Lower G.I. 3

Question 1

29-year-old woman presents with abdominal cramps, diarrhea, 5 pound weight loss of several months duration. Bloody diarrhea began this morning. Suspect? Next step?

Answer 1

IBD

Colonoscopy or barium enema

Question 2

Patient diagnosed with ulcerative colitis. Two months later, returns to the emergency room with bloody diarrhea, abdominal pain, distention. Fever to 101, stable blood pressure, tachycardia to 120. Suspected diagnosis? Confirm diagnosis with? Management?

Answer 2

Toxic megacolon

CT or abdominal radiography

Since patient is stable, NG tube, NPO, TPN, IV fluids, antibiotics, steroids

Question 3

Patient diagnosed with ulcerative colitis. Two months later, returns to the emergency room with bloody diarrhea, abdominal pain, distention. Fever to 101, stable blood pressure, tachycardia to 120. Radiograph shows free air on the CXR. Management?

Answer 3

1 straight to OR

2. Ileostomy with formation of Hartman pouch and total abdominal colectomy

Question 4

Patient diagnosed with ulcerative colitis. Two months later, returns to the emergency room with bloody diarrhea, abdominal pain, distention. Fever to 101, stable blood pressure, tachycardia to 120. Radiograph shows air in wall of colon. Next step?

Answer 4

Signs of impending perforation

Take to OR and preform Hartmans procedure

Question 5

Patient diagnosed with ulcerative colitis. Two months later, returns to the emergency room with bloody diarrhea, abdominal pain, distention. Fever to 101, stable blood pressure, tachycardia to 120. Begin to manage patients medically. How long to attempt medical therapy before taking patient to OR?

Answer 5

3-6 days (Or shorter if worsening fever, leukocytosis or pain)

Question 6

25-year-old who presents with 12 hours of RLQ abdominal pain - work up?

Answer 6

1. Rectal exam and gynecologic exam

2. If normal, treat for appendicitis – hydration, NPO, repeat CBC, serial examinations

Question 7

25-year-old who presents with 12 hours of RLQ abdominal pain - pain in right pelvis could indicate?

Answer 7

Retrocecal appendicitis

Question 8

25-year-old who presents with 12 hours of RLQ abdominal pain - Expected WBC count on UA? Findings that would suggest appendiceal abscess on UA?

Answer 8

WBC count of 8-10/HPF

WBC count of 10,000/HPF

Question 9

25-year-old who presents with 12 hours of RLQ abdominal pain - UA shows RBCs too numerous to count – suspected diagnosis? Test?

Answer 9

UTI or kidney stone

Intravenous pyelogram or CT scan without contrast

Question 10

25-year-old who presents with 12 hours of RLQ abdominal pain - Family history of IBD. Management?

Answer 10

1. CT for thickened loop of bowel or enlarged nodes in terminal ileum
2. Colonoscopy barium enema
3. If positive, steroids and 5-ASA (Must rule out appendicitis before administering steroids)

Question 11

25-year-old who presents with 12 hours of acute RLQ abdominal pain - however, patient also admits a two month history of crampy pain and diarrhea – differential?

Answer 11

1. Appendicitis
2. IBD
3. Constipation
4. Carcinoma

Question 12

How does an appendicitis present if 1. patient is at an advanced age?

2. Patient is five years old?
3. Patient takes high doses of corticosteroids?
4. Patient is pregnant?

Answer 12

1. Vague abdominal complaints, sepsis, altered consciousness
2. Already ruptured
3. No warning signs until perforation sepsis
4. Pain in upper lateral abdomen

Question 13

28-year-old woman presents with appendicitis. Management if:

1. Red, inflamed appendiceal Tip with exudate?
2. Acute gangrenous appendicitis with necrosis extending to the base of the cecum?
3. Perforated appendicitis with localized abscess?
4. Acute appendicitis with 1 cm round, movable mass?
5. Normal appendix?
6. Acute gangrenous appendicitis with necrosis extending to the cecum?

Answer 13

1. Ligate at base and cauterize stump
2. Ligate with sutures. Bury base of cecum to reduce risk of blowout.
3. Remove appendix, leave drain in abscess, leaving skin open on closure
4. Fecalith
5. Remove appendix anyway (eliminate appendicitis in the future)
6. Right colectomy

Question 14

34-year-old man with suspected appendicitis. Diagnosis and management if, on exploration, you find

1. 1 cm yellow mass at tip of appendix
2. 2.2 cm mass at base of appendix
3. 3 cm pedunculated mass at terminal ileum that obstructs lumen

Answer 14

1. Small carcinoid tumor (no need to biopsy). Routine appendectomy if isolated and under 2.0 cm
2. Large carcinoid tumor with malignant behavior (over 2 cm, or involvement of appendiceal base/cecum). Right colectomy
3. Carcinoid tumor or adenocarcinoma. Remove involved ileum and regional lymph nodes.

Question 15

Patient with appendiceal mass. Pathology shows carcinoid tumor. Principal determinants of malignancy? Long term follow-up?

Answer 15

Biological behavior (serotonin and 5-HIAA levels) rather than histologic appearance, location, size

CT scan and octreotide scan

Question 16

60-year-old man with ruptured appendix undergoes surgery and is discharged. One week later, presents with fever, chills, and anorexia. Differential? Management?

Answer 16

Pelvic abscess or wound infection

If abscess, drain percutaneously or surgically

Question 17

60-year-old man with ruptured appendix undergoes surgery and is discharged. One week later, presents with fever, chills, and anorexia. Diagnose pelvic abscess. Management?

Answer 17

1. Drain with percutaneous catheter or surgical drainage

Question 18

Screening guidelines for colon cancer?

Answer 18

1. Colonoscopy every 10 years at age 50
2. Fecal occult blood test + flexible sigmoidoscopy every 5 years at age 50
3. Yearly fecal occult blood test at age 50

Question 19

When to modify colon cancer screening in patients?

Answer 19

1. Family history with first-degree relative. Screen beginning at 40 years
2. History of FAP – genetic counseling, yearly flexible sigmoidoscopy, and colectomy once polyps discovered
3. History of HNCC – colonoscopy every one-two years beginning between age 20-30 and yearly at age 40
4. History of polyps removed by colonoscopy. Follow-up 3 years after
5. History of resected colon cancer. Colonoscopy one year after, then screening at 3-5 year intervals

Question 20

Most productive ways to detect colon cancer recurrence? How accurate?

Answer 20

CEA (carcinoembryonic antigen) measurements

Detects 80% of occurrences