A 57-year-old man is brought to the emergency department because of a 2-day history of fever and right upper quadrant abdominal pain. Examination shows jaundice. Ultrasonography of the abdomen shows cholelithiasis and marked dilation of the biliary duct. An ERCP is performed and reveals pus with multiple brown concrements draining from the common bile duct. Which of the following is the most likely underlying cause of the patient's findings?
Q132
A 51-year-old man with a recent diagnosis of peptic ulcer disease currently treated with an oral proton pump inhibitor twice daily presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago. On physical exam, you find his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness. Given the following options, what is the next best step in patient management?
Q133
A 45-year-old woman comes to the office with a 2-week history of rectal bleeding that occurs every day with her bowel movements. She denies any pain during defecation. Apart from this, she does not have any other complaints. Her past medical history is insignificant except for 5 normal vaginal deliveries. Her vitals are a heart rate of 72/min, a respiratory rate of 15/min, a temperature of 36.7°C (98.1°F), and a blood pressure of 115/85 mm Hg. On rectovaginal examination, there is a palpable, non-tender, prolapsed mass that can be pushed back by the examiner's finger into the anal sphincter. What is the most likely diagnosis?
Q134
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?
Abdominal emergencies US Medical PG Practice Questions and MCQs
Question 131: A 57-year-old man is brought to the emergency department because of a 2-day history of fever and right upper quadrant abdominal pain. Examination shows jaundice. Ultrasonography of the abdomen shows cholelithiasis and marked dilation of the biliary duct. An ERCP is performed and reveals pus with multiple brown concrements draining from the common bile duct. Which of the following is the most likely underlying cause of the patient's findings?
A. Biliary stricture
B. Pancreatic cancer
C. Primary sclerosing cholangitis
D. Mirizzi syndrome
E. Choledocholithiasis (Correct Answer)
Explanation: ***Choledocholithiasis***
- The patient presents with **fever**, **right upper quadrant pain**, and **jaundice** (Charcot's triad), highly suggestive of **acute cholangitis**.
- The presence of **cholelithiasis** on ultrasound, **dilated common bile duct**, and **pus with multiple brown concrements** draining from the CBD during ERCP confirm **choledocholithiasis** (stones in the common bile duct) as the underlying cause of biliary obstruction and subsequent cholangitis.
- **Brown pigment stones** form within the bile duct itself due to bacterial infection and bile stasis, and their presence is pathognomonic for choledocholithiasis with secondary infection.
*Biliary stricture*
- While a biliary stricture can cause biliary dilation and potentially cholangitis, it typically doesn't present with **multiple brown concrements** draining during ERCP.
- The primary pathology would be ductal narrowing, not intraductal stones.
*Pancreatic cancer*
- Pancreatic cancer can cause biliary obstruction and jaundice, but typically presents with **painless jaundice** rather than the acute febrile presentation seen here.
- Ultrasound would more likely show a pancreatic mass rather than primarily cholelithiasis with intraductal stones.
*Primary sclerosing cholangitis*
- This condition involves chronic **inflammation and fibrosis** of bile ducts leading to multifocal strictures, but is not typically associated with **acute presentation** or **brown pigment stones**.
- PSC often presents with chronic symptoms and is associated with inflammatory bowel disease.
*Mirizzi syndrome*
- Mirizzi syndrome involves an **impacted gallstone in the cystic duct or gallbladder neck** causing extrinsic compression of the common hepatic duct.
- While it can cause biliary obstruction, the key finding of **multiple brown concrements within the common bile duct** indicates primary intraductal stone disease rather than extrinsic compression from a single impacted stone.
Question 132: A 51-year-old man with a recent diagnosis of peptic ulcer disease currently treated with an oral proton pump inhibitor twice daily presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago. On physical exam, you find his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness. Given the following options, what is the next best step in patient management?
A. Serum gastrin level
B. Urgent CT abdomen and pelvis (Correct Answer)
C. H. pylori testing
D. Abdominal radiographs
E. Upper endoscopy
Explanation: ***Urgent CT abdomen and pelvis***
- The sudden onset of severe abdominal pain, diffuse tenderness, and **rebound tenderness** in a patient with a history of peptic ulcer disease (PUD) suggests a **perforated ulcer**, which is a surgical emergency.
- A CT scan is the **most sensitive imaging modality** for detecting **free air** (pneumoperitoneum) and can confirm the diagnosis with >95% sensitivity, helping to localize the perforation and identify complications such as abscess formation.
- CT also helps evaluate alternative diagnoses in the acute abdomen and provides detailed anatomic information for surgical planning.
*Serum gastrin level*
- This test is primarily used in the diagnosis of **Zollinger-Ellison syndrome**, a rare condition characterized by gastrinomas leading to severe, refractory PUD.
- It is not indicated in an acute emergency setting with signs of perforation, as it would delay critical diagnostic imaging and management.
*H. pylori testing*
- **_H. pylori_ infection** is a common cause of PUD, but testing for it is part of routine initial management or follow-up for chronic disease.
- Testing would not address the immediate life-threatening complication of suspected perforation and would delay definitive diagnosis.
*Abdominal radiographs*
- An upright chest X-ray or abdominal radiograph can detect **free air under the diaphragm** in cases of perforation and is a reasonable initial imaging test.
- However, plain radiographs have lower sensitivity (75-80%) compared to CT scan and may miss smaller perforations or provide insufficient information about the location and extent of injury.
- In modern practice with readily available CT, cross-sectional imaging is preferred for its superior diagnostic accuracy in evaluating the acute abdomen.
*Upper endoscopy*
- **Upper endoscopy** is a valuable diagnostic and therapeutic tool for stable PUD but is **absolutely contraindicated** in cases of suspected or confirmed hollow viscus perforation.
- Introducing an endoscope with air insufflation could worsen the perforation and lead to further contamination of the peritoneal cavity, increasing morbidity and mortality.
Question 133: A 45-year-old woman comes to the office with a 2-week history of rectal bleeding that occurs every day with her bowel movements. She denies any pain during defecation. Apart from this, she does not have any other complaints. Her past medical history is insignificant except for 5 normal vaginal deliveries. Her vitals are a heart rate of 72/min, a respiratory rate of 15/min, a temperature of 36.7°C (98.1°F), and a blood pressure of 115/85 mm Hg. On rectovaginal examination, there is a palpable, non-tender, prolapsed mass that can be pushed back by the examiner's finger into the anal sphincter. What is the most likely diagnosis?
A. Rectal ulcer
B. Anal fissure
C. Hemorrhoids (Correct Answer)
D. Proctitis
E. Anorectal fistula
Explanation: ***Hemorrhoids***
- The presentation of **painless rectal bleeding** with bowel movements and a **palpable, prolapsed, reducible mass** is classic for hemorrhoids, especially common in multiparous women.
- The absence of pain and the ability to reduce the prolapsed mass are key differentiating features from other perianal conditions.
*Rectal ulcer*
- Rectal ulcers typically present with **painful defecation** and may cause blood in the stool, but are not usually associated with a reducible prolapsed mass.
- They are often associated with other inflammatory conditions or trauma, which are not described here.
*Anal fissure*
- Anal fissures are characterized by **severe pain during and after defecation** due to a tear in the anal canal lining, and the bleeding is usually bright red and minimal.
- The primary symptom is pain, which this patient explicitly denies.
*Proctitis*
- Proctitis involves **inflammation of the rectal lining**, leading to symptoms like tenesmus, urgency, and bloody or purulent discharge, often with abdominal pain.
- It does not typically present with a palpable, prolapsed, reducible anal mass.
*Anorectal fistula*
- Anorectal fistulas are abnormal tracts between the anal canal or rectum and the perianal skin, usually causing **pain, swelling, and purulent discharge**.
- While bleeding can occur, the primary symptom is drainage, and they do not present as a reducible prolapsed mass.
Question 134: 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?
A. Laparoscopic surgical repair
B. Surgical drainage
C. Antibiotic therapy
D. Open surgical repair (Correct Answer)
E. Surgical exploration of the testicle
Explanation: ***Open surgical repair***
- The patient presents with a **painful, non-reducible inguinal hernia** that has likely **incarcerated** or **strangulated**, given the acute onset of severe pain, vomiting, and abdominal distension with hyperactive bowel sounds.
- In cases of suspected incarceration or strangulation, **urgent open surgical repair** is indicated to prevent **bowel ischemia** and its serious complications (e.g., perforation, sepsis).
*Laparoscopic surgical repair*
- While laparoscopic repair is an option for elective hernia repair, it is generally **contraindicated** in cases of **incarcerated or strangulated hernias** due to the higher risk of bowel injury, inadequate assessment of bowel viability, and longer operative times in an emergency setting.
- Also, the patient's **COPD** might make him a less ideal candidate for laparoscopy due to the risks associated with pneumoperitoneum.
*Surgical drainage*
- Surgical drainage is typically performed for abscesses or fluid collections, which are **not the primary issue** in this presentation.
- A hernia involves displacement of organs, not an accumulation of fluid or pus requiring drainage.
*Antibiotic therapy*
- Although antibiotics might be considered as an adjunctive therapy if infection is suspected or confirmed (e.g., with bowel necrosis), they are **not the definitive primary treatment** for an incarcerated or strangulated hernia.
- The mechanical obstruction and potential ischemia require surgical intervention for resolution.
*Surgical exploration of the testicle*
- While the bulge extends into the scrotum, the primary concern is the **incarcerated hernia** itself.
- Surgical exploration of the testicle would be indicated for conditions like testicular torsion, epididymitis, or testicular masses, which are not suggested by the presented symptoms.
