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1. A 2-cm gastric ulcer in the antrum of the stomach is associated
with all of the following EXCEPT
•
•
•
•
•
H. pylori infection
Increased acid secretion
Malignancy
NSAIDs
Atrophic gastritis
1. Answer B
Gastric ulcer classification
I (50%): body/antrum of stomach, along lesser
curvature
Low to normal acid levels
Tx with antrectomy
II (25%): type I + duodenal ulcer
High acid levels
Tx with vagotomy, antrectomy
III (15%): prepyloric
High acid levels
Tx with vagotomy, antrectomy
IV: close to GE jxn
Low to normal acid levels
V: anywhere in stomach, drug-associated
2. A generally healthy 35-year-old man has a 6-hour history of
abdominal pain and nausea. He passes a stool containing
mucous and blood. A CT scan is obtained and shown below.
The best therapeutic intervention would be
a.
colonoscopy
b. IV neostigmine
c.
Barium enema
d. Bowel resection and anastamosis
e.
Nasogastric suction and antibiotics
3.
The most common cause of this condition in adults is
a.
b.
c.
d.
e.
Meckel’s diverticulum
Gallstones
Ischemic bowel disease
Crohn’s disease
Gastrointestinal tumor
2. Answer D
3. Answer E
Intussusceptum: proximal portion that invaginates into distal
bowel
Intussuscipiens: recipient, distal bowel into which proximal
bowel invaginates into
Children: under 3 years old, preceded by nonspecific febrile
illness (viral), hypertrophy of Peyer’s patches
Adults: malignancy (lymphoma)
Dx: CT scan
Tx: resection
4. A 58-year-old woman has had no flatus or bowel movement for 2
days, and intermittent vomiting for the past 24 hours. She has had midepigastric pain for the past 3 years, but has never sought treatment. Diet
modification helped decrease the frequency and severity of pain. She has
never had a previous abdominal operation.
Exam demonstrates a distended abdomen with moderate tenderness to
deep palpation but no rebound. No stool or masses are noted on rectal
exam. An abdominal x-ray is shown.
The most likely etiology is
a. tuberculosis
b. fungal
c. inflammatory
d. neoplastic
e. bacterial
5. The patient is taken to the OR and exploration reveals the
finding shown.
The management of choice is
a.
enterotomy
b. adhesiolysis
c. segmental resection
d. peritoneal washings
e.
intestinal bypass
4. Answer C
5. Answer A
Rigler’s triad: abd xray -- SBO, pneumobilia, radioopaque stone
Xray often non-diagnostic
• Etiology: recurrent cholecystitis with
inflammtion and adhesion formation, stone
erodes through gallbladder into adjacent viscus,
usually duodenum
• Distal ileum common site of obstruction
• Tx: resuscitation, OR  enterotomy
proximal to stone
• Not necessary to deal with cholecystoenteric fistula at initial operation,
spontaneously close in many
• Elective cholecystectomy
• Recurrence rate 5%
6. A previously healthy 25-year-old woman has right lower
quadrant pain and fever. CT confirms appendicitis. After an
uneventful appendectomy, the patient is discharged. The
final report on CT describes a 2.0 cm left adrenal mass.
The patient is asymptomatic. Which of the following is NOT
appropriate?
a.
dexamethasone suppression test
b. measurement of serum potassium and plasma
aldosterone concentration/plasma renin activity ratio
c.
fine-needle aspiration biopsy
d. adrenalectomy if the tumor is functional
follow-up CT in 6 to 12 months
6. Answer C
Adrenalectomy for lesions > 6 cm
Nonfunctioning lesions < 4 cm interval CT or MRI at 6
months and 1 year
4-6 cm adrenalectomy or close observation
90% benign
 r/o subclinical hypercortisolism
 1-mg dexamethasone suppression test overnight
 8 AM plasma cortisol > 3 mg/dL (failure to suppress)
 chk 24-hour urinary free cortisol and plasma ACTH




Aldosteronoma least common
screened for only in patients with HTN or hypokalemia
serum potassium, plasma aldosterone/plasma renin (>20)
confirm with 24-hour urinary aldosterone levels
 Pheochromocytoma
 fractionated urinary and/or plasma catecholamines,
metanephrines, and urinary vanillylmandelic acid (VMA)
 Preoperative α-adrenergic blockade with
phenoxybenzamine
- administered for at least 1 week before operation
- Side effects: reflex tachycardia, nasal congestion
 intravenous fluids
 β-Adrenergic blockade for reflex tachycardia
- do not give until adequate α-blockade established
7. A 43-year-old man with alcoholic cirrhosis has had two
episodes of variceal hemorrhage treated acutely with
sclerotherapy. Lab values are as follows: albumin 3.3 g/dL; total
bilirubin 1.2 mg/dL, alkaline phosphatase 120units/mL, PT 12
sec (control 11.5 sec), PTT 36 sec, aspartate amino transferase
30 units/L, and alanine amino transferase 25 units/L. He has no
ascites and has never been encephalopathic. Appropriate
management at this time might include each of the following
EXCEPT
a.
b.
c.
d.
e.
distal spleno-renal shunt
endoscopic rubber band ligation
transjugular intrahepatic portosystemic shunt
orthotopic liver transplantation
small diameter H portocaval shunt
7. Answer D
Pt is Child’s class A
Child’s-Pugh Classification (A BATH)
Score
Ascites
(grade)
Bilirubin
(mg/dl)
Albumin
(gm/dl)
PT
(sec
prolonged)
Hepatic
encephalopathy
1
None
<2
> 3.5
<4
None
2
Mild
2-3
2.8 - 3.5
4-6
1-2
3
Severe
>3
< 2.8
>6
3-4
A 5 – 6 Life expectancy: 15 to 20 years, abdominal surgery peri-operative
mortality: 10%
B 7 – 9 Indicated for liver transplantation evaluation, abdominal surgery perioperative mortality: 30%
C >9
Life expectancy: 1 to 3 years, abdominal surgery peri-operative mortality:
82%
Management of variceal bleedings
Acute: Octreotide, endoscopic ligation, sclerotherapy, balloon
tamponade, TIPS
Portosystemic shunts
• Nonselective shunts: more encephalopathy
End-to-side portacaval: all portal flow diverted into systemic circulation, ascites
persists
Side-to-side portacaval, interposition (16 mm), splenorenal: better at controlling
ascites b/c splanchnic venous and intrahepatic sinusoidal drainage still open
• Selective
Distal splenorenal shunt: Distal splenic vein to left renal vein, ligate collateral
veins, can worsen ascites
• Partial shunts
Meso/Portacaval interposition with small-diameter (8 mm) graft, maintains
hepatic portal perfusion