and lower esophageal sphincter hypo- and hyper-tension
..esophageal function for certain therapeutic procedures (eg, antire-
flux surgery, pneumatic dilation for achalasia)
-PERFORMANCE:
..by passing a small tube past the throat and into the esophagus
-COMPLICATIONS:
..extremely uncommon but may include trauma to the nasal passages
^ESOPHAGEAL PH MONITORING
=performed either during esophageal manometry or as a prolonged study in ambulatory patients
^ESOPHAGOSCOPY
-USES:
..evaluate pain or dysphagia
..identify structural abnormalities or bleeding sites
..obtain biopsy specimens
..removal of foreign bodies
..hemostasis by coagulation or variceal banding
..debulking of tumors by laser or bipolar electrocoagulation
..dilatation of webs or strictures
-CAUTIONS:
..no absolute contraindication
..easily performed on an outpatient basis
..requires local anesthesia of the throat and, generally, IV sedation
-COMPLICATIONS:
..rare and usually medication related (eg, respiratory depression)
..bleeding/perforation (less common)
^FEMUR X-RAY
{73550}
^FINGER X-RAY
{73140}
^FOOT X-RAY
{73620}
^FOREARM X-RAY
{73090}
^FUNCTIONAL MAGNETIC RESONANCE IMAGING
(fMRI)
^GASTRIC ANALYSIS
-USES:
..hyperchlorhydria (eg, Zollinger-Ellison syndrome) or hypochlorhydric states (eg
pernicious anemia, atrophic gastritis, Menetriers syndrome)
..unexplained hypergastrinemia in patients with planned acid-reducing
surgery as part of pre- or postoperative assessment
..possibility of incomplete vagotomy in patients with recurrent peptic ulcer disease after a surgical vagotomy
-CAUTION:
..recent active bleeding or pain caused by active ulcer disease.
-PERFORMANCE:
A Levin nasogastric tube is passed. Gastric contents are aspirated and discarded. Four 15-min samples of gastric juice are collected by continuous manual aspiration (basal acid output [BAO])
Next, pentagastrin (6 ug/kg) is given sc, and again, four 15-min samples are obtained
(maximal [or peak] acid output [MAO or PAO]). Samples are titrated with sodium hydroxide to calculate BAO and stimulated MAO secretory rates.
^GASTRIC RADIOGRAPHY
-INCLUDES:UPPER GI EXAMINATION
^GASTRIC-BANDING PROCEDURE
In bariatric surgery, a band is placed around the stomach near its upper end, creating a small pouch and a restricted passage to the larger remaining part of the stomach. Vomiting is a common risk and patients are at greater risk for nutritional deficiencies and the dumping syndrome. Although not all patients are candidates, laparoscopic surgery has reduced mortality rates but advanced surgical skills are required. (N Engl J Med 2004;350(11):1077-9)
^HAND X-RAY
{73120}
^HEMIGLOSSECTOMY
=Excision of part (half?) of tongue
-INDICATIONS:
..Tongue cancer of moderate size
-CONSEQUENCES:
..Reasonably good speech and swallowing function are to be expected
-ALTERNATIVES:
..Radiation therapy with or without chemotherapy
-OTHER:
..Often combined with radical neck dissection and sometimes with excision of part of the mandible
@2004jan27 Donald Shedd, MD
^HIP X-RAY
{73500}
^HUMERUS X-RAY
{73060}
^HYSTERECTOMY
=removal of uterus, total(uterus and cervix), or supracervical(uterus only)
-USES:
..symptomatic fibroids,
..abnormal uterine bleeding unresponsive to hormonal treatment
-FREQUENCY:
..More than a half million hysterectomies on U.S. women each year
. Between 1988 and 1998,the rate of total abdominal hysterectomy has declined, and supracervical hysterectomy has increased substantially.
-COMPLICATIONS AND OUTCOME:
..135 women at four clinical centers, received a total(67) or supracervical hysterectomy(68)
..previously, abdominal hysterectomy was thought to damage nerve structures important to bladder and sexual function and increase operative time and blood loss.
..2 years after surgery, results were similar for total and supracervical hysterectomy
..Hysterectomy by either technique led to significant reductions in most symptoms, including pelvic pain or pressure, back pain, urinary incontinence,
and voiding dysfunction
..no significant differences in rate of complications, degree of symptom improvement, or activity limitation between the two groups.
..women weighing more than 220 pounds at study entry were twice as likely to be
readmitted to the hospital during the 2-year followup period.
@2003Obstetrics & Gynecology 102;453
^HYSTEROSALPINGOGRAPHY
(UTEROSALPINGOGRAPHY)
^IMAGING STUDIES
Radionuclide scanning, ultrasound (US), CT, and MRI have replaced traditional imaging techniques (eg, oral cholecystogram, IV cholangiogram). Invasive radiography (eg, ERCP) allows for sophisticated instrumentation and treatment procedures.
^INTRAVENOUS PYELOGRAPHY
(IVP;EXCRETORY UROGRAPHY;IV UROGRAPHY)
^JOINT SURVEY X-RAY
{76066}
^KNEE X-RAY
{73560}
^LARYNGECTOMY, TOTAL
=Removal of the entire larynx usually including one or two tracheal rings and hyoid bone and epiglottis. At the conclusion of the operation there remains a defect in the wall of the pharynx which is then closed surgically. Requires that a permanent breathing opening, a tracheostoma, be left at the lower part of the neck. Certain patients will have a so-called supra-cricoid laryngectomy in which the reconstruction does not require the permanent tracheostomy. Often combined with radical neck dissection.
-USES:
..Cancer of the larynx that is too far advanced for radiation or partial laryngectomy
-OUTCOME:
..A good proportion of patients will experience long term cure of the cancer.
..Normal laryngeal speech is no longer possible. Patients must learn esophageal speech or use of another method.
__Complications
...Fistula formation
...Infection, total
...Infection, respiratory
...Bleeding
...Narrowing of the stoma
...Difficulty in swallowing
...Recurrence of cancer
@2004mar22 Donald Shedd,MD
^LIVER BIOPSY,PERCUTANEOUS
=provides valuable diagnostic information with relatively small risk and little patient discomfort.
-USES:
..Hepatosplenomegaly of unknown cause
..Unexplained abnormal liver function tests
..Diagnosis and staging of alcoholic liver disease
..Drug-related hepatitis
..Atypical hepatitis
..Diagnosis and follow-up of chronic hepatitis
..intrahepatic cholestasis
..Suspected malignancy (space-occupying lesions)
..Fever of unknown origin after liver transplantation
..Fine-needle biopsy under US guidance detects metastatic car-
cinoma in at least 66% of cases and may es-
tablish the diagnosis despite negative scan-
ning techniques; cytologic examination of
the biopsy fluid yields positive findings in an
additional 10% of cases. Results are less val-
uable in lymphoma and correlate poorly with
the clinical impression of hepatic involve-
ment
..especially valuable in detecting TB or other granulomatous infiltra-
tions
..can clarify graft problems(ischemic injury, rejection, biliary tract dis-
ease, viral hepatitis) after liver transplantation.
-CAUTIONS:
..clinical bleeding tendency or a coagulation disorder(prothrombin time > 3 sec over control values [INR > 1.2] despite giving vitamin K, bleeding time > 10 min)
..severe thrombocytopenia (50,000/u.L)
..severe anemia,
..peritonitis
..marked ascites
..high-grade biliary obstruction
..subphrenic or right pleural infection or effusion.
-PROCEDURE: Performed with the patient under local anesthesia, this bedside procedure entails aspiration(using the Menghini needle or the disposable
and therefore always sharp Jamshedi needle) or cutting (using the disposable Tru-
cut—a variation of the Vim-Silvennan needle). The needle is inserted through an
anesthetized intercostal space anterior to the midaxillary line, just below the point of maximal dullness on expiration. The patient lies still and maintains expiration. The liver is rapidly entered with either suction applied (Jamshedi) or a cutting sheath advanced (Trucut). The result is a procedure that takes
1 to 2 sec and yields a liver specimen 1 mmin diameter and 2 cm long. Occasionally, asecond pass is necessary; if a second or third attempt is unsuccessful, then needle biopsy should be guided by ultrasound (US) or CT.
US-guided biopsies using a biopsy gun,whose spring mechanism fires a modified
Trucut needle, are less painful and provide a high yield. US guidance is particularly useful for sampling focal lesions or avoiding vascular lesions (eg, hemangiomas).
-RESULTS-
At biopsy, the liver's texture can be ascertained on needle insertion: a hard, gritty feel suggests cirrhosis. The biopsy is examined routinely for histopathology. Cytology, frozen section, and culture may be useful in
selected cases. In suspected Wilson's disease, copper content should be measured.
Gross inspection provides information: fragmentation suggests cirrhosis; a fatty liver is pale yellow and floats in formaldehyde; carcinoma is whitish.
-RISK: ..sufficiently safe to perform as an outpatient procedure
-COMPLICATIONS:
..After biopsy, the patient is monitored for 3 to 4 h, during which complications (eg, intra-abdominal hemorrhage, bile peritonitis, lacerated liver) are most likely. Because delayed bleeding can occur as long as 15 days later, discharged patients should remain within 1 h of the hospital. Mild right upper quadrant discomfort sometimes radiating from the diaphragm to the shoulder tip, is common and responds to mild analgesics. Mortality is low at 0.01%; major complications are reportedly about 2%.
-LIMITATIONS:
(1) the need for a skilled histopathologist (many pathologists have little experience with needle specimens)
(2) sampling error (nonrepresentative tissue seldom occurs in hepatitis
and other diffuse conditions but can be a problem in cirrhosis and space-occupying lesions)
(3) inability to differentiate hepatitis etiologicaUy (eg, viral vs. drug-induced); and
(4) occasional errors or uncertainty in cases of cholestasis.
^LIVER BIOPSY,TRANSVENOUS
-RISK:
..surprisingly well tolerated
..requires minimal sedation, if any,except with uncooperative patient
-PERFORMANCE:
..through a catheter inserted into the right internal jugular vein and through the right atrium into the inferior vena cava and hepatic vein, a modified Trucut needle is advanced through the hepatic vein into the liver.
-RESULTS:
..Hepatic vein and wedge pressures can also be obtained.
-LIMITATIONS
..specimen obtained is relatively small
..operator must be skilled in angiography
..can be used even when the patient has a significant coagulation disorder
-RESULTS:
..The yield for liver tissue is > 95% in experienced hands.
-MORBIDITY/MORTALITY:
..complication rate is very low:
..0.2% bleed from puncture of the liver capsule
..One center reported no mortality in > 1000 transvenous biopsies.
^LOOP ELECTROSURGICAL EXCISION PROCEDURE
(LEEP)
^LUMBOSACRAL SPINE X-RAY
{72114}
^MAGNETIC RESONANCE IMAGING
(MRI)
is an exciting, although expensive, technology that may prove advantageous for identification of tumors and hepatic blood flow. Blood vessels are easily identified without contrast agents. Although still evolving, MRI is comparable to CT for detecting mass lesions and can visualize perihepatic vessels and the
biliary system. Magnetic resonance cholangiography is becoming an increasingly useful screening tool before proceeding to more invasive techniques.
^MAMMOGRAPHY
THERMOGRAPHY
(MAMMOTHERMOGRAPHY)
^NASOGASTRIC/INTESTINAL INTUBATION
-USES:
..decompress the stomach in treating gastric atony, ileus, or obstruction
..remove ingested toxins
..obtain a sample of gastric contents for analysis (volume, acid content, blood)
..supply nutrient through tube feeding
-CONTRAINDICATIONS:
..nasopharyngeal or esophageal obstruction
..maxillofacial trauma
..uncontrollable coagulation abnormalities
..large esophageal varices
-PERFORMANCE:
. Levin or Salem sump tube for gastric decompression at analysis, or rarely for short-term feeding
.. Hg-weighted balloon tips facilitate passing the
tube (eg, Miller-Abbott, Cantor) beyond the
stomach for intestinal decompression or
feeding. Very flexible, thin Hg- or tungsten-
tipped tubes (eg, Corpak, Dobbhoff Entri-
flex) are used mainly for prolonged enteral
feeding.
For intubation, the patient sits upright or
lies in the left lateral decubitus position With
the patients head partially flexed, the lubri-
cated tube is inserted through the nares
aimed back and then down to conform with
the nasopharynx. As the tip reaches the pos-
terior pharyngeal wall, the patient should sip
water through a straw. (Violent coughing
with flow of air through the tube during res-
piration indicates that the tube is misplaced
in the trachea.) Aspiration of gastric juice
verifies entry into the stomach. The position
of larger tubes may be confirmed by instilling
20 to 30 mL of air and listening with the
stethoscope under the left subcostal region
for a rush of air.
Smaller, more flexible intestinal feeding
rubes usually require the use of stiffening
wires or stylets. These tubes usually require
fluoroscopic or endoscopic assistance for
passage through the pylorus.
-COMPLICATIONS:
..rare
..nasopharyngeal trauma with or without hemorrhage
..pulmonary aspiration
..traumatic esophageal or gastric hemorrhage/perforation
..intracranial or mediastmal penetration(very rarely)
^PELVIS X-RAY
{72170}
^PERITONEOSCOPY, DIAGNOSTIC
(Laparoscopy)
-USES:
..evaluate intra-abdomina] or pelvic pathology (eg, tumor, endometriosis), operabiUty of patients with cancer, and patients with acute or chronic abdominal pain
..guide liver biopsy under direct visualization
..lymphoma staging
-CAUTION:
..Absolute contraindications include a coagulation or bleeding disorder
poor patient cooperation, peritonitis, intestinal obstruction, and infection of the abdominal wall. Relative contraindications include severe cardiac or pulmonary disease, large abdominal hernias, multiple abdominaloperations, and tense ascites.
-PATIENT PREPARATION-
..CBC; coagulation studies; x-rays of the chest, kidneys, ureters, and bladder; and typing and sensitivity testing for 2 U of whole blood are obtained before the procedure.
-PROCEDURE:
Laparoscopy is performed with sterile technique in a well-equipped endoscopy suite or operating room. A narcotic and short-acting benzodiazepine (eg, midazolam) are given IV while the abdomen is sterilized with an antiseptic solution. Lidocaine 1% is injected into the peritoneum at the site of puncture.
A 5-mm surgical incision is made, and the Venes pneumoperitoneum needle is in-
serted. Nitrous oxide is infused into the abdominal cavity. The incision is extended by 10 to 15 mm, and the cannula with trocar is introduced into the peritoneal cavity. The trocar is removed, and the peritoneoscope is inserted through the cannula. The abdominal contents are examined, and aspiration of as-
citic fluid and biopsy procedures are performed as needed. When the procedure is
completed, the nitrous oxide is expelled bythe patient with a Valsalva maneuver and the cannula is removed. The incision is sutured. An IV line is maintained for 24 h, and the patient is checked at 6 and 24 h for signs of bleeding or infection.
-COMPLICATIONS:
..bleeding
..bacterial peritonitis
..perforation of a viscus.
^PROCEDURES
P -PROCEDURES
P*.0 ====OPERTIVE FUNDAMENTALS
P*.1 ====EXAMINATION
P*.11 =====ENDOSCOPIC PROCEDURES
P*.12 =====IMAGING PROCEDURES
P*.121 ======ULTRASOUND PROCEDURES
P*.122 ======DIAGNOSTIC RADIOLOGY PROCEDURES
P*.123 ======INVASIVE RADIOLOGY PROCEDURES
P*.124 ======COMPUTED RADIOLOGY PROCEDURES
P*.125 ======MAGNETIC RESONANCE PROCEDURES
P*.126 ======POSITRON EMISSION TOMOGRAPHY PROCEDURES
P*.127 ======NUCLEAR MEDICINE PROCEDURES
P*.2 ====ASSESSMENT
P*.3 ====MANIPULATION
P*.4 ====SUPPORT
P*.5 ====INCISION
P*.6 ====REMOVAL/DESTRUCTION
P*.7 ====REPAIR
P*.8 ====REPLACEMENT
P*.9 ====ADJUNCTIVE PROCEDURE
P*.91 =====FUNCTION AID
P*.92 =====PROSTHESIS
P*.0. OPERATIVE FUNDAMENTALS
P*.1 EXAMINATION
(INSPECTION;ENDOSCOPY;IMAGING;_SCOPY)
Inspect
Expose or explore a body site
Examples: Diagnostic cardiac catheterization
Diagnostic thoracoscopy
Diagnostic laparoscopy
Diagnostic arthroscopy
Map Locate the route of passage of electrical impulses in a body site
Examples: Cardiac electrophysiological study
P*.11 ENDOCOPIC PROCEDURES
P*2. ASSESSMENT
P*3. MANIPULATION
(DISLOCATION REDUCTION;INTUBATION;DILATION;INJECTION;INTRODUCTION;
CLOSURE;_PLASTY)
Dilate
Expand or stretch an orifice or the lumen of a tubular or hollow body site
by application of pressure
Examples: Coronary artery angioplasty
Femoral artery angioplasty
Dilate anal sphincter
Dilate esophageal stricture
4. SUPPORT
(STRAPPING;CASTING;SPLINTING;BANDAGING)
5. INCISION
(DRAINAGE;EXPLORATION;DISSECTION)
Drain
Take or let out fluid from a body site
Examples: Pericardial window
I & D of an abscess
Thoracentesis
Paracentesis
6. EXCISION
(DEBRIDEMENT;REMOVAL;SHAVING;ABRASION;TRIMMING;AVULSION;EVACUATION;PEELING;ESCHAROTOMY;DESTRUCTION;_ECTOMY;BIOPSY;OTOMY;RESECTION;AMPUTATION;DECOMPRESSION
REMOVAL, DISABLEMENT)
Excise
Cut out, without replacement, part of a body site
Examples: Temporal artery biopsy
Myocardial aneurysmectomy
Sigmoid polypectomy
Partial adductor tenectomy
Remove
Take out without replacement a mechanical or electronic appliance
which has been previously implanted, or biological or synthetic material
that was used in a replacement, repair or bypass
Examples'. Remove cardiac pacemaker
Remove pulmonary artery monitoring catheter
Remove femoral fixation device
Remove ureteral stent
Destroy
Alter or break down by physical means without taking out part or all of
a body site or its solid contents
Examples: Cauterize hemorrhoidal vein
Sclerose lesser saphenous vein
Ablate Sino-atrial node
Fragment bladder stones
Resect
Cut out. without replacement, an entire body site
Examples: Saphenous vein resection
Total pericardiectomy
Sigmoidectomy
Thumb amputation
Extract
Take out all or part of the solid contents of a body site without taking out
any of the body site
Examples: Evacuate clot from femoral artery
Extract bladder stones
Extract loose body in the knee
Strip
Take out all or part of a body site by the application of force
Examples: Saphenous vein stripping
Phrenic nerve avulsion
7. REPAIR
(CLOSURE;_DESIS;FIXATION;RECONSTRUCTION;FRACTURE SETTING;REVISION;REVISE;CREATE;RELEASE;BYPASS;RESTRICT;DIVIDE;OCCLUDE)
Repair
Correct a congenital or acquired abnormality of a body site
Examples: Patch repair of subclavian artery
Repair atrial septal defect
Repair diaphragmatic laceration
Repair inguinal hernia
Suture laceration of aortic arch
Revise
Redo a portion of a previously performed procedure that has failed to
function as intended. Revisions exclude the complete redo of the
procedure and procedures to correct complications that do not require
the redoing of a portion of the original procedure, such as the control of
bleeding
Examples: Revise femoral-popliteal bypass
Revise cardiac pacemaker lead
Revise gastroenterostomy
Create
Make a new structure that does not physically take the place of a body
site
Examples: Create atrial septal defect _____
Release
Eliminate abnormal compression or restriction of a body site
Examples: Lyse femoral artery adhesions
Free median nerve
Lyse peritoneal adhesions
Free fallopian tube
Bypass
Alter the route of passage for body fluids, gases, impulses and
excretions in, or between body sites including one or more concomitant
anastomoses with or without the use of a device
Examples: Aorto-coronary artery bypass
Spleno-renal shunt
Axillo-femoral bypass
Gastro-jejunal bypass
Restrict
Partially close the orifice or lumen of a tubular or hollow body site
Examples: Pulmonary artery banding
Cervical cerclage
Divide
Separate without taking out a body site into two or more parts
Examples Divide patent ductus arteriosus
Divide inferior vena cava
Divide bundle of His
Occlude
Completely close the orifice or lumen of a tubular or hollow body site
Examples'. Ligate saphenous vein
Embolize anterior cranial artery
Crush fallopian tubes
Ligate vas deferens
Control post op bleeding
8. REPLACEMENT
(EXPLANTATION;IMPLANTATION;REPLANTATION;TRANSPLANTATION;GRAFTING;_PLASTY;TATTOOING;REMOVAL(eg foreign body);_CENTESIS)
Replace
Put in non-living biological material, synthetic material or living
dissimilar tissue that physically takes the place of all or part of a body
site The body site replaced may have been previously taken out,
previously replaced, or may be taken out as part of the replacement
procedure
Examples:
Femoral artery graft
Replace aortic valve
Total hip replacement
Implant
Put in a mechanical or electronic appliance that can be used to monitor,
assist or perform a biological function but does not physically take the
place of a body site
Examples: Implant cardiac pacemaker
Implant diaphragmatic pacemaker
Implant monitoring catheter in pulmonary artery
Implant infusion pump
Transplant
Put in a living body site taken from another area of the same individual
or from another individual or animal, in the place of the same body site.
Examples: Heart transplant
Lung transplant
Adductor tendon transplant
9. ADJUNCTIVE MODALITIES
91. FUNCTION AIDS
92. PROSTHESES
@2006may30 cwb
^PTC
(Percutaneous transhepatic cholangiography)
=involves puncture of the liver with a 22-gauge needle under fluoroscopic or US control to enter the peripheral intrahepatic bile duct system above the common hepatic duct.
-USES:
PTC has a high diagnostic yield but only for the biliary system. Some therapeutic techniques (eg,decompression of the biliary system, insertion of an edoprosthesis) are possible.ERCP generally is preferred, particularly if ducts are not dilated (eg, sclerosing cholangitis). PTC is used after failed ERCP or when altered anatomy (gastroenterostomy) precludes accessing the ampulla. It may complement ERCP in hilar lesions at the porta hepatis.
-COMPLICATIONS:
PTC is generally safe but has a higher complication rate (eg, from sepsis,
bleeding, bile leaks) than ERCP. Local expertise often dictates the choice between PTC and ERCP.
^RADIOACTIVE IODINE UPTAKE
=Evaluation of thyroid function and its affinity for iodine. This is done by administering I-123 or I-131 to the patient for ingestion. After periods of 6 and 24 hours, an external probe is used to measure the amount of radioactive iodine in the thyroid as a percentage of the original dose.
-Uses
..evaluate thyroid function
..aid diagnosis of hyperthyroidism or hypothyroidism
..help distinguish between primary and secondary thyroid disorders
-Cautions
..This test is contraindicated during pregnancy and lactation because of possible teratogenic effects
-Reference interval
--after 6 hours
..3-16% of radioactive iodine accumulates in the thyroid
--after 24 hours
-Interpretations
--below average iodine uptake
..hypothyroidism
..subacute thyroiditis
..iodine overload
--above-normal percentages
..hyperthyroidism
..Hashimoto's disease
..hypoalbuminemia
..ingestion of lithium
..iodine-deficient goiter
-Interference
..Renal failure
..diuresis
..severe diarrhea
..X-ray contrast media studies
..ingesting iodine preparations
..drugs
..An iodine-deficient diet or ingestion of phenothiazines can increase iodine uptake
@2003aug25 kui
^RADIONUCIDE THYROID IMAGING
=Test which allows a visual picture of the thyroid gland by means of a gamma camera. This is done after the ingestion of a radioisotope. This test is most often done upon the discovery of a palpable mass.
-Uses
..assess the size, structure, and position of thyroid gland
..evaluate thyroid function in conjunction with other thyroid tests
-Cautions
..Radionuclide thyroid imaging is contraindicated during pregnancy and lactation
-Reference interval
--normal findings
..butterfly-shaped thyroid; 2" long and 1" wide
-Interpretations
..hyperfunctioning nodules appear as black regions
..hypofunctioning areas appear as white or gray regions
-Interference
..iodine-deficient and use of phenothiazines increase uptake of radioactive iodine
..Renal disease
..ingestion of iodinized salt
..iodine preparation
..iodinated salt substitutes
..use of thyroid hormones, thyroid hormone antagonists, aminosalicylic acid, corticosteroids, multivitamins, or cough syrups containing
inorganic iodides decrease uptake of radioactive iodine
..diarrhea
@2003aug25 kui
^RADIONUCLIDE SCANNING
=involves hepatic extraction of an injected
radiophannaceutical from the blood, most
commonly technetium 99m (""Tc).
-USES:
..US or CT has largely supplanted radionuclide scanning for space-occupying
lesions and diffuse parenchymal disease. Liver-spleen scanning uses ""Tc-sulfur
colloid, which is rapidly extracted from the blood by reticuloendothelial cells. Normally, radioactivity is uniformly distributed. In a
space-occupying lesion > 4 cm (eg, cyst, abscess, metastasis, hepatic tumor), the replaced liver cells produce a cold spot. Generalized liver disease (eg, cirrhosis, hepatitis) causes a heterogenous decrease in liver uptake and increased uptake by the spleen and bone marrow. In hepatic vein obstruction, there is decreased visualization of the liver except for the caudate lobe because of its special drainage into the inferior vena cava.
^SCAPULA X-RAY
{73010}
^SHOULDER X-RAY
{73020}
^SMALL-BOWEL BIOPSY/DUODENAL ASPIRATION
-USES:
..support, confirm, or exclude inflammatory and structural disorders of the
small bowel (eg, celiac sprue, Whipple's disease, Giardia lamblia infection)
-CAUTIONS:
..Uncorrectable coagulation disorders
-PERFORMANCE:
..lubricated tube with a Carey capsule at its end is placed in the oropharynx, and the patient swallows. On entry to the stomach, the tube is manipulated with fluoroscopic guidance through the pylorus to the third or fourth portion of the duodenum.
..biopsy specimen is obtained by producing negative pressure with a syringe while the aspiration port is open. Mucosa is sucked through the port into the tube or capsule and sliced off by a knife activated by the operator via a wire. Fluid samples for diagnosis of Giardia infection are obtained by aspirating duodenal contents
-COMPLICATIONS:
.. Bleeding, entrapment of the tube in the duodenum, bacteremia, and as-
piration of fluid or Hg during passage of the tube occur rarely
-ALTERNATIVES:
..supplanted by endoscopic biopsy, which yields smaller but usually satisfactory tissue samples that are easier to obtain.
^SOLITARY PULMONARY NODULE
(coin lesion)
= an approximately round lesion that is less than 3 cm in diameter, completely surrounded by pulmonary parenchyma, without other abnormalities. Lesions larger than 3 cm are called masses and are often malignant. Incidence of cancer ranges from 10 to 70 percent. Infectious granulomas cause about 80 percent of the
benign lesions, and hamartomas about 10 percent. Coccidioidomycosis should be considered in areas where that is endemic, many such nodules being noncalcified and larger than 3 cm in diameter. Only biopsy can definitively diagnose a lesion. Recent developments include improvements in radiographic imaging.
-REVIEWS:Ost D,Fein AM,Feinsilver SH.The Solitary Pulmonary Nodule. N Engl J Med 2003;348(16):2535-42
^T-TUBE CHOLANGIOGRAPHY
(INTRAVENOUS CHOLANGIOGRAPHY)
^THYROID ULTRASONOGRAPHY
=Test that produces a visualization of the thyroid gland. This is a very noninvasive procedure that involves the use of ultrasonic pulses. This test should be performed upon the discovery of a palpable mass.
-Uses
..evaluate thyroid structure
..differentiate between a cyst and a solid tumor
..monitor the size of the thyroid gland during suppressive therapy
-Reference interval
..uniform echo pattern throughout the gland
-Interpretation
--Cysts
..smooth-bordered, echo-free areas
--Adenomas or carcinomas
..solid and well demarcated
@2003aug25 kui
^TIBIA & FIBULA X-RAY
{73590}
^TOE X-RAY
{73660}
^TOTAL GLOSSECTOMY
=Excision of entire tongue
-INDICATIONS:
..Large cancer of the tongue
-ALTERNATIVES:
..Radiation therapy with or without chemotherapy has a small chance of curing large tongue cancers
-CONSEQUENCES:
..Severe impairment of speech and swallowing
-OTHER:
..Concomitant laryngectomy may or may not the necessary depending upon respiratory status of the patient
@2004jan27 Donald Shedd, MD
^TRANSCUTANEOUS ELECTRIC NERVE STIMULATION
(TENS)
^TROPONIN
(TnI;TnT;Cardiac-specific Troponin I and T)
-SEE ALSO:CK, CK-MB, Myoglobin, Cardiac Biomarkers
=Ideal biomarker of myocardial injury because of absolute specificity of cTnI for cardiac tissue
-BACKGROUND:
..Troponin-I, The contractile unit (or sarcomere) of striated muscle fiber is composed of thick and thin filaments. The thick filament is composed mainly of myosin. Actin, tropomyosin, and troponin comprise the thin filament. Muscle contraction occurs when the thick and thin filaments slide past each other, thereby shortening the length of the sarcomere. The interaction between the thick and thin filaments is regulated by the troponin complex found on the thin filaments
..The troponin complex is composed of three protein subunits: troponin-I (TnI), troponin-T (TnT), and troponin-C (TnC)
..The calcium-mediated contraction of striated muscle (fast-skeletal, slow-skeletal, and cardiac muscle) is regulated by the troponin complex; contraction of smooth muscle is regulated by calmodulin
..Three distinct tissue-specific isoforms of TnI have been identified: two in skeletal muscle and one in cardiac muscle. Although the molecular weight of the two skeletal TnI isoforms is approximately the same (19.8 kDa), 40% of their primary sequence is unique
..The cardiac isoform of TnI (cTnI) has an additional sequence of 31 amino acids at the N-terminus resulting in a molecular weight of 24 kDa and about a 40% difference in primary sequence compared to both of the skeletal TnI isoforms. cTnI has never been isolated from skeletal muscle
..Within the heart, cTnI appears to be uniformly distributed throughout the atria and ventricles.
-USES:
..help diagnose a heart attack
..detect and evaluate mild to severe heart injury
..separate it from chest pain that may be due to other causes
..In patients who have delayed getting treatment and have been having heart-related chest pain, discomfort, or other symptoms such as sweating, radiating pain in the arms, shoulders, jaw, neck, nausea, and/or lightheadedness for more than a day
..stable angina when the patient’s symptoms escalate (when the patient is at rest/no longer ease with treatment)
-PERFORMANCE MODE:
..by itself or along with other cardiac biomarkers (CK, CK-MB, myoglobin)
..usually ordered when a patient first comes into the emergency room and then again at 6 and 12 hours.
-COMPARISON:
..has begun to replace CK and CK-MB tests because it is more specific for heart injury (versus skeletal muscle injury) and is elevated for a longer period of time
-CAUTIONS:
-REFERENCE INTERVAL:
..dependent on age, gender, sample population, and test method
..lab report should include the specific reference range for your test.
-INTERPRETATION:
..cTnI is 100% specific for cardiac injury, it is not 100% specific for AMI
..Normally, troponin levels are very low; even slight elevations can indicate some degree of damage to the heart
..When the patient has significantly elevated troponin concentrations and other clinical signs, such as an abnormal ECG, then it is likely the patient has had a heart attack
..If CK, CK-MB, and myoglobin concentrations are normal but troponin levels are increased, then it is likely that either a lesser degree of heart injury is present or that the injury took place more than 24 hours in the past
..If the first troponin performed is normal but subsequent (6 hour and 12 hour samples) troponin tests are increased, then the heart injury likely occurred within a couple of hours prior to the first test and had not had time to increase
..When a CK test is elevated but a CK-MB and troponin test are normal, then it is likely that whatever symptoms are present are due to another cause, such as skeletal muscle injury.
..When a patient with chest pain and/or known stable angina has normal troponin, CK, and CK-MB concentrations, then it is likely that their heart has not been injured.
..Troponin will remain high for 1-2 weeks after a heart attack
-INTERFERENCE
..not generally affected by damage to other muscles so that muscle injections, accidents, strenuous exercise, and drugs that can damage muscle do not affect troponin levels.
..may also be elevated with acute or chronic conditions such as myocarditis, congestive heart failure, severe infections, kidney disease, dermatomyositis, and polymyositis.
-COST:
-COVERAGE:
@2006apr3 dxc
^ULTRASOUND
(US)
-USES:
morphologic and independent of function US is the most important investigative tool in screening for biliary tract abnormalities and mass lesions in the liver. US is better atdetecting focal lesions (> 1 cm in diameter)than diffuse disease (eg, fatty liver, cirrhosis). In general, cysts are echo-free; solid lesions (eg, tumors, abscesses) tend to be echogenic. The ability to localize focal lesions
permits US-guided aspiration and biopsy.
US is the least expensive, safest, and most sensitive technique for visualizing the biliary system, especially the gallbladder. Accuracy in detecting gallbladder or gallstone disease is close to 100%, although an element of op-
erator skill is needed. Gallstones cast intense echoes with distal shadowing and may move with gravity. Size can be accurately defined,but the number of stones may be difficult to determine because of overlap when many
are present. Criteria for acute cholecystitis include a thickened gallbladder wall, pericholecystic fluid, an impacted stone in the gallbladderneck, and gallbladder tenderness on palpation (Murphy's sign). Polyps of the gallbladder are a frequent incidental finding. Carcinoma presents as a nonspecific solid
mass.
US is the procedure of choice for evaluating cholestasis and differentiating extrahepatic from intrahepatic causes of jaundice. Bile ducts stand out as echo-free tubular structures. The diameter of the common duct is normally < 6 mm, increases slightly with age, and can reach 10 mm after cholecystectomy. Dilated ducts are virtually pathognomonic for extrahepatic obstruction, but normal bile ducts do not exclude obstruction because it may be recent or intermittent US does not readily detect common duct stones, but they may be inferred if the common duct is dilated and stones are identified in the gallbladder. Visualization of
the pancreas, kidney, and blood vessels is an added bonus. Finding enlargement or a mass in the head of the pancreas may reveal the cause of cholestasis or upper abdominal pain.
^UPPER GASTROINTESTINAL ENDOSCOPY
-USES:
..establish the site of upper GI bleeding
..visually define and biopsy abnormalities seen on upper GI series (gastric ulcers, filling defects, mass lesions)
..follow up treated gastric ulcers
..evaluate dysphagia, dyspepsia, abdominal pain, and gastric outlet obstruction
for infection (Helicobacter pylori, G. lamblia, bacterial overgrowth syndrome)
..removal of foreign bodies or gastric or esophageal polyps,
..sclerosis or banding of esophageal varices,
..coagulation of hemorrhage
-CAUTIONS:
..acute shock
..acute MI
..seizures
..acutely perforated ulcer and atlantoaxial subluxation
..uncooperativeness
..coma (unless the patient is intubated)
..coagulopathy (prothrombin time > 3 sec over control, platelet count < 100,000/nL, bleeding time > 10 mm)
..Zenker's diverticulum
..myocardial ischemla
..thoracic aortic aneurysm
-PERFORMANCE:
..The patient should have taken no food for at least 4 h.
..A topical anesthetic is gargled or sprayed into the pharynx, and usually a narcotic and midazolam are given IV for sedation.
..The patient is appropriately positioned and the tip of the endoscope is placed in the hypopharynx. As the patient swallows the endoscope is gently guided through the cricopharyngeal muscle (upper esophageal sphincter) and advanced under direct vision through the stomach into the duodenum Exanimation of all structures may be supplemented by photography, cytology, and biopsy sampling. Therapeutic procedures are used as indicated; eg, sclerotherapy is performed by passing a needle-tipped cannula through the endoscope and injecting the sclerosing agent into the varix
-COMPLICATIONS:
..overall complication rate is 0.1 to 0.2%
..mortality is about 0.03%
..Drug-related complications are most common and include Phlebitis and respiratory depression.
..common procedural complications are aspiration from biopsy sites and perforation
..Transient bacteremia often occurs (8%)but is unassociated with development
of endocarditis. Antibiotic Prophylaxis may be indicated in patients with valvular disease. Patients with a coagulation disorder are more likely to experience a retropharyngeal hematoma or other bleeding complication. Procedures undertaken concurrently(eg, variceal sclerotherapy, stricture dilatations, polypectomy) are associated with
higher complication rates.
^VITALS THROUGH THE FINGER
=A lightweight, ringlike sensor measures the wearer's pulse, blood pressure and cardiac output.A battery-powered motor squeezes the finger like a traditional blood-pressure cuff and optically measures changing pressures
using a beam of light. A model made of a polymer actuator fiber could be built into the gloves or sleeves and programmed to wirelessly transmit vital
signs.
@2006jan23 dxc
^WIRELESS PERSONAL INFORMATION CARRIER
(WPIC;DIGITAL DOG TAG)
=Prototypes can encapsulate more than 20 years of individual medical records-including information on blood type and allergies, doctor's comments, even video and audio files, and can be activated when medics come within 10 yards of a wounded soldier, instantly transmitting files to the medic's PDA.
WPICs could have civilian applications too, helping to simplify routine exams and giving emergency personnel immediate access to patient data.
@2006jan23 dxc
^WOUND VACUUM
=Using a sponge and sticky plastic sheeting as dressing, the device cleanses open gashes by sucking out excess fluids for as many as three days between dressing changes.
-USES:
..in Iraq war has cut rates of infection among wounded U.S. combatants to 1%
..to treat civilian wounds caused by diabetes, vascular diseases and trauma.
@2006jan23 dxc
^WRIST X-RAY
{73100}
^X-RAY STUDIES OF THE ESOPHAGUS
-USES:
..in addition to the standard barium meal,video- and cinefluoroscopy aid
..detecting anatomic conditions (eg, esophageal webs)
..assessing motor disorders (eg, cricopharyngeal spasm, achalasia).
^XERORADIOGRAPHY
CHEST X-RAY
{71010}
RIBS X-RAY
{71110}