A 48-year-old woman with a history of obesity presents with acute onset of diffuse epigastric pain that began a few hours ago and then localized to the right upper quadrant. Further questioning reveals that the pain has been exacerbated by eating but has otherwise been unchanged in nature. Physical exam reveals severe right upper quadrant pain that is accompanied by arrest of respiration with deep palpation of the right upper quadrant. Which of the following symptoms is associated with the most likely etiology of this patient's presentation?
Q32
A 28-year-old woman presents for her annual physical examination. She describes a painless lump in her left breast detected during breast self-examination two weeks ago. She has no previous history of breast lumps and considers herself to be generally healthy. She takes no medication and does not smoke tobacco or drink alcohol. The patient has no personal or family history of breast cancer. Her vitals are normal. Physical examination reveals a firm, 1 to 2 cm mass in the lateral aspect of her left breast. However, no associated skin changes, nipple discharge, or retraction are found. No axillary adenopathy is present. What is the most appropriate next step in the workup of this patient?
Q33
A 27-year-old-man is brought to the emergency department 30 minutes after being involved in a motorcycle accident. He lost control at high speed and was thrown forward onto the handlebars. On arrival, he is alert and responsive. He has abdominal pain and superficial lacerations on his left arm. Vital signs are within normal limits. Examination shows a tender, erythematous area over his epigastrium. The abdomen is soft and non-distended. A CT scan of the abdomen shows no abnormalities. Treatment with analgesics is begun, the lacerations are cleaned and dressed, and the patient is discharged home after 2 hours of observation. Four days later, the patient returns to the emergency department with gradually worsening upper abdominal pain, fever, poor appetite, and vomiting. His pulse is 91/min and blood pressure is 135/82 mm Hg. Which of the following is the most likely diagnosis?
Q34
An institutionalized 65-year-old man is brought to the emergency department because of abdominal pain and distension for 12 hours. The pain was acute in onset and is a cramping-type pain associated with nausea, vomiting, and constipation. He has a history of chronic constipation and has used laxatives for years. There is no history of inflammatory bowel disease in his family. He has not been hospitalized recently. There is no recent history of weight loss or change in bowel habits. On physical examination, the patient appears ill. The abdomen is distended with tenderness mainly in the left lower quadrant and is tympanic on percussion. The blood pressure is 110/79 mm Hg, heart rate is 100/min, the respiratory rate is 20/min, and the temperature is 37.2°C (99.0°F). The CBC shows an elevated white blood cell count. The plain abdominal X-ray is shown in the accompanying image. What is the most likely cause of his condition?
Q35
During the course of investigation of a suspected abdominal aortic aneurysm in a 57-year-old woman, a solid 6 × 5 cm mass is detected in the right kidney. The abdominal aorta reveals no abnormalities. The patient is feeling well and has no history of any serious illness or medication usage. She is a 25-pack-year smoker. Her vital signs are within normal limits. Physical examination reveals no abnormalities. Biopsy of the mass shows renal cell carcinoma. Contrast-enhanced CT scan indicates no abnormalities involving contralateral kidney, lymph nodes, lungs, liver, bone, or brain. Which of the following treatment options is the most appropriate next step in the management of this patient?
Q36
A 72-year-old female presents to the emergency department complaining of severe abdominal pain and several days of bloody diarrhea. Her symptoms began with intermittent bloody diarrhea five days ago and have worsened steadily. For the last 24 hours, she has complained of fevers, chills, and abdominal pain. She has a history of ulcerative colitis, idiopathic hypertension, and hypothyroidism. Her medications include hydrochlorothiazide, levothyroxine, and sulfasalazine.
In the ED, her temperature is 39.1°C (102.4°F), pulse is 120/min, blood pressure is 90/60 mmHg, and respirations are 20/min. On exam, the patient is alert and oriented to person and place, but does not know the day. Her mucus membranes are dry. Heart and lung exam are not revealing. Her abdomen is distended with marked rebound tenderness. Bowel sounds are hyperactive.
Serum:
Na+: 142 mEq/L
Cl-: 107 mEq/L
K+: 3.3 mEq/L
HCO3-: 20 mEq/L
BUN: 15 mg/dL
Glucose: 92 mg/dL
Creatinine: 1.2 mg/dL
Calcium: 10.1 mg/dL
Hemoglobin: 11.2 g/dL
Hematocrit: 30%
Leukocyte count: 14,600/mm^3 with normal differential
Platelet count: 405,000/mm^3
What is the next best step in management?
Q37
A 55-year-old man presents to the emergency department with nausea and vomiting. The patient states that he has felt nauseous for the past week and began vomiting last night. He thought his symptoms would resolve but decided to come in when his symptoms worsened. He feels that his symptoms are exacerbated with large fatty meals and when he drinks alcohol. His wife recently returned from a cruise with symptoms of vomiting and diarrhea. The patient has a past medical history of poorly managed diabetes, constipation, anxiety, dyslipidemia, and hypertension. His temperature is 99.5°F (37.5°C), blood pressure is 197/128 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals a systolic murmur heard loudest along the left upper sternal border. Abdominal exam reveals an obese, tympanitic and distended abdomen with a 3 cm scar in the right lower quadrant. Vascular exam reveals weak pulses in the lower extremities. Which of the following is the most likely diagnosis?
Q38
A 38-year-old man comes to the physician because of a 2-week history of severe pain while passing stools. The stools are covered with bright red blood. He has been avoiding defecation because of the pain. Last year, he was hospitalized for pilonidal sinus surgery. He has had chronic lower back pain ever since he had an accident at his workplace 10 years ago. The patient's father was diagnosed with colon cancer at the age of 62. Current medications include oxycodone and gabapentin. He is 163 cm (5 ft 4 in) tall and weighs 100 kg (220 lb); BMI is 37.6 kg/m2. Vital signs are within normal limits. The abdomen is soft and nontender. Digital rectal examination was not performed because of severe pain. His hemoglobin is 16.3 mg/dL and his leukocyte count is 8300/mm3. Which of the following is the most appropriate next step in management?
Q39
A 26-year-old woman presents to her primary care physician for 5 days of increasing pelvic pain. She says that the pain has been present for the last 2 months; however, it has become increasingly severe recently. She also says that the pain has been accompanied by unusually heavy menstrual periods in the last few months. Physical exam reveals a mass in the right adnexa, and ultrasonography reveals a 9 cm right ovarian mass. If this mass is surgically removed, which of the following structures must be diligently protected?
Q40
A 58-year-old man comes to the physician for the evaluation of intermittent dysphagia for 6 months. He states that he drinks a lot of water during meals to help reduce discomfort he has while swallowing food. He has hypertension and gastroesophageal reflux disease. He has smoked one half-pack of cigarettes daily for 32 years. He does not drink alcohol. Current medications include hydrochlorothiazide and ranitidine. He is 173 cm (5 ft 8 in) tall and weighs 101 kg (222 lb); BMI is 33.7 kg/m2. His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 125/75 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. The abdomen is soft and nontender. A barium esophagogram shows a smooth, circumferential narrowing at the distal esophagus. An upper endoscopy shows a sliding hiatal hernia and a thin mucosal ring at the gastroesophageal junction. Biopsies from the area show normal squamous and columnar epithelium with no dysplasia or malignancy. Which of the following is the most appropriate next step in the management of this patient?
Abdominal emergencies US Medical PG Practice Questions and MCQs
Question 31: A 48-year-old woman with a history of obesity presents with acute onset of diffuse epigastric pain that began a few hours ago and then localized to the right upper quadrant. Further questioning reveals that the pain has been exacerbated by eating but has otherwise been unchanged in nature. Physical exam reveals severe right upper quadrant pain that is accompanied by arrest of respiration with deep palpation of the right upper quadrant. Which of the following symptoms is associated with the most likely etiology of this patient's presentation?
A. Crunching sound upon heart auscultation
B. Pain with passive right leg raising
C. Diffuse substernal pain
D. Pain radiating to the right shoulder (Correct Answer)
E. Hematemesis
Explanation: ***Pain radiating to the right shoulder***
- The patient's presentation with acute epigastric pain localizing to the **right upper quadrant**, exacerbation by eating, and a positive **Murphy's sign** (arrest of respiration with deep palpation of the RUQ) is highly suggestive of **acute cholecystitis**.
- **Referred pain** to the right shoulder or scapula is a classic symptom of cholecystitis due to irritation of the **diaphragm** and shared C3-C5 dermatomes with the phrenic nerve.
*Crunching sound upon heart auscultation*
- A crunching sound synchronous with the heartbeat (Hamman's sign) is indicative of **pneumomediastinum**, a condition unrelated to the patient's abdominal pain.
- This symptom suggests air in the mediastinum, typically due to esophageal rupture or severe asthma, not gallbladder inflammation.
*Pain with passive right leg raising*
- Pain with passive right leg raising (**Psoas sign**) is associated with irritation of the **psoas muscle**, often seen in conditions like **appendicitis** or retroperitoneal abscess.
- This finding is not characteristic of acute cholecystitis, which primarily affects the right upper quadrant.
*Diffuse substernal pain*
- Diffuse substernal pain is a hallmark symptom of **cardiac ischemia** or **gastroesophageal reflux disease (GERD)**.
- While it can sometimes be confused with epigastric pain, the localization to the RUQ and positive Murphy's sign differentiate the patient's condition from these causes.
*Hematemesis*
- **Hematemesis**, or vomiting blood, suggests **upper gastrointestinal bleeding** from conditions like peptic ulcers, esophageal varices, or Mallory-Weiss tears.
- This symptom is unrelated to acute cholecystitis, which involves inflammation of the gallbladder and not direct bleeding into the GI tract.
Question 32: A 28-year-old woman presents for her annual physical examination. She describes a painless lump in her left breast detected during breast self-examination two weeks ago. She has no previous history of breast lumps and considers herself to be generally healthy. She takes no medication and does not smoke tobacco or drink alcohol. The patient has no personal or family history of breast cancer. Her vitals are normal. Physical examination reveals a firm, 1 to 2 cm mass in the lateral aspect of her left breast. However, no associated skin changes, nipple discharge, or retraction are found. No axillary adenopathy is present. What is the most appropriate next step in the workup of this patient?
A. Perform an ultrasound (Correct Answer)
B. Order magnetic resonance imaging of the breast
C. Refer for an ultrasound-guided core biopsy
D. Perform an ultrasound and order a mammogram
E. Order a mammogram
Explanation: ***Perform an ultrasound***
- For women under **30 years old**, ultrasound is the **initial imaging modality** for palpable breast masses due to their **denser breast tissue**, which limits the sensitivity of mammography.
- Ultrasound can differentiate between **solid** and **cystic lesions**, providing crucial information for diagnosis and guiding further management.
*Order magnetic resonance imaging of the breast*
- **MRI** is generally reserved for **high-risk patients** (e.g., strong family history, genetic mutations), assessing the **extent of known cancer**, or evaluating **implant integrity**, not as a primary diagnostic tool for a new palpable mass in a low-risk patient.
- Its high sensitivity can lead to **false positives** and unnecessary biopsies in healthy young women.
*Refer for an ultrasound-guided core biopsy*
- **Biopsy** is performed after initial imaging (ultrasound, and sometimes mammogram) has identified a **suspicious lesion** requiring tissue diagnosis.
- Jumping straight to biopsy without initial imaging is premature and not the standard of care for a **painless, new lump** in a low-risk 28-year-old.
*Perform an ultrasound and order a mammogram*
- While ultrasound is appropriate, **mammography** is typically **not recommended as a first-line imaging** for women under 30 due to **radiation exposure** and reduced sensitivity in **dense breast tissue**.
- Mammography is usually considered for women **over 30 or 40**, or if ultrasound findings are highly suspicious in younger women.
*Order a mammogram*
- **Mammography** is **not the initial imaging modality** of choice for a 28-year-old due to the **density of breast tissue** in younger women, which can obscure masses and reduce the effectiveness of the mammogram.
- Additionally, exposing a younger woman to **radiation** without initial ultrasound evaluation is generally avoided.
Question 33: A 27-year-old-man is brought to the emergency department 30 minutes after being involved in a motorcycle accident. He lost control at high speed and was thrown forward onto the handlebars. On arrival, he is alert and responsive. He has abdominal pain and superficial lacerations on his left arm. Vital signs are within normal limits. Examination shows a tender, erythematous area over his epigastrium. The abdomen is soft and non-distended. A CT scan of the abdomen shows no abnormalities. Treatment with analgesics is begun, the lacerations are cleaned and dressed, and the patient is discharged home after 2 hours of observation. Four days later, the patient returns to the emergency department with gradually worsening upper abdominal pain, fever, poor appetite, and vomiting. His pulse is 91/min and blood pressure is 135/82 mm Hg. Which of the following is the most likely diagnosis?
A. Abdominal compartment syndrome
B. Aortic dissection
C. Splenic rupture
D. Pancreatic ductal injury (Correct Answer)
E. Diaphragmatic rupture
Explanation: ***Pancreatic ductal injury***
- A forceful impact to the **epigastrium** (e.g., falling onto handlebars) can cause **pancreatic injury**, particularly a **ductal transection**, due to the pancreas being compressed against the vertebral column.
- Initial CT scans can be normal because the injury to the **ductal system** takes time to manifest, leading to delayed symptoms like **worsening abdominal pain, fever, vomiting**, and **poor appetite** several days later due to **pancreatitis** or a **pseudocyst** formation.
*Abdominal compartment syndrome*
- This typically presents with **acute abdominal distension**, increased intra-abdominal pressure, and organ dysfunction (e.g., oliguria, respiratory compromise), which are not described here.
- It's an immediate complication of severe trauma or fluid resuscitation, not a delayed presentation like described.
*Aortic dissection*
- Characterized by **sudden-onset, severe, tearing chest or back pain** and often involves hypertension or Marfan syndrome.
- It would manifest immediately with hemodynamic instability and distinct pain, not a delayed presentation of progressive abdominal symptoms.
*Splenic rupture*
- Often causes **left upper quadrant pain**, **Kehr's sign** (referred shoulder pain), and **hemodynamic instability** due to significant blood loss.
- While possible in trauma, a normal initial CT scan makes this less likely, and its symptoms usually appear earlier or are more severe.
*Diaphragmatic rupture*
- Can present with **dyspnea, shoulder pain**, or signs of **herniated abdominal organs** into the chest.
- It causes more immediate respiratory distress or gastrointestinal obstruction symptoms, and the abdominal symptoms described are not typical for this injury.
Question 34: An institutionalized 65-year-old man is brought to the emergency department because of abdominal pain and distension for 12 hours. The pain was acute in onset and is a cramping-type pain associated with nausea, vomiting, and constipation. He has a history of chronic constipation and has used laxatives for years. There is no history of inflammatory bowel disease in his family. He has not been hospitalized recently. There is no recent history of weight loss or change in bowel habits. On physical examination, the patient appears ill. The abdomen is distended with tenderness mainly in the left lower quadrant and is tympanic on percussion. The blood pressure is 110/79 mm Hg, heart rate is 100/min, the respiratory rate is 20/min, and the temperature is 37.2°C (99.0°F). The CBC shows an elevated white blood cell count. The plain abdominal X-ray is shown in the accompanying image. What is the most likely cause of his condition?
A. Sigmoid volvulus (Correct Answer)
B. Intussusception
C. Acute diverticulitis
D. Toxic megacolon
E. Colon cancer
Explanation: ***Sigmoid volvulus***
- The patient’s symptoms of acute **abdominal pain**, distension, and cramping strongly indicate **sigmoid volvulus**, often seen in chronic constipation and institutionalized patients.
- Physical examination revealing **tenderness in the left lower quadrant** and a tympanic abdomen supports the diagnosis of bowel obstruction typically caused by **volvulus**.
*Intussusception*
- Generally presents with **currant jelly stools** and is more common in children; the acute symptoms here are less typical.
- It often involves a **lead point** or associated conditions like **polyps** or tumors, which are not indicated in this case.
*Acute diverticulitis*
- Usually associated with **localized pain** in the left lower quadrant but would present with fever and changes in bowel habits, which the patient lacks.
- Typically shows **peritoneal signs** and may have complications like abscess or perforation, not indicated here.
*Toxic megacolon*
- Commonly associated with underlying **inflammatory bowel disease** or infections, not indicated in this patient with no recent history of **IBD**.
- Symptoms would include severe **diarrhea** and abdominal pain, which do not fit the current acute cramping and constipation pattern.
*Colon cancer*
- While it can cause abdominal symptoms, it presents more insidiously with **weight loss** or **change in bowel habits**, none of which are reported here.
- The acute presentation and findings do not align with a malignancy, which would often be chronic in nature.
Question 35: During the course of investigation of a suspected abdominal aortic aneurysm in a 57-year-old woman, a solid 6 × 5 cm mass is detected in the right kidney. The abdominal aorta reveals no abnormalities. The patient is feeling well and has no history of any serious illness or medication usage. She is a 25-pack-year smoker. Her vital signs are within normal limits. Physical examination reveals no abnormalities. Biopsy of the mass shows renal cell carcinoma. Contrast-enhanced CT scan indicates no abnormalities involving contralateral kidney, lymph nodes, lungs, liver, bone, or brain. Which of the following treatment options is the most appropriate next step in the management of this patient?
A. Sunitinib
B. Radiation
C. Nephrectomy (Correct Answer)
D. Interferon-ɑ (IFN-ɑ)
E. Interleukin 2 (IL-2)
Explanation: ***Nephrectomy***
- The patient has a **localized renal cell carcinoma (RCC)** without evidence of metastasis, as indicated by the CT scan showing no abnormalities in the contralateral kidney, lymph nodes, lungs, liver, bone, or brain.
- **Surgical removal** of the affected kidney (**nephrectomy**) is the **gold standard** and curative treatment for localized RCC.
*Sunitinib*
- **Sunitinib** is a **tyrosine kinase inhibitor** used for advanced or metastatic RCC, not for localized disease.
- It would be considered if the disease had spread beyond the kidney or if surgical resection was not feasible.
*Radiation*
- **Renal cell carcinoma** is generally considered **radioresistant**, making external beam radiation therapy ineffective as a primary treatment.
- Radiation is sometimes used for **palliative care** in metastatic RCC, for example, to relieve bone pain or brain metastases.
*Interferon-ɑ (IFN-ɑ)*
- **Interferon-ɑ** is an **immunotherapy** agent. Its use in RCC has largely been replaced by newer, more effective agents.
- It was historically used for metastatic RCC but is not indicated for localized disease and has significant side effects.
*Interleukin 2 (IL-2)*
- **High-dose interleukin 2 (IL-2)** is another **immunotherapy** agent effective in a subset of patients with metastatic RCC.
- It is not used for localized RCC and carries a risk of serious toxicity, requiring administration in specialized centers.
Question 36: A 72-year-old female presents to the emergency department complaining of severe abdominal pain and several days of bloody diarrhea. Her symptoms began with intermittent bloody diarrhea five days ago and have worsened steadily. For the last 24 hours, she has complained of fevers, chills, and abdominal pain. She has a history of ulcerative colitis, idiopathic hypertension, and hypothyroidism. Her medications include hydrochlorothiazide, levothyroxine, and sulfasalazine.
In the ED, her temperature is 39.1°C (102.4°F), pulse is 120/min, blood pressure is 90/60 mmHg, and respirations are 20/min. On exam, the patient is alert and oriented to person and place, but does not know the day. Her mucus membranes are dry. Heart and lung exam are not revealing. Her abdomen is distended with marked rebound tenderness. Bowel sounds are hyperactive.
Serum:
Na+: 142 mEq/L
Cl-: 107 mEq/L
K+: 3.3 mEq/L
HCO3-: 20 mEq/L
BUN: 15 mg/dL
Glucose: 92 mg/dL
Creatinine: 1.2 mg/dL
Calcium: 10.1 mg/dL
Hemoglobin: 11.2 g/dL
Hematocrit: 30%
Leukocyte count: 14,600/mm^3 with normal differential
Platelet count: 405,000/mm^3
What is the next best step in management?
A. Emergent colonoscopy
B. Contrast enema
C. Colectomy
D. Plain abdominal radiograph
E. Abdominal CT with IV contrast (Correct Answer)
Explanation: ***Abdominal CT with IV contrast***
- The patient presents with **severe abdominal pain, bloody diarrhea, fever, hypotension, tachycardia, abdominal distension, rebound tenderness, and leukocytosis**, all suggestive of **toxic megacolon** complicating her ulcerative colitis.
- An **abdominal CT with IV contrast** is the most appropriate next step to confirm the diagnosis, assess the extent of colonic dilation and inflammation, and rule out complications like perforation.
*Emergent colonoscopy*
- **Colonoscopy** is generally **contraindicated** in suspected toxic megacolon due to the high risk of **perforation** of the severely inflamed and dilated colon.
- While it can diagnose ulcerative colitis, the current acute, severe presentation makes it too risky.
*Contrast enema*
- A **contrast enema** is also **contraindicated** in setting of potential **toxic megacolon** or suspected colonic perforation.
- The pressure from the contrast agent could worsen dilation or cause perforation in an already compromised colon.
*Colectomy*
- **Colectomy** is a surgical intervention reserved for cases of **toxic megacolon** that **fail medical management** or when there is evidence of **perforation** or **ischemia**.
- It is not the *immediate* next step in management without further imaging and attempts at medical stabilization.
*Plain abdominal radiograph*
- A plain abdominal radiograph can show colonic dilation and air-fluid levels, which are indicative of toxic megacolon; however, it has **limited ability to assess the extent of inflammation**, detect complications like **perforation**, or rule out other intra-abdominal pathologies.
- It might be a useful initial screen but is not as comprehensive as a CT scan, especially when a definitive diagnosis and management plan is needed.
Question 37: A 55-year-old man presents to the emergency department with nausea and vomiting. The patient states that he has felt nauseous for the past week and began vomiting last night. He thought his symptoms would resolve but decided to come in when his symptoms worsened. He feels that his symptoms are exacerbated with large fatty meals and when he drinks alcohol. His wife recently returned from a cruise with symptoms of vomiting and diarrhea. The patient has a past medical history of poorly managed diabetes, constipation, anxiety, dyslipidemia, and hypertension. His temperature is 99.5°F (37.5°C), blood pressure is 197/128 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals a systolic murmur heard loudest along the left upper sternal border. Abdominal exam reveals an obese, tympanitic and distended abdomen with a 3 cm scar in the right lower quadrant. Vascular exam reveals weak pulses in the lower extremities. Which of the following is the most likely diagnosis?
A. Enteric nervous system damage
B. Twisting of the bowel
C. Adhesions (Correct Answer)
D. Norovirus
E. Impacted stool
Explanation: ***Adhesions***
- The patient's history of a 3 cm scar in the right lower quadrant suggests a prior abdominal surgery, which is the most common cause of **intra-abdominal adhesions**.
- **Adhesions** can lead to **small bowel obstruction**, causing symptoms like nausea, vomiting, abdominal distension, and tympany, which are all present in this patient.
*Enteric nervous system damage*
- Poorly managed diabetes can cause **diabetic gastroparesis**, which involves damage to the **enteric nervous system** leading to delayed gastric emptying.
- While it can cause nausea and vomiting, it doesn't typically present with significant abdominal distension or tympany, which are indicative of a mechanical obstruction.
*Twisting of the bowel*
- **Volvulus**, or twisting of the bowel, causes acute abdominal pain, distension, and often complete obstruction.
- While it's a possibility for bowel obstruction, the presence of a surgical scar and gradual worsening of symptoms over a week makes **adhesions** a more likely cause in this scenario.
*Norovirus*
- **Norovirus** is a common cause of acute gastroenteritis, characterized by abrupt onset of vomiting and diarrhea, often with a rapid resolution.
- Although his wife has similar symptoms, the patient's symptoms have been ongoing for a week, are exacerbated by fatty meals, and include abdominal distension, which is inconsistent with typical norovirus infection.
*Impacted stool*
- **Fecal impaction** can cause constipation, abdominal pain, and sometimes paradoxical diarrhea.
- While the patient has a history of constipation, the significant **tympanic distension** and persistent vomiting suggest a mechanical obstruction rather than just impacted stool.
Question 38: A 38-year-old man comes to the physician because of a 2-week history of severe pain while passing stools. The stools are covered with bright red blood. He has been avoiding defecation because of the pain. Last year, he was hospitalized for pilonidal sinus surgery. He has had chronic lower back pain ever since he had an accident at his workplace 10 years ago. The patient's father was diagnosed with colon cancer at the age of 62. Current medications include oxycodone and gabapentin. He is 163 cm (5 ft 4 in) tall and weighs 100 kg (220 lb); BMI is 37.6 kg/m2. Vital signs are within normal limits. The abdomen is soft and nontender. Digital rectal examination was not performed because of severe pain. His hemoglobin is 16.3 mg/dL and his leukocyte count is 8300/mm3. Which of the following is the most appropriate next step in management?
A. Anal sphincterotomy
B. Colonoscopy
C. Botulinum toxin injection
D. Sitz baths and topical nifedipine (Correct Answer)
E. Tract curettage
Explanation: ***Sitz baths and topical nifedipine***
- The patient's presentation of severe pain with defecation, bright red blood on stools, and avoidance of defecation is highly suggestive of an **anal fissure**.
- **Sitz baths** provide symptomatic relief by promoting muscle relaxation and increasing blood flow, while **topical nifedipine** acts as a calcium channel blocker to relax the internal anal sphincter, reducing pain and promoting healing.
*Anal sphincterotomy*
- This is a surgical procedure typically reserved for **chronic, refractory anal fissures** that have failed conservative management.
- Performing it as a first-line treatment is **premature** and carries higher risks compared to less invasive options.
*Colonoscopy*
- While the patient has a family history of colon cancer, the clinical presentation with **severe anal pain** and **bright red blood** primarily points to an anal fissure.
- A colonoscopy is generally indicated for evaluating suspicion of malignancy or other colonic pathology, not as an initial step for acute, localized anal pain attributed to a likely fissure.
*Botulinum toxin injection*
- **Botulinum toxin injection** is a treatment for anal fissures, similar to calcium channel blockers, by relaxing the internal anal sphincter.
- It is typically considered when topical treatments have failed, but before surgical intervention, making it not the very first step in management.
*Tract curettage*
- **Tract curettage** is a procedure primarily used for treating **anal fistulas** or **pilonidal cysts/sinuses**, which are different conditions from an anal fissure.
- The patient had pilonidal sinus surgery previously, but his current symptoms are consistent with an anal fissure, not a recurrence of pilonidal disease or an anal fistula.
Question 39: A 26-year-old woman presents to her primary care physician for 5 days of increasing pelvic pain. She says that the pain has been present for the last 2 months; however, it has become increasingly severe recently. She also says that the pain has been accompanied by unusually heavy menstrual periods in the last few months. Physical exam reveals a mass in the right adnexa, and ultrasonography reveals a 9 cm right ovarian mass. If this mass is surgically removed, which of the following structures must be diligently protected?
A. External iliac artery
B. Ureter (Correct Answer)
C. Ovarian ligament
D. Cardinal ligament of the uterus
E. Internal iliac artery
Explanation: ***Ureter***
- During **oophorectomy** (removal of an ovarian mass), the **ureter** is particularly vulnerable to injury due to its close proximity to the **ovary** and its blood supply.
- The right ureter courses directly posterior to the **right ovarian vessels** within the infundibulopelvic ligament, making it susceptible to **ligation** or **transection** during surgical maneuvers.
*External iliac artery*
- The external iliac artery is located more laterally within the **pelvis** and supplies the lower extremity; it is generally not in the immediate surgical field for ovarian mass removal.
- While injury to major pelvic vessels is always a concern, the **anatomical relationship** of the external iliac artery makes it less directly vulnerable compared to the ureter during this specific procedure.
*Ovarian ligament*
- The **ovarian ligament** connects the ovary to the **uterus** and is typically dissected or ligated during oophorectomy.
- Although it is cut during the procedure, it is not a structure that requires meticulous protection in the same way as the **ureter**, as its injury primarily impacts **ovarian removal** rather than causing significant morbidity.
*Cardinal ligament of the uterus*
- The **cardinal ligament** provides support to the **cervix** and **upper vagina** but is generally not directly involved in the removal of an **isolated ovarian mass**.
- Injury to this ligament is more typically associated with **hysterectomy** or procedures involving the **uterus**.
*Internal iliac artery*
- The **internal iliac artery** supplies blood to the **pelvic organs** and is situated deeper within the pelvis, making it less prone to direct injury during an oophorectomy compared to the **ureter**.
- While it gives off branches to the uterus and vagina, its main trunk is not as immediately adjacent to the **ovary** as the ureter.
Question 40: A 58-year-old man comes to the physician for the evaluation of intermittent dysphagia for 6 months. He states that he drinks a lot of water during meals to help reduce discomfort he has while swallowing food. He has hypertension and gastroesophageal reflux disease. He has smoked one half-pack of cigarettes daily for 32 years. He does not drink alcohol. Current medications include hydrochlorothiazide and ranitidine. He is 173 cm (5 ft 8 in) tall and weighs 101 kg (222 lb); BMI is 33.7 kg/m2. His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 125/75 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. The abdomen is soft and nontender. A barium esophagogram shows a smooth, circumferential narrowing at the distal esophagus. An upper endoscopy shows a sliding hiatal hernia and a thin mucosal ring at the gastroesophageal junction. Biopsies from the area show normal squamous and columnar epithelium with no dysplasia or malignancy. Which of the following is the most appropriate next step in the management of this patient?
A. Mechanical dilation (Correct Answer)
B. Iron supplementation
C. Esophageal stent
D. Esophagectomy
E. Nissen fundoplication
Explanation: ***Mechanical dilation***
- The patient's presentation with **intermittent dysphagia to solids**, a thin mucosal ring at the gastroesophageal junction on endoscopy, and a **smooth circumferential narrowing** on barium study is diagnostic of a **Schatzki ring** (B ring).
- Biopsies showing **no dysplasia or malignancy** confirm this is a benign condition.
- **Mechanical dilation** (pneumatic or bougie dilation) is the **first-line treatment** for symptomatic Schatzki rings, with success rates exceeding 90% and providing immediate symptom relief.
- The procedure is safe, minimally invasive, and can be repeated if symptoms recur.
*Iron supplementation*
- **Plummer-Vinson syndrome** (iron deficiency anemia with esophageal webs in the upper esophagus) presents differently from this patient's distal esophageal ring.
- There is no evidence of anemia in this case, and iron supplementation would not address the **mechanical obstruction**.
*Esophageal stent*
- Esophageal stents are reserved for **malignant strictures** or **refractory benign strictures** that fail multiple dilations.
- This would be inappropriate as **first-line therapy** for a benign Schatzki ring and carries higher complication risks (migration, perforation).
*Esophagectomy*
- **Esophagectomy** is a major surgical procedure indicated for **esophageal cancer** or end-stage benign disease (e.g., severe caustic injury, refractory achalasia with megaesophagus).
- This is **grossly excessive** for a benign Schatzki ring, which responds well to simple dilation.
*Nissen fundoplication*
- **Nissen fundoplication** treats **severe GERD** by creating an anti-reflux barrier, but does not address an existing **mechanical stricture or ring**.
- While the patient has GERD (a risk factor for Schatzki rings), the immediate problem is the obstructing ring itself, which requires dilation first.
- Some patients may benefit from fundoplication after dilation if severe reflux persists, but this is not the next step.
