Pretest - GI tract, liver, pancreas Flashcards
74yo woman is admitted with upper GI bleeding. she is started on H2 blockers, but experiences another bleeding episode. endoscopy documents diffuse gastric ulcerations. omeprazole is added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. which of the following is the mechanism of action of omeprazole?
a. blockage of the breakdown of mucosa-damaging metabolites of NSAIDs
b. provision of a direct cytoprotective effect
c. buffering of gastric acids
d. inhibition of parietal cell hydrogen potassium ATPase
e. inhibition of gastrin release and parietal cell acid production
D
–> PPI
exceeding 24h
–> suppression of meal-stimulated and noctural acid secretion.
35yo woman presents with frequent and multiple areas of cutaneous ecchymosis. w/up demonstrates a plt count of 15,000; evaluation of the bone marrow reveals a normal # of megakaryocytes, and US examination demonstrates a normal-sized spleen. based on the exclusion of other causes of thrombocytopenia, she is given a diagnosis of immune idiopathic thrombocytopenic purpura (ITP). which of the following is the most appropriate treatment upon diagnosis?
a. expectant management with close follow-up of plt counts
b. immediate plt transfusion to increase plt counts to >50,000
c. glucocorticoid therapy
d. IVIg therapy
e. referral to surgery for laparoscopic splenectomy
C
the plts are being sheared by immune cells
ITP
- Asx + plt > 30,000 –> expectant management
- significant bleeding/factors + plt < 50,000 or plt <30,000 –> treament with prednisone
- severe bleeding; preop prior to splenectomy –> treatment with IVIg
- acute bleeding –> plt transfusions
- severe symptomatic thrombocytopenia; higher levels of steroids needed; failure of steroid therapy; persistent thrombocytopenia for > 3mo –> splenectomy
59yo woman presents with RLQ pain, nausea, and vomiting. she undergoes an uncomplicated laparoscopic appendectomy. Post-op, the pathology reveals a 2.5cm mucinous adenocarcinoma with lymphatic invasion. Staging workup, including colonoscopy, chest x-ray and CT scan of the abdomen and pelvis, is negative. which of the following is the most appropriate next step in her management
a. no further intervention at this time. follow-u every 6 mo for 2y
b. chemotherapy alone
c. neoadjuvant chemotherapy followed by R hemicolectomy
d. ileocecectomy
e. R hemicolectomy
E
it isnt’ causing her problems, but there was invasion into lymph nodes - concerns for metastasis.
appendiceal adenocarcinoma
41yo man complains of regurgitation of saliva and of undigested food. an esophagram reveals a dilated esophagus and a bird-s beak deformity. manometry shows a hypertensive lower esophgeal sphincter with failure to relax with deglutition. which of the following is the safest and most effective treatment of this condition?
a. medical treatment with sublingual nitroglycerin, nitrates, or CCBs
b. repeated bougie dilations
c. injections of botulinum toxin directly into the lower esophgeal sphincter
d. dilation with a Gruntzig-type (volume-limited, pressure control) balloon
e. surgical esophgagomyotomy
E
achalasia –> due to increased pressure in lower sphincter
Heller myotomy –> more curative than medical management (where achalasia can recur)
a 32yo man with a 3y hx of ulcerative colitis presents for discussion for surgical intervention. the pt is otherwise healthy and does not have evidence of rectal dysplasia. which of the following is the most appropriate elective oepration for this pt?
a. total proctocolectomy with end ileostomy
b. total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy
c. total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and divting ileostomy
d. total abdominal colectomy with ileal rectal anastomosis
e. total abdominal colectomy with end ileostomy and very low Hartmann
B. total proctocolectomy with end ileostomy + ileoanal pounch anastomosis.
–> for older and incontinent pts
rectum is spared for now, but it eventually involves the rectum
–> resect most of the rectal
39yo previously healthy male is hospitalized for 2w with epigastric pain radiating to his back, N&V. initial lab values revealed an elevated amylase level consistent with acute pancreatitis. 5w following discharge, he complains of early satiety , epigastric pain, and fevers. on presentation, his T 38.9C (102F) and his HR 120, WBC 24,000 and amylase is normal. he undergoes a CT demonstrating a 6cmx6cm rim-enhancing fluid collection in the body of the pancreas. which of the following would be the most definitive management of the fluid collection?
a. antibiotic therapy alone
b. CT-guided aspiration with repeat imaging in 2-3d
c. antibiotics and CT-guided aspiration with repeat imaging in 2-3d
d. antibiotics and percutaneous catheter drainage
e. surgical internal drainage of the fluid collection with a cyst-gastrostomy or Roux-en-y cyst-jejunostomy
D
pancreatic cyst/abscess
–> can present 4-6w after an episode of acute pancreatitis.
a previously healthy 79yo woman presents with early satiety and abdominal fullness. CT scan of the abdomen shows a cystic lesion in the body & tail of the pancreas. CT-guided aspiration demonstrates an elevated CEA level. which of the following is the most appropriate treatment option for this pt?
a. distal pancreatectomy
b. serial CT scans with resection if the lesion increases significantly in size
c. internal drainage with roux-en-y cyst-jejunostomy
d. percutaneous drainage of the fluid-filled lesion
e. endosopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement
A
she has sxs –> so can’t just leave it
–> cystadenocarcinoma from thepancreatic body and tail.
no diagnotic laboratory findings.
high CEA, low amylase –> malignancy
tx = aggressive surgical resection
unlikely to be a pseudocyst b/c of high CEA.
56yo woman is referred to you about 3mo after a colostomy subsequent to a sigmoid resection for cancer. she complains that her stoma is not functioning properly. which of the following is the most serious complication of an end colostomy?
a. bleeding
b. skin breakdown
c. parastomal hernia
d. colonic perforation during irritation
e. stomal prolapse
C
Complications (in terms of seriousness)
1) parastomal herniation (when stoma is placed lateral) –> relocation of the stomach / mesh over hernia
2) irregularity of stoma function
3) irritation of skin due to leakage of enteric contents
4) bleeding from exposed mucosa following trauma
5) prolapse –> esp. with transverse loop colostomies likely due to the use of transverse loop to decompress distal colon obstructions. as the intestine decompresses, it retracts from the edge fo teh surrounding fascia –> allows prolapse / herniation fo mobile transverse colon
6) perforation fo stoma –> likely only d/t careless instrumentation
56yo previously healthy physician notices that his eyes are yellow and he has been losing weight. on PE, the pt has jaundice and scleral icterus with a benign abdomen. transcutaneous US of the abdomen demonstrates biliary ductal dilation without gallstones. which of the following is the most appropriate next step in the workup of this patient?
a. esophagogastroduodenoscopy (EGD)
b. endoscopic retrograde cholangiopancreatography (ERCP)
c. acute abdominal series
d. CT scan
e. PET scan
D. painless jaundice = likely pancreatic cancer.
stone in the common bile duct –> would be colicky pain
45yo woman with a history of heavy NSAID drug ingestion presents with acute abdominal pain. she undergoes exploratory laparotomy 30h after the onset of sxs and is found to have a perforated duodenal ulcer. which of the following is the procedure of choice to treat her perforation?
a. simple closure with omental patch
b. truncal vagotomy and pyloroplasty
c. trungal vagotomy and antrectomy
d. highly selective vagotomy with omental patch
e. hemigastrectomy
A
no prior history of peptic ulcer disease –> simple procedure
long-standing ulcer disease = variety of options with benefits & risks
45yo man with a hx of chronic peptic ulcer dz undergoes a truncal vagotomy and antrectomy with a billroth II reconstruction for gastric outlet obstruction. 6w after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain and diarrhea. which of the following would be the best initial management strategy?
a. treatment with a long-acting somatostatin analog
b. dietary advice and counseling that sxs will probably abate within 3mo of surgery
c. dietary advice and counseling that sxs will probably not abate but are not dangerous
d. workup for neuroendocrine tumor (eg carcinoid)
e. preparation for revision to roux-en-y gastrojejunostomy
B
dumping syndrome = it is dangerous.
~ carcinoid syndrome
post-prandial –> releasing too much insulin = hypoglycemia (vasomotor syndrome)
dietary advice
- avoid lots of sugar
- frequent small meals
- separate fluids & solids
60 yo male pt with HCV with a previous hx of variceal bleeding is admitted to the hospital with hematemesis. his BP is 80/60, exam reveals splenomegaly and ascites and initial Hct 25%. Prior to endoscopy, which of the following is the best initial management of the pt?
a. administration of IV octerotide
b. administration of B-blocker (eg propanolol)
c. measurement of prothrombin time and transfusion with cryoglobulin if elevated
d. empiric transfusion of plts given splenomegaly
e. gastric and esophageal balloon tamponade (Sengstaken-Blakemore tube)
A
acute variceal bleed - correct high PT / INR with FFP
tx
1) fluid resuscitation = isotonic crystalloids + blood transfusion
2) octreotide/vasopressin –> to decrease splanchnic blood flow
+ nitroglycerin –> for coronary vasoconstrictive effects
3) sclerotherapy
4) endoscopy + banding
5) balloon tamponade (s/e = aspiration, asphyxiation, ulceration, rebleeding)
when hemodynamically stable
- B-blocker –> prevent recurrent variceal bleeding
32yo alcoholic with end-stage liver disease has been admitted to the hospital 3x for bleeding esophgeal varices. he has undergone banding and sclerotherapy preivously. he admits to currently drinking 6 packs of beer per day. on his abdominal examination, he has a fluid wave. which of the following is the best option for long-term management of this pt’s esophgeal varices
a. orthotopic liver transplantation
b. transection and reanastomosis of the distal esophgaus
c. distal splenorenal shunt
d. end-to-side portocaval shunt
e. transjugular intrahepatic portosystemic shunt (TIPS)
E
cirrhosis
usually use TIPS for the ascites d/t portal hypertension
55yo man complains of chronic intermittent epigastric pain. a gastroscopy demonstrates a 2cm pre-pyloric ulcer. biopsy of the ulcer yields no malignant tissue. after a 6w trial of medical therapy, the ulcer is unchanged. which of the following is the best next step in his management?
a. repeat trial of medical therapy
b. local excision of the ulcer
c. highly selective vagotomy
d. partial gastrectomy with vagotomy and billroth I reconstruction
e. vagotomy and pyloroplasty
D
1) triple therapy
2) vagotomy + distal gastrectomy with gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II)
indications for surgical intervention
- hemorrhage, perforation
- persistent ulcer after medical therapy
- inability to r/out a malignancy
- ulcers associated with acid hypersecretion
45yo man was discovered to have a hepatic flexure colon cancer during a colonoscopy for anemia requiring transfusions. upon exploration fhis abdomen in the OR, an unexpected discontinuous 3cm metastasis is discovered in the edge of the R lobe of the liver. preop, the pt was counseled of this possibility and the surgical options which of the following is the most appropriate management of this pt?
a. a diverting ileostomy should be performed and further imaging obtatined
b. R hemicolectomy
c. R hemicolectomy with local resection of the liver metastasis
d. closure of the abdomen followed by chemotherapy
e. R hemicolectomy with postop radiation therapy to the liver.
C
don’t surgically treat metastatic colon cancer, unless it’s a single lesion that easily resectable
5% of CRC are associated with resectable hepatic metastases.
radiation doesn’t do much for colon cancer or hepatic metastases
42yo man with no hx of use of NSAIDs presents with recurrent gastritis. the pt was diagnosed and treated for Helicobacter pylori 6mo ago. which of the following tests provides the least invasive method to document eradication of the infection?
a. serology testing for H pylori
b. carbon-labeled urea breath test
c. rapid urease assay
d. histologic evaluation of gastric mucosa
e. culturing of gastric mucosa
B
or stool antigen test
22yo college student notices a bulge in his R groin. it is accentuated with coughing but is easily reducible. which of the following hernias follows the path of spermatic cord within the cremaster muscle?
a. femoral
b. direct inguinal
c. indirect inguinal
d. spigelian
e. interparietal
C
direct inguinal = medial to the inferior epigastric vessels
indirect inguinal = lateral to the inferior epigastric vessels
most likely to be an indirect inguinal hernia
80yo man with hx of symptomatic cholelithiasis presents with signs & sxs of a SBO. which of the following findings would provide the most help in ascertaining the diagnosis?
a. coffee grounds aspirate from the stomach
b. pneumobilia
c. leuk count of 40,000
d. pH of 7.5, PCO2 of 50kPa and paradocially acid urine
e. palpable mass in the pelvis
B
gallstone that dug into the duodenom –> now causing SBO
pneumobilia = air in biliary tract –> biliary enteric fistula = gallstone ileus
42yo man has bouts of intermittent crampy abdominal pain and rectal bleeding. colonoscopy is performed and demonstrates multiple hamartomatous polyps. the pt is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy. which of the following is the most likely diagnosis?
a. ulcerative colitis
b. villous adenomas
c. familial polyposis
d. peutz-jeghers syndrome
e. crohn colitis
D
hamartomas - not cancer
tx = polypectomy
70yo woman has N&V, abdominal distension, and episodic crampy midabdominal pain. she has no hx of previous surgery but has a long hx of cholelithiasis for which she has refused surgery. her abdominal radiograph reveals a spherical density in the RLQ. which of the following is the definitive treatment for this pt’s bowel obstruction?
a. ileocolectomy
b. cholecystectomy
c. ileotomy and extraction
d. NG tube decompression
e. IV antibiotics
C
gallstone ileus –> erosion of a stone from the gallbladder inot the duodenum
AXR
- SBO & air in biliary tract (pneumobilia)
tx = ileotomy, removal of stone, and cholecystectomy if safe
53yo man presents to the ED with LLQ pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7cmx8cm rim-enhancing fluid collection int he pelvis. after percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. he returns as an outpatient to clinic 1mo later. he undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. which of the following is the most appropriate next step in this pt’s management
a. expectant management with sigmoid resection if sxs recur
b. cystoscopy to evaluate for a fistula
c. sigmoid resection with end colostomy and rectal pouch (Hartmann procedure)
d. sigmoid resection with primary anastomosis
e. long-term suppressive antibiotic therapy
D
indications for surgical intervention of diveriticular disease
- hemorrhage d/t diverticulosis
- recurrent episodes of diverticulitis
- intractability to medical therapy
- complicated diverticulitis (including abscess, fistula, perforation)
tx
- ABSCESS + diverticulitis –> resection of afffected colon + primary anastomosis
- PERFORATED diveriticulitis –> Hartmann = sigmoid resection with end colostomy & rectal pouch
29yo woman complains of postprandial RUQ pain and fatty food intolerance. US examination reveals no evidence of gallstones or sludge. upper endoscopy is normal, and all of her LFTs are within normal limits. which of the following represents the best management option?
a. avoidance of fatty foods and reexamination in 6mo.
b. US examination should be repeated immediately since the false -neg rate for US in detecting gallstones is 10% to 15%
c. treatment with ursodeoxycholic acid
d. CCK-HIDA scan should be performed to evaluate for biliary dyskinesia
e. laparoscopic cholecystectomy for acalculous cholecystitis
D
suspected cholecystitis
- RUQ US = thickened gallbadder, gallstone, fluid present in gallbladder
- HIDA = biliary dyskinesia. CCK helps stimulate gallbladder contraction
- -> biliary dyskinesia = gallbladder ejection fraction of <35% at 20min
46yo asymptomatic woman is incidentally found to have a 5mm polyp and no stones in her gallbladder on US. which of the following is the best management option?
a. aspiration of the gallbladder with cytologic examination of the bile.
b. observation with repeat US examinations to evaluate for increase in polyp size
c. laparoscopic cholecystectomy
d. open cholecystectomy with frozen section
e. en bloc resection of the gallbladder, wedge resection of the liver, and portal lymphadenectomy
B
gallbladder polyp ==> concerns of gallstone carcinoma
only with evidence of invasion would you do resection –> up to resection of other parts of biliary tract
48yo woman develops pain in the RLQ while playing tennis. the pain progresss and the pt presents to the ED later that day with a low grade fever, a WBC count of 13,000 and complaints of anorexia and nausea as well as persistent, sharp pain of the RLQ. on exam, she is tender in the RLQ with muscular spasm, and there is suggestion of a mass effect. a US is ordered and shows an apparent mass int he abdominal wall. which of the following is the most likely diagnosis?
a. acute appendicitis
b. cecal carcinoma
c. hematoma of the rectus sheath
d. torsion of an ovarian cyst
e. cholecystitis
C
hematoma of rectus sheath RFs
- elderly
- hx of trauma
- sudden muscular exertion
- anticoagulation
sxs = sharp, sudden pain. Abdominal mass that does not change with contractiono f rectus muscles
dx = US, CT showing mass within rectus sheath
tx
- conservative; wait & watch
- if bleeding & severe pain –> surgical evacuation of hematoma & ligation of bleeding vessels
appendix would be retroperitoneal
32yo alcoholic man, recently emigrates from Mexico, presents with RUQ pain and fevers for 2w. CT scan of the abdomen demonstrates a non-rim-enhancing fluid collection in the periphery of the R lobe of the liver. the pt’s serology is positive for Antibodies for Entamoeba histolytica. which of the following is the best initial management option for this pt?
a. treatment with antiamebic drugs
b. percutaneous drainage of the fluid collection
c. marsupialization of the fluid collection
d. surgical drainage of the fluid collection
e. liver resection
A
1) metronidazole
2) laparotomy to evaluate abscess
if not amebic liver absces (ex. pyogenic liver abscess)
–> percutaneous catheer drainage & Abx against GN and anaerobics (E. coli, Klebsiella, bacteroids, enetercoccus, anaerobic strep).
45 yo executive experiences increasingly painful retroseernal heartburn, esp at night. he has been chewing antacid tablets. an esophagogrram shows a hiatal hernia. in determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality?
a. barium swallow with cinefluoroscopy during Valsalva maneuver
b. flexible endoscopy
c. 24h monitoring of esophageal pH
d. measurement of the size of the hernia on upper GI series
e. assessment of the pt’s smoking & drinking hx
B
Dx
- endoscopy –> to evaluate GERD & r/out other diseases
- manometric / pH studies for persistent esophagitis under medical therapy –> to evaluate surgical treatment
Tx
- medical therapy to prevent complications
- surgery if have esophagitis or esophgeal stenosis.
22yo woman is seen in a surgery clinic for a bulge in the R groin. she denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. she has never experienced N/V. on exam, she has a reducible hernia below the inguinal ligament. which of the following is the most appropriate management of this pt?
a. observation for now and f/up in surgery clinic in 6mo.
b. observation for now and f/up in surgery clinic if she develops further sxs
c. elective surgical repair of hernia
d. emergent surgical repair of hernia
e. emergent surgical repair of hernia with exploratory laparotomy to evaluate the small bowel.
C
IF DIRECT/INDIRET hernia = no evidence of incarcerated bowel –> so only do surgery if sxs
FEMORAL HERNIA (below level of inguinal ligament)= high risk of incarceration. not emergent b/c no sxs, but should fix it.
22yo woman presents with painful fluctuant mass in the midline between the gluteal folds. she denies pain on rectal examination. which of the following is the most likely diagnosis?
a. pilonidal abscess
b. perianal abscess
c. perirectal abscess
d. fistula in ano
e. anal fissure
A
definitely an abscess
a. pilonidal abscess = painful fluctuant mass extending from midline & located b/w gluteal clefs
b. perianal abscess = closer to the anus; very painful on examination
c. perirectal abscess = closer to the anus; very painful on examination
d. fistula in ano = chronically draining tract in perianal region; can become pluged & become a perianal / perirectal abscess
e. anal fissure = linear ulcer along anal canal; not an abscess
72yo man s/p post-coronary artery bypass graft (CABG) 5y ago presents with hematochezia, abdominal pain, and fevers. colonoscopy reveals patches of dusky-appearing mucosa at the splenic flexure without active bleeding. which of the following is the most appropriate management of this pt?
a. angiography with administration of intra-arterial papaverine
b. emergent laparotomy with L hemicolectomy and transverse colostomy
c. aortomesenteric bypass
d. exploratory laparotomy with thrombectomy of the inferior mesenteric artery
e. expectant management
E. IV fluids (LOTS), bowel rest, supportive care
ischemic bowel syndrome
the bowel is NOT dead (unlikel acute mesenteric ischemia of the small intestine –> requiring emergent intervention)
indications for treatment of ischemic colitis
- full-thickness necrosis
- perforation
- refractory bleeding
62yo man has been diagnosed with endoscopic biopsy as having a sigmoid colon cancer. he is otherwise healthy and presents to your office for preoperative consultation. he asks a number of questions regarding removal of a portion of his colon. which of the following is most likely to occur after a colon resection?
a. the majority (>50%) of normally formed feces will comprise solid material
b. pts who undergo major colon resections suffer little long-term change in their bowel habits following operation
c. Na, K, Cl, and HCO3 will be absorbed by the colonic epithelium by an active transport process
d. the remaining colon will absorb less water
e. the remaining colon will absorb long-chain FAs that result from bacterial breakdown of lipids.
B
little long-term change after resection of large portions of bowel d/t reseve capacity fo colon for water absorption
R colon = more water, salt (by actie transport), with `passive excretionof K.
39yo woman with no significant PMH and whose only medication is OCPs presents to the emergency room with RUQ pain. CT scan demonstrates a 6cm hepatic adenoma in the R lobe of the liver. which of the following describes the definitive treatment of this lesion
a. cessation of OCPs and serial CT scans
b. intra-arterial embolization fo the hepatic adenoma
c. embolization of the R portal vein
d. resection of the hepatic adenoma
e. systemic chemotherapy
D.
hepatic adenoma
RF = OCPs
tx
1) <4cm –> watch for growth and/or bleeding (they bleed like stink)
2) >4cm –> increase risk of rupture with hemorrhage
Complications
- hemorrhage
- malignant transformation into HCC
