Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
40 Cards in this Set
- Front
- Back
|
A 72 year old man had three large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood. - What is it? - How is the diagnosis made? |
What is it? - The clear aspirate is meaningless because he is not bleeding right now. So the guilty territory can be anywhere from the tip of the nose to the anal canal. Across the board, 3⁄4 of all GI bleeding is upper, and virtually all the causes of lower GI bleeding are diseases of the old: diverticulosis, polyps, cancer and angiodysplasias. So, is old, the overall preponderance of upper is balanced by the concentration of lower causes in old people...so it could be anywhere.
How is the diagnosis made? - Angiography is not the first choice for slow bleeding or bleeding that has stopped. The first choice now is endoscopies, both upper and lower. |
|
|
A 7 y/o boy passes a large bloody BM. - What is it? - How is the diagnosis made? |
What is it? - In this age group, Meckel’s diverticulum leads the list.
How is the diagnosis made? - By radioactively labeled technetium scan (not the one that tags reds cells, but the one that identifies gastric mucosa). |
|
|
A 41 year old man has been in the intensive care unit for two weeks, being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood. - What is it? - Management? |
What is it? - In this setting, it has to be stress ulcer.
Management: It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antiacids or both; but once the bleeding takes place the diagnosis is made as usual with endoscopy. Treatment will be difficult, and it may require angiographic embolization of the left gastric artery. |
|
|
A 59 year old man arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal pain that began about one hour ago, and is now generalized, constant and extremely severe. He lies motionless in the stretcher, is diaphoretic and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants. - What is it? - Management? |
What is it? - Sort of a generic picture of acute abdomen. The time and circumstances attest to the severity and rapid onset of the problem. The physical findings are impressive. He has generalized acute peritonitis.
Management: The acute abdomen does not need a precise diagnosis to proceed with surgical exploration. Lower lobe pneumonia and myocardial infarction to have to be ruled out with chest X-Ray and EKG, and it would be nice to have a normal amylase...but the best answer for this vignette should be prompt emergency exploratory laparotomy. |
|
|
A 62 year old man with cirrhosis of the liver and ascitis, presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis. - What is it? - Diagnosis? - Tx? |
What is it? - Peritonitis in the cirrhotic with ascitis, or the child with nephrosis and ascitis, could be primary peritonitis – which does not need surgery – rather than the garden-variety acute peritonitis secondary to an intraabdominal catastrophe that requires emergency operation.
How is the diagnosis made? - Cultures of the ascitic fluid will yield a single organism.
Treatment will be with the appropriate antibiotics. |
|
|
A 43 year old man develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a rigid abdomen, lies motionless in the examining table, has no bowel sounds and is obviously in great pain, which he describes as constant. X-Ray shows free air under the diaphragms. - What is it? - What needs to be done? |
What is it? - Acute abdomen plus perforated viscus equals perforated duodenal ulcer in most cases. Although I am exaggerating the “sudden onset” by giving the exact minute, vignettes of perforated peptic ulcer will have a pretty sharp time of onset.
What needs to be done? - Emergency exploratory laparotomy. |
|
|
A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization. - What is it? - How is it diagnosed? - Management? |
What is it? - Acute pancreatitis.
How is it diagnosed? - Serum and urinary amylase and lipase determinations. CT scan if the diagnosis is unclear, or in a day or two if there is no improvement.
Management: NPO, NG suction, IV fluids. |
|
|
A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications. - What is it? - How is the diagnosis made? - Management? |
What is it? - Acute cholecystitis.
How is the diagnosis made? - Sonogram should be the first choice. If equivocal, an “HIDA” scan (radionuclide excretion scan).
Medical management in most cases will “cool down” the process. Surgery will follow. |
|
|
A 52 year old man has right flank colicky pain of sudden onset, that radiates to the inner thigh and scrotum. There is microscopic hematuria. - What is it? - Diagnose how? |
What is it? - Ureteral colic ( included here for differential diagnosis).
How is the diagnosis made? - Urological evaluation always begins with a plain film of the abdomen (a “KUB”). Nowadays sonogram often is the next step, but traditionally it has been intravenous pyelogram (IVP). |
|
|
A 59 year old lady has a history of three prior episodes of left lower quadrant abdominal pain for which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness, and a vaguely palpable mass. She has fever and leukocytosis. - What is it? - Diagnosis? - Treatment? |
What is it? - Acute diverticulitis.
How is the diagnosis made? - CT scan.
Treatment is medical for the acute attack (antibiotics, NPO) but elective sigmoid resection is advisable for recurrent disease (like this lady is having). Emergency surgery (resection or colostomy) may be needed if she gets worse or does not respond to treatment. |
|
|
An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passes any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers towards the left lower quadrant with the shape of a parrot’s beak. - What is it? - Management? |
What is it? - Volvulus of the sigmoid.
Management: Proctosigmoidoscopy should relieve the obstruction. Rectal tube is another option. Eventually surgery to prevent recurrences could be considered. |
|
|
A 79 year old man with atrial fibrillation develops and acute abdomen. He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal exam. He has acidosis and looks quite sick. X-Rays show distended small bowel and distended colon up to the middle of the transverse colon. - What is it? |
Acute abdomen in the elderly who has atrial fibrillation, brings to mind embolic occlusion of the mesenteric vessels. Acidosis frequently ensues, and blood in the stool is often seen. unfortunately not much can be done, as the bowel is usually dead. |
|
|
A 53 year old man with cirrhosis of the liver develops malaise, vague right upper quadrant abdominal discomfort and 20 pound weight loss. Physical exam shows a palpable mass that seems to arise from the left lobe of the liver. Alpha feto protein is significantly elevated. - What is it? - Next move? |
What is it? - Probably liver cell carcinoma (hepatoma)
Next move? - CT scan. If confined to one lobe, resection. |
|
|
A 53 year old man develops vague right upper quadrant abdominal discomfort and a 20 pound weight loss. Physical exam shows a palpable liver with nodularity. Two years ago he had a right hemicolectomy for cancer of the ascending colon. His carcinoembryogenic antigen (CEA) had been within normal limits right after his hemicolectomy, is now ten times normal. - What is it? - Next move? |
What is it? - Metastasis to the liver from colon cancer.
Next move? – CT scan to ascertain extent. If mets are confined to one lobe, resection may be done. Otherwise, chemotherapy if he has not had it. |
|
|
A 24 year old lady develops moderate, generalized abdominal pain of sudden onset, and shortly thereafter faints. At the time of evaluation in the ER he is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender, and she has a hemogoblin of 7. There is no history of trauma. On inquiring as to whether she might be pregnant, she denies the possibility because she has been on birth control pills since she was 14, and has never misses taking them. - What is it? - Management? |
What is it? - Bleeding from a ruptured hepatic adenoma, secondary to birth control pills.
Management: It’s pretty clear that she is bleeding into the belly, but a CAT scan will confirm it and probably show the liver adenoma as well. Surgery will follow. |
|
|
A 44 year old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever and leukocytosis and some tenderness in the right upper quadrant. A sonogram reveals a liver abscess. - Diagnosis how? |
Not much of a diagnostic challenge here, but the issue is management, and it is included to contrast it with the handling of the patient in the next vignette. This is a pyogenic abscess, it needs to be drained (the radiologists will do it percutaneously). |
|
|
A 29 year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alkaline phosphatase. Sonogram of the right upper abdominal area shows a normal biliary tree, and an abscess in the liver. - What is it? - Management? |
What is it? - This one is an amebic abscess...very common in Mexico.
Management: Alone among abscesses, this one in most cases does not have to be drained, but can be effectively treated with Metranidazole. Get serology for amebic titers, but don’t wait for the report (it will take 3 weeks). Start the patient on Metranidazole. Prompt improvement will tell you that you are on the right tract. When the serologies come back the patient will be well and your diagnosis will be confirmed. Don’t fall for an option that suggests aspirating the pus and sending it for culture, you can not grow the ameba from the pus. |
|
|
A 42 year old lady is jaundiced. She has a total bilirubin of 6 and the laboratory reports that the unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is zero. She has no bile in the urine. - What is it? - What do you do next? |
What is it? - The vignette in the exam will be adorned with other evidence of hemolysis, but you do not need it to make the diagnosis. This is hemolytic jaundice.
What do you do next? - Try to figure out what is chewing her red cells. |
|
|
A 19 year old college student returns from a trip to Cancun, and two weeks later develops malaise, weakness and anorexia. A week later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alkaline phosphatase is mildly elevated, while the SGOT and SGPT (transaminases) are very high. - What is it? - Management? |
What is it? - Hepatocellular jaundice.
Management: Get serologies to confirm diagnosis and type of hepatitis. |
|
|
A patient with progressive jaundice which has been present for four weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase was twice normal value couple of weeks ago, and now is about six times the upper limit of normal. - What is it? - Next move? |
What is it? - A “generic” example of obstructive jaundice.
Next move? - Sonogram, looking for dilated intrahepatic ducts, possibly dilated extrahepatic ducts as well, and if we get lucky a finding of gallstones. |
|
|
A 40 year old, obese mother of five children presents with progressive jaundice which she first noticed four weeks ago. She has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. She gives a history of multiple episodes of colicky right upper quadrant abdominal pain, brought about by ingestion of fatty food. - What is it? - What do you do next? |
What is it? - Again obstructive jaundice, with a good chance of being due to stones.
What do you do next? - Start with the sonogram. If you need more tests after that, ERCP is the next move, which could also be used to remove the stones from the common duct.
Cholecystectomy will eventually have to be done. |
|
|
A 66 year old man presents with progressive jaundice which he first noticed six week ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He has lost 10 pounds over the past two months, but is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and av ery distended, thin walled gallbladder. - What is it? - What do you do next? |
What is it? - Malignant obstructive jaundice. “Silent” obstructive jaundice is more likely to be due to tumor. A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder is thick-walled, non-pliable.
What do you do next? - You already have the sonogram. Next move is CAT scan and ERCP. |
|
|
A 66 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal pancreatic duct. - What is it? - Next step? |
What is it? - Malignant, but lucky: probably cholangiocarcinoma at the lower end of the common duct. He could be cured with a pancreatoduodenectomy (Whipple operation).
Next move: get brushings of the common duct for cytological diagnosis. |
|
|
A 64 year old lady presents with progressive jaundice which she first noticed two weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated SGOT. The alkaline phosphatase is about ten times the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and very distended, thin walled gallbladder. - What is it? - Next move? |
What is it? - Again malignant, but also lucky. The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an ampullary carcinoma, another malignancy that can be cured with radical surgery.
Next move: Endoscopy. |
|
|
A 56 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. He alkaline phosphatase is about eight times the upper limit of normal. He has lost 20 pounds over the past two months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. - What is it? - How to diagnose |
What is it? - Bad news. Cancer of the had of the pancreas. Terrible prognosis.
How do clinch the diagnosis?: CAT scan –which may show the mass in the head of the pancreas; then ERCP –which will probably show obstruction of both common duct and pancreatic duct. |
|
|
A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brought about by the ingestion of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. Physical exam is unremarkable. - What is it? - Next move? |
What is it? - Gallstones, with biliary colic.
Next move: Sonogram. Elective cholecystectomy will follow. |
|
|
A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications. - What is it? |
If you are alert, you will recognize the picture of acute cholecystitis...in fact this is vignette No. G.l.38, that had been presented in the acute abdomen section. It is repeated here to contrast it with the next one. |
|
|
A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began three days ago. The pain was colicky at first, but has been constant for the past two and a half days. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. She has temperature spikes to 104 and 105, with chills. Her WBC is 22, 000, with a shift to the left. Her bilirubin is 5 and she has an alkaline phosphatase of 2,000 (about 20 times normal). She has had episodes of colicky pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications. - What is it? - Further test? - Management? |
What is it? - Acute ascending cholangitis. Further test?: The diagnosis is already clear. Sonogram might confirm dilated ducts.
Management: This is an emergency decompression of the biliary tract. To achieve the latter ERCP is the first choice, but PTC (percutaneous transhepatic cholangiogram) is another option. |
|
|
A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brougth about by the ingestions of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain, and the pain lasted longer than usual. She has mild tenderness to palpation in the epigastrium and right upper quadrant. Laboratory determinations show a bilirubin of 3.5, an alkaline phosphatase 5 times normal and a serum amylase 3 times normal value. - What is it? - What does she need? |
What is it? - She passed a common duct stone and had a transient episode of cholangitis (the shaking chill, the high phosphatase) and a bit of biliary pancreatitis (the high amylase).
What does she need?: As in many of these cases, start with sonogram. It will confirm the diagnosis of gallstones. If she continues to get well, elective cholecystectomy will follow. If she deteriorates, she may have the sone still impacted at the Ampulla of Vater, and may need ERCP and sphincterotomy to extract it. |
|
|
A 33 year old, alcoholic male, shows up in the E.R. with epigastric and mid-abdominal pain that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant, very severe, and it radiates straight through to the back. He vomited twice early on, but since then has continued to have retching. He has tenderness and some muscle guarding in the upper abdomen, is afebrile and has mild tachycardia. Serum amylase is 1200, and his hematocrit is 52. - What is it? - Management? |
What is it? – Acute edematous pancreatitis.
Management: put the pancreas at rest: NPO, NG sution, IV fluids. |
|
|
A 56 year old alcoholic male is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight thorugh to the back, and is extremely severe. He has a serum amylase of 800, WBC of 18,000 blood glucose of 150, serum calcium of 6.5 and a hematocrit of 40. He is given IV fluids and kept NPO with NG sution. By the next morning, his hematocrit has dropped to 30 the serum calcium has remained below 7 in spite of calcium administration, his BUN has gone up to 32 and he has developed metabolic acidosis and a low arterial PO2. - What is it? - What do you do? |
What is it? – He has hemorrhagic pancreatitis. In fact, he is in deep trouble, with at least eight of Ranson’s criteria predicting 80 to 100% mortality.
What do you do? Very intensive support will be needed, but the common pathway to death from complication of hemorrhagic pancreatitis frequently is by way of pancreatic abscesses that need to be drained as soon as they appear. Thus serial CT scans will be required. |
|
|
A 57 year old alcoholic male is being treated for acute hemorrhagic pancreatis. He was in the intensive care unit fore one week, required chest tubes for pleural effusion, and was on a respirator for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease he begins to spike fever and to demonstrate leukocytosis. - What is it? - How do we confirm it? - What does she need? |
What is it? - Pancreatic abscess.
How do we confirm it? - CT scan.
What does he need? - Drainage. |
|
|
A 49 year old alcoholic male presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen, and actually hard to define. He was discharged from the hospital 5 weeks ago, after successful treatment for acute pancreatitis. - What is it? - Management? |
What is it? - Pancreatic pseudocyst.
Management: You could diagnose it on the cheap with a sonogram, but CT scan is probably the best choice. It will need to be drained, and the radiologist will do it with CT guidance. An older option was to operate and anastomose the pseudocyst to the GI tract. |
|
|
A 55 year old lady presents with vague upper abdominal discomfort, early satiety and a large but ill-defined epigastric mass. Five weeks ago she was involved in an automobile accident where she hit the upper abdomen against the steering wheel. - What is it? - Management? |
What is it? - Again pancreatic pseudocyst, in this case secondary to trauma rather than as a sequela of pancreatitis.
Management: You could diagnose it on the cheap with a sonogram, but CT scan is probably the best choice. It will need to be drained, and the radiologist will do it with CT guidance. An older option was to operate and anastomose the pseudocyst to the GI tract. |
|
|
A disheveled, malnourished individual shows up in the emergency room requesting medication for pain. He smells of alcohol and complains bitterly of constant epigastric pain, radiating straight through to the back that he says he has had for several years. He has diabetes, steatorrhea and calcifications in the upper abdomen in a plain X-Ray. - What is it? - What should you do? |
What is it? - Chronic pancreatitis.
I hope they ask you to recognize this vignette, but not to manage it. There is precious little that can be done for these unfortunate individuals. Stopping the alcoholic intake is the first step (easier said than done). Replacement of pancreatic enzymes and control of the diabetes are obvious needs, but the pain is most difficult to eradicate. Various operations can be done and those would be guided by the anatomy of the pancreatic ducts, thus if forced to go further diagnostic test, pick ERCP. |
|
|
On the first post-operative day after an open cholecystectomy, a patient has a temperature of 101. - What is it? - Management? - What about the third day? |
1st day: - Atelectasis - Listen to the chest, CXR, encourage deep breathing and coughing
3rd day: - UTI - Urinalysis, urinary culture, antibiotics
|
|
|
On the fourth post-operative day after an open cholecystectomy, a patient develops a temperature of 101. There is tenderness to deep palpation in the calf, particularly when the foot is dorsiflexed. - What is it? - Management? |
What is it? - Deep venous thrombosis.
Management: Duplex ultrasound (Doppler flow plus real time B-mode) to confirm diagnosis. Anticagulation to prevent thrombus propagation. |
|
|
Seven days after an inguinal hernia repair, a patient returns to the clinic because of fever. The wound is red, hot and tender. - What is it? - Management? |
What is it? - Wound infection.
|
|
|
Two weeks after an open cholecystectomy a patient develops fever and leukocytosis. The wound is healing well and does not appear to be infected. - What is it? - Management? |
What is it? - A deep abscess. Two locations are prime suspects: subphrenic or subhepatic. Had the operation been an appendectomy, pelvic abscess would be the first pick.
Management: CT scan to find the abscess and to guide the radiologist for the percutaneous drainage. |
|
|
On the fifth post-operative day after a right hemicolectomy for cancer, the dressings covering the midline abdominal incision are fund to be soaked with a clear, pinkish, salmon-colored fluid. - What is it? - Management? |
What is it? - Wound dehiscence.
Management: Keep the patient in bed, tape his belly together and schedule surgery for re-closure of the wound if the patient can take the re-operation. If too sick, the development of a ventral incisional hernia may have to be accepted now and repaired later. On the other hand, if following the discover of the copious, salmon colored, pinkish clear fluid, the patient gets out of bed, or sneezes forcefully, you may be confronted with a bucket-full of small bowel. Evisceration has taken place. In that case, keep the bowel covered and moist with sterile dressings, and rush the patient to the OR for re-closure. |
