Red flags in abdominal pain US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Red flags in abdominal pain. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Red flags in abdominal pain US Medical PG Question 1: A 72-year-old man presents to his primary care physician because he has been having flank and back pain for the last 8 months. He said that it started after he fell off a chair while doing yard work, but it has been getting progressively worse over time. He reports no other symptoms and denies any weight loss or tingling in his extremities. His medical history is significant for poorly controlled hypertension and a back surgery 10 years ago. He drinks socially and has smoked 1 pack per day since he was 20. His family history is significant for cancer, and he says that he is concerned that his father had similar symptoms before he was diagnosed with multiple myeloma. Physical exam reveals a painful, pulsatile enlargement in the patient's abdomen. Between which of the following locations has the highest risk of developing this patient's disorder?
- A. Superior mesenteric artery and renal arteries
- B. Diaphragm and renal arteries
- C. Renal arteries and common iliac arteries (Correct Answer)
- D. Superior mesenteric artery and common iliac arteries
- E. Diaphragm and superior mesenteric artery
Red flags in abdominal pain Explanation: ***Renal arteries and common iliac arteries***
- The most common location for **abdominal aortic aneurysms (AAAs)** is the **infrarenal aorta**, specifically between the renal arteries and the common iliac arteries.
- This segment accounts for **~95% of all AAAs** due to decreased elastin content, hemodynamic stress, and reduced vasa vasorum.
- The patient's presentation with **flank/back pain**, a **pulsatile abdominal mass**, and risk factors like **hypertension** and **smoking** are highly suggestive of an infrarenal AAA [1].
*Superior mesenteric artery and renal arteries*
- This region defines the **suprarenal aorta**, which is less commonly affected by aneurysms than the infrarenal segment.
- Suprarenal aneurysms account for only **~5% of AAAs** and are typically more complex to manage.
*Diaphragm and renal arteries*
- This encompasses a significant portion of the **thoracoabdominal aorta**, including the suprarenal segment.
- While thoracoabdominal aneurysms can occur, they are much less common than infrarenal AAAs and often have different etiologies.
*Superior mesenteric artery and common iliac arteries*
- This range is anatomically imprecise and spans too broad a region, including both suprarenal and infrarenal segments.
- The **superior mesenteric artery** originates anteriorly from the aorta (typically at L1), well above the most common aneurysm site immediately distal to the renal arteries (L1-L2).
- The highest risk is specifically localized to the segment **below the renal arteries**, not this entire broad region.
*Diaphragm and superior mesenteric artery*
- This describes the **supraceliac and proximal suprarenal aorta**, an area significantly less prone to aneurysms compared to the infrarenal segment.
- Aneurysms in this more proximal segment are rare and often have different etiologies (e.g., connective tissue disorders).
Red flags in abdominal pain US Medical PG Question 2: A 70-year-old man presents for his annual check-up. He says he feels well except for occasional abdominal pain. He describes the pain as 4/10–5/10 in intensity, diffusely localized to the periumbilical and epigastric regions, radiating to the groin. The pain occurs 1–2 times a month and always subsides on its own. The patient denies any recent history of fever, chills, nausea, vomiting, change in body weight, or change in bowel and/or bladder habits. His past medical history is significant for hypertension, hyperlipidemia, and peripheral vascular disease, managed with lisinopril and simvastatin. The patient reports a 40-pack-year smoking history and 1–2 alcoholic drinks a day. The blood pressure is 150/100 mm Hg and the pulse is 80/min. Peripheral pulses are 2+ bilaterally in all extremities. Abdominal exam reveals a bruit in the epigastric region along with mild tenderness to palpation with no rebound or guarding. There is also a pulsatile abdominal mass felt on deep palpation at the junction of the periumbilical and the suprapubic regions. The remainder of the physical exam is normal. Laboratory studies show:
Serum total cholesterol 175 mg/dL
Serum total bilirubin 1 mg/dL
Serum amylase 25 U/L
Serum alanine aminotransferase (ALT) 20 U/L
Serum aspartate aminotransferase (AST) 16 U/L
Which of the following is the most likely diagnosis in this patient?
- A. Mesenteric ischemia
- B. Acute pancreatitis
- C. Abdominal aortic aneurysm (Correct Answer)
- D. Acute gastritis
- E. Diverticulitis
Red flags in abdominal pain Explanation: ***Abdominal aortic aneurysm***
- The presence of a **pulsatile abdominal mass**, epigastric bruit, and a history of **hypertension, hyperlipidemia, peripheral vascular disease, and smoking** are highly suggestive of an abdominal aortic aneurysm (AAA).
- The diffuse, radiating abdominal pain, while non-specific, can be associated with an expanding aneurysm, and the patient's age and risk factors significantly increase the likelihood of AAA.
*Mesenteric ischemia*
- Mesenteric ischemia typically presents with **severe abdominal pain out of proportion to physical exam findings**, often postprandial, and can be associated with weight loss due to fear of eating.
- While the patient has vascular risk factors, the pain is described as moderate, infrequent, and subsiding on its own, and there is no mention of weight loss, making it less likely.
*Acute pancreatitis*
- Acute pancreatitis is characterized by **severe epigastric pain that radiates to the back**, often accompanied by nausea, vomiting, and elevated serum **amylase and lipase** levels.
- This patient's pain is diffuse and radiates to the groin, not the back, and his serum amylase is normal, ruling out acute pancreatitis.
*Acute gastritis*
- Acute gastritis typically causes **epigastric pain, nausea, and vomiting**, often triggered by NSAIDs, alcohol, or H. pylori infection.
- The patient's pain is diffuse, radiates to the groin, and occurs infrequently, with no mention of triggers or other gastrointestinal symptoms typical of gastritis.
*Diverticulitis*
- Diverticulitis usually presents with **left lower quadrant pain**, fever, leukocytosis, and changes in bowel habits.
- This patient's pain is periumbilical/epigastric, has no associated fever or changes in bowel habits, and is not consistent with the typical presentation of diverticulitis.
Red flags in abdominal pain US Medical PG Question 3: A 66-year-old man is brought to the emergency department after a motor vehicle accident. The patient was a restrained passenger in a car that was struck on the passenger side while crossing an intersection. In the emergency department, he is alert and complaining of abdominal pain. He has a history of hyperlipidemia, gastroesophageal reflux disease, chronic kidney disease, and perforated appendicitis for which he received an interval appendectomy four years ago. His home medications include rosuvastatin and lansoprazole. His temperature is 99.2°F (37.3°C), blood pressure is 120/87 mmHg, pulse is 96/min, and respirations are 20/min. He has full breath sounds bilaterally. He is tender to palpation over the left 9th rib and the epigastrium. He is moving all four extremities. His FAST exam reveals fluid in Morrison's pouch.
This patient is most likely to have which of the following additional signs or symptoms?
- A. Pain radiating to the back
- B. Gross hematuria
- C. Muffled heart sounds
- D. Free air on chest radiograph
- E. Shoulder pain (Correct Answer)
Red flags in abdominal pain Explanation: ***Shoulder pain***
- The presence of **fluid in Morrison's pouch** (hepatorenal recess) on FAST exam indicates **intra-abdominal bleeding**, likely from a liver or spleen injury.
- **Diaphragmatic irritation** due to intra-abdominal hemorrhage often manifests as referred **shoulder pain** (Kehr's sign), especially on the left side with splenic injury or right side with liver injury.
*Pain radiating to the back*
- While pancreatic injury can cause pain radiating to the back, the primary finding of **fluid in Morrison's pouch** points towards hemoperitoneum, less specifically to pancreatic trauma.
- Significant pancreatic injury would likely involve more severe abdominal tenderness and potentially elevated **amylase/lipase**, which are not mentioned here.
*Gross hematuria*
- **Gross hematuria** would suggest a **renal or urologic injury**, but the patient's primary finding is intra-abdominal fluid in Morrison's pouch, which is more indicative of solid organ injury like the liver or spleen.
- Though concurrent injuries are possible in trauma, hepatorenal fluid points specifically to **hemoperitoneum**, not necessarily kidney damage.
*Muffled heart sounds*
- **Muffled heart sounds** are a component of **Beck's triad** (along with hypotension and jugular venous distension), indicative of **cardiac tamponade** due to fluid around the heart.
- There is no clinical information in the stem suggestive of cardiac injury or tamponade; the fluid is specifically mentioned in the abdomen.
*Free air on chest radiograph*
- **Free air on chest radiograph** (pneumoperitoneum) indicates a **perforated hollow viscus**, such as the bowel or stomach.
- The FAST exam finding of fluid in Morrison's pouch is characteristic of **hemoperitoneum** from a solid organ injury, not free air from a perforation.
Red flags in abdominal pain US Medical PG Question 4: A 72-year-old man comes to the physician because of a 6-month history of intermittent dull abdominal pain that radiates to the back. He has smoked one pack of cigarettes daily for 50 years. His blood pressure is 145/80 mm Hg. Abdominal examination shows generalized tenderness and a pulsatile mass in the periumbilical region on deep palpation. Further evaluation of the affected blood vessel is most likely to show which of the following?
- A. Obliterative inflammation of the vasa vasorum
- B. Formation of giant cells in the tunica media
- C. Necrotizing inflammation of the entire vessel wall
- D. Fragmentation of elastic tissue in the tunica media (Correct Answer)
- E. Accumulation of foam cells in the tunica intima
Red flags in abdominal pain Explanation: ***Fragmentation of elastic tissue in the tunica media***
- This patient's presentation with **intermittent dull abdominal pain radiating to the back**, a **pulsatile periumbilical mass**, and a history of **heavy smoking** is highly suggestive of an **abdominal aortic aneurysm (AAA)**.
- The pathological hallmark of AAA is **degradation and fragmentation of elastic tissue in the tunica media**, caused by chronic inflammation and increased activity of **matrix metalloproteinases (MMPs)**.
- This medial degeneration leads to **weakening of the vessel wall** and progressive **dilation**, ultimately forming an aneurysm.
- While atherosclerosis initiates the process, the actual aneurysm formation is characterized by this elastic tissue destruction in the media.
*Accumulation of foam cells in the tunica intima*
- This describes the **early lesion of atherosclerosis**, which is a **risk factor** for AAA development.
- However, when examining an **established AAA**, the predominant finding is not intimal foam cells but rather **medial degeneration** with elastic tissue fragmentation.
- Atherosclerosis is the underlying cause, but the question asks about findings in the affected vessel (the aneurysm itself).
*Obliterative inflammation of the vasa vasorum*
- This is characteristic of **syphilitic aortitis** (tertiary syphilis), which typically affects the **ascending thoracic aorta**.
- While syphilis can cause aneurysms, the patient's presentation and demographics are more consistent with atherosclerotic AAA.
*Formation of giant cells in the tunica media*
- This finding is associated with **giant cell arteritis** (temporal arteritis), which affects large and medium-sized arteries, particularly the temporal and ophthalmic arteries.
- It presents with headache, jaw claudication, and visual disturbances—features absent in this case.
*Necrotizing inflammation of the entire vessel wall*
- This describes **necrotizing vasculitis** such as **polyarteritis nodosa**, which affects medium-sized muscular arteries.
- While vasculitis can cause aneurysms, the clinical picture of AAA in an elderly smoker with atherosclerotic risk factors points to atherosclerotic pathogenesis, not primary vasculitis.
Red flags in abdominal pain US Medical PG Question 5: A 71-year-old man with hypertension is taken to the emergency department after the sudden onset of stabbing abdominal pain that radiates to the back. He has smoked 1 pack of cigarettes daily for 20 years. His pulse is 120/min and thready, respirations are 18/min, and blood pressure is 82/54 mm Hg. Physical examination shows a periumbilical, pulsatile mass and abdominal bruit. There is epigastric tenderness. Which of the following is the most likely underlying mechanism of this patient's current condition?
- A. Mesenteric atherosclerosis
- B. Gastric mucosal ulceration
- C. Portal vein stasis
- D. Abdominal wall defect
- E. Aortic wall stress (Correct Answer)
Red flags in abdominal pain Explanation: ***Aortic wall stress***
- The patient's presentation with **sudden onset of stabbing abdominal pain radiating to the back**, **hypotension** (BP 82/54 mm Hg), **tachycardia** (pulse 120/min), and a **pulsatile periumbilical mass** with an **abdominal bruit** is highly suggestive of a ruptured **abdominal aortic aneurysm (AAA)**.
- **Aortic wall stress**, often exacerbated by **hypertension** and **smoking**, leads to the progressive weakening and dilation of the aortic wall, eventually resulting in rupture.
*Mesenteric atherosclerosis*
- This condition typically causes **chronic abdominal pain** that is worse after eating (**postprandial angina**) due to inadequate blood supply to the intestines.
- It does not usually present with an acute, catastrophic event like **shock** and a **pulsatile mass**.
*Gastric mucosal ulceration*
- Ulceration can cause **epigastric pain**, but a ruptured ulcer would typically present with signs of **peritonitis** (rigidity, rebound tenderness) and potentially **hematemesis** or **melena**, which are not described.
- It would not cause a **pulsatile periumbilical mass** or the characteristic back pain of an AAA.
*Portal vein stasis*
- **Portal vein stasis** or **thrombosis** often leads to **portal hypertension**, **ascites**, and **gastrointestinal bleeding** from varices.
- It does not explain the acute onset of severe abdominal pain, hypotension, a pulsatile mass, or an abdominal bruit.
*Abdominal wall defect*
- An **abdominal wall defect**, such as a hernia, can cause localized pain and sometimes bowel obstruction.
- However, it does not account for the **hypotension**, **tachycardia**, **radiating pain to the back**, or the **pulsatile mass**, all of which point to a major vascular emergency.
Red flags in abdominal pain US Medical PG Question 6: A 74-year-old man presents to the emergency department with sudden onset of abdominal pain that is most felt around the umbilicus. The pain began 16 hours ago and has no association with meals. He has not been vomiting, but he has had several episodes of bloody loose bowel movements. He was hospitalized 1 week ago for an acute myocardial infarction. He has had diabetes mellitus for 35 years and hypertension for 20 years. He has smoked 15–20 cigarettes per day for the past 40 years. His temperature is 36.9°C (98.4°F), blood pressure is 95/65 mm Hg, and pulse is 95/min. On physical examination, the patient is in severe pain, there is a mild periumbilical tenderness, and a bruit is heard over the epigastric area. Which of the following is the most likely diagnosis?
- A. Acute mesenteric ischemia (Correct Answer)
- B. Chronic mesenteric ischemia
- C. Colonic ischemia
- D. Irritable bowel syndrome
- E. Peptic ulcer disease
Red flags in abdominal pain Explanation: ***Acute mesenteric ischemia***
- The sudden onset of severe, **periumbilical abdominal pain** out of proportion to physical exam findings in a patient with significant **atherosclerotic risk factors** (recent MI, diabetes, hypertension, smoking) is highly suggestive of acute mesenteric ischemia.
- **Bloody loose bowel movements** (due to mucosal sloughing) and the presence of an **epigastric bruit** further support the diagnosis of arterial occlusion to the bowel.
*Chronic mesenteric ischemia*
- This typically presents with **postprandial abdominal pain** (abdominal angina) and **weight loss** due to fear of eating.
- The patient's pain is sudden in onset, not associated with meals, and severe, which is characteristic of acute ischemia.
*Colonic ischemia*
- While it can cause bloody diarrhea, colonic ischemia typically presents with pain localized to the **left or right lower quadrants** and is often less severe than the pain described here.
- The patient's risk factors and abrupt, severe periumbilical pain point away from isolated colonic involvement.
*Irritable bowel syndrome*
- This is a **functional gastrointestinal disorder** characterized by chronic abdominal pain, bloating, and altered bowel habits (constipation, diarrhea, or both).
- It does not present with sudden, severe pain, bloody stools, or in the context of acute cardiovascular events and associated risk factors.
*Peptic ulcer disease*
- This typically causes **epigastric pain** that can be burning or gnawing, often relieved or exacerbated by food, and may cause melena or hematemesis.
- The patient's severe, diffuse periumbilical pain, bloody stools (not melena), and recent MI are not typical for peptic ulcer disease.
Red flags in abdominal pain US Medical PG Question 7: A 5-year-old girl is brought to the physician because of watery discharge from her right eye for 2 weeks. She and her parents, who are refugees from Sudan, arrived in Texas a month ago. Her immunization status is not known. She is at the 25th percentile for weight and the 50th percentile for height. Her temperature is 37.2°C (99°F), pulse is 90/min, and respirations are 18/min. Examination of the right eye shows matting of the eyelashes. Everting the right eyelid shows hyperemia, follicles, and papillae on the upper tarsal conjunctiva. Slit-lamp examination of the right eye shows follicles in the limbic region and the bulbar conjunctiva. There is corneal haziness with neovascularization at the 12 o'clock position. Examination of the left eye is unremarkable. Direct ophthalmoscopy of both eyes shows no abnormalities. Right pre-auricular lymphadenopathy is present. Which of the following is the most likely diagnosis in this patient?
- A. Neisserial conjunctivitis
- B. Trachoma conjunctivitis (Correct Answer)
- C. Acute herpetic conjunctivitis
- D. Angular conjunctivitis
- E. Acute hemorrhagic conjunctivitis
Red flags in abdominal pain Explanation: ***Trachoma conjunctivitis***
- The constellation of **follicles and papillae on the upper tarsal conjunctiva**, **limbal follicles**, **corneal haziness with neovascularization (pannus)**, and **pre-auricular lymphadenopathy** in a child from an endemic region (Sudan) is classic for **trachoma**.
- This chronic form of conjunctivitis is caused by *Chlamydia trachomatis* serovars A, B, and C, leading to progressive scarring that can eventually cause **trichiasis** and blindness.
*Neisserial conjunctivitis*
- This condition typically presents with **hyperacute onset**, **copious purulent discharge**, and significant eyelid swelling, often within days of birth or infection.
- While it can cause corneal involvement, the chronic follicular and papillary changes with limbal follicles and pannus are not characteristic.
*Acute herpetic conjunctivitis*
- Usually presents with **unilateral follicular conjunctivitis**, often accompanied by **periorbital vesicles** or a history of cold sores.
- While it can cause corneal involvement (typically **dendritic ulcers**), the specific follicular changes, presence of papillae, and chronic course leading to pannus seen here are not typical.
*Angular conjunctivitis*
- Characterized by **redness, excoriation, and maceration** primarily localized to the **outer canthus** (angle) of the eye, often caused by *Moraxella lacunata* or *Staphylococcus aureus*.
- It does not present with the diffuse follicular and papillary changes, limbal follicles, or corneal neovascularization described in this patient.
*Acute hemorrhagic conjunctivitis*
- This is typically an **acute, highly contagious viral conjunctivitis** characterized by **subconjunctival hemorrhages**, rapid onset, and usually resolves spontaneously.
- It does not cause chronic follicular changes, limbal follicles, or corneal neovascularization, and the duration in this patient (2 weeks) suggests a more chronic process.
Red flags in abdominal pain US Medical PG Question 8: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Red flags in abdominal pain Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Red flags in abdominal pain US Medical PG Question 9: A 12-month-old boy is brought to the emergency department by his mother for several hours of crying and severe abdominal pain, followed by dark and bloody stools in the last hour. The mother reports that she did not note any vomiting or fevers leading up to this incident. She does report that the boy and his 7-year-old sister recently had “stomach bugs” but that both have been fine and that the sister has gone back to school. The boy was born by spontaneous vaginal delivery at 39 weeks and 5 days after a normal pregnancy. His temperature is 100.4°F (38.0°C), blood pressure is 96/72 mmHg, pulse is 90/min, respirations are 22/min. Which of the following was most likely to play a role in the pathogenesis of this patient’s disease?
- A. Vascular malformation
- B. Hyperplasia of Peyer patches (Correct Answer)
- C. Embolism to the mesenteric vessels
- D. Intestinal mass
- E. Failure of neural crest migration
Red flags in abdominal pain Explanation: ***Hyperplasia of Peyer patches***
- The presentation of a 12-month-old with **severe abdominal pain**, **crying spells**, and **dark, bloody stools** (likely **currant jelly stools**) is highly suggestive of **intussusception**.
- In children, intussusception is most commonly idiopathic, but often associated with recent viral illnesses causing **lymphoid hyperplasia** (Peyer patches) in the ileum, which then acts as a lead point for telescoping.
*Vascular malformation*
- This condition is a less common cause of rectal bleeding in infants and children and typically presents with **painless rectal bleeding**.
- It does not explain the acute, severe abdominal pain and signs of obstruction seen in intussusception.
*Embolism to the mesenteric vessels*
- **Mesenteric ischemia** due to embolism is rare in this age group and usually associated with underlying cardiac conditions or clotting disorders.
- While it can cause severe abdominal pain and bloody stools, the cyclical nature of pain and absence of significant risk factors make it less likely.
*Intestinal mass*
- Although an intestinal mass can be a lead point for intussusception (especially in older children or adults), it is a less common cause in uncomplicated cases in infants compared to **Peyer patch hyperplasia**.
- An intestinal mass would typically remain a fixed mass, and symptoms might be more chronic or progress differently.
*Failure of neural crest migration*
- This describes the pathogenesis of **Hirschsprung disease**, which presents with constipation, abdominal distention, and failure to pass meconium, rather than acute severe abdominal pain and bloody stools.
- The symptoms in this patient are acute and more indicative of an obstructive process like intussusception.
Red flags in abdominal pain US Medical PG Question 10: A 45-year-old male patient with a history of recurrent nephrolithiasis and chronic lower back pain presents to the ER with severe, sudden-onset, upper abdominal pain. The patient is febrile, hypotensive, and tachycardic, and is rushed to the OR for exploratory laparotomy. Surgery reveals that the patient has a perforated gastric ulcer. Despite appropriate therapy, the patient expires, and subsequent autopsy reveals multiple ulcers in the stomach, duodenum, and jejunum. The patient had been complaining of abdominal pain and diarrhea for several months but had only been taking ibuprofen for his lower back pain for the past 3 weeks. What is the most likely cause of the patient's presentation?
- A. H. pylori infection
- B. Cytomegalovirus infection
- C. A vasoactive-intestinal-peptide (VIP) secreting tumor of the pancreas
- D. Chronic NSAID use
- E. A gastrin-secreting tumor of the pancreas (Correct Answer)
Red flags in abdominal pain Explanation: ***A gastrin-secreting tumor of the pancreas***
- The patient's presentation with **multiple ulcers** in the stomach, duodenum, and jejunum, along with **recurrent nephrolithiasis** (often associated with hypercalcemia), and chronic diarrhea, is highly indicative of **Zollinger-Ellison syndrome (ZES)**, which is caused by a gastrin-secreting neuroendocrine tumor (gastrinoma).
- The **severe, sudden-onset upper abdominal pain** and **perforated gastric ulcer** are acute complications of the excessive acid production seen in ZES, which can overwhelm protective mucosal mechanisms.
*H. pylori infection*
- While H. pylori is a common cause of **gastric and duodenal ulcers**, it typically doesn't lead to multiple ulcers extending into the **jejunum**, nor is it directly associated with **recurrent nephrolithiasis**.
- The widespread ulceration and association with chronic diarrhea and recurrent kidney stones strongly suggest a more systemic or diffuse etiology than typical H. pylori infection.
*Cytomegalovirus infection*
- CMV can cause **gastric or intestinal ulcers**, particularly in **immunocompromised individuals**, but it rarely causes multiple ulcers throughout the upper GI tract, including the jejunum, in an otherwise healthy individual.
- CMV infection is not typically associated with **recurrent nephrolithiasis** or the clinical picture of severe **acid overproduction**.
*A vasoactive-intestinal-peptide (VIP) secreting tumor of the pancreas*
- A **VIPoma** primarily causes **severe watery diarrhea** (pancreatic cholera) and **hypokalemia**, often without significant acidosis.
- It typically does not cause **multiple, widespread peptic ulcers** or **recurrent nephrolithiasis**, which are hallmarks of the patient's presentation.
*Chronic NSAID use*
- **NSAID use** can cause **gastric and duodenal ulcers**, and the patient had been taking ibuprofen for 3 weeks. However, the presence of **multiple ulcers** extending into the **jejunum** and the history of **recurrent nephrolithiasis** predating recent NSAID use point away from NSAID use as the primary cause.
- The severity and distribution of ulcers, along with the patient's history, are more consistent with a condition causing chronic, widespread acid hypersecretion rather than NSAID-induced injury.
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