428 Section II / General Surgery

What is secondary hyperaldosteronism?

What diagnostic tests should be performed?

What is the saline infusion test?

What is the preoperative treatment?

What is spironolactone?

What are the causes of Conn’s syndrome?

What is the treatment of the following conditions:

Adenoma?

Unilateral hyperplasia?

Bilateral hyperplasia?

What are the renin levels in patients with PRIMARY hyperaldosteronism?

ADDISON’S DISEASE

Hyperaldosteronism resulting from abnormally high renin levels (renin increases angiotensin/aldosterone)

CT scan, adrenal venous sampling for aldosterone levels, saline infusion

Saline infusion will decrease aldosterone levels in normal patients but not in Conn’s syndrome

Spironolactone, K supplementation

Antialdosterone medication (works at the kidney tubule)

Adrenal adenoma (66%)

Bilateral idiopathic adrenal hyperplasia (30%)

Adrenal cancer ( 1%)

Unilateral adrenalectomy (laparoscopic)

Unilateral adrenalectomy (laparoscopic)

Spironolactone (usually no surgery)

Normal or low (key point!)

What is it?

What are the electrolyte findings?

How do you remember what ADDISON’s disease is?

Acute adrenal insufficiency

HYPERkalemia, hyponatremia

Think: ADDison’s disease ADrenal Down

What is the incidence?

What are the associated risks?

What are the signs/ symptoms?

What are the neurologic symptoms?

What is Whipple’s triad?

Chapter 57 / Endocrine 429

#1 Islet cell neoplasm; half of cell tumors of the pancreas produce insulin

Associated with MEN-I syndrome (PPP Pituitary, Pancreas, Parathyroid tumors)

Sympathetic nervous system symptoms resulting from hypoglycemia: palpitations, diaphoresis, tremulousness, irritability, weakness

Personality changes, confusion, obtundation, seizures, coma

1.Hypoglycemic symptoms produced by fasting

2.Blood glucose 50 mg/dL during symptomatic attack

3.Relief of symptoms by administration of glucose

What is the differential diagnosis?

Reactive hypoglycemia Functional hypoglycemia with

gastrectomy Adrenal insufficiency Hypopituitarism Hepatic insufficiency

Munchausen syndrome (insulin self-injections)

Nonislet cell tumor causing hypoglycemia Surreptitious administration of insulin or

OHAs

What lab tests should be performed?

Glucose and insulin levels during fast; C-peptide and proinsulin levels (if selfinjection of insulin is a concern, as insulin injections have no proinsulin or C-peptides)

What diagnostic tests should be performed?

Fasting hypoglycemia with inappropriately high levels of insulin

72-hour fast, then check glucose and insulin levels every 6 hours (monitor very closely because patient can develop hypoglycemic crisis)

430 Section II / General Surgery

What is the diagnostic fasting insulin to glucose ratio?

What localizing tests should be performed?

0.4

CT scan, A-gram, endoscopic U/S, venous catheterization (to sample blood along portal and splenic veins to measure insulin and localize tumor), intraoperative U/S

What is the medical treatment?

What is the surgical treatment?

What is the prognosis?

GLUCAGONOMA

Diazoxide, to suppress insulin release

Surgical resection

80% of patients have a benign solitary adenoma that is cured by surgical resection

What are the skin findings?

Necrotizing migratory erythema is a red, often psoriatic-appearing rash with serpiginous borders over the trunk and limbs

What is the associated syndrome?

What percentage of patients with ZES have MEN-I syndrome?

What percentage of patients with MEN-I will have ZES?

MEN-I syndrome

25% (75% of cases of Z-E syndrome are “sporadic”)

50%

432 Section II / General Surgery

With gastrinoma, what lab tests should be ordered to screen for MEN-I?

What are the signs/ symptoms?

What causes the diarrhea?

What are the signs?

What are the possible complications?

What is the differential diagnosis of increased gastrin?

Which patients should have a gastrin level checked?

What lab tests should be performed?

What are the associated gastrin levels?

What is the secretin stimulation test?

1.Calcium level

2.Parathyroid hormone level

Peptic ulcers, diarrhea, weight loss, abdominal pain

Massive acid hypersecretion and destruction of digestive enzymes

PUD (epigastric pain, hematemesis, melena, hematochezia), GERD, diarrhea, recurrent ulcers, ulcers in unusual locations (e.g., proximal jejunum)

GI hemorrhage/perforation, gastric outlet obstruction/stricture, metastatic disease

Postvagotomy

Gastric outlet obstruction

G-cell hyperplasia

Pernicious anemia

Atrophic gastritis

Short gut syndrome

Renal failure

H2 blocker, PPI

Those with recurrent ulcer; ulcer in unusual position (e.g., jejunum) or refractory to medical management; before any operation for ulcer

Fasting gastrin level

Postsecretin challenge gastrin level Calcium (screen for MEN-I) Chem 7

NL fasting 100 pg/ml

ZES fasting 200–1000 pg/ml

Basal acid secretion; (ZES 15 mEq/hr, nl 10mEq/hr)

IV secretin is administered and the gastrin level is determined; patients with ZES have a paradoxic increase in gastrin

How can you remember the diagnostic stimulation test for Z-E syndrome?

What tests are used to evaluate ulcers?

What tests are used to localize the tumor?

What is the most common site?

What is the most common NONpancreatic site?

What are some other sites?

Define “Passaro’s triangle.”

Think: “Secret Z-E GAS”: SECRETin

Z-E GAStrin

EGD, UGI, or both

Octreotide scan (somatostatin receptor scan), abdominal CT, MRI, endoscopic ultrasonography (EUS)

Pancreas

Duodenum

Stomach, lymph nodes, liver, kidney, ovary

A.k.a. “gastrinoma triangle,” a triangle drawn from the following points:

1.Cystic duct/CBD junction

2.Junction of the second and third portions of the duodenum

3.Neck of the pancreas

434 Section II / General Surgery

What percentage of gastrinomas are in Passaro’s triangle?

What is the next step if the tumor cannot be localized?

What is the medical treatment?

What is the surgical treatment needed for each of the following: Tumor in head of

pancreas?

Tumor in body or tail of pancreas?

Tumor in duodenum?

Unresectable tumor?

What percentage have malignant tumors?

What is the most common site of metastasis?

What is the treatment of patients with liver metastasis?

What is the surgical option if gastrinoma is in duodenum/head of pancreas and is too large for local resection?

80%

Exploratory surgery (if tumor is not in pancreas, open duodenum and look), proximal gastric vagotomy if not found

H2 blockers, omeprazole, somatostatin

1.Enucleation of tumor

2.Whipple procedure if main pancreatic duct is involved

Distal pancreatectomy

Local resection

High selective vagotomy

66%

Liver

Excision, if technically feasible

Whipple procedure