Gastroenterology

Question 1

What are the types of hiatal hernias?

What is the most common type?

Answer 1

• Type I (sliding)
• Type II (paraesophageal)
• Type III (mixed)
• Type IV (complex with other organs involved)

Type 1 Sliding

Question 2

What is the anatomical defect in a sliding hiatal hernia?

Answer 2

The gastroesophageal junction and part of the stomach slide upward through the esophageal hiatus into the thorax

Question 3

What is the primary risk factor for developing a hiatal hernia?

Answer 3

Increased intra-abdominal pressure, often caused by obesity, heavy lifting, or pregnancy.

Question 4

What are the potential complications of a paraesophageal hernia?

Answer 4

• Strangulation
• Ischemia
• Obstruction of the stomach

Question 5

What is the gold standard diagnostic tool for hiatal hernia?

Answer 5

Esophagogastroduodenoscopy (EGD) or barium swallow study

Question 6

What are the typical symptoms of a sliding hiatal hernia?

Answer 6

GERD symptoms such as heartburn, regurgitation, or dysphagia

Question 7

What are the key anatomical landmarks to identify during a hiatal hernia repair?

Answer 7

• Esophageal hiatus
• Gastroesophageal junction
• Crura of the diaphragm
• Vagus nerve

Question 8

A 45-year-old female presents with a 6-month history of heartburn, regurgitation, and a sensation of food getting stuck in her chest after eating. She denies any weight loss or hematemesis. An upper endoscopy reveals the gastroesophageal junction above the diaphragm with no evidence of esophagitis. What is the most likely diagnosis?

A) Esophageal cancer
B) Barrett’s esophagus
C) Achalasia
D) Sliding hiatal hernia

Answer 8

Sliding hiatal hernia

The most common hiatal hernia is a sliding type, which can present with GERD-like symptoms. The absence of other alarming features (e.g., weight loss or bleeding) suggests a benign cause like a sliding hiatal hernia.

Question 9

A 60-year-old male presents with chest pain, postprandial fullness, and vomiting. Physical exam reveals mild epigastric tenderness. A barium swallow study shows part of the stomach located above the diaphragm, while the gastroesophageal junction remains in its normal position. What is the most appropriate next step in management?

A) Proton pump inhibitor therapy
B) Observation with lifestyle modifications
C) Elective surgical repair
D) Urgent endoscopy

Answer 9

Elective Surgical Repair

This is a paraesophageal hernia, which can cause serious complications like strangulation. Elective surgical repair is recommended in paraesophageal hernia’s to prevent these outcomes.

Question 10

A 67-year-old female with a paraesophageal hernia presents to the emergency room with acute onset of severe chest pain, nausea, and vomiting. Her vitals show tachycardia and hypotension. Abdominal imaging reveals gastric volvulus and signs of ischemia. What is the most appropriate next step in management?
A) Emergency surgical repair
B) Intravenous proton pump inhibitors
C) Barium swallow study
D) Nasogastric decompression

Answer 10

Emergency Surgical Repair

Gastric volvulus is a surgical emergency, and prompt intervention is necessary to prevent further ischemia and necrosis of the stomach.

Question 11

Approximately 85% of hiatal hernias can be treated effectively with diet modifications and PPI’s, if these treatments are not effective what surgical procedure should be considered?

Answer 11

Laparoscopic Nissen fundopication

Question 12

What is the most common cause of appendicitis?

Answer 12

Obstruction of the appendiceal lumen, often by a fecalith (hardened stool), lymphoid hyperplasia, or less commonly by tumors or foreign bodies.

Question 13

What is the classic initial symptom of appendicitis?

Answer 13

Periumbilical pain that later migrates to the right lower quadrant (RLQ) as the inflammation progresses.

Question 14

What is McBurney’s point?

Answer 14

It is a point located two-thirds of the distance from the umbilicus to the anterior superior iliac spine (ASIS). Tenderness at this point is a classic sign of appendicitis.

Question 15

What is the most common complication of untreated appendicitis?

Answer 15

Perforation, which can lead to peritonitis or an intra-abdominal abscess.

Question 16

Which physical exam sign suggests appendicitis if the patient experiences pain upon passive extension of the right hip?

Answer 16

Psoas Sign

Question 17

What is the typical sequence of symptoms in acute appendicitis?

Answer 17

Periumbilical pain → anorexia → nausea/vomiting → RLQ pain

Question 18

What imaging modality is most commonly used to diagnose appendicitis in adults?

Answer 18

CT scan of the abdomen and pelvis with contrast

Question 19

What is the treatment for uncomplicated appendicitis?

Answer 19

Appendectomy

Question 20

What are the typical laboratory findings in acute appendicitis?

Answer 20

Leukocytosis with a left shift (increased neutrophils), but normal labs do not rule out appendicitis

Question 21

What is the most common cause of emergent abdominal surgery in the United States?

Answer 21

Acute appendicitis

Question 22

Can you have an abnormal urinanalysis with appendicitis?

Answer 22

Yes, mild hematuria and pyuria are common in appendicitis w/ pelvic inflammation, resulting in inflammation of the ureter

Question 23

What are the preoperative medications and preperation for an appendectomy?

Answer 23

1. Rehydration with IV fluids (LR)
2. Preoperative antibiotics with anaerobic coverage

Question 24

How long after removal of a NONRUPTURED appendix should antibiotics continue post-op?

Answer 24

24 hours

Question 25

Which antibiotic is used for NONPERFERORATED appendicitis? | What about a perforated appendicitis?

Answer 25

Anaerobic coverage: Cefoxitin, Fefotetan, Unasyn, Cipro, or Flagyl | Broad-Spectrum abx (amp/cipro or zyosyn)

Question 26

A 32-year-old pregnant female presents with right lower quadrant pain, nausea, and vomiting. On physical exam, she has tenderness in the RLQ, and a positive psoas sign. Ultrasound is non-diagnostic. What is the most appropriate next step in management? A) MRI of the abdomen B) CT scan of the abdomen with contrast C) Immediate laparoscopic appendectomy D) Exploratory laparotomy

Answer 26

MRI of the abdomen ## Footnote In pregnant patients, MRI is preferred for diagnosis of appendicitis if ultrasound is non-diagnostic, as CT should be avoided due to radiation risks. Surgery is indicated if imaging confirms appendicitis.

Question 27

A 15-year-old boy presents with diffuse abdominal pain and fever for 2 days. He now has sharp pain in the right lower quadrant, along with nausea and vomiting. On exam, he has rebound tenderness and guarding in the RLQ. His WBC count is 18,000/mm³. What is the most likely complication if his condition is left untreated? A) Bowel obstruction B) Appendiceal perforation C) Pancreatitis D) Intussusception

Answer 27

Appendiceal perforation ## Footnote Untreated appendicitis commonly leads to perforation, which may cause peritonitis or an abscess.

Question 28

What is the first step in treating cholysistitis?

Answer 28

Fluid resuscitation

Question 29

Patients with acute cholecystitis should be given fluids and IV antibiotics. What are the three most common bugs to cause cholecystitis? | What antibiotics are typically used?

Answer 29

* E. coli * Klebselia * Entercococus faecialis | IV ceftriaxone or cipro plus mitronidazole or zosyn

Question 30

What artery supplies the gallbladder?

Answer 30

Cystic Artery ## Footnote The cystic artery is a branch of the right hepatic artery that is given off behind the CBD; it lies in Calot triangle, where it divides into an anterior and a posterior branch and supplies the gallbladder

Question 31

What is Calot's Triangle?

Answer 31

Calot's triangle is formed by the inferior surface of the liver (superior border), the cystic duct (inferior border), and the common hepatic duct (medial border); it is a surgical landmark containing the cystic artery and the cystic lymph node (of Lund) within its boundaries.

Question 32

A 55-year-old male presents with recurrent right upper quadrant abdominal pain and bloating, especially after fatty meals. He has a history of gallstones but no fever or jaundice. Which imaging modality is most appropriate to diagnose chronic cholecystitis in this patient?

Answer 32

Ultrasound

Question 33

What is the mechanism of action of lactulose?

Answer 33

Reduces absorption of ammonium from the gastrointestinal tract

Question 34

What is the 3-6-9 rule?

Answer 34

Bowel is considered dilated when dilation is > 3 cm, 6 cm, and 9 cm for the small bowel, large bowel, and cecum, respectively

Question 35

A previously healthy 8-year-old boy presents to your office with his parents for his annual well-child exam. The parents are wondering about the need for cancer screening, given the patient’s father having a recent diagnosis of colorectal cancer at age 35 years due to familial adenomatous polyposis. Which of the following is the most appropriate guidance? A) Screening starting at age 10 years B) Screening starting at age 25 years C) Screening starting at age 35 years D) Screening starting at age 50 years

Answer 35

Screening starting at age 10 ## Footnote individuals with a known family history of familial adenomatous polyposis should begin screening with either colonoscopy or flexible sigmoidoscopy at age 10 years. Repeat screening is recommended annually until the patient undergoes colectomy, which is the recommended treatment for patients with familial adenomatous polyposis.

Question 36

What surgery is used to treat GERD refractory to medical treatment? | What are the indications for surgery?

Answer 36

Fundoplication ## Footnote Indications for surgery: * Intractability (failure of medical treatment) * Respiratory problems as a result of reflux and aspiration of gastric contents (e.g., pneumonia) * Severe esophageal injury (e.g., ulcers, hemorrhage, stricture, +/- Barrett’s esophagus)

Question 37

What is the most specific diagnostic test for acute cholecystitis? | What is the first line imaging modality for cholecystitis?

Answer 37

HIDA Scan GOLD STANDARD: Perform a radionuclide scanning (HIDA) when clinical suspicion is high with an equivocal ultrasound or when acalculous cholecystitis is suspected. A HIDA scan may be useful if performed during an attack since the scan assesses the patency of the cystic duct | Ultrasound

Question 38

What is cholecystitis?

Answer 38

Inflammation of the gallbladder, usually as a result of a complication of cholelithiasis (gallstones) and obstruction of the biliary duct by gallstones

Question 39

What is Murphy's sign?

Answer 39

Acute RUQ pain/tenderness with palpation with inspiration associated with cholecystitis

Question 40

What is Boas Sign?

Answer 40

Referred pain to the right subscapular area due to phrenic nerve irritation in cholecystitis

Question 41

What is the procedure of choice for uncomplicated acute and chronic cholecystitis? | What is the most common composition of stones?

Answer 41

Laparoscopic cholecystectomy | cholesterol

Question 42

Describe Grey-Turner's Sign?

Answer 42

Flank ecchymosis often related to pancreatitis

Question 43

Which of the radiologic imaging techniques is the most sensitive in diagnosis of acute pancreatitis and pancreatic pseudocyst? A) transabdominal ultrasonography B) contrast-enhanced CT of the abdomen C) magnetic resonance cholangiopancreatography D) plain radiograph (abdominal series)

Answer 43

Contrast-enhanced CT of the abdomen

Question 44

A 67-year-old man presents with abdominal pain and fever for the past 2 hours. Physical exam reveals tenderness below the navel and heme-positive stool. Duplex ultrasound is ordered and demonstrates a complete lack of arterial blood flow to the superior mesenteric artery. Which of the following risk factors would you expect to find in this patient’s history? A) Alcohol use disorder B) Atrial fibrillation C) Cholelithiasis D) Diverticulosis

Answer 44

Atrial fibrillation, this patient has mesenteric ischemia ## Footnote Risk factors for developing acute mesenteric ischemia include any factors that would place the patient at risk for a thromboembolic event, including a history of atrial fibrillation, recent cardiac catheterization, and valvular heart disease. Patients only occasionally present with the classic triad of abdominal pain, fever, and heme-positive stool.

Question 45

Which of the following interventions is recommended to decrease the risk of diverticulosis? A) Avoiding nuts B) Decreased physical activity C) High-fiber diet D) Increased fat intak

Answer 45

High-fiber diet

Question 46

What is Hesselbach's triangle?

Answer 46

* Inguinal ligament * Epigastric vessels * Lateral border of the rectus sheath

Question 47

What is Calot's Triangle?

Answer 47

* Cystic duct * Common hepatic duct * Cystic artery

Question 48

Which parts of the GI tract do not have serosa?

Answer 48

* Esophagus * Middle and distal rectum

Question 49

Which dermatone is at the umbilicus?

Answer 49

T10

Question 50

What are the major layers of an atery?

Answer 50

* Adventitia * Media * Intima

Question 51

What are the actions of cholecystokinin (CCK)? | What inhibits the release of CCK?

Answer 51

* Opens ampulla of Vater * Empties gallbladder * Slows gastric emptying * Stimulates pancreatic acinar cell growth and release of exocrine products | Trypsin and chymotrypsin

Question 52

What stimulates the release of CCK?

Answer 52

Fat, protein, amino acids, and HCl

Question 53

What are the actions of secretin? | Where is secretin produced?

Answer 53

* Releases pancreatic bicarbonate/enzymes/H20 * Releases bile/bicarbonate * Decreases lower esophageal sphincter (LES) tone * Decreases release of gastric acid | Duodenal cells

Question 54

What GI hormone globally inhibits GI function when food stimulates its release?

Answer 54

Somatostatin

Question 55

Where is calcium absorbed?

Answer 55

Doudenum actively, jejunum passively

Question 56

Where is iron absorbed?

Answer 56

Duodenum

Question 57

Where is vitamin B12 absorbed?

Answer 57

Terminal ileum

Question 58

Which hormone primarily controls gallbladder contraction?

Answer 58

CCK

Question 59

What supplement does a patient need after removal of the terminal ilium or stomach?

Answer 59

Vitamin B12

Question 60

What is the blood supply of the liver?

Answer 60

75% from the portal vein, rich in products of digestion 25% from the hepatic artery, rich in oxygen

Question 61

What conditions can mask abdominal pain?

Answer 61

* Steroids * Diabetes * Paraplegia * Opioids

Question 62

What is the most common cause of acute abdominal surgery in the United States?

Answer 62

Acute appendicitis (7% of the population will develop it sometime during their lives)

Question 63

During the GI exam, what should go first, auscultation or palpation?

Answer 63

Auscultation

Question 64

What is the classic position of a patient with peritonitis?

Answer 64

Motion (often with knees flexed)

Question 65

What is the classic position of a patient with a kidney stone?

Answer 65

Cannot stay still, restless, writhing in pain

Question 66

What lab tests are used to evaluate the patient with an acute abdomen?

Answer 66

CBC with differential, chem-10, lipase, type and screen, urinalysis, LFT's

Question 67

What is a "left shift" on CBC differential?

Answer 67

Sign of inflammatory response: Immature neutrophils (bands) Note: many call > 80% of WBC's as neutrophils a "left shift"

Question 68

What diagnosis must be considered in every patient with an acute abdomen?

Answer 68

Appendicitis

Question 69

What is a hernia?

Answer 69

Protrusion of a peritoneal sac through a musculoaponeurotic barrier (abdominal wall), a fascial defect

Question 70

What are the risk factors for hernias?

Answer 70

* Increased intra-abdominal pressure * Straining at defecation or urination * Obesity * Pregnancy * Ascitis * COPD * Congenital sources

Question 71

What is more dangerous: a small or large hernia defect?

Answer 71

Small defect is more dangerous because a tight defect is more likely to strangulate if incarcerated

Question 72

What type of hernia is most commonly seen after gastric bipass surgery?

Answer 72

Petersen's hernia: internal herniation of small bowel through the mesenteric defect from the Roux limb

Question 73

What is a parastomal hernia?

Answer 73

Hernia adjacent to an ostomy (e.g. colostomy)

Question 74

What are the boundaries of Hesselbach's triangle?

Answer 74

1. **Lateral:**Inferior epigastric vessels 2. **Inferior:**Inguinal ligament (Poupart's) 3. **Medial**: Lateral border of the rectus abdominis

Question 75

What nerve runs with the spermatic cord in the inguinal canal?

Answer 75

Ilioinguinal nerve

Question 76

What is the first identifiable subcutaneous named layer?

Answer 76

Scarpa's fascia

Question 77

What is the name of the subcutaneous vein that is ligated during an inguinal hernia repair?

Answer 77

Superficial epigastric vein

Question 78

From what abdominal muscle layer is the cremaster muscle delivered?

Answer 78

Internal oblique

Question 79

What is the spermatic cord (6)?

Answer 79

* Cremasteric muscle fibers * Vas deferens * Testicular artery * Testicular pampiniform venous plexus * +/- hernia sac * Genital branch of the genitofemoral nerve

Question 80

What is the herna sac made of?

Answer 80

Peritoneum (direct) or a patent prcessus vaginalis (indirect)

Question 81

What lies in the inguinal canal in females instead of the VAS?

Answer 81

Round ligament

Question 82

What is the main difference between a direct and an indirect inguinal hernia?

Answer 82

An indirect inguinal hernia passes through the deep inguinal ring and may descend into the scrotum, while a direct inguinal hernia protrudes through the Hesselbach’s triangle and is medial to the inferior epigastric vessels.

Question 83

Which type of inguinal hernia is more common in infants and young adults?

Answer 83

Indirect inguinal hernia

Question 84

What structure passes through the inguinal canal in males?

Answer 84

Spermadic cord (containing the vas deferens, testicular artery, and pampiniform plexus)

Question 85

A 58-year-old male presents with a bulge in his right groin that has been gradually increasing in size over the past 6 months. He reports mild discomfort when lifting heavy objects but denies nausea, vomiting, or changes in bowel habits. On physical exam, you note a bulge that increases in size when he is standing and reduces when he lies down. The bulge is palpable in the inguinal canal and is found to be lateral to the inferior epigastric vessels. What is the most likely diagnosis? A) Direct inguinal hernia B) Indirect inguinal hernia C) Femoral hernia D) Ventral hernia

Answer 85

Indirect inguinal hernia ## Footnote The hernia is located lateral to the inferior epigastric vessels, indicating an indirect inguinal hernia, which follows the pathway of the spermatic cord through the inguinal canal. This is more common than direct inguinal hernias, especially in younger patients.

Question 86

A 72-year-old male presents with a bulge in his left groin. He reports that the bulge becomes more pronounced when he coughs or strains. He denies any pain or discomfort. On exam, you identify a reducible mass in the left groin. The mass is located medial to the inferior epigastric vessels and within Hesselbach’s triangle. What type of hernia is most likely? A) Direct inguinal hernia B) Indirect inguinal hernia C) Femoral hernia D) Umbilical hernia

Answer 86

Direct inguinal hernia ## Footnote A direct inguinal hernia is characterized by a protrusion through Hesselbach’s triangle and is medial to the inferior epigastric vessels. It is more common in older adults due to weakened abdominal muscles.

Question 87

A 36-year-old woman presents with a painful bulge in her right groin. She reports that the pain worsened over the past 24 hours and is now constant. On physical exam, a tender mass is palpated below the inguinal ligament. The mass is not reducible, and there is tenderness to palpation. What is the most appropriate next step in management? A) Observation with close follow-up B) Emergent hernia repair C) CT scan of the abdomen and pelvis D) Manual reduction and discharge home

Answer 87

Emergent hernia repair ## Footnote This patient likely has a femoral hernia, which occurs below the inguinal ligament. Femoral hernias have a high risk of incarceration and strangulation, requiring emergent surgery to prevent bowel ischemia and necrosis.

Question 88

A 42-year-old male presents with a bulge in his groin that appeared suddenly after lifting a heavy object. He reports sharp pain in the area but denies nausea, vomiting, or fever. On physical exam, there is a tender, irreducible mass in the right inguinal region. The bulge is located lateral to the inferior epigastric vessels. The patient’s white blood cell count is elevated. What is the most likely complication of this condition if left untreated? A) Peritonitis B) Bowel obstruction C) Intestinal perforation D) Volvulus

Answer 88

Bowel Obstruction ## Footnote An incarcerated indirect inguinal hernia can lead to bowel obstruction if the herniated bowel becomes trapped and its blood supply compromised. This patient’s irreducible mass, pain, and elevated WBC count suggest incarceration and possible progression to strangulation.

Question 89

A 65-year-old female presents with chronic discomfort in her lower abdomen and groin. She notes a bulge that becomes more noticeable when standing or after heavy meals. On exam, a reducible mass is noted in the area just above the umbilicus. What is the most appropriate treatment option for this patient? A) Watchful waiting B) Laparoscopic hernia repair C) Antibiotics and observation D) Weight loss and observation

Answer 89

Laparoscopic hernia repair ## Footnote The patient likely has a ventral hernia, possibly an umbilical hernia based on the location. In symptomatic patients, surgical repair (laparoscopic or open) is the treatment of choice, especially if the hernia is increasing in size or causing discomfort.

Question 90

A 54-year-old man undergoes elective laparoscopic inguinal hernia repair for a reducible hernia. During the surgery, the surgeon identifies a hernia sac that is lateral to the inferior epigastric vessels. The repair is completed without complications. One month later, the patient presents with persistent groin pain and numbness along the upper thigh and scrotum. Which nerve is most likely injured? A) Genitofemoral nerve B) Femoral nerve C) Ilioinguinal nerve D) Obturator nerve

Answer 90

Ilioinguinal nerve ## Footnote The ilioinguinal nerve runs along the spermatic cord and can be injured during inguinal hernia repair, causing pain or numbness in the groin, upper thigh, and scrotum.

Question 91

A 66-year-old man presents to his primary care provider with fatigue and decreased appetite for the past 3 months. He reports an unintentional 20-pound weight loss in the past 3 months. He has a history of chronic hepatitis C. Which of the following tumor markers is associated with the most likely diagnosis? A) Elevated alpha-fetoprotein B) Elevated cancer antigen 125 C) Elevated cancer antigen 19-9 D) Elevated carcinoembryonic antigen

Answer 91

Elevated alpha-fetoprotein ## Footnote This patient most likely has hepatic carcinoma, which is associated with an elevated alpha-fetoprotein (AFP). Risk factors associated with hepatic carcinoma include chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, chronic alcohol-related cirrhosis, non-alcohol-related fatty liver disease, alpha-1 antitrypsin deficiency, autoimmune hepatitis, Wilson disease, and hemochromatosis.

Question 92

What risk stratification tool is used to assess upper gastrointestinal bleeding?

Answer 92

The Glasgow-Blatchford score

Question 94

A 75-year-old man with a history of diabetes, myocardial infarction, and heart failure presents with an acute onset of mild cramping abdominal pain and bloody diarrhea. On exam, you note localized abdominal tenderness with palpation. Laboratory studies are unremarkable, and fecal pathogen test is negative. Colonoscopy demonstrates friable, edematous mucosa, bluish hemorrhagic nodules, and interspersed pale areas in the affected segment of the bowel. Which of the following segments of the bowel is most likely affected, given the most likely diagnosis? A) Ascending colon B) Proximal transverse colon C) Small bowel D) Splenic flexure

Answer 94

Splenic flexure ## Footnote The ascending colon (A), proximal transverse colon (B), and small bowel (C) are incorrect because they are not areas of the bowels that are most commonly affected by colonic ischemia. In the setting of mesenteric ischemia involving the superior mesenteric artery, these areas would be most likely affected. Colonic ischemia affects watershed areas of the colon where collateral blood supply is limited, such as the splenic flexure and rectosigmoid junction

Question 95

Which physical exam finding is highly suggestive of mesenteric ischemia?

Answer 95

Abdominal pain that is out of proportion to the exam

Question 96

A 68-year-old man with a history of chronic back pain presents with an acute onset of black, tarry stools and is vomiting blood. His chronic back pain is managed with diclofenac and ibuprofen. On exam, he is hypotensive, tachycardic, and dyspneic. A stool guaiac test is positive. Laboratory studies demonstrate an elevated blood urea nitrogen-creatinine ratio. Which of the following is the most common cause of the suspected diagnosis? A) Diverticulosis B) Esophageal varices C) Mallory-Weiss tear D) Peptic ulcer disease

Answer 96

Peptic Ulcer Disease

Question 97

What two symptoms are highly suggestive of upper gestational tract bleeding? | What defines upper GI bleeds?

Answer 97

* Melana (black, tarry, liquid stools) * Hematemesis | Bleeds occuring above the ligament of Trietz

Question 98

What is the most common cause of melana?

Answer 98

Peptic Ulcer Disease

Question 99

What is the most common cause of rectal bleeding in patients younger than 50 years of age?

Answer 99

Hemorrhoids

Question 100

Which bariatric surgery is most effective at reducing the risk of diabetes mellitus?

Answer 100

Biliopancreatic diversion with duodenal switch ## Footnote A biliopancreatic diversion with duodenal switch is a form of bariatric surgery where three-quarters of the stomach is removed and bile and pancreatic juices are introduced at a location farther along the small intestine by relocating the duodenum. This procedure results in a smaller gastrointestinal tract and less caloric absorption

Question 101

Describe a lap-band procedure?

Answer 101

The lap band procedure is a type of bariatric surgery. It refers to the use of a small, inflatable device that is surgically placed around the stomach. The device constricts the stomach and limits the total gastric volume. Since the gastric space is smaller, the patient may experience feelings of early satiety and will not consume as much food.

Question 102

What is the most common bariatric surgery preformed in the U.S.?

Answer 102

A **sleeve gastrectomy** is a bariatric surgical procedure where 80% of the stomach is removed. There is no anastomosis of the intestines. This procedure results in early satiety and smaller gastric volume giving it both restrictive and malabsorptive properties.

Question 103

A 4-week-old male infant presents to the ED with his parent for a 4-day history of projectile vomiting. The parent says the infant is constantly fussy and hungry but vomits after every feeding. Physical exam reveals dry mucous membranes and a small, hard, mobile mass in the right upper quadrant. A pediatric surgeon is consulted and agrees with the initial ED assessment. Which of the following is the most likely diagnosis? A) Intussusception B) Pyloric stenosis C) Rotavirus infection D) Wilms tumor

Answer 103

Pyloric Stenosis

Question 104

What is the most common cause of pyloric stenosis in adults?

Answer 104

Chronic Ulcer Disease

Question 105

A 67-year-old woman presents with abdominal pain for three days. CT abdomen and pelvis with IV contrast showed appendiceal rupture and abscess. She was admitted to the surgical floor, where her daily treatment includes bowel rest, IV fluids, and piperacillin-tazobactam. A percutaneous tube was placed to drain the abscess. On hospital day two, her total drain output is 30 mL with no drainage in the last 10 hours. Her vitals are T 38.4°C, HR 98 bpm, BP 130/68 mm Hg, RR 14 breaths/min, and SpO2 95%. Serial abdominal exams show persistent right lower quadrant tenderness without rebound, guarding, or rigidity. Which of the following is the best next step? A) CT abdomen and pelvis with IV contrast B) Laparoscopic appendectomy C) Open appendectomy D) Switch to PO antibiotics

Answer 105

Laparoscopic appendectomy ## Footnote Laparoscopic appendectomy is indicated in cases of complicated appendicitis that do not improve with nonoperative management.

Question 106

What is Rovsing's Sign?

Answer 106

RLQ pain with palpation of LLQ

Question 107

What is Obturator Sign?

Answer 107

RLQ pain with internal rotation of the hip

Question 108

What is Psoas Sign?

Answer 108

RLQ pain with hip extension

Question 109

What is the typical initial symptom of appendicitis? | What is the treatment?

Answer 109

Crampy or "colicky" pain around the umbilicus | Surgical appendectomy

Question 110

Which of the following is the most common symptom of appendicitis in children? A. Constipation B. Vomiting C. Right lower quadrant pain D. High fever

Answer 110

Right lower quadrant pain

Question 111

A 10-year old child presents with periumbilical pain that later localizes to the right lower quadrant. What is the most likely diagnosis?

Answer 111

Appendicitis

Question 112

What is the most common complication of appendicitis in pediatric patients?

Answer 112

Peritonitis

Question 113

Which imaging study is preferred initially for diagnosing appendicitis in children?

Answer 113

Abdominal Ultrasound

Question 114

True or False: Appendicitis can sometimes present with diarrhea in pediatric patients

Answer 114

True

Question 115

A high fever is typically a primary symptom of appendicitis in children?

Answer 115

False

Question 116

A 9-year-old female presents with a 24-hour history of abdominal pain that initially started around the navel but has now localized to the right lower quadrant. She has vomited twice and reports a decrease in appetite. On examination, she has a fever of 37.8°C (100°F) and tenderness in the right lower quadrant with guarding. What is the next best step in management? A. Administer IV fluids and observe B. Order an ultrasound of the abdomen C. Schedule for immediate surgery D. Start broad-spectrum antibiotics

Answer 116

Order an ultrasound of the abdomen

Question 117

What congenital disorder is classified by the absence or complete closure of a portion of the lumen of the duodenum? | What is seen in utero in this diagnosis?

Answer 117

Duodenal Atresia | Increased levels of amniotic fluid (polyhydramnios)

Question 118

Which of the following is the most common presenting symptom of duodenal atresia in a newborn? A. Bilious vomiting B. Watery diarrhea C. Intermittent abdominal pain D. Jaundice

Answer 118

Bilious vomiting

Question 119

A newborn presents with bilious vomiting within the first 24 hours of life. An abdominal x-ray shows a "double bubble" sign. What is the most likely diagnosis? A. Pyloric stenosis B. Intussusception C. Duodenal atresia D. Necrotizing enterocolitis

Answer 119

Duodenal atresia

Question 120

What is the most appropriate initial management for a newborn diagnosed with duodenal atresia? A. Immediate surgical correction B. Pharmacological closure of the patent ductus arteriosus C. Placement of a nasogastric tube and fluid resuscitation D. Initiation of enteral feeding

Answer 120

Placement of a nasogastric tube and fluid resuscitation

Question 121

Duodenal atresia is commonly associated with which of the following chromosomal abnormalities? A. Trisomy 21 (Down syndrome) B. Turner syndrome C. Klinefelter syndrome D. Trisomy 18

Answer 121

Trisomy 21

Question 122

What is the hallmark presentation of Hirschsprungs Disease?

Answer 122

Delayed passage of meconium

Question 123

A newborn fails to pass meconium within the first 48 hours of life and has abdominal distension. Which diagnostic test is most likely to confirm a diagnosis of Hirschsprung's disease? A. Abdominal ultrasound B. Barium enema C. Rectal biopsy D. Complete blood count (CBC) | What is the definitive treatment for Hirschsprung's disease?

Answer 123

Rectal biopsy | Surgical resection

Question 124

Which part of the intestine is most commonly affected by Hirschsprung's disease? A. The entire colon B. The rectosigmoid region C. The ileum D. The jejunum

Answer 124

The rectosigmoid region

Question 125

A 3-year-old boy is brought to the pediatric clinic by his parents who noticed a bulge in his groin that becomes more apparent when he cries. The bulge is reducible and the child does not appear to be in discomfort while you examine him. Based on this presentation, what is the most likely diagnosis and the recommended management? A. Inguinal hernia; refer for surgical evaluation. B. Umbilical hernia; reassure and observe. C. Hydrocele; schedule a follow-up in six months. D. Testicular torsion; immediate surgical intervention.

Answer 125

Inguinal hernia; refer for surgical evaluation.

Question 126

A 6-week-old male infant presents to the pediatrician with a 2-week history of progressive non-bilious vomiting after feeding. The mother reports that the vomiting is forceful and the infant seems hungry again soon after vomiting. On examination, the infant appears mildly dehydrated and a small olive-sized mass can be palpated in the right upper quadrant of the abdomen. What is the most likely diagnosis and the appropriate diagnostic test? A. Pyloric stenosis; order an abdominal ultrasound. B. Gastroesophageal reflux disease; perform a barium swallow. C. Intussusception; conduct an abdominal CT scan. D. Food allergy; recommend an elimination diet and allergy testing.

Answer 126

Pyloric stenosis; order an abdominal ultrasound

Question 127

An 8-week-old boy is evaluated for projectile vomiting that has progressively worsened over the last 3 weeks. His parents report that he vomits forcefully shortly after each feeding, but he remains eager to eat. Upon examination, the child is noted to be somewhat lethargic and has a palpable olive-like mass in the right upper quadrant. What is the most definitive treatment for this condition? A. Surgical pyloromyotomy B. Administration of prokinetic agents C. Initiation of thickened feedings D. A course of oral antibiotics

Answer 127

Surgical pyloromyotomy

Question 128

A 7-week-old infant with a history of projectile vomiting is diagnosed with pyloric stenosis based on clinical findings and confirmed by ultrasound. Prior to any surgical intervention, which complication must be corrected? A. Hypernatremia B. Hypoglycemia C. Metabolic alkalosis D. Respiratory acidosis | How should it be corrected?

Answer 128

Metabolic alkalosis Pyloric stenosis leads to projectile vomiting, which is typically non-bilious. This condition often results in significant loss of gastric acid (hydrochloric acid). The stomach's continual production and subsequent loss of hydrochloric acid through vomiting leads to a state where there is an abnormal increase in blood pH, known as metabolic alkalosis. | IV fluids

Question 129

What is the most common cause of toxic megacolon? A) Ulcerative colitis B) Crohn's disease C) Ischemic colitis D) Infectious colitis

Answer 129

Ulcerative colitis ## Footnote Toxic megacolon most commonly arises as a complication of inflammatory bowel disease, particularly ulcerative colitis.

Question 130

Which imaging modality is preferred for diagnosing toxic megacolon? A) CT scan B) Abdominal X-ray C) MRI D) Ultrasound

Answer 130

Abdominal x-ray ## Footnote Abdominal X-ray typically shows colonic dilation greater than 6 cm, which is characteristic of toxic megacolon

Question 131

A 35-year-old male with a 10-year history of ulcerative colitis presents to the emergency department with severe abdominal pain, distension, and fever. His vital signs show a heart rate of 120 bpm, BP of 90/60 mmHg, and a temperature of 102°F. Physical exam reveals marked abdominal tenderness with decreased bowel sounds. An abdominal X-ray shows a dilated colon greater than 7 cm. What is the next best step in management? A) Start broad-spectrum antibiotics and IV fluids B) Perform an immediate total colectomy C) Administer corticosteroids and monitor D) Place a nasogastric tube and start bowel rest

Answer 131

Start broad-spectrum antibiotics and IV fluids ## Footnote Initial management of toxic megacolon includes aggressive fluid resuscitation and broad-spectrum antibiotics. Surgery may be needed if there is no improvement with medical management.

Question 132

A 28-year-old female with a history of Crohn’s disease presents with fever, tachycardia, and severe abdominal pain. She reports passing fewer bowel movements than usual over the last 24 hours. Abdominal X-ray reveals dilation of the colon consistent with toxic megacolon. What complication is this patient at greatest risk for if her condition is not promptly treated? A) Perforation B) Stricture formation C) Fistula development D) Malabsorption

Answer 132

Perforation ## Footnote The major complication of toxic megacolon is perforation, which can lead to peritonitis and septic shock

Question 133

A 40-year-old male with a known history of ulcerative colitis is admitted for suspected toxic megacolon. His abdominal X-ray shows colonic dilation, and his WBC count is elevated. He has been on corticosteroids for his ulcerative colitis flares in the past. What medication should be added to his regimen to reduce the inflammatory response? A) Methotrexate B) Infliximab C) Cyclosporine D) Azathioprine

Answer 133

Infliximab ## Footnote Infliximab, a TNF-alpha inhibitor, is often used in severe ulcerative colitis or Crohn’s disease that is refractory to corticosteroids, and it can be helpful in managing toxic megacolon due to underlying IBD

Question 134

Which of the following is the most common complication associated with colonoscopy? A) Perforation B) Hemorrhage C) Anesthesia reaction D) Infection

Answer 134

Perforation ## Footnote Colonic perforation is a rare but serious complication of colonoscopy, particularly in patients with diverticulosis or those undergoing polypectomy

Question 135

What is the recommended screening interval for colonoscopy in a patient with no personal or family history of colorectal cancer and normal findings on the previous colonoscopy?

Answer 135

Every 10 years

Question 136

A 55-year-old male with no significant medical history presents to your office for a routine health checkup. He reports no family history of colorectal cancer and has never had a colonoscopy. What is the best next step in this patient's care? A) Order a fecal occult blood test (FOBT) B) Schedule a screening colonoscopy C) Recommend a sigmoidoscopy D) No screening is required at this time

Answer 136

Schedule a screening colonoscopy ## Footnote Screening begins at age 50 for average risk adults

Question 137

A 60-year-old woman undergoes a routine screening colonoscopy. During the procedure, several polyps are identified and removed. The pathology report shows tubular adenomas. When should this patient have her next colonoscopy? A) In 1 year B) In 3 years C) In 5 years D) In 10 years

Answer 137

In 3 years ## Footnote Patients with adenomatous polyps, especially tubular adenomas, are at increased risk for colorectal cancer and should undergo repeat colonoscopy in 3 years

Question 138

What are the risk factors for developing an incisional hernia? | What is the definitive treatment?

Answer 138

* Advanced age * Immunosuppression * Connective tissue disorders * Malnutrition | Surgical repair

Question 139

Which incision site has the highest incidence of developing an incisional hernia?

Answer 139

Midline incisions

Question 140

A 47-year-old woman presents with complaints of bleeding with bowel movements for the past 2 days and a sensation of fullness in the anal area. The symptoms began after straining with a bowel movement. Physical exam reveals a purple, nodular protrusion from the anus. From what anatomical location did this issue likely arise? A) Internal hemorrhoidal plexus B) Internal pudendal vein C) Perianal dermis D) Superior hemorrhoidal cushion

Answer 140

Superior hemorrhoidal cushion ## Footnote Internal hemorrhoids are a normal anatomical part of the anal canal. These hemorrhoids consist of connective tissue, smooth muscle fibers, and terminal branches of the rectal arteries and veins providing normal closure and pressures in the anal canal. They are located in the right anterior, right posterior, and left lateral areas of the canal and arise from the superior hemorrhoidal cushion.

Question 141

What position should a patient be in to perform an examination for hemorrhoids?

Answer 141

Prone or Left Lateral Position

Question 142

A 27-year-old woman presents with vomiting and 10/10 right lower extremity pain. The symptoms started suddenly 1 hour ago when she was lifting weights. The pain is constant and worsening. She has no significant medical or surgical history, but she noticed a painless mass below her right inguinal crease 1 month ago. Her vital signs are T 37.1°C, HR 107 bpm, BP 141/92 mm Hg, RR 23/min, and SpO2 99%. Her BMI is 22 kg/m2. On examination, she is diaphoretic and pale, and there is a right-sided erythemic mass protruding inferior and lateral to the pubic tubercle. The mass is hot, firm, pulseless, and exquisitely tender to palpation. What is the best way to diagnose this condition? A) Clinical exam B) CT of the abdomen and pelvis with IV contrast C) Hernia sac laparoscopy D) Ultrasound of the abdomen and pelvis | What is the treatment?

Answer 142

Clinical Exam | Strangulated hernias are surgical emergencies

Question 143

What medications should be prescribed to the patient after incision and drainage of a perianal abscess?

Answer 143

* Antibiotics * Stool Softeners * NSAIDs

Question 144

What is the most common gastric carcinoma? | What is Virchow's Node?

Answer 144

Adenocarcinoma | Supraclavicular lymph node on exam associated with gastric cancer

Question 145

Which part of the gastrointestinal tract is most commonly affected by Crohn’s disease? A) Esophagus B) Stomach C) Ileum D) Rectum

Answer 145

Illeum ## Footnote Crohn's disease most commonly affects the terminal ileum and the beginning of the colon, though it can involve any part of the GI tract

Question 146

What is the hallmark microscopic feature of Crohn’s disease? A) Non-caseating granulomas B) Crypt abscesses C) Goblet cell hyperplasia D) Villous atrophy

Answer 146

Non-caseating granulomas ## Footnote The presence of non-caseating granulomas on biopsy is a characteristic finding of Crohn’s disease, although it is not present in all cases.

Question 147

What is the preferred diagnostic test for identifying the extent and severity of Crohn's disease?

Answer 147

Colonoscopy with biopsy ## Footnote Colonoscopy with biopsy is the preferred diagnostic test for evaluating Crohn’s disease and determining the extent of inflammation

Question 148

A 30-year-old female presents with a 6-month history of intermittent abdominal pain, diarrhea, and weight loss. She reports having had several episodes of rectal bleeding. Physical examination reveals tenderness in the right lower quadrant. Lab tests show an elevated C-reactive protein and anemia. Colonoscopy reveals patchy areas of inflammation with ulcerations and skip lesions. What is the most likely diagnosis? A) Ulcerative colitis B) Irritable bowel syndrome C) Crohn’s disease D) Ischemic colitis

Answer 148

Crohn's Disease ## Footnote The patchy areas of inflammation, skip lesions, and right lower quadrant pain are characteristic of Crohn’s disease

Question 149

A 45-year-old male with a long-standing history of Crohn’s disease presents with fever, severe abdominal pain, and distension. Physical examination reveals diffuse tenderness and guarding. A CT scan of the abdomen shows a thickened bowel wall and free air in the abdomen. What is the next best step in management? A) IV corticosteroids B) Immediate surgical consultation C) Oral antibiotics D) Colonoscopy

Answer 149

Immediate surgical consultation ## Footnote The presence of free air suggests bowel perforation, a surgical emergency. Immediate surgical consultation is necessary

Question 150

A 28-year-old female with a known history of Crohn’s disease presents with persistent diarrhea and abdominal cramping despite being on mesalamine for maintenance therapy. Which of the following is the best next step in her management? A) Increase the dose of mesalamine B) Add corticosteroids C) Initiate infliximab therapy D) Perform a colonoscopy

Answer 150

Initiate infliximab therapy ## Footnote Infliximab, a TNF-alpha inhibitor, is often used in patients with moderate to severe Crohn’s disease who are not responsive to mesalamine

Question 151

What is mesalamine?

Answer 151

Mesalamine (also known as 5-aminosalicylic acid or 5-ASA) is an anti-inflammatory medication used to treat inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis. It works by reducing inflammation in the lining of the colon and rectum, helping to control symptoms like abdominal pain, diarrhea, and rectal bleeding.

Question 152

A 40-year-old male with Crohn’s disease presents with perianal pain and drainage. Physical examination reveals a perianal fistula. What is the best initial treatment option for this patient? A) Oral antibiotics B) Fistulotomy C) Seton placement D) Immunosuppressive therapy

Answer 152

Seton placement ## Footnote A seton is often placed in patients with Crohn’s disease who have complex perianal fistulas to allow drainage and prevent abscess formation. Surgical intervention may be required if medical management is insufficient

Question 153

A 36-year-old woman with Crohn’s disease is being evaluated for surgery due to recurrent bowel obstructions. What is the most common surgical procedure performed for this indication? A) Total colectomy B) Partial bowel resection C) Ileostomy creation D) Stricturoplasty

Answer 153

Stricturoplasty ## Footnote Stricturoplasty is a bowel-sparing procedure that is often performed to manage recurrent obstructions caused by strictures in Crohn’s disease

Question 154

What is the most common cause of acute pancreatitis in the U.S.?

Answer 154

Gallstones ## Footnote Gallstones are the most common cause of acute pancreatitis in the U.S., followed by alcohol use. Smaller gallstones are more commonly associated than larger stones as they can travel down the duct more freely.

Question 155

Which serum marker is most specific for the diagnosis of acute pancreatitis?

Answer 155

Lipase

Question 156

What is the most appropriate initial imaging study for suspected acute pancreatitis? A) Abdominal ultrasound B) Abdominal CT scan C) Abdominal X-ray D) MRI

Answer 156

Abdominal ultrasound ## Footnote Abdominal ultrasound is typically the first imaging study used to identify gallstones as a potential cause of acute pancreatitis

Question 157

A 50-year-old male with a history of heavy alcohol use presents with epigastric pain radiating to the back, nausea, and vomiting. His lipase and amylase levels are elevated. What complication is he at greatest risk for during the first 48 hours of hospitalization? A) Pancreatic abscess B) Pseudocyst formation C) Sepsis D) Acute respiratory distress syndrome (ARDS)

Answer 157

Acute respiratory distress syndrome (ARDS) ## Footnote Severe acute pancreatitis can lead to systemic complications such as ARDS, especially in the early stages

Question 158

A 60-year-old man with a history of hyperlipidemia presents with severe abdominal pain, nausea, and vomiting. His lipase and amylase levels are elevated, and a CT scan confirms acute pancreatitis. Triglyceride levels are found to be 1200 mg/dL. What is the best initial treatment? A) IV antibiotics B) NPO (nothing by mouth) and IV fluids C) Urgent cholecystectomy D) Insulin and plasmapheresis

Answer 158

NPO and IV fluids ## Footnote The mainstay of treatment for acute pancreatitis is supportive care, including bowel rest (NPO) and IV fluid resuscitation. Hypertriglyceridemia is a known cause, but initial management focuses on hydration and pain control.

Question 159

A 48-year-old female presents with epigastric pain that started suddenly 24 hours ago and radiates to her back. Her lipase level is significantly elevated, and a CT scan shows diffuse pancreatic enlargement. Over the next few days, she develops a tender, palpable mass in the upper abdomen. What is the most likely complication? A) Pancreatic abscess B) Pancreatic pseudocyst C) Pancreatic necrosis D) Bowel perforation

Answer 159

Pancreatic pseudocyst ## Footnote Pancreatic pseudocyst is a common complication of acute pancreatitis, often presenting weeks after the initial episode as a palpable mass

Question 160

By what mechanism does a Roux-en-Y procedure promote weight loss? A) By bypassing most of the stomach, duodenum, and proximal jejunum B) By creating three small bowel limbs to induce malabsorption C) By partitioning the stomach into a small proximal pouch D) By removing a majority of the greater curvature of the stomach | What surgical method is commonly used for Roux-en-Y gastric bypass?

Answer 160

By bypassing most of the stomach, duodenum, and proximal jejunum | Laproscopic approach

Question 161

A 40-year-old woman presents to the emergency department with right upper quadrant pain. On exam, she is afebrile but has right upper quadrant tenderness. Laboratory testing reveals an alkaline phosphatase of 640 U/L, AST of 204 U/L, and ALT of 220 U/L. The common bile duct measures 9 mm on transabdominal ultrasound, and the gallbladder is present. Which of the following is both diagnostic and therapeutic for the most likely diagnosis? A) Endoscopic retrograde cholangiopancreatography B) Endoscopic ultrasound C) Magnetic resonance cholangiopancreatography D) Right upper quadrant abdominal ultrasound

Answer 161

Endoscopic retrograde cholangiopancreatography

Question 162

True or false: hypoalbuminemia is suggestive of acute liver disease

Answer 162

False, hypoalbuminia indicates chronic liver disease

Question 163

What is the surgical repair of an anal fissure called?

Answer 163

Lateral internal sphincterotomy

Question 164

What is the most common type and location of pancreatic cancer?

Answer 164

Adenocarcinoma in the head of the pancreas

Question 165

A 48-year-old woman with a history of obesity, diabetes mellitus, and hypertension presents with worsening abdominal pain and nausea for the past 2 hours. She reports the pain began after eating a fast food meal. It initially began around the center of her abdomen, but it is now worse in the right upper quadrant of her abdomen and radiates to her right shoulder. She reports the pain has been constant despite taking two doses of omeprazole. On physical exam, she is ill appearing. Palpation of the abdomen reveals significant tenderness in the right upper quadrant. Bloodwork shows total bilirubin of 0.8 mg/dL, alkaline phosphatase of 50 IU/L, and white blood cell count of 14,000/mm3. Which diagnostic study is considered to be the gold standard for the suspected diagnosis? A) Cholescintigraphy B) Computed tomography with intravenous contrast C) Endoscopic retrograde cholangiopancreatography D) Ultrasonography

Answer 165

Cholescintigraphy (HIDA Scan) ## Footnote While an ultrasound is typically the first diagnostic test performed, the gold standard for diagnosing cholecystitis is cholescintigraphy, also known as a HIDA scan.

Question 166

In chronic pancreatitis, are amylase and lipase levels elevated? | What is the diagnostic test of choice for chronic pancreatitis?

Answer 166

No, they are within normal limits | Magnetic resonance cholangiopancreatography (MRCP) ## Footnote This finding is in part due to the fibrosis that occurs in the pancreas with this process and the low levels of the enzymes that are secreted even in the setting of inflammation.

Question 167

Which genetic variations have been associated with chronic pancreatitis?

Answer 167

* CFTR gene (Cystic Fibrosis) * SPINK1 and PRSS1 (Hereditary pancreatitis)

Question 168

What is the treatment for chronic pancreatitis? | What complications are associated with chronic pancreatitis?

Answer 168

* ERCP * Pain control * Nutrition * Surgery | Glucose intolerance, malabsoprtion, and osteoporosis

Question 169

A 40-year-old woman presents to the emergency department with an acute onset of epigastric pain, nausea, fever, and vomiting. On exam, an inspiratory arrest is noted during deep palpation of the right upper quadrant of the abdomen. Laboratory studies demonstrate leukocytosis with a left shift. Her ultrasound image is shown above. Which of the following is the initial intervention indicated for this patient? A) Administration of intravenous fluids B) Outpatient antibiotic therapy C) Refer to surgery for cholecystectomy D) Refer to surgery for cholecystostomy

Answer 169

Administration of intravenous fluids ## Footnote Once the diagnosis of acute cholecystitis is made, administration of intravenous fluids is the next step in management, followed by broad-spectrum intravenous antibiotics, bowel rest, analgesics, and correction of electrolyte abnormalities. Definitive treatment is with laparoscopic cholecystectomy within the first 72 hours.

Question 170

What autosomal dominant genetic disorder is associated with the formation of gastrinoma?

Answer 170

Multiple endocrine neoplasia type 1

Question 171

When should surgical treatment for anal fissures be considered?

Answer 171

For refractory cases or if symptoms last longer than 8 weeks

Question 172

What is the most common symptom of internal hemorroids? | Where do internal hemorroids originate?

Answer 172

Painless rectal bleeding | Above the dentate line

Question 173

What is the best initial treatment for mild symptomatic hemorrhoids? A) Hemorrhoidectomy B) Topical corticosteroids C) Rubber band ligation D) High-fiber diet and increased fluid intake

Answer 173

High-fiber diet and increased fluid intake

Question 174

A 60-year-old woman presents with severe anal pain that began suddenly after lifting a heavy object. On examination, a bluish, swollen mass is visible at the anal verge. What is the most appropriate management for this patient? A) High-fiber diet and increased fluid intake B) Rubber band ligation C) Surgical excision of the thrombosed hemorrhoid D) Oral analgesics and sitz baths

Answer 174

Surgical excision of the thrombosed hemorrhoid

Question 175

A 55-year-old patient with a history of internal hemorrhoids reports ongoing rectal bleeding despite conservative management with fiber supplements and sitz baths. What is the next best step in management? A) Continue conservative treatment B) Rubber band ligation C) Hemorrhoidectomy D) Colonoscopy

Answer 175

Rubber band ligation ## Footnote For internal hemorrhoids that do not respond to conservative management, rubber band ligation is an effective, minimally invasive procedure.

Question 176

A 55-year-old man with alcoholic liver disease presents to the office with upper abdominal pain, weight loss, and anemia. An endoscopy reveals the presence of small- to medium-sized esophageal varices. Which of the following medications is used as primary prophylaxis for the prevention of variceal hemorrhage? A) Isosorbide mononitrate B) Nitroglycerin C) Propranolol D) Vasopressin

Answer 176

Proponolol

Question 177

What is Charcot Triad? | What is the first line treatment for acute cholangitis?

Answer 177

Triad of symptoms for acute cholangitis * Fever * Jaundice * Abdominal Pain | Biliary drainage via ERCP

Question 178

What symptoms comprise the Reynolds pentad?

Answer 178

* Fever * Jaundice * Abdominal Pain * Hypotension * Mental status change

Question 179

What is a femoral hernia? | What type of hernia is most likely to become incarcerated?

Answer 179

A protrusion of tissue inferior to the inguinal ligament through the femoral ring | Femoral hernia

Question 180

What is the most common presentation of Meckel diverticulum?

Answer 180

Painless rectal bleeding in a child 2 years or younger, typically male

Question 181

What type of ulcer is alleviated by ingesting food?

Answer 181

Doudenal Ulcer

Question 182

What are the watershed areas of the colon?

Answer 182

The splenic flexure and rectosigmoid junction

Question 183

Which of the following types of bile duct stones are most likely to be found in primary choledocholithiasis? A) Calcium oxalate stone B) Cholesterol stone C) Mixed stone D) Pigmented stone | What is the most common stone found in cholysistitis?

Answer 183

Pigmented stone | Cholesterol stone ## Footnote In industrialized countries, the secondary form of choledocholithiasis from stones in the gallbladder is the most common. The primary form is less common. Pigmented stones are most commonly seen in the primary form of the disease and are brown in color, resulting from biliary stasis. Patients with biliary stasis, such as those with cystic fibrosis, or older patients with large bile ducts are at higher risk. Patients who have frequent infections of the bile tract are also at risk.

Question 184

What are some complications of choledocholithiasis?

Answer 184

* Cholangitis * Obstructive Jaundice * Biliary cirrhosis * Pancreatitis

Question 185

What is the recommended surgical intervention for internal hemmoriods refractory to medical treatment?

Answer 185

For internal hemorrhoids that do not respond to conservative management, rubber band ligation is an effective, minimally invasive procedure.

Question 186

A 35-year-old man presents to the clinic with a complaint of epigastric pain for about a month. He reports that he has been taking naproxen for the past month due to knee pain. How long after a meal would pain be expected to occur if the symptoms are due to a duodenal ulcer? A) 1 hour B) 3 hours C) 30 minutes D) 9 hours

Answer 186

3 Hours ## Footnote Gastric ulcers cause food-provoked pain or postprandial belching and epigastric fullness, whereas duodenal ulcers often cause pain 2 to 5 hours following a meal or at night between 11 PM and 2 AM when the circadian pattern of acid secretion is maximal.

Question 187

What GI condition typically presents with dysphagia to both liquids and solid foods?

Answer 187

Achalasia

Question 188

What disease is associated with the classic triad of fever, right upper quadrant pain, and jaundice?

Answer 188

Acute cholangitis

Question 189

What is a Schatzki ring?

Answer 189

A circumferential ring in the lower esophagus that can cause dysphagia and often accompanies a sliding hiatal hernia.

Question 190

What is the first-line therapeutic option for achalasia?

Answer 190

Laparoscopic Heller myotomy