04-2 Gen Surg: GI

Question 1

A 62-year-old man describes epigastric and substernal pain that he cannot characterize well. At times his description sounds like gastroesophageal reflux,
at times it does not. Sonogram of the gallbladder, ECG, and cardiac enzymes have been negative.

Answer 1

What is it? The question is, is it gastroesophageal reflux?

Diagnosis. Esophageal pH monitoring.

Question 2

A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing tight clothing, or lying flat in bed at night. He gets symptomatic relief from antacids but has
never been formally treated. The problem has been present for many years, and seems to be progressing.

Answer 2

What is it? The description is classic for gastroesophageal reflux disease (GERD).
Management. The diagnosis is not really in doubt, and with that clinical picture alone thousands of patients are treated with symptomatic medication—but the academicians writing exam questions would want you to recommend endoscopy and biopsies to assess the extent of esophagitis and potential complications.

Question 3

A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing tight clothing, or lying
flat in bed at night. He gets symptomatic relief from antacids but has never been formally treated. The problem has been present for many years, and seems to be progressing. Endoscopy shows severe peptic esophagitis and Barrett esophagus.

Answer 3

Management for Barrett has evolved, and Barrett alone is no longer considered an indication for surgery. In this patient who has not had formal medical management, that should be the first step. Continued symptoms would warrant consideration for fundoplication. Dysplastic
changes would require resection.

Question 4

A 54-year-old obese man gives a history of many years of burning retrosternal pain and heartburn that is brought about by bending over, wearing tight
clothing, or lying flat in bed at night. He gets brief symptomatic relief from antacids, but in spite of faithful adherence to a strict program of medical therapy, the process seems to be progressing. Endoscopy shows severe peptic esophagitis with no dysplastic changes.

Answer 4

Management: He has failed medical management, and has no dysplastic changes. He needs a fundoplication.

Question 5

A 47-year-old woman describes difficulty swallowing, which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to “make it through.” Occasionally she regurgitates large amounts of undigested food

Answer 5

What is it? It sure sounds like achalasia.
Diagnosis. The diagnosis is suggested by a barium swallow (usually the first test) and confirmed by manometry studies. Dilations or surgery are the therapeutic options.

Question 6

A 54-year-old black man with a history of smoking and drinking describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to other solid foods, then soft foods, and is now evident for liquids as well. He locates the place where the food “sticks” at the lower end of the sternum. He has lost 30 pounds of weight.

Answer 6

What is it? A classic for carcinoma of the esophagus (progressive dysphagia, weight loss). Given the detail of race, age, sex, and habits, it is probably squamous cell cancer. Had the history been longstanding reflux, it would suggest adenocarcinoma.
Diagnosis. The diagnosis is made the same way for both: endoscopy and biopsies—but the endoscopist wants a “road map” first: barium swallow. The sequence is barium swallow, then endoscopy and biopsies, then CT scan (to assess extent).

Question 7

I. A 24-year-old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk, and he starts vomiting repeatedly. He initially brings up gastric contents only, but eventually he vomits bright red blood.
II. A 24-year-old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting, and he feels a very severe, wrenching epigastric pain and low sternal pain of sudden onset. On arrival at the ER 1 hour later he still has the pain, is diaphoretic, has fever and
leukocytosis, and looks quite ill.

Answer 7

What is it? Two vignettes that have the same beginnings, with one leading to bleeding (Mallory-Weiss tear), and the other one to perforation (Boerhaave syndrome).
Management. For the patient who is bleeding, endoscopy to ascertain the diagnosis. Bleeding will typically be arterial and brisk, but self-limiting. Photocoagulation can be used if needed. The patient with perforation is facing a potentially lethal problem. Gastrografin swallow will confirm the diagnosis, and emergency surgical repair will follow. Prognosis depends on time elapsed between perforation and treatment.

Question 8

A 66-year-old man has an upper GI endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant retrosternal pain that began shortly after he went home. He looks prostrate and very ill, is diaphoretic, has a fever of 104°F, and a respiratory rate of 30. There is a hint of subcutaneous emphysema at the base of the neck.

Answer 8

What is it? Instrumental perforation of the esophagus. The setting plus the air in the tissues are irtually diagnostic. Do Gastrografin swallow and emergency surgical repair.

Question 9

A 72-year-old man has lost 40 pounds of weight over a 2- or 3-month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.

Answer 9

What is it? Cancer of the stomach is a possibility, along with other etiologies.
Diagnosis. Imaging studies followed by endoscopy and biopsies.
Management. Surgery will be done for cure if possible, for palliation if not.

Question 10

A 54-year-old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen.

Answer 10

What is it? Mechanical intestinal obstruction, caused by adhesions.
Management. NG suction, IV fluids, and careful observation.

Question 11

A 54-year-old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. Five years ago he had
an exploratory laparotomy for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on NG suction and IV fluids, he develops fever, leukocytosis, abdominal tenderness, and rebound tenderness.

Answer 11

What is it? He has strangulated obstruction, i.e., a loop of bowel is dying—or dead—from compression of the mesenteric blood supply.
Management. Emergency surgery.

Question 12

A 54-year-old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for 5 days. He has high-pitched, loud bowel sounds that coincide with the colicky pain, and x-rays show distended loops of small bowel and air-fluid levels. On physical examination a groin mass is noted, and he explains that he used to be able to “push it back” at will, but for the past 5 days has been unable to do so.

Answer 12

What is it? Mechanical intestinal obstruction caused by an incarcerated (potentially strangulated) hernia.
Management. After suitable fluid replacement he needs urgent surgical intervention.

Question 13

A 55-year-old woman is being evaluated for protracted diarrhea. On further questioning she gives a bizarre history of episodes of flushing of the face, with expiratory wheezing. A prominent jugular venous pulse is noted on her neck.

Answer 13

What is it? Carcinoid syndrome.
Diagnosis. Twenty-four-hour urinary collection for 5-hydroxy-indolacetic acid, perform a CT scan to assess liver metastasis, and plan resection based upon the results.

Question 14

A 22-year-old man develops anorexia followed by vague periumbilical pain that several hours later becomes sharp, severe, constant, and well localized to the right lower quadrant of the abdomen. He has abdominal tenderness, guarding, and rebound to the right and below the umbilicus, temperature of 99.6°F, and white blood cell (WBC) count is 12,500, with neutrophilia and
immature forms.

Answer 14

What is it? A classic for acute appendicitis.

Management. Perform emergency appendectomy. If the case had not been typical, do CT scan.

Question 15

A 59-year-old man is referred for evaluation because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his physical examination is remarkable only for 4+ occult blood in the stool. Lab shows a hemoglobin of 5 g/dl.

Answer 15

What is it? Cancer of the right colon.
Diagnosis. Colonoscopy and biopsies.
Management. Blood transfusions and eventually right hemicolectomy.

Question 16

A 56-year-old man has bloody bowel movements. The blood coats the outside of the stool, and has been present on and off for several weeks. For the past 2 months he has been constipated, and his stools have become of narrow caliber.

Answer 16

What is it? Cancer of the distal, left side of the colon.
Diagnosis. Endoscopy and biopsies. If given choices, start with flexible proctosigmoidoscopy (with the 45-cm or 60-cm instrument that any MD can handle). Eventually full colonoscopy (to rule out a second primary) will be needed before surgery.

Question 17

A 77-year-old man has a colonoscopy because of rectal bleeding. A villous adenoma is found in the rectum, and several adenomatous polyps are identified in the sigmoid and descending colon.

Answer 17

The issue with polyps is which ones are premalignant, and thus need to be excised. Premalignant include, in descending order of potential for malignant conversion, familial polyposis (and all variants, such as Gardner), familial multiple inflammatory polyps, villous adenoma, and adenomatous polyp. Benign, which can be left alone, include juvenile, Peutz-Jeghers, isolated, inflammatory, and hyperplastic.

Question 18

A 42-year-old man has suffered from chronic ulcerative colitis for 20 years. He weighs 90 pounds and has had at least 40 hospital admissions for exacerbations of the disease. Because of a recent relapse, he has been placed on high-dose steroids and Imuran. For the past 12 hours he has had severe abdominal pain, temperature of 104°F, and leukocytosis. He looks ill and “toxic.” His abdomen is tender, particularly in the epigastric area, and he has muscle guarding and rebound. X-rays show a massively distended transverse colon, and there is gas within the wall of the colon.

Answer 18

What is it? Toxic megacolon.
Management. Emergency surgery for the toxic megacolon, but the case illustrates all of the other indications for surgery in chronic ulcerative colitis. The involved colon has to be removed, and that always includes the rectal mucosa.

Question 19

A 27-year-old man is recovering from an appendectomy for gangrenous acute appendicitis with perforation and periappendicular abscess. He has been receiving Clindamycin and Tobramycin for 7 days. Eight hours ago he developed watery diarrhea, crampy abdominal pain, fever, and leukocytosis.

Answer 19

What is it? Pseudomembranous colitis from overgrowth of Clostridium difficile.
Diagnosis. The diagnosis relies primarily on identification of toxin in the stools. Cultures take too long, and proctosigmoidoscopic exam does not always find typical changes.
Management. Clindamycin has to be stopped, and antidiarrheal medications (diphenoxylate combined with atropine, paregoric) should not be used. Metronidazole is the usual drug of choice. An alternate drug is vancomycin. Failure of medical management, with a marked leukocytosis and serum lactate above 5 mmol/L, is an indication for emergency colectomy.

Question 20

I. A 60-year-old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation.
II. A 60-year-old man known to have hemorrhoids complains of anal itching and discomfort, particularly toward the end of the day. He has mild perianal pain
when sitting down and finds himself sitting sideways to avoid the discomfort.

Answer 20

What is it? The rule is that internal hemorrhoids bleed but do not hurt, whereas external hemorrhoid hurt but do not bleed.
Management. It is not reassurance and hemorrhoid remedies prescribed over the phone! In all anorectal problems, cancer has to be ruled out first! The correct answer is proctosigmoidoscopic examination (digital rectal exam, anoscopy, and flexible sigmoidoscope). Once the diagnosis has been confirmed, internal hemorrhoids can be treated with rubber-band ligation,
whereas external hemorrhoids or prolapsed hemorrhoids require surgery.

Question 21

A 23-year-old woman describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even
more painful. Physical examination cannot be done, as she refuses to allow anyone to even draw apart her buttocks to look at the anus for fear of precipitating the pain

Answer 21

What is it? A classic description of anal fissure.
Management. Even though the clinical picture is classic, cancer still has to be ruled out. Examination under anesthesia is the correct answer. Medical management includes stool softeners and topical agents. A tight sphincter is believed to cause and perpetuate the problem, and injections with paralyzing agents (botulin toxin) have been proposed. If it gets to surgery, lateral
internal sphincterotomy is the operation of choice. Fissures are preferably treated by calcium channel blockers such as diltiazem ointment 2% topically 3x/daily for 6 weeks. They have an 80-90% success rate. Botox has a 50% rate of healing.

Question 22

A 28-year-old man is brought to the office by his mother. Beginning 4 months ago he has had three operations, done elsewhere, for a perianal fistula, but after each one the area has not healed, and in fact the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures, and fistulas all around the anus, with purulent discharge. There are no palpable masses.

Answer 22

What is it? Another classic. The perianal area has fantastic blood supply and heals beautifully even though feces bathe the wounds. When it does not, you immediately think of Crohn disease.
Management. You still have to rule out malignancy (anal cancer does not heal either if not completely excised). A proper examination with biopsies is needed. The specimens should confirm Crohn. Fistulotomy is not recommended. Most fistulae will get draining setons which will ensure adequate drainage of infection while medical management controls the disease. Remicade in particular has shown to help heal these fistulae.

Question 23

A 44-year-old man shows up in the ER at 11 pm with exquisite perianal pain. He cannot sit down, reports that bowel movements are very painful, and has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant mass between the anus and the ischial tuberosity.

Answer 23

What is it? Another very common problem: ischiorectal abscess.
Management. The treatment for all abscesses is drainage. This one is no exception. But cancer also has to be ruled out. Thus the best option would be an answer that offers examination under anesthesia and incision and drainage. If the patient is diabetic, incision and drainage would have to be followed by very close in-hospital follow-up.

Question 24

A 62-year-old man complains of perianal discomfort and reports that there are fecal streaks soiling his underwear. Four months ago he had a perirectal abscess drained surgically. Physical examination shows a perianal opening in the skin, and a cordlike tract can be palpated going from the opening toward the inside of the anal canal. Brownish purulent discharge can be expressed
from the tract.

Answer 24

What is it? A pretty good description of fistula in ano.
Management. First rule out cancer with proctosigmoidoscopy (necrotic tumors can drain).
Then schedule elective fistulotomy.

Question 25

A 55-year-old HIV-positive man has a fungating mass growing out of the anus, and rock-hard, enlarged lymph nodes in both groins. He has lost a lot of weight, and looks emaciated and ill.

Answer 25

What is it? Squamous cell carcinoma of the anus.
Diagnosis. Biopsies of the fungating mass.
Management. Nigro protocol is combined preoperative chemotherapy and radiation for 5 weeks with 90% cure rate. Surgery is done only if Nigro fails to cure the cancer.

Question 26

A 33-year-old man vomits a large amount of bright red blood.

Answer 26

What is it? Pretty skimpy vignette, but you can already define the territory where the bleeding is taking place: from the tip of the nose to the ligament of Treitz.
Diagnosis. Don’t forget to look at the mouth and nose and then proceed with upper GI endoscopy.

Question 27

A 33-year-old man has had 3 large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic and pale, and has a blood pressure of 90 over 70 and pulse rate of 110.

Answer 27

The point of the vignette is that something needs to be done to define the area from which he is bleeding: with the available information, it could be from anywhere in the GI tract (a vast territory to investigate). Fortunately, he seems to be bleeding right now, thus the first diagnostic move is to place an NG tube and aspirate after you have looked at the nose and mouth.

Question 28

A 33-year-old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic and pale, and has a blood pressure of 90 over 70 and a pulse rate of 110. An NG tube returns copious amounts of bright red blood.

Answer 28

What is it? The area has been defined (tip of the nose to ligament of Treitz). Proceed with endoscopy.

Question 29

A 65-year-old man has had 3 large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic and pale, and has a blood pressure of 90 over 70 and a pulse rate of 110. An NG tube returns clear, green fluid without blood.

Answer 29

What is it? If the NG tube had returned blood, the boundaries would have been tip of the nose to ligament of Treitz. Clear fluid, without bile, would have exonerated the area down to the pylorus, and if there is bile in the aspirate, down to the ligament of Treitz—provided you are sure that the patient is bleeding now. That’s the case here. So, he is bleeding from somewhere distal to the ligament of Treitz. Further definition of the actual site is no longer within reach of upper endoscopy, and except
for anoscopy looking for bleeding hemorrhoids, lower endoscopy is notoriously unrewarding during massive bleeding. If he is bleeding at >2 ml/min (about 1 U of blood every 4 hours), some physicians go straight to the emergency angiogram. Those same physicians would wait and do a colonoscopy later if the bleeding is

Question 30

A 72-year-old man had 3 large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. An NG tube returns clear, green fluid without blood.

Answer 30

What is it? The clear aspirate is meaningless because he is not bleeding right now. So the guilty territory can be anywhere from the tip of the nose to the anal canal. Across the board, three fourths of all GI bleeding is upper, and virtually all the causes of lower GI bleeding are diseases of the old: diverticulosis, polyps, cancer, and angiodysplasias. So, when the patient is young, the
odds overwhelmingly favor an upper site. When the patient is old, the overall preponderance of upper is balanced by the concentration of lower causes in old people—so it could be anywhere.
Diagnosis. Angiography is not the first choice for slow bleeding or bleeding that has stopped. Even the proponents of radionuclide studies don’t have much hope if the patient bled 3 days ago. The first choice now is endoscopies, both upper and lower.

Question 31

A 7-year-old boy passes a large bloody bowel movement.

Answer 31

What is it? In this age group, Meckel diverticulum leads the list.
Diagnosis. By radioactively labeled technetium scan (not the one that tags red cells, but the one that identifies gastric mucosa).

Question 32

A 41-year-old man has been in the ICU for 2 weeks being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions,
and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood.

Answer 32

Management. It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antacids, or both; but once the bleeding takes place, the diagnosis is made as usual with endoscopy. Treatment will be difficult (start with endoscopic attempts—laser and such), and it may require angiographic embolization of the left gastric artery.

Question 33

A 59-year-old man arrives in the ER at 2 am, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal
pain that began suddenly about 1 hour ago, and is now generalized, constant, and extremely severe. He lies motionless on the stretcher, is diaphoretic, and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants.

Answer 33

What is it? Definitely an acute abdomen. The time and circumstances attest to the severity and rapid onset of the problem. The physical findings are impressive. He has generalized acute peritonitis. The best bet is perforated peptic ulcer—but we do not need to prove that.
Management. The acute abdomen does not need a precise diagnosis to proceed with surgical exploration. Lower lobe pneumonia and MI have to be ruled out with chest x-ray and ECG, and it would be nice to have a plain x-ray or CT scan of the abdomen and a normal lipase—but the best answer of this vignette should be prompt emergency exploratory laparotomy.

Question 34

A 62-year-old man with cirrhosis of the liver and ascites presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis.

Answer 34

What is it? Peritonitis in the cirrhotic with ascites, or the child with nephrosis and ascites, could be primary peritonitis—which does not need surgery—rather than the garden-variety acute peritonitis secondary to an intraabdominal catastrophe that requires emergency operation. This is very uncommon.
Diagnosis. Cultures of the ascitic fluid will yield a single organism. Treatment will be with theappropriate antibiotics.

Question 35

A 43-year-old man develops excruciating abdominal pain at 8:18 pm. When seen in the ER at 8:50 pm, he has a rigid abdomen, lies motionless on the examining table, has no bowel sounds, and is obviously in great pain, which he describes as constant. X-ray shows free air under the diaphragm.

Answer 35

What is it? Acute abdomen plus perforated viscus equals perforated duodenal ulcer in most cases. Although I am exaggerating the sudden onset by giving the exact minute, vignettes of perforated peptic ulcer will have a pretty sharp time of onset.
Management. Emergency exploratory laparotomy.

Question 36

A 44-year-old alcoholic man presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of 2 hours. The pain is constant, radiates straight
through to the back, and is accompanied by nausea, vomiting, and retching. He had a similar episode 2 years ago, for which he required hospitalization.

Answer 36

What is it? Acute pancreatitis.
Diagnosis. Serum and urinary amylase or lipase determinations. CT scan will follow if the
diagnosis is unclear, or in a day or two if there is no improvement.
Management. NPO, NG suction, IV fluids.

Question 37

A 43-year-old obese mother of six children has severe right upper quadrant abdominal pain that began 6 hours ago. The pain was colicky at first, radiated to the right shoulder and around toward the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding, and rebound in the right upper quadrant. Her temperature is 101°F, and she has a WBC count of 16,000.
She has had similar episodes of pain in the past brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.

Answer 37

What is it? Acute cholecystitis.
Diagnosis. Sonogram should be the first choice. If equivocal, an HIDA scan (radionuclide excretion scan).
Management. Start medical management (antibiotics, NPO, IV fluids) with the intention of doing laparoscopic cholecystectomy within the same hospital admission.

Question 38

A 52-year-old man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. There is microscopic hematuria.

Answer 38

What is it? Ureteral colic (included here for differential diagnosis).
Diagnosis. Specific CT scan for ureteric colic is CT-KUB. This is a noncontrast CT scan that allows for visualization of a ureteric calculus.

Question 39

A 59-year-old woman has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. She began to feel discomfort 12 hours ago, and now she has constant left lower quadrant pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis.

Answer 39

What is it? Acute diverticulitis.
Diagnosis. In acute diverticulitis, CT scan is the gold standard investigation. After 6 weeks of cooling off, however, all cases must get a colonoscopy to rule out perforated colon cancer.
Management. Treatment is medical for the acute attack (antibiotics, NPO), but elective sigmoid resection is advisable for recurrent disease (like this woman is having). Percutaneous drainage of abscess is indicated if one is present. Emergency surgery (resection or colostomy) may be needed if she gets worse or does not respond to treatment.

Question 40

An 82-year-old man develops severe abdominal distension, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers toward the left lower
quadrant with the shape of a parrot’s beak.

Answer 40

What is it? Volvulus of the sigmoid.
Management. Endoscopic intervention will relieve the obstruction. Eventually, surgery to prevent recurrences should be considered.

Question 41

A 79-year-old man with atrial fibrillation develops an acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-rays show distended small bowel and distended colon up to the middle of the transverse colon.

Answer 41

What is it? Acute abdomen in an elderly person who has atrial fibrillation brings to mind embolic occlusion of the mesenteric vessels. Acidosis frequently ensues, and blood in the stool is often seen. Unfortunately not much can be done, as the bowel is usually dead. Young, aggressive vascular surgeons would call for an angiogram to perform emergency embolectomy, assuming the case is seen very early before the bowel dies.

Question 42

I. A 53-year-old man with cirrhosis of the liver develops malaise, vague right upper quadrant abdominal discomfort, and 20-pound weight loss. Physical
examination shows a palpable mass that seems to arise from the left lobe of the liver. a-fetoprotein is significantly elevated.
II. A 53-year-old man develops vague right upper quadrant abdominal discomfort and a 20-pound weight loss. Physical examination shows a palpable liver with nodularity. Two years ago he had a right hemicolectomy for cancer of the ascending colon. His carcinoembryonic antigen (CEA) had been within normal limits right after his hemicolectomy, but is now 10 times normal.

Answer 42

What is it? Both are good descriptions of cancer in the liver, included to remind you that a-fetoprotein goes with primary hepatoma, whereas CEA goes with metastatic tumor from the colon.
Diagnosis. Both would start with CT scan (with contrast) to define location and extent of tumor.
Management. In the primary hepatoma, resection would be performed if a tumor-free anatomic segment can be left behind. In the metastatic tumor, resection is done if there are no other metastases, it is surgically possible, and the primary is relatively slow growing.

Question 43

A 24-year-old woman develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER she is pale,
tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a hemoglobin of 7 g/dl. There is no history of trauma. On inquiring as to
whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never missed taking them.

Answer 43

What is it? Bleeding from a ruptured hepatic adenoma, secondary to birth control pills.
Management. It’s pretty clear that she is bleeding into the belly, but a CT scan will confirm it and probably show the liver adenoma as well. Surgery will follow.

Question 44

A 44-year-old woman is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and
leukocytosis and some tenderness in the right upper quadrant. A sonogram reveals a liver abscess.

Answer 44

Not much of a diagnostic challenge here, but the issue is management, and it is included to contrast it with the handling of the patient in the next vignette. This is a pyogenic abscess, it needs to be drained (the radiologists will do it percutaneously).

Question 45

A 29-year-old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild
jaundice and an elevated alkaline phosphatase. Sonogram of the right upper abdominal area shows a normal biliary tree and an abscess in the liver.

Answer 45

What is it? This one is an amebic abscess—very common in Mexico.
Management. Alone among abscesses, this one in most cases does not have to be drained, but can be effectively treated with Metronidazole. Get serology for amebic titers, but don’t wait for the report (it will take 3 weeks). Start the patient on Metronidazole. Prompt improvement will tell you that you are on the right track. When the serologies come back, the patient will be well
and your diagnosis will be confirmed. Don’t fall for an option that suggests aspirating the pus and sending it for culture; you cannot grow the ameba from the pus.

Question 46

A 42-year-old woman is jaundiced. She has a total bilirubin of 6, and laboratory reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is 0. She has no bile in the urine.

Answer 46

What is it? The vignette in the exam will be adorned with other evidence of hemolysis, but you do not need it to make the diagnosis. This is hemolytic jaundice.
Management. Try to figure out what is chewing her red cells.

Question 47

A 19-year-old college student returns from a trip to Cancun, and 2 weeks later develops malaise, weakness, and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alkaline phosphatase is mildly elevated, and the transaminases are very high.

Answer 47

What is it? Hepatocellular jaundice.

Management. Get serologies to confirm diagnosis and type of hepatitis.

Question 48

A patient with progressive jaundice that has been present for 4 weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alkaline phosphatase was twice the normal value 2 weeks ago, and now is about six times the upper limit of normal.

Answer 48

What is it? A generic example of obstructive jaundice.
Management. Sonogram, looking for dilated intrahepatic ducts, possibly dilated extrahepatic ducts as well, and if we get lucky, a finding of gallstones.

Question 49

A 40-year-old obese mother of five children presents with progressive jaundice, which she first noticed 4 weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The
alkaline phosphatase is about six times the upper limit of normal. She gives a history of multiple episodes of colicky right upper quadrant abdominal pain, brought about by ingestion of fatty food.

Answer 49

What is it? Again, obstructive jaundice, with a good chance of being caused by stones.
Management. Start with the sonogram. If you need more tests after that, endoscopic retrograde cholangiopancreatography (ERCP) is the next move, which could also be used to remove the stones from the common duct. Cholecystectomy will eventually have to be performed.

Question 50

A 66-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alkaline phosphatase is about six times the upper limit of normal. He has lost 10 pounds over the past 2 months, but is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thin-walled gallbladder.

Answer 50

What is it? Malignant obstructive jaundice. “Silent” obstructive jaundice is more likely to be caused by tumor (although most patients with pancreatic tumor have dull constant pain). A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder
is thick-walled and nonpliable.
Diagnosis. You already have the sonogram. Next move is CT scan. Follow with ERCP if the CT is not diagnostic.

Question 51

A 66-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and
minimally elevated transaminases. The alkaline phosphatase is about six times the upper limit of normal. He is otherwise asymptomatic. A sonogram shows
dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thin-walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal
pancreatic duct.

Answer 51

What is it? Malignant, but lucky: probably cholangiocarcinoma at the lower end of the common
duct. He could be cured with a pancreatoduodenectomy (Whipple operation).
Management. Get brushings of the common duct for cytologic diagnosis.

Question 52

A 64-year-old woman presents with progressive jaundice, which she first noticed 2 weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated transaminases. The alkaline phosphatase is about 10 times the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thin-walled gallbladder.

Answer 52

What is it? Again malignant, but also lucky. The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an ampullary carcinoma, another malignancy that can be cured with radical surgery.
Management. Endoscopy.

Question 53

A 56-year-old man presents with progressive jaundice, which he first noticed 6 weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated transaminases. The alkaline phosphatase is about eight times the upper limit of normal. He has lost 20 pounds over the past 2 months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, and a very distended, thin-walled gallbladder.

Answer 53

What is it? Bad news. Cancer of the head of the pancreas. Terrible prognosis.
Diagnosis. Nowadays, endoscopic ultrasound has become a standard part of the pancreatic head mass work-up. Ultrasound-guided FNAC is increasingly being used for diagnosis. Endoscopic retrograde cholangiopancreatography (ERCP) has a limited role in placing stents to decompress the bile duct if total bilirubin is >20.

Question 54

A white, obese 40-year-old mother of 5 children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestion of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. Physical examination is unremarkable.

Answer 54

What is it? Gallstones, with biliary colic.

Management. Sonogram. Elective cholecystectomy will follow.

Question 55

A 43-year-old obese mother of six children has severe right upper quadrant abdominal pain that began 6 hours ago. The pain was colicky at first, radiated to the right shoulder and around toward the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding, and rebound in the right upper quadrant. Her temperature is 101°F, and she has a WBC count of 12,000. Liver function tests are normal.

Answer 55

What is it? If you are alert, you will recognize the picture of acute cholecystitis—in fact a similar vignette was presented in the acute abdomen section. It is repeated here to contrast it with the next one. She will get a cholecystectomy, as previously mentioned.

Question 56

A 73-year-old obese mother of six children has severe right upper quadrant abdominal pain that began 3 days ago. The pain was colicky at first but has been constant for the past 2.5 days. She has tenderness to deep
palpation, muscle guarding, and rebound in the right upper quadrant. She has temperature spikes of 104 and 105°F, with chills. Her WBC count is 22,000, with a shift to the left. Her bilirubin is 5, and she has an alkaline
phosphatase of 2,000 (about 20 times normal).

Answer 56

What is it? Acute ascending cholangitis.
Diagnosis. The diagnosis is already clear. Sonogram might confirm dilated ducts.
Management. This is an emergency, and many things will be needed at once. The therapy is based on IV antibiotics plus emergency decompression of the biliary tract. To achieve the latter, ERCP is the first choice, but percutaneous transhepatic cholangiogram (PTC) is another option (surgery is a distant third choice).

Question 57

A white, obese 40-year-old mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestion
of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is
accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain, and the pain lasted longer than usual. She has mild tenderness to palpation in the epigastrium and right upper quadrant. Laboratory determinations show a bilirubin of 3.5, an alkaline phosphatase five times normal, and serum amylase three times normal value.

Answer 57

What is it? She passed a common duct stone and had a transient episode of cholangitis (the shaking chill, the high phosphatase) and a bit of biliary pancreatitis (the high amylase).
Management. As in many of these cases, start with sonogram. It will confirm the diagnosis of gallstones. If she continues to get well, elective cholecystectomy will follow. If she deteriorates, she may have the stone still impacted at the ampulla of Vater, and may need ERCP and sphincterotomy to extract it.

Question 58

A 33-year-old alcoholic man shows up in the ER with epigastric and midabdominal pain that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant and very severe, and radiates straight through to the back. He vomited twice early on, but since then has continued to have retching. He has tenderness and some muscle guarding in the upper abdomen, is afebrile,
and has mild tachycardia. Serum amylase is 1,200, and his hematocrit is 52%.

Answer 58

What is it? Acute edematous pancreatitis.

Management. Put the pancreas at rest: NPO, NG suction, IV fluids.

Question 59

A 56-year-old alcoholic man is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight through the back, and is
extremely severe. He has a serum amylase of 800, a hematocrit of 40%, WBC count of 18,000, blood glucose of 150 mg/dl, and serum calcium of 6.5. He is given IV fluids and kept NPO with NG suction. By the next morning, his hematocrit has dropped to 30%, the serum calcium has remained below 7 despite calcium administration, his blood urea nitrogen (BUN) has gone up to 32, and he has developed metabolic acidosis and a low arterial Po2.

Answer 59

What is it? He has hemorrhagic pancreatitis. In fact, he is in deep trouble, with at least eight of Ranson’s criteria predicting 80 to 100% mortality.
Management. Very intensive support will be needed, but the common pathway to death from complications of hemorrhagic pancreatitis frequently is by way of pancreatic abscesses that need to be drained as soon as they appear. Thus serial CT scans will be required. In very selected patients there is a role for necrosectomy to get rid of dead pancreatic tissue.

Question 60

A 57-year-old alcoholic man is being treated for acute hemorrhagic pancreatitis. He was in the ICU for 1 week, required chest tubes for pleural effusion, and
was on a respirator for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease, he begins to
spike fever and to demonstrate leukocytosis.

Answer 60

What is it? Pancreatic abscess.
Diagnosis. CT scan.
Management. Drainage and appropriate antibiotics

Question 61

I. A 49-year-old alcoholic man presents with ill-defined upper abdominal discomfort and early satiety. On physical examination he has a large epigastric mass that is deep within the abdomen and actually hard to define. He was discharged from the hospital 5 weeks ago, after successful treatment for acute pancreatitis.
II. A 55-year-old woman presents with vague upper abdominal discomfort, early satiety, and a large but ill-defined epigastric mass. Five weeks ago she was
involved in an automobile accident in which she hit the upper abdomen against the steering wheel

Answer 61

What is it? The two presentations of pancreatic pseudocyst.
Management. You could diagnose it on the cheap with a sonogram, but CT scan is probably the best choice. Small cysts (under 6 cm) which have not been present too long (less than 6 weeks) can be watched waiting for spontaneous resolution. Bigger or older cysts could have serious complications (rupture, bleeding) and they need intervention. Internal surgical derivation (cystogastrostomy or cystojejunostomy) is the standard surgical treatment. Radiologically guided external drainage is option, often used for infected pseudocysts. The latest and very appealing (if technically feasible) is endoscopic cystogastrostomy, which can only be done for cysts with a completely liquid content without debris.

Question 62

A disheveled, malnourished individual shows up in the ER requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back, that he says he has
had for several years. He has diabetes, steatorrhea, and calcifications in the upper abdomen in a plain x-ray.

Answer 62

What is it? Chronic pancreatitis.
Management. I hope they ask you to recognize this vignette, but not to manage it. There is precious little that can be done for these unfortunate individuals. Stopping the alcoholic intake is the first step (easier said than done). Replacement of pancreatic enzymes and control of the diabetes are obvious needs. Sometimes the pancreatic enzymes will relieve the pain, but if they
do not, the pain will be very difficult to eradicate. Various operations can be performed that would be guided by the anatomy of the pancreatic ducts; thus, if forced to go to further diagnostic tests, pick ERCP.

Question 63

A 9-month-old baby girl is brought in because she has an umbilical hernia. The defect is 1 cm in diameter, and the contents are freely reducible.

Answer 63

Although we routinely recommend elective surgical repair of all hernias (to prevent the ghastly complication of strangulation), there are some exceptions. This is one. Umbilical hernias in babies younger than the age of 5 years may still close spontaneously. Only observation is needed here.

Question 64

An 18-year-old man has a routine physical examination as part of his college registration, and the examination reveals that he has a right inguinal hernia. The
external inguinal ring is about 2.5 cm in diameter, and a hernial bulge can be easily seen and felt going down into his scrotum when he is asked to strain. He is completely asymptomatic and was not even aware of the presence of the hernia.

Answer 64

Elective surgical repair is in order. Even though he is asymptomatic, he should not be exposed to the risk of bowel strangulation. They will not ask you about specific technical details. The hernia is probably indirect. All routine unilateral first-time hernias can be repaired by open or laparoscopic approach with a mesh. Laparoscopy is favored for repair of recurrent inguinal,
bilateral inguinal, and incisional hernias.

Question 65

A 72-year-old farmer is forced by his insurance company to have a physical examination to be issued a life insurance policy. He has been healthy all his
life, and “has never been to the doctor”. At the examination it is found that he has a large, left inguinal hernia that reaches down into the scrotum. Bowel
sounds can be easily heard over it. The hernia is not reducible, and he says that many years ago he used to be able to “push it back,” but for the last 10 or 20 years he has not been able to do so.

Answer 65

A hernia that cannot be pushed back in (reduced) is incarcerated, and one that has compromised blood supply is strangulated. The latter is an emergency. The former is also an emergency if the irreducible state is of new onset, because one does not want to wait for overt signs of dead or compromised bowel before operating. But if he has been this way for 10 or 20 years, obviously
the bowel is alive and well. Elective repair is still indicated, before he runs out of good luck and gets into trouble.