1. answer b gastric ulcer classification i (50%): body/antrum of stomach, along lesser
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1. A 2-cm gastric ulcer in the antrum of the stomach is associated with all of the following EXCEPT H. pylori infection Increased acid secretion Malignancy NSAIDs Atrophic gastritis. 1. Answer B Gastric ulcer classification I (50%): body/antrum of stomach, along lesser curvature - PowerPoint PPT PresentationTRANSCRIPT
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1. A 2-cm gastric ulcer in the antrum of the stomach is associated with all of the following EXCEPT
• H. pylori infection• Increased acid secretion• Malignancy• NSAIDs• Atrophic gastritis
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1. Answer BGastric ulcer classificationI (50%): body/antrum of stomach, along lesser curvature Low to normal acid levels
Tx with antrectomy
II (25%): type I + duodenal ulcerHigh acid levelsTx with vagotomy, antrectomy
III (15%): prepyloric High acid levels
Tx with vagotomy, antrectomy
IV: close to GE jxn Low to normal acid levels
V: anywhere in stomach, drug-associated
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2. A generally healthy 35-year-old man has a 6-hour history of abdominal pain and nausea. He passes a stool containing mucous and blood. A CT scan is obtained and shown below.
The best therapeutic intervention would bea. colonoscopyb. IV neostigminec. Barium enemad. Bowel resection and anastamosise. Nasogastric suction and antibiotics
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3. The most common cause of this condition in adults is
a. Meckel’s diverticulumb. Gallstonesc. Ischemic bowel diseased. Crohn’s diseasee. Gastrointestinal tumor
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2. Answer D3. Answer E
Intussusceptum: proximal portion that invaginates into distal bowel
Intussuscipiens: recipient, distal bowel into which proximal bowel invaginates into
Children: under 3 years old, preceded by nonspecific febrile illness (viral), hypertrophy of Peyer’s patches
Adults: malignancy (lymphoma)Dx: CT scanTx: resection
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4. A 58-year-old woman has had no flatus or bowel movement for 2 days, and intermittent vomiting for the past 24 hours. She has had mid-epigastric pain for the past 3 years, but has never sought treatment. Diet modification helped decrease the frequency and severity of pain. She has never had a previous abdominal operation.
Exam demonstrates a distended abdomen with moderate tenderness to deep palpation but no rebound. No stool or masses are noted on rectal exam. An abdominal x-ray is shown.
The most likely etiology is
a. tuberculosis
b. fungal
c. inflammatory
d. neoplastic
e. bacterial
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5. The patient is taken to the OR and exploration reveals the finding shown.
The management of choice isa. enterotomyb. adhesiolysisc. segmental resectiond. peritoneal washingse. intestinal bypass
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4. Answer C5. Answer ARigler’s triad: abd xray -- SBO, pneumobilia, radioopaque stoneXray often non-diagnostic
• Etiology: recurrent cholecystitis with inflammtion and adhesion formation, stone erodes through gallbladder into adjacent viscus, usually duodenum
• Distal ileum common site of obstruction
• Tx: resuscitation, OR enterotomy proximal to stone
• Not necessary to deal with cholecystoenteric fistula at initial operation, spontaneously close in many
• Elective cholecystectomy
• Recurrence rate 5%
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6. A previously healthy 25-year-old woman has right lower quadrant pain and fever. CT confirms appendicitis. After an uneventful appendectomy, the patient is discharged. The final report on CT describes a 2.0 cm left adrenal mass.The patient is asymptomatic. Which of the following is NOT appropriate?
a. dexamethasone suppression testb. measurement of serum potassium and plasma aldosterone concentration/plasma renin activity ratioc. fine-needle aspiration biopsyd. adrenalectomy if the tumor is functionalfollow-up CT in 6 to 12 months
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6. Answer CAdrenalectomy for lesions > 6 cmNonfunctioning lesions < 4 cm interval CT or MRI at 6
months and 1 year4-6 cm adrenalectomy or close observation90% benign r/o subclinical hypercortisolism 1-mg dexamethasone suppression test overnight 8 AM plasma cortisol > 3 mg/dL (failure to suppress) chk 24-hour urinary free cortisol and plasma ACTH Aldosteronoma least common screened for only in patients with HTN or hypokalemia serum potassium, plasma aldosterone/plasma renin (>20) confirm with 24-hour urinary aldosterone levels
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Pheochromocytoma fractionated urinary and/or plasma catecholamines,
metanephrines, and urinary vanillylmandelic acid (VMA) Preoperative α-adrenergic blockade with
phenoxybenzamine- administered for at least 1 week before operation- Side effects: reflex tachycardia, nasal congestion
intravenous fluids β-Adrenergic blockade for reflex tachycardia
- do not give until adequate α-blockade established
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7. A 43-year-old man with alcoholic cirrhosis has had two episodes of variceal hemorrhage treated acutely with sclerotherapy. Lab values are as follows: albumin 3.3 g/dL; total bilirubin 1.2 mg/dL, alkaline phosphatase 120units/mL, PT 12 sec (control 11.5 sec), PTT 36 sec, aspartate amino transferase 30 units/L, and alanine amino transferase 25 units/L. He has no ascites and has never been encephalopathic. Appropriate management at this time might include each of the following EXCEPT
a. distal spleno-renal shuntb. endoscopic rubber band ligationc. transjugular intrahepatic portosystemic shuntd. orthotopic liver transplantatione. small diameter H portocaval shunt
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7. Answer DPt is Child’s class AChild’s-Pugh Classification (A BATH)
Score
Ascites (grade) Bilirubin
(mg/dl) Albumin (gm/dl)
PT (sec
prolonged)
Hepaticencephalopathy
1None
< 2 > 3.5 < 4 None
2Mild
2 - 3 2.8 - 3.5 4 - 6 1 - 2
3Severe
> 3 < 2.8 > 6 3 - 4
A 5 – 6 Life expectancy: 15 to 20 years, abdominal surgery peri-operative mortality: 10% B 7 – 9 Indicated for liver transplantation evaluation, abdominal surgery peri-operative mortality: 30% C > 9 Life expectancy: 1 to 3 years, abdominal surgery peri-operative mortality: 82%
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Management of variceal bleedings
Acute: Octreotide, endoscopic ligation, sclerotherapy, balloon tamponade, TIPS
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Portosystemic shunts• Nonselective shunts: more encephalopathy End-to-side portacaval: all portal flow diverted into systemic circulation, ascites persistsSide-to-side portacaval, interposition (16 mm), splenorenal: better at controlling ascites b/c splanchnic venous and intrahepatic sinusoidal drainage still open • SelectiveDistal splenorenal shunt: Distal splenic vein to left renal vein, ligate collateral veins, can worsen ascites• Partial shunts Meso/Portacaval interposition with small-diameter (8 mm) graft, maintains hepatic portal perfusion