A 65-year-old Asian American man comes to the clinic for a follow-up appointment for
symptoms of dysphagia. He has had difficulty swallowing solid food off and on for the
past year. He has no difficulty swallowing liquids or pills. He has no significant medical
problems and his only medication is an occasional aspirin for arthritis pain in his knees.
He denies cigarette smoking, but he does drink 1-2 glasses of wine each week. An
outpatient esophagram was performed 3 days ago and the x-ray shown is one of the
films obtained during the study. Based on the findings of the esophagram, this patient is
at increased risk for developing
A. Barrett's esophagus
B. esophageal cancer
C. gastric ulcers
D. gastroesophageal reflux
E. Zencker's diverticulum
Explanation:
The correct answer is E. The esophagram demonstrates an indentation on the posterior
cervical esophagus, which is due to a hypertrophied cricopharyngeus muscle. A
Zencker's diverticulum is a pharyngoesophageal pulsion diverticulum that occurs at the
point of transition between the oblique fibers of the thyropharyngeus muscle and the
horizontal fibers of the cricopharyngeus muscle. A hypertrophied cricopharyngeus
muscle is thought to predispose the development of the diverticulum at this transition
point. This can be an incidental finding or in some patients, as in this case, it can cause
symptoms of dysphagia.
Barrett's esophagus (choice A) is a complication of gastroesophageal reflux disease.
There is metaplasia of the normal cells in the esophagus to what is called "specialized
columnar epithelium". Chronic damage from the acidic gastric contents is believed to
promote the replacement of the normal esophageal epithelium with the metaplastic
columnar cells. This is a predisposing condition for adenocarcinoma of the esophagus.
There is no association with hypertrophy of the cricopharyngeus muscle.
There is no relationship between a hypertrophied cricopharyngeus muscle and
esophageal cancer (choice B).
There is no relationship between a hypertrophied cricopharyngeus muscle and gastric
ulcers (choice C).
There is no relationship between a hypertrophied cricopharyngeus muscle and
gastroesophageal reflux (choice D). Reflux can occur due to a hiatal hernia or a
dysfunctional lower esophageal sphincter.
A 55-year-old banker comes to the office for a routine initial visit. He says that
he has no significant past medical or surgical history. He takes no
medications except for a daily multivitamin. His family history reveals that his
1
mother died of breast cancer and his father committed suicide when he was 5
years old. On further questioning, he reports that he has been working 10 to
12 hours a day and is feeling very stressed at work. He has been drinking 2
to 3 beers a night to help relieve the stress and help him get some sleep. He
vehemently denies ever experimenting with intravenous drugs, but currently
uses marijuana about once a month. He has had 3 different sexual partners
over the past month and does not routinely use condoms. Physical
examination reveals a nodular liver edge of 9-cm in diameter and a tender
abdomen in the right upper quadrant but no rebound or guarding. His
Murphy's sign is negative. His liver function panel shows:
The factor in this patient's history most closely correlated with his condition is
A. alcohol intake
B. drug use
C. family history of cancer
D. His history correlates with biliary tract disease.
E. unsafe sexual practices
Explanation:
The correct answer is E. This patient has multiple different reasons to have
liver damage and cirrhosis. The liver function panel indicates that this patient
probably has cirrhosis, as indicated by synthetic liver disease (coagulopathy
and decreased albumin). His transaminases are more consistent with a viral
etiology than alcoholic hepatitis (ALT>AST), probably viral hepatitis from a
sexual encounter.
Alcoholic hepatitis (choice A) commonly causes liver disease characterized
with an elevated AST > AST. Additionally, cirrhosis secondary to alcoholic
hepatitis routinely causes an enlarged liver edge rather than a normal or
small-sized liver.
The most common cause of viral hepatitis/cirrhosis in the United States is
hepatitis C as a result of intravenous drug use (choice B). However, this
patient denies ever using intravenous drugs and given his candor during the
interview, there is no reason to suspect that he is lying. Marijuana has not
been linked to hepatitis.
The patient's family history of cancer (choice C) doesn't correlate to an
2
increased risk of liver disease.
This patient has a negative Murphy's sign and a normal alkaline
phosphatase. It is incorrect to say that nothing in his history suggests biliary
disease (choice D), because his unsafe sexual practices increase his risk of
hepatitis.
A 51-year-old man is post-procedure day number 2 from an upper endoscopy
and banding for bleeding esophageal varices. The patient has a 7-year
history of chronic active hepatitis and over the past few years has developed
stigmata associated with cirrhosis and worsening portal hypertension. Three
days ago, he presented to the emergency department with bright red blood
per mouth and rectum and a nasogastric tube evacuated bright red blood and
coffee grounds from the patient's stomach. He was admitted to the hospital,
transfused with 2 units of red blood cells and underwent an endoscopy. On
preparation for the patient's discharge, you have a long discussion with your
patient about the course of events. In counseling this patient on his future
risks and course of therapy, you should advise him that:
A. The risk of rebleeding is between 50% and 80% and medical
therapy is indicated
B. The risk of rebleeding is between 50% and 80% and surgical
therapy is indicated
C. The risk of rebleeding is between 50% and 80%, but no therapy is
indicated given the nature of the problem
D. There is no concern for rebleeding
E. There is no concern for rebleeding, he is an imminent candidate for
transplant
Explanation:
The correct answer is A. There is overwhelming data to support the
treatment strategy of some sort of medical therapy (beta blockade,
sclerotherapy, banding) for all patients with an episode of variceal bleeding.
The risk of rebleeding is high and approaches 80% in most series at 1-year.
There is excellent data showing the efficacy of portal-systemic surgical
shunts (side-to-side caval, end-to-side caval, distal splenorenal, TIPS) in
secondary prevention. Medical therapy is indicated in all patients and all
patients should be offered the option of a surgical shunt. The largest
drawback to these procedures is their resultant incidence of
encephalopathy.
The risk or rebleeding is between 50% and 80% and surgical therapy is
indicated (choice B) is incorrect because there are nonsurgical options
available. These options include beta blockade, sclerotherapy, and banding.
It is incorrect to say that the risk of rebleeding is between 50% and 80% but
no therapy is indicated given the nature of the problem (choice C). As stated
3
above, therapy options include beta blockade, sclerotherapy, banding, and
hopefully a liver transplant.
There is a 50% and 80% chance of rebleeding, therefore, there is no
concern for rebleeding (choice D) is incorrect.
Liver transplant (choice E) is of course curative and its 5-year survival rate of
approximately 70% is superior to cirrhotics with Child class C disease who
are treated by other modalities. This answer is incorrect because it starts
with "there is no concern for rebleeding," which is incorrect.
A 58-year-old woman comes to the emergency department complaining of
crampy left upper quadrant pain that is exacerbated by fatty foods. She has a
history of diabetes, hyperlipidemia, and gallstones and her medications
include glyburide, simvastatin, and aspirin. She denies any alcohol or drug
use. She is morbidly obese and her temperature is 37.9 C (100.2 F), blood
pressure is 102/87 mm Hg, pulse is 105/min, and respirations are 23/min. On
examination, her lungs are clear to auscultation bilaterally. Her cardiac
sounds are muffled, although her cardiac rhythm is regular. No murmurs are
audible. She has definite left upper quadrant tenderness to palpation, without
rebound or guarding. Rectal examination shows guaiac-negative brown stool.
Her amylase and lipase levels are elevated. The most appropriate next step
is to order a
A. an abdominal ultrasound
B. a chest radiograph
C. an electrocardiogram
D. a HIDA scan
E. an upper endoscopy
Explanation:
The correct answer is A. Given that this patient has pancreatitis, it is
reasonable to suspect gallstones as its etiology given the available
epidemiologic factors (sex, age, obesity). If gallstones are present, an ERCP
and gallstone removal can be considered.
A chest radiograph (choice B) is not indicated at this juncture given that her
lung exam is benign and there is no evidence of a pulmonary pathology.
An electrocardiogram (choice C) is not indicated at this juncture since
cardiac pathology is not evident on history or exam and the patient appears
to be in sinus rhythm.
A HIDA scan (choice D), sometimes used for the diagnosis of cholecystitis,
is not used in the diagnosis of pancreatitis. An upper endoscopy (choice E)
is not indicated in the setting of pancreatitis without confounding pathologies
4
such as variceal bleeding or gastric ulceration.
A 55-year-old woman comes to the emergency department because of
abdominal pain. She had just finished eating a steak dinner with her family
when she suddenly experienced sharp, crampy pain in the upper right and
middle of her abdomen. The pain has lasted for the past 3 hours and she is
starting to feel nauseous. On physical examination, she is obese and in
obvious discomfort. Her temperature is 38.8 C (101.8 F), blood pressure is
140/87 mm Hg, pulse is 90/min, and respirations are 16/min. Abdominal
examination is significant for focal tenderness and guarding in her right upper
quadrant. She is particularly tender when you palpate her right upper
quadrant as she takes in a deep breath. The most appropriate next step in
the evaluation of her abdominal pain is
A. an abdominal x-ray
B. a CT of the abdomen
C. an endoscopic retrograde cholangiopancreatography (ERCP)
D. serum liver function tests including bilirubin
E. an ultrasonography of the abdomen
Explanation:
The correct answer is E. Crampy pain in the right upper quadrant or
epigastrium is classic for biliary colic. The pain is thought to be due to
obstruction of the cystic duct by gallstones and often follows a fatty meal.
Acute cholecystitis is a concern when biliary colic is accompanied by a fever,
leukocytosis, nausea, and vomiting. Right upper quadrant pain precipitated
by deep inspiration during palpation is known as Murphy's sign and is highly
suggestive of acute cholecystitis. The presence of gallstones in the clinical
setting of right upper quadrant pain and fever is sufficient to make the
diagnosis of acute cholecystitis. Ultrasonography of the abdomen is the
diagnostic test of choice to evaluate for gallstones. Ultrasonography is highly
sensitive and specific for gallstones, and can also demonstrate inflammation
of the gallbladder. During ultrasonography, a sonographic Murphy's sign can
also be tested for by using the transducer to press over the region of the
gallbladder. The presence of gallstones and a sonographic Murphy's sign
are highly suspicious for acute cholecystitis.
An abdominal x-ray (choice A) is not a good study to evaluate for gallstones.
Most gallstones are composed of cholesterol and are radiolucent on
abdominal x-rays. Only 10-15% of gallstones contain enough calcium to
appear radio opaque on x-rays.
A CT of the abdomen (choice B) is not the first or the best test in the
evaluation of gallstones or acute cholecystitis. Most gallstones are
composed of cholesterol and may not be clearly distinguishable from
5
adjacent bile in the gallbladder on a CT scan. A CT scan provides
information about inflammation around the gallbladder and biliary ductal
dilatation, but it is not a sensitive or specific diagnostic study for gallstones.
An endoscopic retrograde cholangiopancreatography or ERCP (choice C) is
performed by gastroenterologists to evaluate the biliary ductal system. It is
the procedure of choice when a common bile duct stone or
choledocholithiasis is suspected. When a patient has gallstones and
common bile duct dilatation on ultrasonography of the abdomen, ERCP is
useful in the evaluation of the biliary system as well as for clearing the
obstructing stone. ERCP is not indicated in cases of simple biliary colic or
acute cholecystitis without signs of common bile duct obstruction.
Serum liver function tests including bilirubin (choice D) can provide useful
information about biliary obstruction. Elevated bilirubin and frank jaundice
are clinical indicators of biliary obstruction, most commonly in the common
bile duct. These serum laboratory tests do not help in the diagnosis of
gallstones or acute cholecystitis.
A 78-year-old woman comes to the geriatric clinic for a follow-up appointment. She was
seen 3 weeks ago in the clinic for a routine appointment and was found to have a
hematocrit of 28%. A rectal examination was positive for heme in the stool. Her only
complaint is a long history of constipation. She has multiple medical problems including
6
diabetes, hypertension, osteoarthritis, and a history of a myocardial infarction many
years ago. To further evaluate her anemia, additional laboratory testing was initiated at
that time. Since her last appointment, she had an outpatient barium enema and is now
returning for the results of all her tests. An x-ray of the recto-sigmoid colon from the
barium enema examination is shown. Serum laboratory tests are as follows:
At this time, the most appropriate next step is to
A. admit the patient to the hospital for further evaluation
B. do a colonoscopy
C. encourage the patient to eat a high fiber diet
D. order serum carcinoembryonic antigen (CEA-125)
E. prescribe iron supplements
Explanation:
The correct answer is B. A colonoscopy is the most appropriate next step in the
management of this patient. Her laboratory tests reveal a microcytic anemia with a low
ferritin, which is consistent with an iron deficiency anemia. This is a common
presentation of colon cancer. The barium enema demonstrates an irregular lesion in the
sigmoid colon that is highly suspicious for an adenocarcinoma of the colon. A
colonoscopy can be performed to evaluate the entire length of the colon for polyps and
masses. It can better characterize the extent of the lesion detected on the barium
enema, as well as allow for a biopsy of the lesion for definitive tissue diagnosis.
Admitting the patient to the hospital for further evaluation (choice A) is not necessary in
this situation. Patients with colon cancer who present with symptoms of bowel
obstruction or perforation will need to be hospitalized to treat their acute disease. This
patient is presenting with more indolent symptoms of colon cancer such as iron
deficiency anemia and chronic constipation. She can be safely evaluated as an
outpatient.
Encouraging the patient to eat a high fiber diet (choice C) is not appropriate
management. She has a lesion on the barium enema that is highly suspicious for
malignancy and requires further evaluation with colonoscopy. A high fiber diet is
recommended for patients with constipation and for the prevention of diverticulosis.
Ordering a serum carcinoembryonic antigen (CEA-125) (choice D) is not the best step
in the management of this patient. CEA-125 is a serum glycoprotein frequently used in
the management of patients once they are diagnosed with colon cancer. CEA-125 is
not a useful screening test for colorectal cancer due to the large numbers of falsepositive and false-negative reports. CEA-125 testing in postoperative patients should be
restricted to patients who will be candidates for resection, in cases of liver or lung
metastases. Routine use of CEA-125 alone for monitoring responses to treatment is not
7
recommended.
Prescribing iron supplements (choice E) is not the appropriate management of this
patient. Her iron deficiency anemia is a secondary sign of her primary diagnosis of
colon cancer. The lesion on the barium enema is highly suspicious for malignancy and
needs further evaluation with colonoscopy. Iron supplementation is good adjuvant care
for this patient, but it does not address the more immediate need to make a diagnosis.
You are seeing a 41-year-old man with alcoholic cirrhosis in your office for a
follow-up visit after a recent upper endoscopy showed significant lower
esophageal varices. His current medications include a multivitamin, folate,
and thiamine. While he strongly denies any continued alcohol use, you are
suspicious that he is still drinking. His blood pressure is 100/63 mmHg, pulse
is 98/min, and respirations are 21/min. Physical examination shows a slightly
protuberant abdomen. Given his varices, you are concerned about an upper
gastrointestinal bleed, especially in the setting of continued alcohol use.
Given this concern, the most appropriate pharmacotherapy to add to his
treatment regimen is
A. aspirin
B. atorvastatin
C. isosorbide mononitrate
D. nadolol
E. warfarin
Explanation:
The correct answer is D. Non-selective beta antagonists such as nadolol
have been shown to decrease the risk of an initial variceal bleed (through a
reduction in splanchnic blood flow) in someone with esophageal varices
(primary prevention).
Aspirin (choice A), an antiplatelet agent, has no role in the primary
prevention of variceal bleeding.
Atorvastatin (choice B), an HMG Co-A Reductase antagonist used in the
management of hyperlipidemia, has no role in the primary prevention of
variceal bleeding.
Nitrates such as isosorbide mononitrate (choice C) should not be started as
monotherapy for the primary prevention of variceal bleeding in cirrhotics
since it has been associated with increased mortality when used alone.
However, it can be used in combination with beta antagonists.
Warfarin (choice E), an oral anticoagulant against vitamin K dependent
clotting factors, has no role in the primary prevention of variceal bleeding.
A 34-year-old intravenous drug abuser who is HIV positive is admitted to the
8
hospital because of gastrointestinal bleeding. He was admitted to the hospital
2 months ago for HIV treatment. At the time of discharge, he was in good
health, able to tolerate regular diet, and take minimal medications. He went
back to work and was feeling well. Two days before presenting to the
hospital, he developed nonspecific abdominal discomfort, which he attributed
to food poisoning and treated himself with lots of hydration. The abdominal
discomfort persisted and he noticed bleeding per rectum, the night before
coming to the hospital. The next morning, he noticed more blood per rectum,
and alarmed by that, decided to come to the hospital. His temperature is 37.
C (99.1 F), blood pressure is 110/70 mm Hg, and pulse is 96/min. His
hematocrit is 28% compared with 34% on discharge a couple of months
earlier. There are no signs of hemodynamic instability. Blood is sent for cross
match and stool is sent for ova and parasites. A nasogastric tube is inserted
and returns clear fluid. The next step in the investigation of this patient's
gastrointestinal bleeding is a(n)
A. barium enema
B. colonoscopy
C. CT scan of the abdomen and pelvis
D. small bowel series
E. upper gastrointestinal endoscopy
Explanation:
The correct answer is B. A colonoscopy is the initial investigation of choice
in gastrointestinal (GI) bleeding in HIV-positive patients. Gastrointestinal
bleeding is an unusual occurrence in HIV infected individuals, but when it
does occur, it is usually related to a complication of an HIV infection. Lower
GI bleeding is twice as common as upper GI bleeding. Upper GI bleeding,
when it occurs, is related to Kaposi's sarcoma or lymphoma 50% of the time.
CMV ulcers do occur in the upper GI tract, but more frequently in lower GI
tract. Lower GI tract bleeding is usually caused by localized colitis of
infectious origin from Cytomegalovirus, herpes simplex, or bacteria. In a
stable patient, colonoscopy is the procedure of choice for localizing the
bleeding and obtaining biopsies to look for specific infections and antibiotic
sensitivities.
A barium enema (choice A) is not as useful as the first investigation, unless
a colonic carcinoma is suspected.
A CT san of the abdomen and pelvis (choice C) may show thickening of the
colon with the infiltration of fat in the surrounding mesentery, but may not be
diagnostic.
A small bowel series (choice D) is rarely indicated as the initial investigation
of choice in investigating gastrointestinal bleeding. If upper gastrointestinal
endoscopy and colonoscopy do not reveal any lesions and the patient
continues to bleed, then one should look for small bowel sources by means
9
of small bowel series or enteroscopy.
Since upper gastrointestinal tract bleeding is less common than lower
gastrointestinal tract bleeding, a upper gastrointestinal endoscopy (choice E)
is not indicated in this patient. Also, a nasogastric tube return does not show
blood in this patient. Although it is difficult to rule out upper gastrointestinal
bleeding, there is no bile in the nasogastric tube, so a colonoscopy should
still be the first investigation of choice.
A 3-year-old boy is brought to the emergency department by his parents
because of a 24-hour history of intermittent, generalized abdominal pain. The
parents tell you that he complains of the pain for 10-minute episodes and
during these times he refuses to walk, but then he spontaneously returns to
his normal activities. This occurred 8-9 times yesterday. Today the symptoms
occurred more frequently and were associated with 3 episodes of non-bloody,
non-billous emesis so the parents brought him into the hospital. There is no
history of fever, constipation, or soiling. On examination the patient appears
tired and has mild diffuse abdominal pain. He has guaiac-positive stool. His
pulse is 125/min. The study most likely to provide a diagnosis is
A. an abdominal x-ray
B. a barium enema
C. a CBC with differential
D. a CT scan of the abdomen
E. a lumbar puncture
Explanation:
The correct answer is B. This patient presents with a very common
complaint in the pediatric population, abdominal pain. The key to this case is
the quality and frequency of this abdominal pain. The pain was described as
being diffuse and intermittent with periods of resolution of the symptoms.
This type of pain pattern, along with emesis, the lethargy seen in the
emergency department, and the guaiac-positive stools should raise red flags
for the diagnosis of intussusception. In intussusception a segment of bowel
(most commonly the distal ileum into the cecum) telescopes into an adjacent
segment causing obstruction. This obstruction tends to resolve and recur
causing the intermittent abdominal pain. The barium enema is diagnostic
and in many cases a curative procedure as well and is therefore the study of
choice in this case.
In a case of diffuse abdominal pain an abdominal x-ray (choice A) could
show a colon full of stool and aid in a diagnosis of constipation causing the
pain. That history was not seen in this case. In intussusception an
abdominal x-ray might show a paucity of air in the area of the
intussusception but it will most likely be inconclusive.
10
In intussusception, a CBC (choice C) might show us a leukocytosis, which
could also be present in an infectious cause of the abdominal pain or in
appendicitis, and therefore would not assist in providing a definitive
diagnosis.
An abdominal CT scan (choice D) would be indicated if there was a higher
index of suspicion for appendicitis, but it is not indicated as a study for
suspected intussusception.
If this patient were febrile along with the lethargy, a lumbar puncture (choice
E) might be warranted to rule out meningitis as a cause for the lethargy. In
this case with the history as given, the spinal tap is not indicated.
A 58-year-old alcoholic with hepatitis C cirrhosis is admitted to the hospital for
management of his ascites. He has been managed as an outpatient with diuretics and
oral lactulose, but over the past few weeks, he reports increasing abdominal girth,
weight gain and lower extremity edema. He has been noncompliant with his low-sodium
diet. His medications include furosemide, spironolactone, lactulose, ciprofloxacin, and
thiamine. On physical examination, he appears grossly edematous and appropriately
responsive. His lungs are clear and his heart is without extra sounds or murmurs. His
abdomen is tense with a fluid wave and shifting dullness on percussion. He has
numerous non-blanching telangiectasias on his torso and abdomen. His testes are small
for his age and there is no asterixis. Admission laboratory studies show:
Sodium
121 mEq/L
Potassium 4.3 mEq/L
Bicarbonate 29 mEq/L
BUN
38 mg/dL
Creatinine 1.5 mg/dL
Urinalysis shows some granular casts and a urinary sodium concentration of <10
mmol/L. The most appropriate therapy is to
A. administer hypertonic saline
B. administer sodium chloride tablets
C. increase the dose of furosemide
D. increase the dose of spironolactone
E. salt restrict
Explanation:
The correct answer is E. True hyponatremia is always hypotonic. There are then three
types of hyponatremia: hypovolemic, euvolemic, or hypervolemic. The therapy for the
hyponatremia depends on both the urinary concentration of sodium as well as the
volume status for each patient. Once the patient's total body volume status has been
estimated, urinary sodium usually allows focusing of the differential diagnosis. For this
11
patient, he clearly has total body volume overload. He has cirrhosis and portal
hypertension. The standard therapy for these patients is salt restriction and
management of volume status with diuretics. This patient, at the core of his therapy
requires salt restriction.
Although some forms of hyponatremia respond to administering hypertonic saline
(choice A), knowing the pathophysiology of this patient's hyponatremia, it can be clearly
seen that this intervention will only aggravate this patient's condition.
Giving the patient sodium chloride tablets (choice B) will clearly not be beneficial to this
patient given the above explanations.
Increasing the dose of furosemide (choice C) or the dose of spironolactone (choice D)
will certainly serve to diurese the patient, but in the presence of a salt load, the kidneys
will respond by avid retention of salt and water and thus aggravate the patient's
condition.
A 91-year-old woman with hypertension comes to the clinic complaining of
constipation for the past 2 months. She had a hysterectomy 10 years ago and
surgery for pelvic floor prolapse 6 months ago. There is hard stool in the vault
on rectal examination. The stool is not grossly bloody but is heme positive.
Laboratory tests reveal a hematocrit of 29% with a reticulocyte distribution
width (RDW) of 33% and a carcinoembryonic antigen (CEA) of 18 ng/ml. The
first test necessary to further evaluate this patient is a(n)
A. colonoscopy
B. colposcopy
C. reticulocyte count
D. ultrasound of the right upper quadrant
E. Westergren sedimentation rate (ESR)
Explanation:
The correct answer is A. Heme positive stools and signs of colonic
obstruction are common in left sided colon cancer. The elevated CEA
supports the diagnosis of colon cancer. The next step is a colonoscopy to
biopsy the lesion. A barium enema may also demonstrate the mass but will
not allow for tissue diagnosis.
Colposcopy (choice B) utilizes a microscope to better visualize the cervix
and take biopsies in women with a positive Pap smear. There is no
indication for this procedure in this patient.
This patient most likely has anemia secondary to gastrointestinal blood loss
as demonstrated by the elevated RDW. If a colon mass is found, further
work up for this mild anemia (choice C) is not warranted.
Right upper quadrant ultrasound (choice D) is not used to stage colon
12
cancer. A CT scan of the abdomen can be used to evaluate the local stage
of the disease as well as assess for liver metastasis. Liver function tests
should precede CT. Statistically, colon cancer is much more likely than a
primary hepatocellular carcinoma or cholangiocarcinoma given the
symptoms of constipation with heme positive stools and an elevated CEA.
Colonoscopy should be performed first given the symptoms of constipation
and the high likelihood of colon cancer.
ESR (choice E) is a nonspecific marker of inflammation and may be
elevated in many situations, including cancer. It is of little clinical value in
this patient.
A 35-year-old man comes to the office because of "heartburn" for 3 months. He tells you
that he has a "burning sensation" in the chest that begins in the "upper stomach and
travels up to the neck." The symptoms worsen when he lies down in bed. He has no
chronic medical conditions and takes no medications. He typically drinks 2-3 cups a
coffee a day, has a glass of wine after dinner, and has a piece of chocolate-covered
peppermint candy before bedtime. Physical examination, an electrocardiogram, a
complete blood count and metabolic profile, and serologic testing for H. pylori are
unremarkable. You recommend that he elevate the head of bed, avoid eating before
bed, and avoid all alcohol, tobacco, chocolate, and caffeine, and schedule a follow-up
visit. He comes back to the office after 2 months and says that his symptoms are
unchanged. At this visit, his temperature is 37.0 C (98.6 F), blood pressure is 120/80 mm
Hg, pulse is 65/min, and respirations are 14/min. Physical examination is unchanged.
The most appropriate next step is to
A. order ambulatory esophageal pH testing
B. order an upper gastrointestinal barium radiograph
C. prescribe famotidine
D. schedule an upper endoscopy
E. schedule esophageal manometry
Explanation:
The correct answer is C. This patient most likely has gastroesophageal reflux disease
(GERD). Reflux disease is usually worse at night because the recumbent position
allows gastric acid contents to go up into the esophagus. Since all of the tests ordered
during the first visit were normal, you were correct in recommending non-pharmacologic
therapy, such as elevation of the head of bed, avoiding eating before bed, and avoiding
alcohol, tobacco, chocolate, and caffeine. Alcohol, tobacco, chocolate, and caffeine all
lower the lower esophageal sphincter pressure leading to gastric reflux. If these
measures are ineffective, pharmacologic therapy with H2 blockers such as cimetidine,
famotidine, or ranitidine is indicated. For more severe symptoms, a proton pump
inhibitor, such as omeprazole or lansoprazole, is indicated.
Ambulatory esophageal pH testing (choice A) is usually reserved for patients who fail
nonpharmacologic and pharmacologic management.
13
An upper gastrointestinal barium radiograph (choice B) is useful in detecting
esophageal rings or strictures, which typically present with dysphagia. This patient
complains of heartburn, not dysphagia.
An upper endoscopy (choice D) is usually indicated only after the failure of
nonpharmacologic and pharmacologic management for GERD and when a patient has
GERD for >5 years, an upper endoscopy is recommended to screen for Barrett's
metaplasia. It is not indicated at this time.
Esophageal manometry (choice E) is typically reserved for cases of GERD when
surgical therapy is being considered.
A 65-year-old woman is admitted to the hospital with severe ascites and fever. She has
a 2-year history of portal hypertension secondary to hepatitis C-induced cirrhosis. The
patient was placed on the liver transplant waiting list 3 months ago. Four months prior
to admission she suffered an upper gastrointestinal bleed secondary to esophageal
varices, which was subsequently banded via endoscopy. Two days ago, the patient
developed abdominal pain, increasing abdominal girth, and fever. She was admitted to
the hospital with the diagnosis of spontaneous bacterial peritonitis. The appropriate
therapy is initiated and over the course of the next 4 days the patient appeared to be
responding well. On the day of discharge you begin to plan her outpatient management
and follow-up care. To prevent further disability from her current acute condition, you
should prescribe
A. hydrochlorothiazide
B. lactulose
C. levofloxacin
D. oral protein supplements
E. propranolol
Explanation:
The correct answer is C. The 1-year risk of recurrent infection in patients surviving
spontaneous bacterial peritonitis (SBP) is as high at 70%. Prophylaxis has been
tested in this group and shown to be efficacious. The rate of recurrence is less with
therapy, although there is no survival benefit. The agents tested have mostly been
fluoroquinolone antibiotics. Levofloxacin is now the preferred agent in that class.
Hydrochlorothiazide (choice A) is a diuretic useful in controlling ascites. It is, however,
not a more important therapeutic intervention than SBP prophylaxis.
Oral lactulose (choice B) is indicated when the patient begins to suffer from hepatic
encephalopathy.
Oral protein supplements (choice D) are never indicated despite the clear nutritional
and total protein deficiency in these patients. The reasoning is that the metabolized
nitrogen products cannot be effectively cleared and often precipitate episodes of
hepatic encephalopathy.
14
Propranolol (choice E) is a non-selective beta-blocker used to prevent variceal
bleeding. This patient has no documented varices at this time and even if they were
present, the efficacy of propranolol for preventing bleeds is questionable.
A 61-year-old woman comes to the emergency department because she is "lightheaded
and dizzy" after having 2 bowel movements over the past hour that consisted of bright
red blood and no stool. She denies any abdominal pain or nausea, but does recall
having crampy abdominal discomfort after eating over the last several days. She tells
you that she has a history of "benign polyps" that are resected endoscopically every
other year in her gastroenterologist's office. Her last colonoscopy was 6 months ago and
3 hyperplastic polyps were removed. Her mother and father both passed away from
complications due to colon cancer. Her temperature is 37.0 C (98.6 F), blood pressure is
100/70 mm Hg, and her pulse is 110/min. Her abdomen is non-tender and soft. There is
no guarding or rebound tenderness present. There is fresh red blood in the rectum, but
there are no palpable masses. Intravenous fluids are started. The most appropriate next
step in management is to
A. order a barium enema
B. order a CT scan of the abdomen
C. order a nuclear bleeding scan of the colon
D. perform flexible sigmoidoscopy
E. perform upper gastrointestinal endoscopy
Explanation:
The correct answer is D. This patient has acute lower gastrointestinal bleeding and after
stabilization with intravenous fluids, requires visualization of the colon. This should first
be done with a flexible sigmoidoscope, which will allow you to see the ano-rectum and
determine if a lesion in this area is the bleeding source. It will also allow you to see the
sigmoid colon, which is the most common site for a diverticular bleed, (one of the most
common causes of a lower GI bleed).
A barium enema (choice A) should not be done in this actively bleeding patient at this
time. It is often useful in patients with diverticulitis, after the acute attack subsides.
A CT scan of the abdomen (choice B) is the diagnostic study to use if this patient
presented with left-sided abdominal pain, nausea, vomiting, fever, and diarrhea, the
symptoms of diverticulitis, not diverticulosis.
A nuclear bleeding scan of the colon (choice C) may be helpful in identifying the exact
site (but not the etiology) of the bleed; however it is often done after a flexible
sigmoidoscopy or colonoscopy.
An upper endoscopy (choice E) is unnecessary at this time because it seems as if this
patient has a lower GI bleed, not an upper GI bleed. A nasogastric tube can be placed
and if blood or coffee-ground material is found, then the source is likely to be in the
15
upper GI tract. However, in this case, bright red blood is seen in the rectum (and yes
there is a possibility that it comes from the upper GI tract), however it seems like this
"painless" bleed is lower GI in nature and requires a flexible sigmoidoscopy at this time.
A 78-year-old nursing home resident is admitted to the hospital because of increasing
left-sided abdominal pain for the past 48 hours. She has had several episodes of bloody
diarrhea according to the nursing attendant at the nursing home. There was no
associated fever or nausea or vomiting. On admission, her temperature is 37.3 C (99.1
F), blood pressure is 90/64 mm Hg, and pulse is 100/min. Her abdomen is soft and
mildly distended without masses or organomegaly. There is moderate tenderness to
palpation in the left lower quadrant, but no associated peritoneal signs. Rectal
examination reveals guaiac-positive stool and no masses. A flexible sigmoidoscopic
examination reveals patchy, depigmented mucosa. The most appropriate initial
management of this patient is
A. angiographic embolization of the inferior mesenteric artery
B. intravenous fluid and bowel rest
C. mesenteric angiogram
D. sigmoid resection and colostomy
E. subtotal colectomy
Explanation:
The correct answer is B. Abdominal pain in an elderly patient associated with bloody
diarrhea and hypotension should arouse the suspicion of ischemic bowel. In this
patient, ischemic bowel is precipitated by dehydration and hypotension. A classical
appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented
patches are suggestive of ischemic colitis. These patients should initially be adequately
hydrated and put on bowel rest. Mucosal ischemia sometimes will improve with these
measures and further therapeutic measures may not be necessary.
Mesenteric angiogram and embolization (choice A) is not essential in this patient. The
bloody diarrhea is from mucosal slough injury from the ischemia and will not be
prevented by embolization.
An angiogram (choice C) is not necessary in the management of ischemic mucosal
colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm
mucosal ischemia, which is managed by intravenous fluids and bowel rest. Transmural
ischemia is confirmed by green sloughing mucosa. Resection of the colon is determined
by the extent of ischemia. A mesenteric angiogram may be useful in diagnosing
mesenteric occlusion, but is not essential, as it is invasive, and diagnosis and
guidelines for resection can be obtained by colonoscopy.
A sigmoid resection and colostomy are indicated (choice D) provided that ischemic
colitis is not controlled and the patient is developing systemic signs of sepsis, which she
does not currently seem to have.
16
Isolated pigmented ischemic colitis in the sigmoid colon (choice E) would not require a
subtotal abdominal colectomy in an elderly patient.
A 50-year-old man with Crohn's disease comes to the clinic for a routine follow-up
appointment. He was diagnosed with Crohn's disease approximately 15 years ago. He is
currently taking prednisone and sulfasalazine, and reports feeling well. He says he still
occasionally has watery diarrhea, but denies fever, abdominal pain, or weight loss. He
had a colonoscopy 1 year ago which demonstrated a few transmural inflammatory
lesions in his descending colon. The most important management of this patient is
A. increase prednisone dose
B. increase sulfasalazine dose
C. prophylactic colectomy
D. surveillance barium enema every year
E. surveillance colonoscopy every year
Explanation:
The correct answer is E. The most important recommendation for this patient is a
surveillance colonoscopy every year in an effort to detect colon cancer early. Although
the risk of colon cancer in Crohn's disease is much less than in ulcerative colitis, the
risk increases significantly with involvement of the colon, and if the disease has been
present for more than 10 years. This patient is at increased risk for colon cancer
because he has had Crohn's disease for at least 15 years and has evidence of colon
involvement. A colonoscopy is recommended because it is superior at detecting small
lesions and biopsy of suspicious lesions can also be performed simultaneously.
An increase in prednisone dosage (choice A) is not indicated in this patient at this time.
He reports feeling well and has only rare episodes of diarrhea. Medication adjustments
should be made based on the patient's symptoms.
An increase in sulfasalazine dosage (choice B) is not indicated in this patient at this
time. He reports feeling well and has only rare episodes of diarrhea. Medication
adjustments should be made based on the patient's symptoms.
Prophylactic colectomy (choice C) is not indicated or recommended for this patient.
Many patients with Crohn's disease who have extensive colitis undergo colectomy early
in the course of disease to relieve persistent symptoms. This patient does not have
severe symptoms nor does he have prior colonoscopy findings of dysplasia to warrant a
colectomy. Prophylactic colectomy is often recommended for patients with ulcerative
colitis with long standing colitis due to the increased risk of colon cancer.
Surveillance barium enema (choice D) is not the best recommendation for this patient.
He has had Crohn's disease for over 10 years and is at increased risk for developing
colon cancer. A barium enema is not as sensitive or specific for the detection of early
colon cancer. Colonoscopy is recommended because it is superior at detecting small
17
lesions and biopsy of suspicious lesions can also be performed simultaneously.
A 37-year-old woman comes to the office because of a "burning sensation" in the chest
for the past 3 months. The "burning" typically begins in the "upper stomach and travels
up to the neck." The symptoms worsen when she lies down to go to sleep. She is a chef
at a local American restaurant, has 3 children, and has been married for 12 years. She
"tries" to eat a healthy diet, but it is difficult because she is around food all day and night.
She has no chronic medical conditions, takes no medications, and does not drink alcohol
or caffeine-containing beverages. She recently quit smoking. Her temperature is 37.0 C
(98.6 F), blood pressure is 120/80 mm Hg, pulse is 65/min, and respirations are 14/min.
Physical examination is unremarkable. An electrocardiogram is unremarkable. A
complete blood count and metabolic profile are normal. Serologic testing for H. pylori is
negative. The most appropriate next step is to
A. order ambulatory esophageal pH testing
B. order an upper gastrointestinal barium radiograph
C. recommend elevation of the head of bed and avoidance of food before
bedtime
D. schedule an upper endoscopy
E. schedule esophageal manometry
Explanation:
The correct answer is C. This patient complains of the classic symptoms of
gastroesophageal reflux disease (GERD). Reflux disease is usually worse at night
because the recumbent position allows gastric acid contents to go up into the
esophagus. Since all of the tests ordered in the case were normal, you should first
recommend non-pharmacologic therapy before continuing with further diagnostic
studies. Elevation of the head of bed, avoiding eating before bed, and avoiding alcohol,
tobacco, chocolate, and caffeine should all be recommended. Alcohol, tobacco,
chocolate, and caffeine all lower the lower esophageal sphincter pressure leading to
gastric reflux. If these measures are ineffective, pharmacologic therapy with a H2
blocker such as cimetidine, famotidine, or ranitidine is indicated. For more severe
symptoms, a proton pump inhibitor, such as omeprazole or lansoprazole, is indicated.
Ambulatory esophageal pH testing (choice A) is usually reserved for patients who fail
nonpharmacologic and pharmacologic management.
An upper gastrointestinal barium radiograph (choice B) is useful in detecting
esophageal rings or strictures, which typically present with dysphagia. This patient
complains of heartburn, not dysphagia.
An upper endoscopy (choice D) is usually indicated only after the failure of
nonpharmacologic and pharmacologic management for GERD and when a patient has
GERD for >5 years, and upper endocsopy is recommended to screen for Barrett's
metaplasia. However, it is not indicated at this time.
Esophageal manometry (choice E) is typically reserved for cases of GERD when
18
surgical therapy is being considered.
A 51-year-old woman with end-stage liver disease due to cryptogenic
cirrhosis is being cared for by your medical team. She was recently admitted
for increasing abdominal girth and confusion. She was diagnosed with
cirrhosis and portal hypertension 3 years ago and has long-standing ascites
and 2 previous admissions for hepatic encephalopathy. She has no allergies.
Her current medications include oral lactulose, ofloxacin, spironolactone, and
furosemide. Over the past few days, the team has been attempting to reduce
her ascites by both repeated large-volume paracentesis and aggressive
diuresis. The patient has been having four to five bowel movements daily
while on lactulose. On reviewing the morning laboratory data, the following
values are noted:
Day 1: Sodium 126 mEq/l, Potassium 3.2 mEq/l, BUN 20 mg/dl, Creatinine
1.1 mg/dl
Day 2: Sodium 129 mEq/l, Potassium 3.5 mEq/l, BUN 29 mg/dl, Creatinine
1.4 mg/dl
Day 3: Sodium 134 mEq/l, Potassium 4.2 mEq/l, BUN 33 mg/dl, Creatinine
1.7 mg/dl
Day 4: Sodium 142 mEq/l, Potassium 4.8 mEq/l, BUN 41 mg/dl, Creatinine
2.1 mg/dl
Day 5: Sodium 148 mEq/l, Potassium 5.2 mEq/l, BUN 55 mg/dl, Creatinine
2.9 mg/dl
The most important management is to
A. administer sodium polystyrene sulfonate, orally
B. bolus 500cc of normal saline
C. discontinue the furosemide
D. discontinue the spironolactone
E. obtain a 12 lead electrocardiogram
Explanation:
The correct answer is D. Aggressive diuresis and fluid management is the
mainstay of therapy for ascites related to liver failure. In the case of this
patient, the aggressive diuresis has caused progressive renal insufficiency.
The potassium sparing diuretic spironolactone is only worsening the
hyperkalemia and should be promptly discontinued until the patient's renal
function returns to normal.
Administering sodium polystyrene sulfonate orally (choice A) would be
indicated if a 12 lead EKG suggested evidence of hyperkalemia (QRS
19
changes, T wave elevations). Kayexalate is a potassium binding resin used
to lower serum potassium.
Bolus 500cc of normal saline (choice B) may help with the worsening prerenal failure, but will not reverse the problem in a definitive manner.
Discontinuing the furosemide (choice C) is not the primary diuretic to
address, since by keeping spironolactone, the potassium elevation will likely
only worsen.
Obtaining a 12 lead electrocardiogram (choice E) is not unwise but given
that the potassium is not severely elevated, discontinuing the offending
diuretic is the most important concept to grasp. Blindly checking an EKG for
a marginally elevated potassium misses the point of a rising creatinine and
potassium in the setting of aggressive diuresis.
A 55-year-old woman is brought to the emergency department by her daughter because
of left lower quadrant abdominal pain, anorexia, fever, and chills for the past 24 hours.
Her temperature is 38.7 C (101.6 F), pulse is 110/min, and respirations are 18/min. She
is awake and alert, although she appears uncomfortable. Examination shows hypoactive
bowel sounds and a soft abdomen with mild voluntary guarding especially in the left
lower quadrant. Digital rectal examination is significant for heme-positive stool. An
electrocardiogram shows a sinus tachycardia at 110 beats per minute. There are no ST
segment changes when compared with old electrocardiograms. A chest x-ray shows no
acute disease. Abdominal x-ray demonstrates no air under the diaphragm and no ileus.
A complete blood count, biochemical profile, cardiac enzymes, amylase, and lipase are
drawn, but results are not yet available. The most appropriate initial management of this
patient is to
A. admit for intravenous antibiotics, nil per os diet, and abdominal CT scan
B. discharge to home on a clear liquid diet and PO antibiotics
C. immediately refer to a gastroenterologist for colonoscopy
D. prepare the patient for immediate surgical exploration
E. send patient for urgent cardiac catheterization
Explanation:
The correct answer is A. This patient most likely has diverticulitis, an inflamed
herniation of the mucosa of the colon through the muscular layer of the bowel wall. The
best way to diagnose diverticulitis is with an abdominal CT scan. The appropriate
management of this patient is admission to the hospital. She should be kept NPO and
given IV antibiotics.
Mild cases of diverticulitis may be treated as an outpatient with a clear liquid diet and
PO antibiotics (choice B). However, this patient is too sick to be discharged and ought
to be treated with IV antibiotics.
A colonoscopy (choice C) is useful to diagnose diverticulosis, but would not be used
20
during an acute attack of diverticulitis because of risk of perforation.
Indications for urgent surgical intervention include abscess formation, severe disease,
or confirmed perforation. This patient does not yet show signs of needing surgical
intervention (choice D).
Abdominal pain is often the presenting sign of cardiac ischemia. However, this patient
has few risk factors, no EKG changes, and does have abdominal exam findings.
Therefore, cardiac catheterization (choice E) would not be indicated. You should,
however, still continue to monitor her cardiac function and obtain cardiac enzymes.
A 37-year-old man comes to the emergency department because of the abrupt onset of
crampy abdominal pain and "bright red blood oozing" from his mouth. There were no
episodes of emesis preceding the hematemesis. The patient has a past medial history
significant for alcoholic cirrhosis documented by liver biopsy 3 years ago. He has been
poorly compliant with medications and has not been seen by a physician for over 2
years. He continues to drink 6-12 beers per day. His blood pressure is 90/40 mm Hg and
pulse is 90/min. Physical examination shows scleral icterus, clear lung fields, a
distended and tense abdomen with a fluid wave, and diffuse spider angiomata on his
chest and abdomen. There is no asterixis. You send him for upper endoscopy, which
reveals grade three esophageal varices with no active bleeding. These varices are
sclerosed. He is admitted to the hospital. The most appropriate next step in
management to prevent morbidity is to
A. admit the patient to the ICU for a re-endoscopy in 48 hours
B. begin intravenous octreotide therapy
C. observe the patient for 48 hours and then discharge to home
D. perform an immediate portal-systemic shunt operation
E. transfuse the patient to a hematocrit greater that 30%
Explanation:
The correct answer is B. About 30-60% of variceal bleeding episodes stop
spontaneously. Therefore, in the setting of a presumed upper gastrointestinal (UGI)
bleed when an endoscopy shows varices but no active lesions, banding and
intravenous somatostatin or its analogue, octreotide, are indicated. These agents are
vasodilators that cause a reflex increase in splanchnic vessel tone and thus serve to
decrease bleeding. This is the standard of care for GI bleeds from varices.
Admitting the patient to the ICU for a re-endoscopy in 48 hours (choice A) is not
indicated as the patient appears hemodynamically stable and does not require ICU
monitoring.
Observe the patient for 48 hours and then discharge to home (choice C) is not
acceptable since most centers choose to re-endoscope patients prior to discharge.
Performing an elective portal-systemic shunt operation (choice D) is certainly an option
in the secondary prevention of UGI bleeds due to varices. It is a highly effective option.
21
The drawback is that the procedures are associated with a significant incidence of
hepatic encephalopathy. As such, there is no indication to refer all patients with variceal
bleeds for elective shunt therapy, but the option should be offered to them.
Transfuse the patient to a hematocrit greater that 30% (choice E) is a "trigger" often
taught but the decision to transfuse a patient should be based upon the patient's clinical
condition and not a number. If the patient is stable and the bleeding has been
controlled, there is no absolute reason why a hematocrit greater than 30 must be
attained. There is in fact recent literature that suggests some critically ill patients do
worse with a more aggressive transfusion strategy (Hct >30) compared to a more
permissive goal (Hct >24).
A 73-year-old man with emphysema comes to the clinic with complaints of
food getting stuck when he swallows, which has been getting progressively
worse over the last 8 months. He denies problems swallowing liquids and
thinks he has lost about 5 pounds. He used alcohol heavily for many years
but quit drinking 10 years ago. He still smokes 1 pack of cigarettes per day
and has done so since age 20. He uses albuterol, steroid inhalers and
theophylline. His blood pressure is 123/73 mm Hg, pulse is 87/min, and
respirations are 20/min. Physical examination reveals bilateral scattered
wheezes in the lungs. A chest x-ray shows hyperexpansion and no nodules.
The most appropriate next step in management is to
A. order a barium esophagram
B. order an esophageal manometry
C. order an esophageal pH probe
D. treat with omeprazole and follow up in 3 months
E. treat with ranitidine and follow up in 3 months
Explanation:
The correct answer is A. This patient most likely has an esophageal
squamous cell carcinoma (the most common type of esophageal
malignancy). In any patient with dysphagia that is progressive for only solids,
it suggests a growing and obstructive lesion. The history of tobacco and
alcohol use, puts this person at a much higher risk of carcinoma. The two
ways to diagnose this are a barium swallow study, which will show the
mucosal mass, or an upper endoscopy study to directly visualize and biopsy
the lesion.
Esophageal manometry (choice B) is used to evaluate dysphagia caused by
motility disorders. These typically present with dysphagia for solids and
liquids and may or may not be progressive.
A pH probe (choice C) is used to evaluate esophageal reflux disease, which
does not in itself typically cause dysphagia, but over long periods of time will
increase the risk of esophageal adenocarcinoma.
22
Both omeprazole (choice D) and ranitidine (choice E) are used to treat
symptoms of gastroesophageal reflux disease and would not address his
dysphagia. Furthermore, waiting 3 months to see the patient again would be
inappropriate.
A 36-year-old woman comes to the office because of a 3-day history of "yellow skin,"
fever, and abdominal pain. The pain is mostly present in the right upper quadrant.
However she sometimes feels it in her right shoulder. She has had several similar
episodes in the past, but they were not accompanied by fever, and skin discoloration.
She is married and has 3 children, none of whom are sick. Her temperature is 39.3 C
(102.7 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 20/min.
Physical examination shows right upper quadrant tenderness. She has the "chills", but
she continues to breathe normally during right upper quadrant palpation. Laboratory
studies show
The most likely diagnosis is
A. acute cholangitis
B. acute cholecystitis
C. acute hepatitis
D. acute pancreatitis
E. biliary colic
Explanation:
The correct answer is A. This patient has fever, jaundice, and right upper quadrant
abdominal pain, Charcot's triad, which is usually diagnostic of acute cholangitis. This
typically occurs because of a stone impacted within the common bile duct. Blockage of
this duct results in cholestatic jaundice, hence the elevated bilirubin, and high alkaline
phosphatase. Gram-negative bacteria penetrate into the biliary ducts, and cause
inflammation with leukocytosis and fever. The pain is due to gallbladder distention. The
treatment involves antibiotics and surgery.
Acute cholecystitis (choice B), is inflammation of the gallbladder and the obstruction of
the cystic duct by a gallstone. Symptoms include right upper quadrant pain, a mild
fever, and possibly nausea and vomiting. Physical examination shows right upper
quadrant pain with inspiratory arrest during palpation, (Murphy's sign). Mild jaundice
23
may occur. The leukocyte count is elevated. Treatment includes antibiotics and surgery.
Acute hepatitis (choice C), manifests with mild right upper quadrant abdominal pain,
nausea, anorexia, and a low-grade fever. Serum alanine aminotransferase and
aspartate aminotransferase are markedly elevated, helping to distinguish this from
cholangitis.
Acute pancreatitis (choice D), typically presents with intense midepigastric pain, usually
radiating to the back, fever, nausea, and vomiting. Very high levels of amylase and
lipase will support the diagnosis. The treatment usually involves insertion of a
nasogastric tube, intravenous fluids, and electrolyte replacement.
Biliary colic (choice E), is episodic right upper quadrant abdominal pain that radiates to
the back, and may be associated with nausea and vomiting. It often occurs after a meal.
It is caused by a transient blockage of the cystic duct with a gallstone. It is not usually
associated with fever or jaundice.
You are called to see a patient with end-stage liver disease secondary to
hepatitis C obtained from injection drug abuse. He reports that he has
experienced increasing abdominal girth for the last 2 weeks. He also notes
that his urine output has been minimal for the last 3 days, producing
approximately 30 cc of urine each day. His temperature is 37 C (98.6 F),
blood pressure is 95/60 mm Hg, pulse is 70/min, and respirations are 19/min.
Physical examination reveals scleral icterus, huge abdominal distention with
bulging flanks, and a fluid wave. His lower extremities have 2+ edema.
Laboratory studies show:
Sodium
128 mEq/dL
Potassium 4.8 mEq/dL
Chloride
98 mEq/dL
Bicarbonate 21 mEq/dL
BUN
28 mg/dL
Creatinine 3.2 mg/dL
Urinalysis
Color
Clear
Specific gravity
1.020
Osmolality
55 mOsmol/kg
Leukocyte esterase Negative
Nitrite
Negative
Protein
Negative
Blood
Negative
Microscopic
Few hyaline casts
Urine Sodium
4 mEq/L
In an effort to increase urine output, you perform a therapeutic paracentesis
and provide a fluid challenge with 500 ml normal saline. Urine output does
not improve. He is "so sick of all of this" and wants to know what is the most
24
effective treatment. He should be told that his condition can be most
effectively managed with
A. continued fluid resuscitation with normal saline
B. intravenous albumin therapy
C. liver transplantation
D. renal dose dopamine therapy
E. treatment with furosemide
Explanation:
The correct answer is C. This patient has hepatorenal syndrome (HRS). The
treatment is a liver transplant. It is seen in end-stage liver disease in patients
with chronic liver disease more often than in acute fulminant hepatic failure.
It is sometimes difficult to differentiate from prerenal azotemia. Typically, the
urine sodium in prerenal azotemia is less than 20 mEq/L, while the urine
sodium with hepatorenal syndrome is less than 10 mEq/L. Urine output will
not increase with a fluid challenge in HRS while it will in prerenal azotemia.
The management of HRS should include removal of ascites, and an attempt
to increase urine output and a small fluid challenge with normal saline or
albumin. Furosemide can be tried but it likely will not work. The prognosis is
very poor unless the patient receives a liver transplant. The kidneys of these
patients are normal and will begin to work with a new liver.
Fluid resuscitation (choice A) has been tried without success already in this
case. Continued aggressive hydration of this patient will likely increase his
extravascular volume (e.g., ascites and lower extremity edema) without
increasing his urine output.
Resuscitation with albumin (choice B) is thought to be helpful in expanding
intravascular volume in cirrhotic patients since their underlying problem is
low oncotic pressure in the intravascular space. Albumin might help to
temporarily bring fluid into the vessels but will likely also eventually become
extravascular. However, this patient is likely not prerenal, so volume
expansion is unlikely to be effective.
Renal dose dopamine (choice D) is controversial. It is thought to work by
dilating renal vasculature and increasing blood flow to the kidneys. At low
doses, dopamine acts selectively in renal vasculature, while at higher doses
it acts non-selectively like norepinephrine. Studies have not shown renal
dose dopamine to be effective but it is still fairly widely used despite
inconclusive evidence.
Furosemide (choice E) is part of the management of cirrhotic patients as a
way to decrease ascites and decrease peripheral edema. In HRS,
furosemide can be attempted but it will likely not work. The most effective
management of this patient with HRS is clearly liver transplant.
25
A 64-year-old woman comes to the emergency department with a 36-hour history of
diffuse abdominal pain, abdominal fullness, nausea, and vomiting. She has no appetite
and is unable to eat or drink secondary to nausea and vomiting, which is bilious in color.
She passed loose brown stool earlier today. She denies any bright red blood per rectum
or bloody vomitus. Her past medical history is notable for endometrial cancer 4 years
ago treated with surgery and radiation. The patient denies ever experiencing similar
symptoms in the past. Her temperature is 37.0 C (98.6 F), blood pressure is 110/70 mm
Hg, pulse is 100/min, and respirations are 16/min. She has a moderately distended
abdomen with diffuse tenderness on palpation. There is no rebound tenderness or
guarding. Bowel sounds are high-pitched. There is no occult blood on rectum
examination. Initial laboratory studies show:
The next most appropriate step to confirm the diagnosis is to obtain
A. a CT scan of the abdomen
B. plain films (supine abdomen x-ray and upright chest and abdomen x-ray)
C. a right upper quadrant ultrasound
D. serum amylase and lipase
E. serum lactate
Explanation:
The correct answer is B. This patient most likely has a small bowel obstruction as
evidenced by prior abdominal surgery, a diffusely tender abdomen, high-pitched bowel
sounds, and nausea and vomiting. Small bowel obstruction usually results from either
mechanical blockage or paralytic ileus. Postoperative adhesions or an incarcerated
inguinal hernia are the most common causes of a mechanical small bowel obstruction.
This patient is at risk for bowel obstruction given her prior abdominal surgery and
radiation, thus putting her at increased risk for adhesion and stricture formation.
Patients with small bowel obstruction typically present with a distended, tender
abdomen, nausea and vomiting, and high-pitched bowel sounds. The presence of
peritoneal signs suggests infarcted bowel or perforation. Laboratory tests may reveal a
normal or elevated white blood cell count, elevated hematocrit secondary to
hemoconcentration, and low potassium and chloride secondary to vomiting. Blood urea
nitrogen and creatinine may be elevated secondary to prerenal azotemia. Plain films
are very helpful in diagnosing small bowel obstruction and should be part of the initial
management of the patient. X-rays of the abdomen commonly reveal gas-filled,
26
distended loops of bowel with air-fluid levels. An upright chest x-ray is needed to
evaluate for possible bowel perforation which is demonstrated by the presence of free
air under the diaphragm.
A CT scan of the abdomen (choice A) is rarely needed to diagnose a small bowel
obstruction and can worsen a patient's symptoms, especially in the setting of a
complete small bowel obstruction. In complete obstruction, administering contrast from
above will add to the degree of fluid and edema proximal to the obstructed bowel. A CT
scan of the abdomen may be helpful later in a patient's course. For example, it may be
necessary to obtain a CT scan to exclude the possibility of a tumor compressing bowel
that leads to obstruction. This imaging modality, however, is not part of the immediate
management.
A right upper quadrant ultrasound (choice C) is used to image the liver, gallbladder, and
ducts. The patient does not have any abdominal symptoms or pain localized to this
region to warrant starting with this imaging modality. An uncommon but important cause
of small bowel obstruction in elderly patients is gallstone ileus. In this setting, a
gallstone erodes through the gallbladder wall and into the small bowel, causing
intraluminal obstruction. Typically, patients will give a history of right-sided upper
abdominal pain at the onset of their symptoms and may demonstrate air in the biliary
tree on ultrasound. This patient, however, does not have any symptoms to suggest the
presence of gallstones.
An elevated serum amylase and lipase (choice D) is useful in diagnosing pancreatitis.
Pancreatitis usually presents with epigastric pain radiating to the back, as well as
nausea and vomiting. The two leading causes of pancreatitis are alcohol abuse and
gallstones. This patient's presentation and exam are not classic pancreatitis as
described above.
An elevated lactate (choice E) is frequently elevated in the setting of hemorrhage,
shock, sepsis, and hypoxia. This patient has an elevated anion gap of which suggests
the presence of a lactic acidosis. An elevated lactate, however, may suggest many
processes as outlined above and thus would not be helpful in confirming the diagnosis
of small bowel obstruction.
A 53-year-old man is admitted to the hospital from the emergency department because
of worsening confusion. He is brought in by a friend who reports that the patient has
"liver disease", has been drinking lately, and has not been taking his medications. The
friend tells you that he has gotten progressively more confused over the past few days.
She only knows a vague history but thinks the patient has "cirrhosis". She does not think
the patient has had a recent fall, even though he has not been without alcohol for any
appreciable length of time. His temperature is 37.0 C (98.6 F), blood pressure is 120/70
mm Hg, and pulse is 100/min. He has deep scleral icterus and his skin is jaundiced. His
lungs are clear, cardiac exam is normal, and he has a distended abdomen with shifting
dullness. He is alert to person only and his neurological exam is normal with the
exception of the inability to perform finger to nose touching and heel to shin maneuvers.
He has asterixis. Laboratory studies show:
27
The most likely cause of his confusion is
A. acute hyponatremia
B. ascending cholangitis
C. hepatic encephalopathy
D. metabolic acidosis
E. subdural hematoma
Explanation:
The correct answer is C. The most important concept to understand from this question
is what complications affect cirrhotics. The evaluation of altered mental status in the
emergency department is a complex topic, but one of the most useful and essential
components of this evaluation is the history. When the history is given of a cirrhotic "not
taking his medications," an understanding that encephalopathy is one of the most likely
diagnosis should come immediately to your mind.
Acute hyponatremia (choice A) is not equivalent to the serum Na of 129mEq/L. Acute
signs of hyponatremia are seen when the serum sodium falls more than 12mEq/L in
less than 24 hours. The signs of such an illness involve nausea, vomiting, confusion,
and focal neurological findings related to brain edema.
Ascending cholangitis (choice B) is not supported by your physical exam or by physical
findings such as the classic Charcot triad (fever, right upper quadrant pain, and
jaundice).
Metabolic acidosis (choice D) is not supported by the data. The patient does have a low
bicarbonate level, but his pH is not known. It is likely acidemic but this is not equivalent
to inferring that the patient is suffering confusion as a result of the acidemia.
Subdural hematoma (choice E) is not the most likely diagnosis in this noncompliant,
cirrhotic patient. The most common cause of SH is tearing of the bridging veins suffered
during a trauma. It is certainly possible, however, since hepatic encephalopathy occurs
in more than half of all cirrhotics with severe impairment of liver function, and since the
friend tells you that he has not been taking his medications, this patient's confusion is
28
most likely due to hepatic encephalopathy.
A 60-year-old man with diabetes and hypertension comes to the clinic
because his wife is worried that his skin is turning yellow. The patient's wife
reports that she first noticed the skin changes about 1 month ago and now
she says "even his eyes look bright yellow!" He drinks a case of beer a week
and smokes 2-3 packs of cigarettes a week. He says he has been feeling well
and denies abdominal pain, nausea, or vomiting. Vital signs are normal. He is
a thin male and the abdominal examination is normal. Laboratory studies
show:
The most appropriate test at this time is
A. CT of abdomen and pelvis
B. endoscopic retrograde cholangiopancreatography (ERCP)
C. mesenteric angiography
D. serum CA19-9
E. upper gastrointestinal barium study
Explanation:
The correct answer is A. The presentation of painless jaundice is highly
suspicious for a pancreatic head mass and in particular adenocarcinoma of
the pancreas. Adenocarcinoma of the pancreas accounts for more than 90%
of pancreatic malignancies and jaundice is present in about 65% of patients.
Risk factors for pancreatic adenocarcinoma include smoking and diabetes.
The best initial evaluation for pancreatic masses is by CT of the abdomen
and pelvis.
Endoscopic retrograde cholangiopancreatography (ERCP) (choice B) is not
the best initial test to evaluate for pancreatic masses because it primarily
evaluates the biliary duct system in the liver and pancreas. It will not define a
mass that does not involve the biliary ducts. An ERCP may show a discrete
stricture in the main pancreatic duct with proximal dilatation.
A mesenteric angiography (choice C) is not the best initial test to evaluate
for pancreatic masses because it primarily evaluates the vascular structures
that supply and drain the pancreas and abdominal organs. Angiography can
be useful preoperatively because it may show displacement or encasement
of the pancreatic or duodenal arteries by a mass. The venous phase is also
useful if the superior mesenteric vein or splenic vein is occluded due to
29
tumor extension.
Serum CA19-9 (choice D) is not the best initial test to evaluate for pancreatic
adenocarcinoma. It is a tumor marker that has been associated with
adenocarcinoma of the pancreas. It is not useful as a screening test, but it
has a high sensitivity and specificity as a marker for recurrent disease or
metastases after the primary pancreatic tumor is resected.
An upper gastrointestinal barium study (choice E) is not the best initial test to
evaluate for pancreatic masses. It is a useful study to evaluate for mucosal
lesions within the esophagus, stomach, and small bowel. In the setting of
pancreatic malignancy or other masses, the upper gastrointestinal barium
study may show a widened loop or an "inverted 3 sign" caused by abnormal
indentation of the pancreas along the medial aspect of the duodenum.
An asymptomatic previously healthy 60-year-old man comes to the office because he is
found to have a liver mass. Recently, he had epigastric and right upper quadrant pain,
which was investigated by means of ultrasound. Sonography demonstrated a lesion in
the right lobe of the liver, but no gallstones or evidence of cholecystitis. Further
investigations by means of endoscopy revealed gastritis from Helicobacter pylori, for
which he was treated. He is concerned about this liver mass and hence, comes to the
office. The liver mass is described as an 8-cm solitary lesion within the right lobe of the
liver. No enterohepatic biliary ductal dilatation was noticed. A CT scan of the abdomen
performed with contrast demonstrated a progressive peripheral to central prominent
enhancement and a central hypodense region. An MRI shows a dense T2 weighted
image. The most appropriate next step in the management of this patient's liver lesion is
A. celiac arteriography
B. observation
C. percutaneous needle biopsy
D. radiation therapy
E. resection
Explanation:
The correct answer is B. The characteristic lesion described in this patient fits in well
with a diagnosis of a cavernous hemangioma. A cavernous hemangioma is a
hamartomatous transformation blood vessel. This can be classically diagnosed with a
contrast CT or a T2 weighted image on MRI. A radiolabeled red blood cell scan can
diagnose a hemangioma, but is not usually necessary. Observation is typically
indicated, as rupture is rare.
Celiac arteriography (choice A) would be able to diagnose a hemangioma, but is not
necessary in the workup of this patient.
A percutaneous needle biopsy (choice C) is contraindicated because of the risk of
30
bleeding.
Radiation therapy (choice D) has no established role in the treatment of a hemangioma.
Resection (choice E) is indicated for a rapidly expanding hemangioma, for a
symptomatic lesion, or if the diagnosis is uncertain. Enucleation is usually carried out in
these cases.
A 48-year-old woman comes to the emergency department with right upper
quadrant pain. Except for minor epigastric and right upper quadrant
discomfort in the past few months, she reports being in good health. She
never sought medical evaluation, but did take over-the-counter antacids. Now
she complains of right upper quadrant pain for the past 4 hours that started
abruptly during the night and woke her up from sleep. Since then, the pain
has been persistent in the right upper quadrant and is progressively getting
worse. Her temperature is 37.9 C (100.2 F), blood pressure is 140/80 mm Hg,
and pulse is 94/min. Chest auscultation reveals slightly diminished breath
sounds in the base of the right lung. Abdominal examination reveals a soft,
distended abdomen with diffuse discomfort, localized to the right upper
quadrant with a positive Murphy's sign. Laboratory studies show a leukocyte
count of 16,000/mm3. Her serum bilirubin is 1.4 mg/dL. The remainder of the
complete blood count, metabolic panel, and liver function tests are within
normal limits. A clinical diagnosis of acute cholecystitis is made and the
patient is referred for sonography. Ultrasonography of right upper quadrant
demonstrated no gallstones, but gallbladder wall thickening with peripheral
cystic fluid. You diagnose her with acute cholecystitis and admit her to the
hospital for treatment with intravenous antibiotic therapy. Three hours after
admission to the hospital, you are called to the floor as she is complaining of
severe abdominal pain, which got worse since admission. On examination,
her vitals are unchanged, but her abdominal examination reveals voluntary
guarding, right upper quadrant pain, and board-like rigidity of the abdomen.
The most appropriate next step is to order
A. an abdominal x-ray, erect and supine
B. a CT scan of the chest
C. a CT scan of the abdomen and pelvis
D. a hepatobiliary nuclear scan
E. an upper gastrointestinal endoscopy
Explanation:
The correct answer is A. This patient presented with sudden onset of right
upper quadrant pain associated with nausea and vomiting. She has had
right upper quadrant and epigastric pain before, associated with her food
intake. These symptoms are classical for a perforated peptic ulcer. In a
perforated peptic ulcer, a patient can still have right upper quadrant localized
tenderness, a thickened gallbladder wall, and pericholecystic fluid from the
31
perforated ulcer. Hence, with any abdominal pain associated with signs,
abdominal x-rays both erect and supine are very essential in the initial
evaluation to rule out any free air. Worsening of the symptoms, development
of board like rigidity, and voluntary guarding are signs of peritonitis from a
perforated peptic ulcer.
A CT scan of the chest (choice B) is not indicated in this patient, as there
were no suspected pulmonary symptoms and no signs.
A CT scan of the abdomen and pelvis (choice C) might reveal free air, free
leakage of the contrast from the perforated peptic ulcer, or infiltration of the
mesentery and omentum in the upper quadrant, suggestive of perforated
peptic ulcer. But, a simple abdominal x-ray is often essential to diagnose
free air, before performing the CT scan of the abdomen and pelvis.
A hepatobiliary scan (choice D) has a high sensitivity for diagnosing acute
cholecystitis, but is not useful in a perforated peptic ulcer.
An upper gastrointestinal endoscopy (choice E) is essential as a primary
investigative tool in elective patients. In patients with peritonitis and a
suspected perforated peptic ulcer, an upper GI endoscopy is not the first
investigational choice.
A 48 year-old man with hypertension and cirrhosis is brought to the
emergency department by his wife because of hematemesis. This morning he
woke up feeling nauseated and vomited "coffee ground" looking material. He
then ate his breakfast and afterwards, vomited bright red blood. His
medications include atenolol, ranitidine, and folate. The most appropriate next
step in evaluating this patient is to
A. assess airway and respiratory status
B. give him an emergent blood transfusion
C. insert a nasogastric tube
D. perform upper endoscopy and sclerotherapy
E. prepare him for immediate laparotomy
Explanation:
The correct answer is A. For all patients that present in an emergency
situation, the same basic approach should be applied. This approach, the
ABCs (airway, breathing, and circulation) are a reminder that these basics
must always be assessed first; the so-called primary survey. Once this is
accomplished, more detailed interventions can be taken based upon
additional findings. A patient that has vomited blood must have their airway
and breathing assessed to ensure that there is no compromise that is lifethreatening.
32
Emergent blood transfusion (choice B) may be appropriate after laboratory
data are obtained that show a low hematocrit or if there are clinical signs
suggestive of profound hypovolemia or shock.
Insertion of a nasogastric tube (choice C) may be appropriate, and is in fact
likely to be appropriate, after the initial primary survey is completed. This
allows for decompression of any remaining blood in the stomach and serves
to evacuate any ongoing losses to prevent additional episodes of emesis.
An upper endoscopy and sclerotherapy (choice D) will likely be the
treatment option of choice once the patient is stable and fully evaluated.
Most common causes of upper GI bleeding are amenable to diagnosis and
treatment by upper endoscopy.
Immediate laparotomy (choice E) may be indicated if the source of the
bleeding can only be corrected surgically. These procedures are however
NOT diagnostic.
A 58-year-old homeless man is brought to the emergency department with severe
hematemesis. He has a history significant for severe alcohol abuse and significant
esophageal varices with bleeding in the past. You notice in his old chart that it was
recommended that he take a multivitamin, folate, and thiamine. His blood pressure is
100/50 mmHg, pulse is 105/min, and respiratory rate is 26/min. Physical examination
shows coarse breath sounds and a protuberant abdomen. Nasogastric lavage yields
fresh blood. Given that you strongly suspect another variceal bleed, the most
appropriate next step in the management of this patient is
A. administration of amiodarone, intravenously
B. administration of nadolol, orally
C. administration of nitroglycerin, intravenously
D. administration of octreotide, intravenously
E. administration of phenylephrine, intravenously
Explanation:
The correct answer is D. Octreotide, a synthetic somatostatin analog, is used in the
acute management of variceal bleeding. It decreases variceal bleeding by decreasing
splanchnic blood flow and decompressing the portal system.
Amiodarone (choice A), an anti-dysrhythmic agent, has no role in the management of a
variceal hemorrhage.
Oral nadolol (choice B) has been shown to be of significant benefit in the primary and
secondary prevention of variceal bleeding, but plays no role in its acute management. A
beta antagonist should also be used in the setting of acute hemorrhage with extreme
caution.
33
Intravenous nitroglycerin (choice C) plays no role in the acute management of a
variceal bleed. This is despite evidence that nitrates play a role in the primary and
secondary prevention of variceal bleeding in combination with beta antagonists.
Vasodilators such as nitroglycerin are also contraindicated with hemorrhage.
Phenylephrine (choice E), an alpha agonist vasopressor, has no role in the
management of variceal hemorrhage. This patient's hemodynamics also do not warrant
vasopressor therapy.
A 67-year-old woman with peripheral vascular disease, bilateral leg claudication, and
hypertension comes to the clinic because of nausea and severe, diffuse abdominal pain
that she rates as 7/10 in intensity for the past 2 days. The pain is related to meals,
particularly lunch. She has smoked a pack of cigarettes per day for the past 30 years.
The patient has a temperature of 36.1 C/(97 F) with a pulse of 80/min and a blood
pressure of 120/80 mm Hg. Abdominal examination demonstrates normal bowel sounds,
no tenderness, and no hepatosplenomegaly. Laboratory studies reveal a leukocyte
count of 4,000/mm3 and a hematocrit of 47%. You should be immediately suspicious of
A. acute appendicitis
B. acute cholecystitis
C. malingering
D. mesenteric ischemia
E. ulcerative colitis
Explanation:
The correct answer is D. Mesenteric ischemia , although uncommon, must remain on
the differential diagnosis of abdominal pain. The hallmark of mesenteric ischemia is
pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely
in a patient with known vascular disease and a history of cigarette smoking. The next
diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most
often compromised vessel.
Acute appendicitis (choice A) may present with atypical symptoms in the elderly, but is
usually present with a fever or elevated white blood cell count. Appendicitis is
uncommon in the elderly.
Acute cholecystitis (choice B) should present with right upper quadrant pain and a
positive Murphy's sign.
Malingering (choice C) should be considered on the differential diagnosis for any patient
complaint. It is, however, diagnoses of exclusion that must be entertained only when an
extensive diagnostic work up is completed and is not suggestive of a disease process.
Ulcerative colitis (choice E) should present with diarrhea, constipation, heme positive
stools, and abdominal pain.
34
A 39-year-old man comes to the office because of "gnawing" abdominal pain and
diarrhea for the past 2 months. He states that the pain is worst about 3 hours after a
meal and it often wakes him at night. He says, "surprisingly, the pain is relieved by food."
He takes a nonsteroidal antiinflammatory drug every couple of weeks for a headache or
back ache, does not smoke cigarettes, and has a couple of glasses of wine on the
weekends. He vaguely recalls that his father and brother have had similar symptoms in
the past. Physical examination shows epigastric tenderness, midway between the
xiphoid process and the umbilicus. There is no rebound tenderness. You prescribe
amoxicillin, bismuth, and metronidazole, and tell him to return in 2 months. He returns for
his follow-up appointment and says that his diarrhea is still present and that the
abdominal pain has not decreased in intensity or quality. Physical examination is
unchanged. Laboratory studies show:
At this time the most appropriate management is to
A. measure serum gastrin levels
B. measure serum secretin levels
C. order a CT scan of the abdomen
D. order an MRI of the abdomen
E. order an ultrasound of the abdomen
Explanation:
The correct answer is A. This patient most likely has Zollinger-Ellison syndrome (ZES),
which is typically characterized by peptic ulcers, increased gastrin secretion, and a
tumor in the pancreas (gastrinoma). Many patients with ZES have multiple endocrine
neoplasia I (MEN I), which is an autosomal dominant disorder consisting of tumors in
the parathyroid gland, pancreas, and pituitary gland. Individuals with ZES often have
multiple recurrent or treatment-resistant peptic ulcers, hypercalcemia, diarrhea, and a
family history of pancreatic, parathyroid, or pituitary tumors. The first study used to
evaluate an individual for ZES is serum gastrin levels. Individuals with ZES typically
have markedly elevated levels of serum gastrin.
The first study used to diagnosis ZES is measuring serum gastrin levels, not serum
secretin levels (choice B).
A CT scan of the abdomen (choice C) or an ultrasound (choice E) may be helpful in
localizing the gastrinoma, after establishing the diagnosis with elevated serum gastrin
levels.
An MRI (choice D) is useful in identifying hepatic metastases of gastrinomas. However,
35
it is not the most appropriate first step in establishing the diagnosis of a gastrinoma.
A 44-year-old man comes to the emergency department complaining of severe
abdominal pain and coffee ground vomitus. The patient is a busy financial executive who
reports that over the past few months he has had increasing abdominal pain associated
with eating. The patient reports some mild reflux of acid in between meals but has no
prior episodes of emesis. This morning, on his way to the office he developed the acute
onset of mid-epigastric pain associated with nausea. Ten minutes later, he vomited
coffee ground-like material. An upper endoscopy is performed and the patient is found to
have a large ulcer in the first portion of the duodenum. There is no visible vessel or
active bleeding seen. He is admitted to the hospital. You go to examine him and he is
awake and alert and wants to know about his disease. At this time the most correct
statement about this patient's condition is:
A. The lesion is benign and is not the cause of the bleed
B. The lesion is premalignant and likely caused the bleeding
C. The lesion must be treated or the bleeding will likely recur
D. The lesion must be treated but the bleeding will still recur
E. There is no effective treatment for this lesion
Explanation:
The correct answer is C. The cause of more than 90% of duodenal ulcers is infection
with Helicobacter pylori. The treatment for these ulcers, when non-bleeding, is antibiotic
therapy. When they have bled, in addition to all of the appropriate therapy for a bleeding
patient, they still need to be tested and treated for infection. Without the proper
treatment for the infection, their ulcers will worsen or they will develop new ones and
they will be at continued risk for bleeding.
The lesion is benign and is not the cause of your bleed (choice A) is incorrect. The
lesion identified in the vignette is the classical lesion for such episodes of bleeding.
The lesion is premalignant and likely caused your bleeding (choice B) is incorrect.
Premalignant lesions that are associated with upper GI bleeding are almost solely
confined to the stomach.
The lesion must be treated but bleeding will still recur (choice D) is incorrect because
therapy for duodenal ulcers is curative and therefore will attenuate, if not abrogate any
future risk of rebleeding.
There is no effective treatment for this lesion (choice E) is incorrect. Very effective
treatment for this infection exists and it includes metronidazole, tetracycline, and
bismuth orally for two weeks. In many centers, an oral macrolide antibiotic such as
clarithromycin and a proton pump inhibitor such as omeprazole are becoming standard
therapy.
36
A 47- year-old man comes to the emergency department because he is "not
feeling well and his abdomen is bloated and painful." He denies any previous
medical history. He reports that he has had similar episodes in the past,
which resolved spontaneously. This episode started 12 hours ago, when he
started feeling discomfort and pain in the abdomen. He has not passed flatus
since then. He is feeling nauseous. His temperature is 38.1 C (100.6 F),
blood pressure is 146/80 mm Hg, pulse is 94/min, respirations are 16/min,
and oxygen saturation is 98% on room air. His abdomen is distended with
fullness in the right upper quadrant and empty in the left lower quadrant. He
has marked tenderness in the left lower quadrant. Rectal examination is
positive for occult blood. His leukocyte count is 16,000/mm3. A chest x-ray is
unremarkable. An abdominal x-ray shows a distended colonic loop pointing
towards the left lower quadrant. The most appropriate next step in
management is to
A. admit the patient for a colonoscopy on the following day
B. obtain an emergency surgical consult and prepare the patient for
the operating room
C. order a barium enema
D. order a CT scan of the abdomen
E. order tap water enemas
Explanation:
The correct answer is B. This patient presents with the classic symptoms
and signs of sigmoid volvulus. An abdominal x-ray is usually diagnostic. The
next step in the management depends upon the clinical examination. In the
absence of peritoneal signs, flexible sigmoidoscopy helps in the detorsion of
the colon. When the volvulus is not treated for a long time, part of the
sigmoid colon can become ischemic. In the presence of a tender abdomen
associated with tachycardia, fever, and a raised total leukocyte count, like in
this patient, ischemia should be suspected. This patient should be taken to
the operating room for immediate detorsion of the volvulus and to resect the
ischemic bowel.
Patients with partial intestinal obstruction should be admitted for nonoperative management to decompress the bowel and a colonoscopic
examination to rule out an obstructing lesion, only in the absence of
peritoneal signs. Nonoperative management (choice A) is contraindicated if
the patient develops peritoneal signs or evidence of complete bowel
obstruction either clinically or radiologically.
A barium enema (choice C) may be diagnostic in the management of colonic
obstruction as an elective investigation. In children with intussusception, it is
both diagnostic and therapeutic. In a patient with peritoneal signs, either an
adult or a child, a barium enema is harmful.
A CT scan of the abdomen (choice D) is helpful to rule out diverticulitis in a
patient with a similar history and physical exam, but without evidence of
37
volvulus on the abdominal x-ray. In patients with diverticulitis, the abdomen
is usually uniformly and mildly distended. In the presence of classic signs of
volvulus, with a distended colonic loop in the right upper quadrant and tip
pointing towards left lower quadrant, a CT scan of the abdomen is not
indicated.
Tap water enemas are harmful in an acute abdomen without a definitive
diagnosis (choice E).
A 62-year-old man comes to the office for a periodic physical
examination. He has no complaints. His past medical history is
significant for mild systolic hypertension, non-insulin dependent
diabetes mellitus, and atrial fibrillation. He is taking enteric-coated
aspirin 81 mg daily and warfarin for his atrial fibrillation. He also
reports that he is taking an herbal medicine for "strength and
vitality". Review of the herbal medicine package reveals that the
medicine contains iron and vitamins. Physical examination is
unremarkable. Abdominal examination is benign. Rectal
examination reveals guaiac-positive stool. Rectal examination and a
repeat guaiac test in the subsequent 2 days reveals guaiac-positive
stools. He denies any recent alteration of bowel habits or recent loss
of weight. The most appropriate next step in the management of this
patient is
A. colonoscopy
B. observation
C. repeat guaiac test after stopping aspirin for 1 month
D. repeat guaiac test after stopping the iron-containing herbal
medicine for 1 month
E. repeat guaiac test after stopping warfarin for 1 month
Explanation:
The correct answer is A. The likelihood that a guaiac-based test will
be positive is directly proportional to the quantity of fecal heme,
which in turn is related to the size and location of the bleeding
lesion. Guaiac-based tests are generally best at detecting large,
more distal neoplasms. The guaiac test can be affected by dietary
factors such as meat and vegetables that contain peroxidase. Iron
by itself does not cause erroneous guaiac-positive stool. Iron in
large quantities can yield black colored stools, which might be
difficult to differentiate from positive guaiac with bluish coloration.
Aspirin or warfarin slightly increases the blood loss in the stool, but
by themselves do not cause guaiac-positive stools. Hence, guaiacpositive stools on 3 different occasions in a 62-year-old patient,
requires colonoscopy to rule out any colonic malignancy.
Observation (choice B) is not an option when guaiac-positive stools
38
are discovered on three different occasions.
A repeat guaiac test after stopping aspirin (choice C) is not
essential; the guaiac positive stools are not caused by aspirin.
A repeat guaiac test after stopping iron containing herbal medicines
(choice D) is not required, as iron by itself does not cause guaiacpositive stools.
A repeat guaiac test after stopping warfarin (choice E) is not
essential, as warfarin by itself, does not cause guaiac-positive
stools.
A 47-year-old man comes to the clinic for follow-up care of his
ascites and cirrhosis. He was diagnosed with cirrhosis due to
hepatitis C 4 years ago that he believes that he contracted from
a blood transfusion. He is anxiously awaiting liver
transplantation. His only other medical history is that he has
diabetes mellitus controlled with insulin. He reports to you that
he avoids all alcohol consumption and takes his medications,
which include spironolactone, furosemide, multi-vitamins,
nadolol, and insulin. He complains, however, that his abdomen
continues to "get bigger" despite the fact he limits his water
intake to less that 1 liter per day. In the office his blood sugar is
198mg/dL. His physical examination is unchanged from
previous visits except for more abdominal distention and 2+
lower extremity edema. In discussing his increasing ascites, he
should be advised that
A. this is because his blood sugar is poorly controlled
B. this is due to his poor compliance with medications
C. this is to be expected since his disease is progressive
D. this is to be expected since he is drinking too much
water
E. this is to be expected since he is not limiting his salt
intake
Explanation:
The correct answer is E. The important concept to understand
from this question is that, although diuretics are effective in
controlling ascites, dietary sodium consumption negates all
such benefit. Any patient who you believe to be compliant with
their medications that has a continued increase in their
ascites, is almost certainly having too much dietary sodium (>2
gm).
This is to be expected because your blood sugar is so poorly
controlled (choice A) is not relevant to the care of this patient's
ascites although it is relevant from a volume standpoint since if
39
he is dehydrated from glucosuria, he will consume more fluids,
and likely salt.
This is to be expected since you have very poor compliance
(choice B) is not an appropriate comment to make to a patient
and furthermore is not supported in your interview with the
patient.
This is to be expected since your disease is progressive
(choice C) is not an acceptable answer since the progressive
nature of disease effects a patient's mental status, bleeding
risk, and infection risk, not necessarily the refractoriness of
their ascites to diuresis.
This is to be expected since you are drinking too much water
(choice D) is propagated throughout medicine as a cause for
both edema due to CHF as well as ascites. In fact, water
consumption, unless truly excessive, is irrelevant to total body
fluid balance. The key determinant of sodium excretion and
thus fluid excretion by the kidney is sodium intake.
A 48-year-old investment banker comes to the office because of a 4-month history of
achy abdominal pain. He says that the pain is exacerbated by meals and he often feels
very nauseous. He is generally very healthy except for some mild lower back pain for
which he takes ibuprofen. He estimates that he has taken 2 over-the counter ibuprofen
pills every 3 days for the past few months. He smokes a half pack of cigarettes a day
and drinks a glass of wine with dinner every night. He works until 10 p.m. on weekdays
and both days of the weekends. He has to take care of his children in his spare time and
says that he is very "stressed out." Physical examination shows mild epigastric
tenderness. A urea breath test is positive and a barium study shows a 1.5 cm discrete
crater in the antrum of the stomach with radiating mucosal folds originating from the
ulcer margin. The most likely cause of this patient's condition is
A. alcohol consumption
B. a bacterial infection
C. chronic use of ibuprofen
D. cigarette smoking
E. psychological stress
Explanation:
The correct answer is B. This patient has a gastric ulcer that is most likely due to an
infection with H. pylori. H. pylori is a Gram-negative rod that can be detected by the
urea breath test, serology, a rapid urease test, or histological evaluation of a biopsy
specimen. The urea breath test has a greater than 90% sensitivity and specificity for H.
pylori, so a bacterial infection is the most likely cause of his condition.
Alcohol consumption (choice A) has been thought to play a role in the pathogenesis of
40
peptic ulcer disease (gastric and duodenal ulcers), but its exact role is not proven.
Since he had a positive urea breath test, H. pylori is the most likely cause of his
condition, not alcohol.
Chronic use of ibuprofen (choice C) is associated with peptic ulcer disease. However,
this patient does not take large amounts of ibuprofen. Also, because he had a positive
urea breath test, he has an H. pylori infection. While it is possible to have an NSAIDinduced gastrointestinal ulceration and a concomitant infection with H. pylori, in this
case his condition is most likely caused by the bacteria.
Cigarette smoking (choice D) has been associated with peptic ulcer disease, but the
exact mechanism is unknown. This patient's positive urea breath test is consistent with
an H. pylori infection. The cigarette smoking may exacerbate his condition, but it is
unlikely to be the main cause.
Psychological stress (choice E) has long been associated with peptic ulcer disease, but
studies on the subject have produced conflicting results. It is possible that this patient's
stress may exacerbate his symptoms but it is very unlikely that it is the cause of his
condition.
A 10-year-old boy is admitted to the pediatrics unit with rectal bleeding and
right lower quadrant abdominal pain. He has no significant past medical
history. Vital signs are: temperature 37.2 C (99 F), blood pressure 90/40 mm
Hg, pulse 80/min, and respirations 11/min. The physical examination is
normal. Rectal examination reveals bright red blood, but no other
abnormalities. A colonoscopy extending to the ileocecal valve is normal
except for a moderate amount of fresh blood. The next step in managing this
patient is to order a(n)
A. abdominal angiography
B. nuclear medicine technetium scan
C. sigmoidoscopy
D. small bowel follow through
E. upper gastrointestinal endoscopy
Explanation:
The correct answer is B. Lower gastrointestinal bleeding in a child with a
negative endoscopy is suspicious for a Meckel's diverticulum (MD). A MD
occurs in 2% of the population and 2% are symptomatic. They occur 2 feet
from the ileocecal valve, are usually 2 inches in length, and contain 2 types
of mucosa (gastric and pancreatic). A MD is a true diverticulum from the
antimesenteric border of the small bowel, and is the most common
congenital abnormality of the gastrointestinal tract. It is usually
asymptomatic, but may develop symptoms, usually before the age of 12.
Bleeding may either be pronounced, as in this case, or present as a subtle
anemia. A technetium-99m pertechnetate scan is about 90% accurate in its
41
diagnosis. Presentation may be bleeding (50%) or obstruction (25%).
Abdominal angiography (choice A) is only useful in the unstable patient with
a rising pulse and potentially, falling blood pressure. In this case, the patient
is hemodynamically stable, and a nuclear medicine technetium scan is
appropriate.
Sigmoidoscopy (choice C) is not necessary, as it will offer no more
information than the previously performed colonoscopy.
A small bowel follow through (choice D) sometimes reveals a Meckel's
diverticulum in asymptomatic patients. It is not the study of choice in this
symptomatic patient.
Upper gastrointestinal endoscopy (choice E) would not be appropriate as
this patient is having lower gastrointestinal bleeding.
A 37-year-old woman comes to the emergency department because of a 30-minute
history of vomiting reddish-brown material. She informs you that she suffers from
fibromyalgia syndrome and uses a number of "pain killers" to control her pain. Her blood
pressure is 120/70 mm Hg and pulse is 110/min, no orthostasis. Physical examination is
unremarkable. Her extremities are cool and her capillary refill is less than 2 seconds. A
nasogastric tube is passed and returns 200 cc of coffee ground material that eventually
clears with normal saline lavage. The patient is then sent for endoscopy. The most likely
cause of this patient's gastrointestinal bleeding is
A. esophageal varices
B. esophagitis
C. gastric neoplasm
D. gastric ulcers
E. Mallory Weiss tears
Explanation:
The correct answer is D. The most common causes of upper gastrointestinal (UGI)
bleeds are peptic ulcer disease (PUD) (45-50%), gastritis (30%), varices (10%), and
then the remainder of causes are due to other disorders such as Mallory-Weiss tears,
esophagitis, and neoplasms. In any patient with a history of "pain killer" use, especially
females with rheumatological conditions, the diagnosis of gastritis or gastric ulcers
secondary to nonsteroidal anti-inflammatory drug (NSAID) use must be suspected. The
most common cause of these two conditions is NSAID use.
Esophageal varices (choice A) are a very common cause of UGI bleeds in patients with
cirrhosis. In the United States, the most common cause of cirrhosis is alcohol and
hepatitis virus infection. Worldwide, Schistosomiasis is the most common cause. Since
this patient has none of the above diseases, the likelihood of her having varices is
almost zero.
42
Esophagitis (choice B) is usually due to acid reflux diseases and is not a significant
cause of GI bleeding. It may lead to a premalignant condition (Barrett esophagus).
Gastric neoplasm (choice C), although accounting for a small percentage of UGI bleed
patients, requires other associated findings of cancer in order to be suspected. Gastric
cancer in particular is associated with early satiety, epigastric pain, palpable abdominal
mass, and certain nitrate containing foods.
Mallory-Weiss tears (choice E) are small esophageal tears induced by vomiting. It
should be suspected in patients who have the triad of hematemesis, alcohol abuse, and
vomiting. It is not a cause of severe or prolonged or recurrent UGI bleeding.
A 67-year-old man comes to the office for a follow-up visit to review the
findings from a colonoscopy that was performed 2 weeks earlier. A 0.9 cm
tubular adenoma was removed from his sigmoid colon. No other lesions were
visualized in the colon. He has no family history of colon cancer and is very
concerned when you tell him that the polyp was adenomatous. All previous
colonoscopies were normal. In explaining the findings to him, you should tell
him that:
A. A chest x-ray should be performed to ensure that there are no
abnormalities associated with the adenoma
B. A colectomy should be performed to avoid the risk of developing
colon cancer
C. Colonoscopy will be required every 6 months to determine if any
new polyps have formed
D. His children should have screening colonoscopies beginning at age
25
E. Tubular adenomas such as his have a low risk of malignant
potential
Explanation:
The correct answer is E. Colonic polyps are very common in older patients,
with approximately 40% of all patients at age 60 having at least 1
adenomatous polyp, (and 50% at age 70). Since there is a link between
polyps and the development of malignancy, it is recommended that polyps
be removed and evaluated. There are 3 types of adenomas—tubular,
tubulovillous, and villous. Tubular adenomas have a low risk for malignant
foci (approximately 5% risk), tubulovillous have an intermediate risk
(approximately 20%), and villous have a high risk (approximately 40%).
A chest x-ray should be performed to ensure that there are no abnormalities
associated with the adenoma (choice A) is incorrect. Since the case does
not say that the tubular adenoma found has any malignant foci, there will not
be any associated changes found in the lung.
A colectomy should be performed to avoid the risk of developing colon
cancer (choice B) is inappropriate. This patient does not have a malignancy
and therefore any additional treatment for this polyp is unnecessary.
43
Prophylactic colectomies are typically recommended for patients with
autosomal dominant polyposis syndrome because it is associated with an
almost 100% risk of colon cancer by age 40.
Patients with a history of colonic polyps need to be followed closely with a
colonoscopy every 1-3 years, not every 6 months (choice C).
Since about 40-50% of all patients in this age range will have at least 1
polyp, it is not that unusual that this 67-year-old patient has a polyp. His
children should NOT have screening colonoscopies beginning at age 25
(choice D) because this is too young and the chance of them having polyps
at that age is small. According to the United States Preventive Services
Task Force, the recommended screening for colon cancer is an annual fecal
occult blood test and/or a sigmoidoscopy every 3-5 years beginning at age
50.
A 69-year-old man is brought to the clinic from his convalescent home,
because of decreased mental status. He has a history of Alzheimer's
disease, depression, hypertension, coronary artery disease, and glaucoma.
There is a “do not resuscitate” (DNR) order on the chart signed by the
patient's wife. His temperature is 37.0 C (98. 6 F), blood pressure is 110/70
mm Hg, and respirations are 16/min. Physical examination shows a
distended abdomen without focal tenderness or peritoneal signs and hard
stool in the rectal vault. The patient is alert and oriented only to person. An
electrocardiogram reveals normal sinus rhythm with a few premature
ventricular contractions (PVC). Laboratory studies are normal. A plain x-ray
of the chest reveals multiple pulmonary nodules. A plain x-ray of the
abdomen demonstrates a distended ascending and transverse colon
measuring 20 cm with copious stool present. The next step in the evaluation
of this patient is to
A. consult with the family to consider comfort care only
B. discharge him to the convalescent home with comfort care only
C. order a barium enema after a preparatory enema
D. order a CT scan of the thorax
E. prepare him for a laparotomy
Explanation:
The correct answer is C. This patient has symptoms of fecal impaction
which is common in the elderly and in debilitated patients. A preparatory
enema to clean out impacted stool is necessary prior to a barium enema
and is likely to be therapeutic in this patient. Subsequent barium enema
could assess the cause of large bowel dilatation which is unusual in the
setting of simple fecal impaction. In this case, colon cancer is a definite
possibility.
A “do not resuscitate” order is not a mandate to forego appropriate
44
minimally invasive diagnostic tests such as an enema. Hence, comfort care
only (choice A) would not be appropriate as a diagnosis of a potentially
easily treatable condition such as stool impaction.
A “do not resuscitate” order is not a mandate to forego appropriate
minimally invasive diagnostic tests such as an enema. Discharge (choice
B) is not yet warranted.
A CT of the thorax (choice D) is not necessary now as there are clearly
multiple nodules on the chest radiograph.
A laparotomy (choice E) is not indicated at this point in the diagnostic
workup. Moreover, surgery would only be performed in a patient with a do
not resuscitate order after consult with the family or durable power of
attorney.
A 39-year-old man comes to the office complaining of a 3-day history of
severe abdominal pain and cramps that are relieved with bowel movements.
He also reports loose, watery stools two to five times per day. He has had
similar symptoms in the past and recalls the first incident being nearly 12
years ago. He tells you that he has been told that he has irritable bowel
syndrome. He states that he has never had any other "tests" and was only
prescribed various medications, some of which seemed to have helped. On
examination, he appears to be in mild distress. His temperature is 38.3 C
(101.0 F). He has mild guarding in his left lower quadrant but no rebound
tenderness. He is tender to direct palpation in his left lower and left middle
quadrants. The most appropriate next step in this patient's care is to
A. prescribe corticosteroids and see the patient in two weeks
B. prescribe loperamide and see the patient in two weeks
C. order a stool Gram stain and culture
D. schedule the patient for an immediate colonoscopy
E. schedule an immediate CT scan of the abdomen
Explanation:
The correct answer is E. Although this patient carries the diagnosis of
irritable bowel syndrome, his presentation on this occasion has some
elements that are concerning. In particular his fever and impressive
abdominal examination coupled with his diarrhea and pain raise a high
suspicion for an acute abdomen of some variety. This process may or may
not be related to any existing abdominal pathology that this patient may
have. He requires imaging of his abdomen to rule out an acute abdominal
process such as abscess, pancreatitis, appendicitis, or even colitis.
Prescribing corticosteroids (choice A) or loperamide (choice B) and seeing
the patient in two weeks presumes that this presentation has a similar
etiology to his past presentations. Again, the impressive abdominal
45
examination and fever makes the likelihood of this being related simply to
irritable bowel syndrome very unlikely.
A stool Gram stain and culture (choice C) would be useful, but not more so
than abdominal imaging.
Arranging for an immediate colonoscopy (choice D) is not correct for two
reasons. First, the bowel preparation required for a good study doesn't make
this test useful for acute situations. Secondly, the test limits visualization of
possible etiologies to those that affect the large bowel.
A 79-year-old man is admitted to the hospital for a gangrenous right foot. He has a long
history of peripheral vascular disease, hypertension, hypercholesterolemia, coronary
artery disease, and has suffered 2 strokes. The patient's daughter visited him at home
today and noticed his foot was black. The patient is admitted to the hospital for a right,
below-the-knee amputation. Over the next 48 hours the patient complains of increasing
abdominal pain. His temperature is 39.8 C (103.6 F), blood pressure is 100/50 mm Hg,
pulse is 120/min, and respirations are 22/min. Physical examination shows a diffusely
tender and distended abdomen and his right foot is unchanged. Stat blood work is drawn
and shows:
The diagnostic procedure most likely to establish the diagnosis is
A. abdominal radiographs flat and upright
B. chest films flat and upright
C. CT scan of the abdomen
D. exploratory laparotomy
E. ultrasound of the abdomen
Explanation:
The correct answer is D. This patient has an ongoing abdominal catastrophe, likely an
ischemic bowel or bowel perforation. This is a typical course for such a patient, an
indolent, smoldering entity to an alarmingly overt one in just a few short hours. Surgical
exploration of the abdomen with possible total colectomy or small bowel resection is
life-saving in such cases.
46
Abdominal radiographs flat and upright (choice A) or chest films flat and upright (choice
B) are useful for the diagnosis of free air and perhaps obstruction, but are not very
useful in the diagnosis of early ischemic bowel. Once the bowel becomes necrotic with
wall thickening, then radiographs may have more utility. Once this finding is present
however, the patient will have deteriorated so severely that death would most certainly
have occurred or will imminently occur.
A CT scan of the abdomen (choice C) is very helpful in these cases and is perfectly
acceptable in cases where surgical exploration is not an option. The gold standard for
diagnosis is direct visualization. The CT can offer radiographic suggestion of the
disease but cannot, to the same degree as laparotomy, confirm the diagnosis. In fact,
once a CT scan suggests it, patients are then scheduled for laparotomy for exploration.
An ultrasound of the abdomen (choice E) has no utility in these situations. This modality
is very useful for biliary and pelvic diagnoses, but not colonic on bowel ones.
A 52-year-old man is brought to the emergency department by his wife
because he has had "bright red blood pouring from his mouth" for the past 20
minutes. The wife tells you that he has a 4-year history of alcoholic cirrhosis
and he continues to drink 1 or 2 beers per day. He also has hypertension and
hypercholesterolemia. Two days prior to admission, he had an episode of
hematemesis and this morning, had an additional episode. He is diaphoretic
with a blood pressure of 80/50 mm Hg and pulse of 110/min. Physical
examination shows scleral icterus and mild jaundice, a tense abdomen, and
cool, moist extremities. The most appropriate immediate action is to
A. begin large volume intravenous fluids
B. insert a Minnesota tube
C. perform an emergent portal-systemic surgical shunt
D. provide intravenous pressors for blood pressure control
E. send a blood bank sample for type and crossmatching
Explanation:
The correct answer is A. The first priority in the management of any patient
with GI bleeding is hemodynamic resuscitation and stabilization. IV fluids
should be given immediately to maintain hemodynamic stability and
adequate urinary output.
A Minnesota tube (choice B) is a type of orogastric tube with a gastric and
esophageal balloon used for tamponade bleeding varices. They have fallen
out of favor primarily due to the availability of endoscopes as well as the
issue of pressure necrosis of the esophagus when they are utilized.
An emergent portal-systemic surgical shunt (choice C) would be a therapy of
last resort if the bleeding cannot be controlled by less invasive measures.
47
Intravenous pressors for blood pressure control (choice D) is not indicated
unless the patient proves refractory to therapy for his initial problem that is
volume loss due to GI bleed. Therapy is volume resuscitation with blood and
fluid.
A blood bank sample for type and crossmatching (choice E) is next on the
priority list once the patient is hemodynamically stable.
A 52-year-old woman with hypertension comes to the office for a follow-up visit to
discuss her recent diagnosis of colonic carcinoma. Her mother has breast and ovarian
carcinomas, her grandmother had breast carcinoma, and her mother's sister had
stomach and ovarian carcinomas. Because of the significant family history, she
underwent screening for colonic, ovarian, and breast carcinomas starting at an early
age. In the last month, she noticed some change in her bowel habits and black colored
stools. She was noted to have guaiac-positive stools and was referred for a
colonoscopy. The colonoscopy examination confirmed a lesion in the right side of the
colon, a biopsy of which identified it as an adenocarcinoma. No other lesions were noted
in the rest of the colon on colonoscopic examination. She underwent an appendectomy
at the age of 12 and a hysterectomy at the age of 31. Both surgical procedures were
uneventful. The patient has 3 healthy children. At this time the most appropriate
management is to advise the patient to consider
A. biannual CT scans of the abdomen and pelvis
B. gene therapy
C. a right hemicolectomy
D. a segmental colectomy
E. a subtotal colectomy and bilateral salpingooophorectomy
Explanation:
The correct answer is E. This patient's family history is strongly suggestive of hereditary
non-polyposis colorectal carcinoma (HNPCC or Lynch syndrome). Lynch syndrome is
due to mutations in mismatch repair genes, and are inherited as autosomal dominant.
This predisposition runs in families to develop into endometrial, ovarian, breast, and
gastric carcinomas. Affected individuals show predominance for right-sided cancers or
multiple cancers and tend to be young when these cancers develop. They often
develop metachronous colorectal cancer. Because of this predisposition, family
members at risk should undergo biannual colonoscopy beginning at the age of 25,
women should have an annual pelvic examinations with endometrial biopsies every 3
years and mammograms at an early age. In a woman who has completed child bearing,
a total colectomy, and a hysterectomy, with a bilateral salpingooophorectomy should be
considered.
A CT scan of the abdomen and pelvis (choice A) is indicated as a metastatic workup,
but not as a therapy for right colonic carcinoma. Biannual CT scans are not a useful
recommendation, as this patient is already diagnosed with colon cancer for which she
48
requires therapy.
Gene therapy (choice B), when available, may prevent multiple carcinomas, but won't
treat an already established cancer.
Right hemicolectomy (choice C) in a patient with known Lynch syndrome may not
prevent further cancers. Physicians should thoroughly discuss the possibilities of the
development of multiple cancers and metachronous cancers in the future with these
patients.
Segmental colonic resection (choice D) is not an option for the treatment of colonic
carcinoma.
A 61-year-old man with a history of ulcerative colitis comes to the
clinic with a 1-week history of abdominal distension and occasional
nausea. He has also had intermittent constipation and diarrhea for
the past 3 weeks. Physical examination reveals an obese male with
a distended abdomen with normal bowel sounds. The abdomen is
diffusely tender to touch. There is no rebound or
hepatosplenomegaly. Rectal examination shows heme-negative
stool. His hematocrit is 44% and leukocyte count is 7000/mm3. The
most appropriate next step in the management of this patient is to
A. do a flexible sigmoidoscopy
B. insert a rectal tube
C. order an abdominal radiograph
D. prepare him for a total colectomy
E. send him for a colonoscopy
Explanation:
The correct answer is C. Patients with ulcerative colitis are at high
risk for toxic megacolon, which is also associated with Clostridium
difficile colitis. Toxic megacolon presents clinically as abdominal
distension and bowel motility disturbances. The next step in
evaluation is an abdominal radiograph which will demonstrate a
distended large bowel. Toxic megacolon is the leading cause of
death in patients with ulcerative colitis and carries a 40% mortality
with each bout of toxic megacolon. Treatment consists of
nasogastric tube insertion, no oral food or drink, rectal tube
insertion, antibiotics, positional maneuvers, and ultimately surgery if
there is no resolution in 2-5 days.
Flexible sigmoidoscopy (choice A) is a screening test used by some
primary care physicians to evaluate for left-sided colon masses.
The sigmoidoscope is unable to view the entire colon and
specifically the right colon. Patients with ulcerative colitis are at high
risk for toxic megacolon which is also found with Clostridium difficile
49
colitis. Toxic megacolon presents clinically as abdominal distension
and bowel motility disturbances. The next step in evaluation is the
abdominal radiograph which will demonstrate a distended large
bowel.
Rectal tube insertion (choice B) is a means to decompress a
distended colon. A diagnosis must first be established by a plain
abdominal radiograph.
Total colectomy (choice D) is necessary in some patients with
ulcerative colitis because of multiple polyps or malignancies. Total
colectomy is also necessary in patients with severe toxic
megacolon, as a last resort treatment. Nevertheless an abdominal
plain film is necessary first to evaluate if a distended colon is
present.
Periodic colonoscopy (choice E) is necessary to assess for the
development of colon cancer, which is much more common in
patients with ulcerative colitis than in the population at large.
Patients with ulcerative colitis are at a high risk for toxic megacolon
which is also found with Clostridium difficile colitis. Toxic
megacolon presents clinically as abdominal distension and bowel
motility disturbances. The next step in evaluation is the abdominal
radiograph which will demonstrate a distended large bowel.
A 1-year-old boy is brought to the office by his mother
because of a swelling in his left grointhat was initially noticed
while giving him a bath 3 months ago. She feels that this
swelling is completely asymptomatic and has grown minimally
in size. The child was born without any difficulties, but
developed a hydrocephalus, for which he underwent a
ventricular peritoneal shunt. Since then he has had no other
significant difficulties, besides some mild upper respiratory
tract infections, which were well controlled. Physical
examination reveals a left-sided easily reducible inguinal
hernia and no other abnormalities. The most appropriate
advice to this child's mother is that
A. a bilateral inguinal hernia repair is indicated
B. a left inguinal hernia repair is indicated
C. observation is all that is indicated
D. repair should be delayed until the child is 2 years of
age
E. reversal of the ventricular peritoneal shunt is
indicated
Explanation:
The correct answer is A. Inguinal hernias in children are
50
usually indirect, resulting from failure of the obliteration of the
processus vaginalis. Treatment requires high ligation and
transection of the sac with or without excision of the distal
component. Repair need not be delayed, unless the infant
has associated medical problems. The complications from
the hernia are most likely to occur during the first 6 months of
life hence, a repair should be performed soon after the
diagnosis. Contralateral exploration of the hernial sac should
be performed routinely in the subset of children who are most
likely to have a clinically occult hernia, children less than 2
years old, females less than 3 years old, patients with
ventricular peritoneal shunts, and patients less than 2 years
old with a left sided hernia.
Left sided repair of hernia (choice B) alone is not the correct
option because in a child under the age of 2 with a
ventricular peritoneal shunt, contralateral occurrence of the
hernia is highly likely and should be repaired at the same
time.
Observation (choice C) may lead to complications of hernia
like irreducibility, incarcerations, strangulation and hence, the
hernia should be repaired as soon as possible.
There is no indication to wait until the age of 2 years (choice
D) to treat a hernia in a child.
Reversal of the ventricular peritoneal shunt (choice E) cannot
be done as the patient has a hydrocephalus and this should
not be considered as an option for a hernia in an infant.
A 56-year-old man is admitted to the hospital because of a 1-day history of acute,
severe, cramping abdominal pain that radiated to his back. The pain was constant and
exacerbated when he tried to eat some food. The patient attempted to self medicate with
acetaminophen, but with no relief. The pain has slowly worsened and he has not had
anything to eat or drink in over a day. On admission to the hospital, his serum amylase
and lipase levels are elevated. The appropriate therapy is initiated and the patient has
improvement in his pain. He is also started on a morphine patient-controlled anesthetic
(PCA) with excellent results. Over the next 24 hours, he remains stable. A follow-up set
of blood chemistries shows a BUN of 26 mg/dL and a creatinine of 1.0 mg/dL with an
unchanged amylase and lipase. A right upper quadrant ultrasound shows gallstones with
no ductal dilation. The patient's other medications, besides the PCA, are diazepam for
sleep and diphenhydramine. The most appropriate next step is to
A. arrange for endoscopic retrograde cholangiopancreatography
B. arrange for hepatobiliary iminodiacetic acid scan
C. arrange for laparoscopic cholecystectomy
51
D. arrange for an open cholecystectomy
E. continue intravenous hydration and nil per os status
Explanation:
The correct answer is E. The correct therapy for pancreatitis is hydration, avoiding oral
intake, and pain control. Given the success of this therapy for this patient over the
previous 24 hours, it should continue.
Some centers will arrange for an ERCP (choice A) within 2 days of a pancreatitis
episode to determine if papillotomy may be beneficial in abrogating the course of the
disease. There is some clinical data for this but it is not yet common practice.
A HIDA scan (choice B) is used to diagnose cholecystitis, it is not indicated given that
the abdominal ultrasound did not show evidence of this entity (gallbladder wall
thickening, sludge).
Arranging for a laparoscopic cholecystectomy (choice C) or open cholecystectomy
(choice D) will eventually be necessary given the pancreatitis and the presence of
gallstones. However, this is not to be done presently and is generally done after the
pancreatitis episode has passed (6-8 weeks).
A 54-year-old man with end-stage liver disease secondary to hepatitis C comes to the
emergency department with fevers and mental status changes over the last 4 days. His
wife reports that he has been compliant with his medications, which include furosemide,
spironolactone, and lactulose up until today when he refused to take them. His
temperature is 38.0 C (100.7 F), blood pressure is 100/70 mmHg, pulse is 103/min, and
respirations are 19/min. Physical examination reveals a confused and slightly combative
male with scleral icterus. His abdomen is distended with bulging flanks, shifting dullness,
and a fluid wave. He has asterixis. There is no nuchal rigidity or photophobia. He is
oriented to person but not place or time. The most appropriate next step in this patient's
management is to
A. determine his ammonia level
B. order a CT scan of the head
C. perform a lumbar puncture
D. perform paracentesis
E. send a urine culture and sensitivity
Explanation:
The correct answer is D. This patient likely has spontaneous bacterial peritonitis. This
diagnosis should be first on your list in any patient with ascites who presents with
fevers, abdominal pain, change in mental status, or with other non-specific complaints.
These patients need to have a paracentesis. This fluid is then sent to the lab for a cell
count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria
on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a
52
positive peritoneal fluid culture. Patients with SBP need to be started on a thirdgeneration cephalosporin.
Ammonia levels (choice A) can be elevated in patients that are encephalopathic. This
patient is encephalopathic as evidenced by his asterixis and mental status changes.
Ammonia levels can be followed if you want additional evidence that this patient's
medications are effectively causing a decrease in those levels, but ammonia should not
be used to make the initial diagnosis of encephalopathy.
CT scan (choice B) is part of the work-up of mental status changes in the elderly, but
acute stroke resulting in mental status changes in a 54-year-old would be less likely.
CAT scan along with LP might be necessary if the paracentesis does suggest
peritonitis.
Lumbar puncture (choice C) is also part of the work-up for mental status changes but
this patient doesn't have headache, high fevers, nuchal rigidity, or photophobia.
Meningitis would be lower on the list of differential diagnoses in this patient and LP is
not indicated as an initial diagnostic procedure.
Urine culture and sensitivity (choice E) is a test that we should all have a very low
threshold to since urosepsis is a very common cause of fevers and mental status
changes in the elderly and in the immunocompromised. This patient should have his
urine evaluated, but the best answer is paracentesis since a positive urine culture would
not rule out confounding peritonitis.
A 9-year-old girl is brought to the office by her mother because of "stomach aches" and
constipation. She has been having one painful, hard bowel movement every 4 to 5 days.
She admits that she never goes to the bathroom in school because she is too
embarrassed, so she "holds it in until she is at home." Many times she is so busy with
after school activities such as ballet, piano, and gymnastics, that the "feeling" often
passes by the time she gets home. The mother tells you that she complains of
abdominal pain when this occurs, but it is too painful to defecate, so she continues to
hold it in. She does not take any medications, has no medical illness, and has had
normal bowel habits until 6 months ago. Physical examination shows mild abdominal
tenderness, a hard mass in the lower abdomen, and a dilated rectum filled with a large
amount of hard, guaiac negative, brown stool. The most appropriate next step is to
A. obtain a consult with a pediatric gastroenterologist
B. obtain an x-ray of the abdomen
C. recommend a balanced diet containing whole grains, fruits, and vegetables
D. recommend a phosphate soda enema
E. schedule anal manometry
Explanation:
The correct answer is D. This patient has fecal impaction that is most likely caused by
school bathroom avoidance. Fecal impaction can be diagnosed by finding a hard mass
in the lower abdomen and a dilated rectum filled with a large amount of hard stool. This
53
often occurs because of fecal stasis in the colon leading to an increased absorption of
fluids, which in turn leads to the accumulation of large, hard stools that are painful to
pass. This pain often leads to avoidance of defecation, even if the child is at home. The
treatment includes disimpaction by oral or rectal medications, dietary and behavior
modification. Disimpaction must be done before starting maintenance therapy.
A consult with a pediatric gastroenterologist (choice A) is usually only necessary after
the child fails therapy, when an organic disease is suspected, or when there is complex
management. This case seems like a simple case of school bathroom avoidance that
can be treated with disimpaction, and dietary, behavior modification. If this fails, a
consult may be considered.
An x-ray of the abdomen (choice B) is not necessary to establish the diagnosis of fecal
impaction if the physical examination reveals a hard mass in the lower abdomen and a
dilated rectum filled with a large amount of hard brown stool. It may be necessary, if the
child refuses a rectal examination.
After a thorough history, physical examination, and disimpaction, you should
recommend a balanced diet containing whole grains, fruits, and vegetables (choice C)
and behavior modification to promote healthy bowel habits.
Anal manometry (choice E) is used in the evaluation of Hirschsprung disease, which is
a cause of constipation in infants and rarely in school-age children. It is caused by a
lack of colonic ganglion cells. Physical examination usually reveals a distended
abdomen, a contracted anal sphincter, and a rectum devoid of stool. The physical exam
of the child in this case is inconsistent with Hirschsprung disease. Also, she admits to
school bathroom avoidance, which is probably the cause of her impaction.
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