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Flashcards in Acute Abdomen - Shelf-Life Deck (24):
1

57 year old presents with abdominal pain. Reports 1 day history of dull, aching abdominal pain - gradually worsened over last 24 hours. Pain radiates to back. Has had nausea, vomitng numerous time and no appetite. PMH of HTN, GERD and alcohol abuse. Febrile, hemodynamically stable. O/E reveals a supine motionless female - tenderness with guarding. CT performed. Which of the following choices represents the ideal management for this patient? 

A. Appendectomy

B. Exploratory lapartomy

C. NBM management, IV hydration and IV pain control 

D. Renal ultrasound

C - NBM management, IV hydration and IV pain control 

  • A diagnosis of acute pancreatitis should always be considered in a patient with abdominal pain and a history of alcoholism. 
  • Presentation of acute pancreatitis varies - pain is typically in the epigastrium, described as a dull worsening ache - radiating to the back 50% of the time (retroperitoneal organ) 
  • Examination reveals an acute abdominal picture with distention, guarding, tenderness - rarely jaundice or icterus may be noted on the patient
  • Some physical findings tested in necrotizing pancreatitis:
    • Cullen sign 
    • Grey-Turner sign
  • CT scan can reveal:
    • Enlargment of the pancreas
    • Pancreatic edema 

Why are other answers wrong? 

  • An appendectomy would be performed for a patient presenting with acute appendicitis
  • An 'ex-lap' would be a valid option in acute abdominal situations but only in the patient who is haemodynamically compromised. 
  • Other than fever - her vital signs are normal 
  • A renal ultrasound would be indicated if renal stones or an obstructing urethral stone was suspected. 
    • Such pathologies typically produce flank or flank and groin pain respectively - which is not described in this patient 

2

After writing an admission order for the patient from the previous question - the consultant demands to know if this patient's status is 'severe'. Which of the following data currently best predict the prognosis for the patient from the previous question? 

A. Age, WBC, glucose, LDH and AST

B. Age, WBC, hematocrit, calcium, ALT

C. Hematocrit, calcium, base deficit, WBC and LDH

D. Hematocrit, BUN, calcium, PaO2, base deficit and fluid sequesteration

A - Age, WBC, glucose, LDH and AST

  • Many sets of critera that stage acute pancreatitis.
  • While there is no standard - the Ranson criteria are frequently tested. 
  • These criteria collect two sets of data, one at admission and another 48 hours later to determine severe disease states. 
  • Each criteria is assigned a single point value.
  • Admission criteria include:
    • Age over 55 
    • WBC greater than 16,000/ uL
    • Blood glucose greater than 200 mg/dl
    • LDH greater than 350 IU/L
    • AST greater than 250 IU/L
  • 48 hour criteria include:
    • hematocrit decrease by 10%
    • BUN increase of 8 mg/dL
    • serum calcium lower than 8mg/dL
    • PaO2 less than 60 mmHg
    • Base deficit greater than 4 mEq/L
    • Estimated fluid sequesteration greater than 600 mL. 

3

A 48 year old is admitted for abdominal pain. Onset of diffuse abdominal pain 2 days prior with nausea, diarrhea, vomiting and chills. PMH - GERD, HTN, Hep. C acquired from IV drug abuse. She is febrile but hemodynamically stable - appears jaundiced. O/E - spider angioma, distention, tympany and fluid wave. Tenderness with guarding througout. Likely diagnosis?

A. Acute cholecystitis 

B. Acute appendicitis

C. Pancreatitis 

D. Perforated viscus 

E. Spontaneous bacterial peritonitis (SBP) 

E - SBP

  • This patient has an acute abdominal picture in the presence of ascites (distended tympanic abdomen with fluid wave) due to her hepatitis (history of IV drug abuse, spider angioma) 
  • Given the combination of this history and these findings , a diagnosis of SBP must be entertained. 
  • This involves bacterial seeding of the ascitic fluid and can present in this manner. 

Why are other answers wrong? 

  • This is an atypical presentation for acute cholecystitis but perhaps tempting given the jaundice as a possible sign of obstructive biliary disease. 
  • Again this is atypical for appendicitis 
  • Pancreatitis is misleading because jaundice is an infrequent finding - also it usually presents with epigastric pain in association with gallstone pathology or alcoholism. 
  • A perforated viscus is usually due to peptic ulcer disease, appendicitis or diverticulitis. 

4

23 year old male medical student presents to A&E with what appears to be appendicitis. Notes sudden onset of right lower quadrant pain while playing tennis 3 hours prior. Immediately stopped playing with some relief, but pain gradually worsened and he vomited several times. Reports being tender. Otherwise is healthy and takes no medications. Vitals - 100.9 degrees farenheit, heart rate - 98, RR - 17, BP - 124/79 and oxygen saturation of 99%. 

On examination there are absent bowel sounds, exquisite abdominal tenderness over the right lower quadrant with tenderness and rebound. There is a firm mass noted in that area. Which of the following is the most likely diagnosis? 

A. Acute appendicitis 

B. Acute herniated bowel 

C. Acute mesenteric ischaemia 

D. Rectus sheath hematoma

E. Urinary obstruction

D - Rectus sheath hematoma 

  • Clinically very similar in presentation to acute appendicitis 
    • Rectus muscle hematomas often involve nausea and vomiting, low grade fever and an acute abdominal picture. 
    • In this patient the onset of abdominal pain during strenous activity and the palpable mass on examination both point to a rectus sheath hematoma. 
    • Surgical consultation can be made to determine the extent of the damage as well as if the injury is severe enough to indicate surgical repair 
  • Why are other answers wrong?
    • Acute appendicitis is a tempting distracter here for many reasons including the location of the pain, the associated gastrointestinal symptoms, the low grade fever and physical examination findings - this is less likely however given the associated activity with onset and the palpable mass. 
    • If a hernias was to present in this manner it would do so secondary to incarceration without or with strangulation. 
    • Presumably we would be provided with the medical history including a preexisting hernia (or chronic abdominal pain) that preceded this incident
    • AMI typically involves an embolus that blocks blood flow to the bowel. 
    • A urinary obstruction produces pain secondary to distention of the renal collecting system, the ureter or bladder. 
    • While the location of this pain may indicate a urethral stone, the presence of a superficial palpable mass makes this less likely. 

5

Which of the following statements best defiens Rovsing sign? 

A. RLQ pain due to drainage of a gastric or duodenal ulcer

B. RLQ pain following hip extension against resistance with the knee in full extension 

C. RLQ pain following internal rotation of the right leg with the hip and knee flexed

D. RLQ rebound tenderness following left lower quadrant palpation

  • ANSWER is D
    • Rosving sign describes palpation of the LLQ that elicits rebound tenderness in the RLQ. 
    • Does not specifiy the appendiceal location 
    • The CT scan reveals a thickened appendix with edema and inflammatory changes 
  • Why are other answers wrong? 
    • (A) describes a Valentino sign and is unique that the pathology differs from the remaining choices 
    • (B) - this statement reflects a positive psoas sign that can be helpful in revealing a 'retrocecal' or 'retroflexed' appendix which happens to lie inflamed on the belly of the psoas muscle. 
    • (C) - this statement describes a positive obturator sign - the obturator sign is helpful in diagnosing a patient with 'pelvic' appendicitis 

6

Which of the following statements best descibes the pathophysiology of acute diverticulitis? 

A - Chronic atherosclerotic disease of the mesenteric vessels causing ischaemia 

B - Inflammation and perforations at weak outpouchings of the colon 

C - Poorly understood mechanism involving modifiable risk factors such as low fiber diet and chronic constipation 

D - Transmural inflammation and perforation causing abnormal adherence to an adjacent structure 

  • ANSWER is B
    • Recall that the pathophysiology of diverticulitis occurs in the presence of diverticulosis 
    • Though the mechanism is not completely elicited - inflammation and macro or micropeforations occurs through these preexisting diverticula. 
    • Obstruction, fistulae formation and necrosis can all be involved 
  • Why are other answers wrong?
    • (A) - this statement describes the pathophysiology of chronic mesenteric ischaemia - we would expect to see pertinent risk factors including CAD and PVD. 
      • Pain from chronic mesenteric ischaemia is typically chronic associated with meals and causes food aversion ('food fear') with subsequent weight loss 
      • The abdominal examination is often normal 
    • (C) - this is a tempting as it describes the pathophysiology of diverticulosis, a condition necessarily preceding the development of diverticulitis. While it appears tricky, it is a helpful and educative distinction to make 
    • (D) - this statement describes the general pathophysiology of fistula formation 
      • A fistula can develop secondary to diverticulitis but is not necessarily involved 
      • A fistula describes the pathology of two abnormally joined viscous organs (enterovesical fistula) - this is not the mechanism of diverticulitis. 

7

19 year old girl presents for sudden onset abdominal pain that has worsened over the past 9 hours. It is worst over he right lower abdomen where it started. She has no associated nausea or vomiting and she denies any sexual activity. She has no past medical or surgical history. Examination reveals tachycardia, a young woman in acute distress and a tender abdomen with guarding and rebound over the RLQ. She is haemodynamically stable - which of the following is the next best step in management? 

A. Exploratory laparotomy 

B. Serum beta-HCG analysis 

C. Serum amylase and lipase levels 

D. CT abdomen 

E. MRI of the abdomen and pelvis 

B - Serum beta-HCG analysis 

  • The best management step for this patient is to rule our pregnancy and the possibility for an ectopic pregnany 
  • The diagnosis must be entertained in the setting of an acute abdomen in a woman of child-bearing age. 
  • Verification should be obtained with a serum level of beta-human chorionic gonadotropin.
  • Though emphasis and trust are always placed in the patient history - this is one item that should always be verified 

Why are other answers wrong? 

  • Exploratory laparotomy would be a suitable management option in patient who is haemodynamically unstable with suspected intraperitoneal injury 
  • Serum amylase and lipase are highly sensitive and specific for suspected cases of acute pancreatitis.
    • Pancreatitis classically involves a history of alcoholism and gallstone disease and typically presents with epigastric pain with or withour radiation to the back 
      • Jaundice is uncommonly associated but can be present 
  • CT abdomen is definitely within the scope of management of this patient - but only after verification of her nonpregnant state. 
  • Proceeding with this test would pose a radiation risk to the developing fetus.
    • This unnecessary radiation should be delayed until an ectopic pregnancy is ruled out 
  • MRI of the abdomen and pelvis is a viable option given the lack of radiation in concerns of the fetus, but other safe imaging modalities (e.g. ultrasound) would be more appropriate initially (all after negative hCG level). 

8

A 16 year old girl presents to A&E with abdominal pain and vomiting. She describes the onset yesterday while in school, occurring near her umbilicus. Her pain was made worse by walking home. She napped without relief and awoke with pain in her lower abdomen. She has not eaten but vomited 2 hours ago. She is febrile and tachycardic. Abdominal examination reveals tenderness in the RLQ with rebound and guarding. Her WBC is 16.2 Pregnancy test is negative. CT shows an inflammed retrocecal appendix. How can her pain best be described? 

A. Peritoneal 

B. Rebound

C. Referred

D. Somatic

E. Visceral

ANSWER -D

  • This case is describing another case of acute appendicitis in which the woman's pain has progressed from her umbilicus to her right lower quadrant.
  • Based on this symptom and her peritoneal signs (rebound, tenderness and guarding) we can assume that she experiencing somatic pain caused by inflammation of the peritoneum.
    • This is caused by inflammation of the appendix in contact with the peritoneum, allowing localization of the pain via somatic type nociceptors (pain fibres) 

Why are other answers wrong? 

  • Peritoneal pain is not a classification category. 
  • Rebound pain describes a physical diagnostic sign 
    • Subjective sensation of pain by the patient upon release of palpation pressure 
  • Referred pain describes pain that is sensed in an area that differs from its true origin - classic examples of this include left upper arm and jaw pain suffered in angina. 
  • Visceral pain in acute appendicitis is classically described by the vague periumbilical pain at the onset of the disease 
    • poorly localised without direct peritoneal irritation and is instead based on embryologic development of the mesenteric nervous system. 

9

You are called to the emergency department to see a 3 1 -year-old Gl0
woman at 27 weeks' gestation. She has been seen by the obstetric service
who verified a normally progressing and uneventful pregnancy
thus far. She is experiencing right upper quadrant abdominal pain of
9-hour duration associated with nausea and vomiting. Ultrasound of
her gallbladder, liver, and bilious structures was unremarkable. Right
renal ultrasound was read as normal. Abdominal examination reveals
tenderness in the right upper quadrant with guarding and rebound.
Which of the following is the most likely diagnosis?


(A) Acute acalculous cholecystitis
(B) Acute appendicitis
(C) HELLP syndrome
(D) Preeclampsia
(E) Right renal colic

Acute appendicitis. The correct answer is acute appendicitis

This question serves to remind you that the anatomical changes of
the obstetric p atient can skew the classic app earance of many conditions

With the presence of a fetus, the appendix may elevate dramatically and
can cause p ain at the right midabdomen or even the right upper quadrant.

Acute appendicitis is the most common reason for surgical exploration in a
gravid woman, and appendectomy is safest during the second trimester. For
these reasons, this atypical presentation of acute appendicitis is frequently
tested.


(A) This is a drawing distraction because this patient's pain is situated
at the right upper quadrant. Additionally, "acalculous" or stone-free pathology
suggests that radiologic studies like ultrasound may be normal. In fact,
ultrasonography in acalculous cholecystitis still reveals classical cholecystitis
signs, but without the stones (sensitivity and specificity near 70%) .

(C) HELLPsyndrome (hemolysis, liver enzymes, low platelet count) is a variant of preeclampsia.


Right upper quadrant pain during HELLP syndrome can occur due
to capsular distention of the liver. The incidence of liver distention is infrequent relative to appendicitis.

(D) Preeclampsia is a complication of pregnancy involving hypertension and proteinuria. Most of the pathophysiology is involved with medium- sized vasculature pathology. Liver distention more commonly occurs in association HELLP syndrome, a severe variant of preeclampsia.


(E) While right renal colic would definitely be included in the differential diagnosis, we are told that this patient underwent a right renal ultrasound which appeared normal. We would expect some abnormality (calculus,
ureteral calculus, hydronephrosis, etc.) to be present with this condition.

10

You are consulted to see a 29-year-old man who was admitted for shortness
of breath secondary to a mediastinal lymphoma. His CD4 count
was measured at 56 cells/mm3 and subsequent workup confirmed HIV
positivity. He is currently complaining of extreme abdominal pain that
started yesterday. He describes it as vague and aching. Palpation reveals
diffuse abdominal tenderness with rebound. Which of the following
is the most common cause of nonsurgical abdominal pain in patients
with AIDS?


(A) Infectious enteritis
(B) Kaposi sarcoma
(C) Non-Hodgkin lymphoma (NHL)
(D) Pancreatitis
(E) Sclerosing cholangitis

The answer is A: Infectious enteritis. This question is testing your knowledge
on abdominal pain workup in a patient with AIDS, whose pathology is
definitely altered with this disease state. The presentation can strongly vary as
well, as patients with AIDS manifest pain differently, and peritoneal signs can
be altered as well. The most common cause of nonsurgical abdominal pain
is infectious enteritis, with cytomegalovirus (CMV), Mycobacterium avium
complex (MAC), and Cryptosporidium comprising over 30% of the cases.

All causes of acute abdominal pain (appendicitis, cholecystitis, diverticulitis,
peptic ulcer disease (PUD ) ) must still be considered.


(B) Kaposi sarcoma would be included in the differential diagnosis,
but comprises a much small number of cases relative to infectious enteritis.


(C) NHL is the second most common cause of nonsurgical abdominal pain in
patients with AIDS. While it appears more common than MAC and Cryptosporidium individually, infectious enteritis stills outweighs it as a whole, which this question is asking.

(D) Pancreatitis is the third most common nonsurgical cause of abdominal pain in patients with AIDS (after infectious enteritis and NHL) . Like NHL, it is more common than MAC and Cryptosporidium enteritis, but less common than infectious enteritis in general.

(E) Sclerosing cholangitis is not necessarily at a higher frequency in patients with AIDS than the general population, but still represents a "nonsurgical" cause of abdominal pain. It is far from being more common than infectious enteritis in this patient population.

11

A 40-year-old G2P2 obese woman is 1 day postoperative following a
laparoscopic cholecystectomy. She has been hemodynamically stable,
a febrile, and without complaints. She is receiving Lovenox, ambulating
with assistance, and performing incentive spirometry with nursing
supervision. Her pain has been well controlled. This morning, she
noticed constant nagging shoulder pain upon awakening. Her vitals are
normal and stable. She denies shortness of breath and leg pain. Which
statement best describes the pathophysiology involved?


(A) Normal pain following positioning for a laparoscopic procedure
(B) Pulmonary embolism
(C) Referred pain due to bilious leakage of the cystic duct
(D) Referred pain due to subdiaphragmatic air

The answer is D: Referred pain due to subdiaphrag matic a i r. The most
likely answer here, given that this patient underwent a laparoscopic procedure, is referred shoulder pain secondary to subdiaphragmatic air. Any gas remaining postoperatively sits under the diaphragm and causes irritation.

The Kehr sign is the phenomenon describing shoulder pain secondary to peritoneal fluid or air; it is based on the anatomical overlap between the nerve roots of the phrenic nerve and the cervical nerves innervating the dermatomes around the shoulder (specifically C3 and C4) .


(A) Postoperative patients may experience "appropriate" abdominal tenderness and soreness, but there is no basis for shoulder pain. Furthermore, we are not given any reason to believe that the patient suffered a musculoskeletal complication while sedated.

(B) While pulmonary embolus would be a concern in a
patient postoperatively, there are many pieces of information that argue against it. She is receiving deep venous thrombosis (DVT) prophylaxis, she is not experiencing either shortness of breath or leg pain, and her vitals are stable (tachycardia is an extremely sensitive sign for pulmonary embolus) .

(C) Bilious leakage of the ductal remnant in this procedure could, in theory, produce Kehr sign as a peritoneal fluid collection; however, the incidence of referred shoulder pain due to residual gas is much more common, and therefore a better answer.

12

A 60-year-old African American man comes to the emergency department
for sudden-onset, diffuse abdominal pain. He describes the pain
as diffuse, 1 0/ 1 0, and sharp in nature that maximized within a few seconds.
He has a past medical history of CAB G X 2, diabetes treated with
Metformin, and atrial fibrillation treated with warfarin. Vitals reveal
tachycardia at 1 06 . Abdominal examination reveals a normal abdomen,
absent bowel sounds, and no tenderness. His INR today is 1 .3 . Which
of the following is the most likely diagnosis?


(A) Hemoperitoneum due to hemorrhagic bowel
(B) Mesenteric ischemia
(C) Myocardial infarction (MI)
(D) Pancreatitis
(E) SBP

The answer is B: Mesenteric ischemia. Acute mesenteric ischemia (AMI)
results from acute cessation of blood flow to the bowel. Risk factors associated include coronary artery disease and peripheral vascular disease. In AMI, arterial embolism to the bowel is the most common cause, with atrial fibrillation being the most common concomitant disease. The classic description is "pain out of proportion to the exam;' which is the case with this patient, as the examination appears normal. Peritoneal signs begin to surface only after necrosis of the bowel occurs.


(A) Hemorrhage of the bowel is a tempting choice given the patient's use of
warfarin for his atrial fibrillation history. However, recall that a therapeutic INR is between 2 and 3; furthermore, because he is subtherapeutic (INR 1 .3), we should more concerned with emboli or thrombi (causing AMI), not hemorrhage.

(C) This patient has serious risk factors for MI including his coronary artery disease; therefore, MI must be included on your differential and should be ruled out with serial troponins. The presentation described, however, is fairly classic for mesenteric ischemia, making it more likely.

(D) Pancreatitis is classically described as a dull, aching abdominal pain in the epigastric area. Risk factors include the presence of gallstones or current alcoholism. Serum amylase and lipase levels are a very effective means of diagnosis.

(E) SBP is typically found in the setting of ascites, which does not seem to be present in this patient. SBP has a range of presentations, but does involve abdominal pain usually of an acute gradual onset.

13

A 57 -year-old man is brought to the hospital by an rescue squad team.
He had been complaining of abdominal pain radiating to his back. The
pain began following dinner. Some hours later, his abdominal pain became "tearing" and he became diaphoretic. He described immediate
dizziness and collapsed. Vital signs in the emergency department
reports a lowest in the emergency department reports a lowest blood
pressure of 90/47 mmHg and a fastest heart rate of 1 06 beats/min. This
patient takes hydrochlorothiazide-lisinopril and as needed sildenafil.
Abdominal examination reveals a pulsatile mass. What is the next best
step in management?

(A) Abdominal ultrasonography
(B) Chest x-ray (CXR)
(C) Computed tomography ( CT) of the abdomen
(D) Exploratory laparotomy
(E) Transesophageal echocardiogram (TEE)

The answer is D: Exploratory laparotomy. This question provided the
classic presentation and triad (hypotension, pulsatile mass, and abdominal
pain) of abdominal aortic aneurysm (AAA) . Additionally, this patient is the
classic patient to present with AAA, as he is male, has hypertension (note the
medication) , and smokes. The question asks for the next step in management
of this patient. Given his hypotension (blood pressure of 90/47 mmHg) and
tachycardia, he is hemodynamically unstable and must proceed to exploratory
laparotomy.


(A) Abdominal ultrasonography is the ideal screening test for those
patients at risk of developing AAA. Given this patient's risk factors of smoking,
hypertension, and his age, he would have been an ideal candidate for screening.Abdominal ultrasound is not ideal in a hemodynamically unstable patient.


(B) CXR is a potential means of diagnosis in patients with thoracic aortic
aneurysm, where it can reveal widening of the aortic knob. Thoracic aortic
aneurysms present with stabbing chest pain that radiates to the back.

(C) CT of the abdomen would be a reasonable option in a patient suffering from a suspected AAA who is hemodynamically stable. However, this patient is not, and requires immediate intervention.

(E) Transesophageal echocardiography would confirm a suspected diagnosis or thoracic aortic aneurysm (likely following the CXR as an initial study) . Thoracic aortic aneurysms present with stabbing chest pain that radiates to the back. Transesophageal examinations are preferred to transthoracic ones based on the proximity to the great vessels.

14

Which of the following statements best describes Murphy sign?

(A) Cessation of inspiration with deep palpation of the right upper quadrant
(B) Painless palpable gallbladder
(C) Referred shoulder pain secondary to diaphragmatic irritation
(D) Right upper quadrant tenderness due to application of an ultrasound probe
(E) Tenderness in the right upper quadrant with deep palpation assisted by inspiration

The answer is A: Cessation of inspiration with deep palpation of the
right upper quadrant. Murphy sign is a commonly tested physical examination
phenomenon and frequently misinterpreted. A patient is first asked to
fully expire as the examiner places his hand in a deep palpation position at the right upper quadrant. The patient is then asked to fully inspire. Traditionally, a positive Murphy sign refers to the cessation of patient inspiration due to pain. Inspiration causes downward movement of the diaphragm, which causes sudden pain when it contacts the inflamed gallbladder.


(B) Palpable gallbladder typically describes Courvoisier sign, a sign suggestive
of carcinoma of the head of the pancreas. The head of the pancreas
leads to obstruction of the common bile duct, leading to gallbladder dilatation.
The process is typically painless, as it involves a chronic, slowly occurring
process (desensitizing the nociceptors) .

(C) This statement describes Kehr sign, which can occur in a wide variety of cases of peritonitis. Kehr sign is unique in that it is referred pain which occurs in the abdominal cavity based on the overlapping nerve roots that innervate the diaphragm as well as sensory nerves of the shoulder.

(D) This is a distracting statement, as it describes the sonographic Murphy sign, which is considered a variant of the Murphy sign. It does not necessarily involve cessation of patient inspiration. It is slightly different from the classically tested Murphy sign.

(E) This statement describes the frequent misinterpretation by students (that the role of inspiration is only to elicit right upper quadrant tenderness ) . Correctly stated, however, a positive Murphy sign describes cessation of inspiration by the patient.

15

You are called to see a 32 -year-old woman who recently underwent a
cesarean delivery. Her complaints include chills, dizziness, and extreme
abdominal pain. Vitals include a temperature of 39°C, heart rate of
1 07 beats/min, respiratory rate of 17 breaths/min, blood pressure of
1 06/98 mmHg, and normal oxygen saturation. Examination reveals
a nervous, diaphoretic woman. There are no bowel sounds during
the abdominal examination, and a focal mass is palpated in the left
lower quadrant. There is diffuse tenderness. White blood cell count is
reported to be 1 8 .2 . Which of the following is the most likely diagnosis?


(A) Abdominal abscess
(B) Acute appendicitis
(C) Acute cholecystitis
(D) Postpartum eclampsia
(E) Uterine atony

The answer is A: Abdominal abscess. This postpartum woman is most
likely suffering from a pelvic abscess following contamination from her recent
cesarean section. Abdominal and pelvic abscesses present with abdominal
pain, fever or chills, and a white blood cell count. A focal palpable mass may or may not be present. Abdominal abscesses, as infections, can proceed to a sepsis-like picture involving hypotension. A white blood cell count further
speaks to the process.


(B) Acute appendicitis is the most common indication for surgical intervention
in the gravid woman. While aspects of this picture could possibly suggest
complication of appendicitis with abscess formation, her pain is left sided.
Furthermore, this is a less likely diagnosis given her recent surgery.

(C) Cholecystitis does have an association in the gravid and parous woman as well as the postoperative period. However, the presentation is strikingly different than the one provided here (pain location, mass location, etc. ) . Her recent procedure makes other diagnoses more concerning.

(D) Eclampsia describes the condition of preeclamspia (hypertension and proteinuria) along with the presence of grand-mal seizures. It is treated with magnesium, but is ultimately expected to resolve with delivery of the child. This is different than the condition described.


(E) Uterine atony describes a condition where the uterus fails to regain tone
immediately following delivery of the child. A laxed, enlarged uterus on examination would reveal the diagnosis. This is quite different than what is presented.

16

A 52 -year-old woman travels to the emergency department complaining
of unbearable reflux. She describes her discomfort as following her
dinner this evening, but unaffected by the over-the-counter medications
which usually alleviate her GERD -like symptoms. She also admits
to nausea as well as weakness and tingling in her left arm. She denies
chest pain and shortness of breath. Her medications include metformin
and insulin, omeprazole, and escitalopram. Which of the following
characteristics most strongly masks the presentation of myocardial
infarction (MI) in this patient?


(A) Age
(B) Depression
(C) Diabetes mellitus
(D) GERD
(E) Taking over-the-counter antacids

The answer is C: Diabetes mellitus. Diabetes, female gender, and advanced
age are known risk factors for "atypical angina (lacking the crushing, localized
chest pain);' and therefore these are patient populations you should treat
extra-cautiously. One theory for the occurrence of atypical angina in diabetics
relates to the neurovascular effects this disease has systemically. In the setting of abdominal pain and/or discomfort, angina with or without MI must be considered, particularly in these patient populations.


(A) Advancing age is a risk factor for atypical angina. Typically, this effect
manifests in the elderly. A patient who is 52 years old may certainly have agerelated atypical angina, but diabetes would far outweigh this age-related risk.

(B) Depression does not appear to be a risk factor for atypical angina, as diabetes is. On the other hand, the major psychiatric condition that clouds the condition of angina is panic disorders, whose symptoms can appear identical.


(D) Symptoms of GERD (abdominal upset, nausea, retrosternal burning, etc.)
are often the one described during atypical angina (if present) . The presence
of GERD, however, does not predispose a patient to atypical angina. There is
danger, however, should a patient confuse atypical angina with his or her "typical reflux symptoms:'

(E) Over-the-counter antacids do not mask symptoms of angina. When taking a complete history, pain due to angina will not be relieved by antacids, but will instead be relieved with nitroglycerin prescribed to patients who have high cardiovascular risk.condition of angina is panic disorders, whose symptoms can appear identical.

(D) Symptoms of GERD (abdominal upset, nausea, retrosternal burning, etc.)
are often the one described during atypical angina (if present) . The presence
of GERD, however, does not predispose a patient to atypical angina. There is
danger, however, should a patient confuse atypical angina with his or her "typical reflux symptoms:'

(E) Over-the-counter antacids do not mask symptoms of angina. When taking a complete history, pain due to angina will not be relieved by antacids, but will instead be relieved with nitroglycerin prescribed to patients who have high cardiovascular risk.

17

45 -year-old man is brought to the emergency department by paramedics.
He was at an amusement park today when he collapsed and
was found to be diaphoretic and experiencing extreme abdominal pain.
He reports that he had been experiencing abdominal pain and constipation
for the entire day and avoiding meals accordingly. He takes no
medications. He had a cholecystectomy 3 years prior. Vitals are normal.
Abdominal examination reveals diffuse tenderness with guarding
and rebound. Chest x-ray reveals subdiaphragmatic air. Which of the
following actions is the best next step in management?


(A) Conservative management
(B) Exploratory laparotomy
(C) Diagnostic and therapeutic endoscopy
(D) Laparoscopic appendectomy

The answer is B: Exploratory laparotomy. Always be able to recognize
this CXR finding for both testing and practical purposes. This film exhibits
"free air;' or subdiaphragmatic air. This finding is pathognomonic for a perfo rated viscus (presumably bowel) until proven otherwise. This is an indication
for immediate exploratory laparotomy.


(A) Conservative medical management is an option in postoperative ileus
or the early stages of a suspected bowel obstruction in stable patients. B ecause the free air in this film indicates a perforation, likely secondary to obstruction based on the history, exploratory laparotomy is indicated.

(C) Endoscopy can be diagnostic and therapeutic for intussucception (when the bowel "sleeves" on itself) . This diagnosis is more common in the pediatric population. Free air would not be an expected finding in intussusception unless necrosis occurs.

(D) Laparoscopic appendectomy would be indicated for cases of acute appendicitis. Based on this history and the description of this patient's symptoms, this is not acute appendicitis. Furthermore, a laparoscopic approach would be less than ideal given a suspected perforation.

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An 80-year-old woman presents to the emergency department with
abdominal pain. She describes the pain as crampy in nature and of a
48-hour duration. Her last meal exacerbated her pain, which preceded bilious vomiting that alleviated her pain. She has since avoided meals.
Her medications include omeprazole, loratadine, albuterol, and Miralax.
Surgical history includes cholecystectomy and appendectomy, both
more than 1 0 years ago. Examination reveals a distended abdomen
with increased bowel sounds, diffusely tender with voluntary guarding.
Air-fluid levels are seen on the flat and upright abdominal x-ray.
Which of the following is the most likely diagnosis?

(A) Iatrogenic cecal volvulus
(B) Iatrogenic small bowel obstruction
(C) Internal bowel herniation through the falciform ligament
(D) Postoperative ileus

The answer is B: Iatrogenic smal l bowel obstruction. Patients with
bowel obstructions often present with colicky abdominal pain worse with
eating, relieved by vomiting (which can be bilious) , and acute constipation.
Air-fluid levels are the classic radiologic finding. The most common cause of
bowel obstruction in developed countries is iatrogenic due to postoperative
adhesions in patients with previous surgeries. In complete bowel obstruction,
small bowel obstructions far outnumber large bowel obstruction.


(A) Cecal volvulus would be a specific type of large bowel obstruction and
therefore less common than small bowel obstructions in general. Furthermore, cecal volvuli involve other risk factors (high fiber diets, chronic recumbency) , with postoperative adhesions being a less significant factor.

(C) While patients with bowel herniation through the falciform ligament do indeed present with bowel obstruction symptoms, they extremely rarely account for obstruction ( < 0 .2%). This is not, therefore, the most likely diagnosis.

(D) Postoperative ileus describes the obstructive-like picture that occurs acutely after surgery. This patient's surgical history is distant, which makes this diagnosis impossible. Additionally, postoperative ileus tends to present more subtly and is associated with discomfort rather than acute pain onset.

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Which statement listed below best defines McBurney point?


(A) Two-thirds the distance from the left anterior superior iliac spine
(ASIS) to the umbilicus
(B) Two -thirds the distance from the right ASIS to the umbilicus
(C) Two -thirds the distance from the umbilicus to the left ASIS
(D) Two-thirds the distance from the umbilicus to the right ASIS

The an swer is D : Two-third s the distance from the umbilicus to the
right ASIS . This question is testing basic abdominal anatomy, sp ecifically
that of McBurney point, the location commonly overlying the inflamed
app endix in acute appendicitis. McBurney point lies between the umbilicus
and the right ASIS, specifically two - thirds the distance toward the ASIS.
A McBurney incision is located here ( at the point of maximal tenderness)
perpendicular to this line. 


(A) This statement does not accurately describe McBurney point, as this
point overlies the appendix, which is located on the right.

(B) While closely describing McBurney point, the problem with this statement is that the point lies closer to the ASIS than the umbilicus. This statement is describing the point being closer to the umbilicus.

(C) This statement does not accurately describe the McBurney point, as this point overlies the appendix, which is located on the right.

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A 52-year-old woman presents to her physician with epigastric pain of
sudden onset. She describes it being in a similar location to the gnawing
sensation she experiences with meals but now is much worse. Her
current medications include omeprazole, loratadine, and a multivitamin,
and she reports a history of H. pylori infection. Physical examination
reveals significant abdominal tenderness in the mid-epigastrium
with involuntary guarding and mild rebound tenderness. What is the
most appropriate next step in the management of this patient?


(A) Colonoscopy, limited to rectosigmoid region
(B) CT of the pelvis
(C) Esophagogastroduodenoscopy (EGD) to duodenum
(D) Upright abdominal plain film x-ray (AXR)

The answer is D: Upright abdominal plain film x-ray (AXR). This patient's
history of H. pylori makes peptic ulcer disease very likely, which should raise
concern for perforation of a preexisting ulcer. This is further supported with
the sudden onset of abdominal pain in the epigastrium. An upright AXR in the
setting of perforation can be very specific if it reveals subdiaphragmatic air. As
an inexpensive diagnostic approach, it is the best first step.


(A) Colonoscopy is incorrect. The patient's history, symptoms, and examination indicate that the pathology involved is the upper gastrointestinal tract. A colonscopy, therefore, would contribute little to this diagnosis.

(B) Computer tomography would be the next best step if the abdominal film appears normal. A CT study would provide more specifics about the perforation including size, severity, and location. In a stable patient, it could be useful in addition to an abdominal film for preoperative intraabdominal details.

(C) In the setting of a perforation (as in peptic ulcer perforation) , and diverticulitis (when microperforations exist or can occur easily) , endoscopy is contraindicated. This would therefore be not an ideal management step, though it is addressing the relevant organ.

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A 53 -year-old man presents to the emergency department because
of abdominal pain. He describes worsening cramping pain in his left
lower abdomen of 8-hour duration. He had been nauseous with diarrhea
for 24 hours. He has a past medical history of hypertension, peptic
ulcer disease status post H. pylori eradication, and history of renal
lithiasis. His medications include hydrocholorothiazide, rabeprazole,
and over-the-counter Miralax. He has never had a colonoscopy. His
last renal calculus episode was 19 years prior. Physical examination
reveals a temperature of 38.2°C, blood pressure of 1 40/70 mmHg, and
pulse of 1 1 0 beats/min. He has abdominal tenderness and guarding
over his left lower quadrant. What is the most appropriate next step in
the evaluation of this patient?


(A) Colonoscopy limited to rectum and sigmoid colon
(B) CT of the abdomen and pelvis
(C) Esophagogastroduodenoscopy (EGD)
(D) No further diagnostic testing is necessary given this clinical diagnosis
(E) Magnetic resonance imaging (MRI) of the abdomen and pelvis

The answer is B : CT of the abdomen and pelvis. Given the symptoms
and physical examination findings, this patient is most likely suffering from
acute diverticulitis. While he is lacking a previous diagnosis of diverticulo sis,
we are also told he has never had a colonoscopy. His Miralax use suggests
constipation, a condition that may predispose to diverticulosis (or may been
a symptom of the disease itself) . CT is the diagnostic gold standard for acute
diverticulitis based on sensitivity and specificity. CT studies reveals colonic
stranding, thickening of bowel, and other involved processes (e.g., abscess,
phlegmon, fistulae, etc . ) .


( A ) Colonoscopy is relatively contraindicated in diverticulitis. There i s
a significant risk of bowel p erforation through a n affected diverticula. This
p atient is already showing signs of perforation based on peritoneal signs.

(C) Despite having a history of peptic ulcer disease, perforation of a peptic
ulcer is a less likely diagnosis given the location of this p atient's pain. Furthermore, patients with peritoneal signs due to an ulcer p erforation would
proceed to exploratory laparotomy, not EGD, which is contraindicated.


( D ) The diagnosis is not certain. While this would deviate from the classic,
typical presentation of renal calculus disease (involving renal or ureteral colic
on the p atient's left side), it is still a possibility given this patient's history.
Further workup is required.

(E) MRI would contribute little to this clinical picture. The patient has a fairly classic presentation and physical examination findings for diverticulitis. Given renal calculus disease is included in the differential based on his history, CT would first be more appropriate to determine which is the cause.

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A 1 6-year-old boy presents to the ambulatory care center of the emergency
department with right lower quadrant pain. He first noted the
onset of pain 10 days prior while doing homework, which worsened
over 1 day. He experienced a warm sensation with relief of his pain
2 days after onset. His pain subsided for some time, but began to recur
2 days prior to presenting. He noted fever and chills, nausea, and
vomiting. Examination reveals a tachycardic, febrile young man in no
acute distress. Abdominal examination reveals right lower quadrant
tenderness with guarding. CT scan reveals appendiceal rupture with a
walled-off abscess. Which of the following is the ideal treatment given
the findings in this patient?


(A) Conservative management
(B) Interval appendectomy
(C) Laparoscopic appendectomy
(D) Open appendectomy

The answer is B: Interval appendectomy. Select cases of acute appendicitis
are prone to rupture; rupture predisposes to abscess formation and possible
sepsis. In cases where the abscess is effectively walled off, it is established that interval appendectomy (appendectomy 8 to 1 2 weeks after allowing the abscess to "cool off") is the gold standard in the pediatric population. Variations on this standard treatment include whether or not to administer antibiotics, and whether or not to begin with percutaneous drainage.


(A) Conservative management is p artially correct, in that interval
appendectomy involves 8 to 1 2 weeks of conservative management prior to
removal of the appendix. This answer is incorrect b ecause it does not mention the appendectomy that occurs later; therefore B is a better answer.


(C) Laparosopic appendectomy would be ideal in an uncomplicated case of
acute appendicitis. A walled off abscess is more so an indication for interval
appendectomy.

(D) Open appendectomy would be an option for acute appendicitis. In the pediatric population, however, lap aroscopic would be the preferred approach. A walled off abscess, however, is more so an indication for interval appendectomy.

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A 1 6-year-old male is brought to the emergency department by his parents
for right-sided abdominal pain. He reports that the pain started
2 hours prior while doing sit-up drills during gym class at school. He
became nauseous and vomited after being picked up by his parents. He
reported alleviation of pain sitting upright in the car. He has no prior
medical or surgical history. Blood pressure is 1 1 8/78 mmHg and pulse is
68 beats/min. Physical examination reveals a young man in acute
distress. The right lower quadrant of his abdomen is diffusely tender without guarding or rebound tenderness. The WBC count is 7800/mm3.
Which of the following is the best first step in attaining a diagnosis?


(A) Complete physical examination
(B) CT of the abdomen
(C) MRI
(D) Scrotal ultrasound
(E) Upright KUB film

The answer is A: Complete physical examinati o n . This question is modeled
after a published case report of a case of testicular torsion that presented
with abdominal pain only. While this clinical picture is atypical for this scenario, it is irrelevant, since further workup for this patient (and any patient)
should start with a complete, head-to -toe physical examination. Remember to
include testicular torsion as a differential for abdominal pain, and to always
complete the history and physical prior to other diagnostics.


(B) CT is a reasonable choice given the symptom of abdominal pain.
While this would not provide the diagnosis of testicular torsion, it would
rule out other diagnoses for right- sided abdominal pain such as appendicitis.


(C) MRI is incorrect. This would take place well after a complete history and
physical examination. Additionally, CT would take precedence.

(D) A scrotal ultrasound would be recommended for this patient, as this is describing a case of testicular torsion. However, scrotal ultrasound would take place after a complete physical examination, including a urogenital examination.

(E) An abdominal plain film showing the kidneys, ureters and bladder (KUB) film, or "kidneys, ureters, bladder" x-ray is similar to an abdominal plain film and is useful in beginning a workup for a patient with suspected renal or ureteral stones. While it is urologic it nature, it has no bearing in testicular torsion, and would not occur before a complete physical examination.

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