Anastomotic leak — MCQs

10 questions

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?

Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following: Hemoglobin 13.1 g/dL Hematocrit 42% Leukocyte count 15,700/mm3 Segmented neutrophils 65% Bands 10% Lymphocytes 20% Monocytes 3% Eosinophils 1% Basophils 0.5% AST 40 U/L ALT 100 U/L Alkaline phosphatase 85 U/L Total bilirubin 1.5 mg/dL Direct 0.9 mg/dL Amylase 90 U/L Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?

Ten days after undergoing emergent colectomy for a ruptured bowel that she sustained in a motor vehicle accident, a 59-year-old woman has abdominal pain. During the procedure, she was transfused 3 units of packed red blood cells. She is currently receiving total parenteral nutrition. Her temperature is 38.9°C (102.0°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. Examination shows tenderness to palpation in the right upper quadrant of the abdomen. Bowel sounds are hypoactive. Serum studies show: Aspartate aminotransferase 142 U/L Alanine aminotransferase 86 U/L Alkaline phosphatase 153 U/L Total bilirubin 1.5 mg/dL Direct bilirubin 1.0 mg/dL Amylase 20 U/L Which of the following is the most likely diagnosis?

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?

A 47-year-old woman presents to the emergency department with abdominal pain. The patient states that she felt this pain come on during dinner last night. Since then, she has felt bloated, constipated, and has been vomiting. Her current medications include metformin, insulin, levothyroxine, and ibuprofen. Her temperature is 99.0°F (37.2°C), blood pressure is 139/79 mmHg, pulse is 95/min, respirations are 12/min, and oxygen saturation is 98% on room air. On physical exam, the patient appears uncomfortable. Abdominal exam is notable for hypoactive bowel sounds, abdominal distension, and diffuse tenderness in all four quadrants. Cardiac and pulmonary exams are within normal limits. Which of the following is the best next step in management?

One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show: Hemoglobin 12.5 g/dL Leukocyte count 18,600/mm3 Platelet count 228,000/mm3 Erythrocyte sedimentation rate 120 mm/h Serum Na+ 134 mEq/L K+ 3.5 mEq/L Cl- 98 mEq/L HCO3- 22 mEq/L Glucose 200 mg/dL Urea nitrogen 60 mg/dL Creatinine 3.2 mg/dL Creatine kinase 750 U/L Which of the following is the most appropriate next step in management?

A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

A 68-year-old man presents to the emergency department with left lower quadrant abdominal pain and fever for 1 day. He states during this time frame he has had weight loss and a decreased appetite. The patient had surgery for a ruptured Achilles tendon 1 month ago and is still recovering but is otherwise generally healthy. His temperature is 102°F (38.9°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is remarkable for an uncomfortable and thin man with left lower quadrant abdominal tenderness without rebound findings. Fecal occult test for blood is positive. Laboratory studies are ordered as seen below. Hemoglobin: 10 g/dL Hematocrit: 30% Leukocyte count: 3,500/mm^3 with normal differential Platelet count: 157,000/mm^3 Which of the following is the most appropriate next step in management?

A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?

Q10

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?

Anastomotic leak US Medical PG Practice Questions and MCQs

Question 1: 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 2: Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following: Hemoglobin 13.1 g/dL Hematocrit 42% Leukocyte count 15,700/mm3 Segmented neutrophils 65% Bands 10% Lymphocytes 20% Monocytes 3% Eosinophils 1% Basophils 0.5% AST 40 U/L ALT 100 U/L Alkaline phosphatase 85 U/L Total bilirubin 1.5 mg/dL Direct 0.9 mg/dL Amylase 90 U/L Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?

A. Intravenous heparin therapy followed by embolectomy
B. Careful observation with serial abdominal examinations
C. Endoscopic retrograde cholangiopancreatography with papillotomy
D. Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy (Correct Answer)
E. Immediate cholecystectomy

Explanation: ***Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy*** - The patient presents with **acalculous cholecystitis**, characterized by severe RUQ pain, fever, leukocytosis, elevated transaminases, and ultrasonographic findings of a distended gallbladder with a thickened wall and pericholecystic fluid, but no stones. - Given his comorbid conditions (diabetes, PVD, recent CABG) and the severity of his illness, empirical **broad-spectrum antibiotics** (like piperacillin-tazobactam) along with image-guided **percutaneous cholecystostomy** for gallbladder decompression are the most appropriate management, avoiding the high risks of immediate surgery. *Intravenous heparin therapy followed by embolectomy* - This approach is indicated for **acute mesenteric ischemia with embolism**, which can present with severe abdominal pain and signs of hypoperfusion. - While the patient has chronic mesenteric ischemia, his current symptoms and imaging findings are more consistent with cholecystitis, and there is no clear evidence of acute embolic event requiring embolectomy. *Careful observation with serial abdominal examinations* - This patient exhibits signs of a severe inflammatory process (fever, leukocytosis, RUQ tenderness, elevated LFTs, and sonographic findings of severe inflammation) and systemic illness, making **conservative observation insufficient** and potentially dangerous. - **Acalculous cholecystitis** is a serious condition with a high risk of complications like perforation and sepsis, especially in critically ill patients, and requires prompt intervention. *Endoscopic retrograde cholangiopancreatography with papillotomy* - **ERCP with papillotomy** is indicated for conditions like **choledocholithiasis** (common bile duct stones) or **cholangitis**, which cause biliary obstruction. - The ultrasound shows **no stones** and features specific to cholecystitis rather than common bile duct obstruction, making ERCP inappropriate as an initial step. *Immediate cholecystectomy* - While cholecystectomy is the definitive treatment for cholecystitis, immediate open or laparoscopic cholecystectomy in a critically ill patient with **acalculous cholecystitis** after recent CABG carries a **very high morbidity and mortality risk**. - **Percutaneous cholecystostomy** offers a safer, less invasive alternative for source control and stabilizes the patient before potential delayed definitive surgery if needed, once the patient's condition improves.

Question 3: Ten days after undergoing emergent colectomy for a ruptured bowel that she sustained in a motor vehicle accident, a 59-year-old woman has abdominal pain. During the procedure, she was transfused 3 units of packed red blood cells. She is currently receiving total parenteral nutrition. Her temperature is 38.9°C (102.0°F), pulse is 115/min, and blood pressure is 100/60 mm Hg. Examination shows tenderness to palpation in the right upper quadrant of the abdomen. Bowel sounds are hypoactive. Serum studies show: Aspartate aminotransferase 142 U/L Alanine aminotransferase 86 U/L Alkaline phosphatase 153 U/L Total bilirubin 1.5 mg/dL Direct bilirubin 1.0 mg/dL Amylase 20 U/L Which of the following is the most likely diagnosis?

A. Hemolytic transfusion reaction
B. Acalculous cholecystitis (Correct Answer)
C. Acute cholecystitis (calculous)
D. Small bowel obstruction
E. Acute pancreatitis

Explanation: ***Acalculous cholecystitis*** - This patient's clinical picture of **fever**, **RUQ tenderness**, **leukocytosis**, and mildly elevated liver enzymes in the setting of recent **major surgery**, **trauma**, and **total parenteral nutrition (TPN)** is highly suggestive of **acalculous cholecystitis**. - **Acalculous cholecystitis** often occurs in critically ill patients due to gallbladder stasis, ischemia, and inflammation, usually without the presence of stones. *Hemolytic transfusion reaction* - While the patient received blood transfusions, a **hemolytic transfusion reaction** typically presents with fever, chills, flank pain, and **hemoglobinuria**, none of which are explicitly mentioned. - Liver enzyme elevations can occur, but the significant RUQ tenderness and absence of signs of hemolysis make it less likely. *Acute cholecystitis (calculous)* - **Acute cholecystitis with gallstones** typically presents with similar symptoms to acalculous cholecystitis (pain, fever), but requires the presence of gallstones causing obstruction. - The clinical context of critical illness, recent surgery, and TPN use points more towards acalculous inflammation rather than stone-related disease. *Small bowel obstruction* - **Small bowel obstruction** would present with more pronounced **abdominal distention**, **vomiting**, and often **high-pitched bowel sounds** followed by absent sounds, which is not the primary picture here. - Although bowel sounds are hypoactive, the focal RUQ tenderness and liver enzyme changes are not typical of a primary small bowel obstruction. *Acute pancreatitis* - **Acute pancreatitis** is usually characterized by **severe epigastric pain** radiating to the back, and significantly elevated **amylase** and **lipase** levels. - The patient's amylase is normal, and lipase is not mentioned but usually tracks with amylase in pancreatitis.

Question 4: 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?

A. Embolization of superior mesenteric artery
B. Atherosclerotic narrowing of the intestinal vessels
C. Small outpouchings in the sigmoid wall
D. Infection with Clostridioides difficile
E. Decreased blood flow to the splenic flexure (Correct Answer)

Explanation: ***Decreased blood flow to the splenic flexure*** - This patient's symptoms are highly suggestive of **ischemic colitis**, which often affects the **splenic flexure** due to its "watershed" area vulnerability. **Cardiopulmonary bypass** and significant **intraoperative blood loss** (leading to hypotension and hypoperfusion) are major risk factors for this condition. - The presentation with **crampy abdominal pain**, **urgent defecation**, and **bloody bowel movements** shortly after cardiac surgery points to colonic ischemia. *Embolization of superior mesenteric artery* - While an acute **SMA embolism** could cause severe abdominal pain and bloody stools, it typically presents with **more diffuse and severe abdominal tenderness**, often with marked tenderness disproportionate to examination findings early on, and rapid progression to peritonitis. - The patient's history of valvular disease and hypercholesterolemia increases the risk of embolization, but the **mild tenderness confined to left quadrants** and decreased bowel sounds are less typical of an acute SMA occlusion. *Atherosclerotic narrowing of the intestinal vessels* - This describes **chronic mesenteric ischemia**, which typically causes **postprandial abdominal pain** (intestinal angina) and weight loss, not acute abdominal pain and bloody diarrhea in the immediate postoperative period. - While the patient has risk factors for atherosclerosis (hypercholesterolemia, diabetes), the acute onset of symptoms following cardiac surgery points to an acute ischemic event rather than chronic narrowing. *Small outpouchings in the sigmoid wall* - This refers to **diverticulitis** or **diverticular bleeding**. While diverticular bleeding can cause painless or painful bleeding, and diverticulitis can cause abdominal pain, the acute onset post-cardiac surgery in the setting of hypoperfusion makes ischemic colitis a more likely diagnosis. - Diverticulitis typically presents with **localized left lower quadrant pain**, fever, and leukocytosis, but the systemic context of recent cardiac surgery and hypoperfusion strongly favors ischemia. *Infection with Clostridioides difficile* - **_Clostridioides difficile_ infection** typically causes **watery diarrhea**, often after antibiotic use, and usually takes several days to develop symptoms after exposure or antibiotic initiation. - Although the patient received perioperative antibiotics, the onset of symptoms within hours of surgery and the presence of **frank bloody stools** are less characteristic of _C. difficile_ infection, which is more commonly associated with non-bloody diarrhea.

Question 5: A 47-year-old woman presents to the emergency department with abdominal pain. The patient states that she felt this pain come on during dinner last night. Since then, she has felt bloated, constipated, and has been vomiting. Her current medications include metformin, insulin, levothyroxine, and ibuprofen. Her temperature is 99.0°F (37.2°C), blood pressure is 139/79 mmHg, pulse is 95/min, respirations are 12/min, and oxygen saturation is 98% on room air. On physical exam, the patient appears uncomfortable. Abdominal exam is notable for hypoactive bowel sounds, abdominal distension, and diffuse tenderness in all four quadrants. Cardiac and pulmonary exams are within normal limits. Which of the following is the best next step in management?

A. Metoclopramide
B. Nasogastric tube, NPO, and IV fluids (Correct Answer)
C. Stool guaiac
D. Emergency surgery
E. IV antibiotics and steroids

Explanation: ***Nasogastric tube, NPO, and IV fluids*** - The patient's symptoms (abdominal pain, bloating, constipation, vomiting, distension, and hypoactive bowel sounds) are highly suggestive of a **bowel obstruction**. - **Nasogastric tube decompression** relieves pressure, **NPO status** prevents further bowel distension, and **intravenous fluids** address dehydration and electrolyte imbalances, stabilizing the patient for further evaluation. *Metoclopramide* - This is a **prokinetic agent** that increases gastrointestinal motility. - Using it in the context of a suspected bowel obstruction could worsen the condition by increasing pressure against the obstruction and potentially leading to **perforation**. *Stool guaiac* - A stool guaiac test detects the presence of **occult blood in the stool**, which is useful for evaluating gastrointestinal bleeding. - While it can be part of a complete workup, it is not the immediate priority for a patient presenting with symptoms of **acute bowel obstruction** requiring stabilization. *Emergency surgery* - While surgery may ultimately be required for a bowel obstruction, it is not the immediate first step unless there are clear signs of **perforation**, **ischemia**, or **strangulation**, which are not specified here. - Initial management involves **stabilization** with NG decompression, NPO, and IV fluids. *IV antibiotics and steroids* - **IV antibiotics** are indicated for suspected infection (e.g., appendicitis, diverticulitis with perforation), but the primary presentation here is mechanical obstruction, not infection. - **Steroids** are typically used for inflammatory conditions or adrenal insufficiency, neither of which is indicated given the patient's symptoms.

Question 6: One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show: Hemoglobin 12.5 g/dL Leukocyte count 18,600/mm3 Platelet count 228,000/mm3 Erythrocyte sedimentation rate 120 mm/h Serum Na+ 134 mEq/L K+ 3.5 mEq/L Cl- 98 mEq/L HCO3- 22 mEq/L Glucose 200 mg/dL Urea nitrogen 60 mg/dL Creatinine 3.2 mg/dL Creatine kinase 750 U/L Which of the following is the most appropriate next step in management?

A. Surgical debridement (Correct Answer)
B. Intravenous clindamycin therapy
C. X-ray of the abdomen and pelvis
D. Vacuum-assisted wound closure device
E. CT scan of abdomen

Explanation: ***Surgical debridement*** - The patient's presentation with **fever**, **tachycardia**, **hypotension**, **purplish discoloration**, **severe pain**, and **crepitus** (crackling sounds) near the incision after abdominal surgery is highly suggestive of **necrotizing fasciitis**. - **Surgical debridement** is the most urgent and critical step to remove necrotic tissue, control the spread of infection, and improve outcomes in necrotizing soft tissue infections. *Intravenous clindamycin therapy* - While broad-spectrum antibiotics, including clindamycin, are essential in managing necrotizing fasciitis, they are **adjunctive to surgical debridement**, not a standalone primary treatment. - Delaying surgery for antibiotic therapy alone would worsen the patient's prognosis and could lead to rapid progression of the infection. *X-ray of the abdomen and pelvis* - An X-ray might show subcutaneous **gas (crepitus)**, which is consistent with necrotizing fasciitis due to gas-producing bacteria. - However, the clinical presentation is already highly indicative of the diagnosis, and waiting for imaging would **delay critical surgical intervention**. *Vacuum-assisted wound closure device* - **VAC therapy** is used for wound management to promote healing after debridement, by creating negative pressure. - It is **not a primary treatment** for an active, spreading necrotizing infection and should only be considered after adequate surgical debridement has been performed. *CT scan of abdomen* - A CT scan can confirm the presence of **gas in the soft tissues** and assess the extent of the infection, providing valuable information. - However, like X-rays, obtaining a CT scan would **delay immediate surgical intervention**, which is paramount given the rapid progression of necrotizing fasciitis.

Question 7: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

A. Diagnostic peritoneal lavage
B. Emergency laparotomy (Correct Answer)
C. Upper gastrointestinal endoscopy
D. Close observation
E. Diagnostic laparoscopy

Explanation: ***Emergency laparotomy*** - The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch). - This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans. - While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST. *Upper gastrointestinal endoscopy* - This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities. - It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma. *Close observation* - Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings. - This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step. *Diagnostic laparoscopy* - **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity. - While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.

Question 8: A 68-year-old man presents to the emergency department with left lower quadrant abdominal pain and fever for 1 day. He states during this time frame he has had weight loss and a decreased appetite. The patient had surgery for a ruptured Achilles tendon 1 month ago and is still recovering but is otherwise generally healthy. His temperature is 102°F (38.9°C), blood pressure is 154/94 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is remarkable for an uncomfortable and thin man with left lower quadrant abdominal tenderness without rebound findings. Fecal occult test for blood is positive. Laboratory studies are ordered as seen below. Hemoglobin: 10 g/dL Hematocrit: 30% Leukocyte count: 3,500/mm^3 with normal differential Platelet count: 157,000/mm^3 Which of the following is the most appropriate next step in management?

A. Ceftriaxone and metronidazole
B. Ciprofloxacin and metronidazole
C. Colonoscopy
D. CT abdomen (Correct Answer)
E. MRI abdomen

Explanation: ***CT abdomen*** - A **CT scan of the abdomen and pelvis** is the most appropriate initial diagnostic step for acute left lower quadrant pain with fever, leukopenia, and a positive fecal occult blood test, as it can efficiently evaluate for **diverticulitis**, bowel perforation, or **colonic malignancy**. - The patient's presentation with constitutional symptoms like **weight loss and decreased appetite** in an older male, along with signs of anemia and occult blood, raises concern for **colorectal cancer**, making imaging a critical next step to differentiate potential etiologies. *Ceftriaxone and metronidazole* - While this is a common antibiotic regimen for suspected **diverticulitis**, it should not be initiated without definitive imaging, especially given the patient's concerning systemic symptoms and signs of **anemia and occult bleeding**, which could indicate a more serious underlying condition. - Empirical antibiotic therapy without a clear diagnosis could delay the identification of conditions like **colorectal cancer** or abscess, which require different management strategies. *Ciprofloxacin and metronidazole* - This is also a typical antibiotic combination for uncomplicated **diverticulitis**; however, giving antibiotics without confirmation of the diagnosis via imaging is inappropriate in this case due to the patient's **systemic symptoms** and signs of **GI bleeding**. - Without imaging to rule out intestinal perforation or malignancy, starting antibiotics could mask symptoms or delay crucial diagnostic and therapeutic interventions. *Colonoscopy* - A **colonoscopy** is indicated to investigate the **positive fecal occult blood** and rule out colorectal malignancy, but it is generally *contraindicated* in the acute setting of suspected diverticulitis due to the risk of **perforation**. - Imaging (like CT) should always precede colonoscopy when acute abdominal pain and inflammation are present to assess for safety and guide the timing of endoscopy. *MRI abdomen* - While **MRI provides excellent soft tissue delineation**, it is typically not the first-line imaging modality for acute abdominal pain presentations in the emergency department. - **CT scans are faster, more readily available**, and provide comprehensive imaging of the bowel, mesentery, and surrounding structures, making them superior for initial evaluation of acute abdominal conditions like diverticulitis or perforation.

Question 9: A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?

A. Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3
B. Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3
C. Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3
D. Hemoglobin: 11 g/dL, Hematocrit: 33%, MCV: 88 µm^3 (Correct Answer)
E. Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3

Explanation: ***Hemoglobin: 11 g/dL, Hematocrit: 33%, MCV: 88 µm^3*** - The patient experienced significant trauma and is experiencing **hemorrhagic shock**, as evidenced by his initial **hypotension** (BP 60/33 mmHg), **tachycardia** (pulse 180/min), and positive **FAST exam** for fluid in Morrison's pouch, indicating intra-abdominal bleeding. - The initial hemoglobin and hematocrit could be mildly decreased due to acute blood loss, but significant drops are often *not immediately apparent* as plasma volume has not yet moved into the intravascular compartment to dilute the remaining red blood cells. A hemoglobin of 11 g/dL and hematocrit of 33% are consistent with **acute blood loss** before significant hemodilution occurs. MCV of 88 µm^3 is within the normal range for **normocytic anemia** seen in acute hemorrhage. *Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3* - While a hemoglobin of 10 g/dL and hematocrit of 30% are consistent with anemia due to blood loss, an **MCV of 110 µm^3** (macrocytic) is not typically seen in acute hemorrhage. - Macrocytic anemia usually results from conditions like **B12 or folate deficiency**, alcoholism, or liver disease, which are not suggested by the acute traumatic scenario. *Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3* - This indicates **polycythemia** (abnormally high red blood cell count), which is the opposite of what would be expected in a patient experiencing acute hemorrhagic shock. - These values would suggest conditions like **polycythemia vera** or severe dehydration, which are not relevant in this acute trauma setting. *Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3* - While a hemoglobin of 7 g/dL and hematocrit of 21% represent significant anemia consistent with major blood loss, these values are typically seen *later* as **hemodilution** occurs, or in cases of chronic blood loss. - An **MCV of 75 µm^3** (microcytic) is generally indicative of **iron deficiency anemia** or thalassemia, which develops over time and is not characteristic of acute traumatic blood loss. *Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3* - These values are within the **normal range** for hemoglobin and hematocrit, which would not be expected in a patient presenting with signs of **hemorrhagic shock** and a positive FAST exam indicating significant internal bleeding. - This would suggest either very minor blood loss or that the values were taken before any bleeding had occurred or before hemodilution had a chance to manifest.

Question 10: 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.

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