Semana 1 y 2 MTA

Question 1

A 56-year-old woman comes to the physician because of a 6-month history of difficulty swallowing food. Initially, only solid food was problematic, but liquids have also become more difficult to swallow over the last 2 months. She also reports occasional regurgitation of food when she lies down. The patient is an avid birdwatcher and returned from a 3-week trip to the Amazon rainforest 3 months ago. She has had a 3.5-kg (7.7-lb) weight loss over the past 6 months. She has not had abdominal pain, blood in her stools, or fever. She underwent an abdominal hysterectomy for fibroid uterus 6 years ago. She has smoked a pack of cigarettes daily for 25 years. Physical examination shows no abnormalities. Her hemoglobin concentration is 12.2 g/dL. A barium esophagram is shown (Birds beak). Esophageal manometry monitoring shows the lower esophageal sphincter fails to relax during swallowing. Which of the following is the most appropriate next step in management?

Answer 1

Gastroesophageal endoscopy

Gastroesophageal endoscopy is indicated in this patient to rule out malignancy (e.g., cancer of the esophagus or the gastroesophageal junction) as a cause of secondary achalasia (pseudoachalasia). Distal esophageal cancer and achalasia can present similarly, which is why it is important to maintain a high index of suspicion for esophageal cancer. Additionally, achalasia itself predisposes to esophageal cancer, although cancer is unlikely to arise within a period of just 6 months. But in this particular patient, significant weight loss and a history of smoking are findings that would support the diagnosis of esophageal cancer, making endoscopic inspection necessary.

Question 2

A previously healthy 57-year-old man comes to the emergency department because of acute retrosternal chest pain that radiates to his back. The pain started suddenly while he was having dinner. A few moments prior to the onset of the pain, he experienced discomfort when trying to eat or drink anything. On the way to the hospital, he took a sublingual nitrate tablet that he had at home, which helped relieve the pain. His pulse is 80/min, respirations are 14/min, and blood pressure is 144/88 mm Hg. Physical examination shows no abnormalities. An ECG shows a normal sinus rhythm with no ST-segment abnormalities. An esophagogram shows areas of diffuse, uncoordinated spasms in several segments along the length of the esophagus. Further evaluation is most likely to show which of the following?

Simultaneous multi-peak contractions on esophageal manometry
Multiple mucosal erosions on endoscopy
High lower esophageal sphincter pressure on esophageal manometry
Mass at the gastroesophageal junction on ultrasonography
Elevated CK-MB levels on serum studies
Significant ST-segment depression on exercise stress test
Esophageal manometry shows hypertensive contractions

Answer 2

Simultaneous multi-peak contractions on esophageal manometry

Simultaneous multi-peak contractions on esophageal manometry are the characteristic finding of DES. Repetitive nonperistaltic, nonprogressive contractions impede the progression of solid and liquid foods down the esophagus, which classically leads to dysphagia and squeezing retrosternal chest pain, as seen in this patient. Symptoms and relieving factors (nitrates) of DES can closely resemble those of cardiac pathology. Therefore, acute coronary syndrome should always be ruled out before considering a gastrointestinal disorder.

Question 3

A 62-year-old man comes to the physician because of a 5-month history of difficulty swallowing solids and liquids. He points to the middle of his sternum, saying “I feel like food is getting stuck there.” He has had a 4.5-kg (10-lb) weight loss over the past 2 months and reports that his symptoms have progressively worsened over the same period. He also reports intermittent heartburn that is worse after drinking coffee. Treatment with over-the-counter pantoprazole has been ineffective. He has not had fever, chills, or night sweats. He underwent a cholecystectomy for cholecystitis 10 years ago and partial bowel resection for complicated sigmoid diverticulitis 5 years ago. He has smoked one pack of cigarettes daily for 20 years. He is 170 cm (5 ft 7 in) tall and weighs 100 kg (220 lb); BMI is 35 kg/m2. His temperature is 36°C (96.8°F), pulse is 68/min, respirations are 18/min, and blood pressure is 150/85 mm Hg. Physical examination shows no abnormalities. Barium esophagram shows dilation of the proximal esophagus with stenosis of the gastroesophageal junction. There is contrast pooling in the lower esophagus. Which of the following is the most likely cause of this patient’s symptoms?

Premature contraction of the esophagus
Degeneration of esophageal myenteric plexus
Fibrosis of esophageal smooth muscle
Outpouching of the upper esophageal wall
Eosinophilic inflammation of the esophagus

Answer 3

Degeneration of esophageal myenteric plexus

Achalasia is caused by progressive degeneration of the esophageal myenteric plexus, resulting in dysfunctional peristalsis, increased resting pressure of the low esophageal sphincter (LES), and esophageal dilation proximal to LES. Patients usually present with a history of progressive dysphagia to both solids and liquids, as seen in this patient, and regurgitation of food. Other common findings include heartburn unresponsive to proton pump inhibitors, and weight loss. In most patients with achalasia, the etiology is unknown (primary achalasia). Secondary achalasia is caused by conditions that compromise esophageal motility, such as esophageal cancer, stomach cancer, Chagas disease, amyloidosis, and sarcoidosis. All patients with achalasia should initially undergo an upper endoscopy to exclude a malignant cause. Esophageal manometry confirms the diagnosis of achalasia.

Question 4

A 45-year-old woman comes to the physician because of a 2-year history of chest cramps after eating and progressively worsening difficulty swallowing solids and liquids. She sometimes regurgitates partially-digested foods and now mainly eats pureed meals. She has had a 4-kg (9-lb) weight loss during the past 6 months despite no change in appetite. She has no history of serious illness. Her only medication is a multivitamin. She smokes five cigarettes daily and drinks two glasses of wine on the weekends. She appears well. She is 163 cm (5 ft 4 in) tall and weighs 63 kg (140 lb); BMI is 24 kg/m2 .Vital signs are within normal limits. Physical examination shows no abnormalities. Esophageal barium swallow shows dilation of the proximal esophagus with stenosis of the gastroesophageal junction and delayed barium emptying. An upper endoscopy shows normal esophageal and gastric mucosa without evidence of mechanical obstruction. Esophageal manometry shows uncoordinated, simultaneous panesophageal pressurization with incomplete lower esophageal sphincter relaxation. Which of the following is the most appropriate next step in management?

Sublingual nitroglycerin
Pneumatic dilation
Oral omeprazole
Botulinum toxin injection
Esophageal stent placement

Answer 4

Pneumatic dilation

In patients with achalasia who have a low to average surgical risk (e.g., younger patients, no comorbidities), the most effective treatment options are pneumatic dilation, peroral endoscopic myotomy, and Heller myotomy. The goal of these treatments is to mechanically disrupt LES muscle fibers and decrease the resting pressure, thereby allowing the passage of ingested solids and liquids into the stomach. None of these treatments is curative, and patients often have recurrent symptoms that may require additional treatment.

Botulinum toxin injections in the LES are an appropriate alternative for patients who have a high surgical risk (e.g., older age, significant comorbidities). Pharmacological treatment with nitrates is the least effective treatment and should only be considered if all other treatment options are unfeasible or unsuccessful.

Question 5

A 45-year-old woman comes to the physician because of progressive difficulty swallowing solids and liquids over the past 4 months. She has lost 4 kg (9 lb) during this period. There is no history of serious illness. She emigrated to the US from Panama 7 years ago. She does not smoke cigarettes or drink alcohol. Cardiopulmonary examination shows a systolic murmur and an S3 gallop. A barium radiograph of the chest is shown (Birds beak). Endoscopic biopsy of the distal esophagus is most likely to show which of the following?

Atrophy of esophageal smooth muscle cells
Presence of intranuclear basophilic inclusions
Infiltration of eosinophils in the epithelium
Absence of myenteric plexus neurons
Presence of metaplastic columnar epithelium

Answer 5

Absence of myenteric plexus neurons

Chagas disease is caused by Trypanosoma cruzi infection, a parasite endemic to regions of Central and South America. In addition to dilated cardiomyopathy, T. cruzi infection can lead to denervation and destruction of myenteric plexus neurons anywhere along the gastrointestinal tract. This results in an inability to relax the lower esophageal sphincter (achalasia), which manifests as progressive dysphagia, weight loss, and a bird-beak sign on barium swallow.

Question 6

Most common cause of portal hypertension

Answer 6

Cirrhosis

Question 7

Main pathologic event leading to achalasia

Answer 7

Degeneration of inhibitory ganglion cells

Question 8

A 65 year old woman presents because of dysphagia to both solids and liquids. A barium enema shows rosary bed

Answer 8

Distal esophageal spasm

Question 9

Which of the following does NOT belong to Charcot´s triad

• RUQ abdominal pain
• Jaundice
• Hypotension
• Fever

Answer 9

Hypotension

Question 10

NOT a criteria for diagnosis of acute pancreatitis
* Amilase and lipase >3 times normal
* Peripancreatic calcifications
* Acute epigastric pain radiating to the back
* Characteristic findings on imaging

Answer 10

Peripancreatic calcifications

Question 11

Levels of amylase and lypase correlate with pancreatitis severity (True or false)

Answer 11

False

Question 12

Which of the following is the least common etiology of acute pancreatitis?
* Alcohol
* Biliar
* Crohns disease of the duodenum
* Hypertrygliceridemia

Answer 12

Crohns disease of the duodenum

Question 13

The following represent exocrine pancreatic insufficiency features associated to chronic pancreatitis, except
* Pancreatogenic diabetes
* Steatorrhea
* Osteoporosis
* Weight loss

Answer 13

Pancreatogenic diabetes

Question 14

Which of the following is the most sensitive and specific indirect test to measure exocrine pancreatic insufficiency
* Fecal chymotrypsin
* Fecal elastase
* Serum trypsinogen
* Secretin test

Answer 14

Fecal elastase

Question 15

Principal factors associated to PUD

Answer 15

An Helicobacter pylori infection and NSAIDs consumption

Question 16

Most common complication of PUD

Answer 16

Acute upper GI bleeding

Question 17

A 35 yo woman traveled to Brasil and presents with dysphagia. She recalls being stung by an insect. Probable pathogen is

Answer 17

Trypanozoma Cruzi

Question 18

Indicated for prevention of recurrent variceal bleeding

Answer 18

Beta blockers

Question 19

A 45-year-old man comes to the physician because of bright red blood in his stool for 5 days. He has had no pain during defecation and no abdominal pain. One year ago, he was diagnosed with cirrhosis after being admitted to the emergency department for upper gastrointestinal bleeding. He has since cut down on his drinking and consumes around 5 bottles of beer daily. Examination shows scleral icterus and mild ankle swelling. Palpation of the abdomen shows a fluid wave and shifting dullness. Anoscopy shows enlarged bluish vessels above the dentate line. Which of the following is the most likely source of bleeding in this patient?

Superior rectal vein
Internal pudendal vein
Inferior mesenteric artery
Inferior rectal vein
Internal iliac vein
Middle rectal artery

Answer 19

Superior rectal vein

Anorectal varices occur in patients with portal hypertension as a result of increased blood flow in the portosystemic anastomoses that connect the superior rectal vein with the inferior and middle rectal veins. The superior rectal vein receives blood from the region of the anal canal above the dentate line and drains into the inferior mesenteric vein (portal venous circulation). The superior rectal vein would be the source of bleeding in the case of lesions located above the dentate line, such as the anorectal varices seen in this patient. The inferior rectal veins, which receive blood from the region below the dentate line and drain into the internal pudendal veins (systemic venous circulation), would be the source of bleeding in the case of lesions located below the dentate line, such as external hemorrhoids.

Question 20

A 45-year-old man is brought to the physician for a follow-up examination. Three weeks ago, he was hospitalized and treated for spontaneous bacterial peritonitis. He has alcoholic liver cirrhosis and hypothyroidism. His current medications include spironolactone, lactulose, levothyroxine, trimethoprim-sulfamethoxazole, and furosemide. He appears ill. His temperature is 36.8°C (98.2°F), pulse is 77/min, and blood pressure is 106/68 mm Hg. He is oriented to place and person only. Examination shows scleral icterus and jaundice. There is 3+ pedal edema and reddening of the palms bilaterally. Breast tissue appears enlarged, and several telangiectasias are visible over the chest and back. Abdominal examination shows dilated tortuous veins. On percussion of the abdomen, the fluid-air level shifts when the patient moves from lying supine to right lateral decubitus. Breath sounds are decreased over both lung bases. Cardiac examination shows no abnormalities. Bilateral tremor is seen when the wrists are extended. Genital examination shows reduced testicular volume of both testes. Digital rectal examination and proctoscopy show hemorrhoids. Which of the following complications, if seen in this patient, would be the strongest indication for the placement of a transjugular intrahepatic portosystemic shunt (TIPS)?

Hepatic veno-occlusive disease
Recurrent variceal hemorrhage
Portal hypertensive gastropathy
Hepatic encephalopathy
Hepatorenal syndrome
Hepatic hydrothorax
Hepatocellular carcinoma

Answer 20

Recurrent variceal hemorrhage

Recurrent esophageal variceal hemorrhage resulting from portal hypertension is an indication for TIPS placement. TIPS can relieve the high portal venous pressure by bypassing the congested liver through a shunt from the portal vein to the hepatic vein. This procedure is also used in patients with acute variceal hemorrhage if first-line pharmacological and endoscopic treatment fails to stop the bleeding.

Following TIPS placement, patients are at increased risk of developing hepatic encephalopathy because blood now bypasses the liver, reducing the elimination of ammonia.

Question 21

A 49-year-old man with alcoholic cirrhosis is brought to the emergency department by his wife because of 2 episodes of vomiting bright red blood over the past 2 hours. His wife reports that he drank 1 bottle of vodka over the past 24 hours. During this time, he has had nausea but no bloody or tarry stool, and no abdominal pain. There is no history of similar episodes. The patient takes no medications. On arrival, he is awake but confused. His temperature is 36°C (96.8°F), pulse is 92/min, and blood pressure is 110/82 mm Hg. Physical examination shows ascites. On mental status examination, he is not oriented to person, place, or time. During the examination, the patient has another episode of vomiting blood. His hemoglobin concentration is 9.5 g/dL. Two large intravenous catheters are placed. Administration of intravenous fluids, octreotide, and ceftriaxone is begun. When vital signs are measured again, his pulse is 94/min and blood pressure is 109/80 mm Hg. Which of the following is the most appropriate next step in management?

Place nasogastric tube
Administer packed red blood cells
Perform endotracheal intubation
Administer oral omeprazole
Administer intravenous nadolol
Perform upper endoscopy

Answer 21

Perform endotracheal intubation

Patients with upper gastrointestinal bleeding who present with altered mental status and/or ongoing hematemesis are at increased risk for aspiration and should be intubated for airway protection. Endotracheal intubation decreases the risk of aspiration and can facilitate upper endoscopy in order to confirm the diagnosis and perform the definitive treatment (e.g., variceal band ligation).

In alcoholic cirrhosis, upper gastrointestinal bleeding raises suspicion for an esophageal variceal hemorrhage. A Mallory-Weiss tear is also an important differential diagnosis in this patient, as it is not known whether the hematemesis was preceded by emesis, retching, and coughing.

NO UPPER ENDOSCOPY PORQUE: Upper endoscopy is both diagnostic and therapeutic in patients with upper gastrointestinal bleeding who are hemodynamically stable. In particular, in patients with suspected esophageal variceal bleeding, endoscopic variceal ligation can achieve hemostasis and prevent recurrent bleeding. The goal for these patients is to perform endoscopy within the first 12 hours of presentation. However, this patient still has ongoing hematemesis and altered mental status, and, therefore, upper endoscopy is not the next best step.

Question 22

A 65-year-old man comes to the physician because of progressive abdominal distension and swelling of his legs for 4 months. He has a history of ulcerative colitis. Physical examination shows jaundice. Abdominal examination shows shifting dullness and dilated veins in the periumbilical region. This patient’s abdominal findings are most likely caused by increased blood flow in which of the following vessels?

Left gastric vein
Hepatic vein
Splenic vein
Superior epigastric vein
Superior mesenteric vein
Superior rectal vein

Answer 22

Superior epigastric vein

The abdominal wall veins (e.g., inferior epigastric vein, superior epigastric vein) drain into the systemic circulation inferiorly via the iliofemoral system and superiorly via the veins of the thoracic wall and axilla. The umbilical vein drains venous blood from the paraumbilical veins into the portal system. Portal hypertension is associated with an impedance to flow in the hepatic portal venous system. This results in a retrograde flow of blood from the portal vein via the umbilical vein into the epigastric veins so that blood can be shunted into systemic circulation (portocaval anastomoses). This shunting of blood causes the paraumbilical abdominal wall veins to dilate, resulting in caput medusae. Other manifestations of portocaval shunting include esophageal varices (shunting between the left gastric vein and esophageal veins) and rectal varices (shunting between the superior rectal vein and middle or inferior rectal veins).

In patients with cirrhosis, ascites is partly caused by the increased hydrostatic pressures present in portal hypertension. Impaired hepatic protein synthesis (especially albumin) also leads to reduced intravascular oncotic pressure that exacerbates ascites. Additionally, splanchnic vasodilation in patients with cirrhosis results in underfilling of the systemic arterial system, which activates the RAAS. Activation of RAAS leads to Na+ and water retention, which aggravates ascites and peripheral edema.

Question 23

A 54-year-old man with alcohol use disorder comes to the emergency department because of vomiting blood for 6 hours. He has had no epigastric pain or tarry stools. His temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 80/50 mm Hg. He is resuscitated with 0.9% saline and intravenous treatment with octreotide and ceftriaxone is begun. Upper endoscopy shows numerous nonbleeding, small- and medium-sized varices, and two large actively bleeding varices in the distal esophagus. Band ligation of the two bleeding varices is performed and hemostasis is achieved. The patient is diagnosed with Child-Pugh class B cirrhosis. In addition to alcohol cessation and nonselective beta blocker therapy, which of the following is the most appropriate recommendation to prevent future morbidity and mortality from this patient’s condition?

Isosorbide mononitrate therapy
Terlipressin therapy
Placement of transjugular intrahepatic portosystemic shunt
Splenorenal shunt surgery
Sclerotherapy of remaining varices
Ligation of remaining varices

Answer 23

Ligation of remaining varices

Endoscopic variceal ligation (EVL) should be performed every 1–2 weeks until all remaining varices have been obliterated, after which endoscopic examination should be performed every 3–6 months. In addition to EVL, medical therapy with nonselective beta blockers (e.g., propranolol) should be initiated. Nonselective beta blockers inhibit β2-adrenoreceptors in the gastrointestinal tract, causing splanchnic vasoconstriction, which decreases the volume of blood in the portal veins and therefore decreases portal venous pressure. The rebleeding rate is 15% with a combination of propranolol and EVL, as propranolol prevents variceal bleeding until the varices are obliterated by EVL, compared to 20–30% with EVL alone and 40–45% with propranolol alone.

Question 24

A 62-year-old man is brought to the emergency department because of a 2-hour history of intermittent bloody vomiting. He has had similar episodes during the last 6 months that stopped spontaneously within an hour. The patient is not aware of any medical problems. He has smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks half a liter of vodka daily. He appears pale and diaphoretic. His temperature is 37.3°C (99.1°F), pulse is 97/min, respirations are 20/min, and blood pressure is 105/68 mm Hg. Cardiac examination shows no murmurs, rubs, or gallops. The abdomen is distended. On percussion of the abdomen, the fluid-air level shifts when the patient moves from the supine to the right lateral decubitus position. The liver edge is palpated 3 cm below the right costal margin. His hemoglobin concentration is 10.3 g/dL, leukocyte count is 4200/mm3, and platelet count is 124,000/mm3. ln addition to administration of intravenous fluids and octreotide, which of the following is the most appropriate initial step in management?

Endoscopic sclerotherapy
Transfusion of packed red blood cells
Ceftriaxone therapy
Transjugular intrahepatic portal shunt
Balloon tamponade
Propranolol therapy

Answer 24

Ceftriaxone therapy

Management of acute esophageal variceal bleeding includes fluid resuscitation, octreotide, and prophylactic antibiotics. Antibiotic prophylaxis (e.g., IV ceftriaxone for seven days) lowers mortality and reduces the risk of rebleeding and infectious complications. Further management of suspected esophageal variceal bleeding involves upper endoscopy within 12 hours of initial presentation to confirm the diagnosis and perform variceal band ligation.

Question 25

A 50-year-old man comes to the physician because of a 6-month history of difficulties having sexual intercourse due to erectile dysfunction. He has type 2 diabetes mellitus that is well controlled with metformin. He does not smoke. He drinks five to six beers daily. His vital signs are within normal limits. Physical examination shows bilateral pedal edema, decreased testicular volume, and increased breast tissue. The spleen is palpable 2 cm below the left costal margin. Abdominal ultrasound shows an atrophic, hyperechoic, nodular liver. Upper endoscopy shows dilated submucosal veins 4 mm in diameter with red patches in the distal esophagus and no bleeding. Which of the following is the most appropriate next step in management of this patient’s esophageal findings?

Injection sclerotherapy
Nadolol therapy
Octreotide therapy
Isosorbide mononitrate therapy
Transjugular intrahepatic portosystemic shunt
Metoprolol therapy

Answer 25

Nadolol therapy

Indications for primary prophylaxis against esophageal variceal hemorrhage include size and appearance of varices, and severity of cirrhosis. Red signs on endoscopy (i.e., red patches on the variceal surface), as seen in this patient, indicate an increased risk for bleeding. Nonselective beta blockers (e.g., nadolol, propranolol) are the first-line pharmacotherapy for primary prophylaxis in patients with nonbleeding varices. These agents cause splanchnic vasoconstriction, which decreases portal blood flow and portal pressure, thereby preventing further enlargement of varices and reducing the risk of hemorrhage. Endoscopic band ligation is an alternative measure for primary prophylaxis that can be considered in individuals with medium or large varices and/or in those who do not respond well to treatment with beta blockers.

Beta blockers should not be used in patients with acute variceal bleeding, as these drugs decrease blood pressure and suppress the physiological increase in heart rate.

**Metoprolol es selective

Question 26

A 42-year-old woman is brought to the emergency department because of a 5-day history of epigastric pain, fever, nausea, and malaise. Five weeks ago she had acute biliary pancreatitis and was treated with endoscopic retrograde cholangiopancreatography and subsequent cholecystectomy. Her maternal grandfather died of pancreatic cancer. She does not smoke. She drinks 1–2 beers daily. Her temperature is 38.7°C (101.7°F), respirations are 18/min, pulse is 120/min, and blood pressure is 100/70 mm Hg. Abdominal examination shows epigastric tenderness and three well-healed laparoscopy scars. The remainder of the examination shows no abnormalities. Laboratory studies show:

Hemoglobin 10 g/dL
Leukocyte count 15,800/mm3
Serum
Na+ 140 mEq/L
Cl− 103 mEq/L
K+ 4.5 mEq/L
HCO3- 25 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 70 U/L
Aspartate aminotransferase (AST, GOT) 22 U/L
Alanine aminotransferase (ALT, GPT) 19 U/L
γ-Glutamyltransferase (GGT) 55 U/L (N = 5–50)
Bilirubin 1 mg/dL
Glucose 105 mg/dL
Amylase 220 U/L
Lipase 365 U/L (N = 14–280)

Abdominal ultrasound shows a complex cystic fluid collection with irregular walls and septations in the pancreas. Which of the following is the most likely diagnosis?

Pancreatic abscess
Pancreatic pseudocyst
Pancreatic cancer
Acute cholangitis
ERCP-induced pancreatitis

Answer 26

Pancreatic abscess

Pancreatic abscess (walled-off necrosis) is a late complication of acute necrotizing pancreatitis. This condition most commonly manifests more than 4 weeks after an episode of acute pancreatitis with fever and a tender abdomen. The complex cystic collection on ultrasound is most likely necrotic material within a fibrous capsule. Drainage is required for symptomatic pancreatic abscesses.

Question 27

A 43-year-old man is brought to the emergency department because of a 6-hour history of severe epigastric pain and vomiting. The pain radiates to his back and he describes it as 9 out of 10 in intensity. He has had 3–4 episodes of vomiting during this period. He admits to consuming over 13 alcoholic beverages the previous night. There is no personal or family history of serious illness and he takes no medications. He is 177 cm (5 ft 10 in) tall and weighs 55 kg (121 lb); BMI is 18 kg/m2. He appears uncomfortable. His temperature is 37.5°C (99.5°F), pulse is 97/min, and blood pressure is 128/78 mm Hg. Abdominal examination shows severe epigastric tenderness to palpation. Bowel sounds are hypoactive. The remainder of the physical examination shows no abnormalities. Laboratory studies show:

Hemoglobin 13.5 g/dL
Hematocrit 45%
Leukocyte count 13,800/mm3
Serum
Na+ 136 mEq/L
K+ 3.6 mEq/L
Cl- 98 mEq/L
Calcium 8.3 mg/dL
Glucose 180 mg/dL
Creatinine 0.9 mg/dL
Amylase 150 U/L
Lipase 865 U/L (N = 14–280)
Total bilirubin 0.8 mg/dL
Alkaline phosphatase 66 U/L
AST 19 U/L
ALT 18 U/L
LDH 360 U/L

An increase in which of the following is most likely to indicate a poor prognosis?

Blood urea nitrogen (BUN)
Lipase
AST/ALT ratio
Alkaline phosphatase
Total bilirubin
Amylase

Answer 27

Blood urea nitrogen (BUN)

In patients with acute pancreatitis, the release of inflammatory cytokines and vascular injury by pancreatic enzymes leads to vasodilation and increased vascular permeability, which can result in significant third-space fluid loss and hemoconcentration. Patients with significant third-space fluid loss usually have a more severe disease course and a worse prognosis. Blood urea nitrogen (BUN) and hematocrit are indicators of the severity of third-space fluid loss and an increase in these is associated with a poor prognosis. Several scoring systems (e.g., Ranson criteria, BISAP) use these indicators to assess the severity and prognosis of patients with acute pancreatitis.

Question 28

A 58-year-old man is admitted to the hospital 1 day after the onset of severe abdominal pain. He has a history of alcohol use disorder, with several previous admissions for intoxication. Twelve hours after admission, he has worsening shortness of breath. His temperature is 38.3°C (100.9°F), pulse is 120/min, respirations are 30/min, and blood pressure is 100/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 85%. The patient is intubated and mechanically ventilated. Physical examination shows diffuse lung crackles, marked epigastric tenderness, and a periumbilical hematoma. Cardiac examination is normal with no murmurs, rubs, or gallops. There is no jugular venous distension. Arterial blood gas analysis on an FiO2 of 0.4 shows:

pH 7.29
PO2 61 mm Hg
PCO2 40 mm Hg
HCO3- 18 mEq/L

An x-ray of the chest shows diffuse bilateral opacities. Which of the following is the most likely cause of this patient’s respiratory symptoms?

Pulmonary embolism
Aspiration pneumonia
Hospital-acquired pneumonia
Acute respiratory distress syndrome
Congestive heart failure
Hepatic hydrothorax

Answer 28

Acute respiratory distress syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) is an inflammatory syndrome characterized by endothelial damage and increased alveolar-capillary permeability, which leads to noncardiogenic pulmonary edema and impaired gas exchange. Primary findings of ARDS include hypoxemic respiratory failure and a PO2/FiO2 ratio of ≤ 300. Chest x-ray typically shows diffuse bilateral infiltrates.

Question 29

A 50-year-old man comes to the emergency department because of severe lower chest pain for the past hour. The pain radiates to the back and is associated with nausea. He has had two episodes of non-bloody vomiting since the pain started. He has a history of hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 30 years. He drinks five to six beers per day. His medications include enalapril and metformin. His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. The lungs are clear to auscultation. Examination shows a distended abdomen with epigastric tenderness and guarding but no rebound; bowel sounds are decreased. Laboratory studies show:

Hemoglobin 14.5 g/dL
Leukocyte count 5,100/mm3
Platelet count 280,000/mm3
Serum
Na+ 133 mEq/L
K+ 3.5 mEq/L
Cl- 98 mEq/L
Total bilirubin 1.0 mg/dL
Amylase 160 U/L
Lipase 880 U/L (N = 14–280)

An ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?

Acute mesenteric ischemia
Boerhaave syndrome
Aortic dissection
Peptic ulcer disease
Pericarditis
Myocardial infarction
Acute pancreatitis

Answer 29

Acute pancreatitis

Severe epigastric pain radiating to the back accompanied by nausea/vomiting and elevated pancreatic enzymes (amylase, lipase) is highly suggestive of acute pancreatitis. Other common features include abdominal distention, decreased bowel sounds, and signs of shock. Approximately ⅓ of the cases are caused by alcohol use. Other causes of pancreatitis can be remembered with the mnemonic “I GET SMASHED”: I = Idiopathic, G = Gallstones, E = Ethanol, T = Trauma, S = Steroids, M = Mumps, A = Autoimmune, S = Scorpion poison, H = Hypercalcemia, Hypertriglyceridemia, E = ERCP, D = Drugs.

Question 30

A 21-year-old college student comes to the emergency department because of a 2-day history of vomiting and epigastric pain that radiates to the back. He has a history of atopic dermatitis and Hashimoto thyroiditis. His only medication is levothyroxine. He has not received any routine vaccinations. He drinks 1–2 beers on the weekends and occasionally smokes marijuana. The patient appears distressed and is diaphoretic. His temperature is 37.9°C (100.3°F), pulse is 105/min, respirations are 16/min, and blood pressure is 130/78 mm Hg. Physical examination shows abdominal distention with tenderness to palpation in the epigastrium. There is no guarding or rebound tenderness. Skin examination shows several clusters of yellow plaques over the trunk and extensor surfaces of the extremities. Hemoglobin concentration is 15.2 g/dL and serum calcium concentration is 7.9 mg/dL. Which of the following is the most appropriate next step in evaluation of the underlying cause of this patient’s condition?

Perform a pilocarpine-induced sweat test
Measure serum mumps IgM titer
Perform an esophagogastroduodenoscopy
Obtain an upright x-ray of the abdomen
Measure serum lipid levels
Measure stool elastase level

Answer 30

Measure serum lipid levels

This patient’s cutaneous eruptive xanthomas are a hallmark finding of hypertriglyceridemia, which can cause acute pancreatitis when triglyceride levels exceed 1000 mg/dL. Other causes of acute pancreatitis include biliary pathology (e.g., gallstones, constriction of the ampulla of Vater), alcohol use, and medications (e.g., sulfonamides, valproic acid, tetracycline, steroids).

The initial diagnostic workup in patients with suspected pancreatitis should include lipase and/or amylase levels, hepatic panel, and some form of abdominal imaging (e.g., abdominal ultrasound or CT). Other laboratory studies should also be performed to determine severity (CBC, BMP, ABG, inflammatory markers, LDH, serum calcium).

Question 31

A previously healthy 31-year-old woman comes to the emergency department because of sudden, severe epigastric pain and vomiting for the past 4 hours. She reports that the pain radiates to the back and began when she was having dinner and drinks at a local brewpub. Her temperature is 37.9°C (100.2°F), pulse is 98/min, respirations are 19/min, and blood pressure is 110/60 mm Hg. Abdominal examination shows epigastric tenderness and guarding but no rebound. Bowel sounds are decreased. Laboratory studies show:

Hematocrit 43%
Leukocyte count 9000/mm3
Serum
Na+ 140 mEq/L
K+ 4.5 mEq/L
Ca2+ 9.0 mg/dL
Lipase 980 U/L (N = 14–280)
Amylase 152 U/L
Alanine aminotransferase (ALT, GPT) 140 U/L

Intravenous fluid resuscitation and analgesic therapy are begun. Which of the following is the most appropriate next step in management?

CT scan of the abdomen with contrast
Ultrasonography of the abdomen
Plain x-ray of the abdomen
Endoscopic retrograde cholangiopancreatography
Measure serum triglycerides
Blood alcohol level assay

Answer 31

Ultrasonography of the abdomen

In patients with acute pancreatitis, following initial management with intravenous fluid resuscitation and analgesia, the next step is to evaluate the underlying cause in order to plan further treatment and prevent recurrence. The most common cause of acute pancreatitis in the United States is biliary obstruction. Abdominal ultrasonography is a highly sensitive imaging modality for detecting gallstones in the biliary and pancreatic duct and should be performed in all patients with acute pancreatitis. It is important to distinguish biliary pancreatitis from a nonbiliary etiology to guide treatment; biliary pancreatitis is managed with cholecystectomy with or without a preceding ERCP.

Question 32

A 54-year-old man is admitted to the hospital 5 hours after the onset of vomiting and severe abdominal pain that radiates to his back. He has no history of serious illness and takes no medications. He smokes one pack of cigarettes and drinks six 12-oz beers daily since losing his job 5 years ago. He appears to be in acute distress. Temperature is 37.4°C (99.3°F), pulse is 84/min, respirations are 18/min and blood pressure is 110/70 mm Hg. Abdominal examination shows a distended abdomen and tenderness to palpation of the epigastrium. Ultrasonography of the abdomen shows an enlarged hypoechoic pancreas. The patient is kept nothing by mouth, and administration of intravenous fluids, analgesics, and antiemetics is begun. Twelve hours after admission, the symptoms have resolved. Bowel sounds are normal. Laboratory studies now show:

Hemoglobin 13.5 g/dL
Hematocrit 52%
Leukocyte count 10,800/mm3
Serum
Creatinine 1.0 mg/dL
Triglycerides 180 mg/dL
Total bilirubin 0.8 mg/dL
Alkaline phosphatase 86 U/L
AST 20 U/L
ALT 21 U/L
γ-glutamyl transferase (GGT) 50 U/L (N = 5–50)
Amylase 350 U/L
Lipase 815 U/L (N = 14-280)

Which of the following is the most appropriate next step in management?

Initiate oral feeding
Initiate total parenteral nutrition
Perform endoscopic retrograde cholangiopancreatography
Administer meropenem
Keep patient nothing by mouth for another 12 hours

Answer 32

Initiate oral feeding

Early oral feeding reduces the risk of infectious complications by decreasing gastrointestinal dysmotility, gut permeability, and the likelihood of bacterial translocation. Therefore, oral feeding should be initiated as soon as tolerated (i.e. not causing pain, nausea, or vomiting), ideally within 24 hours. Complete bowel rest, which was previously recommended, is unnecessary in most patients. Enteral feeding can be delivered orally or via an enteral tube, and success has been demonstrated with various diets (e.g., liquid, low-fat, full-solid).

Question 33

A 55-year-old woman is brought to the emergency department because of worsening upper abdominal pain for 8 hours. She reports that the pain radiates to the back and is associated with nausea. She has hypertension and hyperlipidemia, for which she takes enalapril, furosemide, and simvastatin. Her temperature is 37.5°C (99.5 °F), blood pressure is 84/58 mm Hg, and pulse is 115/min. The lungs are clear to auscultation. Examination shows abdominal distention with epigastric tenderness and guarding. Bowel sounds are decreased. Extremities are warm. Laboratory studies show:

Hematocrit 48%
Leukocyte count 13,800/mm3
Platelet count 175,000/mm3
Serum:
Calcium 8.0 mg/dL
Urea nitrogen 32 mg/dL
Amylase 400 U/L

An ECG shows sinus tachycardia. Which of the following is the most likely underlying cause of this patient’s vital sign abnormalities?

Decreased sympathetic tone
Hemorrhagic fluid loss
Decreased albumin concentration
Abnormal coagulation and fibrinolysis
Decreased cardiac output
Increased excretion of water
Pseudocyst formation
Capillary leakage

Answer 33

Capillary leakage

This patient presents with acute pancreatitis and signs of distributive shock (e.g., tachycardia, hypotension, warm extremities). While most patients with acute pancreatitis will have a mild course, in moderate to severe cases the release of cytokines and inflammatory mediators will lead to capillary leakage, vasodilation, and hypotension. In severe cases, the third spacing of fluid from this inflammatory response can lead to hypovolemic shock. The etiology of acute pancreatitis, in this case, is most likely drug-induced; all three of her medications are associated with acute pancreatitis.

Question 34

A 72-year-old woman comes to the emergency department because of upper abdominal pain and nausea for the past hour. The patient rates the pain as an 8 to 9 on a 10-point scale. She has had an episode of nonbloody vomiting since the pain started. She has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. The patient has smoked two packs of cigarettes daily for 40 years. She drinks 5–6 alcoholic beverages daily. Current medications include glyburide, lisinopril, and oral vitamin D supplements. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. The patient is admitted to the hospital for pain control and intravenous hydration. Which of the following is the most appropriate management of this patient’s pain?

Oral hydrocodone on request
Patient-controlled intravenous hydromorphone
Transdermal bupivacaine on request
Continuous intravenous ketamine
Oral acetaminophen every 6 hours
Oral gabapentin every 24 hours
Transdermal fentanyl every 72 hours

Answer 34

Patient-controlled intravenous hydromorphone

Patient-controlled analgesia (PCA) with intravenous opioids (e.g., hydromorphone or fentanyl) is indicated in patients with severe acute pain (e.g., postoperative pain, malignancy pain, or pain resulting from acute pancreatitis, sickle cell crisis, or burn injuries). With PCAs, patients press a button that releases additional intravenous medication, allowing them to control the amount of analgesic they receive and minimizing the risk of underdosing. The pumps include a lockout period during which no further analgesic can be administered in order to avoid inappropriately high doses and reduce the risk of respiratory depression.

Question 35

A 12-year-old girl is brought to the physician because of a 2-hour history of severe epigastric pain, nausea, and vomiting. Her father has a history of similar episodes of abdominal pain and developed diabetes mellitus at the age of 30 years. Abdominal examination shows guarding and rigidity. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. Which of the following is the most likely underlying cause of this patient’s condition?

Defective bilirubin glucuronidation
Elevated serum amylase levels
Premature activation of trypsinogen
Defective elastase inhibitor
Impaired cellular copper transport

Answer 35

Premature activation of trypsinogen

Premature activation of trypsinogen to trypsin within the pancreas activates the pancreatic digestive enzymes (lipase, amylase, and protease) that cause pancreatic autodigestion and inflammation. This enzymatic pathway is the underlying pathophysiology of acute pancreatitis, regardless of the etiology (e.g., pancreatic ductal blockage in gallstone pancreatitis, pancreatic acinar injury in alcohol-induced pancreatitis). Hereditary pancreatitis, which this patient most likely has, is usually caused by a mutated PRSS1 gene that promotes intrapancreatic trypsinogen activation.

Other genetic variants associated with chronic pancreatitis are mutations in SPINK 1 and CFTR genes.

Question 36

A 43-year-old woman is evaluated for worsening epigastric pain 2 days after admission to the hospital for gallstone removal via endoscopic retrograde cholangiopancreatography. There were no complications during the procedure. The pain is constant and radiates to the back. She has vomited twice since yesterday. She has hypertriglyceridemia treated with gemfibrozil. There is no family history of serious illness. She appears ill. She is 173 cm (5 ft 8 in) tall and weighs 78 kg (172 lb); BMI is 26 kg/m2. Her temperature is 37.5°C (99.5°F), pulse is 78/min, and blood pressure is 129/80 mm Hg. There is tenderness to palpation and abdominal guarding in the epigastric area. Bowel sounds are present. The remainder of the examination shows no abnormalities. ECG shows a regular sinus rhythm. Laboratory studies show:

Hematocrit 43%
Leukocyte count 12,500/mm3
Serum
Na+ 134 mEq/L
Cl- 97 mEq/L
K+ 4.0 mEq/L
Calcium 8.0 mg/dL
Urea nitrogen 43 mg/dL
Glucose 271 mg/dL
Creatinine 1.2 mg/dL
Albumin 3.7 g/dL
Total bilirubin 0.5 mg/dL
Alkaline phosphatase 86 U/L
AST 20 U/L
ALT 21 U/L
γ-glutamyl transferase (GGT) 70 U/L (N = 5–50)
Amylase 476 U/L
Lipase 884 U/L (N = 14–280)

Treatment with intravenous fluids is initiated. Which of the following is the most appropriate next step in management?

Intravenous calcium gluconate therapy
Intravenous imipenem therapy
Repeat endoscopic retrograde cholangiopancreatography
Intravenous prednisone therapy
Intravenous fentanyl therapy
Surgical exploration of the abdomen

Answer 36

Intravenous fentanyl therapy

Post-ERCP pancreatitis is managed similarly to any other cause of acute pancreatitis, with supportive care that includes pain control. Adequate pain control not only improves the patient’s overall well-being but also decreases the risk of hemodynamic instability, which is exacerbated by intense pain. A stepwise approach to managing pain (e.g., WHO analgesic ladder) is appropriate, although intravenous opioids (e.g., fentanyl, hydromorphone), often delivered using a patient-controlled analgesia pump, are typically required to achieve adequate pain control in patients with acute pancreatitis. Although opioids are known to cause sphincter of Oddi dysfunction, there is no evidence showing that opioids aggravate pancreatitis or worsen clinical outcomes.

Other components of supportive care for acute pancreatitis include fluid and electrolyte repletion, antiemetic therapy, and nutritional support. Oral feeding may be started as soon as tolerated (e.g., once the patient has stopped vomiting, both nausea and pain have subsided, and there are no signs of ileus), ideally within 24 hours.

Question 37

What is the most important hormone that promotes sphincter of Oddi relaxation?

Answer 37

Cholecystokinin

Question 38

Drugs that cause acute pancreatitis

Answer 38

Steroids (Corticosteroids)
Azathioprine
Sulfonamides
Loop and thiazide diuretics
Estrogen
Protease inhibitors
NRTIs (Antiretrovirales)
Anticonvulsants (e.g., valproate)
Tetraciclinas

Question 39

After an attack of acute pancreatitis, percentage of patients that will progress to chronic pancreatitis.

Answer 39

10%

Question 40

Best diagnostic test for chronic pancreatitis and findings

Answer 40

Abdominal CT (best initial imaging modality)
- Ductal dilations, stenosis, and calcifications (more sensitive than x-ray)
- Chain-of-lakes appearance of the main pancreatic duct
- Pancreatic atrophy

Question 41

A 45-year-old woman comes to the physician because of early satiety and intermittent nausea for the past 3 months. During this period she has also felt uncomfortably full after meals and has vomited occasionally. She has not had retrosternal or epigastric pain. She has longstanding type 1 diabetes mellitus, diabetic nephropathy, and generalized anxiety disorder. Current medications include insulin, ramipril, and escitalopram. Vital signs are within normal limits. Examination shows dry mucous membranes and mild epigastric tenderness. Her hemoglobin A1C concentration was 12.2% 3 weeks ago. Which of the following is the most appropriate pharmacotherapy for this patient’s current condition?

Omeprazole
Exenatide
Clarithromycin
Metoclopramide
Ondansetron

Answer 41

Metoclopramide

Metoclopramide is the preferred first-line treatment for patients with diabetic gastroparesis because of its prokinetic activity (e.g., inducing gastric contractions, promoting peristalsis, increasing the tone of the fundus) and antiemetic properties. Patients should be started on the lowest possible dose and monitored closely for extrapyramidal side effects (e.g., acute dystonia). In addition, patients with diabetic gastroparesis should be maintained on strict glycemic control to prevent further complications, and they should be advised to avoid eating large fatty meals and raw vegetables. Other drugs used to treat gastroparesis include domperidone and erythromycin.

Question 42

Tx de PRIMERA línea de gastroparesia?

Answer 42

Comidas pequeñas y espaciadas y en varias porciones

Question 43

A 53-year-old woman comes to the emergency department because of weakness and abdominal pain for 24 hours. She has had three bowel movements with dark stool during this period. She has not had vomiting and has never had such episodes in the past. She underwent a tubal ligation 15 years ago. She has chronic lower extremity lymphedema, osteoarthritis, and type 2 diabetes mellitus. Her father died of colon cancer at the age of 72 years. Current medications include metformin, naproxen, and calcium with vitamin D3. She had a screening colonoscopy at 50 years of age which was normal. She appears pale and diaphoretic. Her temperature is 36°C (96.8°F), pulse is 110/min, respirations are 20/min, and blood pressure is 90/50 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. The abdomen is soft and nondistended with mild epigastric tenderness. Rectal examination shows tarry stool. Two large-bore IV lines are placed and fluid resuscitation with normal saline is initiated. Which of the following is the most appropriate next step in management?

CT scan of the abdomen with contrast
Intravenous octreotide
Diagnostic laparoscopy
Colonoscopy
Flexible sigmoidoscopy
Esophagogastroduodenoscopy

Answer 43

Esophagogastroduodenoscopy

Esophagogastroduodenoscopy (EGD) is the preferred next step in the management of UGIB as it allows for bleeding source identification and hemostatic interventions (e.g., cauterization, epinephrine injection). In the case of severe hemorrhaging secondary to PUD, intravenous proton pump inhibitors and blood transfusions can be considered.

Question 44

A 42-year-old man is brought to the emergency department because of several episodes of black, tarlike stool and lightheadedness over the past couple of days. He underwent an appendectomy at the age of 16 years. He has hypertension and tension headaches. He drinks four beers daily. Current medications include amlodipine and naproxen. His temperature is 36.7°C (98°F), pulse is 100/min, and blood pressure is 100/70 mm Hg. The lungs are clear to auscultation. The abdomen is soft, nondistended, and nontender. The liver is palpated 3 cm below the right costal margin. His hemoglobin concentration is 10 g/dL. Intravenous fluid resuscitation is begun. Esophagogastroduodenoscopy shows no abnormalities. Which of the following is the most appropriate next step in management?

Double-balloon enteroscopy
CT enterography
Radionuclide scan
Capsule endoscopy
Colonoscopy
Laparotomy
Angiography

Answer 44

Colonoscopy

Because the esophagogastroduodenoscopy did not find a hemorrhage in the upper GI tract, the next step in the management of this patient is a colonoscopy to evaluate the lower GI tract. Should the colonoscopy also be normal, the small bowel needs to be examined (e.g., via push enteroscopy, push-and-pull enteroscopy, capsule endoscopy).

Question 45

A 48-year-old woman comes to the emergency department because of increasingly severe right upper abdominal pain, fever, and nonbloody vomiting for 5 hours. The pain is dull and intermittent and radiates to her right shoulder. During the past 3 months, she had recurring abdominal discomfort after meals. She underwent an appendectomy at the age of 13 years. The patient has hypertension, type 2 diabetes mellitus, and chronic back pain. She takes bisoprolol, metformin, and ibuprofen daily. She is 171 cm (5 ft 6 in) tall and weighs 99 kg (218 lb); BMI is 35 kg/m2. She appears uncomfortable and is clutching her abdomen. Her temperature is 38.5°C (101.3°F), pulse is 108/min, and blood pressure is 150/82 mm Hg. Abdominal examination shows right upper quadrant abdominal tenderness and guarding. Upon deep palpation of the right upper quadrant, the patient pauses during inspiration. Laboratory studies show:

Hemoglobin 13.1 g/dL
Leukocyte count 10,900/mm3
Platelet count 236,000/mm3
Mean corpuscular volume 89/μm3
Serum
Urea nitrogen 28 mg/dL
Glucose 89 mg/dL
Creatinine 0.7 mg/dL
Bilirubin
Total 1.0 mg/dL
Direct 0.3 mg/dL
Alkaline phosphatase 79 U/L
Alanine aminotransferase (ALT, GPT) 46 U/L
Aspartate aminotransferase (AST, GOT) 56 U/L

An x-ray of the abdomen shows no abnormalities. Further evaluation of the patient is most likely to show which of the following?

History of multiple past pregnancies
Elevated carbohydrate deficient transferrin
History of recent travel to Indonesia
History of recurrent sexually transmitted infections
Frequent, high-pitched bowel sounds on auscultation
Urine culture growing gram-negative rods

Answer 45

History of multiple past pregnancies

A history of multiparity is a significant risk factor for gallstones, which account for 90–95% of cases of acute cholecystitis. The risk of gallstone disease is about 10 times greater among multiparous women than nulliparous women. Higher estrogen levels during pregnancy increase the secretion of cholesterol into bile, while higher progesterone levels decrease the production of hydrophilic bile acids, resulting in a decreased ability of bile to sequester cholesterol. The combination of these effects leads to the supersaturation of bile with cholesterol, which in turn predisposes the patient to gallstone disease.

Question 46

Risk factors of cholelithiasis

Answer 46

Female, Fat, Forty, Fair-skinned, Family history and Fertile

Question 47

A 73-year-old man comes to the emergency department because of a 1-day history of nausea and severe pain in his upper abdomen and right shoulder blade. He was able to eat a little for breakfast but vomited up the meal a couple of hours later. He has type 2 diabetes mellitus treated with metformin. He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week. He appears acutely distressed. His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus. The remainder of the examination shows no abnormalities. Laboratory studies show:

Hemoglobin 14.3 g/dL
Leukocyte count 18,100/mm3
Platelet count 216,000/mm3
Serum
Aspartate aminotransferase (AST) 62 U/L
Alanine aminotransferase (ALT) 38 U/L
Alkaline phosphatase 90 U/L
Total bilirubin 0.9 mg/dL
Direct bilirubin 0.2 mg/dL
Albumin 4.1 g/dL

Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen. Which of the following is the most likely diagnosis?

Chronic pancreatitis with pseudocyst rupture
Emphysematous cholecystitis
Gallstone ileus
Perforated duodenal ulcer
Primary sclerosing cholangitis

Answer 47

Emphysematous cholecystitis

Crepitus in the abdominal wall and gas within the gallbladder wall strongly suggest emphysematous cholecystitis as the most likely cause of this patient’s abdominal (and referred scapula) pain and shock. Patients with this form of cholecystitis are classically elderly men with diabetes. Infection of the gallbladder with gas-forming bacteria requires emergency cholecystectomy, as delays in curative treatment are associated with gangrene and gallbladder perforation.

Question 48

Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mm Hg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs, or gallops. Abdominal examination shows a soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show:

Hemoglobin 13.1 g/dL
Hematocrit 42%
Leukocyte count 15,700/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 20%
Monocytes 3%
Eosinophils 1%
Basophils 0.5%
AST 50 U/L
ALT 80 U/L
Alkaline phosphatase 85 U/L
Total bilirubin 1.5 mg/dL
Direct 0.9 mg/dL
Amylase 90 U/L

Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?

Intravenous heparin therapy followed by embolectomy
Careful observation with serial abdominal examinations
Immediate cholecystectomy
Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy
Endoscopic retrograde cholangiopancreatography with papillotomy

Answer 48

Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy

Acalculous cholecystitis puts this patient at high risk of gallbladder perforation and rapid deterioration. Apart from fluid resuscitation, he should be started on broad-spectrum antibiotics such as piperacillin-tazobactam immediately, and cholecystostomy should be performed to decompress his distended gallbladder. Cholecystectomy is the definitive treatment for acalculous cholecystitis. A percutaneous cholecystostomy, on the other hand, is a less invasive temporizing alternative for severely ill patients (such as this patient, who has several severe diseases and has recently undergone a major surgical procedure) or patients too unstable to be under general anesthesia. If the patient does not improve within 24 hours, a cholecystectomy should be performed.

Question 49

A 44-year-old woman comes to the emergency department because of a 10-hour history of severe nausea and abdominal pain that began 30 minutes after eating dinner. The pain is most severe in the patient’s right upper quadrant and intermittently radiates to her back. She has a history of type 2 diabetes mellitus and hypercholesterolemia. Current medications include metformin and atorvastatin. She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); BMI is 34 kg/m2. Her temperature is 38.8°C (101.8°F), pulse is 100/min, respirations are 14/min, and blood pressure is 150/76 mm Hg. Abdominal examination shows right upper quadrant tenderness with guarding. A bedside ultrasound shows a gall bladder wall measuring 6 mm, pericholecystic fluid, sloughing of the intraluminal membrane, and a 2 x 2-cm stone at the neck of the gallbladder. The common bile duct appears unremarkable. Laboratory studies show leukocytosis and normal liver function tests. Intravenous fluid therapy is begun, and the patient is given ketorolac for pain control. Which of the following is the most appropriate next step in management?

Ursodeoxycholic acid therapy
CT scan of the abdomen with contrast
Endoscopic retrograde cholangiopancreatography
Antibiotic therapy
Percutaneous cholecystostomy
Emergent open cholecystectomy
Elective laparoscopic cholecystectomy in 6 weeks
HIDA scan

Answer 49

Antibiotic therapy

Empiric antibiotic therapy and laparoscopic cholecystectomy are the mainstays of treatment for patients with acute calculous cholecystitis (ACC). This patient with ACC, signs of systemic infection (fever of 38.8°C), and a history of type 2 diabetes mellitus should receive prompt antibiotic therapy. Antibiotic therapy should be targeted against the pathogens most commonly causing ACC, including gram-negative rods and anaerobes. For patients with community-acquired ACC, intravenous piperacillin-tazobactam is an appropriate choice. After initiation of antibiotic therapy, a laparoscopic cholecystectomy should be performed within 2–3 days.

Question 50

One week after undergoing sigmoidectomy with end colostomy for complicated diverticulitis, a 67-year-old man has upper abdominal pain. During the surgery, he was transfused two units of packed red blood cells. His postoperative course was uncomplicated. Two days ago, he developed fever. He is currently receiving parenteral nutrition through a central venous catheter. He has type 2 diabetes mellitus, hypertension, and hypercholesterolemia. He is oriented to person, but not to place and time. Prior to admission, his medications included metformin, valsartan, aspirin, and atorvastatin. His temperature is 38.9°C (102.0°F), pulse is 120/min, and blood pressure is 100/60 mm Hg. Physical examination shows mild conjunctival icterus. Abdominal examination shows tenderness to palpation in the right upper quadrant. There is no rebound tenderness or guarding; bowel sounds are hypoactive. Laboratory studies show:

Leukocytes 13,500 /mm3
Segmented neutrophils 75 %
Serum
Aspartate aminotransferase 140 IU/L
Alanine aminotransferase 85 IU/L
Alkaline phosphatase 150 IU/L
Bilirubin
Total 2.1 mg/dL
Direct 1.3 mg/dL
Amylase 40 IU/L

Which of the following is the most likely diagnosis?

Ischemic hepatitis
Acalculous cholecystitis
Small bowel obstruction
Anastomotic insufficiency
Cholecystolithiasis
Acute pancreatitis
Hemolytic transfusion reaction

Answer 50

Acalculous cholecystitis

Acalculous cholecystitis (AC) should be suspected in critically ill and postoperative patients who develop unexplained fever, sepsis, and leukocytosis, as seen here. Conditions that result in biliary stasis and/or hypoperfusion of the gallbladder such as trauma, surgery, total parenteral nutrition, multiple transfusions, which are also seen here, are risk factors for acalculous cholecystitis. The presence of RUQ tenderness and laboratory evidence of biliary stasis (i.e., elevated bilirubin, and ALP) further support the clinical diagnosis of AC.

NO ES ISQUEMIC HEPATITIS PORQUE: Ischemic hepatitis is typically caused by sudden hypotension and/or thromboses of the hepatic vasculature, both of which are potential intraoperative or postoperative complications of a major surgical procedure as the sigmoidectomy this patient has undergone. Ischemic hepatitis may manifest with RUQ pain, fever, altered mental status, and icterus. However, the characteristic feature is a very high elevation in serum aminotransaminases of >1000 international unit/L (50 times the upper limit of normal), which this patient does not have.

Question 51

A 45-year-old woman comes to the emergency department because of right upper abdominal pain and nausea that have become progressively worse since eating a large meal 8 hours ago. She has had intermittent pain similar to this before, but it has never lasted this long. She has a history of hypertension and type 2 diabetes mellitus. She does not smoke or drink alcohol. Current medications include metformin and enalapril. Her temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure is 130/80 mm Hg. The abdomen is soft, and bowel sounds are normal. The patient has sudden inspiratory arrest during right upper quadrant palpation. Laboratory studies show a leukocyte count of 13,000/mm3. Serum concentrations of alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase are within the reference ranges. Imaging is most likely to show which of the following findings?

Dilated common bile duct with intrahepatic biliary dilatation
Enlargement of the pancreas with peripancreatic fluid
Gas in the gallbladder wall
Fistula formation between the gallbladder and bowel
Gallstone in the cystic duct
Decreased echogenicity of the liver

Answer 51

Gallstone in the cystic duct

The vast majority of cases of acute cholecystitis are due to obstructing gallstones in the cystic duct. In a patient with clinical features of acute cholecystitis (e.g., RUQ pain lasting over 6 hours, fever, and leukocytosis), ultrasonography of the RUQ is indicated. Findings that support the diagnosis include gallbladder wall thickening, gallbladder wall edema, obstructing gallstone, and/or sonographic Murphy sign. Gallstones are a common incidental finding on ultrasound but in this context would also be suggestive of acute cholecystitis. In uncomplicated cholecystitis, cholestasis parameters (ALP, GGT, and bilirubin) are typically normal or only mildly elevated because there is usually no obstruction of the hepatic ducts or common bile duct.

Question 52

A 60-year-old woman comes to the physician because of intermittent abdominal pain for the past month. The patient reports that her pain is located in the right upper abdomen and that it does not change with food intake. She has had no nausea, vomiting, or change in weight. She has a history of hypertension and hyperlipidemia. She does not smoke. She drinks 1–2 glasses of wine per day. Current medications include captopril and atorvastatin. Physical examination shows a small, firm mass in the right upper quadrant. Laboratory studies are within the reference range. A CT scan of the abdomen is shown (Porcelain gallbladder). This patient’s condition puts her at greatest risk of developing which of the following?

Gallbladder adenocarcinoma
Gallbladder perforation
Pancreatic adenocarcinoma
Hepatocellular carcinoma
Pyogenic liver abscess

Answer 52

Gallbladder adenocarcinoma

While the exact pathophysiology of porcelain gallbladder is unknown, it is associated with cholelithiasis and chronic gallbladder inflammation. Porcelain gallbladder is often identified incidentally on abdominal imaging, although it may manifest with right upper quadrant pain, as seen in this patient. There is a small but significant risk of developing gallbladder adenocarcinoma, so the recommended treatment is cholecystectomy.

Question 53

A 35-year-old woman comes to the physician because of nausea and severe abdominal pain for 2 weeks. The pain worsens after meals and, according to the patient, “can last a whole day.” She tried taking ibuprofen for the pain, but it provided only minimal relief. She has no personal or family history of severe illness. Her only medication is an oral contraceptive. She appears uncomfortable. Her temperature is 37.5°C (99°F), pulse is 78/min, respirations are 19/min, and blood pressure is 118/75 mm Hg. She is 172 cm (5 ft 7 in) tall and weighs 82 kg (180 lb); BMI is 28 kg/m2. Examination shows tenderness in the right upper quadrant on abdominal palpation. The liver and spleen cannot be palpated. The remainder of the physical examination shows no abnormalities. Laboratory studies show:

Hemoglobin 13.3 g/dL
Hematocrit 43%
Leukocyte count 13,700/mm3
Serum
Glucose 70 mg/dL
Creatinine 1.1 mg/dL
Total bilirubin 1 mg/dL
Alkaline phosphatase 120 U/L
γ-Glutamyl transpeptidase 35 U/L (N = 5–50)
AST 49 U/L
ALT 60 U/L

Results of a right upper quadrant ultrasonography are inconclusive. Which of the following is the most appropriate next step in management?

Cholescintigraphy (HIDA scan)
Endoscopic retrograde cholangiopancreatography (ERCP)
Magnetic resonance cholangiopancreatography (MRCP)
Computed tomography scan of the abdomen
Magnetic resonance imaging of the abdomen

Answer 53

Cholescintigraphy (HIDA scan)

Cholescintigraphy, also called hepatoiminodiacetic acid scintigraphy (HIDA scan), is the preferred imaging study in patients with both suspected uncomplicated acute cholecystitis and inconclusive findings on abdominal ultrasound, such as this woman. Technetium-99m, a tracer that is selectively secreted into the biliary tree, is injected intravenously and allows for visualization of the biliary tract. An obstructing gallstone and/or inflammatory edema impairs the filling of the gallbladder. The diagnosis is confirmed if the gallbladder cannot be visualized on imaging (i.e., lack of gallbladder filling) within 4 hours.

NOT CT: A CT scan of the abdomen is an alternative imaging modality used to diagnose acute cholecystitis in patients who have inconclusive ultrasound results. CT scan is also used to evaluate possible complications of cholecystitis, such as hemorrhage, emphysematous cholecystitis, gallstone ileus, and gangrenous cholecystitis. However, another alternative study for diagnosing uncomplicated acute cholecystitis is indicated prior to CT.

Question 54

A 42-year-old woman comes to the emergency department because of a 2-day history of right upper abdominal pain and nausea. She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2. Her temperature is 38.5°C (101.3°F). Physical examination shows a distended abdomen and right upper quadrant tenderness with normal bowel sounds. Laboratory studies show:

Leukocyte count 14,000/mm3
Serum
Total bilirubin 1.1 mg/dL
AST 42 U/L
ALT 50 U/L
Alkaline phosphatase 68 U/L

Abdominal ultrasonography is performed, but the results are inconclusive. Cholescintigraphy (HIDA scan) shows normal visualization of the intrahepatic bile ducts, hepatic ducts, common bile duct, and proximal small bowel; visualization of the gallbladder is delayed. Which of the following is the most likely cause of this patient’s symptoms?

Autodigestion of pancreatic parenchyma
Hypomotility of the gallbladder
Fistula between the gallbladder and small intestine
Infection with a hepatotropic virus
Obstruction of the cystic duct
Fibrosis of the common bile duct

Answer 54

Obstruction of the cystic duct

Cholecystitis is usually caused by the passage of gallstones into the cystic duct. Cystic duct obstruction can lead to gallbladder inflammation with symptoms of right upper quadrant abdominal pain, nausea, and fever, as seen in this patient. Cholescintigraphy (HIDA scan) typically shows delayed or absent uptake of radioactive tracer in the gallbladder; a HIDA scan is primarily used to diagnose cystic duct obstruction if RUQ ultrasound fails to show gallstones. In uncomplicated cholecystitis, cholestasis parameters (i.e., ALP, GGT, and bilirubin) are typically normal or only mildly elevated because there is usually no obstruction of the hepatic ducts or common bile duct.

Question 55

A 58-year-old woman comes to the emergency department because of a 2-day history of worsening upper abdominal pain. She reports nausea and vomiting, and is unable to tolerate oral intake. She appears uncomfortable. Her temperature is 38.1°C (100.6°F), pulse is 92/min, respirations are 18/min, and blood pressure is 132/85 mm Hg. Examination shows yellowish discoloration of her sclera. Her abdomen is tender in the right upper quadrant. There is no abdominal distention or organomegaly. Laboratory studies show:

Hemoglobin 13 g/dL
Leukocyte count 16,000/mm3
Serum
Urea nitrogen 25 mg/dL
Creatinine 2 mg/dL
Alkaline phosphatase 432 U/L
Alanine aminotransferase 196 U/L
Aspartate transaminase 207 U/L
Bilirubin
Total 3.8 mg/dL
Direct 2.7 mg/dL
Lipase 82 U/L (N = 14–280)

Ultrasound of the right upper quadrant shows dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder. The pancreas is not well visualized. Intravenous fluid resuscitation and antibiotic therapy with ceftriaxone and metronidazole are begun. Twelve hours later, the patient appears acutely ill and is not oriented to time. Her temperature is 39.1°C (102.4°F), pulse is 105/min, respirations are 22/min, and blood pressure is 112/82 mm Hg. Which of the following is the most appropriate next step in management?

CT scan of the abdomen
Laparoscopic cholecystectomy
Magnetic resonance cholangiopancreatography
Percutaneous cholecystostomy
Extracorporeal shock wave lithotripsy
Endoscopic retrograde cholangiopancreatography

Answer 55

Endoscopic retrograde cholangiopancreatography

Biliary drainage via endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for acute cholangitis. In mild cases that respond well to antibiotic therapy, ERCP is an elective procedure that takes place 24–48 hours after clinical improvement. In patients who do not respond well to antibiotics or who have severe cholangitis (e.g., signs of sepsis), ERCP should be performed emergently. This patient has mental status changes, tachypnea, tachycardia, and a higher fever and lower blood pressure than on admission despite treatment with ceftriaxone and metronidazole, making her a candidate for immediate ERCP.

If ERCP is not possible in this patient, the next step would be percutaneous transhepatic biliary drainage, as it would more reliably drain the entire biliary tree. ERCP itself can actually cause acute cholangitis as a complication, although this is a rare occurrence.

Question 56

A 57-year-old man is brought to the emergency department because of a 2-day history of fever and right upper quadrant abdominal pain. Examination shows jaundice. Ultrasonography of the abdomen shows cholelithiasis and marked dilation of the biliary duct. An ERCP is performed and reveals pus with multiple brown concrements draining from the common bile duct. Which of the following is the most likely underlying cause of the patient’s findings?

Increased alanine aminotransferase activity
Decreased UDP-glucuronyl transferase activity
Decreased heme oxygenase activity
Decreased HMG-coenzyme A reductase activity
Increased cholesterol 7-α hydroxylase activity
Increased β-glucuronidase activity

Answer 56

Increased β-glucuronidase activity

Increased β-glucuronidase activity and subsequent deconjugation of direct bilirubin are most likely responsible for the formation of this patient’s brown pigment gallstones. β-glucuronidase is produced by enteric bacteria and catalyzes the production of unconjugated bilirubin, which is then reabsorbed and recycled, increasing the risk of formation of brown pigment gallstones.

Question 57

A 42-year-old woman is brought to the emergency department because of intermittent sharp right upper quadrant abdominal pain and nausea for the past 10 hours. She vomited three times. There is no associated fever, chills, diarrhea, or urinary symptoms. She has two children who both attend high school. She appears uncomfortable. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2. Her temperature is 37.0°C (98.6°F), pulse is 100/min, and blood pressure is 140/90 mm Hg. She has mild scleral icterus. The abdomen is soft and nondistended, with tenderness to palpation of the right upper quadrant without guarding or rebound. Bowel sounds are normal. Laboratory studies show:

Hemoglobin 14 g/dL
Leukocyte count 9000 mm3
Platelet count 160,000 mm3
Serum
Alkaline phosphatase 238 U/L
Aspartate aminotransferase 60 U/L
Bilirubin
Total 2.8 mg/dL
Direct 2.1 mg/dL

Which of the following is the most appropriate next step in diagnosis?

CT scan of the abdomen
Supine and erect x-rays of the abdomen
Transabdominal ultrasonography
Endoscopic retrograde cholangiopancreatography
HIDA scan of the biliary tract
Upper gastrointestinal series

Answer 57

Transabdominal ultrasonography

Transabdominal ultrasonography is the best next step to diagnose choledocholithiasis. Although transabdominal ultrasound only directly visualizes stones in the bile duct in 25–55% of cases, the diagnosis can often be inferred indirectly from a dilation of the bile duct. It is a low-risk, noninvasive, low-cost, and easily accessible diagnostic tool that is readily available in most hospital settings and can help with risk stratification of patients with choledocholithiasis. Therefore, it is the next best step for patients with suggestive clinical features (acute intermittent RUQ pain), risk factors for cholelithiasis, and cholestatic labs, as in this case.

The next step following transabdominal ultrasonography depends on the overall risk of choledocholithiasis based on clinical presentation, labs, and ultrasound results. High-risk patients proceed to ERCP followed by interval cholecystectomy. Intermediate risk patients may undergo further diagnostic testing (MRCP or endoscopic ultrasound) or laparoscopic cholecystectomy with intraoperative cholangiography. When suspicion for choledocholithiasis is low, but ultrasound demonstrated gallstones or sludge, patients should undergo laparoscopic cholecystectomy without further imaging.

Question 58

A 52-year-old woman comes to the office because of a 4-day history of intermittent right-sided abdominal pain. The pain occurs 2–3 hours after meals and lasts 1-2 hours; it is not accompanied by fever or chills. One month ago, she underwent a percutaneous coronary intervention for an anterior-wall myocardial infarction. Since then, she has been following a rehabilitation regimen to work on her exercise capacity; she is currently able to climb one flight of stairs without shortness of breath. She has coronary artery disease, hypercholesterolemia, and insulin-dependent type 2 diabetes mellitus. She is 160 cm (5 ft 3 in) tall and weighs 88 kg (194 lb); BMI is 34 kg/m2. Abdominal examination shows no tenderness to palpation. Laboratory studies, including liver function tests, are within the reference ranges. ECG shows no signs of acute ischemia or interval changes compared to her last hospitalization. Abdominal ultrasound shows three small, intraluminal gallstones; gallbladder wall thickness is normal. There is no dilation of the intrahepatic or extrahepatic ducts. The patient inquires about the available treatment options for her current condition. In addition to a low-fat diet, which of the following is the most appropriate recommendation for this patient?

Oral bile acid dissolution therapy
Emergency cholecystectomy
Extracorporeal shock wave lithotripsy
Rapid weight loss
Fenofibrate therapy

Answer 58

Oral bile acid dissolution therapy

In patients with uncomplicated symptomatic cholelithiasis who are poor surgical candidates long-term (6–24 months) oral bile acid dissolution therapy with ursodeoxycholic acid (UDCA) is indicated. In addition to a low-fat diet and UDCA therapy, patients should exercise regularly and avoid lithogenic drugs (e.g., estrogen, fibrates). Elective laparoscopic cholecystectomy is the treatment of choice in patients with uncomplicated symptomatic cholelithiasis who have no contraindications for surgery.

Question 59

A 43-year-old woman comes to the emergency department because of a 3-hour history of upper abdominal pain that radiates to her right shoulder and upper back. During this period, she has also had nausea and one episode of nonbloody vomiting. She says the pain is dull and constant. One hour prior to the onset of her current symptoms, she was eating a hamburger and french fries at a local restaurant. She has hypertriglyceridemia and hypertension. She drinks one to two glasses of wine daily. She is 153 cm (5 ft) tall and weighs 92 kg (203 lb); BMI is 39 kg/m2. Her temperature is 36.3°C (97.3°F), pulse is 84/min, respirations are 22/min, and blood pressure is 135/85 mm Hg. The abdomen is soft and there is mild right upper quadrant tenderness to palpation; there is no guarding or rebound. Laboratory studies show a leukocyte count of 9,000/mm3, AST activity of 35 U/L, and ALT activity of 36 U/L; total bilirubin concentration is 0.9 mg/dL. Which of the following is the most likely cause of this patient’s symptoms?

Bacterial infection of the bile ducts
Stone impaction in the common bile duct
Increased intraluminal pressure of the gallbladder
Acute inflammation of the pancreas
Acute inflammation of gallbladder mucosa
Ulcerative lesion of the gastric mucosa

Answer 59

Increased intraluminal pressure of the gallbladder

This patient’s postprandial dull and constant abdominal pain in the RUQ, nausea, and vomiting suggest biliary colic. This condition is caused by increased intraluminal gallbladder pressure as a result of gallbladder contraction against an occluded cystic duct, most commonly due to gallstones. Referred pain to the shoulder and interscapular region, as seen here, can also occur secondary to diaphragmatic irritation via the phrenic nerve. Patients with uncomplicated cholelithiasis usually have normal laboratory values, as seen here; fever and leukocytosis should raise concern for acute cholecystitis or acute cholangitis, and jaundice and hyperbilirubinemia suggest choledocholithiasis (see “Disorders caused by gallstones” table).

Contrary to the name, the pain in biliary colic is not colicky but usually dull and constant.

Question 60

A previously healthy 37-year-old woman, gravida 3, para 2, at 29 weeks’ gestation comes to the physician because of colicky postprandial abdominal pain. Her vital signs are within normal limits. Physical examination shows a uterus consistent in size with a 29-week gestation. Ultrasonography of the abdomen shows multiple 5-mm hyperechoic masses within the gallbladder lumen. Which of the following processes is most likely involved in the pathogenesis of this patient’s condition?

Accelerated gallbladder emptying
Reduced production of cholecystokinin
Decreased caliber of bile duct
Increased secretion of bile acids
Overproduction of bilirubin
Increased secretion of cholesterol

Answer 60

Increased secretion of cholesterol

Beginning in the third trimester of pregnancy, increased circulating estrogen levels result in an increased hepatic cholesterol synthesis and the formation of cholesterol-supersaturated bile. Moreover, higher progesterone levels cause smooth muscle relaxation, decreased and incomplete emptying of the gallbladder, and subsequent bile stasis. Together, cholesterol-rich lithogenic bile and gallbladder stasis predispose to gallstone formation. Similarly, hormone replacement therapy and oral contraceptive use also predispose to cholelithiasis.

Question 61

A 34-year-old woman with Crohn disease comes to the physician because of a 4-week history of nausea, bloating, and epigastric pain that occurs after meals and radiates to the right shoulder. Four months ago, she underwent ileocecal resection for an acute intestinal obstruction. An ultrasound of the abdomen shows multiple echogenic foci with acoustic shadows in the gallbladder. Which of the following mechanisms most likely contributed to this patient’s current presentation?

Increased bilirubin production
Increased hepatic cholesterol secretion
Increased activity of β-glucuronidase
Decreased fat absorption
Decreased motility of the gallbladder
Decreased biliary concentration of bile acids

Answer 61

Decreased biliary concentration of bile acids

Bile acids are normally reabsorbed in the terminal ileum and returned to the liver for reuse via the enterohepatic circulation. Bile acid malabsorption can occur in patients with Crohn disease as they are prone to developing ileitis or complications requiring terminal ileum resection, leading to a decreased concentration of bile acids in the bile. A decreased bile acid to cholesterol ratio causes cholesterol supersaturation and predisposes to cholesterol gallstone formation, which can lead to cholelithiasis and cholecystitis.

Question 62

A 67-year-old woman comes to the physician because of a 5-day history of episodic abdominal pain, nausea, and vomiting. She has coronary artery disease and type 2 diabetes mellitus. She takes aspirin, metoprolol, and metformin. She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2. Her temperature is 38.1°C (100.6°F). Physical examination shows dry mucous membranes, abdominal distension, and hyperactive bowel sounds. Ultrasonography of the abdomen shows air in the biliary tract. This patient’s symptoms are most likely caused by obstruction at which of the following locations?

Third part of the duodenum
Distal ileum
Hepatic duct
Proximal jejunum
Pancreatic duct

Answer 62

Distal ileum

Gallstone ileus is a rare complication of cholecystitis in which a cholecystoenteric fistula forms, through which air can enter the biliary tree. Gallstones can also pass through into the bowel lumen, leading to bowel obstruction and gallstone ileus. The distal ileum is separated from the large intestine by the ileocecal valve, which is the narrowest part of the small intestine and hence the most likely location for gallstone obstruction. Other causes of distal ileal obstruction include fecaliths, Meckel diverticulum, and intussusception.

Question 63

A 38-year-old woman is brought to the emergency department because of three 1-hour episodes of severe, sharp, penetrating abdominal pain in the right upper quadrant. During these episodes, she has had nausea and vomiting. She has no diarrhea, dysuria, or hematuria and is asymptomatic between episodes. She has hypertension and hyperlipidemia. Seven years ago, she underwent resection of the terminal ileum because of severe Crohn disease. She is 155 cm (5 ft 2 in) tall and weighs 79 kg (175 lb); BMI is 32 kg/m2. Her temperature is 36.9°C (98.5°F), pulse is 80/min, and blood pressure is 130/95 mm Hg. There is mild scleral icterus. Cardiopulmonary examination shows no abnormalities. The abdomen is soft, and there is tenderness to palpation of the right upper quadrant without guarding or rebound. Bowel sounds are normal. The stool is brown, and test for occult blood is negative. Laboratory studies show:

Hemoglobin 12.5 g/dL
Leukocyte count 9,500 mm3
Platelet count 170,000 mm3
Serum
Total bilirubin 4.1 mg/dL
Alkaline phosphatase 348 U/L
AST 187 U/L
ALT 260 U/L

Abdominal ultrasonography shows a normal liver, a common bile duct caliber of 10 mm (N < 6) and a gallbladder with multiple gallstones and no wall thickening or pericholecystic fluid. Which of the following is the most likely cause of these findings?

Primary biliary cholangitis
Choledocholithiasis
Acute cholangitis
Primary sclerosing cholangitis
Cholecystitis
Pancreatitis

Answer 63

Choledocholithiasis

Choledocholithiasis most commonly develops as a complication of cholelithiasis. A gallstone that has become lodged in the common bile duct (CBD) can cause colicky pain and biliary obstruction. Patients with choledocholithiasis develop dark urine and pale stool because bilirubin cannot pass through the occluded biliary tract into the intestine, and is excreted with the urine instead. However, these changes are not always apparent in early stage biliary obstruction (e.g., acholic stool may not have passed through the bowel yet). CBD dilation is used as a proxy for suspected obstruction because CBD stones are rarely seen on ultrasound. This patient should undergo an ERCP to confirm the diagnosis of choledocholithiasis and remove the stone. Otherwise, she is at risk of developing ascending cholangitis or biliary pancreatitis (if the stone becomes stuck in the ampulla of Vater and obstructs the pancreatic duct). Also, this patient should undergo gallbladder removal to prevent any future passing of stones.

Question 64

Fourteen days after a laparoscopic cholecystectomy for cholelithiasis, a 45-year-old woman comes to the emergency department because of persistent episodic epigastric pain for 3 days. The pain radiates to her back, occurs randomly throughout the day, and is associated with nausea and vomiting. Each episode lasts 30 minutes to one hour. Antacids do not improve her symptoms. She has hypertension and fibromyalgia. She has smoked 1–2 packs of cigarettes daily for the past 10 years and drinks 4 cans of beer every week. She takes lisinopril and pregabalin. She appears uncomfortable. Her temperature is 37.0°C (98.6° F), pulse is 84/min, respirations are 14/min, and blood pressure is 127/85 mm Hg. Abdominal examination shows tenderness to palpation in the upper quadrants without rebound or guarding. Bowel sounds are normal. The incisions are clean, dry, and intact. Serum studies show:

AST 80 U/L
ALT 95 U/L
Alkaline phosphatase 213 U/L
Bilirubin, total 1.9 mg/dL
Direct 0.7 mg/dL
Amylase 52 U/L

Abdominal ultrasonography shows a common bile duct measuring 11 mm in diameter and no gallstones. Which of the following is the most appropriate next step in management?

Counseling on alcohol cessation
Endoscopic retrograde cholangiopancreatography
Helicobacter pylori stool antigen testing
Proton pump inhibitor therapy
Reassurance and follow-up in 4 weeks
CT scan of the abdomen

Answer 64

Endoscopic retrograde cholangiopancreatography

This patient with postcholecystectomy syndrome has elevated cholestatic parameters and a dilated common bile duct (> 10 mm). These findings can be due either to residual gallstones within the biliary tree or sphincter of Oddi dysfunction (SOD). Although there were no gallstones seen in the common bile duct on abdominal ultrasound, this does not exclude choledocholithiasis because intraductal stones and microliths may be difficult to visualize. An ERCP with sphincterotomy should be performed as ERCP is highly sensitive for most causes of biliary dysfunction and sphincterotomy is indicated for this patient with biliary-type pain, abnormal liver function tests, and a dilated common bile duct. ERCP with sphincter of Oddi manometry is indicated prior to sphincterotomy in patients with less distinct features of SOD (i.e., biliary-type pain but normal common bile duct or cholestatic parameters). While magnetic resonance cholangiopancreatography (MRCP) is an acceptable alternative test for the evaluation of postcholecystectomy syndrome, ERCP is preferred when an intervention is planned, as in this patient.