SURGERY 3 PART 1

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• GI- General-
• IBD-
• Appendix & Acute Abd. Pain
• GI Bleeding-
Abdomen
1. A 41-year-old man complains of regurgitation of saliva and of
undigested food. An esophagram reveals a bird's-beak deformity. Which
of the following statements is true about this condition?

A. Chest pain is common in the advanced stages of this disease

B. More patients are improved by forceful dilatation than by surgical
intervention
C. Manometry can be expected to show high resting pressures of the
lower esophageal sphincter (LES)
D. Surgical treatment consists primarily of resection of the distal
esophagus with reanastomosis to the stomach above the diaphragm
E. Patients with this disease are at no increased risk for the
development of carcinoma
Bird-beak sign
 Achalasia

• hypertension of the LES and failure of the LES to relax on pharyngeal

swallowing.

• premalignant condition of the esophagus. Over a 20-year period, a

patient will have up to an 8% chance of developing carcinoma.
Squamous cell carcinoma is the most common type identified.

• The classic triad of dysphagia (begins with liquids and progresses to

solids) , regurgitation, and weight loss.
• Other symptoms: heartburn, nocturnal coughing, are commonly seen.
 Achalasia

• Manometry is the gold standard test.

• manometry shows five classic findings: 2 of LES, 3 of body of the
esophagus
• LES :
1. hypertensive, with pressures > 35 mmHg .
2. fail to relax with deglutition.
• body of the esophagus:
1. pressure above baseline (pressurization of the esophagus).
2. simultaneous mirrored contractions with no evidence of
progressive peristalsis.
3. low-amplitude waveforms- indicating a lack of muscular tone.
 Achalasia- treatment

• all are directed toward relieving the obstruction caused by the LES.
Non surgical: medications and endoscopic - usually a short-term .

• sublingual nitroglycerin, nitrates, or calcium channel blockers. hours of relief

• Bougie dilation -several months of relief but requires repeated dilations to

be sustainable.
• Injections of botulinum toxin (Botox) directly into the LES (relief
for years, but symptoms recur more than 50% of the time within 6 months).
• Dilation with balloon - effective in 60% of patients, risk for perforation <4%;
however.
 Achalasia

Surgical treatment

Esophagomyotomy - superior results, less traumatic than balloon dilation.

• Laparoscopic Heller myotomy is now the operation of choice.
• Most patients will experience some symptoms of reflux. The decision
to perform an antireflux procedure remains controversial.
Esophagectomy –
• considered in any symptomatic patient with tortuous esophagus
(megaesophagus), sigmoid esophagus, Failure of more than one
myotomy, or an undilatable reflux stricture.
• eliminates the risk for carcinoma
1. A 41-year-old man complains of regurgitation of saliva and of
undigested food. An esophagram reveals a bird's-beak deformity. Which
of the following statements is true about this condition?

A. Chest pain is common in the advanced stages of this disease

B. More patients are improved by forceful dilatation than by surgical
intervention
C. Manometry can be expected to show high resting pressures of the
lower esophageal sphincter (LES)
D. Surgical treatment consists primarily of resection of the distal
esophagus with reanastomosis to the stomach above the diaphragm
E. Patients with this disease are at no increased risk for the
development of carcinoma
2. A 41-year-old man complains of regurgitation of saliva and of
undigested food. An esophagram reveals a dilated esophagus and a
bird’s-beak deformity. Manometry shows a hypertensive lower
esophageal sphincter with failure to relax with deglutition. Which of the
following is the safest and most effective treatment of this condition?

A. Medical treatment with sublingual nitroglycerin, nitrates, or calcium-

channel blockers
B. Repeated bougie dilations
C. Injections of botulinum toxin directly into the lower esophageal
sphincter
D. Dilation with a Gruntzig-type (volume-limited, pressure-control)
balloon
E. Surgical esophagomyotomy
3. The initial pathologic change that leads to the clinical findings of
achalasia is

A. Hypertension of the LES

B. Relaxation of the LES
C. Hypertension of the body of pancreas
D. Diffuse relaxation of the body of the pancreas
E. Reflux
4. Which of the following is primary treatment for Barrett’s
esophagus with low grade dysplasia:

A. Follow up.
B. Ant reflux operation.
C. Endoscopic radiofrequency ablation.
D. Photodynamic therapy.
E. Esophagectomy.
Barrett esophagus
• Complication of gastroesophageal reflux disease (GERD).

• Replacement of the normal stratified squamous

epithelium lining of the esophagus by simple columnar
epithelium with goblet cells (which are usually found lower in
the gastrointestinal tract).

• The medical significance of Barrett's esophagus is its strong

association (~0.5% per patient-year)
with esophageal adenocarcinoma.
4. Which of the following is primary treatment for Barrett’s
esophagus with low grade dysplasia:

A. Follow up.
B. Antireflux operation.
C. Endoscopic radiofrequency ablation.
D. Photodynamic therapy.
E. Esophagectomy.
5. A 70-kg man with pyloric obstruction secondary to ulcer disease is
admitted to the hospital for resuscitation after 1 week of prolonged
vomiting. What metabolic disturbance is expected?

A. Hypokalemic, hyperchloremic metabolic acidosis

B. Hyperkalemic, hypochloremic metabolic alkalosis
C. Hyperkalemic, hyperchloremic metabolic acidosis
D. Hypokalemic, hypochloremic metabolic alkalosis
 pyloric obstruction / stenosis
Pyloric obstruction = emesis = hypokalemic, hypochloremic metabolic
alkalosis.

1. Vomiting >> loss of HCl rich fluid from the stomach >>> alkalosis

2. compensation for the alkalosis >> bicarbonate excretion in urine is

increased.(excreted as a sodium salt).
3. to conserve intravascular volume >>> aldosterone-mediated sodium
absorption occurs >> potassium and hydrogen excretion.
4. This compounds the alkalosis and results in a paradoxical aciduria.
5. A 70-kg man with pyloric obstruction secondary to ulcer disease is
admitted to the hospital for resuscitation after 1 week of prolonged
vomiting. What metabolic disturbance is expected?

A. Hypokalemic, hyperchloremic metabolic acidosis

B. Hyperkalemic, hypochloremic metabolic alkalosis
C. Hyperkalemic, hyperchloremic metabolic acidosis
D. Hypokalemic, hypochloremic metabolic alkalosis
6. A 63-year-old man undergoes a partial gastrectomy with Billroth II
reconstruction for intractable peptic ulcer disease. Which of the
following metabolic disturbance is not potential consequence of this
procedure?

A. Megaloblastic anemia
B. Iron deficiency anemia
C. Osteoporosis
D. Osteolitisfibroecystica
E. Steatorrhea
gastrectomy
 Metabolic Disturbances after gastrectomy
• Anemia:
• The most common metabolic defect appearing after gastrectomy.
• Iron deficiency (more common) – > 30% of patients undergoing
gastrectomy. decreased iron intake and impaired absorption in the
duodenum
• Megaloblastic anemia- impairment in vitamin B12 metabolism.
(lack of intrinsic factor, produced by the parietal cells of the
stomach).
• osteoporosis and osteomalacia - caused by deficiencies in calcium
absorption . calcium is normally absorbed in the proximal intestine—
duodenum and jejunum
• Fat malabsorption is also present, the calcium malabsorption is
further aggravated because fatty acids bind calcium. inadequate
mixing of bile salts and lipase
6. A 63-year-old man undergoes a partial gastrectomy with Billroth II
reconstruction for intractable peptic ulcer disease. Which of the
following metabolic disturbance is not potential consequence of this
procedure?

A. Megaloblastic anemia
B. Iron deficiency anemia
C. Osteoporosis
D. Osteolitisfibroecystica
E. Steatorrhea
7. A 52 years old woman with BMI 45 undergoes laparoscopic sleeve
gastrectomy. Postoperatively she is at greatest risk for which of the
following?

A. Gastric stricture
B. Surgical site infection
C. Gastric leak
D. Pulmonary embolism
E. Delayed gastric emptying
Complication after bariatric surgery

• The most dreaded complication after bariatric surgery is a leak from

the gastrointestinal tract.

• Tachycardia, at times accompanied by tachypnea or agitation, is

often the only manifestation of this severe intra-abdominal problem.

• further diagnostic include: gastrografin esophageal swallow studies

and oral contrast CT scans, and even be prepared to reexplore the
patient before overwhelming sepsis from the leak of gastric contents
induces multisystem organ failure.
7. A 52 years old woman with bmi 45 undergoes laparoscopic sleeve
gastrectomy. Postoperatively she is at greatest risk for which of the
following?

A. Gastric stricture
B. Surgical site infection
C. Gastric leak
D. Pulmonary embolism
E. Delayed gastric emptying
8. A 45-year-old woman with history of heavy nonsteroidal anti-
inflammatory drug ingestion presents with acute abdominal pain. She
undergoes exploratory laparotomy 30 hours after onset of symptoms and
is found to have a perforated duodenal ulcer. Which of the following is the
procedure of choice to treat her perforation?

A. Simple closure with omental patch.

B. Truncle vagotomy and pyloroplasty.
C. Truncle vagotomy and anterectomy.
D. Highly selective vagotomy with omental patch.
E. Hemigastrectomy
perforated duodenal ulcer
• Complication of PUD.

• Patients will complain of sudden onset, frequently severe epigastric

pain.

• In examination: localized peritoneal signs exist . Patients with more

widespread spillage will have diffuse peritonitis.

• chest radiograph will reveal free air.

• The perforation is usually in the first portion of the duodenum

Management:
operative intervention is required in almost all cases.

• Perforations < 1 cm: can generally be closed primarily and buttressed

with well-vascularized omentum.

• For larger perforations, a Graham patch repair with a tongue of healthy

omentum is performed.

• For very large perforations (>3 cm), control of the duodenal defect can
be difficult. The defect should be closed by the application of healthy
tissue, such as omentum or jejunal serosa , with placement of a
duodenostomy tube and wide drainage.

• An alternative in this difficult situation is antrectomy and a Billroth II

reconstruction.
8. A 45-year-old woman with history of heavy nonsteroidal anti-
inflammatory drug ingestion presents with acute abdominal pain. She
undergoes exploratory laparotomy 30 hours after onset of symptoms and
is found to have a perforated duodenal ulcer. Which of the following is the
procedure of choice to treat her perforation?

A. Simple closure with omental patch.

B. Truncle vagotomy and pyloroplasty.
C. Truncle vagotomy and anterectomy.
D. Highly selective vagotomy with omental patch.
E. Hemigastrectomy
9. A 39-year-old previously healthy male is hospitalized for 2 weeks with
epigastric pain radiating to his back, nausea, and vomiting. Initial laboratory
values revealed an elevated amylase level consistent with acute pancreatitis.
Five weeks following discharge, he complains of early satiety, epigastric pain,
and fevers. On presentation, his temperature is 38.9°C (102°F) and his heart
rate is 120 beats per minute; his white blood cell (WBC) count is 24,000/mm3
and his amylase level is normal. He undergoes a CT scan demonstrating a 6
cm by 6 cm rim-enhancing fluid collection in the body of the pancreas. Which
of the following would be the most definitive management of the fluid
collection?

A. Antibiotic therapy alone

B. CT-guided aspiration with repeat imaging in 2 to 3 days
C. Antibiotics and CT-guided aspiration with repeat imaging in 2 to 3 days
D. Antibiotics and percutaneous catheter drainage
E. Surgical internal drainage of the fluid collection with a cyst-gastrostomy or
Roux-en-Y
 Acute pancreatitis
Sterile and Infected Peripancreatic Fluid Collections

• Described in 30% to 57% of patients.

• In contrast to pseudocysts and cystic neoplasias of the pancreas, fluid
collections are not surrounded or encased by epithelium or fibrotic
capsule.

• Treatment is supportive - most fluid collections will be spontaneously

reabsorbed by the peritoneum.
• The presence of fever, elevated white blood cell (WBC) count, and
abdominal pain suggest infection of this fluid.
• Percutaneous drainage and IV administration of antibiotics should be
instituted if infection is present.
Pancreatic Pseudocysts
• Occur in 5% to 15% of patients who have peripancreatic fluid collections
after AP.

• By definition, the capsule of a pseudocyst is composed of collagen and

granulation tissue and it is not lined by epithelium.
• The fibrotic reaction typically requires at least 4 to 8 weeks to develop.

• Up to 50% of patients will develop symptoms: persistent pain, early

satiety, nausea, weight loss, and elevated pancreatic enzyme levels in
plasma suggest this diagnosis.
• The diagnosis is corroborated with by CT or MRI.
Pancreatic Pseudocysts

• Observation is indicated for asymptomatic patients because

spontaneous regression has been documented in up to 70% of cases.

• Surgical drainage has been the traditional approach for pancreatic

pseudocysts.
• However, there is increasing evidence that transgastric and
transduodenal endoscopic drainage are safe and effective

• Definitive treatment depends on the location of the cyst.

• Percutaneous drainage is only indicated for septic patients secondary to

pseudocyst infection because it has a high incidence of external fistula.
9. A 39-year-old previously healthy male is hospitalized for 2 weeks with
epigastric pain radiating to his back, nausea, and vomiting. Initial laboratory
values revealed an elevated amylase level consistent with acute pancreatitis.
Five weeks following discharge, he complains of early satiety, epigastric pain,
and fevers. On presentation, his temperature is 38.9°C (102°F) and his heart
rate is 120 beats per minute; his white blood cell (WBC) count is 24,000/mm3
and his amylase level is normal. He undergoes a CT scan demonstrating a 6
cm by 6 cm rim-enhancing fluid collection in the body of the pancreas. Which
of the following would be the most definitive management of the fluid
collection?

A. Antibiotic therapy alone

B. CT-guided aspiration with repeat imaging in 2 to 3 days
C. Antibiotics and CT-guided aspiration with repeat imaging in 2 to 3 days
D. Antibiotics and percutaneous catheter drainage
E. Surgical internal drainage of the fluid collection with a cyst-gastrostomy or
Roux-en-Y
10. A 32-year-old alcoholic with end-stage liver disease has been admitted to
the hospital 3 times for bleeding esophageal varices. He has undergone
banding and sclerotherapy previously. He admits to currently drinking a 6
packs of beer per day. On his abdominal examination, he has a fluid wave.
Which of the following is the best option for long-term management of this
patient’s esophageal varices?

A. Orthotopic liver transplantation

B. Transection and reanstomosis of the distal esophagous
C. Distal splenorenal shunt
D. End -to- side portocaval shunt
E. Transjugular intrahepatic portosystemic shunt(TIPS)
definitive treatment- Variceal Hemorrhage

Options available for definitive treatment include:

• Pharmacotherapy
• Chronic endoscopic treatment
• TIPS - transjugular intrahepatic portosystemic shunting
• Shunt operations (e.g., nonselective, selective, partial)
• Liver transplantation.
• The most effective treatment regimen usually requires two or more of
these therapies in sequence.

• In most centers, initial treatment consists of pharmacotherapy or

endoscopic therapy with portal decompression by means of TIPS or an
operative shunt reserved for failures of first-line treatment
definitive treatment- Variceal Hemorrhage

• patients with well-compensated liver disease: portosystemic shunts

can be used to prevent recurrent variceal bleeds.

• Patients with poorly compensated liver disease: who develop

recurrent variceal bleeds should undergo transjugular intrahepatic
portosystemic shunting.

• patients with Child C cirrhosis (poorly compensated liver disease),

surgical shunting should be avoided because of increased operative
mortality
definitive treatment- Variceal Hemorrhage

• Hepatic transplantation is contraindicated in a patient who is

actively drinking.

• Esophageal transection and reanastomosis, or the Sugiura

procedure, are typically reserved for patients with splanchnic venous
thrombosis who are not shunt candidates
10. A 32-year-old alcoholic with end-stage liver disease has been admitted to
the hospital 3 times for bleeding esophageal varices. He has undergone
banding and sclerotherapy previously. He admits to currently drinking a 6
packs of beer per day. On his abdominal examination, he has a fluid wave.
Which of the following is the best option for long-term management of this
patient’s esophageal varices?

A. Orthotopic liver transplantation

B. Transection and reanstomosis of the distal esophagous
C. Distal splenorenal shunt
D. End -to- side portocaval shunt
E. Transjugular intrahepatic portosystemic shunt(TIPS)
11. A 60 years old man present for elective laparoscopic
cholecystectomy. On examination of his abdomen after insertion of
the laparoscope, an incidental Meckel’s diverticulum is noted.
What is the most appropriate management for this condition?

A. Diverticulectomy
B. Segmental bowel resection
C. Inversion of the diverticulum
D. Enteroscopy
E. There is no need to resect the diverticulum
 Meckel’s Diverticulum
• True diverticulum in that it contains all layers of the small bowel wall.

• Congenital remnant of the omphalomesenteric duct, occurring in

approximately 2% of the general population. M=F

• Located on the antimesenteric border of the ileum 45 to 60 cm proximal

to the ileocecal valve

• It’s often 2 inches in length.

• contains two types of ectopic mucosa (gastric and pancreatic).
 Meckel’s Diverticulum

• Meckel’s diverticula may be complicated by inflammation,

perforation, hemorrhage, or obstruction.

• GI bleeding: caused by peptic ulceration of adjacent intestinal

mucosa from hydrochloric acid secreted by ectopic parietal cells
within the diverticulum.

• Intestinal obstruction associated with Meckel’s diverticulum is

usually caused by intussusception or volvulus around an abnormal
fibrous connection between the diverticulum and posterior aspect of
the umbilicus.
 Meckel’s Diverticulum- treatment

symptomatic Meckel’s diverticulum:

• surgical intervention with resection of the diverticulum or resection
of the segment of ileum bearing the diverticulum.

• Segmental intestinal resection is required for treatment of patients

with bleeding because the bleeding site is usually in the ileum
adjacent to the diverticulum.

• Resection of the diverticulum for nonbleeding Meckel’s diverticula

can be performed using a hand-sewn technique or stapling across
the base of the
Meckel’s Diverticulum- treatment

Incidentally found Meckel’s diverticulum:

• Children: asymptomatic diverticula found in children during

laparotomy is generally recommended to be resected.

• Adults: controversial.
• Meckel’s diverticulum becoming symptomatic in the adult patient
was estimated as 2% or less; morbidity rates from incidental removal
is ~12% in some studies,

• epidemiologic population-based study by Cullen and associates

recommends that an incidentally found Meckel’s diverticulum be
removed at any age up to 80 years as long as no additional
conditions (e.g., peritonitis) make removal hazardous
11. A 60 years old man present for elective laparoscopic
cholecystectomy. On examination of his abdomen after insertion of
the laparoscope, an incidental Meckel’s diverticulum is noted.
What is the most appropriate management for this condition?

A. Diverticulectomy
B. Segmental bowel resection
C. Inversion of the diverticulum
D. Enteroscopy
E. There is no need to resect the diverticulum
12. A 40 years old female admitted to the ER for fever 38.5°C and RLQ
pain. On exam she has tenderness and peritonitis located to the RLQ. Labs
are normal, except WBC 18,000. Abdominal CT demonstrate right sided
diverticulitis with no evidence of an abscess, free air or contrast leak.
What is the most appropriate initial management?

A. Nothing per OS, IV fluids and antibiotics.

B. Colonoscopy.
C. Right hemicolectomy with end ileostomy.
D. Right hemicolectomy and primary anastomosis.
E. Fiber enriched diet.
diverticulitis
Uncomplicated diverticulitis : disease not associated with free
intraperitoneal perforation, fistula formation, or obstruction,

• It can often be treated with antibiotics on an outpatient basis.

• If the patient has significant pain characteristic of localized

peritonitis,
hospitalization and IV antibiotics are indicated.

• usually respond promptly to antibiotic treatment, with marked

improvement in symptoms within 48 hours.
 diverticulitis
• After the symptoms have subsided for at least 3 weeks, investigative
studies should be conducted to establish the presence of diverticula and
to exclude cancer, which can mimic diverticulitis. (colonoscopic
Examination)

• If a patient suffers recurrent attacks of diverticulitis, surgical treatment

should be considered. It has generally been recommended that
sigmoidectomy be offered after two uncomplicated attacks of
diverticulitis to prevent a future complicated episode

• for sigmoidectomy because of recurrent attacks of diverticulitis

obviously needs to consider the patient’s overall health and lifestyle,
frequency of the attacks, and debility associated with each attack.
12. A 40 years old female admitted to the ER for fever 38.5°C and RLQ
pain. On exam she has tenderness and peritonitis located to the RLQ. Labs
are normal, except WBC 18,000. Abdominal CT demonstrate right sided
diverticulitis with no evidence of an abscess, free air or contrast leak.
What is the most appropriate initial management?

A. Nothing per os, IV fluids and antibiotics.

B. Colonoscopy.
C. Right hemicolectomy with end ileostomy.
D. Right hemicolectomy and primary anastomosis.
E. Fiber enriched diet.
13. patient with known diverticular disease of the colon has a 5-day
history of worsening pain in the left lower quadrant. He now has fever
and had diarrhea this morning. On examination he is found to have
fullness in the lower left quadrant with guarding. What would the best
management now include?

A. Diagnostic laparoscopy
B. Immediate operative exploration
C. Air-contrast enema
D. Colonoscopy
E. CT scan of the abdomen and pelvis
The diagnosis of diverticulitis
Clinical manifestations:

• Tenderness, cramps, or pain in the abdomen (usually in the lower

left side but may occur on the right) that is sometimes worse
when you move.
• Fever and chills.
• A bloated feeling, abdominal swelling, or gas.
• Diarrhea or constipation.
• Nausea and sometimes vomiting.
• Loss of appetite.
The diagnosis of diverticulitis

• The diagnosis of diverticulitis can often be presumed with a fair

degree of reliability by a careful history and physical examination
and it is reasonable to begin treatment with antibiotics on this
evidence alone.

• However, if the diagnosis is in doubt, four diagnostic tests can be

considered:
1. computed tomography (CT) of the abdomen,
2. magnetic resonance imaging (MRI)
3. abdominal ultrasound
4. water-soluble contrast enema.
WHY CT??
• There has been more experience with CT, which is considered by
most surgeons to be the preferred test to confirm the suspected
diagnosis of diverticulitis.

• It reliably reveals the location of the infection, extent of the

inflammatory process, presence and location of an abscess, and
sympathetic involvement of other organs, with secondary
complications such as ureteral obstruction or a fistula to the bladder.

• In addition, an abscess detected by CT may often be drained by a

percutaneous approach with the aid of CT guidance.
Operation ??

• Elective resection and primary anastomosis can then be undertaken

following successful nonoperative treatment of an abscess and after
the inflammation has subsided.

• A patient who becomes hemodynamically unstable during a period

of conservative management or does not improve with nonoperative
measures will require prompt surgical exploration.

• In this setting, resection of the diseased segment is generally

preferred
13. patient with known diverticular disease of the colon has a 5-day
history of worsening pain in the left lower quadrant. He now has fever
and had diarrhea this morning. On examination he is found to have
fullness in the lower left quadrant with guarding. What would the best
management now include?

A. Diagnostic laparoscopy
B. Immediate operative exploration
C. Air-contrast enema
D. Colonoscopy
E. CT scan of the abdomen and pelvis
14. A 53 year old man presents to the emergency room with left lower
quadrant pain, fever, and vomiting. CT scan of the abdomen and pelvis
reveals a thickened sigmoid colon with inflamed diverticula and a 7cm by 8cm
rim enhancing fluid collection in the pelvis. After percutaneous drainage and
treatment with antibiotics, the pain and fluid collection resolve. He returns as
an outpatient to clinic 1 month later. He undergoes a colonoscopy, which
demonstrates only diverticula in the sigmoid colon. Which of the following is
the most appropriate next step in this patient’s management?

A. Expectant management with sigmoid resection if symptoms recur

B. Cystoscopy to evaluate for a fistula
C. Sigmoid resection with end colostomy and rectal pouch (Hartmann
procedure)
D. Sigmoid resection with primary anastomosis
E. Long-term suppressive antibiotic therapy
15. A 75-year-old female is admitted to the ER with lower abdominal pain
accompanied by nausea of two days. Her temperature is 37.9 stable vital
signs. Left lower abdominal tenderness. WBC count of 14.000 and CT scan
demonstrates sigmoid diverticula with 5 cm abscess near the sigmoid colon.
What the next most appropriate step?

A. Broad spectrum IV antibiotics and observation

B. Broad spectrum oral antibiotics . NPO and observation
C. Laparotomy with sigmoid resection
D. Laparotomy with excision drainage
E. CT guided percutaneous abscess drainage
F. A or/and E
Complicated diverticulitis

• Unless the abscess is small (<2 cm in diameter), it should be

drained, and the preferred method of drainage is a percutaneous
route guided by CT or ultrasound.

• Adequate drainage of the abscess, accompanied by the

administration of IV antibiotics, usually results in a rapid clinical
improvement.

• Elective surgery should be offered after the patient has

completely recovered from the infection, usually approximately 6
weeks after drainage of the abscess
15. A 75-year-old female is admitted to the ER with lower abdominal pain
accompanied by nausea of two days. Her temperature is 37.9 stable vital
signs. Left lower abdominal tenderness. WBC count of 14.000 and CT scan
demonstrates sigmoid diverticula with 5 cm abscess near the sigmoid colon.
What the next most appropriate step?

A. Broad spectrum IV antibiotics and observation

B. Broad spectrum oral antibiotics . NPO and observation
C. Laparotomy with sigmoid resection
D. Laparotomy with excision drainage
E. CT guided percutaneous abscess drainage
F. A or/and E
16. An 80-year-old man is admitted to the hospital complaining of
nausea, abdominal pain, distention, and diarrhea. A cautiously performed
trans anal contrast study reveals an apple-core configuration in the
rectosigmoid area. Which of the following is the most appropriate next
step in his management?

A. Colonoscopic decompression and rectal tube placement

B. Saline enemas and digital disimpaction of fecal matter from the rectum
C. Colon resection and proximal colostomy
D. Oral administration of metronidazole and checking a Clostridium
difficile titer
E. Evaluation of an electrocardiogram and obtaining an angiogram to
evaluate for colonic mesenteric ischemia
classic apple-core lesion
Large bowel obstruction

dynamic (mechanical):
• characterized by blockage of the large bowel (luminal, mural, or
extramural),
• resulting in increased intestinal contractility as a physiologic
response to relieve the obstruction.

Pseudoobstruction
• characterized by the absence of intestinal contractility,
• often associated with decreased or absent motility of the small
bowel and stomach.
 Large bowel obstruction
Intraluminal causes of colorectal obstruction :
• Fecal impaction
• inspissated barium
• foreign bodies.
Intramural causes
• Carcinoma
• inflammation (e.g., diverticulitis, Crohn’s disease, lymphogranuloma
venereum, tuberculosis, schistosomiasis),
• Hirschsprung’s disease (aganglionosis),
• Ischemia
• Radiation
• intussusception, and anastomotic stricture.
Large bowel obstruction
Extraluminal causes :
• adhesions (the most common cause of small bowel obstruction, but rarely a
cause of colonic obstruction)
• Hernias
• tumors in adjacent organs
• Abscesses
• volvulus.

Most common causes:

• Colorectal cancer (most common cause in the United States)
• Colonic volvulus (more common cause in Russia, Eastern Europe, and
Africa)
Large bowel obstruction

Regardless of the cause of the blockage, the clinical manifestations of

large bowel obstruction include :

• failure to pass stool

• flatus associated with increasing abdominal distention
• cramping abdominal pain.

Management
• medical preparation (eg, hydration, normalization of electrolytes),
• surgical management of his mechanical obstruction.
 Large bowel obstruction
Surgical treatment
1. If the cause of the obstruction is a cancer of the distal or mid rectum, the
preferred treatment is to relieve the obstruction by a loop colostomy and
then treat the cancer with neoadjuvan chemoradiation, with the plan to
resect the primary lesion at a later time.

2. if the obstructing cancer is in the sigmoid colon, the surgical options

include:
1. Hartmann’s operation (sigmoidectomy with descending
colostomy and closure of the rectal stump),
2. sigmoidectomy with primary colorectal anastomosis (with or
without intraoperative colonic lavage)
3. abdominal colectomy with ileorectal anastomosis.
Large bowel obstruction

3. Right-sided colonic obstruction, whether caused by cancer or the

result of volvulus, is generally treated by resection and primary
anastomosis of the ileum and transverse colon.
16. An 80-year-old man is admitted to the hospital complaining of
nausea, abdominal pain, distention, and diarrhea. A cautiously performed
transanal contrast study reveals an apple-core configuration in the
rectosigmoid area. Which of the following is the most appropriate next
step in his management?

A. Colonoscopic decompression and rectal tube placement

B. Saline enemas and digital disimpaction of fecal matter from the rectum
C. Colon resection and proximal colostomy
D. Oral administration of metronidazole and checking a Clostridium
difficile titer
E. Evaluation of an electrocardiogram and obtaining an angiogram to
evaluate for colonic mesenteric ischemia
17. Fine needle aspiration biopsies are often useful for which of
the following entities?

A. Thyroid nodules
B. Breast mass
C. Liver mass
D. Lymphoadenopathy
E. Lung mass
18. A 60-years-old male referred to the ER due to nausea and increase
abdominal pain over the last 3 h. Past medical history is positive for
IHD, PVD and AF. He is not treated with anticoagulant due to peptic
ulcer bleeding. On admission he seen in sever pain, temperature 37.9,
BP 140/90, abdomen soft with diffuse tenderness and decrease
peristalsis. What is most appropriate diagnosis?

A. bowel Obstruction
B. mesenteric Ischemia
C. peptic ulcer perforation
D. acute cholecystitis
Acute mesenteric ischemia
• is a syndrome caused by inadequate blood flow through the
mesenteric vessels, resulting in ischemia and eventual gangrene
of the bowel wall.

• it is a potentially life-threatening condition.

 Mesenteric ischemia
Clinical presentation:
• Early in the course of AMI,.- abdominal pain (tenderness is minimal
to nonexistent). The abdomen may be distended. Stool may be
positive for blood.
• Peritoneal signs develop late, when infarction with necrosis or
perforation occurs. Tenderness becomes severe and may indicate
the location of the infarcted bowel segment.
• A palpable tender mass may be present.
• Bowel sounds range from hyperactive to absent.

• Fever, hypotension, tachycardia, tachypnea, and altered mental

status are observed.
19. A 70-year-old female is brought to ER for acute severe diffuse
abdominal pain, nausea. She has hypertension s/p CVA, diabetes and
hyperlipidemia. She has a fever of 38.2, blood pressure 150/90, pulse
110 beats/minute. On examination the abdomen is markedly tender.
Without peristalsis positive grading and positive rebound. WBC is
17.000. What is the most likely diagnosis?

A. Acute pancreatitis
B. Ruptured aortic aneurism
C. Bowel ischemia
D. Acute cholecystitis
E. Acute appendicitis
20. A 19-year-old female complains of constipation and sharp pain
on defecation accompanied by mild fresh blood. On examination –
lateral right anal fissure. What topical treatment can be offered to
this patient?

A. Calcium channel Blockers (Nifedipine)

B. Beta Blockers (Metoprolol)
C. Lidocaine and Steroids
D. Anal gel containing Botulinum Toxin
Anal fissure
• a painful linear tear or crack in the distal anal canal.
• in the short term, usually involves only the epithelium and, in the
long term, involves the full thickness of the anal mucosa.
• tend to occur in younger and middle-aged persons.
Anal fissure
• A history of constipation or passage of hard stools may be
present.
• rectal pain: described as burning, cutting, or tearing that occurs
with bowel movements.
Pain occurs with sitting, moving, defecating, and even coughing
• Spasm of the anus is very suggestive for an anal fissure.

• Typically, bright-red blood appears on the surface of stools, but

blood usually is not mixed into stool and is present only in a small
amount. Occasionally, blood is found on toilet paper after wiping.

• A patient with an anal fistula may complain of recurrent

malodorous perianal drainage, pruritus, recurrent abscesses,
• Initial therapy for an anal fissure is medical in nature, and more
than 80% of acute anal fissures resolve without further therapy.
• The goals of treatment are to relieve the constipation and to
break the cycle of hard bowel movement, associated pain, and
worsening constipation.
• Softer bowel movements are easier and less painful for the
patient to pass.