PAINE #PANCE Pearl – Pulmonology


Carcinoid lung tumors are a rare pulmonary malignancy and have classic, characteristics signs and symptoms associated with them.

  1. What are the PULMONARY specific symptoms?
  2. What are the classic SYSTEMIC symptoms of carcinoid syndrome?


  1. Carcinoid lung tumors typically arise in the proximal airways and patienta can have obstructing symptoms such as dyspnea, cough, wheezing, chest pain, and recurrent pneumonia due to impaired sputum clearance. These tumors are also hypervascular and hemoptysis is also common.
  2. Since carcinoid tumors are neuroendocrine tumors they produce and secrete a host of vasoactive substances that can cause a host of specific signs and symptoms. The classic presentation for carcinoid syndrome include flushing, telangiectasias, diarrhea, and bronchospasm


Cheyne-Stokes Respirations

Other Known Aliasesnone

Definitionoscillating, crescendo-decrescendo pattern of progressive deeper and faster breathing followed a gradual decrease culminating in a period of apnea

Clinical Significance this pattern is theorized to be a delay in changes to ventilation after detection of PaCO2 changes. This lag causes the classic respiratory pattern. Conditions associated with this include cardiac disease, neurologic disease, sedation, acid-base disturbances, prematurity in infancy, and rapid altitude changes.

HistoryNamed after John Cheyne (1777-1836) , who was a British surgeon and received his medical doctorate at the age of 18 from Edinburgh University. He would serve as a military surgeon for several years before joining his father’s medical practice and ultimately, moving to Dublin for the majority of his career. Some have credited him as “The Father of Medicine in Ireland”. He would describe his eponymous findings in his 1818 article entitled ” A case of apoplexy in which the fleshy part of the heart was converted to fat”

William Stokes (1804-1878), was an Irish physician and received his medical doctorate from the University of Edinbugh in 1825. He was a leader and pioneer in the adaptation of the Parisian school of anatomical diagnosis and helped introduce the stethoscope to clinical practice in Ireland. He would note his eponymous findings in his 1854 textbook entitled ” The Diseases of the Heart and Aorta” and cited Dr. Cheyne as observing this first.


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. Cheyne J. A case of apoplexy in which the fleshy part of the hear was converted into fat. Dubin Hospital Records. 1818;2:216-223. [link]
  7. Stokes W. The Diseases of the Heart and the Aorta. 1954. Dublin. [link]

#62 – Pleural Effusions


Pleural Anatomy and Physiology

  • 2 types of pleura in the thorax
    • Parietal pleura
      • Which covers the chest wall and diaphragm
      • 30-40 micrometers thick
      • Contains lymphatic stomata
        • Holes between the mesothelial and subpleural layers that allow for drainage into the lymphatic system
      • Contains intercostal microvessels
        • Produce interpleural fluid
    • Visceral pleura
      • Which covers the lung parenchyma
      • 20-80 micrometers thick
      • Contain bronchial microvessels
        • Arise from pulmonary veins and produce interpleural fluid
  • The interpleural space is between them and produces 0.1-0.2 mL/kg (10-20 mL per hemithorax) of fluid to keep these pleura from adhering to each other and maintain lubrication
    • This fluid is constantly produced (0.01 mL/kg/hr) and absorbed
    • Originates from the systemic pleural microvessels
      • Theorized that parietal is more important
        • Intercostal microvessels are closer to the interpleural space
        • Higher filtration pressure than pulmonary veins
    • Dependent on balance of hydrostatic pressure opposed by the counterbalancing osmotic pressure and membrane permeability
      • Transudative fluid collection
        • Increased hydrostatic pressure
        • Decreased oncotic pressure
      • Exudative fluid collection
        • Decreased pleural membrane permeability
        • Lymphatic blockage

Associated Diseases and Causes

Clinical Presentation

  • Symptoms      
    • Patients can be asymptomatic, have fluid specific symptoms, and have disease specific symptoms
    • Fluid specific
      • Dyspnea
      • Cough
      • Pleuritic chest pain
    • Disease specific
      • Fever, hemoptysis, orthopnea, peripheral edema, weight changes, ascites
  • Physical Examination
    • Fluid specific
      • Decreased or asymmetric chest wall movement
      • Decreased breath sounds
      • Dullness to percussion
      • Decreased tactile fremitus
      • Pleural friction rub
      • (+) egophony
    • Disease specific
      • Crackles, JVD, hepatosplenomegaly, lymphadenopathy, S3 gallop, pitting edema,

Imaging in Suspected Pleural Effusions

  • Chest Radiograph
    • Blunting of the costophrenic angle
      • At least 150mL needed on PA
      • At least 50mL needed on lateral decubitus
    • At least 500mL needed for diaphragm obliteration
  • Computed Tomography
    • Can detect as little as 2mL of fluid
  • Ultrasound
    • Can detect as little as 20mL
    • Phased array probe with patient sitting upright
    • Scan posterior/lateral caudal to cranial to find fluid line
    • (+) spine sign


  • Once the diagnosis is made, a thoracentesis needs to be performed for biochemical fluid analysis

Fluid Analysis

  • Routine fluid labs
    • Cell count and differential
    • pH
    • Protein
    • LDH
    • Glucose
    • Cholesterol
  • Non-routine
    • N-terminal BNP
    • Triglycerides
    • Creatinine
    • Amylase
    • Cancer-related biomarkers
  • Lights Criteria
    •  Exudative if one (1) of following present:
      • Pleural/serum protein ratio > 0.5
      • Pleural/serum LDH > 0.6
      • Pleural fluid LDH > 2/3rd ULN of serum LDH
    • Lights Criteria Criticism
      • Needs both pleural fluid and serum
      • Newer studies use only pleural fluid
        • Exudative if one (1) of the following:
          • Pleural fluid cholesterol > 45 mg/dL
          • Pleural fluid protein > 2.6 g/dL
          • Pleural fluid LDH > 0.45x ULN of serum LDH


  • Non-malignant effusions
    • Treat underlying condition
    • Repeated drainage for symptomatic patients
    • If persistent:
      • Repeat thoracentesis as needed
      • Revisit primary diagnosis
      • Consider pleurodesis
        • Chemical
          • Talc slurry or doxycycline through chest tube
        • Mechanical
          • VATS
      • Indwelling pleural catheter
        • Reserved for patients who decline, fail, or not candidates for pleurodesis
  • Malignant effusions
    • Can be complicated

Cottage Physician (1898)


  1. Lai-Fook SJ. Pleural mechanics and fluid exchange. Physiol Rev. 2004; 84(2):385-410. [pubmed]
  2. Jantz MA, Antony VB. Pathophysiology of the pleura. Respiration. 2008; 75(2):121-33. [pubmed]
  3. Feller-Kopman D, Light R. Pleural Disease. N Engl J Med. 2018; 378(8):740-751. [pubmed]
  5. Saguil A, Wyrick K, Hallgren J. Diagnostic approach to pleural effusion. Am Fam Physician. 2014; 90(2):99-104. [pubmed]
  6. Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA. 2009; 301(3):309-17. [pubmed]
  7. Chesnutt AN, Chesnutt MS, Prendergast NT, Prendergast TJ. Pleural Effusion. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. McGraw-Hill; Accessed July 05, 2020.
  8. Light RW. Disorders of the Pleura. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill; Accessed July 05, 2020.
  9. Moskowitz H, Platt RT, Schachar R, Mellins H. Roentgen visualization of minute pleural effusion. An experimental study to determine the minimum amount of pleural fluid visible on a radiograph. Radiology. 1973; 109(1):33-5. [pubmed]
  10. Radiopaedia. Pleural Effusions.
  11. Gonlugur U, Gonlugur TE. The distinction between transudates and exudates. J Biomed Sci. 2005; 12(6):985-90. [pubmed]
  12. Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. Chest. 1997; 111(4):970-80. [pubmed]
  13. Steger V, Mika U, Toomes H, et al. Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses. Ann Thorac Surg. 2007; 83(6):1940-5. [pubmed]
  14. Patil M, Dhillon SS, Attwood K, Saoud M, Alraiyes AH, Harris K. Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis. Chest. 2017; 151(3):626-635. [pubmed]
  15. Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018; 198(7):839-849. [pubmed]
  16. Bibby AC, Dorn P, Psallidas I, et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J. 2018; 52(1):. [pubmed]


Light’s Criteria

Other Known Aliasesnone

Definitionset of laboratory findings in pleural effusions that helps differentiate the fluid as transudative or exudative

Clinical Significance after performing a diagnostic thoracentesis, the fluid can be sent to the lab for biochemical analysis. The results of this analysis can tell the medical team the whether the fluid is transudative or exudative, which can narrow down the causes and provide a diagnostic schema for management.

HistoryNamed after Richard W. Light, a practicing pulmonologist from Vanderbilt University in Nashville, TN. He received his medical doctorate from Johns Hopkins University in 1968 and completed his residency and fellowship there in 1972. He would spend the next 20 years at UC-Irvine building his international reputation as an expert on pleural diseases. He is the author and editor for 16 current textbooks, including the gold standard textbooks Pleural Diseases and The Textbook of Pleural Diseases, as well as authored more than 450 peer reviewed articles. His eponymous criteria were first introduced in 1972 in an article he published as a fellow in the Annals of Internal Medicine….his very first paper as a physician.


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972; 77(4):507-13. [pubmed]
  7. Biography of Richard Light.
  8. Newman JH. Giants in chest medicine: Richard W. Light, MD. Chest. 2014; 146(5):1152-1154. [pubmed]

PAINE #PANCE Pearl – Surgery


Surgery is a major physiologic stress and often is accompanied by biochemical derangements that effect homeostasis in the post-operative period. Describe the most common clinical scenarios that can cause each of the four main acid-base imbalances in a post-surgical patient.


  • Metabolic Acidosis
    • Lactic acidosis (HAGMA)
      • Under-resuscitation
      • Blood loss
    • Hyperchloremia (NAGMA)
      • High chloride load from NaCl
  • Metabolic Alkalosis
    • Volume contraction and bicarbonate reabsorption
    • GI loss from NG tube suction or emesis
  • Respiratory Acidosis
    • Opioid medications causing depressed respiratory drive
  • Respiratory Alkalosis
    • Splinting from pain


Roux-en-Y Anastomosis

Other Known Aliasesend-to-end surgical anastomosis

Definitiongastrointestinal tract is divided into two limbs (proximal, Roux limb and a distal limb) and are re-anastomosed farther down the GI tract, typically in the jejunum

Clinical Significance this type of surgery is the traditional form of gastric bypass, where the proximal, Roux limb serves as the food reservoir and somach and the distal limb allows for physiologic drainage of gastric, hepatic, and pancreatic enzymes to aid in digestion. Other conditions it can be used is are chronic pancreatitis, alkaline gastritis, and various GI substitution procedures.

HistoryNamed after César Roux (1857-1934), who was a Swiss surgeon and received his medical doctorate from the University of Bern 1880. He would stay on at his alma mater and assist Theodor Kocher until 1887, when he became chief of surgery at cantonal hospital of Lausanne. He would go on to have a modest career in surgery notable for two historical accomplishments. In 1893, he performed his eponymous procedure on a patient with gastric strictures from peptic ulcer disease to alleviate his obstruction symptoms. In 1926, the year of his retirement, he was the first surgeon to successfully remove a pheochromocytoma….7 months before Charles Mayo performed the same operation in the United States. Harvey Cushing visited his clinic in 1900 and said “he is a rough diamond-looks like Kipling-does excellent work and comes nearer to being the kind of man I am looking for than anyone else I have seen”.


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. C. Roux. De la gastroenterostomie. Revue de chirurgie, 1893, 13: 402-403.
  7. Hutchison R, Hutchinson AL. César Roux and His Original 1893 Paper. Obesity Surgery. 2010;20;953-956 [link]

PAINE #PANCE Pearl – Surgery


Surgery is a major physiologic stress and often is accompanied by biochemical derangements that effect homeostasis in the post-operative period. Describe the most common clinical scenarios that can cause each of the four main acid-base imbalances in a post-surgical patient.


Whipple Procedure

Other Known Aliasespancreaticoduodenectomy

Definitionpancreaticoduodenectomy cholecystectomy, choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy

Clinical Significance this type of surgery is performed to resect pancreatic head tumors. It generally performed at large, high-volume medical centers as this has been shown to reduce mortality to less than 5%. An experienced surgeon can complete this surgery in < 6 hours with < 500mL of blood loss. Barring any postoperative complications, most patients are discharged from the hospital in 7-10 days.

HistoryNamed after Allen Oldfather Whipple (1881-1963), who was an American surgeon and received his medical doctorate from Columbia University College of Physicians and Surgeons in 1908. He was appointed faculty at Columbia and Presbyterian Medical Centers before going on to become professor of surgery at his alma mater for the next 25 years. He published the report of his eponymous surgery in 1935 and only performed it 37 times in his lifetime. He also supervised Virginia Apgar and advised her to pursue a career in anesthesiology because he saw an “energy and ability to make significant contributions” that would advance both fields. Other notable accomplishments include helping establish the American Board of Surgery and establishing another eponymous diagnostic triad for insulinoma.


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. Whipple AO, Parsons WB, Mullins CR. TREATMENT OF CARCINOMA OF THE AMPULLA OF VATER. Ann Surg. 1935; 102(4):763-79. [PDF]
  7. Johna S. Allen Oldfather Whipple: A Distinguished Surgeon and Historian Dig Surg. 2003; 20(2):154-162. [link]

#61 – Cholelithiasis and Cholecystitis



  • 4 anatomic areas of gall bladder
    • Fundus
      • Rounded, blind end that extends 1-2 cm beyond the liver margin
      • Contains most of the smooth muscle
    • Body
      • Main storage area
      • Contains the elastic tissue allowing for distention
        • Normally holds 30-50mL and can stretch to 300mL
    • Infundibulum (Hartmann’s Pouch)
      • Mucosal outpouching at the junction of the neck and cystic duct
    • Neck
      • Lies in the deepest part of the fossa
  • Cystic Artery
    • Branch of the right hepatic artery
    • Found in the cystohepatic triangle
      • Cystic duct, common hepatic duct, superior/inferior margin of liver
      • Triangle of Calot
        • Cystic duct, common hepatic duct, cystic artery
        • Lymph node can be found in near the insertion of the cystic artery
          • Calot’s node (Lund’s or Mascagni’s)
  • Cystic duct
    • Spiral valves of Heister
      • Mucosal folds in the proximal cystic duct that make cannulation difficult
    • Joins the common hepatic duct to form the common bile duct
    • Highly variable anatomy


  • 80% of bile is stored in the gall bladder
    • Infundibulum secretes glycoproteins to protect mucosa
  • Cholecystokinin released from neuroendocrine cells of the duodenum during meal
    • Stimulates release of bile from gallbladder
      • 50-70% over 30-40 minutes
    • Causes relaxation of Sphincter of Oddi
  • Vagal stimulation causes contraction of gallbladder

Stone Formation

  • Major solutes in bile are bilirubin, bile salts, phospholipids (lecithin), and cholesterol
  • 80% are cholesterol
    • Supersaturation of bile with cholesterol exceeds the ability of phospholipids and bile salts to maintain solubility

Pathogenesis of Cholecystitis

  • Phospholipid A (secreted by the gall bladder mucosa) released in response to gall bladder trauma (stone)
    • Catalyzes conversation of lecithin to lysolecithin
      • Leads to mucosal and luminal irritation and inflammation

Epidemiology and Risk Factors

  • 90-95% of patients with cholecystitis have stones
    • Only 20% of patients with stones with develop cholecystitis
    • 10-15% of patients have stones on autopsy
  • Risk Factors
    • High fat diet
    • Older age
    • Female > male
    • Higher BMI
      • Rapid weight loss
    • Pregnancy
    • Previous surgeries
      • Terminal ileum resection, gastric/duodenal surgery

Signs and Symptoms

  • History
    • Right upper quadrant abdominal pain
      • Steady, “boring” pain lasting hours
      • Worsened by fatty foods
    • Right scapular pain (Boas’ sign)
      • Hyperesthesia between 9th-11th rib
    • Fever, nausea, vomiting, anorexia
  • Physical Examination
    • Fever, tachycardia
    • Peritoneal signs
      • Pain with movement and percussion
    • Voluntary and involuntary guarding
    • +/- jaundice
    • Inspiratory arrest on deep RUQ palpation (Murphy’s sign)

Diagnostic Studies

  • Laboratory Studies
    • Leukocytosis with neutrophilic shift
    • LFTs generally normal, but may show:
      • Elevated direct (conjugated) bilirubin
      • Elevated alkaline phosphatase
      • Elevated GGT
  • Ultrasound is the initial test of choice
    • Length > 10 cm
    • Wall thickness > 3mm
    • Pericholecystic fluid
    • Sludge
  • Cholescintigraphy using 99m Tc-hepatic iminodiacetic acid (HIDA) Scan
    • Used if ultrasound is inconclusive
    • Intravenous injection of HIDA and visualization of dye in gallbladder, bile ducts, and small bowel within 30-60min
      • If not visualized after 1 hour, morphine can be given and waiting 3-4 hours
        • If no visualization = cholecystitis
  • Magnetic Resonance Cholangiopancreatography (MRCP)
    • Used if evidence of choledocolithiasis or elevated LFTs


  • Admission
  • IV fluids
  • NSAIDs
    • Ketorolac 30-60mg IV/IM
  • Opioids
    • Meperidine NOT superior to morphine
  • Antibiotics
    • Low Risk
    • High Risk
  • Indication for Emergent Cholecystectomy
    • Necrosis
    • Perforation
    • Emphysematous cholecystitis
    • High fever
    • Hemodynamic instability
  • Interval Cholecystectomy (low risk)
    • Within 3 days of admission after therapies above and clinical improvement
    • Most can be discharged in 1-2 days postop
  • Gall bladder drainage (high risk)
    • Percutaneous cholecystostomy
      • Critically ill or septic
      • > 72 hours from symptom onset
      • Failure of antibiotic therapy
      • No coagulopathy
    • Endoscopic transpapillary/transmural drainage
      • Liver disease
      • Ascites
      • Coagulopathy
    • If improvement within 72 hours, proceed with laparoscopic cholecystectomy
      • If not, may need emergent open cholecystectomy
Percutaneous Cholecystostomy

Management Algorithm

Steps of Laparoscopic Cholecystectomy

  1. Dissect peritoneum overlying the cystic duct and artery
  2. Division and clipping of cystic duct close to gallbladder
    • Perform intraoperative cholangiogram to evaluate CBD
    • If clear, then two clips close to common bile duct and ligate
  3. Dissect cystic artery, one clip close distal and two clips proximal, and ligate
  4. Dissection of gall bladder from liver bed
  5. Cauterize, irrigate, suction, and obtain hemostasis of liver bed
  6. Remove gall bladder

Cottage Physician (1898)


  1. Blackbourne LH.  Surgical Recall.  6th Edition.  2012.
  2. Halpin V. Acute cholecystitis. BMJ Clin Evid. 2014; 2014:. [PDF]
  3. Haisley KR, Hunter JG. Gallbladder and the Extrahepatic Biliary System. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz’s Principles of Surgery, 11e. McGraw-Hill; Accessed June 14, 2020.
  4. Haubrich WS. Calot of the triangle of Calot. Gastroenterology. 2002; 123(5):1440. [pubmed]
  5. Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996; 28(3):267-72. [pubmed]
  6. Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994; 154(22):2573-81. [pubmed]
  7. Park MS, Yu JS, Kim YH, et al. Acute cholecystitis: comparison of MR cholangiography and US. Radiology. 1998; 209(3):781-5. [pubmed]
  8. Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol. 2001; 96(4):1266-72. [pubmed]
  9. Okamoto K, Suzuki K, Takada T, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25(1):55-72. [pubmed]
  10. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(2):133-64. [pubmed]
  11. Hatzidakis AA, Prassopoulos P, Petinarakis I, et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol. 2002; 12(7):1778-84. [pubmed]