A 56-year-old man is seen in the hospital for a chief complaint of intense thirst and polyuria. His history is significant for recent transsphenoidal resection of a pituitary adenoma. With regard to the man's fluid balance, which of the following would be expected?

Increased extracellular fluid osmolarity

An 82-year-old woman presents with 2 months of foul-smelling, greasy diarrhea. She says that she also has felt very tired recently and has had some associated bloating and flatus. She denies any recent abdominal pain, nausea, melena, hematochezia, or vomiting. She also denies any history of recent travel and states that her home has city water. Which of the following tests would be most appropriate to initially work up the most likely diagnosis in this patient?

Tissue transglutaminase antibody test

CT of the abdomen with oral contrast

A 54-year-old man comes to the physician because of diarrhea that has become progressively worse over the past 4 months. He currently has 4–6 episodes of foul-smelling stools per day. Over the past 3 months, he has had fatigue and a 5-kg (11-lb) weight loss. He returned from Bangladesh 6 months ago after a year-long business assignment. He has osteoarthritis and hypertension. Current medications include amlodipine and naproxen. He appears pale and malnourished. His temperature is 37.3°C (99.1°F), pulse is 76/min, and blood pressure is 140/86 mm Hg. Examination shows pale conjunctivae and dry mucous membranes. Angular stomatitis and glossitis are present. The abdomen is distended but soft and nontender. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 8.9 g/dL Leukocyte count 4100/mm3 Platelet count 160,000/mm3 Mean corpuscular volume 110 μm3 Serum Na+ 133 mEq/L Cl- 98 mEq/l K+ 3.3 mEq/L Creatinine 1.1 mg/dL IgA 250 mg/dL Anti-tissue transglutaminase, IgA negative Stool culture and studies for ova and parasites are negative. Test of the stool for occult blood is negative. Fecal fat content is 22 g/day (N < 7). Fecal lactoferrin is negative and elastase is within normal limits. Which of the following is the most appropriate next step in diagnosis?

PAS-stained biopsy of small bowel

IgG against deamidated gliadin peptide

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?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 63-year-old man comes to the emergency department because of pain in his left groin for the past hour. The pain began soon after he returned from a walk. He describes it as 8 out of 10 in intensity and vomited once on the way to the hospital. He has had a swelling of the left groin for the past 2 months. He has chronic obstructive pulmonary disease and hypertension. Current medications include amlodipine, albuterol inhaler, and a salmeterol-fluticasone inhaler. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 101/min, and blood pressure is 126/84 mm Hg. Examination shows a tender bulge on the left side above the inguinal ligament that extends into the left scrotum; lying down or applying external force does not reduce the swelling. Coughing does not make the swelling bulge further. There is no erythema. The abdomen is distended. Bowel sounds are hyperactive. Scattered rhonchi are heard throughout both lung fields. Which of the following is the most appropriate next step in management?

Surgical exploration of the testicle

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Meckel's Diverticulum, Technetium scan

Extra-adrenal Pheochromocytoma, PET DOPA scan

Adrenal Pheochromocytoma, MIBG scan

Intestinal Lymphoma, PET-CT scan

All the following statements regarding this condition are true except:

Broad-base of this defect should be amputated at its base

It is remnant of vitello intestinal duct

This condition can be a lead point for ileoileal or ileocolic intussusception

This condition is mostly asymptomatic

It is the most common congenital anomaly of the gastrointestinal tract

Ostomy creation and management for USMLE Step 2 CK: High-Yield Surgery Lessons

🔬 Stoma Science 101

A stoma is a surgically created opening connecting an internal organ (bowel) to the body surface.

Ideal Stoma: Pink-red, moist, "rosebud" appearance, protrudes 1-2 cm.
Types & Characteristics:

Feature	Ileostomy	Colostomy (End)
Location	RLQ	LLQ (Sigmoid)
Output	Liquid, continuous	Formed, intermittent
Volume	High (>1L/day)	Low
Spout	Everted (protects skin)	Flush with skin
GI Content Flow & Stoma Type

⭐ High-Output Stoma: Output >1.5-2 L/day. Leads to dehydration, hypomagnesemia, and hypokalemia. Manage with loperamide, octreotide, and fluid/electrolyte replacement.

Ileostomy and Colostomy Anatomical Locations

👜 Anatomy - Bags, Bowels & Belly

Stoma Siting: Pre-op marking is critical.
- Through rectus abdominis muscle (↓hernia risk).
- Avoids skin folds, scars, bony prominences, beltline.
- Visible to patient for self-care.

Feature	Ileostomy	Colostomy (Descending/Sigmoid)
Location	Right Lower Quadrant (RLQ)	Left Lower Quadrant (LLQ)
Appearance	Spouted/Everted (protects skin)	Flush with skin
Effluent	Liquid, continuous, enzyme-rich	Formed stool, intermittent
Volume	High (500-1500 mL/day)	Low (200-600 mL/day)

⚠️ A dusky, purple, or black stoma indicates ischemia and is a surgical emergency. A healthy stoma is "beefy red."

🩹 Management - The Ostomy Owner's Manual

Appliance Care:
- Change pouching system every 3-7 days.
- Empty pouch when 1/3-1/2 full to prevent leakage and skin irritation.
- Clean peristomal skin with water; dry completely before applying a new appliance.
Diet & Hydration:
- Initially low-residue/fiber diet.
- Avoid gas-producers (e.g., beans, cabbage) & blockage risks (e.g., nuts, popcorn).
- Crucial hydration, especially for ileostomies, to prevent dehydration.

Ostomy Type	Output Characteristics
Ileostomy	Liquid to pasty; continuous
Colostomy	Pasty to formed; intermittent

Changing a Two-Piece Ostomy Pouching System

⚠️ Complications - When Stomas Go Rogue

Early (<30 days) vs. Late (>30 days)

Complication	Key Features & Management
Ischemia/Necrosis	Dusky/black stoma. ⚠️ Surgical emergency if deep.
High Output	>2L/day. Risk of dehydration, ↓Na, ↓K, ↓Mg.
Retraction	Stoma pulls below skin level. Pouching issues.
Parastomal Hernia	Most common late complication. Bulge near stoma.
Prolapse	Telescoping of bowel through stoma.
Stenosis	Narrowing of stoma lumen. ↓ output, cramping.

⭐ Parastomal hernias are the most common late complication. Most are managed conservatively with observation and support belts. Surgery is reserved for symptomatic cases (e.g., obstruction, strangulation, or severe skin/appliance issues).

💡 High-Output Stoma Management:

⚡ Biggest Takeaways

Ileostomies have high-volume, liquid output, posing a major risk for dehydration and electrolyte abnormalities (↓Na+, ↓K+).

Colostomies have lower-volume, more formed stool; consistency depends on location (transverse vs. sigmoid).

Stoma ischemia is the most feared early complication; a dark, dusky, or black stoma is a surgical emergency.

Parastomal hernia is the most common late complication.

Hartmann's procedure creates an end colostomy and rectal stump, typically for complicated diverticulitis.

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