A 19-year-old woman is brought to the emergency room by her mother. She found her daughter pale, cold to the touch, and collapsed next to her bed earlier this morning. The patient has no previous medical or psychiatric history, but the mother does report that her daughter has not had her periods for the last 3 months. In the emergency department, the patient is alert and oriented. Her vitals include: blood pressure 80/60 mm Hg supine, heart rate 55/min. On physical examination, the patient appears pale and emaciated. A urine pregnancy test is negative. She is suspected of having an eating disorder. Which of the following treatment options would be contraindicated in this patient?

Selective serotonin reuptake inhibitors

A 64-year-old woman has progressively worsening abdominal pain 5 hours after an open valve replacement with cardiopulmonary bypass. The pain is crampy and associated with an urge to defecate. The patient reports having had 2 bloody bowel movements in the last hour. Her operation was complicated by significant intraoperative blood loss, which prolonged the operation and necessitated 2 transfusions of red blood cells. She has hypercholesterolemia and type 2 diabetes mellitus. The patient received prophylactic perioperative antibiotics and opioid pain management during recovery. Her temperature is 37.9°C (98.9°F), pulse is 95/min, and blood pressure is 115/69 mm Hg. Examination shows a soft abdomen with mild tenderness to palpation in the left quadrants but no rebound tenderness or guarding. Bowel sounds are decreased. Rectal examination shows blood on the examining finger. Which of the following is the most likely underlying cause of this patient's symptoms?

Decreased blood flow to the splenic flexure

Embolization of superior mesenteric artery

Atherosclerotic narrowing of the intestinal vessels

Small outpouchings in the sigmoid wall

Infection with Clostridioides difficile

A 52-year-old man comes to the physician because of a 3-month history of upper abdominal pain and nausea that occurs about 3 hours after eating and at night. These symptoms improve with eating. After eating, he often has a feeling of fullness and bloating. He has had several episodes of dark stools over the past month. He has smoked one pack of cigarettes daily for 40 years and drinks 2 alcoholic beverages daily. He takes no medications. His temperature is 36.4°C (97.5°F), pulse is 80/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows epigastric tenderness with no guarding or rebound. Bowel sounds are normal. Which of the following treatments is most appropriate to prevent further complications of the disease in this patient?

Amoxicillin, clarithromycin, and omeprazole

Intravenous vitamin B12 supplementation

Fundoplication, hiatoplasty, and gastropexy

Distal gastrectomy with gastroduodenostomy

Eight hours after undergoing an open right hemicolectomy and a colostomy for colon cancer, a 52-year-old man has wet and bloody surgical dressings. He has had episodes of blood in his stools during the past 6 months, which led to the detection of colon cancer. He has hypertension and ischemic heart disease. His younger brother died of a bleeding disorder at the age of 16. The patient has smoked one pack of cigarettes daily for 36 years and drinks three to four beers daily. Prior to admission, his medications included aspirin, metoprolol, enalapril, and simvastatin. Aspirin was stopped 7 days prior to the scheduled surgery. He appears uncomfortable. His temperature is 36°C (96.8°F), pulse is 98/min, respirations are 14/min, and blood pressure is 118/72 mm Hg. Examination shows a soft abdomen with a 14-cm midline incision that has severe oozing of blood from its margins. The colostomy bag has some blood collected within. Laboratory studies show: Hemoglobin 12.3 g/dL Leukocyte count 11,200/mm3 Platelet count 210,000/mm3 Bleeding time 4 minutes Prothrombin time 15 seconds (INR=1.1) Activated partial thromboplastin time 36 seconds Serum Urea nitrogen 30 mg/dL Glucose 96 mg/dL Creatinine 1.1 mg/dL AST 48 U/L ALT 34 U/L γ-Glutamyltransferase 70 U/L (N= 5–50 U/L) Which of the following is the most likely cause of this patient's bleeding?

Insufficient mechanical hemostasis

A 42-year-old woman comes to the physician for a routine health maintenance examination. She has generalized fatigue and has had difficulties doing her household duties for the past 3 months. She has eczema and gastroesophageal reflux disease. She has a history of using intravenous methamphetamine in her youth but has not used illicit drugs in 23 years. Her medications include topical clobetasol and pantoprazole. She is 160 cm (5 ft 3 in) tall and weighs 105 kg (231 lb); BMI is 42 kg/m2. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 145/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. Pelvic examination shows a normal vagina and cervix. Laboratory studies show: Hemoglobin 13.1 g/dL Leukocyte count 7,800/mm3 Platelet count 312,000/mm3 Serum Na+ 141 mEq/L K+ 4.6 mEq/L Cl- 98 mEq/L Urea nitrogen 12 mg/dL Fasting glucose 110 mg/dL Creatinine 0.8 mg/dL Total cholesterol 269 mg/dL HDL-cholesterol 55 mg/dL LDL-cholesterol 160 mg/dL Triglycerides 320 mg/dL Urinalysis is within normal limits. An x-ray of the chest shows no abnormalities. She has not lost any weight over the past year despite following supervised weight loss programs, including various diets and exercise regimens. Which of the following is the most appropriate next step in management of this patient?

Phentermine and topiramate therapy and follow-up in 3 months

Metformin and statin therapy and follow-up in 3 months

A 37-year-old man presents to the physician. He has been overweight since childhood. He has not succeeded in losing weight despite following different diet and exercise programs over the past several years. He has had diabetes mellitus for 2 years and severe gastroesophageal reflux disease for 9 years. His medications include metformin, aspirin, and pantoprazole. His blood pressure is 142/94 mm Hg, pulse is 76/min, and respiratory rate is 14/min. His BMI is 36.5 kg/m2. Laboratory studies show: Hemoglobin A1C 6.6% Serum Fasting glucose 132 mg/dL Which of the following is the most appropriate surgical management?

Laparoscopic Roux-en-Y gastric bypass

No surgical management at this time

Laparoscopic adjustable gastric banding

Biliopancreatic diversion and duodenal switch (BPD-DS)

Laparoscopic sleeve gastrectomy

A 69-year-old man is brought to the emergency department because of a 1-week history of recurring black stools. On questioning, he reports fatigue and loss of appetite over the last 3 months. Twenty years ago, he underwent a partial gastrectomy for peptic ulcer disease. The patient's father died of metastatic colon cancer at the age of 57 years. He is 163 cm (5 ft 4 in) tall and weighs 55 kg (121 lb); BMI is 20.8 kg/m2. He appears chronically ill. His temperature is 36.5°C (97.7°F), pulse is 105/min, and blood pressure is 115/70 mm Hg. The conjunctiva appear pale. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. There is a well-healed scar on the upper abdomen. His hemoglobin concentration is 10.5 g/dL and his mean corpuscular volume is 101 μm3. An upper endoscopy shows a large nodular mass on the anterior wall of the lesser curvature of the gastric stump. Biopsy samples are obtained, showing polypoid, glandular formation of irregular-shaped and fused gastric cells with intraluminal mucus, demonstrating an infiltrative growth. Which of the following is the most appropriate next step in the management of this patient?

Stool antigen test for H. pylori

Treatment with PPI, clarithromycin, and amoxicillin

Bariatric surgery procedures and complications for USMLE Step 1: High-Yield Surgery Lessons

🎯 Patient Selection Criteria

Primary Indication: Based on Body Mass Index (BMI), calculated as $BMI = \frac{weight(kg)}{height(m)^2}$.
General Requirements:
- Age 18-65 (flexible).
- Documented failure of non-surgical weight loss programs.
- Psychological stability & commitment to lifestyle changes.
- Acceptable operative risk.

⭐ Absolute Contraindications: Active substance/alcohol abuse, severe uncontrolled psychiatric illness (e.g., psychosis, severe depression), end-stage organ disease (e.g., portal HTN, severe cardiac disease), and inability to comprehend risks/benefits.

🔪 Management - The Surgical Options

Gastric Bypass vs. Vertical Sleeve Gastrectomy

Procedure	Mechanism	Avg. %EWL	Key Complications/Notes
Sleeve Gastrectomy (SG)	Restrictive: Removes ~80% of stomach (fundus/ghrelin source).	~60%	Worsens/causes GERD; staple line leak. Most common procedure globally.
Roux-en-Y Bypass (RYGB)	Restrictive & Malabsorptive: Small pouch + bypasses duodenum/prox. jejunum.	~70%	Dumping syndrome, marginal ulcers, internal hernia, severe nutritional deficiencies (Fe, B12, Ca, Vit D).
Adjustable Gastric Band	Restrictive: Inflatable band around cardia.	~50%	Band slippage/erosion, port issues. Reversible but less effective; high re-operation rate.

Common Post-Op Complications:
- Early (<30 days): Anastomotic leak (⚠️ tachycardia is earliest sign), VTE, wound infection.
- Late (>30 days): Cholelithiasis (rapid weight loss → prophylactic ursodiol), nutritional deficiencies, dumping syndrome (esp. RYGB).

⚠️ Complications - Post-Op Pitfalls

Early (<30 days)
- Anastomotic Leak: Most feared. Presents with tachycardia, fever, oliguria, abdominal pain.
- Hemorrhage: At staple line or anastomosis.
- VTE (DVT/PE): High risk; requires aggressive prophylaxis.
- Wound Infection: Common due to adipose tissue.

⭐ Tachycardia >120 bpm is the most sensitive early sign of an anastomotic leak post-bariatric surgery. Investigate aggressively, even with normal vitals otherwise.

Late (>30 days)
- Nutritional Deficiencies:
  - Iron, B12, Folate: Anemias. B12 deficiency also causes neuropathy.
  - Thiamine (B1): Risk of Wernicke's encephalopathy (ataxia, confusion, ophthalmoplegia).
  - Ca/Vit D: ↑ risk of osteoporosis & fractures.
- Dumping Syndrome: Rapid emptying of hyperosmolar chyme.
- Cholelithiasis: Due to rapid weight loss. Prophylaxis with ursodiol.
- Stenosis/Stricture: At anastomosis; causes dysphagia/vomiting.
- Internal Hernia (RYGB): Intermittent, severe pain. High suspicion needed.

⚡ Biggest Takeaways

Roux-en-Y Gastric Bypass (RYGB) combines restriction and malabsorption, risking dumping syndrome and internal hernias.

Sleeve gastrectomy is a popular restrictive procedure; its main complication is new or worsening GERD.

Anastomotic leak is the most feared early (<30 days) complication; suspect with unexplained tachycardia.

Rapid weight loss increases risk for cholelithiasis; consider ursodiol prophylaxis.

Lifelong supplementation is mandatory, especially for iron, B12, calcium, and vitamin D post-RYGB.

Thiamine deficiency can cause Wernicke's encephalopathy, a critical neurological emergency.

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