A 15-year-old boy is admitted with a history

and physical findings consistent with

appendicitis. Which finding is most likely to
be positive?
A Pelvic crepitus
B Iliopsoas sign
C Murphy sign
D Flank ecchymosis
E Periumbilical ecchymosis

The answer is B
The iliopsoas sign is pain in the lower abdomen
and psoas region that is elicited when the thigh is
flexed against resistance. It suggests an
inflammatory process, such as appendicitis.
Crepitus suggests a rapidly spreading gas-forming
infection. Murphy sign is elicited by palpating the
right upper quadrant during inspiration and
suggests acute cholecystitis. Flank and
periumbilical ecchymoses suggest retroperitoneal
hemorrhage.
A 50-year-old man is admitted with massive bright red rectal
bleeding. He recently had a barium enema that
demonstrated no diverticular or space-occupying lesion.
Nasogastric suction reveals no blood but does produce
yellow bile. The patient continues to bleed. What is the next
diagnostic step?
A Repeat barium enema
B Colonoscopy
C Upper gastrointestinal series
D Mesenteric angiography
E Small bowel follow-through with barium
The answer is D

The most likely cause of massive lower gastrointestinal bleeding in the
absence of diverticula is an angiodysplastic lesion of the colon, particularly
the right colon. An upper gastrointestinal series and small bowel studies
should be done only after an exhaustive colonic workup has failed to
demonstrate the source of bleeding. Colonoscopy in the face of massive
bleeding is unreliable and difficult and carries the risk of colonic perforation.
In addition, it will not usually demonstrate an angiodysplastic lesion. A repeat
barium enema is also unlikely to help. The most helpful study in this patient
would be selective mesenteric angiography.
A 15-year-old boy awakens with sudden onset of right
lower quadrant and scrotal tenderness accompanied
by nausea and vomiting. Which of the following is the
most appropriate diagnosis and represents a surgical
emergency?

A Acute prostatitis
B Acute epididymitis
C Torsion of the testicle
D Acute appendicitis
E Gastroenteritis
The answer is C

The history described would be more typical for either testicular torsion
or acute epididymitis, of which only torsion represents a surgical
emergency. Torsion of the testicle is likely the result of an abnormal
attachment of the tunica vaginalis around the cord that allows the testis
to twist (bell-clapper deformity). Compromise of the blood supply causes
exquisite pain and produces gangrene and atrophy of the testis unless the
torsion is treated immediately. Torsion is usually seen in young males,
most often occurring spontaneously and even during sleep. It is
associated with an onset of severe pain and is accompanied by nausea,
vomiting, and abdominal pain. Acute prostatitis may present with vague
abdominal pain. A more typical presentation for appendicitis would be
pain preceded by nausea or anorexia. This presentation is not typical for
gastroenteritis (which is not a surgical emergency).
A 47-year-old woman presents with dysphagia to both solids and
liquids equally. She has experienced a 10-kg weight loss over the last
several months. A barium swallow reveals a birdlike narrowing in the
distal esophagus. What is the underlying cause of her symptoms?


A Disorganized, strong nonperistaltic contractions in the esophagus
B Failure of the lower esophageal sphincter to relax
C Hiatal hernia
D Barrett's esophagus
E Esophageal stricture secondary to untreated gastroesophageal
reflux
The answer is B

(This patient is presenting with classic symptoms of
achalasia. The dysphagia to both solids and liquids is classic,
as is the bird-beak narrowing on radiographs. The underlying
defect is failure of the lower esophageal sphincter to relax,
causing increased pressure in the esophagus and
dysfunctional swallowing. Disorganized, strong nonperistaltic
contractions in the esophagus are characteristic of diffuse
esophageal spasm. Strictures typically have dyspahgia to
solids well before liquids cause symptoms.
A 45-year-old male executive is seen because he is vomiting
bright red blood. There are no previous symptoms. The man
admits to one drink a week and has no other significant
history. In the hospital, he bleeds five units of blood before
endoscopy. What is the most likely diagnosis?


A Gastritis
B Duodenal ulcer
C Esophagitis
D Mallory-Weiss tear
E Esophageal varices
The answer is B


Massive upper gastrointestinal bleeding is usually due to a
bleeding source proximal to the ligament of Treitz. The cause is
most likely to be a posterior duodenal ulcer that is eroding into
the gastroduodenal artery. Gastritis, esophagitis, a Mallory-Weiss
tear, and esophageal varices are less likely causes of massive
upper gastrointestinal bleeding.
A 45-year-old man is seen in the emergency department after vomiting bright red
blood. He has no previous symptoms. He drinks one alcoholic beverage a day.
7. What is the most reliable method for locating the lesion responsible for the
bleeding?



A Upper gastrointestinal series
B Exploratory laparotomy
C Upper endoscopy
D Arteriography
E Radionuclide scanning
The answer -C

Upper endoscopy is the most reliable method for precisely locating the site of
upper gastrointestinal bleeding. Endoscopy can almost always be used unless
bleeding is massive. Patients who are unstable or have blood losses requiring
more than six units of blood within a 24-hour period require surgical
intervention. Unstable patients should not typically be transported to
interventional radiology. A Blakemore tube is only useful for bleeding
esophageal varices. This patient, who does not have a history indicative of
cirrhosis, is unlikely to have bleeding from varicies.
After several hours in the hospital, he begins to have recurrent bleeding. He is
transferred to a critical care bed and is persistently hypotensive despite
trasnfusion of nine units of packed red blood cells. Which is the most appropriate
next step in management of this patient?



A Upper endoscopy with attempt at cauterization of bleeding
B Transport to the interventional radiology unit to identify and embolize bleeding
source
C Placement of a Blakemore tube to temporarily tamponade bleeding and to
allow for stabilization of blood pressure
D Laparotomy to control bleeding
E Infusion of vasopressin and additional units of blood
The answer are 8-d (Chapter 11, IV B). Upper
endoscopy is the most reliable method for
precisely locating the site of upper
gastrointestinal bleeding. Endoscopy can
almost always be used unless bleeding is
massive. Patients who are unstable or have
blood losses requiring more than six units of
blood within a 24-hour period require surgical
intervention. Unstable patients should not
typically be transported to interventional
radiology. A Blakemore tube is only useful for
bleeding esophageal varices. This patient, who
does not have a history indicative of cirrhosis,
is unlikely to have bleeding from varicies.
A 25-year-old man is admitted with a history of sudden onset of severe
midepigastric abdominal pain. Upright chest radiograph reveals free
intraperitoneal air. What is the therapy for this patient?

A Upper endoscopy
B Barium swallow
C Gastrografin swallow
D Observation
E Laparotomy
The answer is E

Free air within the peritoneal cavity signals perforation of a hollow
viscus. It is present in about 80% of gastroduodenal perforations.
Because free peritoneal air is rarely secondary to other causes,
additional studies in this patient would not be necessary before
laparotomy.
During exploration for a transverse colon tumor, a surgeon incidentally notices a 2-
cm diverticulum of the small bowel located 2 ft proximal to the ileocecal valve.
Which of the following statements are not true?


A This diverticulum should be resected when found due to an associated increased
risk of malignancy
B This is an example of the most common type of diverticulum of the
gastrointestinal tract, present in 2% of the population
C It is more commonly found in men than women
D When symptomatic in children, it presents as a source of bleeding
E It can cause obstruction via intussusception
The answer is A (Chapter 12, II C). Meckel's
diverticulum is the most common diverticulum
of the gastrointestinal tract and goes by the
rule of 2's: 2 ft from ileocecal valce, 2%
incidence, 2 cm long, 2:1 male to female ratio.
They can cause bleeding due to heterotropic
gastric mucosa as well as intussusception and
obstruction. An asymptomatic Meckel's
diverticulum should not be resected.
A 33-year-old man with no significant past medical history presents to the emergency
room with abdominal pain and nausea. He is afebrile, and laboratory studies reveal a
serum amylase level of 1200 U/L.
38. Which of the following would not be part of initial management?

A Intravenous hydration
B Nasogastric decompression
C Abdominal imaging with ultrasound and/or CT scan
D ERCP to evaluate pancreatic duct anatomy
E Intravenous narcotic pain medicine
Ten days into his course of pancreatitis, this patient is found to have a fluid
collection measuring 4 cm in diameter near the tail of his pancreas. He had a
recurrence of his abdominal pain when he was restarted on a diet 2 days prior but is
otherwise asymptomatic. He remains on total parenteral nutrition. Appropriate
management of this collection would include which of the following?


A CT-guided aspiration to assess for infection
B Endoscopic drainage via an ultrasound-guided cystogastrostomy
C Operative debridement and external drainage
D CT-guided percutaneous drainage
E Observation alone
The answers are 38-D), 39-E . Uncomplicated
acute pancreatitis is best managed
conservatively with nasogastric
decompression, intravenous hydration, bowel
rest, and pain medicine. Imaging with
ultrasound, CT scan, magnetic resonance
imaging, or magnetic resonance
cholangiopancreatography can be useful in
establishing a possible etiology (gallstones) or
detecting complications. Endoscopic
retrograde cholangiopancreatography (ERCP)
should not be used routinely during the acute
presentation due to the risk of ERCP-
associated pancreatitis complicating the acute
situation. ERCP should be reserved for specific
cases where there is evidence of biliary
obstruction. Evaluation of pancreatic duct
anatomy can be helpful on an interval basis to
help assess causes of chronic or recurrent
pancreatitis.