V.

Complications of Minimal Access Surgery (Laparoscopy or Thoracoscopy)

A. Technique failures

1. Needle or trocar injury to a

solid organ.

hollow viscus.

blood vessel.

nerve.

2. Hypotension

secondary to decreased venous return because of increased pressure within the abdomen.
vena caval compression after insufflation of air.

3. Damage to adjacent organs

when using heat-producing instruments (e.g., electrocautery, harmonic scalpel, lasers).

4. Extraperitoneal insufflation

during attempted injection of air (e.g., CO 2 or helium) into the peritoneal space.

5. Trocar site herniation or wound infection.

6. Rarely, an air embolus can occur

if the pneumoperitoneum is inadvertently exposed to venous blood flow (i.e., large venous injury during the operation).

B. Pneumothorax

can occur with insufflation of air into the peritoneal space especially with surgery near the diaphragmatic hiatus (e.g., Nissen
fundoplication) [see Chapter 11].

C. A laparoscopic procedure

should be converted to an open procedure if it cannot be completed safely or if a significant technique failure has occurred.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers or
by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.
1. A 28-year-old man was involved in a high-speed motor vehicle accident where he sustained a closed
comminuted left femur fracture. He subsequently underwent operative fixation by placement of an
intramedullary nail. On postoperative day 2, the patient was noted to have dyspnea and fever (39.5°C).
Other vital signs were a blood pressure of 136/74 mm Hg, pulse of 120 beats/min, respiration of 32/min.
Oxygen saturations were 100% using a 40% face tent. The physical examination was significant for the
patient being minimally arousable, having diffuse fine crackles on pulmonary auscultation, and widespread
petechiae involving the axilla, chest, and upper arms. Which of the following statements most closely
describes the above condition?
(A) An immediate pulmonary angiogram is both diagnostic and therapeutic for this condition
(B) Treatment of this condition requires rapid administration of cyclo-oxygenase inhibitors, fresh
frozen plasma, and platelets
(C) Microscopic examination of blood, urine, and sputum may be helpful in making the diagnosis
(D) Early long-bone fracture fixation has little influence on the development of this condition
(E) The prognosis of this condition is proportional to the degree of renal insufficiency
 1–C. Fat emboli originate from bone marrow and enter the circulation through torn venules, causing
direct occlusion of small blood vessels in the lung, brain, and skin. The embolic plugs generate toxic free-
fatty acids and cause platelets to release serotonin. Severe cases cause fat emboli syndrome, which has
been described in trauma victims 12–72 hours after injury. Bergman's triad—neurodysfunction (mild
confusion with or without focal deficits), respiratory insufficiency (dyspnea, hyperoxemia), and petechiae
(axilla, chest, proximal arms)—as well as fever and tachycardia are seen. Fat droplets in the blood, urine,
or sputum; elevated serum lipase or fatty acid levels; leukopenia or thrombocytopenia; and decreased
serum albumin and calcium confirm the diagnosis. Treatment is predominantly supportive (e.g., positive
pressure ventilation, increasing albumin, calcium), however early fixation of long-bone fractures is
paramount. Prognosis is proportional to the degree of pulmonary insufficiency.

2. A 32-year-old man was recovering from acute necrotizing pancreatitis, which required operative débridement. On postoperative day
9 he had a large, melenic stool. Routine hematologic studies showed a drop in hematocrit from 32% to 26%. A nasogastric tube was
placed, which returned minimal “coffee ground” residue (guaiac-positive) with a pH of 4.5. Which of the following statements is true
regarding this patient's condition?

(A) Gastrointestinal protection should not routinely be instituted because of the side effects of mucosal-protective drugs

(B) Emergent exploratory laparotomy is indicated to quickly identify the source of bleeding
(C) Gastric ulcers are most likely present, necessitating immediate treatment for Helicobacter pylori

(D) Proton pump inhibition is an effective method for preventing this condition

(E) Upper and lower endoscopy have little role in identifying the source of bleeding

2–D. M ucosal inflammation and hemorrhage occurs frequently in severely ill and septic patients. Diffuse gastritis, duodenitis, and shallow
ulcerations are often seen with endoscopy. If the ulceration involves large blood vessels, however, significant bleeding may occur. This is
most likely caused by a breakdown of the protective mucosal barrier, rendering the intestinal lining susceptible to the corrosive acidic
environment. Effective preventative measures include inhibiting acid production (e.g., histamine receptor antagonists, proton pump
inhibitors) or augmenting the mucosal barrier (e.g., misoprostol, sucralfate [Carafate], antacids) because these agents have few side
effects. Emergent laparotomy is not indicated unless medical management fails and the source of bleeding cannot be stopped by any other
means (e.g., endoscopy, angiography). Although Helicobacter pylori is a known cause of gastrointestinal ulcer disease and bleeding, it has
little influence on stress gastritis or duodenitis.

3. A 65-year-old man underwent an uneventful open inguinal herniorrhaphy, but during overnight observation was found to have
vomited while he slept. He received aggressive suctioning but later that day he displayed a fever of 39.0°C. Other vital signs were a
blood pressure of 140/70 mm Hg, pulse of 90 beats/min, and respiration of 24/min. Oxygen saturations were 92% with a 40% face tent.
There were thick crackles on auscultation of the lungs. Chest radiograph was significant for bilateral infiltrates. Which of the following
statements most accurately reflects the patient's current clinical condition?

(A) Cefazolin is the antibiotic of choice for treatment of this condition because of its activity against oral flora

(B) Pneumonias resulting from this condition are associated with minimal morbidity and mortality

(C) The left upper lobe is the most frequently involved pulmonary segment

(D) Nasogastric suction tubes and endotracheal tubes do not uniformly prevent this complication
(E) Bronchoscopy has little role in the diagnosis or treatment of this condition

3–D. Aspiration of abdominal contents into the lungs can be a serious complication associated with significant morbidity and mortality. The
magnitude of lung injury is proportional to the volume, the frequency, and the pH of the aspirate. Risk factors include decreased
sensorium (i.e., narcosis, stroke), nasogastric tube placement, intestinal obstruction, and pregnancy. The most commonly affected
segments include the posterior right upper lobe, superior right lower lobe, or superior and posterior basal left lower lobes. Treatment
involves re-establishment of the airway (if necessary), aggressive airway hygiene, and adequate fluid resuscitation. Although intubation is
helpful, aspiration into the airway can still occur. Antibiotic use for large volume aspiration is controversial. However, pneumonia resulting
from aspiration can be secondary to a variety of organisms and ideal antibiotic selection should be based on culture results. Bronchoscopy
is an important tool for pulmonary hygiene and may be used if necessary.

4. During a routine postoperative check, a 67-year-old woman who had undergone resection of an infrarenal, abdominal aortic
aneurysm complained of peri-incisional tenderness and some light-headedness. Her vital signs were a blood pressure of 110/40 mm Hg,
pulse of 130 beats/min, respiration of 24/min, and temperature of 37.9°C. She had 25 mL urine output for the last 2 hours. On
examination, she had dry mucus membranes, there were faint bibasilar crackles on pulmonary auscultation, her abdomen was mildly
distended, the incisional dressing was clean and dry, and her feet were cool to the touch. Hematocrit dropped from 43% to 27%. Which
of the following statements is true of her condition?

(A) These findings are suggestive of acute myocardial infarction with congestive heart failure

(B) Plain radiographs are the most sensitive imaging modality for determining the cause of abdominal pathology

(C) M ore potent narcotic analgesics may be helpful because her examination suggests a sympathetic nervous system response to
poor postoperative pain control

(D) The presence of infection and sepsis is sufficient to explain all of the physical signs

(E) Operative exploration may be necessary if nonoperative measures fail to correct this condition

4–E. Hemoperitoneum is the most common cause of hypovolemic shock in the first 24 hours after abdominal surgery. Signs include low-
grade fever, tachycardia, hypotension, oliguria, and peripheral vasoconstriction. The diagnosis is confirmed by demonstrating increasing
anemia on routine hematologic tests. A computed tomography (CT) scan showing fluid in the abdomen consistent with blood may also be
used if the clinical picture is questionable. Treatment consists of volume resuscitation, possible blood transfusion, correction of
coagulopathy (if one exists), and re-operation with meticulous hemostasis if other measures fail. Although tachycardia is sometimes an
indication of poor pain control, or infection and sepsis, there are enough other signs to quickly rule these out as the source of the
current problem.

5. A 45-year-old, obese man was involved in a high-speed motor vehicle accident. He was hypotensive at the scene and was noted to
have a distended abdomen upon presentation. He was quickly evaluated and taken to the operating room for an exploratory
laparotomy. Which of the following is true with regard to adequate closure of the abdomen after this procedure?

(A) Permanent suture materials should not be used for closing the fascial layers because of the increased risk of local inflammation
(B) The instability of wound closure is decreased by the removal of devitalized tissue

(C) Body habitus and nutritional status are not important factors influencing wound stability

(D) Wound dehiscence is uncommon, although when it does occur it is usually during the first or second postoperative day

(E) Evisceration of the abdominal contents is a uniformly fatal event

5–B. Inadequate closure of fascial layers is the most important factor in determining the likelihood of dehiscence. Other important factors
contributing to dehiscence events include increased intra-abdominal pressure (e.g., obesity, severe pulmonary disease, excess
postoperative coughing, bowel obstruction, and cirrhosis with ascites formation) and deficient wound healing (e.g., infection, seroma or
hematoma formation, drain placement, chronic disease, malnutrition, or chronic steroid use). Suture material for fascial closure should not
be rapidly dissolvable because these layers are so important to wound integrity. Devitalized tissue predisposes to wound infection and
should be eliminated. Dehiscence is a partial or total disruption of anatomic layers after surgical closure. Evisceration is wound dehiscence
with the extrusion of abdominal contents. This is a highly morbid event, however not uniformly fatal. Treatment would consist of rapid
wound coverage with sterile, moist towels, and emergent surgical exploration and repair.

6. A 53-year-old, obese woman with a history of Type II diabetes and chronic obstructive pulmonary disease (COPD) underwent mesh
closure of an abdominal incisional hernia. She tolerated the procedure well and was discharged from the hospital the following
morning. Which of the following factors would LEAST likely contribute to the incidence of postoperative complications in this patient?

(A) A small enterotomy made while dissecting the fascial layers was closed with dissolvable suture after minimal spillage of intestinal
contents

(B) Her last hemoglobin A1C was 11.7 and she has a history of an anaphylactic reaction to penicillin

(C) She is morbidly obese and has significant lower extremity claudication when attempting exercise

(D) She has end-stage COPD and her medications include prednisone 20 mg per day

(E) She had previously smoked 2 packs of cigarettes per day for 40 years, but has not smoked for the last 5 years

6–E. Factors contributing to most postoperative complications include the failure of operative techniques, the magnitude of the operation,
the general medical condition of the patient, or chronic medications taken by the patient. The high hemoglobin A1C level signifies poorly
controlled diabetes. This may lead to poor wound healing. Obesity and peripheral vascular disease may be associated with cardiovascular
complications and poor wound healing. Chronic steroid use may also lead to problems with wound healing, adrenal insufficiency, and
immunosuppression. M oreover, COPD may predispose the patient to pulmonary complications. Smoking is a significant risk factor for
postoperative complications, however not having smoked for over 5 years will significantly decrease the incidence of all complications,
including pulmonary problems.

7. After an uneventful laparoscopic inguinal herniorrhaphy, a 58-year-old man had the urinary catheter removed and began to ambulate.
During routine vital sign checks, he was noted to have had no urine output over the previous 8 hours. An intravenous bolus of saline
(500 mL) did not stimulate voiding. Straight catheterization revealed 1000 mL of urine. Urinalysis showed a specific gravity of 1.018, a
pH of 6, moderate blood, and negative leukocyte esterase and nitrites. There were 23 red blood cells/high power field (hpf) and 2
white blood cells/hpf. What is the most appropriate treatment for his failure to void?

(A) Catheterization and initiation of hemodialysis

(B) Catheterization and antibiotic administration

(C) Catheterization and administration of furosemide

(D) Catheterization and administration of mannitol

(E) Catheterization alone with continued observation

7–E. Postoperative urinary retention is a common problem especially after pelvic and perineal procedures or after spinal anesthesia. The
causes in those cases appear to be interference with the normal autonomically mediated bladder emptying and overdistention of the
bladder that inhibits contraction of the smooth muscle. Prevention of this includes catheterization of the bladder for long cases or for
those where large volumes of intravenous fluids are used. Removing the bladder catheter and encouraging early postoperative voiding is
also useful. If this is unsuccessful, in and out catheterization to decompress the bladder is used. The catheter should be left in place if
the volume obtained is over 1000 mL. An indwelling catheter left for 4–5 days should be used if prior insertions were traumatic or if there is
a continued inability to void. Formal urologic follow-up may be necessary.

8. A 75-year-old, obese woman with a history of insulin-dependent Type II diabetes mellitus underwent an uneventful laparoscopic
cholecystectomy. She was slow to wake after the operation and was taken to the postoperative recovery unit intubated but breathing
on her own. Vital signs were stable and all laboratory studies were within normal limits. Head computed tomography (CT) scan was
interpreted as age-appropriate atrophy with no mass lesions or midline shift. She was taken to the intensive care unit where she slowly
began to awaken over the next 48 hours. Which of the following most likely contributed to this patient's depressed level of
consciousness postoperatively?
 (A) Cerebrovascular accident

(B) Poor metabolism of anesthetics

(C) Acute myocardial infarction

(D) Hypoxic brain injury

(E) Hypoglycemic coma

8–B. Prolonged altered consciousness after general anesthesia may result from poor metabolism of anesthetic agents by the patient. Risk
factors include advanced age, renal or hepatic insufficiency, and obesity. Other more serious events (e.g., hypoxic brain injury, diabetic
coma, hypoglycemia) must be ruled out. Cerebral vascular accidents (e.g., strokes) may occur secondary to hypertensive, embolic, or
thrombotic injury. After a cerebrovascular accident, patients may remain obtunded for up to 72 hours and then recover without
neurologic deficits. Those with deficits, however, may have paralysis, abnormal reflexes, posturing, or convulsions. Treatment includes
aspirin and anticoagulation if not contraindicated.

9. A 65-year-old woman with an open tibia/fibula fracture of her left lower extremity underwent uneventful débridement and external
fixation. Her initial postoperative course was uneventful. On postoperative day 4, she was noted to have mild swelling of her left ankle
and a fever of 38.6°C. Her wounds were without signs of infection and there were no palpable cords. Which of the following is the
most likely cause of this patient's findings?

(A) Fat emboli

(B) Iatrogenic lymphatic disruption

(C) Thrombophlebitis

(D) Deep venous thrombosis

(E) Ascending lymphangitis

9–D. Deep venous thrombosis remains an important cause of postoperative morbidity because of the high prevalence and the potentially
life-threatening consequences. Clot may propagate from the deep venous system of the lower leg into the femoral and iliac systems. M ost
pulmonary emboli originate from above the knee. Risk factors include Virchow's triad: vascular stasis (e.g., venous insufficiency, obesity),
abnormal vessel walls (e.g., fractures), and hypercoagulability (e.g., estrogen therapy, pregnancy, cancer). Diagnosis is sometimes difficult
because 50% of patients have no symptoms; the remainder have lower extremity swelling, fever, and pain as well as the classic positive
Homan's sign characterized by calf pain with foot dorsiflexion. Fat emboli are not associated with ankle swelling. Iatrogenic lymphatic
disruption is rare except with extensive resections of nodal groups. Thrombophlebitis typically presents with erythema, tenderness, and a
palpable cord over the affected vein.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 10–12

A. Pneumonia

B. Pulmonary atelectasis

C. Fat emboli

D. Adult respiratory distress syndrome

E. Pneumothorax

F. Hemothorax

G. Pulmonary embolism

H. Air emboli

Select the most likely source of each patient's clinical problem.

10. A 16-year-old boy was diagnosed with acute appendicitis and subsequently underwent an uneventful laparoscopic appendectomy.
He was admitted to the hospital overnight for observation. At 3:00 am, he was found to have a fever of 38.7°C. His examination was
significant for bibasilar crackles and cough on deep inspiration. The surgical wounds were clean without signs of infection. (SELECT 1
SOURCE) B. Pulmonary atelectasis

10–B. Atelectasis, or the partial collapse of alveoli, accounts for 90% of postoperative pulmonary complications and occurs most frequently
in the first 48 hours after surgery. Closure of small (smaller than 1 mm) bronchioles leads to a ventilation/perfusion (V/Q) mismatch and
subsequent hypoxemia. The mechanism of the febrile response remains unknown, however, but is usually self-limited. The diagnosis is made
by both radiographic (e.g., characteristic discoid infiltrate, elevated hemidiaphragm) and physical examination signs, including scattered
basilar crackles and decreased breath sounds.

11. A 52-year-old man underwent an orthotopic liver transplantation for cirrhosis secondary to hepatitis C. On postoperative day 4 the
patient developed rapidly worsening respiratory failure secondary to presumed aspiration with diffuse airspace disease noted
bilaterally on chest radiograph. On postoperative day 5 the patient underwent a liver biopsy for worsening liver function as well. The
patient continues to deteriorate and rapidly develops hypotension refractory to volume resuscitation and pressors. On examination the
patient is noted to have significantly decreased breath sounds on the right compared with the left, with hyperresonance to percussion.
Diffuse crackles are noted on the left. (SELECT 1 SOURCE) E. Pneumothorax
11–E. In critically ill patients all of these conditions can contribute to respiratory compromise and even hypotension. In patients with
refractory hypotension in this setting, one should always consider tension pneumothorax as a potential cause. Pneumothorax is a potential
complication of a liver biopsy because of the proximity of the lung and pleural space when passing the biopsy needle. Although a
hemothorax can also occur, hyperresonance to percussion is suggestive of a pneumothorax.

12. A 32-year-old woman had a postgastric bypass for morbid obesity 6 days ago. Because of significant incisional pain, she was slow to
ambulate. At 2:00 pm, while walking to the bathroom, she experienced sharp chest pain, cough, wheezing, hemoptysis, and syncope.
Physical examination was significant for a pleural friction rub. Electrocardiogram was unchanged, but there was a wedge-shaped area of
diminished pulmonary vascular markings at the periphery of her left lung. (SELECT 1 SOURCE) G. Pulmonary embolism

12–G. Pulmonary embolism remains one of the most common causes of sudden death in hospitalized patients. M echanical obstruction of
the pulmonary arterial system occurs secondary to migration of a thromboembolus, usually from the deep venous system of the lower
extremities. If the blockage is large enough, decreased cardiac output, hypotension, and impaired oxygenation caused by bronchospasm
and vasospasm occur. Other signs include hemoptysis, pleural friction rub, new cardiac gallop, and electrocardiogram changes.
Radiographically, diminished pulmonary vascular markings (Westermark's sign), pleural effusion, and a new pulmonary infiltrate may be
present. Confirmation is possible with a ventilation/perfusion (V/Q) scan or pulmonary arteriogram.
 The amino acids metabolized by the liver

are theoretically thought to contribute to encephalopathy of liver failure.

Early clinical studies suggest

these formulas may benefit encephalopathy, but further studies are ongoing to assess their impact on overall outcome.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 52-year-old, alcoholic man with a 4–5 day history of vomiting and epigastric abdominal pain is
admitted to the hospital with a diagnosis of acute pancreatitis. The patient states that he has not eaten a
meal in over 1 month and has been binge drinking during that time. He refuses to eat because of
persistent vomiting and is started on enteral tube feeds containing medium chain triglycerides. Which of
the following statements is appropriate regarding administration of medium chain triglycerides?
(A) They are converted to chylomicrons within the enterocyte.
(B) They require pancreatic lipase for absorption.
(C) They are transported to the liver via lymphatic channels.
(D) They may prevent steatorrhea associated with enteral feeding.
(E) They form micelles in the presence of bile salts.
1–D. Medium chain triglycerides are absorbed directly by enterocytes and transported to the liver via the
portal vein. Unlike long chain triglycerides, medium chain triglycerides do not require bile salts or
pancreatic lipase for absorption. Once long chain fatty acids are degraded to and absorbed by the
enterocyte, they are then reconverted to triacylglycerols to form chylomicrons that are transported
through lymphatic channels and then into the bloodstream. Medium chain triglycerides do not undergo
this process and therefore are considered useful in patients with pancreatic insufficiency. Malabsorption of
long chain triglycerides may also lead to steatorrhea, which may be prevented with the use of medium
chain triglycerides.

2. A 66-year-old, 70-kg man undergoes extensive small bowel resection for mesenteric ischemia and receives parenteral nutritional
support. He is receiving 5 g/kg/day of carbohydrates, 0.2 g/kg/day of nitrogen, and 0.6 g/kg/day of lipids. Which of the following most
closely approximates the number of calories this patient is receiving each day?

(A) 2850
(B) 1800

(C) 2450

(D) 3500

(E) 2100

2–E. Carbohydrates produce ~ 4 kcal/g of substrate while lipids produce ~ 9 kcal/g substrate. Proteins produce ~ 4 kcal/g of substrate as
well. Protein content may be frequently expressed as grams of nitrogen: 6.25 g of protein = 1 g of nitrogen. Therefore 0.2 g/kg/day of
nitrogen = 1.25 g/kg/day of protein. Using these values, this patient is receiving approximately [(4 kcal/g × 5 g carbohydrates) + (9 kcal/g ×
0.6 g lipids) + (4 kcal/g × 1.25 g protein)] × 70 kg = 2128 kcal/day.

3. A 65-year-old man undergoes an emergent sigmoid colectomy with colostomy for a perforated diverticulum. On postoperative day 3
the patient develops persistent fever with a white blood cell count of 24,000. An abdominal computed tomography (CT) scan reveals a
large fluid collection in the left lower quadrant. The patient's heart rate is 130, with a blood pressure of 90/60. Which of the following
statements is true regarding this patient's metabolic state?

(A) The insulin/glucose ratio is probably high compared to normal.

(B) This patient is probably in positive nitrogen balance.

(C) Glutamine levels are probably increased in this patient.

(D) Alanine levels are probably increased in this patient.

(E) The respiratory quotient (RQ) value in this patient is probably ≥ 1.0.

3–D. Alanine produced by the muscle tissue is a major precursor for gluconeogenesis in the liver and therefore is likely to be elevated in
the setting of severe stress where glucagon, cortisol, and catecholamines all play a role in stimulating gluconeogenesis. Frequently in this
setting patients become hyperglycemic because of a relative inhibition of insulin secretion as well as a peripheral resistance to the effects
of insulin. This would be associated with a relatively low insulin/glucose ratio. In severe stress, there is generally a net proteolysis,
resulting in a negative nitrogen balance, while the goal of nutritional therapy and recovery is to produce neutral nitrogen balance.
Glutamine levels decrease during stress. In addition, with a relatively prolonged stress (postoperative day 3) there is significant utilization
of lipids (lipolysis) resulting in a respiratory quotient (RQ) of ~ 0.7.

4. A 55-year-old man with metastatic carcinoid disease presents to the office complaining of persistent diarrhea for 2–3 weeks. He
denies any other symptoms although his wife states that he seems “confused” at times. He states that he has been eating well although
his wife states his appetite has been very poor for the past few months. He is currently only taking a topical steroid prescribed by his
family physician for a persistent rash. Which of the following is the most appropriate definitive therapy for this patient's condition?

(A) Administer loperamide.

(B) Supplement his diet with vitamins.

(C) Administer somatostatin.

(D) Supplement his diet with zinc.

(E) Administer octreotide.

4–B. This patient's triad of symptoms (dermatitis, diarrhea, and dementia) is characteristic of pellagra associated with niacin deficiency. In
humans, despite inadequate intake of niacin, tryptophan can be converted to niacin. However, in patients with carcinoid syndrome,
tryptophan may be diverted to synthesis of serotonin, resulting in an increased risk of niacin deficiency. Thus, in this patient,
supplementation with vitamins, specifically niacin, may help to relieve his current triad of symptoms. Zinc deficiency is not associated with
this triad of symptoms. Although excess serotonin can lead to diarrhea, treatment of serotonin excess with octreotide will not treat the
underlying vitamin deficiency, nor will administration of the antidiarrheal agent, loperamide.

5. A 72-year-old man has recently undergone extensive resection of a primary squamous cell carcinoma of the tongue with radical neck
dissection. Postoperatively he is found to have extensive esophageal candidiasis with severe diffuse ulceration. His past medical history
is significant for a previous sigmoid resection for diverticular disease and he has had intermittent symptoms of nausea and vomiting over
the past several months which seem to resolve on their own. Which of the following would be the most appropriate reason for
parenteral versus enteral nutritional support?

(A) Severe esophageal ulceration

(B) Extensive oropharyngeal resection

(C) Severe sepsis

(D) Small bowel obstruction secondary to adhesions

(E) Previous abdominal surgery precludes percutaneous placement of gastrostomy tube

5–D. A high-grade small bowel obstruction is a contraindication to the use of enteral nutritional support. Although severe ulceration of the
esophagus may be a relative contraindication to placement of a nasoenteric feeding tube, this patient is still an excellent candidate for a
gastrostomy tube or a jejunostomy tube for enteral nutritional support. Sepsis is not a contraindication to enteral nutritional support
although attention should first be focused on the underlying cause of sepsis before nutritional therapy is initiated. This patient's extensive
oropharyngeal resection is not a contraindication to placement of a direct enteral feeding tube such as a gastrostomy tube, which can be
placed percutaneously as well as with an open surgical technique in the setting of previous abdominal surgery with significant adhesions.

6.A 68-year-old woman is transferred to a tertiary care hospital after a recent extensive small bowel resection at an outside hospital.
She has been diagnosed with short bowel syndrome following the surgery and has received parenteral nutritional support for
approximately 3 months. The patient cannot remember exactly what she is taking but she states that she hangs 1 large bag of clear-
yellow fluid 3 times a day at home administered through a central venous catheter. She presents with complaints of worsening fatigue
and hair loss. Her hematocrit is 34%, white blood cell count 6,000, and platelets 45,000. For managing this patient it would be most
appropriate to administer

(A) Niacin

(B) Vitamin C

(C) Zinc

(D) Iron
(E) Lipids

6–E. This patient is suffering from sequelae of essential fatty acid deficiency. Today, this is generally avoided in patients receiving
parenteral nutritional therapy by co-administering lipid emulsions with the carbohydrate and amino acid solutions characteristic of
parenteral therapy, although inadvertent failure to administer such lipids may result in essential fatty acid deficiency. Characteristics of
such a deficiency include fatigue, dermatitis, ecchymoses, alopecia, anemia, edema, thrombocytopenia, and respiratory distress. This
patient's signs and symptoms are not characteristic of niacin deficiency (pellagra), vitamin C deficiency (scurvy), or zinc deficiency.
Although a coexisting iron deficiency could contribute to the anemia, administering iron would not address the primary deficiency causing
the entire myriad of findings.

7. A 37-year-old woman sustains 50% full-thickness burn injury to her torso, neck, and upper extremities. Upon admission appropriate
fluid resuscitation and local burn wound care are initiated. She is also intubated and receiving 100% oxygen for significant inhalational
injury with significant burns to the face and oropharynx. Which of the following is an appropriate statement regarding nutritional
supplementation in this patient?

(A) Parenteral nutritional support should be initiated immediately because of the facial and oropharyngeal burn injuries.

(B) Parenteral nutritional support should be initiated immediately because of the risk of aspiration associated with burn injury-
induced gastric ileus.

(C) Enteral nutritional support should be initiated immediately despite the oropharyngeal burns and potential risk of aspiration.
 (D) Enteral nutritional support should be initiated within 48–72 hours of the initial injury to allow for adequate volume resuscitation.

(E) Enteral nutritional support should be initiated only if there are no sites available for central venous catheter placement for total
parenteral nutrition secondary to burn injury.

7–C. Studies have shown a significant benefit of enteral nutritional therapy in improving overall outcome in patients with severe burn
injuries. In addition, this benefit is increased if enteral therapy can be initiated early in the course of therapy for burn injury and even as
early as at the time of initial admission. Facial and oropharyngeal burn injury does not preclude the use of enteral nutrition support nor
does the risk of aspiration associated with gastric ileus. Generally speaking, although particularly true for burn patients, enteral nutritional
support is preferred over parenteral nutritional support when the gastrointestinal tract is functional and available.

8. A 25-year-old man sustains a 45% full-thickness burn injury to his lower extremities and torso. After adequate initial fluid
resuscitation and local wound care he is awake and alert. On hospital day 3, his heart rate is 130, blood pressure is 130/80, and
respiration rate is 24. He is also noted to have a blood glucose of 300 despite administration of 12 units of regular insulin. His blood
urea nitrogen is 45 and his creatinine is 1.8. Which of the following statements is appropriate with regard to this patient's metabolic
state?

(A) The major source of glucose for the burn wound is probably via glycogenolysis.
(B) Protein requirements are 1 g/kg/day to avoid excessive azotemia with associated renal insufficiency.

(C) Insulin stimulation of lipolysis plays a critical role in providing glucose for peripheral tissues.

(D) Catecholamines and glucagon play a critical role in stimulating glucose production via hepatic gluconeogenesis.

(E) Cortisol, catecholamines, and glucagon play a critical role in stimulating net protein anabolism in this setting.

8–D. During severe stress such a significant thermal injury, cortisol, glucagon, catecholamines, and sympathetic nervous stimulation all play
a role in stimulating glucose production via lipolysis and hepatic gluconeogenesis. To provide substrates for gluconeogenesis, these agents
also stimulate net protein catabolism. Glycogen stores within the body are rapidly depleted in the setting of severe injury within 12–24
hours, therefore after this period glycogenolysis is not the major source of glucose production. Patients with burn injuries have a
significantly increased requirement for protein intake given the massive proteolysis. This requirement is ~ 1.5–2.5 g protein/kg/day and
protein restriction should not be initiated because of the risk of worsening azotemia. Insulin is a major stimulus for lipogenesis.

9. A 65-year-old man undergoes pancreatic débridement for alcohol-induced necrotizing pancreatitis. He is noted to be malnourished
on admission to the intensive care unit. He is initially alert but unable to wean from the ventilator postoperatively. He is started on
parenteral nutritional therapy with 35 kcal/kg/ day with 60% as carbohydrates, 30% as lipids, and 10% kcal as protein. His prealbumin
slowly improves over the next several days and his glucose levels remain relatively stable (130–190). Over a 10-day period the patient
fails to wean from the ventilator and becomes more confused and lethargic. He also gradually develops a worsening picture of
cardiogenic shock. For definitive management of this patient's underlying problem, which of the following is most appropriate to be
administered?

(A) Thiamine

(B) KPO 4-

(C) Niacin

(D) Insulin

(E) Lipids
9–A. This patient is manifesting symptoms of thiamine deficiency including Wernicke's encephalopathy, and eventual cardiomyopathy (wet
beriberi). This may be seen in severely malnourished patients, particularly in alcoholics. Thiamine supplementation in this setting is the
most appropriate therapy. The time course is not consistent with acute refeeding syndrome and hypophosphatemia. Additionally, his
glucose levels appear to be stable, thus additional insulin would not treat the underlying condition. The clinical manifestations are also not
consistent with either a niacin deficiency or an essential fatty acid deficiency.

10. A 65-year-old man underwent resection of the distal 150 cm of his small bowel for severe mesenteric ischemia 3 months ago. He
has since recovered and is receiving supplemental enteral nutritional support through a gastrostomy tube in addition to eating small
amounts of food each day. He now presents with the complaint of worsening fatigue and malaise over the past several weeks. He has
noted an improvement in his appetite and denies any increase in bowel habits. On examination, he appears pale but without muscle
wasting or other signs of weight loss. His laboratory results: K+ × 4.5, Cl - = 110, blood urea nitrogen = 14, creatinine = 1.2, Mg2+ = 2.5,
PO4- = 5.0, and Ca2+ = 8.5. His hematocrit is 25%, white blood cell count is 5,000, platelets are 150,000, and mean red cell volume is
125. Which of the following would be the most appropriate therapy in the definitive management of this patient's current condition?

(A) Vitamin B12 supplementation

(B) Folate supplementation

(C) Iron supplementation

(D) Administration of 2 U packed red blood cells

(E) Essential fatty acid supplementation

10–A. This patient has findings characteristic of megaloblastic anemia caused by inadequate supplementation of vitamin B12 after extensive
resection of the distal small bowel. The worsening fatigue and malaise in association with the significant decrease in the hematocrit and a
large mean cell volume are characteristic. Vitamin B12 is primarily absorbed in the terminal ileum and resection can result in a B12
deficiency. B12 is currently not available as an enteral supplement so must be provided by intravenous or intramuscular administration in
this setting. Although folate may be associated with a megaloblastic anemia, this would not be associated with resection of the terminal
ileum. The clinical picture and laboratory data are also not consistent with iron or essential fatty acid deficiency. Administration of packed
red blood cells would acutely help with the anemia but it would not address the underlying condition.
 Unvaccinated HBIG + HB vaccine HB vaccine

Vaccinated

Anti-HBs ≥ 10 mIU/mL* No treatment No treatment

Anti-HBs < 10 mIU/mL HBIG + 1 dose HB vaccine No treatment

Adapted from MMWR 1991; 40(RR–13):1–25.

Anti-HBs = serum antibody to hepatitis B surface antigen; HB = hepatitis B; HBIG = hepatitis B immune globulin; HBsAg = serum
hepatitis B surface antigen.
*Exposed individuals should be tested for serum anti-HBs antibody titers.

C. Human immunodeficiency virus (HIV)

1. The risk of transmission of HIV

after percutaneous injury from an infected individual is 0.2% to 0.5%.

The estimated HIV transmission rate per operation from an HIV-positive patient to the surgeon is 1/130,000.

2. Chemoprophylaxis

a. with an antiretroviral regimen, including zidovudine (AZT) and lamivudine (3TC) ± a protease inhibitor [i.e., indinavir (IDV)],
decreases the rate of seroconversion after occupational exposure to HIV.

1. This ideally should be administered within 1 to 2 hours after exposure, although prophylaxis may be considered up to 2 weeks
later in high-risk exposures.

2. Recommendation of postexposure chemoprophylaxis depends on the exposure risk and the associated morbidity of the
antiretroviral regimen.

3. Regimens are often individualized based on the source's antiretroviral therapy and the potential for HIV-resistant strains.

b. after a percutaneous injury is recommended if exposure involves a large volume of HIV-positive blood (i.e., deep large-bore IV
injury) or exposure to blood with a high titer of HIV [i.e., end-stage acquired immunodeficiency syndrome (AIDS)].

c. should be offered when blood or various bodily fluids [e.g., semen; vaginal secretions; cerebrospinal fluid (CSF); synovial, pleural,
peritoneal,

pericardial, and amniotic fluids] are introduced percutaneously or when contact with mucous membranes occurs.

d. should be offered with skin exposure to these bodily fluids when exposure involves a high titer of HIV, prolonged contact, an
extensive area of exposure, or an area with visibly compromised skin integrity.

e. should not be offered when the exposure does not increase the risk of HIV seroconversion.

For example, there have been no definitively confirmed cases of seroconversion after a solid suture needle injury from an
asymptomatic HIV-positive patient.

This includes exposure to urine, saliva, or feces.

3. Testing of exposed individuals for HIV antibodies

should be performed at 6 weeks, 12 weeks, and 6 months, with seroconversion typically occurring within 6 to 12 weeks.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
Questions 1–4
A 62-year-old man underwent an elective left hemicolectomy with primary anastomosis for Stage II colon
adenocarcinoma. Twenty-four hours postoperatively, his temperature was 38.8°C (102°F), his heart rate
 (HR) was 100 beats/min, and his blood pressure (BP) was 150/90 mm Hg. Breath sounds were diminished
in both lung bases, while the rest of the physical examination was unremarkable. Chest radiograph
revealed bibasilar atelectasis. Seven days postoperatively, his temperature increased to 39°C (102.2°F),
his HR increased to 130 beats/min, and his BP was 90/60 mm Hg. His lungs were clear on physical
examination and there was no evidence of wound infection. The patient complained of increasing
abdominal bloating and worsening abdominal pain.
1. In regard to this patient's immediate postoperative fever, which of the following is an appropriate
statement?
(A) The patient's fever was due to a wound infection
(B) Prophylactic perioperative antibiotics have been shown to prevent the development of
nosocomial pneumonia in the postoperative patient
(C) Improved pain control may have indirectly helped to decrease the patient's temperature
(D) All peripheral intravenous catheters should have been immediately removed because of their risk
of infection
(E) Pulmonary atelectasis causes fever by bacterial stimulation of inflammatory mediators
1–C. Fever occurring in the first 48 hours postoperatively without any obvious source of infection after
careful evaluation may arise from a pulmonary source of inflammatory mediator stimulation associated
with atelectasis. This process is not felt to be bacterial or infectious in nature and can frequently be
alleviated by measures that improve the patient's ability to ventilate collapsed alveoli such as incentive
spirometry or improved pain control, which may allow for improved respiratory effort. Prophylactic
perioperative antibiotics do not decrease the rate of postoperative pneumonia, though they decrease the
wound infection rate in selected cases. Although rare, wound infections can occur within the first 24 to 48
hours postoperatively with aggressive strains of Streptococcus or Clostridium. Inspection of all
intravenous (IV) sites is essential in evaluating the postoperative patient with fever; however, immediate
removal of all peripheral IV catheters is not warranted.

2. Which of the following statements is true regarding the use of perioperative prophylactic antibiotics in this patient?

(A) Prophylactic antibiotics should be administered 24 hours before surgery to decrease the rate of wound infection

(B) If no spillage of fecal material occurred, antibiotics are not indicated because it is a clean case

(C) Shaving the evening before surgery decreases the wound infection rate compared with shaving immediately before incision

(D) A preoperative bowel preparation with nonabsorbable antibiotics alone decreases the rate of postoperative infectious
complications

(E) The most important intra-operative factor in preventing postoperative wound infections is appropriate dosing of prophylactic
antibiotics

2–D. For elective surgery on the colon, a preoperative bowel preparation with nonabsorbable antibiotics and cathartic agents decreases
the rate of postoperative infectious complications, although prophylactic intravenous (IV) antibiotics may also provide some additional
benefit. There is no decrease in infection rates if prophylactic perioperative antibiotics are administered 24 hours preoperatively versus
within 1 hour of surgery. In addition, shaving the skin at the incision site the evening before surgery provides no benefit in decreasing
wound infection rates and may actually increase the wound infection rate secondary to the induction of microabscess formation. The
most important factors in decreasing the postoperative wound infection rate are attention to proper surgical technique and adequate
surgical débridement when appropriate. An uncomplicated elective colon resection involves controlled entry into the gastrointestinal
tract and is considered a clean-contaminated case.

3. Which of the following is an appropriate consideration in the diagnosis and treatment of this patient?

(A) This patient probably has an early nosocomial pneumonia

(B) A decrease in this patient's temperature when incentive spirometry is initiated would prove that atelectasis is the source of
fever

(C) Antibiotics should be started for treatment of a potential urinary tract infection

(D) An abdominal computed tomography (CT) scan is appropriate to rule out a potential intra-abdominal source of infection

(E) Antifungal therapy should be initiated immediately

3–D. Although there are many potential sources of nosocomial infection in the postoperative patient, an intra-abdominal source should
always be considered after abdominal surgery. An abdominal computed tomography (CT) scan would be a valuable diagnostic examination in
this patient to assess the abdomen for potential sources of infection. Although thorough evaluation for other potential sources of
infection is necessary, there is no evidence provided suggesting that the patient has clinically relevant pneumonia, nor is there any
evidence of a urinary tract infection at this point. Routine administration of antifungal agents without any evidence of a fungal infection is
not indicated.

4. For wound infections presenting in the early postoperative period (< 48 hours), which of the following statements is true?

(A) Clostridium and streptococcus species are frequent pathogens

(B) The bacterial contamination leading to wound infection typically occurs in the postoperative period
 (C) The rate of wound healing is unaffected by wound infections occurring in the early postoperative period

(D) Débridement of an infected wound should be performed if antibiotic therapy fails

(E) They are generally caused by slow-growing, nonvirulent bacteria

4–A. Although rare, wound infections occurring within the first 48 hours postoperatively in an otherwise uncomplicated case frequently
are caused by fast-growing, virulent strains of clostridium or streptococcus species. Bacterial introduction into the wound that results in
postoperative infection most often occurs intraoperatively rather than postoperatively. Treatment involves adequately débriding
devitalized or necrotic tissue and providing adequate drainage of an infected wound, with antibiotics serving as adjuncts in the therapy.
Wound infections are a leading cause of wound healing failure. Risk factors for the development of wound infections include the presence
of foreign bodies, poor approximation of wound edges, tissue ischemia (i.e., inadequate fluid resuscitation or sutures too tight), and the
presence of devitalized tissue, hematomas, or seromas.

5. A 22-year-old man underwent percutaneous pin fixation of a right ankle fracture as an outpatient. Three days later he presents at
the emergency department complaining of vomiting and mild shortness of breath, but denies any pain. The wound is without obvious
drainage or erythema. His temperature is 39°C (102.2°F), his heart rate is 140 beats/min, and his blood pressure is 90/40 mm Hg. His
chest radiograph is clear and his creatinine is 3.4. Which of the following statements is true regarding this patient?
(A) The causative organism is most likely a clostridial species

(B) An intra-abdominal source of infection is likely

(C) Outpatient antibiotic therapy is indicated

(D) Renal failure is secondary to associated bacteremia

(E) A desquamating erythematous rash is characteristic

5–E. Toxic shock syndrome (TSS) is most often caused by virulent strains of Staphylococcus or Streptococcus and may frequently produce a
rapid fulminant course. A diffuse desquamating erythematous rash, frequently away from the site of injury, is characteristic of TSS and may
provide a clue to the diagnosis. The pathogenesis of TSS is related to a toxin called toxic shock syndrome toxin (TSST) produced locally by
these bacteria and not necessarily by bacteremia. Although possible, a concomitant intra-abdominal source of infection is unlikely given
this scenario. Outpatient management would be inappropriate given his condition and potential for continued rapid deterioration.

6. After a routine right inguinal hernia repair, a 42-year-old man develops erythema over the incision. A wound infection is diagnosed
and the patient is discharged to home on 10 days of ciprofloxacin. Three weeks later he returns with complaints of persistent watery
diarrhea with a low-grade fever. His temperature is 38.3°C (101°F), his heart rate is 80 beats/min, and his blood pressure is 125/65 mm
Hg. Which of the following is the most appropriate next step in the management of this patient?

(A) Intravenous (IV) vancomycin therapy

(B) Colonoscopy

(C) No treatment, because the cause is probably viral

(D) Oral clindamycin

6–B. Following a course of antibiotics, one should always be suspicious of the diagnosis of pseudomembranous colitis in a patient with the
history given. Although this process could be viral, appropriate diagnostic measures should be taken to rule out pseudomembranous colitis.
It is generally appropriate to try to confirm the presence of Clostridium difficile cytotoxin in stool specimens, although identifying
plaque-like pseudomembranous lesion by colonoscopy would be highly suggestive of such a diagnosis; but this is not routine. Treatment is
with oral or intravenous (IV) metronidazole, or nonabsorbable oral vancomycin, although metronidazole is the preferred treatment given
the cost considerations and the potential risk of developing vancomycin-resistant Enterococcus strains.

Questions 7–8

A 24-year-old migrant farm worker presents to the emergency department with complaints of pain at the site of a 4-cm laceration on his
right leg. The patient states that he was cut by the end of a shovel while working 2 days earlier, but did not seek medical attention at that
time because he was able to stop the bleeding. The patient does not recall ever having been immunized for tetanus.

7. Which of the following is the most important initial step in the management of this patient?
(A) Admission to the hospital and administration of intravenous (IV) broad spectrum antibiotics with close observation of the wound

(B) Administration of tetanus toxoid

(C) Oral antibiotics and scheduling of close follow-up as an outpatient

(D) Wound inspection, irrigation, and débridement

(E) Careful closure of the laceration with administration of broad spectrum IV antibiotics

7–D. Although intravenous (IV) antibiotics and appropriate tetanus immunization should be administered early in the course of treatment,
initial attention should be devoted to inspection, irrigation, and adequate débridement of the injured site. In a dirty wound with exposure
to soil contaminants such as this one, closure of the laceration is inappropriate given the high risk of infection. The decision to manage
such a patient as an outpatient should be individually based after adequate assessment of the patient and the wound.

8. Which of the following would be the most appropriate regimen with regard to prophylaxis for tetanus?

(A) Administration of tetanus booster

(B) Administration of a full dose of tetanus toxoid

(C) Administration of tetanus toxoid in the dominant arm and tetanus immune globulin in the nondominant arm
 (D) Administration of tetanus toxoid and tetanus immune globulin in the nondominant arm

(E) Administration of tetanus toxoid and tetanus immune globulin in the gluteal region

8–C. In an unimmunized patient with a tetanusprone wound, a full regimen of both tetanus toxoid and tetanus immune globulin should be
administered. When administering the toxoid (antigen) in conjunction with immune globulin (antibody to the antigen) injections should be
performed at separate sites to avoid any potential interaction between the antigen and antibody, which could potentially interfere with
both the passive and active immunization.

Directions: Each group of items in this section consists of lettered options followed by a set of numbered items. For each item, select the
appropriate lettered option(s) most closely associated with it. Each lettered option may be selected once, more than once, or not at all.
Questions 9–12

M atch each scenario with the correct causative organism.

A. Staphylococcus aureus
B. Clostridium tetani

C. Clostridium difficile

D. Candida albicans

E. Bacteroides fragilis
F. Escherichia coli

G. Pseudomonas aeruginosa

H. Klebsiella pneumoniae

I. Proteus mirabilis

J. Haemophilus influenzae

9. A 48-year-old man has been in the intensive care unit for 5 weeks after a severe motor vehicle accident with multiple injuries. He
has been on broad spectrum antibiotics for 3½ weeks. He now has persistent fever with associated worsening refractory hypotension.
There is no obvious source of infection on physical examination, by abdominal computed tomography (CT), or on chest radiograph. The
only new finding is the presence of new retinal lesions on funduscopic examination. (SELECT 1 ORGANISM) D. Candida albicans

9–D. Definitive diagnostic criteria for disseminated candidal sepsis include endophthalmitis, positive tissue cultures for Candida, burn
wound invasion, and positive peritoneal cultures in the setting of peritonitis. The presence of Candida in blood cultures and in cultures of
multiple other sites (three or more sites) is also highly suggestive of the development of candidal sepsis in the critically ill patient.
Disseminated candidiasis can often produce a rapid fulminant course with an associated high mortality rate (> 50%). Such infection should
be considered in the critically ill patient receiving long-term broad spectrum antibiotics.

10. A 68-year-old, alcoholic man has been in the hospital for 36 hours after a motor vehicle accident with multiple orthopedic injuries.
He develops a fever with painful swelling of his right cheek. There is purulent material noted at the opening of Stensen's duct. There is
no other obvious source of infection on physical examination or chest radiograph. (SELECT 1 ORGANISM) A. Staphylococcus aureus

10–A. Although parotitis is an uncommon cause of postoperative fever, it should be considered in the differential diagnosis. Dehydration, as
may be seen in alcoholic patients, is a risk factor for the development of parotitis with partial obstruction of the parotid duct contributing
to the infectious or inflammatory process. The most common organism found in such infections is Staphylococcus aureus. Parotitis typically
presents with fever, a swollen painful cheek, and purulent exudate from the opening of the parotid duct (Stensen's duct).

11. A 48-year-old woman has been in the intensive care unit for 3 weeks after repair of a grade III liver laceration and colonic
perforation sustained from a motor vehicle accident. She has been ventilator-dependent since admission and has received 2 weeks of
broad spectrum antibiotics for a presumed intra-abdominal source of infection. She now has persistent fever with a worsening infiltrate
on chest radiograph. Computed tomography (CT) scan reveals no obvious intra-abdominal source of infection and the rest of the physical
examination is normal. Sputum cultures reveal gram-negative rods. (SELECT 2 ORGANISMS) A. Staphylococcus aureus
G. Pseudomonas aeruginosa
11–A, G. Nosocomial pneumonia is a common complication seen in critically ill, hospitalized patients, particularly in patients who require
prolonged ventilatory assistance. Diagnostic criteria include productive purulent sputum, radiographic evidence of an infiltrate, positive
cultures of sputum or lavage specimens without significant oral contamination, respiratory compromise, and fever. Although many
organisms may be identified as the inciting agent, overall, the two most common organisms identified in nosocomial pneumonia are
Pseudomonas aeruginosa (gram-negative rod) and Staphylococcus aureus (gram-positive cocci).

12. A 52-year-old man has been in the intensive care unit for 4 weeks after a surgical débridement for necrotizing pancreatitis. He
remains ventilator-dependent and has been on intravenous (IV) antibiotics for aspiration pneumonia. The patient now has a persistent
fever without any obvious source of infection on physical examination. His chest radiograph reveals resolution of a right lower lobe
infiltrate and CT scan of the abdomen reveals no obvious source of infection. Proctoscopic examination reveals plaque-like lesions on
the mucosa of the distal sigmoid colon. (SELECT 1 ORGANISM) C. Clostridium difficile

12–C. The diagnosis of pseudomembranous colitis should always be considered as a potential source of infection in any patient receiving
long-term antibiotic therapy. Symptomatology may be more subtle in the critically ill patient. Although not routine, the identification of
characteristic pseudomembranous lesions on endoscopic examination of the rectosigmoid provides adequate diagnostic criteria for this
disease. Confirmation of Clostridium difficile cytotoxin in stool specimens may also confirm the diagnosis.
 are benign tumors that constitute 90% of bone tumors of the hand.

The classic finding is calcific stippling of the lytic bone defect, which is commonly seen in the proximal phalanges and distal
metacarpals.

5. Glomus tumors

are comprised of blood vessels and unmyelinated nerves of a heat-regulating arteriovenous shunt.

a. Although most patients will have no symptoms, lesions under the fingernail may be associated with severe pain.
b. Treatment is by total excision.

F. Compartment syndromes of the upper extremity

1. This syndrome develops when a compartment of tissue (e.g., muscle) bounded by noncompliant structures (e.g., fascia, bone) develops
a significant increase in pressure.

The most common cause of compartment syndrome is trauma.

a. Increased pressure leads to inhibition of venous outflow with a subsequent decrease in arterial inflow, resulting in tissue
ischemia.

b. Compartment pressures greater than 30–40 mm Hg significantly inhibit muscle perfusion.

c. Volkmann ischemia is irreversible muscle necrosis that may occur within 2 hours of onset of injury.

d. Nerve compression results in paresthesia and hypoesthesia.

e. Flow through major vessels is generally maintained, thus distal pulses may remain palpable, even after irreversible muscle
necrosis.

2. The most common site of compartment syndrome in the upper extremity is in the anterior forearm compartment.

a. Signs and symptoms occur in the following order

pain out of proportion to the injury.

weakness of the compartment muscles.

increased tenseness of the compartment.

hypoesthesia of nerves passing through the compartment.

b. Compartment syndrome may present

as flexion of the digits with resistance to passive extension.

c. The diagnosis

is clinical, based on a high index of suspicion from the history of a predisposing trauma or medical condition and progressive
signs of muscle and nerve ischemia.

can be confirmed by compartment pressure measurements that are above 30 mm Hg.

3. Prompt surgical decompression by adequate fasciotomy is the only treatment for the early stage of compartment syndromes.

a. The important features of the incision used are adequate exposure, maintenance of skin coverage of the median nerve at the wrist,
and avoidance of longitudinal cuts across the wrist and elbow skin creases.

b. Judicious débridement of necrotic muscle should be performed.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. Which of the following characteristics of keloids most appropriately differentiates a keloid from a
hypertrophic scar?
(A) Decreased fibroblast density
(B) Increased fibroblast density
 (C) Increased collagen density
(D) Increased perivascular sclerosis
(E) Growth beyond the incision site
1–E. Unlike hypertrophic scars, keloids typically overgrow the boundaries of the initial incision site. This
differentiation is generally made by clinical examination. Light microscopy alone cannot be used to make
this differentiation because there are no differences in the architecture or quantity of collagen or the
number of fibroblasts. Perivascular sclerosis also occurs in both disorders. Although the specific
biochemical cause of abnormal scar production has not been identified, increased collagen production and
decreased collagen lysis have been demonstrated.

2. Which of the following is a mechanism of keloid formation?

(A) Altered ratio of collagen production and collagenase activity

(B) Excessive fibroblast proliferation

(C) Excessive collagenase synthesis

(D) Excessive collagen cross-linking

(E) Prolonged acute inflammation

2–A. Studies of the origin of keloids and hypertrophic scars suggest that both excessive collagen production and decreased collagenase
activity may be responsible for abnormal collagen formation. Excessive cross-linking and prolonged inflammation are not thought to be
primary mechanisms. Although collagen production is increased in hypertrophic scars and keloids, it does not result from an excessive
number of fibroblasts in the wound or from specific abnormal types of fibroblasts.

3. A 16-year-old girl sustains a needle prick to the left index finger over the distal palmar surface. Initially, she notices little
discomfort. However, 3 days after the injury she develops intense pain in the distal phalanx that wakes her up at night. Regarding this
situation, which of the following is the most appropriate statement?

(A) She has an acute paronychial infection

(B) Drainage is accomplished via an incision over the most tender region

(C) Incision through the volar surface of the finger often results in a tender scar

(D) Cultures of the finger will most likely produce a gram-negative rod

(E) Late sequelae of this type of infection seldom involve the bone

3–B. This patient has a felon, not a paronychial infection. Untreated, the infection may progress to involve the distal phalanx. The most
likely organisms are gram-positive cocci. The scar on the volar surface may be tender initially, but no more so than a scar elsewhere on
the hand. Incision and drainage is indicated in this situation, with the incision placed directly over the point of maximal tenderness.

4. A 62-year-old woman has had a clicking sensation of her thumb for 4 months. On examination, she has tenderness and a palpable
nodule at the level of the proximal interphalangeal joint. The thumb exhibits full active and passive range of motion, but active
extension results in a clicking noise. Which of the following is the most appropriate initial step in the management of this patient?
(A) Physical therapy

(B) Splinting of the thumb

(C) Oral administration of an anti-inflammatory agent

(D) Injection of a corticosteroid into the flexor tendon sheath

(E) Surgical release of the A1 annular pulley

4–D. This patient has stenosing flexor tenosynovitis of the thumb (trigger thumb). When she flexes or extends her thumb, triggering
occurs. Primary, or idiopathic, trigger finger is common, and middle-aged women are most frequently affected. Secondary causes include
gout, rheumatoid arthritis, diabetes mellitus, and other diseases that cause connective tissue changes. The most appropriate initial
treatment is to inject corticosteroid into the flexor tendon sheath. Splinting and corticosteroid injection are equally effective in treating
trigger finger, but corticosteroid injection has been shown to be more successful when the thumb is affected. Surgical release of the A1
annular pulley is indicated when corticosteroid injection fails or if the digit is locked. Physical therapy has no effect on the nodule
causing the triggering. Anti-inflammatory agents are not likely to be successful as the sole treatment of this disease.

Questions 5–6

A 16-year-old boy presents to the office immediately after a cut injury to the palm of his right hand. The cut was caused by a clean razor
blade. Physical examination reveals a 2-cm laceration at the base of the long finger. The patient is able to flex the metacarpophalangeal
(M CP) joint but he cannot flex either interphalangeal joint in that finger.

5. Which of the following is the most likely diagnosis?

(A) Lacerated flexor digitorum profundus tendon

(B) Lacerated flexor digitorum superficialis tendon

(C) Combined laceration of the superficialis and profundus tendon

 (D) Laceration of the intrinsic muscle to the long finger

(E) Transection of the radial nerve

5–C. Flexion of the metacarpophalangeal (M CP) joint is accomplished via intrinsic muscles of the hand. This may be preserved even when
the extrinsic flexion mechanism is disrupted. The goal of flexor tendon repair is to restore interphalangeal joint flexion. The flexor
digitorum superficialis inserts on the base of each middle phalanx and causes proximal interphalangeal (PIP) flexion. The flexor digitorum
profundus inserts on the base of each distal phalanx and is responsible for distal interphalangeal (DIP) flexion. Laceration of the intrinsic
muscle to the long finger would not explain the patient's inability to flex the PIP and DIP joints. The radial nerve is responsible for the
extensors, not flexors, of the hand.

6. Which of the following is the most appropriate treatment plan for this patient?

(A) Immediate tendon repair

(B) Regional anesthesia, extension of the skin wound, and exploration to confirm the diagnosis

(C) Careful cleansing of the wound, placement of the appropriate dressing, and hand immobilization before definitive primary surgical
repair
(D) Cleansing of the wound, primary skin closure, hand immobilization, and delayed repair using tendon graft

(E) Observation only

6–C. The goal of flexor tendon repair is to restore interphalangeal joint flexion. Proper wound cleansing, dressing, immobilization, and
prophylactic antibiotics allow delay of primary repair if a hand surgeon is not immediately available. With this cut, primary repair of the
tendon is the most appropriate operative technique without the need for tendon grafts. Delayed repair (2–6 days after injury) is indicated
when the degree of wound contamination is uncertain or if the initial treatment has been delayed beyond several hours. Grossly
contaminated wounds, those with significant tendon disruption, or wounds with significant associated injuries to the soft tissue, bone,
nerve, or blood vessels are treated by secondary repair in 3–6 weeks, after the wound has healed and edema and callus formation subside.

Questions 7–9

A 45-year-old man suffers a 45% total body surface area (TBSA, partial and full-thickness) burn to the neck, face, trunk, and lower
extremities sustained in an industrial explosion. Other injuries include a severe LeFort II maxillary fracture, a pulmonary contusion with rib
fractures, and a crush injury to the right arm and hand. The patient is unresponsive with labored respirations and his current blood
pressure is 70/40 mm Hg.

7. Which of the following should be the primary concern in the emergency room?

(A) The facial fractures

(B) The 45% TBSA burns

(C) Endotracheal intubation

(D) The crush injury to the right upper extremity

(E) Splinting of the chest for the rib fractures

7–C. Trauma evaluations are generally approached in the same systematic manner to avoid missing life-threatening injuries. The ABCs
(airway, breathing, circulation) of trauma is a useful mnemonic for the sequential approach to potential life-threatening injuries during a
trauma evaluation. While the crush injury and burns may be quite disfiguring and obvious, in patients with respiratory distress initial
attention should be directed toward providing an adequate airway, typically via endotracheal intubation. Facial fractures can also be dealt
with once the life-threatening injuries are controlled.

8. The patient is appropriately resuscitated and further work-up reveals no additional thoracic or intra-abdominal injuries. Thirty-six
hours after the injury, his blood pressure is 130/85 mm Hg and urine output is maintained at 30 mL/hour. The patient is also awake and
alert. Physical examination of his right arm reveals it to be tense and painful. Pulses in the extremity are noted by Doppler
examination. Which of the following is the most appropriate next step in the management of this patient?

(A) High-dose corticosteroids

(B) Arm evaluation, analgesics, and close observation

(C) Fasciotomies

(D) Compressive dressings

(E) Burn excision and grafting

8–C. The patient is developing a compartment syndrome secondary to his crush injuries. Immediate treatment includes fasciotomies to
prevent irreversible muscle necrosis and nerve damage. There is no role for corticosteroids in the treatment of his compartment
syndrome. Arm elevation may be a temporizing measure before fasciotomy but is not adequate for definitive treatment. Compressive
dressings may mask his findings and irreversible necrosis can ensue. Pulses may be present even during the late stages of compartment
syndrome. Although burn excision and grafting are important, initial attention to release of compartment pressure with fasciotomy is
essential.

9. Three days after the initial injury, the patient's wounds are débrided in the operating room. Coverage of the burns to his thorax,
abdomen, and lower extremities is best accomplished via which of the following?

(A) Local (random pattern) skin flaps

(B) Free flaps using microvascular transfer

 (C) Full-thickness skin grafts

(D) Split-thickness skin grafts

(E) M yocutaneous flaps

9–D. This patient has a large amount of surface area that requires coverage. This is best accomplished using meshed split-thickness skin
grafts, which are harvested at a thickness of 12–15 one-thousandths of an inch. Skin and myocutaneous flaps will not adequately cover his
wounds, and the donor site morbidity precludes their use. Similarly, full-thickness skin grafts require the donor sites to be covered with
skin grafts and this too limits their use. In this patient, split-thickness skin grafts will accomplish the coverage needed while minimizing
donor site morbidity.

10. Which of the following statements is correct regarding wound healing and persistent local tissue hypoxia?

(A) Fibroblasts are stimulated by low oxygen tension

(B) High lactate levels inhibit macrophage production of angiogenesis factor

(C) Low oxygen tension is the most common cause of poor wound healing
(D) Collagen synthesis is stimulated by hypoxia

(E) Wound healing is not affected by alterations in tissue oxygen tension

10–C. Oxygen deficiency of the tissues is the most common cause of poor wound healing. Proper tissue oxygenation requires sufficient
inspired PO 2, transfer of oxygen to hemoglobin, ample hemoglobin for transport, and adequate vascularity of the tissues. M ost healing
problems associated with diabetes mellitus, irradiation, small vessel atherosclerosis, and chronic infection are a result of a faulty oxygen
delivery system. Transiently low wound tissue oxygen levels stimulates cell migration, growth factor release, and collagenase production.
Similarly, high lactate levels stimulate the macrophage to produce angiogenesis factors. Fibroblasts are oxygen sensitive and are inhibited
by low tissue oxygen tension. Collagen synthesis is also inhibited by low tissue oxygen.

11. During the first 4 days after an injury, which of the following cells are most critical to wound healing?

(A) Fibroblast

(B) Lymphocyte

(C) M yofibroblast
(D) Platelet

(E) M acrophage

11–E. M acrophages play a critical role in the inflammatory phase of wound healing and in the modulation of collagen production. These
cells affect wound healing through multiple secretory factors and receptors. Studies of the role of macrophages have shown a marked
inhibition in the process of wound débridement and collagen production with administration of antimacrophage serum early in wound
healing. Although lymphocytes also modulate wound healing by secreting interleukin-2, transforming growth factor-β, and other
lymphokines, these substances do not appear until inflammation has resolved, approximately 3 days after injury.

12. A 45-year-old, obese man develops a wound infection on postoperative day 10. The patient undergoes wound débridement,
followed by dressing changes to the open wound and systemic antibiotics. Allowing this wound to heal by wound contraction and
epithelialization (i.e., secondary intention) means that the wound will spend a prolonged period of time in which of the following
phases?

(A) Inflammatory

(B) Proliferative

(C) Fibroblastic

(D) Remodeling

(E) M aturation

12–A. In healing by secondary intention, the inflammatory phase continues until the wound surface is closed by epithelium. In this case,
coverage with epithelium may not be complete for several weeks to months, depending on the size of the defect. When a wound is closed
primarily, the inflammatory phase usually lasts from 4–6 days. The rest of the phases listed should proceed normally once the wound has
closed by contraction and epithelialization.

13. Which of the following is the most appropriate option for closing a large wound once the wound appears “clean”?

(A) Split-thickness skin graft

(B) Full-thickness skin graft

(C) Local skin flap

(D) M yocutaneous flap

(E) Cadaveric skin grafting

13–D. The choice for coverage depends on the wound's size and depth. Because bone will probably be débrided before definitive closure,
the resulting defect will have a significant amount of dead space. A myocutaneous flap provides excellent coverage and obliterates the
dead space. In addition, the added vascularity of the transposed muscle will aid in fighting infection by allowing the egress of inflammatory
cells. Skin grafts and a local skin flap will not provide the bulk needed to close the dead space. Cadaveric skin grafts serve as a temporary
biologic dressing before definitive closure; they are not appropriate for long-term use.
Directions: Each of the numbered items or incomplete statements in this section is negatively phrased, as indicated by a capitalized word
such as NOT, LEAST, or EXCEPT. Select the ONE lettered answer or completion that is BEST in each case.

14. A 65-year-old man with a past medical history of chronic obstructive pulmonary disease (COPD), diabetes mellitus, and peripheral
vascular disease undergoes an uncomplicated three-vessel coronary artery bypass grafting (CABG) using both internal mammary arteries.
His sternal wound is closed primarily using sternal wires and buried subcuticular sutures using absorbable, synthetic suture. Eight days
postoperatively, the patient develops a fever, and on examination there is crepitance in the sternal wound. Factors predisposing the
patient to a sternal wound infection include all of the following EXCEPT

(A) M ale gender

(B) COPD

(C) Diabetes mellitus

(D) Peripheral vascular disease

(E) Use of both internal mammary arteries versus using only one
14–A. Tissue hypoxia is the most common cause of poor wound healing. Conditions that lower oxygen delivery to tissues include lung
disease, cigarette smoking, hypovolemia, anemia, hypotension, and low concentrations of inspired oxygen. Peripheral vascular disease is
associated with tissue hypoxia and poor wound healing. Diabetes mellitus has multiple effects on different aspects of wound healing and
predisposes this patient to wound infection. For example, diabetes is associated with an inhibition of the early inflammatory response and
proliferation of fibroblasts and endothelial cells. The use of bilateral internal mammary arteries for revascularization procedures (e.g.,
CABG) has recently been demonstrated as being associated with an increased risk of postoperative sternal wound infection, verus using
only a single internal mammary artery while maintaining adequate perfusion of the area by the remaining mammary artery. While old age
may lead to impaired wound healing, being male does not.
 respiratory rate > 20 breaths/minute or PaCO 2 < 32 mm Hg.

white blood cell count > 12,000 or < 4000 cells/mm3.

b. Sepsis may be used to describe SIRS as a result of infection.

c. Septic shock is refractory hypotension resulting from sepsis.

d. Multiple system organ failure

is a late manifestation of SIRS associated with a very high mortality.

1. Severe failure

of the respiratory, cardiovascular, renal, and hepatic systems may be present.

2. Causes

may include infection, severe trauma, and massive burn injuries.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 5-year-old, 25-kg boy is now postoperative day 1 from an open appendectomy for nonperforated
appendicitis. He is still experiencing some nausea and has minimal bowel sounds upon physical
examination. The patient is afebrile and is otherwise healthy. Which of the following electrolyte solutions
and rate of administration would be most appropriate for providing maintenance postoperative hydration
in this patient?
(A) 5% dextrose in 3/4 normal saline at 65 mL/hr
(B) 5% dextrose in normal saline at 85 mL/hr
(C) Normal saline (0.9%) at 65 mL/hr
(D) 5% dextrose in 1/4 normal saline at 85 mL/hr
(E) 5% dextrose in 1/4 normal saline at 65 mL/hr
1–E. The standard formulas for determining the rate of administration of maintenance fluids are as
follows:
[(100 mL/kg × 10 kg) + (50 mL/kg × 10 kg) + (20 mL/kg × 5 kg)]/24 hr
or
(4 mL/kg/hr × 10 kg) + (2 mL/kg/hr × 10 kg) + (1 mL/kg/hr × 5 kg)
Using these formulas, a 25-kg patient would require a rate of approximately 65 mL/hr over 24 hours. In
addition, 1/4 normal saline (38.5 mEq/L of Na+) would most appropriately provide the daily maintenance
sodium requirements of 1–2 mEq/kg/day (25–50 mEq/day) in this patient, whereas administration of
normal saline (145 mEq/L Na+) would give well in excess of normal daily maintenance requirements. It is
important to remember, however, that these formulas serve only as guidelines. Clinical assessment of the
patient's condition and fluid status are the most important components of determining the rate and type
of fluid administered.

2. A 64-year-old man undergoes upper endoscopy for chronic gastrointestinal bleeding that reveals mild gastritis but no evidence of
ulceration or active bleeding. Rectal examination is heme-positive but without gross blood. Immediately after starting a blood
transfusion for symptomatic anemia, the patient becomes confused. His blood pressure is 70/30 mm Hg, his heart rate is 145 beats/min,
and his temperature is 39°C (102.2°F). Which of the following is the most appropriate next step in the management of this patient?

(A) Slow the rate of infusion of blood and give diphenhydramine

(B) Discontinue blood transfusion and give intravenous (IV) antibiotics

(C) Increase rate of infusion of blood and perform immediate upper endoscopy

(D) Discontinue blood transfusion and administer a bolus of crystalloid solution

(E) Discontinue blood transfusion and administer calcium gluconate intravenously

2–D. This patient is showing signs of rapid clinical deterioration secondary to ABO incompatibility. In this setting, immediate steps include
discontinuing the transfusion and administering crystalloid solution. These steps, in association with appropriate management of the
respiratory system [airway, breathing, and circulation (ABCs)], are crucial in the treatment of these patients. Administration of antibiotics
or calcium gluconate would not treat the primary origin of the problem, nor would they provide significant benefit in the volume
resuscitation of a hemodynamically unstable patient in this situation. Although one should always be concerned about acute massive
gastrointestinal bleeding in patients that deteriorate so rapidly, the absence of significant pathology on recent endoscopy and the
temporal relationship to the blood transfusion make a transfusion reaction more likely, thus negating the need for immediate upper
endoscopy at this point in the evaluation.

3. A 53-year-old woman is undergoing an elective sigmoid resection for recurrent diverticulitis. Intraoperatively, the patient requires
transfusion of 2 units of packed red blood cells (PRBCs) for significant blood loss early in the case. After starting the transfusion, the
anesthesiologist notes that the patient's blood pressure is now 70/40 mm Hg, having dropped from 120/80 mm Hg. There is no intra-
abdominal bleeding noted, however her urine has suddenly become very dark. Electrocardiogram (ECG) reveals sinus tachycardia
without evidence of myocardial ischemia. Which of the following is the most frequent cause of this patient's current condition?
(A) Primary bacterial contamination of donor blood

(B) Clerical errors in matching donor blood to recipient

(C) Inadequate screening of donor blood for leukocytes

(D) Recipient antibody formation to minor antigens on donor blood cells

(E) Binding of serum calcium by citrate present in donor blood

3–B. This patient is having a severe transfusion reaction secondary to ABO incompatibility. The cardiovascular instability and hemoglobinuria
are temporally related to transfusion without other obvious causes for the clinical scenario. The most common cause of a transfusion
reaction occurring secondary to ABO incompatibility is a clerical error in matching the appropriate donor blood to the recipient. Although
this occurs rarely, it can result from errors in the blood bank or with the medical personnel administering the blood. Thus, great care
should be taken to assure appropriate matching occurs at all levels. Recipient antibody formation to antigens other than ABO system may
rarely cause mild immune reactions, although this occurs infrequently. Binding of serum calcium and primary bacterial contamination of
donor blood is rare. Screening of donor blood for leukocytes is not routinely performed or required.

4. A 19-year-old man sustains orthopedic injuries after a motor vehicle accident. During evaluation and treatment, he receives 4 units
of packed red blood cells (PRBCs) for significant blood loss. His family asks about the risk of his contracting human immunodeficiency
virus (HIV) from blood transfusion. Which of the following is the approximate risk of transmission of HIV from each unit of PRBCs?

(A) 1/300

(B) 1/3000

(C) 1/50,000

(D) 1/300,000

(E) 1/1,000,000
4–D. Although viral transmission with blood transfusion is rare, it can still occur and must be considered when transfusions are performed.
The reported risk of transmission of human immunodeficiency virus (HIV) per unit of blood transfused is estimated to be approximately
1/300,000. Donated blood is routinely screened for HIV contamination; however, despite an excellent sensitivity of these tests, they do not
identify absolutely all HIV-contaminated blood samples.

5. A 62-year-old, 90-kg woman undergoes exploratory laparotomy and resection of an obstructing sigmoid colon cancer.
Postoperatively, the patient is transferred to the surgical floor where she receives normal saline at 100 mL/hr. The next morning she is
tachycardic with a heart rate of 120 beats/min and a blood pressure of 95/60 mm Hg. Her urine output is diminished to 20 mL/hr. Her
physical examination is remarkable for a distended abdomen without bowel sounds and with mild tenderness. Her hematocrit is now
36% (it was 33% the night before). Abdominal radiograph shows a gasless abdomen, and a chest radiograph is read as “normal.” Which of
the following is the most likely source for her hypotension in the intensive care unit the day after surgery?

(A) Renewed bleeding within the abdominal cavity

(B) Gastrointestinal bleeding from stress ulceration

(C) Acute gastric dilation with a vasovagal response

(D) Third space losses within the peritoneum

(E) Septic shock from gram-negative organisms

5–D. The most likely cause of volume loss and hypotension in this patient is inadequate provision of fluid in the setting of significant third
space losses after major intra-abdominal surgery. The peritoneum and the intestinal lumen can accommodate a large amount
(approximately 18 L) of third space fluid, which can occur in the setting of intra-abdominal infections, intestinal obstruction, and even
postoperatively. The increase in the hematocrit may be secondary to volume loss (i.e., plasma loss) with hemoconcentration of the red
blood cells (RBCs). This also makes massive bleeding unlikely in this setting. Acute gastric dilation can result in hypotension, although this
would have been noted on the abdominal radiograph. Septic shock occurring this early in the postoperative course for elective surgery is
unlikely unless perforation has occurred. However, perforation is frequently associated with other signs and symptoms, such as peritoneal
signs (e.g., guarding, rebound pain) and identification of free peritoneal air on radiograph evaluation.

6. A 26-year-old man sustains multiple injuries in a motor vehicle accident, including multiple rib fractures, a pulmonary contusion,
pelvic fracture, and a left femur fracture. On hospital day 2 the patient is on the ventilator in synchronized intermittent mandatory
ventilation (SIMV) mode set at a rate of 14. FIO2 is 50%, tidal volume is set at 800 ml, and positive end-expiratory pressure (PEEP) is 2
cm H2O. An arterial blood gas reveals a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 60 mm Hg, and a HCO3- of 22 mEq/L. Which of the
following ventilatory changes would be most appropriate for improving this patient's oxygenation?

(A) Increase the PEEP from 2 to 8 cm H20

(B) Increase the respiratory rate from 14/min to 18/min

 (C) Increase the tidal volume from 800 ml to 1000 ml

(D) Increase the FIO 2 to 75%

(E) Change from SIM V mode to pressure-control mode

6–A. The most appropriate measure to manage this patient's hypoxia is to increase the positive end-expiratory pressure (PEEP) from 2 cm
H2O to 8 cm H2O. This helps to improve ventilation of collapsed alveoli and the ventilation/perfusion mismatch resulting from this collapse.
Increasing the FIO 2 would also help to improve oxygenation but is also associated with other complications if used chronically (e.g., direct
pulmonary toxicity). Excessive PEEP may also be associated with complications such as pneumothorax, although this rarely occurs with low
levels of PEEP (i.e., 2 cm H2O to 8 cm H2O). Increasing the respiratory rate and increasing the tidal volume would improve ventilation (i.e.,
PaCO 2) but would not specifically address the issue of oxygenation. Altering the mode of ventilation is not necessary in this situation
because simpler measures are available to address the hypoxia.

7. A 32-year-old man sustained a left femur fracture after a steel beam fell on his legs and trapped him underneath. It was
approximately 2 hours before coworkers were able to locate him and remove the beam. On admission, the patient received 2 units of
packed red blood cells (PRBCs) for hypotension and had significant blood loss from the femur fracture. On hospital day 2, the patient is
noted to have frequent runs of ectopy on the electrocardiogram (ECG) monitor. Widened QRS complexes are also noted. His urine is
dark red, but microscopic examination of the urine reveals no red blood cells (RBCs). Which of the following events is most likely
responsible for this patient's current findings?

(A) Hemolysis secondary to the blood transfusion

(B) Acute tubular necrosis secondary to hypovolemia

(C) An unrecognized kidney laceration

(D) Fat embolus syndrome

(E) Rhabdomyolysis

7–E. The most likely cause of the findings in this patient is hyperkalemia associated with rhabdomyolysis. Extensive necrosis of muscle tissue
can occur after crush injuries without visible signs of necrosis noted at the level of the skin. Necrosis of muscle cells with subsequent lysis
can lead to release of large amounts of K+ from the cytoplasm of these cells, resulting in the widened QRS complex and ectopy seen on
the ECG. Hemolysis related to blood transfusion would generally not result in severe hyperkalemia unless it was associated with ABO
incompatibility, which occurs within minutes to hours of transfusion. Acute tubular necrosis may occur after periods of hypovolemia and
may lead to renal failure and hyperkalemia; however, this generally does not present acutely, as in this patient. Unilateral kidney injuries
can occur in the absence of hematuria, although in an otherwise healthy individual this would not affect renal function. Hyperkalemia is
not a typical characteristic of fat embolus syndrome.

8. A 65-year-old man with non–insulin-dependent diabetes mellitus (NIDDM) is postoperative day 2 after undergoing an elective colon
resection for adenocarcinoma. The patient is poorly responsive. On examination, the patient is obtunded, his pupils are pinpoint, his
heart rate is 130 beats/min, and his blood pressure is 70/50 mm Hg. A patient care assistant states that the patient was awake 1 hour
before, but somewhat confused. Arterial blood gas reveals a pH of 7.29, PaCO2 of 75 mm Hg, PaO2 of 70 mm Hg, and a HCO3+ of 23
mEq/L. Which of the following is the most appropriate initial step in the management of this patient?

(A) Administer an insulin bolus immediately

(B) Obtain a chest radiograph immediately

(C) Administer naloxone and control the airway

(D) Administer sodium bicarbonate

(E) Obtain a ventilation-perfusion (V/Q) scan to rule out pulmonary embolus

8–C. This patient has a severe acute respiratory acidosis with a pH of 7.29 and a PaCO 2 of 75 mm Hg with minimal compensatory changes in
HCO 3- levels. In a postoperative patient with acute respiratory acidosis and pinpoint pupils, one should be concerned about overdose with
narcotic analgesics. Initial treatment of this patient should involve appropriate management of the airway, with intubation if necessary, and
administration of naloxone, an antagonist to narcotic analgesics. Hyperglycemia in a patient with non-insulin-dependent diabetes mellitus
(NIDDM ) is unlikely to present with a severe respiratory acidosis, as opposed to metabolic acidosis and so the insulin bolus is not useful.
NaHCO 3 does not treat the primary cause of acidosis in this situation and would not be indicated. A chest radiograph may play a role in
the evaluation of this patient, but not in the immediate management of acute severe respiratory acidosis. Acute pulmonary embolus is
unlikely to be associated with an isolated respiratory acidosis; however, if it is suspected, appropriate diagnostic evaluation and treatment
should be initiated after initial resuscitative measures are taken.

9. A 55-year-old woman underwent a Whipple procedure for pancreatic adenocarcinoma. Postoperatively, she develops a
pancreaticocutaneous fistula, which drains approximately 400 mL/day. On evaluation, the patient is noted to be tachycardic with a
heart rate of 115 beats/min and a blood pressure of 100/80 mm Hg. Her skin is noted to be dry, and her urine output has decreased
significantly over the past 2–3 days. Labs reveal a Na+ of 140 mEq/L, Cl - of 120 mEq/L, and HCO3- of 15 mEq/L. To resuscitate this
patient, which of the following is the most appropriate fluid?

(A) 5% dextrose in normal saline (0.9%)

(B) 5% dextrose in ½ normal saline (0.45%)

(C) 5% albumin solution

(D) Lactated Ringer's solution

(E) 5% dextrose in water + insulin bolus

9–D. Pancreatic fistulae are frequently associated with a significant loss of HCO 3-, leading to a metabolic acidosis. This patient's low HCO 3-
level in the absence of a significant anion gap {Na+ (140)–[Cl- (120) + HCO 3-(15)] = 5} in the setting of a pancreatic fistula and dehydration
suggests a significant loss of fluid and HCO 3- from this source. Appropriate resuscitation with a crystalloid solution that resembles the fluid
being lost is necessary. Lactated Ringer's solution contains 28 mEq/L of lactate, which is quickly metabolized to HCO 3- by the liver. Other
saline and albumin solutions do not contain HCO 3- and, although they are appropriate solutions in most situations, would not be the best
choice for this patient. Insulin should be given when one expects severe hyperglycemia as the primary problem, although the acidosis
associated with severe hyperglycemia is generally associated with a large anion gap (> 12).

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 10–16

A. Cardiogenic shock due to extrinsic causes

B. Cardiogenic shock due to intrinsic causes

C. Hypovolemic shock secondary to blood loss

D. Hypovolemic shock secondary to third space losses

E. Hypovolemic shock secondary to insensible losses

F. Septic shock

G. Neurogenic shock

For each patient description, select the associated type(s) of shock.

10. A 65-year-old, otherwise healthy man underwent laparoscopic cholecystectomy 3 weeks ago for acute cholecystitis and
cholelithiasis. Now he presents with fever, chills, and right upper quadrant (RUQ) pain, and a new onset of confusion, according to his
wife. He is tachycardic (130 beats/min), he appears flushed, and his skin is warm. (SELECT 1 TYPE OF SHOCK) F. Septic shock

10–F. Septic shock is associated with severe peripheral vasodilation with increased cardiac output. This leads to flushing and warm skin to
palpation, in contrast to hypovolemic shock, which results in peripheral vasoconstriction. Other signs and symptoms are related to the
primary infection, such as fever, chills, and leukocytosis. This patient is experiencing symptoms suggestive of cholangitis or a peritoneal
infection related to the recent surgery.

11. A 19-year-old man presents to the emergency department by ambulance with a stab wound adjacent to the left nipple region. His
blood pressure is 50/30 mm Hg and he is unresponsive. (SELECT 2 TYPES OF SHOCK) A. Cardiogenic shock due to extrinsic causes
C. Hypovolemic shock secondary to blood loss
11–A, C. Hypovolemia secondary to blood loss is an obvious cause of shock after a stab wound to the chest either from injury to major
blood vessels or direct injury to the heart. However, this injury can also result in cardiogenic shock due to extrinsic causes such as
cardiac tamponade from injury to the pericardium and tension pneumothorax from lung injury. Theoretically, direct injury to a major
coronary vessel can result in a myocardial infarction, even in a young patient. However, consideration of the previous potential causes of
shock should be considered first and foremost.

12. A 23-year-old medical student suddenly becomes faint and dizzy while observing a right inguinal hernia repair in the operating
room. The student collapses and during evaluation is noted to have a blood pressure of 85/50 mm Hg. (SELECT 1 TYPE OF SHOCK)
G. Neurogenic shock
12–G. This is a classic vasovagal response resulting in acute transient peripheral dilation with subsequent hypotension and syncope. This
response is a form of neurogenic shock, although different from the typical description of patients with a spinal injury.

13. A 42-year-old, obese woman presents with a 2–3 day history of persistent nausea and vomiting. Her blood pressure is 80/50 mm Hg
with a heart rate of 140 beats/min. She is noted to have an unreducible umbilical hernia on examination. Abdominal radiograph reveals
a high-grade small bowel obstruction. During operative repair of the incarcerated hernia, there is no evidence of strangulation. (SELECT
1 TYPE OF SHOCK) D. Hypovolemic shock secondary to third space losses

13–D. This patient's hypotension is secondary to hypovolemia from third space losses as well as dehydration from frank gastrointestinal
losses associated with vomiting. Several liters of fluid can be sequestered (“third spaced”) in the intestine when bowel obstruction occurs.
If this fluid is not replaced or is combined with other losses from the gastrointestinal tract, it can result in hypotension and even
hypovolemic shock.

14. A 25-year-old man is admitted to the neurosurgery intensive care unit after a motor vehicle accident. On admission the patient is
noted to have a blood pressure of 120/80 mm Hg with a heart rate of 105 beats/min. Upon evaluation he is found to have a complete
spinal cord injury at the sixth cervical vertebrae, as well as a bruise on his abdomen in the distribution of his seatbelt and a bruise on
his chest from hitting the steering wheel. Six hours after admission the patient's blood pressure gradually falls to 60/40 mm Hg and the
patient becomes unresponsive. (SELECT 4 TYPES OF SHOCK) A. Cardiogenic shock due to extrinsic causes B. Cardiogenic shock due to intrinsic
causes C. Hypovolemic shock secondary to blood loss G. Neurogenic shock
14–A, B, C, G. Although the spinal injury can result in neurogenic shock in this patient, one must consider several causes of shock,
particularly in a patient with traumatic injuries sustained from blunt trauma. The bruise on the abdomen can be a harbinger of intra-
abdominal injuries (e.g., splenic or liver trauma), which can result in immediate or delayed hypovolemic shock secondary to blood loss.
Blunt trauma to the chest can result in a myocardial contusion, which can infrequently result in impaired cardiac function and intrinsic
cardiogenic shock. Blunt chest trauma can also result in a tension pneumothorax or cardiac tamponade (extrinsic cardiogenic shock) by
various mechanisms.

15. A 35-year-old man sustains a 50% full-thickness burn injury to his torso and lower extremities during a house fire. Over the next 2
days, the patient develops a worsening paralytic ileus and a gradual decrease in his blood pressure to 80/60 mm Hg despite following
the Parkland formula for determining the amount of fluid to give after a burn injury. (SELECT 2 TYPES OF SHOCK)
D. Hypovolemic shock secondary to third space losses E. Hypovolemic shock secondary to insensible losses
15–D, E. Burn injuries can be associated with large amounts of insensible fluid losses from evaporation of fluid directly from the exposed
wounds. These patients require large amounts of fluid for maintenance and resuscitation because of these losses. In addition, this patient's
paralytic ileus can result in significant third spacing of fluid, also contributing to hypovolemia.

16. During placement of a triple lumen catheter in a 72-year-old woman, the patient suddenly becomes hypotensive with a blood
pressure of 60/30 mm Hg during advancement of the guidewire. (SELECT 3 TYPES OF SHOCK)
A. Cardiogenic shock due to extrinsic causes B. Cardiogenic shock due to intrinsic causes C. Hypovolemic shock secondary to blood loss
16–A, B, C. Placement of any central venous catheter can cause multiple injuries, resulting in hypotension and shock. Lung injury with
tension pneumothorax can result from such placement. In addition, advancement of the guidewire or the catheter itself can perforate the
major blood vessels involved and the myocardium, resulting in severe blood loss or cardiac tamponade (extrinsic cardiogenic shock).
Advancement of catheters or guidewires through the heart can also incite various arrhythmias, resulting in cardiac failure and intrinsic
cardiogenic shock.
 M ore than 105 organisms/g of tissue is considered significant.

Organism identification can also be determined.

3. Specific signs of burn wound infection include

the conversion of second degree burns to full-thickness burns

green pigmentation.

discoloration or change of burned areas.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 20-year-old man presents to the emergency room after being involved in a bar fight. Other than
some abrasions on his face and hands, the patient has a laceration on the side of his neck. Exploration of
this wound at the bedside reveals a large superficial laceration that does not penetrate the platysma
muscle. Which of the following is most appropriate in the initial management of this patient?
(A) Immediate surgical neck exploration
(B) Angiography to evaluate for vascular injury
(C) Aggressive irrigation and local wound care
(D) Evaluation of the esophagus via endoscopy
(E) Evaluation of the esophagus via esophagography
1–C. A stab wound that does not penetrate the platysma needs no further evaluation. Meticulous wound
care and local irrigation are needed, however significant injury to the deep structures of the neck is
unlikely without penetration of the platysma. If the stab wound did penetrate the platysma, evaluation
and treatment would be determined by the zone of the neck injured, as well as the presence or absence
of signs suggestive of an injury to vital structures. Such signs include frank arterial bleeding, hematoma
formation, bruit, cerebral changes indicative of an ischemic or embolic event, stridor, dysphonia,
hemoptysis, hematemesis, dysphagia, odynophagia, or subcutaneous air.

2. A 16-year-old man is brought to the emergency room after his clothes caught on fire. He has severe burns to both his upper
extremities. What signs would indicate the need for an escharotomy?

(A) Circumferential burns with severe blistering and erythema

(B) Circumferential burns with severe pain over the affected area

(C) Circumferential partial-thickness burns over the elbow joint

(D) Circumferential burns with an absence of the left radial pulse

(E) Circumferential superficial burns over the elbow joint

2–D. An escharotomy is a procedure that involves placement of full-thickness longitudinal incisions over sites of severe burn injury to
prevent and treat vascular compromise and ischemia secondary to swelling and edema formation at the burn site. Full-thickness incisions
to the level of healthy adipose tissue are necessary for adequate compartmental decompression. Indications for escharotomy in an
extremity include circumferential burns with absent distal pulses or with significant neurologic changes. Superficial burns generally do not
result in such an injury and the presence of partial-thickness burns over a joint does not mandate performance of an escharotomy.
Blistering, erythema, and pain are not indications for escharotomy.

3. A 58-year-old woman presents to the emergency room after a motor vehicle accident. Despite 2 liters of intravenous fluid, her heart
rate is still 130 beats per minute and her systolic blood pressure is 86 mm Hg. Her chest radiograph reveals normal lung fields with no
evidence of pneumothorax or hemothorax, although there is a small amount of air noted between the diaphragm and the liver. Pelvic
radiograph also reveals a fracture of the pubic symphysis and the right sacroiliac. Which of the following is most appropriate initial step
in the evaluation and treatment of this patient?

(A) Obtain an immediate angiogram of the pelvis.

(B) Obtain an abdominal/pelvis computed tomography scan.

(C) Perform immediate diagnostic peritoneal lavage.

(D) Perform abdominal ultrasound and pelvic fixation.

(E) Perform immediate exploratory laparotomy.

3–E. Free air seen under the diaphragm after a motor vehicle accident is an indication for immediate surgical exploration of the abdomen
because of the likelihood of a visceral injury. Performance of an abdominal computed tomography (CT) scan, abdominal ultrasound, or
diagnostic peritoneal lavage is not necessary when free air is present in the abdomen. Operative pelvic fixation and angiography of the
pelvis may be important in the management of this patient but should not precede performance of a laparotomy.

4. An 18-year-old man is admitted to the hospital after sustaining a burn injury from a gasoline fire. His entire anterior trunk, left
upper extremity, and both complete anterior thighs are affected. All areas appear to be at least partial-thickness burns. What is the
estimated total body surface area of burn injury involvement?

(A) 18%

(B) 27%
(C) 36%

(D) 55%

(E) 60%

4–C. Total body surface area (TBSA) estimates used to quantify the extent of burn injuries in adults is based on the “rule of nines.” The
anterior trunk is equal to 18%. The left upper extremity is equal to 9%. Each lower extremity is equal to 18%, thus each anterior thigh is
approximately 4.5%, and making a total of 9% TBSA involved in the lower extremity. Therefore 18 + 9 + 2(4.5) = 36%.

5. After being hit on the left side, a 24-year-old football player becomes unconscious. He regains consciousness and is brought
emergently to the hospital. After initial resuscitation, performance of an abdominal computed tomography (CT) scan reveals a splenic
injury involving the vessels within the hilum with significant intraperitoneal bleeding. Which of the following statements is true
regarding the management of this patient?

(A) Nonoperative management with bedrest is indicated for this splenic injury.

(B) This patient will need to be immunized with vaccines against Haemophilus, Pneumococcus, and Neisseria.

(C) If a splenectomy is performed, this patient will require lifelong antibiotic therapy.

(D) This injury is a grade 1 splenic injury because of the involvement of the hilum.

(E) If nonoperative treatment is performed, this patient could return to play football in 2 weeks.

5–B. A severe splenic injury involving the splenic hilum requires immediate splenectomy and should not be managed with observation and
bedrest. Some minor splenic injuries can be managed nonoperatively with bedrest and observation if there is no hemodynamic instability or
significant intraperitoneal hemorrhage. Conservative treatment of minor splenic injuries with strict bedrest for 5 days would still require
avoidance of contact sports with limited activity for approximately 6 weeks. Patients undergoing a splenectomy should receive
immunization against encapsulated organisms, specifically Haemophilus, Pneumococcus, and Neisseria. Grading of splenic injuries is
complex although grade 1 injuries are characterized by small (< 1 cm) lacerations not involving the capsule while grade V injuries include
those with complete devascularization or avulsion of the spleen or a completely shattered spleen.

6. A 46-year-old woman suffered a full-thickness burn to 10% of her body, a partial-thickness burn to 30% of her body, and first degree
burns to an additional 20% of her body. She weighs 50 kg and the burn occurred just before admission. What is the estimated amount of
fluids she will need for the first 24 hours?

(A) 2 liters
(B) 3.6 liters

(C) 8.0 liters

(D) 12.4 liters

(E) 14.4 liters

6–C. Resuscitation fluid is determined using the Parkland formula, which estimates the volume of fluid to be administered during the first 24
hours after a severe burn injury. The formula is: volume = (% TBSA burned) × (weight in kg) × (4 mL), where TBSA = total body surface area.
It is important to calculate the TBSA in this formula using only second and third degree burns. First degree burns are not used in
calculating fluid resuscitation. So for this patient, the calculation is volume = (10% [full-thickness] + 30% [partial-thickness]) × 50 kg × 4 mL =
8000 kg/mL, which = 8.0 L.

7. A 27-year-old man sustains a gunshot wound to the abdomen with a small caliber handgun. There is a small entrance wound in the
right lower quadrant and an exit wound on the back directly posterior to the entrance wound. His blood pressure is 120/60 mm Hg and
his heart rate is 95 beats per minute. Exploratory laparotomy reveals a 1.5-cm laceration on the antimesenteric border of the ascending
colon with no other injuries discovered. There is minimal fecal leakage. Which statement is true regarding the management of this
patient?

(A) A pelvic angiogram should be performed postoperatively.

(B) A right colectomy and a diverting ileostomy should be performed.

(C) A completely diverting colostomy should be performed.

(D) This patient's injury can be managed with primary repair.

(E) If hematuria is present a nephrectomy should be performed.

7–D. Historically, a colostomy was performed in most patients with colonic injuries to avoid anastomotic leaking and wound infection.
Recently, it has become evident that for many colon injuries a colostomy is not required. Patients with small injuries, especially to the
right-sided colon, with minimal fecal soilage, and who are hemodynamically stable are appropriately managed with primary repair or closure
of the injured segment. A pelvic injury is not indicated based on the clinical and intraoperative findings. Hematuria alone would not be an
indication for nephrectomy, although the renal system and kidney should be carefully inspected intraoperatively for potential injury after
a gunshot wound (GSW) to this area. The absence of other injuries at exploratory laparotomy warrant no further surgery or radiologic
tests.

8. A 19-year-old cross country runner presents to the emergency room after falling off a 9-foot ridge and landing on his right side. He is
complaining of some tenderness over his right lower ribs with no abdominal tenderness to palpation. His blood pressure is 128/74 mm
Hg with a pulse of 96 beats per minute. An abdominal computed tomography (CT) scan is performed, which reveals a grade III liver
injury with intra-abdominal bleeding. Which statement is true regarding this patient?

(A) Hypotension and tachycardia are often late findings of shock in young athletes.
(B) Hepatic arteriography is the preferred examination in the evaluation of liver injuries.

(C) A 9-foot fall is not sufficient enough to cause a severe liver injury.

(D) The lack of abdominal tenderness is inconsistent with intra-abdominal bleeding.

(E) A diagnostic peritoneal lavage should be performed to confirm bleeding.

8–A. Because of the well-adapted cardiovascular response, young athletes may frequently develop significant hypotension and tachycardia
only as a late finding even in the presence of severe hypovolemia or blood loss. Patients on β blockers also can have a blunted tachycardic
response to hypovolemia. The fact that abdominal tenderness was not present is not abnormal. Acute bleeding in the abdomen does not
always cause peritoneal irritation. Hepatic arteriography may be used in some situations to treat hepatic injuries, however it is generally
not preferred over computed tomography (CT) scan for evaluation. There is no need to perform diagnostic peritoneal lavage when
bleeding is seen on CT scan.

9. An elderly male is involved in a motor vehicle accident. He states he was going approximately 45 mph when his car struck a car that
stopped abruptly in front of him. His blood pressure is 110/74 mm Hg, with a heart rate of 87 beats per minute. After thorough
examination his only injuries include a nondisplaced right femur fracture with intact peripheral pulses and some minor abrasions.
Which of the following would be appropriate to confirm the absence of a cervical spine injury in this patient?

(A) A normal lateral neck film with no cervical tenderness or pain during examination

(B) A normal anterior posterior film with no cervical tenderness or pain during examination

(C) A normal computed tomography (CT) scan of the cervical spine with pain upon lateral neck motion

(D) Lateral, anterior-posterior, and odontoid views with no cervical tenderness or pain during examination

(E) Physical examination alone with no cervical tenderness or pain during examination

9–D. To adequately confirm the absence of a cervical spine injury in a patient at a potential risk for such injury (i.e., high-speed motor
vehicle accident) radiographs must be performed. To rely on the physical examination alone, the patient must be alert and oriented and
have no distracting injuries (e.g., femur fracture) or be under the influence of drugs. Radiographs needed to evaluate the cervical spine
are a lateral, anterior-posterior, and open mouth odontoid views. It is important to visualize all seven cervical vertebrae. If a physical
examination is reliable and negative for tenderness or pain with full range of motion, no further evaluation needs to be performed. Even
with a normal computed tomography (CT) scan, however, the presence of pain during range of motion testing should prompt an evaluation
for a potential ligamentous injury.

10. A 4-year-old girl is brought in by her parents after she apparently was burned during her bath. Her feet, buttocks, and perineum are
badly scalded with blistering skin. Her legs have no blistering, but are mildly red and somewhat tender to the touch. Which of the
following is true regarding admission criteria for burn injured victims?

(A) Children with deep partial-thickness burns on ≤ 30% total body surface area (TBSA) can be managed as outpatients with close
follow-up.

(B) Patients with full-thickness burns to the perineum only can be managed as outpatients with close follow-up.

(C) Children with full-thickness burns to the feet only can be managed as outpatients with close follow-up.

(D) All patients with superficial burns to the entire torso region and both lower extremities require inpatient treatment.

(E) All children with burn injuries and a concern of possible abuse should be admitted for inpatient treatment.

10–E. Partial-thickness burns to the face, perineum, hands, or feet are criteria for admission and inpatient management. The total body
surface area (TBSA) burned in this patient is greater than 10% and she is only 4 years old. This is also criteria for admission. Although this
could simply be an unintentional accident, the question of abuse or neglect needs to be addressed and is an adequate indication for
admission in any child regardless of extent of injury. Patients with superficial burns (e.g., minor sunburn) generally do not require
inpatient treatment and can be managed appropriately as outpatients.

11. A 43-year-old patient who has been in the intensive care unit for 7 days following a severe 70% total body surface area (TBSA) burn
has become increasingly tachycardic and mildly hypotensive with a decrease in urine output. Based upon changes in the color and odor
of the burn wound, you suspect burn wound sepsis. Which organisms are most likely to be involved?

(A) Staphylococcus aureus, Pseudomonas species, and Bacteroides species

(B) Staphylococcus aureus, Streptococcus species, and Pseudomonas species

(C) Candida albicans, Bacteroides species, and Escherichia coli

(D) Candida albicans, E. coli, and Proteus species

(E) E. coli, Bacteroides species, and Clostridium difficile

11–B. Changes in burn wound color and odor may occur when burn wound sepsis is occurring. The most common organisms involved in
burn wound infections include Staphylococcus aureus, Pseudomonas species, Streptococcus species, and Candida albicans. Confirmation of
significant burn wound infection requires performing quantitative cultures of a biopsy specimen of the affected burn area.

12. A patient is complaining of shortness of breath after falling off his tractor and getting run over by the rear wheel. Physical
examination reveals a blood pressure of 82/40 mm Hg, a heart rate of 122 beats per minute, short shallow respirations, breath sounds
louder on the left than on the right, and tracheal shifting toward the patient's left. What is the most likely diagnosis?
(A) Right tension pneumothorax

(B) Left tension pneumothorax

(C) Cardiac tamponade

(D) Severe tracheal injury

(E) Right flail chest

12–A. The most likely diagnosis in this patient is a tension pneumothorax. Injury to the lung parenchyma caused by rib fractures from blunt
chest trauma may result in development of a pneumothorax. As air continues to enter the pleural space with each inspiration, the
intrapleural pressure continues to rise, resulting in lung collapse and even compression of vascular structures within the mediastinum
(e.g., superior vena cava). This results in decreased venous return to the heart and rapid development of shock. This may also cause
shifting of mediastinal structures such as the trachea away from the side of the pneumothorax. Cardiac tamponade is not associated with
unilateral decreased breath sounds. Tracheal injuries are rare after blunt trauma to the chest. A flail chest can cause shallow respirations
and unilateral decreased breath sounds but it is not always associated with development of a pneumothorax.

13. A 49-year-old man presents to the emergency room after being hit by a car while walking down the road. Minimal history is
available from the emergency medical technicians. He is conscious upon arrival and moving all 4 extremities. The most appropriate
initial step in the evaluation of this patient is to

(A) Remove all clothing and inspect for injuries.

(B) Ask the patient his name.

(C) Place a Foley catheter after a rectal examination.

(D) Evaluate the patient's pupils.

(E) Obtain chest and pelvis radiographs.

13–B. Although all of the procedures listed are important in the evaluation of the traumatized patient within the first few minutes, it is
essential to proceed systematically with the ABC's (Airway, Breathing, Circulation), in that order. One of the easiest ways to assess for
airway patency in a conscious patient is by determining the patient's ability to talk. If a patient can verbalize normally, the airway is likely
patent.

14. A 17-year-old woman is seen in the emergency room with severe burns to both of her hands. She seems very responsible, and is
with her parents who are very willing to help take care of her at home. She is not complaining of any pain and wonders if she can be
treated as an outpatient. Which of the following statements is true regarding the management of this patient?

(A) This patient can be adequately managed as an outpatient with close follow-up.

(B) Skin grafting should be performed in 1–2 months to provide the best outcome.

(C) Her burns are likely to be superficial partial-thickness burns.

(D) Early skin grafting (within days) will decrease contracture formation.

(E) Wound cleansing and application of antibiotic ointment is adequate treatment.

14–D. The fact that these burns are painless makes it highly likely that they are a full-thickness burn. Any burn of that degree to the hands
requires inpatient treatment. If left untreated, deep partial-thickness and full-thickness burns will heal slowly with significant scar
formation and contracture formation. The gold standard is to do a split-thickness skin grafting within days after adequate excision and
débridement of the burn.

15. A 52-year-old, 60-kg woman is admitted to the hospital immediately after being involved in a house fire. She has approximately
50% total body surface area (TBSA) burns that are at least partial-thickness burns. She has not received any intravenous (IV) fluids up to
this point. Which of the following is the most appropriate IV fluid and rate of administration that should initially be given to this
patient?

(A) Lactated Ringer's at 500 mL/hr

(B) 5% Dextrose in H2O at 750 mL/hr

(C) Lactated Ringer's at 1000 mL/hr

(D) 5% Dextrose in H2O at 1000 mL/hr

(E) Lactated Ringer's at 750 mL/hr

15–E. The Parkland formula is used to calculate an estimated volume of intravenous (IV) fluids to administer during the first 24 hours after a
burn. Thus, 12 liters of IV fluids will need to be given to this patient during the first 24 hours. However, half of the fluid needs to be given
in the first 8 hours after the injury; this means that approximately 6 liters will need to be given over an 8-hour period (750 mL/hr). Initial
losses are isotonic, and therefore need to be replaced with an isotonic crystalloid such as lactated Ringer's.
 Table 9-6. Other Causes of Acute Abdominal Pain Not Requiring Surgery

Cardiac M yocardial infarction (typically inferior), pericarditis

Pulmonary Pneumonia, pulmonary embolism, pneumothorax, empyema

Other thoracic Reflux disease

Endocrine Adrenal insufficiency, diabetic ketoacidosis

Metabolic Acute intermittent porphyria, uremia, hypercalcemia

Toxic Venom from snakes and scorpions, lead poisoning, drugs, alcohol

Hematologic Hemolytic crisis (sickle cell anemia), rectus sheath hematoma (warfarin use)

Neurogenic Herpes zoster, spinal cord/nerve root compression from tumor or abscess, tabes dorsalis

Gastroenteritis, pseudomembranous colitis, hepatitis, spontaneous bacterial peritonitis, tuberculosis

Infection
peritonitis, malaria, numerous bacterial/viral infections

Congenital Familial M editerranean fever

Musculoskeletal Vertebral compression of abdominal wall nerves

Vascular Splenic infarction

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 65-year-old woman with a long history of atrial fibrillation presents to the emergency department
with a history of sudden onset of constant, severe abdominal pain. After the onset of the pain, she
vomited once and had a large bowel movement. No flatus has passed since that time. Her vital signs are:
heart rate, 124 beats/min (irregular); respiration, 18/min; blood pressure, 140/60 mm Hg; temperature,
38.0°C. Physical examination reveals a mildly distended abdomen that is mildly tender diffusely. There are
no peritoneal signs. Electrocardiogram reveals the patient to be in atrial fibrillation but otherwise normal.
Chest radiograph is unremarkable. Ten years ago, this patient underwent a vaginal hysterectomy. Which
of the following would be most appropriate in the subsequent evaluation of this patient?
(A) Abdominal ultrasound
(B) Upper gastrointestinal endoscopy
(C) Abdominal computed tomography scan
(D) Mesenteric vessel arteriogram
(E) Upper gastrointestinal contrast study
1–D. The triad of a cardiac arrhythmia, sudden onset of severe abdominal pain, and gut emptying is
classic for embolic mesenteric ischemia. This patient's pain is also out of proportion to the physical
examination, another classic sign of mesenteric ischemia. In this setting, the most appropriate initial
 diagnostic study should be an arteriogram of the mesenteric arterial supply to characterize the extent and
location of disease. Abdominal ultrasound, computed tomography scanning, and upper endoscopy are
useful in other situations in which the clinical findings are more subtle or suggestive of other specific intra-
abdominal diagnoses.

2. A 44-year-old, obese woman presents to the emergency department with a history of acute onset of severe epigastric pain radiating
toward the back. The pain began several hours after dinner. The patient has no significant past medical history and denies any previous
surgery. She takes no medications. On examination, the patient has marked epigastric tenderness with guarding and hypoactive bowel
sounds. Her vital signs are: heart rate, 110 beats/min; blood pressure, 120/50 mm Hg; respiration, 28/min; temperature, 38.0°C.
Amylase level is 2500 units. Which of the following is the most likely cause of this patient's pain?
(A) Gallstones

(B) Alcohol abuse

(C) Hyperparathyroidism

(D) Hyperlipidemia

(E) Peptic ulcer disease

2–A. The history, physical examination, and elevated amylase are all consistent with pancreatitis. Gallstones and alcohol account for 90% of
the cases of pancreatitis in the United States. A high amylase level (over 1000) suggests gallstones over alcohol abuse. Age in the 40s, being
female, and obesity are also risk factors for gallstones. Hyperparathyroidism and hyperlipidemia are rare causes of pancreatitis. A ruptured
peptic ulcer could present in a similar manner but the elevated amylase suggests pancreatitis. A history of epigastric discomfort or antacid
use would also suggest ulcer disease.

3. A 40-year-old man presents with significant right flank pain radiating down to his testicle. The pain is intermittent and severe in
nature. Microscopic hematuria is present on urinalysis, but there are no white blood cells. Leukocyte esterase and nitrates are
negative. His vital signs are: heart rate, 88 beats/min; blood pressure, 130/60 mm Hg; respiration, 20/min; temperature, 37.2°C. Which
of the following is the most appropriate next step in the management of this patient?

(A) Intravenous antibiotics

(B) Immediate laparotomy

(C) Intravenous fluids and pain medication

(D) Computed tomography (CT) scan of the abdomen

(E) Immediate orchiopexy

3–C. Urinary tract calculi classically present with flank pain that is colicky in nature with radiation to the ipsilateral testicle and red blood
cells and stones in the urine. Appropriate treatment of an initial episode of this disease generally involves administering intravenous fluids
to assure appropriate hydration and to provide adequate pain control [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs)] during passage
of the stone. Ultrasound and intravenous pyelogram (IVP) are the tests of choice in diagnosing patients with recurrent or complicated
urinary tract stones. A computed tomography scan could also show stones but is not as sensitive as ultrasound or IVP. The patient's clinical
presentation, in addition to the urinalysis findings of no white blood cells, nitrates, leukocyte esterase, or bacteria, makes infection
possible, but less likely. Immediate orchiopexy would be appropriate if testicular torsion were suspected. This generally presents with
acute abdominal pain and extreme tenderness in the affected testicle.

4. A 50-year-old woman presents to the emergency department with abdominal pain and jaundice. Her vital signs are: heart rate, 80
beats/min; blood pressure, 130/72 mm Hg; respiration, 18/min; temperature, 37.0°C. Examination reveals tenderness in the right upper
quadrant (RUQ) and a positive Murphy's sign. Which of the following statements regarding this patient is true?

(A) Referred pain would likely be to the right shoulder or scapula.

(B) This disease is characterized by Charcot's triad.

(C) Jaundice is rarely present in these patients.

(D) Etiology of the pain would likely be present on abdominal film.

(E) M orphine is the most appropriate analgesic to use in this patient.

4–A. Cholecystitis is caused when a gallstone is impacted in the cystic duct. Referred pain is to the right shoulder and scapula. Jaundice
may be present, despite the fact that there is no obstruction of the common bile duct. Charcot's triad is associated with ascending
cholangitis, which results from bacterial infection of the biliary tree after a gallstone is impacted in the common bile duct. Only 15% of
gallstones are radio-opaque, thus an abdominal film is not likely to show the etiology of the pain. M orphine should probably be avoided in
patients with cholecystitis as it theoretically contracts the sphincter of Oddi, which will prevent stone passage and possibly increase the
risk of complications such as pancreatitis.

5. A 23-year-old man presents to the emergency department complaining of scrotal pain. The pain began 4 days ago but has gradually
worsened. The patient now feels hot and his scrotum is too tender to allow for examination. His vital signs are: heart rate, 90
beats/min; respiration, 20/min; blood pressure, 120/60 mm Hg; temperature, 38.5°C. Which of the following is the most likely
diagnosis?

(A) Testicular torsion

(B) Hydrocele

(C) Epididymitis
 (D) Urethritis

(E) Spermatocele

5–C. This patient most likely has acute epididymitis. The patient does not complain of penile discharge or dysuria, making urethritis less
likely. Spermatocele and hydrocele are generally not associated with testicular tenderness. Testicular torsion can present with severe
testicular pain and is a surgical emergency. However, torsion is generally associated with a more acute onset of pain (within minutes to
hours) and is not commonly associated with fever.

6. A 50-year-old woman presents to the emergency room with ripping chest pain that is now radiating into the abdomen. The patient
has unequal pulses in the upper extremities. Her vital signs are: heart rate, 125 beats/min; respiration, 20/min; temperature, 36.5°C.
Which of the following statements is true?

(A) The patient will most likely be hypotensive on presentation.

(B) S-T segment elevation in the anterior leads is diagnostic.

(C) Coronary artery disease is the likely etiology of the pain.

(D) M agnetic resonance imaging of the chest is usually used to make the diagnosis.

(E) A new heart murmur can be associated with this disease.

6–E. Thoracic aortic dissection is most commonly a complication of hypertension. Patients most commonly present with hypertension and
chest pain radiating to the back, although dissections involving the lower thoracic or abdominal aorta may also cause abdominal pain. S-T
segment changes can occur with aortic dissections, but are not diagnostic because they may also occur with myocardial infarction.
Coronary artery disease can present with similar chest pain in addition to abdominal pain, although this scenario is most likely associated
with aortic dissection. A computed tomography (CT) scan of the chest or aortogram are usually used to make the diagnosis. M agnetic
resonance imaging could also make the diagnosis but is generally too time consuming in this setting. New heart murmurs may occur with
ascending aortic dissections, causing aortic valve incompetence.

7. A 60-year-old man presents to the emergency room with sudden abdominal pain and an expanding, pulsatile abdominal mass on
examination. His vital signs are: heart rate, 130 beats/min; blood pressure, 70/20 mm Hg; respiration, 30/min; temperature, 36.0°C.
Which of the following is the most appropriate next step in the management of this patient?

(A) Emergency computed tomography (CT) of the abdomen

(B) Emergency CT of the chest

(C) Emergency aortogram

(D) Emergency laparotomy

(E) Volume resuscitation and observation

7–D. The triad of acute abdominal pain, a pulsatile abdominal mass, and hypotension is classic for a ruptured abdominal aortic aneurysm
(AAA). This patient should be taken to the operating room immediately. Performing a computed tomography (CT) scan or aortogram in this
situation would only delay definitive operative treatment and is not indicated in this patient.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 8–12

A. Small bowel obstruction

B. Large bowel obstruction

C. Cholecystitis

D. Ureteral calculi

E. Pyelonephritis

F. Pancreatitis

For each clinical description, select the most likely diagnosis(es).

8. A 39-year-old man presents to the emergency room with severe vomiting and increasing abdominal pain. Abdominal radiograph shows
multiple dilated loops of small bowel and air-fluid levels throughout the abdomen. The patient underwent an emergent splenectomy 1
year ago after a motor vehicle accident. (SELECT 1 DIAGNOSIS) A. Small bowel obstruction

8–A. A small bowel obstruction characteristically presents with nausea, vomiting, abdominal pain, and eventually failure to pass stool or gas.
Adhesions after surgery are the most common cause of small bowel obstruction in the United States. Abdominal films typically show
multiple fluid levels. The clinical presentation in association with a history of previous abdominal surgery is more consistent with a small
bowel obstruction than a large bowel obstruction.

9. A 48-year-old woman presents to the emergency room with severe epigastric pain radiating to the lumbar area. The pain is
somewhat relieved with upright posture. The patient has had severe nausea and vomiting since the onset of pain. Chest and abdominal
films are unremarkable. Urinalysis is normal. (SELECT 2 DIAGNOSES) C. Cholecystitis F. Pancreatitis

9-C, F. Gallstones and alcohol are the major causes of pancreatitis. These patients typically present with severe epigastric pain radiating
to the lumbar area or left shoulder and with nausea, vomiting, and anorexia. Pain is sometimes relieved with upright posture. Amylase is
generally elevated in these patients. Cholecystitis may also present with similar signs and symptoms. These patients frequently have an
elevated alkaline phosphatase. Biliary ultrasound is often diagnostic.

10. A 60-year-old man presents with epigastric pain after eating. The pain seems to radiate to the right scapula. Examination reveals
tenderness in the epigastric area, but no rebound or guarding are present. Amylase and lipase are normal. Chest and abdominal films
are unremarkable. (SELECT 1 DIAGNOSIS) C. Cholecystitis

10–C. Cholecystitis is caused by gallstones and typically presents with vague epigastric pain that eventually progresses to somatic pain in
the right upper quadrant (RUQ). Alkaline phosphatase is generally elevated. Pancreatitis can present with epigastric pain; however,
amylase is usually elevated.

11. A 35-year-old man presents with flank pain radiating to the ipsilateral testicle. The pain came on suddenly 2 hours ago. Urinalysis
shows red blood cells. Chest and abdominal films are unremarkable. Laboratory values are unremarkable. Vital signs are normal.
(SELECT 1 DIAGNOSIS) D. Ureteral calculi

11–D. Ureteral calculi typically present with severe pain in the flank region with radiation to the ipsilateral testicle. Urinalysis generally
shows hematuria and possibly stones or crystals. Pyelonephritis could present with flank pain; however, these patients generally have a
fever along with red and white blood cells in their urine. The pain from pyelonephritis is gradual in nature and is not as acute as that
found with ureteral calculi.

12. A 65-year-old man presents with gradually increasing abdominal pain and obstipation over the past several weeks. The patient
denies any nausea or vomiting. Vital signs are normal. Examination reveals abdominal distension and guaiac-positive stools. (SELECT 1
DIAGNOSIS) B. Large bowel obstruction

12–B. Large bowel obstructions typically present with gradually increasing abdominal distension and eventual failure to pass gas or stool.
Abdominal films commonly show dilated loops of large bowel, and possibly dilated loops of small bowel, depending on whether or not the
ileocecal valve is competent. Cancer is the most common cause of large bowel obstruction. A history of guaiac-positive stools and
obstipation is very suspicious for adenocarcinoma of the colon.

Questions 13–16
For each clinical scenario, select the most appropriate management plan(s).

A. Take the patient to the operating room.

B. Admit for medical treatment and observation.

C. Perform an abdominal ultrasound.

D. Perform a computed tomography (CT) scan of the chest and abdomen.

E. Perform a magnetic resonance imaging scan of the abdomen.

F. Discharge the patient with close follow-up.

13. A 65-year-old man presents to the emergency room with abdominal pain for the past 12 hours. The patient has nausea and has
vomited once. The patient also has anorexia. On examination, a midline abdominal scar is noted and the pain is noted to be poorly
localized. Plain films show some air–fluid levels but there is air and stool distally. The small bowel appears dilated. (SELECT 1
MANAGEMENT PLAN) B. Large bowel obstruction

13–B. Nausea, vomiting, anorexia, and abdominal pain associated with air–fluid levels on abdominal plain film are signs of small bowel
obstruction. The presence of stool and air distal to the site of obstruction is suggestive of a partial obstruction. In some patients with a
partial small bowel obstruction and previous abdominal surgery, a course of inpatient management with bowel rest, volume resuscitation,
and nasogastric tube decompression may be attempted. No additional diagnostic tests are necessary at this time.

14. A 45-year-old man presents with nausea and vomiting 1 hour after eating. The patient now has developed dull, epigastric
discomfort, and watery diarrhea 5 hours later, although the vomiting has ceased and the patient is able to drink liquids. Abdominal
films and labs are unremarkable. Past medical history is unremarkable and the patient does not take any medications. The patient tells
you that his daughter has also started having diarrhea. (SELECT 1 MANAGEMENT PLAN) F. Discharge the patient with close follow-up.

14–F. Nausea and vomiting preceding abdominal pain, watery diarrhea, and epigastric discomfort following a meal is classic for
gastroenteritis. Often, other family members will have similar symptoms. In this setting additional diagnostic tests are unnecessary.
Computed tomography (CT) scan and ultrasound of the abdomen are likely to be poor yield in this patient. This patient does not require
immediate surgery. Whether or not to discharge or admit a patient to the hospital can be a difficult decision. Because the patient is able
to tolerate liquids, outpatient management with close follow-up is appropriate.

15. A 60-year-old man presents with tearing-like chest pain radiating to his back and abdomen. Electrocardiogram is normal. The
patient is hypertensive and tachycardic but is otherwise alert and oriented. (SELECT 1 MANAGEMENT PLAN)
D. Perform a computed tomography (CT) scan of the chest and abdomen.
15–D. This patient may potentially have a dissection of the thoracic aorta descending into the abdomen. A computed tomography (CT) scan
of the chest or an aortogram are appropriate diagnostic studies for confirming a dissection, although a transesophageal echocardiogram
can also provide for excellent visualization of this portion of the aorta and may frequently be used to diagnose a suspected thoracic aortic
dissection. Surgery and admission to the hospital may eventually be necessary; however, a diagnostic study is the most appropriate next
step. Ultrasound could possibly detect a dissection but it is not as sensitive as the other studies noted.

16. A 54-year-old woman with a past medical history significant for ulcerative colitis presents to the emergency room with severe
abdominal pain, rebound, guarding, and abdominal distention. Supine plain films show a transverse colon diameter of 13 cm. (SELECT 1
MANAGEMENT PLAN) A. Take the patient to the operating room.
16–A. This patient most likely has toxic megacolon. This is a complication of ulcerative colitis and is manifested by rapid distention, usually
of the transverse colon. Initial management of uncomplicated toxic megacolon includes aggressive fluid resuscitation and administration of
steroids. However, when associated with signs and symptoms of peritonitis or perforation, this becomes a surgical emergency. No further
diagnostic studies are necessary at this point, based on the patient's medical history and current abdominal findings.
 b. Alkalis cause liquefactive type necrosis.

This necrosis results in the destruction of surface lipoproteins and penetration deep into muscle and surrounding tissues.

3. Management

a. Induction of vomiting is contraindicated

because it may re-expose the esophagus to the inciting agent.

b. Nasogastric tube placement is contraindicated

because of the possibility of perforation of the friable, injured mucosa.

c. Early endoscopy is indicated

to evaluate and grade the injury, which helps to determine treatment (Table 11–3).

d. Surgical indications include

continued bleeding.

free mediastinal or peritoneal air.

evidence of peritonitis or mediastinitis.

e. Delayed complications include

stricture.

a 500-fold increase in the risk of esophageal cancer.

development of an aortoesophageal fistula.

Table 11-3. Classification and Treatment of Esophageal Burns

G r ade Finding s o n Endo sco py Tr eatm ent

I M ucosal edema and hyperemia Observation for 24–48 hours, then discharge if stable

Patient is kept NPO for several days and parenteral nutrition is

M ucosal ulcerations, pseudo-membrane
II started. Esophagram is obtained in 2–4 weeks to look for stricture
formation, sloughing
formation.

Deep ulcerations with eschar formation;

Treatment is similar to grade II injuries in the absence of
III severe edema with obliteration of the
complications such as bleeding or perforation.
lumen

NPO = nothing by mouth.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 52-year-old man is referred for evaluation of dysphagia. Endoscopy reveals an ulcerated mass near
the gastroesophageal junction and biopsies of this lesion are positive for adenocarcinoma. Which of the
following statements is true?
(A) Most esophageal cancers are diagnosed early
(B) Neither chemotherapy nor radiation therapy alone have been shown to improve survival in these
 patients
(C) Smoking and alcoholism are important risk factors for development of this lesion
(D) With surgical resection, the 5-year survival for patients with esophageal cancer approaches 75%
(E) Cancers in the gastroesophageal junction tend to metastasize to cervical lymph nodes
1–B. Most esophageal cancers grow to a significant size before producing symptoms of dysphagia
because the esophagus lacks a serosa, thus permitting the smooth muscle in the esophagus to stretch
and accommodate the enlarging mass. Because of this, most esophageal cancers present at an advanced
stage that often precludes cure. The overall 5-year survival rate for patients with esophageal cancer after
attempted curative resection is only 40%–50%. While smoking and alcohol abuse are important risk
factors for squamous cell cancers, Barrett's esophagus is the most important risk factor for the
development of adenocarcinoma. Tumors in the distal third of the esophagus tend to metastasize to
caudad lymph nodes.

2. A 47-year-old man presents with complaints of dysphagia when eating solid food. He denies any history of weight loss and is not
anemic on laboratory evaluation. A barium swallow reveals a smooth, nonulcerated filling defect in the middle third of the esophagus
that is highly suspicious for a leiomyoma. Which of the following statements is true regarding this patient?

(A) Endoscopy and biopsy is indicated before proceeding with surgical resection

(B) These tumors can generally be enucleated without the need for esophageal resection

(C) M ultiple lesions are noted in at least 50% of cases

(D) Resection is indicated even in small, asymptomatic lesions due to malignant potential

(E) Dysphagia is an uncommon presenting symptom

2–B. Esophageal leiomyomas are generally asymptomatic until they grow large enough to produce dysphagia, which is the most common
presenting symptom. They are solitary in approximately 90% of cases and small, asymptomatic lesions can generally be followed with serial
examinations, because these lesions have almost no malignant potential. Endoscopy is indicated to rule out malignancy, but if leiomyoma is
suspected biopsy is contraindicated because it may make subsequent resection much more difficult due to scarring at the biopsy site.

3. A 51-year-old woman presents for evaluation of postprandial epigastric pain associated with intermittent episodes of
gastroesophageal reflux. Upper gastrointestinal contrast study reveals a type III esophageal hernia and Barrett's changes are noted on
endoscopic examination of the distal esophagus. Of the following statements, which most appropriately pertains to this patient?

(A) The presence of a type III esophageal hernia is an indication for surgery

(B) Type III esophageal hernias are the least common type

(C) Fundoplication is not indicated in this patient

(D) Complications occur in less than 5% of patients with this type of hernia
(E) M anometry is not necessary before proceeding with fundoplication in this patient

3–A. Because of the risk of complications such as gastric volvulus and ischemia associated with type II and type III esophageal hernias, it is
generally recommended that these defects be surgically repaired once they are identified. Complications can occur in as many as 30% of
patients with type I and type II esophageal hernias. Fundoplication is not always indicated in these patients, because many will have no
signs or symptoms of gastroesophageal reflux disease. However, if the patient complains of reflux symptoms, has signs of reflux on
esophagogastroduodenoscopy (e.g., Barrett's changes), or if there is evidence of an incompetent lower esophageal sphincter on
manometry, then a fundoplication is indicated.

4. A 40-year-old man presents with a 6-month history of dysphagia for both solids and liquids, as well as regurgitation of undigested
food after meals. Esophagram shows a dilated esophagus with a significant “bird's beak” narrowing at the lower esophageal sphincter
(LES). Manometry reveals poor esophageal peristalsis and a very hypertensive LES. Which of the following statements is true regarding
this patient's condition?

(A) M edical treatment with nitrates and calcium channel blockers is successful in most cases

(B) The surgical procedure of choice for this disorder is a long esophageal myotomy

(C) Although dysphagia is common, regurgitation is unusual in these patients

(D) Rigid or pneumatic LES dilation can offer a long-term success rate as high as 80%

(E) M anometry is not indicated if the patient has the classic presenting symptoms and esophagram findings

4–D. This patient presents with the classic symptoms and manometric findings associated with achalasia. Regurgitation is common in
patients with long-standing disease as they often retain undigested food in the dilated proximal esophagus. M edical therapy has a long-
term success rate of less than 20% and is reserved for those patients with mild disease. The surgical treatment of choice in these patients
is a lower esophageal myotomy designed to disrupt the lower esophageal sphincter, not a long esophageal myotomy. M anometry is always
indicated in the work-up of any patient who presents with symptoms of esophageal dysmotility.

5. A 33-year-old man presents to the emergency room 30 minutes after having ingested alkaline drain cleaner. He is currently stable
and exhibits no signs of respiratory distress. Examination of the oropharynx reveals only mild erythema of the posterior pharynx.
Which of the following statements is true regarding the treatment of this patient?

(A) Induction of vomiting is indicated if the ingestion occurred less that 1 hour ago
 (B) Alkali ingestion tends to cause a less serious injury because the stomach acid largely neutralizes it

(C) Early endoscopy is indicated to evaluate the extent of injury

(D) The lack of severity of the oropharyngeal injury indicates that the esophageal injury is not likely to be severe and endoscopy is
not indicated

(E) There is a 2- to 4-fold increase in the risk of esophageal cancer in these patients

5–C. Early endoscopy is indicated to evaluate and grade the injury, which helps to determine treatment. The induction of vomiting after
ingesting either acid or alkaline substances is contraindicated because further injury to the esophagus may occur as the caustic
substance is expelled. Alkaline substances result in liquefactive necrosis in the wall of the esophagus and stomach, which causes deeper
burns and thus a more significant injury. The severity of the oropharyngeal injury can be a poor indicator of the severity of the more distal
gastrointestinal tract. The risk of esophageal cancer in these patients is increased 500-fold.

6. A 70-year-old man presents with dysphagia, occasional regurgitation of undigested food, and chronic halitosis. Manometric studies
are normal but a barium esophagram reveals a 4-cm Zenker's diverticulum. Which of the following statements is true?

(A) This is the least common diverticulum of the esophagus

(B) A Zenker's diverticulum is a true diverticulum

(C) This type of diverticulum is most common in the third and fourth decades of life

(D) A Zenker's diverticulum occurs just distal to the cricopharyngeus muscle

(E) The procedure of choice in this patient would be a cricopharyngeal myotomy and diverticulectomy

6–E. Zenker's diverticula are the most common diverticula of the esophagus and are generally seen in the fifth to eighth decades of life.
This is a pulsion type of diverticulum and is considered a pseudodiverticulum because it does not involve all layers of the esophageal wall.
Zenker's diverticula occur just proximal to the cricopharyngeus muscle and the surgical procedure of choice to repair these defects is a
cricopharyngeal myotomy. A diverticulectomy should also be performed if the diverticulum is greater than 2 cm.

7. A 42-year-old woman with scleroderma presents with symptoms of gastroesophageal reflux disease (GERD) that have persisted
despite 6 months of adequate medical therapy. Which of the following statements best describes her condition?

(A) Further medical therapy is warranted before surgical intervention is considered

(B) Therapy is generally aimed at controlling gastroesophageal reflux

(C) Because this disease affects primarily the distal esophagus, resection of this segment is curative

(D) The risk of esophageal cancer is higher in these patients

(E) No further work-up is needed in this patient before proceeding with surgery

7–B. Scleroderma is a disease that affects primarily smooth muscle resulting in atrophy and collagen deposition. The distal esophagus is
composed entirely of smooth muscle and is thus affected to a greater degree than the proximal esophagus, which is primarily striated
muscle. The presence of scleroderma does not change the evaluation and treatment of symptomatic gastroesophageal reflux disease
(GERD). Treatment in these patients is aimed at preventing gastroesophageal reflux and the basic treatment and evaluation is the same as
for patients without scleroderma. When symptoms are refractory to medical therapy, fundoplication is usually the next recommended step
in treatment. Resection of the distal esophagus is not indicated unless there is evidence of severe dysplasia or adenocarcinoma of the
distal esophagus secondary to the effects of chronic GER. The risk of esophageal cancer in these patients is the same as in any patient
with chronic GER.

8. A 47-year-old man presents with a 6-month history of intermittent chest pain and dysphagia for both solids and liquids. Cardiac
work-up is negative and standard barium esophagram was unremarkable. Esophageal manometry reveals high amplitude contractions and
intermittent normal peristalsis with simultaneous contractions 40% of the time. Which of the following statements is true regarding
this patient's condition?

(A) Surgery is the treatment of choice

(B) M edical therapy includes nitrates and H2-blockers

(C) In patients with incapacitating dysphagia, 80%–90% report palliation of their symptoms with surgical intervention

(D) Esophagram is the gold standard for identification of this disorder

(E) Surgical therapy consists of a distal esophageal myotomy

8–C. Patients with diffuse esophageal spasm usually present with chest pain and dysphagia for both solids and liquids. Although surgical
intervention consisting of a long esophageal myotomy can be very successful in treating these patients, it is reserved only for those
patients who have incapacitating dysphagia. M edical therapy consists of nitrates and calcium channel blockers as well as sedatives and
muscle relaxants. H2-blockers have no role in the treatment of esophageal spasm. Although video esophagram may be included in the work-
up of these patients, manometry is the gold standard in identifying all of the esophageal spasm disorders.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 9–12

A. Gastroesophageal reflux disease

B. Esophageal leiomyoma

C. Zenker's diverticulum

D. Type I esophageal hernia

E. Type II esophageal hernia

F. Type III esophageal hernia

G. Esophageal cancer
H. Caustic ingestion

I. Nutcracker esophagus

J. Boerhaave's syndrome

K. Achalasia
L. Diffuse esophageal spasm

M . Barrett's esophagus

M atch the following case scenarios with the most appropriate cause(s).

9. A 40-year-old man presents with a 1-year history of progressive dysphagia. He first noted difficulty swallowing only solids but his
symptoms recently progressed to liquids as well. Esophagram reveals a distal esophageal stricture that is benign by biopsy. (SELECT 2
CAUSES) A. Gastroesophageal reflux disease H. Caustic ingestion

9–A, H. In addition to Barrett's changes in the distal esophagus, gastroesophageal reflux disease (GERD) can also result in stricture
formation secondary to repeated injury to the esophageal mucosa. Stricture formation is also a late complication of ingesting a caustic
substance and can occur years after the original injury. It is imperative that any newly diagnosed esophageal stricture be biopsied to rule
out malignancy. M ultiple biopsies should be obtained from the involved mucosa because foci of malignancy could easily be missed if only a
single biopsy is obtained.

10. A 56-year-old woman presents with progressive dysphagia for solids and liquids as well as intermittent chest pain. She noticed some
relief in her symptoms after she was recently started on a calcium channel blocker for hypertension but her symptoms have recently
returned. (SELECT 3 CAUSES) I. Nutcracker esophagus K. Achalasia L. Diffuse esophageal spasm

10–I, K, L. Dysphagia for both solids and liquids accompanied by intermittent chest pain is the typical presentation of patients suffering
from esophageal spasm disorders. The only way to effectively distinguish these syndromes from one another is to evaluate the patient with
esophageal manometry. Achalasia can also be associated with dysphagia and occasional chest pain that may be relieved with nitrates or
calcium channel blockers.

11. A 58-year-old man presents with a history of dysphagia and intermittent regurgitation of undigested food. (SELECT 2 CAUSES)
C. Zenker's diverticulum K. Achalasia
11–C, K. Both achalasia and a Zenker's diverticulum should be suspected in a patient who presents with a history of dysphagia as well as
the regurgitation of undigested food. The history of this type of regurgitation is important in differentiating these disorders from other
causes of dysphagia. In achalasia, swallowed food is unable to pass into the stomach because of poor peristalsis and a hypertensive lower
esophageal sphincter (LES). The proximal esophagus eventually dilates and serves as a reservoir for undigested food that is eventually
regurgitated by the patient. Patients with a Zenker's diverticulum generally report regurgitation symptoms that are less severe as the
diverticulum is a smaller reservoir. A Zenker's can be documented by esophagram, which may also show the esophageal changes of
achalasia. M anometry is the gold standard in the diagnosis of achalasia.

12. A 56-year-old man presents with a history of 4 episodes of right lower middle lobe pneumonia in the past year. He also reports the
presence of a persistent, dry cough. Pulmonary work-up, including bronchoscopy, has been negative and he is a nonsmoker. A barium
esophagram recently obtained was normal. (SELECT 1 CAUSE) A. Gastroesophageal reflux disease

12–A. Some patients with symptomatic gastroesophageal reflux disease (GERD) have an absence of gastrointestinal complaints. Other
symptoms such as recurrent pneumonia caused by occult aspiration and chronic cough from reflux irritation of the upper airway should
prompt a full work-up for GERD. Significant GER can often be missed on barium esophagram and definitive tests—including upper
endoscopy, manometry, and 24-hour pH probe—should be performed to evaluate the lower esophagus as well as the lower esophageal
sphincter, and to document the presence of reflux.
1. Symptoms include

postprandial epigastric pain.

nausea.
vomiting.

2. Diagnosis

is made with endoscopic confirmation of bile reflux and biopsy-proven gastritis.

3. Treatment

Sucralfate may be used to bind bile.

Surgery is rarely required.

E. Gastric volvulus

is very rare.

results from torsion of the stomach secondary to laxity of the ligamentous support to the stomach.
is frequently associated with a diaphragmatic hernia.

Treatment involves emergent detorsion and fixation of the stomach.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 63-year-old woman underwent placement of a percutaneous endoscopic gastrostomy tube 1 day
ago. Today she is tachycardic with a heart rate of 135 beats/min and a blood pressure of 95/45 mm Hg.
Her abdomen is distended and notably tender. Abdominal plain film radiograph reveals a large amount of
free air. A small amount of contrast added to the gastrostomy tube confirms appropriate placement within
the stomach. Her hematocrit is 37% and her white blood cell count is within normal limits. Her calcium is
7.8 mg/dL. Which of the following is the most likely cause of this patient's symptoms?
(A) Injury to the esophagus during endoscope placement
(B) Injury to the liver during placement of the gastrostomy tube
(C) Injury to the transverse colon during placement of the gastrostomy tube
(D) Traumatic injury to the spleen during placement of the gastrostomy tube
(E) Acute pancreatitis caused by retrograde flow of gastric contents into the ampulla of Vater
1–C. Although rare, major complications associated with gastrostomy tube placement may occur, given
the proximity of several major organs. Hemorrhage secondary to inadvertent placement of the
percutaneous needle may be secondary to lacerations of the liver (superomedial), spleen (lateral), or
major vessels along the greater or lesser curvature of the stomach. In addition, the proximity of the colon
inferiorly makes colon perforation a significant risk factor. Given the scenario of an acute abdomen
associated with free air on the abdominal film, injury to the transverse colon is most likely. Although
simultaneous injury to other organs with associated hemorrhage is possible, the most likely primary origin
of this patient's clinical findings is perforation of the transverse colon. Acute pancreatitis may occur with
endoscopic manipulation of the biliary tree, but is rarely a complication of gastrostomy tube placement.

2. A 35-year-old trauma victim with a severe closed head injury is post-trauma day 14. After surviving an eventful intensive care unit
stay, he has recently undergone elective tracheostomy and percutaneous gastrostomy tube placement. Today he is febrile to 39°C
(102.2°F) and tachycardic to 125 beats/min. He is comatose secondary to his head injury, but his abdomen is quiet and rigid to
palpation. Which of the following is the most appropriate next step in the management of this patient?

(A) Esophagogastroduodenoscopy (EGD)

(B) Emergent laparotomy

(C) Barium swallow

(D) A barium enema to identify any source of colonic injury

 (E) Immediate removal of the gastrostomy tube with observation

2–B. Given this patient's scenario with severe diffuse abdominal pain and a suspected bowel perforation, an exploratory laparotomy with
appropriate surgical management of the injury is indicated. Other potential life-threatening injuries associated with an acute abdomen may
also be identified at the time of operation. Endoscopy, barium swallow, or a barium enema would simply delay therapy for potential life-
threatening intra-abdominal injuries that may exist in this patient and are therefore not indicated in this situation. Barium studies may
actually worsen the situation by introducing barium into the peritoneal cavity.

3. A 69-year-old, white woman with a history of chronic mesenteric ischemia has recently undergone superior mesenteric artery (SMA)
saphenous vein bypass grafting after presenting with acute SMA occlusion. On postoperative day 3 she was returned to the operating
room and underwent small bowel resection and reanastomosis with duodenojejunostomy. Now, 48 hours after her second surgery, she
is passing large melanotic stools and her hematocrit has fallen from 32% to 20%. Despite aggressive resuscitation with crystalloid and 2
units of packed red blood cells (PRBCs), her hematocrit remains 21%. If an upper gastrointestinal source of bleeding is suspected, which
of the following would be the most appropriate next step?

(A) Esophagogastroduodenoscopy (EGD)

(B) Emergent laparotomy

(C) M esenteric vessel arteriography

(D) Vasopressin administration

(E) Placement of a Sengstaken-Blakemore tube

3–A. After initial resuscitative efforts, esophagogastroduodenoscopy (EGD) would be the most appropriate diagnostic, and frequently
therapeutic measure for this patient. M ost causes of upper gastrointestinal bleeding can be diagnosed by endoscopy. In addition, several
therapeutic techniques for upper gastrointestinal bleeding can also be performed endoscopically (e.g., electrocautery, banding of
varices). Given this presentation, exploratory laparotomy or angiography are not indicated at this point in the work-up. Angiography may
be indicated when a gastrointestinal source of bleeding is suspected but not confirmed by endoscopic techniques. Both administering
vasopressin and placing a Sengstaken-Blakemore tube are useful for variceal bleeding; however, without confirming variceal bleeding as the
source of hemorrhage, these techniques would not be indicated.

4. A 63-year-old man with no significant past medical history is admitted with an acute abdomen secondary to gastric perforation. If a
definitive ulcer procedure is performed on this patient, which of the following procedures is associated with the lowest ulcer
recurrence rate?

(A) Truncal vagotomy

(B) Truncal vagotomy and pyloroplasty

(C) Vagotomy and antrectomy

(D) Parietal cell vagotomy

(E) Gastric bypass

4–C. Among the choices provided, vagotomy with a simultaneous antrectomy has the lowest ulcer recurrence rate. However, this
procedure is associated with a higher morbidity secondary to anastomotic complications (e.g., leak or stricture) or problems associated
with denervation of the proximal stomach and distal bowel. Complications include postvagotomy diarrhea, dumping syndrome, delayed
gastric emptying, and alkaline reflux gastritis.

5. A thin, cachectic, 61-year-old woman presents to the office requesting a prescription for a “strong heartburn medicine.” She
complains of gnawing abdominal pain after meals. Upon further questioning she admits to an unwanted 25-pound weight loss over the
previous 3 months. She is a nonsmoker. Physical examination is unremarkable except for some mild epigastric tenderness. Rectal
examination is heme-negative. Which of the following would be the most appropriate definitive diagnostic test for this patient?

(A) Esophagogastroduodenoscopy (EGD) with biopsy

(B) Esophageal manometry

(C) M agnetic resonance image (M RI) of the abdomen

(D) Upper gastrointestinal barium swallow

(E) Angiography of mesenteric vessels

5–A. A recent 25-lb unintended weight loss should raise suspicion for a possible malignancy in any patient. This patient's symptoms of
epigastric pain in association with the weight loss should raise suspicion for an upper gastrointestinal malignancy such as gastric
carcinoma. Among the choices above, endoscopy with biopsy of any suspicious lesions would be the most appropriate definitive diagnostic
examination.
Findings on upper gastrointestinal barium swallow may be suggestive of ulcerative disease or malignancy, but endoscopic biopsy would
allow for histologic verification of suspicious lesions. Angiography would not provide adequate information for definitive diagnosis.
Esophageal manometry is useful for diagnosis of esophageal dysmotility disorders but would not be useful in this situation. M agnetic
resonance imaging (M RI) would not allow for biopsy and tissue diagnosis.

6. An obese, 45-year-old businessman comes to the office for a routine physical examination. He states that his father and grandfather
have died from stomach cancer. He admits to smoking one pack of unfiltered cigarettes a day and to moderate alcohol consumption
only on weekends. He also states that he takes an antacid pill after meals for heartburn. All of the following are considered risk factors
for gastric adenocarcinoma EXCEPT:
(A) Helicobacter pylori infection
 (B) Smoking

(C) High-fat diet

(D) Previous gastric surgery

(E) Alkaline reflux gastritis

6–C. A diet high in saturated fats is associated with a relative increased risk for developing colon adenocarcinoma but has not been shown
to be associated with gastric adenocarcinoma. A diet that includes nitrates is a significant risk factor for gastric adenocarcinoma. Other
significant risk factors include H. pylori infection, smoking, previous gastric surgery, and chronic alkaline reflux gastritis.

7. A 42-year-old woman presents to the office with a 2-month history of increasing nausea and nonbilious vomiting associated with a
15-lb weight loss. Upon upper gastrointestinal endoscopy, biopsy reveals Helicobacter pylori and a low-grade lymphoma. Which of the
following is the most appropriate statement regarding the management of gastric lymphoma?

(A) Treatment is limited to radiation therapy alone

(B) Treatment consists of surgery alone

(C) Some lymphomas may regress with treatment of H. pylori

(D) Overall 5-year survival is less than 20%

(E) Obstructive symptoms are a contraindication to surgery

7–C. There is a small subset of lymphomas that are specifically associated with the presence of Helicobacter pylori. These lesions arise from
mucosal-associated lymphoid tissue (M ALT). There is evidence suggesting that many of these lesions may regress with eradication of H.
pylori. Overall management of gastric lymphomas remains controversial. Treatment generally involves a combination of chemotherapy,
radiation therapy, and surgery, although recent studies have suggested that chemoradiation therapy alone may be adequate. Overall
survival for all stages of gastric lymphoma is greater than or equal to 50%. Obstructive symptoms may frequently be an indication for
surgery, rather than a contraindication.

8. A 62-year-old man with a history of alcoholic cirrhosis presents to the emergency room with a 4-hour history of hematemesis. His
abdomen is soft. He is tachycardic with a heart rate of 121 beats/min and has a blood pressure of 98/58 mm Hg. Which of the following
is the most appropriate step in the immediate management of this patient?

(A) Airway control and resuscitation

(B) Intravenous vasopressin infusion

(C) Placement of a Sengstaken-Blakemore tube

(D) Performance of a barium swallow

(E) Upright chest radiograph to evaluate for free air

8–A. Whatever the cause of bleeding in this patient, the first and foremost important step in his management is securing a functional
airway (e.g., endotracheal intubation) and adequate volume resuscitation (e.g., crystalloid and blood products when necessary).
Administering intravenous vasopressin or placing a Sengstaken-Blakemore tube are appropriate in the management of esophageal varices
but should not precede initial resuscitative measures. Although a chest radiograph should be performed early in the course of
management to rule out potential pulmonary pathology and to identify a pulmonary source of hemorrhage, it should not precede
resuscitation. A barium swallow is not indicated in this situation.

9. A 68-year-old man presents to the emergency room complaining of severe intense abdominal pain that came on suddenly and quickly
reached peak intensity. Upon evaluation, the patient is lying completely still, is tachycardic, and has an ashen-gray appearance. Upon
further questioning he reveals that the pain began in his epigastric region and then moved down to the right quadrants. His abdomen is
rigid and extremely tender. Laboratory investigation reveals a white blood cell count of 30,000 and a hematocrit of 44%. Which of the
following is the most likely cause of this patient's clinical presentation?

(A) M allory-Weiss tear

(B) Bleeding duodenal ulcer

(C) Acute gastritis

(D) Perforated peptic ulcer

(E) Gastric lymphoma

9–D. Gnawing epigastric pain that suddenly progresses to severe intense epigastric pain is frequently associated with perforated peptic
ulcer disease. Patients may rapidly develop peritonitis and tend to lie very still to prevent further peritoneal irritation. A M allory-Weiss tear
is generally precipitated by forceful retching or coughing before development of pain. Although pain associated with acute gastritis may
come on rapidly, it is generally not associated with rupture and peritoneal irritation. Gastric lymphoma may present with a perforation but
is a rare occurrence relative to perforated peptic ulcer disease. Although a bleeding duodenal ulcer is a possibility despite a normal
hematocrit, perforation and hemorrhage from peptic ulcer disease rarely occur simultaneously and bleeding ulcers are unlikely to cause
peritonitis unless bleeding is directly into the peritoneum.

10. An 85-year-old man presents with a 3-day history of severe abdominal pain. The patient's temperature is 39.4°C (103°F), he is
tachycardic with 130 beats/min, and he has a blood pressure of 80/40 mm Hg. The patient is becoming more tachypneic, and upon
placement of a Foley catheter no urine is produced. His abdomen is rigid and plain abdominal film demonstrates free air under the right
hemidiaphragm. His past medical history is significant for coronary artery disease, emphysema, chronic renal insufficiency secondary to
insulin-dependent diabetes mellitus, as well as manic depression. Which of the following is the most appropriate operation to perform
on this patient?
 (A) Pyloromyotomy

(B) Omental patching with or without a vagotomy

(C) Gastrectomy

(D) Billroth II
(E) Vagotomy and antrectomy

10–B. Given this patient's other comorbidities and the persistence of severe hypotension, the most appropriate operation would be one
that effectively treats the perforation and minimizes the time the patient is in the operating room. Omental patching of a perforated ulcer
involves oversewing the greater omentum directly over the perforated intestine. Additionally, a vagotomy may be done quickly as an acid-
reducing procedure. If Helicobacter pylori is identified, appropriate treatment is also important to prevent recurrence postoperatively. A
gastrectomy or antrectomy with a Billroth I, Billroth II, or Roux-en-Y gastrojejunostomy are effective in the treatment of this disease but
would likely significantly increase the operative time and would not be the best choice given this scenario.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 11–21

A. Alkaline reflux gastritis

B. Dumping syndrome

C. Gastric volvulus

D. M allory-Weiss tear

E. Hemobilia
F. Duodenal ulcer

G. Gastric ulcer

H. Afferent loop syndrome

I. Aortoduodenal fistula

J. Cushing's ulcer

K. Curling's ulcer

For each clinical scenario, select the most appropriate upper gastrointestinal disorder(s).

11. An elderly man with a history of an abdominal aortic aneurysm repair 10 years ago presents with a history of one episode of
hematemesis. He is currently hemodynamically stable, but appears very anxious and scared. Upon endoscopy, there is no evidence of
bleeding to the level of the pylorus. (SELECT 2 DISORDERS) F. Duodenal ulcer I. Aortoduodenal fistula

11–F, I. Despite the history of a previous abdominal aortic aneurysm repair, this patient could still potentially have a duodenal ulcer, which
remains one of the most frequent causes of upper gastrointestinal bleeding in this population. Although rare (0.05%), one must always
suspect aortoenteric fistula in any patient with a history of an abdominal aortic aneurysm repair or a history of aortic surgery. This patient
may have experienced what is known as a “sentinel bleed,” which is usually followed by massive hemorrhage within 48 hours. The most
accurate means of diagnosis is angiography, although preparations for emergent surgery should be made immediately upon diagnosis in case
rebleeding occurs during the evaluation. Treatment involves closure of the duodenum and reconstruction of the aortic graft.

12. A 30-year-old woman presents with a 3–4-day history of bloody bilious emesis. The patient has no medical illnesses but did sustain
a significant liver laceration treated with several weeks of bedrest after a high-speed motor vehicle accident 3 months earlier. Upper
endoscopy does not reveal any evidence of gastric ulceration or gastritis. There is noted to be minimal blood-tinged bile around the
region of the ampulla of Vater without obvious signs of duodenal ulceration or inflammation. (SELECT 1 DISORDER) E. Hemobilia

12–E. Hemobilia is another rare cause of massive upper gastrointestinal bleeding that must be considered when the source cannot be
localized to the stomach or duodenum. Pseudoaneurysms resulting from blunt trauma to the liver may erode into the lumen of the biliary
tract, leading to bilious bloody emesis. This may also be seen with chronic pancreatitis, which may cause erosion of a peripancreatic
artery into the pancreatic duct. Endoscopy may demonstrate arterial blood from the ampulla of Vater. Angiography is frequently used for
diagnosis and embolization therapy.

13. A 45-year-old motorcyclist suffered a severe closed head injury 2 days ago. Today he has an unexplained drop in his hematocrit
from 43% to 25%, and his guaiac stool test is positive. Aspiration of the nasogastric tube contents are grossly positive for blood.
(SELECT 3 DISORDERS) F. Duodenal ulcer G. Gastric ulcer J. Cushing’s ulcer

13–F, G, J. The most likely diagnosis would be Cushing's ulcer, which is the eponym for acute gastritis associated with severe neurologic
injury. Classically, Cushing's ulcer is solitary and can be located anywhere from the distal esophagus to the fourth portion of the
duodenum. Perforation is the most common complication. The pathogenesis may be related to centrally mediated gastric hypersecretion.
Cushing's ulcers generally occur in the stomach but can also occur in the duodenum. Additionally, the patient could have had peptic ulcer
disease previously with the presentation of gastric or duodenal ulcers at this time.

14. A 56-year-old woman was caught in a house fire started by a kerosene heater. She was immediately brought to the surgical
intensive care unit and resuscitated and débrided. Her total body surface area (TBSA) burn estimate is 40% partial and full thickness
burns. Thirty-six hours after admission the patient's nasogastric tube drains 1 L of bright red blood over a 1-hour period. Endoscopy
reveals diffuse mucosal bleeding. (SELECT 1 DISORDER) K. Curling's ulcer

14–K. Curling's ulcer is a variant of acute gastritis associated with a thermal burn injury of greater than 35% of total body surface area
(TBSA). Curling's ulcer is usually found in the duodenum and also has the tendency to perforate. Endoscopy may be both diagnostic and
therapeutic.

15. A 48-year-old woman with severe rheumatoid arthritis reports dull epigastric pain aggravated by food. She ingests 2400 mg of
ibuprofen daily. Her vital signs are stable. She is guaiac-negative. Abdominal examination reveals moderate epigastric pain, but no
rebound tenderness. You empirically discontinue her nonsteroidal anti-inflammatory drug (NSAID) therapy and the symptoms resolve
within 6 weeks. (SELECT 2 DISORDERS) F. Duodenal ulcer G. Gastric ulcer
15–F, G. This patient most likely has a gastric ulcer as a result of her nonsteroidal anti-inflammatory drug (NSAID) use, although she could
still potentially have a duodenal ulcer. Only endoscopy or barium swallow would differentiate these two possible diagnoses. Gastric ulcers
typically present with dull, gnawing epigastric pain that may be precipitated or aggravated by food. Type V gastric ulcers can be located
anywhere in the stomach and are usually associated with the use of NSAIDs. Treatment is medical therapy and withdrawal of the offending
agent if possible. Surgery is rarely indicated, however one should be suspicious for carcinoma should the ulcer persist.

16. A 50-year-old man complains of epigastric pain relieved by antacids. Endoscopic biopsy of the antral mucosa is positive for
Helicobacter pylori. A barium swallow shows enlarged gastric mucosa and evidence of duodenal bulb spasm. (SELECT 1 DISORDER)
F. Duodenal ulcer
16–F. This patient has a classic presentation of a duodenal ulcer. Over 90% of duodenal ulcers are associated with Helicobacter pylori.
Eradication of H. pylori heals the ulcer in over 90% of patients. Characteristic radiographic findings include demonstration of an ulcer
crater and associated duodenal spasm. Typically, duodenal ulcer pain is relieved by ingestion of antacids or food.

17. An elderly man who has been debilitated in a nursing home for the past 6 years and who has a history of paraesophageal hernia
presents to the emergency room complaining of sudden, severe, substernal chest pain. The patient is febrile with a temperature of
39°C (102.2°F) and his white blood cell count is 25,000. After proper placement of a nasogastric tube, the tip is noted to be in the left
hemithorax upon chest radiograph. (SELECT 1 DISORDER) C. Gastric volvulus

17–C. Although rare, gastric volvulus typically occurs in patients who have herniation of the stomach through the diaphragm (e.g.,
paraesophageal hernia, traumatic diaphragmatic hernia). Gastric volvulus results from spontaneous torsion of the stomach compromising
tissue perfusion, which may lead to necrosis, as suggested by this patient's elevated temperature and white blood cell count. Patients
often present with chest pain, although cardiac evaluation is generally unremarkable. The diagnosis should be suspected when the chest
radiograph reveals a retrocardiac air bubble or demonstrates the presence of the tip of the nasogastric tube in the hemithorax above the
level of the diaphragm. Treatment involves emergent laparotomy and resection or detorsion of the affected stomach, depending on the
presence or absence of necrosis.

18. A 43-year-old, previously healthy woman presents to the emergency room with a 3-hour history of hematemesis. The patient states
that she has had the “stomach flu” for 3 days and has been vomiting bilious emesis during her illness. She notes that the emesis became
bloody after an episode of “dry heaves” this morning. (SELECT 1 DISORDER) D. Mallory-Weiss tear
18–D. M allory-Weiss syndrome is the result of a linear tear in the mucosa of the gastric cardia, which typically results from violent retching
or vomiting. Often a history of alcohol abuse or recent binge drinking is obtained, although this syndrome may occur in other clinical
settings as well (e.g., severe coughing). The typical presentation involves initial nonbloody emesis followed later by hematemesis. Usually,
the bleeding is painless. Evaluation with endoscopy allows for accurate diagnosis and rules out other sources of hematemesis. The majority
of patients heal spontaneously without surgical intervention.

19. A 52-year-old woman with a recent Billroth I reconstruction (gastroduodenostomy) after ulcer surgery reports that within minutes
after eating a meal she experiences weakness, palpitations, dizziness, diaphoresis, and a strong desire to lie down. You advise her to
eat smaller meals and to avoid liquids with her meals. She returns in 4 weeks reporting improvement in her symptoms. You reassure
her that most likely all of her symptoms will resolve with time. (SELECT 1 DISORDER) B. Dumping syndrome

19–B. Dumping syndrome is divided into early and late dumping. This patient is experiencing the more common early dumping syndrome
often termed “early vasomotor dumping,” which is caused by the rapid onset of cardiovascular symptoms. Typical symptoms include
nausea, vomiting, abdominal pain, excessive flatus, palpitations, dizziness, and diaphoresis. Symptoms can follow any meal, but worst
offenders are foods high in carbohydrates and sugars. Over 90% of patients are successfully treated with dietary manipulation and time.
Somatostatin analogs such as octreotide may be used before meals if dietary manipulations fail. Surgery is rarely indicated. When
necessary, surgical reconstruction to a Roux-en-Y gastrojejunostomy may provide excellent relief of symptoms.

20. A 59-year-old man is 1 week postoperative from a Billroth II reconstruction (gastrojejunostomy) performed after antrectomy and
vagotomy for chronic gastric outlet obstruction secondary to duodenal ulcer disease. He has been eating regular food for 1 day,
although he now reports intermittent colicky right upper quadrant (RUQ) pain relieved by bilious vomiting. His abdomen is distended.
Plain abdominal film reveals a single dilated segment of bowel in the RUQ. (SELECT 1 DISORDER) H. Afferent loop syndrome

20–H. Afferent loop syndrome is present only after Billroth II reconstructions and is caused by intermittent obstruction of the afferent
limb. The classic symptoms are intermittent right upper quadrant (RUQ) or epigastric pain that is relieved by bilious vomiting. Evaluation
consists of radionucleotide scanning, which may demonstrate a massively dilated afferent limb. Severe dilation of the afferent loop can
result in rupture and peritonitis, thus urgent surgical intervention is generally required. Conversion to a Roux-en-Y gastrojejunostomy is an
appropriate surgical option.

21. A 46-year-old woman is 2 months postoperative from a gastroduodenostomy (Billroth I) performed to treat her ulcer disease. She
complains of severe upper abdominal pain that is burning in nature. She reports that the pain usually occurs just after eating a large
meal. Endoscopic examination reveals a “beefy red” gastric mucosa. Biopsy demonstrates both acute and chronic inflammation. (SELECT
1 DISORDER) A. Alkaline reflux gastritis

21–A. Alkaline reflux gastritis is largely a diagnosis of exclusion. Patients complain of severe upper abdominal burning and often bilious
vomiting. One must exclude marginal ulceration, afferent loop syndrome, chronic gastroparesis, and anastomotic stricture first. Endoscopy
typically reveals marked gastritis and a “beefy red” appearance in the presence of bile reflux into the stomach. Radionucleotide scanning
may demonstrate this bile reflux. Diagnosis is often made with biopsy that demonstrates acute and chronic inflammation of the mucosa.
There is no specific medical treatment, although there has been some success with the use of sucralfate. Surgery is rarely necessary.
 Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 57-year-old woman with a history of thyroid resection for papillary thyroid carcinoma is admitted
after 2 weeks of frequent vomiting. Her only medications include over-the-counter aluminum hydroxide
taken occasionally for mild epigastric discomfort. On physical examination, the patient is notably
dehydrated. Work-up shows complete small bowel obstruction. Her serum chloride is 90 mEq/dL (low),
potassium is 2.9 mEq/dL (low), bicarbonate is 35 mEq/dL (high), and urine pH is low (acidic). Which of the
following is the explanation for the alkalotic serum and acidic urine?
(A) Renal bicarbonate loss
(B) Use of aluminum-based antacids
(C) Renal conservation of potassium with hydrogen loss
(D) Stool losses of hydrogen
(E) Excess gastrointestinal absorption of bicarbonate
1–C. Patients with vomiting of long duration frequently lose large amounts of potassium and hydrogen
ions found in gastric secretions. In addition, dehydration leads to an aldosterone-mediated resorption of
sodium in the distal tubules of the kidney in exchange for secretion of potassium and hydrogen ions into
the urine. In the setting of dehydration and severe hypokalemia, hydrogen ions are preferentially secreted
in the urine in exchange for sodium to prevent additional loss of potassium. This produces a “paradoxical”
acid urine from a patient with hypokalemic metabolic alkalosis. Renal bicarbonate loss would produce
serum acidosis rather than alkalosis. Stool losses of hydrogen ions are insignificant, although significant
bicarbonate may be lost in patients with severe diarrhea. Aluminum-based antacids also will not cause this
electrolyte abnormality.

Questions 2–3

A 53-year-old man with a previous extensive resection of the terminal ileum for a strangulated hernia returns 2 years later without interim
follow-up complaining of fatigue, malaise, and weakness. His stools are noted to be heme-negative on physical examination. He is eating
without difficulty. His blood smear shows anemia with many hypersegmented neutrophils.

2. Which of the following is the most appropriate therapy for the primary cause of his anemia?

(A) Parenteral iron sulfate

(B) Blood transfusion

(C) Parenteral vitamin B12

(D) Oral vitamin B12

(E) Oral iron sulfate

2–C. The patient most likely has pernicious anemia secondary to vitamin B12 deficiency following ileal resection. Parenteral [intravenous
(IV)] vitamin B12 obviates the absorption problem caused by terminal ileum resection. Oral B12 administration may be ineffective secondary
to inadequate absorption. Blood transfusion would be inappropriate in this setting and would not address the likely cause of the anemia.
Iron supplementation would be appropriate for patients with microcytic anemia secondary to iron deficiency and may provide some
benefit in this patient if a concomitant iron deficiency exists. However, hypersegmented neutrophils represent a characteristic sign of B12
deficiency and may occasionally be present without obvious macrocytic changes in red blood cells. IV iron therapy is rarely indicated for
treatment of iron deficiency.

3. Which of the following would most likely be associated with nutritional disorders similar to those seen with resection of the
terminal ileum?

(A) Peptic ulcer disease

(B) Crohn's disease

(C) Diverticulosis

(D) Colonic ulcerative colitis

(E) Segmental jejunal resection

3–B. Among the choices listed, Crohn's disease frequently affects the terminal ileum and may cause malabsorption of vitamin B12. Peptic
ulcer disease may be associated with blood loss anemia but not with vitamin B12 deficiency, although gastric resection for peptic ulcer
disease may lead to a deficiency in intrinsic factor with subsequent B12 malabsorption and deficiency. Diverticulosis and ulcerative colitis
may both be associated with significant blood loss anemia but are not characteristically associated with vitamin B12 deficiency. Jejunal
resection will generally not affect vitamin B12 absorption.

Questions 4–5
During an operation for presumed appendicitis, the patient's appendix is found to be normal. The terminal ileum, however, is found to be
markedly thickened and feels rubbery to firm. The serosa is edematous and inflamed and the mesentery is thickened with fat growing
about the bowel circumference.

4. Which of the following is the most likely diagnosis?

(A) Ileal Crohn's disease

(B) M eckel's diverticulitis

(C) Ulcerative colitis

(D) Ileocecal tuberculosis

(E) Ileal carcinoid

4–A. Crohn's disease can present acutely, and when it involves the terminal ileum may clinically resemble appendicitis. The bowel in this
patient has the characteristic gross findings and inflammatory changes of Crohn's disease including the “creeping fat” within the
mesentery. M eckel's diverticulitis can mimic appendicitis but it presents as an inflammatory phlegmon located approximately 50 cm (2 feet)
from the ileocecal valve and does not have the bowel changes seen in this patient. Ulcerative colitis is usually confined to the large bowel
and, although it may occasionally be associated with inflammatory changes of the ileal mucosa (backwash ileitis), it is generally not
associated with full-thickness changes described above. Tubercular ileitis is rare in the United States, although it can produce scarring
and stenosis of the distal ileum with enlarged mesenteric lymph nodes. Demonstration of caseation and acid-fast bacilli on lymph node
biopsy confirms the diagnosis. Ileal carcinoid would present as a mass in the ileum and would not be associated with the inflammatory
changes seen in this patient.

5. After identifying a normal appendix and inflammatory changes are noted to be limited to the terminal ileum, the surgeon plans to
perform the appropriate operation. Intraoperatively, which of the following procedures would be the most appropriate to perform in
this patient?

(A) Resection of the appendix only

(B) Resection of involved ileum and appendix

(C) Placement of peritoneal drains and appendectomy

(D) Enterotomy with inspection of the ileal mucosa

(E) Right hemicolectomy with lymph node dissection

5–A. When acute Crohn's disease is encountered during exploration for presumed appendicitis, the appropriateness of appendectomy is
somewhat controversial. The incidence of enterocutaneous fistula after operation in patients with Crohn's disease is higher than in
patients without it, but fistulae usually arise from the diseased ileum and not the appendiceal stump. Therefore, if the stump is not
involved, many surgeons perform an appendectomy. This simplifies the differential diagnosis if right lower quadrant (RLQ) pain returns at a
later date. The ileum should not be resected unless there is evidence of obstruction, perforation, or fistula formation. Drain placement is
not indicated in this patient and may even increase the risk of fistula formation with extensive inflammatory changes in the ileum. In
addition, performing an enterotomy may also increase the risk of fistula formation and would be of little, if any, benefit in the management
of this patient.

6. A 65-year-old man undergoes a right hemicolectomy with a primary anastomosis for a stage II, right-sided, colon adenocarcinoma.
Five months postoperatively the patient presents with a distal ileocutaneous fistula. Which of the following is the most appropriate
initial therapy?
(A) Prompt exploration and interruption of the fistula tract

(B) Prompt exploration and bypass of the fistula

(C) A 4–6-week trial of low residue or elemental enteral nutrition or hyperalimentation

(D) Prompt exploration with resection of the involved ileum and primary anastomosis

(E) Ileostomy and ileocecal resection

6–C. Because most fistulas close with proper supportive care and hyperalimentation or low-residue elemental nutrition, this should be
attempted before any operation. If needed, the preferred operation is resection of the fistula in continuity with the diseased segment of
bowel, followed by reanastomosis. Bypass operations should be avoided, or operations that just resect the fistula or only the involved
bowel are not appropriate. Ileostomy and ileocecal resection are not indicated at this point in the management of this patient.

7. A 49-year-old, white man presents to the emergency room with complaints of a 2- to 3-day history of worsening nausea and
vomiting. The patient has undergone a previous small bowel resection for Meckel's diverticulitis. The patient's abdomen is distended
but nontender. Initial resuscitative measures are taken. Which of the following radiologic studies would be most helpful in the initial
evaluation of this patient?

(A) Intravenous (IV) pyelogram

(B) Barium enema

(C) Abdominal ultrasound

(D) Supine and upright abdominal films

(E) Abdominal and pelvic computed tomography (CT) scan

7–D. The simplest test that will show the obstruction is the plain abdominal film. Plain films may show gas-filled loops and air-fluid levels.
These findings may be more subtle if the obstruction is proximal. Gas in small bowel outlines valvulae conniventes, which run the entire
transverse diameter of bowel. In mechanical obstruction, the distal bowel empties out past the point of obstruction because the bowel
retains its ability to move. So a mechanical bowel obstruction has too much gas proximally, and distal to the obstruction it will empty. In
paralytic ileus there is a uniform gas pattern in the stomach, small bowel, and colon because the bowel has lost its motility. Intravenous
(IV) pyelogram, abdominal ultrasound, and abdominal computed tomography (CT) scanning may frequently be useful in evaluating patients
with these symptoms, but they generally should not preclude acquisition of plain radiographs of the abdomen in the setting of a suspected
obstruction.

8. Which of the following is a frequent cause of paralytic ileus?

(A) Bezoars
(B) Annular pancreas

(C) Cecal volvulus

(D) Intussusception

(E) Peritonitis
8–E. Among the choices listed, peritonitis is the most likely cause of paralytic ileus. The most common cause of paralytic ileus is abdominal
surgery. Bezoars frequently found in the stomach may cause a mechanical obstruction of the stomach. Annular pancreas may cause a
mechanical obstruction of the duodenum, while cecal volvulus and intussusception may cause a mechanical obstruction of the small bowel.

9. A 20-year-old college student presents with right lower quadrant (RLQ) pain, fever, anorexia, and leukocytosis. He undergoes
appendectomy. Pathological report reveals a 1-cm carcinoid at the tip of the appendix without involvement of the mesentery.
Appropriate therapy includes which of the following?

(A) Reexploration and cecectomy

(B) Reexploration and right hemicolectomy

(C) Reexploration with mesenteric node biopsy

(D) Chemotherapy

(E) No further therapy

9–E. Carcinoid tumors of the appendix usually require no more than simple appendectomy. Exceptions are lesions larger than 2 cm, lesions
with nodal involvement or serosal spread, or lesions at the base of the appendix near the cecum; right hemicolectomy would be the
correct operation for these situations. Cecectomy alone would not be sufficient if the carcinoid tumor met the criteria for further
resection. Reexploration with biopsy is not needed because the site of the tumor is known. Chemotherapy is not used for treatment of
carcinoid tumors, although medications, such as octreotide, are used to control symptoms of carcinoid syndrome.

10. A 42-year-old woman is found to have a solid, irregular, asymptomatic lesion in the right lobe of her liver during an abdominal
computed tomography (CT) scan performed for a trauma evaluation. One week later the patient undergoes percutaneous biopsy of the
lesion, which reveals a carcinoid tumor. Efforts to identify the primary source of this lesion are undertaken. Which of the following is
the most frequent site of carcinoid tumors?

(A) Jejunum

(B) Liver

(C) Ileum

(D) Appendix

(E) Colon

10–D. The most common site of carcinoid tumors is the appendix. Hepatic metastases may lead to the carcinoid syndrome. One of 500
appendectomies will reveal carcinoid tumor. Carcinoid tumors may metastasize to the liver but are not usually primary. Eighty-five percent
are found in the appendix, 13% in the small intestine (ileum), and 2% in the rectum.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 11–20

For each clinical scenario, select the correct diagnosis(es).

A. Adhesions

B. Inguinal hernia

C. Intussusception

D. Cecal adenocarcinoma

E. Paralytic ileus

F. Crohn's disease

G. Ogilvie's syndrome
H. M idgut volvulus
I. Bezoar

J. Annular pancreas

11. A 1-year-old with a history of cystic fibrosis presents with 1 day of nausea, vomiting, and intermittent severe abdominal pain. Her
mother states that the child has passed stools that are red with clots and mucus. (SELECT 1 DIAGNOSIS)

11–C. Intussusception should be considered in any child younger than 2 years old with intermittent, colicky, abdominal pain. It occurs
more commonly in males, and 75% of the cases are in children under 2 years old. At first the vomitus is only gastric contents but eventually
becomes bilious. The stool is often described as “currant jelly” (i.e., purple clots with mucus and blood streaking). In most cases,
definitive diagnosis and therapy can be effected by barium enema. If this is not successful, operative intervention with reduction of the
“lead point” of the intussusception may be necessary. C. Intussusception

12. A 67-year-old with a history of thoracic aortic aneurysm repair presents with a 1-day history of bilious vomiting. Physical
examination reveals a swollen right groin that is tender and erythematous. The patient is febrile with rebound and guarding. (SELECT 1
DIAGNOSIS) B. Inguinal hernia
12–B. Incarcerated hernias represent hernias that are not easily reducible by standard nonoperative means (i.e., mild sedation with
application of steady, mild, constant pressure). Incarcerated hernias are the most common cause of small bowel obstruction in the world,
with the inguinal region being a frequent site. If the incarcerated hernia has been present for only a few hours, gentle manual reduction
may be possible. The presence of a hernia in association with fever, tachycardia, rebound tenderness, guarding, and erythema over the
hernia suggests the presence of a strangulated hernia. Strangulation occurs when the perfusion of the incarcerated bowel is
compromised, resulting in ischemia and necrosis. This is an indication for immediate operative intervention with resection of the affected
bowel and repair of the hernia defect.

13. A 35-year-old woman presents with a 2- to 3-week history of worsening nausea and vomiting. The patient also gives a history of
chronic intermittent diarrhea, which she has “learned to live with.” On physical examination the abdomen is distended with
hyperactive bowel sounds. A small bowel follow-through reveals multiple consecutive strictures of the distal ileum. (SELECT 1
DIAGNOSIS) F. Crohn's disease

13–F. The finding of multiple consecutive strictures in the distal small bowel is very suggestive of Crohn's disease. Other characteristics of
Crohn's may also be present, such as diarrhea, abdominal pain, and perianal disease. Stricture formation and small bowel obstruction is a
frequent problem in patients with Crohn's disease.

14. A 47-year-old with a history of melanoma presents with a 2-day history of nausea; vomiting; and intermittent, crampy, abdominal
pain. A right lower quadrant (RLQ) mass is noted on physical examination. (SELECT 2 DIAGNOSES)

14–C, D. M elanoma is the most common extraintestinal tumor to metastasize to the small intestine. M etastatic disease to the colon may
present with small bowel obstruction (SBO). Obstruction may be secondary to a mass effect of the lesion, causing direct luminal
obstruction, or the mass may result in intussusception. Intussusception may present with signs and symptoms of SBO and intermittent,
crampy, abdominal pain. In adults with suspected intussusception, early surgical exploration is indicated because many are associated with
malignancy. Colonic adenocarcinoma may also present as an SBO. M etastatic colon cancer can affect any part of the intestine while right-
sided colon lesions can cause obstruction at the level of the ileocecal valve. C. Intussusception D. Cecal adenocarcinoma

15. A 72-year-old woman, 2 days postoperative from a laparoscopic cholecystectomy, presents with complaints of persistent nausea and
vomiting. She denies abdominal pain. On physical examination, the abdomen is distended and without bowel sounds. Nasogastric tube
placement and suctioning results in drainage of 1.5 L over the initial hour after placement. Her serum potassium is 2.9 mEq/dL.
Abdominal radiograph reveals diffuse dilation of the small bowel. (SELECT 1 DIAGNOSIS) E. Paralytic ileus

15–E. Among the choices provided, paralytic ileus is the most likely cause of this patient's symptoms. Although laparoscopic surgery is less
likely to be associated with a persistent postoperative ileus versus open abdominal procedures, ileus may still occur. Dehydration with
hypokalemia may also contribute to the persistence of a postoperative ileus.

16. A 12-year-old boy with severe mental retardation is brought from a group home with 1 week of nausea, poor feeding, and
intermittent vomiting. On physical examination a palpable mass is noted above the umbilicus in the midline. Bowel sounds are normal.
Plain films show an enlarged stomach with mottling but without evidence of small bowel dilation. (SELECT 1 DIAGNOSIS) I. Bezoar

16–I. A bezoar represents a cumulative mass of ingested nondigestible material [e.g., trichobezoar (hair), phytobezoar (plant material)].
Ingestion of such material may be seen in children or in patients with poor gastric emptying (i.e., after gastric surgery) and may also be
associated with certain psychiatric disorders. Bezoars frequently cause obstruction at the level of the stomach and frequently require
endoscopic or surgical removal, although some types of bezoars may respond to enzymatic digestion.

17. A 1-month-old presents with a 1-day history of bilious vomiting and abdominal pain. She has not been feeding well and her
fontanelles are depressed. She is lethargic and has not had a wet diaper in more than 12 hours. Plain abdominal radiographs reveal a
proximal small bowel obstruction. (SELECT 2 DIAGNOSES) H. Midgut volvulus J. Annular pancreas

17–H, J. M alrotation with midgut volvulus is a surgical emergency. It usually occurs in infancy (75% in the first month of life). Common
findings are bilious vomiting, vascular collapse, and blood from the rectum. An upper gastrointestinal study will best show malrotation. This
condition occurs when there is incomplete rotation of the midgut around the superior mesenteric artery. The base of the mesentery is
congenitally narrow and the entire midgut can twist on its blood vessels and result in vascular compromise of the bowel. If this condition is
ignored, bowel necrosis can occur. In addition, constriction of the second portion of the duodenum by a circumferential segment of
pancreatic tissue can cause a proximal obstruction in very young children. This annular pancreas is secondary to abnormal migration of the
pancreatic bud during embryologic development. Although this could also cause the symptoms mentioned above, bilious vomiting in a
newborn is a malrotation with midgut volvulus until proven otherwise given the severe consequences of this process.

18. A 37-year-old man presents with complaints of worsening nausea, vomiting, and abdominal pain. His history is significant for a
previous laparoscopic cholecystectomy for gangrenous cholecystitis 12 years ago. He states that he has had similar symptoms in the
past, but they resolved on their own. Plain film of the abdomen shows multiple dilated loops of small bowel. (SELECT 1 DIAGNOSIS)
A. Adhesions
18–A. In Western countries where abdominal operations are common, adhesions are the most common cause of intestinal obstruction.
Peritoneal irritation from any cause causes local outpouring of fibrin and adhesion formation. Substances such as hyaluronidase, steroids,
and fibrinolysis have been instilled into the peritoneum without success in preventing adhesions. Conservative management with
nasogastric suction may be curative but operative lysis of adhesions may be necessary.

19. A 47-year-old man presents with a 2-week history of worsening nausea and vomiting. The patient has also noted a 10-lb weight loss
over the past month. He has had no previous surgery and there are no masses noted on physical examination. Rectal examination
reveals no masses, but shows heme-positive stools. Plain film of the abdomen shows multiple air-fluid levels in the small intestine and
no air in the colon. (SELECT 1 DIAGNOSIS) D. Cecal adenocarcinoma

19–D. Right-sided colon cancers may occasionally mimic small bowel obstruction (SBO) by causing obstruction at the level of the ileocecal
valve. Recent weight loss and heme-positive stools should raise suspicion for the diagnosis of colon adenocarcinoma. Although this is a rare
cause of SBO, a water-soluble (e.g., gastrografin) enema may help rule out such pathology in the absence of signs of more common causes
of obstruction.

20. An 82-year-old, retired coal miner is hospitalized in the coronary care unit with an acute myocardial infarction. He has had no
previous surgery and there are no masses noted on physical examination. Two days into his hospitalization he develops abdominal
distention and crampy pain. Plain films reveal no evidence of small bowel dilation. Barium enema reveals a massively dilated right
colon without obvious masses. (SELECT 1 DIAGNOSIS) G. Ogilvie's syndrome

20–G. The cause of Ogilvie's syndrome remains unclear but may be related to altered motility of the colon from imbalance of sympathetic
and parasympathetic tone to the colon. It is seen mainly in patients hospitalized with severe illnesses. Bowel sounds are usually present
and there may be diarrhea. Abdominal radiographs show massive dilation of the colon (predominantly right and transverse) with little or no
small bowel dilation. Decompressive colonoscopy is the therapeutic procedure of choice. A generalized paralytic ileus characteristically
affects the small bowel in addition to the colon while this variant, Ogilvie's syndrome, may frequently affect the colon without involving the
small bowel.
 Excisional hemorrhoidectomy is the best choice for symptomatic hemorrhoids with a substantial external component or internal
hemorrhoids refractory to banding.

F. Rectal prolapse

is a complete intussusception of the rectum through the anus.

1. This process involves all layers of the rectum and appears as a large mass protruding from the anus.
2. Folds in the mucosa are circumferential as opposed to radial, which differentiates

rectal prolapse from other conditions such as prolapsed hemorrhoid or rectal polyp.

3. Rectal prolapse is more common in elderly women and institutionalized patients and is associated with long-term anal outlet
obstruction.

Patients are often incontinent of stool and have pudendal neuropathy.

4. Treatment involves rectopexy (fixation of the rectum) in the absence of a redundant sigmoid or low anterior resection of the
rectosigmoid colon.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 44-year-old woman with a 24-year history of ulcerative colitis presents with persistent melanotic,
loose stools for the past 6 months. Her disease had been well controlled medically with steroids until her
recent problems. Colonoscopic biopsy of a 6-cm mass in the descending colon reveals adenocarcinoma.
After the proper procedure is performed in this patient, which of the following pathologic characteristics of
ulcerative colitis might be seen in the resected segment?
(A) Full thickness involvement
(B) Sparing of the rectal segment
(C) Crypt abscesses
(D) “Creeping fat” around the affected bowel
(E) Segments of normal bowel between areas of disease (“skip areas”)
1–C. Of the listed gross and microscopic pathologic findings, only crypt abscesses are characteristic of
ulcerative colitis. The remaining findings are typically seen in Crohn's disease. Ulcerative colitis involves
only the mucosa and submucosa and virtually always involves the rectum and spreads proximally.
“Creeping fat” is not unique to Crohn's disease and can be seen in any full thickness inflammatory process
involving the bowel.

Questions 2-3

An 83-year-old woman in a nursing home presents with a 24-hour history of obstipation and distended abdomen. Her vital signs and
laboratory tests are normal. Plain abdominal film reveals a massively dilated loop of bowel in the lower abdomen.

2. Which of the following is the most likely diagnosis for this patient?

(A) Small bowel obstruction

(B) Fecal impaction

(C) Cecal volvulus

(D) Sigmoid volvulus

(E) Ogilvie's syndrome

2–D. Sigmoid volvulus is most common in elderly and institutionalized individuals and usually presents with acute obstruction, abdominal
distention, and obstipation. Plain films reveal a U-shaped, dilated loop of bowel in the lower abdomen. Ogilvie's syndrome, or colonic
pseudo-obstruction, usually involves the entire large bowel. Small bowel obstruction would appear as “stair stepping” of loops of small
bowel on plain film examination. Cecal volvulus appears as a bean-shaped loop of bowel in the left upper quadrant (LUQ) of the abdomen.

3. Which of the following is the most appropriate next step in the treatment of this patient?
(A) Immediate surgery
 (B) Flexible sigmoidoscopy

(C) Barium enema

(D) Admission and observation

(E) Discharge with laxatives

3–B. Sigmoidoscopy is usually both diagnostic and therapeutic in cases of sigmoid volvulus. Decompression should be followed by elective
sigmoid resection to prevent recurrence of the volvulus. A barium enema study would be helpful in confirming the diagnosis but would not
be therapeutic and is not the best choice in treating this patient. Immediate surgery is not indicated because the volvulus may be
reduced by colonoscopy, allowing for an adequate bowel preparation and elective sigmoid resection with a primary anastomosis. Should
colonoscopic reduction of the volvulus not be possible, emergent surgical resection with formation of a colostomy would be indicated.

Questions 4-5

A 35-year-old truck driver presents with perianal pain and pain on defecation for 2 days. He has no prior history of medical problems and
reports only a low-grade fever. Digital rectal examination (DRE) reveals a tender mass at the anal verge.
4. Which of the following is the most likely diagnosis for this patient?

(A) Perianal abscess

(B) Supralevator abscess

(C) Hemorrhoids

(D) Anal fissure

(E) Rectal cancer

4–A. Perianal abscess is the most likely etiology of acute-onset perianal pain with fever. A supralevator abscess would be higher in the
rectum and would not likely be palpable on digital rectal examination (DRE). Hemorrhoids are not generally tender unless thrombosed nor
do they present with fever. An anal fissure would not likely be associated with fever or a tender mass. Rectal cancer would be unlikely in
this patient and generally presents as an ulcerated mass that is usually not painful.

5. Which of the following is the most appropriate next step in the management of this patient?

(A) Admission and antibiotics

(B) Incision and drainage

(C) Excisional hemorrhoidectomy

(D) Lateral sphincterotomy

(E) Colonoscopy

5–B. Incision and drainage without delay is the most appropriate treatment for a perirectal or perianal abscess. Attempts to treat with
antibiotics in the absence of drainage are generally unsuccessful. Colonoscopy is generally not indicated unless there is concern of some
underlying colonic pathology such as ulcerative colitis or Crohn's disease. Lateral sphincterotomy is the treatment for anal fissures that are
refractory to conservative therapy.

Questions 6-7

A 67-year-old man presents with sudden onset massive bleeding from the rectum. He has no prior history of gastrointestinal problems and
denies any abdominal pain. He has been previously healthy and takes no medications. A nasogastric tube is placed and clear bile without
blood is aspirated from the stomach.

6. All of the following would be an appropriate next step EXCEPT:

(A) Bleeding scan

(B) Type and crossmatch

(C) Colonoscopy

(D) Angiography

(E) Admission to the hospital

6–C. The patient should be admitted, typed and crossmatched for blood, and observed for further bleeding. Bleeding scan and angiography
can locate the area in question if the patient is actively bleeding (at least 0.5 mL/min for bleeding scan and 1.0 mL/min for angiography).
However, colonoscopy is usually not useful because the large amount of bleeding in the colon usually makes visualization of the colonic
mucosa impossible. Colonoscopy would be an appropriate diagnostic step if the bleeding stopped and if the colon could be adequately
prepped.

7. Which of the following is the most likely cause of the massive lower gastrointestinal bleeding in this patient?

(A) Hemorrhoids

(B) Cancer

(C) Peptic ulcer disease

(D) Diverticulosis
 (E) Ischemic colitis

7–D. The most common causes of massive lower gastrointestinal bleeding in adults are diverticular disease and angiodysplasia. Although not
a choice in this question, angiodysplasia consists of arteriovenous malformations of the mucosa that are a frequent cause of right-sided
colonic bleeding. Angiodysplasia can frequently be treated by colonoscopic coagulation of the lesion. Hemorrhoids and colon cancer
rarely cause massive lower gastrointestinal bleeding although colon cancer is a frequent cause of occult gastrointestinal bleeding.
Ischemic colitis may cause lower gastrointestinal bleeding but is characteristically associated with severe abdominal pain.

Questions 8-9

A 27-year-old woman presents with a history of chronic bloody diarrhea, abdominal cramping, and weight loss. The diagnosis of ulcerative
colitis is made.

8. Which of the following is true regarding the management of this patient?

(A) High-dose steroids are used as a maintenance therapy to prevent relapse

(B) Surgery is rarely curative in this disease

(C) An appropriate surgical option would include a total proctocolectomy

(D) Barium enema is the diagnostic test of choice for this disease

(E) The risk of cancer is 70% after 20 years of active disease

8–C. Appropriate surgical options for ulcerative colitis include total proctocolectomy with an end ileostomy or with an ileoanal
anastomosis. Subtotal colectomy with ileorectal anastomosis can also be performed in patients with ulcerative colitis if rectal disease is
mild. This provides a better chance for rectal continence and more normal bowel function. However, the rectum should be monitored
closely because cancers can still arise in this segment. Surveillance is easily done in the office with a rigid proctoscope. Steroids are used
to treat acute exacerbations of the disease and are not used for maintenance therapy. Colonoscopy is generally considered to be the
most appropriate diagnostic test for identifying ulcerative colitis. The risk of developing colon cancer is 10% at 20 years.

9. Which of the following is true regarding the surgical management of this disease?
(A) Removal of the entire colon is rarely necessary

(B) If the rectum is removed it is impossible to provide anal continence for the patient

(C) Because the cancer risk is so high in this disease, subtotal colectomy is recommended as soon as the diagnosis is made

(D) This disease is confined to the colon and does not affect other parts of the bowel

(E) Surgery offers the best chance for cure in these patients

9–E. If the entire colon and rectum are removed, surgery is essentially curative. Surgery is not indicated at the time of diagnosis if there is
no sign of dysplasia on biopsy and symptoms can be controlled with medical therapy. Close follow-up is necessary to detect cancers or
areas of dysplasia early. Either of these noted on colonoscopic biopsy is an indication for surgical resection. Although ulcerative colitis
does not affect other parts of the bowel primarily, the distal ileum can become inflamed if the proximal colon is involved, a condition
termed “backwash ileitis.”

10. A 68-year-old woman was referred by her primary care physician who noted occult positive stools on routine physical examination.
Barium enema subsequently revealed a mass in the ascending colon. The appropriate examination was performed and the lesion was
found to be a poorly differentiated adenocarcinoma. At surgery, the mass was noted to invade through the entire thickness of the
bowel with two positive nodes and no distant metastases. Which of the following is the stage of this cancer according to the Astler-
Coller modification of Dukes staging system?

(A) D

(B) B1

(C) B2

(D) C1

(E) C2

10–-E. Nodal disease automatically makes this lesion a Dukes stage C in the Astler-Coller modification system. Full thickness invasion places
it in the C2 category, worsening the prognosis.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 11-20

A. Ulcerative colitis

B. Crohn's disease

C. Salmonella enterocolitis

D. Yersinia enterocolitis

E. Cytomegalovirus enterocolitis
F. Neutropenic enterocolitis

G. Pseudomembranous colitis

H. Internal hemorrhoids

I. External hemorrhoids
J. Tubular adenoma

K. Villous adenoma
L. Hyperplastic polyp

M . Rectal adenocarcinoma

N. Colonic adenocarcinoma

For each patient description, select the most appropriate diagnosis.

11. A 45-year-old man presents with persistent diarrhea 3 weeks after hospitalization for sepsis. (SELECT 1 DIAGNOSIS)
G. Pseudomembranous colitis
11–G. This patient likely received multiple antibiotics during his recent admission for sepsis. Thus, antibiotic-associated pseudomembranous
colitis caused by Clostridium difficile is the most likely cause of those listed. It is important to remember that pseudomembranous colitis
can follow the administration of any antibiotic and the onset of symptoms can be as many as 6 weeks after discontinuing antibiotic
therapy.

12. A 32-year-old woman presents with 4 months of chronic diarrhea, which is occasionally bloody. Rigid proctoscopy is normal.
(SELECT 1 DIAGNOSIS) B. Crohn's disease

12–B. Although both Crohn's and ulcerative colitis can present in this manner, Crohn's would be a more likely diagnosis in the absence of
rectal involvement. Further work-up of this patient should include colonoscopic survey of the entire colon to look for pathology and
obtain biopsy as needed.

13. A 52-year-old renal transplant patient presents with bloody diarrhea and elevated liver enzymes. Colonoscopy reveals mucosal
ulcerations and submucosal hemorrhage. (SELECT 1 DIAGNOSIS) E. Cytomegalovirus enterocolitis

13–E. Cytomegalovirus enterocolitis generally affects immunocompromised patients such as those with acquired immune deficiency
syndrome (AIDS) and transplant patients. Cytomegalovirus can also involve other organs, and the elevated liver enzymes in this patient may
indicate hepatic involvement. Cytomegalovirus enterocolitis can mimic surgical problems and should be considered in any
immunocompromised patient. Treatment is with gancyclovir.

14. A 45-year-old leukemic patient who is currently undergoing chemotherapy presents with abdominal pain. Abdominal films reveal
air in the wall of the cecum. (SELECT 1 DIAGNOSIS) F. Neutropenic enterocolitis

14–F. Neutropenic enterocolitis generally affects patients receiving high-dose chemotherapy. Plain films usually reveal the appearance of
obstruction with air in the wall of the bowel (pneumatosis intestinalis). These patients can be managed conservatively unless perforation of
the bowel occurs. Such a complication would require emergent laparotomy and resection of the diseased segment.

15. A 16-year-old man presents with right lower quadrant (RLQ) abdominal pain and fever. The appendix is normal at operation.
(SELECT 1 DIAGNOSIS) D. Yersinia enterocolitis

15–D. Yersinia enterocolitica infection can cause mesenteric adenitis, which will produce symptoms identical to acute appendicitis in the
absence of a diseased appendix.

16. A 67-year-old woman has a small polyp removed by colonoscopy. Pathology reveals thickened mucosa without atypia. (SELECT 1
DIAGNOSIS) L. Hyperplastic polyp

16–L. A colonic polyp that exhibits thickened mucosa without atypia on pathologic examination is a benign hyperplastic polyp and requires
no further follow up.

17. A 69-year-old man presents with decreased caliber of stools and blood from the rectum. A firm mass is noted on rectal examination.
(SELECT 1 DIAGNOSIS) M. Rectal adenocarcinoma

17–M. A firm mass in the rectum that is large enough to cause a decreased caliber of stools but is otherwise asymptomatic is likely to be a
rectal cancer in a 69-year-old man. Although benign adenomas can become large enough to cause such symptoms, they generally have a
rubbery consistency and do not tend to be firm on examination. Treatment would likely consist of abdominoperineal resection with
subsequent chemotherapy and radiation therapy depending on the stage of the disease.

18. A 58-year-old man with a history of occult positive stools has a 3-cm polyp removed. Pathology reveals a long, finger-like glandular
arrangement. (SELECT 1 DIAGNOSIS) K. Villous adenoma

18–K. Villous adenomas have a long, finger-like glandular arrangement on pathologic examination. They also tend to be larger than tubular
adenomas, with 60% being larger than 2 cm. Villous adenomas have a higher incidence of harboring foci of cancer and should be excised
either through a colonoscope or by laparotomy and segmental resection of the involved bowel.

19. A 43-year-old woman presents with blood from the rectum after bowel movements. Rectal examination reveals a soft, spongy mass
just above the dentate line. (SELECT 1 DIAGNOSIS) H. Internal hemorrhoids

19–H. Internal hemorrhoids are located just above the dentate line, are covered by mucosa, and have a soft, spongy consistency. They can
prolapse and bleed but do not generally cause pain or itching. Red blood from the rectum only after bowel movement is a common
complaint with internal hemorrhoid disease. Treatment consists of either rubber-band ligation or surgical excision.
20. A 31-year-old woman presents with 6 months of chronic diarrhea. Colonoscopy reveals areas of cobblestoning of the colonic mucosa
dispersed between areas of normal mucosa. (SELECT 1 DIAGNOSIS) B. Crohn's disease

20–B. Cobblestoning of the mucosa and “skip lesions” are typical of Crohn's disease and can be seen on colonoscopy. Ulcerative colitis
tends to involve the colon in a continuous manner, starting with the rectum and moving proximally.
 can result in a transudate formation within the peritoneal space.

1. Initial medical management

with diuretics and dietary salt restriction successfully relieves ascites 95% of the time.

2. Spironolactone

is often a first line diuretic because of the associated hyperaldosterone state often seen with ascites.

3. Denver and LeVeen shunts

are subcutaneous shunts that drain ascitic fluid from the peritoneal cavity to the central venous system.

Disseminated intravascular coagulation (DIC) is a known complication of peritoneovenous shunting of ascitic fluid.

4. Spontaneous bacterial peritonitis

is frequently a fatal complication of persistent ascites.

a. Risk factors include

nephrotic syndrome.

systemic lupus, particularly in children.

b. Infection is often monomicrobial.

E. coli is the most common precipitating agent, followed by Pneumococcus.

Hemolytic streptococci and Pneumococcus are the most common organisms in children.

c. Characteristic findings include

fever.

abdominal pain.

serum leukocytosis.

d. Diagnostic findings

Elevated white blood cell count (> 500/mL)

Large numbers of polymorphonuclear leukocytes within the ascitic fluid (> 250/mm3)

Blood cultures and ascitic fluid cultures are often positive, but not always.

e. Treatment

is with broad spectrum antibiotics.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 22-year-old man sustained a gunshot wound to the right upper quadrant (RUQ) and was severely
hypotensive on arrival to the emergency room. Intraoperatively, the patient was noted as having a large
liver parenchymal injury with severe hemorrhage. A Pringle maneuver was performed to control the
hemorrhage for better visualization of the injured parenchyma. After confirmation of appropriate
placement of the vascular clamp for the Pringle maneuver, there is persistent bleeding of bright red blood
from the liver parenchyma just medial to the falciform ligament. Which of the following structures would
mostly likely cause the persistent hemorrhage from the liver parenchyma?
(A) Portal vein
(B) Common hepatic artery from celiac axis
(C) Left hepatic artery arising from left gastric artery
(D) Blood supply to the common bile duct
(E) Blood vessels within the hepatoduodenal ligament
1–C. The “Pringle maneuver” is a technique occasionally used in hepatic surgery to control persistent
hemorrhage within the liver. It involves compression of the structures within the hepatoduodenal
 ligament, including the common hepatic artery, the common bile duct, and the portal vein. Typically, the
portal vein is posterior to both the common bile duct and the hepatic artery. The hepatic artery is usually
medial to the common bile duct. Although there are many anomalies within the hepatic vascular system,
one of the most common is the left hepatic artery arising from the left gastric artery. This anomalous
artery may not be occluded upon performing the Pringle maneuver and thus may result in persistent
parenchymal hemorrhage despite this maneuver. In addition, persistent hemorrhage may also result from
back-bleeding arising from injuries to the hepatic veins or to the inferior vena cava, which are not
occluded with the Pringle maneuver.

Questions 2–4
A 62-year-old man with a well-known history of alcohol abuse presents to the emergency room with persistent hematemesis and
hypotension. Endoscopic examination confirms the presence of diffusely bleeding esophageal and gastric varices.

2. Which of the following are characteristic of the portal venous system and portal hypertension?

(A) Normal portal pressure is generally greater than 12 mm Hg

(B) Esophageal varices arise from dilated branches of coronary veins

(C) The portal vein runs anterior to the common bile duct in the hepatoduodenal ligament
(D) Caput medusa is formed by periumbilical branches of the recanalized ductus arteriosum

(E) Portal pressure > 18 mm Hg may lead to valvular incompetence and subsequent varices

2–E. The portal venous system is a valveless system capable of transmitting elevated portal pressures throughout many collateral venous
systems. Portal pressure is generally below 12 mm Hg, although wide variations may exist with and without the development of varices. The
coronary veins are a collateral venous system draining blood from the esophagus and cardiac region of the stomach which, when dilated,
can produce the characteristic esophageal varices. Increased portal pressure may also lead to dilated periumbilical veins and the
characteristic caput medusa.

3. Which of the following treatment strategies would be inappropriate in the management of this patient?

(A) Endoscopic sclerotherapy or band ligation

(B) Emergent portosystemic shunt procedure for refractory bleeding

(C) Emergent splenectomy for the gastric varices

(D) Liver transplantation

(E) Placement of a Sengstaken-Blakemore tube

3–C. Initial management of the patient with actively bleeding varices involves evaluation and control of the airway and initiation of
aggressive volume resuscitation. Endoscopy with sclerotherapy with or without band ligation of esophageal varices is an appropriate next
step in the management of actively bleeding esophageal varices. In certain situations where endoscopy is not readily available, placing a
Sengstaken-Blakemore tube to tamponade the bleeding varices is an acceptable alternative or it may be used as an adjunct to endoscopy.
Emergent surgical formation of a portosystemic shunt (i.e., portocaval, mesocaval) to relieve portal pressure is performed less frequently
now because of endoscopic therapies but is an appropriate alternative in the treatment of refractory bleeding from esophageal varices.
Treatment of isolated gastric varices generally requires splenectomy to allow for selective decompression of the varices. However,
performing a splenectomy in this patient with diffuse portal hypertension may worsen the hemorrhage from the esophageal varices and is
not indicated. Definitive treatment of esophageal varices is liver transplantation.

4. Selective portosystemic shunts have which one of the following characteristics?

(A) Ineffective at lowering venous pressure within esophageal varices

(B) Contraindicated for refractory esophageal varices

(C) M ay cause worsening of ascites

(D) Higher risk of encephalopathy compared with nonselective portosystemic shunts

(E) Large side-to-side portocaval shunt

4–C. Selective and nonselective portosystemic shunts are both excellent at reducing portal venous pressure and may be used for
treatment of esophageal varices. Other less invasive techniques that effectively control bleeding esophageal varices have decreased the
need for surgical shunt procedures for the management of bleeding esophageal varices. Nonselective shunts are associated with a higher
risk of hepatic encephalopathy when compared with selective shunts because almost all portal venous blood is shunted directly into the
systemic venous system with nonselective shunts. Selective shunts are known to cause worsening ascites in patients and these shunts are
typically contraindicated in patients with significant ascites. A side-to-side portocaval shunt is a type of nonselective shunt.

5. A 45-year-old woman presented to the emergency room with right upper quadrant (RUQ) abdominal pain and fever. The patient
states that she had a cholecystectomy 2 years earlier. Computed tomography (CT) scan reveals a 6-cm, fluid-filled mass in the right lobe
of the liver that was not noted to be present by ultrasound 2 years ago. Which of the following is the appropriate definitive treatment
for the potential cause of this patient's condition?

(A) “Triple” antibiotics alone for a large pyogenic liver abscess

(B) Antibiotics alone for uncomplicated amebic liver abscess

 (C) Percutaneous drainage of fluid from echinococcal cyst

(D) Antibiotics alone for a ruptured amebic liver abscess

(E) “Triple” antibiotics alone for a ruptured pyogenic liver abscess

5–B. Treatment of most liver abscesses requires adequate drainage, with medical therapy generally serving an adjunctive role. Complicated
or large pyogenic liver abscesses such as this one almost always require drainage either percutaneously or surgically. Echinococcal cysts
require surgical drainage of cyst fluid followed by instillation of hypertonic saline to kill the remaining organisms. M edical treatment alone
is inadequate and drainage, without instillation of hypertonic saline, will not adequately treat the infection. Uncomplicated amebic liver
abscesses are an exception in that they may be adequately treated with antibiotic therapy (i.e., metronidazole) alone, although
complicated abscesses (i.e., rupture) still generally require surgical management.

6. A 63-year-old man underwent elective cholecystectomy for chronic biliary colic. Intraoperatively, a 2-cm, irregular mass was
identified in the right lobe of the liver. Biopsy revealed a primary hepatocellular carcinoma. Thorough evaluation revealed no evidence
of metastatic disease. The patient subsequently underwent resection of this lesion. All of these are potential risk factors for
development of hepatocellular carcinoma EXCEPT
(A) Hemochromatosis

(B) Wilson's disease

(C) Hepatic adenoma

(D) Focal nodular hyperplasia

(E) Alcoholic cirrhosis

6–D. The most common risk factors for the development of hepatocellular carcinoma are cirrhosis secondary to hepatitis B or C infection
and alcohol-induced cirrhosis. Other potential risk factors include various disease processes that affect the liver such as hemochromatosis,
Wilson's disease, and glycogen storage diseases. There is approximately a 10% risk of malignant transformation of hepatic adenomas to
hepatocellular carcinoma. An association between the development of hepatocellular carcinoma and blood-group B has also been
demonstrated. Focal nodular hyperplasia is a benign liver lesion that has not been shown to undergo malignant degeneration or
transformation.

7. Which of the following would be included in a true functional right hepatic lobectomy?

(A) Hepatic segment IV

(B) All hepatic segments to the right of Cantlies line and segment IV

(C) All hepatic segments to the right of Cantlies line and the entire quadrate lobe

(D) All segments to the right of the falciform ligament

(E) Hepatic segments V–VIII

7–E. A true functional right hepatic lobectomy would include all hepatic segments of the right lobe including segments V–VIII. A right
hepatic trisegmentectomy would include hepatic segments IV–VIII. The quadrate lobe includes segments of both the true right and left
hepatic lobes, while segment I is the caudate lobe and is not included in a right lobectomy. Cantlies line is an imaginary line to the right of
the falciform ligament that divides the true functional right and left hepatic lobes.

Questions 8–9

A 57-year-old man with a history of alcohol-induced cirrhosis and chronic hepatic insufficiency presents to the emergency room with
complaints of increasing shortness of breath and abdominal bloating worsening over the past 2 weeks. On physical examination, his
abdomen is firm but nontender, with notable shifting dullness. In addition, breath sounds are decreased in both lung bases with bibasilar
crackles noted. There is no evidence of infiltrate on chest radiograph. His white blood cell count is 9,000 with a normal differential. His
prothrombin time is 18, blood urea nitrogen 68, creatinine is 3.5, and albumin is 1.4. Blood and urine cultures are negative.

8. Which of the following is an appropriate statement regarding the management of ascites and its associated complications?

(A) Spontaneous bacterial peritonitis requires prompt surgical drainage

(B) Diuretics should not be used in the initial management of ascites

(C) Peritoneovenous shunts have been shown to improve overall survival in patients with ascites

(D) Disseminated intravascular coagulation is a complication of peritoneovenous shunting

(E) Transjugular intrahepatic portosystemic shunts (TIPS) have no role in the management of refractory ascites

8–D. M ost cases of ascites can be managed adequately with diuretic therapy. Other techniques for managing refractory ascites include
periodic percutaneous drainage, transjugular intrahepatic portosystemic shunts (TIPS), and the surgical placement of peritoneovenous
shunts. Peritoneovenous shunts such as the Denver or LeVeen shunts have not been shown to improve survival in patients with liver failure
and severe ascites. These shunts are associated with an increased risk of disseminated intravascular coagulation. Spontaneous bacterial
peritonitis can often be treated nonsurgically with antibiotic therapy.

9. The renal failure in this patient has which of the following characteristic findings?

(A) Renal arteriolar vasodilatation

(B) Urine osmolality < 1.010

(C) M any urinary casts on urinalysis
 (D) Low urine sodium

(E) Renal function typically does not recover after liver transplantation

9–D. Renal insufficiency secondary to hepatorenal syndrome clinically resembles prerenal causes of renal failure. Characteristics include
renal arteriolar vasoconstriction, high urine osmolality, and low urine sodium. Urinary casts typical of acute tubular necrosis are rarely
seen in hepatorenal syndrome. Renal function often recovers upon liver transplantation.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.
Questions 10–22

A. Simple cysts

B. Cystadenocarcinoma
C. Hepatic adenoma

D. Hepatocellular carcinoma

E. Hemangioendothelioma

F. Focal nodular hyperplasia

G. Pyogenic liver abscess

H. Cavernous hemangioma

I. Echinococcal cyst

J. Polycystic disease

K. Fibrolamellar hepatocellular carcinoma

L. Hepatoblastoma

M . Amebic liver abscess

10. A 48-year-old woman with a history of primary ovarian carcinoma 2 months after total abdominal hysterectomy and bilateral
salpingo-oophorectomy (TAH BSO) and staging laparotomy presents with a new 2-cm mass in the right lobe of the liver. (SELECT 1
DIAGNOSIS) B. Cystadenocarcinoma

10–B. Although cystic hepatic lesions are frequently infectious in nature or otherwise benign, they can include malignant metastatic
tumors such as ovarian and pancreatic cystadenocarcinomas. In addition, other solid metastatic tumors may undergo central necrosis and
appear as cystic lesions.

11. A 42-year-old woman is found to have a 2-cm, solid mass in the left lobe of the liver during an ultrasound evaluation for biliary
colic. Before elective cholecystectomy, a positive red blood cell scan confirms that the lesion is benign. (SELECT 1 DIAGNOSIS)
H. Cavernous hemangioma
11–H. Cavernous hemangiomas are benign tumors of the liver, and are the most common primary lesions of the liver. Hemangiomas may be
adequately differentiated from other lesions by computed tomography (CT) examination, although the diagnoses are frequently confirmed
by characteristic findings on a red blood cell radionuclide scan.

12. A 34-year-old man presents to the emergency room with a 3-day history of fever and worsening right upper quadrant (RUQ)
abdominal pain. Ultrasound reveals a 4-cm, fluid-filled mass in the right lobe of the liver. Attempted percutaneous drainage resulted in
a scant amount of thick fluid. Routine bacterial cultures of the aspirated fluid and of the blood were negative. The patient has
complete resolution of symptoms with metronidazole therapy. (SELECT 1 DIAGNOSIS) M. Amebic liver abscess

12–M. An amebic liver abscess caused by Entamoeba histolytica can frequently present with fever and right upper quadrant (RUQ)
abdominal pain. A fluid-filled mass may be seen on ultrasound or by computed tomography (CT) scan. The fluid within the cyst is often very
thick and tenacious and is described as having an “anchovy-paste” consistency. Although most infectious lesions of the liver require
drainage, débridement, or both, amebic liver abscesses frequently resolve with metronidazole therapy alone.

13. During an elective cholecystectomy, a 43-year-old woman is noted as having a 1-cm, superficial, blue, smooth cystic mass in the
right lobe of the liver. (SELECT 1 DIAGNOSIS) A. Simple cysts

13–A. Simple liver cysts are a common incidental finding identified radiographically or at the time of intra-abdominal surgery. These lesions
are generally solitary and, upon direct visualization, have a characteristic blue hue. Asymptomatic lesions do not require resection.

14. During a routine complete blood count, a 43-year-old woman is found to have a platelet count of 53,000. During a thorough
evaluation of the thrombocytopenia, an abdominal computed tomography (CT) scan reveals a 5-cm, benign-appearing mass in the right
lobe of the liver. Additional laboratory tests are all unremarkable. (SELECT 1 DIAGNOSIS) H. Cavernous hemangioma

14–H. Kasabach-M erritt syndrome is a rare syndrome characterized by sequestration of platelets, potentially leading to a
thrombocytopenic coagulopathy. This syndrome is occasionally associated with large cavernous hemangiomas because of platelet
sequestration within these lesions. This syndrome may also occur in children with hemangioendotheliomas, although these benign tumors
are rare in adults.

15. An 18-month-old healthy boy is noted as having a small palpable mass in the right upper quadrant (RUQ) of the abdomen. Ultrasound
reveals a 1-cm, solid, benign-appearing lesion in the periphery of the right lobe of the liver. (SELECT 1 DIAGNOSIS)
E. Hemangioendothelioma
15–E. Hemangioendotheliomas are benign vesiculiform tumors seen almost exclusively in children younger than 2 years old. These tumors
can easily be differentiated from other tumors, such as hepatoblastomas, with routine radiographic techniques.

16. A 38-year-old woman has been in a motor vehicle accident. During a trauma evaluation, she is found to have a 3-cm, asymptomatic,
solid mass in the left lobe of the liver by abdominal computed tomography (CT). The lesion is determined to be benign. However, an
elective resection of the lesion is planned given the risk of malignant transformation. (SELECT 1 DIAGNOSIS) C. Hepatic adenoma
16–C. Hepatic adenomas are benign tumors typically presenting as an asymptomatic lesion identified radiographically as an incidental
finding. These tumors are almost exclusively found in women of child-bearing age and are associated with oral contraceptive use. M alignant
transformation to hepatocellular carcinoma may occur in a small percentage of hepatic adenomas. In addition, there is a risk of
spontaneous rupture of these lesions with significant hemorrhage resulting. These factors provide support for the elective resection of
medium-sized or large asymptomatic hepatic adenomas.

17. A 52-year-old woman has a 2-cm, solid mass within the right lobe of the liver. A computed tomography (CT) scan reveals a lesion
with a central stellate scar. (SELECT 1 DIAGNOSIS) F. Focal nodular hyperplasia

17–F. Radiographic evidence of a central stellate scar is a characteristic finding of focal nodular hyperplasia. Unfortunately, this finding is
not always present and this lesion is often difficult to differentiate from a hepatic adenoma. Unlike a hepatic adenoma, these lesions are
not associated with malignant transformation or rupture. Therefore asymptomatic lesions do not require resection. These lesions are
composed of hyperplastic Kupffer cells that are easily identified by a sulfur colloid scan.

18. During attempted laparoscopic drainage of a benign, 4-cm cystic lesion in the right lobe of the liver, a 38-year-old patient
developed rapid onset of hypotension with associated difficulty in ventilation. There was no obvious hemorrhagic source, and emergent
chest radiograph was normal. (SELECT 1 DIAGNOSIS) I. Echinococcal cyst
18–I. Upon drainage of an echinococcal cyst, great emphasis is placed upon avoiding peritoneal spillage of the cyst contents because of
the risk of spread of the infection as well as the rare occurrence of anaphylaxis.

19. A 63-year-old man with a history of hepatitis B-induced cirrhosis presents with a 20-lb weight loss over the past 3 months.
Abdominal computed tomography (CT) scan reveals a 4-cm, irregular, solid mass in the right lobe of the liver. Additional thorough
evaluation of the patient is negative. (SELECT 1 DIAGNOSIS) D. Hepatocellular carcinoma

19–D. Hepatocellular carcinoma is the most common primary malignant tumor of the liver. Cirrhosis of the liver is the greatest risk factor
for development of this tumor. However, metastatic tumors, overall, remain the most common lesions found in the liver.

20. A 34-year-old, thin woman has a large, palpable, irregular liver edge on physical examination. In addition, the left kidney is easily
palpable and irregular on physical examination. All liver function tests are within normal limits. Blood urea nitrogen is 45 and
creatinine is 3.2. (SELECT 1 DIAGNOSIS) J. Polycystic disease

20–J. Adult polycystic disease is characterized by multiple cystic lesions in both the liver and kidney. It is inherited as an autosomal
dominant trait and may present with an enlarged palpable liver or kidneys. Hepatic function (i.e., liver function tests, albumin level,
prothrombin time, partial thromboplastin time) is typically unaffected despite extensive cystic involvement of the liver. M orbidity is
characteristically associated with renal dysfunction secondary to cystic involvement of the kidneys.

21. A 33-year-old woman is brought to the emergency room by her husband after she had been complaining of abdominal pain and then
suddenly collapsed. Her blood pressure on arrival is 70/40 mm Hg and her abdomen is noted to be tense. Intraoperatively, the patient
is found to have a large hemoperitoneum. (SELECT 1 DIAGNOSIS) C. Hepatic adenoma

21–C. Spontaneous rupture of a hepatic adenoma with hypotension and a hemoperitoneum is a characteristic complication of these benign
tumors. These tumors are associated with oral contraceptive use. There is also an increased risk of rupture of hepatic adenomas with oral
contraceptive use. Although other diagnoses may present with hypotension and a hemoperitoneum (i.e., ruptured ectopic pregnancy), a
hepatic adenoma should always be considered as a potential source in women of child-bearing age.

22. A 63-year-old man presents to the emergency room with fever and right upper quadrant (RUQ) pain. He is currently being treated as
an outpatient for a bout of diverticulitis. Ultrasound reveals a 4-cm, fluid-filled mass in the right lobe of the liver. (SELECT 1 DIAGNOSIS)
G. Pyogenic liver abscess
22–G. Pyogenic abscesses account for approximately 80% of all infectious lesions of the liver. Pyogenic liver abscesses can often present
without an obvious source of infection elsewhere, although intra-abdominal infections such as appendicitis, diverticulitis, and biliary tree
infections often serve as a primary source of bacteria.
 entering the cyst; most common type. (B) Lateral saccular cystic dilation. (C) Choledochocele represented by an intraduodenal
cyst. (D) M ultiple extrahepatic cysts, intrahepatic cysts, or both. (E) Single or multiple intrahepatic cysts; Caroli's disease. (Adapted
with permission from Blackbourne LH: Surgical Recall. Baltimore, Williams & Wilkins, 1994, p 219.)

B. Hemobilia

is defined as bleeding into the biliary tree.

1. Most cases in the United States

are due to trauma or iatrogenic injury.

2. The classic presentation includes

biliary colic.

jaundice.

guaiac-positive stools.

3. Diagnosis

often requires arteriography.

4. Treatment of persistent hemobilia may include

embolization.

surgical ligation.

C. Ascariasis

is a parasitic infection that can produce ductal obstruction.

D. Mirizzi syndrome

is a rare cause of biliary duct obstruction due to gallbladder pathology without common duct stone involvement.

1. A large stone within the gallbladder may compress the CBD because of anatomic proximity.

2. Local spread of inflammation from the gallbladder to the bile duct may also result in ductal narrowing.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 37-year-old woman presents 1 week after a laparoscopic cholecystectomy with complaints of fever,
abdominal pain, back pain, and vomiting. Vital signs include: temperature, 38.7° C; blood pressure,
110/80 mm Hg; pulse, 120/min; respiration, 18/min. There is some tenderness in the right upper
quadrant (RUQ) with voluntary guarding but no rebound tenderness or distension. Laboratory results
include: white blood cells = 18,000; hematocrit = 34; platelets = 572; Na+ 130; K+ = 3.3; Cl- = 95; CO2 =
29; blood urea nitrogen = 31; creatinine = 0.9; total bilirubin = 8.1; conjugated bilirubin = 6.8; alkaline
phosphatase = 700; aspartate aminotransferase (AST) = 150; alanine aminotransferase (ALT) = 209;
and lipase = 40. RUQ ultrasound was performed and revealed a dilated common bile duct, no gallbladder,
and no significant fluid collections. Which of the following is the most appropriate next step in the
management of this patient?
(A) Antibiotics, fluid resuscitation, and observation
(B) Radionuclide hepatobiliary iminodiacetic acid (HIDA) scan
 (C) Plain radiograph of the abdomen
(D) Take the patient to the operating room
(E) Endoscopic retrograde cholangiopancreatography (ERCP)
1–E. In addition to iatrogenic biliary tree injury, another complication of laparoscopic cholecystectomy is
retained common duct stones, which can lead to obstruction and eventually cholangitis. Endoscopic
retrograde cholangiopancreatography (ERCP) would be the examination of choice for evaluation. Not only
can the common duct obstruction be identified, but therapeutic measures can be undertaken (e.g.,
sphincterotomy and stone extraction). If these measures are unsuccessful, surgery may be indicated but
would not generally be the initial therapy. Fluid resuscitation and antibiotics are important but the key to
initial therapy is to relieve the obstruction. A HIDA scan would help to identify the lesion but ERCP
provides better visualization in addition to the potential therapeutic role.

2. A 54-year-old, African-American man with a history of hypertension and sickle cell trait presents with a 24-hour history of nausea,
vomiting, and abdominal pain. The patient describes the pain as crampy in nature and worse after eating. His temperature is 38.4° C,
blood pressure is 150/96 mm Hg, pulse 105/min, and respiration 6/min. His abdomen is tender in the right upper quadrant (RUQ) and
the patient cannot take a deep breath when the examiner is palpating the RUQ. Laboratory results include: white blood cells = 15,000;
hematocrit = 39; platelets = 112; total bilirubin = 1.0; conjugated bilirubin = 0.1; and alkaline phosphatase = 62. Which of the
following is the most appropriate diagnostic study in the initial evaluation of this patient?

(A) Radionuclide hepatobiliary iminodiacetic acid (HIDA) scan

(B) Plain films of the abdomen

(C) RUQ ultrasound

(D) Computed tomography (CT) scan of the abdomen

(E) M agnetic resonance cholangiopancreatography (M RCP)

2–C. This clinical picture is consistent with acute cholecystitis. Right upper quadrant (RUQ) ultrasound is the examination of choice for
initial evaluation of a patient with possible cholecystitis. Plain films of the abdomen are rarely useful in this situation because only 5% of
gallstones appear on such radiographs. A HIDA scan may be used when ultrasound findings are inconclusive; however, it should not be
performed as an initial study. M agnetic resonance cholangiopancreatography (M RCP) provides excellent visualization of the biliary tree but
it is still limited by cost and inconvenience. Computed tomography (CT) scans are generally not useful in the straightforward evaluation of
cholecystitis.

3. A 62-year-old, white woman with a history of hypertension, hypercholesterolemia, and peptic ulcer disease presents to the clinic
after a routine laparoscopic cholecystectomy. Surgical pathology reveals a 3 mm × 3 mm × 4 mm adenocarcinoma in the wall of the
gallbladder that extends into but not through the muscularis layer. A chest radiograph and abdominal computed tomography (CT) scan
show no evidence of metastases. Which of the following is the appropriate treatment for this patient's disease?

(A) The patient has been treated appropriately and no further surgery is necessary

(B) Perform a choledochojejunostomy as a palliative measure for relief of potential obstructive symptoms

(C) Perform a wedge resection of the liver around the gallbladder and a regional lymphadenectomy
(D) Perform a pancreaticoduodenectomy to obtain wide margins around the gallbladder

(E) Perform a wedge resection of the liver around the gallbladder, a regional lymphadenectomy, and excision of all trocar sites

3–E. The appropriate treatment for this gallbladder cancer is a radical cholecystectomy. The patient has already had her gallbladder
removed and therefore needs to have the procedure completed with a liver resection with 2–3 cm margins around the gallbladder and a
regional lymphadenectomy. In addition, the laparoscopic trocar sites must also be excised to prevent tumor seeding. Wider resections
such as a Whipple's operation or palliative procedures are not indicated at this time.

4. A 68-year-old, Vietnamese man with a history of hypertension, asthma, and arthritis presents with complaints of pruritus that has
gradually worsened over the past 3 weeks. Most recently he also reports some nausea and vomiting. He reports having lost
approximately 15 pounds in the past month and attributes this to his nausea and vomiting. On physical examination his temperature is
37.6° C, blood pressure is 160/90 mm Hg, pulse is 87/min, and respirations are 13/min. He is a thin male in no acute distress.
Laboratory results include: white blood cells = 8.2; hematocrit = 42; platelets = 208; Na+ = 132; K+ = 4.0; blood urea nitrogen = 32;
creatinine = 0.7; total bilirubin = 12.0; conjugated bilirubin = 10.8; alkaline phosphatase = 812; amylase = 35; lipase = 60; aspartate
aminotransferase (AST) = 212; and alanine aminotransferase (ALT) = 230. A right upper quadrant (RUQ) ultrasound was performed before
the patient's referral and reveals no gallstones, gallbladder wall thickening, or common duct dilation. There is, however, intrahepatic
ductal dilation. Which of the following is the most likely diagnosis?

(A) Cholangitis

(B) Cholangiocarcinoma

(C) Pancreatitis

(D) Pancreatic cancer

(E) Choledocholithiasis

4–B. The presentation of a patient with painless jaundice and no history of abdominal surgery is consistent with either pancreatic cancer
or cholangiocarcinoma. The finding of intrahepatic ductal dilation suggests obstruction of the biliary system above the common duct and
therefore makes pancreatic cancer less likely. Cholangiocarcinoma and more specifically, tumors involving the upper third of the biliary
tree (Klatskin tumors), is the most likely etiology of these findings. Cholangitis often produces a fever and this patient is not febrile.

5. A 42-year-old man with a history of diabetes mellitus and inflammatory bowel disease presents because of a 3-day history of
worsening itching. The patient denies any fever, chills, or abdominal pain but does report two episodes of vomiting. The patient also
claims to have lost 12 pounds in the last 2 months. After further questioning, the patient reports having had several similar episodes in
the past that resolved spontaneously. On physical examination he is jaundiced. Rectal examination is trace positive for blood.
Laboratory results include: white blood cell count = 10.0; hematocrit = 33; platelets = 256; blood urea nitrogen = 28; creatinine = 1.1;
total bilirubin = 9.0; conjugated bilirubin = 7.6; alkaline phosphatase = 1000; aspartate aminotransferase (AST) = 78; alanine
aminotransferase (ALT) = 152; prothrombin time (PT) = 12.2; and partial thromboplastin time (PTT) = 21.8. Which of the following is the
most likely diagnosis?
(A) Primary sclerosing cholangitis (PSC)

(B) Choledocholithiasis

(C) Biliary colic

(D) Cholangiocarcinoma
(E) Cholangitis

5–A. This is a characteristic presentation of primary sclerosing cholangitis (PSC). The patient is relatively young and therefore malignancy is
less likely. Furthermore, he describes a history of fluctuating symptoms, which is characteristic of PSC and not of cholangiocarcinoma. The
lack of pain makes the diagnosis of biliary colic and choledocholithiasis less likely. Of concern is the patient's anemia, guaiac-positive
stools, and weight loss. This may be due to colon cancer, which is an increased risk in patients with PSC and ulcerative colitis.

6. A 75-year-old woman has been in the intensive care unit for the past 3 weeks because of a 20% burn to her back and left arm. Her
course has been complicated by adult respiratory distress syndrome (ARDS) and a non-Q wave myocardial infarction. Her cardiovascular
status is currently tenuous. Over the past week the patient's white blood cell count has been rising and she grimaces with palpation of
the abdomen. Her current white blood cell count is 18,000 with a left shift. Her other laboratory results are unremarkable except for a
hematocrit of 29. Current vital signs include: temperature, 38.4° C; blood pressure, 88/48 mm Hg; pulse, 120/min; and respiration,
26/min. Abdominal films are unremarkable. A right upper quadrant (RUQ) ultrasound was performed and revealed a distended
gallbladder, thickened gallbladder wall, pericholecystic fluid, no gallstones, and normal common bile ducts. Which of the following is
most appropriate in the initial management of this patient?

(A) Endoscopic retrograde cholangiopancreatography (ERCP) with stone removal

(B) Emergent open cholecystectomy

(C) Cholecystostomy

(D) Laparoscopic cholecystectomy

(E) Intravenous (IV) antibiotics and observation

6–C. Acalculous cholecystitis characteristically affects critically ill patients. An appropriate management strategy in an unstable patient
with cholecystitis is cholecystostomy that involves percutaneous placement of a catheter in the gallbladder to provide for drainage until
the patient is stable enough to tolerate formal cholecystectomy. With simple antibiotics and observation serious morbidity and mortality
can affect up to 60% of these patients. On the other hand, the patient is not well enough to tolerate the stress of surgery, so a
temporizing measure is needed. Endoscopic retrograde cholangiopancreatography (ERCP) is not indicated in the setting of cholecystitis.

7. A 56-year-old woman with a history of hypertension and gout presents with a 3-day history of worsening abdominal pain, back pain,
nausea, and vomiting. The patient claims she has had a history of crampy abdominal pain after eating for almost 1 year but most
recently she has been suffering from constant pain. Her temperature is 36.7° C, blood pressure is 168/85 mm Hg, and pulse is 92/min.
She is tender to palpation in the midepigastric region and right upper quadrant (RUQ). Laboratory results include: white blood cell
count = 10,000; hematocrit = 42; platelets = 210; Na+ = 138; K+ = 3.4; Cl - = 96; CO2 = 29; blood urea nitrogen = 34; creatinine = 1.3;
total bilirubin = 1.2; conjugated bilirubin = 0.3; aspartate aminotransferase (AST) = 50; alanine aminotransferase (ALT) = 80; alkaline
phosphatase = 210; amylase = 400; and lipase = 566. Abdominal films are consistent with an ileus. RUQ ultrasound reveals sludge, no
wall thickening, no pericholecystic fluid, and a normal bile duct. Which of the following is the most likely cause of this patient's
pathology?

(A) Obstruction of the cystic duct by a gallstone

(B) A malignancy obstructing the common hepatic duct

(C) Idiopathic inflammatory strictures of the bile ducts

(D) Passage of a gallstone through the ampulla of Vater

(E) Obstruction and bacterial infection of the biliary tree

7–D. The most common cause of pancreatitis in the United States is gallstone disease, including passage of a gallstone. Evidence for this
includes the long history of biliary colic, which suggests calculous biliary disease. Furthermore, the elevation in alkaline phosphatase
suggests recent irritation to the bile ducts, such as that caused by stone passage. In addition, the right upper quadrant (RUQ) ultrasound
findings include the precursor to gallstones in the gallbladder as well as a normal duct, which weighs against other diagnoses, including
primary sclerosing cholangitis (PSC), cholangitis, and cholangiocarcinoma. There was also no evidence on ultrasound of active biliary tree
obstruction.

8. A 54-year-old, white woman presents with a 48-hour history of worsening crampy abdominal pain. Her pain is exacerbated by eating
and is associated with nausea and vomiting. Her temperature is 38.7° C, pulse is 101/min, blood pressure is 130/82 mm Hg, and
respiration is 19/min. Her abdomen is tender in the right upper quadrant (RUQ) and she cannot take a deep breath when the examiner
palpates in the RUQ. She has no peritoneal signs. Laboratory results include: white blood cells = 16,000; hematocrit = 38; platelets =
316; Na+ = 134; K+ = 3.6; Cl - = 101; CO2 = 22; blood urea nitrogen = 21; creatinine = 1.0; total bilirubin = 2.0; conjugated bilirubin =
0.8; alkaline phosphatase = 67; aspartate aminotransferase (AST) = 62; alanine aminotransferase (ALT) = 61; and amylase < 30. RUQ
ultrasound reveals a distended gallbladder with pericholecystic fluid and multiple echogenic foci in the gallbladder. The common duct
appears normal. Which of the following is the most appropriate next step in the management of this patient?

(A) Exploratory laparotomy

(B) Computed tomography (CT) scan of the abdomen

(C) Laparoscopic cholecystectomy

(D) Cholangiopancreatography
(E) Hepatobiliary iminodiacetic acid (HIDA) scan

8–C. The history of colicky pain worsened by eating is classic for cholecystitis. On physical examination the patient has a positive M urphy's
sign. Her laboratory tests show evidence of infection but her normal bilirubin and alkaline phosphatase suggest no common duct
involvement. The right upper quadrant (RUQ) ultrasound visualizes stones in the gallbladder. The next step for this patient is a
cholecystectomy to remove her gallbladder. Further diagnostic tests, such as a HIDA or computed tomography (CT) scan, are not
necessary because of the clear evidence of cholecystitis. Endoscopic retrograde cholangiopancreatography (ERCP) is not necessary
because there is no suggestion of common duct pathology.

9. A 68-year-old, diabetic, hypertensive, African-American man was found to have gallstones on an abdominal computed tomography
(CT) scan performed as part of a metastatic work-up. The man denies any symptoms except for occasional heartburn, which is treated
medically. His vitals signs include: temperature, 37.1° C; blood pressure, 160/90 mm Hg; pulse, 87/min; and respiration, 12/min. His
abdomen is soft, nontender, and nondistended. He has normoactive bowel sounds. Which of the following is an appropriate statement
regarding the management of this patient?

(A) The patient must have a cholecystectomy

(B) This patient is at no increased risk of developing cholecystitis, versus a diabetic patient without gallstones

(C) If the patient had vague abdominal pain, a laparoscopic cholecystectomy may be helpful

(D) If the patient develops symptoms suggestive of cholecystitis, a CT scan should be repeated
(E) A laparoscopic cholecystectomy for acute cholecystitis is contraindicated in this patient because of the diabetes

9–C. Surgery for asymptomatic gallstones is not absolutely indicated. The patient's age and diabetes may lead many surgeons to perform a
cholecystectomy, but these are relative indications. On the other hand, a cholecystectomy could help this patient, especially if there is a
history of vague complaints. A right upper quadrant (RUQ) ultrasound would be the test of choice for initial evaluation if symptoms
suggestive of cholecystitis were to develop, not a computed tomography (CT) scan. A laparoscopic approach is not contraindicated
because of diabetes. The presence of gallstones in any population is associated with an increased risk of cholecystitis versus those
without stones.

10. A 4-year-old boy was in his usual state of good health until approximately 1 month ago when he developed cholangitis. As part of
the work-up an endoscopic retrograde cholangiopancreatography (ERCP) was performed and revealed segmental dilation of the common
bile duct. A computed tomography (CT) scan was also performed and revealed several intrahepatic cysts, the segmental dilation of the
common duct, and no masses. Which of the following is the most appropriate recommendation for this patient?

(A) This is a normal anatomic variant and no surgery is indicated

(B) The patient should have a repeat ERCP to perform a sphincterotomy

(C) The patient should have a cholecystectomy to prevent gallbladder involvement

(D) The patient should have the region of segmental dilation removed followed by biliary reconstruction

(E) The patient should have the dilated region excised, the head of the pancreas removed, and then a biliary bypass

10–D. The most likely diagnosis in this case is a choledochal cyst. There is an increased risk of cholangiocarcinoma associated with this
congenital abnormality, therefore the recommendation is to have the cyst excised and the biliary tree reconstructed, often with a Roux-
en-Y choledochojejunostomy or hepaticojejunostomy. There is no pathology in the pancreas, thus the head of the pancreas should not
be removed with the cyst. Additionally, a sphincterotomy would not relieve the obstruction in this patient.

11. A 49-year-old, obese man presents to the emergency room with a 24-hour history of fever, chills, and abdominal pain. He describes
crampy pain in the midepigastric region with radiation to the right shoulder. He also reports some associated nausea and vomiting. His
vital signs include: temperature, 38.9° C; blood pressure, 156/96 mm Hg; pulse, 99/min; and respiration, 16/min. His sclera are
anicteric, his heart is regular, and his lungs are clear to auscultation except for occasional wheezes. Laboratory results include: white
blood cells = 14,000; hematocrit = 42; platelets = 221; Na+ = 132; K+ = 3.3; Cl = 100; CO2 = 21; blood urea nitrogen = 20; creatinine =
1.5; glucose = 266; total bilirubin = 1.2; conjugated bilirubin = 0.1; alkaline phosphatase = 242; and amylase = 30. A right upper
quadrant (RUQ) ultrasound was attempted but because of the patient's size the gallbladder could not be adequately visualized. Which of
the following is the most appropriate next step in the management of this patient?

(A) Endoscopic retrograde cholangiopancreatography (ERCP)

(B) Hepatobiliary iminodiacetic acid (HIDA) scan

(C) Oral cholecystogram

(D) Percutaneous transhepatic cholangiography

(E) The patient should be taken to the operating room

11–B. This patient has a presentation that is highly suggestive of acute cholecystitis. When a right upper quadrant (RUQ) ultrasound is
equivocal, the next test of choice is nuclear imaging of the biliary tree, such as a HIDA scan. An oral cholecystogram can give the same
information as the HIDA scan but it is much more time-consuming and the reliability is lower owing to the patient's vomiting.
Cholangiography is not indicated before the HIDA scan but may be necessary if common duct obstruction is diagnosed. Surgery may be
necessary, but not before confirming the diagnosis in this setting.

12. A 71-year-old, white man with a history of diabetes mellitus, coronary artery bypass surgery, and a 80 pack-year smoking history
presents to the office complaining of severe itching that is not improved with home remedies. He denies fever, chills, or abdominal
pain. On physical examination he is a thin, jaundiced, elderly man in no acute distress. Vital signs include: temperature, 36.8° C; pulse,
67/min; blood pressure, 145/67 mm Hg; respiration, 13/min. Laboratory results include: white blood cells = 8000; hematocrit = 32;
platelets = 201; Na+ = 134; K+ = 3.6; Cl - = 101; CO2 = 24; blood urea nitrogen = 31; creatinine = 1.6; glucose = 278; total bilirubin =
11.1; conjugated bilirubin = 8.9; alkaline phosphatase = 1002; and amylase = 100. A computed tomography (CT) scan is performed and
reveals dilated intrahepatic ducts but no visualization of the extrahepatic ducts because of a 2 cm × 2 cm × 3 cm mass that appears to
involve the common hepatic duct and cystic duct. There is no obvious lymphadenopathy. Which of the following is the most
appropriate next step in the management of this patient?

(A) Computed tomography (CT) scan of the chest and a bone scan

(B) Percutaneous transhepatic cholangiography (PTC)

(C) Exploratory laparotomy

(D) Biliary ultrasound

(E) Radical pancreaticoduodenectomy

12–B. This patient is presenting with obstructive jaundice from a mass involving the common hepatic duct and the cystic duct. This is most
likely due to gallbladder cancer with extension down the cystic duct but may also be due to cholangiocarcinoma. The next step in
evaluation would be cholangiography. Percutaneous transhepatic cholangiography (PTC) is preferred because it can characterize the
extent of involvement of the proximal biliary tree, which is important for surgical planning. In addition, a drain may be left in the
intrahepatic bile ducts or a stent may be placed to decompress the dilated biliary system. After this has been performed clinical staging
and surgical planning can be accomplished. Although computed tomography (CT) may further define a mass lesion and be used in staging, it
is not as effective as PTC at outlining the degree of biliary tree involvement. Exploratory laparotomy is not indicated in this setting.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 13–15

A. Distended gallbladder with thickened wall and pericholecystic fluid. M ultiple echogenic foci in the gallbladder. Normal common bile
duct and liver.
B. Normal gallbladder except for a single echogenic foci. Common bile duct distended. Normal liver.

C. Normal gallbladder. Extrahepatic bile ducts not visualized. Intrahepatic ducts distended.

D. Normal gallbladder. Normal liver and bile ducts.

E. Focal stricture of the distal common bile duct with proximal dilation.

M atch the right upper quadrant (RUQ) ultrasound result most consistent with the clinical presentation.

13. A 56-year-old, white man with a history of tobacco abuse, hypertension, recent unintentional 80-lb weight loss, and squamous cell
cancer of the lung presents with a 24-hour history of right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. He has had
similar pains over the past 2 weeks, mostly after eating, but they had resolved spontaneously. The patient denies fever and chills. His
temperature is 36.7° C. Physical examination findings are significant for scleral icterus and RUQ tenderness to palpation. Significant
laboratory findings include white blood cells = 7800, total bilirubin = 6.8, conjugated bilirubin = 5.6, and alkaline phosphatase = 670.
(SELECT 1 RESULT) B. Normal gallbladder except for a single echogenic foci. Common bile duct distended. Normal liver.

13-B. This patient is presenting with choledocholithiasis most likely related to cholesterol stones formed in the gallbladder caused by his
rapid weight loss. Therefore one would expect to see common duct distension caused by the cholesterol stone. In addition, one might
expect to find evidence of stone formation in the gallbladder, such as another stone or sludge.

14. A 53-year-old, morbidly obese, white woman with a history of diabetes presents with a 36-hour history of worsening crampy
midepigastric and right upper quadrant (RUQ) abdominal pain. She claims the pain was initially bad only after meals but has since
become constant. She also complains of nausea, vomiting, and fever. Her temperature is 38.5° C. Her physical examination is significant
for anicteric sclera, RUQ pain, and inspiratory arrest with deep palpation in the RUQ. Significant laboratory findings include white
blood cells = 14,000, K+ = 3.3, Cl - = 96, CO2 = 30, total bilirubin = 1.1, and alkaline phosphatase = 64. (SELECT 1 RESULT)
A. Distended gallbladder with thickened wall and pericholecystic fluid. Multiple echogenic foci in the gallbladder. Normal common bile duct and liver.
14-A. This patient is presenting with classic acute cholecystitis. Characteristic findings of acute cholecystitis on right upper quadrant
(RUQ) ultrasound could reveal gallstones, a distended gallbladder, pericholecystic fluid, and thickening of the gallbladder wall.

15. A 58-year-old, diabetic, African-American man with a history of hypertension and hypercholesterolemia presents with a 48-hour
history of progressively worsening constant right upper quadrant (RUQ) pain, fever, nausea and vomiting. Vital signs include:
temperature, 39.1° C; pulse, 120/min; blood pressure, 100/59 mm Hg; respiration, 21/min. Physical examination is significant for
icteric sclera and RUQ tenderness. Significant laboratory findings include white blood cells = 17,000; alkaline phosphatase = 670; total
bilirubin = 7.8; conjugated bilirubin = 6.5; aspartate aminotransferase (AST) = 350; alanine aminotransferase (ALT) = 390; and amylase =
45. (SELECT 1 RESULT) B. Normal gallbladder except for a single echogenic foci. Common bile duct distended. Normal liver.

15-B. This patient is presenting with cholangitis. Characteristic findings include fever; right upper quadrant (RUQ) pain; icteric sclera
(Charcot's triad); and elevated bilirubin, alkaline phosphatase, and transaminases. The RUQ ultrasound should show evidence of biliary
obstruction, the dilated ducts. The ultrasound picture of cholangitis and choledocholithiasis are very similar but the clinical picture can
easily separate the two. The most likely cause of cholangitis in this setting is choledocholithiasis.
 Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 52-year-old man presented to his primary care physician 3 months ago with severe epigastric pain
after an episode of hematemesis. Esophagogastroduodenoscopy (EGD) at that time revealed two large
peptic ulcers in the first portion of the duodenum. He was placed on omeprazole after Helicobacter
pylori titers were negative. After 6 weeks he returned to his physician with improved but continued pain.
Repeat EGD revealed that the original ulcers were significantly smaller but there were several new ulcers
both in the duodenum and in the antrum of the stomach. What is the next most appropriate step in the
management of this patient?
(A) Repeat EGD in 6 weeks
(B) Abdominal ultrasound
(C) Highly selective vagotomy
(D) Vagotomy and pyloroplasty
(E) Secretin stimulation test
1–E. This patient may have Zollinger-Ellison syndrome (gastrinoma with intractable peptic ulcer disease),
although this must be initially confirmed. A secretin stimulation test is often diagnostic. In patients with
ZE syndrome, secretin administration increases serum gastrin levels, in contrast to the normal physiologic
inhibition of gastrin secretion by secretin. Repeating the esophagogastroduodenoscopy (EGD) is
unnecessary at this time because the patient does not seem to be actively bleeding. Abdominal ultrasound
would not be particularly helpful, but once diagnosed, a gastrinoma can at times be localized by
endoscopic ultrasound. Neither ulcer operation (vagotomy or pyloroplasty) is indicated before ruling out a
gastrinoma.

2. A patient with a suspected gastrinoma has a markedly elevated serum gastrin level and the level failed to drop appropriately after
secretin administration. Abdominopelvic computed tomography (CT) scan failed to reveal any pancreatic mass. Endoscopic ultrasound
was also unrevealing. Which of the following would be the most appropriate next step in managing this patient?

(A) Distal pancreatectomy

(B) Vagotomy and pyloroplasty

(C) M obilization of the duodenum and intraoperative ultrasound

(D) Whipple procedure (pancreaticoduodenectomy)

(E) M etronidazole, omeprazole, and clarithromycin therapy

2–C. Gastrinomas are located in the gastrinoma triangle in the majority of cases. They can often be seen by abdominal computed
tomography (CT), magnetic resonance imaging (M RI), or endoscopic ultrasound. Other localizing modalities include selective portal venous
gastrin sampling or radiolabeled octreotide scanning. Alternatively, as in this question, it is reasonable to explore the abdomen, initially
focusing on the gastrinoma triangle by exposing and examining the duodenum and pancreatic head using intraoperative ultrasound. Neither
distal pancreatectomy nor a Whipple procedure should be performed before more aggressive attempts are made at localizing the tumor.
Ulcer operations are not indicated in patients with Zollinger-Ellison syndrome; even those with unresectable or metastatic tumors should
be treated with omeprazole. This patient does not have Helicobacter pylori, thus antibiotic therapy would not be appropriate.

3. A 45-year-old man presents to the emergency room complaining of severe epigastric pain that radiates to his back and left scapula.
He has had severe nausea and vomiting associated with the pain for 3 days. Nothing seems to relieve his pain. He drinks about a fifth of
bourbon a day. He has not had a bowel movement in several days. He also complains of a very dry mouth. He is afebrile and
normotensive with a heart rate of 110 beats/min. He is mildly tender on abdominal examination. His serum amylase level is 650 IU/L.
Which of the following is the most appropriate initial step in the management of this patient?

(A) Exploratory laparotomy and pancreatic débridement

(B) Discharge and close follow up as outpatient

(C) Obtain an abdominopelvic computed tomography (CT) scan

(D) Perform esophagogastroduodenoscopy (EGD)

(E) Admit for intravenous (IV) hydration and withhold oral feeding

3–E. This patient has acute pancreatis most likely secondary to alcoholism. He does not appear to have peritonitis nor is he in extremis. He
has signs of intestinal ileus and is assuredly dehydrated. The initial management of a patient with acute pancreatitis should be fluid
resuscitation and restriction of oral intake. Surgery for acute pancreatitis is reserved for patients with complications of pancreatitis or
infected pancreatic necrosis. Discharging a severely dehydrated patient with acute pancreatitis would not be safe.
Esophagogastroduodenoscopy would not be helpful in the initial management of this patient and would not be well tolerated. An
abdominopelvic computed tomography (CT) scan is useful in evaluating patients with severe, acute pancreatitis, to help in identifying signs
of pancreatic necrosis and fluid collections, but it is not indicated initially in patients with uncomplicated pancreatitis.

4. A 57-year-old man with a history of biliary colic presents with a 2-day history of severe epigastric and left upper quadrant (LUQ)
pain, intractable nausea, and vomiting. He was admitted to an outside hospital for intravenous (IV) hydration, but over the first 24
hours of his hospital course he became progressively more ill. Abdominopelvic computed tomography (CT) scan demonstrated an
enlarged common bile duct, a markedly edematous pancreas with portions of the pancreas which do not enhance, and several liters of
ascites. His left flank became markedly ecchymotic, and his abdomen became progressively more distended. He was then transferred to
the intensive care unit at your tertiary care hospital. Despite infusion of 10 L of crystalloid over the last 12 hours, he remains
hypotensive. Laboratory studies reveal a white blood cell count of 24,000, a Po2 of 55 mm Hg, a blood glucose of 280 mg/dL, bilirubin
of 4.3, and a lactate dehydrogenase of 495 IU/L. Based on Ranson's criteria, which of the following indicates this patient's mortality risk
upon entering the intensive care unit?

(A) 0%
(B) 20%

(C) 40%
(D) 80%

(E) 100%

4–C. This patient has hemorrhagic necrotizing pancreatitis which is made evident by his Grey Turner sign (left flank ecchymosis) and the
computed tomographic findings. With a history of biliary colic, the pancreatitis is likely secondary to gallstones. He has at least six of
Ranson's criteria, notably (1) age over 55, (2) fluid sequestration > 10 L, (3) white blood cell count > 16,000, (4) Po 2 < 60, (5) glucose > 200,
(6) lactase dehydrogenase > 350. His mortality risk is at least 40%.

5. A patient with necrotizing pancreatitis would benefit most from which of the following therapeutic measures?

(A) Placement of a pulmonary artery catheter

(B) Blood transfusion

(C) Endoscopic pancreatic stent placement

(D) Emergent surgical exploration

(E) Initiation of broad spectrum antibiotic therapy with imipenem/cilastatin

5–E. While placement of a pulmonary artery catheter may help manage the fluid resuscitation of this patient, its use has not been shown
to significantly improve patient outcome. Blood transfusion may be appropriate to improve oxygen-carrying capacity in the setting of
retroperitoneal hemorrhage, but without blood loss or hemolysis there is no benefit to transfusion. Placement of an endoscopically placed
pancreatic stent in the setting of necrotizing pancreatitis would likely worsen the pancreatitis. Emergent surgical exploration is not
recommended in the initial treatment of patients with sterile necrotizing pancreatitis because patient survival has not been improved by
this approach. The patient with necrotizing pancreatitis should be assumed to have sterile necrosis until proven otherwise. Those patients
who have culture-proven bacterial sepsis or signs of deterioration despite aggressive supportive care should undergo a fine-needle
aspiration of pancreatic fluid collections or necrotic debris for Gram stain and culture to prove the presence of infected necrosis. The
presence of infected necrosis then dictates surgical débridement. The use of imipenem/cilastatin in patients with necrotizing pancreatitis
has been shown to decrease infection-related complications and, therefore, would benefit the patient.

6. A patient with a high-output pancreatic fistula is most likely to suffer from which one of the following metabolic derangements?

(A) Hyponatremia
(B) Hyperkalemia

(C) Respiratory alkalosis

(D) M etabolic acidosis

(E) M etabolic alkalosis

6–D. Patients with high-output pancreatic fistulae can develop a profound metabolic acidosis secondary to loss of bicarbonate in the
pancreatic secretions. These patients may partially compensate by increasing their minute ventilation, however this compensation is not
enough to cause an alkalosis. Octreotide therapy is often helpful in decreasing the volume of output from the fistula, and thus decreasing
the amount of lost bicarbonate. These patients generally do not develop significant hyponatremia or hyperkalemia.

7. A 39-year-old woman presents with severe epigastric pain, nausea and vomiting. She states she has been anorexic for 2 days. She
weighs 240 lb and gave birth to her fourth child 2 years ago. Examination reveals mild tachycardia and abdominal tenderness in the
epigastrium and the left upper quadrant (LUQ). Ultrasound examination demonstrates multiple large gallstones in the gallbladder and a
dilated common bile duct. The pancreas was poorly visualized secondary to her body habitus. Her serum bilirubin is measured at 3.8
mg/dL, amylase at 1,200 IU/L, lipase at > 6,000 IU/L, and white blood cell count at 17,500. In addition to intravenous (IV) hydration,
which of the following is the most appropriate approach to managing this patient?

(A) Antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy

(B) Antibiotics and exploratory laparotomy

(C) Observation

(D) Antibiotics and observation

(E) Antibiotics and laparoscopic cholecystectomy

7–A. This patient has gallstone pancreatitis with both laboratory and ultrasound evidence suggesting an impacted gallstone at the ampulla
of Vater. The most appropriate care would involve fluid resuscitation followed by endoscopic stone extraction, cholangiopancreatography,
and sphincterotomy. Any time endoscopic retrograde cholangiopancreatography (ERCP) is performed, the patient should be given
prophylactic antibiotics because of the associated risk of cholangitis. Based on the information given, neither exploratory laparotomy nor
cholecystectomy is indicated at this time. The patient's gallbladder should be removed electively after resolution of her gallstone
pancreatitis to prevent recurrence. Observation in the setting of an impacted gallstone is likely to worsen the severity of pancreatitis and
lead to cholangitis.

8. A 73-year-old man is brought to your clinic by his wife because of her concerns of his “wasting away.” He describes having lost 60 lb
over the last 6 months. He appears cachectic with a scaphoid abdomen. You note a fullness to his epigastrium. Abdominopelvic
computed tomography (CT) reveals a mass in the head of the pancreas and a 3-cm hypodense lesion in the liver. Which of the following
is appropriate in the management of this patient?

(A) Pancreaticoduodenectomy (Whipple procedure)

(B) Image-guided percutaneous biopsy of the liver lesion

(C) Radiotherapy

(D) Choledochojejunostomy

(E) Total pancreatectomy

8–B. This patient likely has pancreatic carcinoma with a metastasis to the liver. First, the liver lesion should be biopsied before embarking
on resection of the primary tumor. This could be achieved either percutaneously, laparoscopically, or by laparotomy. If feasible,
percutaneous needle biopsy is the least invasive and the most desirable as a first step in planning the care of this patient. A Whipple
procedure is generally not indicated in patients with stage IV pancreatic carcinoma. Total pancreatectomy is no longer recommended for
pancreatic carcinoma. Biliary bypass (choledochojejunostomy) is not indicated in patients with metastatic pancreatic carcinoma who do
not have biliary obstruction. Radiotherapy for end-stage pancreatic carcinoma is ineffective.

9. A 41-year-old woman with human immunodeficiency virus (HIV) presents to her physician with complaints of bleeding gums and easy
bruising throughout her extremities. Examination reveals a palpable spleen below the left costal margin, multiple soft tissue
ecchymoses of her extremities, and multiple petechiae on her hands and feet. Blood counts reveal a platelet count of 27,000/µL.
Evaluation of the plasma reveals antiplatelet antibodies. Which of the following is the most appropriate initial therapy?

(A) Glucocorticoids

(B) Platelet infusions

(C) Splenectomy

(D) M ethotrexate

(E) Danazol

9–A. Patients with human immunodeficiency virus (HIV) are at increased risk of developing idiopathic thrombocytopenic purpura (ITP),
which is what this patient has. Patients typically develop antiplatelet antibodies that appear to facilitate platelet sequestration and
destruction in the spleen. Initial therapy includes using steroids and intravenous (IV) immunoglobulin (Ig)G therapy to induce a remission.
Patients will typically respond to the steroids by an increase in their platelet counts. If the platelet counts begin to fall upon steroid
withdrawal, splenectomy is indicated. Refractory cases that do not respond to steroids may respond to other agents like
cyclophosphamide and danazol. Platelet infusions should generally not be given to patients with ITP before splenectomy because these
platelets will quickly be sequestered in the spleen and will not function. Immediately after splenectomy, platelets may be given. Life-
threatening hemorrhage should be treated with emergent IgG therapy. M ethotrexate is an antineoplastic agent and therefore not
appropriate in this case.

10. A 54-year-old woman presents with complaints of intermittent episodes of marked diaphoresis and palpitations. She describes
feeling like her heart is racing during these episodes, and it makes her feel quite anxious. She has learned that eating food will relieve
her symptoms. Screening laboratory tests reveal a blood glucose level of 55 mg/dL. The woman weighs 122 lb and appears otherwise
healthy. A fasting glucose level performed the next day was 50 mg/dL and her serum insulin level was markedly above fasting norms.
Abdominopelvic computed tomography (CT) demonstrated a discrete, 1-cm tumor in the body of the pancreas. Which of the following is
the most appropriate therapy for this patient?

(A) Oral propranolol therapy

(B) Wide local excision of the tumor

(C) Distal pancreatectomy

(D) Enucleation of the tumor

(E) Pancreaticoduodenectomy

10–D. This woman has an insulinoma. She is experiencing catecholamine surges at times of profound hypoglycemia as a compensatory
mechanism to promote glycogenolysis and release of glucose stores. Propranolol may help ameliorate the palpitations and anxiety, but it
will not address the underlying problem. Over 90% of insulinomas are benign, and most can be successfully enucleated. The lesion
described is small and enucleation should be curative. Distal pancreatectomy is possible, but is more resection than is necessary, and
pancreaticoduodenectomy would not address her tumor.

11. A 38-year-old woman with no history of alcohol use or cholelithiasis has suffered from intermittent epigastric abdominal pain,
nausea, and vomiting for most of her adult life. She takes no medicines. Recently, evaluations have included
esophagogastroduodenoscopy, an upper gastrointestinal barium study, and an abdominal ultrasound that have all been unrevealing. She
now presents with the same constellation of symptoms. Examination is unremarkable, however laboratory studies reveal an amylase of
1200 IU/L and a lipase of 4400 IU/L. Repeat abdominopelvic computed tomography (CT) scan reveals only an edematous pancreatic head.
Which of the following is the next most reasonable diagnostic or therapeutic modality?

(A) Endoscopic ultrasound

(B) Percutaneous transhepatic cholangiography (PTHC)

 (C) Enteroclysis

(D) Hepatobiliary scintigraphy (HIDA scan)

(E) Endoscopic retrograde cholangiography (ERCP)

11–E. This patient has signs of acute pancreatitis based on her clinical presentation, laboratory, and radiologic evaluation. With no history
of alcohol consumption or gallstones other causes must be ruled out. Pancreas divisum is often a cause of intermittent acute pancreatitis
in patients in whom other causes have been ruled out. The best way to identify an anatomical cause of this patient's acute pancreatitis is
by endoscopic retrograde cholangiography (ERCP). M oreover, ERCP has the advantage over other imaging techniques by allowing treatment
options at the time of the investigation (i.e., endoscopic sphincterotomy or pancreatic duct stent placement). Repeat ultrasound would
offer no additional information. Percutaneous transhepatic cholangiography (PTHC) is more difficult in the absence of a dilated biliary tree
and does not often provide good detail of the pancreatic ductal anatomy. Enteroclysis will not address the question of etiology of
pancreatitis. Hepatobiliary scintigraphy does not provide any image of the pancreatic ducts.

12. A 22-year-old woman presents to the emergency room after having fallen off a galloping horse. She complains of left lower chest
wall pain and is mildly short of breath. She is hemodynamically stable. There is a large bruise over her left flank. Chest radiograph
demonstrates several fractured ribs on the lower left side. Abdominopelvic computed tomography (CT) scan reveals a 1 × 3 cm2
subcapsular splenic hematoma and some fluid adjacent to the spleen. Which of the following is the most appropriate next step in the
management of this patient?

(A) Emergent splenectomy

(B) Splenorrhaphy
(C) Pneumococcal vaccine administration

(D) Chest wall splinting

(E) Bedrest and observation

12–E. This patient has a grade II splenic injury and is hemodynamically stable. This warrants a conservative management with close
observation and bedrest for a defined period of time (3–7 days). Emergent splenectomy would be premature and likely subject this patient
to the risks of laparotomy and splenectomy unnecessarily. Splenorrhaphy would be an appropriate option (as would splenectomy) if this
patient did not tolerate conservative management (i.e., she continued to bleed and required blood transfusions while being observed).
The pneumococcal vaccine should only be given if the patient undergoes splenectomy. Chest wall splinting is unnecessary, would further
restrict her chest wall motion, and would not address her splenic injury.

13. A 26-year-old man presents to his primary physician with complaints of intermittent, crampy epigastric pain, nausea, and vomiting
shortly after eating. He usually vomits undigested food and this relieves the pain and nausea. He has preferred to eat soft foods his
whole life, and he often relies on liquids. He is otherwise healthy and well-developed. Upper gastrointestinal barium study reveals a
markedly narrowed second portion of the duodenum. Laboratory studies are unremarkable. Which of the following is the most likely
diagnosis for this patient?

(A) Gallstone pancreatitis

(B) Pancreatic carcinoma

(C) Pancreas divisum

(D) Annular pancreas

(E) Cholelithiasis

13–D. This patient has symptoms of gastric outlet obstruction or, as in this case, duodenal obstruction. Several of these diseases could
result in duodenal obstruction. However, the fact that he is young, otherwise healthy, and has avoided solid foods all his life suggests he
has a congenital problem. He does not describe symptoms of biliary colic nor does he have signs of cancer. Episodic pain is not typical
during bouts of acute pancreatitis, and pancreas divisum does not cause duodenal obstruction. Annular pancreas fits best with his history,
his constellation of present symptoms, and his upper gastrointestinal study.

14. A 44-year-old woman was hospitalized 3 weeks earlier with acute pancreatitis believed to be secondary to the azathioprine
therapy, which was used as maintenance immunosuppressive for her transplanted kidney. The azathioprine therapy was discontinued,
and she gradually recovered. She presents to clinic today with a new complaint of early satiety, intermittent nausea, and one episode
of postprandial vomiting. Abdominopelvic computed tomography (CT) reveals a 5-cm, round, fluid collection within the lesser sac.
Which of the following is the most appropriate therapy for the management of this patient?

(A) Observation and follow-up CT in 3–6 weeks

(B) Laparotomy and cystgastrostomy

(C) Gastroscopy and endoscopic cystgastrostomy

(D) Percutaneous drainage

(E) Restart azathioprine therapy

14–A. This patient, who recovered from an episode of acute pancreatitis 3 weeks ago, appears to have an evolving pancreatic pseudocyst.
The majority of small pseudocysts (< 5 cm) will resolve spontaneously. Those larger are likely to require intervention. Pseudocysts should
not be drained until they have a mature capsule, which generally takes 6–8 weeks from the time of the acute pancreatitis. Therefore,
none of the drainage procedures (laparotomy and cystgastrostomy; gastroscopy and endoscopic cystgastrostomy; percutaneous drainage)
are appropriate only 3 weeks after the resolution of the acute pancreatitis. The inciting agent—azathioprine—should not be restarted this
early. It can be substituted with other agents if necessary.

15. Patients having undergone splenectomy are at increased risk of developing overwhelming sepsis from which of the following
organisms?

(A) Helicobacter pylori

(B) Klebsiella pneumoniae

(C) Bacteroides fragilis

(D) Staphylococcus aureus

(E) Enterococcus faecium

15–B. Overwhelming postsplenectomy infection (OPSI) is an uncommon event, occurring at a rate of 0.3%–1.8% among adults over an 8-year
follow-up. The mortality rate of postsplenectomy sepsis is approximately 50%, and thus it must be taken very seriously. Encapsulated
organisms are the usual causes. Among the organisms listed only Klebsiella pneumoniae is encapsulated.

16. A 48-year-old, alcoholic male has been hospitalized over the last 20 years more than 30 times for episodes of acute pancreatitis. He
now presents to the emergency department complaining of mid-back pain and horribly malodorous and frequent soft stools. He
describes that the stools float in the toilet. He also explains that he has lost 30 lb over the last 6 months. Which of the following
therapeutic measures is the best option to improve this patient's health maintenance?

(A) Total pancreatectomy

(B) Oral pancreatic enzyme replacement

(C) Total parenteral nutrition

(D) Octreotide therapy

(E) High-fat diet

16–B. This patient has chronic pancreatitis and signs of pancreatic insufficiency with steatorrhea and weight loss secondary to
malabsorption. Total pancreatectomy is not likely to improve the patient's health. Oral pancreatic enzyme replacement will treat both this
patient's fatty stools and his malabsorption. He should also initiate a high-carbohydrate, high-protein diet to stabilize his weight. Although
total parenteral nutrition may help this patient's malnourishment acutely, it is not a good option as it would restrict his activities, require a
central venous catheter, carry a significant risk of morbidity, not provide optimal nutrition, and be quite costly. Octreotide therapy would
likely make this patient's symptoms worse, as it would inhibit any remaining pancreatic exocrine function. A high-fat diet would worsen this
patient's steatorrhea.

17. A 57-year-old, male alcoholic with chronic pancreatitis has had several episodes of acute pancreatitis in the last year. Today he
presents to the emergency department with hematemesis. After admission to the intensive care unit and resuscitation,
esophagogastroduodenoscopy (EGD) reveals large gastric varices, one of which is actively bleeding. The bleeding varix is successfully
banded, but over the next 12 hours the patient's hematocrit continues to fall despite blood transfusions, and fresh blood continues to
drain from a nasogastric tube. Upon review of an abdominal computed tomography (CT) scan performed 1 month ago you note a
markedly calcified pancreas, large gastric varices, and no enhancement of the splenic vein. Which of the following is the most
appropriate next step in the management of this patient?

(A) Emergent splenectomy

(B) Repeat EGD and sclerotherapy

(C) Sengstaken-Blakemore tube placement

(D) Excision of the gastric varices

(E) Intravenous (IV) vasopressin

17–A. This patient developed splenic vein thrombosis secondary to pancreatitis. He has since developed sinistral portal hypertension with
massive gastric varices formed from the enlarged short gastric veins, which now drain the splenic blood supply completely. Splenectomy
will cure this patient's left-sided portal hypertension. It should be understood that emergent laparotomy in the setting of variceal bleeding
carries a high mortality rate. Repeat esophagogastroduodenoscopy (EGD) in a patient with actively bleeding, large gastric varices that have
failed one attempt at banding is not likely to be successful, will delay definitive therapy, and will increase his mortality risk. Sengstaken-
Blakemore tubes are useful as a temporizing measure in patients with intractable esophageal varices, however they do not work well with
gastric varices. Excision of the varices is not curative and risks inappropriate gastric devascularization. Intravenous (IV)) vasopressin may be
temporizing, but does not address the underlying pathology and has not been shown to reduce mortality in this setting.

18. A 33-year-old woman presents with complaints of frequent paroxysms of profuse diaphoresis and a “racing heart.” She has seen
several physicians about these concerns, but none have “helped her.” Occasionally, these episodes result in her fainting. She generally
feels better if she eats right after the onset of symptoms. A portable glucometer demonstrates that she has a normal blood glucose
level in your clinic. Reports from other physicians demonstrate that she has had several low blood glucose levels and elevated insulin
levels documented. She explains that her symptoms do not occur every day. Which of the following laboratory tests may aid in
establishing her diagnosis?

(A) Glucagon level

(B) Lactate dehydrogenase level

(C) Erythrocyte sedimentation rate

(D) C-peptide level

(E) Somatostatin stimulation test

18–D. This patient may be feigning illness by administering insulin surreptitiously. This possibility can be excluded by measuring either
proinsulin or C-peptide (an insulin precursor) levels. None of the other tests would be likely to aid in the diagnosis. Somatostatin is an
inhibitory enzyme, not a stimulating one.
5. Treatment is local excision without axillary node dissection.

B. Occult breast cancer

is breast cancer presenting as axillary metastases with an unknown primary.

1. Fifty-five to seventy-five percent of these patients are found to have cancer after mastectomy.
2. Radiation therapy may be an option for patients who desire breast conservation.

3. Treatment is usually modified radical mastectomy.

C. Male breast cancer

1. Overview

a. There are approximately 900 new cases of male breast cancer per year, about 1% of breast cancer cases.

b. M ean age of presentation is 60–65.

2. Risk factors include

previous radiation.

family history.

Klinefelter's syndrome.

protracted hyperestrogenemic state.

3. These tumors are

ductal in origin, and 80% are estrogen receptor-positive.

tend to metastasize early in the course of the disease.

4. Treatment is a modified radical mastectomy.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A newborn is found to have an additional nipple in the right axilla. Which of the following characteristics
are most likely to be associated with this condition?
(A) Amastia
(B) Hypoplasia of the ipsilateral chest
(C) Hypoplasia of the ipsilateral breast
(D) Normal development
(E) Bilateral breast hyperplasia
1–D. The failure of the regression of the milk line results in accessory breast tissue. The most common
congenital breast anomaly is accessory nipple(s), or polythelia, and is associated with normal breast
development. Accessory breast tissue, separate from the main breast mound, is most commonly found in
the axilla. A complete accessory breast, possessing both breast tissue and nipple, is rare. Abnormal or
total regression of the milk line may lead to underdevelopment of the breast, or amastia, and is usually
associated with hypoplasia of the ipsilateral chest wall and pectoralis muscles, or Poland syndrome.

2. A newborn is examined immediately after birth and is found to have bilateral breast hyperplasia with an associated creamy-white
discharge. What is the most appropriate evaluation for this patient?

(A) Immediate computed tomography (CT) scan of the brain to evaluate for a microadenoma and possible surgery

(B) Observation with reassurance to the parents that this is a known normal phenomenon

(C) Bilateral ductography and simple mastectomy to remove diffuse papillomas

 (D) Close observation of the newborn and thyroid supplementation

(E) Close observation and a toxin scan of both mother and infant

2–B. The epithelial bud differentiates from the retained thoracic portion of the milk line, developing from the seventh week of gestation to
birth. This bud forms into the nipple and functional breast tissues. Thus, these tissues may respond to in utero maternal hormone
stimulation by hypertrophy and the postbirth production of colostrum. Therefore, although a microadenoma causing an increase in
prolactin levels is the most common cause of bilateral nipple discharge in adults, in the newborn population this is a known normal
phenomenon and requires only observation and reassurance of the parents. Diffuse papillomatosis is primarily seen in an older population
and produces a serous discharge. Both hyperthyroidism and hypothyroidism have been associated with a bilateral discharge, but this is
rare and is usually seen in adults. There are a few toxins that can cause developmental abnormalities in the newborn, however these
usually cause extensive global abnormalities.

3. A 45-year-old, premenopausal woman presents to her doctor with a new breast mass discovered on self-breast examination. It is a
small, firm, mobile mass in the left lower outer quadrant of her breast. There are no skin changes or dimpling and no lymph nodes
palpable in her axilla. Which of the following histories would confer the greatest concern that this mass represents an invasive ductal
carcinoma?
(A) Her sister had postmenopausal breast cancer

(B) She had her menarche before age 12

(C) She had never been pregnant

(D) She had a history of atypical lobular hyperplasia

(E) She had been on birth control pills (BCPs) for 5 years when in her 20s

3–D. The risk of breast cancer increases with age, and the majority of invasive ductal carcinomas present as a new mass on physical
examination. All of the histories described are considered risk factors for the development of breast cancer. However, having never been
pregnant, having an early menarche before age 12, or having a sister who had postmenopausal breast cancer all confer a lower risk than
having the premalignant changes of atypical lobular hyperplasia, estimated to be four to five times the risk. In addition, both lobular
carcinoma in situ (LCIS) and lobular hyperplasia are strong risk factors for the development of invasive ductal carcinoma. Birth control pills
(BCPs) have not been shown to confer an increased long-term risk for breast cancer.

4. A 48-year-old, premenopausal woman presents to her doctor for routine health maintenance. She is found to have a small, firm
palpable breast mass in her left breast. The patient undergoes a bilateral mammogram (MMG) to evaluate for concurrent disease,
subclinical breast disease presenting simultaneously with the mass. The MMG shows no abnormalities, including no microcalcifications
or mass effect near the area of the palpable breast mass. Which of the following is the most appropriate next step in the evaluation of
this patient?

(A) Close observation to evaluate for increases in size or decreased mobility

(B) Ultrasound evaluation in 1 year

(C) Fine needle aspiration (FNA) for cellular evaluation

(D) Excisional biopsy and axillary node dissection

(E) Core needle biopsy and axillary node dissection

4–C. There are a large number of women without risk factors who develop breast cancer each year. The most common presentation for
breast cancer is a new mass on physical examination. Therefore, great care must be taken to rule out breast cancer in any women who
present with a new breast mass; observation is inadequate in this patient. Even though the sensitivity of a mammogram (M M G) increases
with age due to replacement of dense parenchymal tissues by fatty tissues, palpation detects 10%–20% of M M G-negative cancers. M ost
women over the age of 30 presenting with a new mass on physical examination require a definitive, cell-based, diagnosis. If a cyst was
found on an ultrasound study, suggesting a benign process, close follow-up and serial exams may be indicated rather than immediate
biopsy. A fine needle aspiration (FNA) would be the most appropriate next step in this patient owing to the pretest's likelihood that this
lesion is malignant. However, if the FNA was nondiagnostic, excisional biopsy or a core needle biopsy would be indicated. Axillary node
dissection would be premature at this point.

5. A 54-year-old woman presents with a clinically node-positive, 3-cm infiltrating ductal carcinoma in her left breast. She has no other
symptoms. Which of the following would be appropriate for the initial evaluation of this patient?

(A) Chest radiograph, bone scan, complete blood count with liver function tests, bilateral mammogram (M M G), and a computed
tomography (CT) scan of the liver

(B) Chest radiograph, bone scan, bilateral M M G, and a CT scan of the liver

(C) Chest radiograph, complete blood count with liver function tests, and a bilateral M M G

(D) Chest radiograph, bone scan, and a complete blood count with liver function tests

(E) Chest radiograph, bone scan, bilateral M M G, and a CT scan of the liver

5–C. This patient is presenting with a locally advanced tumor and therefore has a relatively high risk for metastatic disease. Infiltrating
ductal carcinoma usually spreads to regional lymph nodes first, then can metastasize to the lungs, liver, and bone. Therefore, a chest
radiograph and liver function tests are indicated. Bone metastases will either be painful or cause an increase in alkaline phosphatase. If
the patient does not have either of these, then a bone scan is not indicated. A bilateral mammogram (M M G) is indicated in all patients
presenting with recurrent disease to evaluate for concurrent disease. A computed tomography (CT) scan of the liver is not as sensitive for
small liver metastases, and therefore would only be obtained if the liver function tests were abnormal.

6. A 34-year-old woman underwent a wide local excision, axillary node dissection, and postoperative radiation to her left breast for a
node-positive, 2-cm, infiltrating ductal carcinoma 3 years ago. She received adjuvant chemotherapy at that time. She now presents with
a new 2-cm mass in the same breast, and it shows infiltrating ductal carcinoma. She has no other symptoms and has no palpable lymph
nodes. Which of the following is the most appropriate treatment for this patient?

(A) Re-excision to free margins, second axillary node dissection, and radiation therapy

(B) Combination chemotherapy alone

(C) Left total mastectomy

(D) Left modified mastectomy

(E) Combination chemotherapy and radiation therapy

6–C. Local recurrence in the breast occurs in approximately 10% of patients who are treated with wide local excision, axillary node
dissection, and radiation therapy. “Salvage” total mastectomy is usually required and survival rates approach those obtained when a
modified radical mastectomy is performed originally. In the absence of palpable lymph nodes, a second lymph node dissection is
unnecessary. The effect of radiation on tissues is cumulative and does not diminish with time. Therefore, use of more radiation therapy in
this patient increases the risk of toxicity to normal tissues and thus is usually not considered appropriate. Chemotherapy alone would be
inappropriate because of a lower long-term survival with this approach.

Questions 7-8

7. A 43-year-old professional woman presents to your office with questions about breast cancer screening. She has never had a
mammogram previously, but does monthly self-breast examinations and has not noted any masses. Her mother was diagnosed with
breast cancer at age 65, but she has no other relatives with cancer. She has had 3 children and her menarche was at age 13. The best
screening routine for this patient is to obtain a baseline mammogram

(A) At age 45, then every 2 years after age 50

(B) Now, then every 2 years thereafter

(C) Now, then every 2 years until age 50, then yearly thereafter

(D) Now, and then every 6 months thereafter

(E) Now, and then every 5 years thereafter

7–C. This woman has only one risk factor for developing breast cancer; her mother was diagnosed with postmenopausal disease. All women,
however, should obtain a baseline mammogram (M M G) between the ages of 35 and 39. Then, if there are no abnormalities, a screen M M G
should be obtained every 1–2 years between the ages of 40 and 49, and yearly thereafter. An M M G should be obtained in all women over
the age of 30 that present with breast symptoms even when there are no palpable lesions. M ammography can detect 90% of nonpalpable
breast lesions.

8. This patient undergoes a bilateral mammogram (MMG) and is discovered to have an area of microcalcifications in her right breast. She
then undergoes a needle localized excisional biopsy that demonstrates a cellular, monomorphic pattern, with poorly cohesive intact
cells, nuclear crowding, and a variation in nuclear size, prominent nucleoli, and clumping of the chromatin. There is no evidence of
microinvasion and the largest diameter is 1 cm. The margins are negative. Which of the following management options is most
appropriate?

(A) M odified radical mastectomy

(B) Reassuring the patient that the process is benign

(C) Axillary node dissection with postoperative breast radiation therapy

(D) Breast radiation therapy alone

(E) Axillary node dissection alone

8–D. This patient's lesion is most consistent with ductal carcinoma in situ (DCIS), therefore simple reassurance is inappropriate. Other
findings on mammogram (M M G) that are suggestive of DCIS include asymmetric densities, ductal asymmetry, and distortion of normal breast
architecture and skin or nipple distortion. Once a diagnosis of DCIS has been made, there are multiple factors that help determine the
most appropriate treatment. Patient's preference and reliability for close follow-up, breast size, and family history are all taken into
account. In this patient, local control of her DCIS was obtained with the lumpectomy. If this lesion had been observed, there would be
approximately a 30% chance that it would develop into an invasive carcinoma. Because the lesion was small (< 3 cm in diameter) and there
was no evidence of microinvasion, an axillary node dissection is not indicated. Although some may advocate the use of a modified radical
mastectomy for such lesions, most people would agree that this is too aggressive for DCIS. Postoperative radiation therapy has been shown
to be beneficial in reducing the local recurrence rate for small DCIS lesions.

9. A 55-year-old woman status post-breast conservation therapy for ductal carcinoma in situ (DCIS) develops a large, fixed node in her
right axilla. There are no breast masses on physical examination, and a bilateral mammogram (MMG) demonstrates no abnormalities.
You obtain a fine needle aspiration (FNA) from the axillary mass, which shows adenocarcinoma cells. Which of the following is the most
appropriate next step in the management of this patient?
(A) Axillary node dissection for staging, and radiation therapy to the breast

(B) Axillary node dissection for staging alone

(C) Radical mastectomy

(D) M odified radical mastectomy

(E) Radiation to the axillary mass without surgery

9–D. In any patient with ductal carcinoma in situ (DCIS), close follow-up with breast examination and mammogram is essential. This patient
now has evidence of regional metastatic disease with an unknown primary. In this case, axillary node dissection is not only used for
staging, but is also considered therapeutic because of the overall reduction in tumor mass. However, axillary node dissection alone does
not adequately treat the unknown primary, and thus a mastectomy is indicated. Radiation of the axilla may also treat the regional disease,
but this is inadequate and does not address the unknown primary breast lesion. M ost people would agree that a radical mastectomy is too
aggressive for such a patient. A modified radical mastectomy, the removal of all the breast tissue combined with an axillary node
dissection, is the most appropriate therapy for this patient because it provides treatment for the regional disease as well as for the
unknown primary. Approximately 55%–75% of patients with occult breast cancer are found to have lesion on mastectomy.

10. A 28-year-old woman presents to your office with painful breasts. She states that she used to suffer from pain in her breasts only
before her period, but the pain now never goes away and she can no longer function normally. She does take birth control pills (BCPs),
but does not smoke and does not drink coffee. On physical examination, you find no dominant masses and no nodes positive in her
axilla. No nipple discharge is expressible. Over the next few months you try to treat her pain conservatively, but without success.
Which of the following is the best approach to the treatment of this patient?

(A) Continue with observation alone because the process is self-limiting

(B) Prescribe more potent pain relieving drugs such as narcotics

(C) Launch an extensive work-up for invasive ductal carcinoma

(D) Prescribe danazol, with follow-up to evaluate for side effects

(E) Obtain bilateral ultrasounds to localize the fibroadenomatous disease

10–D. The patient is suffering from mastodynia, which is rarely associated with malignancy, or fibroadenomas. She has progressed from
cyclic to continuous mastodynia and thus represents a population of patients who are usually refractory to conservative therapy.
However, in this situation, treatment with reassurance alone is inappropriate because of the disabling nature of her disease. Narcotics do
not provide good pain relief for such a disease. Danazol has been shown to be very effective for such patients, as well as low-dose
tamoxifen. Danazol is usually well tolerated, but may cause amenorrhea, body fat redistribution, hirsutism, acne, weight gain, and
deepening of the voice. Long-term use has been associated with liver function abnormalities.

11. A 37-year-old woman presents to the clinic with a history of left-sided bloody nipple discharge. She denies any pain or any changes
on self-breast examination. She has no other complaints. She is very concerned because her sister died at the age of 42 of breast
cancer. On physical examination, you cannot appreciate any dominant masses. There is a small amount of blood-tinged nipple discharge.
On mammogram (MMG), there are no abnormalities seen. Which of the following is the most appropriate next step in the evaluation and
treatment of this patient?

(A) Observation with strict instructions to return when and if the bloody discharge occurs again

(B) Ultrasound to evaluate for any cystic masses

(C) Re-examination in 6 months with bilateral mammogram (M M G)

(D) Simple mastectomy and close follow-up

(E) Ductography and potential subareolar excision

11–E. M ost causes of nipple discharge are benign, however, spontaneous nipple discharge that is bloody tinged may represent cancer.
Therefore, in low risk patients, observation combined with serial examinations is probably sufficient. However, in the high-risk patient,
great care is required to confirm the diagnosis of an intraductal papilloma and observation is inadequate. Intraductal papillomas are the
most common cause of bloody nipple discharge, although half the time the discharge is serous. These are usually small, nonpalpable lesions
close to the nipple that are usually not seen on mammogram (M M G) or ultrasound, so evaluation in 6 months with M M G or ultrasound
would usually miss the papilloma. Diagnosis is generally made by ductography and curative treatment consists of subareolar excision. There
is no increased risk of cancer, so simple mastectomy may be too aggressive for the treatment of this disease. Diffuse papillomatosis affects
multiple ducts and both breasts. The papillomas are larger and the discharge is serous, not bloody. With this diagnosis, there is an
increased risk of breast cancer (40%), therefore simple mastectomy may be indicated.

12. A 66-year-old woman returns to your office 10 years after being treated for advanced left breast cancer. At that time, she had a
radical mastectomy and radiation therapy to her axilla for regional control. She states that for the last 4 years, she has noticed swelling
in her left hand and now is somewhat distressed because there seems to be a rash progressing up her arm. On physical examination, she
does have 4+ pitting edema in her hand as well as multiple painless purplish red nodules that seem to be spreading up her arm. Which
of the following is the most likely diagnosis for this mass?
(A) Bacterial cellulitis

(B) Paraneoplastic coagulopathy

(C) Post-traumatic hematoma

(D) Lymphangiosarcoma

(E) Lymphoma

12–D. Long-standing lymphedema of any kind predisposes to the development of lymphangiosarcoma. M ost of these tumors develop in
patients with massive lymphedema, usually as a result of the combination of a complete axillary node dissection (including the level III
nodes) and axillary radiation. A single discrete tumor is rarely encountered. Rather, purplish red nodules are usually seen and are easily
mistaken for bacterial cellulitis. These tumors are almost always high-grade and spread rapidly to involve most of the arm as well as the
shoulder and chest wall. Pulmonary metastases are also commonly found at the time of diagnosis. M ost patients die within 2 years of
presentation. If these lesions represented a post-traumatic hematoma or the manifestations of a paraneoplastic coagulopathy, they would
probably be painful. Lymphomas are typically solitary masses.

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 13-17

A. Infiltrating ductal carcinoma

B. Comedo intraductal carcinoma

C. Lobular carcinoma in situ

D. M edullary carcinoma
E. Inflammatory carcinoma

M atch each histologic type of breast cancer with the most likely associated description.

13. Associated with lymphocytic infiltration and a good prognosis. (SELECT 1 TYPE) D. Medullary carcinoma

13–D. M edullary carcinoma usually presents as a palpable mass with smooth borders on mammogram (M M G) that mimic a benign condition.
However, histologic examination reveals its malignant nature and typically has marked lymphocytic infiltration. Overall, it carries a relatively
good prognosis.

14. Significant likelihood of multicentric ipsilateral disease. (SELECT 2 TYPES) B. Comedo intraductal carcinoma C. Lobular
carcinoma in situ
14–B, C. The comedo form of ductal carcinoma in situ (DCIS) has the highest microinvasive rate and multicentric rate of these lesions. It is
best treated with lumpectomy and postoperative radiation therapy. Lobular carcinoma in situ (LCIS) is also characterized by a high rate of
multicentricity.

15. Highest likelihood of bilateral disease. (SELECT 1 TYPE) C. Lobular carcinoma in situ

15–C. Lobular carcinoma in situ (LCIS) is usually considered a major risk factor for ductal carcinoma and usually presents as an incidental
finding on breast biopsy of another lesion in postmenopausal women. Approximately 20%–25% of women who are found to have LCIS will
develop breast cancer within 15 years of the diagnosis, with both breasts being at equal risk.

16. Dermal lymphatic invasion. (SELECT 1 TYPE) E. Inflammatory carcinoma

16–E. Inflammatory carcinoma, a variant of infiltrating ductal carcinoma, is characterized by the clinical appearance of inflammation (peau
d'orange, warmth, edema, and pain) secondary to dermal lymphatic invasion. Its prognosis is poor.

17. Most common carcinoma presenting as a breast mass. (SELECT 1 TYPE) A. Infiltrating ductal carcinoma

17–A. Although there are variants of infiltrating ductal carcinoma, overall this lesion is the most common malignancy presenting as a breast
mass.
 is characterized by persistent disease in patients with secondary hyperparathyroidism despite renal transplantation secondary to
dysregulated parathyroid function.

is associated with hypercalcemia and elevated PTH levels.

2. Treatment often requires surgical resection with subtotal thyroidectomy.

F. Parathyroid carcinoma

1. Compared with adenomas patients with parathyroid carcinomas are younger, with an equal male:female ratio.
2. Patients are more frequently symptomatic with elevated levels of calcium, PTH, and alkaline phosphatase.

3. Histologically, characteristics include

a trabecular pattern.

mitotic figures.

capsular invasion.
angioinvasion.

4. The affected glands are often adherent to surrounding tissue.

5. Treatment is with radical resection of the involved gland, the ipsilateral thyroid gland, and regional lymph nodes.

Chemotherapy and radiation therapy provide no additional benefit.

The recurrence rate is ~50%.

Long-term prognosis is poor.

Survival depends on complete resection at the initial operation.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. During a routine check-up, an otherwise healthy 38-year-old woman is found to have hypercalcemia on
a routine chemistry panel. Additional work-up reveals an elevated parathyroid hormone (PTH) levels as
well. At the time of operation, which of the following histopathologic findings would suggest the presence
of parathyroid carcinoma in this patient?
(A) Diffuse proliferation of chief cells in all 4 glands
(B) Sheets of chief cells in all 4 glands
(C) Focal chief cell hyperplasia extending through the capsule
(D) Focal chief cell hyperplasia compressing a normal rim of tissue
(E) Focal chief cell hyperplasia in 2 different glands
1–C. Differentiating a parathyroid adenoma from a carcinoma may sometimes be difficult. Adenomas are
characterized by focal chief cell hyperplasia compressing a normal rim of parathyroid tissue. Characteristic
histologic findings of a carcinoma include microvascular invasion and invasion of the surrounding capsule.
Focal hyperplasia in 2 glands is suggestive of multiple adenomas. Diffuse proliferation of chief cells, or
sheets or cords of chief cells in all 4 glands is suggestive of diffuse parathyroid hyperplasia.

2. A 35-year-old woman presents with flank pain and hematuria, and during evaluation is found to have calcium phosphate stones in her
urine along with hypercalciuria and hypercalcemia. Subsequent work-up reveals an elevated parathyroid (PTH) level. After resolution of
this episode of renal colic, she undergoes elective neck exploration. Initial exploration of the right neck posterior to the right lobe of
the thyroid reveals 2 diffusely enlarged parathyroid glands, which are successfully removed. Which of the following is the most
appropriate statement regarding the subsequent management of this patient?

(A) No additional exploration if an adenoma is identified on frozen section

(B) Exploration of the left side only if hyperplasia is identified

(C) Exploration of the left side only if an adenoma is identified

(D) Resection of 3.5 parathyroid glands if an adenoma is seen on frozen section

(E) Performance of frozen sections and exploration of the left side

2–E. As many as 15%–20% of patients will have multiple adenomas at the time of surgery. During a neck exploration for parathyroid disease,
identification of all glands is important if diffuse hyperplasia is a concern. In the patient described, frozen sections of the initial 2 glands
should be performed to confirm the presence of parathyroid tissue in the resected specimens. Despite the findings, exploration of the left
side should be performed for the reasons mentioned above.

3. A 42-year-old woman presents for elective total thyroidectomy for a follicular carcinoma of the thyroid gland diagnosed by fine
needle aspiration (FNA). Intraoperatively, ligation of which of the following vessels is necessary to obtain complete vascular control of
the thyroid gland in this patient?

(A) Inferior and superior thyroid arteries; and inferior, middle, and superior thyroid veins

(B) Inferior, middle, and superior thyroid arteries; and inferior and superior thyroid veins
(C) Inferior and superior thyroid arteries and veins; and thyroid ima artery

(D) Inferior, superior, and middle thyroid veins; and superior, middle, and thyroid ima arteries

(E) Inferior, middle, and superior thyroid arteries and veins; and thyroid ima vein

3–A. A general understanding of the arterial and venous supply to the thyroid gland is essential for adequate vascular control during
resection. The thyroid gland is generally supplied by 2 major arteries: the inferior and superior thyroid arteries. A small percentage of
patients (10%–15%) will have an accessory thyroid ima artery arising directly from the aortic arch. There are 3 major veins draining the
thyroid gland: the superior, inferior, and middle thyroid veins. Variations of both the arterial and venous systems may exist.

4. A 56-year-old woman presents to the office with a 2-cm neck mass just left and lateral to the trachea in the inferior lobe of the left
thyroid gland. Fine needle aspiration (FNA) reveals a moderately differentiated tumor that stains strongly for amyloid. In addition, her
calcitonin is elevated. Which of the following is the most appropriate therapy for this patient?

(A) Total thyroidectomy with radioiodine (131I) ablation therapy

(B) Total thyroidectomy with bilateral lymph node dissection

(C) Total thyroidectomy with left-sided lymph node dissection

(D) Left lobectomy and isthmusectomy with left-sided lymph node dissection

(E) Left lobectomy and isthmusectomy alone

4–C. The presence of amyloid on histologic examination is a classic finding for medullary carcinoma of the thyroid. These tumors arise from
parafollicular, or C, cells and may secrete calcitonin, which is also a characteristic diagnostic finding. Treatment involves total
thyroidectomy and central lymph node dissection on the side of the lesion. If bilateral tumors are identified, then bilateral lymph node
dissection may be required. A lobectomy and isthmusectomy would be inadequate therapy for this tumor. These tumors are insensitive to
radioiodine (131I) ablation therapy, although external beam radiation therapy to the neck is considered in some patients with this disease.

5. A 47-year-old woman presents to the office with complaints of a 4-month history of worsening fatigue and weight gain. Palpation of
the thyroid gland reveals an irregular lobulated gland bilaterally. Laboratory evaluation demonstrates serum antimicrosomal antibodies.
Which of the following best describes the histologic findings that are likely to be identified upon biopsy of this patient's thyroid?
(A) Diffuse sheets and cords of chief cells

(B) Proliferation of parafollicular cells with amyloid

(C) Well differentiated tumor with psammoma bodies

(D) Diffuse lymphocytic infiltrate with germinal centers

(E) Follicular cell proliferation with vascular invasion

5–D. The presence of antimicrosomal or antithyroglobulin antibodies in the serum is suggestive of Hashimoto's thyroiditis, which is a
frequent cause of hypothyroidism. This disease can present with a diffusely enlarged gland although a firm, rubbery, multilobulated gland
may also be present and may mimic thyroid tumors. The characteristic histopathologic finding of Hashimoto's thyroiditis is diffuse
lymphocytic infiltrate with normal germinal centers. Diffuse sheets and cords of chief cells suggests diffuse parathyroid hyperplasia.
Parafollicular, or C, cell proliferation with the presence of amyloid is suggestive of medullary thyroid carcinoma. Psammoma bodies are
characteristic of papillary tumors. Extensive follicular cell proliferation with vascular invasion is suggestive of a follicular carcinoma.

6. A 41-year-old woman presents to the office with a 3-cm nodule in the right lobe of the thyroid gland involving part of the isthmus.
Fine needle aspiration (FNA) of the lesion reveals a well differentiated lesion with lamellar mineral deposits surrounding necrotic cells
(psammoma body). Which of the following is the most appropriate treatment for this patient?

(A) Right lobectomy with isthmusectomy and radioiodine (131I) therapy

131
(B) Total thyroidectomy and postoperative I therapy

(C) Total thyroidectomy alone

(D) Right lobectomy with isthmusectomy alone

(E) Total thyroidectomy with right-sided lymph node dissection

6–B. Psammoma bodies are a classic histologic finding of papillary carcinoma of the thyroid gland. Appropriate surgical treatment of large
papillary carcinomas near the isthmus includes total or near total thyroidectomy with postoperative radioiodine (131I) ablation therapy
because these lesions are sensitive to 131I. A lymph node dissection is generally not required in these patients. For some small papillary
carcinomas (< 1.5 cm) involving 1 lobe only, some advocate lobectomy and isthmusectomy alone; however, in this setting this would be
considered inadequate treatment.

7. A 54-year-old woman undergoes an elective total thyroidectomy for follicular cell carcinoma. The dissection was noted to be
somewhat difficult but the patient tolerated the procedure well. Twelve hours postoperatively the patient is noted to be very anxious.
On physical examination she is noted to have facial fasiculations and facial muscle twitching to palpation. Which of the following is the
most appropriate therapy for this patient?
(A) Administration of calcium supplements

(B) Direct laryngoscopy to identify paralyzed vocal cord

(C) Re-exploration and evacuation of hematoma

(D) Immediate reintubation

(E) Immediate forearm implantation of inadvertently resected parathyroid tissue

7–A. Postoperative hypoparathyroidism with resultant hypocalcemia is most commonly caused by devascularization of the parathyroid
glands rather than removal of all the glands. After thyroid surgery, permanent hypoparathyroidism is quite rare, although temporary
hypocalcemia may be present. Signs and symptoms of the resultant hypocalcemia in the postoperative period include paresthesias, tetany,
seizures, mental status changes, Chvostek sign (facial twitching with tapping of the facial nerve), and Trousseau sign. Treatment involves
administration of calcium supplements (e.g., intravenous calcium gluconate). Recurrent laryngeal nerve injury is unlikely to cause these
signs and symptoms; thus, laryngoscopy or reintubation is not necessary. A hematoma is also unlikely to present in this manner. Delayed
forearm transplantation, hours after removal of the specimen would not be helpful acutely and is unlikely to be successful.

8. A 35-year-old man with a 5-year history of end-stage renal disease requiring hemodialysis presents to the emergency room with
complaints of right leg pain after minor trauma to the area. Plain radiographs reveal a fracture line along the tibia with notable bone
demineralization and soft tissue calcification. Further work-up reveals elevation of parathyroid hormone (PTH) and a decreased ionized
calcium level. Which of the following is the most appropriate treatment measure for this patient's underlying condition?

(A) Resection of 3.5 parathyroid glands

(B) Resection of all parathyroid glands with autotransplantation

(C) Radiation therapy to the parathyroid glands

(D) Calcium supplements, vitamin D, and alteration of dialysis fluid

(E) Calcium restriction and alteration of dialysis fluid

8–D. This patient has characteristic findings of secondary hyperparathyroidism in a patient on chronic hemodialysis. The presence of a
pathologic fracture precipitated by minor trauma with bone demineralization and soft tissue calcification in association with an elevated
parathyroid hormone (PTH) and hypocalcemia is characteristic of this disease. Treatment involves administering calcium supplements,
vitamin D, and adding calcium to dialysate fluid. Calcium restriction and altering dialysis fluid are contraindicated in this setting.
Parathyroid resection is not indicated in the treatment of secondary hyperparathyroidism. Radiation therapy plays no role in the
treatment of hyperparathyroidism.

9. A 75-year-old man presents to the office for a routine check-up. The patient states that he has been doing well except for some mild
low-back pain, which he attributes to working too much in the yard. A chemistry panel reveals an elevated calcium level but no other
significant abnormalities. Plain radiographs reveal multiple lytic lesions within the vertebral bodies of L4 and L5. After a thorough
physical examination, which of the following tests is most appropriate in the subsequent evaluation of this patient?

(A) Serum parathyroid hormone (PTH) levels and neck ultrasound

(B) Serum PTH levels and measurement of creatinine clearance

(C) Neck exploration and resection of 3.5 parathyroid glands

(D) Transrectal ultrasound of the prostate and prostate-specific antigen levels

(E) Serum PTH and computed tomography (CT) scan of the neck

9–D. M alignancy is a frequent cause of hypercalcemia. In the setting described, metastatic disease to the lumbar vertebrate should be
suspected as the cause of hypercalcemia rather than a primary disorder of the parathyroid gland. Adenocarcinoma of the prostate gland
frequently metastasizes to the vertebral bodies and produces characteristic osteoblastic lesions, as described. Transrectal ultrasound of
the prostate and measurement of prostate-specific antigen levels would be appropriate in the evaluation of this patient before any work-
up of parathyroid disease. M ultiple myeloma may also cause osteoblastic lesions; this is seen most commonly in men 50–60 years old. Other
tumors that should be considered in this setting include lung, colon, and breast (women > men) cancers. M easurement of PTH or neck
exploration would not be useful in the evaluation or management of this patient's primary disease process.

10. A 46-year-old woman presents to the office with a 3-cm mass in the right lobe of the thyroid. On physical examination, the mass is
noted to be cystic in nature. Fine needle aspiration (FNA) of the cyst reveals colloid. Which of the following is the most appropriate
management strategy for this patient?

(A) No further therapy and continued observation

(B) Total thyroidectomy alone

(C) Right lobectomy and isthmusectomy

(D) Total thyroidectomy and radioiodine (131I) therapy

(E) Total thyroidectomy and right-sided lymph node dissection

10–A. M ost cystic masses are benign in nature and represent simple colloid-filled cysts. Simple needle-guided drainage of these lesions is
adequate therapy. Recurring lesions or cystic lesions that persist for longer than 3 months may require resection. It should be noted that
some carcinomas of the thyroid may undergo central necrosis and appear cystic, although cytology will generally identify these lesions.
Formal resection in the setting of a simple colloid nodule is not indicated. Formal resection or ablation therapy is not required for simple
cystic lesions that respond to needle-guided drainage.
 elevated urinary catecholamines and metabolites.

presence of the ret oncogene

4. Treatment

a. Unilateral or bilateral adrenalectomy

should be performed for unilateral and bilateral pheochromocytomas, respectively.

b. Thyroidectomy and parathyroidectomy

can be performed simultaneously 1–2 weeks after adrenalectomy.

c. A total thyroidectomy with central lymph node dissection

is generally performed for medullary thyroid tumors.

M any surgeons advocate total thyroidectomy with a radical neck dissection for M TC associated with M EN II.

d. A total parathyroidectomy with autotransplantation

is generally performed for hypercalcemia or an enlarged parathyroid gland.

5. Differences between familial (MEN) and sporadic forms

a. Medullary thyroid carcinoma

is usually bilateral with MEN.

is often more aggressive when associated with M EN.

is unilateral with sporadic forms.

b. Pheochromocytomas

are usually bilateral (60%–80%) with MEN.

are unilateral (90%) with sporadic forms.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 26-year-old woman presents with anxiety and hypertension, and is diagnosed with a presumed
pheochromocytoma based on preliminary laboratory studies. Which of the following diagnostic tests is
contraindicated for pheochromocytoma?
(A) Computed tomography (CT)
(B) Magnetic resonance imaging (MRI)
(C) Metaiodobenzylguanidine (MIBG) radionuclide scanning
(D) Selective arteriography
(E) Ultrasound
1–D. Computed tomography (CT), magnetic resonance imaging (MRI), metaiodobenzylguanidine (MIBG)
scans, and ultrasound can all be used in the work-up of a suspected adrenal mass. Ultrasound is the least
useful of these tests owing to limited resolution and limited visualization of surrounding anatomy. In
addition, ultrasound can only visualize tumors larger than 2 cm. CT scan provides more information about
surrounding anatomical structures and is useful for detecting tumors as small as 1 cm. MIBG selectively
accumulates in chromaffin tissue and will do so more rapidly in a pheochromocytoma than in normal
tissue. Selective angiography is contraindicated because a sudden increase in intraglandular pressure can
cause a massive release of catecholamines and precipitate a hypertensive crisis.

2. Which of the following adrenal masses could be treated with observation and follow-up after a complete metabolic work-up?

(A) Nonfunctioning, 3-cm, solid adrenal mass in a 38-year-old man

(B) Nonfunctioning, 7-cm, cystic adrenal mass in a 25-year-old woman

(C) Functioning, 2-cm, cystic mass in a 45-year-old woman

 (D) Nonfunctioning, solid mass that has doubled in size in 1 year in a 67-year-old man

(E) A 10-cm, solid adrenal mass in a 56-year-old man

2–A. General criteria that are considered indications for surgical intervention for an adrenal mass include functional tumors of any size,
tumors that increase in size during follow-up, and nonfunctional tumors that are 6 cm or larger. These tumors are at greatest risk for
harboring malignancy. Nonfunctioning adrenal tumors smaller than 6 cm are unlikely to harbor malignancy and some surgeons advocate
simple observation and follow-up computed tomography (CT) scans in 3 to 6 months. Some surgeons use 3–4 cm as the upper limit instead of
6 cm.

3. A 45-year-old man presents with a 4-cm adrenal mass that has been diagnosed as a pheochromocytoma by preoperative testing.
Preoperative preparation in this patient should initially include which of the following?

(A) Administration of phenoxybenzamine

(B) Administration of propranolol, followed by phenoxybenzamine

(C) Administration of furosemide

(D) Fluid restriction

(E) Administration of propranolol

3–-A. The physiologic effects seen in a patient with a pheochromocytoma are a result of α- and β-adrenergic stimulation. α-Receptor
blockade (e.g., phenoxybenzamine, phentolamine) should be instituted before surgery to counteract the diffuse vasoconstriction seen in
patients with an active pheochromocytoma. The vasodilation that ensues after α blockade will result in a functional hypovolemia, making
diuretic therapy (e.g., furosemide) and fluid restriction contraindicated before surgery. β-antagonist therapy (e.g., propranolol) is often
needed after α antagonist therapy is instituted to counteract the reflex tachycardia that may result. However, β-antagonist therapy
should never be started before α blockade, as it can result in unopposed α stimulation from the pheochromocytoma, causing malignant
hypertension and congestive heart failure.

4. A 40-year-old woman who has been treated with prednisone for 2 years for rheumatoid arthritis undergoes emergent splenectomy
after a motor vehicle accident. Postoperatively, the patient develops fever, abdominal pain, nausea, and vomiting. Laboratory data
reveal hyperkalemia, hypoglycemia, and hyponatremia. Immediate measures should include which of the following?

(A) Rapid correction of hyponatremia

(B) Administration of saline, glucose, and dexamethasone

(C) Saline infusion and fludrocortisone

(D) Intravenous hydrocortisone alone

(E) Plasma adrenocorticotropic hormone (ACTH) and cortisol levels after initiation of therapy
4–B. Emergency measures in the treatment of acute adrenal insufficiency include establishment of intravenous (IV) access, immediate
assessment of serum electrolyte, glucose, and adrenocorticotropic hormone (ACTH) levels, and subsequent infusion of 2–3 liters of isotonic
saline. Treatment with IV dexamethasone should also be instituted. Initiation of therapy before measuring plasma ACTH and cortisol may
interfere with assessment of these hormones. Rapid correction of hyponatremia is rarely indicated, as central pontine myelinolysis can
result. Fludrocortisone has no role in the acute management of acute adrenal insufficiency, although it is used in the treatment of
chronic insufficiency. Hydrocortisone alone without adequate administration of fluids is inadequate therapy.

5. A 45-year-old man presents to the emergency room after having fallen from a height of 12 feet. He complains only of abdominal pain,
and a computed tomography (CT) scan is eventually performed to evaluate his abdomen. No injuries are noted but a 5-cm solid adrenal
mass is detected. Which of the following studies is inappropriate in the work-up of this lesion?

(A) Serum potassium

(B) Serum aldosterone

(C) Fine needle aspiration (FNA)

(D) Chest radiograph

(E) Urine metanephrines

5–C. The work-up of adrenal incidentalomas should include serum and urine testing to assess the possibility of a functional tumor. A chest
radiograph should also be obtained to rule out the possibility of a metastatic lesion from the chest. Fine needle aspiration (FNA) has no
place in the work-up of a new adrenal lesion because the information obtained is rarely helpful unless the lesion is metastatic. In addition,
FNA may be dangerous because of the risk of precipitating a hypertensive crisis in a patient with a pheochromocytoma.

6. A 62-year-old man presents with an 8-cm, nonfunctioning adrenal tumor. Which of the following statements is true regarding the
surgical approach in this patient?

(A) The anterior approach is usually used for patients with potential bilateral disease

(B) The posterior approach is used for lesions larger than 5 cm because of greater exposure of the retroperitoneum

(C) The lateral approach is the preferred method for patients with bilateral adrenal disease

(D) Laparoscopic adrenalectomy is contraindicated in right-sided lesions because of the short adrenal vein

(E) Laparoscopic adrenalectomy is contraindicated in lesions larger than 4 cm

6–A. Adrenal tumors can be removed by a variety of surgical approaches. An anterior approach is preferred for suspected bilateral tumors
because it allows for inspection of both glands through a single incision. The posterior approach is generally better tolerated
postoperatively but gives only limited exposure. The lateral approach is used for large, unilateral tumors or for bilateral tumors in obese or
high-risk patients, although it is not generally the preferred method because of the postoperative pain and morbidity associated with
bilateral subcostal flank incisions. Laparoscopic adrenalectomy is more difficult in right-sided and large lesions, but is not contraindicated
in either scenario.

Directions: Each set of matching questions in this section consists of four to twenty-six lettered options followed by several numbered
items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more than once,
or not at all.

Questions 7–11

A. Cushing's disease

B. Ectopic adrenocorticotropic hormone (ACTH) syndrome

C. Adrenal carcinoma/adenoma
D. Hyperaldosteronism

E. Adrenogenital syndrome

F. Pheochromocytoma

G. Primary hyperparathyroidism
H. M ultiple endocrine neoplasia (M EN) II syndrome

M atch the following surgical causes of hypertension with their respective clinical scenarios.

7. A 30-year-old man presents with truncal obesity, hypertension, and weakness. Work-up reveals increased urine cortisol and
decreased plasma ACTH. (SELECT 1 CAUSE) C. Adrenal carcinoma/adenoma

7–C. This patient exhibits the signs and symptoms of plasma cortisol excess. Possible causes include Cushing's disease, ectopic
adrenocorticotropic hormone (ACTH) syndrome, adrenal cancer, adrenal adenoma, and iatrogenic causes. However, the fact that this
patient's plasma ACTH is decreased rules out Cushing's disease (primary pituitary source). Although not one of the choices listed, it should
be noted that ACTH may be decreased in the presence of signs and symptoms of Cushing's syndrome with exogenous administration of
corticosteroids.

8. A 65-year-old man presents with truncal obesity, hypertension, and weight loss. Work-up reveals increased urinary cortisol and
ACTH. (SELECT 2 CAUSES) A. Cushing's disease B. Ectopic adrenocorticotropic hormone (ACTH) syndrome

8–A, B. There are numerous potential causes of Cushing's syndrome. Both ectopic adrenocorticotropic hormone (ACTH) production and
Cushing's disease would produce elevated cortisol and ACTH. These two possible causes can usually be differentiated from one another
with the aid of a dexamethasone suppression test.

9. A 30-year-old man presents with hypertension and weakness. Work-up reveals the following laboratory values: Na1 = 153, K1 = 1.9,
blood pressure = 150/98, central venous pressure = 15. (SELECT 1 CAUSE) D. Hyperaldosteronism

9–D. Elevated serum sodium, decreased serum potassium, and hypertension are the classic signs of hyperaldosteronism (i.e., Conn's
syndrome). Work-up of this patient would include 24-hour urine aldosterone as well as plasma renin activity. Diagnostic studies are needed
to differentiate adrenal hyperplasia from an adenoma because the treatments differ for these two possible causes (medical therapy for
hyperplasia versus surgical treatment for an adenoma).

10. A 26-year-old man presents with episodic hypertension and anxiety. Work-up reveals increased urinary vanillylmandelic acid (VMA)
and metanephrines. (SELECT 1 CAUSE) F. Pheochromocytoma

10–F. Complaints of episodic hypertension should raise suspicion for a pheochromocytoma, especially in young patients. Increased levels of
catecholamine breakdown products (vanillylmandelic acid and metanephrines) in the urine essentially confirms the diagnosis. Further
localization studies include abdominal computed tomography (CT), magnetic resonance imaging (M RI), or metaiodobenzylguanidine (M IBG)
scan.

11. A 30-year-old woman presents with a 4-month history of hypertension and a thyroid mass. Work-up reveals hypercalcemia. (SELECT
1 CAUSE) H. Multiple endocrine neoplasia (MEN) II syndrome

11–H. The diagnosis of pheochromocytoma should be considered in any young patient who presents with hypertension. Furthermore, the
additional finding of a thyroid mass should raise suspicion for the multiple endocrine neoplasia (M EN) II syndrome (pheochromocytoma,
medullary thyroid cancer, and hyperparathyroidism). Preoperative work-up should include serum calcium levels in patients with suspected
M EN II syndrome because any parathyroid dysfunction can be addressed at the same time as the thyroid mass. Should a
pheochromocytoma also be present, it should be addressed first at a separate procedure.
4. Resection of isolated pulmonary metastasis may be associated with a 20%–30% increase in the 5-year survival rate.

5. The role of chemotherapy in the treatment of metastatic disease is still being investigated.

H. Kaposi's sarcoma

is a rare, aggressive sarcoma seen most commonly in severely immunosuppressed patients (e.g., acquired immunodeficiency syndrome
[AIDS]).

1. These lesions involve the skin or mucous membranes and occasionally the intestinal tract.

2. Surgery is indicated with intestinal perforation or hemorrhage, although overall survival is very low.

I. Desmoid tumors

may be considered low-grade sarcomas or a reactive process.

1. When resected, desmoids frequently recur locally but rarely metastasize.

2. Trauma or surgery commonly precedes the development of desmoids.

3. These lesions are divided into three subgroups.

a. Extra-abdominal desmoids

tend to occur on the muscles of the back, shoulders, chest wall, and thigh.

b. Abdominal desmoids

arise in the musculoaponeurotic structures of the anterior abdominal wall.

classically occur during or following pregnancy.

c. Intra-abdominal desmoids

are associated with Gardner's syndrome.

may be associated with diffuse retroperitoneal fibrosis.

Review Test
Directions: Each of the numbered items or incomplete statements in this section is followed by answers
or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each
case.
1. A 54-year-old man presents to the office with a complaint of a mass in his left thigh increasing in size
over the past several months. On examination, the patient is noted to have a firm 6-cm mass on his left
anterior thigh with no other significant findings. An incisional biopsy reveals a soft tissue sarcoma. Which
of the following is the most appropriate statement regarding the initial evaluation and management of this
patient?
(A) A sentinel lymph node biopsy should be performed because sarcomas spread almost uniformly
through lymphatics to lymph nodes
(B) A chest radiograph should be obtained because sarcomas spread almost uniformly by a
hematogenous route with a majority going to the lung
(C) Resection alone is the next step because growth is so slow that where it spreads is not a
concern
(D) Multiple local skin biopsies should be performed because sarcomas usually spread superficially
through the skin
(E) Immediate amputation should be performed because of the aggressive nature of sarcomas
occurring in the extremities
1–B. A chest radiograph is essential in the evaluation of patients with sarcomas because the lung is the
most common site of metastasis. In contrast, sarcomas rarely metastasize via the lymphatics, and thus
biopsy of the sentinel lymph node is not routinely performed. Preoperative evaluation of patients with
sarcoma allows for identification of metastatic disease, which occurs frequently with these lesions.
 Sarcomas preferentially spread via hematogenous routes and rarely spread superficially to the skin. In
addition, performing multiple biopsies may increase the likelihood of tumor seeding of the blood and
metastasis. Limb-sparing procedures are currently preferred over amputation in the management of most
extremity sarcomas.

2. A 66-year-old, diabetic woman underwent a lumpectomy/axillary node dissection with postoperative radiation therapy 17 years ago
for breast adenocarcinoma. The patient gives a history of a severe skin “reaction” to the radiation and a history of chronic swelling of
the affected arm. She now presents with a mass in the upper portion of the affected extremity, recently diagnosed as a
lymphangiosarcoma. Which of the following factors in this patient is thought to be most important in the source of this sarcoma?

(A) History of previous breast malignancy

(B) Chronic lymphedema

(C) History of radiation exposure

(D) Advanced age

(E) History of chronic diabetes

2–B. The pathogenesis of the development of lymphangiosarcomas in these patients is related to the presence of chronic lymphedema.
These lesions often occur outside the irradiated field and are not specifically related to the pre-existing breast cancer. Advanced age and
a history of diabetes are also not direct risk factors for the development of these lesions. Lymphangiosarcomas may also arise in association
with lymphedema caused by filarial infection (elephantiasis) or other chronic lymphedematous states.

3. A 54-year-old construction worker presents to the office for a routine check-up. He is noted to have a 6-mm, dark lesion under the
fingernail of a finger on his left hand. He denies any trauma to the area. The area is nontender with no evidence of infection. Which of
the following is an appropriate statement regarding the lesion identified in this patient?

(A) This is the most common form of melanoma

(B) This lesion occurs most commonly in white males

(C) This lesion developed from a subungual hematoma

(D) This is the most aggressive form of melanoma

(E) This lesion can also develop on the soles of the feet

3–E. Although overall these lesions are rare, acral lentiginous melanomas generally occur in regions of the body not exposed to the sun,
including the palms, soles, and subungual regions. This form of melanoma most commonly occurs in patients with dark skin. Although these
tumors are frequently mistaken for traumatic subungual hematomas, these tumors do not develop specifically from these injuries.
M elanomas of the digits frequently require amputation for adequate resection. The most aggressive type of melanoma is the nodular
variant, not acral lentiginous lesions.

4. Three years ago, a 55-year-old man had a sarcoma resected from his anterior superior thigh that had positive margins on the
pathology specimen. He was treated with postoperative radiation therapy to salvage his leg. Unfortunately he developed a recurrent
lesion that appears to be 4–5 cm medial to the femoral neurovascular bundle. Which of the following is the most appropriate treatment
measure for this patient?

(A) Surgical resection

(B) Doxorubicin and ifosfamide combination

(C) Immunotherapy combined with interferon-α

(D) Observation until lesion becomes symptomatic

(E) Radiation therapy alone

4–A. Surgical re-resection is still the most appropriate treatment strategy even for recurrent lesions. Radiation therapy may play an
adjunctive role but is not the best therapy when used alone. Chemotherapy and immunotherapy play little, if any, role in the local
treatment of recurrent disease. Observation alone would be inappropriate.

5. A 63-year-old woman presents to the office for a routine check-up. She states that she recently read an article that discussed the
different types of skin cancer and that a friend of hers recently had a basal cell cancer removed. She is inquiring about her risk for the
development of skin cancer. In describing the risk factors for development of nonmelanoma skin cancers to this patient, which of the
following is accurate regarding the relative risks?

(A) Pre-existing keratoacanthoma is a greater risk than pre-existing Bowen's disease

(B) Immunocompetence is a greater risk than immunosuppression

(C) Brown eyes is a greater risk than blue eyes

(D) Brunette hair is a greater risk than blonde hair

(E) Ultraviolet (UV)B exposure is a greater risk than UVA exposure

5–E. Exposure to ultraviolet (UV) light is a risk factor for the development of nonmelanoma skin cancers, although among the different
types, UVB light is associated with a greater risk than UVA light. Bowen's disease is a premalignant lesion that predisposes to squamous cell
carcinoma, while a keratoacanthoma is a benign lesion. Immunosuppression is also a significant risk factor for skin cancers. Other
characteristics that may be associated with a greater risk of skin cancer development include fair skin, blue eyes, and blonde hair. These
factors are generally related to the sensitivity of the patient's skin to light exposure.

6. During routine chest radiography, a 63-year-old man is found to have an isolated 1-cm mass in the upper lobe of his right lung. Biopsy
of the lesion reveals a melanoma. In addition to examining all skin and mucous membrane surfaces, which of the following would be
most appropriate in the subsequent evaluation of this patient to identify the primary lesion?
(A) Funduscopic examination, proctoscopy, and chest computed tomography (CT).

(B) Funduscopic examination and abdominal CT

(C) Chest CT
(D) Chest and abdominal CT

(E) Funduscopic examination and small bowel contrast study

6–A. By far the most common site of melanoma is on the skin surfaces, therefore, all patients should undergo extensive examination of skin
surfaces to identify the primary lesion. If a primary skin lesion is not identified, other potential sites for melanoma development include the
mucous membranes (e.g., mouth, nasal passages), on the fundus of the eye, and in the anorectal region. Otoscopy is also essential to
identify potential lesions within the ear canal. Therefore, a careful funduscopic examination should be performed, in addition to careful
evaluation of the anorectum with proctoscopy if necessary. A chest and abdominal computed tomography (CT) and a small bowel contrast
study are not routinely indicated in this setting. Approximately 5% of patients will not have an identifiable primary lesion in the setting of
metastatic disease.

7. During an abdominal computed tomography (CT) scan performed for complaints of vague abdominal discomfort, a 55-year-old man is
found to have a 6-cm mass near the midline in the retroperitoneum suggestive of a sarcoma. Which of the following is an appropriate
statement regarding the evaluation and management of this patient?

(A) The presence of multiple peritoneal implants is an appropriate indication for surgical resection of asymptomatic disease

(B) In addition to surgical resection, radiation therapy is a key component of the treatment regimen

(C) Because of the location of this lesion, metastases are more likely found in the liver versus the lung
(D) Given the patient's age and location of the tumor, this lesion is most likely a rhabdomyosarcoma

(E) After initial surgical resection, if the lesion recurs locally, re-resection is appropriate

7–E. Repeat surgical resection is still the most appropriate treatment strategy for locally recurring sarcomas. The presence of peritoneal
implants is generally a contraindication to surgical resection of asymptomatic sarcomas. Preoperative assessment may also include
angiography to rule out potential vascular invasion, which is another common contraindication to resection of the lesion. Radiation of the
retroperitoneum is associated with significant morbidity and does not play a significant role in the treatment of recurrent retroperitoneal
sarcomas. Although visceral sarcomas may frequently metastasize to the liver, retroperitoneal sarcomas rarely do; and the lung is generally
the most common location of metastatic disease. The most common lesions in this site in patients in this age group are leiomyosarcomas
and liposarcomas.

8. A 45-year-old woman presents to the office with complaints of a hard mass in her abdomen. She is otherwise healthy and has 3
children, 1 recently born by cesarean section. Upon examination, the patient is noted to have a firm, 3-cm, subcutaneous mass, inferior
to the umbilicus and just lateral to the midline. Excisional biopsy of the lesion reveals a desmoid tumor. Upon discussion of this lesion
with the patient during follow-up, which of the following is an appropriate statement regarding the nature of this lesion?

(A) These lesions rarely recur after resection

(B) These lesions may be a high risk for metastasis

(C) These lesions may behave like low-grade sarcomas

(D) These lesions are frequently associated with retroperitoneal fibrosis

(E) Postoperative chemotherapy is a key component of therapy

8–C. Desmoid tumors are soft tissue tumors that can behave like low-grade sarcomas; however, they rarely metastasize. Despite the low
frequency of metastasis, these lesions frequently recur locally despite resection. There are 3 subgroups of desmoid tumors and the
abdominal wall desmoids frequently occur during or following pregnancy and may be related to previous scars. The intra-abdominal
desmoids are associated with Gardner's syndrome and are prone to the development of retroperitoneal fibrosis. The primary treatment is
surgical resection, with some lesions responding to radiation therapy. Chemotherapy does not play a significant role in the treatment of
these lesions.
Appendix

Appendix: Comprehensive Examination

Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the
statement. Select the ONE lettered answer or completion that is BEST in each case.

1. A 65-year-old man is admitted to the surgical intensive care unit following pancreatic débridement for necrotizing pancreatitis. The
patient is extubated, although his respiratory status remains guarded. Parenteral nutrition therapy is initiated with 35 kcal/kg/day;
65% is administered as carbohydrates, 30% as lipids, and 5% as protein. The patient also receives vitamin supplements. Over the next
24 hours the patient complains of worsening fatigue and numbness around his lips. He develops a tremor in both hands and becomes
more lethargic as the day continues until he must be reintubated. This patient's abnormality would be most adequately treated if he
were administered

(A) KPO 4-

(B) M gCl2

(C) KCl
(D) Thiamine

(E) Insulin

2. A 27-year-old, 80-kg, male athlete sustained deep partial-thickness burns to approximately 60% total body surface area (TBSA). He
has been receiving lactated Ringer's in direct accordance with the Parkland formula calculations for volume resuscitation, however, he
remains tachycardic with a heart rate of approximately 110 beats/min. Which of the following is true with regard to fluid management
in this patient?

(A) A Foley catheter is not necessary in this patient if he is awake

(B) A urine output of 30 mL/hour is not satisfactory in this patient

(C) Tachycardia is the most reliable marker of inadequate resuscitation

(D) One 18-gauge intravenous (IV) catheter is sufficient for treating this patient

(E) If significant peripheral edema is present, IV fluid rates should be decreased

3. A 70-year-old man with an asthma exacerbation suffers a first time episode of atrial fibrillation in the hospital. The ventricular
response is 160, but the patient's blood pressure remains stable. The decision is made to cardiovert the rhythm, however, secondary to
increasing dyspnea. Ketamine is administered intravenously, the man loses consciousness but continues to spontaneously ventilate, and
is successfully converted to sinus rhythm after one 100 J synchronized cardioversion. Upon awakening he complains of intensely
frightening illusions. Which of the following premedications could have lessened this unwanted side effect?
(A) Propofol

(B) Fentanyl

(C) Lidocaine

(D) Etomidate

(E) M idazolam

4. A 15-year-old boy is admitted with the chief complaint of right lower quadrant abdominal pain, nausea, vomiting, and anorexia for
the past 5 hours. His vital signs are: respiration, 24/min; heart rate, 90 beats/min; blood pressure, 120/70 mm Hg; temperature, 38.3°C.
Which of the following findings is most likely to be present in this patient?

(A) Pelvic crepitus

(B) Psoas sign

(C) M urphy's sign

(D) Flank ecchymosis

(E) Periumbilical ecchymosis

5. A 63-year-old man is being treated with a 7-day course of oral antibiotics for an acute episode of diverticulitis. Now, 4 days into the
course of antibiotics, the patient presents with persistent fever and worsening pain and advancing erythema in the perineal area. Upon
evaluation, he is felt to have worsening necrotizing fasciitis of the perineum extending to and including the scrotum. Which of the
following would be an appropriate treatment strategy for this patient?

(A) Aggressive débridement of the affected tissue with orchiectomy and intravenous (IV) antibiotics

(B) Aggressive débridement of the affected tissue with sparing of the testes and IV antibiotics
 (C) Sitz baths 4 times a day and broad spectrum oral antibiotics

(D) Sitz baths 4 times a day and broad spectrum IV antibiotics

(E) Aggressive débridement of the affected tissue with orchiectomy and immediate resection of affected colon with primary
reanastomosis

6. A 42-year-old man undergoes elective laparoscopic hernia repair for bilateral inguinal hernias. On postoperative day one, the patient
develops worsening abdominal pain associated with nausea and vomiting. On physical examination, the patient is noted to have severe
abdominal pain with rebound and guarding. Which of the following is the most likely cause of this patient's findings?
(A) Strangulation of bowel

(B) Recurrence of the hernia

(C) Iatrogenic bowel injury

(D) Wound infection

(E) Adhesion formation

7. A 45-year-old woman underwent an uneventful total colectomy for ulcerative colitis. On postoperative day 5, the patient was found
to be minimally responsive. Physical examination reveals a temperature of 40.0°C; blood pressure of 70/36 mm Hg; pulse of 130/min;
respiration of 32/min; and cold, clammy skin, diaphoresis, and cool extremities. There was 85 mL of urine output overnight. Laboratory
studies showed a white blood cell count of 2.2, hematocrit = 44.1, platelets = 700,000, Na+ = 145, K+ = 5.9, Cl - = 111, HCO3- = 18,
blood urea nitrogen = 64, and creatinine = 3.0. Urinalysis was significant for renal tubular cells. Which of the following statements is
true regarding this patient's renal function?

(A) This patient is anuric and must immediately be started on hemodialysis

(B) Treating the initial condition has little effect in allowing renal function to recover
(C) Certain drugs and transfusion reactions are potential etiologies of this condition

(D) Persistent disease will result in severe metabolic alkalosis, hypokalemia, and dehydration

(E) In most patients, this complication is irreversible

8. A 65-year-old woman presents with obstructive jaundice and a history of 20-lb weight loss. She denies any complaints of fever, pain,
nausea, or vomiting. Her abdominal examination is unremarkable. An endoscopic retrograde cholangiopancreatography (ERCP) has been
performed and reveals a focal common bile duct stenosis with dilation of the common hepatic and intrahepatic ducts. Significant
laboratory values include a normal white blood cell count, total bilirubin = 12.0, conjugated bilirubin = 11.2, alkaline phosphatase =
2000, and normal transaminases. Which of the following is the most likely diagnosis?

(A) Primary sclerosing cholangitis

(B) Cholangitis

(C) Choledochal cyst

(D) M irizzi's syndrome

(E) Cholangiocarcinoma

9. A 30-year-old healthy woman presents to the office 1 year after having an uncomplicated cesarean section. She complains of a
persistently large, unsightly scar at the surgical site, which is found to be a hypertrophic scar. Intralesional triamcinolone improves the
appearance of the scar. The effect of this drug is best described by which of the following mechanisms?

(A) Enhancement of collagenase activity

(B) Decrease in the number of active fibroblasts

(C) Increase in collagen turnover, making the scar more susceptible to local pressure treatment

(D) Inhibition of intracellular collagen synthesis

(E) Inhibition of extracellular intermolecular collagen cross-linking, increasing collagen solubility

10. A 50-year-old man receives a transfusion of packed red blood cells (PRBCs) for anemia secondary to chronic gastrointestinal
bleeding. Fifteen minutes after the infusion begins, the patient develops back pain, chills, fever, and dark urine. His temperature is
38.8°C (102°F), his pulse rate is 124/min, his respiratory rate is 28/min, and his blood pressure is 116/44 mm Hg. Examination reveals
moderate respiratory distress and crackles throughout his lung fields. Which of the following is the most likely source of this patient's
problem?

(A) Infection secondary to bacterial contamination of donor blood

(B) Donor leukocytes reacting with the recipient's red blood cells (RBCs)

(C) Recipient antibodies reacting to donor RBCs

 (D) Volume overload secondary to rapid administration of blood

(E) Hypocalcemia secondary to citrate in the donor blood

11. One month after an orthotopic liver transplant, a 43-year-old woman presents to the office with complaints of fatigue and
weakness. On physical examination she is noticeably jaundiced. She denies fever or chills. Her aspartate aminotransferase (AST) and
alanine aminotransferase (ALT) are significantly elevated, as is her total bilirubin. Her chest radiograph is clear, and blood and urine
cultures are negative. Doppler ultrasound of the right upper quadrant reveals no fluid collections and a patent hepatic artery and portal
vein. Liver biopsy reveals portal lymphocytic infiltration and injury to the bile canaliculi. Which of the following is the most
appropriate initial therapy for this patient?
(A) Glucocorticoids

(B) Cyclosporine

(C) Cyclophosphamide

(D) Azathioprine
(E) M ycophenolate mofetil

12. A 73-year-old man with chronic obstructive pulmonary disease is hospitalized for recurrent pneumothoraces. He has been critically
ill in the surgical intensive care unit with multiple bouts of pneumonia and sepsis for 5 weeks. On reviewing his laboratory data you
notice a steady trend downward of his hematocrit from 48% to 21%. Which of the following would be the most appropriate initial step
in the management of this patient?

(A) Emergent laparotomy

(B) Observation

(C) Colonoscopy
(D) Nasogastric tube placement and stools for guaiac

(E) Immediate mesenteric angiography

13. An 18-year-old college student presents with 4 hours of severe chest and epigastric pain after a night of binge drinking. She states
that she vomited several times upon returning home and that the pain began shortly thereafter. She is currently stable and her chest
radiograph reveals pneumomediastinum and a pleural effusion on the left side. Which of the following is true regarding this scenario?

(A) As is the case in more than 75% of cases, this patient can be treated successfully with intravenous (IV) hydration and antibiotics
alone

(B) Primary repair of the esophagus is unlikely to be successful in this patient

(C) Boerhaave's syndrome is the most common cause of esophageal perforation

(D) Despite proper intervention, survival is generally less than 50% in this patient

(E) Radical procedures such as esophageal exclusion are usually not necessary in patients who present within 24 hours of the injury

14. A 35-year-old man with hypertension and end-stage renal disease secondary to systemic lupus erythematosus is receiving an
axillary block as the anesthetic for an arterioventricular fistula placement. During injection of the local anesthetic (bupivacaine) into
the axilla, the patient abruptly seizes. Which of the following agents given intravenously would be most appropriate in the treatment
of this patient's seizure?

(A) Fentanyl

(B) Succinylcholine

(C) M idazolam

(D) Etomidate

(E) Lidocaine

15. A 57-year-old man with severe liver disease from alcohol abuse is admitted to the hospital with worsening ascites and
encephalopathy. He is placed on the recipient list for a donor liver and managed in the intensive care unit. Because of his
encephalopathy, he is unable to eat; therefore, he is started on enteral nutritional support via a nasoduodenal feeding tube. He is
receiving 1.3 mg protein/kg/day with a predominance of branched-chain amino acids. Which of the following is an appropriate
statement regarding the administration of branched-chain amino acid to patients in this setting?

(A) Branched-chain amino acids include leucine, isoleucine, and alanine

(B) M uscle preferentially metabolizes these amino acids

(C) The liver preferentially metabolizes these amino acids

(D) Branched-chain amino acids act as hepatotoxins in liver failure

(E) Branched-chain amino acids are nonessential amino acids

16. A 72-year-old man is evaluated in the emergency room with a primary complaint of nausea and vomiting for 2–3 days and a 2- to 3-
week history of intermittent right upper quadrant pain. His past surgical history is significant for triple coronary artery bypass surgery.
Physical examination reveals a distended abdomen with hyperactive bowel sounds. Rectal examination is heme-negative. His
temperature is 37.7°C (100°F), his heart rate is 105 beats/min, and his blood pressure is 140/75 mm Hg. His abdominal radiograph
shows multiple step-ladder air–fluid levels throughout the abdomen and notable air within the biliary tree. Which of the following is
the most likely diagnosis?

(A) Superior mesenteric artery syndrome

(B) Cancer of the colon

(C) Obstruction caused by adhesions

(D) Sigmoid diverticulitis

(E) Gallstone ileus

17. A 64-year-old man presents to your office with right breast hyperplasia. He states that he has only noticed his right breast getting
bigger over the last few months, but his wife stated that she thought he had always been a little bigger on the right. He states that he
does drink, but no more than a few beers each night. On physical examination, you notice that his right breast is larger than his left,
and there is a firm mass just under the nipple. There are no palpable masses in his axilla, but the mass does seem to be fixed to the
chest wall. Which of the following is the most appropriate treatment for this patient?
(A) A lumpectomy, axillary node dissection with postoperative radiation therapy

(B) Fine needle aspiration (FNA) and, if malignant disease is discovered, a modified radical mastectomy

(C) FNA and, if malignant disease is discovered, a radical mastectomy

(D) Systemic chemotherapy alone

(E) Observation

18. A 62-year-old man with a history of a previous episode of diverticulitis presents to the emergency room with complaints of fever,
nausea, and abdominal pain that is greatest in the left lower quadrant. Computed tomography (CT) scan reveals multiple sigmoid
diverticula, a 4-cm abscess in the left lower quadrant, and free air in the peritoneum. Which of the following is the most appropriate
course of management for this patient?

(A) Percutaneous drainage of the abscess and administration of intravenous (IV) antibiotics

(B) Emergent resection of the affected colon with end colostomy and abscess drainage

(C) Percutaneous drainage of the abscess, IV antibiotics, and elective resection at a later date

(D) Emergent total colectomy with abscess drainage

(E) Emergent operative drainage of the abscess, IV antibiotics, and elective resection of the colon at a later date

19. Which of the following is characteristic of malignant tumors of the liver?

(A) α-Fetoprotein may be elevated with hepatic metastases or hepatocellular carcinoma

(B) Alcoholic cirrhosis is the most common cause of hepatocellular carcinoma worldwide

(C) Hepatocellular carcinoma is the most common malignant lesion of the liver

(D) Fibrolamellar variant of hepatocellular carcinoma is associated with a worse prognosis compared with hepatocellular carcinoma

(E) Hepatoblastoma is generally insensitive to chemotherapy

20. A 34-year-old man with acquired immunodeficiency syndrome (AIDS) and a recent episode of Pneumocystis carinii infection has
been suffering from progressive symptoms of early satiety, abdominal bloating, weight loss, and intermittent, dull left upper quadrant
abdominal pains. Physical examination reveals a markedly enlarged spleen, the tip of which is palpable in the left lower quadrant.
Abdominopelvic computed tomography (CT) scan confirms massive splenomegaly but no other masses are identified. Antiplatelet
antibodies are not identified in his blood. Which of the following is the most appropriate therapy for this patient?

(A) Elective splenectomy

(B) Plasmapheresis

(C) Emergent splenectomy

(D) Intravenous (IV) gamma globulin

(E) Splenic artery embolization

21. A 42-year-old woman with a history of Graves' disease currently being treated medically presents with a 3-cm mass in the left lobe
of the thyroid. Fine needle aspiration (FNA) reveals follicular cell carcinoma. Before induction, during palpation of the thyroid gland,
the patient develops sudden fever and tachycardia intraoperatively. Which of the following is the most appropriate treatment measure
in this setting?

(A) Administration of calcium carbonate

(B) β-Blockade, propylthiouracil (PTU), and Lugol's solution

(C) Thyroxine administration

(D) M echanical cooling and dantrolene

(E) Administration of 4 units of packed red blood cells (PRBCs)

22. A 65-year-old, obese woman underwent a left hemicolectomy with primary re-anastomosis for colon adenocarcinoma. On
postoperative day 14, the patient complains of abdominal pain, anorexia, and fever (temperature of 39.1°C). Her physical examination
is significant for mild diffuse abdominal tenderness, a mildly distended abdomen with few bowel sounds, and guarding in the left lower
quadrant. Laboratory studies show a white blood cell count of 16.9 (91% polys), and are otherwise within normal limits. Computed
tomography (CT) scan of the abdomen reveals a fluid collection in the left lower quadrant. An anastomotic leak is diagnosed. Which of
the following is true regarding her intestinal anastomoses?
(A) Anastomotic leaks occur more frequently in the colon than in the small bowel because of the increased bowel wall thickness of
the colon

(B) Avoidance of gross contamination while making anastomoses has little impact on the incidence of leakage because the abdomen
may be easily irrigated before closure
(C) The presence of a leak requires immediate re-operation with exteriorization of the bowel

(D) Ensuring the absence of distal obstruction is important in creating successful intestinal anastomoses

(E) Percutaneous drainage should not be attempted because it carries a high failure rate

23. A 38-year-old, African-American woman with a history of gastroesophageal reflux disease and sickle cell disease presents with a 36-
hour history of nausea, vomiting, and right upper quadrant pain. The pain is described as spasmodic in nature and is exacerbated by
eating. The patient denies fever, chills, and previous abdominal surgery. Her vital signs are: temperature, 36.9° C; pulse, 101/min;
blood pressure, 140/86 mm Hg; and respiration, 13/min. Her abdomen is soft but tender to palpation in the right upper quadrant. Her
laboratory results are: white blood cells = 6000; hematocrit = 34; platelets = 212; Na+ = 132; K+ = 4.1; Cl - = 104; CO2 = 25; blood urea
nitrogen = 14; creatinine = 0.8; glucose = 89; total bilirubin = 7.5; conjugated bilirubin = 6.6; alkaline phosphatase = 540; and amylase
= 41. A right upper quadrant ultrasound reveals multiple gallstones and a distended common duct but no other abnormalities. Which of
the following statements is appropriate regarding this patient's condition?

(A) The patient most likely has a common bile duct obstruction from a stone formed in the gallbladder

(B) The pathogenesis of this patient's condition is related to bile stasis and bacterial deconjugation of bilirubin

(C) Fluctuating symptoms are uncommonly associated with this disease

(D) Pain on palpation is an uncommon finding in this disease

(E) An endoscopic retrograde cholangiopancreatography (ERCP) may be diagnostic but plays no role in the treatment of this disease

24. A 45-year-old woman sustains multiple injuries in a motor vehicle accident, including a splenic laceration requiring emergent
splenectomy, a transverse process fracture of the third lumbar vertebrae, and a fracture of the shaft of the left tibia. During placement
of a Swan-Ganz catheter via the left subclavian vein, the patient suddenly develops hypotension with a blood pressure of 80/60 mm Hg
initially. A chest tube is placed without improvement in her blood pressure. A large quantity of blood is noted to be coming out of the
endotracheal tube. Which of the following is the most likely cause of this patient's hypotension?

(A) Tension pneumothorax

(B) Severe hemothorax

(C) Cardiac perforation

(D) Pulmonary artery perforation

(E) Acute pulmonary embolus

25. A 28-year-old woman presents to the surgical clinic with a known history of a thyroid nodule. History reveals that her mother and
sister died secondary to thyroid cancer and a hypertensive crisis, respectively. Fine needle aspiration (FNA) of the thyroid mass reveals
medullary thyroid carcinoma. Which of the following is correct regarding further treatment of this patient?

(A) Surgical treatment of her thyroid cancer involves lobectomy and isthmusectomy

(B) If a pheochromocytoma is found, a laparoscopic approach is contraindicated in this patient

(C) If a pheochromocytoma is found, the posterior approach should be used

(D) If hyperparathyroidism is found, the patient can generally be managed with parathyroidectomy of the adenoma

(E) Urine tests for catecholamines, metanephrines, vanillylmandelic acid, parathyroid hormone, and calcium should be obtained
26. A 62-year-old woman presents with a 3-cm, dark, elevated mass on her upper back. The report of an incisional biopsy of the lesion
performed at another hospital states that the lesion is a melanoma, 0.7 mm thick. Which of the following is the most appropriate
therapy for the treatment of the primary lesion?

(A) Wide local excision of the lesion with 1-cm margins

(B) Cryosurgical ablation of the lesion

(C) Wide local excision of the lesion with 5-cm margins

(D) M ohs' microsurgical technique of surgical resection

(E) Wide local excision of the lesion with 2-cm margins

27. A 45-year-old woman presents with a 3-cm neck mass in the right lobe of the thyroid partially involving the isthmus. Fine needle
aspiration (FNA) of the lesion reveals a poorly differentiated Hürthle cell variant of follicular carcinoma. Which of the following is the
most appropriate treatment for this patient?

(A) Lobectomy and isthmusectomy followed by radioiodine (131I) ablation therapy

131
(B) Total thyroidectomy followed by I ablation therapy

(C) 131I ablation therapy followed by total thyroidectomy

(D) Total thyroidectomy with node dissection for positive nodes

(E) Lobectomy and isthmusectomy

28. After a motor vehicle accident, a 28-year-old woman was found to have a 3-cm, simple liver cyst on computed tomography (CT) scan
during her evaluation in the emergency room. The patient was found to have isolated orthopedic injuries and was discharged 2 days
later. Which of the following would be a contraindication to surgical management or percutaneous drainage of a simple liver cyst in this
patient?

(A) Pain associated with cyst

(B) Fever, chills, and positive cultures from cyst contents

(C) Hemorrhage within cyst

(D) Rupture of cyst

(E) Presence of von M eyenburg complexes (biliary ductal epithelium) within biopsy specimen of cyst wall

29. A 38-year-old man presents with a firm nodule in his neck and hypertension that has been refractory to medical therapy.
Subsequent work-up also reveals a pheochromocytoma as the probable source of the patient's hypertension as well as a medullary
thyroid cancer consistent with the diagnosis of the multiple endocrine neoplasia (MEN) II syndrome. Which of the following is true
regarding the sequence of treatment of this patient?

(A) Immediate resection of the pheochromocytoma should be performed, followed by resection of the medullary cancer at a later
date

(B) Control of hypertension and resection of the pheochromocytoma and the medullary cancer during the same procedure

(C) Control of hypertension and resection of the pheochromocytoma, followed by neck exploration and resection of the medullary
cancer at a later date

(D) Resection of the cancerous lesion first, followed by resection of the pheochromocytoma

(E) Resection of the pheochromocytoma, followed by neck irradiation

30. A 30-year-old man sustained multiple injuries in a motor vehicle accident. On hospital day two, he remains intubated in the
intensive care unit in critical condition and it is decided that enteral nutritional support should be initiated. During placement of a
nasogastric feeding tube to 40 cm the patient's blood pressure is noted to drop precipitously to 50/30 mm Hg. During forceful
insufflation of air through the feeding tube there are no sounds noted over the epigastric region. Which of the following would be the
most appropriate definitive step in the management of this patient?

(A) Removal of the feeding tube and fluid resuscitation

(B) Removal of the feeding tube and chest tube placement

(C) Injection of contrast through the feeding tube to assess placement

(D) Removal of the feeding tube and immediate laparotomy

(E) Removal of the feeding tube and immediate pulmonary angiogram

31. A 59-year-old woman is taken to the operating room and undergoes an exploratory laparotomy for a high-grade small bowel
obstruction. During the operation she is found to have a large leiomyoma that is obstructing the distal ileum. A large segment of the
terminal ileum is resected with the tumor. Which of the following long-term nutritional risks is associated with this procedure?
 (A) Dumping syndrome

(B) Pernicious anemia

(C) Hypercalcemia

(D) Afferent loop syndrome

(E) Iron deficiency anemia

32. A 29-year-old, breast-feeding mother presents to the clinic with the primary complaint of right breast tenderness. She states that
the tenderness began suddenly, and was first associated with pain when she began breast-feeding, but now is continuous. She denies
fever, chills, or any other associated symptoms. On physical examination, she has a tender right breast with an area of erythema in the
lower outer quadrant. There is no expressible discharge and no definitive masses to palpation. Which of the following is the most
appropriate treatment for this patient?

(A) Place patient on nonsteroidal anti-inflammatory drugs (NSAIDs)

(B) Antibiotics to cover skin organisms, Staphylococcus aureus, and discontinue breast-feeding until pain resolves

(C) Antibiotics to cover skin organisms, S. aureus, and continue breast-feeding

(D) Consider placing patient on danazol

(E) Reassure the patient that with continued breast feeding her pain should resolve

33. A patient who has been diagnosed with diverticular disease presents with massive hemorrhage. After the site of bleeding is well
localized, the patient continues to bleed and requires 5 units of blood over the next 24 hours. Which of the following therapies will
provide the lowest morbidity and least chance of rebleeding?

(A) Surgical resection of the diseased segment

(B) Angiographic embolization of the bleeding vessel

(C) Angiographic vasopressin infusion

(D) Subtotal colectomy

(E) Further observation and transfusion as needed

34. A 16-year-old boy presents to the emergency room 36 hours after being bitten in the hand during an altercation. He is febrile
[39.0°C (102.2°F)] and he has purulent drainage from the 2-cm wound over the metacarpophalangeal joint of his ring finger. The finger
cannot be actively extended. Which of the following is the most appropriate management strategy?

(A) Topical cleansing followed by oral antibiotics

(B) Débridement and irrigation followed by intravenous (IV) antibiotics

(C) Repair of the affected extensor tendon followed by skin closure

(D) Repair of the affected extensor tendon followed by open packing

(E) Application of a sterile dressing and close observation

35. A 59-year-old man presents to the emergency department with complaints of persistent fever and mild left lower quadrant
abdominal pain for the previous 4 days. The patient is otherwise healthy and denies nausea or vomiting. Physical examination reveals
localized pain to deep palpation in the left lower quadrant without rebound or guarding. Subsequent computed tomography (CT) scan
reveals a localized 8-cm pelvic abscess with multiple diverticula noted throughout the sigmoid colon. Which of the following is the
most appropriate next step in the management of this patient?

(A) Percutaneous drainage of the abscess with adjunctive antibiotics

(B) Immediate laparotomy with resection of adjacent bowel

(C) Antibacterial agents alone should be sufficient treatment

(D) Antibiotic therapy directed against principally aerobic bacteria

(E) Antifungal therapy should be initiated because of a significant risk of fungal contamination

36. A 55-year-old man has been experiencing chronic epigastric burning pain for the past 10 years. He initially was able to control his
symptoms with over-the-counter medications. However, his pain has persisted despite a 12-month course of ranitidine and most
recently a 6-month course of omeprazole. Repeat endoscopy reveals a persistent duodenal ulceration without active bleeding. Multiple
biopsies reveal no evidence of malignancy or Helicobacter pylori. Which of the following operations is associated with the lowest
morbidity, but the highest recurrence in this patient?

(A) Truncal vagotomy

(B) Truncal vagotomy and pyloroplasty

(C) Vagotomy and antrectomy

 (D) Parietal cell (highly selective) vagotomy

(E) Total gastric resection

37. A 21-year old woman is brought to the emergency room because she has been experiencing lower abdominal pain for the past 8
hours that has been getting progressively worse. The date of her last menstrual period was 8 weeks ago. The patient was found by
paramedics to be pale and lethargic. Examination now reveals a distended abdomen with rigidity and guarding diffusely. Her vital signs
are: heart rate, 120 beats/min; blood pressure, 70/30 mm Hg; respiration, 28/min; temperature, 36.0°C. Which of the following is the
most likely diagnosis?

(A) Appendicitis
(B) Crohn's disease

(C) Ectopic pregnancy

(D) Perforated duodenal ulcer

(E) Torsed ovary

38. A 24-year-old man is involved in a motor vehicle accident resulting in a severe closed head injury. This injury is believed to be
irreversible and evaluation for possible organ donation is undertaken. Which of the following would exclude him as a heart-beating
organ donor?

(A) Absence of response to painful stimuli

(B) Intact deep tendon reflexes

(C) Intact gag reflex

(D) Core body temperature of 38.2°C

(E) The requirement of 10 µg/kg/min of dopamine for hemodynamic stability

39. A 55-year-old woman undergoes an excisional biopsy for a palpable breast mass. The biopsy results return indicating invasive ductal
adenocarcinoma of less then 1 cm in diameter, and no cancer cells at the margin of the biopsy. Which of the following is the most
appropriate next step in the treatment of this patient?

(A) Axillary node dissection or sampling for staging, and radiation therapy to the breast

(B) Axillary node dissection for staging alone

(C) Radiation therapy to the breast alone

(D) Simple mastectomy

(E) Radical mastectomy

40. Work-up of a right-sided colon mass found in a 68-year-old, otherwise healthy woman reveals an incompletely resected
adenocarcinoma upon colonoscopic polypectomy. The patient subsequently undergoes an elective segmental colonic resection of the
lesion, which confirms adenocarcinoma upon pathologic evaluation. Which of the following adjuvant therapies would be appropriate in
the further management of this patient?

(A) Chemotherapy for stage III adenocarcinoma

(B) Chemotherapy for stage I adenocarcinoma

(C) Radiation therapy for stage II adenocarcinoma

(D) Radiation therapy for stage III adenocarcinoma

(E) Chemotherapy and radiation therapy for stage III adenocarcinoma

41. A 180-kg, 21-year-old man with spina bifida and lower extremity paralysis is in the medical intensive care unit with urosepsis. The
patient also has a history of a seizure disorder. The patient was extubated after a prolonged period of intubation, however, his
respiratory status continues to deteriorate and the decision is made to reintubate. His blood pressure is 78/40 mm Hg, respiration rate
exceeds 30/min, and the SaO2 is 89% on 100% oxygen. The anesthesiologist judges the airway to be difficult because of limited neck
motion and inability to visualize the uvula with mouth opening. Which of the following is the most appropriate strategy in the initial
airway management of this patient?

(A) Rapid sequence intubation with etomidate and rocuronium

(B) Rapid sequence intubation with thiopental and rocuronium

(C) Rapid sequence intubation with propofol and rocuronium

(D) Topical anesthesia (lidocaine) to the airway

(E) Intubation after administration of ketamine and rocuronium

42. A 79-year-old woman underwent an uneventful abdominal-perineal resection for a rectal cancer. She was slow to recover and on
postoperative day 10, she was noted to have an open, excoriated wound near her buttocks and blisters on both heels. Which of the
following statements most accurately reflects this condition?

(A) This is a common complication in all populations of postoperative patients

(B) Frequent bathing and skin conditioners frequently cause this complication

(C) Quantitative skin cultures are necessary to ensure proper treatment of the colonizing flora

(D) Early mobilization and frequent position changes have little impact in preventing this complication
(E) M aintaining proper nutritional status is helpful in the prevention and treatment of this condition

43. A 55-year-old, obese woman presents with a painful 4-cm mass just below the umbilicus in the midline. The patient states that she
had noticed the mass for several years but presents today because of progressively worsening pain associated with the mass over the
past day. On physical examination there is an exquisitely tender mass just under the umbilicus. Although difficult, the mass is
eventually reduced with firm pressure and moderate sedation. After reduction of the mass, the patient continues to complain of
abdominal pain and is noted to have significant guarding and rebound tenderness. Which of the following is the most appropriate
treatment strategy for this patient?

(A) Immediate abdominal exploration

(B) Immediate local wound exploration and hernia repair

(C) Discharge and plan for elective hernia repair

(D) Discharge and elective hernia repair if the hernia recurs

(E) Observation and exploration if the pain worsens

44. A 32-year-old man presents with a history of intermittent dysphagia, most often following a hurried swallow. These episodes
generally occur with solids and he reports a history of mild gastroesophageal reflux symptoms. Upper endoscopy reveals the presence
of a Schatzki's ring. Which of the following statements is true regarding this patient?

(A) This patient almost certainly has an associated type II esophageal hernia

(B) A Schatzki's ring is covered by columnar epithelium on both the upper and lower surfaces

(C) This is a premalignant lesion, similar to Barrett's esophagus

(D) Symptomatic lesions generally respond to either rigid or pneumatic dilation of the ring

(E) The presence of gastroesophageal reflux symptoms and a Schatzki's ring is an indication for fundoplication without any further
preoperative studies

45. A 44-year-old is started on parenteral nutritional therapy for acute necrotizing pancreatitis. He undergoes pancreatic débridement
and shows some improvement in the immediate postoperative period. On postoperative day 3, the patient gradually becomes
increasingly lethargic and confused. His heart rate is 140 beats/min, blood pressure is 80/40 mm Hg, and respiration is 24/min. His K+ =
3.7, Na+ = 145, Cl - = 120, blood urea nitrogen = 75, and creatinine = 1.7. His hematocrit is 45%. Arterial blood gas is pH 7.24, PO2 = 85
on 2 L nasal cannula, PCO2 = 30, and HCO3- = 19. He is currently receiving fluids via parenteral nutrition with 35 kcal/kg/day: 60%
carbohydrates, 35% kcal as lipids, and the rest as protein. He is also receiving morphine sulfate via a patient-controlled analgesia pump.
Which of the following would most likely account for this patient's current status?

(A) Deficiency in thiamine

(B) Hypoglycemia

(C) Hyperglycemia

(D) Dehydration

(E) M orphine overdose

46. A patient presents to the emergency room after sustaining a gunshot injury to the right chest. The entrance wound is
approximately 2 inches below the nipple and along the anterior axillary line with an exit wound near the posterior axillary line on the
right. Along with the placement of a chest tube, treatment should include which of the following?

(A) Performance of a subxiphoid window

(B) Immediate aortogram

(C) Immediate median sternotomy

(D) Exploratory laparotomy

(E) No further treatment

47. A 52-year-old man with a history of hypertension is referred for biopsy-proven gastric adenocarcinoma. The patient states that the
cancer was found when he underwent a routine upper endoscopy for the evaluation of his epigastric pain. The pain has been recent in
onset, about 1 month. Otherwise, the patient denies any melanotic stools or weight loss. Extensive evaluation does not demonstrate
any metastatic disease. Which of the following would be the best advice to give to this patient?

(A) Undergo chemotherapy and radiation only

(B) Undergo surgical resection

(C) Have a repeat computed tomography scan (CT) in 6 months to evaluate for regression

(D) Undergo a gastric bypass for symptomatic relief

(E) Undergo radiation therapy alone

48. A 57-year-old woman underwent an abdominal hysterectomy for fibroids 8 years ago. She now presents to the emergency room
with a 2-day history of worsening nausea and vomiting, as well as complaints of crampy central and lower abdominal pain. On physical
examination her temperature is 37.7°C (100°F), her heart rate is 110 beats/min, her respiratory rate is 16/min, and her blood pressure
is 140/80 mm Hg. Her abdomen is distended and mildly tender but without rebound or guarding. Initial management should include
which of the following?

(A) Ultrasound examination of the abdomen

(B) Nasogastric tube placement

(C) Immediate exploratory laparotomy

(D) Administration of analgesics and antiemetics

(E) Continued observation in the emergency room

49. A 65-year-old man recently diagnosed with renal cell carcinoma presents to the office with complaints of increased abdominal
bloating. On physical examination, he is found to have a tense, but nontender abdomen with shifting dullness. The liver edge is also
palpable 6 cm below the costal margin. Computed tomography (CT) scan reveals tumor extending through the inferior vena cava to the
right atrium. In this patient, which of the following is the most likely cause of ascites and portal hypertension?

(A) Alcoholic cirrhosis

(B) Budd-Chiari syndrome

(C) Schistosomiasis

(D) Cirrhosis secondary to Hepatitis B

(E) Portal vein thrombosis

50. A 65-year-old man presents for an elective total knee replacement. His is otherwise in a good state of health but reports that he
remembers being on a ventilator for a long time after a laparoscopic cholecystectomy 5 years prior. A review of his chart reveals that
he received succinylcholine and the prolonged paralysis was thought to have been the result of a pseudocholinesterase deficiency.
Which of the following agents could potentially result in prolonged muscle relaxation if used in this patient?
(A) Pancuronium

(B) Vecuronium

(C) Atracurium

(D) Rocuronium

(E) M ivacurium

51. A patient who had sustained a severe crush injury to both the lower extremities 2 days prior is noted to have frequent long runs of
ventricular tachycardia on the electrocardiogram (ECG) monitor, although his blood pressure is stable at 115/75 mm Hg. A formal ECG
reveals deep S waves, peaked T waves, and widening of the QRS complex. Which of the following is the most appropriate initial
therapy in the management of this patient?

(A) Administer 1 mg of epinephrine

(B) Administer insulin and 25% dextrose in water

(C) Administer sodium bicarbonate

(D) Administer potassium chloride

(E) Administer calcium gluconate

52. A 33-year-old, intravenous drug abuser presents to the emergency department febrile (40°C) complaining of left upper quadrant
abdominal pain. He is tachycardic with a blood pressure of 110/50 mm Hg. Examination reveals a systolic ejection murmur over the
right sternal border, several tiny erythematous lesions on the palm of his right hand, and a tender left upper quadrant. Echocardiogram
reveals several vegetations on the tricuspid valve. Abdominal ultrasound reveals a fluid-filled mass within the spleen measuring 4 × 5
cm2. A peripheral blood smear is notable for gram-positive cocci. Which of the following is the best treatment option for this patient?
 (A) Image-guided drainage of the splenic lesion alone

(B) Intravenous (IV) antibiotics alone

(C) IV antibiotics and cardiac catheterization

(D) IV antibiotics and splenectomy

(E) Splenectomy alone

53. An 80-year-old man presents to the office with a history of “abdominal fullness” sensation that has been worsening over the past
several months. A computed tomography (CT) scan reveals a 9-cm lesion suggestive of a retroperitoneal sarcoma. Which of the following
is the most important prognostic factor in this patient?

(A) Age of the patient

(B) Number of positive lymph nodes

(C) Histologic grade

(D) Aneuploidy

(E) Location of the lesion

54. A 68-year-old man presents to the office after noting a neck mass. On examination, he has a 1.5-cm mass in the left lobe of the
thyroid gland. Which of the following characteristics is most suggestive that this thyroid nodule is benign?

(A) The presence of only 1 nodule

(B) The lesion is cystic

(C) History of radiation exposure

(D) Family history of multiple endocrine neoplasia (M EN) II

(E) Dysphagia or hoarseness

55. A 68-year-old woman presents after referral from a primary care physician who noted occult positive stools on routine physical
examination. The patient denies any previous history of bleeding from her rectum but has noticed a significant decrease in the caliber
of her stools over the past several months. Which of the following is the most appropriate diagnostic method in the evaluation of this
patient?

(A) Computed tomography (CT) scan

(B) Colonoscopy

(C) Flexible sigmoidoscopy

(D) Laparoscopy

(E) Exploratory laparotomy

56. A 25-year-old woman with recurrent episodes of headaches, sweating, and hypertension is noted to have elevated vanillylmandelic
acid (VMA) and metanephrines. Computed tomography (CT) scan reveals no abnormalities in either adrenal gland. Which of the following
is the most likely location of the pheochromocytoma?

(A) Bladder

(B) Bifurcation of the aorta

(C) Paravertebral ganglia

(D) Carotid body

(E) Thorax

57. A 68-year-old man presents to the office with a 7-cm mass in his posterior right thigh. A recent biopsy revealed a high-grade
sarcoma. A complete work-up revealed no evidence of metastatic disease. Which of the following is the most appropriate definitive
treatment for this patient?

(A) Surgical resection plus combination chemotherapy

(B) External beam radiation alone

(C) Surgical resection plus immunotherapy

(D) Surgical resection plus radiation therapy

(E) Surgical resection alone

58. A 43-year-old woman undergoes elective left thyroid lobectomy and isthmusectomy for follicular cell carcinoma. Mobilization of
the lobe was initially difficult but the patient tolerated the procedure well and was transferred to the postoperative recovery room
where she was extubated. Twelve hours later, the patient is noted to be developing worsening shortness of breath and stridor with
associated anxiety. Which of the following is the most likely cause of her current condition?

(A) Left recurrent laryngeal nerve injury

(B) Hematoma formation

(C) Bilateral recurrent laryngeal nerve injury

(D) Bilateral superior laryngeal nerve injury

(E) Thyroid storm syndrome

59. A 45-year-old woman consults her gynecologist for menorrhagia and during the review of systems she also reports weakness and
fatigue. Work-up includes a serum aldosterone level, which is elevated. Which of the following clinical findings would most likely be
found in this patient?

(A) Hyperkalemia

(B) Edema

(C) Hypotension
(D) Expanded blood volume

(E) Oliguria

60. A 35-year-old woman is found to have a 2-cm, solid mass in the right lobe of the liver on computed tomography (CT) scan evaluation
during a trauma work-up following a motor vehicle accident. Based on the CT scan findings, the lesion is diagnosed as a benign hepatic
adenoma. The patient otherwise was found to have no major injuries and was discharged the following day. In the office, the patient
denies any symptoms potentially related to the adenoma. Which of the following is an appropriate statement regarding hepatic
adenomas?

(A) Administration of oral contraceptive agents may produce regression of the lesion

(B) These lesions are benign and are not associated with malignant transformation

(C) The risk of rupture of these lesions is an appropriate indication for surgical resection in some cases

(D) Further diagnostic studies should be performed because these lesions rarely occur in women of child-bearing age

(E) The patient should be reassured that there is no indication for surgery on this lesion unless it becomes symptomatic

61. A 35-year-old woman presents to your office with the primary complaint of nodular, painful, lumpy breast tissue. She states that
her symptoms include mastodynia and sometimes nipple discharge. She has noted that her pain increases just before her menses and
seems to diminish after, but rarely is she asymptomatic. She has a history of irregular menses, but was able to have 3 children. She is of
a normal body weight and has never been on birth control pills. On physical examination, you discover that she has very tender breasts
with no dominant masses. You obtain a mammogram and discover an area of microcalcifications. A needle localized excisional biopsy
reveals microscopic and macroscopic cysts with fibrosis, adenosis with lymphocytic infiltration, and regularity of nuclei with an
absence of mitoses. Which of the following is the best treatment for this patient?

(A) M odified radical mastectomy

(B) Reassuring the patient that the process is benign with close follow-up
(C) Axillary node dissection with postoperative radiation therapy

(D) Radiation therapy alone

(E) Reassurance in combination with pain control alone

62. A 34-year-old, diabetic man undergoes combined kidney-pancreas transplantation. The pancreatic exocrine drainage is performed
using an enteric anastomosis. Close monitoring of which of the following is most effective in monitoring for pancreatic rejection?

(A) Glucose levels

(B) Urinary amylase levels

(C) Fecal amylase levels

(D) Serum amylase levels

(E) Serum creatinine levels

63. A 25-year-old man presents to the emergency department with acute onset of severe abdominal pain. His vital signs are: heart rate,
135 beats/min; blood pressure, 70/20 mm Hg; respiration, 30/min; temperature, 36.0°C. Examination reveals a rigid abdomen. Which of
the following is the most appropriate next step in the management of this patient?

(A) Obtain a detailed history

(B) Insert a urinary catheter

 (C) Obtain a computed tomography (CT) of the abdomen and pelvis

(D) Provide fluid resuscitation

(E) Perform a barium enema

64. A 45-year-old man presents for evaluation with complaints of epigastric pain and gastroesophageal reflux. He has been treated with
proton pump inhibitor therapy for 3 months without relief of his symptoms. Which of the following statements is true regarding further
treatment of this patient?

(A) If 24-hour pH probe reveals gastroesophageal reflux, surgery is indicated without further work-up
(B) An additional 3 months of medical therapy is recommended before surgery

(C) The presence of a 5-cm tongue of Barrett's esophagus with dysplasia is an indication for surgery

(D) M anometry is not indicated, because the patient has no difficulty swallowing

(E) Barrett's changes can be cured by Nissen fundoplication

65. A 38-year-old, asymptomatic, human immunodeficiency virus (HIV)-positive woman presents with complaints of a new breast mass in
her right breast noted on routine self-examination. She states that she noticed the mass about 1 month before and that it has gradually
increased in size. On physical examination, there is a 2-cm, firm mass in the upper outer quadrant of the right breast without any
evidence of palpable axillary nodes. Core needle biopsy reveals ductal adenocarcinoma. Which of the following is appropriate regarding
the management of this patient?

(A) Treatment should be palliative, given the likelihood of unrecognized metastatic disease

(B) Administration of prophylactic perioperative antibiotics two days before and after any surgery, given the increased risk of wound
infections in HIV-positive patients

(C) A modified radical mastectomy is favored over lumpectomy with lymph node dissection and postoperative radiation therapy
because of the risk of wound complications with radiation

(D) Breast reconstruction is contraindicated, given the risk of wound healing problems in the HIV-positive patient
(E) Either a modified radical mastectomy or lumpectomy with lymph node dissection and postoperative radiation therapy would be
appropriate in an HIV-positive patient

66. A 62-year-old male smoker with a history of peripheral vascular disease presents to the office for a routine visit. On physical
examination the patient is noted to have a 2-cm nonhealing ulcer on his right leg at the site of previous skin grafting for a burn injury
15 years previously. The patient states that the ulcer has not bothered him and that he has been taking good care of it with frequent
cleansing and dressing changes at home. He states that the ulcer has remained stable in size since he first noticed it 5 months ago.
Distal pulses are noted by Doppler. Which of the following is most appropriate in the initial management of this patient?
(A) Continued wound care with subsequent arteriography

(B) Aggressive wound débridement and continued wound care at home

(C) Biopsy of wound

(D) Regrafting of wound with split-thickness skin graft

(E) Recommended cessation of smoking and observation of wound as outpatient

67. A 65-year-old woman with a history of coronary artery disease is admitted to the hospital with a high-output pancreaticocutaneous
fistula 6 weeks after a Whipple procedure performed for treatment of pancreatic cancer. She complains of nausea, vomiting, and
weakness. Her physician has great difficulty maintaining adequate serum levels of potassium. Which of the following coexisting
electrolyte imbalances may be contributing to this patient's condition?

(A) Hyponatremia

(B) Hypomagnesemia

(C) Hypocalcemia

(D) Hypercalcemia

(E) Hypermagnesemia

68. A 45-year-old woman who is a known alcoholic presents to the emergency department in extremis. Foul-smelling, bloody vomit is
grossly visible on her dress. Her skin is cold and ashen gray. Her blood pressure is 80/40 mm Hg and her heart rate is 130 beats/min.
Her abdomen is cachectic and her stool is guaiac-positive. Initial nasogastric tube placement evacuates 1200 ml of bright red blood.
After initial management steps are taken, including administration of 2 L of normal saline and 2 units of packed red blood cells (PRBCs),
the patient's heart rate is 109 beats/min with a blood pressure of 98/65 mm Hg. However, nasogastric aspirate still demonstrates
significant bright red blood. Which of the following is the most appropriate next step in the management of this patient?

(A) Immediate laparotomy

 (B) Vasopressin infusion

(C) Esophagogastroduodenoscopy (EGD)

(D) Placement of Sengstaken-Blakemore tube

(E) Administration of omeprazole, continued intravenous fluids, and observation

69. A 28-year-old man presents to the emergency room with the complaint of recurrent, colicky, midabdominal pain. Physical
examination reveals a palpable abdominal mass and several areas of increased pigmentation on his lips, palms, and soles. He states that
his mother had a polyp removed from her colon several years ago. Which of the following is the most likely diagnosis?
(A) Familial polyposis with malignant degeneration

(B) Gardner's syndrome with intussusception

(C) Peutz-Jeghers syndrome with intussusception

(D) Symptomatic Crohn's disease

(E) Human immunodeficiency virus (HIV) enteropathy

70. A 38-year-old, previously healthy, white woman presents 1 week after a laparoscopic cholecystectomy at an outside institution.
Approximately 3 days after her surgery she developed recurrent high fever associated with abdominal pain. She is placed on broad
spectrum antibiotics with some improvement in her clinical course. Abdominal computed tomography (CT) scan reveals a moderately
large fluid collection in the gallbladder fossa. Cholangiography demonstrates a leak in the common bile duct. Which of the following
statements is appropriate regarding the management of this patient?

(A) There is no role for administration of antibiotics

(B) Proximal biliary decompression and external drainage can be used to control the leak

(C) Immediate surgical intervention is necessary to prevent further spread of infection

(D) Surgical intervention is required in most cases to allow for resolution of the leak

(E) A Roux-en-Y choledochojejunostomy is contraindicated

71. A 45-year-old woman presents to the office with a nontender right groin mass. The patient states she noticed the mass
approximately 1 week ago after working in the garden all day. On examination, the mass is approximately 5 cm and is soft. Which of
the following is the most likely cause of this mass?

(A) Femoral hernia

(B) Direct inguinal hernia

(C) Indirect inguinal hernia

(D) Obturator hernia

(E) Femoral artery aneurysm

72. After an uneventful laparoscopic cholecystectomy, a 58-year-old woman had the urinary catheter removed and began to ambulate.
During routine vital sign checks, she was noted to have had no urine output over the previous 8 hours. An intravenous bolus of normal
saline (500 mL) was ordered but did not stimulate voiding. She underwent straight catheterization of her bladder, which revealed 1000
mL of urine. Urine analysis showed a specific gravity of 1.022, a pH of 5, moderate blood, and positive leukocyte esterase and nitrites.
There were 23 red blood cells/high power field (hpf) and 212 white blood cells/hpf. What is the most likely explanation for her failure
to void?

(A) Bilateral ureteral obstruction

(B) Acute renal failure (ARF)

(C) Urinary tract infection

(D) Hemorrhagic cystitis

(E) Normal urinary retention

73. A 52-year-old man with a history of stage I colon cancer treated with surgical resection 1 year ago develops chronic renal failure
due to diabetes. Which of the following is the best recommendation for this patient?

(A) Treatment with hemodialysis without future transplantation

(B) Treatment with continuous ambulatory peritoneal dialysis without future transplantation

(C) Kidney transplantation within the next year

(D) Hemodialysis for 1 year followed by kidney transplantation

(E) Hemodialysis for 3 months followed by kidney transplantation

74. A 50-year-old woman is receiving a lumbar epidural to provide anesthesia for a transabdominal hysterectomy. During administration
of local anesthetic (lidocaine) through the epidural catheter, the woman complains of shortness of breath then rapidly becomes
unresponsive and apneic. The local anesthetic had been injected in small divided doses and at no point did the catheter aspirate
cerebrospinal fluid or blood. She is promptly intubated and given 100% oxygen with positive pressure ventilation. Which of the
following is the most likely cause of this patient's symptoms?
(A) Unintentional subdural or subarachnoid injection

(B) Allergic reaction to lidocaine

(C) Narcotic overdose

(D) Pulmonary embolization

(E) M yocardial infarction

75. A 55-year-old, alcoholic man has been receiving parenteral nutrition for the past 4 weeks following a protracted course of critical
illness associated with an episode of necrotizing pancreatitis. Over the past 2–3 days he has tolerated oral intake of water and other
liquids and some pureed foods. The next morning his parenteral nutrition is stopped and he continues to tolerate oral water. Later that
morning, the patient becomes lethargic and confused, and eventually becomes unresponsive. Which of the following is the most
appropriate initial management strategy for this patient?

(A) Fluid resuscitation and immediate pulmonary arteriogram

(B) Fluid resuscitation and immediate head computed tomography (CT)

(C) Administration of naloxone and fluid resuscitation

(D) Fluid resuscitation and chest tube placement

(E) Fluid resuscitation and serum glucose analysis

76. A 67-year-old man presents to the office for a routine check-up. His wife states that he has a dark skin lesion on his back that she
would like examined. Which of the following factors would most likely suggest that this is a benign lesion?

(A) 6-mm, smooth lesion, with areas of black and purple pigmentation

(B) 6-mm, blue lesion, with irregular borders

(C) 6-mm, blue lesion, increased in size from 3-mm 1 month ago

(D) 6-mm, smooth, dark purple lesion

(E) 8-mm, smooth, blue lesion, with a central ulceration

Directions: Each set of matching questions in this section consists of a list of four to twenty-six lettered options followed by several
numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be selected once, more
than once, or not at all.

Questions 77–79

A. Amylase

B. Alkaline phosphatase

C. Lactic acid

D. Hematocrit

E. Leukocyte esterase

F. Lactate dehydrogenase

G. Thyroid hormone

H. Serum myoglobin

For each clinical scenario, select the laboratory value or values that are likely to be abnormal.

77. A 60-year-old woman with a history of gallstones presents to the emergency room with severe epigastric pain radiating to the back,
nausea, vomiting, and anorexia. Her vital signs are: heart rate, 80 beats/min; blood pressure, 120/70 mm Hg. The patient has had good
urine output. Ultrasound of the right upper quadrant shows small gallstones throughout the biliary tree. (SELECT 2 LAB VALUES)
A. Amylase B. Alkaline phosphatase
78. A 30-year-old, pregnant woman with a gestational age of 30 weeks presents to the emergency room with suprapubic discomfort and
dysuria. Her vital signs are: heart rate, 90 beats/min; blood pressure, 125/70 mm Hg; respiration, 24/min; temperature, 38.3°C.
Abdominal films are unremarkable. (SELECT 1 LAB VALUE) E. Leukocyte esterase

79. A 70-year-old woman presents to the emergency room with pain localized to the upper abdomen. Abdominal ultrasound reveals
pericholecystic fluid. The patient takes no medications and has no significant past medical history. Her vital signs are: blood pressure,
130/80 mm Hg; heart rate, 88 beats/min; respiration, 18/min; temperature, 38.3°C. (SELECT 1 LAB VALUE) B. Alkaline phosphatase

Questions 80–81

A. Radical pancreaticoduodenectomy

B. Radical cholecystectomy
C. Roux-en-Y hepaticojejunostomy

D. Roux-en-Y choledochojejunostomy

E. Cholecystojejunostomy

F. Percutaneous cholecystostomy
G. End-to-end primary anastomosis with T-tube placement

For each clinical scenario, select the most appropriate procedure.

80. A 47-year-old, white man with a previous laparoscopic cholecystectomy performed 1 year ago presents with a 6-month history of
fluctuating jaundice, pruritus, and abdominal pain. Computed tomography (CT) scan has been performed and reveals no mass lesions but
distension of the intrahepatic ducts. A cholangiogram reveals a 3-cm segmental narrowing of the common bile duct near the cystic duct
remnant. (SELECT 2 PROCEDURE) C. Roux-en-Y hepaticojejunostomy D. Roux-en-Y choledochojejunostomy

81. A 68-year-old, African-American man with a history of hypertension, coronary artery bypass surgery, and bilateral inguinal hernia
repairs presents with a 2-week history of jaundice and pruritus. Laboratory examination is significant for elevated total and conjugated
bilirubin. Computed tomography (CT) scan of the abdomen reveals distended intrahepatic and extrahepatic biliary ducts to the level of
the common bile duct. No mass lesions or lymphadenopathy are identified. A cholangiogram reveals a stricture of the common bile duct
approximately 2 cm from the ampulla of Vater. Cytology on brushings is suggestive of adenocarcinoma. (SELECT 1 PROCEDURE)
A. Radical pancreaticoduodenectomy
Questions 82–86

A. Gastrinoma

B. Pituitary adenoma

C. Vasoactive intestinal peptide tumors (VIPoma)

D. Insulinoma

E. Incidentaloma

F. Glucagonoma

G. Somatostatinoma

M atch each of the following case scenarios with the associated endocrine neoplasm.

82. A 35-year-old man presents with a history of recurrent bleeding gastric ulcers refractory to 1 year of intensive medical therapy.
(SELECT 1 NEOPLASM) A. Gastrinoma

83. A thin, 37-year-old, otherwise healthy man was recently diagnosed with diabetes mellitus. In addition, he is noted to have a 3-cm
mass in the head of the pancreas. (SELECT 2 NEOPLASMS) F. Glucagonoma G. Somatostatinoma

84. A 33-year-old woman presents with recurrent episodes of diaphoresis and palpitations. Her symptoms are often exacerbated by
minimal fasting. (SELECT 1 NEOPLASM) D. Insulinoma

85. A thin, 38-year-old man presents to the office with complaints of a recurring erythematous rash over his chest, abdomen, and
thighs. He states that the rash presents as patches that come and go and appear in different areas each time. (SELECT 1 NEOPLASM)
F. Glucagonoma

86. A 43-year-old woman presents to the office with complaints of persistent watery diarrhea over the past several months. An
abdominal computed tomography (CT) scan reveals a 2-cm mass in the head of the pancreas. (SELECT 2 NEOPLASMS)
A. Gastrinoma C. Vasoactive intestinal peptide tumors (VIPoma)

Questions 87–89

A. History of pelvic inflammatory disease

B. Gallstones

C. Bedridden state
D. Chronic steroid use

E. Atherosclerosis

F. Atrial fibrillation

G. History of myocardial infarction

H. Chronic laxative use

I. Rheumatic fever

For each clinical scenario, select the most appropriate risk factor(s) for that disease.
87. A 22-year-old woman presents with abdominal pain, vaginal bleeding, and an ultrasound showing a gestational sac in the ampullary
part of the fallopian tube. (SELECT 1 RISK FACTOR) A. History of pelvic inflammatory disease

88. A 64-year-old man with progressively increasing abdominal and back pain presents with an 8-cm pulsatile abdominal mass. (SELECT
1 RISK FACTOR) E. Atherosclerosis

89. A 70-year-old man with dementia is admitted from a local nursing home with severe left lower quadrant pain, abdominal distention,
and constipation. An extremely dilated sigmoid colon is present on abdominal film and appears to taper both proximally and distally.
(SELECT 2 RISK FACTORS) C. Bedridden state H. Chronic laxative use

Questions 90–94

A. Tension pneumothorax

B. Cardiac tamponade

C. M assive liver injury

D. Aortic disruption

E. Tension hemothorax

F. Flail chest
G. Femur fracture

H. Pelvic fracture

I. Spinal cord injury

J. Closed head injury

M atch the following cause(s) of hypotension with the clinical scenario listed below.

90. A 19-year-old man is shot from behind, with a gunshot entrance wound below and just medial to the right scapula. The exit wound
is visualized 3–4 finger breadths superior to the inferior costal margin along the anterior axillary line. The patient is hypotensive with
decreased breath sounds on the right. (SELECT 4 CAUSES OF HYPOTENSION)
A. Tension pneumothorax B. Cardiac tamponade C. Massive liver injury E. Tension hemothorax

91. A 23-year-old man presents to the emergency room with hypotension. He was involved in a head-on, high-speed motor vehicle
accident. He was not wearing his seatbelt and the emergency medical technician noted deformation of the steering wheel. The patient
has normal breath and heart sounds although he is tachycardic. His chest film reveals normal lung fields bilaterally, however his
mediastinum appears to be slightly widened with no visualization of the aortic knob. The patient's abdominal and pelvic computed
tomography (CT) scan are normal. (SELECT 1 CAUSE OF HYPOTENSION) D. Aortic disruption

92. The driver in a high-speed motor vehicle accident presents to the emergency room with hypotension and tachycardia. Examination
reveals normal breath sounds bilaterally. Heart sounds are muffled with enlarged jugular veins. Chest and pelvis films appear normal.
Abdominal examination is unremarkable, with a negative diagnostic peritoneal lavage. (SELECT 1 CAUSE OF HYPOTENSION)
B. Cardiac tamponade
93. A 35-year-old woman presents to the emergency room after being struck in the lower back and buttocks region with a steel beam.
She is conscious but confused, hypotensive, and has a heart rate of 90 beats/min. Examination reveals normal reactive pupils, normal
chest and abdominal examinations, and no movement of her lower extremities. Her legs and thighs appear normal with no evidence of
trauma. Her chest film is normal. Pelvic radiograph reveals a fracture of the superior ramus on the right and a right acetabular fracture.
Rectal examination reveals loss of normal tone of the sphincter muscle. (SELECT 2 CAUSES OF HYPOTENSION)
H. Pelvic fracture I. Spinal cord injury
94. A 23-year-old man presents to the emergency room after being hit in his left chest with a baseball bat. He is hypotensive,
tachypneic, and has no breath sounds noted on the left side. Heart sounds are normal and his upper airway is open, although the
trachea is deviated to the right. (SELECT 2 CAUSES OF HYPOTENSION)
A. Tension pneumothorax E. Tension hemothorax
Questions 95–96
A. Dilutional coagulopathy

B. Disseminated intravascular coagulation

C. Heparin-induced coagulopathy

D. von Willebrand's disease

E. Hemophilia A

F. Hypothermia-induced coagulopathy
G. Primary fibrinolysis

H. Vitamin K deficiency

For the each of the following clinical scenarios, select the most likely diagnosis(es).

95. A 44-year-old man sustained a gunshot wound to his left chest and left upper quadrant that required emergent exploratory
laparotomy, splenectomy, and left hemicolectomy. On postoperative day 3, he was noted to have necrotizing fasciitis at the blast
wound. He subsequently developed acute oliguric renal failure that required intermittent hemodialysis. On postoperative day 20, after
a hemodynamically stable hemodialysis session, the patient was noted to be bleeding from his central line and hemodialysis catheter
sites. Coagulation profile had the following results: prothrombin time (PT) = 14.0 seconds, partial thromboplastin time (PTT) > 200
seconds, platelets = 230,000. (SELECT 1 DIAGNOSIS) C. Heparin-induced coagulopathy

96. A 32-year-old woman was involved in a high-speed motor vehicle accident where she sustained blunt abdominal injury. She was
hypotensive at the scene and throughout most of the operation to resect her damaged intestine. Upon presentation to the intensive
care unit, however, she remained hypotensive despite administration of 12 L of crystalloid, 12 units of

packed red blood cells (PRBCs), and 5 units of fresh frozen plasma. Current vital signs include a blood pressure of 70/40 mm Hg, heart
rate of 140 beat/min, and temperature of 34.5°C. Laboratory studies showed prothrombin time (PT) = 16.2, partial thromboplastin time
(PTT) = 48.3, and platelets = 18,000. In addition, she was noted to be bleeding from her wound, mucous membranes, and at all catheter
sites. (SELECT 3 DIAGNOSES)
A. Dilutional coagulopathy B. Disseminated intravascular coagulation F. Hypothermia-induced coagulopathy
Questions 97–100

A. Packed red blood cells (PRBCs)

B. Fresh frozen plasma

C. Cryoprecipitate

D. Recombinant factor VIII

E. Single donor platelets

F. Desmopressin

G. 5% Albumin

H. 25% Albumin

I. Heparin sodium

J. Warfarin

For each patient description, select the most appropriate treatment.

97. A 38-year-old female diabetic with acute renal failure requires urgent removal of her gallbladder but has an elevated bleeding time
after receiving hemodialysis. Prothrombin time (PT) and partial thromboplastin time (PTT) are normal. (SELECT 2 MODES OF
TREATMENT) E. Single donor platelets F. Desmopressin

98. A 29-year-old man presents with a tibial fracture that will require intraoperative fixation. The patient gives a history of “excessive
bleeding” with a tonsillectomy as a child. His PT and PTT are normal, although his bleeding time is elevated. Intraoperatively, there is
a significant amount of blood loss from oozing, without any obvious sources of arterial or venous bleeding. (SELECT 2 MODES OF
TREATMENT) B. Fresh frozen plasma C. Cryoprecipitate

99. A 78-year-old woman requires urgent replacement of an implanted defibrillator. She has been taking warfarin for an artificial heart
valve. Before surgery, the surgeon wishes to reverse the effects of warfarin. (SELECT 1 MODE OF TREATMENT) B. Fresh frozen plasma

100. A 45-year-old woman with protein C deficiency presents with worsening aortic stenosis secondary to a bicuspid aortic valve. The
patient undergoes replacement of this valve with an artificial mechanical valve. Postoperatively, the surgeon wishes to provide
anticoagulation therapy to prevent thrombus formation on the valve. (SELECT 2 MODES OF TREATMENT) I. Heparin sodium J. Warfarin
Answers and Explanations
1–A. This patient is experiencing a classic manifestation of refeeding syndrome. Refeeding syndrome is seen in severely malnourished
patients when aggressive calorie support is initiated, particularly when a large percentage of those calories are provided as carbohydrates.
The infusion of carbohydrates results in rapid and extensive peripheral uptake and utilization of glucose. The intracellular utilization of
glucose requires the use of a significant amount of intracellular PO 4-, therefore potentially resulting in severe hypophosphatemia.
Characteristics include malaise, lethargy, perioral paresthesias, tremors, dysarthrias, coma, and even death. Treatment involves slowing
administration of nutritional support and administration of PO 4- salts. Thiamine would most likely be provided in the vitamin
supplementation and would generally not be associated with such a temporal relationship to parenteral nutrition administration. Insulin
may help to decrease overall serum glucose levels, however, it would not specifically address the most serious acute issue of severe
hypophosphatemia. M gCl2 administration also does not address the primary issue of hypophosphatemia.

2–B. In an adult, satisfactory urine output is 0.5–1.0 mL/kg/hour, and in a patient with a large burn it needs to be measured continuously
with a Foley catheter. An appropriate goal for adequate urine output in this patient is 40–80 mL/hr based on his weight of 80 kg. In a
patient with severe burns a minimum of two large-bore intravenous (IV) lines are necessary. Burn patients are extremely hypermetabolic,
and have numerous reasons to be tachycardic other than hypovolemia. Edema secondary to leaky vascular membranes is common in
patients with severe burn injuries and is not a marker of overhydration.

3–E. Ketamine is unique among anesthetic agents in that it provides anesthesia, analgesia, and possibly amnesia. It is also a potent
bronchodilator and tends to maintain cardiac output and blood pressure. Unfortunately, emergence reactions are common. M idazolam, a
benzodiazepine with reliable anxiolytic and amnestic properties, can greatly attenuate these reactions. Propofol, fentanyl, lidocaine, and
etomidate are other anesthetic agents frequently used for cardioversions, however, these agents do not provide the effective amnestic
effect provided by midazolam.

4–B. This patient most likely has appendicitis based on his age and presenting symptoms. The psoas sign is pain in the lower abdomen and
psoas region that is elicited when the thigh is flexed against resistance. It suggests an intra-abdominal inflammatory process most
frequently associated with appendicitis. Crepitus suggests a rapidly spreading gas forming infection and is a rare finding. M urphy's sign
suggests acute cholecystitis, while flank and periumbilical ecchymosis suggest retroperitoneal hemorrhage, often caused by hemorrhagic
pancreatitis.

5–B. This patient has developed necrotizing fasciitis of the perineal and scrotal region (Fournier's gangrene) probably originating from an
intra-abdominal source (e.g., diverticulitis). M anagement requires early and aggressive surgical débridement of the affected region.
Generally, given the differential blood supply between the scrotum and the testicles, as well as the thick dartos fascia surrounding the
testicles, superficial infections of the scrotum extending from the perineum do not affect the testicles, thus orchiectomy is generally not
necessary. In some circumstances, persistent infections in the perineal region require fecal diversion with a colostomy to avoid persistent
fecal contamination and inhibition of healing. Although resection of the affected colon would be considered appropriate, a primary
reanastomosis would not provide for fecal diversion. Sitz baths and antibiotics would be inadequate therapy without surgical débridement.

6–C. Although rare, one of the potentially serious complications associated with laparoscopic intraperitoneal hernia repair is the risk of
iatrogenic bowel injury. It is unlikely that a strangulated hernia went undiagnosed prior to or during an elective inguinal hernia repair. It is
also unlikely that the hernia would recur by postoperative day 1. In addition, wound infections and adhesion formation do not develop this
quickly in the postoperative period and would not necessarily be associated with rebound and guarding.

7–C. Acute renal failure (ARF) is defined as an abrupt change in renal function such that plasma creatinine and urea levels are elevated.
Oliguria (< 0.5 mL/kg urine output per hour) or anuria are usually present. Prerenal failure suggests inadequate blood flow to the kidney.
Causes of intrinsic renal failure include acute tubular necrosis, nephrotoxicity secondary to drugs, hemoglobinuria, and myoglobinuria.
Postrenal failure causes usually present with acute anuria caused by any obstruction to urinary flow from the collecting ducts to the
urethra. The fractional excretion of sodium (FENa) and urine specific gravity can help to delineate prerenal causes from other causes of
acute renal failure. Urinalysis including cytology may assist in identifying an intrinsic renal injury. Hemodialysis may be necessary as a bridge
due to severe hyperkalemia, metabolic acidosis, uremic complications, and volume overload until renal function returns to normal. M ost
cases of acute renal failure in this setting will resolve.

8–E. A focal bile duct stenosis in the absence of a history of abdominal surgery is highly suggestive of a biliary neoplasm. Furthermore, this
patient presented with a history of painless jaundice, which is also suggestive of malignancy. Primary sclerosing cholangitis may also
present with a focal stenosis but usually at an earlier age and with a fluctuating clinical course. Cholangitis and M irizzi's syndrome would be
highly unlikely in a patient with a normal white count and no pain.

9–A. Corticosteroids decrease hypertrophic scarring by enhancing collagenase activity. This is related to an increase in collagen
degradation within the hypertrophic scar. Injecting corticosteroids directly into a scar prevents acute inflammation in the healing wound.
Injecting keloids and hypertrophic scars with corticosteroids has no effect on the number of fibroblasts present. Collagen turnover is not
increased in treated scars. Pressure treatment is not necessary after corticosteroid injection. Corticosteroids do not affect intracellular
collagen synthesis or extracellular collagen cross-linking. The cross-linking process contributes to the tensile strength in a healing wound.
Increased collagen solubility is not caused specifically by cross-linking.

10–C. Fever, chills, back pain, hemoglobinuria, and rapid deterioration of the cardiovascular and respiratory systems are classic signs of a
severe immune reaction to transfused blood caused by ABO incompatibility, as seen in this patient. The cause of this reaction is preformed
antibodies in the recipient's serum reacting to nonself antigens on the donor's red blood cells (RBCs) [i.e., patients with Type A blood have
antibodies to Type B RBCs]. Bacterial contamination of donor blood is rare and generally would not present within the first few minutes of
administration. Donor leukocytes can react with recipient cells, but this is not generally associated with a severe transfusion reaction. It
may, however, cause fever and chills in a small number of patients. Volume overload secondary to too-rapid administration of blood can be
associated with dyspnea and respiratory insufficiency, but is not associated with the other findings. Hypocalcemia rarely occurs, even with
massive transfusions, and would not be associated with the findings in this patient.

11–A. Glucocorticoids are used in most multidrug immunosuppression protocols. In addition, they are commonly used as the first line
therapy for rejection by administration of boluses over one to several days. If steroids fail, monoclonal or polyclonal antibodies are added
to the regimen. Cyclosporine and azathioprine are essential in maintenance therapy but play no role in the treatment of acute rejection.
M ycophenolate mofetil decreases the rate of rejection particularly for kidney transplants, but again plays little or no role in the treatment
of acute rejection once it has developed. Cyclophosphamide is rarely used in transplant recipients either for maintenance or for
treatment of rejection.

12–D. Although hemorrhage in such a patient could originate from many different sources, upper gastrointestinal bleeding is a frequent
cause of hemorrhage in critically ill surgical patients generally resulting from acute stress gastritis. The patient's risk factors include
hospitalization with a long stay in the intensive care unit and sepsis. Although airway management and volume resuscitation are initial
management steps, early placement of a nasogastric tube may confirm that the bleeding is from an upper gastrointestinal source. In
addition, checking the stools for blood (i.e., guaiac test) may also provide support for a gastrointestinal source of bleeding in patients with
a falling hematocrit. In the absence of other signs of an intra-abdominal process (e.g., acute abdomen), emergent laparotomy or
mesenteric angiography are not indicated at this point in the management of this patient.

13–E. Although conservative medical management of esophageal perforation is appropriate for a small, select group of patients, it is
generally reserved for those who have no evidence of sepsis or communication of the rupture with the pleural or peritoneal cavities. In
theory, these patients have already “defended themselves” against the rupture and should do well with conservative management with
antibiotics and drainage. Boerhaave's syndrome ruptures tend to be the most morbid because of the high incidence of pleural or
peritoneal contamination and delayed diagnosis. Survival in these patients is 75%–85% and those presenting earlier tend to fare better than
those presenting after 72 hours. Patients who present less than 24 hours after the injury are generally candidates for reinforced primary
closure of the perforation. Esophageal rupture secondary to Boerhaave's syndrome usually results in a tear on the left lateral wall, just
above the diaphragm. Thus, a left pleural effusion is a common finding on chest radiograph.
14–C. Both the benzodiazepines and most barbiturates are excellent anti-epileptics. Propofol and etomidate also likely possess antiseizure
properties but it is thought that etomidate in low doses may provoke seizures. Either midazolam or a low dose of thiopental would rapidly
terminate this seizure caused by this unintentional intravascular injection of bupivacaine. Succinylcholine would mask the convulsions, and
narcotics (such as fentanyl) also do not suppress seizures. Lidocaine is not as toxic as bupivacaine, but can cause seizures if too much is
given intravenously.
15–B. Branched-chain amino acids are essential amino acids and include leucine, isoleucine, and valine. These amino acids are
preferentially metabolized by the muscle and therefore in the setting of significant liver disease administering these substrates may
decrease the overload of total protein and provide for mechanisms of more efficient glucose production. Administration of nutritional
supplements with a high percentage of branched-chain amino acids versus other amino acids may decrease the degree of encephalopathy
seen in patients with severe liver failure. These amino acids are not preferentially metabolized by the liver and do not act as hepatotoxins.

16–E. Gallstone ileus is the obstruction of the small intestine (usually at the ileocecal valve) caused by a gallstone that has entered the
duodenum through a fistula formed between an inflamed gallbladder and the duodenum. The usual signs of intestinal obstruction are
found, plus air in the biliary tree. There is usually a history of attacks of cholecystitis or cholelithiasis. While air in the biliary tree may
represent cholangitis, this finding in association with a small bowel obstruction (SBO) without other identifiable causes should raise
suspicion for gallstone ileus. Superior mesenteric artery syndrome is a rare cause of duodenal obstruction caused by external compression
of the third portion of the duodenum by the overlying vessel. It is characteristically seen in patients with rapid weight loss or those in
SPICA casts. The obstruction is proximal and is not associated with distension of small bowel as described above. Right-sided colon cancer
can mimic distal SBOs but is not associated with air in the biliary tree. Because the patient has not had prior abdominal surgery, adhesive
obstructions would be improbable. Uncomplicated sigmoid diverticulitis is generally not associated with air in the biliary tree.

17–C. Even though less than 1% of all breast cancer occurs in men, it is most likely that this patient is suffering from breast cancer. There
are approximately 900 new cases of male breast cancer per year and most cases present with an isolated mass or enlargement of a single
breast. The mean age of presentation is 60–65 years with a prominent risk factor being a protracted hyperestrogenemic state. These
tumors are ductal in origin, and 80% are estrogen receptor-positive. These tumors tend to become systemic early, with axially node
metastasis, or involvement with the chest wall or skin. Therefore, they usually present at a late stage, and a lumpectomy and axillary node
dissection is inadequate to remove the majority of the tumor burden. Treatment is a radical mastectomy after the diagnosis is confirmed
with fine needle aspiration (FNA) or biopsy. Chemotherapy is needed for adjuvant therapy, but is inadequate single therapy.

18–B. The presence of free peritoneal air in the setting of acute diverticulitis is an indication for emergent laparotomy and resection of
the affected colon with formation of an end colostomy and performance of a Hartmann's procedure (oversewing of the unaffected
rectosigmoid distal to the resection site creating a pouch drained through the anus). Reanastomosis of the colon to the proximal end of
this pouch can be performed at a later date. Percutaneous drainage of such an abscess may be appropriate in some cases of diverticulitis,
but not in the presence of free peritoneal air. The affected colon needs to be resected emergently in this setting, given the likelihood of
a free colonic perforation. Resection of the diseased colon is sufficient in this setting without the need for a total colectomy.

19–A. M etastatic neoplasms most often originating from the colon, breast, or lung are the most common etiology of malignant liver tumors,
while hepatocellular carcinoma is the most common primary malignant lesion of the liver. Worldwide, the most common cause of
hepatocellular carcinoma is cirrhosis secondary to hepatitis B infection. α-Fetoprotein is a tumor marker for hepatocellular carcinoma,
although it is nonspecific, with elevations also noted in patients with liver metastases, teratocarcinomas, yolk sac tumors, and even
cirrhosis. Hepatoblastomas are characteristically very sensitive to chemotherapy.

20–A. Hypersplenism will occasionally occur in patients with acquired immunodeficiency syndrome (AIDS). Criteria for splenectomy are the
same for patients with human immunodeficiency virus (HIV) as for those without it. Symptomatic splenomegaly (i.e., hypersplenism) caused
by a condition which is otherwise not reversible is an indication for splenectomy. Emergent splenectomy, however, is not indicated.
Ideally, this patient would be given the appropriate vaccinations against encapsulated organisms 10 days before the splenectomy.
Plasmapheresis would be of no benefit in this patient. Intravenous (IV) gamma globulin is a medical therapy given to patients with idiopathic
thrombocytopenic purpura (ITP). Splenic artery embolization is not indicated for the treatment of hypersplenism.

21–B. Thyroid storm generally presents in patients with undiagnosed or inadequately treated hyperthyroidism and can be precipitated by
manipulation or palpation of the gland. Preventative measures include preoperative administration of β-blockers and propylthiouracil (PTU)
until the patient becomes euthyroid. Treatment of an acute presentation of thyroid storm (fever, tachycardia) involves mechanical
cooling, administration of oxygen, β-blockers, PTU, and iodide salt solutions (e.g., Lugol's solution or potassium iodide). Administration of a
large amount of iodide with uptake into the thyroid effectively inhibits production of triiodothyronine (T3) and thyroxine (T4), resulting in
a rapid decrease in serum thyroid hormone levels (Wolff-Chaikoff block).

Thyroid storm is not related to calcium metabolism, and T4administration is contraindicated in this setting. Dantrolene is used for malignant
hyperthermia, which would be unlikely to develop before induction of anesthesia. Administration of blood products is not indicated in this
setting.
22–D. An anastomotic leak is a devastating complication. Principles of performing proper anastomoses include ensuring good blood supply
to both ends of bowel (colonic anastomoses are at higher risk because of their more tenuous blood supply), creating a tension-free,
serosa-to-serosa, watertight apposition with inverted mucosal surfaces, avoiding gross contamination, and avoiding distal obstruction. Some
large bowel anastomotic leaks may be well localized with percutaneous drainage of fluid collections or small abscesses serving as
appropriate therapy without the need for immediate reoperation. Severe leaks may result in terrible complications, including abscess
formation, enterocutaneous fistulas, or diffuse peritonitis, which will require resuscitation and nasogastric aspiration, followed by
laparotomy and exteriorization of free bowel ends.

23–A. This patient has choledocholithiasis. She has secondary common duct stones, most likely representing black pigment stones caused
by hemolysis from her sickle cell disease. Brown pigment stones are formed from a combination of bile stasis and bacterial deconjugation
of bilirubin. Choledocholithiasis commonly presents with a fluctuating history of pain and jaundice. An endoscopic retrograde
cholangiopancreatography (ERCP) may be used not only to diagnose a common duct obstruction but also to treat the condition by
removing the stone. Because of the multiple stones present in the gallbladder, some surgeons may take such a patient to the operating
room for cholecystectomy and intraoperative choledocoscopy with stone extraction.

24–D. All of these complications can occur during placement of a Swan-Ganz (pulmonary artery) catheter. Inappropriate needle placement
can result in a pneumothorax or hemothorax. Cardiac perforation and perforation of the pulmonary artery can occur while advancing the
catheter through these structures. Although rare, dislodgment of a large venous thrombus during placement can occur, resulting in a
pulmonary embolus. However, sudden hypotension and hemoptysis occurring during placement of this catheter suggests rupture or
perforation of the pulmonary artery. Immediate recognition of this injury is essential for appropriate treatment because mortality with this
injury is high.

25–E. The patient described displays the characteristics of the multiple endocrine neoplasia (M EN) IIA syndrome, which can include
medullary thyroid cancer, hyperparathyroidism, and pheochromocytomas. Any patient who presents with medullary thyroid cancer and a
history suspicious for the M EN syndrome should be evaluated for a possible pheochromocytoma and parathyroid abnormalities, including
urine tests for catecholamines, metanephrines, vanillylmandelic acid, parathyroid hormone, and calcium. Treatment of medullary thyroid
cancer involves total thyroidectomy rather than lobectomy because this type of thyroid cancer tends to be multicentric. Patients with
the M EN syndrome who present with a pheochromocytoma have a 50% chance of having bilateral adrenal involvement and should thus be
approached transabdominally to evaluate both adrenal glands. A laparoscopic approach is not contraindicated in these patients.
Parathyroid disease in these patients is almost always diffuse hyperplasia rather than a solitary adenoma.

26–A. For melanomas less than or equal to 1 mm thick, appropriate treatment of the primary lesion involves wide local excision with 1-cm
margins. Establishing general guidelines for adequate margins based upon the thickness of the lesion prevents excessive resections that are
difficult to close and attempts to prevent local recurrences because of inadequate margins. M ohs' microsurgical technique is
contraindicated in the treatment of melanomas because this may not involve en bloc resection of the entire lesion. Cryosurgical ablation is
also contraindicated for melanomas because this does not allow for assessment of the depth of invasion of the lesion versus resection.

27–D. The treatment of Hürthle cell tumors of the thyroid is somewhat controversial. In general, like for follicular cell carcinomas, a total
thyroidectomy is considered the most appropriate procedure when surgery is performed. Unlike other follicular carcinomas and papillary
tumors, the Hürthle cell variant is characteristically resistant to uptake of radioiodine (131I) and thus resistant to 131I ablation therapy. In
addition, many advocate formal lymph node dissection when positive nodes are identified. Lobectomy and isthmusectomy is generally
considered inadequate resection, particularly for aggressive Hürthle cell tumors.

28–E. Asymptomatic simple liver cysts generally do not require treatment. There is no associated risk of malignant transformation and the
small risk of rupture does not necessitate treatment of such cysts. The walls of simple liver cysts often contain islands of biliary ductal
epithelium known as von M eyenburg complexes. Indications for resection or unroofing of the cyst with subsequent oversewing of the cyst
wall include symptoms (i.e., pain), rupture, hemorrhage, indeterminate diagnosis, and infection. Initial percutaneous drainage of infected
cysts is also an appropriate alternative.

29–C. In patients with the multiple endocrine neoplasia (M EN) II syndrome who present with both medullary thyroid cancer and a
pheochromocytoma, the pheochromocytoma should be addressed first. Preoperative treatment with α- and β-adrenergic blockade should
be followed by surgical resection. The medullary thyroid cancer should be addressed at a later date with total thyroidectomy. In addition,
subtotal parathyroidectomy may be performed if hypercalcemia secondary to parathyroid hyperplasia is identified preoperatively.

30–B. Inadvertent placement of a feeding tube within the airway (e.g., trachea, bronchus) is estimated to occur [asymptotically equal to]
5% of the time when attempting to place nasoenteric tubes in critically ill patients. Although very rare, significant bronchial injury,
including perforation with subsequent development of a tension pneumothorax, can occur and must be recognized and treated
immediately by removing the feeding tube and placing a chest tube, based on your clinical assessment of the patient. Fluid resuscitation is
important but will not address the primary catastrophic event. In this setting, prompt removal of the feeding tube is essential and injection
of contrast is foolish. In addition, the initial steps in the management of this patient do not require performing emergent laparotomy or a
pulmonary angiogram given the likelihood of the diagnosis based upon the temporal relationship with feeding tube placement.

31–B. Pernicious anemia can result from several pathophysiologic mechanisms. Loss of cells that make intrinsic factor from autoimmune
disease results in the inability to absorb the vitamin B12. Loss of the terminal ileum results in malabsorption of vitamin B12, which results in
pernicious anemia. Bacterial overgrowth in segments of bowel (e.g., blind loops) may also lead to consumption of the vitamin by the
bacteria, with subsequent deficiency. B12 deficiency results in defects in blood cell maturation, as well as peripheral nerve metabolism.
Dumping syndrome characteristically occurs after gastric surgery, resulting from disruption of pyloric function or bypass of the pylorus.
Ileal resections are not a cause of hypercalcemia. The majority of dietary iron is absorbed within the duodenum; thus, iron deficiency
anemia is not a characteristic directly related to ileal resection.

32–C. Infectious mastitis is a relatively uncommon disease, representing a bacterial infection of an obstructed milk duct. Staphylococcus
aureus is by far the most common pathogen. It primarily affects women who are breast-feeding. M ost cases begin as skin cellulitis, and if
caught early, may be treated with antibiotics alone. If caught late in the course, after abscess formation, surgical incision and drainage are
required. There is no need to stop breast-feeding with infant-safe agents during antibiotic therapy for infectious mastitis, and some
believe that the continued stimulation and drainage may aid in treatment. It is important to keep in mind that whenever a primary
infection of the breast is suspected clinically, inflammatory breast cancer must be considered in the differential diagnosis and ruled out.
Treating this patient with reassurance, nonsteroidal anti-inflammatory drugs (NSAIDs), or danazol would be ineffective in relieving the
breast infection.

33–A. Because the site of bleeding had been isolated in this patient, a segmental resection is possible and will cause less morbidity than a
subtotal colectomy. However, if the site of bleeding had not been identified, a subtotal colectomy would be indicated because it is the
only way to ensure a curative resection and prevent future bleeding. Angiography with embolization or vasopressin infusion is associated
with a high rate of rebleeding and a low but significant risk of bowel perforation. These techniques can, however, be useful alternatives in
high-risk patients.

34–B. Infected wounds of the hand are treated by aggressive surgical débridement, open drainage, and wound exploration. During these
procedures, foreign bodies are removed and devitalized tissue is débrided. The most common pathogen in human bite wounds is
Staphylococcus aureus. Eikenella corrodens is also frequently cultured. Penicillin is generally included in the antibiotic regimen in these
wounds, although broad spectrum antibiotics are frequently used initially until culture and sensitivity data are available. Primary closure is
never appropriate for

treating a human bite wound because of the high risk of wound contamination and subsequent infection. Tendon lacerations are repaired
secondarily after a minimum of 5–7 days.
35–A. Percutaneous or transrectal drainage of pelvic abscesses is an appropriate alternative to laparotomy for treating localized abscesses,
although inability to provide adequate drainage or signs and symptoms of peritoneal involvement may require operative intervention.
Without adequate drainage of such an abscess, antibiotics alone would be insufficient therapy. Although antibiotic coverage should be
adjusted based on the culture results, initial empiric therapy should be directed against both aerobes and anaerobes. Empiric therapy
with antifungal agents has not been demonstrated to provide additional benefit to such patients.

36–D. For elective surgery of intractable ulcer disease (persistence or recurrence of symptoms despite adequate medical therapy) parietal
cell vagotomy is frequently preferred among the options listed because of the relatively low morbidity associated with this procedure.
Procedures involving a truncal vagotomy are associated with an increased risk of gastric emptying problems versus parietal cell vagotomy.
Antrectomy and total gastric resection require disruption of intestinal continuity with formation of new anastomoses, thus resulting in a
higher complication rate as well. Unfortunately, parietal cell vagotomy is reported as having the highest ulcer recurrence rate among
these options, although in experienced hands this may not be the case.

37–C. A woman of childbearing age with hypotension, abdominal distension, and acute abdominal pain should be suspected of having a
ruptured ectopic pregnancy. Complications of Crohn's disease, such as perforation, would generally not present in such an acute manner
without a history of previous symptoms. A perforated duodenal ulcer generally would not present with progressive lower abdominal pain,
but rather sudden onset of severe epigastric pain and rigidity. Ovarian torsion does not typically cause hypotension. A ruptured appendix
can lead to hypotension, abdominal rigidity, and guarding, but this is unlikely to occur in the first 8 hours of abdominal pain.

38–C. M any donor organs come from young, previously healthy individuals who sustain irreversible brain injury. The presence of brain death
must be determined before donation as determined by: (1) deep coma without response to painful stimuli, (2) absence of spontaneous
respiration in the presence of elevated CO 2, (3) absence of movement, (4) absence of brain stem reflexes (e.g., gag reflex), (5) absence of
hypothermia, and (6) absence of depressant drugs. Supportive findings include an isoelectric electroencephalogram, absence of
intracranial blood flow, or massive cerebral tissue destruction.

39–A. There are four groups, or levels, of axillary breast nodes defined by their relation to the pectoralis minor muscle. An axillary node
dissection is the removal of level I, II, and III lymph nodes. It is considered a staging procedure because it has never been shown to directly
improve patient outcome. Rather, it is used to direct adjuvant therapies and predict survival. When combined with postoperative radiation
to the breast, axillary lymph node dissection is as effective as a modified radical mastectomy. Axillary node dissection without radiation
therapy to the breast is associated with a higher local recurrence rate. A simple mastectomy, or subcutaneous mastectomy, removes the
bulk of the breast tissue, but provides no information about the axillary node status. A radical mastectomy is the en bloc excision of the
breast, the overlying skin, pectoralis major and minor muscles, and the level I, II, and III lymph nodes. For a patient with an early stage
breast cancer, this operation is considered too aggressive.

40–A. Chemotherapy is generally indicated in the treatment of stage III colon cancers. This corresponds to Dukes stages C1 and C2. Survival
is improved with postoperative adjuvant chemotherapy in these patients. An appropriate chemotherapy regimen would include 5-
fluorouracil and levamisole. Chemotherapy is not indicated in stage I lesions; however, current studies are examining the potential benefit
in advanced stage II lesions. Radiation therapy is not indicated in the treatment of colon cancer, although it is used in treating rectal
cancer.

41–D. A rapid sequence intubation is performed by giving a fast-acting induction agent with a fast-acting paralytic when intubating
conditions are desired as quickly as possible. The administration of a paralytic is based on the anesthesiologist's belief after examining the
patient's airway that the intubation will be successful. If intubation fails, the patient must be mask ventilated. If the patient can't be mask
ventilated, an emergent cricothyrotomy should be performed.

The safest management is to keep the patient spontaneously ventilating, topically anesthetize the airway, and perform the intubation while
the patient is awake. Propofol and thiopental could produce unwanted hypotension in this patient, while etomidate, in theory, could
trigger a seizure.

42–E. Pressure sores, or decubitus ulcers, are the bane of postoperative patient care in critically ill, obese, and incapacitated patients.
These populations of patients are unable to move on their own and are at high risk of developing pressure ulcers, usually near their
sacrum. Prevention is best with early mobilization or frequent position changes. There are numerous methods to treat these ulcers,
including special air mattress beds and protective coverings placed over the involved area. Adequate nutrition and proper hygiene also
help to prevent sores or to assist in their healing. Wound care to ulcers is best done by daily mechanical débridement (wet-to-dry dressing
changes).

43–A. The presence of significant rebound tenderness and guarding suggests the presence of peritonitis probably secondary to rupture of
a necrotic, strangulated portion of the intestine. This requires immediate abdominal exploration even after the hernia was able to be
reduced. Local wound exploration would not allow for identification and treatment of necrotic bowel. Discharge and elective repair would
be inappropriate in the setting of peritoneal signs. Observation would only delay the inevitable.
44–D. A Schatzki's ring is a submucosal, circumferential ring in the distal esophagus that is covered by columnar epithelium on the lower
surface and squamous epithelium on the upper surface. Almost all patients with this benign lesion have an associated sliding (type I)
esophageal hernia. Gastroesophageal reflux symptoms may be present secondary to the effects of the type I hernia but they often
respond to conservative management. The mere presence of a Schatzki's ring in not an absolute indication for surgical intervention when
gastroesophageal reflux symptoms are present. A complete work-up including upper endoscopy, manometry, and 24-hour pH probe is
warranted before any surgical intervention is considered.
45–D. Although parenteral nutritional therapy can provide for maintenance fluid requirements in some settings, it should not be
considered the sole source of hydration in many other settings. Patients with necrotizing pancreatitis can have large volume deficits
secondary to third spacing of fluid and aggressive replacement of these deficits with crystalloid, not total parenteral nutrition, should be
performed and closely monitored. The severe metabolic acidosis associated with a blood urea nitrogen/creatinine ratio much greater than
20 is consistent with severe volume depletion from inadequate volume resuscitation. This is the most likely source of this patient's current
condition.
46–D. Gunshot wounds to the abdomen require performance of an exploratory laparotomy. Although this patient may have been shot in
the lateral chest, it is important to recognize that the diaphragm rises to the level of the fourth intercostal space on expiration. Thus, gun
shot wounds at or below this level need to have the abdomen evaluated surgically. A subxiphoid window and a sternotomy are not
necessary because the injury does not seem to have traversed the “box.” Similarly, an immediate aortogram to evaluate the great vessels is
not necessary given the path of injury and the clinical presentation provided.

47–B. Definitive treatment for resectable gastric carcinoma is surgical resection. The generally poor survival associated with gastric
adenocarcinoma is due to the advanced stage of most carcinomas at the time of diagnosis. However, surgical resection is curative for
lesions confined to the stomach without significant lymph node disease. Currently, radiation and chemotherapy play a minor role in
treatment. A gastric bypass procedure is used to treat morbid obesity. In many situations, palliative surgical resection, gastrojejunostomy,
or both, may provide temporary relief of symptoms for incurable disease.
48–B. This patient most likely has a small bowel obstruction secondary to adhesions. The first step in the management of this patient
should be to insert a nasogastric tube to relieve symptoms and reduce the risk of aspiration of stomach contents. While radiological
studies are appropriate, they should not delay the initiation of treatment with a nasogastric tube. Exploratory laparotomy is necessary in a
patient with no prior surgical history and no evidence of a paralytic ileus; however, conservative treatment of obstruction caused by
adhesions with placement of a nasogastric tube will frequently result in complete resolution of obstructive symptoms. Analgesics

and antiemetics do not address the primary cause of this patient's symptoms. Continued observation in the emergency room without
intervention is not appropriate.
49–B. Hepatic vein occlusive disease, or Budd-Chiari syndrome, is a rare postsinusoidal cause of portal hypertension resulting from
occlusion of hepatic venous outflow from the liver. A frequent cause of Budd-Chiari syndrome is thrombotic occlusion. This can often be
idiopathic, although hematologic disorders such as polycythemia vera, paroxysmal nocturnal hemoglobinuria, hypercoagulable states, and
myeloproliferative disorders may precipitate thrombosis. Other causes include vena caval web formation, infection, trauma, and various
tumors including hepatocellular carcinoma, renal cell carcinoma, and adrenal carcinoma.

50–E. Although mivacurium is a nondepolarizing agent, it is also metabolized by pseudocholinesterase. Therefore, use of mivacurium in the
setting of pseudocholinesterase deficiency should be avoided. The other agents listed are not metabolized by pseudocholinesterase and
therefore would be acceptable alternatives for this patient.

51–E. The initial management of severe symptomatic hyperkalemia involves early administration of Ca2+, which stabilizes the electrical
potential of the myocardium to prevent the development of life-threatening arrhythmias. Ca2+ administration does not, however, decrease
the K+ levels in the serum. Subsequent measures to decrease serum K+ include administering insulin and NaHCO 3, which cause an
intracellular shift of K+. Sodium polystyrene sulfonate enemas may also absorb K+ in the colon, preventing recirculation of this pool of K+.
Early hemodialysis should also be performed to provide rapid removal of K+ from the serum.

52–D. Intravenous (IV) drug abusers are prone to developing bacterial endocarditis and can subsequently develop splenic abscesses. Gram-
positive organisms are most common in these individuals. This patient has several stigmata of endocarditis including the tricuspid systolic
ejection murmur and Janeway lesions of the right palm. The abdominal ultrasound demonstrates signs of a splenic abscess. IV antibiotics
are absolutely indicated in this patient with bacterial endocarditis. Cardiac catheterization is not indicated with a patient who is
hemodynamically stable and has no signs of right-sided cardiac failure. The combination of antibiotics and splenectomy is the most
definitive treatment. Occasionally, splenic abscesses can be drained percutaneously, but there should be a relatively low threshold to
perform splenectomy. Regardless, percutaneous drainage alone would not be adequate therapy.

53–C. Unlike most other nonsarcomatous lesions, one of the most important prognostic factors for sarcomas is the histologic grade of the
tumor. Factors important in grading sarcomas include cellularity, level of differentiation, pleomorphism, necrosis, and number of mitotic
figures. Although the age of the patient, lymph node involvement, and location of the lesion all play a role in predicting the rate of
recurrence and overall mortality, these factors are generally not as significant as the histologic grade of the lesion.

54–B. Although thyroid nodules are usually benign, all thyroid nodules may potentially represent a malignancy. There are some factors that
increase the likelihood of the presence of malignancy in a thyroid nodule. Cystic lesions are almost always benign lesions, though rarely
some malignant tumors may develop central necrosis and subsequently appear cystic. The presence of a single nodule is a bigger risk
factor for malignancy compared with the presence of multiple nodules, as are seen in benign conditions of the thyroid (e.g., Hashimoto
thyroiditis). A history of radiation exposure to the neck significantly increases the risk of malignancy. A family history of multiple endocrine
neoplasia (M EN) II syndrome increases the risk of development of medullary thyroid carcinoma. The presence of symptoms associated with
a thyroid nodule such as dysphagia or hoarseness is highly suggestive of an invasive malignancy as well.

55–B. This patient's presentation is highly suggestive of a colon cancer that is causing a partial obstruction of the colonic lumen. Among
the choices given, the most appropriate initial step in the evaluation of this patient would be a colonoscopy to attempt to identify a
potential mass and obtain a tissue diagnosis with biopsy. A barium enema would also be an appropriate test to evaluate the colon with this
presentation. Flexible sigmoidoscopy would not allow for visualization of the entire colon and thus would be inadequate in this situation.
Laparotomy or laparoscopy could certainly obtain a tissue diagnosis. However, these procedures are unnecessarily invasive in this case,
particularly if the lesion is benign or if it is a cancerous lesion amenable to colonoscopic resection.

56–B. Extra-adrenal sites of chromaffin tissue include the bladder, paravertebral ganglia, the carotid body, and the renal hilum. However,
the most common site of chromaffin tissue outside of the adrenal gland is in the organ of Zuckerkandl, which is located at the aortic
bifurcation. Any of these sites can harbor an extra-adrenal pheochromocytoma, termed a paraganglioma.

57–D. The current recommendation for local treatment of primary extremity sarcomas larger than 5 cm is wide en bloc surgical excision
with postoperative local radiation therapy. Radiation therapy alone is inadequate. Surgical resection alone is generally adequate for lesions
smaller than 5 cm. Except for some pediatric sarcomas, chemotherapy has not been shown to provide significant benefit in the treatment
of sarcomas. Currently, different types of immunotherapy are being studied for their efficacy in the treatment of sarcomas.
58–B. Unilateral recurrent laryngeal nerve injuries do not result in respiratory compromise and often go unrecognized or may cause
hoarseness. Patients with superior laryngeal nerve injury classically develop a weakened voice, which may go unnoticed but may have a
significant impact on singers. Bilateral recurrent laryngeal nerve injuries can result in paralysis of the vocal cords in the adducted position,
causing airway obstruction and respiratory compromise. After bilateral recurrent nerve injuries, stridor and respiratory distress generally
present in the immediate postoperative period following extubation in the recovery room. The diagnosis is unlikely to be delayed for 12
hours in this setting. Hematoma formation from persistent postoperative oozing or frank bleeding can result in delayed airway obstruction
and respiratory distress, as described. Treatment involves immediate evacuation of the hematoma at the bedside or in the operating room,
depending on the status of the patient. Thyroid storm syndrome would generally present intraoperatively during manipulation of the
thyroid gland.

59–D. Hyperaldosteronism (i.e., Conn's syndrome) is a rare disorder characterized by autonomous secretion of aldosterone, causing
hypokalemia, expanded blood volume, and hypertension. These fluid and electrolyte disturbances can be attributed to the effect of
aldosterone on the distal convoluted tubule, which causes sodium reabsorption in exchange for potassium. Potassium depletion generally
causes symptoms of polyuria and polydipsia, and edema is characteristically absent. Women may also have menstrual abnormalities.

60–C. Hepatic adenomas are found predominantly in women of child-bearing age with a distinct positive correlation between oral
contraceptive use and the development of adenomas. There is also noted to be a slight increase in patients with diabetes. Frequently,
even asymptomatic hepatic adenomas require elective resection because of an approximate 10% risk of malignant transformation, and
because of the risk of rupture of these tumors leading to hemorrhage and hypotension or even shock. Occasionally these tumors will
regress when oral contraceptives are discontinued, although if regression does not occur, surgical resection is indicated.

61–B. The presentation and pathologic presentation of this patient's breast disease is most consistent with sclerosing adenosis, a histologic
subtype of fibrocystic disease. The most common presentation is a cluster of microcalcifications on mammogram without an associated
palpable mass or pain. It is the benign breast disease that is most likely to be confused with breast cancer histologically and
radiographically. The regularity of nuclei and absence of mitosis are the keys to distinguish it from ductal cancer. Once this diagnosis has
been made, reassurance is the only required therapy because sclerosing adenosis does not confer an increased risk of cancer.
Additionally, in this patient, with her painful lumpy breasts, close follow-up is probably indicated due to the difficulty of performing self-
breast examination. Treatment of pain should first focus on the elimination of known causative agents.

62–E. The detection of pancreatic rejection can be difficult. When performed during the same operation, rejection of a renal graft usually
precedes pancreatic rejection, and thus monitoring of serum creatinine is effective in identifying potential pancreatic rejection. Glucose
levels often increase after irreversible rejection has occurred. Urinary amylase is useful when bladder anastomosis is present but not for
enteric drainage. Fecal and serum amylase levels are not reflective of pancreatic rejection.

63–D. Although early identification of the primary cause of abdominal pain is important, initial management of this patient in shock should
be aggressive volume resuscitation. Once his condition is stabilized, a secondary assessment including a detailed history and physical
examination

should be performed to diagnose the nature of the illness. Diagnostic procedures can then be performed based on clinical suspicion.

64–C. All patients with symptoms of gastroesophageal reflux who are being considered for surgical therapy should undergo 24-hour pH
probe, endoscopy, and manometry. The pH probe documents acid reflux, endoscopy looks for the pathologic changes of reflux (e.g.,
Barrett's esophagus, stricture) in the distal esophagus, and manometry evaluates esophageal motility to ensure that the patient can
tolerate a fundoplication. This patient has had an adequate trial of medical therapy and has failed. Further attempts at medical therapy
are not necessary before proceeding with surgical therapy. Barrett's changes are not cured by surgical intervention but their progression
is halted. Foci of adenocarcinoma can still develop within Barrett's mucosa and life-long endoscopic surveillance is needed in these
patients.

65–E. Asymptomatic human immunodeficiency virus (HIV)-positive patients undergoing elective operative procedures do not exhibit an
increased rate of infection or wound healing complications compared with HIV-negative patients. Appropriate therapy for this patient, as
in HIV-negative patients, would include either a modified radical mastectomy or lumpectomy with lymph node dissection and postoperative
local radiation therapy, with or without breast reconstruction.

66–C. This lesion may represent the development of a neoplasm (most likely a squamous cell carcinoma) at the site of a previous wound
(M arjolin ulcer). The history of a persistent nonhealing ulcer that does not improve with 5 months of local wound care at the site of a
previous injury is suggestive of such a lesion. Thus, biopsy of the lesion is essential in the initial management of this patient to rule out
malignancy. Cessation of smoking and continued wound care are important in the treatment of this wound, but do not address the issue of
a potential malignancy.

67–B. A pancreatic fistula is frequently associated with significant losses of many electrolytes. Pancreatic secretions contain large amounts
of Na+, K+, and HCO 3- and significant amounts of M g2+. Hypokalemia refractory to aggressive replacement therapy should raise suspicion for
a coexisting hypomagnesemia, which can also precipitate K+ losses. Hypermagnesemia is unlikely in the presence of pancreatic fluid losses,
as is hypercalcemia. Hypocalcemia would generally not be associated with the described symptoms. Hyponatremia may rarely be associated
with the described symptoms, although refractory hypokalemia is more likely associated with low M g2+.

68–C. Upper endoscopy is the most reliable method for localizing the source of an upper gastrointestinal bleed. This modality allows
treatment of many lesions including peptic ulcer disease and variceal bleeding. For variceal bleeds, one may also use a Sengstaken-
Blakemore tube, vasopressin infusion, or somatostatin infusion for temporizing control before definitive treatment. Of significant note, at
least 20% of patients with esophageal varices and upper gastrointestinal bleeding will have a gastric or duodenal ulcer as the source of
bleeding; hence the value of a full endoscopic examination. Omeprazole therapy alone is not primary in the management of acute upper
gastrointestinal bleeding.

69–C. Peutz-Jeghers syndrome is an autosomal dominant familial disease characterized by mucocutaneous pigmentation and intestinal
polyposis. The polyps are hamartomas that are most frequently located in the jejunum and ileum but can also be found in the stomach,
duodenum, colon, and rectum. It is generally believed that their malignant potential is very low. Peutz-Jeghers syndrome can produce
abdominal symptoms caused by intussusception or hemorrhage; as many as one third of patients present with abdominal pain and a
palpable abdominal mass as a result of the intussusception. An operation is indicated for abdominal pain or bleeding; it should be limited to
conservative resection of involved bowel rather than be an attempt to resect all polyps detected during exploration. While familial
polyposis, Gardner's syndrome, and Crohn's disease can cause obstruction, the physical findings of mucocutaneous pigmentation make
Peutz-Jeghers syndrome the most likely diagnosis. Human immunodeficiency virus (HIV) enteropathy characteristically presents with
malabsorption and diarrhea rather than intussusception.
70–B. Initial management of common duct injuries not detected during surgery is generally conservative. The patient is placed on broad
spectrum antibiotics and a combination of external drains and endoscopically or percutaneously placed stents are used to decompress the
biliary system. Surgery is delayed because the intense inflammation caused by the leak can make repair

extremely difficult. M any leaks will resolve with conservative management, but if not, a biliary bypass procedure may be necessary.
71–C. The most common primary hernia in women is an indirect inguinal hernia. Inguinal hernias occur much more frequently in men than
in women. Femoral hernias occur more commonly in women than in men, although femoral hernias are not as common in women as are
indirect and direct inguinal hernias. Obturator hernias are very rare and do not generally present with a groin mass. Femoral artery
aneurysms are also quite rare.
72–C. Urinary tract infections are among the most common nosocomial infections seen and are a frequent cause of postoperative
complications. Hesitancy, dysuria, and inability to void are commons symptoms. Positive leukocyte esterase and nitrites as well as cytologic
evidence of leukocytes provides strong evidence for an infection. Treatment involves appropriate antibiotic administration. Bilateral
ureteral obstruction is rare in this situation and would generally not be associated with such a large amount of urine in the bladder.
Infection may contribute to urinary retention and would not be considered “normal” retention. The findings are not consistent with
acute renal failure (ARF) or hemorrhagic cystitis.
73–D. Transplant immunosuppression is associated with rapid tumor growth. Patients who undergo curative resection of malignancies
should wait at least 2 years (without evidence of recurrence) before undergoing transplantation. Kidney transplantation has been
demonstrated to have a better quality of life and decreased mortality compared with continuous ambulatory peritoneal dialysis and
hemodialysis.

74–A. This patient suffered either an unintentional subdural or subarachnoid injection with anesthesia above the level of the cervical spine
into the central nervous system. Epidural anesthesia requires much larger doses and volumes of local anesthetic to provide the same
sensory level of anesthesia as with spinal anesthesia. Therefore, for an epidural, the anesthetic is given in divided doses when bolused in
case the catheter migrates out of the epidural space. Subdural cannulation can occur despite correct epidural placement and is only
recognized after an unusually high block after a modest amount of local anesthetic. Hypotension and bradycardia secondary to block of
the sympathetic chain are likely to result in this setting and must be aggressively treated.

75–E. Hypoglycemia is a frequent complication of acute cessation of parenteral nutritional therapy because the intravenous carbohydrate
load is suddenly discontinued. The patient's symptoms and temporal relationship to discontinuation of the parenteral nutrition therapy is
consistent with a hypoglycemic event and initial evaluation should involve checking serum glucose before other major steps are taken. All
of the other choices may be reasonable management steps in a patient who abruptly becomes unresponsive; however, in the scenario
described, serum glucose analysis is the most prudent step in the initial evaluation.

76–D. It is important to note that any skin lesion of this sort can be malignant. However, there are some findings that may provide
additional clues to the malignant potential of some lesions. The classic mnemonic (ABCD) of evaluation of skin lesions is a useful initial tool.
Findings suggestive of malignancy include Asymmetry in color (multiple shades), Border irregularity, Color variation (multiple colors in same
lesion), and Diameter of the lesion (larger lesions are more likely to be malignant). Other factors suggestive of malignancy include
nodularity of the lesion, ulceration, itching, bleeding, or lesions that change rapidly over time. Therefore, among the choices, a smooth
lesion with consistent coloring throughout is more likely to be benign than the other lesions listed.
77–A, B. Severe epigastric pain radiating to the back, nausea, vomiting, and anorexia are all signs of pancreatitis, although similar symptoms
may also be present with cholecystitis or choledocholithiasis. An elevated amylase is commonly found in patients with pancreatitis, while
alkaline phosphatase may be elevated in patients with cholecystitis or choledocholithiasis. Identification of multiple gallstones throughout
the biliary tree may be associated with pancreatitis or cholecystitis. Other ultrasound findings consistent with cholecystitis include
gallbladder wall thickening, pericholecystic fluid, and distension of the gallbladder.

78–E. Suprapubic pain and dysuria are classic signs of urinary tract infection. Leukocyte esterase,

nitrates, white blood cells, red blood cells, and bacteria on urinalysis are all signs of infection.

79–B. Ultrasound findings associated with cholecystitis include a distended gallbladder, gallbladder wall thickening, pericholecystic fluid,
gallstones, and a sonographic M urphy's sign. Alkaline phosphatase is commonly elevated in patients with cholecystitis. Pancreatitis would
typically present with pain in the epigastric region; however, pericholecystic fluid would not be a typical finding.

80–C, D. This patient has a biliary stricture caused by previous biliary surgery. Surgical bypass is indicated and a choledochojejunostomy or
hepaticojejunostomy may be performed. In these procedures a portion of the jejunum is anastomosed to the common bile duct to permit
drainage of bile around the stricture. A ductal anastomosis above the cystic duct is considered a hepaticojejunostomy, while an
anastomosis below the cystic duct is considered a choledochojejunostomy. Thus the choice between these two procedures depends on
the location and extent of the lesion. Primary reanastomosis of the remaining bile duct is sometimes possible in these situations but biliary
enteric bypass procedures are currently preferred in most settings.

81–A. This patient has a lesion in the lower third of the common bile duct, which is highly suspicious for cholangiocarcinoma. Also high on
the differential is pancreatic carcinoma. Regardless, the procedure of choice for treating resectable carcinomas in this area is radical
pancreaticoduodenectomy (Whipple's operation). This involves resecting the gallbladder, common bile duct, head of the pancreas,
duodenum, and perhaps the distal stomach.

82–A. Gastrinomas cause the Zollinger-Ellison syndrome with intractable peptic ulcers and very high serum gastrin levels. Although these
tumors are uncommon, this diagnosis should be considered in any patient with refractory peptic ulcer disease.

83–F, G. Both glucagonomas and somatostatinomas may be associated with the development of glucose intolerance and diabetes mellitus.
Glucagonomas may also be associated with a characteristic rash called necrolytic migratory erythema. Somatostatinomas may also be
associated with steatorrhea and gallstone development.

84–D. Insulinomas are characterized by a marked catecholamine surge because of a profound insulin-induced hypoglycemia. The
hypoglycemia frequently worsens with periods of fasting. The catecholamine surge results in diaphoresis, palpitations, and anxiety.

85–F. Glucagonomas are generally characterized by new onset of glucose intolerance or diabetes mellitus and a characteristic rash called
necrolytic migratory erythema.

86–A, C. Vasoactive intestinal peptide tumors (VIPomas) are tumors that are associated with the development of profuse watery diarrhea.
VIPomas cause the Verner-M orrison, or WDHA syndrome, with watery diarrhea, hypokalemia, and achlorhydria. In addition, although
gastrinomas are generally associated with refractory peptic ulcer disease, these tumors frequently present with persistent chronic
diarrhea. Approximately 10%–20% of gastrinomas may present with diarrhea as the only symptom.

87–A. This patient most likely has an ectopic pregnancy. Of the choices listed, pelvic inflammatory disease is the most significant risk
factor for ectopic pregnancy. Previous ectopic pregnancy and prior tubal manipulation are also significant risk factors.

88–E. This patient has an abdominal aortic aneurysm that is possibly expanding and is at risk for rupture based on the size and the
symptoms described. Among the choices listed, only atherosclerosis is a significant risk factor for abdominal aortic aneurysms.

89–C, H. This patient most likely has a sigmoid volvulus. These patients classically present with left lower quadrant pain, distention, and
constipation. Plain films usually show closed loop of bowel and may have the classic “bird's beak” abnormality, which is a tapering of the
colon where it is twisted. Significant risk factors for sigmoid volvulus include a chronic bedridden state, pregnancy, laxative use, prior
surgery, and residence in psychiatric or nursing home facilities.

90–A, B, C, E. A patient with a right-sided chest wound with decreased breath sounds could have either a tension hemothorax or a tension
pneumothorax leading to hypotension. It is also important to recognize the potential risk for liver injury, given the location of the gunshot
wounds. Any penetrating injury below the fourth intercostal space warrants exploratory laparotomy to rule out possible abdominal injury.
Furthermore, with injuries to this area, cardiac tamponade should be considered as a potential source of hypotension.

91–D. Aortic injury should be suspected in all patients involved in high-speed motor vehicle accidents. A widened mediastinum and loss of
the aortic knob are signs of possible aortic arch injury. Other signs on chest radiograph include capping of the left lung or a left sided
pleural effusion.

92–B. This patient has all three classic signs of cardiac tamponade—hypotension, muffled heart sounds, and jugular venous distension, or
Beck's triad. The presence of all three signs is unusual but often in the presence of hypotension without other obvious causes and with
blunt chest trauma, cardiac tamponade should be suspected.

93–H, I. This patient has a documented pelvic fracture confirmed radiographically, which can lead to significant hemorrhage within the
pelvis. The patient also has signs of a spinal cord injury, with no movement of her lower extremities and loss of anal sphincter tone
characteristic of such an injury.

94–A, E. A hypotensive patient with a chest injury and unilateral decreased breath sounds warrants concern for either a tension
hemothorax or a tension pneumothorax as a cause of shock. Tracheal deviation is a characteristic sign that the intrapleural pressure is
significantly increased and probably causing impaired venous return to the heart, leading to hypotension. Emergent decompression with
chest tube placement should be performed in either case.

95–C. Iatrogenic sources of abnormal bleeding are usually secondary to excess anticoagulation by either heparin or warfarin. Prolonged
prothrombin time (PT) is suggestive of over-coumadinization, while a prolonged partial thromboplastin time (PTT) is indicative of excess
heparinization. Correction of both may be done acutely with fresh frozen plasma, while vitamin K may also be used to correct an abnormal
PT. This patient was relatively stable at the time of the bleeding and this episode followed a session of hemodialysis. Heparin is often used
both during hemodialysis to prevent blood clotting in the dialysis machine and to maintain the patency of dialysis catheters while not in
use. The only coagulation abnormality noted was a prolonged PTT, indicative of over-heparinization.

96–A, B, F. Disseminated intravascular coagulation is a severe sequelae of trauma, sepsis, or severe hypoxia. Generalized activation of the
intrinsic and extrinsic coagulation systems can be caused by many factors including severe trauma and hypotension. Coagulation system
activation consumes the available endogenous clotting factors and stimulates the fibrinolytic system. Severe hypothermia can also inhibit
coagulation. Rapid administration of fluids and packed red blood cells (PRBCs) with severe blood loss without adequate replacement of
platelets and coagulation factors can also lead to significant dilution of coagulation factors and platelets, contributing to such a
coagulopathy. Treatment involves early recognition and elimination of the underlying condition, prevention and aggressive treatment of
hypothermia, intensive supportive care, as well as rapid administration of fresh frozen plasma, cryoprecipitate, vitamin K, and platelets.
Prognosis in this setting is poor.

97–E, F. Renal failure is frequently associated with impairment of platelet function leading to an increased bleeding time even without
alterations in prothrombin time (PT) and partial thromboplastin time (PTT). Spontaneous bleeding occurs infrequently with this disorder,
although it can lead to significant bleeding intraoperatively. When treatment is indicated, administration of platelets can alleviate
symptomatic bleeding. In addition, administering desmopressin can improve function of the patient's platelets in this setting.

98–B, C. Given the normal prothrombin time (PT) and partial thromboplastin time (PTT) with an abnormal bleeding time in a patient with a
history of bleeding abnormalities, this patient most likely has a deficiency in von Willebrand factor. This is rarely associated with
spontaneous bleeding, although it can be associated with abnormal bleeding after severe injury or surgery.

The most appropriate treatment of von Willebrand factor deficiency would be cryoprecipitate, which could be given in this situation.
Fresh frozen plasma contains a small amount of this factor and could also be used, although in the presence of von Willebrand factor
deficiency, cryoprecipitate is preferred.

99–B. Reversing the effects of warfarin therapy requires replacement or regeneration of the anticoagulation factors affected by this
therapy (i.e., factors II, VII, IX, and X). Administering vitamin K can reverse the effects of warfarin, although this generally takes 6–12 hours
before adequate improvement in coagulation occurs. Fresh frozen plasma is a good source of these key coagulation factors and can be
administered in situations in which rapid reversal of the effects of warfarin is necessary.
100–I, J. Patients receiving artificial mechanical valves generally require anticoagulation therapy to prevent thrombus formation on the
valve. In this situation, both heparin and warfarin therapy may play a role in such therapy. Initially, heparin therapy can be started to
provide rapid anticoagulation until the effects of warfarin become therapeutic, at which time the heparin can be discontinued and the
warfarin continued chronically. In patients without protein C deficiency, starting heparin therapy before administering warfarin is essential
because warfarin therapy can initially cause an acute increase in protein C function with a procoagulant effect. Thus, heparin provides an
anticoagulation effect during this transient period.