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Self-Assessment Questions

Gastroenterology

GastrointestinalEmergencies: Review Questions

Douglas G. Adler, MD

Dr. Adler is an assistant professor of medicine and director of therapeutic endoscopy, Huntsman Cancer Center, University of Utah, Salt Lake City, UT.



Choose the single best answer for each question.



Figure

1. A 50-year-old man undergoes a screening colonoscopy. He has no family history of colorectal cancer. During the colonoscopy, a 2-cm cecal polyp is removed using an endoscopic snare and electrocautery. In the recovery room, the patient develops severe acute periumbilical pain and has a distended abdomen. He becomes tachycardic but is otherwise hemodynamically stable. He does not have peritoneal signs. What is the next best course of action?

  1. Abdominal computed tomography (CT) scan
  2. Abdominal radiographs
  3. Abdominal ultrasound
  4. Emergent surgical consultation
  5. Observation
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2. A 68-year-old woman undergoes a laparoscopic appendectomy for acute appendicitis. The patient has a history of congestive heart failure and diabetes. The surgery is difficult; the surgeon converts to an open procedure that lasts 4 hours and is complicated by several episodes of hypotension. On postoperative day 1, the patient has a single episode of coffee-ground emesis, and a gastroenterology consultation is obtained. Upper endoscopy demonstrates complete esophageal mucosal necrosis with dark, friable mucosa (Figure). The stomach and duodenum are normal. The patient is hemodynamically stable and clinically not in distress. What is the next step in this patient’s management?

  1. Barium swallow to rule out perforation
  2. Emergency surgery
  3. Obtain multiple esophageal biopsy specimens to rule out a superimposed infection
  4. Place a nasogastric tube to aspirate blood and decompress the stomach
  5. Strict NPO (nothing by mouth) status, aggressive acid suppression, and observation
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3. A 20-year-old woman is found somnolent and confused by her roommate in their college dormitory. The roommate states that the patient was very distraught over a poor grade on an important examination and shows an empty bottle of acetaminophen that she found in the room. When full, the bottle contained thirty 500 mg tablets. An acetaminophen overdose is suspected, and the patient is found to have an extremely high acetaminophen level. Other toxicology screening tests are negative. The exact timing of her ingestion is unknown. The patient also has evidence of severe hepatitis. What is the best first-line therapy in this setting?

  1. Gastric lavage
  2. Activated charcoal
  3. Liver transplantation
  4. N-acetylcysteine
  5. Serum of ipecac
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  4. A 43-year-old man with known ulcerative colitis is admitted to the hospital for a severe disease flare with copious bloody stools and dehydration. After stool studies show no evidence of infection, the patient is administered high-dose intravenous steroids. On hospital day 2, the patient develops fevers and a rigid, painful, and distended abdomen, and laboratory tests reveal an elevated white blood cell count. An abdominal CT scan demonstrates massive distension of the entire colon with associated pneumatosis in the cecum and right colon. What is the next best step in this patient’s management?
  1. Emergency colonoscopy with placement of a decompression tube
  2. Insertion of a nasogastric tube for decompression
  3. Insertion of a rectal tube for decompression
  4. Neostigmine administration to pharmacologically induce decompression
  5. Urgent surgical evaluation
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5. A 62-year-old man presents to the emergency department for a food bolus impaction. The patient states that approximately 8 hours ago he was eating a piece of pork without his dentures and swallowed a large bolus that he feels has not “gone down.” He presented for evaluation when he realized he would not be able to sleep in his current condition. The patient has a history of a prior food bolus impaction under similar circumstances, and previous examination also disclosed a Schatzki’s ring in his distal esophagus. The patient is unable to clear his secretions and is spitting saliva into a cup. He is otherwise stable with normal vital signs and a normal abdominal examination. What is the next best therapeutic option for this patient?

  1. Gastrograffin swallow to confirm the food bolus and identify the level of obstruction
  2. Glucagon administration
  3. Observation
  4. Surgical evaluation
  5. Upper endoscopy to remove the food bolus from the esophagus
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6. A 70-year-old man presents to his physician with a 7-day history of right upper quadrant pain and fevers. He has been unable to eat and believes he has lost several pounds. On examination, the patient is febrile, tachycardic, and borderline hypotensive. He has hepatomegaly and right upper quadrant tenderness. Laboratory testing reveals marked leukocytosis. A right upper quadrant ultrasound, performed to evaluate for cholecystitis, demonstrates a normal gallbladder but identifies a 6-cm fluid collection in the right hepatic lobe. CT scan demonstrates a low-density lesion with peripheral enhancement. The patient is diagnosed with a pyogenic abscess. Fluids and broad-spectrum antibiotics are administered. What is the next best step in this patient’s management?

  1. Aspiration of a small amount of fluid from the abscess to obtain culture and antibiotic sensitivity data
  2. Endoscopic retrograde cholangiopancreatography to internally drain the abscess if it communicates with the biliary tree
  3. Observation
  4. Percutaneous drainage of the abscess via interventional radiology
  5. Surgical drainage of the abscess for definitive therapy
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