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A Blind loop syndrome

BPyelonephritis

CRecurrent Crohn's disease

DIntra -abdominal abscess

EPseudomembranous enterocolitis View Answer

23.After successful surgery and discharge from the hospital, which of the following is true?

AIf the diseased bowel is removed, therapy with prednisone and metronidazole can best prevent a recurrence.

BThe chance of a cure is greater than 60%.

CThe recurrence rate is higher than 50% during the next 5–10 years.

DIf the terminal ileum is removed, the risk of a recurrence is less.

EIf the terminal ileum is removed, the patient will require long-term therapy with oral iron to prevent anemia. View Answer

Questions 24–25

A 63 -year -old man presents with a 3-day history of increasing cramping abdominal pain, constipation, and intermittent vomiting. He continues to pass gas. Other than the present complaints, he has been healthy. Examination reveals a distended abdomen with high-pitched bowel sounds. No localized tenderness and no rectal masses are present. The stool is heme positive.

24.Diagnostically, the first step should be to perform which of the following?

A Total colonoscopy

B Mesenteric angiography

C Flat plate and erect abdominal radiographs

D Upper gastrointestinal radiographs with small bowel follow-through E Barium enema

View Answer

25.Therapeutically, the first step should be which of the following?

A A Fleet enema, clear liquids by mouth, and careful observation

B Emergency colonoscopy for colonic decompression

C Intravenous fluids, nasogastric suction, and careful observation

D Colonoscopic decompression with use of a rectal tube, if necessary

E Immediate exploratory laparotomy

View Answer

Questions 26–27

A 60 -year -old patient who is finishing a course of antibiotic therapy for bacterial pneumonia develops cramping abdominal pain and profuse watery diarrhea. A diagnosis of pseudomembranous or antibiotic -associated colitis is suspected.

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26. Which of the following is the quickest way to establish the diagnosis ?

A Stool culture B Barium enema

C Stool titer for Clostridium difficile toxin

DProctoscopy

EBlood culture View Answer

27.What would the initial treatment involve?

A Metronidazole B Vancomycin C Imodium

D Cephalexin

E Total abdominal colectomy View Answer

28.During exploration for a transverse colon tumor, a surgeon incidentally notices a 2-cm diverticulum of the small bowel located 2 ft proximal to the ileocecal valve. Which of the following statements are not true?

A This diverticulum should be resected when found due to an associated increased risk of malignancy

B This is an example of the most common type of diverticulum of the gastrointestinal tract, present in 2% of the population C It is more commonly found in men than women

D When symptomatic in children, it presents as a source of bleeding E It can cause obstruction via intussusception

View Answer

29.A 55 -year-old man presents with a 24 -hour history of increasingly severe left lower quadrant abdominal pain. On examination, he has tenderness localized in the left lower quadrant with rebound. Fever and leukocytosis are present. The clinical suspicion of diverticulitis would best be confirmed by which of the following?

A Barium enema B Colonoscopy

C CT scan of the abdomen and pelvis

D Magnetic resonance imaging of the abdomen and pelvis E Chest radiograph

View Answer

30.A 45 -year-old woman with diabetes presents with a 2-day history of acute perirectal pain. On examination, a tender fluctuant mass is present to the left of the anus. What treatment should be administered at this time?

A Broad -spectrum antibiotic therapy

B Abscess drainage and excision of the fistulous tract C Incision and drainage of the abscess

D Continued observation

E Treatment of Crohn's disease View Answer

Questions 31–32

A 34 -year -old female patient in previous good health presents in the emergency department with spontaneous intraperitoneal hemorrhage. Her only medication is an oral contraceptive that she has been taking for the past 5 years. During resuscitation, a bedside ultrasound reveals a large amount of intraperitoneal blood and a 3-cm mass in the right lobe of the liver.

31. What is the likely cause of her hemorrhage?

AHepatoma

BHemangioma

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C Focal nodular hyperplasia

D Hepatic cell adenoma

E Metastatic neoplasm

View Answer

The patient continues to bleed and requires transfusion.

32.What further treatment should be undertaken?

A Observation in the intensive care unit B Right hepatic artery ligation

C Right hepatic lobectomy

D Angiographic embolization of hepatic artery E CT portogram

View Answer

33.A 45 -year-old man presents to the emergency room with 24 hours of left lower quadrant abdominal pain. Examination reveals fever and focal tenderness in the left lower quadrant but no generalized peritoneal signs. CT scan reveals a collection containing air and fluid. Optimal management of this patient includes which of the following?

A Admission for intravenous antibiotics and serial abdominal exams

B Urgent operation with resection of diseased bowel and primary anastomosis C Urgent operation with resection of diseased bowel and diverting colostomy

D Colonoscopy to rule out the possibility of a perforated cancer followed by CT-guided drainage E CT-guided drainage followed by bowel resection once the patient has fully recovered

View Answer

Questions 34–36

A 52 -year -old alcoholic man with known cirrhosis presents to the emergency department with hematemesis.

34. After resuscitation and stabilization, which procedure should take place?

AArteriography

BUpper gastrointestinal series

CEndoscopy

DTagged red cell scan

ELiver biopsy

View Answer

Work-up reveals acutely bleeding esophageal varices.

35. What should the next treatment be ?

A Transjugular intrahepatic portosystemic shunt

B Emergency portacaval shunt

CSplenectomy

DSclerotherapy

EGastroesophageal devascularization View Answer

After appropriate therapy, the bleeding ceases and the patient stabilizes. He is found to be a Child's C alcoholic cirrhotic who has been abstinent for 1 year. Evaluation for an orthotopic liver transplant has begun.

36. If his variceal bleeding recurs, it could be managed by all except which of the following?

A Portacaval shunt B Mesocaval shunt C Sclerotherapy

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D Transjugular intrahepatic portosystemic shunt

E Selective Warren shunt

View Answer

37. A 73 -year-old previously healthy man presents to the emergency room with several days of jaundice followed by 12 hours of right upper quadrant pain and fever. He is mildly hypotensive. CT scan of the abdomen reveals dilatation of the biliary tree. The next step in management includes which of the following?

A Laparoscopic cholecystectomy

B Open cholecystectomy and T tube placement

C Open cholecystectomy and choledochojejunostomy

D Fluid resuscitation, antibiotics, and endoscopic retrograde cholangiopancreatography (ERCP) E Fluid resuscitation and hepatitis serologies

View Answer

Questions 38–39

A 33 -year -old man with no significant past medical history presents to the emergency room with abdominal pain and nausea. He is afebrile, and laboratory studies reveal a serum amylase level of 1200 U/L.

38.Which of the following would not be part of initial management ?

A Intravenous hydration

B Nasogastric decompression

C Abdominal imaging with ultrasound and/or CT scan D ERCP to evaluate pancreatic duct anatomy

E Intravenous narcotic pain medicine View Answer

39.Ten days into his course of pancreatitis, this patient is found to have a fluid collection measuring 4 cm in diameter near the tail of his pancreas. He had a recurrence of his abdominal pain when he was restarted on a diet 2 days prior but is otherwise asymptomatic. He remains on total parenteral nutrition. Appropriate management of this collection would include which of the following?

A CT-guided aspiration to assess for infection

B Endoscopic drainage via an ultrasound -guided cystogastrostomy C Operative debridement and external drainage

D CT-guided percutaneous drainage E Observation alone

View Answer

40.A 59 -year-old patient undergoes exploration for a 4-cm mass in the head of the pancreas that has caused obstructive jaundice. The patient had a biliary stent endoscopically placed prior to the procedure with complete resolution of jaundice. At the time of surgery, two small liver metastases are noted. Which of the following is not part of appropriate management at this point?

A Transduodenal pancreatic biopsy B Hepaticojejunostomy

C Gastrojejunostomy D Cholecystectomy

E Celiac ganglion nerve block View Answer

41.A 65 -year-old patient presents with a history significant for obstructive jaundice and weight loss. A workup reveals a 2.5-cm mass in the head of the pancreas; needle aspiration reveals adenocarcinoma. Which of the following findings on preoperative CT scan would preclude operative exploration for curative resection?

A Presence of replaced right hepatic artery

B Loss of fat plane between tumor and portal vein

C Loss of fat plane between tumor and superior mesenteric artery

D Occlusion of gastroduodenal artery

E Occlusion of superior mesenteric vein

View Answer

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Directions: The group of items in this section consists of lettered options followed by a set of numbered items. For each item, select the lettered option(s) that is(are) most closely associated with it. Each lettered option may be selected once, more than once, or not at all.

Match the portion of the stomach, duodenum, or pancreas to the appropriate arterial supply.

42.Body and tail of pancreas

A Left gastric artery

B Right gastroepiploic artery C Splenic artery

D Vasa brevia (short gastric arteries) E Superior mesenteric artery

View Answer

43.Duodenum and head of pancreas

A Left gastric artery

B Right gastroepiploic artery

C Splenic artery

D Vasa brevia (short gastric arteries)

E Superior mesenteric artery

View Answer

44.Proximal lesser curvature of stomach

A Left gastric artery

B Right gastroepiploic artery C Splenic artery

D Vasa brevia (short gastric arteries) E Superior mesenteric artery

View Answer

45.Distal greater curvature of stomach

A Left gastric artery

B Right gastroepiploic artery

C Splenic artery

D Vasa brevia (short gastric arteries)

E Superior mesenteric artery

View Answer

46. Fundus of stomach

A Left gastric artery

B Right gastroepiploic artery C Splenic artery

D Vasa brevia (short gastric arteries) E Superior mesenteric artery

View Answer

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Answers and Explanations

1. The answer is B (Chapter 9, I C 6 b). The iliopsoas sign is pain in the lower abdomen and psoas region that is elicited when the thigh is flexed against resistance. It suggests an inflammatory process, such as appendicitis. Crepitus suggests a rapidly spreading gas -forming infection. Murphy sign is elicited by palpating the right upper quadrant during inspiration and suggests acute cholecystitis. Flank and periumbilical ecchymoses suggest retroperitoneal hemorrhage.

2. The answer is D (Chapter 9, IV C 2 b (1)). The most likely cause of massive lower gastrointestinal bleeding in the absence of diverticula is an angiodysplastic lesion of the colon, particularly the right colon. An upper gastrointestinal series

and small bowel studies should be done only after an exhaustive colonic workup has failed to demonstrate the source of bleeding. Colonoscopy in the face of massive bleeding is unreliable and difficult and carries the risk of colonic perforation. In addition, it will not usually demonstrate an angiodysplastic lesion. A repeat barium enema is also unlikely to help. The most helpful study in this patient would be selective mesenteric angiography.

3.The answer is C (Chapter 9, I C 3 d (5)). The history described would be more typical for either testicular torsion or acute epididymitis, of which only torsion represents a surgical emergency. Torsion of the testicle is likely the result of an abnormal attachment of the tunica vaginalis around the cord that allows the testis to twist (bell-clapper deformity). Compromise of the blood supply causes exquisite pain and produces gangrene and atrophy of the testis unless the torsion is treated immediately. Torsion is usually seen in young males, most often occurring spontaneously and even during sleep. It is associated with an onset of severe pain and is accompanied by nausea, vomiting, and abdominal pain. Acute prostatitis may present with vague abdominal pain. A more typical presentation for appendicitis would be pain preceded by nausea or anorexia. This presentation is not typical for gastroenteritis (which is not a surgical emergency).

4.The answer is B (Chapter 10, II B ). This patient is presenting with classic symptoms of achalasia. The dysphagia to both solids and liquids is classic, as is the bird -beak narrowing on radiographs. The underlying defect is failure of the lower esophageal sphincter to relax, causing increased pressure in the esophagus and dysfunctional swallowing. Disorganized, strong nonperistaltic contractions in the esophagus are characteristic of diffuse esophageal spasm. Strictures typically have dyspahgia to solids well before liquids cause symptoms.

5.The answer is B (Chapter 9, Table 9-1). Massive upper gastrointestinal bleeding is usually due to a bleeding source proximal to the ligament of Treitz. The cause is most likely to be a posterior duodenal ulcer that is eroding into the gastroduodenal artery. Gastritis, esophagitis, a Mallory-Weiss tear, and esophageal varices are less likely causes of massive upper gastrointestinal bleeding.

6.The answer is C (Chapter 9, IV B , C). Arteriography is most often used as the initial evaluation step for continued bleeding after anorectal bleeding sources have been eliminated by endoscopy. Arteriography allows identification of diverticular bleeding as well as an angiodysplastic lesion of the right colon. Surgery is generally not indicated until four to six units of blood have been shed. Coagulation products are of no use unless the patient has abnormal clotting studies. Saline lavage of the colon is not a routine procedure.

7.The answer are 7-C (Chapter 9, III E 1). Upper endoscopy is the most reliable method for precisely locating the site of upper gastrointestinal bleeding. Endoscopy can almost always be used unless bleeding is massive. Patients who are unstable or have blood losses requiring more than six units of blood within a 24 -hour period require surgical intervention. Unstable patients should not typically be transported to interventional radiology. A Blakemore tube is only useful for bleeding esophageal varices. This patient, who does not have a history indicative of cirrhosis, is unlikely to have bleeding from varicies.

8.The answer are 8-d (Chapter 11, IV B ). Upper endoscopy is the most reliable method for precisely locating the site of upper gastrointestinal bleeding. Endoscopy can almost always be used unless bleeding is massive. Patients who are unstable or have blood losses requiring more than six units of blood within a 24 -hour period require surgical intervention. Unstable patients should not typically be transported to interventional radiology. A Blakemore tube is only useful for bleeding esophageal varices. This patient, who does not have a history indicative of cirrhosis, is unlikely to have bleeding from varicies.

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9.The answer is C (Chapter 9, II A 3 a). Obstructing adhesive bands after abdominal surgery are the most common cause of intestinal obstruction. They may be diffuse or solitary. A partial small bowel obstruction often responds to conservative management with nasogastric decompression and hydration. Complete small bowel obstruction typically requires operative intervention.

10.The answer is E (Chapter 9, I F 1 c [1] ). Free air within the peritoneal cavity signals perforation of a hollow viscus. It is present in about 80% of gastroduodenal perforations. Because free peritoneal air is rarely secondary to other causes, additional studies in this patient would not be necessary before laparotomy.

11.The answer is C (Chapter 10, II A 3–4 ). This patient's symptoms are consistent with a Zenker's diverticulum. A barium swallow would be diagnostic but not therapeutic. Endoscopy is contraindicated secondary to the risk of diverticular perforation by the endoscope. Surgical myotomy of the cricopharyengeous muscle with resection or suspension of the diverticulum is the treatment of choice. Computed tomography (CT) scan of the chest is not necessary. Changing the diet would not alter the underlying pathology.

12.The answer is A (Chapter 10, II D 4). Development of esophageal strictures is an indication for surgical antireflux