Pretest - GI tract, liver, pancreas Flashcards

1
Q

74yo woman is admitted with upper GI bleeding. she is started on H2 blockers, but experiences another bleeding episode. endoscopy documents diffuse gastric ulcerations. omeprazole is added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. which of the following is the mechanism of action of omeprazole?

a. blockage of the breakdown of mucosa-damaging metabolites of NSAIDs
b. provision of a direct cytoprotective effect
c. buffering of gastric acids
d. inhibition of parietal cell hydrogen potassium ATPase
e. inhibition of gastrin release and parietal cell acid production

A

D
–> PPI

exceeding 24h
–> suppression of meal-stimulated and noctural acid secretion.

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2
Q

35yo woman presents with frequent and multiple areas of cutaneous ecchymosis. w/up demonstrates a plt count of 15,000; evaluation of the bone marrow reveals a normal # of megakaryocytes, and US examination demonstrates a normal-sized spleen. based on the exclusion of other causes of thrombocytopenia, she is given a diagnosis of immune idiopathic thrombocytopenic purpura (ITP). which of the following is the most appropriate treatment upon diagnosis?

a. expectant management with close follow-up of plt counts
b. immediate plt transfusion to increase plt counts to >50,000
c. glucocorticoid therapy
d. IVIg therapy
e. referral to surgery for laparoscopic splenectomy

A

C

the plts are being sheared by immune cells

ITP

  • Asx + plt > 30,000 –> expectant management
  • significant bleeding/factors + plt < 50,000 or plt <30,000 –> treament with prednisone
  • severe bleeding; preop prior to splenectomy –> treatment with IVIg
  • acute bleeding –> plt transfusions
  • severe symptomatic thrombocytopenia; higher levels of steroids needed; failure of steroid therapy; persistent thrombocytopenia for > 3mo –> splenectomy
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3
Q

59yo woman presents with RLQ pain, nausea, and vomiting. she undergoes an uncomplicated laparoscopic appendectomy. Post-op, the pathology reveals a 2.5cm mucinous adenocarcinoma with lymphatic invasion. Staging workup, including colonoscopy, chest x-ray and CT scan of the abdomen and pelvis, is negative. which of the following is the most appropriate next step in her management

a. no further intervention at this time. follow-u every 6 mo for 2y
b. chemotherapy alone
c. neoadjuvant chemotherapy followed by R hemicolectomy
d. ileocecectomy
e. R hemicolectomy

A

E

it isnt’ causing her problems, but there was invasion into lymph nodes - concerns for metastasis.

appendiceal adenocarcinoma

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4
Q

41yo man complains of regurgitation of saliva and of undigested food. an esophagram reveals a dilated esophagus and a bird-s beak deformity. manometry shows a hypertensive lower esophgeal sphincter with failure to relax with deglutition. which of the following is the safest and most effective treatment of this condition?

a. medical treatment with sublingual nitroglycerin, nitrates, or CCBs
b. repeated bougie dilations
c. injections of botulinum toxin directly into the lower esophgeal sphincter
d. dilation with a Gruntzig-type (volume-limited, pressure control) balloon
e. surgical esophgagomyotomy

A

E

achalasia –> due to increased pressure in lower sphincter
Heller myotomy –> more curative than medical management (where achalasia can recur)

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5
Q

a 32yo man with a 3y hx of ulcerative colitis presents for discussion for surgical intervention. the pt is otherwise healthy and does not have evidence of rectal dysplasia. which of the following is the most appropriate elective oepration for this pt?

a. total proctocolectomy with end ileostomy
b. total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy
c. total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and divting ileostomy
d. total abdominal colectomy with ileal rectal anastomosis
e. total abdominal colectomy with end ileostomy and very low Hartmann

A

B. total proctocolectomy with end ileostomy + ileoanal pounch anastomosis.

–> for older and incontinent pts

rectum is spared for now, but it eventually involves the rectum

–> resect most of the rectal

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6
Q

39yo previously healthy male is hospitalized for 2w with epigastric pain radiating to his back, N&V. initial lab values revealed an elevated amylase level consistent with acute pancreatitis. 5w following discharge, he complains of early satiety , epigastric pain, and fevers. on presentation, his T 38.9C (102F) and his HR 120, WBC 24,000 and amylase is normal. he undergoes a CT demonstrating a 6cmx6cm rim-enhancing fluid collection in the body of the pancreas. which of the following would be the most definitive management of the fluid collection?

a. antibiotic therapy alone
b. CT-guided aspiration with repeat imaging in 2-3d
c. antibiotics and CT-guided aspiration with repeat imaging in 2-3d
d. antibiotics and percutaneous catheter drainage
e. surgical internal drainage of the fluid collection with a cyst-gastrostomy or Roux-en-y cyst-jejunostomy

A

D
pancreatic cyst/abscess

–> can present 4-6w after an episode of acute pancreatitis.

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7
Q

a previously healthy 79yo woman presents with early satiety and abdominal fullness. CT scan of the abdomen shows a cystic lesion in the body & tail of the pancreas. CT-guided aspiration demonstrates an elevated CEA level. which of the following is the most appropriate treatment option for this pt?

a. distal pancreatectomy
b. serial CT scans with resection if the lesion increases significantly in size
c. internal drainage with roux-en-y cyst-jejunostomy
d. percutaneous drainage of the fluid-filled lesion
e. endosopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement

A

A
she has sxs –> so can’t just leave it

–> cystadenocarcinoma from thepancreatic body and tail.

no diagnotic laboratory findings.

high CEA, low amylase –> malignancy

tx = aggressive surgical resection

unlikely to be a pseudocyst b/c of high CEA.

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8
Q

56yo woman is referred to you about 3mo after a colostomy subsequent to a sigmoid resection for cancer. she complains that her stoma is not functioning properly. which of the following is the most serious complication of an end colostomy?

a. bleeding
b. skin breakdown
c. parastomal hernia
d. colonic perforation during irritation
e. stomal prolapse

A

C

Complications (in terms of seriousness)

1) parastomal herniation (when stoma is placed lateral) –> relocation of the stomach / mesh over hernia
2) irregularity of stoma function
3) irritation of skin due to leakage of enteric contents
4) bleeding from exposed mucosa following trauma
5) prolapse –> esp. with transverse loop colostomies likely due to the use of transverse loop to decompress distal colon obstructions. as the intestine decompresses, it retracts from the edge fo teh surrounding fascia –> allows prolapse / herniation fo mobile transverse colon
6) perforation fo stoma –> likely only d/t careless instrumentation

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9
Q

56yo previously healthy physician notices that his eyes are yellow and he has been losing weight. on PE, the pt has jaundice and scleral icterus with a benign abdomen. transcutaneous US of the abdomen demonstrates biliary ductal dilation without gallstones. which of the following is the most appropriate next step in the workup of this patient?

a. esophagogastroduodenoscopy (EGD)
b. endoscopic retrograde cholangiopancreatography (ERCP)
c. acute abdominal series
d. CT scan
e. PET scan

A

D. painless jaundice = likely pancreatic cancer.

stone in the common bile duct –> would be colicky pain

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10
Q

45yo woman with a history of heavy NSAID drug ingestion presents with acute abdominal pain. she undergoes exploratory laparotomy 30h after the onset of sxs and is found to have a perforated duodenal ulcer. which of the following is the procedure of choice to treat her perforation?

a. simple closure with omental patch
b. truncal vagotomy and pyloroplasty
c. trungal vagotomy and antrectomy
d. highly selective vagotomy with omental patch
e. hemigastrectomy

A

A

no prior history of peptic ulcer disease –> simple procedure

long-standing ulcer disease = variety of options with benefits & risks

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11
Q

45yo man with a hx of chronic peptic ulcer dz undergoes a truncal vagotomy and antrectomy with a billroth II reconstruction for gastric outlet obstruction. 6w after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain and diarrhea. which of the following would be the best initial management strategy?

a. treatment with a long-acting somatostatin analog
b. dietary advice and counseling that sxs will probably abate within 3mo of surgery
c. dietary advice and counseling that sxs will probably not abate but are not dangerous
d. workup for neuroendocrine tumor (eg carcinoid)
e. preparation for revision to roux-en-y gastrojejunostomy

A

B

dumping syndrome = it is dangerous.
~ carcinoid syndrome

post-prandial –> releasing too much insulin = hypoglycemia (vasomotor syndrome)

dietary advice

  • avoid lots of sugar
  • frequent small meals
  • separate fluids & solids
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12
Q

60 yo male pt with HCV with a previous hx of variceal bleeding is admitted to the hospital with hematemesis. his BP is 80/60, exam reveals splenomegaly and ascites and initial Hct 25%. Prior to endoscopy, which of the following is the best initial management of the pt?

a. administration of IV octerotide
b. administration of B-blocker (eg propanolol)
c. measurement of prothrombin time and transfusion with cryoglobulin if elevated
d. empiric transfusion of plts given splenomegaly
e. gastric and esophageal balloon tamponade (Sengstaken-Blakemore tube)

A

A

acute variceal bleed - correct high PT / INR with FFP

tx
1) fluid resuscitation = isotonic crystalloids + blood transfusion
2) octreotide/vasopressin –> to decrease splanchnic blood flow
+ nitroglycerin –> for coronary vasoconstrictive effects
3) sclerotherapy
4) endoscopy + banding
5) balloon tamponade (s/e = aspiration, asphyxiation, ulceration, rebleeding)

when hemodynamically stable
- B-blocker –> prevent recurrent variceal bleeding

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13
Q

32yo alcoholic with end-stage liver disease has been admitted to the hospital 3x for bleeding esophgeal varices. he has undergone banding and sclerotherapy preivously. he admits to currently drinking 6 packs of beer per day. on his abdominal examination, he has a fluid wave. which of the following is the best option for long-term management of this pt’s esophgeal varices

a. orthotopic liver transplantation
b. transection and reanastomosis of the distal esophgaus
c. distal splenorenal shunt
d. end-to-side portocaval shunt
e. transjugular intrahepatic portosystemic shunt (TIPS)

A

E

cirrhosis

usually use TIPS for the ascites d/t portal hypertension

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14
Q

55yo man complains of chronic intermittent epigastric pain. a gastroscopy demonstrates a 2cm pre-pyloric ulcer. biopsy of the ulcer yields no malignant tissue. after a 6w trial of medical therapy, the ulcer is unchanged. which of the following is the best next step in his management?

a. repeat trial of medical therapy
b. local excision of the ulcer
c. highly selective vagotomy
d. partial gastrectomy with vagotomy and billroth I reconstruction
e. vagotomy and pyloroplasty

A

D

1) triple therapy
2) vagotomy + distal gastrectomy with gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II)

indications for surgical intervention

  • hemorrhage, perforation
  • persistent ulcer after medical therapy
  • inability to r/out a malignancy
  • ulcers associated with acid hypersecretion
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15
Q

45yo man was discovered to have a hepatic flexure colon cancer during a colonoscopy for anemia requiring transfusions. upon exploration fhis abdomen in the OR, an unexpected discontinuous 3cm metastasis is discovered in the edge of the R lobe of the liver. preop, the pt was counseled of this possibility and the surgical options which of the following is the most appropriate management of this pt?

a. a diverting ileostomy should be performed and further imaging obtatined
b. R hemicolectomy
c. R hemicolectomy with local resection of the liver metastasis
d. closure of the abdomen followed by chemotherapy
e. R hemicolectomy with postop radiation therapy to the liver.

A

C

don’t surgically treat metastatic colon cancer, unless it’s a single lesion that easily resectable

5% of CRC are associated with resectable hepatic metastases.

radiation doesn’t do much for colon cancer or hepatic metastases

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16
Q

42yo man with no hx of use of NSAIDs presents with recurrent gastritis. the pt was diagnosed and treated for Helicobacter pylori 6mo ago. which of the following tests provides the least invasive method to document eradication of the infection?

a. serology testing for H pylori
b. carbon-labeled urea breath test
c. rapid urease assay
d. histologic evaluation of gastric mucosa
e. culturing of gastric mucosa

A

B

or stool antigen test

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17
Q

22yo college student notices a bulge in his R groin. it is accentuated with coughing but is easily reducible. which of the following hernias follows the path of spermatic cord within the cremaster muscle?

a. femoral
b. direct inguinal
c. indirect inguinal
d. spigelian
e. interparietal

A

C

direct inguinal = medial to the inferior epigastric vessels
indirect inguinal = lateral to the inferior epigastric vessels

most likely to be an indirect inguinal hernia

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18
Q

80yo man with hx of symptomatic cholelithiasis presents with signs & sxs of a SBO. which of the following findings would provide the most help in ascertaining the diagnosis?

a. coffee grounds aspirate from the stomach
b. pneumobilia
c. leuk count of 40,000
d. pH of 7.5, PCO2 of 50kPa and paradocially acid urine
e. palpable mass in the pelvis

A

B

gallstone that dug into the duodenom –> now causing SBO

pneumobilia = air in biliary tract –> biliary enteric fistula = gallstone ileus

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19
Q

42yo man has bouts of intermittent crampy abdominal pain and rectal bleeding. colonoscopy is performed and demonstrates multiple hamartomatous polyps. the pt is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy. which of the following is the most likely diagnosis?

a. ulcerative colitis
b. villous adenomas
c. familial polyposis
d. peutz-jeghers syndrome
e. crohn colitis

A

D

hamartomas - not cancer

tx = polypectomy

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20
Q

70yo woman has N&V, abdominal distension, and episodic crampy midabdominal pain. she has no hx of previous surgery but has a long hx of cholelithiasis for which she has refused surgery. her abdominal radiograph reveals a spherical density in the RLQ. which of the following is the definitive treatment for this pt’s bowel obstruction?

a. ileocolectomy
b. cholecystectomy
c. ileotomy and extraction
d. NG tube decompression
e. IV antibiotics

A

C

gallstone ileus –> erosion of a stone from the gallbladder inot the duodenum

AXR
- SBO & air in biliary tract (pneumobilia)

tx = ileotomy, removal of stone, and cholecystectomy if safe

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21
Q

53yo man presents to the ED with LLQ pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7cmx8cm rim-enhancing fluid collection int he pelvis. after percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. he returns as an outpatient to clinic 1mo later. he undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. which of the following is the most appropriate next step in this pt’s management

a. expectant management with sigmoid resection if sxs recur
b. cystoscopy to evaluate for a fistula
c. sigmoid resection with end colostomy and rectal pouch (Hartmann procedure)
d. sigmoid resection with primary anastomosis
e. long-term suppressive antibiotic therapy

A

D

indications for surgical intervention of diveriticular disease

  • hemorrhage d/t diverticulosis
  • recurrent episodes of diverticulitis
  • intractability to medical therapy
  • complicated diverticulitis (including abscess, fistula, perforation)

tx

  • ABSCESS + diverticulitis –> resection of afffected colon + primary anastomosis
  • PERFORATED diveriticulitis –> Hartmann = sigmoid resection with end colostomy & rectal pouch
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22
Q

29yo woman complains of postprandial RUQ pain and fatty food intolerance. US examination reveals no evidence of gallstones or sludge. upper endoscopy is normal, and all of her LFTs are within normal limits. which of the following represents the best management option?

a. avoidance of fatty foods and reexamination in 6mo.
b. US examination should be repeated immediately since the false -neg rate for US in detecting gallstones is 10% to 15%
c. treatment with ursodeoxycholic acid
d. CCK-HIDA scan should be performed to evaluate for biliary dyskinesia
e. laparoscopic cholecystectomy for acalculous cholecystitis

A

D

suspected cholecystitis

  • RUQ US = thickened gallbadder, gallstone, fluid present in gallbladder
  • HIDA = biliary dyskinesia. CCK helps stimulate gallbladder contraction
    • -> biliary dyskinesia = gallbladder ejection fraction of <35% at 20min
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23
Q

46yo asymptomatic woman is incidentally found to have a 5mm polyp and no stones in her gallbladder on US. which of the following is the best management option?

a. aspiration of the gallbladder with cytologic examination of the bile.
b. observation with repeat US examinations to evaluate for increase in polyp size
c. laparoscopic cholecystectomy
d. open cholecystectomy with frozen section
e. en bloc resection of the gallbladder, wedge resection of the liver, and portal lymphadenectomy

A

B

gallbladder polyp ==> concerns of gallstone carcinoma

only with evidence of invasion would you do resection –> up to resection of other parts of biliary tract

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24
Q

48yo woman develops pain in the RLQ while playing tennis. the pain progresss and the pt presents to the ED later that day with a low grade fever, a WBC count of 13,000 and complaints of anorexia and nausea as well as persistent, sharp pain of the RLQ. on exam, she is tender in the RLQ with muscular spasm, and there is suggestion of a mass effect. a US is ordered and shows an apparent mass int he abdominal wall. which of the following is the most likely diagnosis?

a. acute appendicitis
b. cecal carcinoma
c. hematoma of the rectus sheath
d. torsion of an ovarian cyst
e. cholecystitis

A

C

hematoma of rectus sheath RFs

  • elderly
  • hx of trauma
  • sudden muscular exertion
  • anticoagulation

sxs = sharp, sudden pain. Abdominal mass that does not change with contractiono f rectus muscles

dx = US, CT showing mass within rectus sheath

tx

  • conservative; wait & watch
  • if bleeding & severe pain –> surgical evacuation of hematoma & ligation of bleeding vessels

appendix would be retroperitoneal

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25
Q

32yo alcoholic man, recently emigrates from Mexico, presents with RUQ pain and fevers for 2w. CT scan of the abdomen demonstrates a non-rim-enhancing fluid collection in the periphery of the R lobe of the liver. the pt’s serology is positive for Antibodies for Entamoeba histolytica. which of the following is the best initial management option for this pt?

a. treatment with antiamebic drugs
b. percutaneous drainage of the fluid collection
c. marsupialization of the fluid collection
d. surgical drainage of the fluid collection
e. liver resection

A

A

1) metronidazole
2) laparotomy to evaluate abscess

if not amebic liver absces (ex. pyogenic liver abscess)
–> percutaneous catheer drainage & Abx against GN and anaerobics (E. coli, Klebsiella, bacteroids, enetercoccus, anaerobic strep).

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26
Q

45 yo executive experiences increasingly painful retroseernal heartburn, esp at night. he has been chewing antacid tablets. an esophagogrram shows a hiatal hernia. in determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality?

a. barium swallow with cinefluoroscopy during Valsalva maneuver
b. flexible endoscopy
c. 24h monitoring of esophageal pH
d. measurement of the size of the hernia on upper GI series
e. assessment of the pt’s smoking & drinking hx

A

B

Dx

  • endoscopy –> to evaluate GERD & r/out other diseases
  • manometric / pH studies for persistent esophagitis under medical therapy –> to evaluate surgical treatment

Tx

  • medical therapy to prevent complications
  • surgery if have esophagitis or esophgeal stenosis.
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27
Q

22yo woman is seen in a surgery clinic for a bulge in the R groin. she denies pain and is able to make the bulge disappear by lying down and putting steady pressure on the bulge. she has never experienced N/V. on exam, she has a reducible hernia below the inguinal ligament. which of the following is the most appropriate management of this pt?

a. observation for now and f/up in surgery clinic in 6mo.
b. observation for now and f/up in surgery clinic if she develops further sxs
c. elective surgical repair of hernia
d. emergent surgical repair of hernia
e. emergent surgical repair of hernia with exploratory laparotomy to evaluate the small bowel.

A

C

IF DIRECT/INDIRET hernia = no evidence of incarcerated bowel –> so only do surgery if sxs

FEMORAL HERNIA (below level of inguinal ligament)= high risk of incarceration. not emergent b/c no sxs, but should fix it.

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28
Q

22yo woman presents with painful fluctuant mass in the midline between the gluteal folds. she denies pain on rectal examination. which of the following is the most likely diagnosis?

a. pilonidal abscess
b. perianal abscess
c. perirectal abscess
d. fistula in ano
e. anal fissure

A

A

definitely an abscess

a. pilonidal abscess = painful fluctuant mass extending from midline & located b/w gluteal clefs
b. perianal abscess = closer to the anus; very painful on examination
c. perirectal abscess = closer to the anus; very painful on examination
d. fistula in ano = chronically draining tract in perianal region; can become pluged & become a perianal / perirectal abscess
e. anal fissure = linear ulcer along anal canal; not an abscess

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29
Q

72yo man s/p post-coronary artery bypass graft (CABG) 5y ago presents with hematochezia, abdominal pain, and fevers. colonoscopy reveals patches of dusky-appearing mucosa at the splenic flexure without active bleeding. which of the following is the most appropriate management of this pt?

a. angiography with administration of intra-arterial papaverine
b. emergent laparotomy with L hemicolectomy and transverse colostomy
c. aortomesenteric bypass
d. exploratory laparotomy with thrombectomy of the inferior mesenteric artery
e. expectant management

A

E. IV fluids (LOTS), bowel rest, supportive care

ischemic bowel syndrome

the bowel is NOT dead (unlikel acute mesenteric ischemia of the small intestine –> requiring emergent intervention)

indications for treatment of ischemic colitis

  • full-thickness necrosis
  • perforation
  • refractory bleeding
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30
Q

62yo man has been diagnosed with endoscopic biopsy as having a sigmoid colon cancer. he is otherwise healthy and presents to your office for preoperative consultation. he asks a number of questions regarding removal of a portion of his colon. which of the following is most likely to occur after a colon resection?

a. the majority (>50%) of normally formed feces will comprise solid material
b. pts who undergo major colon resections suffer little long-term change in their bowel habits following operation
c. Na, K, Cl, and HCO3 will be absorbed by the colonic epithelium by an active transport process
d. the remaining colon will absorb less water
e. the remaining colon will absorb long-chain FAs that result from bacterial breakdown of lipids.

A

B

little long-term change after resection of large portions of bowel d/t reseve capacity fo colon for water absorption

R colon = more water, salt (by actie transport), with `passive excretionof K.

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31
Q

39yo woman with no significant PMH and whose only medication is OCPs presents to the emergency room with RUQ pain. CT scan demonstrates a 6cm hepatic adenoma in the R lobe of the liver. which of the following describes the definitive treatment of this lesion

a. cessation of OCPs and serial CT scans
b. intra-arterial embolization fo the hepatic adenoma
c. embolization of the R portal vein
d. resection of the hepatic adenoma
e. systemic chemotherapy

A

D.

hepatic adenoma
RF = OCPs
tx
1) <4cm –> watch for growth and/or bleeding (they bleed like stink)
2) >4cm –> increase risk of rupture with hemorrhage

Complications

  • hemorrhage
  • malignant transformation into HCC
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32
Q

43yo man without sxs is incidentally noted on CT scan to have a 4cm lesion in the periphery of the L lobe of the liver. the lesion enhances on the arterial phase of the CT scan and has a central scar suggestive of focal nodular hyperplasia (FNH). which of the following is the recommended treatment of this lesion?

a. no further treatment is necessary
b. wedge resection of the lesion
c. formal L hepatectomy
d. intra-arterial emoblization of the lesion
e. radiofrequency ablation of the liver lesion

A

A

do nada

rarely symptomatic
no associated risk of malignant degeneration / rupture with hemorrhage

FSH = “hot” lesion
hepatic adenoma = “cold” lesion

33
Q

57yo previously acoholic man with a hx of chronic pancreatitis presents with hematemesis. endoscopy reveals isolated gastric varices in the abscess of esophgeal varices. his LFTs are normal and he has stigmata of end-stage liver disease. US demonstrates normal protal flow but a thrombosed splenic vein. he undergoes banding, which is intiially successful, but he subsequently rebleeds during the same hospitalization. attempts to control the bleeding endoscopically are unsuccessful. which of the following is the most appropriate next step in management?

a. transjugular intrahepatic portosystemic shunt
b. surgical portocaval shunt
c. surgical mesocaval shunt
d. splenectomy
e. placement of a sengstaken-blakemore tube

A

D

1) octreotide = to decrease spelnic flow
2) sengstaken-blakemore tube = balloon for hemostasis
3) splenectomy –> for thrombosis, and sequelae of complicated esophageal/gastric varices (with acute hemorrhage) d/t portal HTN

tx
1) fluid resuscitation = isotonic crystalloids + blood transfusion
2) octreotide/vasopressin –> to decrease splanchnic blood flow
+ nitroglycerin –> for coronary vasoconstrictive effects
3) sclerotherapy
4) endoscopy + banding
5) balloon tamponade (s/e = aspiration, asphyxiation, ulceration, rebleeding)

when hemodynamically stable
- B-blocker –> prevent recurrent variceal bleeding

34
Q

a previously healthy 15yo boy is brought to the ED with complains of about 12h of progressive anorexia, nausea & pain of the RLQ. on exam, he is found to have a rectal temp of 38.2C (100.7F) and direct and rebound abdominal tenderness localizing to McBurney point as well as involuntary guarding in the RLQ. at operation through a McBurney type incision, the appendix and cecum are found to be normal, but the surgeon is impressed by the marked edema of the terminal ileum, which also has an overlying fibrinopurulent exudate. which of the following is the most appropriate next step.

a. close the abdomen after culturing the exudate
b. perform a standard appendectomy
c. resect the involved terminal ileum
d. perform a ileocolic resection
e. perform a ileocostomy to bypass the inovolved terminal ileum

A

B

edema and abscess –> likely IBD / Crohns. Abscess

sxs of regional enteritis (IBD) –> chronic & slowly progressive course with intermittent symptom-free periods
- anorexia, abdominal pain, diarrhea, fever, weight loss

indications for appendectomy

  • appendicitis
  • disease of terminal ileum, AS LONG as no involvemnet of cecum at the base of the appendix

indications for further resection
- further enteritis around cecum

35
Q

32yo woman undergoes a cholecystectomy for acute cholecystitis and is discharged home on the POD6. she returns to the clinic 8o after the operation for a routine visit, and is noted by the surgeon to be jaundiced. lab values on readmission show total bili 5.6, direct bili 4.8, alk phos 250, SGOT 52, and SGPT 51. US shows dilated intrahepatic ducts. the pt undergoes transhepatic cholangiogram showing very thin common bile duct (biliary stricture).

a. choledochoplasty with insertion of a T tube
b. end-to-end choledochocholedocal anastaomosis
c. roux-en-Y hepaticojejunostomy
d. percutaneous transhepatic dilatation
e. choledochoduodenostomy

A

C.

resect / bypass

iatrogenic injury of the CBD, usuallly in proximal portion of extrahepatic biliary system.

b/c it’s proximal –> end-to-side choedochojejunostomy (Roux-en-Y) performed over a stent.

primary repair would leaad to recurrent stricture.

36
Q

after complete removal of a sessile polyp of 2cmx1.5cm found 1 finger length above the anal mucocutaneous margin, the pathologist reports it to have been a villous adenoma that contained CIS. which of the following is the most appropriate next step in management?

a. reexcision of the biopsy site with wider margins
b. abdominaoperineal rectosigmoid resection
c. anterior resection of the rectum
d. external radiation therapy to the rectum
e. no further therapy

A

E

1 finger length above the anal mucoutaneous margin

no further treatment indicated if:

  • no vascular / lymphatic invasion present
  • adequate negative marign
  • cancer is not poorly differentiated.
37
Q

62yo man has been noticing progressive difficulty swallowing, first solid food and now liquids as well. a barium study shows a ragged narrowing just above the carinal level. endoscopic biopsy confirms SCC. which of the following provides the most accurate information regarding the T stage of an esophgeal carcinoma

a. CT
b. PET
c. MRI
d. endoscopic US
e. bronchoscopy

A

D

see how large it is & what else it involves

38
Q

53yo woman with a hx of vagotomy and antrectomy with billroth II reconstruction for peptic ulcer disease with recurrent abdominal pain. an EGD demonstrates that ulcer and serum gastrin levels are >1000 on 3 separate determinations (nml = 40-150). which of the following is the best test for confirming a diagnosis of gastrinoma?

a. 24h urine gastrin level
b. a secretin stimulation test
c. a serum glucagon level
d. a 24h urine secretin level
e. a serum glucose : insulin ratio

A

B

vagotomy - must have been a type 2 / 3 –> with acid hypersecretion

high levels of secretin –> should decrease gastrin (inhibition of gastric acid)

but if gastrin is high ==> independent of negative feedback - then must be a gastrinoma

39
Q

52yo man with a family hx of MEN1 has an elevated gastrin level and is suspected to have a gastrinoma. which of the following is the most likely location for his tumor?

a. fundus of stomach
b. antrum of stomach
c. within the triangle formed by the junction of the 2nd and 3rd portion fo the duodenum, the junction of the neck and; body of the pancreas, and the junction of the cystic and CBD
d. tail of the pancreas
e. within the triangle formed by the inferior edge of the liver, the cystic duct, and the common hepatic duct

A

C

MEN1 = pancreas, parathyroid, pituitary

must involve the pancreas and other gut

90% of gastrinomas are located within the gastrinoma triangle

  • junciton of 2nd & 3rd portions of duodenum
  • junction of neck and body of pancreas
  • junction of cystic and CBD
40
Q

73yo woman presents to the ED complaining of severe epigastric pain radiating to her back, N&V. CT scan of the abdomen demonstrates inflammation and edema of the pancreas. a RUQ US demonstrates the presence of gallstones of the gallbladder. which of the following is an important prognostic sign in acute pancreatitis according to Ranson’s criteria

a. amylase level
b. age
c. Tbili level
d. albumin level
e. lipase level

A

B

gallstone causing pancreatitis

Ranson’s criteria for severity of disease - for prediction of mortality

<2 criteria = 0% mortality
3-5 criteria = 10-20% mortality
>6 = >50% mortality

SET #1

  • age
  • WBC count
  • LDH
  • AST
  • glucose

SET #2

  • decrease in Hct
  • BUN
  • serum Ca
  • base deficit
  • estimated fluid sequestration.
41
Q

55yo man who is extremely obese reports weakness, sweating, tachycardia, confusion, and HA whenever he fasts for more than a few hours. he has prompt relief of sxs when he eats. Lab examination reveals an inappropriately high level of serum insulin during the episodes of fasting. which of the following is the most appropriate treatment for his condition?

a. diet modification to include frequent meals
b. long-acting somatostatin analogue octreotide
c. simple excision of the tumor
d. total pancreatectomy
e. chemotherapy and raidiation

A

C

insulinoma - likely in the pancreas.

== > surgical removal

Whipple triad (insulinoma)

1) attacks precipitated by fasting or exertion
2) fasting blood glucose conc. <50
3) sxs relieved by oral / IV glucose administration

42
Q

57yo woman sees blood on the toilet paper. her doctor notes the presence of an excoriated bleeding 2.8cm mass at the anus. biopsy confirms the clinical suspicion of anal cancer. in planning the management of a 2.8cm epidermoid carcinoma of the anus, which of the following is the best initial management strategy?

a. abdominoperineal resection
b. wide local resection with b/l inguinal node dissection
c. local radiation therapy
d. systemic chemotherapy
e. combined radiation therapy and; chemotherapy

A

E. Nigro protocol = external radiation + synchronous chemo (fluorouracil & mitomycin)

lower rectal vessels

should at least do a sentinel node
–> epidermoid cancers of anal canal metastasize to inguinal nodes & perirectal / mesenteric nodes

radical procedure (WLE + inguinal node dissection) for treatment failure & recurrence

43
Q

80yo man is admitted to teh hospital complaining of nausea, abdominal pain, distention & diarrhea. a cautiously performed transanal contrast study reveals an apple-core configuration in the rectosigmoid area. which of the following is the most appropriate next step in his management?

a. colonoscopic decompression & rectal tube placement
b. saline enemas & digital disimpaction of fecal matter from the rectum
c. colon resection and proximal colostomy
d. oral administration of metronidazole & checking a C. diff titer
e. evaluation of an electrocardiogram & obtaining an angiogram to evaluate for colonic mesenteric ischemia.

A

C

colon cancer.

1) fluid resuscitation
2) surgical management o fmechanical obstruction = resection + proximal colostomy

44
Q

46yo woman who was recently diagnosed with Crohn disease asks about the need for surgery. which of the following findings would be an indication for an immediate exploratory laparotomy?

a. intestinal obstruction
b. enterovesical fistula
c. ileum-ascending colon fistula
d. enterovaginal fistula
e. free perforation

A

E

definitely the most emergent reason.

45
Q

50yo man presents to the ED with a 6h hx of excruciating abdominal pain and distention. the abdominal film shows very dilated loops of large bowel and multiple air fluid levels.

a. emergent celiotomy
b. upper GI series with SB follow-through
c. CT scan of the abdomen
d. barium enema
e. sigmoidoscopy

A

E. AXR = showing likely cecal / sigmoid volvulus that is causing backup into the large colon

SB follow through only indicated for SBO.

46
Q

a septuagenerian woman undergoes an uncomplicated resection of an abdominal aneurysm. 4d after surgery, the pt presents with sudden onset of abdominal pain and distention. an abdominal radiograph demonstrates an air-filled, kidney bean-shaped structure in the LUQ. which of the following is the most appropriate management at this time?

a. decompression of the large bowel via colonoscopy
b. placement of the NGT and administration of low-dose cholinergic drugs
c. administration of a gentle saline enema and encouragement of ambulation
d. operative decompression with transverse colostomy
e. R hemicolectomy

A

E

cecal volvulus (R sided) = axial rotation of terminal ileum, cecum, and ascending colon w/ twisting of associated mesentery

tx = R hemicolectomy

1) immedate surgery to correct volvulus and prevent ischemia
2) R hemicolectomy to remove dead tissue

Operative decompression of transverse colon (IMA) would not decompress cecum / provide detorsion / allow restoration of adequate blood supply to R colon (SMA)

47
Q

45yo man presents with RUQ abdominal pain and fever. CT scan shows a large, calcified cystic mass in the R lobe of the liver. echinoccus is suggested by the CT findings. which of the following is hte most appropriate management of echinococcal liver cysts?

a. percutaneous atheter drainage
b. medical tx with abendazole
c. medical tx with steroids
d. medical tx with metronidazole
e. total pericystectomy

A

E

1) percutaneous drainage –> surgical resection , enucleation , evacuation of the cysts.
2) 0.5% silver nitrate / hypertonic saline into cyst during surgery
3) steroids, epinephrine during surgery for anaphylactic rxn
Mebendazole / abendzaole to shrink the cysts.

48
Q

28yo woman who is 15w pregnant has new onset of N&V, R-sided abdominal pain. she has been free of nausea since early in her 1st trimester. the pain has become worse over the past 6h. which of the following is the most nonobstetric surgical disease of the abdomen during pregnancy

a. appendicitis
b. cholecystitis
c. pancreatitis
d. intestinal obstruction
e. acute fatty liver of pregnancy

A

A –> 1/1700 pregnancies

most prevalent extrauterine indication for laparotomy in pregnancy

by 20w gestation, the appendix often lies at the level of the umbilicus & more lateral than usual

complications = appendiceal perforation greatly increases the chance of premature labor & fetal mortality (20%)

1) appendicitis
2) biliary tract disease = biliary colic, cholecystitis
3) pancreatitis, intestinal obstrution, acute fatty liver of pregnancy

49
Q

56yo woman has nonspecific complaints that include an abnormal sensation when swallowing. an esophagram is obtained. which of the following is the most likely to require surgical correction.

a. large sliding esophageal hiatal hernia
b. paraesophageal hiatal hernia
c. traction diverticulum of eesophagus
d. schatzki ring of distal esophagus
e. esophageal web

A

B

hole in diaphragm caused by normal respiration creating negative pressure in thoracic cavity –> leading to abdominal viscera

SLIDING HERNIA = most common; not a cause of surgical concern
tx = expectant management

PARAESOPHAGEAL HERNIA = concerns of vascular compromise / obstructive displacement of hollow viscera –> concerns for strangulation, obstruction
tx = surgical repair

expectant management with Schatzki ring / esophgeal web

50
Q

65yo man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. the following abdominal radiograph is obtained, showing VERY dilated loops of large bowel, esp. on L side. which of the following is the most appropriate initial management of this pt?

a. urgent colostomy or cecostomy
b. discontinuation of anticholinergic medications & narcotics and correction fo metabolic d/o
c. digital disimpaction of fecal mass in the rectum
d. diagnostic and therapeutic colonoscopy
e. detorsion of volvulus and colopexy or resection

A

B. Ogilvie syndrome –> massive cecal & colonic dilation W/OUT mechanical obstruction (no transition point found)
“acute pseudo-obstruction”

1) DISCONTINUE ANTICHOLNERGICS, narcotics, meds that may contribute to ileus
2) strict bowel rest, with IV hydration, and correction of electrolytes

3) if >10cm and/or persistent ==> cautious endoscopic colonic decompression or use of neostigmine (increased ACh)
4) if PERFORATION ==> surgery

51
Q

48yo man prsents with jaundice, melena, and RUQ abdomian pain after undergoing a percutaneous liver biopsy. endoscopy shows blood coming from the ampulla of Vater. which of the following is the most appropriate first line of therapy for major hemobilia?

a. correction of coagulopathy, adequate biliary drainage, and close monitoring
b. transarterial embolization
c. percutaneous transhepatic biliary drainage
d. ligation of bleeding vessels
e. hepatic resection

A

B. hemobilia = blood in biliary tree.
SXS ==> Quincke triad = RUQ pain, jaundice, GI bleeding
CAUSES ==> iatrogenic injury (transhepatic choleangiogram / catheter drianage); spontaneous bleeding during anticoagulation, gallstones, parasitic infections / abscesses, neoplastic lesions

DX = angiography, endoscopy

TX

1) MAJOR = transarterial embolization (95%)
2) MINOR = correction of coagulopathy

52
Q

30yo female pt who presents with diarrhea and abdominal discomfort is found at colonscopy to have colitis confined to the transverse and descending colon. a biopsy is performed. which of the following is a finding consistent with this pt’s diagnosis?

a. the inflammatory process is confined to the mucosa and the submucosa
b. the inflammatory rxn is likely to be continuous
c. superficial as opposed to linear ulcerations can be expected
d. noncaseating granulomas can be expected in up to 50% of pts
e. microabscesses within crypts are common.

A

D. Crohns

Ulcerative colitis

  • continuous (+rectum)
  • crypts
  • mucosa / submucosa
  • superficial ulcerations
  • abscesses
  • toxic megacolon
  • dysplasia or carcinoma

Crohns

  • noncaseating granulomas
  • skipped lesions
  • linear ulcerations
  • deeper (transmural)
  • fistulas
  • perforation
  • fistulas between the colon and segments of intestine, bladder, vagina, urethra, and skin
53
Q

24yo man presents to the ED with abdominal pain and fever. CT scan of the abdomen reveals inflammation of the colon. he is referred to a gastroenterologist to be evaluated for IBD (Crohn dz v. ulcerative colitis). which of the following indications for surgery is more prevalent in pts with Crohn disease?

a. toxic megacolon
b. massive bleeding
c. fistulas between the colon and segments of intestine, bladder, vagina, urethra, and skin
d. intractable disease
e. dysplasia or carcinoma

A

C

Ulcerative colitis

  • continuous (+rectum)
  • crypts
  • mucosa / submucosa
  • superficial ulcerations
  • abscesses
  • toxic megacolon
  • dysplasia or carcinoma

Crohns

  • noncaseating granulomas
  • skipped lesions
  • linear ulcerations
  • deeper (transmural)
  • fistulas
  • perforation
  • fistulas between the colon and segments of intestine, bladder, vagina, urethra, and skin
54
Q

an upper GI series is performed on a 71yo woman who presented with several months of chest pain that occurs when she is eating. the film shows the barium swallow going down the esophagus and then spilling out to the left.
investigation reveals a microcytic anemia and erosive gastritis on upper endoscopy. which of the following is the most appropriate initial management of this pt?
a. cessation of smoking, decreased caffeine intake, and avoidance of large meals before lying down.
b. antacid
c. histamine-2 blocker
d. PPI
e. surgical treatment

A

E

paraesophageal hernia ==> SURGERY

complications
- bleeding, ulceration, obstruction, necrosis of stomach wall, and perofration

55
Q

54yo man complains that his eyes are yellow. his bilirubin is elevated. his exam is unremarkable. a CT of the abdomen shows a small mass in the head of the pancreas encasing the superior mesenteric artery. cytology from the ERCP is positive for cancer. which of the following is the most appropriate treatment for the pt?

a. pancreaticoduodenectomy
b. pancreaticoduodenectomy + reconstruction of the SMA
c. total pancreatectomy
d. total pancreatectomy+reconstruction of the SMA
e. chemoradiation therapy

A

E

encasing the SMA (T4) - unresectable…

tx = chemotherapy and radiation

CT changes of unresectability

  • encasing SMA
  • extension beyond pancreatic capsule & into the retroperitoneum
  • involvement of neural or
56
Q

28yo woman presents with hematochezia. she is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the R colon and old blood coming form above the ileocecal valve. which of the following is the test of choice in this pt?

a. angiography
b. SB enteroclysis
c. CT of the abdomen
d. Tc-99m pertechnetate scan
e. SB endoscopy

A

D

Bleeding from the SB, but not able to be found on endoscopy.

Most common cause of SB bleeding in pts <30yo ==> Meckel diverticulum, with ectopic gastric mucosa –> acid secretion –> SB ulceration

Tc-99m pertechnetate scan ==> for ectopic gastric mucosa in SB (usually ileum)

57
Q

32 yo woman undergoes an uncomplicated appendectomy for acute appendicitis. the pathology report notes the presence of a 1cm carcinoid tumor in the tip of the appendix. which of the following is the most appropriate management of this pt?

a. R hemicolectomy
b. R hemicolectomy and chemotherapy
c. chemotherapy only
d. radiation only
e. no furhter treatment

A

E

carcinoids are easily resectable. and have good outcomes.

Carcinoid tumor <1cm ==> simple appendectomy
Carcinoid tumor >2cm ==> R hemicolectomy (decreases locoregional recurrence)
tumor @ base of appendix / invading mesentery ==> R hemicolectomy

58
Q

58yo man presents with a bulge in his R groin associated with mild discomfort. on exam, the bulge is easily reducible and does not descend into the scrotum. which of the following changes is most concerning for possible strangulation requiring emergent repair of the hernia?

a. increase in size of the hernia
b. descent of the hernia into the scrotum
c. development of a 2nd hernia in the L groin
d. inability to reduce hernia
e. worsening pain over the hernia with walking

A

D. esp. when was previously reversible.

hernia itself can be irritating - but pain is not the bad one.

59
Q

35yo woman presents with abdominal pain and jaundice. subsequent ERCP reveals the congenital cystic anomaly of her biliary system, where there seems to be a very large CBD
which of the following is the most appropriate treatment?
a. cholecystectomy with resection of the extrahepatic biliary tract and Roux-en-Y hepaticojejunostomy
b. internal drainage via choledochoduodenostomy
c. internal drainage via choledochojejunostomy
d. percutaneous transhepatic biliary drainage
e. liver transplantation

A

A. congenital cystic dilations of extrahepatic biliary ducts.

TX = complete resection of cyst + cholecystectomy + roux-en-Y hepaticojejunostomy

Complications
- malignant changes in choledochal cysts

if dilated INTRAHEPATIC biliary cyst = Caroli disease
T = liver transplantation

60
Q

36yo man is in your ICU on mechanical ventilation following thoracotomy for a 24h old esophageal perforation. his WBC is markedly elevated, and he is febrile, hypotensive, and coagulopathic. his NGT fills with blood and continues to bleed. which of the following findings on upper endoscopy would be most suspicious for stress gastritis?

a. multiple, shallow lesions with discrete areas of erythema along with focal hemorrhage in the antrum.
b. multiple shallow lesions with discrete areas of erythema along with focal hemorrhage in the fundus
c. multiple deep ulcerations extending into and thru the muscularis mucosa in the antrum
d. multiple deep ulcerations extending into and thru the muscularis mucosa in the fundus
e. single deep ulceration extending into and thru the muscularis mucosa in the antrum

A

B

acute gastric / duodenal erosive lesions ==> DECREASED SPLANCHNIC BLOOD FLOW; ISCHEMIC DAMAGE TO THE MUCOSA

  • superficial
  • multiple
  • body, fundus (NOT antrum)

chronic benign gastric ulcers ==> INCREASED GASTRIC SECRETION
- lesser curvature, antrum

61
Q

35yo man presents with RUQ pain, fever, jaundice, and shaking chills. US of the abdomen demonstrates gallstones, normal gallbladder wall thickness, and CBD of 1.0cm. the pt is admitted to the hospital and given IV fluids and antibiotics. he continues to be febrile with increasing WBCs. which of the following is the most appropriate next step in this pt’s management?

a. ERCP
b. placement of a cholecystostomy tube
c. laparoscopic cholecystectomy
d. open cholecystectomy
e. emergent operation and decompression of the CBD with T tubr

A

A

nml CBD = 30mm (for his age)

not chronic

dilated CBD –> likely stone in the CBD. cholecystectomy won’t necessarily fix it

charcot’s triad
- fever, jaundice, ruq pain.

62
Q

88yo man with a hx of end stage renal fialure, severe coronary artery disease, and brain mets from lung cancer presents with acute cholecystitis. his family wants “everything done.” which of the following is the best management option in this pt?

a. tube cholecystostomy
b. open cholecystectomy
c. . laparoscopic cholecystectomy
d. IV abx followed by elective cholecystectomy
e. lithotripsy followed by long-term bile acid therapy.

A

A

acute cholecystitis is not an absolute indication foor cholecystectomy

Tube cholecystostomy ==> for high-risk, critically ill pts with multisystem disease + cholecystitis

Open/lapy ==> can be done on outpatient basis

63
Q

after a weekend drinking binge, a 45yo man presents to the hospital with abdominal pain, nausea & vomiting. on exam, the pt is noted to have tenderness to palpation in the epigastrium. lab tests reveal an amylase of 25,000 (nml <180). the pt is medically managed and sent home after 1w. CT scan done 4w later shows fluid collection next to the pancreas. currently the pt is asymptomatic. which of the following is the most appropriate inital management in this pt?

a. distal pancreatectomy
b. percutaneous catheter drainage
c. endoscopic drainage
d. surgical drainage
e. no intervention is warranted at this time.

A

E

likely peripancreatic “pseudo”abscess

b/c it can go away, usually within 6w.

Complications

  • gastric outlet obstruction
  • extrahepatic biliary obstruction
  • spontanoeus rupture & hemorrhage

if persists >6w

  • -> excision
  • -> external drainage
  • internal drainage into GI ==> usually into stomach or Roux-en-Y limb of jejunum

NOT PERCUTNAOUS CATHETER DRAINAGE –> b/c it can lead to catheter-induced infection & persistent pancreatic fistula.

64
Q

54yo man presents with sudden onset of massive, painless, recurrent hematemesis. upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. endoscopic modalities fail to stop the bleeding. which of the following is the most appropriate surgical management of this pt?

a. wedge resection of the lesion
b. wedge resection of the lesion with truncal vagotomy
c. wedge resection of the lesion with highly selective vagotomy
d. wedge resection of the lesion with truncal vagotomy and antrectomy
e. subtotal gastrectomy

A

A. with embolization of the artery
—> dieulafoy lesion = located within 6cm distal to GE junction
= abnormally large submucosal artery that protrudes through a small, solitary mucosal defect –> can bleed spontaneously & massively

proximal part = not very acid-producing

Tx = gastrotomy + wedge resection of lesion

65
Q

during an appendectomy for acute appendicitis, a 4cm mass is found in the midportion of the appendix. frozen section reveals this lesion to be a carcinoid tumor. which of the following is the most appropriate management of this pt?

a. appendectomy
b. appendectomy , then colonoscopy
c. appendectomy, then PET scan
d. R hemicolectomy
e. total proctocolectomy

A

D

1-2cm ==> these have good prognosis; only need to resect appendix

> 2cm (esp. if at base of appendix) ==> R hemicolectomy

66
Q

45yo man is examined for a yearly executive physical. a mass is palpated in the rectum, and a biopsy suggests carcinoid. which of the following findings is most likely to be associated with the carcinoid syndrome?

a. tumor <2cm
b. tumor < 2cm + ulceration
c. tumor >2cm
d. involvement of regional lymph nodes
e. hepatic metastases

A

C

rectal carcinoids

  • slow growing
  • locally invasive
  • 15% chance of mets
  • systemic sxs of carcinoid syndrome ONLY WITH HEPATIC METASTASIS

<2cm –> low malignant potential

tx

1) wide local transanal resection (+ muscle layer)
2) MORE AGGRESSIVE = abdominoperineal / low anterior resection

67
Q

US is performed on a pt with RUQ pain. it demonstrates a large gallstone in the cystic duct but also a polypoid mass in the fundus. which of the following is an indication of cholecystectomy for a polypoid gallbladder lesion?

a. size >0.5cm
b. presence of clinical sxs
c. pt age of >25y
d. presence of multiple small lesions
e. absence of shadowing on US

A

B

symptomatic lesions should be removed regardless of size

gallbladder polyps

  • usually in 30s-50s
  • DX = US
  • 90% pseudotumors (BENIGN)
  • 10% adenomas (BENIGN)

malignant

  • solitary , >1.0cm, more common in >50yo.
  • increased incidence if lesions are associated with gallstones.

Tx

  • SYMPTOMATIC = cholecystectomy
  • ASYMPTOMATIC = follow with US (unless associated with gallstones)
68
Q

an alcoholic man has been suffering excruciating pain from chronic pancreatitis recalcitrant to analgesics and splanchnic block. a surgeon recommends pancreatectomy. a pt who has a total pancreatectomy might be expected to develop which of the following complications

a. DM and steatorrhea
b. DM and constipation
c. hypoglycemia
d. hypoglycemia dn steatorrhea
e. hypoglycemia

A

A

69
Q

45yo woman has an incidental finding of a liver mass on CT scan. MRI is suggestive of a hemangioma. which of the following is the most appropriate management strategy for this pt?

a. observation
b. discontinuous of OCPs
c. percutaneous biopsy of the lesion to confirm the diagnosis
d. resection of the hemangioma
e. liver transplantation

A

A. hepatic hemangioma = most common of all liver tumors. no evidence of malignant transformation.

OCPs associated with hepatic adenoma

70
Q

57yo woman presents with adenocarcinoma of the R colon. lab evaluation demonstrates an elevation of CEA to 123. which of the following is the most appropriate use of CEA testing in pts with colorectal cnacer?

a. as a screening test for CRC
b. to determine which pts should receive adjuvant therapy
c. to determine which pts should receive neoadjuvant therapy
d. to monitor for postop recurrence
e. to monitor for preop metastatic disease

A

D

to follow to see if the chemo is working.

obtained q3mo during the first 2y after surgery to detect early recurrence.

71
Q

61yo woman with a hx of unstable angina complains of hematemesis after retching and vomiting following a night of binge drinking. endoscopy reveals a longitudinal mucosal tear at the GE junction, which is not actively bleeding. which of the following is the next recommended step in the management of this pt?

a. angiography with embolization
b. balloon tamponade
c. exploratory laparotomy, gastrotomy and oversewing of the tear
d. systemic vasopressin infusion
e. expectant management

A

E

Mallory Weiss tear - most will stop.

RFs = cirrhotics, alcoholics

(diffdx: boerhave - when tear transmurally right through the esophagus).

tx (persistent bleeding)

1) balloon tamponade
2) endoscopic control / arterial embolism
3) surgical - gastrotomy & oversewing of the tear
4) IV & intra-arterial infusions of vasopressin (contraindicated in pts with coronary artery disease)

72
Q

select the most appropriate diagnosis for each pt
a. symptomatic cholelithiasis
b. acute cholecystitis
c. gallstone pancreatitis
d. choledocholithiasis
e. cholangitis
62yo man presents with RUQ abdominal pain and jaundice. he is afebrile with normal vital signs. on lab findings he has elevated levels of bilirubin and alk phos. US demonstrates gallstones, normal gallbladder wall thickness, no pericholecystic fluid and a CBD of 1.0cm

A

D

should be 0.6cm = large CBD

anythign >0.4cm

Charcot’s triad = jaundice, fever, RUQ pain.

73
Q

select the most appropriate diagnosis for each pt
a. symptomatic cholelithiasis
b. acute cholecystitis
c. gallstone pancreatitis
d. choledocholithiasis
e. cholangitis
36yo woman prsents with RUQ abdominal pain and jaundice. she is febrile and tachycardiac. on lab results, she has leukocytosis and elevated levels of bilirubin and alk phos. US demonstrates gallstones, normal gallbladder wall thickness, no pericholecystic fluid and a CBD of 1.0cm

A

E.

Charcot’s triad = jaundice, fever, RUQ pain.

74
Q

select the most appropriate diagnosis for each pt
a. symptomatic cholelithiasis
b. acute cholecystitis
c. gallstone pancreatitis
d. choledocholithiasis
e. cholangitis
55yo man presents with intermittent RUQ abdominal pain. each episode of pain lasts 1-2h. he is aferile with normal VS. on lab results, he has no leukocytosis and normal levels of bilirubin, alkaline phosphatase, amylase and lipase. US demonstrates gallstones, nml gallbladder wall thickness, no pericholecystic fluid, and a CBD of 3mm.

A

A

gallstones with normal sized CBD

75
Q

select the most appropriate diagnosis for each pt
a. symptomatic cholelithiasis
b. acute cholecystitis
c. gallstone pancreatitis
d. choledocholithiasis
e. cholangitis
23yo woman presents with epigastric abdominal pain and nausea. she is afebrile with normal VS. on lab results, she has no leukocytosis with normal level sof bilirubin and alk phos. the amylase and lipase are elevated. US demonstrates gallstones, normal gallbladder wall thickness, no pericholecystic fluid, and a CBD of 3mm.

A

C

76
Q

select the most appropriate surgical procedure for each pt.
a. low anterior resection
b. abdominoperineal resection
c. subtotal colectomy with end ileostomy
d. total proctocolectomy with ileo-anal J pouch
e. sigmoid resection with end colostomy (Hartmann procedure)
f. transanal excision
g. diverting colostomy
a 37 yo man with a 10hx of ulcerative colotis who has a sessile plyp 10cm from the anal verge with high-grade dysplasia.

A

D

need to take a lot of it out.
==> total proctolectomy + end ileostomy / ileoanal J-pouch anastamosis

if closer to anal verge –> low anterior resection

indications for operation in UC

  • high-grade dysplasia / carcinoma
  • toxic megacolon = fever, abd pain, marked dilation of total bowel
  • massive colonic bleeding
  • intractability to medical therapy
77
Q

select the most appropriate surgical procedure for each pt.
a. low anterior resection
b. abdominoperineal resection
c. subtotal colectomy with end ileostomy
d. total proctocolectomy with ileo-anal J pouch
e. sigmoid resection with end colostomy (Hartmann procedure)
f. transanal excision
g. diverting colostomy
60yo woman with recurrent SCC of the anus after chemoradiation

A

B

marjolin ulcer = SCC (here ofhte anus)
tx
1) chemoradiation with Nigro protocol
2) PERSISTENT DISEASE = abdomino-perineal resection (remove rectum & anus with formation of a permanent end colostomy)

78
Q

select the most appropriate surgical procedure for each pt.
a. low anterior resection
b. abdominoperineal resection
c. subtotal colectomy with end ileostomy
d. total proctocolectomy with ileo-anal J pouch
e. sigmoid resection with end colostomy (Hartmann procedure)
f. transanal excision
g. diverting colostomy
68yo woman with fecal incontinence who presents with a large fixed adenocarcinoma 3cm from the anal verge.

A

B

3cm from the anal verge

indications for abdominoperineal resection

  • marjolin ulcer of the anus
  • distal rectal cancer that involves the sphincters or are too close to obtain an adequate marin / where sphincter-sparing surgery is contraindicated (i.e. useless) d/t fecal incontinence

can also use preoperative / neoadjuvant chmo to cause distal rectal cancers to shrink –> to then allow a sphincter-sparing operation

79
Q

select the most appropriate surgical procedure for each pt.
a. low anterior resection
b. abdominoperineal resection
c. subtotal colectomy with end ileostomy
d. total proctocolectomy with ileo-anal J pouch
e. sigmoid resection with end colostomy (Hartmann procedure)
f. transanal excision
g. diverting colostomy
33yo man with a hx of Crohn disease presents with severe abdominal pain and fever. on exam, his HR is 130 , BP 105/62, and Temp 38.9C (102F). workup reveals a leukocytosis of 32,000. plain films reveal a markedly dilated large colon.

A

C

large bowel obstruction / toxic megacolon
==> subtotal colectomy with end-ileostomy