Abdominal Pain Case 4

A 45-year-old man goes to an emergency department because he is experiencing severe abdominal pain, which is radiating straight through to his back. The pain began several hours after an admitted alcoholic binge, and has not changed in position, although it has become worse.

Q 1

Which of the following would be the most likely cause of this type of pain?

/ A. Acute appendicitis

/ B. Acute hepatitis

/ C. Acute pancreatitis

/ D. Chronic hepatitis

/ E. Myocardial infarction

Q 2

In addition to alcohol use, which of the following is a common predisposing factor for this patient's disease?

/ A. Biliary tract stones

/ B. Duodenal cancer

/ C. Gastric carcinoma

/ D. Kidney stones

/ E. Peptic ulcer

Q 3

Marked serum elevation of which of the following markers would most strongly substantiate the likely diagnosis?

/ A. Acid phosphatase

/ B. Amylase

/ C. Aspartate aminotransferase

/ D. AIkaline phosphatase

/ E. Creatinine kinase

Q 4

The patient has a severe course that requires treatment in an ICU. CIinically, he appears similar to patients with sepsis, with fever, elevated white count, hypotension, increased pulse rate, shallow and rapid breathing, oliguria, and a blunted sensorium, in addition to his pain and abdominal tenderness. These clinical findings are most likely related to which of the following?

/ A. Activation of the inflammatory cascade

/ B. AIcohol withdrawal symptoms

/ C. AIIergic reaction to alcohol

/ D. Drug toxicity effect

/ E. Secondary infection with mixed flora gut bacteria

Q 5

The patient's condition resolves in about two weeks, but he continues to drink after leaving the hospitaI. When seen several years later, he has had a number of similar episodes, and now has chronic severe abdominal pain. CT scan demonstrates a single, smooth-walled, fluid filled space in the tail of the pancreas, which can be reached by the radiologist for CT-guided aspiration with an approach from the back. The fluid aspirated is yellowish, clear, and acellular. Which of the following is the most likely diagnosis?

/ A. Pancreatic microcystic adenoma

/ B. Pancreatic mucinous cystadenocarcinoma

/ C. Pancreatic mucinous cystadenoma

/ D. Pancreatic pseudocyst

/ E. Pancreatic solid-cystic tumor

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Abdominal Pain Case 4 Answers

A1

The correct answer is C. The typical pain described occurs in approximately 50% of patients with acute pancreatitis. Other patients may have milder pain or even, uncommonly, pain first felt in the lower abdomen.

The pain of acute appendicitis (choice A) is often felt first as referred pain near the umbilicus, with tenderness on palpation in the left lower quadrant.

Acute hepatitis (choice B) can cause pain referred to the right shoulder.

Chronic hepatitis (choice D) does not usually cause pain.

Myocardial infarction (choice E) can cause substernal pain and pain radiating to the left shoulder.

A2

The correct answer is A. The overwhelmingly most common predisposing factors for acute pancreatitis are gallstones (more specifically tiny ones that lodge in the extrahepatic bile duct system) and alcohol abuse.

Rarely, nearby cancers (choices B and C) can occlude the pancreatic duct system and cause a secondary acute pancreatitis.

Kidney stones (choice D) have no relationship with pancreatitis.

Peptic ulcers (choice E) that erode into the pancreas can uncommonly secondarily inflame the pancreas

A3

The correct answer is B. The usual markers for pancreatitis are amylase and lipase. Marked elevation of amylase usually means either pancreatic disease or salivary gland disease; lipase will be elevated in pancreatic disease but not salivary gland disease. If you see elevated amylase on a USMLE question, you should think of pancreatitis or salivary gland disease (mumps, salivary gland stone). However, you should be aware, for your general medical knowledge, that modest elevations of amylase can be seen in a much wider variety of settings (often reflecting either subclinical pancreatic damage or hemoconcentration of pancreatic enzymes), including GI obstruction, mesenteric thrombosis and infarction, macroamylasemia (a genetic condition with abnormal amylase), renal disease, ruptured tubal pregnancy, lung cancer, acute alcohol ingestion, and following abdominal surgery.

Associate acid phosphatase (choice A) with diseases involving the prostate and, to lesser degrees, bone, the heart, platelets, and the liver.

Associate aspartate aminotransferase (choice C) with diseases of the heart, muscle, liver, pancreas (though not as important for diagnosis as amylase and lipase), and brain.

Associate alkaline phosphatase (choice D) with diseases of bone, liver, and to lesser degrees, lung and heart.

Associate creatinine kinase (choice E) with diseases of the heart, muscle, brain, and the general body (trauma, surgery).

A4

The correct answer is A. Acute pancreatitis can either be relatively mild, or a severe condition that may cause death. It is thought that, in severe cases, leakage of enzyme-containing pancreatic secretions into the tissues/and or blood stream causes cleavage of precursors, thus strongly activating the complement and inflammatory cascades. These, in turn, produce abundant cytokines, which worsen the symptoms. The clinical result is similar to sepsis, with risk of multi-organ failure and death. The treatment of acute pancreatitis is primarily supportive, and may include careful attention to fluid resuscitation, oxygen supplementation, cardiovascular support, dialysis, management of electrolyte abnormalities, pain control, and total parenteral nutrition.

Alcohol allergy (choice C) or withdrawal (choice B) do not play any additional part in most of these symptoms once the pancreatitis has developed.

Infection (choice E) and drug toxicity (choice D) are also not a necessary part of the clinical picture, although physicians may worry that the patient's general clinical status is masking other, potentially more treatable, problems.

A5

The correct answer is D. Pancreatic pseudocyst is a fairly common complication of both acute and chronic pancreatitis, and appears to develop when trapping of pancreatic digestive juices (containing amylase, lipase, and proteases) causes a "digestion" of part of the pancreas, leaving a fluid filled cystic space. The term "pseudocyst", rather than "cyst", is used by purists because the space does not have an epithelial lining, and is hence not a "true cyst". Pseudocysts are usually solitary and typically measure 5-10 cm in diameter. They can be surgically excised (and the surrounding tissue will typically show evidence of chronic pancreatitis in long-standing cases) or sometimes, if the anatomy is favorable, drained into adjacent hollow viscera. Some are medically managed if small.

Most true neoplasms of the pancreas contain (often large numbers of) smaller, multiple, cysts. These tumors can be benign or malignant, and the ones with mucus-secreting epithelium (choices B and C) are more common than those with a serous lining (choices A and E).

Abdominal Pain Case 2

A 47-year-old woman presents to the emergency department with cra mping/colicky abdominal pain. The current episode of pain began several hours ago, following a fatty meaI. The pain began slowly, and rose in intensity to a plateau over the course of several hours. The patient reports that she had had several other episodes of similar pain during the past several months, with long intervening periods of freedom from pain. On physical examination, she is noted to have tenderness to deep palpation in the right upper quadrant of the abdomen near the rib cage. The patient also reports that she is experiencing shoulder/back pain at a site she identifies near the right lower scapula, but no tenderness can be elicited during the back and shoulder examination.

Q 1

Which of the following organs is the most likely source of this woman's pain?

/ A. Appendix

/ B. Diaphragm

/ C. Esophagus

/ D. Gallbladder

/ E. Stomach

Q 2

Which of the following techniques would be most appropriate to demonstrate the patient's most likely diagnosis?

/ A. Colonoscopy

/ B. CT scan of the abdomen

/ C. Esophagoduodenoscopy

/ D. MRI scan of the abdomen

/ E. UItrasonography

Q 3

Following appropriate diagnostic studies, the patient is taken to the surgical suite. During the surgery, the surgeon inserts his fingers from

right to left behind the hepatoduodenal ligament. As he does so, his fingers enter which of the following?

/ A. Ampulla of Vater

/ B. Common bile duct

/ C. Epiploic foramen

/ D. Greater peritoneal sac

/ E. Portal vein

Q 4

During the cholecystectomy, the surgeon ligates the cystic artery. This is typically a branch of which of the following?

/ A. Gastroduodenal artery

/ B. Left gastroepiploic artery

/ C. Right gastroepiploic artery

/ D. Right hepatic artery

/ E. Superior pancreaticoduodenal artery

Q 5

Pathologic examination of the specimen removed by the surgeon demonstrates the presence of numerous yellow stones (shown above).

These are most likely composed primarily of which of the following?

/ A. Bilirubinate

/ B. Calcium phosphate

/ C. Cholesterol

/ D. Cystine

/ E. Struvite

Q 6

If this patient had a small stone lodge near the ampulla of Vater, which of the following complications would be most likely to occur?

/ A. Crohn disease

/ B. Diabetes mellitus

/ C. Pancreatitis

/ D. Peptic ulcer

/ E. Polyarteritis nodosa

Q 7

If this patient had refused surgical treatment, which of the following would be the most appropriate pharmacotherapy to provide definitive

treatment and thereby relieve associated pain?

/ A. Ampicillin

/ B. CIofibrate

/ C. Meperidine

/ D. Oxycodone

/ E. Ursodiol

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Abdominal pain Case 2 Answers

A1

The correct answer is D. This woman most likely has gallstones. Cholelithiasis, or the formation of calculi (gallstones) within the gallbladder, is very common in the United States, with over 500,000 cholecystectomies being performed yearly. While many cases of gallstone disease are symptomatic, right upper quadrant pain with referral of the pain to the lower right scapula should specifically suggest gallbladder disease. The pattern of episodes of several hours of pain followed by long periods of freedom from pain is also typical of symptomatic gallstone disease.

The appendix (choice A) would most likely cause lower abdominal pain.

Pain from irritation of the diaphragm (choice B) can cause right upper quadrant pain and referred pain in the supraclavicular area (rather than the subscapular pain of biliary colic). The absence of right upper quadrant tenderness to palpation, and the history of pain after a fatty meal also argue against this diagnosis.

Esophageal pain (choice C) related to regurgitation of gastric contents (heartburn) can occur postprandially, but tends to radiate into the neck, throat, or even face.

Peptic ulcer pain of gastric origin (choice E) is usually described as causing burning, gnawing, or hunger, and may be relieved by eating.

A2

The correct answer is E. Real-time ultrasonography, with 98% sensitivity and 95% specificity, is considered the method of choice for diagnosing possible gallbladder stones.

Colonoscopy (choice A) and esophagoduodenoscopy (choice C) might be helpful for excluding alternative diagnoses, but would not themselves establish a diagnosis of gallstone disease.

CT (choice B) and MRI (choice D) scans of the abdomen are expensive tests whose use is not warranted, since real-time ultrasonography performs as well or better.

A3

The correct answer is C. The space behind the stomach, hepatoduodenal ligament, and hepatogastric ligament is the omental bursa. This space can be entered by passing through the epiploic foramen of Winslow, as described in the question stem.

The common bile duct enters the duodenum through the ampulla of Vater (choice A).

The hepatoduodenal ligament contains the common bile duct (choice B), the portal vein (choice E), and the hepatic artery.

The greater peritoneal sac (choice D) lies anterior to the stomach and hepatoduodenal ligament.

A4

The correct answer is D. The cystic artery is generally a branch of the right hepatic artery.

The gastroduodenal artery (choice A) is a branch of the (common) hepatic artery.

The left gastroepiploic artery (choice B) is a branch of the splenic artery.

The right gastroepiploic artery (choice C) is a branch of the gastroduodenal artery.

The superior pancreaticoduodenal artery (choice E) is a branch of the gastroduodenal artery.

A5

The correct answer is C. The stones are gallstones, and their yellow color indicates that they are composed of cholesterol. Cholesterol stones are the most common form of gallstones. Risk factors include female sex, multiparity, obesity, increased age (female, fat, forty, and fertile) and North American Indian race.

Bilirubinate (choice A) gallstones, which are usually associated with hemolytic anemias, are less common, brown, rather than yellow, and often faceted.

Calcium phosphate (choice B), cystine (choice D), and struvite (choice E) composition can be seen in kidney stones

A6

The correct answer is C. A small gallstone obstructing the pancreatic outflow is a well-known cause of acute pancreatitis. The other conditions listed are not caused by gallstones

A7

The correct answer is E. The question is asking, "Which of the following will eradicate a gallstone?" When a gallstone is eliminated the pain will subsequently be eliminated. This question is NOT asking, "which of the following is the most appropriate form of pain control?". Ursodiol (ursodeoxycholic acid) is a hydrophilic bile acid that is used to dissolve small (<>

Analgesics and antibiotics, such as ampicillin (choice A), are administered when appropriate, but do not help eradicate the stones.

Clofibrate (choice B) is an antihyperlipidemic that is associated with the development of gallstones. High-risk patients, such as diabetics and the elderly, should be watched closely.

As a side note, if this question were asking: "which of the following is the most appropriate form of pain control in this patient", the most appropriate answer would be meperidine. Meperidine (choice C) is the narcotic of choice since it causes the least amount of spasm of the sphincter of Oddi. In other words, meperidine is preferred over oxycodone (choice D).

Gastrointestinal Bleeding case 5

A 47-year-old, darkly pigmented man with a known history of alcohol abuse begins vomiting large quantities of blood and is brought by ambulance to the emergency department.

Q 1

In the emergency department, the man is found to have a temperature of 36.7 C (98.1 F), blood pressure of 65/40 mm Hg and dropping rapidly, a weak pulse of 130/min, and respirations of 29/min. These vital signs suggest that which of the following is developing?

/ A. Congestive heart failure

/ B. Meningitis

/ C. Pneumonia

/ D. Septicemia

/ E. Shock

Q 2

A blood sample is drawn and an IV Iine is started. While the patient is being cross-matched, the physical examination is continued. The patient's sclerae are noted to be icteric and his nail beds and palms have a yellowish hue. A caput medusa

is noted. Which of the following is the most accurate description of a caput medusa?

/ A. Ecchymoses over the mastoid process

/ B. Paradoxical increase in venous distension and pressure during inspiration

/ C. Reflex movement of the eyes in the opposite direction to that in which the head is moved

/ D. Small bony masses found on the terminal phalanges

/ E. Varicose veins radiating from the area of the umbilicus

Q 3

Caput medusa specifically suggests which of the following diagnoses?

/ A. BIadder infection

/ B. Duodenal ulcer

/ C. Gastric ulcer

/ D. Pancreatitis

/ E. Portal hypertension

Q 4

Which of the following is the most common cause of this patient's disorder in the United States?

/ A. Hepatic cirrhosis

/ B. Hepatic vein thrombosis

/ C. Hepatocellular carcinoma

/ D. Metastatic disease to the liver

/ E. Portal vein thrombosis

Q 5

Endoscopic studies demonstrate that this patient has bleeding esophageal varices, and the bleeding is successfully stopped with

sclerotherapy. What percentage of patients with bleeding esophageal varices have another episode of variceal bleeding at a subsequent

time?

/ A. 5%

/ B. 25%

/ C. 40%

/ D. 70%

/ E. 95%

Q 6

Following blood transfusions and sclerotherapy, the patient initially feels reasonably well and is able to converse with medical personneI. Over

the next 12 hours, while he does not begin to rebleed, his mental status deteriorates. Arterial blood levels of which of the following would be

most helpful in confirming the likely diagnosis?

/ A. Ammonia

/ B. Angiotensin l

/ C. Calcitonin

/ D. Carbon monoxide

/ E. Ceruloplasmin

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Gastrointestinal Bleeding case 5 answers

A1

The correct answer is E. The patient's low and dropping blood pressure, tachycardia, high respiratory rate, and slightly below normal body temperature are all consistent with impending shock. At this point, the other conditions listed in the choices have not yet been ruled out, but clinically, the patient should begin to be immediately treated for the shock, even if the therapeutic workup for underlying conditions must be temporarily deferred

A2

The correct answer is E. Medusa was a goddess with snakes instead of hair on her head. The caput medusa (Medusa's head) is an old term still in fairly common use for numerous varicose veins radiating over the abdomen from the area of the umbilicus.

Choice A describes Battle's sign, which is suggestive of basal skull fracture.

Choice B describes Kussmaul's sign, which is seen in constrictive pericarditis.

Choice C describes the doll's eye sign, which is looked for in the evaluation of comatose patients and suggests functional integrity of the brainstem tegmental pathways and cranial nerves involved in eye movement.

Choice D describes Heberden's nodules, which are seen in osteoarthritis.

A3

The correct answer is E. The caput medusa develops when severe portal hypertension induces dilation of the anastomotic channels between the portal venous system and the systemic venous system, some of which involve the superficial veins near the umbilicus. The other answers are distracters.

A4

The correct answer is A. The overwhelmingly most common cause of portal hypertension in the United States is hepatic cirrhosis, which is usually due to either alcoholism or hepatitis viral infection. In this patient's case, the diagnosis of cirrhosis is further clinically substantiated by his jaundice, as evidenced by his sclera, nail beds, and palms. (Look in these areas on individuals in whom dark skin pigmentation may mask the jaundice generally.) The other entities listed are occasional causes of portal hypertension.

A5

The correct answer is D. Patients who have had one episode of bleeding from esophageal varices have an approximately 70% chance of developing a second incident of bleeding, and one third of these episodes of rebleeding is fatal.

A6

The correct answer is A. Hepatic encephalopathy is seen in end-stage cirrhosis patients, and can either present or worsen in the presence of gastrointestinal bleeding. The blood in the upper gastrointestinal tract behaves essentially as a high protein load, and increases the absorption of ammonia and nitrogen, which cannot be appropriately metabolized by the liver. GI bleeding may also predispose for inadequate renal function secondary to hypotension.

Angiotensin I (choice B) is part of the renin-angiotensin-aldosterone system for blood pressure and sodium ion control.

Calcitonin (choice C) is a hormone secreted by the thyroid, which may be increased in medullary carcinoma of the thyroid.

Carbon monoxide (choice D) increases in the blood in smokers.

Ceruloplasmin (choice E) is a copper-carrying protein monitored in patients with Wilson disease.

Gastrointestinal Bleeding case 4

A 25-year-old man presents to the emergency department complaining of passing bright red blood per rectum. He reports no prior episodes of gastrointestinal bleeding, but he has had occasional lower abdominal pain and diarrhea for the past ten months. He reports a 7 kg weight Ioss since the onset of these symptoms. He denies sick contacts. On examination, he is febrile with moderate, diffuse abdominal pain to palpation and percussion. Rectal examination is positive for blood.

Q 1

Which of the following is the most likely diagnosis?

/ A. Chronic pancreatitis

/ B. Duodenal ulcer

/ C. Infectious colitis

/ D. Inflammatory bowel disease

/ E. Ischemic colitis

Q 2

A colonoscopy is performed and mucosal ulceration with bleeding extending continuously from the rectum to the cecum is seen. The terminal

ileum is spared. Had the terminal ileum been affected, the patient would have been at risk for which of the following conditions?

/ A. Diabetes mellitus

/ B. Folate deficiency

/ C. Iron deficiency anemia

/ D. Kwashiorkor

/ E. Pernicious anemia

Q 3

At colonoscopy the colonic mucosa appears granular, and is ulcerated. Numerous crypt abscesses and pseudopolyps are observed. Which of

the following is the most likely diagnosis?

/ A. Celiac disease

/ B. Clostridium difficile colitis

/ C. Crohn disease

/ D. Rectal diverticulosis

/ E. Ulcerative colitis

Q 4

Several months pass and this patient's symptoms progress. He continues to have frequent bloody diarrhea and abdominal pain. Abruptly, this

patient experiences the acute onset of severe abdominal pain and is taken to the emergency department by friends. In the emergency

department, he is febrile, and his abdomen is rigid, with severe pain to palpation and percussion. Laboratory findings are consistent with

dehydration. Amylase and lipase are normaI. Which of the following most likely explains this patient's new findings?

/ A. Abdominal aortic aneurysm rupture

/ B. Acute pancreatitis

/ C. Bowel perforation and peritonitis

/ D. Sepsis from fulminant infectious colitis

/ E. Severe ischemic colitis

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Gastrointestinal Bleeding case 4 answers

A1

The correct answer is D. Patients with inflammatory bowel disease can present with a variety of symptoms. While ulcerative colitis and Crohn disease patients may have distinct presentations, mixed presentations are common. Distinguishing Crohn disease and ulcerative colitis is difficult, based on clinical findings. Symptoms typical for Crohn disease include: abdominal pain, fever, diarrhea, weight loss, and anal disease. Symptoms typical for ulcerative colitis include: bloody diarrhea, fever, and weight loss.

Chronic pancreatitis (choice A) presents as epigastric pain that radiates to the back, weight loss, and steatorrhea. In many cases, a history of alcoholism is present. Thus the location of this patient's pain and his lower GI bleeding are not consistent with chronic pancreatitis.

Duodenal ulcer (choice B) may present as epigastric pain, and with severe disease, severe bleeding may be present. Patients with duodenal ulcer rarely have diarrhea and weight loss. Thus this diagnosis is unlikely.

Infectious colitis (choice C) presents as abdominal pain and bleeding. Many infectious agents may cause GI bleeding, including Salmonella, Shigella, Campylobacter jejuni, and E. coli. The chronic nature of this patient's complaints and the lack of sick contacts suggests a different diagnosis.

Ischemic colitis (choice E) presents as acute onset of severe abdominal pain often with copious bright red blood per rectum. On examination, they display the classic finding of "pain out of proportion to examination." They are typically elderly patients with a history of atherosclerotic or embolic disease.

A2

The correct answer is E. Pernicious anemia is a hypochromic, megaloblastic anemia that may be associated with neurologic complications. It occurs as a result of a lack of vitamin B 12. The B12/intrinsic factor complex is absorbed in the terminal ileum by active transport. If this patient's ulcerative colitis extended into the terminal ileum, this condition could complicate his disease. Crohn disease almost invariably affects the terminal ileum, and this malabsorptive condition is more common in that setting. Ulcerative colitis usually affects only the colon, but ileal extension has been observed.

Diabetes mellitus (choice A) is an endocrine condition, and is unrelated to the absorptive capacity of the terminal ileum.

Folate (choice B) is absorbed in the proximal small intestine. Ileal involvement would not affect its absorption.

Iron (choice C) is also absorbed in the proximal small intestine. Ileal involvement would not affect its absorption.

Kwashiorkor (choice D) is protein malnutrition. Protein is absorbed throughout the small intestine. Ileal involvement would not affect its absorption.

A3

The correct answer is E. Granular, flat mucosa with ulcers, crypt abscesses, and pseudopolyps are characteristic findings in ulcerative colitis.

Celiac disease (choice A) is a disease of the intestine resulting from a hypersensitivity to the protein gluten. The intestinal mucosa is smooth and atrophic.

Clostridium difficile colitis (choice B) or "pseudomembranous colitis" is a colonic infection seen after extensive antibiotic use, which disturbs the colonic flora, promoting overgrowth of C. difficile. Fibrinous pseudomembranes are seen in the colon at colonoscopy.

Endoscopic evaluation of Crohn disease (choice C) reveals swollen mucosa with transverse fissures and linear ulcers. Biopsy findings demonstrate transmural involvement with granuloma formation.

Diverticula are outpouchings of the intestinal mucosa. They may bleed, or they may become infected, leading to a painful condition, diverticulitis. The findings here do not suggest diverticulosis (choice D).

A4

The correct answer is C. This patient's chronic course with acute exacerbation suggests that this patient has viscus perforation with peritonitis secondary to exacerbation of his ulcerative colitis. The inflammatory processes in ulcerative colitis can be so severe that erosion from inflammation can cause colonic perforation. Bowel contents then leak into the peritoneal cavity, causing peritonitis. Peritonitis is characterized by fever, severe abdominal pain, abdominal tenderness to palpation and percussion, and rigidity of the abdominal wall.

Abdominal aortic aneurysm rupture (choice A) presents as abdominal pain that radiates to the back. It is accompanied by hemodynamic instability that may deteriorate to shock. This presentation is not consistent with findings in this patient.

Acute pancreatitis (choice B) can cause severe abdominal pain and fever. The pain, however is usually epigastric and radiating to the back. Typically nausea and vomiting accompany pancreatitis. Amylase and lipase are elevated.

This patient does not display the symptoms of sepsis (choice D). In sepsis, patients are febrile with hemodynamic instability.

Ischemic colitis (choice E) can lead to perforation and peritonitis, and if the patient had symptomatology consistent with ischemic colitis, it could be the source of this patient's peritonitis. This patient did not report bright red blood per rectum, or "pain out of proportion to examination," making ischemic colitis less likely.